The Brachial plexus

The Brachial plexus

 The Brachial plexus
1. The brachial plexus is formed
by the union of the anterior
Fig 6.29 p 775
rami of C5-C8 & T1 (the roots
of the BP).
2. The roots pass laterally
between the anterior and
middle scalene muscles with
the subclavian artery.
3. Sympathetic fibers from the
middle and inferior cervical
ganglia join the roots as they
pass between the scalenes.
Fig 6.28 p 774

In the supraclavicular area the roots unite to form trunks:

1. Superior trunk – C5& C6
2. Middle trunk – C7 continues
3. Inferior trunk – C8 & T1
Fig 6.28 p 774

• As the trunks pass lateral to the 1st rib each trunk splits into anterior
and posterior divisions as they pass beneath the clavicle and enter
the cervicoaxillary canal:
– Anterior divisions innervate the muscles of the anterior compartment in
the arm and forearm.
– Posterior divisions innervate muscles of the posterior compartment of
the arm and forearm
• Fig 2.08 p 21 Grant’s Dissector 13th Ed., Patrick
Tank

• Divisions form cords in the area superior to the pectoral minor:

– Superior & middle anterior divisions unite the from the lateral cord
– Inferior division of the inferior trunk forms the medial cord
– Posterior divisions unite to form the posterior cord.
Fig 6.28 p 774

• To simplify understanding and remembering the BP in

can be divided into supraclavicular & infraclavicular
segments by the clavicle
 Supraclavicular branches
There are four, they arise from roots, a trunk and a division*
Root branches
• Dorasl scapular nerve:pierces middle scalene and passes
inferiorly to the rhomboids
• Long thoracic nerve: from C5,6,7 roots passes inferiorly on to the
surface of the Serratus anterior
Trunk branch
• Nerve to subclavius: passes directly to the inferior surface of
clavicle gives branch to sternoclavicular joint
Division branch
• Suprascapular nerve: runs parallel to the suprascapular artery to
the suprascapular notch (beneath the suprascapular ligament)
supplies the supraspinatus m. around the greater scapular notch to
the infraspinatus m.
*Small braches arise from all roots to supply the scalene and longus
coli muscles.
• C5 gives a root to the Phrenic nerve (C3-5)
 Supraclavicular branches

Fig 6.29 p 775

Fig 6.28 p 774

• Infraclavicular Branches - -arise from the cords and can be

divided into branches and little branches (very unscientific).
 Infraclavicular Branches
Cords BIG branches little
Musculocutaneous Lateral pectoral
Lateral ☻ Lateral
Posterior Axillary Upper Subscapular
Radial Lower Subscapular
Thoracodorsal
Ulnar Medial pectoral
Medial ☻ Medial Medial brachial cutaneous
Medial ante brachial cutaneous

☻ The lateral & medial braches join to form the

Median nerve
Fig 6.31 p 785

Cords Big Branches Little Branches

Lateral Musculocutaneous Lateral pectoral
Lateral branch
 Fig 2.09 p 21, Grant’s Dissector
13th Ed., Patrick Tank

Cords Big Branches Little branches

Posterior Axillary Upper subscapular
Radial Lower subscapular
Thoracodorsal
 Fig. 6.31, p 785

Cords Big branches Little branches

Medial Ulnar Medial pectoral
Medial branch Medial brachial cutaneous
Medial antebrachial cutaneous
• Figure 206.1.— Schematic representation of the brachial plexus nerves and
muscles. (PS): paraspinal muscles; (R): rhomboid muscle; DS: dorsoscapular
nerve; LT: long thoracic nerve: (SA): serratus anterior muscle; SF:
sympathetic fibers for the eye; (M of M) muscle of Muller: (DP) dilator of the
pupil; (SS): supraspinatus muscle; (IS): infraspinatus muscle; SPS:
suprascapular nerve; PL: pectoralis lateralis nerves; (P): pectoralis muscle;
PM: pectoralis medialis nerve; (TM): teres major muscle; (SBS): subscapularis
muscle; SBS: subscapularis nerve; TD: thoracodorsal nerve; (LD): latissimus
dorsi muscle; MC: musculocutaneous nerve; (Bi): biceps muscle; (Br):
brachialis muscle; M: median nerve; U: ulnar nerve; A: axillary nerve; (TMi):
teres minor muscle; (D): deltoid muscle; R: radial nerve.
 Brachial Plexus Root Injuries
• Upper brachial plexus injury
– Erb-Duchenne Palsy
• C5&C6 root injury, caused by stretch between the head and
shoulder, shoulder stops head/neck don’t.
• The most commonly involved nerves are the suprascapular
nerve, musculocutaneous nerve, and the axillary nerve.
• Waiter’s tip deformity- arm adducted, medially rotated and
pronated. Why?
• Sensory loss where?
• Major cause is obstetric injury ($$$$$$$$)
   
                                       

Figure 216.1.— Typical posture of a neonate with Duchenne-Erb palsy [A and

B]. The posture consists of arm adduction and internal rotation, extended
elbow, forearm pronation, palmar flexion of the wrist, and good finger
movements. The presence of wrist flexion indicates minimal or no
involvement of C7
.
• Figure 216.2.— Schematic representation of the brachial plexus and its
nerves and muscles. Site of injury. A: C5 root and C6 spinal nerve; B: upper
trunk; (PS): paraspinal muscles; (R): rhomboid muscle; DS: dorsoscapular
nerve; LT: long thoracic nerve; (SA): serratus anterior muscle; (SS):
supraspinal muscle; (IS): infraspinal muscle; SPS: suprascapular nerve; PL:
pectoral lateralis nerve; (P): pectoralis muscle; PM: pectoralis medialis nerve;
SF: sympathetic fibers to the eyes; (M of M): muscle of Müller; (DP): dilator
pupillary muscle; (TM): teres major muscle; (SBS): subscapularis muscle;
SBS: subscapularis nerves; TD: thoracodorsal nerve; (LD): latissimus dorsi
muscle; MC: musculocutaneous nerve; (Bi): biceps muscle; (Br): brachialis
muscle; M: median nerve; U: ulnar nerve; A: axillary nerve; (TMi): teres minor
muscle; (D): deltoid muscle; R: radial nerve.
 Brachial Plexus Injuries
• Lower brachial plexus injury
– Klumpke palsy
• C7,C8&T1 injury
• Arm abduction injury
• Paralysis of the muscles of the distal forearm and
hand (all ulnar innervated) plus distal radial &
median innervated muscles.
• Horner's syndrome (ptosis,meiosis, anhydrosis) if
T1 sympathetics involved.
• Figure 220.2.— Site of injury in Klumpke palsy. [A] Root of T1 and spinal nerve of C8. [B]
Lower trunk. The green lines at T1 represent the most frequent origin of sympathetic fibers for
the eyes. (PS): paraspinal muscles; (R): rhomboid muscle; DS: dorsoscapular nerve; LT: long
thoracic nerve; (SA): serratus anterior muscle; (SS): supraspinal muscle; (IS): infraspinal
muscle; SPS: suprascapular nerve; PL: pectoral lateralis nerve; (P): pectoralis muscle; PM:
pectoralis medialis nerve; SF: sympathetic fibers to the eyes; (M of M): muscle of Müller; (DP):
dilator pupillary muscle; (TM): teres major muscle; (SBS): subscapularis muscle; SBS:
subscapularis nerves; TD: thoracodorsal nerve; (LD): latissimus dorsi muscle; MC:
musculocutaneous nerve; (Bi): biceps muscle; (Br): brachialis muscle; M: median nerve; U:
ulnar nerve; A: axillary nerve; (TMi): teres minor muscle; (D): deltoid muscle; R: radial nerve.
 Brachial Plexus Injuries
• Lower brachial plexus injury
– Klumpke palsy
• C7,C8&T1 injury
• Arm abduction injury
• Paralysis of the muscles of the distal forearm and
hand (all ulnar innervated) plus distal radial &
median innervated muscles.
• Horner's syndrome (ptosis,meiosis, anhydrosis) if
T1 sympathetics involved.
 Brachial Plexus Variations
Brachial Plexus Variations in Human Fetuses.
ANATOMIC REPORTS
• Neurosurgery. 53(3):676-684, September 2003.
Uysal, Ismihan Ilknur M.D.; Seker, Muzaffer Ph.D.;
Karabulut, Ahmet Kagan M.D., Ph.D.; Buyukmumcu,
Mustafa Ph.D.; Ziylan, Taner Ph.D.
• This study was performed with 200 BPs from
spontaneously aborted fetuses without detectable
malformations. The BPs were composed mostly of the
C5, C6, C7, and C8 nerves and the T1 nerve (71.5%). A
prefixed plexus was observed in 25.5% of cases, and a
postfixed plexus was observed in 2.5% of cases.
• Another study BPs noted phrenic nerve formation by
C5,6&7 in 20% of specimens***
BP Anomalies
 Brachial Plexus
• Really cool procedure, do the same in lab!
End