THE BRACHIAL PLEXUS

BY JOHN AYUBA
Brachial plexus

• a network of nerve fibres that supplies the

skin & musculature of the:

 upper limb

 parts of the shoulder & pectoral regions

Brachial plexus (contn.)

• originates in the root of the neck

• passes through the interscalene space

• passes through costoclavicular corridor

Course of brachial plexus through interscalene space & costoclavicular
corridor
Brachial plexus (contn.)

• continues into axillary cavity to reach

the root of the upper extremity

• in the axilla its terminal branches are

constituted
Brachial plexus (contn.)

• for much of its course, the plexus is

accompanied by the:

 axillary artery

 subclavian artery

 axillary vein
Brachial plexus (contn.)

• common arrangement is such that the

plexus is formed by the anterior (ventral)
rami (branches) of:

 last four cervical spinal nerves

 first thoracic spinal nerve

Brachial plexus (contn.)

• hence the contributing nerves are:

 cervical spinal nerves C5, C6, C7 & C8

 first thoracic spinal nerve, T1

The spinal cord outflow at
each vertebral level. The
anterior rami of vertebral
levels C5-C8 and T1 make
up the roots of the
brachial plexus
Brachial plexus (contn.)

• however, the origin of the plexus may

shift by:

 one spinal cord segment upwards

or

 one spinal cord segment downwards

Brachial plexus (contn.)

• this results in either:

 a pre-fixed brachial plexus

or

 a post-fixed brachial plexus

Brachial plexus (contn.)

• in a pre-fixed plexus:

 contribution by C4 is large

 contribution from T1 is absent

 hence C4 – C8 constitute plexus

Brachial plexus (contn.)

• in a post-fixed plexus, there is:

 contribution by T2

 C5 contribution is absent

 hence C6 – T2 constitute plexus

Brachial plexus (contn.)

• consists of five components:

(i) roots (ii) trunks

(iii) divisions (iv) cords

(v) terminal branches

Brachial plexus (contn.)

• following mnemonic can help you

remember the components:

 Read That Damn Cadaver Book

Components of
the brachial plexus
Brachial plexus (contn.)

• roots & trunks are located in the neck

• divisions located posterior to the clavicle

• cords located in the axilla

Roots

• refer to the origin of the brachial plexus

from the spinal cord

• roots involved belong to spinal nerves

C5, C6, C7, C8 & T1
Roots (contn.)

• at each vertebral level, paired spinal

nerves arise, one on either side of the body

• they leave the spinal cord via the

intervertebal foramina of the vertebral
column
Spinal nerve, spinal nerve branches (rami) & spinal nerve
roots
Formation of s spinal
nerve & its branches
(rami)
Roots (contn.)

• each nerve then divides into anterior &

posterior ramus (ramus = branch)

• roots of the brachial plexus are formed by the

anterior (ventral) rami of spinal nerves C5-T1
Roots (contn.)

• anterior rami pass between the anterior &

middle scalene (interscalene space)

• posterior (dorsal) rami go on to innervate

the skin & musculature close to the
vertebral column
Deep dissection of the neck – anterior view: note brachial plexus – the
roots are located between anterior & middle scalene muscles
Trunks

• union of the anterior rami of spinal nerves

C5, C6, C7, C8 & T1 forms three trunks

• structures are named according to their

anatomical position

• trunks lie lateral to the interscalene

space superior to the clavicle
Trunks (contn.)

• hence the following trunks are formed:

 upper (superior) trunk

 middle trunk

 lower (inferior) trunk

Trunks (contn.)

• upper trunk formed by union of C5 & C6

anterior rami

• middle trunk is isolated continuation

of C7 anterior ramus

• lower trunk formed by union of C8 &

T1 anterior rami
Formation of trunks
Deep
dissection
of the
neck –
note
formation
of trunks
of the
brachial
plexus
Divisions

• each trunk divides into two branches

known as the anterior & posterior
divisions

• divisions lie posterior to the clavicle

Deep dissection of neck – note formation of divisions of brachial plexus
 2 1
Deep dissection of
the neck – note
formation of the
divisions of the
3 brachial plexus:
4
1. Upper trunk
2. Anterior division
5 3. Posterior
division
4. Middle trunk
6 5. Anterior division
6. Posterior
division
7. Posterior
division
7 8. Anterior division
8 9 9. Lower trunk
Divisions (contn.)

• there are now three anterior & three

posterior divisions

• these divisions pass into the axilla

Divisions (contn.)

• anterior divisions contain neurons

which are destined to flexor muscles

• posterior division has axons destined

to extensor muscles
Brachial plexus – formation of divisions: note that anterior divisions
contain axons for flexor muscles while posterior divisions carry axons
for extensor muscles
Cords

• anterior & posterior divisions enter axilla

& combine to form three cords

• latter are named according their position

relative to the axillary artery
Cords (contn.)

• cords are:

 lateral cord (lateral to axillary artery)

 medial cord (medial to axillary artery)

 posterior cord (posterior to axillary artery)

Relations between the
cords & axillary artery
Cords (contn.)

• lateral cord formed by:

 anterior division of the superior trunk

 anterior division of the middle trunk

Cords (contn.)

• posterior cord formed by:

 posterior division of the superior trunk

 posterior division of the middle trunk

 posterior division of the inferior trunk

Cords (contn.)

• medial cord is formed by:

 anterior division of the inferior trunk

only
Brachial plexus –
formation of cords
Terminal branches

• the three cords give rise to five terminal

branches in the axilla

• terminal branches continue into the upper

limb to provide motor & sensory
innervation
Brachial plexus –
terminal branches
Terminal branches (contn.)

• terminal branches are:

 musculocutaneous nerve
 axillary nerve
 median nerve
 radial nerve
 ulnar nerve
 Note how the different
spinal roots (& their
divisions) contribute
to the different
terminal branches
(see colour codes)

Terminal branches:

31 - Musculocutaneous nerve
37 - Axillary nerve
33 - Median nerve
38 - Radial nerve
35 - Ulnar nerve
Terminal branches (contn.)

• nerves derived from the posterior cord end up

in the posterior compartment of the arm &
forearm

• this is because the posterior cord is

constituted by divisions that contain neurons
for extensor muscles of the upper limb
Terminal branches (contn.)

• hence terminal branches for the posterior

(extensor) compartments are:

 radial nerve

 axillary nerve
Terminal branches (contn.)

• nerves derived from lateral & medial cords

innervate muscles located in the anterior
compartment

• this is because these cords are derived from

divisions containing neurons for flexor
muscles of the upper limb
Terminal branches (contn.)

• hence the terminal branches for the

anterior (flexor) compartments are:

 musculocutaneous nerve

 median nerve

 ulnar nerve
Brachial plexus –
terminal branches
Brachial plexus – formation of terminal branches
Musculocutaneous nerve

• roots: C5, C6, C7

• motor component – innervates:

 brachialis muscle
 biceps brachii muscle
 corocobrachialis muscle
Musculocutaneous nerve (contn.)

• sensory component (lateral antebrachial cutaneous

nerve) innervates:

 the lateral half of the anterior forearm skin

 a small lateral portion of the posterior

forearm skin

• articular branches innervate the joint capsule

of the elbow
Formation of musculocutaneous nerve
 Musculocutaneous
nerve: cutaneous
distribution (right
upper limb)

Anterior view Posterior view

Axillary nerve

• roots: C5 and C6

• motor component – innervates:

 deltoid muscle

 teres minor muscle

Axillary nerve (contn.)

• sensory component - gives off:

• superior lateral cutaneous nerve of arm

 it innervates the inferior region of the

deltoid (“regimental badge area”)
Formation of axillary nerve
 Axillary nerve:
cutaneous distribution
– right upper limb

Anterior view Posterior view

Median nerve

• roots: C6 – C8 and T1

• motor component - innervates:

 most of the flexor muscles in the forearm

 the thenar muscles
 the two lateral lumbrical muscles that
move the index & middle fingers
Median nerve (contn.)

• sensory component - gives off the palmar

cutaneous branch:

 innervates the lateral part of the palm

skin
Median nerve (contn.)

• sensory component – gives off the digital

cutaneous branch:

 innervates skin of the lateral three-and-

half fingers on the anterior (palmar)
surface of the hand
Formation of median nerve
 Median nerve:
cutaneous
distribution -
right upper limb
Anterior view

Posterior view
Radial nerve

• roots: C5-C8 and T1

• motor component - innervates the:

 triceps brachii & anconeus

 extensor muscles in the posterior

compartment of the forearm
Radial nerve (contn.)

• sensory component – innervates:

 posterior aspect of the arm & forearm

skin (posterior brachial & antebrachial
cutaneous nerves)

 posterior, lateral aspect of the hand skin

(by its superficial branch)
Formation of radial nerve
 Radial nerve:
cutaneous
distribution –
right upper
limb

Anterior view Posterior view

Ulnar nerve

• roots: C8 and T1

• motor component – innervates:

 muscles of the hand (apart from thenar

muscles & two lateral lumbricals)
 flexor carpi ulnaris
 medial half of flexor digitorum profundus
Ulnar nerve (contn.)

• sensory component – innervates:

 anterior & posterior skin of medial

one-and-half fingers (palmar & dorsal
branches)

 skin of associated palm area (palmar

branch)
Formation of ulnar nerve
 Ulnar nerve:
cutaneous
distribution
– right upper
limb

Anterior view Posterior view

 (C8, T1)
(C8, T1)

Summary of cutaneous nerve

distribution of the 5 terminal
branches (right upper limb)
Summary of
cutaneous nerve
distribution of
the 5 terminal
branches (right
upper limb)
Cutaneous
nerves &
superficial veins
of shoulder &
arm
Cutaneous
nerves &
superficial veins
of shoulder &
forearm
Other branches

• there are other nerves that arise from

all 5 components of the brachial plexus
Other branches (contn.)

(I) from roots:

 long thoracic nerve/nerve to serratus

anterior (C5, C6, & C7)

 dorsal scapular n./nerve to rhomboids (C5)

 branches to scalene muscles & longus colli

(C5, C6, C7, and C8)
Other branches (contn.)

(II) from trunks:

 suprascapular nerve (C5 and C6)

 nerve to subclavius (C5 and C6)

Other branches (contn.)

(III) from cords:

1. from lateral cord:

 lateral pectoral nerve (C5, C6, and C7)

Other branches (contn.)

2. from medial cord:

 medial pectoral nerve (C8 and T1)

 medial cutaneous nerve of arm (T1)

 medial cutaneous nerve of forearm

(C8 and T1)
Other branches (contn.)

3. from posterior cord:

 thoraco-dorsal nerve/nerve to latissimus

dorsi (C6, C7, and C8)

 upper subscapular nerve (C5 and C6)

 lower subscapular nerve (C5 and C6)

Other branches of
the brachial plexus
Some clinical aspects

• there are two major types of injuries that

can affect the brachial plexus

 an upper brachial plexus injury that affects

the superior roots

 a lower brachial plexus injury that affects

the inferior roots
Lesions of the brachial plexus

• nerve injuries vary in severity:

 from a mild stretch of nerves

to

 nerve root tearing away from the

spinal cord
Lesions of the brachial plexus (contn.)

• injuries include the following:

 avulsion

 rupture

 neuroma

 neurapraxia
Some of the possible brachial
plexus lesions
Lesions of the brachial plexus (contn.)

• avulsion:

 nerve is torn away from its attachment

at the spinal cord

 this is the most severe type of injury

Lesions of the brachial plexus (contn.)

• rupture:

 nerve is torn, but not at the spinal cord

attachment
Lesions of the brachial plexus (contn.)

• neuroma:

• scar tissue grows around the injury site,

resulting in:

 compression of the injured nerve

 nerve failing to send signals to the muscles

Lesions of the brachial plexus (contn.)

• neurapraxia:

 nerve has been stretched & damaged

but not torn

 most common type of injury

 such injuries normally heal on their own

Conditions involving brachial plexus injuries

• these include:

 Erb’s palsy (Erb–Duchenne palsy)

 Klumpke palsy

 brachial plexus compression syndrome

Upper brachial plexus injury – Erb’s palsy

• involves the upper root nerves of C5, C6

• commonly occurs where there is excessive

increase in the angle between the neck
& shoulder

• this stretches (or can even tear) the nerve

roots
Erb’s palsy (contn.)

• can occur as a result of:

 a difficult birth (dystochia)

 shoulder trauma in the adult

Shoulder dystochia

• occurs when anterior shoulder is obstructed

behind the symphysis pubis

• during manipulation to deliver the fetus, the

the neck & posterior shoulder are stretched

• this may cause injury to the upper brachial

plexus roots
Pubic symphysis

Two-dimensional sagittal view of shoulder dystocia during which the

anterior shoulder is impacted behind the pubic symphysis.
Excessive stretching of the head & neck away from the shoulder during
traction maneuvers in a case of shoulder dystochia
Shoulder trauma

• usually follows trauma that causes severe

stretching between the neck & shoulder, e.g.,

 a high fall in which one lands on

the shoulder

 heavy impact during physical sports,

e.g., rugby, American football, etc.
Stretching the shoulder &
neck due to a fall from
the height and landing on
the shoulder
Erb’s palsy (contn.)

nerves affected:

• only nerves derived from C5 or C6 roots

are affected:

 musculocutaneous
 axillary
 suprascapular
Erb’s palsy (contn.)

• effect on motor functions:

• following movements are lost or greatly

weakened:

 abduction at shoulder
 lateral rotation of arm
 supination of forearm
 flexion at shoulder
Erb’s palsy (contn.)

• effect on sensory functions:

 loss of sensation down lateral side of arm

• this is territory covered cutaneous

branches of the axillary & musculo-
cutaneous nerves
Erb’s palsy (contn.)

• affected limb hangs limply

• medially rotated by the unapposed

action of pectoralis major
Erb’s palsy (contn.)

• forearm is pronated due to the loss of

biceps brachii

• position is known as ‘waiter’s tip’, & is

characteristic of Erb’s palsy
Erb’s palsy -
waiters’ tip
position
The waiters’ tip position, characteristic of
Erb’s palsy. Coloured part represents skin
area that has lost sensation.
Lower brachial plexus injury – Klumpke palsy

• involves lower root nerves derived

from C8, T1

• lower brachial plexus injury results from

excessive abduction of the arm

• has a much lower incidence than Erb’s

palsy
Klumpke palsy (contn.)

• excessive abduction of the arm may occur

following, for example:

 traction on an abducted arm as in

dystochia

 person catching a branch as they fall from

a tree
Klumpke palsy (contn.)

• traction on an abducted arm may occur as

the infant is being pulled from the birth
canal

• in such a situation, the arm is stretched

& extended arm above the head
Traction of the fetus with an extended arm above the head – leading
to an excessive increase in the angle between the trunk and the right
upper limb
Klumpke palsy (contn.)

• in the adult, such an increase in the angle

may occur as one catches a branch while
falling from a tree
Klumpke palsy (contn.)

• effect on motor functions:

 loss of adduction of the thumb

(ulnar nerve)

 loss of abduction & adduction of

metacarpophalangeal joints
(deep branch of ulnar n. & median n.)
Effect on motor functions (contn.):

• there is paralysis of the interosseous

& lumbrical muscles

• these muscles:

 flex the metacarpophalangeal joints

 extend proximal & distal inter-

phalangeal joints
Effect on motor functions (contn.):

• hence there is:

 loss of flexion of metatarsophalangeal joint

(deep branch of ulnar n. & median n.)

 loss of extension of interphalangeal joints

(deep branch of ulnar n. & median n.)
Effect on motor functions (contn.):

• overall effect resulting from the above

motor deficits leads to a ‘claw hand’

• there is paralysis of the flexors of the

wrist & fingers (C6, C7 & C8), & all
intrinsic muscles of the hand (C8 & T1)
A claw hand results
as one attempts to
assume “fist”
position (lightly
shaded)
Effect on sensory function:

• is due to loss of ulnar & medial

antebrachial cutaneous nerves

• sensory loss to the ulnar side of the:

 forearm
 hand
 ulnar 1.5 digits
Claw hand and sensory distribution of ulnar nerve
Brachial plexus compression syndrome

• caused by compression of the

neurovascular structures in the
cervicoaxillary region

• may be congenital or acquired

Brachial plexus compression syndrome (contn.)

• neurovascular structures involved are:

 subclavian vessels

 brachial plexus
Brachial plexus compression syndrome (contn.)

• subdivided into:

 scalene syndrome or cervical rib syndrome

 costo-clavicular syndrome

 hyper-abduction syndrome
Scalene syndrome

• caused by narrowing of interscalene

space by:

 a cervical rib

or

 a ligamentous structure
Scalene syndrome (contn.)

• condition occurs in about 1% of the

population

• cervical rib narrows the interscalene space

Scalene syndrome (contn.)

• sometimes there is no bony contact

between the cervical rib & the first rib

• instead, this site is occupied by a

ligamentous structure
Scalene syndrome (contn.)

• trunks of the brachial plexus & subclavian

artery traverse this space

• narrowing of the space causes

compression of the neurovascular
structures from below & behind
Cervical rib
forming complete
bony union with
first rib – note
neurovascular
bundle passing
behind the
anterior scalene
muscle
Ligamentous
structure
connecting the
cervical rib
to the first rib
Scalene syndrome (contn.)

• symptoms include:

 pain radiating down the arm, chiefly on

the ulnar side of the hand

 ischemic muscle pain (caused by

poor blood supply) in the upper limb
Costoclavicular syndrome:

• is compression of neurovascular bundle

between first rib & clavicle

• caused by narrowing of the costoclavicular

space
Costoclavicular syndrome (contn.):

• narrowing of this space is rare

• condition common in individuals with:

 drooping shoulders
 retracted shoulders (due to carrying heavy
loads)
 a previous clavicular fracture
Costoclavicular syndrome (contn.):

• symptoms similar to those associated with

scalene syndrome

• may include signs of venous stasis due

compromised return through subclavian
vein
Costoclavicular syndrome – note compression of
neurovascular bundle between clavicle & first rib
Hyperabduction syndrome:

• compression of neurovascular bundle

below pectoralis minor & coracoid process

• rare condition
Hyperabduction syndrome (contn.):

• condition precipitated by maximum

abduction or elevation of the arm on
the affected side

• symptoms include radiating pain in the

upper limb
Hyperabduction syndrome - bundle compressed beneath tendon of
pectoralis minor under coracoid process.