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Anatomy

Upper Limb

Question 63 of 180

A 34 year old woman sustains a midshaft humerus fracture with nerve damage falling off a horse. Which of the following movements would most likely be affected by this nerve injury:

Answer:

The radial nerve innervates the muscles of the posterior arm and forearm, primarily involved in extension of the forearm, wrist and fingers (and supination of the forearm). Damage to this nerve in the mid humerus is likely to spare the triceps brachii muscle, so you would not expect loss of extension of the forearm or arm. The pronators of the forearm are innervated by the median nerve. Abduction of the arm is primarily produced by the deltoid and supraspinatus innervated by the axillary nerve and suprascapular nerve respectively.

Radial Nerve Injury

Table: Clinical Features of Radial Nerve Injury

Lesion In axilla In spiral groove In forearm (superficial branch) In forearm (deep branch)
Mechanism Glenohumeral joint dislocation, fracture of proximal humerus, ‘Saturday night syndrome’ Fracture of midshaft of humerus Stabbing/laceration of forearm Fracture of radial head or posterior dislocation of radius
Motor Loss Loss of extension at elbow, wrist and fingers, weakness of supination Loss of extension at wrist and fingers (triceps brachii spared), weakness of supination None Weakness of extension at wrist and fingers (extensor carpi radialis spared)
Sensory Loss Lower lateral arm, posterior arm, posterior forearm, dorsum of lateral hand and three and a half fingers Dorsum of lateral hand and three and a half fingers (cutaneous branches of arm and forearm spared) Dorsum of lateral hand and three and a half fingers None
Signs Wrist drop (unopposed wrist flexion), weakness of hand grip (finger flexion is weak as the long flexor tendons are not under tension) Wrist drop, weak hand grip None Wrist drop not typically seen (extensor carpi radialis spared)

Radial Nerve Injury in the Axilla

MECHANISM OF INJURY:

Radial nerve injury at the axilla may occur in glenohumeral joint dislocation, in fractures of the proximal humerus, through incorrect use of axillary crutches, or due to 'Saturday Night' palsy.

CLINICAL FEATURES:

Loss of extension of the forearm due to paralysis of the triceps brachii and loss of extension of the wrist and fingers (predominantly MCPJs, as extension at the IPJs is primarily a function of the lumbrical and interosseous muscles) and weakness of supination due to paralysis of the muscles of the posterior compartment of the forearm. All four cutaneous branches of the radial nerve are affected and there is loss of sensation over the lateral and posterior arm, the posterior forearm and the dorsal surface of the hand and lateral three and a half digits. There is unopposed wrist flexion, giving the appearance of wrist drop.

Radial Nerve injury in the Arm

MECHANISM OF INJURY:

The radial nerve in the arm is most susceptible to midshaft fractures of the humerus due to its course in the spiral groove.

CLINICAL FEATURES:

Extension of the forearm is not affected as the triceps brachii is spared. There is loss of extension of the wrist and MCPJs of the fingers and weakness of supination of the forearm. The cutaneous branches of the arm and forearm have already arisen and sensation loss occurs only on the dorsum of the lateral hand and three and a half digits.

Radial Nerve Injury in the Forearm

Radial nerve damage in the forearm may present as superficial branch or deep branch damage.

SUPERFICIAL BRANCH:

The superficial branch is most commonly damaged by stabbing or laceration to the forearm and results in loss of sensation over the dorsum of the lateral hand and three and a half digits.

DEEP BRANCH:

The deep branch may be damaged by fracture of the radial head or posterior dislocation of the radius and results in weakness of extension of the wrist and fingers, but not typically with wrist drop (as the extensor carpi radialis is spared).

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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