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BRACHIAL PLEXUS
ANATOMY ▶ UPPER LIMB ▶ NERVES ▶ BRACHIAL PLEXUS

The brachial plexus is a bundle of nerves at the base of the neck, it is made up of
the C4, C5, C6, C7, C8 and T1 spinal nerves. These nerves come from several
regions of the spine, including four cervicals and one thoracic region.
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The nerves form midline cords that branch into smaller branches to supply motor
and sensory innervation to the chest, shoulder, arm and hand. The brachial plexus
is a bundle of nerves at the base of the neck that forms three main divisions to
supply motor innervation to parts of the chest, shoulder and arm. These three
cords include several spinal segments (C4-8) as well as one thoracic segment
(T1).
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Brachial Plexus

≣ COMPONENTS OF THE BRACHIAL PLEXUS

 The brachial plexus is a complex network of nerves that originates in the neck
and extends into the arm. It is made up of four main components: roots, trunks,
divisions, and cords.
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The roots of the brachial plexus are located in the neck, divisions behind the
clavicle and the cords in the axilla. and they give rise to the trunks.

≣ ROOTS OF THE BRACHIAL PLEXUS

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The roots of the brachial plexus are the anterior rami of C5 to C8, and most of T1.
Close to their origin, the roots receive gray rami communicates from the
sympathetic trunk. These carry postganglionic sympathetic fibres onto the roots
for distribution to the periphery.

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.
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Brachial Plexus

≣ TRUNKS OF THE BRACHIAL PLEXUS

The three trunks of the brachial plexus originate from the roots, pass laterally
over rib I, and enter the axilla:
 The superior trunk is formed by the union of C5 and C6 roots.
The middle trunk is a continuation of the C7 root.
The inferior trunk is formed by the union of the C8 and T1 roots.

The inferior trunk lies on rib I posterior to the subclavian artery; the middle and
superior trunks are more superior in position.

≣ DIVISIONS OF THE BRACHIAL PLEXUS

Each of the three trunks of the brachial plexus divides into an anterior and a
posterior division:

The three anterior divisions form parts of the brachial plexus that ultimately
give rise to peripheral nerves associated with the anterior compartments of
the arm and forearm.
The three posterior divisions combine to form parts of the brachial plexus
that give rise to nerves associated with the posterior compartments.
No peripheral nerves originate directly from the divisions of the brachial
plexus.

≣ CORDS OF THE BRACHIAL PLEXUS

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

The lateral cord results from the union of the anterior divisions of the upper
and middle trunks and therefore has contributions from C5 to C7—it is
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positioned laterally to the second part of the axillary artery.

The medial cord is medial to the second part of the axillary artery and is the
continuation of the anterior division of the inferior trunk—it contains
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contributions from C8 and Tl.

The posterior cord occurs posterior to the second part of the axillary artery
and originates as the union of all three posterior divisions—it contains
contributions from all roots of the brachial plexus (C5 to T1).

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.

≣ BRANCHES OF THE BRACHIAL PLEXUS

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 Brachial Plexus: Branches

BRANCHES OF THE ROOTS

In addition to small segmental branches from C5 to C8 to muscles of the neck

and a contribution of C5 to the phrenic nerve, the roots of the brachial plexus give
rise to the dorsal scapular and long thoracic nerves.

THE DORSAL SCAPULAR NERVE

Originates from the C5 root of the brachial plexus.

Passes posteriorly, often piercing the middle scalene muscle in the neck.
To reach and travel along the medial border of the scapula and innervates the
rhomboid major and minor muscles from their deep surfaces.

THE LONG THORACIC NERVE

Originates from the 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, and lies on
the superficial aspect of the serratus anterior muscle.

BRANCHES OF THE TRUNKS

The only branches from the trunks of the brachial plexus are two nerves that
originate from the superior trunk (upper trunk): the suprascapular nerve and the
nerve to the subclavius muscle.
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The suprascapular nerve (C5 and C6):

originates from the superior trunk of the brachial plexus,

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passes laterally through the posterior triangle of the neck and through the
suprascapular foramen to enter the posterior scapular region,
innervates the supraspinatus and infraspinatus muscles, and
is accompanied in the lateral parts of the neck and in the posterior scapular
region by the suprascapular artery.

The nerve to the subclavius muscle (C5 and C6) is a small nerve that:

Originates from the superior trunk of the brachial plexus.

Passes anteroinferiorly over the subclavian artery and vein.
Innervates the subclavius muscle.

BRANCHES OF THE LATERAL CORD

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Brachial Plexus: Branches of Lateral Cord

Three nerves originate entirely or partly from the lateral cord of the brachial
plexus.
 The lateral pectoral nerve is the most proximal of the branches from the
lateral cord. It passes anteriorly, together with the thoracoacromial artery, to
penetrate the clavipectoral fascia that spans the gap between the subclavius
and pectoralis minor muscles, and innervates the pectoralis major muscle.
The musculocutaneous nerve is a large terminal branch of the lateral cord. It
passes laterally to penetrate the coracobrachialis muscle and pass between
the biceps brachii and brachialis muscles in the arm, and innervates all three
flexor muscles in the anterior compartment of the arm, terminating as the
lateral cutaneous nerve of the forearm. 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.

BRANCHES OF THE MEDIAL CORD

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Brachial Plexus: Branches of Medial Cord

The medial cord of the brachial plexus has five branches.

 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.
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.
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.
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 is a large terminal branch of the medial cord. However, near
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its origin, it often receives a communicating branch from the lateral root of
the median nerve originating from the lateral cord and carrying fibers from
C7. The ulnar nerve passes through the arm and forearm into the hand where
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it innervates all intrinsic muscles of the hand (except for the three thenar
muscles and the two lateral lumbrical muscles). On passing through the
forearm, branches of the ulnar nerve innervate the flexor carpi ulnaris muscle
and the medial half of the flexor digitorum profundus muscle. The ulnar nerve
innervates skin over the palmar surface of the little finger, medial half of the
ring finger, and associated palm and wrist, and the skin over the dorsal
surface of the medial part of the hand.

Median nerve

The median nerve is 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 and through the arm, into
the forearm, where its branches innervate most of the muscles in the anterior
compartment of the forearm. However, it does not innervate the flexor carpi
ulnaris muscle and the medial half of the flexor digitorum profundus muscle,
which are innervated by the ulnar nerve.
 The median nerve 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, and
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.

The musculocutaneous nerve, the lateral root of the median nerve, the median
nerve, the medial root of the median nerve, and the ulnar nerve form an M over
the third part of the axillary artery. This feature, together with penetration of the
coracobrachialis muscle by the musculocutaneous nerve, can be used to identify
components of the brachial plexus in the axilla.

BRANCHES OF THE POSTERIOR CORD

Five nerves originate from the posterior cord of the brachial plexus:

The superior subscapular nerve

The thoracodorsal nerve
The inferior subscapular nerve
The axillary nerve
The radial nerve.

All these nerves except the radial nerve innervate muscles associated with the
posterior wall of the axilla; the radial nerve passes into the arm and forearm.

1. The superior subscapular, thoracodorsal, and inferior subscapular nerves

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originate sequentially from the posterior cord and pass directly into muscles
associated with the posterior axillary wall. The superior subscapular nerve is
short and passes into and supplies the subscapularis muscle.
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2. 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.
3. The inferior subscapular nerve also passes inferiorly along the posterior
axillary wall and innervates the subscapularis and teres major muscles.
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. A superior lateral cutaneous nerve of the 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 region. The
axillary nerve is accompanied by the posterior circumflex humeral artery.
6. The radial nerve is the largest terminal branch of the posterior cord. It 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. It is accompanied through the triangular interval by the profunda
 brachii artery, which originates from the brachial artery in the anterior
compartment of the arm. The radial nerve and its branches innervate all
muscles in the posterior compartments of the arm and forearm, and 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.
7. The posterior cutaneous nerve of the arm (posterior brachial cutaneous
nerve) originates from the radial nerve in the axilla and innervates skin on the
posterior surface of the arm.

≣ SPINAL SEGMENT, NERVES AND

DISTRIBUTION TABLE
Spinal Nerve(s) Distribution
Segments
c4-c6 Nerve to Subclavius muscle
subclavius
C5 Dorsal scapular Rhomboid and levator scapulae muscles
nerve
C5-C7 Long thoracic Serratus anterior muscle
nerve
C5,C6 Suprascapular Supraspinatus and infraspinatus muscles;
nerve sensory from shoulder joint and scapula
C5-T1 Pectoral nerves Pectoralis muscles
(medial and
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lateral)
c5,c6 Subscapular Subscapularis and teres major muscles
nerves
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Q-C8 Thoracodorsal Latissimus dorsi muscle

nerve
c5 – c6 Axillary nerve Deltoid and teres minor muscles; sensory
from the skin of the shoulder
C8,T1 Medial Sensory from skin over anterior, medial
antebrachial surface of arm and forearm
cutaneous nerve
C5-T1 Radial nerve Many extensor muscles on the arm and
forearm (triceps brachii, anconeus, extensor
carpi radialis, extensor carpi ulnaris, and
brachioradialis muscles); supinator muscle,
digital extensor muscles, and abductor pollicis
muscle via the deep branch; sensory from
skin over the posterolateral surface of the
limb through the posterior brachial cutaneous
nerve (arm), posterior antebrachial cutaneous
 nerve (forearm), and the superficial branch
(radial portion of hand)
C5-C7 Musculocutaneous Flexor muscles on the arm (biceps brachii,
nerve brachialis, and coracobrachialis muscles);
sensory from skin over lateral surface of the
forearm through the lateral antebrachial
cutaneous nerve
C6-T1 Median nerve Flexor muscles on the forearm (flexor carpi
radialis and palmaris longus muscles);
pronator quadratus and pronator teres
muscles; radial half of flexor digitorum
profundus muscle, digital flexors (through the
anterior interosseous nerve); sensory from
skin over the anterolateral surface of the
hand
C8-T1 Ulnar nerve Flexor carpi ulnaris muscle, ulnar half of flexor
digitorum profundus muscle, adductor pollicis
muscle, and small digital muscles through the
deep branch; sensory from skin over medial
surface of the hand through the superficial
branch
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≣ CLINICAL CORRELATION OF THE BRACHIAL

PLEXUS
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LESIONS OF THE BRACHIAL PLEXUS

For understanding the effects of the lesions of the brachial plexus, the student
will find it helpful to know the spinal segments, which control the various
movements of the upper limb:

Adduction of the shoulder is controlled by C5 segment.

Abduction of the shoulder is controlled by C6 and C7 segments.
Flexion of the elbow is controlled by C5 and C6 segments.
The extension of the elbow is controlled by C6 and C7 segments.
Flexion of the wrist and fingers is controlled by C8 and T1 segments.

The important lesions of the brachial plexus are as follows:

Erb’s Paralysis (upper plexus injury)

It is caused by the excessive increase in the angle between the head and
shoulder, which may occur by fall from the back of horse and landing on shoulder
or traction of the arm during the birth of a child. This involves upper trunk (C5 and
C6 roots) and leads to a typical deformity of the limb called policeman’s tip
 hand/porter’s tip hand/waiter’s tip hand. In this deformity, the arm hangs by the
side, adducted and medially rotated, and the forearm is extended and pronated.
The detailed account of clinical features of Erb’s paralysis is as follows:

Adduction of the arm due to paralysis deltoid muscle.

Medial rotation of arm due to paralysis supraspinatus, infraspinatus, and
teres minor muscles.
Extension of the elbow, due to paralysis of biceps brachii.
Pronation of forearm due to paralysis of biceps brachii.
Loss of sensation (minimal) along the outer aspect of the arm due to the
involvement of roots of C6 spinal nerve.

Klumpke’s Paralysis (lower plexus injury)

It is caused by the hyperabduction of the arm, which may occur when one falls on
an outstretched hand or an arm is pulled into machinery or during delivery
(extended arm in a breech presentation. The nerve roots involved in this injury are
C8 and T1 and sometimes C7. The clinical features of Klumpke’s paralysis are as
follows:

Claw hand, due to paralysis of the flexors of the wrist and fingers (C6, C7, and
C8), and all intrinsic muscles of the hand (C8 and T1).
Loss of sensations along the medial border of the forearm and hand (T1).
Horner’s syndrome, (characterized by partial ptosis, miosis, anhydrosis, and
enophthalmos) due to the involvement of sympathetic fibres supplying head
and neck, which leave the spinal cord through T1.
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SURGICAL APPROACH TO AXILLA

The axilla is approached surgically through the skin of the floor of axilla for the
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excision of axillary lymph nodes to treat the cancer of the breast. The structures
at risk during this procedure are intercostobrachial nerve, long thoracic nerve,
thoracodorsal nerve, and thoracodorsal artery. Effort should be made to
safeguard the above structures.

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ANATOMY ▶ UPPER LIMB ▶ NERVES ▶ BRACHIAL PLEXUS

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