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Key Important Nerve Injuries with the Resulted Defects

1

Motor Sensory Typical mechanism of

injury & notes
Musculo- Elbow flexion Lateral part Isolated injury is rare
cutaneous (supplies biceps of the
usually injured as part of
brachii) and forearm
nerve brachial plexus injury
supination
(C5-C7)

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Axillary nerve Shoulder Inferior Humeral neck

abduction region of fracture/dislocation
(C5, C6)
(deltoid muscle) the deltoid
Results in
muscle
→ flattened deltoid

Radial nerve Extension Small area Humeral midshaft fracture

(forearm, wrist, between
(C5-T1)
fingers, thumb) the dorsal Palsy results in
aspect of
→ wrist-drop
the 1st and
2nd
metacarpals

Median nerve LOAF muscles Palmar Wrist lesion

aspect of
(C6-T1) → carpal tunnel syndrome
Features depend lateral 3½
on the site of fingers
the lesion:

wrist: paralysis
of thenar
muscles,
opponens
pollicis

elbow: loss of
pronation of
forearm and
weak wrist
flexion

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Ulnar nerve Intrinsic hand Medial 1½ Medial epicondyle fracture

muscles except fingers
(C8, T1)
LOAF Damage may result
in → claw hand
Wrist flexion
Long thoracic Serratus anterior Often during sport e.g.
nerve following a blow to the
ribs, lifting weights.
(C5-C7)
Also, a possible
complication of
mastectomy

Damage results in
→ winged scapula

√ LOAF muscles:
• Lateral two lumbricals • Opponens pollis
• Abductor pollis brevis • Flexor pollis brevis

A young man presents with sudden pain in the chest while lifting weights. He
is unable to lift the arm above the head, difficulty in abducting his left hand
beyond 90, when the arm is stretched out against resistance, the scapula is
noticed to be prominent. Injury to which of the following nerves is affected?
A. Dorsal scapula nerve
B. Long thoracic nerve

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C. Posterior interosseus nerve

D. Axillary nerve
E. Thoracodorsal nerve

Long thoracic nerve (C5-C7) Serratus Often during sport e.g. following a
anterior blow to the ribs, lifting heavy objects.
Also, possible complication of
mastectomy

Damage results in a winged scapula

When long thoracic nerve “that innervates serratus anterior muscle” is injured:
√ The pain will be more severe on contralateral tilting of head (i.e. if the right
scapula is affected, tilting the head to the left increases the pain”.
√ On performing push-ups against a wall, the scapula winging increases.
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An important differential Dx:

√ Injured Accessory nerve (the 11th Cranial Nerve)

(e.g. during a surgery of the POSTERIOR Triangle of Neck)
→ Dropped Scapula = Unable to move the shoulder.
√ On abducting the arm at the shoulder level, the winging increases.
√ The accessory nerve is the CN XI (the 11th Cranial Nerve) → supplies trapezius
muscle and sternocleidomastoid.

An important differential Dx:

(e.g. humeral neck fractur, or after shoulder dislocation)

Injury to Axillary nerve may occur, leading to:
→ Paralyzed deltoid muscle + Loss of Sensation of the skin over deltoid.

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Key Key Phrases for Nerve Damage for PLAB 1

2

Wrist Drop Radial Nerve

Foot Drop Common Peroneal

Nerve or
Sciatic Nerve

Claw Hand Ulnar Nerve

Paraesthesia of thumb, index, MIDDLE finger Median Nerve

Paraesthesia of little finger + ring finger Ulnar nerve

Paraesthesia of the ‘’dorsal’’ aspect of the THUMB ± Radial Nerve

“dorsal” area between 1st (Thumb) and 2nd (Index) fingers

Numbness on Superior aspect of upper arm just Axillary Nerve

below shoulder joint
Numbness over deltoid, Paralyzed deltoid

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Fibular Neck Fracture Common Peroneal

Nerve

Femur Neck Fracture Sciatic Nerve

Acetabular Fracture Sciatic Nerve

Humeral Shaft Fracture Radial Nerve

Humeral Neck Fracture Axillary Nerve

Winged “prominent” Scapula Long thoracic nerve

↑ winging/ dropping on pushing a wall

Dropped Scapula Accessory nerve (11th

CN)
↑ winging/ dropping on abducting the arm at the
shoulder level.

Monteggia Fracture: (Anterior Dislocation of the Radial Nerve

head of radius + Fracture of the proximal 1/3 of the
Ulna)

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Paraesthesia and impaired sensation in both hands Peripheral

(Glove distribution) Neuropathy

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The Monteggia fracture is a fracture of the proximal third of the ulna

with dislocation of the proximal head of the radius → Radial Nerve.

Other Clinchers for Anatomy:

◙ Ulnar Nerve (C8-T1) injury

- Claw hand →
(Due to ulnar nerve damage causing paralysis of the lumbricals. A claw hand
presents with a hyperextension at the metacarpophalangeal joints and flexion
at the proximal and distal interphalangeal joints of the 4th and 5th fingers).

- Also, loss of sensation over the 5th finger (the little finger) + a variable area
of the 4th (ring) finger both dorsal and palmar aspects.

◙ Radial Nerve (C5-T1)

- Motor supply to the Extensors of the (thumb, fingers, wrist and forearm).
If damaged → Wrist Drop

- Radial nerve can be compressed against the operating table (medial aspect
of the arm) during an operation →
(Saturday Night Palsy).

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- Also, Crutch palsy (a compression against the spiral groove on the medial
aspect of humerus).

- Injury to the Radial nerve can also lead to sensory loss of the dorsal aspect
of the THUMB ± a small area over the dorsal aspect between 1st and 2nd
fingers.

Notes on Fingers Flexors

- Unable to flex the ‘’Proximal’’ interphalangeal joints AND

Metacarpophalangeal (MCP) joint →
Flexor Digitorum Superficialis

- Unable to flex the ‘’Distal’’ interphalangeal joints →

Flexor Digitorum profundus

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Notes on Fingers Extensors

• Extensor Digitorum
→ (Extends the middle three fingers: index, middle and ring).

• Extensor Digitorum
→ (Extends all fingers at MCP and IP joints).

Pollicis = Thumb

• Extensor Pollicis Longus

→ (Extends the Thumb at the interphalangeal joints “IP”).

N.B. Full extension of a thumb is achieved by extensor pollicis LONGUS.

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N.B. Long=IP

• Extensor Pollicis Brevis

→ (Extends Thumb at Metacarpophalangeal MCP joints)

Key ◙ During a laparoscopic cholecystectomy, the midline structure that is pierced

3 is → Linea Alba.

◙ While performing laparoscopy, the anatomical structure(s) to be pierced

while inserting a port at the midway point between umbilicus and anterior
superior iliac spine is
→ Internal oblique muscle and external oblique aponeurosis.

◙ While performing a laparoscopic cholecystectomy, the first anatomical

structure(s) to be pierced while inserting a port at the midway point between
Anterior midline and mid-axillary line is
→ External oblique aponeurosis and Internal oblique muscle.

◙ When inserting a chest drain into the 5th ICS anterior to mid-axillary line, not
only the vessels (VAN) intercostal Vein, Artery and Nerve can be pierced, but
also intercostal MUSCLE is liable to be pierced

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Proximal Biceps Tendon Rupture:

Muscle bunches up in the distal arm → Popeye appearance.

Distal Biceps Tendon Rupture:

Single traumatic event (e.g. flexion against resistance), sudden sharp tearing
sensation, painful swollen elbow, weakness of flexion and supination.
“The patient feels that something in the cubital fossa has ruptured”
→ Biceps Tendon Rupture

Other Notes:
- De Quervain’s disease: (= washer woman = mammy thumb): Pain under
root of thumb (tenosynovitis).

- Tennis elbow = lateral epicondylitis → affected wrist extension, mainly

due to overuse e.g. in tennis players.

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- Golfer’s Elbow = Medial epicondylitis: all flexors to fingers and pronator

are affected. Seen in baseball players, construction injury, plumber injury.

Key Points on the Nerves of the Eye

4

LR6 (SO4) O3

• Lateral Rectus muscle → supplied by Abducens Nerve (6th CN).

• Superior Oblique muscle → supplied by Trochlear Nerve (4th CN)
• Oculomotor Nerve (3rd CN)

O : T : A Law
(3rd ,4th ,6th )
Same, Opposite, Same side

• Oculomotor (3rd)
√ Controls most of the eye muscles, constricts the pupils, innervates the
Levator palpebrae superioris.
√ Its injury leads to →
Dilated pupil (Mydriasis), Ptosis (On the Same side),

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Others: outward gaze, diplopia

Also, in 3rd nerve palsy → down and out appearance (on looking forwards, the
affected eye deviated inferiorly and laterally).

• Trochlear (4th)

Diplopia on Downward gaze ((Opposite side)) “i.e., Vertical Diplopia”

e.g., while climbing the stairs, if he looks at the left and sees double
→ then the lesion is on the right.

• Abducens (6th)

Diplopia on Lateral gaze ((Same side). “i.e. Horizontal Diplopia”

If he looks at left and sees double → then the lesion is on the left ((Same Side)).

Remember O:T:A
O (Oculomotor) 3rd CN T (Trochlear) 4th CN A (Abducens) 6th CN
Same side Opposite side Same side
Dilated pupil, ptOsis Diplopia on Downgaze Diplopia on Lateral gaze

OTA
Oculomotor (3rd), Trochlear (4th), Abducens (6th)

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Same, Opposite, Same

Ptosis, Downward gaze, Lateral Gaze

Example (1)
After getting a hit on his face, a boy sees double when climbing the stairs. He
also sees double when looking to the right side.
The affected nerve is → Left Trochlear nerve
Climbing the stairs = “downward gaze” → Trochlear → opposite side →
diplopia when looking to the Right → the Left trochlear nerve is affected.

Example (2)
A man presents complaining of diplopia while climbing down the stairs. What
is the likely affected nerve?
Climbing the stairs = Downward gaze.
Diplopia on Downward gaze → Trochlear Nerve (4th CN). Opposite.

Example (3)
A patient with right eye ptosis, outward gaze and diplopia.

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The likely affected structure → Right Oculomotor nerve (3rd CN)

Remember: PtOsis → Oculomotor. (Same Side).

Example (4)
A man complains of double vision when looking to the right.
The likely affected nerve is → Right Abducens
Diplopia on lateral gaze → Abducens nerve (Same Side)

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Key Sensory innervation of the medial and lateral Foot

5

- Loss of sensation in MEDIAL Foot → Saphenous Nerve.

- Loss of Sensation in LATERAL Foot → SuraL Nerve.
- Foot Drop: Common Peroneal Nerve.

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• Saphenous Nerve is the Largest Cutaneous branch of the Femoral Nerve. It

is purely Sensory. It supplies the Medial Foot. It can be injured during
Varicose vein surgery, vein harvest for bypass surgery, or Knee arthroscopy.

Key √ The order of the Intercostal Vessels (VAN), Vein, then Artery, then Nerve.
6
√ Any of these vessels can be pierced during chest drain insertion.
√ In addition to VAN, intercostal muscles can also be pierced during chest
drain insertion.

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They are located at the inferior border of a rib. Therefore, the insertion of the
chest-drain ‘’intercostal tube’’ should be at the superior border of a rib.

The site of Chest Drain → the safe triangle, locates at:

(5th Intercostal space, slightly anterior to the mid-axillary line).

◙ The boundaries of the safe triangle (The site f insertion of

intercostal tube- Chest Drain) are:
Anteriorly: Pectoralis Major.
Posteriorly: Latissimus Dorsi.
Superiorly: Base of Axilla.
Inferiorly: 5th intercostal space.

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Key Notes on Lymphatic Drainage

7

• Gonads (Ovary, Testis) → Para-aortic LNs

• Skin (Perineum, Scrotum, Vulva) → Superficial inguinal LNs

Tongue:
• Tip of tongue: Submental LNs.

• Anterior 2/3 of tongue: Submandibular LNs.

• Posterior 1/3 of tongue: Jugulo-Omohyoid (Deep Cervical LNs).

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• LNs of Posterior Oropharynx → Deep Cervical LNS or (=Jugular LNs)

• The skin over the Medial Malleolus drains into the inguinal LNs.
• The skin over the Lateral Malleolus → popliteal LNs → inguinal LNs.

Example
A woman with ovarian cancer, the likely LNs to be involved are:
→ Para-aortic LNs

Example
A patient with a non-healing ulcer over the medial malleolus. What are the
draining lymph nodes?
→ Inguinal LNs.

• Lymph nodes drainage (a different collection):

- Skin (scrotum, vulva, perineum) → Superficial inguinal LNs

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- Drain all below umbilicus → Superficial inguinal LNs, except Gonads and
Lateral foot
√ Gonads (testis, ovaries) → Para-aortic LNs
√ Lateral foot → Popliteal LNs
- Deep lymphatics of glans, clitoris → External iliac LNs

Key • Peroneal Strike:

8
A blow just below knee → Temporary loss of motor and sensory function (from
30 seconds to 5 minutes) → foot drop → the affected nerve is
→ Common Peroneal Nerve

Remember that, the two motor branches of the common peroneal nerve:
• Superficial peroneal nerve → Supplies the lateral Compartment of leg →
evert the foot.

• Deep peroneal nerve → Supplies the Anterior Compartment of the leg →

dorsiflex the foot.

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Key • Extensor Digitorum → (Extends the middle three fingers: index, middle and ring).
9

• Extensor Digitorum → (Extends all fingers at MCP and IP joints).

• Extensor digiti minimi → (Extends the little finger).

• Extensor indices → (Extends the index finger).

• Extensor Pollicis → (Thumb)

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• Extensor Pollicis Longus → Extends the Thumb at the interphalangeal joints IP.

N.B. Full extension of a thumb is achieved by extensor pollicis LONGUS.

N.B. Long=IP

• Extensor Pollicis Brevis → Extends Thumb at Metacarpophalangeal MCP

joints.

Q) A patient with an injury on his hand cannot extend the distal phalanx of
his ring finger. What is the affected muscle?

The ring finger has no specific muscle like in the thumb (pollicis) for instance;
therefore, pick the bulk one (Extensor Digitorum) which extends index, middle
and ring fingers.

Don’t get confused with FLEXORS!

- Unable to flex the ‘’Proximal’’ interphalangeal IP joints AND
Metacarpophalangeal (MCP) joint

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→ Flexor Digitorum Superficialis.

- Unable to flex ‘’Distal’’ interphalangeal joints

→ Flexor Digitorum profundus.

Other Clinchers for Anatomy:

Ulnar Nerve (C8-T1) injury

- Claw hand → (due to ulnar nerve damage causing paralysis of the
lumbricals. A claw hand presents with a hyperextension at the
metacarpophalangeal joints and flexion at the proximal and distal
interphalangeal joints of the 4th and 5th fingers).
- Also, loss of sensation over the 5th finger (the little finger) + a variable area
of the 4th (ring) finger both dorsal and palmar aspects.

Radial Nerve (C5-T1)

- Motor supply to the Extensors of the (thumb, fingers, wrist and forearm).
If damaged → Wrist Drop
- Radial nerve can be compressed against the operating table (medial aspect
of the arm) during an operation → (Saturday Night Palsy).

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- Also, Crutch palsy (a compression against the spiral groove on the medial
aspect of humerus).
- Injury to the Radial nerve can also lead to sensory loss of the dorsal aspect
of the THUMB ± a small area over the dorsal aspect between 1st and 2nd
fingers.

Key ◙ Short saphenous Vein:

10
The only vein that runs on the LATERAL aspect of the leg.
◙ In contrast: The long (great) Saphenous Vein runs on the MEDIAL aspect of
the angle.

◙ Do not get confused with NERVES:

Saphenous nerve runs medially, Sural nerve runs laterally.

◙ So, on the Medial aspect of a leg

→ Long (great) Saphenous Vein + Saphenous Nerve.

◙ On the Lateral aspect of a leg

→ Short Saphenous Vein + Sural Nerve.

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◙ Q) Varicose veins on the lateral aspect of the leg. The affected vein is
→ Short Saphenous Vein.

Key - Fracture of the neck of the Fibula leads to an injury of →

11
Common peroneal nerve → Foot drop
(inability to evert or to dorsiflex the foot)

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• Fibular Nerve “Common peroneal nerve” supplies biceps femoris (which

flexes the Knee).
• It, also, gives TWO MOTOR branches:

Superficial Fibular (Which innervates the Lateral compartment of the leg,

and its injury causes inability to evert the foot).
Deep fibular nerve (Which innervates the Anterior compartment of the leg
and also extends the digits, and its injury causes inability to dorsiflex the
foot).

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The injury of Common peroneal Nerve leads to FOOT DROP (No dorsiflexion,
No eversion of foot).
• The Common peroneal nerve gives also FOUR SENSORY branches:
Sural communicating → (lower posterolateral leg).
Lateral Sural Cutaneous → (Upper Lateral Leg)
Superficial Fibular (peroneal) → (Skin of Anterolateral leg except the skin
between first and second toes)
Deep Fibular (peroneal) → (Skin between the first and second toes)

Key C8 radiculopathy
12
Affects thumb abduction and extension, causes ulnar deviation of the wrist,
and causes paraesthesia of a thin area on the forearm which runs down to
include the little finger.

T1 Radiculopathy
Affects Fingers Abduction and Adduction, Pain and Paraesthesia along the
affected nerve.

To Summarise:
- Thumb movement weakness, Wrist Ulnar deviation, Little finger
Paraesthesia → C8 nerve root injury.
- Fingers’ Abduction and Adduction weakness → T1 nerve root injury.

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- Loss of Thumb Sensation, Loss of elbow flexion → (C5,6) erb’s palsy

The motor function of the nerve roots of an upper limb

C5, C6, C7, C8
Flex, extend, extend, flex
elbow, wrist, elbow, fingers

C5 C6 C7 C8
Flex Extend Extend Flex
elbow wrist elbow Fingers

Adduct and Abduct Fingers → T1

N.B. There is nothing called (C8 Vertebral injury), but there is (C8 Nerve root
lesion) which is manifested by impaired thumb movement + Wrist ulnar
deviation + Little finger paraesthesia.

C6: Thumb / C7: Middle three fingers / C8: little (Pinky) finger.

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Example (1)
A patient presents with pins and needles sensation of the skin over the
lateral posterior area of the distal forearm including the little finger,
weakness of thumb extension, wrist ulnar deviation and slight loss of the
muscle of the affected hand.
The likely affected structure → C8 Root.

Example (2)
A man complains of pain on the medial side of his right forearm. There is
weakness of finger abduction and adduction as well as thumb adduction. No
abnormality with finger flexion. The right-hand muscles are slightly
atrophied.
The likely affected structure → T1 Nerve Root Injury

Example (3)
A 55 YO man presents complaining of a neck pain, left arm discomfort and
left-hand weakness. On examination, he has weakness in abducting and
adducting the fingers of his left hand. MRI reveals a left-sided disc herniation
in one area of spinal cord. What is the likely affected nerve root?

The likely affected structure → T1 Nerve Root Injury

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Example (4)
A 30 YO man has neck pain that radiates to his left shoulder and left middle
finger. He also has decreased sensation on his left index and middle fingers.
Left arm shows reduced triceps reflex. He also has difficulty straightening his
left elbow.
What is the most likely affected nerve root?

[C5 / C6 / C7 / C8 / T1]

He has a problem on extending his elbow. Thus → C7 is most likely affected.

C5 C6 C7 C8
Flex Extend Extend Flex
elbow wrist elbow Fingers

Key Transpyloric plane

13
Transpyloric plane (or Addison’s plane) is a transverse line located
midway between sternal notch and symphysis pubis.

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◙ The Important Transpyloric Plane

= The level of L1
= The level of the 9th Rib ‘’its anterior end’’
= The level of the pylorus of the stomach = Fundus of the Gall Bladder.

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◙ So, the TIP of the 9th costal cartilage correlates the Fundus of GB.

The level of 9th CC → Many structures

But the (Tip) of 9th CC → (Fundus) of GB

Structures at the level of L1 → Transpyloric plane

• 9th Costal Cartilage,

• GB fundus,
• Stomach pylorus,
• Kidney hilum,
• SMA (Superior mesenteric artery),
• Celiac trunk.

Key • Perforation of a Posterior (Gastric) Ulcer (Fundus or Body of Stomach)

14
→ accumulation of pus in the Lesser Sac (behind the stomach)
→ Abscess formation that passes to the peritoneal cavity through the
Foramen of Winslow
→ Generalized Peritonitis.

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• Perforation of Posterior (Pyloric) Or (Duodenal) Ulcer

→ Retroperitoneal Abscess.

Key • CVE (Stroke) of the Temporal lobe

15
→ (Memory Impairment, Superior homonymous quadrantinopias).

PiTs:
Parietal lobe affected → inferior homonymous quadrantinopias
Temporal → superior homonymous quadrantinopias

Temporal lobe lesion:

Long-term memory loss + changes of sexual behaviour + (Visual defect) which is
→ superior homonymous quadrantinopias

Frontal lobe lesion:

changes of personality and SOCIAL behaviour, no visual field defect.

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Example
An elderly with a Hx of Stroke presents with impaired long-term memory,
altered sexual behaviour and visual defect. What is this visual defect?

His Affected lobe is → the Temporal lobe.

PiTs → Temporal lobe → Superior Homonymous Quadrantinopias.

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Key The Rule of 17 for the Side of Deviation

16

10 + 7: Deviation to the Opposite side of the lesion

12 + 5: to the Same side of the lesion

10 vague, 7 facial, 12 hypoglossal, 5 trigeminal

• 7th CN injury → Facial deviation (towards the opposite side)

• 10th CN injury → Uvular deviation (towards the opposite side)

• 5th CN injury → Jaw deviation (at the same side)

• 12th CN injury → Tongue deviation (at the same side as the injury)

Example
If tongue is deviated towards the right and there is an injury on the right side
of the neck (the same side)
The likely injured structure → hypoglossal (12th) CN

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10th (vagus): Uvular deviation (opposite side)

7th (facial): Facial deviation (opposite side)

12th (hypoglossal): Tongue deviation (same side)

5th (trigeminal): Jaw deviation (same side)

Key The Lymphatic drainage of the Testis → Para-aortic LNs.

17
The Lymphatic drainage of the Scrotum → Superficial inguinal LNs.

Remember:
• Gonads (Ovary, Testis) → Para-aortic LNs

• Skin (Perineum, Scrotum, Vulva) → Superficial inguinal LNs

Key The Common bile duct (CBD) connects with the Pancreatic duct to form
18
→ the Ampulla of Vater (Hepatopancreatic ampulla)
at the middle of the second part of duodenum.

So, Ampulla of Vater = Hepatopancreatic ampulla.

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Example:
ERCP was done and found a calculus in the 2nd part of duodenum. What is the
structure that contains this calculus?

→ Hepatopancreatic Ampulla (Or) The Ampulla of Vater

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Key Remember that,

19

Common peroneal nerve gives superficial peroneal (which runs laterally and
everts the foot), and Deep peroneal (which runs anteriorly and dorsiflex the
foot and give sensation to the area between 1st and 2nd toes).

Example:
A man sat cross-legged for 40 minutes. He found himself unable to dorsiflex
his left foot and there is loss of sensation over the area between the big toe
and the second toe. What is the affected nerve?

→ Deep Peroneal (Deep Fibular) nerve which is a branch of the common

peroneal nerve.

- PED: Peroneal nerve: Eversion, Dorsiflexion of the foot.

- TIP: Tibial nerve: Inversion, Planter flexion of the foot.

Key The Common Bile duct (CBD) lies in a close proximity to the head of pancreas.
20 Therefore, the initial presentation in 70% of head of pancreas cancer patients
present with Jaundice due to the obstruction of CBD by the tumour.

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Key Saturday Night Palsy → Wrist drop → ((Radial Nerve)):

21

Radial nerve can be compressed against the operating table (medial aspect of
the arm) during an operation. This is called Saturday Night Palsy.

Key LNs of Posterior Oropharynx → Deep Cervical LNS or (=Jugular LNs)

22

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Key Scenario:
23
A man complains of pain on the medial side of his right forearm. There is
weakness of finger abduction and adduction as well as thumb adduction. No
abnormality with finger flexion. The right-hand muscles are slightly atrophied.
What is the likely affected structure?

→ T1 Nerve Root Injury

• Fingers’ Abduction and Adduction weakness → T1 nerve root injury.

• Thumb movement weakness, Wrist Ulnar deviation, Little finger
Paraesthesia → C8 nerve root injury.
• Loss of Thumb Sensation, Loss of elbow flexion → (C5,6) erb’s palsy

Key Trigeminal Nerve branches: Ophthalmic, Maxillary, Mandibular.

24

Maxillary Nerve:
The 2nd branch of the trigeminal nerve, it supplies a number of structures:

• Sinuses: ethmoid, maxillary, sphenoid,

• Mucosa: palate, roof of pharynx, nasal mucosa,

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• Others: lower eyelid, upper lip, upper teeth and gum, nares, Parts of the
meninges.

N.B. The palate is a mucous membrane.

Example:
Herpes Zoster Virus along the dermatome of the maxillary nerve. What is the
MUCOSA that would be affected?
→ The Palate.

Key The Deep Inguinal Ring is located about 1 inch (2.5 cm)
25
ABOVE the midpoint of the inguinal ligament.

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Key LAD (Left Anterior Descending Artery) is a continuation of the Left Coronary
26
Artery, and it runs inside the Anterior Interventricular groove).

Key • The skin at the Medial Malleolus drains into the inguinal LNs.
27
• The skin over the Lateral Malleolus → popliteal LNs → inguinal LNs.
Remember that: During a surgery of melanoma of the feet, the inguinal LNs
are dissected. So, medial malleolus skin is drained to the inguinal LNs.

Example:
A patient with a non-healing ulcer over the medial malleolus. What are the
draining lymph nodes? → Inguinal LNs.

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Key ◙ Glioma is a tumour arising from the glial cells in the brain or spinal cord. So,
28 the dura matter is to be opened during the surgery.

DAP (from outside inwards): Dura → Arachnoid → Pia

Key • Extensor Digitorum → Extend all fingers at MCP and IP joints.

29

• Extensor Digitorum Communis → extends the phalanges first, then the

wrist, then finally the elbow. It also tends to separates the fingers while
extending them.

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Example:
An elderly woman with Rheumatoid Arthritis has fallen down the stairs and she
is now unable to extend her right-hand fingers at the metacarpophalangeal
joints and the interphalangeal joints. What is the likely affected tendon?

→ Extensor Digitorum.

Key A man presents complaining of diplopia while climbing down the stairs. What
30 is the likely affected nerve?

Climbing the stairs = Downward gaze = Vertical Diplopia

Diplopia on Downward gaze → Trochlear Nerve (4th CN). Opposite.

Remember O:T:A
O (Oculomotor) 3rd CN T (Trochlear) 4th CN A (Abducens) 6th CN
Same side Opposite side Same side
Dilated pupil, ptosis Diplopia on Downgaze Diplopia on Lateral gaze

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Key • Ataxic Hemiparesis (same side) + Dysarthria

31
→ Lacunar infarct (Internal Capsule). Internal capsule is a part of lacunas.

• “Contralateral” hemiplegia or Sensory Loss + Dysphasia + Homonymous

Hemianopia
→ Cerebral infarct.

• Quadriplegia, Vertigo, Diplopia, Locked-in syndrome

→ Brainstem infarct.

Scenario:
An elderly woman had a stroke and developed paralysis of left upper and left
lower limbs (Hemiparesis) and difficulty in speaking.

The likely affected anatomical site → Internal Capsule (Lacunas)

For those who do not know where is the internal capsule:

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For your own knowledge

Locked-in Syndrome or Pseudocoma

√ The patient is aware but cannot move or communicate verbally due to
complete paralysis of nearly all voluntary muscles in the body except for
vertical eye movements and blinking.
√ Cognitive function is usually unaffected.
√ Communication is possible through eye movements or blinking.
√ Locked-in syndrome is caused by a damage to the pons, a part of
the brainstem that contains nerve fibres that relay information to other areas
of the brain.

Key • Central retinal artery is a branch of the Ophthalmic artery which is a branch
32 of the Internal carotid artery.

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• Internal Carotid A. → Ophthalmic A. → Central Retinal A.

• Amaurosis Fugax: Painless, Temporary and Recurrent loss of vision that lasts
from a few seconds to a few minutes due to embolism (transient occlusion)
of the Central retinal artery.

• Usually resolves quickly.

• Risk Factors: Atherosclerosis▐ Hypertension.

• A patient may describe it as “A black Curtin Coming Down”

• The embolus in Amaurosis Fugax comes from atherosclerotic Internal carotid

artery while in Transient Ischemic Attack (TIA), the emboli of the cerebral
hemispheres come from the heart.

Amaurosis Fugax may present as “painless unilateral loss of vision with a

sensation that a black curtain has come down over the patient’s vision”.
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However, Amaurosis Fugax is “transient”; usually resolves in 5-30 minutes.

It is due to temporary retinal ischemia “transient occlusion of the central
retinal artery”.

Scenario:
An elderly man presents with a 4-hour sudden painless loss of vision of the
right eye. He has Hx of recurrent and transient episodes of sudden loss of
vision of the same eye. The patient is a heavy smoker and has hypertension.

• The likely affected artery → Central Retinal Artery.

Key A white lesion on the middle third of the tongue drains to which LNs?
33

→ Submandibular LNs

• Tip of tongue: Submental LNs.

• Anterior 2/3 of tongue: Submandibular LNs.

• Posterior 1/3 of tongue: Jugulo-Omohyoid (Deep Cervical LNs).

Key • Trigeminal Nerve (the 5th CN) has 3 divisions:

34

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√ 1st: Ophthalmic
√ 2nd: Maxillary
√ 3rd: Mandibular

• Trigeminal nerve (5th CN) → gives the Mandibular nerve (the third division).
• → The mandibular nerve gives the Inferior alveolar nerve (which innervates
the lower teeth).
• → The inferior alveolar nerve gives the Mental nerve that supplies Chin,
Lower lip (Skin and Mucosa).

Trigeminal → Mandibular → Inferior Alveolar → Mental

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• Inferior Alveolar Nerve is often injured during dental procedures and

mandibular trauma.

Therefore, a loss of sensation of the lower lip and chin after a mandibular
trauma/fracture is usually due to the injury of
→ Inferior Alveolar nerve.

Key • Unilateral Injury to the Recurrent laryngeal nerve

35
→ Hoarseness of voice.

• Bilateral Injury to the Recurrent laryngeal nerve

→ Aphonia ± Airway obstruction.

• Injury to the External branch of (superior) laryngeal nerve

→ Loss of high-pitched sound = (Dysphonia) = (Mono toned voice).

N.B. About 18% of Lung cancer patients experience hoarseness of voice due to
compression of the tumour on the recurrent laryngeal nerve.

Recurrent laryngeal nerve is a branch of Vagus nerve (10th CN)

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A patient with lung cancer on chemotherapy presents with hoarseness

→ Recurrent Laryngeal Nerve Palsy.

Others:
- Hypoglossal Nerve (12th) → Tongue muscles

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- Phrenic nerve → Diaphragm

Key Important Anatomical Levels

36

• Umbilicus level → L3/L4

• The level of iliac crest → L4

We know that the umbilicus level is between L3 and L4. Therefore, the iliac
crest (below the umbilicus level) would be L4.

• Umbilical Dermatome: T10

• Transpyloric plane → L1 → 9th Costal Cartilage, GB fundus, Stomach pylorus,

Kidney hilum, SMA (Superior mesenteric artery), Celiac trunk.

All these structures are at the L1 level.

N.B. Transpyloric plane (or Addison’s plane) is a transverse line located

midway between sternal notch and symphysis pubis.

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• T8: IVC (Inferior Vena Cava)

• T10: Oesophegus (O → O ▐ Oesophagus → T1O)
• T12: Aorta

Mnemonic (IOA) → I Opened A door → IVC, Oesophagus, Aorta (T8, 10, 12).

Key When inserting a chest drain in the 5th ICS anterior to mid-axillary line, not only
37 the vessels (VAN) intercostal Vein, Artery and Nerve can be pierced, but also
intercostal MUSCLE is liable to be pierced.

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Key • Extensor Pollicis Longus

38
→ (Extends the Thumb at the interphalangeal joints “IP”).

• Extensor Pollicis Brevis

→ (Extends Thumb at Metacarpophalangeal MCP joints)

Example:
A man with a Hx of fractured radius presents with inability to extend his thumb
at the interphalangeal joint.

The likely Affected structure → Extensor Pollicis Longus.

Key Example:
39
A man with a Hx of Rheumatoid arthritis hits the door by his hand and presents
with inability to extend his thumb at the metacarpophalangeal joint. However,
he is able to extend his thumb at the interphalangeal joint.

The likely Affected structure → Extensor Pollicis Brevis.

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• Extensor Digitorum → Extend all fingers at MCP and IP joints.

• Extensor Digitorum Communis → extends the phalanges first, then the

wrist, then finally the elbow. It also tends to separates the fingers while
extending them.

Example:
An elderly woman with Rheumatoid Arthritis has fallen down the stairs and she
is now unable to extend her right-hand fingers at the metacarpophalangeal
joints and the interphalangeal joints. What is the likely affected tendon?

→ Extensor Digitorum.

Key An important landmark above the 5th intercostal space and just anterior
40 to the mid-axillary line
→ the site of Chest Drain Insertion.

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Key A patient with right eye ptosis, outward gaze and diplopia.
41

The affected structure → Right Oculomotor nerve (3rd CN)

Remember: PtOsis → Oculomotor. (Same Side)

O:T:A
O (Oculomotor) 3rd CN T (Trochlear) 4th CN A (Abducens) 6th CN
Same side Opposite side Same side
Dilated pupil, ptosis Diplopia on Downgaze Diplopia on Lateral gaze

Key Structures at the level of L1 → Transpyloric plane

42
• 9th Costal Cartilage,
• GB fundus,
• Stomach pylorus,
• Kidney hilum,
• SMA (Superior mesenteric artery),
• Celiac trunk.

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Key Paraesthesia (Loss of sensation) of the little finger + ring finger

43
→ Ulnar nerve

Remember that:
• Paraesthesia of the lateral three fingers (thumb, index, MIDDLE) fingers
→ Median Neve. (nearly 3 and a half fingers)

• Paraesthesia of little finger + ring finger (both dorsal and palmar)

→ Ulnar nerve

• Paraesthesia of the dorsal aspect of the THUMB ± a small dorsal area

between 1st (Thumb) and 2nd (Index) fingers
→ Radial Nerve.

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Key A blow or a trauma to the lateral aspect of the area below the knee
44
→ Peroneal Strike

The resulting lesion → foot drop (inability to evert or dorsiflex foot)

The affected nerve → Common peroneal nerve.

Key If the strike was above the knee and the resulted abnormality was foot drop,
45 the affected nerve is also
→ Common peroneal nerve.

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Key There is no C8 vertebra, it is just a nerve root that emerges below C7.
46
Also:

Median nerve: C5-T1

Ulnar nerve: C8-T1

These are roots, not vertebrae.

Both Median and Ulnar nerves are responsible for the weakness of the hands

Important: On a lateral neck X-ray, the lowest level needed to be seen after
a neck injury is → C7-T1
These are vertebrae (to be seen on X-ray). C8 is not vertebra; it is a nerve root.

In a suspected Cervical fracture, we need to get X-ray of all cervical vertebrae

from C1 to C7

Sometimes, [C7-T1 junction] does not appear on AP, Lateral, Open-moth

odontoid (the peg view) X-rays. Hence, requesting what is called (Swimmer
Lateral view) is required.

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Again, if this does not show C7-T1 junction → request CT Scan.

Key A sudden fall on a knee → pain and swelling below the knee cap → The
47 affected structure is either infrapatellar or prepatellar bursa.

Prepatellar bursitis is the most common type among the knee bursae
inflammations. The prepatellar bursa is a thin bursa in front of the knee
(between the knee and the patella). It is commonly seen in people who kneel a
lot such as housemaids and plumbers.

Features:
√ redness, pain, swelling, inability to flex knee
√ Rest usually relieves the symptoms.
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Remember that:
- Housemaid Knee: Prepatellar bursitis.
- Clergyman or jumper’s Knee: Infrapatellar bursitis.

Key Again:
48
Scrotum drains to → Inguinal LNs. (particularly: Superficial inguinal LNs)
While testis drains to → para-aortic LNs

Key A man complains of double vision when looking to the right.

49
The likely affected nerve is → Right Abducens

Diplopia on lateral gaze → Abducens nerve (Same Side)

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O:T:A
O (Oculomotor) 3rd CN T (Trochlear) 4th CN A (Abducens) 6th CN
Same side Opposite side Same side
Dilated pupil, ptOsis Diplopia on Downgaze Diplopia on Lateral gaze
Key Nerve roots of the important deep tendon reflexes
50

So:

Biceps C5 and C6

Brachioradialis C6 and C7

Triceps C7 and C8

Ankle (Achilles) S1 and S2

Anal (contraction of external sphincter) S2-S4

Knee L3 and L4

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Key The land mark that is midway between symphysis pubis and suprasternal
51 notch → Transpyloric plane (L1 Level)

Notes:

• Suprasternal notch = jugular notch = fossa jugularis sternalis.

• Facial Nerve (7th) Lesion

→ facial weakness + Loss of taste of the Anterior 2/3 of tongue.

• Vagus Nerve (10th) lesion

→ Weak cough, Vocal Cord Paralysis with Dysphonia, uvular deviation.
Also, parasympathetic loss of Respiratory, GIT, CVS.

• Trigeminal Nerve (5th) lesion:

- Weakness of the muscles of Mastication.
- Deviation of Jaw towards the same side of the weak pterygoid muscle
- Loss of facial sensation

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• Glossopharyngeal Nerve (9th) lesion:

- Loss of gag reflex
- Loss of taste from the Posterior 1/3 of the tongue
- Loss of general sensation from posterior pharynx, tonsils, and soft palate.

So, Loss of Taste Sensation:

√ Ant. 2/3: Facial Nerve (7th)

√ Post. 1/3: Glossopharyngeal (9th)

• Hypoglossal Nerve (12th):

→ Innervates the muscles of the tongue. An injury to it would

deviate the tongue to the same side as the injury side.

Also Remember:

10 + 7: Deviation to the Opposite side of the lesion

12 + 5: to the Same side of the lesion

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10 vague, 7 facial, 12 hypoglossal, 5 trigeminal

• 7th CN injury → Facial deviation (towards the opposite side)

• 10th CN injury → Uvular deviation (towards the opposite side)

• 5th CN injury → Jaw deviation (at the same side)

• 12th CN injury → Tongue deviation (at the same side as the injury)

Key Dupuytren’s contracture

52
• A condition in which there is fixed forward curvature of one or more
fingers, caused by the development of a fibrous connection between
the finger tendons and the skin of the palm.
• Dupuytren’s contracture has a prevalence of about 5%.
• It is more common in older male patients.
• 60-70% have a positive family history.

• Specific causes include:

Manual labour ▐ Phenytoin treatment

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Alcoholic liver disease ▐ Trauma to the hand

DM ▐ Smoking

• Mechanism
→ Formation of thickened fibrous tissue within the palmar fascia. √ imp

• Rx → Fasciotomy

Scenario:

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A 38-year old man is unable to extend and straighten his 4th and 5th fingers
(ring and little fingers). A firm nodule was found on the distal palmar crease
in the same line with the ring finger. His father has a Hx of a similar condition.

◙ The likely diagnosis → Dupuytren’s contracture.

◙ The likely mechanism
→ Formation of thickened fibrous tissue within the palmar fascia.

Key Sensory Loss Responsible Nerve Roots in LL:

53

3 in the thigh ▐ 2 in the shin ▐ 1 in the foot

• Groin and pelvic Girdle → L1

• Anterior thigh → L2
• Inner (Medial) thigh and distal anterior thigh → L3

• Inner (medial) shin → L4

• Outer (Lateral) shin and Dorsum of the foot → L5

• Lateral Foot → S1

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Scenario (1):
A man develops severe low back pain shooting down his right leg after lifting
heavy objects. His Ankle and Knee reflexes are intact. He has reduced sensory
stimulus over the dorsum of the right foot.

The likely nerve root affected → L5

Knee reflex is intact → (Not L3 or L4)

Ankle Reflex is intact → (Not S1 or S2)
Reduced sensation over the foot dorsum (and lateral shin) → L5

Scenario 2:
A patient with DM present for routine check-up. His reflexes and motor
functions are normal. However, there is a deficit in fine touch sensation on
the medial aspect of his lower right leg.

The likely dermatome to be affected → L4

(inner shin = Medial side of a leg = L4)

Key A 40 YO man had a left elbow injury. Following that, he developed a loss of
54 sensation over the ulnar side of his left hand. His hand looks “Claw”.
Which movement against resistance would help confirm an injury to the
affected nerve?

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♦ The injured nerve is → Ulnar nerve (Claw hand + Paraesthesia of little finger
+ ring finger “ulnar border”).

♦ As the ulnar nerve supplies dorsal and palmar interossei that are involved in
fingers adduction and abduction, the answer would be:
→ Abduction of the fingers

Key The level of iliac Crest → L4

55

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Key ◙ Paraesthesia (Loss of sensation) of the little finger + ring finger

56
→ Ulnar nerve

Remember that:

◘ Paraesthesia of the lateral three fingers (thumb, index, MIDDLE) fingers

→ Median Neve.

◘ Paraesthesia of little finger + ring finger (both dorsal and palmar)

→ Ulnar nerve.

◘ Paraesthesia of the dorsal aspect of the THUMB ± a small dorsal area

between 1st (Thumb) and 2nd (Index) fingers

→ Radial Nerve.

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Key ◙ During a laparoscopic cholecystectomy, the midline structure that is pierced

57 is → Linea Alba.

◙ While performing laparoscopy, the anatomical structure(s) to be pierced

while inserting a port at the midway point between umbilicus and anterior
superior iliac spine is
→ Internal oblique muscle and external oblique aponeurosis.

◙ While performing a laparoscopic cholecystectomy, the first anatomical

structure(s) to be pierced while inserting a port at the midway point between
Anterior midline and mid-axillary line is
→ External oblique aponeurosis and Internal oblique muscle.

◙ When inserting a chest drain in the 5th ICS anterior to mid-axillary line, not
only the vessels (VAN) intercostal Vein, Artery and Nerve can be pierced, but
also intercostal MUSCLE is liable to be pierced.

Key After a right wrist injury, a man lost sensation over the palmar side of the
58 index, thumb, middle fingers and half the ring finger. There is also atrophy of
the thenar eminence. He cannot touch his right little finger with his right
thumb.
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The likely injured nerve is → Median nerve.

Key A man sustained a trauma below the knee and presented with loss of foot
59 dorsiflexion. The affected nerve is:
→ Common peroneal nerve.

Key During chest drain Insertion, the structure that might be damaged
60

→ Intercoastal Artery

Also, intercostal VAN (Vein, Artery, Nerve) and intercostal muscles.

Key The level of iliac Crest → L4

61

Key ◙ A swelling behind the knee (in the popliteal fossa), usually asymptomatic,
62 round, smooth, non-tender → Baker cyst (popliteal cyst)

Key ◙ Numbness and Tingling of the thumb, index and middle fingers
63

→ Think of Carpal Tunnel Syndrome (Median Nerve)

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√ Pregnancy is an important risk factor for Carpal Tunnel Syndrome (due to

fluid retention).

√ Tinel Test is not always positive in Carpal Tunnel Syndrome “very low
sensitivity”.

◙ The Transverse Carpal Ligament compresses the MEDIAN nerve.

◙ Thus, the treatment would be → Cut the Transverse Carpal Ligament

to release the pressure on the median nerve.

♠ Note: Transverse Carpal Ligament is also called = Flexor Retinaculum =

Anterior Annular Ligament.

Key A man is unable to abduct and adduct his fingers, X-ray neck showed cervical
64 vertebrae showing degenerative changes. The likely nerve root of brachial
plexus affected?

a. C5
b. C6
c. C7
d. C8
e. T1

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C8 radiculopathy
Affects thumb abduction and extension, ulnar deviation of the wrist, and
causes paraesthesia of a thin area on the forearm which runs down to include
the little finger.

T1 Radiculopathy
Affects Fingers Abduction and Adduction, Pain and Paraesthesia along the
affected nerve.

Key Patient with cut to the wrist and inability to flex the distal phalanx of little
65 finger. Which structure is damaged?

A) flexor digitorum profundus

B) flexor digitorum superficialis
C) ulnar nerve

- Unable to flex the ‘’Proximal’’ interphalangeal joints AND

Metacarpophalangeal (MCP) joint →
Flexor Digitorum Superficialis.

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- Unable to flex the ‘’Distal’’ interphalangeal joints →

Flexor Digitorum profundus.

Key A man who works as a builder was working with a screwdriver and felt that
66 something gives way in his upper arm. There is a bulging present in the upper
part of his arm.

A. Tendon rupture
B. Muscle haematoma

- Proximal Biceps Tendon Rupture: Muscle bunches up in the distal arm,

Popeye appearance.

- Distal Biceps Tendon Rupture: Single traumatic event (e.g. flexion against
resistance), sudden sharp tearing sensation, painful swollen elbow,
weakness of flexion and supination.

The patient feels that something in the cubital fossa has ruptured

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Key A man with crutches having weakness on the left arm on dorsiflexion of
67 wrist, and wrist drop, structure affected?

a. C5
b. C6
C. Radial nerve
D. Interosseous nerve
E. Median nerve

Radial Nerve (C5-T1)

- Motor supply to the Extensors of the (thumb, fingers, wrist and forearm).
If damaged → Wrist Drop

- Radial nerve can be compressed against the operating table (medial aspect
of the arm) during an operation →
(Saturday Night Palsy).

- Also, Crutch palsy (a compression against the spiral groove on the medial
aspect of humerus).

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- Injury to the Radial nerve can also lead to sensory loss of the dorsal aspect
of the THUMB ± a small area over the dorsal aspect between 1st and 2nd
fingers.

Key A young man presents with sudden pain in the chest while lifting weights. He
68 is unable to lift the arm above the head. He also has difficulty in abducting his
left arm beyond 90. When the arm is stretched out against resistance, the
scapula is noticed to be prominent. Injury to which of the following nerves is
affected?

A. Dorsal scapula nerve

B. Long thoracic nerve
C. Posterior interosseus nerve
D. Axillary nerve
E. Thoracodorsal nerve

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Long thoracic nerve (C5-C7)

Serratus anterior

Long thoracic nerve (C5-C7) Serratus Often during sport e.g. following a
anterior blow to the ribs. Also, possible
complication of mastectomy

Damage results in a winged scapula

Key Femoral Nerve Injury:

69

e.g. a stab injury to the inguinal area.

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√ Weakness on hip flexion.

√ Weakness on knee extension.
√ Loss of sensation, Paraesthesia over the medial side of the thigh.

Key Lower limb anatomy

70

Nerve Motor Sensory Typical mechanism of injury &

notes
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Femoral Knee Anterior and Hip and pelvic fractures

nerve extension, medial aspect of Stab/gunshot wounds
thigh flexion the thigh and
lower leg
Obturator Thigh Middle part of Anterior hip dislocation
nerve adduction Medial thigh

Lateral None Lateral and Compression of the nerve near

cutaneous posterior the ASIS → meralgia
nerve of surfaces of the paraesthetica, a condition
the thigh thigh characterised by pain, tingling and
numbness in the distribution of
the lateral cutaneous nerve
Tibial Foot Sole of foot Not commonly injured as deep
nerve plantarflexion and well protected.
and inversion Popliteal lacerations, posterior
knee dislocation
Common Foot Dorsum of the Injury often occurs at the neck of
peroneal dorsiflexion foot and the the fibula
nerve and eversion lower lateral Tightly applied lower limb plaster
Extensor part of the leg cast
hallucis longus
Injury causes foot drop

Superior Hip abduction None Misplaced intramuscular injection

gluteal Hip surgery
nerve Pelvic fracture
Posterior hip dislocation

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Injury results in a positive

Trendelenburg sign
Inferior Hip extension None Generally injured in association
gluteal and lateral with the sciatic nerve
nerve rotation
Injury results in difficulty rising
from seated position. Can’t jump,
can’t climb stairs

Key A young ’an presents’with sudden pain in the chest while lifting weights. He
68 is unable to lift the arm above the head. He also has difficulty in abducting his
left arm beyond 90. When the arm is stretched out against resistance, the
scapula is noticed to be prominent. Injury to which of the following nerves is
affected?

A. Dorsal scapula nerve

B. Long thoracic nerve
C. Posterior interosseus nerve
D. Axillary nerve
E. Thoracodorsal nerve

Long thoracic nerve (C5-C7)

Serratus anterior

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Long thoracic nerve (C5-C7) Serratus Often during sport e.g. following a
anterior blow to the ribs. Also, possible
complication of mastectomy

Damage results in a winged scapula

Key A 21 YO male presents complaining of inability to grip objects with his right
71 hand. He has noticed this issue since he had trauma to his hand while playing
rugby a few days ago. On examination, the patient cannot flex the distal
phalanx of his right ring finger. What is the most likely affected structure?

→ Flexor digitorum profundus.

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Notes on Fingers Flexors

- Unable to flex the ‘’Proximal’’ interphalangeal joints ± Metacarpophalangeal

(MCP) joint →
Flexor Digitorum Superficialis

- Unable to flex the ‘’Distal’’ interphalangeal joints →

Flexor Digitorum profundus

Key A 55 YO man presents complaining of a neck pain, left arm discomfort and
72 left-hand weakness. On examination, he has weakness in abducting and
adducting the fingers of his left hand. MRI reveals a left-sided disc herniation
in one area of spinal cord. What is the likely affected nerve root?

→ T1

Remember:
C8 radiculopathy

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Affects thumb abduction and extension, ulnar deviation of the wrist, and
causes paraesthesia of a thin area on the forearm which runs down to include
the little finger.

T1 Radiculopathy
Affects Fingers Abduction and Adduction, Pain and Paraesthesia along the
affected nerve.

Also Remember:
The motor function of the nerve roots of an upper limb
C5, C6, C7, C8
Flex, extend, extend, flex
elbow, wrist, elbow, fingers

C5 C6 C7 C8
Flex Extend Extend Flex
elbow wrist elbow Fingers

Adduct and Abduct Fingers → T1

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Key The arterial supply of the Lower Limbs:

73

External iliac → Femoral → Popliteal → Anterior tibial → Dorsalis pedis

(The obstructed artery is always one level proximal “above” the

affected muscle group).
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Or, one level above the artery that cannot be felt.

Example 1:
An elderly with Hx of smoking and uncontrolled DM presents with
pain on calf muscles after walking. He has to rest for a while to be
able to continue walking. Popliteal artery and dorsalis pedis cannot
be felt.

• The likely occluded artery is → femoropopliteal artery.

Example 2:
A patient whose femoral and popliteal pulses are not felt.

• The likely occluded artery → External iliac artery.

Claudication pain in Peripheral Arterial Disease

The level of ischemia:

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♦ Aorto-iliac artery occlusion:

Pain in buttocks, thighs ± Erectile Dysfunction (Leriche Syndrome).

♦ Common iliac artery occlusion:

→ pain extends to just above inguinal ligament.

♦ Femoral artery occlusion:

→ pain in leg (below inguinal ligament). Femoral pulse is felt but the pulses
below it are not felt.

♦ Femoro-politeal
→ Pain is below knee.

Key ◙ Pregnancy can predispose to Guyon’s canal syndrome

74
(Ulnar nerve compression at wrist
→ numbness over little finger + half the ring finger).

◙ Pregnancy can predispose to Carpal tunnel syndrome

(Median nerve compression
→ numbness over thumb, index and middle fingers).

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Key A young man fell down on his right shoulder and arm and presents
75 with the following:
Weakness of right shoulder abduction and external rotation.
Numbness over the lateral side of the right arm.
Numbness over the lateral side of the right forearm.

What is the likely affected structure?

Answer:
→ Upper brachial plexus = superior trunk of the brachial plexus.

√ Weakness of right shoulder abduction and external rotation = axillary nerve =

C5, C6.
√ Numbness of lateral arm = axillary nerve = C5, C6.
√ Numbness of lateral forearm = musculocutaneous nerve = C5, C6, C7

Upper brachial plexus = C5, C6, C7

Lower brachial plexus = C8, T1

Key A young man fell on outstretched arm and was treated surgically.
76
6 months later, he presents with the following:
√ Decreased sensation of little finger and medial half if the ring finger.

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√ Wasting of the interosseous muscles.

√ Inability to cross the two fingers (little + ring) or abduct his little finger.
What is the likely affected structure?

Answer:
→ Lower brachial plexus = Inferior trunk of the brachial plexus.
Another correct answer → Ulnar nerve.

√ All given 3 features indicate damage to Ulnar nerve.

√ Ulnar nerve = C8, T1
√ C8 and T1 = inferior (lower) trunk of brachial plexus.

Upper brachial plexus = C5, C6, C7

Lower brachial plexus = C8, T1

Remember:
◙ Ulnar nerve injury (C8, T1):
♦ Claw hand + Paraesthesia of little finger + ring finger “ulnar border”.

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♦ The ulnar nerve supplies dorsal and palmar interossei that are involved in
fingers adduction and abduction → interosseous muscles wasting, no
abduction/ adduction of fingers.

Key Meralgia paresthetica:

77
Burning, numbness or tingling sensation of the lateral thigh due to
injury of → Lateral femoral cutaneous nerve.

Key ◙ Neck injury followed by asymmetrical chest movements:

78
The injured nerve is → Phrenic nerve. “it controls diaphragm”.

Key A 30 YO man has neck pain that radiates to his left shoulder and left middle
79 finger. He also has decreased sensation on his left index and middle fingers.
Left arm shows reduced triceps reflex. He also has difficulty straightening his
left elbow.
What is the most likely affected nerve root?

[C5 / C6 / C7 / C8 / T1]

Answer:

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• He has reduced triceps reflex.

→ Thus, the affected nerve root is either C7 or C8.

• He has a difficulty to straighten “extend’ his elbow → C7

Remember from Key 12:

The motor function of the nerve roots of an upper limb

C5, C6, C7, C8
Flex, extend, extend, flex
elbow, wrist, elbow, fingers

C5 C6 C7 C8
Flex Extend Extend Flex
elbow wrist elbow Fingers

Key Parkinson’s disease is a progressive neurodegenerative co’dition caused

80 by degeneration of dopaminergic neurons in the substantia nigra →
Low levels of dopamine → This results in a classic triad of features:
bradykinesia, resting tremors and rigidity. The symptoms of
Parkinson’s disease are characteristically asymmetrical.

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• In a recent exam, it was asked about the most likely affected anatomical
structure in Parkinson’s disease. The answer was: Substantia nigra.

• Patients with Parkinson’s disease → impairment of the neurons in the

substantia nigra → Low levels of dopamine.

Key A 30 YO man sees double vision when he looks to the left side.
81 When he closes either his right or left eye, his vision normalises.
What is the likely affected nerve?
A) Left third cranial nerve.
B) Left fourth cranial nerve.
C) Right fourth cranial nerve.
D) Left sixth cranial nerve.
E) Right sixth cranial nerve.

• Abducens (6th)

Diplopia on Lateral gaze ((Same side). “i.e., Horizontal Diplopia”

If he looks at left and sees double → then the lesion is on the left ((Same Side)).

Remember O:T:A
O (Oculomotor) 3rd CN T (Trochlear) 4th CN A (Abducens) 6th CN
Same side Opposite side Same side
Dilated pupil, ptOsis Diplopia on Downgaze Diplopia on Lateral gaze

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Key After tympanoplasty, a patient developed decreased taste sensation

82 and decreased salivation.

What is the most likely injured nerve?

→ Facial Nerve (7th CN).

• Facial nerve (7th) innervates the anterior two-thirds of the tongue whereas
glossopharyngeal nerve (9th) innervates the posterior one-third.
• Facial nerve supplies sublingual and submandibular glands (salivation).
• Tympanoplasty has the risk to stretch the chorda tympani (which is a branch of
the facial nerve).
• Tympanoplasty is the surgical procedure performed to repair a perforated
tympanic membrane, with/ without reconstruction of the ossicles, with the aim
of preventing reinfection and restoring hearing ability. Microscopic and
endoscopic approaches are utilized for tympanoplasty.
• This is usually temporary, and the taste can return several weeks after surgery.

Key A 33-year-old woman has numbness and paraesthesia in her lateral

83 three fingers and a half of the right hand. She finds it difficult to close
the buttons of her shirt due to this numbness. Her right hand looks
less bulky than the other normal hand. She works at an office job and
she has a history of type 2 diabetes mellitus. What is the most likely
affected nerve?

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→ Median nerve.

Remember that:
• Paraesthesia of the lateral three fingers (thumb, index, MIDDLE) fingers
→ Median Neve. (Nearly the lateral 3 and a half fingers)

• Paraesthesia of little finger + ring finger (both dorsal and palmar)

→ Ulnar nerve

• Paraesthesia of the dorsal aspect of the THUMB ± a small dorsal area

between 1st (Thumb) and 2nd (Index) fingers
→ Radial Nerve.

◘ The risk factors here are: DM and her work nature.

◘ Her affected hand looks less bulky because there is wasting in the thenar
eminence secondary to median nerve palsy (less bulky, ape-like).

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Key Infra-Orbital Nerve

84

• It is a branch of Maxillary Nerve, which is a branch of Trigeminal Nerve.

• Its injury (eg, during boxing, orbital blowout fractures) can lead to:
→ Altered sensation or numbness of cheek, upper lip, and lower eyelid on
the injured side.

Infraorbital nerve distribution

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Key The Origin of the Nuclei of the Cranial Nerves (CN Origin)
85
2,2,4,4
• Cerebrum → 2 nuclei → CN I and II. (1 and 2).
• Midbrain → 2 nuclei → CN III and IV. (3 and 4).
• Pons → 4 nuclei → CN V, VI, VII, VIII. (5, 6, 7 and 8).
• Medulla → 4 nuclei → CN IX, X, XI, XII. (9, 10, 11 and 12).

Example:
A man with blurry painful right eye + right eye ptosis, dilated right pupil
unresponsive to light + when he looks forwards, the right eye deviates inferiorly
and laterally (down and out appearance).
• The likely affected nerve → Oculomotor nerve (3rd CN).
• The likely location of the lesion → Midbrain.

◙ Remember Oculomotor (3rd)

√ Its injury leads to → Dilated pupil (Mydriasis), Ptosis (On the Same side),
Others: outward gaze, diplopia.
Also, in 3rd nerve palsy → down and out appearance (on looking forwards, the
affected eye deviated inferiorly and laterally).

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Key T1 Radiculopathy:
86
• Numbness of the medial aspect of the upper arm (ipsilateral).
• Weakness of the hand (ipsilateral).
• Difficulty to abduct and adduct fingers (ipsilateral).

Scenario:
A man presents with neck pain, right arm discomfort, right hand weakness,
numbness and tingling over the medial aspect of the upper right arm, and
weakness in right fingers abduction and adduction.
The likely affected nerve root → T1.

The motor function of the nerve roots of an upper limb

C5 C6 C7 C8
Flex Extend Extend Flex
elbow wrist elbow Fingers
Adduct and Abduct Fingers → T1

Key A man had ankle injury and had below-knee cast that extends to the top of
87 the foot. A few weeks later, the cast had been removed. However, he is now
unable to dorsiflex his foot.
→ Inability to Dorsiflex → Foot Drop → Common peroneal nerve injury.

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