Brachial plexus

a. Roots: anterior rami of spinal nerves C5-T1

 pass between anterior and medial scalene muscles
b. Trunks: converge
 Superior: combination of C5 and C6 roots.
 Middle: continuation of C7.
 Inferior: combination of C8 and T1 roots.
c. Divisions: division of trunks (post △)
 Anterior
 Posterior
d. Cords: combined division (axillary artery)
 Lateral: ant division—superior, middle trunk
 Post: post division—post trunk
 Middle: ant division—inf trunk
e. Branches:
 Major— all nerves below
 Minor
Musculocutaneous Lateral cord of brachial Motor: Injury (uncommon)
Nerve plexus (C5-C7) anterior compartment of the arm
 coracobrachialis (flexion) Motor functions
muscle Biceps brachii (supination) Weak Flexion at shoulder and elbow –
 flexor compartment Brachialis performed by pectoralis major and
 deep fascia (lat. Coracobrachialis brachioradialis
Biceps brachii) Sensory: Weak Supination of forearm - performed
 lat. biceps tendon, lateral cutaneous nerve of by brachioradialis.
brachioradialis forearm → anterolateral aspect
of forearm Sensory function
loss of sensation over lateral side of the
forearm.

Axillary nerve posterior cord from the Motor: Motor functions

brachial plexus (C5-C6)  Teres minor (RC)- unable to abduct the affected limb beyond
external rotation (post 15 degrees.
 Post- axillary artery terminal branch)
 Ant- subscapularis Sensory functions
 Deltoid: abduction (ant upper lateral cutaneous nerve of arm – loss
 quadrangular space— terminal branch) of sensation over the inferior deltoid
surgical neck of (‘regimental badge area’).
humerus: Sensory:
 Post terminal branch  post terminal branch
 Ant terminal branch  teres minor
 Articular branch  upper lateral cutaneous
nerve
 inferior portion of the
deltoid
Ulnar nerve medial cord brachial plexus
(C8- T1)
Descend (medial):
 axillary artery (lateral),
axillary vein (medial) –
medial arm brachial artery
 Flexor carpi ulnaris
 Muscular
 Palmar cutaneous
Dorsal cutaneous
Motor:
 Ant compartment- Flexor carpi ulnaris, Froment’s sign
Flexor digitorum profundus (medial half) ulnar nerve palsy –paralysis of the adductor pollicis
 Hand
 Hypothenar muscles (flexor digiti minimi
brevis, abductor digiti minimi, opponens
digiti minimi)
 Medial two lumbricals
 Adductor pollicis
 Palmar
 & dorsal interossei of the hand

Sensory:
 Palmar cutaneous branch –medial half of
palm.
 Dorsal cutaneous branch –dorsal surface of
medial 1 ½ fingers, associated dorsal hand
area.
 Superficial branch –palmar surface of the
medial 1 ½ fingers.

Radial nerve Motor

 3 heads of the triceps brachii—
extension arm at elbow
 brachioradialis
 extensor carpi radialis longus
(posterior forearm)
 deep branch- remaining muscles of
post forearm.
Sensory
4 branches (cutaneous innervation) - 3
arise in upper arm:
 Lower lat cutaneous– lat aspect of
arm
 Post cutaneous–post surface of arm.
 Post cutaneous nerve forearm –
strip of skin down middle of post
forearm.
 superficial branch (terminal
division)- dorsal surface of lateral 3
½ digits & associated area on
posterior cord of the brachial plexus (C5-T1)
dorsum of the hand.
 posterior: axillary artery—radial groove
 anterior: lateral epicondyle
Axilla-dislocation at the shoulder joint, fracture of proximal humerus.
Motor- unable to extend at forearm, wrist and fingers. Unopposed flexion of wrist- wrist-drop.
Sensory functions –loss of sensation over lat/ post arm, post forearm, dorsal surface of lateral 3 ½
digits.
Radial Groove- fracture of humeral shaft.
Motor functions
WEAK triceps brachii (not paralysed)
unable to extend at the wrist and fingers.
Unopposed flexion of wrist - wrist-drop.
Sensory functions –
Loss of sensation dorsal surface of lateral 3 ½ digits.
Forearm
a. Superficial Branch
Stabbing or laceration of forearm
Motor NONE
Sensory Loss of sensation dorsal surface of lateral 3 ½ digits, dorsum of hand
b. Deep Branch
Fracture of radial head, posterior dislocation of radius
Motor posterior forearm
Wrist-drop does not occur- extensor carpi radialis longus unaffected,
Sensory NONE

 Deep branch (motor): muscles in post compartment

of forearm.
  Superficial branch (sensory): cutaneous innervation
of the dorsal hand and fingers.
Median nerve
medial and lateral cords (C6-T1)
brachial plexus in axilla
brachial artery
ant compartment (cubital fossa)
2 branches:
 Anterior interosseous nerve –deep muscles in ant
forearm.
 Palmar cutaneous nerve–lateral palm.
carpal tunnel – 2 branches:
 Recurrent branch – thenar muscles.
 Palmar digital branch – palmar surface, fingertips
of lateral 3 ½ digits, 2 lumbrical muscles.
Branches of the brachial Spinal roots
plexus
Motor
 Superficial layer – pronator teres,
flexor carpi radialis, palmaris
longus.
 Intermediate layer – flexor
digitorum superficialis.
 anterior interosseous
 Deep layer – flexor pollicis longus,
pronator quadratus, lateral ½ of
flexor digitorum profundus
 **pronation forearm, flexion wrist,
digits of hand
 recurrent branch- thenar muscles
(thumb)
 palmar digital- flexion at MCP
joints, extension IP joints of index,
middle fingers
Sensory
 Palmar cutaneous branch- lateral
aspect of the palm
 does not pass through carpal tunnel,
 Palmar digital cutaneous branch –
palmar surface, fingertips of lateral
3 ½ digits.
Lateral cord and branches of the brachial plexus
Course Motor innervation
carpal tunnel syndrome (CTS)
mononeuropathy: increased tissue pressure within carpal tunnel.
 Tinel’s sign – elicit pain in median nerve distribution.
 Phalen’s manoeuvre – holding wrist in flexion for 60 seconds to elicit numbness/pain in
median nerve distribution.
Elbow: Supracondylar fracture of the humerus.
Motor functions:
 Flexors, pronators (paralysed) except flexor carpi ulnaris, medial ½ of flexor digitorum
profundus
 forearm constantly supinated
 WEAK wrist flexion is weak
 Flexion at thumb- prevented
 Unable to flex at MCP joints/ extend at IP joints of the index and middle fingers.
Sensory functions:
 thenar eminence is wasted
 hand of benediction- make a fist- only little & ring fingers can flex completely
Wrist: Lacerations just proximal to the flexor retinaculum.
Motor functions: Thenar muscles paralysed, lateral 2 lumbricals.
 opposition of thumb
 flexion of the index and middle fingers.
Sensory functions:
hand is held in same position as damage at elbow— forearm is unaffected
Sensory innervation
Musculocutaneous nerve C5–C7 Pierces the coracobrachialis muscle Muscles of the anterior compartment of the arm Lateral aspect of the forearm (via the lateral antebrachial
Courses between the biceps brachii and  Biceps cutaneous nerve of the forearm)
the brachialis  Brachialis
Continues as the lateral cutaneous nerve of arm  Coracobrachialis

Lateral pectoral nerve Passes anterior to the axillary artery Pectoralis major None
Sends a branch to the medial pectoral nerve Sometimes the pectoralis minor
Pierces the clavipectoral fascia
Terminates by supplying the pectoralis major

Lateral root of median The largest terminal branch of the lateral cord
nerve Passes medially to join a similar branch from
the medial cord to form the median nerve
Forearm: all flexors (anterior compartment) except for those
supplied by the ulnar nerve
Hand: thenar muscles and lateral two lumbricals
Radial ⅔ of the palm
Palmar aspect of the radial 3 ½ fingers (i.e., the thumb, index
finger, middle finger, and radial side of the ring finger)
Dorsal aspect of the distal phalanges of the radial 3 ½ fingers
Autonomous sensory zone: tip of the index finger

Medial cord and branches of the brachial plexus

Branches of the brachial
plexus
Medial root of median nerve
Medial pectoral nerve
Spinal roots Course Motor innervation Sensory innervation
C8–T1 Courses between the biceps and the triceps in the arm Same as for the lateral root Same as for the lateral root
Passes through the cubital fossa, flanked by the biceps tendon and the brachial artery
Enters the forearm by passing between the two heads of the pronator teres
Courses along the forearm between the flexor digitorum superficialis and flexor digitorum
brevis
Passes through the carpal tunnel, beneath the flexor retinaculum, to enter the wrist
Terminates by dividing into digital nerves
Passes posterior to the axillary artery Pectoralis major None

Medial brachial cutaneous
nerve (medial cutaneous
nerve of arm)
Pierces through the pectoralis minor Pectoralis minor
Terminates by supplying the pectoralis major
Courses medial to the axillary and brachial veins None Inferomedial aspect of the arm
Becomes superficial at the mid-arm by piercing the deep fascia

Medial antebrachial Becomes superficial at the mid-arm by piercing the deep fascia None Skin over the medial forearm
cutaneous nerve (medial Accompanies the basilic vein in the forearm and distal arm
cutaneous nerve of forearm)
Ulnar nerve Courses medial to the axillary artery within the medial bicipital groove Forearm: flexor carpi ulnaris and Palmar and dorsal aspects of
Courses dorsally at the medial upper arm, where it perforates the medial intermuscular the medial half of the flexor digitorum the medial side of the hand
septum and enters the posterior (extensor) compartment profundus Palmar and dorsal aspects of the ulnar 1
Courses within the groove for the ulnar nerve around the ulnar joint (gives off the articular Hand: intrinsic muscles of the hand except ½ fingers (i.e., the little finger and the
branches and the muscular branches) for the thenar muscles and ulnar side of the ring finger)
Passes through the cubital tunnel back to the flexor aspect of the arm (gives off two lateral lumbricals Autonomous sensory zone: tip of the
the dorsal branch and the cutaneous palmar branch) little finge
Divides above the wrist into its terminal branches (superficial branch and deep branch)

Posterior cord and branches of the brachial plexus

Branches of Spinal roots Course Motor innervation Sensory innervation
the brachial plexus

Upper subscapular C5 Short course: terminates by supplying the subscapularis muscle Subscapularis None
nerve

Radial nerve C5–T1 Dorsal to the axillary artery (gives off muscular branches) Muscles of the posterior compartment of Radial ⅔ of the dorsal aspect of the hand
Passes through the triangular interval together with the deep brachial artery and vein on the arm: triceps Dorsal aspect of the radial 3 ½ fingers (except the
the extensor aspect of the upper arm and courses distally within the radial groove (gives brachii, anconeus muscles area supplied by the median nerve)
off the posterior cutaneous nerve, inferior lateral cutaneous nerve) Lateral part of the brachialis muscle Autonomous sensory
Punctures the lateral intermuscular septum of arm and courses to the radial tunnel in Posterior compartment of the forearm zone: 1st web space (between the thumb and
the cubital fossa (giving off muscular branches, posterior cutaneous nerve of forearm) index finger)

Axillary nerve C5-C6 Courses dorsally through the lateral axillary fold Shoulder joint Skin of the superolateral arm (over the inferior
Courses around the surgical neck of the humerus Teres minor part of the deltoid muscle)
Divides into three branches innervating the deltoid muscle Deltoid muscle
Posterior branch ends as the superior lateral cutaneous nerve of arm
Lower subscapular C6–C8 Short course: terminates by supplying the subscapularis muscle Subscapularis None
nerve Sends a branch to the teres major muscle Teres major

Thoracodorsal nerve C6 Courses alongside the thoracodorsal vessels along the ventral aspect of the latissimus dorsi Latissimus dorsi None
muscle Sometimes the teres major