BRACHIAL PLEXUS

BRACHIAL PLEXUS

 the nerve fibers derived from different segments of the spinal cord to be
arranged and distributed efficiently in different nerve trunks to the various
parts of the upper limb.
 The brachial plexus is formed in the posterior triangle of the neck by the
union of the anterior rami of the 5th, 6th, 7th, and 8th cervical and the 1st
thoracic spinal nerve
COMPONENTS

 Roots – C5 – T1
 Trunks – Upper – C5 and C6, Middle – C7, Lower – C8 and T1
 Divisions – Anterior and Posterior
 Cords –in relation to the AXILLARY ARTERY
 – Lateral Cord - anterior divisions of the upper and middle trunk
 - Medial Cord - the anterior division of the lower trunk
 - Posterior Cord - the posterior divisions of all three trunks
 Branches
CORD

 lie above and lateral to the first part of the axillary artery
 MEDIAL CORD - crosses behind the artery to reach the medial side of the
second part of the artery.
 POSTERIOR CORD - lies behind the second part of the artery
 LATERAL CORD - on the lateral side of the second part of the artery
 form the main nerve trunks of the upper limb continue this relationship to
the artery in its third part.
LATERAL CORD

 Lateral pectoral nerve

 Musculocutaneous nerve
 Lateral root of median nerve
MEDIAL CORD

 Medial pectoral nerve

 Medial cutaneous nerve of arm and
 Medial cutaneous nerve of forearm
 Ulnar nerve
 Medial root of median nerve
POSTERIOR CORD

 Upper and lower subscapular nerves

 Thoracodorsal nerve
 Axillary nerve
 Radial nerve
BRANCHES FOUND IN THE AXILLA

 The nerve to the subclavius (C5 and 6)

 supplies the subclavius muscle
 give a contribution (C5) to the phrenic nerve; this branch, when present, is
referred to as the accessory phrenic nerve.
 Long thoracic nerve (C5, 6, and 7)
 arises from the roots of the brachial plexus in the neck and enters the axilla
by passing down over the lateral border of the 1st rib behind the axillary
vessels and brachial plexus
 Supplies the serratus anterior muscle
BRANCHES FOUND IN THE AXILLA

 The lateral pectoral nerve

 arises from the lateral cord of the brachial plexus and supplies the
pectoralis major muscle.
 The musculocutaneous nerve
 from the lateral cord of the brachial plexus, supplies the coracobrachialis
muscle, and leaves the axilla by piercing that muscle.
 The lateral root of the median nerve is the direct continuation of the lateral
cord of the brachial plexus.
 joined by the medial root to form the median nerve trunk, but no branches
in axilla
BRANCHES FOUND IN THE AXILLA

 The medial pectoral nerve

 from the medial cord of the brachial plexus,
 supplies and pierces the pectoralis minor muscle, and supplies the
pectoralis major muscle.
 The medial cutaneous nerve of the arm (T1)
 arises from the medial cord of the brachial plexus
 joined by the intercostobrachial nerve (lateral cutaneous branch of the
2nd intercostal nerve).
 It supplies the skin on the medial side of the arm.
BRANCHES FOUND IN THE AXILLA

 The medial cutaneous nerve of the forearm

 from the medial cord of the brachial plexus and descends in front of the
axillary artery.
 The ulnar nerve (C8 and T1)
 from the medial cord of the brachial plexus and descends in the interval
between the axillary artery and vein.
 gives off no branches in the axilla
BRANCHES FOUND IN THE AXILLA

 The medial root of the median nerve

 from the medial cord of the brachial plexus
 Crosses in front of the third part of the axillary artery to join the lateral root
of the median nerve.
 The upper and lower subscapular nerves
 from the posterior cord of the brachial plexus and supply the upper and
lower parts of the subscapularis muscle.
 the lower subscapular nerve supplies the teres muscle.
BRANCHES FOUND IN THE AXILLA

 The thoracodorsal nerve

 arises from the posterior cord of the brachial plexus and runs downward to
supply the latissimus dorsi muscle.
 The axillary nerve is one of the terminal branches of the posterior cord of
the brachial plexus.
 It turns backward and passes through the quadrangular space
 Having given off a branch to the shoulder joint, it divides into anterior and
posterior branches
BRANCHES FOUND IN THE AXILLA

 The radial nerve

 Largest branch of the brachial plexus and lies behind the axillary artery.
 Gives off branches to the long and the medial heads of the triceps muscle
and the posterior cutaneous nerve of the arm.
 The latter branch is distributed to the skin on the middle of the back of the
arm.
TENDON REFLEXES

 Biceps brachii tendon reflex: C5 and 6 (flexion of the elbow joint by

tapping the biceps tendon).
 Triceps tendon reflex: C6, 7, and 8 (extension of the elbow joint by tapping
the triceps tendon).
 Brachioradialis tendon reflex: C5, 6, and 7 (supination of the radioulnar
joints by tapping the insertion of the brachioradialis tendon).
UPPER LESIONS OF THE BRACHIAL
PLEXUS

 from excessive displacement of the head to the opposite side and

depression of the shoulder on the same side.
 causes excessive traction or even tearing of C5 and 6 roots of the plexus.
 It occurs in infants during a difficult delivery or in adults after a blow to or
fall on the shoulder (usually trauma)
UPPER LESIONS OF THE BRACHIAL
PLEXUS

 PARALYSIS
 the supraspinatus (abductor of the shoulder)
 infraspinatus (lateral rotator of the shoulder)
 the subclavius (depresses the clavicle)
 the biceps brachii (supinator of the forearm, flexor of the elbow, weak flexor of
the shoulder)
 the greater part of the brachialis (flexor of the elbow) and
 coracobrachialis (flexes the shoulder);
 deltoid (abductor of the shoulder)
 teres minor (lateral rotator of the shoulder
UPPER LESIONS OF THE BRACHIAL
PLEXUS

 ERB-DUCHENNE PALSY
 Upper limb hang limply by the side
 medially rotated (due to the the unopposed sternocostal part of the
pectoralis major);
 the forearm will be pronated (because of loss of the action of the biceps)
 The position of the upper limb in this condition has been likened to that of
a porter or waiter hinting for a tip (WAITER’S TIP APPEARANCE)
 there will be a loss of sensation down the lateral side of the arm.
LOWER LESIONS OF THE BRACHIAL
PLEXUS

 usually traction injuries caused by excessive abduction of the arm - a

person falling from a height
 The 1st thoracic nerve is usually torn.
 The nerve fibers from this segment run in the ulnar and median nerves to
supply all the small muscles of the hand
LOWER LESIONS OF THE BRACHIAL
PLEXUS

 The hand has a clawed appearance (hyperextension of the

metacarpophalangeal joints and flexion of the interphalangeal joints)
 The extensor digitorum is extends the metacarpophalangeal joints
(unopposed by the lumbricals and interossei);
 The flexor digitorum superficialis and profundus and flex the middle and
terminal phalanges, respectively (unopposed by the lumbricals and
interossei) – KLUMPKE’S PALSY
 loss of sensation will occur along the medial side of the arm
 C8 damage - loss of sensation in the medial side of the forearm, hand,
and medial two fingers.
NERVES

 AXILLARY NERVE – ABDUCTORS

 MUSCULOCUTANEOUS NERVE – FLEXORS OF THE ARM
 RADIAL NERVE – EXTENSORS OF THE ARM, FOREARM AND HAND
 MEDIAN NERVE – FLEXORS OF THE MEDIAL 2/3s of FOREARM AND HAND
 ULNAR NERVE – FLEXORS OF THE MEDIAL 1/3s of FOREARM AND HAND
LESIONS OF NERVES

 LONG THORACIC NERVE

- Blows to the posterior triangle of the neck or mastectomy
- Paralysis of Serratus anterior – “Winged Scapula”
 AXILLARY NERVE
 shoulder dislocations or fractures of the surgical neck of the humerus.
 Paralysis of the deltoid and teres minor muscles result and there is inability
to ABDUCT
LESIONS OF NERVES

 RADIAL NERVE - commonly damaged in the axilla and in the spiral groove.
AXILLA
- badly fitting crutch pressing up into the armpit or by a drunkard falling asleep
with one arm over the back of a chair – SATURDAY NIGHT PARALYSIS
- badly damaged in the axilla by fractures and dislocations of the proximal end
of the humerus
- The patient is unable to extend the elbow joint, the wrist joint, and the fingers.
- Wristdrop, or flexion of the wrist occurs as a result of the action of the
(unopposed flexors)
LESIONS OF NERVES

 RADIAL NERVE -
 SPIRAL GROOVE - . The prolonged application of a tourniquet to the arm in
a person and fractures of the shaft of the radius
 Motor: The patient is unable to extend the wrist and the fingers, and
wristdrop occurs.
 Sensory: A variable small area of anesthesia is present over the dorsal
surface of the hand and the dorsal surface of the roots of the lateral three
and a half fingers..
LESIONS OF NERVES

 MUSCULOCUTANEOUS NERVE
 the biceps and coracobrachialis are paralyzed and the brachialis muscle
is weakened (the latter muscle is also supplied by the radial nerve)
 There is also sensory loss along the lateral side of the forearm
LESIONS OF NERVES

 MEDIAN NERVE - ELBOW

 injured occasionally in the elbow region in supracondylar fractures of the
humerus.
 It is most commonly injured by stab wounds or broken glass just proximal to
the flexor retinaculum or suicidal attempts
LESIONS OF NERVES

 MEDIAN NERVE
 MOTOR
 The pronator muscles of the forearm and the long flexor muscles of the wrist
and fingers, with the exception of the flexor carpi ulnaris and the medial half of
the flexor digitorum profundus, will be paralyzed.
 the forearm is kept in the supine position; wrist flexion is weak and is
accompanied by adduction.
 SENSORY
 lost on the lateral half or less of the palm of the hand and the palmar aspect of
the lateral three and a half fingers.
 also occurs on the skin of the distal part of the dorsal surfaces of the lateral
three and a half fingers
LESION OF NERVES

 MEDIAN NERVE – WRIST

 MOTOR:
 The muscles of the thenar eminence are paralyzed and wasted so that the
eminence becomes flattened.
 The thumb is laterally rotated and adducted. The hand looks flattened and
“apelike.” – APE HAND
 Opposition movement of the thumb is impossible.
 The first two lumbricals are paralyzed.
 CARPAL TUNNEL SYNDROME - a burning pain or “pins and needles” along the
distribution of the median nerve to the lateral three and a half fingers and
weakness of the thenar muscles.
LESIONS OF NERVES

 ULNAR NERVE
- commonly injured at the elbow, where it lies behind the medial
epicondyle, (fractures)
- the wrist, where it lies with the ulnar artery in front of the flexor retinaculum.
(Stab wounds)
LESIONS OF NERVES

 ULNAR NERVE – ELBOW

 MOTOR
 flexor carpi ulnaris and the medial half of the flexor digitorum profundus
muscles are paralyzed
 The profundus tendons to the ring and little fingers will be functionless, and the
terminal phalanges of these fingers are therefore not capable of being
markedly flexed.
 Flexion of the wrist joint will result in abduction, owing to paralysis of the flexor
carpi ulnaris.
 Small muscles of the hands – paralyzed
 SENSORY - Loss of skin sensation will be observed over the anterior and posterior
surfaces of the medial third of the hand and the medial one and a half fingers.
LESIONS OF NERVES

 ULNAR NERVE – WRIST

 Motor:
 The small muscles of the hand will be paralyzed and show wasting, except
for the muscles of the thenar eminence and the first two lumbricals.
 The clawhand is much more obvious in wrist lesions because the flexor
digitorum profundus muscle is not paralyzed, and marked flexion of the
terminal phalanges occurs.
 FROMENT’S SIGN
LESIONS OF NERVES

 ULNAR NERVE
 Sensory:
 The main ulnar nerve and its palmar cutaneous branch are usually
severed; the posterior cutaneous branch, which arises from the ulnar nerve
trunk about 2.5 in. (6.25 cm) above the pisiform bone, is usually
unaffected.
 confined to the palmar surface of the medial third of the hand and the
medial one and a half fingers and to the dorsal aspects of the middle and
distal phalanges of the same fingers.
Thank you