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1. Peripheral Nerves of Upper
Limb
(Radial, Median and Ulnar Nerves)
Prepared by:
Intern Dr. Sunil Baniya
Shree Birendra Hospital

2. Upper Limb Anatomy
Skeleton:
Total bone = 64 (31.07%)
[32 in each]
Shoulder = 2
Arm = 1
Forearm = 2
Wrist (Carpals) = 8
Metacarpals = 5
Phalanges = 14

3. Muscles:
 Arm: 4
oAnterior Compartment: 3
[Musculocutaneous nerve]
•Biceps brachii
•Brachialis
•Coracobrachialis
oPosterior Compartment: 1 [Radial nerve]
•Triceps brachii

4. Forearm: 20
 Flexor/ Anterior Compartment: 8 [Median nerve]
{Medial to lateral}
◦ Superficial: 4
 Flexor carpi ulnaris [Ulnar nerve]
 Palmaris longus
 Flexor carpi radialis
 Pronator teres
◦ Intermediate: 1
 Flexor digitorum superficialis
◦ Deep: 3
 Flexor digitorum profundus [ Medial half- Ulnar nerve]
 Flexor pollicis longus
 Pronator quadratus

5.  Extensor/ Posterior Compartment: 12 [Radial
nerve]
◦ Superficial: 7
 Brachioradialis
 Extensor carpi ulnaris
 Extensor digiti minimi
 Extensor digitorum
 Extensor carpi radialis brevis
 Extensor carpi radialis longus
 Anconeus
◦ Deep: 5
 Extensor indicis
 Extensor pollicis longus
 Extensor pollicis brevis
 Abductor pollicis longus
 Supinator

6. Hand: 20
[Ulnar nerve]
 Palmaris brevis
 Adductor pollicis
 Dorsal interossei: 4
 Palmer interossei: 4
 Lumbricals: 4
[Lateral 2 = Median
nerve]
• Thenar muscles
[Median nerve]
o Opponens pollicis
o Flexor pollicis brevis
o Abductor pollicis brevis
• Hpothenar muscles
o Opponens digiti minimi
o Flexor digiti minimi
brevis
o Abductor digiti minimi

7. Peripheral Nerves of Upper Arm

9. Radial Nerve:
Course:
 Axilla: long head of Triceps
 Arm:
◦ As it enter:
 Posterior cutaneous nerve of arm
 Medial head of Triceps
◦ Radial groove: Lateral head of Triceps
◦ Anconeus muscle
◦ Cutaneous branch to arm and forearm

10. Axillary artery
Brachial artery

11. Inferior
lateral
cutaneous
nerve of
arm
Posterior cutaneous nerves of arm
Posterior cutaneous
nerve of forearm

12. o Pierces lateral intermuscular septum from behind at
middle and lower 3rd of arm to come anteriorly at
distal 3rd
 Elbow:
◦ Superficial branch - sensory
◦ Deep branch – motor
(Extensor carpi radialis bravis & supinator)
◦ Pierces supinator & reaches posterior compartment
of forearm : Extensor muscles of forearm & hand

15. Anatomical
snuffbox

16. Major motor branches:
 Before radial groove: Long head and medial head of
triceps
 After radial groove:
◦ Before crossing elbow:
Lateral head of triceps, Anconeus, brachioradialis, Extensor
carpi radialis longus
◦ After crossing elbow:
 Before piercing supinator: Extensor carpi radialis brevis,
Supinator
 After piercing supinator: Extensor muscles of forearm and
hands

17. S.N. Types of Radial Nerve
Palsy
Extension
Elbow Wrist Fingers
(MCP)
1 Very High
Injury around Axilla and above
the radial groove.
(eg. Crutch palsy)
Lost Lost
(Wrist
drop)
Lost
(Finger drop)
2 High
Injury in the radial groove, so
Triceps innervation is
preserved. (eg. Saturday Night
palsy, Holstein Lewis Palsy)
Preserved Lost
(Wrist
drop)
Lost
(Finger drop)
3 Low
Injury below the radial groove,
so the triceps and wrist
extensor innervation is
preserved. (PIN
Palsy)
Preserved Preserved Lost
(Finger drop)

18. Sensory
Examination:
Autonomous zone: 1st
dorsal web space of hand
Assessment:
 Fine touch
 Pinprick
 Two point discrimination
 Vibration

19. Median Nerve

20. Median Nerve
Course:
 Arm: descends adjacent to the brachial artery
 Forearm: enters between two heads of Pronator teres
◦ Proximal 3rd: passes deep to the origin of Flexor
digitorum superficialis
◦ Middle 3rd: descends between Flexor digitorum
superficialis and profundus
◦ Distal 3rd : 5 cm above the wrist becomes superficial
and lies between FDS and Flexor Carpi Radialis
 Hand: enters palm by passing deep to flexor retinaculum

22. anterior interosseus
nerve
flexor digitorum profundus
Flexor digitorum superficialis

23. Median
Nerve
Proper palmer digital nerves
Palmer cutaneous nerve

24. Major Motor branches:
 Arm: nil
 Forearm:
◦ Proximal 3rd: All Flexors except Flexor carpi ulnaris
& medial half of flexor digitorum profundus
◦ Distal 3rd: nil
 Hand:
◦ Thenar muscles (Abductor pollicis brevis, Flexor
pollicis brevis & Opponens pollicis)
◦ First two lumbricals

25. S.N. Types Results
1 High palsy
(Injury
proximal to
the elbow)
• Paralysis of all flexors except FCU & medial half
of FDP
• Paralysis of thenar muscles, first two lumbricals
• Pointing Index deformity/ Oschner clasp test
• Ulnar deviation of wrist on palmer flexon
• Pen test +ve
• Inability to perform OK sign/ Kiloh Nevin sign
(FDP+FPL)
• Benediction test +ve (unable to flex index &
middle finger on lifting hand)
• Hitchhiker’s sign (Inability to flex thumb- Flexor
pollicis longus)
2 Low palsy
(Injury distal
to the elbow
esp. in distal
3rd of forearm)
• Paralysis of hand muscles (thenar and first two
lumbricals)
• Ape thumb deformity (Paralysed oppenens
pollicis & unopposed evtensor pollicis longus )
• Pen test +ve (Abductor pollicis brevis)

26. Sensory Examination
Autonomous
Zone:
 Palmer aspect:
lateral 3 & half
fingers
 Dorsal aspect:
lateral 3 & half
distal digit

27. Ulnar Nerve

28. Ulnar Nerve
Course:
 Arm: medial to axillary artery
 Junction of middle & distal 3rd of arm: pierces medial
intermuscular septum and reach to posterior compartment
 Elbow: superficially behind medial epicondyle
 Forearm: enters between two head of Flexor carpi ulnaris
then runs medially and anterior to flexor digitorum profundus
 Wrist: passes in front of flexor retinaculum just lateral to
pisiform bone and divides into superficial & deep branches at
palm

35. Major motor branches:
 Arm: nil
 Forearm:
◦ Proximal 3rd:
-Flexor carpi ulnaris
-Medial half of flexor digitorum profundus
◦ Distal 3rd : nil
 Hand:
◦ Superficial branch: Hypothenar muscles
◦ Deep branch:
-Adductor pollicis
-All interossei &
-Medial two lumbricals

36. S.N. Types of Ulnar
Nerve Palsy
Result
1 High
(Injury proximal to elbow)
• Motor & sensory deficits in forearm
& hands
2 Low
(Injury
distal to
elbow )
Junction of
middle & lower
3rd of forearm
• FDP & FCU spared
• Motor & sensory lost in rest of hand
& fingers
Proximal to
Guyon’s canal
• FDP, FCU & dorsal sensation spared
Distal to
Guyon’s canal
• Spared: FDP, FCU,Hypothenar
muscles, Palmaris brevis, dorsal &
volar sensation
• Lost: Interossei & Lumbricals
(medial 2)

37. Examinations:
 Flexor carpi ulnaris: on flexing wrist against
gravity hand deviates towards radial side
 Abductor digiti minimi: abduct little finger
against resistance on flat table
 Interossei: at MCP joints
◦ Palmer- ADduction (PAD)
◦ Dorsal- ABduction (DAB)
 Egawa’s test: palm facing downward in flat table
move middle finger sideways

38.  Card test: hold card between two extended fingers
tightly, power assessed
 First dorsal interossei: Abduct index finger against
resistance
 Lumbericals: flexon at MCP Joints
 Adductor pollicis: firm grasp of book between
thumb and index finger with thumb fully extended
thumb
 Book test/Froment’s sign: If ulnar nerve is injured,
flexor pollicis longus is used in place of adductor
pollicis with flexed PIP

39. Claw Hand (Main-en-Griffe):
 Deformity with hyperextended MCPs and flexed IP joints
of fingers
◦ True claw hand (median & ulnar nerve) &
◦ Ulnar claw hahnd/ A claw like hand (ulnar nerve only)
 Ulnar paradox:
◦ ‘higher the lesion in ulnar nerve; less is the deformity and vice-
versa’
◦ Cause: Injury at elbow – paralysis of medial half of FDP – less
obivious flexion of IP joints – atypical claw hand
◦ Usual: low lesion – unopposed action FDP over paralysed medial 2
lumbricals – claw hand

41. Sensory
Examination:
 Dorsal aspect: little and
ring finger except lateral
half of tip of ring finger
 Ventral aspect: little
finger and medial half of
ring finger
Dorsal
view

42. Examination of Peripheral
Nerves of Upper Limb

43. Look:
 Deformities
 Skin and nail changes (sudomotor changes)
 Muscle wasting (Hypothenar and thenar
muscles)
 Patient picking up a small object
Feel:
 Temperature

44.  Tenderness - bimanual palpation of joints (MCP,
PIP, DIP, Carpometacarpal, Wrist, Elbow)
 Anatomical snuffbox tenderness- scaphoid #
 Thenar and hypothenar muscle bulk
 Tinel’s test

45. Move:
A) Range of motion (ROM):
 Elbow:
◦ Flexion:
 Active : 145°
 Passive : 160°
◦ Extension: bringing back to anatomical position from
flexion
 Wrist: flexion & extension, adduction and abduction
 MCP: flexion & extension, adduction and abduction
 PIP, DIP: flexion & extension

46. B) Muscle power (MRC grading: 0-5) and
special tests for individual nerves
Measure:
 Both limb simultaneously & compare for any asymmetry present
 Landmark: Elbow joint (tip of olecranon)
◦ Above Elbow: Midpoint between the acromian tip & olecranon (esp in
children below 5 years = malnutrition)
◦ Below Elbow: Fixed distance below the olecranon (10cm)

47. Upper Limb Examination based
on myotomes and dermatomes
Motor Examination:
 C 5 = shoulder abduction
 C 6 = elbow flexion/ wrist extension
 C 7 = elbow extension/ wrist flexion/ finger extension
 C 8 = finger flexion
 T 1= finger abduction

48. Sensory Examination Nerve
Roots
Reflexes
Site
Antecubital
fossa just
proximal to
elbow
Lateral side C 5 Biceps Jerk
Medial side T 1
dorsal surface
of proximal
phalanx of
Thumb C 6 Supinator Jerk
(Brachioradialis
reflex)
Middle finger C 7 Triceps Jerk
Little finger C 8

49. References:
 Apley’s System of Orthopaedics and Fractures 9th
edition
 Gray’s Anatomy for Students 3rd edition
 McRae Clinical Orthopaedic Examination 5th edition
 MBBS viva made easy by Prof Amit Joshi
 Clinical Assessment and Examination in Orthopedics 2nd
edition
 Anatomyzone youtube videos