The Roots Value of Each Branch Is Given in Brackets

The brachial plexus is the plexus of nerves formed by the anterior (ventral) rami of lower four
cervical and the first thoracic (i.e., C5, C6, C7, C8, and T1) spinal nerves with little contribution
from C4 to T2 spinal nerves
Branches of the Roots
The roots value of each branch is given in brackets.
1 Nerve to serratus anterior (long thoracic nerve) (C5–C7).
It only supplies serratus anterior muscle, one of the key muscles, for overhead abduction.
2 Nerve to rhomboids (dorsal scapular nerve) (C5).
This nerve supplies rhomboid minor and rhomboid major muscles, responsible for retraction of the
shoulder girdle gives a branch to levator scapulae.
3 Branches to longus colli and scaleni muscles (C5–C8) and branch to phrenic nerve (C4). The root of
phrenic nerve from C5 is small one, the main root is from C4. Phrenic nerve is the sole motor nerve
supply of thoracoabdominal diaphragm. In addition, it carries afferent fibres from mediastinal pleura,
fibrous pericardium and part of the parietal peritoneum.
Branches of the Trunks

These arise only from the upper trunk which gives two branches:
1 Suprascapular (C5, C6). This nerve supplies supraspinatus and infraspinatus muscles.
2 Nerve to subclavius (C5, C6). It supplies the small subclavius muscles. It may give a root for
phrenic nerve.
Branches of the Cords

Branches of lateral cord
1 Lateral pectoral (C5–C7). This nerve supplies both pectoralis major and pectoralis minor muscles.
2 Musculocutaneous (C5–C7). This is the nerve of muscles of front of arm, i.e. coracobrachialis both
the long and short heads of biceps brachii and the brachialis muscles.
3 Lateral root of median (C5–C7). It joins the medial root of median nerve. Median nerve is the
chief nerve of the muscles of front of forearm and of muscles of thenar eminence.
Branches of medial cord

1 Medial pectoral (C8, T1). It also supplies both the pectoralis minor and pectoralis major muscles.
2 Medial cutaneous nerve of arm (C8, T1) carries sensory impulses from a small area of medial side
of arm.
3 Medial cutaneous nerve of forearm (C8, T1) carries sensory impulses from large area of medial
side of the forearm.
4 Ulnar (C7, C8, T1). C7 fibres reach by a communicating branch from lateral root of median nerve.
This is the nerve of one and a half muscles of front of forearm and 15 intrinsic muscles of the palm.
5 Medial root of median nerve(C8, T1). It joins the lateral root and gets distributed with branches of
median nerve.
Branches of posterior cord

1 Upper subscapular (C5, C6). This nerve supplies large multipennate subscapularis muscles.
2.Medial subscapular/Thoracodorsal/Nerve to latissimus dorsi (C6–C8). Only supplies muscles of
its name. It is also called thoracodorsal nerve.
3 Lower subscapular (C5, C6). It helps upper subscapular nerve in supplying of the subscapularis
muscles. In addition, it supplies the teres major muscle.
4 Axillary (circumflex) (C5, C6). It is responsible for supplying one of the important muscles of the
shoulder, the deltoid. It also supplies small teres minor muscle.
5 Radial (C5–C8, T1). This is the thickest branch of brachial plexus. It supplies all the three heads of
triceps brachii muscle. Then it supplies 12 muscles on the back of forearm.
Lesions of the Brachial plexus: For understanding the effects of the lesions of the brachial plexus,
the student will find it helpful to know the spinal segments, which control the various movements of
the upper limb:
– Adduction of the shoulder is controlled by C5 segment.
– Abduction of the shoulder is controlled by C6 and C7 segments.
– Flexion of the elbow is controlled by C5 and C6 segments.
– Extension of the elbow is controlled by C6 and C7 segments.
– Flexion of the wrist and fingers is controlled by C8 and T1 segments.
The important lesions of the brachial plexus are as follows:

(a) Erb’s paralysis (upper plexus injury): It is caused by the excessive increase in the angle between
the head and shoulder, which may occur by fall from the back of horse and landing on shoulder or
traction of the arm during birth of a child (Fig. 4.12). This involves upper trunk (C5 and C6 roots) and
leads to a typical deformity of the limb called policeman’s tip hand/porter’s tip hand/waiter's tip
hand. In this deformity, the arm hangs by the side, adducted and medially rotated, and forearm is
extended and pronated (Fig. 4.13). The detailed account of clinical features of Erb’s paralysis is as
follows:
– Adduction of arm due to paralysis deltoid muscle.
– Medial rotation of arm due to paralysis supraspinatus, infraspinatus, and teres minor muscles.
– Extension of elbow, due to paralysis of biceps brachii.
– Pronation of forearm due to paralysis of biceps brachii.
– Loss of sensation (minimal) along the outer aspect of arm due to involvement of roots of C6 spinal
nerve
(b) Klumpke’s paralysis (lower plexus injury): It is caused by the hyper abduction of the arm, which
may occur when one falls on an outstretched hand or an arm is pulled into machinery or during
delivery (extended arm in a breech presentation (Fig. 4.14). The nerve roots involved in this injury are
C8 and T1 and sometimes C7. The clinical features of Klumpke’s paralysis are as follows:
– Claw hand, due to paralysis of the flexors of the wrist and fingers (C6, C7, and C8), and all intrinsic
muscles of the hand (C8 and T1).
– Loss of sensations along the medial border of the forearm and hand (T1).
– Horner’s syndrome, (characterized by partial ptosis, miosis, anhydrosis, and enophthalmos) due to
involvement of sympathetic fibres supplying head and neck, which leave the spinal cord through T1.
The important features of Erb’s and Klumpke’s paralysis are enumerated in Table 4.2.
• Surgical approach to axilla: The axilla is approached surgically through the skin of the floor of
axilla for the excision of axillary lymph nodes to treat the cancer of the breast. The structures at risk
during this procedure are
(a) intercostobrachial nerve,
(b) long thoracic nerve,
(c) thoraco-dorsal nerve, and
(d) thoraco-dorsal artery.
Effort should be made to safeguard the above structures.
Anterior Compartment of the arm
Posterior Compartment of the arm

Triceps Brachii
Carpal Tunnel syndrome

a. This syndrome consists of motor, sensory, vasomotor and trophic symptoms in the hand caused by
compression of the median nerve in the carpal tunnel. Examination reveals wasting of thenar eminence
(ape-like hand), hypoaesthesia to light touch on the palmar aspect of lateral 3½ digits. However, the skin
over the thenar eminence is not affected as the branch of median nerve supplying it arises in the forearm.
b. Froment’s sign/book holding test: The patient is unable to hold the book with thumbs and other fingers.
c. Paper holding test: The patient is unable to hold paper between thumb and fingers. Both these tests are
positive because of paralysis of thenar muscles.
d. Motor changes: Ape-/monkey-like thumb deformity (Fig. 9.40), loss of opposition of thumb. Index and
middle fingers lag behind while making the fist due to paralysis of 1st and 2nd lumbrical muscles (Fig.
9.43).
e. Sensory changes: Loss of sensations on lateral 3½ digits including the nail beds and distal phalanges on
dorsum of hand (Fig. 9.41).
f. Vasomotor changes: The skin areas with sensory loss is warmer due to arteriolar dilatation; it is also
drier due to absence of sweating due to loss of sympathetic supply.
g. Trophic changes: Long-standing cases of paralysis lead to dry and scaly skin. The nails crack easily
with atrophy of the pulp of fingers.
Flexor Retinaculum
Flexor retinaculum (Latin to hold back) is a strong fibrous
band which bridges the anterior concavity of the carpus
and converts it into a tunnel, the carpal tunnel (Fig. 9.15).
Attachments
Medially, to:
1 The pisiform bone, and
2 The hook of the hamate.
Laterally, to:
1 The tubercle of the scaphoid, and
2 The crest of the trapezium
Priximally, Pisiform to tubercle of the scaphoid. Distally, Hook of hamate to crest of trapezium.
The structures passing superficial to the flexor retinaculum are:
i. The palmar cutaneous branch of the median nerve
(Fig. 9.16).
ii. The tendon of the palmaris longus.
iii. The palmar cutaneous branch of the ulnar nerve.
iv. The ulnar vessels.
v. The ulnar nerve.
Flexor carpi ulnaris is partly inserted on retinaculum. The thenar and hypothenar muscles arise from the
retinaculum.
The structures passing deep to the flexor retinaculum are: (Contents of carpal tunnel)
i. The median nerve (Fig. 9.15).
ii. Four tendons of the flexor digitorum superficialis.
iii. Four tendons of the flexor digitorum profundus.
iv. The tendon of the flexor pollicis longus.
v. The ulnar bursa.
vi. The radial bursa.
vii. The tendon of the flexor carpi radialis lies between the retinaculum and its deep slip, in the groove on
the trapezium.
Frozen shoulder: This is a common occurrence. Pathologically, the two layers of the synovial membrane
become adherent to each other. Clinically, the patient (usually 40–60 years of age) complains of
progressively increasing pain in the shoulder, stiffness in the joint and restriction of all movements
particularly external rotation,abduction and medial rotation. As the contribution of the glenohumeral joint
is reduced, the patient shows altered scapulohumeral rhythm due to excessive use of scapular motion while
performing overhead flexion and abduction. The surrounding muscles show disuse atrophy.
The disease is self-limiting and the patient may recover spontaneously in about two years and much earlier
by physiotherapy.

The Roots Value of Each Branch Is Given in Brackets

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The brachial plexus is the plexus of nerves formed by the anterior (ventral) rami of lower four

Branches of the Trunks

Branches of the Cords

Branches of medial cord

Branches of posterior cord

The important lesions of the brachial plexus are as follows:

Posterior Compartment of the arm

Carpal Tunnel syndrome

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