Pathoanatomy of

peripheral nerve
injuries
Nerve fibre
• An axon of a nerve cell is termed nerve fibre. The bundles of
nerve fibres found in the centralnervous system (CNS) are
referred to as nerve tracts while the bundles of nerve fibres
found in the peripheral nervous system are called peripheral
nerves.
• Two types of nerve fibres are present in the nervous system,
viz. myelinated and non-myelinated.
Classification of peripheral
nerve
• According to the axonal diameter and speed of conduction
• Type A fibres :- large diameter, myelinated axons . Motor
neurons supplying skeletal muscles and most sensory neurons have
type A fibres.
• Type B fibres :- medium-diameter, myelinated axons
• Type C fibres :- small-diameter non-myelinated axons
• All types of fibres in group A and B are myelinated whereas
group C fibres are nonmyelinated.
• The type B and C fibres are primarily found in the ANS, which
supplies internal organs such as stomach, intestine.
• The group A fibres are further classified into somatic sensory
(I, II, III) and motor (a, (3,7)subgroups.
Peripheral nerves
• According to the area of innervation the nerve fibres within the
spinal nerves may be classified into the following types:-
1.Somatic sensory fibres.
2. Somatic motor fibres
3.Visceral sensory fibres
4. Visceral motor fibres (also called autonomic motor fibres)
Structure of peripheral nerve
• Each peripheral nerve trunk consists of a number of nerve
fibre bundles or fasciculi.
• There are three protective coverings of connective tissue in
each nerve trunk:
1.Endoneurium: surrounds the individual nerve fibres, it lies
between the nerve fibres within a nerve bundle.
2. Perineurium: surrounds the bundle of nerve fibres.
3. Epineurium: surrounds and encloses the bundles of nerve
fibres forming the nerve trunk (i.e. it surrounds the entire nerve).
 Pathology
• The injuries of peripheral nerve are quite common and can occur
due to compression,traction, trauma, injection, cuts, etc.
• The nerve injuries are of three types:
1. Neurotmesis
2. Axonotmesis
3. Neuropraxia
• Recovery can occur in cases of neuropraxia and axonotmesis but
functional loss is inevitable in case of neurotmesis.
Grading of injury(by
Sunderland)
1.First degree injury (1°)
• Most commonly seen and is secondary to ischaemia
• caused by direct pressure to a nerve for a limited time
2.Second degree injury(2°)- Prolonged and/or severe pressure,
damages the nerve fibers at the pressure point eventually
causing death of axon locally and distally.
3.Third degree injury(3°) - Endoneurial tubes becoming
interrupted.
4.Fourth degree injury- Fascicles becoming disorganised.
5.Fifth degree injury- Through and through cutting of nerve
fibers i.e. complete transection.
Degeneration and Regeneration of
peripheral nerves after injury

Degeneration of the nerve fibre occurs by :-

(a) in the nerve fibre
(i) the distal segment that is separated from the cell body,
(ii) a portion of axon proximal to the injury, and
(b) possibly in the cell body from which the axon arises.
• Changes in the nerve fibre
■ The distal segment immediately undergoes degeneration from
the site of lesion to its termination.This process of anterograde
degeneration is called Wallerian degeneration.
■ The degeneration also extends proximally from the site of
lesion, for a short distance as far as the first node of Ranvier.
Changes in nerve cell body
■ The cell body swells and nucleus becomes eccentric.
■ The Nissl bodies disintegrate and become fine and granular,
and dispersed throughout the cytoplasm, a process known as
chromatolysis.
The amount of swelling of the cell body and chromatolysis is
greatest when the injury to the axon is close to the cell body. The
changes that occur in the cell body following an injury to its axon
are referred to as retrograde degeneration.
Regeneration of nerve fibre
• The macrophages migrate at the site of lesion and remove the debris by
phagocytoses.
• The Schwann cells then proliferate and fill the endoneural tube to form a
solid cellular cord(column of cells). The endoneural sheath and the
contained cord of Schwann cells is known as band fibre.
• A small gap that exists between the proximal and distal stumps is also
filled by the proliferating Schwann cells. The macrophages probably
secrete the substances the nerve growth factors that cause proliferation
of Schwann cells.
• The proximal axon now gives rise to multiple sprouts with bulbous tips
that enter the proximal end of endoneural tube of distal segment.
• The course of sprouts is guided by the cord of Schwann cells. Several
sprouts from different axons may enter into one endoneural tube but only
one of the sprouts from each axon persists, the remainders degenerate.
The persisting sprout now grows distally to reinnervate a motor or sensory
end organ
Factors necessary for
satisfactory regeneration
• Endoneural sheath should be intact,
• Distance between proximal and distal stumps should not be
more than few millimetres.
• Infection should be absent at the site of wound.
• Presence of nerve growth factors.
• Proper physiotherapy:
Brachial Plexus Injury
• Brachial plexus is formed by the union of the ventral rami of
lower four cervical nerves (C5,6,7,8) and the greater part of
the ventral ramus of the first thoracic nerve (T1).

• PREFIXED TYPE OF PLEXUS

When the branch from C4 is large , the branch from T2 is
frequently absent and the branch of T1 is reduced in size.

POSTFIXED TYPE OF PLEXUS

The branch from C4 may be very small or entirely absent.
The Contribution of C5 is reduced in size but that of T1 is larger
and T2 is always present.
• The plexus consists of
 Roots ,
 Trunks ,
 Divisions ,
 Cords , and
 Branches
• The roots join to form trunks.
• Roots C5 & C6 ----- Upper Trunk
• Root C7 -------- Middle Trunk
• Roots C8 & T1----- Lower Trunk
• Each trunk divides into ventral and dorsal division, which
supply anterior and posterior aspect of upper limb.
• These divisions join to form cords
• Lateral cord----ventral divisions of the upper & middle trunks.
• Medial cord----ventral division of the lower trunk.
• Posterior cord----dorsal divisions of all the three trunks.
Branches of the plexus for the
upper limb
A.Branches of the Roots
1. Nerve to Serratus Anterior ( Long Thoracic Nerve)
2. Nerve to Rhomboideus ( Dorsal Scapular Nerve)
B.Branches of the Trunks
These arise only from the Upper Trunk Which gives two branches
1. Suprascapular nerve (C5,C6)
2. Nerve to subclavius (C5,C6)
C. Branches of the Cords

i. Branches of Lateral cord ii. Branches of Medial Cord iii. Branches of

Posterior Cord

1. Lateral Pectoral ( C5-C7) 1. Medial Pectoral (C8,T1) 1. Upper Subscapular

2. Musculocutaneous ( C5-C7) 2. Medial Cutaneous nerve of (C5,C6)
3. Lateral root of Median ( C5- Arm (C8,T1) 2. Nerve to Latissimus
C7) 3. Medial Cutaneous nerve of Dorsi (Thoracodorsal)
Forearm (C8,T1) (C6,C7,C8)
4. Ulnar (C7,C8,T1) 3. Lower
C7 fibres reach by a Subscapular(C5,C6)
communicating branch from 4. Axillary (circumflex)
lateral root of median nerve. (C5,C6)
5. Medial Root of Median 5. Radial (C5-C8,T1)
(C8,T1)
Brachial plexus injury
⮚ Upper trunk
injury
• ERB’S POINT
It is the junction of the ventral primary rami of C5 and C6
forming the upper trunk of the brachial plexus .
The trunk being short , the suprascapular nerve and nerve to
subclavius which arise directly from it and the anterior and
posterior divisions of trunk all lie close to the Erb’s point and
may be involved in any injury at this point.
Erb’s paralysis
• It is the paralysis resulting from a lesion of the upper trunk at
the Erb’s point .
• It is caused by the forcible downward traction of the shoulder
with lateral displacement of the head to the other side .
• The limb assumes a characteristic “ waiter’s tip ” position.
Klumpke’s paralysis
• Paralysis resulting from the lesion of the lower trunk (C8 &
T1)
• It is caused by forceful upward traction of the arm .
• The area of distribution mainly of T1 is involved , i.e., all the
intrinsic muscles of hand are affected and
• Flexors of wrist are affected due to C8 root involvement.
• The hand assumes a characteristic deformity described as
claw hand ----
MCP are hyperextended
IP are flexed
• Horner syndrome
Ptosis - drooping or falling of upper eyelid
Miosis -constricted pupil
Anhydrosis --absence of sweating
Enopthalmos - sinking of the eyeball into the bony cavity that
protects the eye
Loss of ciliospinal reflex - pupillary dilation in response to
noxious stimuli, such as pinching, to the face, neck, or upper
trunk.
Winging of scapula
• Clinical condition in which the medial border of the scapula
becomes unduly prominent.
• Paralysis of long thoracic nerve ( nerve of bell ) which
supplies serratus anterior .
• It can be demonstrated by asking the patient to push against
the wall with outstretched hands .
• The scapula on affected side becomes winged due to
unopposed action of the rhomboids and levator scapulae
while the paralysed serratus anterior is not contracting.
Crutch paralysis
• It is due to the damage to the brachial plexus in the axilla
from the pressure of crutch .
• Radial nerve is frequently implicated and ulnar nerve suffers
next in frequency .
Saturday night palsy
• Radial nerve palsy
• Due to the prolonged pressure on the nerve in the spiral
groove of the humerus .
• This occurs when a drunkard falls into sleep ( on sat night)
with his arm hanging over the back of the chair . In the
morning , he is suffering from the wrist drop which is
temporary.
⮚ Lower Trunk
injury
• Pronator Teres Syndrome
• Pronator Teres Syndrome is a result of the to the position of
this muscle that sits over your median nerve, the pressure on the
nerve can elicit pain while hindering your forearm movement. It
occurs when your pronator teres muscle becomes tight or
overworked, compressing the median nerve. Hammering,
repeatedly using a screwdriver, cleaning fish can lead to overuse
of the pronator teres. Symptoms include pain and reduced
mobility. Carpal Tunnel Syndrome symptoms are often confused
with pronator teres syndrome, however in this case symptoms
worsen with elbow movements. Pronator Teres Syndrome test
can be used for assessment of the syndrome.
• Pronator Teres Syndrome (PTS) is a compression
neuropathy of the median nerve at the elbow. It is not as
common as compression at the wrist which is
Carpal Tunnel Syndrome (CTS). PTS and CTS present
similarly, however PTS can be distinguished by a lack of
sensation in the distribution of the palmar cutaneous branch
of the median nerve (PCBMN) and the absence of common
CTS test findings. The PCBMN branches off of the median
nerve proximally to the carpal tunnel. Because of its site of
origin, this nerve can be affected by median nerve entrapment
of the forearm (such as in PTS), but will not be affected by
entrapment in the carpal tunnel.
• Technique
• The patient stands with the elbow in 90 degrees of flexion. The
clinician then places one hand on the client's elbow for
stabilization and the other hand grasps the patient's hand in a
handshake position. The patient maintains their forearm in a
neutral position while the therapist attempts to supinate the
patient's forearm, requiring the patient to actively resist this
movement by engaging their pronator muscles (as they try to
move into pronation). While holding the resistance against
pronation, the clinician extends the patient's elbow. If the
patient's pain or discomfort is reproduced, there is a good chance
of median nerve compression by the pronator teres. The patient
should keep the elbow relaxed during the test, because holding
the elbow firmly in flexion will not allow elbow extension.
• Evidence
• There are three main maneuvers that are performed in order to evaluate for
Pronator Teres Syndrome (PTS). These maneuvers are the pronator
compression test, resisted pronation/supination and resisted flexion of the
proximal interphalangeal joint (IPJ) of the 3rd digit. The pronator
compression test is positive when pain or paresthesia is reproduced after
applying 30 seconds of pressure proximally and laterally to the proximal
edge of the pronator teres muscle belly. According to Rodner, Tinsley and
O’Malley, a positive pronator compression test is “the most common sign of
pronator teres syndrome.[1]” Resisted pronation and supination (described
above in the Technique section), are tested to determine if the symptoms of
PTS are reproduced. Finally, resisted flexion of the proximal IPJ of the
3rddigit may reproduce pain and paresthesia in patients with PTS due to the
median nerve entrapment at the heads of the flexor digitorum superficialis.
• In order to substantiate the use of these examination findings, additional
studies should be considered to establish diagnostic values such as
sensitivity and specificity
Anterior interosseous
syndrome
• The anterior interosseous nerve (AIN) is the terminal motor
branch of the median nerve. It branches from the median
nerve in the proximal forearm just below to the elbow joint. It
is about 5–8 cm distal to the lateral epicondyle and 4 cm
distal to the medial epicondyle. It then passes between the two
heads of the pronator teres muscle to run deep along the
interosseous membrane along with anterior interosseous
artery. and innervate following three muscles from proximal
to distal, flexor pollicus longus (FPL), the index and long
fingers of the flexor digitorum profundus (FDP), and the
pronator quadratus (PQ).
• AIN is a motor nerve so true AIN syndrome presentation will present with
motor deficits only. There won't be any sensory complain. Poorly localized
pain in the forearm and cubital fossa is usually the primary complaint along
with difficulty bringing the distal phalanx of the thumb and index finger
together. The patient may also complain of having difficulty forming a fist or
the inability to button their shirts. [1][2]
• On a physical examination, the patient will show weakness of the FLP and
FDP to the index finger with a positive Pinch Grip test (Froment’s sign);
rather than making the "OK" sign, the patient will clap the sheet between the
index finger and an extended thumb. [1]
• Sign of Benediction: When a patient is asked to make a fist, the patient will
not be able to flex the 2nd and 3rd finger showing hand of benediction. It is
different from Ulnar claw hand.
• AINS can be confounded by the Martin-Gruber anastomosis, present in up to
25% of the population: in these cases, the anterior interosseous nerve gives
off branches to the ulnar nerve, creating atypical motor innervation patterns
of the forearm and hand and thus effacing the typical clinical symptoms.
Ape thumb
• Ape hand deformity is a condition in which the thumb is
permanently rotated and adducted, resulting in a loss of its
opposable function. This deformity is caused by damage to
the distal median nerve, which supplies the muscles that
control the thumb.[1] Abduction of the thumb is the ability to
move the perpendicular (90°) away from the plane of the
palm. The opposition is the ability of the first metacarpal to
swing over the palmar surface of the hand so that the thumb
and the tip of the little finger are in contact. The thumb may
also experience limited flexion and extension.
• The term "ape hand" is however misleading as apes have
opposable hands but due to the limitations in the function of
the thumb, some people believe it makes the hand looks like
that of an ape.
• Mechanism of Injury / Pathological Process
• The mechanism of injury is a deep injury to the arm, forearm
and wrist causing damage to the median nerve thereby
causing impairment to the thenar muscles and
opponens policis. [2]
• Clinical Presentation
• The condition is a part of median nerve palsy and it typically
presents with problems moving the thumb in various planes.
There is a limited range of motion of the thumb.
Carpal Tunnel Syndrome
• Carpal tunnel syndrome (CTS) is an entrapment
neuropathy caused by compression of the median nerve as it
travels through the wrist's carpal tunnel. Normal tissue
pressure within the tunnel is approximately 3-7mm Hg. CTS
can result in pressure with greater than 30mm Hg.
• The carpal tunnel includes the median nerve and nine flexor
tendons.
• The flexor tendons include
• Four tendons from the flexor digitorum profundus
• Four tendons from the flexor digitorum superficialis
• One tendon from the flexor pollicis longus.
Cubital tunnel syndrome
• Cubital tunnel syndrome (CBTS) is a peripheral nerve compression syndrome. It
is an irritation or injury of the ulnar nerve in the cubital tunnel at the elbow. This
is also termed ulnar nerve entrapment and is the second most common
compression neuropathy in the upper extremity after carpal tunnel syndrome.
[1] [2]
It represents a source of considerable discomfort and disability for the
patient and may, in extreme, cases lead to a loss of function of the hand. Cubital
tunnel syndrome is also often misdiagnosed. [3]
• Peripheral nerve compression syndromes are characterised by chronic irritation
and pressure lesions on the sites where nerves have to pass through narrow
anatomic spaces and fibro-osseous structures. The main clinical manifestation of
this type of compression are paresthesia, sensory impairment and paresis. [4]
• Cubital tunnel syndrome can also be caused by traction, pressure or ischemia of
the ulnar nerve which passes through the cubital tunnel at the medial side of the
elbow.[5] Pain or paraesthesia in the fourth and fifth finger and pain in the medial
aspect of the elbow, which may extend proximally or distally, is caused by
compression of the ulnar nerve. There is only limited evidence that proves the
effectiveness of nonsurgical and surgical interventions to treat cubital tunnel
syndrome.
Guyon tunnel Syndrome
• Guyon Canal syndrome which is also known as Ulnar Tunnel
Syndrome is a relatively rare peripheral ulnar neuropathy.
Guyon canal syndrome is also known as ulnar tunnel syndrome
or handlebar palsy.[1]It is defined as a compression of the distal
ulnar nerve at the level of the wrist as it enters the hand
through a space called ulnar tunnel or Guyon canal. The
clinical presentation can be purely sensory, purely motor or
both depending on the location of the nerve compression.[2][3][1]
• The ulnar nerve is one of the major nerves of the hand and
travels down the neck through the medial epicondyle, than
passes under the forearm muscles than to the little finger along
side the palm.[1]
Wartenberg’s Syndrome
• Wartenberg's Syndrome is described as the entrapment of
the superficial branch of the radial nerve[1] with only sensory
manifestations and no motor deficits. In this condition, the
patient reports pain over the distal radial forearm associated
with paresthesia over the dorsal radial hand.[2]This should not
be confused with Wartenberg's Sign which refers to the
slightly greater abduction of the fifth digit, due to paralysis of
the adducting palmar interosseous muscle and unopposed
action of the radial innervated extensor muscles (digiti
minimi, digitorum communis )
• Meralgia Paraesthetica
• Meralgia Paraesthetica (MP), also known as Bernhardt-Roth
or LFCN (lateral femoral cutaneus nervus) neuralgia, comes
from the greek term meros algos meaning thigh pain.
MP is caused by damage to the nervus cutaneus femoris
lateralis (LFCN). The most common cause of damage to this
nerve is entrapment at the level of the inguinal ligament.
• Patients may have symptoms like pain, burning, numbness, muscle
aches, coldness, lightning pain or buzzing on the anterolateral aspect
of the thigh. [5][6] As mention before, in “clinical relevant anatomy”,
there it supplies sensory innervation to the skin of the anterolateral and
lateral aspects of the thigh. The patient with MP will experience
symptoms, superficial as well as deep tissue, in this part of the thigh.
• A patient can have light pain with spontaneous resolution or may have
more severe pain that limits function. Patients may report pain when
standing or walking for a long time. The pain can be reduced in a
sitting position, because when sitting, the tension in the LCTN or
inguinal ligament reduces. This reduction in tension may result in
reduction of the symptoms. [7] Each patient will have their own specific
clinical presentation and distribution of symptoms. [5]
As mentioned before in “clinical relevant anatomy”, the LFCN
supplies sensory innervation to the skin of the anterolateral and lateral
aspects of the thigh.
NERVE LEVEL OF CLINICAL
COMPRESSION/INJURY MANIFESTATIONS
Median nerve At the level of elbow • Pronator teres
syndrome
• Anterior interosseous
syndrome
At the level of forearm • Ape thumb
At the level of wrist • Laceration just above
the flexor retinaculum
Carpal tunnel
syndrome

Ulnar nerve At the level of elbow • Cubital tunnel

syndrome
At the level of wrist • Guyon’s tunnel
syndrome

Radial nerve At the level of axilla • Crutch palsy

At the level of arm • Saturday night palsy
At the level of forearm • Wrist drop
At the level of wrist • Wartenberg’s
syndrome
NERVE LEVEL OF CLINICAL
COMPRESSION/INJURY MANIFESTATIONS

Axillary nerve At the level of axilla • Loss of abd. and

extension of the arm

Sciatic nerve At buttocks • Injection palsy

• Compression between
the heads of piriformis
Posterior thigh • Loss of knee flexion

At the level of leg • Foot drop

(peroneal branch)
At the level of leg (tibial • Calcaneovalgus
brach) • Dorsiflexion and
eversion of the foot
Femoral nerve At the level of pelvis • Loss of knee
extension
NERVE LEVEL OF CLINICAL
COMPRESSION/INJURY MANIFESTATIONS

Lateral femoral At the level of thigh Meralgia parasthetica

cutaneous nerve

Obturator nerve At the level of thigh Loss of adduction at

thigh

Superior gluteal nerve At the level of buttocks Pelvic drop on walking

Inferior gluteal nerve At the level of hip Loss of extension at hip