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Upper limb and peripheral nerve covers injury and reconstruction of the nerves that drive the arm and hand. Brachial plexus injury is split into obstetric palsy, where questions turn on natural history and the timing of exploration, and adult traction injury, where the level of injury — preganglionic or postganglionic — and the time since injury decide what can be reconstructed. Peripheral nerve injury and repair covers the Seddon and Sunderland classifications, degeneration and regeneration, primary repair, nerve grafts and conduits. Nerve transfers, such as the Oberlin transfer for elbow flexion or the anterior interosseous to ulnar motor branch transfer, are tested as a principle: using an expendable donor close to the target muscle. Expect overlap with the hand category, particularly in examination findings and compression neuropathy.
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Six weeks after a motorcycle crash, a 23-year-old has paralysis of the long finger flexors and hand intrinsics, with anaesthesia of the little finger and medial forearm. Shoulder and elbow function are normal. Nerve conduction studies show a normal ulnar sensory nerve action potential recorded from the anaesthetic little finger.
Where is the lesion most likely to be?
Five months after a closed humeral shaft fracture treated in a functional brace, a 45-year-old still has complete wrist and finger drop. Brachioradialis shows no clinical activity, EMG shows fibrillations without motor unit potentials, and Tinel's sign remains at the fracture site. The fracture has united.
What is the most appropriate management?
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Also in this domain: Wrist cross-section
Look for signs of a very proximal lesion: Horner’s syndrome, a raised hemidiaphragm, scapular winging or rhomboid weakness, and preserved sensory nerve action potentials in an anaesthetic limb. These indicate root avulsion, which needs nerve transfer rather than repair.
Transfer of an expendable fascicle of the ulnar nerve to the motor branch to biceps, to restore elbow flexion after an upper trunk (C5–C6) injury. It is the standard example of using a redundant donor close to the target muscle.
For short gaps in small sensory nerves, such as digital nerves. Longer gaps, and gaps in mixed or motor nerves, are usually reconstructed with autologous nerve graft.
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