Upper Limb

• What are the different 'parts' of the brachial plexus?

  Roots

  Trunks

  Divisions

  Cords

  Branches
• What nerves contribute to the brachial plexus?

  C5 - T1
• What are the terminal branches from the brachial plexus?

  Musculocutaneous

  Axillary

  Radial

  Median

  Ulnar
• What does the musculocutaneous nerve innervate?

  Lateral forearm skin

  Muscles in anterior arm

  • coracobrachialis
  • brachialis
  • biceps brachii
• What does the radial nerve innervate?

  Posterior compartment of arm & forearm

  • triceps brachii
  • brachioradialis
  • extensor carpi radialis longus
  • extensor carpi radialis brevis
  • extensor digitorum
  • extensor digiti minimi
  • extensor carpi ulnaris
  • anconeus
  • supinator
  • abductor policis longus
  • extensor policis brevis
  • extensor policis longus
  • extensor indices

  Posterior skin
• What is carpal tunnel syndrome?

  Compression of median nerve at the wrist

  Most common nerve entrapment

  Most common non-trauma hand problem
• What does the axillary nerve innervate?

  Deltoid

  Teres minor

  Superolateral skin of arm
• What are the typical symptoms of carpal tunnel syndrome?

  Pain (often burning)

  Tingling

  Numbness in area innervated by median nerve

  Weakness in small muscles supplied by motor branches of median nerve

  • abductor policis brevis
  • opponens policis
• Carpal tunnel syndrome - pathophys

  Median nerve gets pressure on it -> local nerve ischaemia -> numbness, tingling, pain/burning in median nerve distribution

  Often symptoms occur at night (wakes the pt)

  Long term increased pressure in carpal tunnel -> thenar atrophy (will not recover)
• What are the RFs of carpal tunnel syndrome?

  Female

  Inheriting smaller carpal tunnel

  Older age

  Pregnancy (often resolves with delivery)

  Heavy manual work & vibrating machinery

  Thyroid disease

  Trauma

  RA

  Ganglion cyst
• How can you test for carpal tunnel syndrome?

  Tinel's sign (tapping over median nerve at wrist)

  Phalen's test (hold in flexion for 1 min)

  Durkan's test (press over carpal tunnel with thumbs for around 30 secs)
• What are the Inx for carpal tunnel syndrome?

  Clinical diagnosis

  Nerve conduction electrophysiology tests (not necessary for diagnosis)

  -> may help for confirmation, localisation, selection for surgery, prognosis, complex causes, persistent/recurrent symptoms after treatment
• What is the treatment of carpal tunnel syndrome?

  1st line

  • night splints
  • activity modification (avoid wrist flection & extension)

  2nd line

  • steroid injections (usually temporary relief)
  • useful in pregnancy (when syndrome is temporary)

  3rd line

  • surgical release of transverse carpal ligament -> increases size of carpal tunnel & decreases pressure
  • usually don't get function back for a few months
• What does the median nerve innervate?

  Muscles in anterior forearm & some intrinsic hand muscles

  • pronator teres
  • flexor carpi radialis
  • palmaris longus
  • flexor digitorum superficialis
  • lateral 1/2 flexor digitorum profundus
  • flexor policis longus
  • pronator quadratus
  • lateral 2 lumbricals
  • opponens policis
  • abductor policis brevis
  • flexor policis brevis

  Skin in lateral hand
• What does the ulnar nerve innervate?

  Muscles in the anterior compartment of forearm & hand

  • flexor carpi ulnaris
  • medial 1/2 flexor digitorum profundus
  • medial 2 lumbricals
  • opponens digiti minimi
  • abductor digiti minimi
  • flexor digiti minimi
  • adductor policis
  • palmar interossei (PADS)
  • dorsal interossei (DABS)

  Skin of medial hand (palmar & dorsal)