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Examination of Lymphatic System
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organism (LGV, Chlamydia type L1, 2, 3). In LGV,
lesion is small, painless and commonly unnoticed in
primary genital stage. Secondary stage lesion develops
in 2 weeks. In males inguinal lymph nodes; in females
intrapelvic and pararectal nodes are involved. Eventually suppuration of inguinal nodes occurs leading
into discharging sinuses. Frei intradermal test becomes
positive in 6 weeks and remains positive for life time.
In tertiary stage, eye, joints, meninges may get involved
after many years. Repeated chronic inflammation,
lymphatic blockage, scarring can cause rectal stricture
and vulval elephantiasis (esthiomene) in females.
Soft Chancre/Soft Sore/Ducreyi’s Ulcer/
Chancroid/Bubo
This is a venereal disease which presents with
multiple irregular genital ulcers that appear 3 days
after infection with bacteria, Haemophillus ducreyi.
They are acute painful, tender, non-indurated ulcers.
Floor shows yellowish slough with purulent discharge.
Edge is oedematous and inflamed. Acute regional
lymphadenitis with suppuration occurs presenting as
tender, soft or firm swelling. Such soft fluctuant
inguinal swelling is termed as bubo.
Infectious Mononucleosis (Glandular Fever)
It is an acute self limiting disease caused by Epstein
Barr virus in young adults who presents with fever,
sore throat, rashes, tender, elastic, lymphadenopathy ,
splenomegaly, abnormal lymphocytes in the peripheral
smear, and subclinical hepatitis with altered liver
function tests. Initially there is neutropenia, later
leucocytosis develops. There are atypical mononuclear
cells which are T cell reactive lymphoblasts.
Lymphoma and lymphatic leukaemia are dif ferential
diagnoses. Blood picture may mimic lymphatic leukaemia. Heterotopic antibodies (Paul-Bunnel antibodies)
develop in the serum which agglutinates sheep red
cells. Paul-Bunnel test is diagnostic. Test becomes
positive during early phase of infection and disappears
in 2 months. So test is diagnostic of recurrent and
new infections. Inactivated serum of patient is diluted
to two times and mixed with equal quantity of 1%
suspension of sheep erythrocytes to see agglutination
of 100 or above.
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Toxoplasmosis
It is caused by Toxoplasma gondii, intracellular
protozoa, transmitted from mammals to humans who
eat raw or underdone meat, causes generalised
lymphadenopathy and fever in children. Congenital
infection may cause life threatening neonatal jaundice,
encephalomyelitis, hydrocephalus, microcephaly,
blindness and intracerebral calcification.
Cat Scratch Fever
It is a type of psittacosis (psittacos means parrot) caused
by Chlamydia psittaci. After cat scratch or droplet
infection, it presents with inflammatory features at
the site, fever, malaise, anorexia, regional lymph node
enlargement after 2 weeks which suppurates with sterile
pus inside that often bursts open. Skin test using human
lymph node pus as antigen is diagnostic. It mimics
chronic or tuberculous lymphadenitis. Pus, tissue
smears, spleen, lungs, brain show LCL bodies. Flu
like syndrome, fatal pneumonia, meningoencephalitis,
endocarditis, pericarditis are dangerous complications
carrying 20% mortality.
Syphilitic Adenitis
It occurs as generalised shotty, firm, discrete, nontender lymphadenopathy especially epitrochlear and
suboccipital lymph nodes. Often it is seen in primary
syphilis also. It is not seen in tertiary syphilis. For
detail please refer Chapter 2: Examination of an Ulcer.
Sarcoidosis
It is a differential diagnosis for lymph node mass. It
is basically a granulomatous condition of unknown
aetiology with bilateral hilar lymphadenopathy; along
with involvement of lungs, liver, spleen, lymph nodes,
lacrimal glands, parotid glands, CNS, associated with
hypercalciuria, and acute onset of erythema nodosum
in the skin. Fever and loss of weight are not common.
It shows non-caseating granuloma with epithelioid
cells, positive Kveim-Siltzbach skin test (80%); and
high levels of serum angiotensin converting enzyme
(SAGE). Investigations needed are CT chest; mediastinoscopy; nodal biopsy; slit-lamp examination of
eye. Often shows abnormal immunoglobulins in the
circulation. It is treated by corticosteroids with good
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SRB’s Clinical Surgery
response. It should be differentiated from other causes
of lymphadenopathy especially Hodgkin’ s lymphoma.
Secondaries in Lymph Nodes
Metastatic disease in regional lymph nodes occurs by
lymphatic spread usually be permeation upto first nodal
level and later by embolisation. Head and neck cancers
account for 80% cases in neck nodes. In axilla,
carcinoma breast is the common cause; others are skin
malignancies in upper limb, chest wall, etc. Carcinoma
in lower limb, perineum, penis, scrotum, genitalia
spreads to groin lymph nodes. These lymph nodes
are stony hard (Fig. 7.36), with smooth surface,
initially non-tender but soon become tender by tumour
necrosis, nerve infiltration, and fungation (Figs 7.36
to 7.38). They are initially mobile, but eventually
become fixed and nonmobile as it gets adherent to
muscle, and bone. Infiltration to regional major vessels
causes absence of pulsation (example carotid in
neck), nerve infiltration causes neurological deficits
(infiltration of hypoglossal nerve causes its palsy
leading to deviation of tongue towards same side (Fig.
7.37) and wasting of tongue muscle of that side/spinal
accessory nerve infiltration causes poor shrugging of
the shoulder); venous obstruction causes oedema of
distal part (groin secondaries can cause venous oedema
of lower limb). Few sarcomas (rhabdomyosarcoma,
Fig. 7.37: Advanced secondaries in neck with fungation and
hypoglossal nerve palsy showing deviation of tongue towards
the same side.
Fig. 7.36: Secondaries in cervical node. It is fixed
advanced disease. It is stony hard in consistency.
Fig. 7.38: Fungating secondaries in inguinal lymph nodes
on the right side. It is an advanced disease.
synovial sarcoma) can cause secondaries in lymph
nodes. Secondaries from malignant melanoma are
usually pigmented.
Chronic Lymphatic Leukaemia
It is a haematological disorder with generalised
lymphadenopathy , splenomegaly, bleeding tendencies
(bleeding gums), fever, anaemia, decreased weight.
Peripheral smear (lymphocytosis) and bone marrow
aspiration is diagnostic.
Lymphomas
They are progressive neoplastic condition of lymphoproliferative system arising from stem cells. They are
3rd most common malignancy in children comprising
Examination of Lymphatic System
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193
lymphoma—Type 1. B-cell neoplasms—subtype I—
of precursor B cell—Acute lymphoblastic leukaemia
(ALL), Lymphoblastic leukaemia (LBL); subtype II —
of peripheral B cell—all B cell related NHL.
T ype 2. T cell putative NK cell neoplasms— subtype
I—of precursor T cell—ALL, LBL T cell related;
subtype II—of peripheral T cell and NK cell includes
all T cell related NHL. T ype 3. Hodgkin’s lymphoma—
subtype I—predominant HL-nodular lymphocyte type;
subtype II—classical HL-nodular sclerosis, lympho-
cyte rich, mixed cellularity, lymphocyte depletion.
Hodgkin’s Lymphoma (HL-Thomas Hodgkin)
It is the commonest type of lymphoma having fleshy ,
A
pinkish gray, rubbery lymph nodes on gross; with
malignant lymphocytes, reticulum cells, histiocytes,
giant cells with two large mirror image nuclei [Reed-
Sternberg giant cells (RS cells are also observed
occasionally in other conditions like glandular fever)]
on microscopy . Predominant and classical HL are the
types. Rye’s classification includes lymphocytic
predominance; mixed cellularity; nodular sclerosis
(commonest); lymphocytic depletion. Features: It is
common in males; common in young and elderly
(bimodal); presents as painless enlargement of lymph
nodes which are smooth, firm (India rubber consis-
tency), non-tender. Neck is the commonest location
(80%); commonly seen in lower deep cervical and
posterior triangle nodes (Fig. 7.40). Axillary , media-
B
Figs 7.39A and B: Lymphoma in an old man and in a
child. Both could be Hodgkin’s lymphomas.
15% of paediatric cancers. It is often genetically predisposed. It is commonly associated with Sjogren’s
syndrome, Wiskott-Aldrich syndrome, ataxia telangiectasia, Epstein-Barr virus infection, celiac sprue,
H. pylori infection (MALT lymphoma), ionising
radiation (Figs 7.39A and B).
Types: Hodgkin’s lymphoma (HL); Non-Hodgkin’s
lymphoma (NHL). WHO modified REAL (Revised
European American Lymphoma) classification of
Fig. 7.40: Hodgkin’s lymphoma in an adolescent boy.
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SRB’s Clinical Surgery
stinal, inguinal, abdominal—are the other groups which
may be involved. Consecutive and symmetrical involvement; splenomegaly (45%) is common. Hepatomegaly , jaundice, constitutional symptoms (stage B)
like weight loss, fever, pruritus, anaemia, bone pain
are other features. Mediastinal involvement may cause
SVC obstruction. Bone involvement may present with
sternal tenderness, vertebral pain. Anaemia, pancytopenia is common. Ann Arbor clinical staging (Ann
Arbor is a place): Stage I: Confined to one group of
lymph nodes; Stage II: More than one group of lymph
nodes on one side of the diaphragm; Stage III: Nodes
on both sides of the diaphragm; Stage IV: Extra nodal
involvement like liver, bone marrow. ‘S’ is added to
stage if spleen is involved; ‘B’ is added for presence
and ‘A’ for absence of constitutional symptoms. ‘E’
is added for extranodal spread. Stage III (1) is nodes
above the renal vein and stage III (2) is below.
Differential diagnoses are tuberculous adenitis; NHL;
HIV; chronic lymphatic leukaemia; non-specific
adenitis; sarcoidosis; secondaries in lymph nodes.
Staging laparotomy which was earlier done is not
commonly advocated now. After opening abdomen,
splenectomy is done to remove the tumour bulk and
to avoid irradiation of splenic area which often causes
pulmonary fibrosis. Biopsies are taken from both lobes
of the liver (needle biopsy) and from para-aortic, celiac,
mesenteric, iliac nodes. In females ovaries are fixed
behind the uterus to prevent radiation oophoritis
(ovarian translocation).
Fig. 7.41: Non-Hodgkin’s lymphoma with fungation in
the axilla.
Burkitt’s lymphoma (Malignant lymphoma of Africa)
It is common in South Africa and New Guinea; common
in chidren; Epstein-Barr virus may be the cause; often
associated with infectious mononucleosis; common
in malaria endemic area. It is common in jaw either
upper or lower; neck nodes are commonly involved;
multifocal, rapidly growing, painless lesion. Other
group of lymph nodes also can be affected. Often
bilateral renal involvement (75%) is common. Ovaries
are commonly affected in females. Histology shows
primitive lymphoid cells with large clear histiocytes
(starry sky pattern). It can be endemic African type—
common in jaw; non endemic sporadic type—common
in abdomen; aggressive type—seen in HIV patients.
Non-Hodgkin’s Lymphoma (NHL)
It occurs in middle-aged and elderly. It is more
aggressive than HL. Lymph node involvement is
asymmetrical and non-contiguous. General condition
is poor. Inner Waldeyer, epitrochlear and peripheral
nodes are commonly involved. Hepatomegaly is
common. Spleen is not commonly involved. V ertebral
involvement and paraplegia can develop which
warrants radiotherapy for spine. Cachexia, secondary
infection and immunosuppression are more common.
Rappaport and working classifications are used. It can
be nodular or diffuse. It can be B cell or T cell type. It
can be precursor cell type or peripheral cell type. It can
be small, large, cleaved, uncleaved, etc. It can be low
grade, intermediate grade or high grade. Carcinoma or
sarcomas can mimic NHL often (Fig. 7.41).
Cutaneous T Cell Lymphoma
Cutaneous T cell lymphoma comprises mycosis fungoides, Sezzary syndrome, reticulum cell sarcoma of skin
and other skin lymphocytic dysplasias. Mycosis
fungoides is commonest among them. Cutaneous T
cell lymphoma can be indolent (commonly mycosis
fungoides); aggressive (Sezzary syndrome); provisional (granulomatous/panniculitis like T cell lymphoma).
Initial macular/patch/plaque phase slowly changes into
tumour phase with painful, pruritic erythroderma often
with visceral spread. Alopecia mucinosa and follicular
mucinosis are common in mycosis fungoides. Lymph
nodes may get involved. Tumour cells in peripheral
smear are also important in deciding therapy and
prognosis. Multiple skin biopsies/peripheral smear/
node biopsy/immunohistochemistry/pheo or geno-
Examination of Lymphatic System
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typing are important investigations. Prognosis depends
on extent of skin involvement (more than 10% body
surface area carries poor prognosis)/nodal spread/
blood spread. Sezzary syndrome is a type of cutaneous
T cell lymphoma with skin lesions with special Sezzary
cells having cribriform nucleus. It is often associated
with leukaemias. It is treated like any other cutaneous
T cell lymphoma.
Lymphoedema
It is accumulation of fluid/lymph in extracellular and
extravascular compartment, commonly in subcutaneous tissue. It is due to defective lymph drainage.
It is accumulation of increased protein rich interstitial
fluid.
Kinmonth classification
Primary: Less common; without any identifiable
cause. It is common in females; common in lower
limb and left side. It can be Lymphoedema congenita—
present at birth, < 2 years (Fig. 7.42), familial type
is called as Nonne-Milroy’s disease; Lymphoedema
praecox—present at puberty, between 2-35 years of
age; 80% of primary Lymphoedema belong to this
type; familial type is called as Letssier-Meige’s
syndrome; Lymphoedema tarda—Present in adult after
35 years of age, Lymphangiographically it can be
hypoplasia (70%); aplasia (15%); hyperplasia/varicose
lymphatics (15%).
Secondary: Most common; is due to a definitive
acquired cause. Causes are—trauma; inguinal/axillary
block dissections; filarial lymphoedema; tuberculosis,
syphilis, fungal infection, advanced fixed nodal
Fig. 7.42: Congenital lymphoedema right side in a
young girl.
195
malignancy in axilla or groin; radiotherapy; nonspecific recurrent bacterial infection of nodes; rare
causes like Rheumatoid arthritis, snake bite, insect
bite, DVT , chronic venous insufficiency . Wuchereria
bancrofti is the cause for filarial lymphoedema.
Recurrent lymphangitis causes obliteration of lymph
vessels → dermal lymphatic backflow → retrograde
obliteration (or die back of lymphatics) → oedema
initially pitting but later nonpitting → recurrent
cellulitis—thickening of skin → accumulation of
proteins, growth factor, glycosaminoglycons → activation of collagens and keratinocytes → protein rich
lymphoedematous tissue formation → deposition of
ground substance, subdermal fibrosis → dermal
thickening and dermal proliferation → fissuring →
cracks-ulceration-abscess formation → stout leg with
unbearable weight → elephantiasis. Rarely it may
cause protein losing diarrhoea, chylous ascites,
chylothorax, chyluria, lymphorrhoea. Recurrent
lymphadenitis occurs in the region which aggravates
the condition. Disease in the limb is confined to skin
and subcutaneous tissue, i.e. often, only superficial
lymphatics are involved by the disease, deep lymphatics are not. Superficial and deep lymphatics are
not communicating with each other (Unlike the veins
in the limb where superficial and deep veins are freely
communicating with each other). Sites of lymphoedema—(1) Lower limb—commonest. (2) Upper
limb. (3) Scrotum and penis (Ram’s horn penis).
(4) Breast-requires reduction mammoplasty . (5) Labia.
(6) Eyelid. (7) Localised lymphoedema. Clinical
features: Swelling in the foot, extending progressively
in the leg; Buffalo hump in the dorsum of the foot;
squaring of toes; skin over the dorsum of foot cannot
be pinched because of subcutaneous fibrosis—
Stemmer’s sign (Figs 7.46A and B); initially pitting
oedema which later becomes nonpitting (Figs 7.43A
and B and 7.44); eczema, fissuring, papillae formation,
ulceration, lymph ooze, loss of normal perimalleolar
shape→ùtree trunk pattern; elephantiasis (Figs 7.45A
and B); recurrent fever; malaise; headache; athlete’s
foot; joint pain; limb disability; social discomfort are
the features. Brunner’s grading of lymphoedema—
Latent—subclinical: No clinically apparent lymphoedema. Grade I: Pitting oedema which more or less
disappears on elevation of the limb— is due to excess
deposition of interstitial fluid. Grade II: Nonpitting
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A
B
Figs 7.43A and B: Early lymphoedema left side. It is
pitting in nature.
oedema develops which does not reduce on elevation.
Grade III: Oedema with irreversible skin changes like
fibrosis, papillae, fissuring. It may be mild lymph-
oedema - < 20% excess of limb volume; moderate
- 20-40% excess of limb volume; severe - > 40% excess
of limb volume.
Differential diagnoses: (1) Cardiac causes, hypoproteinaemias, malnutrition, nephrotic syndrome. (2)
Fig. 7.44: Late lymphoedema—non-pitting in nature.
Myxoedema. (3) Trauma. (4) Venous diseases like
DVT , etc. (5) Lipodystrophy and lipoidosis. (6) Arterial
diseases including A- V malformations. (7) Gigantism.
(8) Drug induced—steroids, oestrogens, nifedipine.
Complications: Skin thickening; abscess formation;
recurrent cellulitis; maggots’ formation; nonhealing
ulcers; septicaemia; lymphadenitis; lymphangiosarcoma (Stewart-T r eves syndr ome in post-mastectomy
limb).
Acute Lymphangitis
It is the bacterial infection of lymphatic vessels from
a focus in the draining area. Usually gram positive
staphylococci and streptococci are the causative
organisms. Clinically there will be fever, raised, thin,
painful, tender, visible red streaks of lymphatic vessels
which are obvious. Blanching on pressure is typical.
Tender palpable regional lymph node in axilla or groin
is common. It is common in upper and lower limbs.
Primary focus may be small in digits/interdigital space/
plantar aspect of foot/in the nails. Condition may lead
into cellulitis once tissue planes get infected. T oxaemia,
septicaemia may occur.
Chylous Ascites
It is collection of lymph in the peritoneal cavity. It
is due to obstruction of intestinal lymphatics and leak.
Examination of Lymphatic System
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A B
Figs 7.45A and B: Elephantiasis leg in a young male and middle aged female.
197
A
Figs 7.46A and B: Changes in foot in lymphoedema—Buffalo hump; squaring of toes;
B
non-pinchable skin over the dorsum (Stemmer’s sign).
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Causes: Congenital lymphatic abnormalities (in
children commonest); malignancy either nodal
secondaries or nodal primary causing obstruction
(commonest cause in adult); tuberculosis causing block
in lymph drainage and rupture and leak into the
peritoneal cavity; filarial lymphoedema causing
obstruction; post-surgical cause. Features: Ascites
often massive; severe malnutrition and protein
deficiency; features specific to the cause. Ascitic fluid
aspiration is chalky white in colour and it shows
chylomicrons. T riglyceride level more than 110 mg/
dl is diagnostic. It should be studied for fat globules,
proteins, AFB and malignant cells. Laparoscopy and
biopsy is necessary when lymphoma/secondaries are
suspected. CT scan and CT guided biopsy may be
needed. Lymphangiography is done especially in
congenital type to find out the site of leak. Medium
chain fatty acids, total parenteral nutrition, operative
ligation of leaking duct—are the treatment.
Chylothorax
It is accumulation of lymph in the pleural cavity. It
is common on right side because of long course of
thoracic duct towards right side. Causes: Injury due
to trauma/surgeries in neck or chest. Surgical trauma
is the commonest cause—may be oesophageal
surgeries, pneumonectomy , cervical sympathectomy,
neck dissections or aortic surgeries; tuberculosis;
lymphoma or secondaries in the mediastinum;
SRB’s Clinical Surgery
carcinoma lung or oesophagus. Features: Chest pain,
dyspnoea, pleural effusion; Protein loss and malnutrition; Pleural tap will show chalky white fluid rich
in chylomicrons and triglyceride level > 110 mg/dl
in pleural fluid is diagnostic; Chest X-ray, CT chest
are needed. Treatment: ICT placement; TPN; often
pleurodesis using bleomycin, talc, tetracycline or
pleural stripping is needed; Thoracic duct ligation is
beneficial in traumatic/iatrogenic cases either by open
or thoracoscopic method. It is done if leak persists
for more than a week.
Chyluria
It is passage of milky white chylous urine, which is
aggravated after fatty meal. It may be due to obstruction
in intestinal lymphatic vessels leading to high lymphatic
pressure causing diversion of lymph into renal
lymphatics or it may often be due to rupture of intestinal
lymphatics into renal pelvis or ureter leading into
lymphourinary fistula. Commonest cause is filarial.
Other causes are tumour, tuberculosis, malaria and
ascariasis infestation. Urinary infection, protein loss
is common. It mimics bacterial/tuberculous pyuria or
phosphaturia. Condition causes severe psychological
and nutritional problem. Urine study, culture, IVU,
lymphangiography, U/S abdomen is needed. Treatment
is low fat protein rich diet, antibiotics, DEC, plenty
of oral fluid intake, ligation of dilated lymphatics
through laparotomy or sclerosing the lymph vessels.
Examination of Peripheral Nervous System
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Examination of
Peripheral
199
8
History taking begins with:
Name:
Address:
Age:
Sex:
Occupation:
Occupational hazard like working in lead and arsenic
related industries can cause neurological problems.
Nervous System
History
History of Present Illness
History of Trauma
Trauma is the most common way by which a nerve is
injured. Incised/penetrating/deep wounds can cause
nerve injury . Sometimes fracture/dislocation can cause
adjacent nerve injury. Fracture of shaft of humerus can
injure radial nerve; supracondylar fracture of humerus
can cause median/ulnar or radial nerve palsy; fracture
of medial epicondyle of humerus can cause ulnar nerve
injury; axillary nerve may be injured in subcoracoid
shoulder dislocation or fracture neck of humerus;
sciatic nerve (commonly common peroneal part) is
injured in posterior dislocation of hip or supracondylar
or subtrochanteric fractures of the femur. Fracture neck
of femur may injure lateral popliteal nerve.
Traction injury can cause avulsion, neuropraxia
or other types of nerve injuries causing typical lesions.
Often seen in injuries to brachial plexus. Forcible
increase in angle between neck and shoulder can cause
injury to upper trunk of brachial plexus. During difficult
labour, foetal head is pulled out with traction against
shoulder causing typical upper trunk brachial plexus
injury . Upper trunk lesion is called as Erb-Duchenne
palsy. Injury to lower trunk of brachial plexus can
occur when the arm is forcibly hyperabducted causing
typical Klumpke’s palsy .
Entrapment neuropathy can cause typical nerve
lesions due to compression. T ardy ulnar palsy occurs
at medial epicondyle of humerus due to trapping of
ulnar nerve in the callus formed after fracture of medial
epicondyle and supracondylar fracture.
History of loss of sensation or loss of power: After
nerve injury sensory and motor functions of the area
of distribution by that particular nerve may be affected.
Partial injury of a cutaneous nerve may cause intense
burning pain along the distribution of nerve (causalgia)
immediately after injury or often even many months
after the healing.
Other related history: History of taking injections into
the arm or thigh may cause irritation of adjacent nerve
causing nerve injury. In the arm, axillary nerve may
be affected causing paralysis of deltoid. In the thigh
sciatic nerve may get injured by injections.
History suggestive of diabetes mellitus, alcohol
intake, and leprosy are also important in nerve lesions.
Earlier history of diphtheria is significant as it may
cause post-diphtheric paralysis.
Local Examination
Inspection
Attitude and Deformity
Erb’s palsy/Obstetrician’s paralysis: ‘Policeman
receiving the tip’ or ‘Porter’s tip hand’ occurs in injury
to upper trunk of brachial plexus (Figs 8.1A and B).
It occurs due to traction injury; often in obstructed
labour or during anaesthesia. Here junction of C5 and
C6 is affected (Erb’ s point). Nerve to subclavius, suprascapular nerve, and nerve to serratus anterior, dorsal
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SRB’s Clinical Surgery
claw hand; cutaneous anaesthesia and analgesia along
the medial border of the forearm and hand; Horner’s
syndrome causing ptosis, miosis, anhydrosis, enophthalmos and loss of ciliospinal reflux which is due
to injury to sympathetic innervations of head and neck
that leave spinal cord through T
in the anaesthetised skin like warmness, dryness,
absence of sweating and; trophic changes (Fig. 8.2).
; vasomotor changes
1
Fig. 8.2: Anatomy of brachial plexus.
A
Figs 8.1A and B: Erb’s point and Erb’s palsy. Note
the typical ‘policeman receiving tip’ sign.
scapular nerve to rhomboideus emerge close to
this point. Muscles paralysed are—biceps, deltoid,
brachialis, brachioradialis; partly supraspinatus,
infraspinatus and supinator. Here arms hang by the
side of the body adducted and medially rotated; forearm
extended and pronated. There is loss of abduction and
lateral rotation of the shoulder; loss of flexion and
supination of forearm; absence of biceps and supinator
jerks; loss of sensation over the skin over lower part
of the deltoid.
Klumpke’s paralysis: Here injury is to lower trunk
of brachial plexus. It is due to undue abduction of
the arm after fall from a height while clutching
something with hands. Here C8 and T1 nerve roots
are involved. Muscles paralysed are intrinsic muscles
of hand, ulnar flexors of wrist and fingers. It causes
Wrist drop is seen in radial nerve palsy where there
is paralysis of extensor muscles; winging of scapula
with prominent vertebral border of scapula is seen
in paralysis of serratus anterior due to injury to long
thoracic nerve of Bell; ‘ape thumb’ deformity is due
to paralysis of opponens pollicis in median nerve palsy;
‘pointing index’ is due to paralysis of lateral half of
the flexor digitorum profundus supplied by median
nerve. Paralysis of dorsiflexors and evertors due to
lateral popliteal nerve injury causes foot drop (Figs
8.3A and B).
Wasting of muscles: Atrophy of particular muscles
supplied by the nerve will be obvious. It is compared
to opposite side in unilateral lesion. Wasting is often
observed in interossei, thenar and hypothenar muscles,
forearm, arm muscles, calf and thigh muscles. Muscle
girth should be measured at specific point and
compared to opposite side (Fig. 8.4).
Inspection of the Skin
Skin is inspected for dryness, glossiness, loss of skin
folds and subcutaneous fat—features of paralysis.
Vasomotor changes, cyanosis, excess sweat, brittle
nails are observed in partial injury of the nerve.
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