FOURTH EDITION SAUNDERSFOURTH EDITION AIDS TO THE EXAMINATION OF THE PERIPHERAL NERVOUS SYSTEMW.B, SAUNDERS An imprint of Harcourt Publishers Limited (© The Guarantors of Brain 2000 (By isa vegseredeademak of Harcourt Fuishes ited The right of the Guarantors of Brain to be identified as authors of this work has been asserted by them in accordance with the Copyright Designs and Patents Act 1988 All rights reserved. No part ofthis publication may be reproduced, stored in a retrieval system, oF transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers (Harcouet Publishers Limited, Harcourt Place, 32 Jamestown Road, London NW1 7BY), ora licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Rod, London W1P OLE. Some of the material in this work is © Crown copyright 1976, Reprinted by permission of the Controller of Her Majesty's Stationery Office First published 2000 ISBN 0 7020 2512 7 British Library Cataloguing in Publicat A catalogue record for this book is availabe from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Printed in China Commissioning Edor Michael Parkinson giao | Project Development Manager: Sarah Keer Kece remus ee Projet Manager: Frances Affleck ; Designer Judith WeightPREFACE In 1940 Dr George Riddoch was Consultant Neurologist to the Army. He realised the necessity of providing centres to deal with peripheral nerve injuries during the war. In collaboration with Professor J. R. Learmonth, Professor of Surgery at the University of Edinburgh, peripheral nerve injury centres were established at Gogarburn near Edinburgh and at Killearn near Glasgow. Professor Learmonth wished to have an illustrated guide on peripheral nerve injuries for the use of surgeons working in general hospitals. In collaboration with Dr Ritchie Russell, a few photographs demonstrating the testing of individual muscles were taken in 1941. Dr Ritchie Russell returned to Oxford in 1942 and was replaced by Dr M. J. McArdle as Neurologist to Scottish Command. The photographs were completed by Dr McArdle at Gogarburn with the help of the Department of Medical Illustration at the University of Edinburgh. About twenty copies in oose-leaf form were circulated to surgeons in Scotland, In 1945 Professor Learmonth and Dr Riddoch added the diagrams illustrating the innervation of muscles by various peripheral nerves modified from Pitzes and Testut (Les Newfs en Schemas, Doin, Paris, 1925) and also the diagrams of cutaneous sensory Gistributions and dermatomes. This work was published by the Medical Research Council in 1943 as Aids to the Investigation of Peripheral Nerve Injures (War Memorandum No. 7). It became a standard work and over the next thirty years many thousands of copies were printed. twas thoroughly re diagrams and was republished under the title Aids to the Examination of the Peripheral Nenous System (Memorandum No. 45), reflecting the wide use made of this booklet by sludents and practitioners and its more extensive use in clinical neurology, which was rather different from the war time emphasis on nerve injuries. Im 1984 the Medical Research Council transferred responsibility for this publication to the Guarantors of Brain for whom a new edition was prepared. Modifications were made to ‘ed between 1972 and 1975 with new photographs and many new some of the diagrams and a new diagram of the lumbosacral plexus was included. Most of the photographs for the 1943, 1975 and 1986 editions show Dr McArdle, who died in 1989, as the examining physician. A new set of colour photographs has been prepared for this edition, the diagrams of the brachial plexus and lumbosacral plexus have been retained, but all the other diagrams have been redrawn,ACKNOWLEDGEMENTS The Guarantors of Brain are very grateful to: Patricia Archer rxo for the drawings of the brachial plexus and lumbosacral plleus Ralph Hutchings for the photography Paul Richardson for the artwork and diagrams Michael Hutchinson mo 10s for advice on the neuro-anatommy Sarah Keer-Keer (Harcourt Publishers) for her help and encouragement.Introduction 1 Spinal accessory nerve 3 Brachial plexus 4 Musculocutaneous nerve 12 Axillary nerve 14 Radial nerve 16 Me jan nerve 24 Ulnar nerve 30 Lumbosacral plexus 37 Nerves of the lower limb 38 Dermatomes 56 Nerves and root supply of muscles 60 Commonly tested movements 62 CONTENTSINTRODUCTION This alas is intended as a guide to the examination of patients with lesions of peripheral nerves and nerve roots. These examinations should, if possible, be conducted in a quiet room where patient and examiner will be free from distraction. For both motor and sensory testing it is important that the patient should first be warm, The nature and object of the tests should. be explained to the patient so that his interest and co-operation are secured, If either shows signs of fatigue, the session should be discontinued and resumed later. Motor testing A muscle may act as.a prime mover, as a fixator, as an antagonist, ot as a synergist. Thus, flexor carpi ulnatis acts as a prime mover when it flexes and adducts the wrist; as a fixator when it immobilises the pisiform bone during contraction of the adductor digiti minimi; as an antagonist when it resists extension of the wrist; and as a synergist when the digits, but not the wrists, are extended. As far as possible the action of each muscle should be observed separately and a note made of those in which power has been retained as well as of those that are weak or paralysed. It is ustal to examine the power of a muscle in relation to the movement of a single joint. It has long been customary to use a 0 to 5 scale for recording muscle power, but i is generally recognised that subdivision of grade 4 may be helpful No contraction Flicker or trace of contraction Active movement, with gravity eliminated Active movement against gravity Active movement against gravity and resistance Normal power Grades 4-, 4 and 4+, may be used to indicate movement against slight, moderate and strong resistance respectively. The models employed in this work were not chosen because they showed unusual ‘muscular development; the ease with which the contraction of muscles is identified varies with the build of the patient, and itis essential that the examiner should both look for and endeavour to feel the contraction of an accessible muscle and/or the movement of its tendon. In most of the illustrations the optimum point for palpation has been marked. Muscles have been arranged in the order of the origin of their motor supply from nerve trunks, which is convenient in many examinations. Usually only one method of testing each muscle is shown but, where necessary, multiple illustrations have been included if a ‘muscle has more than one important action. The examiner should apply the tests as they are illustrated, because the techniques shown will eliminate many of the traps for the inexperienced provided by ‘trick’ movements. It should be noted that each of the methods used tests, as a rule, the action of muscles at a single joint, When testing a movement, the limb should be firmly supported proximal to the relevant joint, so that the test is confined to the chosen muscle group and does not require the patient to fix the limb proximally by muscle contraction. In this book, this principle isSPINAL ACCESSORY NERVE Fig. 1 Trapezius (Spinal accessory nerve and tient is elevating the he thick upper part of the muscle can be seen and felt 2 Trapezius (Spinal accessory net patient is pushing the pal nded. Arrow: the lower fib ith the elbows fullyPOSTERIOR CORD LATERAL CORDRACHIAL PLEXUS 5 Fig.4 The approximate area within which sensory changes may be found in complete ions of the brachial plexus (C5, C6, C7, CB, T1). ate area within which sensory changes may be found in lesions of the of the brachial plexus,6 BRACHIAL PLEXUS Fig.6 The approximate area within which sensory changes may be found in lesions of the lower roots (C8, T1) of the brachial plexus.BRACHIAL PLEXUS 7 Fig. 7 Rhomboids (Dorsal scapular nerve; C4, C5) The patient is pressing the palm of his hand backwards against the examiner's h. Arrow: the muscle bellies can be felt and sometimes seen. Fig. 8 Serratus anterior (Long thoracic nerve; C5, C6, C7) The patient is pushing against a wall. The left serratus anterior is paralysed and there is winging of the scapula.HIAL PLEXUS Fig. 9 Pectoralis Major: Clavicular Hea ateral pectoral nerve; C5, C6) The upper arm is above the horizontal and the patient is pushing forward aga ers hand. Arrow: the clavicular head of pectoralis major can be seen and felt. Fig. 10 Pec erves; C6, C7 oe Falis Major: Sternocostal Head (Lateral and med pectoral The patient is adducting the upper arm against resistance Arrow: the sterno-costal tRACHIAL PLEXUS 9 a wa natus (Suprascapular nerve; C5, C6) Fig. 11. Supr. The patient is abducting the upper arm a Arrow: the muscle belly can be felt and sometimes seen. ar nerve; C5, Fig. 12. Infraspinatus (Suprasea nt is externally rotating per arm at the shoulder against resistance. The ‘right hand is resisting thi arm with the ng the elbow and preventing abduction of and felt. jement and supporting the fo ight angle; his left hand iss10 BRACHIAL PLEXUS vy Fig. 13. Latissimus Dorsi (Thoracodorsal nerve; C5, C7, CB) The upper arm is horizontal and the patient is adducting it against resistance. Lower arrow: the muscle belly can be seen and felt. The upper arrow points to teres major. w 4 ot y ? & 7 Fig. 14 Latissimus Dorsi (Thoracodorsal nerve; C6, C7, C8) The Muscle bellies can be felt to contract when the patient coughs.MUSCULOCUTANEOUS NERVE {ULOCUTANEOUS NERVE Fig. 16 Diagram of the musculocutaneous nerve, its major cutaneous branch and the muscles which it suppliesMUSCULOTANEOUS NERVE 13 Fig. 17 The approximate area within which sensory changes may be found in lesion: the musculocutaneous nerve. (The distribution of the lateral cutaneous nerve of the forearm.) yee Fig. 18 Biceps (Musculocutaneous nerve; C5, C6) The patient is flexing the supinated forearm against resistance. Arrow: the muscle belly can be seen and fett.AXILLARY NERVE AXILLARY NERVE JPPER CUTA NERVE OF TH RADIAL NERVE Fig. 19 Diagram of the axillary nerv it supplies its major cutaneous branch and the muscles which _ Fig. 20. The approximate area within which sensory changes may be found in lesions of the axillary nerveAXILLARY NERVE 15 Fig.21. Deltoid (Axillary nerve; C5, C6) ne patient is abducting the upper arm against resistance Arrow: the anterior and middle fibres of the muscle can be seen and felt Fig. 22 Deltoid (Axillary nerve; C5, C6) The patient is retracting the abducted upper a Arrow: the posterior fibres of delt nid can be seen and feltRADIAL NERVE AXILLARY NERVE SUPERFICIAL RADIAL NEFVE Fig. 23 Diagram of the radial nerve, its major cutaneous branch and the muscles which it supplies.RADIAL NERVE 17 Fig. 24 The approximate area within which sensory changes may be found in high lesions of the radial nerve (above the origin of the posterior cutaneous nerves of the arm and forearm). The average area is usually considerably smaller, and absence of sensory changes has been recorded. Fig. 25 The approximate area within which sensory changes may be found in lesions of the radial nerve above the elbow joint and below the origin of the posterior cutaneous nerve of the forearm. (The distribution of the superficial terminal branch of the radial nerve.) Usual area shaded, with dark blue line; ight blue lines show small and large areas,RADIAL NE 19 Fig. 28 Brachioradialis (Radial nerve; C5, C6) The patient is flexing the forearm against resistan supination. Arrow: the muscle be e with the forearm mid n be seen and fel20 RADIAL NERVE Fig. 29 Supinator (Radial nerve; C6, C7) The patient is supinating the forearm agai elbow. sistance with the forearm extended at tRADIAL NERVE 21 a Fig. 30 Extensor Carpi Ulnaris (Posterior interosseous nerve; C7, CB) The patient is extending and adducting the hand at the wrist against resistance Arrows: the muscle belly and the tendon can be seen and felt Fig. 31 Extensor Digitorum (Posterior interosseous nerve; C7, ) The patient's hand is firmly supported by the examiner’ right hand. Extension at the metacarpophalangeal joints is maintained against the resistance of the fingers of the examiner's left hand. Arrow: the muscle belly can be seen and felt,22. RADIAL NERVE Fig. 32 Abductor Pollicis Longus (Posterior interosseous nerve; C7, C8) The patient is abducting the thumb at the carpo:-metacarpal joint in a plane at right angles to the palm. Arrow: the tendon can be seen and felt anterior and closely adjacent to the tendon of extensor pollicis brevis (cf. Fig. 34). Fig. 33 Extensor Pollicis \Gus (Posterior interosseous nerve; C7, C8 The patient is extending the thumb at the interphalangeal joint against resistance. Arrows. the tendon can be seen and felt.RADIAL NERVE 23 Fig. 34 Extensor Pollicis Brevis (Posterior interosseous nerve; C7, CB) The patient is extending the thumb at the metacarpophalengeal joint against resistance Arrow. the tendon can be seen and felt (ef. Fig. 32Fig. 35 Diagram of the median MEDIAN NERVE ies that th erve (ef. Figs. its cutaneous branches and the muscles which itMEDIAN NERVE 25 Fig. 36 The approximate areas within which sensory changes may be found in lesions of he median nerve in: A the forearm, B the carpal tunneFig. 38 hMEDIAN NERVE 27 Fig. 39. Flexor Digitorum Superficialis (Median nerve; C7, C8, T1) The patient is flexing the finger at the proximal interphalageal joint against resistance with the proximal phalanx fixed. This test does not eliminate the possibility of flexion at he proximal interphalangeal joint being produced by flexor digitorum profundus Fig. 40. Flexor Digitorum Profundus | and Il (Anterior interosseous nerve; C7, CB) The patient is flexing the distal phalanx of the index finger against resistance with the middle phalanx fixed28 MEDIAN NERVE Fig. 41. Flexor Pollicis Longus (Anterior interosseous nerve; C7, C8) The patient is flexing the distal phalanx of the thumb against resistance while the proximal phalanx is fixed. ss Fig. 42 Abductor Pollicis Brevis (Median nerve; C8, T1) The patient is abducting the thumb at right angles to the palm against resistance, Arrow: the muscle can be seen and feltMEDIAN NERVE 29 Fig. 43 Opponens Pollicis (Median nerve; C8, T1) The patient is touching the base of the little finger with the thumb against resistance v Fig. 44 1st Lumbrical-interosseous Muscle (Median and ulnar nerves; CB, T1) The patient is extending the finger at the proximal interphalangeal joint against resistance with the metacarpophalangeal joint hyperextended anULNAR NERVE f f ULNAR NERVE [\ sensory MEDIAL CUTANEOUS Dorsal cutaneous { i Palmar evtaneous ¥ 3) — peep motor branch \ ‘Superficial terminal Motor or pale brews Third lamical —{ Fourtnlumbrical Fig. 45 Diagram of the ulnar nerve, its cutaneous branches and the muscles which it supplies.ULNAR NERVE 31 Fig. 46 The approximate areas within which sensory changes may be found in lesions of the ulnar nerve: A above the origin of the dorsal cutaneous branch, B below the origin of the dorsal cutaneous branch and above the origin of the palmar branch, C below the origin of the palmar branch.32 ULNAR NERVE Fig. 47 The approximate area within which sensory changes may be found in lesions of the medial cutaneous nerve of the forearm a Fig. 48 Flexor Carpi Ulnaris (Uinar nerve; C7, CB, T1) The patient is abducting the little finger against resistance. The tendon of flexor carpi ulnaris can be seen and felt (arrow) as the muscle comes into action to fix the pisiform bone from which abductor digiti minimi arises. If flexor carpi ulnaris is intact, the tendon is seen even when abductor digiti minim is paralysed (see also Fig. 49).ULNAR NERVE 33 Fig. 49. Flexor Carpi Ulnaris (Ulnar nerve; C7, €8, 71) The patient is flexing and adducting the hand at the wrist against resistance. Arrow the tendon can be seen and felt. Fig. 50. Flexor Digitorum Profundus Ill and IV (Ulnar nerve; C7, €8) The patient is flexing the distal interphalangeal joint against resistance while the middle phalanx is fixed.34 ULNAR NERVE Fig. 51 Abductor Digiti Minimi (UInar nerve; C8, T1) The patient is abducting the litle finger against resistance Arrow: the muscle belly can be felt and seen, Fig. 52. Flexor Digiti Minimi (UInar nerve; C8, T1) The patient is flexing the little finger at the m with the finger extended at both inter tacarpophalangeal joint against resistance halangeal joints.ULNAR NERVE 35 x aN Fig. $3 First Dorsal Interosseous Muscle (UInat nerve; C8, T1) The patient is abducting the index finger against resistance. Arrow. the muscle belly can be felt and usually seen, Fig. 54 Second Palmar interosseous Muscle (Ulnar nerve; C8, T1) The patient is adducting the index finger against resistance,Fig.55 Adductor Pollicis (Uinar nerve; C8, T1) 19 the thumb at right angles to the palm against the resistance of the examiner's finger.LUMBOSACRAL PLEXUS Genitotemoral nerve FEMORAL NERVE pudendal nerve Nerve to Superior and external sphincter inferior gluteal nerves Perineal nerve SCIATIC NERVE espana or otters of thigh { OBTURATOR NERVE Intermediate Obturator externus Medial Adductor longus Adductor brevis Nerves to quadriceps [Adduetor magnus Vastus lateralis, Guiaceous Posterior cutaneous Vastus medialis, nerve of thigh Saphenous nerve SCIATIC NERVE \ OY Common peronea! Guab\ Tibial Fig. 56 Diagram of the lumbosacral plexus, its branches and the muscles wh h they supply.NERVES OF THE LOWER LIMB OBTURATOR NERV Vastus medals INTERMEDIATE CUTANEOUS xsi rie NERVE OF THE THIGH {EAFICIAL PERONEA onus longus ATERAL CUTANEOUS NERVE OF THE CALF SAPHENOUS NERVE Fig. 57 Diagram of the nerves on the anterior aspect of the lower limb, their cutaneous branches and the muscles which they supply.NERVES OF THE LOWER LIMB 39 Semitoncinosu poSTENOR OUT NERVE OF THE THIGH AL NERVE AL NERVE | suRAL Fig. 58 Diagram of the nerves on the posterior aspect of the lower limb, ranches and the muscles which they supply40 NERVES OF THE LOWER LIMB Fig. 59 The approximate area within which sensory changes may be found in lesions of the lateral cutaneous nerve of the thigh. Usual area shaded, with dark blue line; large area indicated with light blue line. Fig. 60 The approximate area within which sensory changes may be found in lesions of the femoral nerve. (The distribution of the intermediate and medial cu the thigh and the saphenous nerve.)NERVES OF THE LOWER LIMB 41 Fig. 61 The approximate area within which sensory changes may be found in lesions of the obturator nerve. Fig. 62 The approximate area within which sensory changes may be found in lesions of the posterior cutaneous nerve of the thigh.42 NERVES OF THE LOWER LIMB Fig. 63 The approximate area within which sensory changes may be found in lesions of the trunk of the sciatic nerve. (Modified from M.R.C. Special Report No. 54, 1920.) Fig. 64 The approximate area within which sensory changes may be found in lesions of poth the sciatic and the posterior cutaneous nerve of the thigh,NERVES OF THE LOWER LIMB 43 Fig. 65 The approximate area within which sensory changes may be found in lesions of the common peroneal nerve above the origin of the superficial ps from M.R.C. Special Report No. 54, 1920.) eroneal nerve. (Modified Fig. 66 The approximate area within which sensory changes may be found in lesions of the deep peroneal nerveFig. 67 T he sural nerv approximate area within which sensory changes may be found in lesions of Fig. 68 The approximate area within which sensory s may be found in lesions o the tibial nerve. (Modified from M.R.C. Special Report No. 54, 1920.)NERVES OF THE LOWER LIMB 45 7 NERVE LATERAL PLANTAR | SAPHENOUS NERVE NER Fig. 69. The approximate areas supplied by the cutaneous nerves to the sole of the foot46 NERVES OF THE LOWER LIMB 2and 3 spinal nerves and femoral nerve; L1, L2, L3) Fig. 70. tliopsoas (Branches from L The patient is flexing the thigh at the hip against resistance with the leg flexed at the knee and hip. i Fig. 71 Quadriceps Femoris (Femoral nerve: L2, L3, L4) The patient is extending the leg against resistance with the limb flexed at the hip and knee. To detect slight weakness, the leg should be fully flexed at the knee. Arrow the muscle belly of rectus femoris can be seen and feltNERVES OF THE LOWER LIMB 47 v Fig. 72 Adductors (Obturator nerve; L2, 13, L4) ‘The patient lies on his back with the leg extended at the knee, and is addu against resistance. The muscle bellies can be felt, ng the limb — Fig. 73 Gluteus Medius and Minimus (Superior gluteal nerve; L4, L5, $1) The patient lies on his back and is internally rotating the thigh against resistance with the imb flexed at the hip and knee.48 NERVES OF THE LOWER LIMB » Fig. 74 Gluteus Medius and Minimus and Tensor Fasciae Latae (Superior gluteal nerve; LA, is'st The patient lies on his back with the leg extended and is abducting the limb against resistance. Arrows: the muscle bellies can be felt and sometimes see y Fig. 75 Gluteus Maximus (Inferior gluteal nerve; L5, $1, $2) The patient lies on his back with the leg extended at the knee and is extending the limb at the hip against resistanNERVES OF THE LOWER LIMB 49 Fig. 76 Hamstring Muscles (Sciatic nerve. Semite 15, $1, 82) dinosus, semimembranosus and biceps; ient lies the knee against resistance his back with the limb flexed at the hip and knee and is flexing the leg Fig. 77 Hamstring Muscles (Sciatic nerve. Semitendinosus, semimembranosus and biceps; Us, $1, $2 atient lies on his face 2 Arrows: the tendons of the xing the le (laterally) and se the knee against resistance. itendinosus (medially) can be felt50 NERVES OF THE LOWER LIMB Fig. 78 Gastrocnemius (Tibial nerve; $1, $2) The patient lies on his back with the leg extended and is plantar-flexing the foot against resistance. Arrow: the muscle bellies can be seen and felt, To detect slight weakness, the patient should be asked to stand on one foot, raise the heel from the ground and maintain this position, > > mw \ Fig. 79 Soleus (Tibial nerve; 51, 52) The patient lies on his back with the limb flexed at the hip and knee and is plantar-flexing the foot against resistance. The muscle belly can be felt and sometimes seen. Arrow. the Achilles tendonNERVES OF THE LOWER LIMB 51 Fig. 80. Tibialis Posterior (Tibial nerve; L4, LS) ‘The patient is inverting the foot against resistance Arrow. the tendon can be seen and felt. Fig. 81. Flexor Digitorum Longus, Flexor Hallucis Longus (Tibial nerve: LS, $1, $2) The patient is flexing the toes against resistanc52 NERVES OF THE LOWER 4 Fig. 82 Small muscles of the foot (medial and lateral plantar nerves; 51, 52) he patient is cupping the sole of the foot; the small muscles can be felt and sometime — Fig. 83 Tibialis Anterior (Deep peroneal nerve; LA, L he patient is dorsiflexing the foot against resistance. Arrows: the muscle belly and its tendon can be seen and felt.NERVES OF THE LOWER LIMB Fig. 84 Extensor 0 The patient is dorsiflexing the toes against resistance. The tendons passing to the lateral four toes can be seen and fel itorum Longus (Deep peroneal nerve; LS, $1)54 NERVES OF THE LOWER LIMB Fig. 85 Extensor Hallucis Longu The patient is dorsiflexing the distal phalanx of the big toe against resistance, Arrow: the tendon can be seen and felt (Deep peroneal nerve; L5, St)NERVES OF THE LOWER LIMB 55 Fig. 86 Extensor Digitorum Brevis (Deep peroneal nerve; L5, S1) The patient is dorsiflexing the proximal phalanges of t he muscle belly can be felt and sometimes seen. e toes against resistan Fig. 87 Peroneus Longus and Brevis (Superficial peroneal nerve; L5, $1) patient is everting the foot against resistance. Upper arrow: the tendon of peroneus brevis. Lower arrow: the tendon of peroneus longus.