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Brachial plexus
Dr M Idris Siddiqui
LEARNING OBJECTIVES
• Mention formation of brachial plexus
(roots, trunk, division, and cords)
• Discuss the relation of b...
Brachial plexus
• The brachial plexus is a network of nerve
formed by cervical and thoracic spinal nerves fibres
that supp...
Supra
Clavicular
Roots
Found to emerge between the scalenus anterior
and scalenus medius muscles.
Trunks
Traverses the low...
Brachial plexus
• The plexus is formed by the anterior primary
rami (divisions) of the cervical spinal nerves
C5, C6, C7 a...
Brachial plexus
• In the axilla and the proximal aspect
of the upper limb, the three cords
give rise to five major branche...
Prefixed & postfixed brachial plexus
• When branch of C4 is large, branch from T1 is
reduced (from T2 absent), the brachia...
Brachial plexus
• The brachial plexus is divided into five parts.
• The roots and trunks are
located in the neck,
division...
RELATIONS OF THE BRACHIAL PLEXUS
• Brachial plexus lies at the posterior triangle of the
neck between the angle formed by ...
Roots
• The ‘roots’ refer the beginning of the brachial
plexus. They are formed by the spinal nerves C5, C6,
C7, C8 and T1...
Trunks
• At the base of the neck, the roots of the brachial
plexus converge, forming three trunks.
Superior
trunk
A combin...
Trunks
• The trunks begin to move laterally, crossing
the posterior triangle of the neck.
• The roots and trunks enter the...
Divisions
• Within the posterior triangle of the neck, each trunk
divides into two branches.
• One division travels anteri...
Cords
• Once the anterior and posterior divisions
have entered the axilla, they combine
together to form three nerves.
• T...
Cords
– .
The lateral cord
is formed by
The anterior division of the superior
trunk
The anterior division of the middle
tr...
Cords
• The cords give rise to the major branches of the
brachial plexus.
• Most of the major peripheral nerves of the upp...
Branches from the roots & trunk
From roots
(3 nerves)
Dorsal scapular nerve to rhomboids
& leavator scapulae
Long thoracic...
Brachial plexus
Branches of the Lateral Cord
• Three nerves originate entirely or partly from the
lateral cord.
1. The lateral pectoral ne...
Branches of the Lateral Cord
1. The lateral pectoral nerve is the most
proximal of the branches from the lateral
cord.
• I...
Branches of the Lateral Cord
2. The lateral root of the median nerve is
the largest terminal branch of the
lateral cord an...
Branches of the Lateral Cord
3. The musculocutaneous
nerve is a large terminal branch
of the lateral cord, terminating as
...
Branches of the Medial Cord
• The medial cord has five branches.
1. The medial pectoral nerve (C8,T1)
2. The medial cutane...
Branches of the Medial Cord
1. The medial pectoral nerve is the most proximal
branch.
• It receives a communicating branch...
Branches of the Medial Cord
2. The medial cutaneous nerve of the arm (medial
brachial cutaneous nerve) passes through the
...
Branches of the Medial Cord
3. The medial cutaneous nerve of the forearm
(medial antebrachial cutaneous nerve) originates
...
Branches of the Medial Cord
4. The medial root of the median
nerve passes laterally to join with a
similar root from the l...
Branches of the Posterior Cord
• Five nerves originate from the posterior
cord of the brachial plexus:
1. The superior sub...
Branches of the Posterior Cord
1. The superior subscapular nerve is short and
passes into and supplies the subscapularis
m...
Branches of the Posterior Cord
3. The thoracodorsal nerve is the longest
of these three nerves and passes
vertically along...
Branches of the Posterior Cord
4. The axillary nerve originates from the
posterior cord and passes inferiorly and
laterall...
Major Branches
• In the axilla and the proximal aspect of the upper
limb, the three cords give rise to five major
branches...
Musculocutaneous Nerve
• Roots: C5, C6, C7.
• Motor Functions: Innervates the
brachialis, biceps brachii and
coracobrachia...
Axillary Nerve
• Roots: C5 and C6.
• Motor Functions: Innervates the
teres minor and deltoid muscles.
• Sensory Functions:...
Median Nerve
• Roots: C6 – T1. (Also contains fibres from C5 in
some individuals).
• Motor Functions: Innervates most of t...
Radial Nerve
• Roots: C5-C8 and T1.
• Motor Functions: Innervates the triceps
brachii, and the extensor muscles in the
pos...
Ulnar Nerve
• Roots: C8 and T1.
• Motor Functions: Innervates the muscles of
the hand (apart from the thenar muscles and
t...
"Erb's point"
.
• A Erb’s point : Is the region on upper trunk
of brachial plexus where :
• It is formed by union two root...
Lesions of the Brachial Plexus
Clinical Relevance
• Injury to the Brachial Plexus
• An intact brachial plexus is vital for the
normal function of the upp...
Lower Brachial Plexus Injury
Klumpke Palsy
• A lower brachial plexus injury results from excessive
abduction of the arm (e...
Upper Brachial Plexus Injury
Erb’s Palsy
• Erb’s palsy commonly occurs where there is excessive increase in the angle
betw...
Erb's palsy: upper brachial plexus injury
• Arm cannot be raised, since deltoid (axillary nerve ) &
spinati muscles (supra...
Compression of the cords
• Pain radiating dfown the arm
• Hand numbness
• Hand weakness
• Caused by prolonged hyperabducti...
Klumpke paralysis: lower brachial plexus injury
• Weakness in intrinsics of hand as well as long
flexors & extensors of th...
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
Brachial plexus
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Brachial plexus

  1. 1. Brachial plexus Dr M Idris Siddiqui
  2. 2. LEARNING OBJECTIVES • Mention formation of brachial plexus (roots, trunk, division, and cords) • Discuss the relation of brachial plexus also in connection to clavicle (Supra, retro, infra clavicular parts • Enumerate the branches arising the different cords
  3. 3. Brachial plexus • The brachial plexus is a network of nerve formed by cervical and thoracic spinal nerves fibres that supplies the skin and musculature of the upper limb. • It begins in the root of the neck, passes through the axilla, and enters the upper arm. • The brachial plexus is divided by the clavicle into: – Supraclavicular – Retroclavicular – Infraclavicular parts.
  4. 4. Supra Clavicular Roots Found to emerge between the scalenus anterior and scalenus medius muscles. Trunks Traverses the lower part of the posterior triangle of the neck Retro Clavicular Divisions Lies behind the 1/3 rd of clavicle. Infra Clavicular Cords The cords of the brachial plexus derived their names based on their relationship with the 2nd part of the axillary artery
  5. 5. Brachial plexus • The plexus is formed by the anterior primary rami (divisions) of the cervical spinal nerves C5, C6, C7 and C8, and the first thoracic spinal nerve, T1. • In addition two communicating twigs usually join the plexus: • a) A twig from C4 descends to C5 • b) A twig from T2 ascends to T1.
  6. 6. Brachial plexus • In the axilla and the proximal aspect of the upper limb, the three cords give rise to five major branches. • These nerves continue into the upper limb to provide innervation to the muscles and skin present.
  7. 7. Prefixed & postfixed brachial plexus • When branch of C4 is large, branch from T1 is reduced (from T2 absent), the brachial plexus is called prefixed. – i.e. The superiormost root (anterior ramus) of the plexus is C4 and the inferiormost root is C8, it is a prefixed brachial plexus. • When branch of C4 is smaller(or absent), branch from T2 is lager. The brachial plexus is called postfixed.i.e. – When the superior root is C5/C6 and the inferior root is T2, it is a postfixed brachial plexus.
  8. 8. Brachial plexus • The brachial plexus is divided into five parts. • The roots and trunks are located in the neck, divisions behind the clavicle and the cords in the axilla. Roots Trunks Divisions Cords branches
  9. 9. RELATIONS OF THE BRACHIAL PLEXUS • Brachial plexus lies at the posterior triangle of the neck between the angle formed by the clavicle and the stenocleidomastoid muscle. • Found to emerge between the scalenus anterior and scalenus medius muscles. • It is covered by the skin, deep fascia, and platysma muscle – It is also crossed by suprascapular nerve, external jugular vein, and inferior belly of Omohyoid muscle
  10. 10. Roots • The ‘roots’ refer the beginning of the brachial plexus. They are formed by the spinal nerves C5, C6, C7, C8 and T1. • At each vertebral level, paired spinal nerves arise. They leave the spinal cord via the intervertebral foramina of the vertebral column. • Each spinal nerve then divides into anterior and posterior nerve fibres. The roots of the brachial plexus are formed by the anterior primary divisions of spinal nerves C5-T1 – The posterior divisions go on to innervate the skin and musculature of the trunk. • Close to their origin, the roots receive gray rami communicantes from the sympathetic trunk.
  11. 11. Trunks • At the base of the neck, the roots of the brachial plexus converge, forming three trunks. Superior trunk A combination of C5 and C6 roots Middle trunk A continuation of C7 Inferior trunk A combination of C8 and T1 roots
  12. 12. Trunks • The trunks begin to move laterally, crossing the posterior triangle of the neck. • The roots and 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. • The inferior trunk lies on rib I posterior to the subclavian artery; the middle and superior trunks are more superior in position.
  13. 13. Divisions • Within the posterior triangle of the neck, each trunk divides into two branches. • One division travels anteriorly (toward the front of the body) and the other posteriorly (towards the back of the body). Thus, they are known as the anterior and posterior divisions. • There are three anterior and three posterior nerve fibres. These divisions leave the posterior triangle and pass into the axilla region. They recombine in the next part of the brachial plexus. – No peripheral nerves originate directly from the divisions of the brachial plexus.
  14. 14. Cords • Once the anterior and posterior divisions have entered the axilla, they combine together to form three nerves. • These nerves are named by their position relative to the axillary artery.
  15. 15. Cords – . The lateral cord is formed by The anterior division of the superior trunk The anterior division of the middle trunk The posterior cord is formed by The posterior division of the superior trunk The posterior division of the middle trunk The posterior division of the inferior trunk The medial cord is formed by The anterior division of the inferior trunk
  16. 16. Cords • The cords give rise to the major branches of the brachial plexus. • Most of the major peripheral nerves of the upper limb originate from the cords of the brachial plexus. • Generally, nerves associated with the anterior compartments of the upper limb arise from the medial and lateral cords and nerves associated with the posterior compartments originate from the posterior cord.
  17. 17. Branches from the roots & trunk From roots (3 nerves) Dorsal scapular nerve to rhomboids & leavator scapulae Long thoracic nerve to serratus ant. Nerve to subclavius From upper trunk (one nerve) Suprascapular nerve to supraspinatus & infraspinatus *NO BRANCH ARISES FROM THE MIDDLE OR FROM THE LOWER TRUNK
  18. 18. Brachial plexus
  19. 19. Branches of the Lateral Cord • Three nerves originate entirely or partly from the lateral cord. 1. The lateral pectoral nerve (C5,6,7) 2. The musculocutaneous nerve(C5,6,7) 3. The lateral root of the median nerve (C5,6,7)
  20. 20. Branches of the Lateral Cord 1. The lateral pectoral nerve is the most proximal of the branches from the lateral cord. • It passes anteriorly, together with the thoraco-acromial artery, to penetrate the clavipectoral fascia that spans the gap between the subclavius and pectoralis minor muscles, and innervates the pectoralis major muscle.
  21. 21. Branches of the Lateral Cord 2. The lateral root of the median nerve is the largest terminal branch of the lateral cord and passes medially to join a similar branch from the medial cord to form the median nerve.
  22. 22. Branches of the Lateral Cord 3. The musculocutaneous nerve is a large terminal branch of the lateral cord, terminating as the lateral cutaneous nerve of the forearm.
  23. 23. Branches of the Medial Cord • The medial cord has five branches. 1. The medial pectoral nerve (C8,T1) 2. The medial cutaneous nerve of the arm (medial brachial cutaneous nerve) (T1,2) 3. The medial cutaneous nerve of the forearm (medial antebrachial cutaneous nerve) (C8,T1) 4. The medial root of the median nerve (C8,T1) 5. The ulnar nerve (C7,8,T1)
  24. 24. Branches of the Medial Cord 1. The medial pectoral nerve is the most proximal branch. • It receives a communicating branch from the lateral pectoral nerve and then passes anteriorly between the axillary artery and 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. • Other branches occasionally pass around the inferior or lateral margin of the pectoralis minor muscle to reach the pectoralis major muscle.
  25. 25. Branches of the Medial Cord 2. The medial cutaneous nerve of the arm (medial brachial cutaneous nerve) passes through the axilla and into the arm where it penetrates deep fascia and supplies skin over the medial side of the distal third of the arm. In the axilla, the nerve communicates with the intercostobrachial nerve of T2. • Fibers of the medial cutaneous nerve of the arm innervate the upper part of the medial surface of the arm and floor of the axilla.
  26. 26. Branches of the Medial Cord 3. The medial cutaneous nerve of the forearm (medial antebrachial cutaneous nerve) originates just distal to the origin of the medial cutaneous nerve of the arm. • It passes out of the axilla and into the arm where it gives off a branch to the skin over the biceps brachii muscle, and then continues down the arm to penetrate the deep fascia with the basilic vein, continuing interiorly to supply the skin over the anterior surface of the forearm. • It innervates skin over the medial surface of the forearm down to the wrist.
  27. 27. Branches of the Medial Cord 4. The medial root of the 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. 5. The ulnar nerve.
  28. 28. Branches of the Posterior Cord • Five nerves originate from the posterior cord of the brachial plexus: 1. The superior subscapular nerve (C5,6) 2. The thoracodorsal nerve to Latissmus dorsi (C6,7,8) 3. The inferior subscapular nerve (C5,6) 4. The axillary nerve (C5,6) 5. The radial nerve(c5,6,7,8,T1)
  29. 29. Branches of the Posterior Cord 1. The superior subscapular nerve is short and passes into and supplies the subscapularis muscle. 2. The inferior subscapular nerve also passes inferiorly along the posterior axillary wall and innervates the subscapularis and teres major muscles
  30. 30. Branches of the Posterior Cord 3. The thoracodorsal nerve is the longest of these three nerves and passes vertically along the posterior axillary wall. • It penetrates and innervates the latissimus dorsi muscle.
  31. 31. Branches of the Posterior Cord 4. The axillary nerve originates from the posterior cord and passes inferiorly and laterally along the posterior wall to exit the axilla through the quadrangular space. It passes posteriorly around the surgical neck of the humerus and innervates both the deltoid and teres minor muscles. 5. The radial nerve.
  32. 32. Major Branches • In the axilla and the proximal aspect of the upper limb, the three cords give rise to five major branches. These nerves continue into the upper limb to provide innervation to the muscles and skin. – 1) MEDIAN – 2) ULNAR NERVE – 3) MUSCULOCUTANEOUS NERVE – 4) AXILLARY NERVE – 5) RADIAL NERVE
  33. 33. Musculocutaneous Nerve • Roots: C5, C6, C7. • Motor Functions: Innervates the brachialis, biceps brachii and coracobrachialis muscles. • Sensory Functions: Gives off the lateral cutaneous branch of the forearm, which innervates the lateral half of the anterior forearm, and a small lateral portion of the posterior forearm.
  34. 34. Axillary Nerve • Roots: C5 and C6. • Motor Functions: Innervates the teres minor and deltoid muscles. • Sensory Functions: Gives off the superior lateral cutaneous nerve of arm, which innervates the inferior region of the deltoid (“regimental badge area”).
  35. 35. Median Nerve • Roots: C6 – T1. (Also contains fibres from C5 in some individuals). • Motor Functions: Innervates most of the flexor muscles in the forearm, the thenar muscles, and the two lateral lumbricals that move the index and middle fingers. • Sensory Functions: Gives off the palmar cutaneous branch, which innervates the lateral part of the palm, and the digital cutaneous branch, which innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand.
  36. 36. Radial Nerve • Roots: C5-C8 and T1. • Motor Functions: Innervates the triceps brachii, and the extensor muscles in the posterior compartment of the forearm. • Sensory Functions: Innervates the posterior aspect of the arm and forearm, and the posterior, lateral aspect of the hand.
  37. 37. Ulnar Nerve • Roots: C8 and T1. • Motor Functions: Innervates the muscles of the hand (apart from the thenar muscles and two lateral lumbricals), flexor carpi ulnaris and medial half of flexor digitorum profundus. • Sensory Functions: Innervates the anterior and posterior surfaces of the medial one and half fingers, and associated palm area.
  38. 38. "Erb's point" . • A Erb’s point : Is the region on upper trunk of brachial plexus where : • It is formed by union two roots – Ventral rami of C5&C6 • It divides into two divisions – anterior and posterior divisions • It provides origin to two nerves – suprascapular and nerve to subclavius
  39. 39. Lesions of the Brachial Plexus
  40. 40. Clinical Relevance • Injury to the Brachial Plexus • An intact brachial plexus is vital for the normal function of the upper limb. • There are two major types of injuries that can affect the brachial plexus. • An upper brachial plexus injury affects the superior roots, and a lower brachial plexus injury affects the inferior roots.
  41. 41. Lower Brachial Plexus Injury Klumpke Palsy • A lower brachial plexus injury results from excessive abduction of the arm (e.g person catching a branch as they fall from a tree). It has a much lower incidence than Erb’s palsy. • Nerves affected: Nerves derived from the T1 root – ulna and median nerves. • Muscles paralysed: All the small muscles of the hand (the flexors muscles in the forearm are supplied by the ulna and median nerves, but are innervated by different roots). • Sensory functions: Loss of sensation along medial side of arm. • The metacarpophalangeal joints are hyperextended, and the interphalangeal joints are flexed. This gives the hand a clawed appearance.
  42. 42. Upper Brachial Plexus Injury Erb’s Palsy • Erb’s palsy commonly occurs where there is excessive increase in the angle between the neck and shoulder – this stretches (or can even tear) the nerve roots, causing damage. It can occur as a result of result of a difficult birth or shoulder trauma. • Nerves affected: Nerves derived from solely C5 or C6 roots; musculocutaneous, axillary, suprascapular and nerve to subclavius. • Muscles paralysed: Supraspinatus, infraspinatus, subclavius, biceps brachii, brachialis, coracobrachialis, deltoid and teres minor. • Motor functions: The following movements are lost or greatly weakened – abduction at shoulder, lateral rotation of arm, supination of forearm, and flexion at shoulder. • Sensory functions: Loss of sensation down lateral side of arm, which covers the sensory innervation of the axillary and musculocutaneous nerves. • The affected limb hangs limply, medially rotated by the unopposed action of pectoralis major. The forearm is pronated due to the loss of biceps brachii. This is position is known as ‘waiter’s tip’, and is characteristic of Erb’s palsy.
  43. 43. Erb's palsy: upper brachial plexus injury • Arm cannot be raised, since deltoid (axillary nerve ) & spinati muscles (suprascapular nerve) are paralyzed • Elbow flexion is weakened because of weakness in biceps & brachialis; • Weakness in retraction and protraction of scapula - due to paralysis of rhomboids and serratus anterior, if roots are damaged above their junction • Lateral arm loses sensation • "Waiter's Tip" position, where the limb hangs limp in a medially rotated position • Usually caused by an increased angle between neck and shoulder, eg. falling on your head.
  44. 44. Compression of the cords • Pain radiating dfown the arm • Hand numbness • Hand weakness • Caused by prolonged hyperabduction, eg. painting the ceiling; cords get pinched between coracoid process and pectoralis minor tendon.
  45. 45. Klumpke paralysis: lower brachial plexus injury • Weakness in intrinsics of hand as well as long flexors & extensors of the fingers, and you get a "claw hand" • A sensory deficit ialong the medial aspect of the arm, forearm, hand • Associated Horner's syndrome – Caused when the arm is suddenly pulled superiorly, eg. when you grab something while falling vertically down.
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