THE BRACHIAL PLEXUS IN A NUTSHELL

the brachial plexus is a complex intercommunicating network of nerves formed by spinal nerves C5,
C6, C7, C8 and T1

it supplies all sensory innervation to the upper limb and most of the axilla, with the exception of an
area of the medial upper arm and axilla, which is supplied by the intercostobrachial nerve T2

it supplies all motor innervation to the muscles of the upper limb and shoulder girdle, with the
exception of trapezius, which is supplied by the spinal accessory nerve IX

it also supplies autonomic innervation to the upper limb by intercommunicating with the stellate
ganglion of the sympathetic trunk at the level of T1, where it gains sympathetic fibres which supply
specialist functions:
o

vasomotor stimulates vasoconstriction of arteries, arterioles and capillaries resulting in skin pallor
and coldness
pilomotor stimulates contraction of arrector pili muscles within hair follicles, making hairs stand on

o
end
o

sudomotor or secretomotor stimulates production of sweat from sweat glands

the brachial plexus begins as the anterior rami of five spinal nerve roots C5-T1, which emerge from
the intervertebral foramen of their respective vertebrae to lie in the posterior triangle of the neck between
the anterior and medial scalene muscles

the five spinal nerves quickly unite to form superior, middle and inferior trunks, which continue to
pass laterally between the anterior and medial scalene muscles and cross the base of the posterior
triangle of the neck, where they can be found behind the subclavian artery. They pass over the apex of
the lung and the first rib towards the clavicle.

behind the middle third of the clavicle, each trunk splits into an anterior division and a posterior
division. These continue to pass downwards behind the clavicle to enter the axilla.

the six divisions combine to form lateral, posterior and medial cords. These are distributed around
and named according to their relationship with the second part of the axillary artery, which is located
behind the pectoralis minor muscle. The cords travel laterally with the axillary artery towards the arm. The
artery and cords are ensheathed by an extension of the prevertebral fascia known as the axillary sheath
this is a target for brachial plexus nerve blocks.

the cords divide around the third part of the axillary artery into their five terminal branches:
the musculocutaneous, axillary, radial, median and ulnar nerves. These are summarised below and
described in detail in a separate article here.

the brachial plexus gets its blood supply from various branches of the subclavian artery along its
length, including:
o

ROOTS vertebral artery, anterior and posterior spinal arteries

TRUNKS + DIVISIONS ascending and deep cervical arteries, superior intercostal artery

CORDS axillary artery

STRUCTURE OF THE BRACHIAL PLEXUS

The diagram below summarises the structure and branches of the brachial plexus in all its
demoralising glory. You can click to make it bigger!

Some key points to take away from this diagram are:

o

the brachial plexus is easier to learn if you break it down into its component segments and tackle
them one at a time: these are roots, trunks, divisions, cords and terminal branches

ROOTS: there are five nerve roots from C5-T1, which give three nerve branches: the dorsal
scapular nerve, the long thoracic nerve and 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, which is not shown on the
diagram.

TRUNKS: the five nerve roots combine to form three trunks. The superior trunk is formed
from C5 and C6. The middle trunk is formed from C7. The inferior trunk is formed from C8 and T1.
The superior trunk gives two nerve branches: the suprascapular nerve and the nerve to subclavius.
The middle and inferior trunks do not give off any extra branches.

DIVISIONS: there are six divisions in total, comprising an anterior division and a posterior
division from each of the three trunks. Anterior division fibres usually supply flexor muscles,
and posterior division fibres usually supplyextensors. There are no extra nerve branches arising from
the divisions.

CORDS: the divisions combine to form three cords, which are distributed around the axillary artery:

o
o

the lateral cord is formed from the anterior divisions of the superior and middle trunks. It gives one
extra nerve branch: the lateral pectoral nerve.

the posterior cord is formed from the posterior divisions of the superior, middle and inferior trunks.
It gives three nerve branches: the upper subscapular nerve, the thoracodorsal nerve and the lower
subscapular nerve.

the medial cord is formed from the anterior division of the inferior trunk. It gives three nerve
branches: the medial pectoral nerve, the medial cutaneous nerve of the arm (also known as the medial
brachial cutaneous nerve) and the medial cutaneous nerve of the forearm (also known as the medial
antebrachial cutaneous nerve).

TERMINAL BRANCHES: the three cords branch to form five terminal nerve branches which supply
the upper limb. The lateral cord gives the musculocutaneous nerve and the lateral root of the median
nerve. The posterior cord gives the axillary nerve and the radial nerve. The medial cord gives
the medial root of the median nerve and the ulnar nerve.

it is very easy to panic when given a diagram or prosection of the brachial plexus to label in exams.
The way to stay calm is to look for the M shape formed around the axillary artery by
the musculocutaneous, median and ulnar nerves. This is a really easy landmark to find and will give you
your bearings. Once you have found this, you should be able to confidently identify those three nerves. You
will then be able to identify the small axillary nerve and large radial nerve originating from the posterior cord
behind the axillary artery. The medial cutaneous nerves of the arm and forearm can be found travelling
down the arm below the ulnar nerve. The three branches from the posterior cord should also be easy to
spot you will see the two small subscapular nerves and the large thoracodorsal nerve between them,
which forms a bundle with the thoracodorsal artery and vein to supply latissimus dorsi. Any extra branches
you can spot after that will definitely be merit points!

there are many recognised anatomical variations to this structure, which may affect over 50% of
people! The most significant ones include:
o

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 helpfully decide to arise from different cords, intercommunicate with
others or be completely absent. Thankfully, while this is probably totally fascinating to neurologists and plastic
surgeons, you should never be given an atypical brachial plexus in your exams!

You will be expected to know what each of the nerves of the brachial plexus actually does. I have
provided a brief outline of the origin and function of each of the nerve branches below. I have also
covered the five terminal branches to the upper limb in lots more detail in a separate article here.

NERVES OF THE BRACHIAL PLEXUS:

BRANCHES FROM THE NERVE ROOTS
DORSAL SCAPULAR NERVE C5
o

ORIGIN: C5 nerve root of the brachial plexus

SENSORY SUPPLY: none

MOTOR
SUPPLY: levator
scapulae (elevates
minor (stabilise, retract and medially rotate scapula)

scapula), rhomboid

major and rhomboid

LONG THORACIC NERVE (OF BELL) C5/C6/C7

o

ORIGIN: C5, C6 and C7 nerve roots of the brachial plexus

SENSORY SUPPLY: none

MOTOR SUPPLY: serratus anterior (protracts and stabilises scapula)

CLINICAL SIGNIFICANCE: the long thoracic nerve often crops up in exam questions. An injury to the
long thoracic nerve, for example as a result of a sports injury or damage during axillary surgery, results in
winging of the scapula on examination. The deformity may be visible at rest, and a classic way to elicit
or exaggerate it in an OSCE is by asking the patient to push against a wall and looking for abnormal
posterior protrusion of the scapula on the affected side.

FIRST INTERCOSTAL NERVE T1

o

ORIGIN: T1 nerve root of the brachial plexus

SENSORY SUPPLY: narrow strip of skin over first intercostal space

MOTOR SUPPLY: first intercostal muscles (elevate and depress ribcage during inspiration and
expiration)

NERVES OF THE BRACHIAL PLEXUS:

BRANCHES FROM THE TRUNKS
SUPRASCAPULAR NERVE C5/C6
o

ORIGIN: superior trunk of the brachial plexus

SENSORY SUPPLY: glenohumeral and acromioclavicular joints

MOTOR SUPPLY: supraspinatus (stabilises and abducts shoulder) and infraspinatus (stabilises and
externally rotates shoulder)

NERVE TO SUBCLAVIUS C6
o

ORIGIN: superior trunk of the brachial plexus

SENSORY SUPPLY: none

MOTOR SUPPLY: subclavius (depresses clavicle and elevates first rib)

NERVES OF THE BRACHIAL PLEXUS:

BRANCHES FROM THE CORDS
LATERAL PECTORAL NERVE C5/C6/C7

ORIGIN: lateral cord of the brachial plexus

SENSORY SUPPLY: none to skin, but it is thought to play an important role in the sensation of chest
wall pain, for example after mastectomy or breast implant insertion, and is therefore a target for regional
nerve blocks

MOTOR SUPPLY: upper clavicular part of pectoralis major (flexes, adducts and internally rotates
shoulder)

UPPER SUBSCAPULAR NERVE C5/C6

o

ORIGIN: posterior cord of the brachial plexus

SENSORY SUPPLY: none

MOTOR SUPPLY: subscapularis (stabilises and internally rotates shoulder)

LOWER SUBSCAPULAR NERVE C5/C6

o

ORIGIN: posterior cord of the brachial plexus

SENSORY SUPPLY: none

MOTOR SUPPLY: subscapularis (stabilises and internally rotates

major (adducts and internally rotates shoulder, protracts and depresses scapula)

shoulder)

and teres

THORACODORSAL NERVE C6/C7/C8

o

ORIGIN: posterior cord of the brachial plexus

SENSORY SUPPLY: none

MOTOR SUPPLY: latissimus dorsi (extends, adducts and internally rotates shoulder, externally
rotates trunk)

CLINICAL SIGNIFICANCE: the thoracodorsal nerve is vulnerable to injury during axillary dissection,
for example during lymph node clearance for breast cancer. This results in shoulder movement
weakness, which is best elicited on examination by asking the patient to place the dorsum of their hand on
the opposite buttock to test extension, adduction and internal rotation. Thankfully, most patients do not
suffer from significant loss of function in terms of day-to-day activities, but elderly people may struggle to
pull themselves up from a sitting position, and young climbers or bodybuilders are likely to notice
significantly reduced performance on the affected side.

MEDIAL PECTORAL NERVE C8/T1

o

ORIGIN: medial cord of the brachial plexus

SENSORY SUPPLY: none to skin, may have a role in sensation of chest wall pain following breast
surgery

MOTOR SUPPLY: pectoralis minor (stabilises scapula, raises ribs during inspiration) and lower
sternocostal part of pectoralis major (extends, adducts and internally rotates shoulder)

MEDIAL CUTANEOUS NERVE OF ARM T1

o

ORIGIN: medial cord of the brachial plexus

SENSORY SUPPLY: skin of lower third of medial arm

MOTOR SUPPLY: none

MEDIAL CUTANEOUS NERVE OF FOREARM C8

o

ORIGIN: medial cord of the brachial plexus

SENSORY SUPPLY: skin over biceps muscle, antecubital fossa and medial forearm

MOTOR SUPPLY: none

NERVES OF THE BRACHIAL PLEXUS: THE

TERMINAL BRANCHES
These are the five most important ones for your exams! Ive summarised them here and also
provided a separate, more detailed article on the nerve supply to the upper limb (with its own
summary diagram!) here.

MUSCULOCUTANEOUS NERVE C5/C6/C7

o

ORIGIN: lateral cord of the brachial plexus

SENSORY SUPPLY: lateral forearm

MOTOR SUPPLY: anterior compartment of arm: biceps (flexes elbow,

forearm), brachialis (flexes elbow) and coracobrachialis (adducts shoulder, flexes elbow)

CLINICAL SIGNIFICANCE: musculocutaneous nerve injuries are rare, but result in very weak elbow
flexion and weak forearm supination which can be very disabling.

AXILLARY NERVE C5/C6

o

ORIGIN: posterior cord of the brachial plexus

SENSORY SUPPLY: sergeants patch over lower deltoid

supinates

MOTOR SUPPLY: deltoid (abducts, flexes and extends shoulder) and teres minor (stabilises and
externally rotates shoulder)

CLINICAL SIGNIFICANCE: the axillary nerve may be injury by shoulder dislocations or proximal
humeral fractures, resulting in numbness over the sergeants patch and profound weakness of shoulder
abduction from 15-90. Other examination findings include deltoid wasting and weakness of shoulder
flexion, extension and external rotation.

RADIAL NERVE C5/C6/C7/C8/T1

o

ORIGIN: posterior cord of the brachial plexus

SENSORY SUPPLY: posterior arm and forearm, lateral of dorsum of hand and proximal dorsal
aspect of lateral 3 fingers

MOTOR SUPPLY: the radial nerve supplies the posterior compartment of arm, which
contains triceps (extends and adducts shoulder, extends elbow). It also supplies the entirety of
the posterior
compartment
of
the
forearm.
This
consists
of brachioradialis (flexes
elbow), anconeus (extends elbow, stabilises elbow joint), supinator (supinates forearm), extensor carpi
radialis longus and brevis (extend and abduct wrist), extensor carpi ulnaris (extend and adduct
wrist), extensor digitorum, extensor pollicis longus and brevis, extensor indicis and extensor digiti
minimi (extend thumb and fingers at MCPJs and IPJs) and abductor pollicis longus (abducts thumb).

CLINICAL SIGNIFICANCE: radial nerve injuries are commonly due to compression, for example by
leaning or lying on the arm for extended periods, excessively tight plaster casts or prolonged tourniquet
use. It can also be damaged by fractures of the humerus or radius, or by stab wounds. Radial nerve injury
results in loss of innervation to the muscles of the posterior compartments of the arm and forearm. This
manifests as numbness in the radial nerve distribution and a wrist drop deformity with very weak
extension of the elbow, wrist and fingers.

MEDIAN NERVE C5/C6/C7/C8/T1

o

ORIGIN: lateral and medial cords of the brachial plexus

SENSORY SUPPLY: thenar eminence, lateral palm of hand, palmar aspect of lateral 3
fingers, and dorsal fingertips of lateral 3 fingers

MOTOR SUPPLY: all muscles of anterior compartment of forearm EXCEPT flexor carpi ulnaris and
the medial two parts of flexor digitorum profundus. The median nerve therefore supplies pronator teres,
flexor carpi radialis, palmaris longus, flexor digitorum superficialis, the lateral two parts of flexor digitorum
profundus, flexor pollicis longus and pronator quadratus. These forearm muscles flex the wrist, the proximal
interphalangeal joints of all four fingers and the distal interphalangeal joints of the index and middle fingers.
They also pronate the forearm and abduct the wrist. The median nerve also supplies the LOAF muscles of
the hand: the lateral two lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis
brevis. The lumbricals flex the MCPJs and extend the IPJs of the index and middle finger. The muscles of
the thenar eminence flex, abduct and oppose the thumb.

CLINICAL SIGNIFICANCE: the median nerve is 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. It can also be injured by supracondylar fractures of the humerus and stab
wounds or lacerations to the forearm or wrist.

ULNAR NERVE C8/T1

o

ORIGIN: medial cord of the brachial plexus

SENSORY SUPPLY: hypothenar eminence, medial palm of hand, palmar aspect of lateral 1
fingers, medial dorsum of hand and dorsal aspect of medial 1 fingers

MOTOR SUPPLY: the ulnar nerve supplies just two muscles in the anterior compartment of the
forearm: flexor carpi ulnaris, which flexes and adducts the wrist, and the medial two parts of flexor
digitorum profundus, which flex the DIPJs of the ring and little fingers. It also supplies all of the intrinsic
muscles of the hand EXCEPT the LOAF muscles supplied by the median nerve. These can be
remembered
as
the HILA muscles: hypothenar eminence, interossei, medial
two lumbricals and adductor pollicis. The hypothenar eminence consists of opponens digiti minimi, flexor
digiti minimi brevis and abductor digiti minimi, which oppose, flex and abduct the little finger respectively.
The palmar interossei adduct the fingers, whilst the dorsal interossei abduct them. The medial two
lumbricals flex the MCPJs and extend the IPJs of the ring and little fingers. Adductor pollicis adducts the
thumb it is worth noting that this muscle does not form part of the thenar eminence and actually lies
deep beneath it as a separate structure.

CLINICAL SIGNIFICANCE: the ulnar nerve may be injured by supracondylar fractures of the
humerus, medial epicondylar fractures, stab wounds to the forearm or wrist, or compression at either the
cubital tunnel in the elbow or Guyons canal in the wrist. This results in 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.

REAL ANATOMY: PROSECTED SPECIMENS

This labelled prosection specimen really nicely sums up all the parts of the brachial plexus:

Labelled prosection showing the parts of the brachial plexus

(image from http://tinyurl.com/ojluc8n )
Here is an awesome in-depth video review of the anatomy of the axilla from jono03 on YouTube,
which begins with a thorough breakdown of the brachial plexus and a systematic approach to finding
all the branches. It really is a fabulously thorough bit of teaching, and its creator has lots of other

dissection videos available on his channel that would be great to bookmark for revision purposes.
Remember, the M shape is the key to unlocking which nerves are which!

Here is another wonderfully concise video from RocketdoggyVT on YouTube, which walks you
through a good quality prosection of the brachial plexus and shows you pretty much all of the nerve
branches. As an added bonus, he also shows you the axillary artery and its branches.

REAL ANATOMY: RADIOLOGY

The brachial plexus is usually assessed using an MRI scan, which is the best imaging method for
looking at soft tissues. Here are some images of a normal brachial plexus, and some interesting
pathological cases. See how many of the parts you can identify on the scans!

This coronal MRI scan shows the normal appearance of the brachial plexus you can
see the C5, C6 and C7 nerve roots emerging from the vertebrae and converging
further down into the trunks, divisions and roots.
(image from Chhabra et al 2012 full article available at http://tinyurl.com/nmf3bbk )

This MRI shows a patient who recently underwent neck surgery. The C5 and C6 nerve
roots have been completely severed (neurotmesis) and there is evidence of posttraumatic neuroma formation at their ends. The patient was treated with nerve
transfer surgery.
(image from Chhabra et al 2012 full article available at http://tinyurl.com/nmf3bbk )

This MRI of a patient with neurofibromatosis type 1 (NF1) shows large plexiform
neurofibromas of both brachial plexuses, affecting nerve roots C5, C6, C8, T1 and
T2.
(image from Paradowski et al 2005 available from http://tinyurl.com/p3q6vwe )

This MRI shows a malignant peripheral nerve sheath tumour (neurosarcoma) of

the upper trunk of the brachial plexus.
(image from Chhabra et al 2012 full article available at http://tinyurl.com/nmf3bbk )

This coronal CT scan shows a Pancoast tumour in the apex of the right lung, invading
the lower brachial plexus. These tumours classically cause Horners
syndrome and hand muscle wasting.
(image from Mohammad Niknejad on Radiopaedia.org available
from http://tinyurl.com/npyptdl )

REAL ANATOMY: SURGICAL

Severe brachial plexus injuries can be treated successfully with nerve grafts or nerve transfers. This
video from NEUROSURGERY Journal on YouTube shows a double fascicular nerve transfer for
a patient who sustained a severe upper brachial plexus injury during a car accident. The video
outlines the procedure and shows the preoperative examination findings, including wasting of deltoid
and biceps muscles, inability to flex the elbow, and preservation of wrist and hand movements. It
then shows a clear dissection of the distal brachial plexus with isolation of the musculocutaneous,
median and ulnar nerves the fibres look so much nicer in real life than they do in prosections! The
surgeons demonstrate stimulation of nerve fibres to produce different wrist and hand movements.
Appropriate fibres from the median and ulnar nerves are then selected and used to reconstruct the
musculocutaneous nerve supply to the biceps and brachialis muscles using microsurgical
techniques.

CLINICAL ANATOMY: OSCE EXAMINATION +

BRACHIAL PLEXUS INJURIES
If you require a refresher of how to perform neurological examination of the upper limb, here is
our super awesome (and rather sexy) Geeky Medics OSCE guide:
.

BRACHIAL PLEXUS INJURIES

It is possible for the brachial plexus to be injured at the level of the cervical nerve roots or trunks in
the neck, causing a syndrome of neurological deficits and clinical features. The most common three
youll need to know about are Erbs palsy, Klumpkes palsy and Horners syndrome. Brachial
plexus injuries are rare, but are often used in exams to test your anatomical knowledge! I will just
summarise the key features below so you dont lose the will to live entirely.
There are several different types and pathologies of nerve injuries:
o

neurapraxia the nerve is stretched and damaged but not torn

rupture the nerve is torn at a point along its length

o
o

axonotmesis the nerve fibre is partially severed: the axon and myelin sheath are torn but the
surrounding epineurium, perineurium and connective tissues are preserved. Natural recovery is possible through
axonal regeneration, so these injuries can often be managed conservatively.

neurotmesis the nerve fibre completely severed. There is no prospect of natural recovery, so this
type of injury requires surgery to restore function.

avulsion the nerve root is torn off the spinal cord at its origin
post-traumatic neuroma a growth of scar tissue at the site of a previous nerve injury, which leads
to compression

UPPER BRACHIAL PLEXUS INJURY: ERBS PALSY

o

SITE OF INJURY: superior trunk of the brachial plexus (C5/C6) occasionally the middle trunk (C7)
is also involved

MECHANISM: traction injury due to excessive lateral neck flexion towards the contralateral side, or
excessive shoulder depression, resulting in violent stretching +/- tearing of the upper portion of the brachial
plexus

CAUSES: the classical cause is a traction injury during difficult or obstructed childbirth, such as
shoulder dystocia requiring emergency forceps delivery, or breech presentations with the arms raised
above the head. The stretching mechanism can also be caused by falls onto the neck/shoulder or
excessive traction on the arm, for example during sports (often known as burner syndrome), motorbiking
accidents or attempts to reduce a shoulder dislocation. It can also result from direct trauma by clavicle
fractures, gunshot wounds or stab injuries.

NERVES
subclavius

CLINICAL FEATURES: Erbs palsy results in loss of sensation to the skin over the sergeants patch,
lateral arm and lateral forearm. There is wasting of the deltoid, supraspinatus and infraspinatus muscles

INJURED:

musculocutaneous, axillary and suprascapular

nerves,

and nerve

to

and the anterior compartment of the arm, with loss of shoulder abduction and external rotation, elbow
flexion and wrist supination. This results in a waiters tip deformity characterised by a limp, adducted,
internally rotated shoulder, an extended elbow and a pronated wrist. Biceps reflex is absent. Wrist
flexion, wrist extension and finger movements are usually preserved. If C7 is involved, elbow and wrist
extension will also be diminished and the wrist may be held in fixed flexion. Severely affected untreated
babies may be left with stunted arm growth, joint contractures and circulatory problems.

Clinical photographs showing Erbs palsy in a baby and an adult. You can clearly
see the waiters tip deformity, and in the adult the wasting of the deltoid and
biceps muscles is much more prominent.
(images from Heise et al 2015 http://tinyurl.com/pewjkxr and www.withtrauma.com )

LOWER BRACHIAL PLEXUS INJURY: KLUMPKES PALSY

o

SITE OF INJURY: inferior trunk of the brachial plexus (C8/T1)

MECHANISM: traction injury due to excessive force placed on an abducted shoulder results in
violent stretching +/- tearing of the lower portion of the brachial plexus

CAUSES: Klumpkes palsy is the rarest brachial plexus syndrome. The most common cause is a
traction injury during difficult childbirth, such as an arm presentation requiring force on the arm to
successfully deliver the rest of the baby. The same mechanism can also be caused by a falling person
grabbing onto something, e.g. grabbing a branch when falling from a tree, or by other causes of
excessive abduction such as motorbiking accidents. Direct trauma can result from clavicle fractures,

gunshot wounds or stabbings. It can also be caused by compression of the lower plexus by a mass in the
root of the neck, such as lymphoma or lung cancer.
o
o

NERVES INJURED: median and ulnar nerves

CLINICAL FEATURES: Klumpkes palsy results in loss of skin sensation in the median and ulnar
distributions of the hand the sensory supply to the lateral dorsum of the hand is preserved as this comes
from the radial nerve. There is also loss of sensation in medial forearm and arm. The injury affects the
motor nerve fibres to all small intrinsic muscles of the hand. There is therefore generalised wasting of hand
muscles with a loss of MCPJ flexion, IPJ extension, finger abduction and adduction, and opposition. The
anterior compartment of the forearm is also affected, resulting in loss of wrist flexion. This results in a claw
hand deformity affecting all four fingers, characterised by IPJ flexion and MCPJ hyperextension at rest,
and an inability to extend the fingers. The wrist is classically held supinated. Shoulder and movements are
usually preserved. T1 injuries may be associated with Horners syndrome, and there may be associated
superior/middle trunk injuries. Interestingly, the godmother of British baking Mary Berry has a claw hand
deformity of her left hand due to childhood polio clearly it doesnt stop her making awesome cakes!

TOTAL/COMPLETE BRACHIAL PLEXUS INJURY

o
o

o
o

SITE OF INJURY: entire brachial plexus C5/C6/C7/C8/T1

MECHANISM: usually severe or complex traction injuries sustained during difficult childbirth or high
speed road traffic accidents, resulting in violent stretching +/- tearing of all nerve roots
NERVES INJURED: entire brachial plexus
CLINICAL FEATURES: totally limp,
associated Horners syndrome

dangling,

atrophied

and

numb

upper

limb with

HORNERS SYNDROME
o

SITE OF INJURY: T1 nerve root

MECHANISM: any injury to the T1 nerve root associated with loss of sympathetic function

o
o

CAUSES: acquired Horners syndrome may be due to a traction injury, direct trauma, cerebral
pathology or extrinsic compression. The classical cause in exams is usually a Pancoast tumour in the
apex of the lung.
NERVES INJURED: T1 nerve root, sympathetic trunk or stellate ganglion
CLINICAL FEATURES: Horners syndrome causes loss of sympathetic nerve supply to the face and
neck. The key features are ipsilateral partial ptosis (drooping eyelid), miosis (constricted
pupil), anhidrosis (loss of sweating on affected side of face), dilatation lag (slowly dilating pupil)
and enophthalmos (eye appears sunken). With traction injuries there may be associated Klumpkes palsy.
With nerve root compression there may be associated hand/arm pain and wasting of the intrinsic
muscles of the hand this should trigger alarm bells for an underlying malignancy!

THORACIC OUTLET SYNDROME

o

SITE OF INJURY: trunks of brachial plexus, classically the inferior trunk but can affect any or all of the
trunks

MECHANISM: compression of neurovascular structures at the level of the thoracic outlet between
the root of the neck and the upper thorax. The thoracic outlet is bounded by the scalene muscles, the first
rib, and the clavicle.

CAUSES: may be due to a congenital fibrous tissue band, cervical rib or musculoskeletal
abnormality, or an acquired pathology such as whiplash trauma, repetitive strain/sports injury, malunion
of a clavicular fracture, or an underlying malignancy such as lymphoma or lung cancer.

NERVES INJURED: classically the ulnar nerve, but may affect any combination of nerves supplying
the upper limb. In about 5% of cases, compression may also affect the subclavian artery and/or vein which
run with the trunks through the thoracic outlet.

CLINICAL FEATURES: thoracic outlet syndrome leads to a combination of neurological and vascular
symptoms. Neurological features include wasting of the intrinsic muscles of the hand with reduced
grip strength, and some patients may experience numbness or paraesthesia. Some patients report
neuropathic pain affecting the arm, shoulder and neck. Vascular symptoms tend to be brought on or
exacerbated by vigorous overhead activities, such as lifting or throwing. Subclavian artery
compression causes aching or painful claudication of the arm, pallor and extreme cold; severe cases
may lead to ischaemia with ulceration and gangrene. Subclavian vein compression can result in diffuse
arm pain and swelling, venous distension and cyanosis. Venous obstruction may lead to thrombosis of
the subclavian or axillary veins, which is known as Paget-Schroetter syndrome.

BRACHIAL NEURITIS/PLEXITIS
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SITE OF INJURY: any part of brachial plexus may affect individual nerves/cords or entire plexus

MECHANISM: inflammatory reaction against the nerves of the brachial plexus

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CAUSES: brachial neuritis may be idiopathic (Parsonage-Turner syndrome). Commonly recognised

triggers include bacterial, viral or parasitic infections, immunisations, trauma, childbirth, recent surgery
or radiotherapy, and systemic inflammatory disorders such as lupus, polyarteritis nodosa or other types
of vasculitis. It may also occur as part of a polyneuropathy, such as Guillain-Barre syndrome or motor
neurone disease, or as a paraneoplastic syndrome associated with lymphoma.
NERVES INJURED: any component of brachial plexus
CLINICAL FEATURES: brachial neuritis classically starts with sudden onset of excruciating
shoulder and arm pain on the affected side, followed by the development of paralysis and atrophy of
affected muscle groups within a couple of weeks. The onset of symptoms may be preceded by prodromal
symptoms of a systemic infection, or another immunological trigger such as trauma, surgery or
immunisation. The syndrome is particularly associated with hepatitis E virus infection occurring bilaterally
in up to 10% of cases. Patients usually present acutely due to the severity of the pain, and tend to support
the affected arm in an adducted, internally rotated position. The phrenic nerve or lower cranial nerves
may also be affected in a minority of cases.

SUMMARY
I hope you found this guide helpful and now feel able to approach this nightmarish subject with
confidence. As long as you remember to look for the M shape, you should be totally fine. Once
you have triumphed over the brachial plexus, you have officially won at anatomy forever. Good luck,
and may the forceps be with you!
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