In open, dirty w ounds, w here there is a high risk of infection, the sectioned nerve should be ignored, and the w ound infection should be treated. Later, w hen the w ound has healed satisfactorily, the nerve should be explored, and the cut ends of the nerve should be sutured together.
Table 3-4 Important Features Found in Cervical and Lumbosacral Root Syndromes
Ro o t
Injur y Der m ato m e Pain M uscles Supplied M o v em ent W eak ness Reflex Inv o lv ed
C5 Lateral side of upper
part of arm Deltoid and biceps brachii Shoulder abduction,
elbow flexion Biceps
C6 Lateral side of forearm Extensor carpi radialis
longus and brevis Wrist extensors Brachioradialis
C7 M iddle finger Triceps and flexor carpi radialis
Extension of elbow and
flexion of wrist Triceps
C8 M edial side of forearm Flexor digitorum superficialis
and profundus Finger flexion None
L1 Groin Iliopsoas Hip flexion Cremaster
L2 Anterior part of thigh Iliopsoas, sartorius, hip adductors
Hip flexion, hip
adduction Cremaster
L3 M edial side of knee Iliopsoas, sartorius, quadriceps, hip adductors
Hip flexion, knee extension, hip adduction
Patellar
L4 M edial side of calf Tibialis anterior, quadriceps Foot inversion, knee
extension Patellar
L5 Lateral side of lower leg and dorsum of foot
Extensor hallucis longus, extensor digitorum longus
Toe extension, ankle
dorsiflexion None
S1 Lateral edge of foot Gastrocnemius, soleus Ankle plantar flexion Ankle jerk
S2 Posterior part of thigh Flexor digitorum longus, flexor hallucis longus
Ankle plantar flexion,
toe flexion None
For a patient w ith a healed w ound and no evidence of nerve recovery, the treatment should be conservative.
Sufficient time should be allow ed to elapse to enable the regenerating nerve fibers to reach the proximal muscles.
If recovery fails to occur, the nerve should be explored surgically.
In those cases in w hich connective tissue, bone fragments, or muscles come to lie betw een the cut ends of a
severed nerve, the nerve should be explored; if possible, the cut ends of the nerve should be brought together and sutured.
The nutrition of the paralyzed muscles must be maintained w ith adequate physiotherapy. Warm baths, massage, and w arm clothing help to maintain adequate circulation.
The paralyzed muscles must not be allow ed to be stretched by antagonist muscles or by gravity. Moreover, excessive shortening of the paralyzed muscles leads to contracture of these muscles.
Mobility must be preserved by daily passive movements of all joints in the affected area. Failure to do this results in the formation of adhesions and consequent limitation of movement.
Once voluntary movement returns in the most proximal muscles, the physiotherapist can assist the patient in
performing active exercises. This not only aids in the return of a normal circulation to the affected part but also helps the patient to learn once again the complicated muscular performance of skilled movements.
Table 3-5 Branches of the Brachial Plexus and Their Distribution
Br anches Distr ibutio n
Roots
Dorsal scapular
nerve (C5) Rhomboid minor, rhomboid major, levator scapulae muscles
Long thoracic
nerve (C5-7) Serratus anterior muscle
Upper trunk
Suprascapular
nerve (C5-6) Supraspinatus and infraspinatus muscles
Nerve to
subclavius (C5-6) Subclavius
Lateral cord
Lateral pectoral
nerve (C5-7) Pectoralis major muscle
M usculocutaneous nerve (C5-7)
Coracobranchialis, biceps brachii, brachialis muscles; supplies skin along lateral border of forearm when it becomes the lateral cutaneous nerve of forearm
Lateral root of
median nerve (C5-7) See medial root of median nerve
Posterior cord
Upper subscapular
nerve (C5-6) Subscapularis muscle
Thoracodorsal
nerve (C6-8) Latissimus dorsi muscle
Lower subscapular
nerve (C5-6) Subscapularis and teres major muscles
Axillary nerve (C5- 6)
Deltoid and teres minor muscles; upper lateral cutaneous nerve of arm supplies skin over lower half of deltoid muscle
Radial nerve (C5-8, T1)
Triceps, anconeus, part of brachialis, brachioradialis, extensor carpi radialis longus; via deep radial nerve branch supplies extensor muscles of forearm: supinator, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, extensor indicis, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis; skin, lower lateral cutaneous nerve of arm, posterior cutaneous nerve of arm, and posterior cutaneous nerve of forearm; skin on lateral side of dorsum of hand and dorsal surface of lateral 3½ fingers;
articular branches to elbow, wrist, and hand
M edial cord
M edial pectoral
nerve (C8, T1) Pectoralis major and minor muscles
M edial cutaneous nerve of arm joined by intercostal brachial nerve from second intercostals nerve (C8, T1-2)
Skin of medial side of arm
M edial cutaneous nerve of forearm (C8, T1)
Skin of medial side of forearm
Ulnar nerve (C8, T1)
Flexor carpi ulnaris and medial half of flexor digitorum profundus, flexor digiti minimi, opponens digiti minimi, abductor digiti minimi, adductor pollicis, third and fourth lumbricals, interossei, palmaris brevis, skin of medial half of dorsum of hand and palm, skin of palmar and dorsal surfaces of medial 1½ fingers
M edial root of median nerve (with lateral root) forms median nerve (C5-8, T1)
Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, first two lumbricals (by way of anterior interosseous branch), flexor pollicis longus, flexor digitorum profundus (lateral half), pronator quadratus, palmar cutaneous branch to lateral half of palm and digital branches to palmar surface of lateral 3½ fingers; articular branches to elbow, wrist, and carpal joints