Section One  The basics
See DVD
Clinical examination of the patient
with brachial plexus palsy
Stephen M. Russell, MD, John E. McGillicuddy, MD
SUMMARY BOX
1. Brachial plexus and upper extremity musculoskeletal
anatomy must be thoroughly understood in order to
properly examine, diagnose, and localize brachial
plexus injuries.
2. The clinical examination of a patient with a brachial
plexus injury requires practice, and should be
performed in a comprehensive, step-wise fashion for
each patient.
3. Proximal brachial plexus injuries may be localized
based on the deficits observed with palsies affecting
one or more spinal nerves.
4. Distal brachial plexus injuries may be localized required for optimal patient care.
based on the deficits observed with palsies affecting
one or more terminal branches of the plexus (ie,
Introduction
The complex regional anatomy, along with the
nuance and range of upper extremity function, can
make physical examination and lesion localization
within the brachial plexus a daunting task for
the clinician. Nevertheless, once brachial plexus
anatomy is mastered, the components of this
structure can be considered separately during the
examination, making lesion localization more
straightforward. As with any injury affecting the
musculoskeletal system, physical examination
begins with a visual inspection and palpation of the
affected limb, assessment of passive joint range of
motion, inspection of joint/bone integrity, as well
as a thorough neurological evaluation. Examining
a patient over time (i.e., serial examinations) is a
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DOI: 10.1016/B978-1-4377-0575-1.00003-4
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CHAPTER 3 
musculocutaneous, median, ulnar, radial, and axillary
nerves).
5. Sensory testing and the motor examination of smaller,
direct branches off the brachial plexus (eg, dorsal
scapular nerve) further localize the lesion within the
plexus and help confirm the diagnosis.
6. Serial examinations over time, as well as corroboration
with electrophysiological and imaging results, improve
diagnostic accuracy.
7. Consistent, reproducible, and comprehensible
documentation of clinical examination results are
very important but often forgotten component of
the diagnostic process.
In this chapter, the physical examination of bra-
chial plexus injury will be described, along with
comments on how to integrate abnormal findings
into one’s thought process regarding lesion locali-
zation and diagnosis. The technique for examining
muscles innervated by direct branches of the bra-
chial plexus will be discussed in the text and photo-
illustrated. Examination techniques for muscles
innervated by the major terminal branches of the
brachial plexus (ie, median, ulnar, musculocutane-
ous, and radial nerves) will not be reviewed in the
text, but will be described in the video presentation
associated with this chapter. Other sources may be
reviewed for additional detail regarding upper
extremity motor testing.1,2,3
 Section One  The basics
Visual inspection and
general assessment
The patient should disrobe above the waist. Women
are instructed to wear a sports bra so that they do
not have to wear a gown during the examination,
as a gown limits global comparison of the affected
versus non-affected sides (Figure 3.1). Shoulder
position in relation to the normal shoulder may
indicate a trapezius palsy. Scapular winging at rest
should be documented. Any atrophy is noted, both
from an anterior and posterior view. Previous surgi-
cal scars and penetrating wounds, healed and
unhealed, are examined. Trophic skin changes can
result from nerve injury; they can present as ulcers
or wounds on the hand and often heal very poorly.
The paraspinal muscles, supraclavicular space,
infraclavicular space, axilla, and upper arm are all
inspected and palpated. Palpation begins in a gentle
manner and progresses to a more deep assessment
of the soft tissues. The course of the brachial plexus
is tapped by a reflex hammer or the examiner’s
fingers to check for Hoffman-Tinel’s sign. The
pupils should be examined to exclude Horner’s syn-
drome, which would indicate a very proximal injury
to the T1 spinal nerve, usually its avulsion from the
spinal cord. Pulses in the extremities are assessed,
and auscultation and percussion of the lungs to
exclude paralysis of a hemidiaphragm secondary to
a phrenic nerve palsy.
Passive range of motion of joints
Passive range of joint motion should be tested,
including the cervical spine, shoulder, scapula,
Figure 3.1  This patient has severe atrophy affecting his left
shoulder girdle secondary to a brachial plexus injury.
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elbow, wrist, and hand. Contractures and patho-
logical signs (e.g., simian hand, muscle atrophy) are
documented. Any subluxation of the shoulder,
including partial dislocation at rest secondary to
rotator cuff muscle paralysis, should be carefully
assessed. Point tenderness, marked joint trauma
and contractures, or significant pain on passive
movement may be signs of musculoskeletal injury
preventing limb motion, and not neurological
injury per se.
Muscle examination techniques
TENTTMuscle (see video)
Documentation of motor strength requires an easy
to remember and readily applicable grading scale.
Use of a standardized scale is paramount for docu-
menting a patient’s examination over time, as well
as for comparing different individuals before and
after treatment. The Medical Research Council pub-
lished the classic motor function grading scale
(MRC grading scale) shortly after World War II.1
This grading scale is presented in Table 3.1, and
ranges from 5 (full strength) to 0 (no muscle con-
traction). The MRC grading scale is the best known
and most utilized throughout the world. The sim-
plicity of the MRC grading scale no doubt has con-
tributed to its popularity; however, it has certain
limitations that should be recognized. For example,
it does not take into consideration range of motion,
tends to be weighted toward weaker contractions,
and is poorly applicable to certain muscles (e.g.,
rhomboids). In response to these deficiencies,
other grading scales have been described. The
Louisiana State University (LSU) motor function
grading scales are popular amongst peripheral
Table 3.1  Medical Research Council motor function
grading scale
Grade Function
5 Full strength
4 Movement against resistance
3 Movement against gravity only
2 Movement with gravity eliminated
1 Muscle contraction but no movement
0 No muscle contraction
 Clinical examination of the patient with brachial plexus palsy
nerve surgeons and are specific for each major
peripheral nerve or element of the brachial plexus.4
This section presents the examination technique
for muscles innervated by direct branches of the
brachial plexus. Examination techniques for other
distal upper extremity musculature are well-known,
are presented elsewhere in detail,1,3,4 and are illus-
trated in the video supplement to this chapter.
The long thoracic nerve is a proximal branch of the
brachial plexus, arising from the proximal C5, C6,
and C7 spinal nerves, that innervates the serratus
anterior muscle. This muscle originates on the
lateral surfaces of the upper 8 ribs and inserts on
the entire medial border of the scapula. It pulls the
scapula away from the midline and forward around
the thorax (scapular abduction). It also rotates the
lateral angle of the scapula upward. Most impor-
tantly, however, this muscle fixes and stabilizes
the scapula so that muscles originating from it
can function properly. Furthermore, anterior arm
flexion is stabilized by the serratus anterior, with
flexion above 90 degrees mostly due to upward
rotation of the scapula. Injury to the long thoracic
nerve causes winging of the scapula. Winging may
occur at rest, is most noticeable at the inferomedial
angle, and is classically worsened when the patient
pushes forward against resistance. Winging contin-
ues when the upper extremity is locked in extension
with the shoulder girdle protracted forward (ante-
riorly). To test this muscle, instruct patients to reach
for a point on the wall in front of them, and then
apply resistance at the hand or wrist while stabiliz-
ing the thorax with the other hand (Figure 3.2). A
common mistake is to not have patients displace
their shoulder girdle far enough forward, because
without doing so, scapular winging due to trapezius
Figure 3.2  Testing serratus anterior.
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3
or rhomboid weakness may be misdiagnosed as a
long thoracic palsy. It is important to note that all
3 causes of scapular winging cause winging when
the arm is pushed against resistance across the chest
with the arm bent. Only serratus anterior weakness
will show severe winging when pushing the fully
extended arm forward (protracting) against resist-
ance (Figure 3.3).
The dorsal scapular nerve is a very proximal branch
from the C5 spinal root. This nerve innervates both
the major and minor rhomboid muscles. The
rhomboids connect the medial edge of the scapulae
to the spinal column. When contracted, the rhom-
boids pull the scapula toward the midline (scapular
adduction and retraction) and superiorly (down-
ward rotation of the lateral angle). The rhomboids
move the scapula in the opposite direction to that
of the serratus anterior muscles. With chronic den-
ervation, wasting of this muscle deep to the trape-
zius is evident. With rhomboid weakness, there
may be mild scapular winging at rest, especially at
the inferior medial edge. The scapula may also be
displaced laterally and inferiorly and rotated later-
ally. To test the rhomboids, have patients place their
palm facing outward on their lower back. Instruct
them to push the palm away from the lower back
as the examiner applies resistance to the hand as
well as to the arm (the arm is pushed anterolater-
ally around the thorax) (Figure 3.4). The rhom-
boids are observed and palpated along the medial
scapular border during this maneuver. If the rhom-
boids are weak, only resist at the hand. An alternate
method to examine the rhomboids is to have
patients bring their shoulders and scapulae together
Figure 3.3  Scapular winging is present on the patient’s right
side secondary to a spinal accessory palsy.
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 Section One  The basics

Figure 3.4  Testing rhomboids. Note palpation along the medial

border of the scapula.

posteriorly. In this position, the contracted rhom-

boids can be palpated between the lower aspects of
the scapulae. The dorsal scapular nerve can also
provide partial innervation to the levator scapulae
as it passes underneath this muscle. This muscle
assists the upper trapezius in shrugging the
shoulders.
The suprascapular nerve (C5, C6) originates from
the upper trunk of the brachial plexus and passes
the inferior belly of the omohyoid to the supras-
Figure 3.5  Testing supraspinatus.
capular notch through which it passes to the pos-
terior surface of the scapula. The suprascapular
nerve innervates the supraspinatus and infraspina-
tus muscles. The supraspinatus attaches to the supe-
rior aspect of the humeral head and mediates the
initial 20-30 degrees of arm abduction. The infra-
spinatus attaches to the posterior lateral aspect of
the humeral head and is the primary external
rotator of the arm. Test the supraspinatus muscle
by having patients abduct a straight arm from their
side against resistance (Figure 3.5). Test the infrasp-
inatus muscle by having patients flex their forearm
to 90 degrees, and while stabilizing their elbow
against their side, instruct them to externally rotate
their arm against resistance, like a tennis swing
(Figure 3.6). Contraction can be observed and pal-
pated over the scapula while testing these muscles. Figure 3.6  Testing infraspinatus. It is important to keep the
With chronic denervation, atrophy above (suprasp- patient’s arm firmly against his side to prevent abduction
mimicking external rotation.
inatus) or below (infraspinatus) the scapular spine
is readily appreciated.
The axillary nerve (C5, C6) arises from the poste- deltoid. The posterior division gives a branch to the
rior cord deep to the axillary artery and divides into teres minor, innervates the posterior portion of the
an anterior and posterior division near the humeral deltoid, and gives a sensory branch to the lateral
neck as it passes medially and posteriorly to it. The shoulder region. The teres minor assists the infra-
anterior division innervates the anterior and lateral spinatus in externally rotating the arm. It also

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 Clinical examination of the patient with brachial plexus palsy 3

Figure 3.7  Testing deltoid.

Figure 3.8  Testing posterior deltoid. The patient should be
instructed to both raise his arm and move it posteriorly in the
weakly assists the teres major in adducting an same movement.
extended arm. It is not possible to test this muscle
in complete isolation, but one may observe and
palpate it if the patient is thin. The deltoid is the
prime abductor, as well as flexor (lifting the arm in
front of the body) of the arm. The initial 30 degrees
of abduction is primarily controlled by the suprasp-
inatus, whereas abduction above 90 degrees has an
important trapezius and serratus component that
tilts the shoulder girdle upward. Therefore, test the
deltoid by having patients abduct their arm between
30 and 90 degrees against resistance (Figure 3.7).
The deltoid has 3 separate heads: the anterior,
lateral, and posterior. Abducting the arm to the side
and slightly in front of the body tests the anterior
and lateral heads of the deltoid. To assess the pos-
terior head, have patients place a straightened arm
at almost 90 degrees abducted, and then ask them
to move the arm posteriorly and superiorly against
resistance (Figure 3.8).
The lateral pectoral nerve (C5, C6) is a branch from
the lateral cord. It often communicates with the
medial pectoral nerve (C6-T1) and predominantly
innervates the clavicular head of the pectoralis
major. To test the clavicular head, and therefore the
lateral pectoral nerve, have patients abduct their Figure 3.9  Testing the clavicular head of pectoralis major. The
muscle can be palpated immediately below the clavicle.
arm to 90 degrees with their forearm in flexion.
Then, against resistance at the medial elbow, have
them swing their arm toward midline (Figure 3.9). arm against resistance (Figure 3.10). The pectoralis
The medial pectoral nerve originates from the minor cannot be adequately isolated from the pec-
medial cord and innervates the pectoralis minor toralis major and, therefore, cannot be tested in
and then pierces the clavipectoral fascia to inner- isolation.
vate the sternal head of the pectoralis major. This The upper and lower subscapular nerves (C5, C6)
nerve almost always communicates with the lateral originate from the posterior cord. The upper sub-
pectoral nerve. To test the sternal head of the pec- scapular nerve is not very long and enters and
toralis major, patients should begin with their innervates the subscapularis muscle. The subscapu-
forearm flexed 90 degrees and their arm abducted laris muscle, along with the teres major (and latis-
about 30 degrees. Instruct the patient to adduct the simus dorsi and pectoralis major), internally rotates

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 Section One  The basics

Figure 3.12  Testing teres major. The muscle can be felt in the
posterior axillary fold along the lateral margin of the scapula.

Figure 3.10  Testing the sternal head of the pectoralis major.

The muscle can be palpated in the anterior axillary fold.

Figure 3.11  Testing internal rotation of the arm, a composite of

subscapularis, teres major, and pectoralis major. Difficult to sort
out, but pectoralis and teres can be seen and felt during this test
and weakness may be apparent in one. There is no way to solely
evaluate the subscapularis.

Figure 3.13  Testing latissimus dorsi. The muscle can be seen

the arm. The subscapularis muscle cannot be com-
pletely isolated, but one can test internal arm rota-
tion as a composite test (Figure 3.11). The lower
subscapular nerve innervates the lower half of the
subscapularis muscle, as well as the teres major. To
test the teres major, begin by having the patients
abduct their arm to 90 degrees with the palm down.
Instruct them to adduct their extended arm against
resistance while you inspect the teres major (Figure
3.12). Contraction of the teres major can be felt
between the humerus and the lateral border of the
scapula just below the shoulder joint.
Another branch off the posterior cord is the
thoracodorsal nerve (C7, C8), which innervates
and felt on the lateral chest wall below the level of the scapula.
the latissimus dorsi muscle. To assess the latissimus
dorsi, have patients adduct their arm when the
forearm is flexed 90 degrees with the palm facing
forward (Figure 3.13). Muscle contraction can be
palpated along the posterolateral chest wall. Latis-
simus dorsi contraction can also always be felt
during a deep cough. In summary, all the branches
from the posterior cord act to adduct and internally
rotate the arm, a point worth remembering.
Although the spinal accessory nerve (cranial nerve
XI) is not a branch of the brachial plexus, it is
important to evaluate this nerve’s function because

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 Clinical examination of the patient with brachial plexus palsy
it is often used as a donor nerve during brachial
plexus reconstruction, and it plays a major role in
scapular and shoulder function. It stabilizes the
scapula, thus allowing other shoulder girdle muscles
to move the arm. Spinal accessory nerve palsy
causes trapezius weakness. A patient with a weak
trapezius reports trouble abducting the arm above
the head (laterally), as well as major shoulder girdle
discomfort. At rest, the affected shoulder often lies
lower than the unaffected one. Even with a com-
plete trapezius palsy, shoulder shrug weakness
seldom occurs. This is because the levator scapulae
muscle also shrugs the shoulders (innervated by the
C3 and C4 ventral rami, via the cervical plexus).
Weakness of the sternocleidomastoid muscle is
rare, not only because its motor branches from the
spinal accessory nerve branch quite proximally, but
also because this muscle receives innervation from
the cervical plexus. Secondary to the trapezius
weakness, a spinal accessory palsy also causes
scapular winging. Trapezius winging is mild at rest
and usually involves the upper border of the
scapula, although this is variable. Trapezius winging
may be brought out by abducting the fully extended
arm to 90 degrees. All types of winging (serratus
anterior, trapezius, and rhomboid) are worse when
an arm (partially flexed at the elbow) is pushed
across the chest or in front of the body against
resistance. However, only serratus anterior weak-
ness causes winging when an extended, protracted
arm is resisted. The presence of rhomboid weakness
helps differentiate rhomboid versus trapezius
winging.
Spinal myotomes as a template
for the proximal brachial plexus
Spinal nerve myotomes (the muscles innervated by
axons from a specific spinal nerve) remain useful
for clinical evaluation of patients with proximal
brachial plexus lesions. By matching the pattern of
neurological deficit to each or a combination of
spinal myotomes, lesions may be localized to the
spinal nerve or trunk level. The C5 to T1 spinal
nerve myotomes are subsequently reviewed.
Muscular innervation of the C5 spinal nerve
includes arm abduction and external rotation.
These 2 arm movements are very important for
upper extremity function and are classically lost
with upper brachial plexus injuries, including neo-
natal palsy (i.e., Erb’s palsy). The terminal branches
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3
mediating these movements include the axillary
nerve to the deltoid muscle, and the suprascapular
nerve to the supra- and infraspinatus muscles. A
composite movement involving all 3 of these
muscles, and therefore predominantly mediated by
the C5 nerve root, is abduction of the arm. Begin-
ning with the arms straight along the side of the
body, the patient abducts them to 90 degrees while
simultaneously externally rotating them so that
the undersurface of the upper arm faces forward.
The C5 dermatome covers the lateral portion of the
shoulder and arm down to the elbow.
Muscular innervation of the C6 spinal nerve
includes forearm supination and flexion, as well as
arm extension/adduction. The radial nerve carries
C6 innervation to the supinator (supination) and
brachioradialis (forearm flexion with arm partially
supinated), and the musculocutaneous nerve carries
fibers to the biceps brachii (forearm flexion and
supination) and brachialis (forearm flexion). The
latissimus dorsi extends and adducts the arm via
the thoracodorsal nerve, which is primarily C6
mediated (C7 can also provide major innervation
to this muscle). A composite C6 body movement
would be a classic underhand chin-up. For this
movement, the supinated forearm flexes and latis-
simus dorsi contracts, pulling the chin over the bar.
Lateral volar forearm and thumb are the sensory
territory of the C6 spinal nerve.
With an upper trunk lesion, as expected, the C5
and C6 innervated muscles are weak. Therefore, the
limb assumes a characteristic position at rest sec-
ondary to the unopposed action of the remaining
musculature. Patients characteristically have their
affected arm adducted and internally rotated (unop-
posed pull of pectoralis major), forearm extended
and pronated (unopposed pull of the triceps and
pronator teres), and the wrist and fingers flexed
(from weak finger and wrist extensors [C6
co-innervated]). This position is also called a wait-
er’s tip hand. Weakness involving the rhomboids
(dorsal scapular nerve), serratus anterior (long tho-
racic nerve), and/or diaphragm (phrenic nerve),
helps localize the injury more proximally to the C5
and C6 spinal nerves where these branches origi-
nate, rather than the upper trunk per se. A lesion
involving the upper trunk, or alternatively both the
C5 and C6 spinal nerves, yields a sensory loss
involving the lateral one-half of the arm and
forearm, as well as the whole thumb.
Because the middle trunk is only comprised
of fibers from the C7 spinal nerve, they will be
27
 Section One  The basics

considered together. Muscular control of the C7

nerve root includes the triceps (radial nerve), flexor
carpi radialis (median nerve), flexor carpi ulnaris
(ulnar nerve), and pronator teres (median nerve).
The C7 also provides innervation to the wrist exten-
sors, finger extensors, and finger flexors. However,
innervation to these latter muscles is either variable
or strongly shared with other nerve roots (ie, C6,
C8), and therefore will not be considered an auton-
omous innervation of C7. Therefore, the composite
movement of the C7 spinal nerve and middle trunk
is the triceps pushdown. This movement is made
when you push down on a tabletop when getting
up from being seated at a table. For this to occur,
one places the forearms in pronation (pronator
teres), flexes the wrists (flexor carpi radialis and
ulnaris), and contracts the triceps to extend the
forearms. A person with a middle trunk palsy
cannot do this. The volar and dorsal aspects of the
long (middle) finger are almost exclusively within
the C7 dermatome. Lesions of the middle trunk,
comprised solely of C7 fibers, logically causes the
same pattern of sensory loss as does a pure C7
palsy.
The C8 spinal nerve provides motor input to
many of the long finger flexors (and extensors), as
well as to the hand intrinsic muscles, sharing this
latter innervation with T1. Some of the most
common muscles to become weak with a C8 palsy
include the flexor profundi to the index and long
finger (distal interphalangeal joint flexion), thenar
intrinsics including abductor pollicis brevis and
opponens pollicis, and extensors to the thumb,
index, and long finger. Therefore, a quick and easy
way to assess C8 function would be to have the
patient grasp and release your fingers, with atten-
tion paid especially to the first 3 digits. A patient
with a C8 palsy will have trouble doing this
smoothly, strongly, and repetitively. The C8 der-
matome covers the medial, or ulnar, one-third of
the hand, including the little finger and lateral
hypothenar eminence.
The T1 spinal nerve is best tested in near isolation
by having patients spread their fingers. This move-
ment is mediated by the dorsal interossei muscles,
which are predominantly T1 innervated. Atrophy of
the first dorsal interosseus muscle, when present, is
readily observed. The T1 sensory dermatome mainly
covers the medial half of the forearm.
Because the lower trunk is comprised of the C8
and T1 nerve roots, injuries affecting this element
cause marked hand weakness, including both hand
Figure 3.14  This patient has a “simian” hand deformity on the
right, secondary to a complete lower trunk brachial plexus palsy.
grasp and finger spreading, as well as severe atrophy
and trophic changes (Figure 3.14). Injury to both
the C8 and T1 spinal nerves is called a Klumpke’s
palsy. When a Horner’s sign is present, T1 rootlet
avulsion from the spinal cord is likely.
“Plus” palsies as a template for the
distal brachial plexus
To assess the distal brachial plexus, one needs to
be familiar with patterns of neurological deficits
that may occur following injury to the terminal
branches of the plexus: musculocutaneous, median,
ulnar, radial, and axillary nerves. With this pre­
requisite knowledge, diagnosis of injury localized
to the brachial plexus cords is straightforward,
being more or less a variation or combination of
one or more of these major branches. Analogous
to the proximal brachial plexus injury being
assessed using its spinal nerve components, the
distal plexus is evaluated in the context of its major
terminal branches.
The lateral cord is formed by the anterior divi-
sions of both upper and middle trunks, and there-
fore, contains fibers from C5, C6, and C7. This cord
terminates by providing the median nerve’s lateral
component (C5-C7), and then continuing distally
as the musculocutaneous nerve. As expected, an
isolated lesion to the lateral cord consists of a mus-
culocutaneous nerve palsy, plus a partial median
nerve deficit; that is, one only involving the median
nerve’s C5 to C7 portion. This deficit pattern may
be termed a musculocutaneous “plus” palsy.

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 Clinical examination of the patient with brachial plexus palsy
The classic musculocutaneous palsy causes
forearm flexion weakness secondary to biceps
brachii, coracobrachialis, and brachialis weakness,
and sensory loss in the lateral forearm (lateral ante-
brachial cutaneous nerve). As alluded to earlier,
median nerve function can be divided into lateral
(C5-C7; lateral cord) and medial (C8-T1; medial
cord) components. The lateral cord provides all the
median nerve’s sensory fibers (the medial cord does
not provide any cutaneous sensation to the median
nerve). Therefore, sensory loss in the lateral palm
and first 3 digits occurs with a lateral cord injury.
Although the lateral cord component is primarily
sensory, it also controls the more proximal median
innervated muscles (pronator teres and flexor carpi
radialis) so that weakness in pronation and wrist
flexion will be seen. Any wrist flexion will be from
flexor carpi ulnaris (medial cord) and will show
ulnar deviation as well. Furthermore, weakness of
the clavicular head of the pectoralis major should
also occur, considering that the medial pectoral
nerve, which innervates this muscle, originates from
the lateral cord.
The medial cord is a continuation of the lower
trunk’s anterior division, containing C8 and T1
nerve fibers. The medial cord provides the medial
contribution of the median nerve, containing C8
and T1 fibers, and then continues as the ulnar nerve
into the arm. Therefore, an isolated medial cord
lesion consists of an ulnar nerve palsy, plus loss of
the C8 and T1 components of the median nerve.
An ulnar palsy would cause weakness in wrist
flexion (flexor carpi ulnaris), distal interphalangeal
joint flexion weakness involving the ring and little
fingers (flexor digitorum profundi), little finger
movements (opponens, flexor, and abductor digiti
minimi), and finger abduction and adduction
(interossei). Medial cord sensory loss involves the
medial one-third of the hand. As mentioned, the
medial component of the median nerve controls
median innervated hand intrinsics, including the
opponens pollicis, flexor pollicis brevis (superficial
head), abductor pollicis brevis, and the first 2 lum-
bricals. Therefore, a medial cord lesion, or ulnar
“plus” palsy, would, in addition to causing ulnar
motor loss, cause median innervated thumb weak-
ness and trouble extending the proximal inter-
phalangeal joints of the first 2 fingers (lumbricals).
The medial cord also has a few side branches that
can be utilized to confirm medial cord involve-
ment. The medial brachial and antebrachial cutane-
ous nerves originate from the distal medial cord
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3
and mediate sensation over the medial aspect of the
arm and forearm, respectively. The medial pectoral
nerve originates from the proximal medial cord,
and if damaged, leads to weakness in the sternal
head of the pectoralis major.
The posterior cord comprises the posterior divi-
sion of all 3 trunks and contains input from C5 to
C8. Because the 2 terminal branches of the poste-
rior cord are the radial and axillary nerves, a com-
bination palsy of these 2 nerves is the hallmark of
a posterior cord injury. Therefore, a posterior cord
injury may also be called a radial axillary palsy. A
radial palsy causes weakness in forearm extension
(triceps), forearm supination (supinator), wrist
extension (extensor carpi radialis longus and brevis,
extensor carpi ulnaris), and finger/thumb extension
(superficial and deep finger extensors). Radial nerve
sensory loss involves the posterior arm (posterior
brachial cutaneous nerve) and forearm (posterior
antebrachial cutaneous nerve), the lower lateral
aspect of the arm (lower lateral brachial cutaneous
nerve), and lateral dorsal hand (superficial sensory
radial nerve). An axillary nerve palsy causes arm
abduction weakness secondary to deltoid paralysis.
An axillary nerve lesion can also cause sensory loss
in the upper lateral arm (upper lateral brachial
cutaneous nerve), especially if the patient is exam-
ined soon after injury. Furthermore, arm adduction
and internal rotation weakness helps confirm pos-
terior cord damage, because these muscles are con-
trolled by the minor branches off the posterior cord
(upper and lower subscapular, and thoracodorsal
nerves).
Divisional injuries to the
brachial plexus
Unfortunately, isolated injury to one of the brachial
plexus divisions can be difficult to clinically dif-
ferentiate from cord or trunk level lesions. Never-
theless, an isolated injury to one or more divisions
yields neurological deficits which are the same, or
less severe, than a cord level injury. For example, an
injury to the anterior division of the lower trunk
(C8/T1) should involve nearly all fibers in the
medial cord. A divisional injury involving the
lateral cord can affect either the anterior division of
either the upper (C5/C6) or middle trunks (C7).
With an ability to readily diagnose proximal and
distal brachial plexus lesions, one can perform a
mental deduction to account for a divisional injury.
29
 Section One  The basics

Fortunately, injuries only involving the divisions carry this sensation. Lesions of the middle trunk,
are infrequently encountered. comprised solely of C7 fibers, logically cause the
same pattern of sensory loss as does a pure C7 palsy.
The C8 dermatome covers the medial, or ulnar,
Sensibility testing in patients with
one-third of the hand, including the little finger and
brachial plexus injuries lateral hypothenar eminence. The dorsal ulnar cuta-
neous and palmar ulnar cutaneous nerves, along
The C5 dermatome covers the lateral portion of the with the superficial sensory division of the ulnar
shoulder and arm down to the elbow (Figure 3.15). nerve, carry sensation from this area. The T1 sensory
Sensation from this area is carried in part by the dermatome mainly covers the medial half of the
upper lateral cutaneous nerve from the axillary forearm, with its sensory fibers being carried by the
nerve, as well as the lower lateral brachial cutaneous medial antebrachial cutaneous nerve, a distal branch
nerve from the proximal radial nerve. Lateral of the medial cord. A lower trunk, or combination
forearm and thumb are the sensory territory of the C8 and T1 spinal nerve lesion, causes a sensory loss
C6 spinal nerve. This sensation is carried in part by in the medial portion of the forearm and hand,
the lateral antebrachial cutaneous nerve off the including the little finger. Of note, the medial arm is
musculocutaneous nerve, and for the thumb, by the mostly covered by the T2 dermatome, with the axilla
terminal sensory branches of both the median (and some proximal medial arm) covered by T3.
(volar surface) and radial (dorsal surface) nerves. A
lesion involving the upper trunk, or alternatively
both the C5 and C6 spinal nerves, yields a sensory
Step-by-step examination of the
loss involving the lateral one-half of the arm and brachial plexus (see video)
forearm, as well as the whole thumb.
The volar and dorsal aspects of the long finger are Despite localization being based on spinal myo-
almost exclusively within the C7 dermatome. The tomes and “plus” palsies, for simplicity, one
sensory division of the median nerve (volar aspect should proceed proximal to distal when examining
of the finger and nail bed) and the superficial muscles of the shoulder girdle, arm, and hand
sensory radial nerve (dorsal aspect of the finger) (Table 3.2).

Great occipital nerve

C2 Small occipital nerve
V Great auricular nerve
V Cervical cutaneous nerve
Ophthalmic branch
Maxillary branch Posterior rami of
V C3
cervical nerves
Mandibular branch
Posterior supraclavicular
C4 nerve
Cervical cutaneous nerves
T2
Supraclavicular nerves C3 T3 Axillary nerve
Posterior thoracic rami

Post. Mid. Ant. C4 T4 Intercostobrachial

Lateral thoracic rami

Axillary nerve
T5 cutaneous nerve
Intercostobrachial T2 T6
C5 C5 Medial brachial
cutaneous nerve T3 T7
T2 T8 cutaneous nerve
Medial brachial T4 T9
cutaneous nerve T5 T10 Lower lateral
T2
Anterior thoracic rami
Lateral thoracic rami

T6 T11 cutaneous nerve

Lower lateral brachial T12
cutaneous nerve T7 Posterior brachial
T1
(branch of radial nerve) T8 cutaneous nerve
C6 (branch of
T9
Medial antebrachial T1 C6 radial nerve)
cutaneous nerve
Posterior
Lateral antebrachial Medial antebrachial antebrachial
cutaneous nerve cutaneous nerve cutaneous
(musculocutaneous) C7 C8
Lateral antebrachial nerve
C6 cutaneous nerve
Radial nerve C8
C7 (musculocutaneous) Median
Median nerve Ulnar nerve
Ulnar nerve nerve
B
B
Superficial
A
A radial nerve

Figure 3.15  Upper extremity dermatome schematic.

30
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 Clinical examination of the patient with brachial plexus palsy 3
Start with the back. Examination begins with the
Table 3.2  Step-by-step brachial plexus examination
patient facing away from the examiner. The pres-
ence of scapular winging, muscle atrophy, and
Anatomic area Examination targets
asymmetry of the shoulders and scapulae at rest are
Back noted. Next, the patient shrugs their shoulders
Observation upward to assess trapezius and levator scapulae
function. Having the patient bring the scapulae
Rhomboids
together assesses the rhomboids. The latissimus
Latissimus dorsi dorsi is palpated bilaterally and the patient is asked
Trapezius
to cough. The patient is instructed to raise his arms
above his head to check trapezius function. Next,
Scapular winging the patient should reach toward the wall with the
Shoulder affected arm. Scapular winging is assessed, with the
upper extremity extended straight and protracted
Supraspinatus
(long thoracic palsy), then partially flexed at the
Deltoid elbow (all types of winging).
Posterior deltoid Next, examine the shoulder. Beginning with the
arm straight along his side, the patient is instructed
Teres major
to abduct the arm. In doing so, the supraspinatus
Pectoralis major and deltoids are assessed. With the arm horizontal
Infraspinatus to the floor, the posterior head of the deltoid (pos-
terior movement) and teres major (downward
Arm
movement) are tested. The patient then flexes the
Triceps arm 90 degrees at the elbow and both the clavicular
Biceps
head of the pectoralis major (lateral pectoral nerve)
followed by the sternal head (medial pectoral
Brachioradialis nerve) are assessed. Facing the patient’s flank, exter-
Forearm nal arm rotation is tested (infraspinatus).
Proceed to test the arm, then forearm. The triceps
Supinator
are examined with the arm flexed at the shoulder,
Pronators bringing it parallel to the floor in order to elimi-
Wrist flexion nate the effect of gravity. Forearm flexion at the
elbow is tested with the forearm fully supinated
Wrist extension
(biceps brachii) and half supinated (brachioradia-
Finger extension lis). Supination and pronation are tested with the
Hand elbow straight to isolate supinator and pronator
teres function. Next, wrist movement is assessed.
Observation The patient flexes the wrist (flexor carpi radialis
Finger flexion and ulnaris), and then the arm is pronated and
Thenar intrinsics
the forearm extensors are tested (extensor carpi
radialis longus and brevis and extensor carpi
Hypothenar intrinsics ulnaris). With the arm placed on a flat surface,
Interossei the long forearm finger extensors (extensor digi-
torum communis, extensor indicis, extensor digiti
Lumbricals
minimi, and extensors pollicis longus and brevis)
Skin are also evaluated.
Sensation Next, examine the hand. The hand is first observed
at rest for signs of atrophy. The patient should open
Horner’s syndrome
and close the hand so an ulnar claw hand or “ben-
Hoffman-Tinel’s sign ediction” (median nerve) sign can be observed, if
present. Next, the thumb is evaluated further,
including abduction, adduction, opposition, and

31
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 Section One  The basics
flexion. Check for OK and Froment’s signs. Flexion
at the proximal (flexor digitorum superficialis) and
distal (flexor digitorum profundus) interphalangeal
joints is assessed. Abduction and opposition of the
little finger are evaluated, as well as Wartenburg’s
and palmaris brevis signs. Finger abduction (dorsal
interossei), adduction (palmar interossei), and
extension at the interphalangeal joints is tested
(lumbricals).
Finally, evaluate the skin. Sensation with light
touch and pinprick is tested from the shoulder
down to the hand. Testing is performed circumfer-
entially on the arm, forearm, and hand. The finger-
tips are also tested, which is especially important.
Any abnormality or asymmetry between the upper
extremities is further evaluated, including assess-
ment of 2-point discrimination and localization
(patients close their eyes). Lack of sweating on the
fingertips may be observed with an ophthalmo-
scope. The neck and axilla are palpated and observed
for scars and masses. Pulses and biceps and triceps
reflexes (C6, C7) are also tested.
Brachial plexus examination in infants
For infants and toddlers, the brachial plexus exami-
nation is based more on observation than on
muscular testing based on examiner command.
Therefore, additional time should be taken during
a consultation with an infant so that all functional
deficiencies may be observed. It is suggested that
the mother be present and intermittently hold and/
or interact with the child to pacify them as needed.
Furthermore, if possible, a pediatric physical thera-
pist should be present during the preoperative con-
sultation, both to help note deficits as well as to
document the patient’s baseline neuromuscular
evaluation.
The following signs should be noted. Presence of
a Horner’s syndrome that would indicate a lower
plexus avulsion or proximal lower plexus injury
should be documented. Limb atrophy and length
discrepancies should be noted. The shoulder, arm,
and hand range of motion, including internal and
external rotation, should be passively tested. Any
shoulder crepitus, marked discomfort, or incon-
gruities along the clavicle on palpation are docu-
mented and may indicate a fracture or dislocation.
Skin breakdown, infections, or repetitive biting or
sucking of the hand or fingers may indicate neuro-
pathic pain. The resting position of the arm and
32
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hand may reveal a classic Erb-Duchenne (upper
plexus) or Dejerine-Klumpke (lower plexus) palsy.
Spontaneous use of each arm is observed. Arm
usage and range of motion is viewed when the child
interacts with the mother or with toys. The normal
arm may be gently immobilized to provoke move-
ment in the affected arm in response to toys, keys,
or food. For example, can the child bring a cookie
to the mouth with the affected hand? The child can
be placed prone to observe lifting of the torso by
one or both arms, as well as arm symmetry during
crawling or rolling. The neuromuscular examina-
tion may be supplemented with an MRI (or CT
myelogram) of the cervical spine to document
pseudomeningoceles, chest radiograph to check for
clavicular fractures and paralysis of the hemidia-
phragm, MRI of the shoulder to evaluate dysplastic
changes involving the glenohumeral joint, and
serial electromyography. Because these tests may be
invasive or require sedation, they are applied on a
case-by-case basis.
Summary
Once brachial plexus anatomy is understood and
muscular examination techniques are mastered, the
physical examination of brachial plexus injuries can
be broken down into anatomical components,
which makes diagnosis and localization readily
achievable. With experience, the examination
becomes routine and may be customized based on
each individual’s clinical history.
Acknowledgments
The authors thank Dr. Anthony Wang and Ms. Amy Yamasaki for
their assistance with creating the video associated with this chapter.
References
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