ELBOW

PROBLEMS:
PARALYSIS
UPPER LIMB ORTHOTICS
PARALYSIS

• Lack of motor power at the elbow prevents the patient from reaching
effectively throughout the workspace, even though complete passive
motion of the joints may be possible
• Knowledge of myopathy, partial or central neuropathy or injury
indicates the external forces required to compensate for motor loss.
• Additional problems such as anesthesia, bilateral disability, trunk
disturbances and prognosis for recovery also affect orthotic
management.

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FLACCID
PARALYSIS OF
ELBOW
EXTENSORS
FLACCID PARALYSIS OF ELBOW EXTENSORS

• Inability to straighten the elbow forcefully may result from damage to

the radial nerve or from specific lesions of the brachial plexus or spinal
cord

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BRACHIAL PLEXUS

The brachial plexus is a vast

network of nerves originating from
the anterior rami of C5 to T1, which
extends through the axilla into the
shoulder, arm, and hand, providing
afferent, or sensory, nerve fibers
from the skin, as well as efferent, or
motor, nerve fibers to the muscles.
The brachial plexus is divided into
five roots, three trunks, six
divisions, three cords, and five
terminal branches.

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BRACHIAL PLEXUS; ROOTS

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BRACHIAL PLEXUS; TRUNKS

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BRACHIAL PLEXUS; CORDS

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BRACHIAL PLEXUS; TERMINAL BRANCHES

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RADIAL NERVE PALSY

• Damage to the radial nerve at the level of the proximal humerus, results
from the humerus fracture or compression by a poorly fitted crutch
which compress the axilla.
• Radial nerve innervates the triceps as well as wrist and finger extensors.
• Paralysis of the triceps also weakens shoulder stability since it
participates in stabilizing the joint.

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RADIAL NERVE PALSY

Functional deficits due to radial nerve palsy:

• With the shoulder in neutral position, the patient can allow gravity to
extend the elbow.
• Patient with radial nerve palsy cannot
 extend his elbow powerfully enough to assist transfers from the wheel chair
 depress the arm strongly enough to stabilize objects on table
 reach forward effectively when the shoulder is flexed or abducted.

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RADIAL NERVE
SUPPLY
Radial nerve innervation:
Brachioradialis
Extensors of the wrist and fingers
Supinators
Triceps

Mnemonic: BEST

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LESIONS THROUGH THE MIDDLE TRUNK OF BRACHIAL PLEXUS

• The middle trunk, C7, gives rise to most fibers of radial nerve.
• Consequently, compression, transaction, or avulsion of this trunk will abolish active
extension of elbow.

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LESIONS THROUGH THE 7TH CERVICAL CORD

• In addition to extensive paralysis of hand and wrist, the C6 quadripleagic has

minimal activity of triceps, pectoralis major, latissmus dorsi and serratus anterior.
• Weakened elbow extensors affect transfers and bilateral elbow and shoulder
weakness interferes with effective wheelchair propulsion.

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TRICEPS

Origins Long head - infraglenoid tubercle of the

scapula
Medial head - posterior surface of the
humerus (inferior to radial groove)
Lateral head - posterior surface of the
humerus (superior to radial groove)
Insertion Olecranon of ulna and fascia of forearm
Action Elbow joint: extension of the forearm 
Shoulder joint: extension and adduction
of the arm (long head)
Innervation Radial nerve (C6-C8)

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PECTORALIS MAJOR

Origin Clavicular part: anterior surface of

medial half of clavicle
Sternocostal part: anterior surface of
sternum, Costal cartilages of ribs 1-6

Insertion Crest of greater tubercle of humerus

Action Shoulder joint: Arm adduction, Arm

internal rotation, Arm flexion (clavicular
head), arm extension (sternocostal
head);
Scapulothoracic joint: Draws scapula
anteroinferiorly
Innervation Lateral and medial pectoral nerves (C5-
T1)

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LATISSIMUS DORSI MUSCLE

Origin Vertebral part: Spinous processes of

vertebrae T7-T12, Thoracolumbar
fascia
Iliac part: Posterior third of crest of
ilium
Costal part: Ribs 9-12
Scapular part: Inferior angle of
scapula
Insertion Intertubercular sulcus of the humerus

Innervation Thoracodorsal nerve (C6-C8)

Functions Shoulder joint: Arm internal rotation,
Arm adduction, Arm extension;
Assists in respiration
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SERRATUS ANTERIOR

Origin Upper eight ribs

Insertion Medial border and inferior angle of

scapula
Innervation Long thoracic nerve (C5- C7)

Function Draws scapula anterolaterally,

Rotates scapula

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ORTHOTIC MANAGMENT

In isolated paralysis of non-dominant side:

• The patient with isolated paralysis of the elbow extensors may refuse
any orthotic device, particularly if problem is confined to non-dominant
hand.
• He will let gravity straighten his elbow

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ORTHOTIC MANAGMENT

Frequently, extensor paralysis is

associated with wrist and hand
extension and shoulder stabilization
problems.
Mechanical assistance is required in
either, unilateral and bilateral.

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FLACCID PARALYSIS
OF ELBOW FLEXORS
FLACCID PARALYSIS OF ELBOW FLEXORS

Loss of active elbow flexion is much more disabling.

Functional deficits;
• Unilateral prevents bimanual lifting
• Bilateral flexor paralysis is severely handicapping: unless the patient has some
means of moving the forearm and hand against gravity.
• He will not be able to feed, groom or dress himself unaided.

Damage to the flexors themselves, as seen in muscular dystrophy, or to the

musculocutaneous nerve, the brachial plexus or the spinal cord may weaken or
abolish elbow flexion.
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MUSCULOCUTANEOUS NEUROPATHY

This nerve supplies the biceps and brachialis, which are the most powerful
elbow flexors. Consequently, compression or severance interferes
considerably with active elbow extension.

The patient’s only remaining resource is radially innervated

brachioradialis.
To use brachioradialis effectively, the patient must put on stretch by
pronating the forearm when flexing the elbow.

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MUSCULOCUTANEOUS NEUROPATHY

This nerve supplies the biceps and brachialis, which are the most powerful
elbow flexors. Consequently, compression or severance interferes
considerably with active elbow flexion.
The patient’s only remaining resource is radially innervated
brachioradialis.
To use brachioradialis effectively, the patient must put on stretch by
pronating the forearm when flexing the elbow.
Pronator teres, wrist flexors and extrinsic finger flexors, also exert slight
flexion force on the elbow.
Forceful shoulder and trunk motion can bring the hand towards the body.
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MUSCULOCUTANEOUS NEUROPATHY

Musclocutaneous lesion prevents position of supination, as the biceps is

also a major supinator of the forearm.
• Although the radially innervated supinator can perform almost half of
the supinator work when the elbow is extended.
• Radially innervated supinator muscles functional capacity is less than
one-third that of the biceps, when the elbow is flexed.
• Weak supination, prevents one from performing powerful twisting
motion, as with a screw driver.

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MUSCULOCUTANEOUS NEUROPATHY

Local neuropathy creates imbalance between flexors and extensors, and

between forearm pronators and supinators. If the arm is not mobilized, the
patient is vulnerable to contracture, which adds to the functional deficit.
Fixed pronation is likely, not only because the pronator teres, and
quadratus are unaffected, but also because pronation favors the one
remaining elbow flexor, brachioradialis.

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MUSCULOCUTANEOUS NEUROPATHY

Biceps paralysis also affects the shoulder.

• Normally, the long tendons of biceps and that of coracobrachialis are
innervated by musculocutaneous nerve.
• These muscles act as ligamentous bands over the humeral head,
depressing it against the glenoid fossa, thus when an individual flexes
the shoulder, the humerus and scapula can move smoothly.
• Paralysis and subsequent arm atrophy may allow shoulder, subluxation,
compromising arm movements even more.

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MUSCULOCUTANEOUS NEUROPATHY

Myopathic patients display a similar pathomechanical picture. These

people presents bilateral paralysis and generally are wheelchair bound, by
the time their elbows are severely weakened. By spending most of the day
sitting with the forearms on the arm rests of the wheelchair, they tend to
form elbow flexion contarctures, whuch limit markedly effectiveness of
any mechanical assists.

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BICEPS

Origin Short head - Apex of the Coracoid

process of the scapula
Long head - Supraglenoid tubercle
of the scapula

Insertion Radial tuberosity of the radius

Deep fascia of forearm

Innervation Musculocutaneous nerve (C5- C6)

Function Flexion and supination of the
forearm at the elbow joint, weak
flexor of the arm at the
glenohumeral joint
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BRACHIALIS MUSCLE

Origin Distal half of anterior surface of

humerus

Insertion Coronoid process of the ulna;

Tuberosity of ulna 
Innervation Musculocutaneous nerve (C5,C6);
Radial nerve (C7)
Functions Strong flexion of forearm at the
elbow joint

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BRACHIORADIALIS MUSCLE

Origin Lateral supracondylar ridge of

humerus, lateral intermuscular
septum of arm
Insertion (Proximal to) styloid process of
radius
Action Elbow joint: Forearm flexion
(when semi pronated)
Innervation Radial nerve (C5-C6) 

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PRONATOR TERES MUSCLE

Origin Humeral head: medial

supracondylar ridge of humerus
Ulnar head: Coronoid process of
ulna
Insertion Lateral surface of radius (distal to
supinator)
Action Pronation of forearm at the
proximal radioulnar joint, flexion
of the forearm at the elbow joint
Innervation Median nerve (C6, C7)

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CORACOBRACHIALIS MUSCLE

Origin Coracoid process of the scapula

Insertion Anteromedial surface of the
humerual shaft
Action Adduction and flexion of the arm
at the shoulder joint
Innervation Musculocutaneous nerve (C5- C7)

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LESIONS THROUGH THE UPPER TRUNK OF BRACHIAL PLEXUS

• The most common site of brachial plexus injury involves the spinal roots
C5 and C6.
• These roots can be stretched by inferiorly directed force on the shoulder.
• Consequently, the patient cannot flex the elbow actively because all
flexors are denervated.
• Neither can he supinate the forearm, for the supinator, as well as the
biceps are paralyzed.
• Involvement of extensor carpi radialis weakens wrist extension and
thereby wrist-finger tenodesis.
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LESIONS THROUGH THE UPPER TRUNK OF BRACHIAL PLEXUS

Shoulder weakness compounds the disability. The upper trunk supplies the
deltoid and supraspinatus; thus the patient with severance or compression
of the upper trunk cannot flex the shoulder powerfully, nor can he rotate
the joint externally, for the supraspinatus and teres minor also depend on
this trunk.

The combination of paralysis accounts for the characteristic limb posture:

The arm is limp at the side, internally rotated and pronated.

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EXTENSOR CARPI RADIALIS

Origin Lateral supracondylar ridge of

humerus, lateral intermuscular
septum of arm
Insertion Posterior aspect of base of
metacarpal bone 2
Actions Wrist joints: Hand extension, hand
abduction (radial deviation)
Innervation Radial nerve (C5-C8)

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DELTOID MUSCLE

Origins Lateral 1/3 of Clavicle (clavicular

part), Acromion (acromial
part), Spine of scapula (spinal part)

Insertion Deltoid tuberosity of humerus

Innervation Axillary nerve (C5, C6)
Function Clavicular part: flexion and
internal rotation of the arm,
Acromial part: abduction of the
arm beyond the initial 15°
Spinal part: extension and external
rotation of the arm.

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SUPRASPINATUS MUSCLE

Origin Supraspinous fossa of scapula

Insertion Greater tubercle of humerus
Action Shoulder joint: abduction of arm,
stabilization of the humeral head in
the glenoid cavity
Innervation Suprascapular nerve (C5, C6)

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INFRASPINATUS MUSCLE

Origin Infraspinous fossa of scapula

Insertion Greater tubercle of humerus
Action Shoulder joint: Arm external
rotation; 
Stabilizes humeral head in glenoid
cavity
Innervation Suprascapular nerve (C5, C6)

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TERES MINOR MUSCLE

Origin Lateral border of scapula

Insertion Greater tubercle of humerus 
Action Shoulder joint: Arm external
rotation, arm adduction; 
Stabilizes humeral head in glenoid
cavity 

Innervation Axillary nerve (C5, C6)

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LESION THROUGH 6TH CERVICAL CORD SEGMENT

• Ordinarily, the sixth segment innervates most of the elbow musculature.

• Transection at this level results in total paralysis of the triceps, and the
partial weakness of biceps and partial weakness of biceps, brachialis and
brachioradialis.

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ELBOW PROBLEMS

• The C5 quadriplegic cannot move his forearm against the resistance of

gravity.
• The patient with spinal neuropathy, like the individual with muscular
dystrophy is apt to form elbow flexion contractures, if the elbow remains
flexed on the wheelchair armrests.
• Deltoid and shoulder rotator cuff weakness diminishes the vigour with
which the quadriplegic can place and stabilize his shoulders.

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ORTHOTIC MANAGMENT

Orthosis for flexor paralysis, consist

of an elbow joint, to lock the elbow
in the flexed position, and in some
cases to assist the elbow flexion.

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ORTHOTIC MANAGMENT

When flexor weakness is a pert of larger

problem, as in case with the lesion
through the upper trunk of brachial
plexus, the patient will be more receptive
to the mechanical assistance, then he
would be with a musculocutaneous
neuropathy.

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ORTHOTIC MANAGMENT

The spinal injury i.e. C5 quadriplegic requires aid

to flex and extend the elbows as well as
prehension assistance so that he can use his
function in a useful workspace.
If, however, the forearm rests on the lapboard or
similar surface which eliminates the force of
gravity, the patient can transport the hands by
using shoulder and trunk motions to augment the
residual elbow flexor force.

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ORTHOTIC MANAGMENT

Early motor assistance will help to avoid elbow

flexion contracture.

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