Saint Louis University

School of Medicine
Dr. Abiog 10/16/15 | Brachial Plexus: Formation, Scapulo-Humeral Rhythm

Transcribers: Paggao, Perez, Reyes  Supplies 3 muscles at the back:

o Levator Scapularis
 Brachial Plexus o Rhomboids (major and minor) which are
 Shoulder Girdle & the Scapulohumeral Rhythm mainly for retraction
 Anatomy and Clinical Correlations B. Long Thoracic Nerve
 Motor function
A. Spinal Nerves: In the Beginning  Supplies Serratus posterior, superior and
 Spinal nerves connect to the spinal cord by the inferior
dorsal root and ventral root C. Nerve to Subclavius
o Dorsal root contains sensory fibers  Small nerve; has no specific name
o Cell bodies are located in the dorsal root  Still important because of protective
ganglion; contains sensory fibers mechanism and movement for the clavicle
o Ventral root contains motor fibers D. Suprascapular Nerve
arising from anterior gray column (cell  motor in function; supplies muscles in the
bodies in gray matter of spinal cord – no Supraspinous fossa and Infraspinous fossa
ganglia) E. Lateral Pectoral Nerve
 Branch into dorsal ramus (branch) and ventral  for pectoralis major
ramus which contain sensory and motor fibers F. Musculocutaneous
 Rami communicantes – connect to the base of  Straight
the ventral ramus  Has muscular function and skin function
o Lead to the sympathetic chain ganglion G. Thoracodorsal
(only one)  Supplies the Latissimus Dorsi
Four Plexus H. Lower Subscapular Nerve
 Group of nerves where problems might arise  Supplies the Subscapularis and Teres major
 All plexus are from ventral rami I. Axillary Nerve
(Upper to lower)  Deltoid and Teres minor
1. Cervical Plexus J. Middle Pectoral Nerve – how many muscles does it
2. Brachial Plexus supply?
3. Lumbar Plexus  It supplies the pectoralis minor and the
4. Sacral Plexus sternocostal head of the pectoralis major
 Subclavius muscle must be removed to expose the K. Medial Antebrachial
clavicle  Seen in the forearm
 Anterior scalene muscle – landmark that suggests L. Medial Brachial
that you can already expose brachial plexus  Found in the medial arm
M. Ulnar nerve
B. Brachial Plexus Formation  Important function for hand movements
 Most proximal to spinal cord
It is divided into:
1. Roots – C5, C6, C7, C8, and T1
2. Trunks – C5 and C6 forms the superior/upper trunk, C7
forms the middle, and C8 and T1 forms the inferior
3. Divisions – Anterior and Posterior
4. Cords – Lateral, Posterior, and
Medial (have the longest nerve)

Terminal Branches

A. Dorsal Scapular Nerve

 More proximally
 Supplies the medial aspect of scapula

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Dr. Laygo | Brachial Plexus: Formation, Scapulo-Humeral Rhythm
Branch Innervated muscles o with 3 layers of muscle: superficial,
Dorsal scapular nerve Rhomboids (Major and median, and deep
Minor) and Levator scapulae 4. Ulnar
Long thoracic nerve Serratus anterior, superior,  Supplies the Flexor Carpi Ulnaris, part of the
and posterior Flexor Digitorum Profundus, and most of the
Nerve to subclavius Subclavius hand intrinsic (MEMORIZE!)
Suprascapular nerve Supraspinatus and 5. Radial
Infraspinatus  Innervates essential all extensor muscles of
Lateral pectoral nerve Pectoralis major elbow, ribs, fingers and palm
Musculocutaneous Biceps brachii, Brachialis, and  The boundaries of the neurovascular bundle from
Coracobrachialis inter scalene triangle
Thoracodorsal nerve Latissimus dorsi  Anterior: Anterior scalene
Lower subscapular nerve Subscapularis and Teres  Posterior: Posterior scalene
major  Base: Ribs
Axillary nerve Deltoid and Teres minor
Middle pectoral nerve Pectoralis major and minor  Aneurysmal dilatation
Medial antebrachial nerve Skin on anterior and medial  Congenital anomaly seen in neurovascular
surfaces of forearm as fas as bundle
wrist  C7 transverse process is extra-long creating
Medial brachial nerve Skin on the medial brachial an illusion of forming a rib
side of arm
Ulnar nerve Muscles in forearm and C. Brachial Plexus Injury
hands 1. Erb’s Palsy
Radial Nerve (Motor) Extensor muscles  Erb – Duchenne’s Palsy/Upper Radicular Palsy
Sensory: Posterolateral region of the  Injury on C5 – C6, and upper trunk
 Lateral Brachial extensor forearm…  Affected muscles:
Cutaneous Skin on brachium, dorsum o Deltoid
 Posterior Brachial of forearm, triceps and o Infraspinatus
Cutaneous brachioradialis. o Biceps
 Posterior Antebrachial 2. Waiter’s tip sign
Cutaneous  Arm medially rotated, forearm extended and
pronated
 The Brachial plexus organizes nerves of the muscles 3. Klumpke’s Palsy (Lower Radicular Palsy)
of upper limb  Affects C7 – T1 and lower trunk
 One posterior nerve: Radial Nerve  “Claw Hand”
 Three anterior radial nerves: 4. Compression of the neurovascular bundle in the
 Musculocutaneous axilla
 Median  Causes ischemia and paresthesia in the
 Ulnar upper limb, exacerbated by elevation of the
limb above the head
Important Nerves 5. Painful Shoulder
6. Rotator Cuff Tendinitis
1. Axillary  When the arm is raised, the rotator cuff may
 Innervates the Deltoid and Teres Minor impinge against the under surface of the
 Affected when there is numbness in deltoid acromion.
region 7. Rotator cuff tears
 Repeated impingement (or other conditions)
2. Musculocutaneous may weaken the rotator cuff and eventually
 Sends fibers to the biceps brachii, brachialis, cause partial or complete tears in it, usually
and coracobrachialis (BBC) = “be beautiful after the age of 40.
country”  Injury such as falling may precipitate a tear.
3. Median Manifestations include weakness, atrophy of
 Branches to most of the flexor muscles of supraspinatus and infraspinatus muscles,
forearm – pain, and tenderness

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Dr. Laygo | Brachial Plexus: Formation, Scapulo-Humeral Rhythm

In a complete tear of the supraspinatus D. Kinesiology of the Scapulothoracic Articulation
tendon, active abduction at the ELEVATION DEPRESSION
glenohumeral joint is severely impaired. Upper trapezius *** Lower trapezius ***
8. Calcific tendinitis Levator scapulae *** Pectoralis minor ***
 Refers to a degenerative process in the Rhomboid major Minor roles played by:
tendon that is associated with the deposition Rhomboid minor  Pectoralis major (LF)
of calcium salts. Sternocleidomastoid  Latissimus dorsi (LF)
 Like rotator cuff tendinitis, it usually involves  Serratus Anterior (LF)
the supraspinatus tendon.  Subclavius
 Acute, disabling attacks of shoulder pains RETRACTION PROTRACTION
may occur usually in patients over 30 years Middle trapezius *** Serratus anterior ***
old and most often in women. Rhomboid major *** Pectoralis minor ***
9. Bicipital tendinitis Rhomboid minor ***
 Inflammation of the long head of the biceps Lower trapezius
and may cause anterior shoulder pain. UPWARD ROTATION DOWNWARD ROTATION
10. Acromioclavicular arthritis Upper trapezius *** Pectoralis minor ***
 Not a common cause of shoulder pain. Lower trapezius *** Rhomboid major ***
 When present, it is usually the result of Serratus anterior *** Rhomboid minor ***
direct injury to the shoulder girdle with Pectoralis major
resulting degenerative changes. Latissimus dorsi
 Tenderness is localized over the *** PRIME MOVERS
Acromioclavicular joint.  Upper trapezius and lower trapezius have opposite
11. Adhesive capsulitis actions but will synergistically help each other
 aka “Frozen Shoulder”  What is medial - pectoralis minor or major?
 Mysterious fibrosis of the glenohumeral joint o P. major is more medial
capsule manifested by diffuse, dull, aching
pain in the shoulder and progressive E. Scapulohumeral Rhythm
restriction of motion but usually no localized “Shoulder girdle is composed of seven joints, all moving
tenderness. synchronously and simultaneously, each incumbent upon
 The condition is usually unilateral and occurs the other, in a smoot integrated manner with dysfunction
in persons aged 50 -70.
resulting from the impairment of any of the participating
 There is often an antecedent painful
joint.” – Dr E. A. Codman
disorder of the shoulder or possibly another
condition that has decreased shoulder
movements. Every 15o of arm 10o occurs at the GH & 5o
 The course is chronic, limiting movements to abduction scapular rotation at ST
years but the disorder often resolves As the humerus Approximately 12 – 15o
spontaneously, at least partially. abducts 30o Elevation occurs at the clavicle
 Difficulty in all planes of motion. At 90o arm abduction Clavicle reaches its highest
(MEMORIZE!) elevation at 30o
12. Winged scapula 60o GH abduction
 Medial winging is secondary to weakness of 30o Scapular rotation at ST
Serratus Anterior articulation
180o Full arm 120o humeral abduction
GOOD TO KNOW abduction 60o scapular rotation
Clavicle rotates 45o to give
 Athletes with shoulder impingement
additional 30o of elevation
1. Dwight Howard – center for the LA Lakers
F. Muscles of the Shoulder Region
2. Kerri Walsh – Olympic gold medalist for beach
volleyball
3. JD Drew – former right fielder for the Boston Red a. 7 muscles from trunk to shoulder girdle
Sox b. 9 muscles from shoulder girdle to humerus
c. 2 muscles trunk to humerus

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Dr. Laygo | Brachial Plexus: Formation, Scapulo-Humeral Rhythm
G. Muscles from the Trunk to Shoulder Girdle
 Recall origin, insertion, innervation, and action
1. Trapezius – has 3 fibers
2. Serratus anterior
a. Translator action: pushing
b. Rotatory action: upward
3. Rhomboid major
a. Translator action: retraction
4. Rhomboid minor
5. Pectoralis minor
6. Levator scapula
a. primary elevator
7. Subclavius

H. Muscles from Shoulder Girdle to Humerus

1. Deltoid
2. Supraspinatus
a. Scaption – movement 45o in inclined planed
3. Infraspinatus – external rotation
4. Teres minor – external rotation
5. Subscapularis – internal rotation
6. Teres major
7. Coracobrachialis
8. Biceps brachii
9. Triceps brachii

I. Muscles from Trunk to Humerus

1. Latissimus dorsi
2. Pectoralis major

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