HUMAN ANATOMY

LECTURE SERIES
EKWERE OKON EKWERE, PhD
DEPARTMENT OF HUMAN ANATOMY
UNIVERSITY OF JOS, NIGERIA.
UPPER LIMB
BRACHIAL PLEXUS
 Brachial Plexus - Introduction
• Nerves entering the upper limb provide the
following important fns:
ü sensory innervation to the skin and deep
structures eg. joints
ü motor innervation to the muscles
ü influence over the diameters of the blood vessels
by the sympathetic vasomotor nerves
ü sympathetic secretomotor supply to the sweat
glands.
Brachial Plexus - Introduction
• At the root of the neck, the nerves form a
complicated plexus called the brachial
plexus (BP).
• allows nerve fibers from different
segments of spinal cord to be arranged
and distributed efficiently in different nerve
trunks to the various parts of the upper
limb.
…..Brachial Plexus - Introduction
• Most nerves in the upper limb arise from
BP, a major nerve network supplying the
upper limb
• it begins in the neck and extends into the
axilla.
• Almost all branches of BP arise in the
axilla (after the plexus has crossed the 1st
rib).
 Brachial Plexus - Formation
• by the anterior rami (ventral rami) of C5 to C8,
and most of the anterior ramus of T1.
• originates in the neck, passes laterally and
inferiorly over 1st rib, and enters the axilla.
• Proximal parts of plexus are posterior to the
subclavian artery in the neck, while more distal
regions of the plexus surround the axillary artery.
• from medial to lateral, are roots, trunks,
divisions, and cords.
.....Brachial Plexus - Formation
.....Brachial Plexus - Formation
.....Brachial Plexus - Formation
.....Brachial Plexus - Formation
.....Brachial Plexus - Formation
 Brachial Plexus - Parts
• Roots lie between scalenus anterior and scalenus
medius.
• The three trunks (upper, middle and lower) lie in the
posterior triangle of the neck, pass over the 1st rib to lie
behind the clavicle.
• The divisions form behind the middle third of the
clavicle around the axillary artery.
• The cords lie in the axilla and are related medially,
laterally and posteriorly to the second part of the axillary
artery.
• Terminal nerves (branches) arise from the cords
surrounding the third part of the axillary artery.
 .....Brachial Plexus - Parts
• Roots - are the anterior rami of C5 to C8, and
most of T1
• Trunks :
ü superior trunk is formed by the union of C5 and
C6 roots
ü middle trunk is a continuation of the C7 root
ü inferior trunk is formed by the union of the C8
and T1 roots
 .....Brachial Plexus - Parts
• Divisions - Each of the three trunks of the brachial plexus
divides into an anterior and a posterior division:
• the three anterior divisions form parts of the brachial
plexus that ultimately give rise to peripheral nerves
associated with the anterior compartments of the arm
and forearm;
• the three posterior divisions combine to form parts of the
brachial plexus that give rise to nerves associated with
the posterior compartments.
• No peripheral nerves originate directly from the divisions
of the brachial plexus.
 .....Brachial Plexus - Parts
• Cords - The three cords of BP originate from the divisions and
are related to the second part of the axillary artery.
• lateral cord results from the union of the anterior divisions of
the upper and middle trunks and therefore has contributions
from C5 to C7-it is positioned lateral to the second part of the
axillary artery;
• medial cord is medial to the second part of the axillary artery
and is the continuation of the anterior division of the inferior
trunk-it contains contributions from C8 and T1.
• posterior cord occurs posterior to the second part of the
axillary artery and originates as the union of all three posterior
divisions-it contains contributions from all roots of the brachial
plexus (C5 to T1).
 .....Brachial Plexus - Parts
•The products of plexus formation are
ümultisegmental
üperipheral (named) nerves.
•The brachial plexus is divided by the clavicle into:
üSupraclavicular
üinfraclavicular parts
Supraclavicular Branches
•4 branches of the supraclavicular part arise from the roots (anterior rami) and
trunks of the brachial plexus (dorsal scapular nerve, long thoracic nerve, nerve
to subclavius, and suprascapular nerve) and are approachable through the
neck.
Include:
• Suprascapular nerve (C5,6): passes through the suprascapular
notch to supply supra- and infraspinatus muscles.
• Long thoracic nerve (of Bell) (C5,6,7): supplies serratus anterior.
 Brachial Plexus – Parts
Infraclavicular branches
•Branches of the infraclavicular arise from the cords of the brachial plexus and
are approachable through the axilla.
•3 branches arise from the lateral cord, whereas the medial and posterior cords
each give rise to 5 branches.
Include
• Medial and lateral pectoral nerves: supply pectoralis major and
minor.
• Medial cutaneous nerves of the arm and forearm.
• Thoracodorsal nerve (C6,7,8): supplies latissimus dorsi.
• Upper and lower subscapular nerves: supply subscapularis and
teres major.
 Brachial Plexus – Parts
• muscular branches arise from all five roots of the plexus
(anterior rami C5 -T1), which supply the scaleni and longus
colli muscles.
• The C5 root of the phrenic nerve (considered a branch of the
cervical plexus) arises from the C5 plexus root, joining the C3-
C4 components of the nerve on the anterior surface of the
anterior scalene muscle.
Variations of the Brachial Plexus
• In addition to the five anterior rami (C5-C8 & T1) that
form the roots of the brachial plexus, small contributions
may be made by the anterior rami of C4 or T2
• prefixed brachial plexus & postfixed brachial plexus
 …..Brachial Plexus – Parts
• Prefixed B.P. occurs when the superiormost root
(anterior ramus) of the plexus is C4 and the inferiormost
root is C8.
• Postfixed B.P. - when the superior root is C6 and the
inferior root is T2. where the inferior trunk of the plexus
may be compressed by the 1st rib, producing
neurovascular symptoms in the upper limb.
Variations may also occur in:
ü divisions
ü Cords
ü origin of the formation of trunks
ü and/or combination of branches
 Brachial Plexus – Parts
üin the relationship to the axillary artery and
scalene muscles eg, lateral or medial cords
may receive fibers from anterior rami inferior
or superior to the usual levels, respectively.
üIn some individuals, trunk divisions or cord
formations may be absent in one or other
parts of the plexus without changing the
makeup of the terminal branches.
 Brachial Plexus – Branches
• Roots • Lateral cord
ü Dorsal scapular nerve
(C5) üLateral pectoral
ü Long thoracic nerve (C5, nerve
6, and 7) üMusculocutaneous
• Upper trunk
nerve
ü Nerve to subclavius (C5
and 6) üLateral root of
ü Suprascapular nerve median nerve
(supplies supraspinatus
and infraspinatus
muscles)
 …..Brachial Plexus – Branches
• Medial cord • Posterior cord
ü Medial pectoral nerve ü Upper subscapular
ü Medial cutaneous nerves
nerve of arm ü Lower subscapular
ü medial cutaneous nerves
nerve of forearm ü Thoracodorsal nerve
ü Ulnar nerve ü Radial nerve
ü Medial root of median ü Axillary nerve
nerve
 Mnenomics for nerves of BP
Lateral cord- Posterior cord-
•Love
•Me
•U
•Lily •L
Medial cord- •T
•Most
•Medical
•R
•Men •A
•Use
•Morphine
 .....Brachial Plexus - Branches
from the roots-
•Dorsal scapular nerve:
üoriginates from the C5 root of the brachial plexus
üpasses posteriorly, often piercing the middle scalene muscle in the
neck, to reach and travel along the medial border of scapula.
üinnervates the rhomboid major and minor muscles from their deep
surfaces.
•Long thoracic nerve:
üoriginates from the anterior rami of C5 to C7
üpasses vertically down the neck, through the axillary inlet, and
down the medial wall of the axilla to supply the serratus anterior
muscle.
ülies on the superficial aspect of the serratus anterior muscle.
 .....Brachial Plexus – Branches
from the superior (upper) trunk:
•suprascapular nerve (C5 and C6) supplies the
supraspinatus and infraspinatus muscles
•nerve to subclavius muscle (C5 and C6) is a small nerve
that:
üoriginates from the superior trunk of the brachial plexus
üpasses anteroinferiorly over the subclavian artery and
vein & innervates the subclavius muscle.
üImportant clinically as it may give a contribution (C5) to
the phrenic nerve; this branch - accessory phrenic nerve.
 .....Brachial Plexus - Branches
from the lateral cord
•The lateral pectoral nerve - most proximal of the branches from the
lateral cord, passes anteriorly, together with the thoraco-acromial artery,
to penetrate the clavipectoral fascia that spans the gap between the
subclavius and pectoralis minor muscles and innervates the pectoralis
major muscle.
•The musculocutaneous nerve - a large terminal branch of the lateral
cord, passes laterally to penetrate the coracobrachialis muscle and
pass between the biceps brachii and brachialis muscles in the arm, and
innervates all three flexor muscles in the anterior compartment of the
arm, terminating as the lateral cutaneous nerve of forearm.
•The lateral root of median nerve - largest terminal branch of the
lateral cord and passes medially to join a similar branch from the
medial cord to form the median nerve
 .....Brachial Plexus – Branches
from the medial cord - 5 branches:
• medial pectoral nerve is the most proximal branch,
receives a communicating branch from the lateral
pectoral nerve and then passes anteriorly between the
axillary artery and axillary vein. Branches of the nerve
penetrate and supply the pectoralis minor muscle.
Some of these branches pass through the muscle to
reach and supply the pectoralis major muscle. Other
branches occasionally pass around the inferior or
lateral margin of the pectoralis minor muscle to reach
the pectoralis major muscle.
 .....Brachial Plexus - Branches
• medial cutaneous nerve of arm (medial brachial cutaneous
nerve) passes through the axilla and into the arm where it
penetrates deep fascia and supplies skin over the medial side of the
distal third of the arm. In the axilla, the nerve communicates with the
intercostobrachial nerve of T2. Fibers of the medial cutaneous
nerve of arm innervate the upper part of the medial surface of the
arm and floor of the axilla.
• The medial cutaneous nerve of forearm (medial antebrachial
cutaneous nerve) originates just distal to the origin of the medial
cutaneous nerve of arm. It passes out of the axilla and into the arm
where it gives off a branch to the skin over the biceps brachii
muscle, and then continues down the arm to penetrate the deep
fascia with the basilic vein, continuing inferiorly to supply the skin
over the anterior surface of the forearm. It innervates skin over the
medial surface of the forearm down to the wrist.
 .....Brachial Plexus - Branches
• medial root of median nerve passes laterally to join with a similar
root from the lateral cord to form the median nerve anterior to the
third part of the axillary artery.
• ulnar nerve is a large terminal branch of the medial cord, near its
origin, it receives a communicating branch from the lateral root of
the median nerve originating from the lateral cord and carrying fibers
from C7. The ulnar nerve passes through the arm and forearm into
the hand where it innervates all intrinsic muscles of the hand (except
for the three thenar muscles and the two lateral lumbrical muscles).
On passing through the forearm, branches of the ulnar nerve
innervate the flexor carpi ulnaris muscle and the medial half of the
flexor digitorum profundus muscle. The ulnar nerve innervates skin
over the palmar surface of the little finger, medial half of the ring
finger, and associated palm and wrist, and the skin over the dorsal
surface of the medial part of the hand.
 .....Brachial Plexus - Branches
• Median nerve - formed anterior to the third part
of the axillary artery by the union of lateral and
medial roots originating from the lateral and
medial cords of the brachial plexus. It passes
into the arm anterior to the brachial artery,
through the arm into the forearm where
branches innervate most of the muscles in the
anterior compartment of the forearm (except for
the flexor carpi ulnaris muscle and the medial
half of the flexor digitorum profundus muscle,
which are innervated by the ulnar nerve).
 .....Brachial Plexus - Branches
• The median nerve continues into the hand to innervate:
ü the three thenar muscles associated with the thumb;
ü the two lateral lumbrical muscles associated with movement
of the index and middle fingers;
ü the skin over the palmar surface of the lateral three and one-
half digits and over the lateral side of the palm and middle of
the wrist.
• The musculocutaneous nerve, the lateral root of the median
nerve, the median nerve, the medial root of the median nerve,
and the ulnar nerve form an m over the third part of the
axillary artery. This feature, together with penetration of the
coracobrachialis muscle by the musculocutaneous nerve, can
be used to identify components of the brachial plexus in the
axilla.
 .....Brachial Plexus - Branches
from the posterior cord:
•upper (superior) subscapular nerve
•lower (inferior) subscapular nerve
•thoracodorsal nerve
•radial nerve
•axillary nerve
 .....Brachial Plexus – Branches
• The superior subscapular nerve is short and passes into
and supplies the subscapularis muscle.
• The inferior subscapular nerve also passes inferiorly along
the posterior axillary wall and innervates the subscapularis
and teres major muscles.
• thoracodorsal nerve is the longest of these three nerves and
passes vertically along the posterior axillary wall, penetrates
and innervates the latissimus dorsi muscle.
 .....Brachial Plexus – Branches
• The radial nerve - largest terminal branch of the
posterior cord, lies behind the axillary artery.
• It passes out of the axilla and into the posterior
compartment of the arm by passing through the
triangular interval between the inferior border of the teres
major muscle, the long head of the triceps brachii
muscle, and the shaft of the humerus.
• The radial nerve and its branches innervate:
ü all muscles in the posterior compartments of the arm and
forearm
ü the skin on the posterior aspect of the arm and forearm,
the lower lateral surface of the arm, and the dorsal
lateral surface of the hand.
 .....Brachial Plexus – Branches
• axillary nerve passes inferiorly and laterally along
the posterior wall to exit the axilla through the
quadrangular space. It passes posteriorly around the
surgical neck of the humerus and innervates both
the deltoid and teres minor muscles.
• superior lateral cutaneous nerve of arm
originates from the axillary nerve after passing
through the quadrangular space and loops around
the posterior margin of the deltoid muscle to
innervate skin in that region. The axillary nerve is
accompanied by the posterior circumflex humeral
artery.
 .....Brachial Plexus – Branches
• Most of the major peripheral nerves of the
upper limb originate from the cords of the
brachial plexus. Generally, nerves
associated with the anterior compartments
of the upper limb arise from the medial
and lateral cords and nerves associated
with the posterior compartments originate
from the posterior cord.
.....Brachial Plexus – Branches
.....Brachial Plexus – Branches
.....Brachial Plexus – Branches
.....Brachial Plexus – Branches
 …..Applied Anatomy/Clinical
considerations or importance
Brachial Plexus Injuries
•Injuries to the brachial plexus affect movements and
cutaneous sensations in the upper limb. Disease, stretching,
and wounds in the lateral cervical region (posterior triangle) of
the neck (or in the axilla) may produce brachial plexus injuries.
Signs and symptoms depend on the part of the plexus involved.
Injuries to the brachial plexus result in paralysis and anesthesia.
Testing the person's ability to perform movements assesses the
degree of paralysis. In complete paralysis, no movement is
detectable. In incomplete paralysis, not all muscles are
paralyzed; therefore, the person can move, but the movements
are weak compared with those on the normal side. Determining
the ability of the person to feel pain (e.g., from a pinprick of the
skin) tests the degree of anesthesia.
 Applied Anatomy/ Clinical
importance or considerations
• Brachial plexus injuries are usually the result of
blunt trauma producing nerve avulsions and
disruption. These injuries are usually devastating for
the function of the upper limb and require many
months of dedicated rehabilitation for even a small
amount of function to return.
• Spinal cord injuries in the cervical region and direct
pulling injuries tend to affect the roots of the brachial
plexus. Severe trauma to the first rib usually affects
the trunks. The divisions and cords of the brachial
plexus can be injured by dislocation of the
glenohumeral joint.
 …..Applied Anatomy/ Clinical
importance or considerations
Brachial plexus injuries
•Brachial plexus injuries may occur from traction on the arm
during birth. The force of downward traction falls upon roots
C5 and 6, resulting in paralysis of the deltoid and short
muscles of the shoulder, and of brachialis and biceps which
flex and supinate at the elbow. The arm, therefore, hangs
limply by the side with the forearm pronated and the palm
facing backwards, like a porter hinting for a tip (Erb
Duchenne paralysis). In adults this lesion is seen in violent
falls on the side of the head and shoulder forcing the two
apart and thus putting a tearing strain on the upper roots of
the plexus.
 .....Applied Anatomy/Clinical
considerations or importance
• Injuries to superior parts of the brachial plexus (C5 and C6)
usually result from an excessive increase in the angle
between the neck and the shoulder. These injuries can occur
in a person who is thrown from a motorcycle or a horse and
lands on the shoulder in a way that widely separates the neck
and shoulder. When thrown, the person's shoulder often hits
something (e.g., a tree or the ground) and stops, but the head
and trunk continue to move. This stretches or ruptures
superior parts of the brachial plexus or avulses (tears) the
roots of the plexus from the spinal cord. Injury to the superior
trunk of the plexus is apparent by the characteristic position of
the limb (waiter's tip position), in which the limb hangs by
the side in medial rotation. Upper brachial plexus injuries can
also occur in a newborn when excessive stretching of the
neck occurs during delivery.
 .....Applied Anatomy/Clinical
considerations or importance
• As a result of injuries to the superior parts of the brachial
plexus (Erb-Duchenne palsy), paralysis of the muscles of the
shoulder and arm supplied by the C5 and C6 spinal nerves
occurs: deltoid, biceps, brachialis, and brachioradialis. The
usual clinical appearance is an upper limb with an adducted
shoulder, medially rotated arm, and extended elbow. The
lateral aspect of the upper limb also experiences loss of
sensation. Chronic microtrauma to the superior trunk of the
brachial plexus from carrying a heavy backpack can produce
motor and sensory deficits in the distribution of the
musculocutaneous and radial nerves. A superior brachial
plexus injury may produce muscle spasms and a severe
disability in hikers (backpacker's palsy) who carry heavy
backpacks for long periods.
 …..Applied Anatomy/ Clinical
importance or considerations
• Erb–Duchenne paralysis- Excessive downward
traction on the upper limb during birth can result
in injury to the C5 and C6 roots. This results in
paralysis of the deltoid, the short muscles of the
shoulder, brachialis and biceps. The combined
effect is that the arm hangs down by the side
with the forearm pronated and the palm facing
backwards. This has been termed the ‘waiter’s
tip’ position.
 .....Applied Anatomy/Clinical
considerations or importance
• Acute brachial plexus neuritis (brachial plexus
neuropathy) is a neurologic disorder of unknown
cause that is characterized by the sudden onset of
severe pain, usually around the shoulder (Rowland,
2000). Typically, the pain begins at night and is
followed by muscle weakness and sometimes
muscular atrophy (neurologic amyotrophy).
Inflammation of the brachial plexus (brachial
neuritis) is often preceded by some event (e.g.,
upper respiratory infection, vaccination, or non-
specific trauma). The nerve fibers involved are
usually derived from the superior trunk of the
brachial plexus.
 .....Applied Anatomy/Clinical
considerations or importance
• Compression of cords of the brachial plexus may result
from prolonged hyperabduction of the arm during
performance of manual tasks over the head, such as
painting a ceiling. The cords are impinged or
compressed between the coracoid process of the
scapula and the pectoralis minor tendon. Common
neurologic symptoms are pain radiating down the arm,
numbness, paresthesia (tingling), erythema (redness of
the skin caused by capillary dilation), and weakness of
the hands. Compression of the axillary artery and vein
causes ischemia of the upper limb and distension of the
superficial veins. These signs and symptoms of
hyperabduction syndrome result from compression of the
axillary vessels and nerves.
 …..Applied Anatomy/ Clinical
importance or considerations
• Upward traction on the arm (e.g. in a forcible breech
delivery) may tear the lowest root, T1, which is the
segmental supply of the intrinsic hand muscles. The
hand assumes a clawed appearance because of the
unopposed action of the long flexors and extensors of
the fingers; the extensors,inserting into the bases of the
proximal phalanges, extend the m/p joints while the
flexor profundus and sublimis, inserting into the distal
and middle phalanges, flex the i/p joints (Klumpke’s
paralysis). There is often an associated Horner’s
syndrome (ptosis and constriction of the pupil), due to
traction on the cervical sympathetic chain.
 .....Applied Anatomy/Clinical
considerations or importance
• Injuries to inferior parts of the brachial plexus
(Klumpke paralysis) are much less common.
Inferior brachial plexus injuries may occur when
the upper limb is suddenly pulled superiorly for
example, when a person grasps something to
break a fall or a baby's upper limb is pulled
excessively during delivery. These events injure
the inferior trunk of the brachial plexus (C8 and
T1) and may avulse the roots of the spinal
nerves from the spinal cord. The short muscles
of the hand are affected, and a claw hand
results.
 …..Applied Anatomy/ Clinical
importance or considerations
• Klumpke’s paralysis- Excessive upward
traction on the upper limb can result in injury to
the T1 root. As the latter is the nerve supply to
the intrinsic muscles of the hand this injury
results in ‘clawing’ (extension of the
metacarpophalangeal joints and flexion of the
interphalangeal joints) due to the unopposed
action of the long flexors and extensors of the
fingers. There is often an associated Horner’s
syndrome (ptosis, pupillary constriction and
ipsilateral anhidrosis) as the traction injury often
involves the cervical sympathetic chain.
 …..Applied Anatomy/ Clinical
importance or considerations
• The radial nerve may be injured in the axilla by the
pressure of a crutch (‘crutch palsy’) or may be
compressed when a drunkard falls into an intoxicated
sleep with the arm hanging over the back of a chair
(‘Saturday night palsy’).
• Fractures of the humeral shaft may damage the main
radial nerve, whereas its posterior interosseous branch,
to the extensor muscles of the forearm, may be injured in
fractures or dislocations of the radial head. An ill-placed
incision to expose the head of the radius taken more
than three fingers’ breadth below the head will divide the
nerve as it lies in the supinator muscle.
 …..Applied Anatomy/ Clinical
importance or considerations
• A mass of malignant supraclavicular lymph
nodes or the direct invasion of a pulmonary
carcinoma (Pancoast’s syndrome) may produce
a similar neurological picture by involvement of
the lowest root of the plexus. Not infrequently,
the lower trunk of the plexus (C8, T1) is pressed
upon by a cervical rib, or by the fibrous strand
running from the extremity of such a rib, resulting
in paraesthesiae along the ulnar border of the
arm and weakness and wasting of the small
muscles of the hand.
 …..Applied Anatomy/ Clinical
importance or considerations
• The lower trunk of the plexus (C8, T1) may be
pressed upon by a cervical rib, or by the fibrous
strand running from the extremity of such a rib,
resulting in paraesthesiae along the ulnar border
of the arm and weakness and wasting of the
small muscles of the hand – cervical rib
syndrome.
• Cervical rib - extra rib which, arises from C7-
congenital anomaly located above the normal 1st
rib. When present-entrapment of lower trunk of
Brachial plexus or subclavian artery between the
cervical rib & scalenus muscles.
 .....Applied Anatomy/Clinical
considerations or importance
Brachial Plexus Block
•Injection of an anesthetic solution into or immediately
surrounding the axillary sheath interrupts nerve impulses
and produces anesthesia of the structures supplied by the
branches of the cords of the plexus. Sensation is blocked in
all deep structures of the upper limb and the skin distal to
the middle of the arm. Combined with an occlusive
tourniquet technique to retain the anesthetic agent, this
procedure enables surgeons to operate on the upper limb
without using a general anesthetic. The brachial plexus can
be anesthetized using a number of approaches, including
an interscalene, supraclavicular, and axillary approach or
block (Leonard, et al., 1999).
.....Applied Anatomy/Clinical
considerations or importance
.....Applied Anatomy/Clinical
considerations or importance
 References
• Anatomy at a glance- Faiz and Moffatt
• Clinical Anatomy by regions – Richard
Snell
• Gray’s Anatomy for students
• Clinically oriented Anatomy-Moore and
Dalley
• Clinical Anatomy-Harrold Ellis
• Gross Anatomy-Chung and Chung