Nerve Injury Treatment & Surgery | Hand Surgery Associates

Nerve Injuries in the Upper Limb and Hand

Nerve injuries in the upper limb and hand can result in life-changing loss of function, discomfort, and long-term complications if not properly treated.

Commonly Injured Nerves

Brachial plexus – A network of nerves that control muscle movements and sensation in the entire shoulder, arm, and hand. Injuries can result in partial or complete paralysis of the entire arm and hand.
Axillary nerve – Controls the deltoid muscle. Injury leads to weakness in lifting the arm.
Median nerve – controls finger and wrist flexion and sensation in the thumb, index, middle and ring fingers. Injury causes pain and numbness in the hand and difficulty flexing the fingers and thumb
Ulnar nerve – controls the small muscles in the hand, and sensation in the ring and little fingers. Injury causes pain and numbness in the ring and little fingers and weakness when pinching or gripping things.
Radial nerve – controls wrist and finger extension, and sensation on the back of the hand. Injury caused inability to extend the wrist and fingers, and pain or numbness at the back of the hand.
Digital nerves – control sensation in the fingers. Injury causes numbness and pain in the finger.

Causes of Nerve Injury

Nerves in the upper limb can be damaged by:

Sudden, excessive stretching or pulling of the arm
Lacerations or deep cuts from sharp objects
Crushing injuries, often from machinery or road accidents
Severe burns or electrical injuries (very rare)

Injuries are frequently seen in:

Motor vehicle accidents
Workplace injuries, especially involving tools or heavy equipment
Domestic accidents, such as cuts with knives or glass
Sports injuries, particularly in contact or high-speed sports

Symptoms of Hand & Upper Limb Nerve Injury

Common Symptoms of Nerve Injury:

Numbness or reduced sensation in the fingers, hand, or forearm
Sharp, shooting or radiating pain
Abnormal sensations such as burning or freezing cold feeling, tingling or “ants crawling” sensation, crushing or squeezing discomfort, and sudden electric shock-like pain
Muscle weakness or paralysis with difficulty moving the arm or fingers
Difficulty with fine motor control, such as gripping, pinching or writing
Abnormal finger or hand posture, due to imbalance in muscle activity
Wasting of muscles causing the hand and upper limb to look smaller

The specific areas of numbness and weakness of the hand, wrist, forearm, or elbow will depend on which nerve has been damaged.

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Brachial Plexus

The brachial plexus is a complex network formed by the C5, C6, C7, C8, and T1 spinal nerves, located in the neck and shoulder region. These nerves pass below the collarbone before extending into the arm, forearm, and hand.

Injuries to the brachial plexus may result in:

Partial or complete paralysis of the upper limb
Loss of sensation in the shoulder, arm, and hand
Weakness in shoulder, elbow, wrist, and hand movements

Brachial Plexus

Injuries to the brachial plexus may result in:

Partial or complete paralysis of the upper limb
Loss of sensation in the shoulder, arm, and hand
Weakness in shoulder, elbow, wrist, and hand movements

Axillary Nerve

The axillary nerve controls the deltoid muscle, enabling you to lift your arm overhead. It can be injured during:

Shoulder dislocations
Upper humerus fractures

Damage may result in:

Inability to raise the arm fully
Muscle wasting, giving the shoulder a flattened appearance

Axillary Nerve

The axillary nerve controls the deltoid muscle, enabling you to lift your arm overhead. It can be injured during:

Shoulder dislocations
Upper humerus fractures

Damage may result in:

Inability to raise the arm fully
Muscle wasting, giving the shoulder a flattened appearance

Median Nerve

The median nerve runs along the front of the elbow, down the centre of the forearm, and into the palm. It controls:

Most of the finger and wrist flexor muscles
Fine movements of the thumb
Sensation in the palm, thumb, index, middle, and part of the ring finger

Injuries of the median nerve may cause:

Difficulty gripping and doing fine work with the hand
Numbness in much of the palm and fingers

Median Nerve

The median nerve runs along the front of the elbow, down the centre of the forearm, and into the palm. It controls:

Most of the finger and wrist flexor muscles
Fine movements of the thumb
Sensation in the palm, thumb, index, middle, and part of the ring finger

Injuries of the median nerve may cause:

Difficulty gripping and doing fine work with the hand
Numbness in much of the palm and fingers

Ulnar Nerve

The ulnar nerve travels behind the elbow on the inner side, down the forearm, and into the hand. It controls:

The small muscles in the hand for fine finger movement
Flexion of the wrist and little finger
Sensation to the little finger and part of the palm

Ulnar nerve injury can cause:

Numbness in the little finger and part of the hand
Weak grip and pinch, clumsiness
“Claw hand” deformity with curling of the little and ring fingers

Ulnar Nerve

The ulnar nerve travels behind the elbow on the inner side, down the forearm, and into the hand. It controls:

The small muscles in the hand for fine finger movement
Flexion of the wrist and little finger
Sensation to the little finger and part of the palm

Ulnar nerve injury can cause:

Numbness in the little finger and part of the hand
Weak grip and pinch, clumsiness
“Claw hand” deformity with curling of the little and ring fingers

Radial Nerve

The radial nerve travels behind the arm and forearm and is responsible for:

Extending the wrist, fingers, and thumb
Providing sensation to the back of the hand and thumb

Common causes of injury include:

Humerus fractures
Compression from prolonged pressure (e.g. “Saturday night palsy”)

Damage to this nerve may lead to:

“Dropped wrist” or “dropped fingers” due to inability to extend them
Numbness and pain on the back of the hand, particularly near the thumb

Radial Nerve

The radial nerve travels behind the arm and forearm and is responsible for:

Extending the wrist, fingers, and thumb
Providing sensation to the back of the hand and thumb

Common causes of injury include:

Humerus fractures
Compression from prolonged pressure (e.g. “Saturday night palsy”)

Damage to this nerve may lead to:

“Dropped wrist” or “dropped fingers” due to inability to extend them
Numbness and pain on the back of the hand, particularly near the thumb

Digital Nerves

These fine nerves run through the palm to the fingertips and supply sensation to each finger.

They are often injured in:

Cuts or lacerations to the fingers or palm. Even small cuts may injure these nerves.

Injury can result in:

Loss of sensation to part of the fingertip
Severe pain or hypersensitivity
Difficulty using the finger, particularly in delicate tasks

Digital Nerves

These fine nerves run through the palm to the fingertips and supply sensation to each finger.

They are often injured in:

Cuts or lacerations to the fingers or palm. Even small cuts may injure these nerves.

Injury can result in:

Loss of sensation to part of the fingertip
Severe pain or hypersensitivity
Difficulty using the finger, particularly in delicate tasks

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How is the Diagnosis Made?

Diagnosing nerve injuries requires a detailed description of the injury and symptoms, followed by a thorough clinical examination by a surgeon who specialises in peripheral nerve conditions.

The examination involves systematic testing of muscle strength and sensation in the hand and upper limb. These results are carefully compared with those on the uninjured side.

What Tests Are Needed?

In certain cases, additional tests may be necessary to assess the severity of the injury and guide treatment. These may include:

Nerve conduction and EMG studies
Imaging studies such as X-ray, ultrasound, or MRI

Nerve Conduction

Imaging Studies

Nerve Conduction and EMG Studies

You may be referred to a neurologist for nerve conduction or electromyography (EMG) studies. These tests are crucial for evaluating the severity of nerve injuries and determining whether the nerve will recover without surgery.

Electrodes are placed on the hand and arm to deliver electrical impulses. By measuring the speed and strength of these signals, doctors can assess the functional integrity of the nerves. In some cases, fine needles are inserted into weakened or paralysed muscles to detect whether nerve control is completely lost or showing early signs of recovery.

Imaging Studies

If a fracture is suspected, an X-ray will be performed to determine whether bone fragments are stretching or compressing nearby nerves.

In instances of nerve injury without visible wounds, imaging techniques such as ultrasound or MRI are used to see the nerves. These scans can reveal whether a nerve is compressed, stretched, or torn.

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What is the Treatment for Nerve Injury?

The treatment of nerve injuries depends on the type and severity of the damage. In some cases, such as mild stretching or blunt trauma, nerves can heal on their own.

However, more serious injuries particularly those involving cut nerves or prolonged compression—often require surgery to restore function.

What Can Be Done to Repair the Nerves?

The goal of nerve surgery is to allow effective nerve regeneration. This allows the damaged nerve fibres to reconnect with the muscles or skin they previously supplied, thereby restoring lost movement or sensation.

Direct Microsurgical Repair

For clean cutting injuries, the severed ends of the nerve are carefully stitched together under a microscope using ultra-fine sutures.

Nerve Graft

When a segment of a nerve is severely damaged (commonly seen in crushing injuries), a nerve graft is used to bridge the gap. A less vital nerve from another part of the body (often from the inner arm or side of the foot) is harvested and used to replace the damaged portion. This may cause minor sensory loss but the overall gain in function typically outweighs this drawback.

For smaller defects, a piece of commercially prepared nerve from cadavers is used. This avoids any sensory loss and additional scars.

Direct Microsurgical Repair

For clean cutting injuries, the severed ends of the nerve are carefully stitched together under a microscope using ultra-fine sutures.

Nerve Graft

For smaller defects, a piece of commercially prepared nerve from cadavers is used. This avoids any sensory loss and additional scars.

Nerve Transfer

When nerve damage is irreparable, nerve transfer may be performed. Here, a less essential but healthy nerve is redirected to a more important muscle that has lost its original nerve. This is like rewiring the muscles.

It is particularly useful in brachial plexus injuries.

Neurolysis

When nerves are trapped in dense scar tissue, they may fail to recover even if the nerve itself is not severely damaged.

Neurolysis is a surgical procedure used to free these nerves from the surrounding scar tissue. By relieving the compression, the nerves are given a better chance to recover.

Nerve Transfer

It is particularly useful in brachial plexus injuries.

Neurolysis

When nerves are trapped in dense scar tissue, they may fail to recover even if the nerve itself is not severely damaged.

Neurolysis is a surgical procedure used to free these nerves from the surrounding scar tissue. By relieving the compression, the nerves are given a better chance to recover.

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What Kind of Recovery Can I Expect After Nerve Surgery?

Nerve recovery is a slow but progressive process. On average, damaged nerves regenerate at a rate of approximately 1 millimetre per day, starting around two weeks after surgery. To estimate your recovery timeline, measure the distance from the site of the nerve injury to the area the nerve supplies (muscle or skin). As a general guide, it takes:

1 month to grow approximately 2.5cm (1 inch)
1 year to grow 30cm (1 foot)

You will only start to recover function once the nerve has recovered to the skin or muscle. This may take months or even years for maximum recovery.

Is Full Recovery Possible?

If a nerve is severely damaged and requires surgical repair, full recovery is unlikely, but meaningful improvement in function is common. Outcomes vary significantly based on the injury type, patient age, and time to treatment.

General recovery expectations after nerve surgery are:

20% achieve near-normal function
50% experience reasonable function, but with persistent weakness or numbness
30% have poor or no recovery

While these figures may seem discouraging, it’s important to understand that doing nothing eliminates the chance of any recovery. Untreated nerve injuries can also result in chronic forearm pain, elbow muscle pain, or even debilitating nerve-related syndromes.

Results are better

in younger people, especially those below 20 years old
in cutting injuries that are repaired properly under a microscope
the earlier the nerve is repaired
with proper nerve injury rehabilitation therapy after the repair

Results are better

in younger people, especially those below 20 years old
in cutting injuries that are repaired properly under a microscope
the earlier the nerve is repaired
with proper nerve injury rehabilitation therapy after the repair

If you think you may have a nerve injury, it is important to see a doctor who specialises in managing these injuries as soon as possible to avoid delaying treatment.

At Hand Surgery Associates we have more than 80 years of combined experience in managing all kinds of nerve injuries of the upper limb.

Our specialists are trained at renowned centres of excellence for nerve surgery in Singapore and excel in all types of nerve surgery. We also have therapists who specialise in post-nerve injury rehabilitation.