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Brachial Plexus and Peripheral Nerves

http://accessphysiotherapy.mhmedical.com/data/multimedia/grandrounds/br
achial/media/brachial_print.html

by Annie Burke-Doe, PT, MPT, PhD

Practicing physical therapist and associate professor at the University of St.


Augustine for Health Sciences in San Diego, California

Slide 1: Brachial Plexus and Peripheral Nerves

Welcome to neuroanatomy in physical therapy. I am Dr. Annie Burke-Doe,


the practicing physical therapist and an associate professor at the
University of St. Augustine for Health Sciences in San Diego, California. This
lecture series has been developed for physical therapists embarking on the
study of neurology. In this presentation, we will focus on the anatomy of the
cervical spinal roots and their relationship to the vertebral structures,
regions on innervation, and common clinical disorders that will be presented
as cases with questions and answers.
Slide 2: Brachial Plexus

Pictured here on slide 2, we see the brachial plexus, which innervates the
pectoral girdle and the upper limb, with contributions from the ventral rami
of spinal nerves C5 through T1. The nerves that form this plexus originate
from the trunks and cords. Trunks are large bundles of axons contributed by
several spinal nerves. Cords are smaller branches that originate at trunks.
Both trunks and cords are named according to their location relative to the
axillary artery, a large artery supplying the upper limb. Therefore, we have
superior, middle, and inferior trunks and lateral, medial, and posterior cords.
As a physical therapy student and future practitioner, it will be important to
have a working knowledge of the brachial plexus. One way to remember the
brachial plexus organization is using the acronym ROBERT TAYLOR DRINKS
COLD BEER.
Slide 3: Brachial PlexusLearn to Draw!

Romm and Chu provide an illustrative way for students to learn to draw the
brachial plexus in five minutes or less. Spending time on learning to draw
the plexus will help you through those difficult anatomy exams, and
understanding the plexus will help you clinically determine where damage
in the peripheral pathway exists. Use the mouse to click forward to begin
each element. Start by drawing two headless arrows to the right. Add a
headless arrow to the left. Add a "W." Draw an "X." Add just a branch of the
"Y." Label C5, C6, C7, C8, and T1. Then label the major branches:
musculocutaneous, median, ulnar, radial, and axillary.
Slide 4: Brachial Plexus

This diagram now includes the main branches and main nerve roots with
proper connections. Physical therapists will use more complex diagramming
that includes four "3s." Again, use your mouse to forward through the
diagram. The first "3" is the branches to C5, 6, 7, which form the long
thoracic nerve. Next, each of the headless arrows has three nerves attached
to it. To the top headless arrow, add its "3." Label these dorsoscapular
nerve, suprascapular nerve, lateral pectoral nerve. Add the "3" to the
middle headless arrow. Label the second headless arrow: subscapular and
thoracodorsal nerve. Add the final "3" on the bottom headless arrow. Label
the last "3": medial pectoral, medial brachial cutaneous, and medial
antebrachial cutaneous. Remember, the brachial cutaneous goes to the
brachium or arm, and the medial antebrachial cutaneous goes to the
antebrachium or forearm. The nerve to the forearm starts distally. Now,
label the roots, trunks divisions, cords, and terminal branches. Finally,
physical therapists also need to know the nerve to the subclavius. Here is
your complete brachial plexus diagram. Remember, practice makes perfect.
Slide 5: Brachial Plexus

Moving distally, the lateral cord forms the musculocutaneous nerve and,
together with the medial cord, forms the median nerve. The posterior cord
nerve branches will form the axillary, radial, thoracodorsal, and subscapular
nerves. The medial cord's other major nerve is the ulnar nerve.
Slide 6: The Musculocutaneous Nerve

The musculocutaneous nerve , pictured here, innervates the biceps,


brachialis, and coracobrachialis. The biceps is a flexor of the shoulder and
elbow and a supinator of the forearm. To understand its full function,
envision a man driving a corkscrew into a bottle of wine (supinating), pulling
out the cork (elbow flexion), and drinking the wine (shoulder flexion).
Sensation is provided to the lateral surface of the forearm through the
lateral antebrachial cutaneous nerve branch.
Slide 7: The Axillary Nerve

The axillary nerve pictured here innervates the deltoid and the teres minor.
The deltoid is a three-part muscle: the anterior deltoid flexes, the middle
deltoid abducts, and the posterior deltoid extends the shoulder. Of the three
motions, the deltoid acts most powerfully in abduction. The C5 neurologic
level supplies sensation to the lateral arm from the summit of the shoulder
to the elbow. The purest patch of axillary nerve sensation, pictured here on
the right, lies over the lateral portion of the deltoid muscles. This localized
sensory area within the C5 dermatome is useful for indicating specific
trauma to the axillary nerve, as well as general trauma to the C5 nerve root.
Slide 8: The Radial Nerve

The radial nerve innervates the triceps, extensor carpi radialis and ulnaris,
supinator, and extensor pollicis. Motor functions include: extension at all
arm, wrist, and proximal finger joints below the shoulder; forearm
supination; and thumb abduction in the plane of the palm. The triceps is the
primary elbow extensor. It is important because it permits the patient to
support himself or herself on a cane or standard crutch.
Slide 9: The Radial Nerve

The radial nerve supplies sensation, as pictured here, to the skin over the
posterolateral surface of the arm through the posterior brachial cutaneous
nerve, posterior antebrachial cutaneous nerve, and the superficial radial
nerve branch.
Slide 10: The Median Nerve

The median nerve innervates flexor carpi radialis, palmaris longus, pronator
quadratus, pronator teres, and the digital flexors. Motor functions include
thumb flexion and opposition, flexion of digits 2 and 3, wrist flexion and
abduction, and forearm pronation. Sensation, pictured here at the top,
includes the skin over the anterolateral surface of the hand. When the
median nerve is damaged, the thenar eminence may atrophy, and the
patient will not be able to oppose the thumb, resulting in ape-hand
deformity, pictured on the right side of the slide.
Slide 11: The Ulnar Nerve

The ulnar nerve innervates flexor digitorum profundus, adductor pollicis,


and small digital muscles. Motor function includes: finger adduction and
abduction other than the thumb; thumb adduction; flexion of the digits 4
and 5; as well as wrist flexion and wrist adduction. Sensation, which is
pictured at the top, includes the skin over the medial surface of the hand
through the superficial branch. With damage to the ulnar nerve, a claw-hand
deformity is manifested by flattening of the transverse metacarpal arch and
longitudinal arches with hyperextension of the MCP joints and flexion of the
PIP and the DIP joints - deformities produced by the imbalance of this
intrinsic and extrinsic musculature.

Slide 12: Case 1: Pain in the Neck


The following cases are designed for you to read and answer the questions
in preparation for your course work in neurology and licensure preparation.
Please proceed through each case and determine the answer to the
questions.
Slide 37: References

Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science. 4th
ed. New York: McGraw-Hill; 2000.
Seigal A, Sapru HN. Essential Neuroscience. New York: Lippincott
Williams & Wilkins; 2006.
Blumenfeld, H. Neuroanatomy through Clinical Cases. Sunderland,
MA: Sinauer Associates; 2002.
Goodman C, Fuller K, et al. Pathology Implications for the Physical
Therapist. 3rd ed. St. Louis, MO: Saunders; 2008.
Panus PC, Jobst EE, Masters SB, Katzung B, Tinsley SL, Trevor AJ:
Pharmacology for the Physical Therapist, 11e. New York, NY:
McGraw-Hill; 2009.
http://www.accessphysiotherapy.com/content/6092707. Accessed
March 6, 2012.
Romm, DS, Chu, DA. Learn the brachial plexus in five minutes or
less. Chicago, Illinois: American Medical Association.
http://www.ama-
assn.org/resources/doc/mss/brachial_plex_how_to.pdf. Accessed May
10, 2011.
.:.