Anatomy of the Brachial Plexus

February 2021
Objectives:
By the end of the presentation the Viewer should :
•Demonstrate an appreciation/understanding of what the Brachial Plexus is

•Show familiarity with the following organizational definitions of the plexus: Roots,
Trunks, Divisions, Cords, & Branches

•Exhibit knowledge of which spinal nerve root levels contribute axons to different
parts of the plexus by being able to follow/draw/sketch the axonal pathways
(efferent/motor and afferent/sensory) through the components of the brachial plexus

•Be able to name the (5 major terminal branch) nerves of the plexus & what they do

•Be able to define cutaneous nerves and dermatomes and differentiate them from
each other, identifying territories/maps in the upper limb

•Be able to predict (from a synthesis of this knowledge) motor/sensory deficits that
may clinically present from damage to different parts of the Brachial Plexus
 Key terms/Definitions
• Brachial – of, relating to, or situated in the arm or an armlike process eg. the
brachial artery of the upper arm.
Merriam-Webster dictionary
• Plexus – an intricate network, e.g. “the plexus of international relations”
in ANATOMY - a network of nerves or vessels in the body
• Brachial plexus - “is a network of nerves formed by the anterior rami of the
lower four cervical nerves and first thoracic nerve (C5, C6, C7, C8, and T1).
This plexus extends from the spinal cord, through the cervicoaxillary canal in
the neck, over the first rib, and into the armpit. It supplies afferent and
efferent nerve fibers to the chest, shoulder, arm, forearm, and hand”
(Wikipedia)
Nerve plexuses arising
from the Spinal Cord
can either be somatic
or visceral
 When it comes to the Architecture (i.e.
Organization, Structure, Patterning) of the
Brachial Plexus
think of two (magic) numbers:
5 and 3
STRUCTURE = Brachial Plexus defined into 5 regions

R  ROOTS (5)

T  TRUNKS (3)

D  DIVISIONS (6)

C  CORDS (3)

B  BRANCHES
(5 terminal + numerous other pre-terminal/collateral)
Mnemonic : Remember To Drink Cold Beers
SOURCE = Arises from 5 Spinal nerve segments
• 5 ROOTS
• 1st Thoracic + Lowest 4 Cervical
• ROOTS – ventral/anterior rami of C5-
T1 spinal nerves, which give three
(collateral) nerve branches:
• The dorsal scapular nerve
• The long thoracic nerve
• The first intercostal nerve.
• It is important to remember that C5 also
gives fibres which join fibres from C3 and
C4 to form the phrenic nerve.
NB: Brachial Plexus ROOTS Spinal Nerve ROOTS

X
√

X
Brachial Plexus ends in 5 (terminal) BRANCHES
Having accounted for the 5 ROOTS and 5 Terminal BRANCHES
1
2
3
3 TRUNKS – formed by the
combination of the 5
ROOTS:
• Upper 2 roots (C5 and C6) form
Superior/Upper trunk

• 2 lowest roots (C8 and T1) unite to

form Inferior/Lower trunk

• Middle/intermediate trunk is formed

from the remaining C7 root

Upper trunk = superior of the 3  only

one that has branches:
suprascapular nerve and
nerve to subclavius
5 ROOTS  3 TRUNKS and 5 Terminal BRANCHES arise from 3 CORDS

53
35
DIVISIONS
Each TRUNK ends by splitting into 2 – an Anterior and Posterior DIVISION
3 Trunks  3 X 2 = 6 Divisions
• anterior divisions of the upper, middle, and lower trunks
• posterior divisions of the upper, middle, and lower trunks

• NB - in the anatomical position, the anterior divisions are superficial to the

posterior divisions

Anterior division fibres usually supply flexor muscles

Posterior division fibres usually supply extensors
There are no nerve branches arising from the divisions
3 inner components/areas flanked by 3 Trunks proximally
…and 3 Cords distally

1
2
3
3 TRUNKS 6 DIVISIONS  regroup into 3 CORDS.

• Posterior Cord formed

from all 3 posterior divisions
of the trunks (C5-C8, T1)

• Lateral Cord - anterior

divisions of the upper and
middle trunks (C5-C7)

• Medial cord is simply a

continuation of the anterior
division of the lower trunk
(C8, T1)
• All three cords of the brachial
plexus lie above and lateral to
the first part of the axillary
artery
• The medial cord crosses behind
the artery to reach the medial
side of the second part of the
artery.
• The posterior cord lies behind
the second part of the artery,
and the lateral cord lies on the
lateral side of the second part of
the artery.
• Thus, it is their respective
placement relative to the 2nd
part of the Axillary artery, for
which the cords are named.
Terminal Branches = 5
• Plexus starts with 5 ROOTS
has 5 Parts,
ends in 5 Terminal BRANCHES
• 5 Roots  3 Trunks
6 Divisions
3 Cords  5 Terminal branches
5-3-6-3-5
• The lateral cord gives rise to
the musculocutaneous nerve
& lateral root of the median
• The posterior cord gives rise
to the axillary & radial nerves
• The medial cord gives rise to
the medial root of the median
& the ulnar nerve
 Mnemonic: Most Alcoholics Really Must Urinate

•Musculocutaneous
•Axillary nerve
•Radial nerve
•Median nerve
•Ulnar nerve
A common structure
used to identify part of
the brachial plexus in
cadaver dissections is
the M or W shape
made by the
musculocutaneous
nerve, lateral cord,
median nerve, medial
cord, and ulnar nerve
 Brachial Plexus branches
• Roots  3
• Trunks  Superior only  2
• Divisions  0
• Cords  Lateral  3
Posterior  5
Medial  5

2 branches from each

cord contribute to the 5
terminal branch nerves
Diagram of the brachial plexus using color to illustrate the contributions of each
nerve root to the branches

By Brachial_plexus.svg: Selketderivative work: mcstrother (Marshall Strother) - Brachial_plexus.svg, CC BY-SA 3.0,

https://commons.wikimedia.org/w/index.php?curid=8833181
Spinal nerve ROOTS
are
ROOTLETS
Collateral (Nerve) Branches from the Roots
1 Dorsal Scapular Nerve (C5)
NO Sensory supply
Motor supply to Levator scapulae (elevates scapula) & the Rhomboids (major and minor -
stabilise, retract and medially rotate scapula)

2 Long Thoracic Nerve (C5/C6/C7)

NO Sensory supply
Motor supply to Serratus anterior (protracts and stabilises scapula)
Clinical significance
An injury to this nerve -- “winging” of the scapula on examination, esp when patient pushes
against a wall  appears as an abnormal posterior protrusion of the scapula on the affected
side.

3 First Intercostal Nerve (T1)

Sensory supply  A narrow strip of skin over first intercostal space
Motor supply  First intercostal muscles (elevate and depress the rib cage during inspiration
and expiration)
Collateral Nerve Branches from the Trunks
1 Suprascapular Nerve (C5/C6)
Origin  Superior trunk of the brachial plexus
Sensory supply  Glenohumeral and acromioclavicular joints
Motor supply  Supraspinatus (stabilises and abducts shoulder)
Infraspinatus (stabilises and externally rotates shoulder)

2 Nerve to Subclavius (C6)

Origin  Superior trunk of the brachial plexus
NO Sensory supply
Motor supply  Subclavius (depresses clavicle and elevates the first rib)
Collateral Branches from the Cords
Magic number 5
+ 3 on the inside

All cords give rise to a total of 5 branches each except for one
Lateral has 3

Each of the cords contributes 2 branches to the 5 terminal nerves

Lateral = 3 - 2 = 1 collateral branch
Posterior cord = 5 - 2 = 3 collateral branches
Medial cord = 5 - 2 = 3 collateral branches
Collateral Nerve of the Lateral cord

Lateral Pectoral Nerve (C5/C6/C7)

• Origin  Lateral cord of the brachial plexus

• NO (cutaneous) sensory supply  however implicated in

thoracic wall pain sensations in medical procedures like
mastectomy or breast implants
• Motor supply  (Upper clavicular part of) Pectoralis major
(flexes, adducts and internally rotates shoulder
)
Collateral Nerves of the Posterior cord
Upper Subscapular Nerve (C5/C6)
• NO Sensory supply
• Motor supply  Subscapularis (stabilises and internally rotates shoulder)

Thoracodorsal Nerve (C6/C7/C8) (aka Middle Subscapular)

• NO Sensory supply
• Motor supply  Latissimus dorsi (extends, adducts and internally rotates shoulder,
externally rotates trunk)

Lower Subscapular Nerve (C5/C6)

• NO Sensory supply
• Motor supply  Subscapularis (stabilises and internally rotates shoulder)
Teres major (adducts and internally rotates shoulder, protracts and
depresses scapula)
Collateral Nerves of the Medial cord
Medial Pectoral Nerve (C8/T1)
• Sensory supply  None to the skin, but may have a role in the sensation of chest wall
pain following breast surgery
• Motor supply  Pectoralis minor (stabilises scapula, raises ribs during inspiration)
Lower sternocostal part of the pectoralis major (extends, adducts and
internally rotates shoulder)

Medial Cutaenous Nerve of the Arm (T1)

• Sensory supply  Skin of the lower third the of the medial arm
• NO Motor supply

Medial Cutaneous Nerve of the Forearm (C8)

• Sensory supply  Skin over biceps muscle, antecubital fossa and medial forearm
• NO Motor supply
5 Terminal Branches
Recall MARMU.

a) Musculocutaneous Nerve (C5/C6/C7)

• Origin  Lateral cord of the brachial plexus
• Sensory supply  Lateral forearm
• Motor supply  Anterior compartment of the arm:
• Biceps (flexes elbow, supinates forearm)
• Brachialis (flexes elbow)
• Coracobrachialis (adducts shoulder, flexes elbow)

Clinical significance
Musculocutaneous nerve injuries rare, but result in very weak elbow
flexion and weak forearm supination which can be very disabling.
b) Axillary Nerve (C5/C6)
• Origin  Posterior cord of the brachial plexus
• Sensory supply  “Sergeant’s patch” over the lower deltoid
• Motor supply 
• Deltoid (abducts, flexes and extends shoulder)
• Teres minor (stabilises and externally rotates shoulder)

Clinical significance
• Nerve vulnerable during shoulder dislocations or proximal humeral fractures
• Injury  numbness over the sergeant’s patch
• profound weakness of shoulder abduction from 15-90°
• deltoid wasting
• also weakness of shoulder flexion, extension and external rotation.
c) Radial Nerve (C5/C6/C7/C8/T1)
• Origin  Posterior cord of the brachial plexus
• Sensory supply  Posterior arm and forearm, Lateral ⅔ of the dorsum of the hand,
Proximal dorsal aspect of lateral 3½ fingers
• Motor supply
• posterior compartment of the arm (triceps extends & adducts shoulder, extends
elbow)
• posterior compartment of the forearm  has Brachioradialis (flexes elbow), Anconeus
(extends elbow, stabilises elbow joint), Supinator (supinates forearm), Abductor pollicis
longus (abducts thumb) + Extensors (i.e. E. carpi radialis longus & brevis; E. carpi
ulnaris; E. digitorum; E. pollicis longus & brevis; E. indicis; and E. digiti minimi)

Clinical significance
• Compression injuries, eg leaning or lying on the arm for extended periods, excessively tight
shirts, plaster casts or prolonged tourniquet use, as well as humeral or radial fractures
• Nerve injury = loss of motor innervation to the posterior compartments of the arm and
forearm  numbness + “wrist drop” deformity with very weak extension of the elbow,
wrist and fingers.
d) Median Nerve (C5/C6/C7/C8/T1)
• Origin  Lateral and medial cords of the brachial plexus
• Sensory supply 
• Thenar eminence, the lateral ⅔ of the palm of the hand
• Palmar aspect of lateral 3½ fingers
• Dorsal fingertips of lateral 3½ fingers
• Motor supply 
• All muscles of the anterior compartment of forearm EXCEPT flexor carpi ulnaris and
the medial two parts of flexor digitorum profundus.
• the LOAF muscles of the hand: the lateral two lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Clinical significance
Most commonly damaged by compression within the carpal tunnel at the wrist, resulting in
numbness of the median nerve distribution to the hand, wasting of the thenar eminence,
weak grip strength and a “hand of benediction” deformity due to an inability to flex the
index or middle fingers.
e) Ulnar Nerve (C8/T1)
• Origin  Medial cord of the brachial plexus
• Sensory supply  Hypothenar eminence
Medial ⅓ of the palm of the hand
Palmar aspect of the lateral 1½ fingers
Medial ⅓ of the dorsum of the hand
Dorsal aspect of the medial 1½ fingers
• Motor supply  supplies just two muscles in the anterior compartment of the forearm
• Flexor carpi ulnaris, which flexes and adducts the wrist
• (medial two parts of) flexor digitorum profundus, which flex the distal interphalangeal
joints (DIPJs) of the ring and little fingers.
• also all intrinsic muscles of the hand EXCEPT LOAF muscles (the HILA muscles:
Hypothenar eminence, Interossei, medial two Lumbricals, & Adductor pollicis)

Clinical significance
Imjury  numbness in the ulnar distribution to the hand, wasting of the hypothenar
eminence and intrinsic muscles of the hand, a “claw hand” deformity due to an inability to
extend the ring and little fingers, and weak finger abduction and adduction.
Dermatomes & Cutaneous (Innervation) Fields

Why study dermatomes and cutaneous innervation?

- Familiarity helps health practitioners better understand nerve injury
symptoms
- This information about dermatomes and regions of cutaneous innervation is
valuable in the (neurologic) clinical evaluation process

- Tactile dermatomes are larger than pain dermatomes

- Contiguous dermatomes overlap (damage to one nerve root may cause either no
detectable anesthesia or sensory loss)
- When the sensory and motor levels disagree, the motor level is a more reliable
indicator of level of injury & patient disability
Making sense of Upper Limb
dermatome maps from
embryonic development
Dermatome – an area of skin
supplied by sensory neurons
from a single spinal cord level
Dermatome (definition cont’d)

….and maybe distributed by

more than one peripheral
nerve

Cutaneous field – an area of

skin supplied by sensory
neurons from a single
peripheral nerve
Cutaneous field (definition cont’d)

… and may be distributed by more than

one spinal cord level
INJURY to the ventral ramus (or ROOT) is the only way to lose the
ENTIRE DERMATOME

If one injures a Peripheral Nerve, one loses sensation in the

entire CUTANEOUS field
Clinical Anatomy: Brachial Plexus Injuries
Neck injuries may affect Brachial Plexus (cervical and
thoracic) nerve roots or trunks  syndromes of
neurological deficits and clinical features

Focus on the most representative/common three

Erb’s palsy, Klumpke’s palsy and Horner’s
syndrome
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.

Upper Brachial Plexus Injury – Erb’s Palsy

Erb’s palsy commonly occurs where there is an excessive increase in the angle between the neck and shoulder, which
stretches (or even tears) the nerve roots of C5 and C6. 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: Movements that are lost or greatly weakened include abduction at shoulder, lateral rotation of arm,
supination of forearm, and flexion at shoulder.
Sensory functions: Loss of sensation down lateral aspect 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. The wrist is weakly flexed due to the normal increased tone of the wrist flexors relative to the
wrist extensors. This is position is known as ‘waiter’s tip’, and is characteristic of Erb’s palsy.
The waiters’ tip position,
characteristic of Erb’s palsy.
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 – ulnar and median nerves.
Muscles paralysed: All the intrinsic hand muscles (the flexor muscles in the
forearm are also supplied by the ulnar and median nerves, but are innervated
by different roots). The primary symptom is a “claw hand,” caused by the
unopposed action of the finger extensor muscles. The lumbrical muscles flex
the metacarpophalangeal joints and extend the interphalangeal joints, so their
paralysis will cause the opposite: extension of the MCP and flexion of the IP
joints.
Sensory functions: Loss of sensation along medial side of arm
Erb-Duchenne palsy (waiter's tip)

Shoulder rotated forward  loss of shoulder abduction and

external rotation, elbow flexion and wrist supination

Affected arm diminished in length & girth

Winging of affected scapula

Loss of sensation to the skin over the “sergeant’s patch”,

lateral arm and forearm

Atrophy of the deltoid, supraspinatus and infraspinatus

muscles and the anterior compartment of the arm,

“waiter’s tip” deformity = limp, adducted, internally rotated

shoulder, extended elbow; pronated wrist, absent biceps
reflex
Patient exhibiting Horner’s syndrome  loss of sympathetic nerve supply to the face & neck
• Miosis (constricted pupil)
• Ipsilateral partial ptosis (drooping eyelid)
• Anhidrosis (loss of hemifacial sweating)
• Other: dilatation lag (slowly dilating pupil) & enophthalmos (eye appears sunken)
Brachial Plexus in a nutshell (5-3-6-3-5)
• complex intercommunicating network of anterior rami of spinal nerves C5, C6, C7, C8 & T1

• Supplies all sensory innervation to the upper limb and most of the axilla, EXCEPT an area of
the medial upper arm and axilla (innervated by the intercostobrachial nerve T2)

• Motor innervation to ALL muscles of the upper limb and shoulder girdle, except for
trapezius (spinal accessory nerve XI)

• autonomic innervation to the upper limb by intercommunicating with the stellate ganglion
of the sympathetic trunk at the level of T1:
- Vasomotor – vasoconstriction of arteries/arterioles/capillaries  in skin pallor & coldness
- Pilomotor – contraction of arrector pili muscles within hair follicles  goose bumps
- Sudomotor or secretomotor – production of sweat from sweat glands
Total/Complete Brachial Plexus Injury
Injury to entire brachial plexus C5/C6/C7/C8/T1

Causes:
• severe or complex traction injuries sustained during difficult childbirth
• high-speed road traffic accidents  violent stretching +/- tearing of all nerve roots

The entire brachial plexus nerves are injured

Totally limp, dangling, atrophied and numb (no sensations) upper limb with
associated Horner’s syndrome
Anatomical variations to the Brachial Plexus
Variants exist but the most significant ones include:
• Pre-fixed brachial plexus – contributing nerve roots all moved up
one, therefore the plexus is derived from C4-C8

• Post-fixed brachial plexus – contributing nerve roots all moved

down one, therefore the plexus is derived from C6-T2

• Individual nerves may also arise from different cords,

intercommunicate with others or be completely absent
Additional Reading/References
Drake et al; “Gray’s Anatomy for Students” – Elsevier Saunders 2004

Netter FH; “Atlas of Human Anatomy, 5th Edition” – Elsevier Saunders 2010

Sinnatamby CS; “Last’s Anatomy, 12th Edition” – Churchill Livingstone 2011

Snell RS; “Clinical Anatomy by Regions, 9th Edition” – Lippincott Williams and
Wilkins 2011
 Thank you!!!
Questions : rob.chidavaenzi@gmail.com