BRACHIAL PLEXUS INJURY

● Musculocutaneous nerve:​ Originates from nerve roots C5-C7 and flexes

muscles in the upper arm, at both the shoulder and elbow.
● Axillary nerve:​ Stems from nerve roots C5 and C6; it helps the shoulder
rotate and enables the arm to lift away from the body.
● Median nerve:​ Starts in nerve roots C6-T1 and enables movement in the
forearm and parts of the hand.
● Radial nerve:​ Begins in nerve roots C5-T1 and controls various muscles in
the upper arm, elbow, forearm and hand.
● Ulnar nerve:​ Rooted in C8-T1, it allows for fine motor control of the fingers.

● “Waiter’s tip”​ positioning of arm suggests upper plexus injury, with arm
adducted, shoulder internally rotated, elbow extended, forearm pronated,
with wrist/fingers flexed
● Winged scapula​ indicates injury to long thoracic nerve (C5, C6, C7)
● Elbow flexed postur​e indicates injury to C7 root in isolation
● Flail limb with no motor function​ suggests pan-brachial plexus injury
(including roots C5-C8, with or without T1)
● Horner syndrome​ (eyelid ptosis, pupillary miosis, and anhidrosis) indicates
injury to lower plexus with injury to the T1 root proximal to sympathetic and
somatic motor fiber separation.

THINGS TO REMEMBER:

● The brachial plexus is formed by the anterior rami of C5-T1

● The median nerve innervates most muscles of the anterior compartment,
EXCEPT the flexor carpi ulnaris and the medial part of the flexor digitorum
profundus
● There are only two nerves which come off the roots of the brachial plexus:
long thoracic (C5-C7) and dorsal scapular (C5)
● The ​lateral cord gives rise​ to the following nerves: Lateral pectoral,
musculocutaneous and the lateral root of the median nerve. The
thoracodorsal nerve​ comes off the ​posterior cord.
● The ulnar nerve innervates all the intrinsic muscles of the hand EXCEPT the
three thenar muscles and the lateral two lumbricals (1and 2)-these muscle
are innervated by the MEDIAN nerve
 ● The dorsal scapula nerve innervates the rhomboids
● The cords lie around the axillary artery
● The brachial plexus is a somatic plexus formed by the anterior rami of
C5-C8, and most of the anterior ramus of T1
● The roots and trucks of the brachial plexus lie in the posterior triangle of
the neck.
● The superior trunk is formed from C5 and C6. The middle trunk is formed
for C7 alone, and the inferior trunk is formed from C8 and T1.
● The posterior cord gives rise to the following nerves: upper subscapular,
thoracodorsal, lower subscapular, axillary, and radial.
● The medial cutaneous nerve of the FOREARM supplies skin over the
anterior part of the forearm and the biceps. The medial nerve of the ARM
supplies the skin on the medial side of the upper arm.
● The brachial plexus passes between the anterior and middle scalene
muscles
● The suprascapular never originates from the superior trunk

Brachial plexus injury at birth generally takes one of two forms:

● Erb’s Palsy, or Erb’s Duchenne Palsy​: involves cervical nerve roots C5, C6,
and sometimes C7. These nerves are at the top of the brachial plexus, and
send electrical impulses to the shoulder and upper arm. a common injury of
the upper brachial plexus nerves, causing numbness and ​loss of motion
around the shoulder and an inability to flex the elbow, lift an arm or bring
objects to the mouth.
● This group of nerves work on reaching, lifting, and bringing the arm above
the head (for tasks such as dressing, assisting in feeding, and of course
playing). When C7 is involved, the ability to extend the elbow against
gravity is limited as well as picking up wrist (to give high five, throw a ball,
etc).
 ●
● 2) Klumpke’s Palsy:​ impacts the lower nerve roots (C8-T1), in which the
shoulder is spared and the elbow is functional, but the wrist and hand are
paralyzed.​ ​a less common injury that affects the lower brachial plexus,
leading to loss of motion and/or sensation in the wrist and hand, such as
being unable to move fingers.

OTHER injuries:

● 3) Total Plexus Palsy:​ involves the entire brachial plexus and results in a
flaccid or paralyzed arm. It can also be seen in conjunction with a Horner’s
sign, which presents as drooping of the eye on the same side of the
affected arm. Additionally, the phrenic nerve can be affected causing some
diaphragmatic paralysis on the affected side.
● One type of brachial plexus injury is called a "stinger" or "burner." Stingers
occur with compression or overstretching of the nerves that run from the
neck to the arm, usually during collisions in contact sports.

● Avulsion.​ In this most severe brachial plexus injury, the nerve root has been
torn from the spinal cord. These types of injuries may not be repairable
with surgery. EX: ​Horner’s syndrome
● Stretch (Neuropraxia​). When the nerve is mildly stretched, it may heal on
its own or require simple, nonsurgical treatment methods to return to
normal function.
● Rupture​. A more forceful stretch of the nerve may cause it to tear partially
or fully. These types of injuries can sometimes be repaired with surgery.
● Upper-Trunk Palsy Injury- ​Upper-trunk palsy occurs when the angle
between the shoulder and the neck forcibly widens, such as when a fall
forces the shoulder down and the head to the opposite side.
● Lower-Trunk Palsy Injury
 ● Lower-trunk palsy occurs when the angle between the arm and the chest
wall forcibly widens. This may damage the lower nerves and the lower
trunks.
● Pan-Plexus Palsy Injury
● Pan-plexus palsy may occur if the force of the injury is extreme. In
pan-plexus palsy, all levels of the nerves and trunk are damaged. This
results in complete paralysis of the arm and hand, which is often referred
to as "flail limb."

● Subclavian steal syndrome​ is a condition whereby the subclavian artery is

stenosed but not occluded. When the affected limb is exercised and
increased blood flow required, this is ‘stolen’ in the form of retrograde flow
from other branches distal to the narrowing. This is commonly from the
vertebral artery, resulting in presyncope or syncope.
● Thoracic outlet syndrome​ may be caused by the presence of a cervical rib,
which is a congenital overgrowth of the 7​th​ cervical vertebral lateral process
joining the first rib. This may cause a lower brachial plexus compression
with or without subclavian artery compression.
● Holmes-Adie syndrome​ describes an association between pupil myotonia
and altered lower limb reflexes. The affected pupil is often more dilated
than its counterpart, slow to react to accommodation and reacts poorly to
light. The reflexes of the lower limbs may be reduced or even absent. Often
a benign incidental finding in young women.
● Pickwickian syndrome​ is another name for obesity hypoventilation
syndrome; irrelevant to this question but an interesting name.
●

NERVE INJURY
● 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​. this muscle fixes and stabilizes the scapula so that muscles
originating from it can function properly.​ Injury to the long thoracic nerve
causes winging of the scapula
● The​ ​dorsal scapular nerve ​is a very proximal branch from the C5 spinal root.
This nerve ​innervates both the major and minor rhomboid muscles​.
rhomboids connect the medial edge of the scapulae to the spinal column.
When contracted, ​the rhomboids pull the scapula toward the midline
(scapular adduction and retraction) and superiorly (downward rotation of
the lateral angle).​ The rhomboids move the scapula in the opposite
direction to that of the serratus anterior muscles. With chronic
denervation, wasting of this muscle deep to the trapezius is evident. The
scapula may also be displaced laterally and inferiorly and rotated laterally.
● The ​suprascapular nerve ​(C5, C6) o ​ riginates ​from the upper trunk of the
brachial​ plexus and passes the inferior belly of the omohyoid to the
suprascapular notch through ​which it passes to the posterior surface of
the scapula.​ The ​suprascapular nerve innervates the supraspinatus and
infraspinatus muscles​. The supraspinatus attaches to the superior aspect of
the humeral head and mediates the initial 20-30 degrees of arm abduction.
The infraspinatus attaches to the posterior lateral aspect of the humeral
head and is the primary external rotator of the arm.
● The ​axillary nerve ​(C5, C6)​ arises from the p ​ osterior cord deep ​to the
axillary artery​ and ​divides into an anterior and posterior division​ near the
humeral neck as it passes medially and posteriorly to it. The anterior
division innervates the anterior and lateral deltoid. The posterior division
gives a branch to the teres minor, innervates the posterior portion of the
deltoid, and gives a sensory branch to the lateral shoulder region.
● The initial 30 degrees of abduction is primarily controlled by the
supraspinatus, whereas abduction above 90 degrees has an important
trapezius and serratus component that tilts the shoulder girdle upward.
Mr Unlucky has never been the superstitious type, frequently crossing paths with
black cats and breaking mirrors for fun. Earlier this morning, however, he ducked
underneath a ladder in the street and unfortunately received a direct blow to the
middle portion of his clavicle from a paint tin from the sky.
Which part of the brachial plexus most commonly lies deep to the clavicle?
A. Divisions
B. Nerves
C. Cords
D. Roots
E. Trunks

Billy is a ten-year-old who has fallen from a tree. He’s been a fairly lucky
ten-year-old, as a primary survey in the emergency department has revealed no
issues with his airway, cervical spine, breathing, circulatory system or neurological
status. On examination of his limbs, however, he appears to have unfortunately
developed a rare deformity whereby the right wrist and metacarpophalangeal
joints are held in extension, the interphalangeal joints are flexed, and he has
abnormal sensation over the ulnar border of the hand.
Which roots of the brachial plexus do you suspect have been injured?
A. C4-C5
B. C5-C6
C. C8-T1
D. C6-C7
E. C7-C8
Which of the following muscles does NOT derive its motor innervation from the
posterior cord of the brachial plexus?
A. Latissimus Dorsi
B. Subscapularis
C. Triceps
D. Deltoid
 E. Serratus Anterior
As part of your revision of the pathology of carpal tunnel syndrome, you thought
it might be a helpful exercise to follow the path of the implicated nerve from the
wrist all the way up to the spinal cord.
This particular nerve in question is derived from which two cords of the brachial
plexus?

A. Posterior and Lateral

B. Medial and Lateral
C. Medial and Posterior
D. Median and Lateral
E. Posterior and Anterior
30-year-old Duke Athie limps into the orthopedic long bone clinic for review of his
complicated tibial fracture. From reading his notes you see that he had a motorcycle
accident ten years ago in which he broke both legs and injured his neck. You introduce
yourself, but when you offer to shake his hand he grimaces and awkwardly shrugs the
right side of his chest in response. You notice that his right arm is held unnaturally; it is
turned inward at the shoulder, tucked into his side, fully extended at the elbow and his
fingers are pointing out behind him.

At which level do you suspect his brachial plexus may have been compromised?

A. C4-C5

B. C5-C6

C. C7-C8

D. C8-T1

E. C6-C7

Mr Vintner is involved in an implausible accident with a sharp piece of glass, which

penetrates through pectoralis major and narrowly avoids both pectoralis minor and the
axillary artery. It does, however, completely transect his musculocutaneous nerve. He is
left virtually unable to flex his right arm and struggles to supinate, to the extent that he
can no longer use a corkscrew and has to import wine in screw-top bottles only.
Which of the following structures is NOT innervated by the musculocutaneous nerve or
its branches?

A. Biceps Brachii

B. Supinator

C. Skin (sensation) on the Radial aspect of the forearm

D. Brachialis

E. Coracobrachialis

Mr Bloggs has dislocated his shoulder in an ill-advised attempt to jump over a cow. You
remember hearing of a medicolegal case in which a doctor was sued for failing to
document axillary nerve sensation prior to reducing such a dislocation, and thus being
unable to demonstrate that he had not caused the axonotmesis when it was later
discovered. You find that Mr Bloggs, fortunately, has intact sensation in the distribution
of the axillary nerve.

From which cord of the brachial plexus does the axillary nerve arise?

A. Upper

B. Posterior

C. Medial

D. Lateral

E. Lower

You are observing Dr Gasser anaesthetise a patient prior to open rotator cuff repair
surgery. She intends to perform a regional nerve block affecting the brachial plexus and
asks you about the relevant anatomy.

Between which two muscles do the roots of the brachial plexus emerge?

A. Anterior and middle scalene

B. Pectoralis minor and major

C. Sternocleidomastoid and anterior scalene

D. Middle and posterior scalene

 E. Anterior and posterior scalene

Which of the following brachial plexus nerve roots continues alone as a trunk?

A. C5

B. C8

C. C7

D. T1

E. C6

A competitive motorcyclist is involved in a 'high-side' dismount whereby he is thrown up

and over his motorbike, landing hard on his shoulder with his neck flexed toward the
contralateral side. He sustains a comminuted open clavicular fracture in addition to an
upper rib and proximal humerus fractures.

Which syndrome is he at risk of developing following complete brachial plexus

injury (i.e. avulsion of the nerve roots)?

A. Subclavian steal syndrome

B. Pickwickian syndrome

C. Holmes-Adie syndrome

D. Thoracic outlet syndrome

E. Pickwickian Syndrome

F. Horner's syndrome

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