Anatomy of Brachial Plexus

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It is formed by the anterior branches (rami) of spinal nerves C5 to C8 and by a part of T1. Composed of Roots, Trunks, Divisions, Cords & Branches.

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Posterior root meninge al Posterior

Anterior root

Anterior Communicati ng

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Paraspinal EMG to differentiate Plexopathy from Radiculopathy

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Supraclavicular portion: roots, and trunks Infraclavicular portion : divisions, cords, & branches.

Upper plexus - upper trunk and lateral cord Lower plexus - lower trunk and medial cord.

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Roots & Trunks enter the posterior triangle of the neck by passing between the anterior scalene and middle scalene muscles and lie superior and posterior to the subclavian artery.

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The three cords of the brachial plexus originate from the divisions and are related to the second part of the axillary artery

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Branches of the roots

Segmental branches : from C5 to C8 to muscles of the neck Phrenic nerve : contribution from C5

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Dorsal scapular nerve: Originates from the C5 root Passes posteriorly, piercing middle scalene muscle in the neck, to reach and travel along the medial border of scapula Innervates the rhomboid major & minor muscles from their deep surfaces.

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Long thoracic nerve: Originates from anterior rami of C5 to C7 Passes vertically down the neck, through the axillary inlet, and down the medial wall of the axilla to supply the serratus anterior muscle Lies on the superficial aspect of the serratus anterior muscle.

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Branches of the trunks

Suprascapular nerve (C5 and C6): Originates from the superior trunk of the brachial plexus; It runs posteriorly through the suprascapular Notch, beneath the suprascapular ligament, to innervate the supraspinatus muscle Then around the glenoid process of the spine of the scapula in the spinoglenoid notch to reach the infraspinous fossa and innervate the infraspinatus.

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Nerve to subclavius muscle (C5 and C6) Originates from the superior trunk Passes anteroinferiorly over the subclavian artery and vein Innervates the subclavius muscle.

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Branches of the lateral cord

Lateral pectoral nerve C5-C7 : Most proximal of the branches from the lateral cord Passes anteriorly, together with the thoracoacromial artery, to penetrate the clavipectoral fascia Innervates the pectoralis major muscle.
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Musculocutaneous nerve C5 C7 : Terminal branch of the lateral cord Passes laterally to penetrate the coracobrachialis muscle and pass between the biceps brachii and brachialis muscles in the arm Innervates all three flexor muscles in the anterior compartment of the arm (coracobrachialis, brachialis, and biceps brachii) Terminating as the lateral cutaneous nerve of forearm.

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Lateral root of median nerve : Largest terminal branch of the lateral cord Passes medially to join a similar branch from the medial cord to form the median nerve

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Branches of the medialnerve C8, T1 : cord Medial pectoral

Most proximal branch Receives a communicating branch from the lateral pectoral nerve Passes anteriorly between the axillary artery & axillary vein. Branches of the nerve penetrate and supply the pectoralis minor muscle. Some of these branches pass through the muscle to reach and supply the pectoralis major muscle

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Medial cutaneous nerve of arm C8,T1 : Passes through the axilla and into the arm In the axilla, the nerve communicates with the intercostobrachial nerve of T2. Fibers of the medial cutaneous nerve of arm innervate the upper part of the medial surface of the arm & floor of the axilla.

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Medial cutaneous nerve of forearm C8,T1 : Originates just distal to the origin of the medial cutaneous nerve of arm. Passes out of the axilla and into the arm where it gives off a branch to the skin over the biceps brachii muscle It innervates skin over the medial surface of the forearm down to the wrist.

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Medial root of median nerve : Passes laterally to join with a similar root from the lateral cord to form the median nerve anterior to the third part of the axillary artery.

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Ulnar nerve C8, T1 : It often receives a communicating branch from the lateral root of the median nerve and carrying fibers from C7. Ulnar nerve passes through the arm and forearm into the hand In the forearm, branches of the ulnar nerve innervate the flexor carpi ulnaris muscle & medial half of the flexor digitorum profundus muscle. It innervates all intrinsic muscles of the hand (except for the 3 thenar muscles and the 2 lateral lumbrical muscles). Innervates skin over the palmar surface of the little 8/28/12

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median nerve C6 T1 : formed anterior to the third part of the axillary artery by the union of lateral and medial roots originating from the lateral and medial cords of the brachial plexus . It passes into the arm anterior to the brachial artery, Than into the forearm where branches innervate most of the muscles in the anterior compartment of the forearm (except for the flexor carpi ulnaris muscle & medial half of the flexor digitorum profundus muscle.
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continues into the hand to innervate: the three thenar muscles associated with the thumb; the two lateral lumbrical muscles associated with movement of the index and middle fingers; the skin over the palmar surface of the lateral three and one-half digits and over the lateral side of the palm and middle of the wrist.
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Branches of the posterior cord

Superior subscapular nerve C5, C6 : Supplies the subscapularis muscle. Inferior subscapular nerve C5, C6 : Passes inferiorly along the posterior axillary wall and innervates the subscapularis and teres major muscles. Thoracodorsal nerve C6 C8: Is the longest of these three nerves and passes vertically along the posterior axillary wall. It penetrates and innervates the latissimus 8/28/12 dorsi muscle.

Axillary nerve C5, C6 : Passes inferiorly & laterally along the posterior wall to exit the axilla through the quadrangular space It passes posteriorly around the surgical neck of the humerus & innervates both the deltoid & teres minor. Superior lateral cutaneous nerve of arm originates from the axillary nerve after passing through the quadrangular space and loops around the posterior margin of the deltoid muscle to innervate skin in that 8/28/12 region.

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Radial nerve C5 C8 : Passes out of the axilla and into the posterior compartment of the arm by passing through the triangular interval between the inferior border of the teres major muscle, the long head of the triceps brachii muscle, and the shaft of the humerus. Innervate all muscles in the posterior compartments of the arm and forearm; The skin on the posterior aspect of the arm and forearm, the lower lateral surface of the arm, and the dorsal lateral surface of the hand.
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Total Plexus Paralysis : usually due to severe trauma Motor Signs: The entire arm is paralyzed and hangs limp at the patient's side. All the arm's musculature may undergo rapid atrophy. Sensory Signs: There is usually complete anesthesia of the arm distal to a line extending obliquely from the tip of the shoulder down to the medial arm halfway to the elbow. Reflex Signs : The entire upper extremity is areflexic.
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Upper Plexus Paralysis (Erb-Duchenne Type) lesion that results from damage to C5, C6 root or upper trunk. Motor Signs : The muscles supplied by the C5 & C6 roots are paralyzed or paretic and atrophic. deltoid, biceps, brachioradialis, and brachialis, and occasionally, the supraspinatus, infraspinatus, and subscapularis as well. position of the limb - is internally rotated and adducted and the forearm is extended and pronated, the palm therefore facing out and backward. This is the so-called policeman's tip or porter's tip position. Shoulder abduction (deltoid and supraspinatus), 8/28/12 elbow flexion (biceps, brachioradialis, brachialis),

Very proximal lesions may also cause weakness of the rhomboids, levator scapulae, serratus anterior, and scalene muscles. in some cases of obstetric brachial plexopathy, injured phrenic nerve or C3 - C5 roots may sprout into the adjacent injured upper and middle trunks of the brachial plexus. This aberrant regeneration produces co-contraction of the diaphragm and proximal limb muscles, resulting in the phenomenon referred to as respiratory synkinesis or the breathing arm. This reinnervation may not be limited to the upper cervical roots because cases have been described of respiratory synkinesis selectively affecting intrinsic 8/28/12 hand muscles (breathing hand).

Sensory Signs : Sensation is usually intact, but there may be some sensory loss over the outer surface of the upper arm, especially over the deltoid muscle. Reflex Signs : The biceps and brachioradialis reflexes are depressed or absent.

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Middle Plexus Paralysis Lesions of the middle trunk or the corresponding individual anterior primary ramus of C7 root are rare. C7 fibers to the radial nerve are primarily involved, and therefore the extensors of the forearm, hand, and fingers are paretic (including the triceps, anconeus, extensor carpi radialis and ulnaris, extensor digitorum, extensor digiti minimi, extensor pollicis longus and brevis, abductor pollicis longus, and extensor indicis). Forearm flexion is spared because the brachioradialis and brachialis are innervated predominantly by the fifth and sixth cervical segments. The triceps reflex may be depressed or absent, and a sensory defect, although inconsistent and often patchy, may occur over the extensor surface of the forearm and the radial aspect of the dorsum of the hand.

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Lower plexus paralysis (dejerine-klumpke type) Results from injury to the c8 & t1 or the lower trunk of the plexus. Motor signs : all the musculature supplied by the eighth cervical and first thoracic roots are paretic and eventually atrophic. Weakness of wrist and finger flexion and weakness of the intrinsic hand muscles. Often with claw hand deformity.

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Sensory Signs : Sensation may be either intact or lost on the medial arm, medial forearm, and ulnar aspect of the hand. Reflex Signs : The finger flexor reflex (C8 &T1) is depressed or absent. Autonomic Signs : When the first thoracic root is injured, the sympathetic fibers, destined for the superior cervical ganglion (and eventually the eye, upper lid, and face), are interrupted. Therefore, an ipsilateral Horner syndrome
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Lesions of the Lateral Cord paresis of the muscles innervated by the musculocutaneous nerve - biceps, brachialis, and coracobrachialis lateral head of the median nerve - pronator teres (forearm pronation), flexor carpi radialis (radial wrist flexion), palmaris longus (wrist flexion), flexor digitorum superficialis (middle phalangeal flexion of the second through fourth digits), flexor pollicis longus (flexion of the distal phalanges of the thumb), flexor digitorum profundus I and II (flexion of the distal phalanges of the second and third fingers), and pronator quadratus (forearm pronation).

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The biceps reflex is depressed or absent. Sensory loss may occur on the lateral forearm (the area of distribution of the lateral cutaneous nerve of the forearm, a branch of the musculocutaneous nerve).

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Lesions of the medial cord Weakness of the muscles innervated by the Ulnar nerve - flexor carpi ulnaris (ulnar wrist flexion), flexor digitorum iii and iv (flexion of the terminal digits of the fourth and fifth fingers), and all the ulnar-innervated small hand muscles. Medial head of the median nerve (the median-innervated intrinsic hand muscles). Abductor pollicis brevis (abduction of the metacarpal of the thumb), opponens pollicis (opposition of the thumb), superficial head of the flexor pollicis brevis (flexion of the proximal phalanx of the thumb), and the first and second lumbricals.

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With proximal lesions of the medial cord, the medial pectoral nerve may be injured, resulting in some paresis of the lower sternocostal portion of the pectoralis major muscle and of the pectoralis minor. Finger flexor reflex is decreased or absent. Medial cutaneous nerves of the arm and forearm are branches of the medial cord, a sensory loss may be evident on the medial arm and forearm.

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Lesions of the posterior cord Subscapular nerve - teres major and subscapularis (internal rotators of the humerus) Thoracodorsal nerve - latissimus dorsi Axillary nerve - deltoid (arm abduction) and teres minor (lateral rotation of the shoulder joint) as well as variable sensory loss in the distribution of the lateral cutaneous nerve of the arm (skin of the lateral arm).
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Radial nerve - elbow extension, wrist extension, forearm supination, and finger extension. Triceps and brachioradial reflexes are decreased or absent Variable sensory loss is present on the entire extensor surface of the arm and forearm and on the back of the hand and dorsum of the first four fingers.

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