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Brachial Plexus &
Nerves
ANAT331 UL4
Dr Phil Blyth
Grays 2nd pp700-9,720-4,743-4,751,770-2
 The Upper Limb
Pectoral girdle (clavicle & scapula)
with upper humerus = shoulder
region

Arm

Forearm

Hand

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig7.1
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 Lectures
1.  General principles & superficial structures
2.  Shoulder and axilla G2nd p665-683,684-694,709
3.  Deep fascia, arm & forearm muscles
G2nd pp710-7,731-41,745-750
4.  Brachial plexus and nerves, G2nd
pp700-9,720-4,743-4,751,770-2

5.  Elbow joint G2nd 724-730

6.  Cubital fossa, carpal tunnel, wrist
7.  Arteries, veins & lymphatics
8.  Hand 5
 Overview

  Brachial Plexus

  Roots, Trunks, Divisions, Cords

  Peripheral nerves

  Nerve injuries

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 Brachial plexus

  Plexus: "a network of
nerves”

  Brachial plexus of nerves

formed in the neck,

  Enters the axilla where

  It surrounds the axillary
artery

Netter FH. Atlas of Human Anatomy. 4th ed. 2006, Saunders 7

 Nerve supply of the limbs

  Mixed spinal nerves exit
vertebral foramina
Dorsal & Ventral
Roots
Spinal nerve

  Dorsal ramus smaller

  supplies skin & muscles of
back

  Ventral ramus larger

  forms all major somatic
plexuses

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 1.60
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Brachial plexus Roots
Trunks C5

Divisions C6
C7
Cords
C8
T1

1st rib

Netter FH. Atlas of Human Anatomy. 4th ed. 2006, Saunders 9

Roots deep in neck. Trunks in the posterior triangle.
Divisions behind clavicle. Cords in the axilla.

Superior cervical
sympathetic ganglion

Gray ramus
communicans

Middle cervical
sympathetic ganglion

Inferior cervical
sympathetic ganglion

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.51
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 Brachial plexus

  Plexus: "a network of nerves”

  roots formed by ventral rami of spinal nerves

  C5 – T1

  roots combine
trunks

  trunks divide
anterior + posterior divisions

  divisions combine
cords

  cords divide and combine
peripheral nerves

  Musculocutaneous nerve (C5,6,7)

  Axillary nerve (C5,6)

  Radial nerve (C5-C8[T1])

  Median nerve (C6-T1)

  Ulnar nerve (C7,8,T1)
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Musculocutaneous

Median

Radial &
Axillary

Ulnar

* Musculocutaneous nerve (C5,6,7) * Axillary nerve (C5,6) * Radial nerve (C5-C8[T1])

• Median nerve (C6-T1) * Ulnar nerve (C7,8,T1)
Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.51
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Cords - related to 2nd part of axillary
artery

Lateral Cord

Posterior Cord Medial Cord

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.51
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Most major nerves originate from the cords

© Netter

NB Ulnar nerve (C7,8,T1) receives C7 fibres from branch of lateral cord 14

Branches of Roots (4)
& Trunks (1)

Dorsal scapular nerve

Nerve to subclavius C5 branch to phrenic nerve

Suprascapular nerve

Long thoracic nerve

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.53
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 Learn the Brachial Plexus
in Five Minutes or Less

By Daniel S. Romm , M.D. Romm

Chief, Physical Medicine and
Rehabilitation
Department of Veterans Affairs, Biloxi,
Mississippi
and Dennis A. Chu , M.D. Chu

http://www.ama-assn.org/ama1/pub/upload/mm/15/brachial_plex_how_to.pdf
 The steps

  2Headless arrows to the right.

  1Headless arrow to the left.

  W on the right

  X in the middle

  Y(just the tail) in the middle

  Label the branches

  The four 3s

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 Branches from Lateral Cord (3)
Lateral pectoral nerve

Musculocutaneous nerve

Median nerve
(lateral ‘head’)

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Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students.
2nd Edition Fig 7.54
Branches from Medial Cord (5)

Medial pectoral nerve

Medial cutaneous nerves of

arm and forearm

Median nerve
(medial ‘head’)

Ulnar nerve

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.54
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 Branches from Posterior Cord (5)

Superior subscapular nerve

Axillary nerve

Thoracodorsal nerve

Radial nerve
Inferior subscapular nerve

Radial n supplies all muscles of posterior compartment arm & forearm + skin
Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.55
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Identifying nerves: the musculocutaneous
nerve penetrates coracobrachialis

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Identifying nerves: median nerve forms the
letter ‘M’ over axillary artery (lateral & medial cords)

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Brachial plexus injuries

  Obstetric

  Trauma (e.g. motorbike)

  Partial & Total

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 Brachial plexus injuries

Upper root (C5 & C6) injuries mostly affect musculocutaneous & axillary n
Lower roots (C8 & T1) distributed more with ulnar nerve
Netter FH. Atlas of Human Anatomy. 4th ed. 2006, Saunders
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Brachial plexus injuries
Upper root injuries: (C5 & 6)
Shoulder and biceps weakness
or paralysis

Lower root injuries: C8 & T1

Weakness of distal upper limb
& clawing of fingers

Complete injury: C5 –T1

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 Peripheral nerve injury

  Swelling of cell body, inflammatory infiltrate, distal

Wallerian degeneration

  Growth factors produced by Schwann cells stimulate

the proximal nerve tissue to sprout new axons within
24h

  Regrowth of axons only in myelinated peripheral nerve

fibres, progressing at 1-4 mm/d, continuing over
months

  Some axons eventually reach and reinnervate the

distal stump. If the axons fail to progress past the
injury site, a neuroma may form
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 Peripheral nerve injuries
•  Neurapraxia: mild injury, nerve
components remain intact, recovers
completely
Neurapraxia
•  Axonotmesis: Wallerian
degeneration distally, recovery often
complete because connective tissues
Axonotmesis
remain intact

•  Neurotmesis: transection of the

nerve, disruption of perineurium, Neurotmesis
minimal recovery

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Axillary nerve

  branch of posterior cord
Axillary nerve

  winds around surgical neck Posterior circumflex humeral artery
humerus

  supplies deltoid and teres Radial nerve
minor and becomes upper
lateral cutaneous nerve of
arm

  - may be injured in
dislocation of shoulder or #
neck of humerus

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.37
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 Lateral cord of the brachial plexus

Musculocutaneous nerve

Coracobrachialis muscle Cutaneous innervation

of lateral cutaneous
nerve of forearm
Biceps brachii muscle

Brachialis muscle

Lateral cutaneous
nerve of forearm

Netter FH. Atlas of Human Anatomy. 4th ed. 2006, Saunders 29

 Musculocutaneous nerve

  - branch of lateral cord

  - passes through coracobrachialis

  - supplies coracobrachialis, biceps brachii, and
brachialis

  - becomes lateral cutaneous nerve forearm

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 Median nerve

  arises from lateral and
medial cords

  in arm runs with brachial

artery and crosses from
lateral to medial

  no muscular branches in
arm Median nerve

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.54
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 Median nerve

Median nerve

  In forearm enters between 2
heads of pronator teres,
runs down between FDS &
FDP, lying between Palmaris
Anterior interosseous nerve
longus and Flexor carpi
radialis at wrist

  Supplies most forearm flexor
muscles (with anterior
interosseous branch) and
some hand muscles

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.86
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 Hand: Median nerve

Digital nerves

Flexor retinaculum (bridges

over carpal tunnel) Recurrent branch

Palmar branch
Median nerve

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.109
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Median nerve injury (at wrist)

  eg in carpal tunnel, laceration of wrist

  loss of sensation, lateral 3½ digits

  paralysis of thenar muscles

  loss of coordination and strength of thumb
& inability to oppose thumb

  paralysis of first two lumbricals

  impaired fine control index & middle fingers

  problems with buttons, etc
Netter FH. Atlas of Human Anatomy. 4th ed. 2006, Saunders 34
 Median nerve injury (at elbow)

  in addition ….

  loss of flexion of interphalangeal joints 2nd and 3rd
finger (index and middle). Why not 4th and 5th?

  Often complex injuries

  eg plate glass laceration of tendons and nerves

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 Ulnar nerve Medial cord

  - from medial cord

  - runs medially in arm,
penetrating medial
intermuscular septum to Ulnar nerve
enter posterior compartment

  passes behind medial Medial intermuscular septum

epicondyle

  no branches in arm
Medial epicondyle

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.67
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 Ulnar nerve

Ulnar nerve Flexor carpi

ulnaris (cut)

  In forearm, enters ant compartment

between 2 heads of Flexor carpi ulnaris Flexor digitorum
superficialis
and runs down to wrist on FDP

  supplies Flexor carpi ulnaris and medial ½
Flexor digitorum profundus

  medial to ulnar artery at wrist

  supplies most intrinsic hand muscles Dorsal (sensory)
branch of ulnar

  palmar & dorsal branches given off nerve
proximal to wrist
Palmar branch

  does NOT pass under flexor retinaculum of ulnar nerve

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Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students.
2nd Edition Fig 7.86
 Hand: Ulnar nerve

Deep branch of Superficial branch

ulnar nerve of ulnar nerve

Ulnar nerve Ulnar artery

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Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students.
2nd Edition Fig 7.108
 Ulnar nerve injury

  "clawhand" appearance, >> in 4th & 5th digits

  MCP joints extended, IP joints flexed (most
intrinsic muscles of hand paralysed)

  Sensory loss medial 1½ digits

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  In the forearm most flexor muscles are supplied by
median nerve

  Exceptions (supplied by ulnar nerve)

  flexor carpi ulnaris

  medial half of flexor digitorum profundus

  In the hand most muscles supplied by ulnar nerve

  Exceptions (supplied by median nerve)

  thenar eminence

  lateral two lumbrical muscles

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 Radial
nerve
Profunda brachii artery
- from the posterior cord

- in posterior compartment of arm

Radial nerve
(in radial groove)
- winds around humerus in spiral
groove and pierces lateral
intermuscular septum Lower lateral cutaneous
nerve of arm

- passes in front of lateral epicondyle &

divides into two branches before
entering forearm Posterior cutaneous
nerve of forearm
- supplies triceps and all extensor
muscles of forearm

- cutaneous branches to back of hand

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.68
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 Radial nerve

  - divides into deep &
superficial branches under
brachioradialis Radial nerve

  deep branch passes through

2layers of supinator to
posterior compartment Deep branch

(posterior interosseous n) of radial nerve

  superficial branch passes

dorsally under brachioradialis Superficial branch
radial nerve
tendon and on to dorsum of
hand (sensory) Supinator

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Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students.
2nd Edition Fig 7.74
 Hand: Radial nerve

Only the superficial (sensory) branch enters the hand

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Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students.
2nd Edition Fig 7.110
 Radial nerve injury

  paralysis of extensor muscles of forearm
wrist drop

  digits slightly flexed at MCP joints

  IP joints may be extended weakly by lumbricals and
interossei (median & ulnar nerves)

  sensory loss on dorsum of hand

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 Useful ‘rules’
Spinal nerve roots can be tested by:

  cutaneous sensation (dermatomes)

  joint movements (myotomes)

  tendon reflexes

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Dermatome

  area of skin supplied by a
single spinal cord segment

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Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students.
2nd Edition Fig 7.15
 Myotomes
Elbow flexion C5,6
Abduction arm C5

Finger abd/add T1
Finger flexion C8

Drake, R. L., W. Vogl, et al. (2010). Gray's anatomy for students. 2nd Edition Fig 7.04,88
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 Identify the nerves at risk
and consider the functional
effects of injury

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Sources of
illustrations ©

  Drake RL, et al. Gray’s Anatomy for Students (2005), Elsevier Inc (G)

  Moore KL & Dalley AF, Clinically Oriented Anatomy. 5th ed. (2005),
LWW (M5)

  Netter FH. Atlas of Human Anatomy. 4th ed. 2006, Saunders

  Schuenke M et al. Thieme Atlas of Anatomy, 2006 (& DVD 2007)

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 Terms Requirements

  Thou shalt attend the labs, and swipe your card ☺

  Thou shalt check your student email.

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