STEVEN ANGELO E.

CRUZ, PTRP
WHAT IS PERIPHERAL NERVE INJURY?
 Nerves
 Spinal Nerves & Cranial Nerves
 Plexuses
 Cervical
 Brachial
 Lumbar
 Sacral
Nerve coverings
 Cranial Nerves & Spinal
Nerves
 Surrounded by
connective tissue
sheaths
 Cranial nerves
 Have central motor and/or sensory
nuclei within the brain
 Peripheral nerve fibers that emerge from
the brain and exit from the skull
 12 pairs of cranial nerves
 Cranial nerves
 Olfactory
 Optic
 Oculomotor
 Trochlear
 Trigeminal
 Abducens
 Facial
 Vestibulocochlear
 Glossopharyngeal
 Vagus
 Accessory
 Hypoglossal
 Cranial Nerves Relation to the
CNS
Cranial Nerves CNS
Olfactory nerve
Optic nerve
CN 3-4
CN 5-8
CN 8-12
CN CRANIAL EXIT
1
2
3,4,6

5 V1 –
V2 –
V3 –

7 2 exits
1.
2.

8
9-11
12
 Functional Groupings of Cranial
Nerves
Groups Cranial Nerves
Special Sensory Input
Pure Motor
Mixed Nerves
Parasympathetic Function
Vagal System
Eye Movements
NERVE INJURY
 Classification
 Generalized, proximal or distal
 Mononeuropathies vs. Polyneuropathies
 Symmetric vs. Asymmetric
 Acute vs. Chronic
SEDDON’S CLASSIFICATION
SEDDON’S NEUROPRAXIA AXONOTMESIS NEUROTMESIS
CLASSIFICATIO
N
AXON Intact Interruption Interruption

MYELIN SHEATH Local Myelin injury Connective Connective Tissue

Tissue/Schwann Disruption
Cell Intact

CONDUCTION Impaired Failure Failure

ETIOLOGY Nerve Nerve Crush Nerve Transection

Compression
SEDDON’S CLASSIFICATION
SUNDERLAND’S CLASSIFICATION
 PERIPHERAL NERVE PERIPHERAL NERVE
DEGENERATION REGENERATION

1. Primary Degeneration 1. Collateral Sprouting

(AKA Traumatic or 2. Axonal Re-growth
Retrograde
Degeneration)
2. Secondary
Degeneration (AKA
Wallerian Degnrtion)
PERIPHERAL NERVE
DEGENERATION
1. Primary Degeneration
 Aka Traumatic or Retrograde Degeneration
 Less common
 Axonal degeneration from point of injury and
proceeds proximally

2. Secondary Degeneration
 Aka Wallerian Degeneration
 From point of injury then proceeds distally
 Begins with myelin retraction 3 days post injury
 Chromatolysis follwed by edema
PERIPHERAL NERVE
REGENERATION
1. Collateral Sprouting
 Axon of intact motor unit innervates dennervated
nerve fiber
 Smaller branches, thinner myelin and weaker
NMJ

2. Axonal Re-Growth
 Growing along the original pathways
 1-2mm/day
 Shorter the distance the better the prognosis
OUTLINE:
1. Non-Traumatic PNI
a. Metabolic Conditions
b. Infectious
c. Hereditary Conditions
d. Toxic Neuropathies
2. Cranial Nerve Injuries
3. Plexopathies
4. Upper Extremity Mononeuropathies
5. Lower Extremity Mononeuropathies
6. Other ek ek
A. METABOLIC CONDITIONS
1. Diabetes Mellitus
 Type I & Type II
 Associated c CN 3 & 6 injury & Median
Nerve (CTS)
 Sensory>Motor; Distal>Proximal
 (+) Glove Stocking Phenomenon
 Most common symptoms of diabetic
B. INFECTIOUS
1. LEPROSY (HANSEN’S DISEASE)
 Culprit: mycobacterium leprae
 Associated with CN 5 & 7 injury
 Ulnar, median, common peroneal, superficial
radial, digital posterior articular and sural
nerves
 Spared: soles of the foot and palm
 Medication: Dapsone
2. LYME’S DISEASE
 Culprit: borrelia burgdorferi
 3 stages: early infection, disseminated
infection & late stage infection
 Large Fiber axonopathy, causing a sensory
polyneuropathy
 Meningitis is the most common neurologic
abnormality
 MC cranial nerve – VII
 LE>UE
C. HEREDITARY CONDITIONS
1. Heredirtary Sensory and Motor
Neuropathy (HSMN)
 Most common inherited peripheral neuropathy
 Characterized by segmental demyelination &
remyelination of the peripheral nerves resulting
in a slowing of signal conduction
 Inherited & progressive at a very slow rate
 Large myelinated motor fibers are the most
severely affected
 HALLMARK: peroneal & distal leg muscle
atrophy, weakness sensory loss & areflexia
Type HSMN Description

Charcot Marie Tooth AD Inheritance; 20 to 40y/o

I Disease Type I Hypertrophic Demyelinating Neuropathy
(CMTD) Onion Bulbs – repeated cycles of de &
remyelination
Inverted Champagne Bottle legs

Charcot Marie Tooth AD Inheritance; >40 y/o

II Disease Type II Neuronal axonal type
(CMTD) Inverted Champagne Bottle legs
LE>UE
(N) NCV

Dejerine-Sottas Delayed motor milestones

III Wheelchair bound by early adulthood
Generalized areflexia
Assoc with Ulnar & Sural nerve affectation
Type HSMN Description

Refsum’s Disease Severe early onset

IV Mitochondira affected
Initial s/sx nightblindness d/t retinitis
pigmentosa

Spino-Cerebellar Spastic Paraplegia

V Degeneration

•AR Inheritance
VI Optic Atrophy – Dysfunctional VOR

Retinitis Pigmentosa
VII
D. TOXIC NEUROPATHIES
 Chronic exposure in the workplace, home
environment etc.
 Abuse i.e. Huffing of solvents
 Intentional Poisoning
 Medication Side effects

SUBSTANCE AFFECTATION
LEAD Radial Nerve affectation
ARSENIC Mimic AIDP, flaccid quadriparesis, facial
weakness, respiratory failure
MANGANESE Parkinson-like symptoms

COPPER Hepatolenticular degeneration

CRANIAL NERVES
1. OLFUCKTORY NERVE
 Type: Sensory
 Function: ?
 1. OLFUCKTORY NERVE
CONDITION DESCRIPTION
Anosmia Lack of smell

Hyposmia Decrease sensitivity to smell

Hyperosmia Increase sensitivity to smell

Dysosmia Distorted smell sensation

Cacosmia Perception of bad smell

Parosmia Sensation of smell in the

absence of appropriate stimulus
Rhinorrhea CSF leakage d/t fracture
2. OPTIC NERVE
 Type: Sensory
 Function: ?
2. OPTIC NERVE
REFLEXES
 Direct & Consensual Light Reflex
 Stimulus: Light
 Afferent: ?
 Efferent: ?
 Response:
○ Direct Light Reflex: ?
○ Consensual Light Reflex:?

 Accommodation Reflex
 Stimulus: eyes directed from a distant to a near
object
 Response:
○ Medial Recti contraction →
○ Ciliary muscle contraction →
3. OCULOMOTOR NERVE
 Type:
 Functions
 Eye movements
 Parasympathetic Function: ?
3. OCULOMOTOR NERVE
 3. OCULOMOTOR NERVE
CONDITION DESCRIPTION

External Strabismus Inability to turn the eye vertically or inward

AKA exotropia

Ptosis Drooping of the upper eyelid with inability to raise the

eyelid voluntarily
Mydriasis Pupillary dilation due to unopposed action of the radial
muscles supplied by the SNS

Anisocoria Unequal pupil size (4mm difference)

Diplopia Subjective phenomenon reported to be present with the

patient is looking with both eyes

Adie’s Pupil Unilateral dilated pupil

Lesion in the parasympathetic postganglionic fibers of the
ciliary ganglion
Argyll-Robertson Pupil AKA Syphilitic Pupil or Prostitue’s pupil
Damage to ciliary ganglion
4. TROCHLEAR & 6. ABDUCENS
NERVE
 Type: Motor
 Function: Eye movements
 Has a VERTICAL & HORIZONTAL
diplopia
 compensation
5. TRIGEMINAL NERVE
 Type: Mixed
 Functions
 Sensory:
 Motor:
 5. TRIGEMINAL NERVE
Division Innervation/ Function

Opthalmic Division Cornea, skin of forehead, scalp, eyelids, and nose mucous
membrane of paranasal sinuses and nasal cavity

Maxillary Division Skin of face over maxilla

Teeth of upper jaw
Mucous membrane of nose, the maxillary sinus, and palate

Mandibular Division Skin of cheek, skin over mandible and side of head
teeth of lower jaw and temporomandibular joint
Mucous membrane of mouth and anterior part of tongue
Motor Innervation
5. TRIGEMINAL NERVE
Manifestations:
 Temporalis weakness and atrophy
 Weakness of muscles of mastication
 Trismus
 Deviation of the jaw towards?
 Impaired corneal and jaw jerk reflexes
REFLEXES:
 Corneal Reflex
 Afferent:
 Efferent:
 Stimulus: touch on the cornea
 Response: ?

 Jaw Jerk Reflex

 Afferent & Efferent: Trigeminal Nerve
 Stimulus: Tap on the tip of the chin
 Response: Jaw Jerk
 Tic Doloreaux
 AKA Trigeminal Neuralgia/Suicide’s
disease/Fothergill’s disease/Prosopalgia
 Severe pain in the CN V distribution
 May be associated c MS
 Sturge-Weber Syndrome
 A rare form of phakomatosis
 Encephalotrigeminalangiomatosis
○ Tangling of vessels and nerves affecting
opthalmic and maxillary division of the CN V
○ (+) Port wine stain spots/firemark
7. FACIAL NERVE
 Type: Mixed
 Motor Function
 Muscles of Facial Expression
 Stapedius Muscle
 Stylohyoid
 Posterior Belly of Digastrics
7. FACIAL NERVE
 Bell’s Palsy
 Maybe idiopathic
 Complication of DM
 Exposure to cold or chill; viral infection
(herpes simplex or herpes zoster), diabetes,
middle ear infection or surgery, tumor that
invades the temporal bone, fractures of the
temporal bone
 REFLEXES DESCRIPTION

Marin-Amat AKA Meuller-kannberg syndrome or Reverse Marcus

Syndrome Gunn Phenomenon
Closure of the eye when the patient opens mouth
forcefully and maximally
Marcus Gunn AKA Trigeminal-Oculomotor Synkinesis
Phenomenon Elevation of the ptotic eye on movement of the jow to the
contralateral side

Chvostek Sign AKA Weiss Sign

Tapping of the parotid gland causes twitching of the face
Hypocalcemia, respiratory alkalosis etc.

Bell’s Phenomenon When attempt is made to close the eyelids, the eyeball o
n the affected side may turn upward

Crocodile tears AKA Bogorad’s Syndrome, Gustatol-acrimal Reflex

Unilateral lacrimation on eating because the salivary
secretory fibers to the submaxillary and sublingual glands
have grown along the path of the lacrimal nerve to
innervate the gland
 RAMSAY-HUNT Syndrome
 Bells Palsy associated with?
 Herpetic eruptions of the I/L eardrum, post
part of the auricle canal, pinna & soft palate
 Facial paralysis c I/L deafness

 Moebius Syndrome
 Congenital disorder characterized by
Bilateral facial palsy secondary to nuclear
hypoplasia
8. VESTIBULOCOCHLEAR NERVE
 Type: Sensory
 Functions:
 Hearing
 Balance & Equilibrium
8. VESTIBULOCOCHLEAR NERVE
 Benign Paroxysmal Vertigo
 Secondary to dislodged otoconia
 Vertigo & Nystagmus (<60s or 1-2 min is short term)

 Menniere’s Disesase
 Endilymphatic hydrops
 Overproduction of endolymph and decrease
absorption
 Episodic vertigo, aural fullness, aching, Tinnitus and
fluctuating hearing loss
 htv
 Perilymphatic Fistula
 Abnormal communication between fluid filled inner
ear and air filled middle ear
 Sudden or profound hearing loss, tinnitus, vertigo
worsened by valsalva maneuver, light headedness &
dizziness.

 Acoustic Neuroma
 Originates in the vestibular division and can impinge
other structures
 Vertigo, hearing loss, facial weakness, facial sensory
loss and gait abnormality
9. GLOSSOPHARYNGEAL NERVE
 Type: Mixed
 Rarely involves alone
 Manifestations:
 Decrease salivation
 Carotid Sinus sensitivity
 Decreased taste sensation in post 1/3 of the
tongue
10. VAGUS NERVE
 Type: Mixed
 May be injured peripherally or
intramedullarly
 Complete bilateral transection is FATAL
 Palatoglossus
 Manifestations
 Weakness of palate, larynx & pharynx
 Palatal movements: Uvula deviates towards?
 Hoarseness of voice
 Dysphagia & cardiac arrythmia
 Ineffective Gag reflex
 Right Vagus Nerve Left Vagus Nerve

Enters thorax & passes post to root of Enters thorax & crosses the (L) side of
R lung → Pulmonary Plexus aortic arch, descend posterior to root
of lung → Pulmonary Plexus

Passes posterior to esophagus → Passes anterior to esophagus →

Esophageal Plexus Esophageal Plexus

Enters Abdomen through Esophageal opening

Posterior Vagal Trunk Anterior Vagal Trunk
Stomach Stomach
Duodenum Liver
Liver upper part of the duodenum
Kidneys Head of the pancreas
Small and large intestines as far as
the distal third of the transverse colon
 Gag or Pharyngeal Reflex
 Afferent:
 Efferent:
 Stimulus: Touching posterior pharynx
 Response: gag response

 Baroreceptor Reflex
 Stimulus: Increase BP
 Response:
○ Decrease HR & Contractility
○ Vasodilation

 Chemoreceptor Reflex
 Stimulus: ↓O2, ↑CO2 & H ions
 Response: ↑ Respiration
11. SPINAL ACESSORY NERVE
 Type: Motor
 MOI:
 Direct blow
 Traction due to shoulder depression with neck
rotation to C/L side
 Radical neck dissection – biopsy
 Any surgical procedures on the Post Triangle of
the neck
 Others
 Pain with sh abd and inability to abd arm
beyond 90
12. HYPOGLOSSAL
 Type:
 Atrophy of the affected side
 Deviation of the tongue towards

Muscles of the Tongue Action

Styloglossus Retraction
Hyoglossus Depression
Genioglossus Protrusion
Palatoglossus Elevation
SPINAL NERVES
SPINAL NERVES
 31 pairs
 Cervical?
 Thoracic?
 Lumbar?
 Sacral?
 Coccygeal?
 Cervical Plexus
Superficial/ Cutaneous Branches
Lesser occipital (C2) Posterior border fo the SCM to the scalp
behind the auricle
Great Auricular (C2, Skin behind the auricle and on the parotid
C3) gland
Transverse Cervical Skin over the anterior cervical triangle
(C2, C3)
Supraclavicular Skin over the upper pectoral, deltoid, &
(C3,C4) outer trapezius
Skin of clavicle & shoulder
Deep/ Muscular Branches
Ansa Cervicalis (C1- Infrahyoid muscles: Omohyoid,
C3) Sternoihyoid & Sternothyroid
Phrenic (C?-C?) Motor & Sensory supply to ??
Brachial Plexus
 From the Nerve Roots
Dorsal scapular nerve (C5)
Long Thoracic Nerve (C5-C7)

From the Trunk

Nerve to subclavius (C5,C6) Subclavius
Suprascapular Nerve (C5,C6)

From the Medial Cord

Medial Pectoral Nerve (C8-T1) Pectoralis Major
Pectoralis Minor
Medial Cutaneous Nerve Skin on medial side of arm
(C8-T1/T2)
Ulnar Nerve(C8-T1)
Medial Root of Median Nerve
 From the Lateral Cord
Lateral Pectoral Nerve (C5-C7)
Musculocutaneous Nerve
(C5-C7)
Lateral root of Median Nerve (C5- -
C7)

From the Posterior Cord

Upper Subscapular nerve (C5,C6)
Lower Subscapular nerve (C5,C6)
Axillary Nerve (C5,C6)
Thoracodorsal Nerve (C6,C7,C8)
Radial Nerve (C5-T1)
Lumbar Plexus
 Nerve innervation
Iliohypogastric nerve (L1) Internal oblique
Transversus abdominis
Lateral cutaneous branch – Skin on lateral side
of buttocks
medial cutaneous branch – Skin above pubis
Ilioinguinal nerve (L1) Internal oblique
Transversus abdominis
Femoral Branch – upper & medial thigh
Anterior Scrotal Nerve – skin on root of penis/
mons pubis & anterior scrotum/labia majora
Genitofemoral nerve Cremaster muscle, scrotum, labia majora
Skin on femoral triangle, anterior proximal thigh
(L1,L2) Afferent arm of cremasteric reflex
Lateral Femoral Anterior & lateral thigh and knee
Cutaneous nerve (L2,L3)
 Nerve innervation
Superior Gluteal Nerve
(L4,L5,S1)
Inferior Gluteal Nerve (L5, S1,
S2)
Nerve to Piriformis (S1,S2) Piriformis
Nerve to Quadratus Femoris Quadratus Femoris & Inferior Gemellus
(L5, S1)
Nerve to Obturator Internus (L5, Obturator internus and superior gemellus muscles
S1)
Posterior Femoral Cutaneous Skin over medial aspect of buttock
Nerve (S1,S2,S3)
PLEXOPATHIES
PLEXOPATHIES
 Stinger or Burner
Syndrome
 MOI: Contact sports, Traction
(forceful SH depression + C/L
Lat flexion) or Compression (
Rotation & Extension of neck
towards I/L SH)
 Motor weakness of biceps
and shoulder muscles,
numbness, paresthesia,
transient, acute onset,
dyesthetic pain, tngling and
burning
 American football
 Rucksack Palsy
 MOI: compression d/t
backpack straps
 Upper Brachial plexus
or Long Thoracic Nerve
affected
 Isolated scapular
winging, global
weakness of UE,
shoulder pain and
paresthesias
 More likely to occur in
the non-dominant side
 Pancoast Tumor
 Tumor of the
Superior pulmonary
sulcus at the apex of
the lung
 Affects the lower
trunk of the brachial
plexus
 Often with an
associated Horner
syndrome
 ERB DUCHENNE
PALSY
 C5-C6 Nerve roots
(upper trunk)
 MOI:
○ Nerve traction or
compression
○ Obstetrical injury –
difficult delivery with
shoulder dystocia,
forceps delivery or
prolonged labor
 Manifestations
○ Waiter’s Tip deformity
○ Sh ADIR, elbow E, FA
Pronated, Wrist F
 DEJERINE
KLUMPKE PALSY
 C8-T1 Nerve roots
(lower trunk)
 MOI:
○ Violent Upward pull of
the shoulder
○ Fall on hyper abducted
shoulder
○ Obstetric traction injury
 Manifestations
○ Clawhand deformity
○ Intrinsic Hand muscle
weakness & atrophy
○ Sensory loss on medial
side of arm
WHICH IS ERB DUCHENNE? WHICH IS
KLUMPKE?
 IDIOPATHIC
BRACHIAL NEURITIS
 AKA Parsonage-Turner
Syndrome
 Affects young adults
 Affected Nerves:
PARSSL
 Manifestations
○ Presents with acute
severe shoulder pain
lasting days to weeks
followed by painless
paresis of the upper
extremity with slow but
gradual recovery
 THORACIC OUTLET
SYNDROME
 Medial cord or lower
trunk of brachial
plexus
 Axillary or subclavian
vessels
 Subtypes
 Cervical Rib
 Scaleneus Anticus
Syndrome
 Costoclavicular
Syndrome
 Manifestations
 Hand weakness and
atrophy
○ Intrinsic hand mm to
entire limb
○ Eventual paralysis
○ Paresthesia to what
nerve distribution?
○ Radiating pain
○ Raynaud’s
Phenomenon and
diminished Radial
Pulse
 Special Tests?
Upper Extremity
Mononeuropathies
 LONG THORACIC
NERVE INJURY
 MOI:
○ Direct blow or traction
injury
○ Compression against
internal chest wall
○ Heavy effort above
shoulder height
○ Repetitive strain
 Presentation:
○ Pain with Fully flexing
the extended arm
○ Weak muscle?
 SUPRASCAPULAR
NERVE INJURY
 Injured as it passess throught
the suprascapular notch
under transverse scapular
ligament
 MOI:
○ Fall on posterior shoulder
○ Traction e.i. Overhead serves
in v.ball
○ Cocking and follow through
phase of throwing
○ Improper crutch use
 Manifestation
○ Pain and sensory alteration on
top of the sh from clavicle to
spine of scapula
 MUSCULOCUTANEO
US NERVE
 MOI:
○ In conjucntion with
Brachial Plexus Injury
or Axillary Artery Injury
○ Puttiplat or Bankart
Surgery
○ Gunshot wound
○ Phlebotomy
○ Anterior humeral
dislocation
 Manifestation
○ Weak?
○ Sensory alteration?
 AXILLARY NERVE
INJURY
 Most common injured
nerve in the shoulder
 MOI:
○ Most common cause?
○ Compression d/t
improper use of
crutches
○ Trauma or surgery
 Manifestation
○ Inability to abduct the
arm
○ Sensory loss over
shoulder
MEDIAN NERVE
 Level of the Arm
 Humeral Supracondylar
Process Syndrome
 Level of Elbow
 Lacertus Fibrosus
Syndrome
 Level of Forearm
 Pronator Teres Syndrome
 Anterior Interosseous Nn
Syndrome
 Level of Wrist
 Carpal Tunnel Syndrome
 Level of Arm
 Humeral Supracondylar
Process Syndrome
 MOI:
○ Compression at the
Ligment of Struthers (abn
spur on humeral shaft to
medial epicondyle)
○ Trauma or Inflammation
 Manifestations
○ All muscles innervated by
Median Nerve
○ (+) Active Benedictine
Sign
○ Deep aching pain in the
elbow & FA
○ Sensory loss on median
nn distribution
○ Diminished radial pulse
Level of Elbow
 Lacertus Fibrosus
Syndrome
 MOI:
○ Compression d/t
hematoma formation
or tightness of
lacertus fibrosus
 Manifestation:
○ Similar with
supracondylar
process syndrome
 Level of Forearm
 Pronator Teres
Syndrome
 AKA Grocery Bag
Neuropathy
 MOI:
○ Compression Between 2
heads of Pronator Teres or
Between the bridging
fascial band of FDS
muscle
○ Trauma
 Manifestations
○ All muscles innervated by
median nerve except P.T
○ Dull Aching Pain on elbow
or FA exacerbated by
pronation or finger flexion
 Level of Forearm
 ANTERIOR INTEROSSEOUS
NERVE SYNDROME
 Pure motor nerve
 AKA Kiloh-Nevin yndrome
 MOI:
○ Compression between 2
heads of P.TS
○ Compression by the Gantzer
Muscle
 Manifestation
○ (+) OK sign or Pinch Sign or
Pinch Deformity
○ Weakness of Muscles it
innervates
○ FPL – first muscle to be
affected
Level of Wrist
 Carpal Tunnel Syndrome
 Most common entrapment
neuropathy
 F>M
 MOI:
○ Idiopathic
○ Increased or decreased Canal
Volume
○ Double Crush Syndrome
 Manifestations
○ Ape hand deformity
○ (+) Flick Sign
○ Special Tests?
○ Pain, numbness & paresthesia/
dyesthesia on 1st-4th digits
○ Tingling paresthesias on
thumb, index and long fingers
○ Exacerbates at night (nocturnal
pain)
ULNAR NERVE
 Level of Arm
 Arcade of Struther’s
Syndrome
 Level of Elbow
 Tardy Ulnar Palsy
 Cubital Tunnel Syndrome
 Level of Wrist
 Handlebar Palsy
Level of Arm
 Compression under
Arcade of Struthers
 Fascial band
connecting brachialis
and triceps brachii
 Manifestations
○ Bishop’s Hand/ Ulnar
Claw Hand/ Passive
Benedictine Sign
○ Froment’s Sign
○ Warternburg Sign
 Level of Arm
 Tardy Ulnar Palsy
 Symptoms of nerve
injury come on long
after the patient has
been injured
 MOI:
○ Compression d/t
swelling,
osteophytes, or
repeated
microtrauma
○ Increased Carrying
angle
Level of Elbow
 Cubital Tunnel
Syndrome
 Most common site of
elbow entrapment
 2nd most common
entrapment
neuropathy
 MOI:
○ Traction as nerve
traverses on ulnar
groove
 Manifestation
○ All innervated muscles
except FCU
○ (+) Tinel’s Sign on
elbow
Level of Wrist
 Handlebar Palsy
 AKA Cycler’s
Palsy/Biker’s
Palsy/Stick Palsy
 MOI
○ Compression under
pisohamate canal or
Guyon’s Canal
 Manifestations
○ Severe Clawhand
deformity
○ Hand Intrinsic muscle
wasting
RADIAL NERVE
 Level of Axilla
 Crutch Palsy
 Level of Arm
 Honeymooner’s Palsy
 Level of Forearm
 PINS
 Radial Tunnel Syndrome
 Level of Wrist
 Cheiralgia Paresthetica
Level of Axilla
 Crutch Palsy
 d/t imporper crutch
use
 Manifestations
○ Weakness of ALL
nerve innervated by
radial nerve
Level of Arm
 Honeymooner’s Palsy
 AKA Saturday Night
Palsy
 Most common radial
nerve neuropathy
 MOI:
○ Compression as the
nerve passes bet spiral
groove & lateral
intramuscular septum
○ Humeral fx
 Manifestation
○ All muscles innervated
by radial nerve except?
○ (+) Wrist Drop
 Level of Forearm
 Posterior Interosseous
Nerve Syndrome
 AKA Supinator Syndrome/
Arcade of Frohse
Syndrome
 Pure motor nerve, branch
given off anterior to lateral
epicondyle
 Arcade of Frohse – fibrous
arch in the supinator
muscle occurring in 30% of
population
 MOI:
○ Compression between 2
heads of Supinator
○ Monteggia Fracture
○ Elbow d/L, FOOSH
○ Use of canadian crutches
Level of Forearm
 PINS
 Manifestations
○ Involvement of FA
extensor muscles
except?
○ (+) Functional Wrist
Drop
○ (+) Pseudo-Claw
Hand Deformity
○ Radial deviation
with wrist ext
 Level of Forearm
 Radial Tunnel Syndrome
 Deep branch of Radial
Nerve
 MOI:
○ Compression at the
entrance to the tunnel
anterior to the Head of
Radius, near ECRL at
distal border of Supinator
 Manifestations
○ Mimic tennis elbow and
DQT
○ Deep aching pain on upper
dorsal FA without
tenderness on Lat Epi or
Radial Head
○ (+) Long-Finger Sign
Level of the Wrist
 Cheiralgia Paresthetica
 AKA Wartenburg’s Disease/
Superficial Radial Neuropathy/
Wristwatch Syndrome/ Dog
Handler’s Syndrome/ Handcuff
Palsy
 Superficial Branch of Radial
Nerve – Pure Sensory
 MOI:
○ Compression
○ Trauma
 Manifestations
○ Nocturnal Pain
○ Numbness, burning or tingling
○ Palmar & Ulnar Wrist Flexion
or forced Pronation
Lower Extremity Mononeuropathies
Hockey Player’s Syndrome
 Ilioinguinal Nerve
(L1)
 MOI:
 Compression d/t
transverse abdominis
muscle spasm
 Injury to the external
oblique aponeurosis
 Manifestation
 Sensory alteration and
pain on L1 dermatome
and on scrotum/labia
 Pain with I/L Hip E &
C/L Torso Rot
Genitofemoral Nerve Injury
 MOI:
 Iatrogenic –
genitourinary or
abdominal
operations
 Compression d/t
Psoas Abscess
 Manifestation
 Burning pain and
paresthesia in the
groin, scrotum/labia
Femoral Nerve
 MOI
 Anterior dislocation of
femur
 Trauma
 Compression
 Manifestation
 Weak Iliacus, Psoas,
Sartorius, Pectineus &
Quadriceps
 Quadriceps Wasting
 Decreased sensation on
medial distal thigh
(AFCN) and Medial leg &
foot (saphenous nn)
 Lost DTRs
Superior Gluteal Nerve Injury
 MOI:
 Compression
between piriformis &
inferior border of the
G. Minimus
 Manifestations
 Weakness of?
 Trendelenburg Gait
 Acute gluteal pain and
tenderness lateral to
greater sciatic notch
Sciatic Nerve Injuries
 Most common
nerve injured in
the Hip Region
 Symptoms
usually show in
the common
peroneal nerve
distribution
Sciatic Nerve Injuries
 Piriformis Syndrome
 AKA Fat Wallet Syndrome
 MOI
○ Compression in the pelvic
outlet as it runs inferior to
Piriformis mm
○ When nerve passes
through the piriformis
instead of under
 Manifestations
○ Weak Hib Abd and ER
○ (+) Sign of Pace & Nagel
○ (+) Freiberg Sign
○ Burning pain paresthesia
Sciatic Nerve Injuries
 Injection Palsy
 Most frequent cause
of sciatic nerve
injury
 MOI
○ Badly placed
intramuscular
injection
 Manifestation
○ Weak knee flexion
○ Decreased
sensation on sciatic
nn distribution
Common Peroneal Nerve
 Most frequently
injured as it winds
around the fibular
head
 Most commonly
injured nerve in the
LE
 Manifestations
 All muscles supplied
by deep and superfical
peroneal nerves
 Steppage gait
 Altered sensation on
lateral aspect of foot
and dorsum of foot and
1st web space
Common Peroneal Nerve Injuries
 Strawberry Picker’s
Palsy
 MOI:
○ Spending long
hours in a squatting
position
 Manifestation
○ Mentioned already
Common Peroneal Nerve Injuries
 Superficial Peroneal
Nerve Injury
 MOI
○ Traction injury d/t
lateral ankle sprains
○ Compression above
lateral malleolus
 Manifestations
○ Weak P. Longus and
Brevis – equinovarus
appearance
○ (-) foot eversion and
stability
○ Altered sensation
greater with activity
Common Peroneal Nerve Injuries
 Deep Peroneal
Nerve Injury
 MOI
○ Compression d/t
trauma, tight
shoelaces, or high
heeled shoes
○ Soccers and
runners who wear
tight fitting shoes
 Manifestations
○ Foot Drop & High
Steppage Gait
○ Burnign pain on 1st
web space
Common Peroneal Nerve Injuries
 Anterior Tarsal
Tunnel Syndrome
 AKA Ski-boot
Syndrome
 MOI
○ Compression as it
passes under the
inferior extensor
retinaculum
 Manifestations
○ EDB weakness
Tibial Nerve
Tibial Nerve Injuries
 Popliteal Entrapment
Syndrome
 MOI
○ Trauma
○ Compression as nerve
passes over popliteus &
under soleus
○ Popliteal artery may also be
compressed
○ Baker’s Cyst
 Manifestations
○ (-) PF, Inv of foot; (-) Flex,
abd/add of toes
○ Sensory alteration at sole fo
foot
○ Weak Dorsalis Pedis
Tibial Nerve Injuries
 Medial Plantar Nerve
Injury
 AKA Jogger’s Foot
 More common than
lateral plantar nerve
injury
 MOI
○ Entrapment at the
longitudinal arch
○ Stressed d/t repetitive
foot pronation
○ Hindfoot valgus
 Manifestations
○ Aching pain on
longitudinal arch,
burning pain on heel
○ Altered sensation in the
sole behind hallux