Download MBBS Anatomy PPT 97 Median & Ulnar Notes

Objectives


? Origin, course & relation of median & ulnar nerves.

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? Motor & sensory distribution

? Carpal tunnel syndrome

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? Claw hand

? Motor & sensory effects in cases of lesion of median

& ulnar nerves

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? Clinical signs/tests

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Median & Ulnar nerves

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Ulnar & Median nerves - Brachial plexus

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Median Nerve

Origin : (C5,6,7, & 8, T1)
? median nerve is formed
? by union of lateral and medial roots

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? originating from lateral and medial

cords of brachial plexus.

? anterior to third part of axillary artery

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Median Nerve

Origin : C5,C6,C7 & C8, T1
? median nerve is

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formed anterior to
third part of axillary
artery by union of
lateral and medial

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roots originating
from lateral and
medial cords of
brachial plexus.

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Median Nerve in Arm

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? At inferior margin of teres major muscle.
? Passes vertically down on medial side of arm in anterior

compartment and is related to brachial artery throughout
its course:

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? proximal region lateral to brachial artery;
? distal region at mid point it crosses to medial side

of brachial artery and lies anterior to elbow joint.

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Median nerve has NO major branches in arm, but a branch
to one of muscles of the forearm, pronator teres muscle,
may originate from it immediately proximal to elbow joint.

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Median Nerve in Arm

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Median nerve - C5,C6,C7 +
C8,T1

Origin: 2 roots - medial &
lateral cords of brachial plexus.

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medial root crosses 3rd part of
axillary artery & join lateral
root , runs down on lateral
side of brachial artery.

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Mid of arm, it crosses brachial
artery from lateral to medial
and continues down on its
medial side.

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At elbow, it lies medial to
tendon of biceps & is crossed
by bicipital aponeurosis.
? no branches in arm.

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Median Nerve in Forearm

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? Median nerve passes

into forearm anterior to
elbow joint, where

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branches innervate most
of muscles in anterior
compartment of forearm
(except for flexor carpi
ulnaris muscle and

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medial half of flexor
digitorum profundus
innervated by ulnar
nerve).

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Median nerve

In cubital fossa - lies deep to

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bicipital aponeurosis.
Leaves cubital fossa & runs
b/w two heads of pronator
teres.
Descends b/w flexor

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digitorum superficialis &
flexor digitorum profundus.
It reach palm deep to flexor
retinaculum or through
carpal tunnel deep to tendon

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of palmaris longus & lateral
to tendon of flexor digitorum
superficialis.

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Muscular: Pronator teres,

Median nerve in forearm Flexor carpi radialis , Palmaris

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longus & Flexor digitorum
superficialis.
Palmar cutaneous branch: at
distal part of forearm &

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superficial to flexor
retinaculum - skin of
lateral 2/3 of palm.
Articular: elbow joint.
Anterior interosseous nerve:

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between FPL & FDP, anterior
to interosseous membrane.
It supplies : FPL+PQ+ lateral
half of FDP.
Articular branches: wrist &

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distal radioulnar joint.



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Median Nerve in Hand

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? Median nerve continues into hand by

passing deep to flexor retinaculum.

? It innervates: Three thenar muscles of

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thumb , Lateral 2 lumbrical muscles
associated with movement of index and
middle fingers;

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? Skin over palmar surface of lateral three &

half digits and over lateral side of palm
and middle of wrist.

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Median Nerve in Hand

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? Enters palm through carpal

Median n in hand

tunnel, deep to flexor

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retinaculum & divides
lateral & medial branches.

? Lies a fingerbreadth distal to

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tubercle of scaphoid.

? Muscular: Thenar ? Muscles 5 .
? Abductor pollicis brevis.
? Flexor pollicis brevis. Thenar

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? Opponens pollicis

Emi

nenec

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e

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Ms.

(deep to the above 2 ms.).

? Lateral 2 lumbricals (1st & 2nd ).

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? Digital cutaneous branches : to

palmar aspect of lateral 3 ?
fingers

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Median Nerve Lesion

? Injury of median nerve at different levels

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cause different syndromes.

? In arm and forearm the median nerve is

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usually not injured by trauma because of
its relatively deep position.

? Median nerve can be damaged:

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Elbow region
At wrist above flexor retinaculum
In carpal tunnel

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Median Nerve Lesion in Elbow Region

? Damaged in

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supracondylar fracture
of humerus

? Muscles affected are:
? Pronator muscles of

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the forearm

? All long flexors of

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wrist and fingers
except FCU and
medial half of FDP

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Median Nerve Lesion at Wrist

? Often injured by penetrating wounds (stab wounds or

broken glass) of the forearm.

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? Motor:
? Thenar muscles are paralyzed and atrophy in time so thenar

eminence becomes flattened

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? Opposition & abduction of thumb are lost, and thumb and

lateral two fingers are arrested in adduction & hyperextension
position .

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? Apelike hand
? Sensory & trophic changes are same as in elbow

region injuries

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Carpal Tunnel Syndrome

? The commonest neurological

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problem associated with median
nerve is compression beneath
flexor retinaculum at wrist.

? Motor: Weak motor function of

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thumb, index & middle finger

? Sensory: Burning pain or pi s

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a d eedles along distribution
of median nerve to lateral 3?
fingers

No sensory changes over palm as palmer cutaneous branch

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is given before median nerve enters carpal tunnel.


Lesion of median nerve - above elbow

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? Weakness of flexion - wrist due

to paralysis of FCR & PL.

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? Loss of pronation - paralysis of

pronator teres & quadratus.

? Loss of flexion of middle

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phalanges of medial 4 fingers -
paralysis of FDS.

? Loss of flexion of terminal

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phalanges of index & middle
fingers - paralysis of lateral ? of
? FDP.

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? The most serious

disability of median

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nerve injuries is:

? Loss of opposition

of the thumb. The

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delicate pincer-like
action is not
possible

? Loss of sensation

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from thumb and
lateral 3? fingers &

lateral of the pal

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Median Nerve

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? Origin: Medial and lateral cords

Motor

All muscles in anterior compartment of forearm

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(except flexor carpi ulnaris and medial half of flexor
digitorum profundus), three thenar muscles of the
thumb and two lateral lumbrical muscles

Sensory

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Skin over palmar surface of lateral three and one-half
digits and over lateral side of the palm and middle of
wrist

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Motor Effects:

Wasting
of thenar

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? Loss of pronation. Hand is kept in

eminence

supine position

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? Wrist shows weak flexion, and

ulnar deviation

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? Loss of flexion on interphalangeal

joints of the index and middle
fingers

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? Weak flexion of ring and little

Ulnar deviation

finger

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? Thumb is adducted and laterally

rotated, with loss of flexion of
terminal phalanx and loss of

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opposition

? Wasting of thenar eminence

? Hand looks flattened and

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apelike , and presents an inability

to flex three most radial digits
when asked to make a fist.

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? Sensory Effects: Loss of

sensation from:

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? The radial side of the palm
? Palmar aspect of the lateral

3? fingers

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? Distal part of the dorsal

surface of the lateral 3?
fingers

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? Trophic Changes:

? Dry and scaly skin
? Easily cracking nails

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? Atrophy of the pulp of

fingers

Lesion of median nerve -above elbow

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Loss of flexion of thumb - Flexor pollicis
longus & brevis

Loss of opposition of thumb - Opponens

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pollicis.

Flatting/Wasting of Thenar eminence -
atrophy.
Ape ha d - Ape thumb deformity

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Thenar eminence is flattened and thumb
is adducted & hyperextended.

Loss of cutaneous sensations - hollow of
palm + palmar surfaces of lateral 3 ?

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fingers.

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Lesion of median nerve -

above wrist

Loss of opposition of thumb

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paralysis - opponens pollicis.

Flattening of thenar
eminence - atrophy of thenar
muscles.

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Ape ha d or Ape thu b

Deformity.

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Loss of cutaneous sensations
- palmar surfaces of the
lateral 3 ? fingers.

Carpal tunnel syndrome

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? Compression of median nerve - carpal tunnel.
? Slight flattening of thenar eminence due to

wasting of thenar eminence muscles.

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? Accompanied by bur i g pai or pi & eedles

with diminished cutaneous sensations on palmar
aspect of lateral 3 ? fingers.

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? No paresthesia occurs over the thenar eminence

(because this area is supplied by palmar
cutaneous branch of median N) , arises in distal

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part of forearm & descends superficial to flexor
retinaculum.


Carpal tunnel syndrome

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Carpal tunnel syndrome

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Ulnar nerve C8T1

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Origin : medial cord of
brachial plexus , runs
medial to brachial artery -
middle of arm.

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At coracobrachialis
insertion, - pierces medial
intermuscular septum, is
accompanied by superior
ulnar collateral artery ? and

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enter posterior
compartment of arm.

At elbow - posterior to
medial epicondyle.

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No branches in arm.

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Ulnar nerve in forearm

? It continues downward

to enter in forearm

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? b/w two heads of

flexor carpi ulnaris.

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? It runs down forearm

between FCU and FDP.

? In lower half of forearm

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it lies medial to ulnar
artery.

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? Muscular: FCU & FDP

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Ulnar nerve in Forearm

? Flexor carpi ulnaris.

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? Medial ? of FDP

? Articular: elbow joint.

? Dorsal or posterior

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cutaneous branch:

? Dorsal surface - medial

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1/3rd of hand 1? fingers.

? Palmar cutaneous

branch : to supply skin of

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palm of hand and medial
1? fingers.

? FDP ? lateral ? Median N

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? Medial ? Ulnar N

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Ulnar nerve in Hand

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Ulnar nerve in Hand

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? Enters the palm superficial to flexor

retinaculum,

? close to lateral border of pisiform bone.

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? Then it divides into superficial & deep

branches.

? Superficial branch:

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? It supplies palmaris brevis
? palmar aspect of medial 1? fingers.

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Ulnar nerve in Hand

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Deep branch:
? Runs b/w abductor digiti minimi & flexor digiti minimi.

? pierces opponens digiti minimi.

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? Then passes laterally within concavity of deep palmar

arch.

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? lies deep to flexor tendons.

? It supplies 14 muscles :

? Three hypothenar muscles.

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? Adductor pollicis.

? All dorsal & palmar interossei.

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? Medial 2 lumbricals.

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Lesion of ulnar nerve above elbow - atrophy of
hypothenar muscles

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Lesion of ulnar nerve above elbow

? Weakness of flexion at wrist paralysis of FCU
? Loss of flexion of terminal phalanges of ring & little

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fingers paralysis of medial ? of FDP

? Paralysis of all interossei & medial 2 lumbricals (3rd &

4th).

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? Characteristic deformity is - partial claw hand.
? Atrophy of hypothenar muscles.
? Fingers - hyperextended at metacarpophalangeal joints

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& flexed at interphalangeal joints - ring & little finger.

? Loss of adduction of hand & thumb due to paralysis of

flexor carpi ulnaris & adductor pollicis.

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Lesion of ulnar

nerve above

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elbow - Loss of

cutaneous sensations

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on front & dorsum of

medial 1/3 of hand +

medial 1 ? fingers.

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? It leads to paralysis of

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Lesion of ulnar

intrinsic muscles of hand as

nerve above

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described above.

wrist

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? deformity claw hand
? Loss of cutaneous sensations

of medial 1 ? fingers.

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Test for Palmar interossei

Test for adductor &

for adduction of fingers.

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opponens pollicis.


Test for Palmar interossei for

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Test for adductor &

adduction of fingers.

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opponens pollicis.

1. Which one of these nerves is concerning with the carpal tunnel
syndrome ?
a.ulnar nerve.

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b.radial nerve.
c.median nerve.
d.axillary nerve.

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2. Which muscle has double nerve supply ?
A Biceps.
B Extensor digitorum superficialis.
C flexor digitorum profundus.
D Triceps.

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3. Ape hand is the characteristic deformity due to lesion of :
A Radial nerve.
B Ulnar nerve.
C Median nerve.

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D Axillary nerve.


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Pattern of injury

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Pattern of root contribution to plexus:

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Upper trunk lesion: Sensory loss in C5 & C6



Middle trunk lesion: Sensory loss in C7

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Lower trunk lesion: Sensory loss in the combined C8
& T1 dermatomes

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Principles of localization

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Certain sites
Ulnar nerve & median nerve at elbow
Carpal tunnel ? median nerve
Single nerve - Elbow extension ~ Radial
Multiple nerves - Elbow flexion ~

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Musculo cutaneous, Median


Complete claw

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hand

Affection of:

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1- Most of the small muscles of the hand (T1)

2- Ulnar flexors of the flexor compartment of forearm are partially

affected (C8)

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WINGING OF

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SCAPULA


Injury to axillary nerve

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Anterior

Shoulder Dislocation

Dislocated Head

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Normal Head


WRIST DROP

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Median nerve injury at elbow

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(hand of benediction)

Median nerve injury

A- Above Elbow:

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B- Above Wrist:

1- Loss of pronation

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1- No Loss of pronation

2- Week flexion

2- No Week flexion

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3- Ulnar deviation

3- No Ulnar deviation

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4- Inability to flex thumb

4- No Inability to flex thumb

5- Inability to oppose fingers

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5- Inability to oppose fingers

6- Inability to flex middle digits

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6- No Inability to flex middle digits

7- Inability to flex Index

7- No Inability to flex index and middle fingers

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middle fingers

-Sensory loss

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- Sensory loss

-Ape hand deformity

- Ape hand deformity

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Adducted &

Extended

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extended

index and

thumb

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middle

Flat thenar

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eminence

Flexed little and ring

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CARPAL TUNNEL

SYNDROME

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Ulnar nerve injury

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A - Above Elbow:
1- Week flexion
2- Loss of adduction
3- Inability to adduct thumb
4- Inability to put hand in writing position

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- Sensory loss
- Partial claw hand deformity

B - Above Wrist:
1- No Week flexion

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2- No Loss of adduction
3- Inability to adduct thumb
4- Inability to put hand in writing position
- Sensory loss to fingers only
- Partial claw hand deformity is more

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prominent (Ulnar paradox)

Ulnar canal syndrome/Guyon tunnel syndrome

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Handlebar neuropathy

? Symptoms
? Tingling
? Numbness

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? Pain on the outside or middle of the forearm; this

sensation of discomfort may run all the way to the
little finger.

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? Treatment
? Anti-inflammatory medications
? Wrist splints
? Therapeutic exercises

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An inability to oppose the thumb to the little

finger can result from damage to the

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________ nerve.

a) Axillary

b) Musculocutaneous

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c) Radial

d) Ulnar

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e) Median


Hyperextension of the proximal phalanges of

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the little and ring fingers can result from
damage to the ________ nerve.

a) Ulnar

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b) Axillary

c) Radial

d) Median

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e) Musculocutaneous

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Wrist drop can result from damage to the

________ nerve.

a) Median

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b) Ulnar

c) Radial

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d) Anterior interosseous

e) Axillary

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