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Spinal nerve is formed by the union of a
ventral nerve root and a dorsal nerve
root.
After emerging from the intervetebral
foramen, it divides into a dorsal ramus
and a ventral ramus.
The dorsal rami innervates the
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ventral rami innervates the
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Those in the upper cervical region unite to form
the cervical plexus and those in the lower cervical
region plus the first thoracic ramus unite to form
the brachial plexus. This is the same in lumbar and
sacral region.
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It will depend on the nature and degree of
the initial trauma.
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The degenerative changes the distal
segment of a peripheral nerve fiber (axon
and myelin) undergoes,
when its continuity with its cell body is
interrupted by a focal lesion
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Regrowth of the axon will take place down the endoneurial tube.
The proliferation of the schwann cells helps to guide the axon
down the tube and they may bridge the gap.
The stump of the axon develops a swelling and from this a number
of fibers grow into the surrounding tissue.
Regeneration of the axon will grow at the rate of 1-2mm/day.
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Also called as circumflex nerve, C5-C6, branch of the
posterior cord of brachial plexus.
Type of lesion is usually a neuropraxia or axonotmesis.
Clinical features: inability to abduct the arm because of
the paralysis of the deltoid and teres minor.
Muscle wasting, can be observed by the loss in contour
over the shoulder.
Sensory loss is minimal and seen in the lower half of the
muscle
Loss of
deltoid
contour and
greater
tubercle
prominent.
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Physiotherapy management:
passive abduction of the shoulder should be
carried out.
Full range of other shoulder movements
should be maintained.
Later, the muscle has to be strengthened
using the standard criteria. ( grade 1 to 5)
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Also called as nerve to serratus anterior or nerve of bell. (C5,
6, 7)
Branch of the roots of brachial plexus and supplies the
serratus anterior muscle.
Causes: sudden pressure on the shoulder from above or
carrying heavy loads on the shoulder.
functions of SA: Protraction of the scapula, overhead
abduction, and steadies the scapula during carrying weight.
Clinical features:
Periscapular pain.
“winging of scapula”
Inferior angle and medial border of the scapula are unduly
prominent.
Unable to do punching or pushing actions nor able to elevate
the upper limbs above 90.
No sensory impairments.
Special test: forward pressure against wall or external
resistance will make the inferior angle and medial
border more prominent.
 Physiotherapy management is the same.
Scapulothoracic bracing.
Surgical muscle transfer from pec maj to scapula to
decrease pain, winging and restore shoulder ROM. (7091%)
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The radial nerve (C5, 6, 7, 8,T1) , which arises from the
posterior cord of the brachial plexus,
The superficial radial nerve is sensory and supplies the skin
over the lateral part of the dorsum of the hand and the
dorsal surface of the lateral three and a half fingers
proximal to the nail beds
The deep branch supplies the extensor carpi radialis brevis
and the supinator in the cubital fossa and all the extensor
muscles in the posterior compartment of the forearm.
dermatomes
Radial nerve
Injuries to the Radial Nerve in the Axilla:
In the axilla• Crutch palsy,
• Saturday night palsy
It can also be badly damaged in the axilla by fractures and
dislocations of the proximal end of the humerus.
Motor
•The triceps, the anconeus, and the long extensors of the
wrist are paralyzed.
•The patient is unable to extend the elbow joint, the wrist
joint, and the fingers.
• Wristdrop, or flexion of the wrist,
Median Nerve Injuries
From a clinical standpoint, the median nerve is injured
occasionally in the elbow region in supracondylar fractures of
the humerus.
• It is most commonly injured by stab wounds or broken glass
just proximal to the flexor retinaculum;
Sensory
Skin sensation is lost on the lateral half or less of the palm of
the hand and the palmar aspect of the lateral three and a half
fingers.
Sensory loss also occurs on the skin of the distal part of the
dorsal surfaces of the lateral three and a half fingers.
Motor
The pronator muscles of the forearm and the long
flexor muscles of the wrist and fingers, with the
exception of the flexor carpi ulnaris and the medial
half of the flexor digitorum profundus, will be
paralyzed.
As a result, the forearm
is kept in the supine position;
wrist flexion is weak and is
accompanied by adduction.
Motor: The thumb is laterally rotated and adducted. The
hand looks flattened and “ape-like.”
Opposition movement of the thumb is impossible. The first
two lumbricals are paralyzed,
which can be recognized clinically when the patient is asked
to make a fist slowly, and the index and
middle fingers tend to lag behind
the ring and little fingers.
Carpal Tunnel Syndrome
it is an entrapment neuropathy caused by compression of
median nerve in the carpal tunnel, in middle aged women .
cause is idiopathic in most patients
precipitating factors :
1. Diabetes mellitus
2. pregnancy : due to edema
3. Rheumatoid arthritis , hypothyroidism and acromegaly : due
to connective tissue thickening
clinical features
. pain , numbness , tingling or an " electric shock " feeling in
thumbs and finger supplied by the median nerve , especially
after using the hand or at night wakening the patient from
sleep .
2. The condition is usually bilaterally
3. sometimes sensory loss of radial three and half digits
4. weakness and wasting of abductor pollicis brevis
5. Tinel's sign : tapping on the carpal tunnel produces pain
Diagnosis
diagnosis is clinical confirmed by nerve conduction velocity
(NCV) that shows slowing of conduction over the wrist
Management :
1. Rest
2. Splinting at night
3. Local injection of corticosteroid
4. IF pregnancy is the cause - give diuretics
5. IF myxedema - give thyroxine
6.Surgical decompression of the nerve in carpal tunnel if all
above measures fail
The ulnar nerve, which arises from the medial cord of the
brachial plexus (C8 and T1 )
it supplies the flexor carpi ulnaris and the medial half of
the flexor digitorum profundus.
The palmar cutaneous branch supplies the skin over the
hypothenar eminence;
the posterior branch supplies the skin over the
medial third of the dorsum of the hand and the medial one
and a half fingers.
 The injuries at the elbow are usually associated with
fractures of the medial epicondyle.
 The superficial position of the nerve at the wrist makes
it vulnerable to damage from cuts and stab wounds
In longstanding cases the hand assumes the characteristic
“claw” deformity
Wasting of the paralyzed muscles results in flattening of the
hypothenar eminence and loss of the convex curve to the
medial border of the hand.
•Examination of the dorsum of the hand will show hollowing
between the metacarpal bones caused by wasting of the dorsal
interosseous muscles
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EMG
SD curve
NCV
Tinels sign
Sweat test
Skin resistance test
Electrical stimulation
Femoral Nerve Injury
The femoral nerve can be injured in stab or gunshot
wounds, but a complete division of the nerve is rare.
The following clinical features are present when the nerve
is completely divided:
Motor: The quadriceps femoris muscle is paralyzed,
and the knee cannot be extended. In walking, this is
compensated for to some extent by use of the adductor
muscles.
Sensory: Skin sensation is lost over the anterior and
medial sides of the thigh, over the medial side of the lower
part of the leg, and along the medial border of the foot as
far as the ball of the big toe.
Sciatic Nerve Injury
The nerve is sometimes injured by penetrating wounds,
fractures of the pelvis, or dislocations of the hip joint.
It is most frequently injured by badly placed
intramuscular injections in the gluteal region.
Motor: The hamstring muscles are paralyzed, but
weak flexion of the knee is possible because of the
action of the sartorius (femoral nerve) and gracilis
(obturator nerve).
All the muscles below the knee are paralyzed, and the
weight of the foot causes it to assume the plantar-flexed
position, or foot drop.
Sensory: Sensation is lost below the knee, except for an
area down the medial side of the lower part of the leg and
along the medial border of the foot as far as the ball of the
big toe, which is supplied by the saphenous nerve (femoral
nerve).
Sciatica can be caused
prolapse of an intervertebral disc with pressure on one or
more roots of the lower lumbar and sacral spinal nerves,
pressure on the sacral plexus or
sciatic nerve by an intrapelvic tumor, or
inflammation of the sciatic nerve.
Common Peroneal Nerve Injury
It is commonly injured in fractures of the neck of the fibula
and by pressure from casts or splints.
Motor: The muscles of the anterior and lateral
compartments of the leg are paralyzed cause the foot to
be plantar flexed (foot drop) and inverted, an attitude
referred to as equinovarus.
Sensory: Loss of sensation occurs down the anterior and
lateral sides of the leg and dorsum of the foot and toes,
including the medial side of the big toe
When the injury occurs distal to the site of origin of the lateral
cutaneous nerve of the calf, the loss of sensibility is
confined to the area of the foot and toes.
Tibial Nerve Injury
Motor: All the muscles in the back of the leg and the sole
of the foot are paralyzed. The opposing muscles dorsiflex
the foot at the ankle joint and evert the foot at the subtalar
and transverse tarsal joints, an attitude referred to as
calcaneovalgus.
Sensory: Sensation is lost on the sole of the foot; later,
trophic ulcers develop.
Initial care during stage of paralysis:
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To prevent or reduce oedema
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Positioning,
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Active movements,
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Massage,
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To prevent contractures
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Passive movements to full joint ROM
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To maintain activity and power of unaffected muscles
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Facilitate movement by supporting limb or functional splinting
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Electrical stimulation by IDC or pulsed electromagnetic energy
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Encourage use of unaffected muscles in the limb
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To maintain function
Functional splints, active use
To maintain activity and power of unaffected muscles
Facilitate movement by supporting limb or functional splinting
Electrical stimulation by IDC or pulsed electromagnetic energy
Encourage use of unaffected muscles in the limb
To maintain function
Functional splints, active use
To look after areas where there is any sensory disturbance
Care for areas of anaesthesia
Stage of recovery
Recovery program includes motor or sensory re-education