BRACHIAL PLEXUS

 Summary
 Mnemonics
 Clinical Relations
5 ROOTS
3 TRUNKS
6 DIVISIONS
3 CORDS
 SUMMARY

 Brachial plexus is a plexus of anterior rami of C5,

C6, C7, C8 & T1 Spinal nerves. So there are 5 roots.
 C5+C6 = UPPER TRUNK
 C7 = MIDDLE TRUNK
 C8+T1 = LOWER TRUNK so there are 3 trunks.
 Every trunk has 2 divisions, Anterior & Posterior so
there are 6 divisions. (3*2)
 Posterior divisions of all 3 trunks combine
together to form posterior cord.
 Anterior divisions of upper+middle trunk = Lateral
cord
 Anterior division of lower trunk continues as
Medial Cord.
 Position of plexus= Cervico Brachial
 Clavicle divides the plexus into two portions.

1)UPPER SUPRACLAVICULAR PORTION = Roots +

Trunks + Divisions lie here in posterior triangle of
 INFRACLAVICULAR REGION = Cords of
Brachial plexus lie in this region.

 Cords of plexus + Axillary artery + Axillary

vein together are enclosed in a sheath of
connective tissue called AXILLARY
SHEATH.
 Position of this axillary sheath can be
verified by pulsating 3rd part of axillary
artery.

 Reference Point for positioning and

naming of cords as lateral’medial &
posterior is AXILLARY ARTERY(2nd part).
 NERVE ROOT VISE
CLASSIFICATION
 C5 = Dorsal Scapular nerve

 C5 + C6 =
 Supra scapular nerve Subclavius nerve can
 Nerve to subclavius also give contribution
 Upper subscapular nerve to the phrenic nerve.
 Lower subscapular nerve (C5) This branch, if
 Axillary Nerve present, is called,
ascessory phrenic
Nerve.
 C5 + C6 + C7 =
 Long thoracic nerve
 Lateral pectoral nerve
 Musculocutaneous nerve
 Lateral root of median nerve

 C6 , C7 , C8 = thoracodorsal nerve
  C5, C6, C7, C8, T1
 Radial nerve
 Medial root of median nerve

 C8, T1
 Medial pectoral nerve
 Medial cutaneous nerve of
arm
 Medial cutaneous nerve of
forearm
 Ulnar nerve

 Medial cutaneous nerve of arm is sometimes innervated by T2 also.

 Ulnar nerve is BETWEEN axillary artery and vein

 Radial nerve is the largest branch of brachial plexus. It is BEHIND Axillary

artery.
 Terminal and lateral nerve branches
arise at ROOT, TRUNK & CORD level.
(Snell’s tables)
 Lateral cord branches: Rugby players are Long
Legged Movers

Lateral pectoral nerves

Lateral root of median nerve
Musculocutaneous nerve

Medial cord branches: Rugby players Make

Many Moves Using Muscles

Medial pectoral
Medial cutaneous nerve of arm
MNEM Medial cutaneous nerve of forearm
ONICS Ulnar nerve

Medial root of median nerve

Posterior cord branches: Rugby players are
ULTRA competitive

Upper subscapular
Lower subscapular
Thoracodorsal nerve
Radial nerve
Ulnar nerve supply ALL intrinsic
muscles of hand EXCEPT LOAF muscles.

The median nerve supplies the LOAF muscles

of the hand:

 Lateral two lumbricals

 Opponens pollicis
 Aductor pollicis brevis
 Flexor pollicis brevis
Clinical relations
Brachial plexus injury
Injuries to the brachial plexus affect both
motor and sensory functions in the upper limb.
Different injuries, such as inflammation,
stretching, and wounds in the lateral cervical
region of the neck or in the axilla may cause
brachial plexus injuries, and the manifestations
depend on the part of the plexus that is
affected. In any case, injuries to the brachial
plexus are followed by paralysis and
anesthesia of the respective supply area of
the affected nerves.
 UPPER LESIONS OF BRACHIAL PLEXUS

*Also called Erb Duchenne Palsy

*Damage to C5 & C6 roots of plexus due to excessive
displacement of head to the opposite side and depression
of shoulder on the same side. This can occur in
 Difficult delivery in adults
 Blow or fall to shoulder in adults

Those nerves that arise from C5 and C6 will be affected

leading to paralysis in muscles they supply.
 Suprascapular nerve leading to paralyzed supraspinatus
and infraspinatus muscles.

 Nerve to subclavius leading to paralyzed subclavius

muscle.

 Musculocutaneous nerve leading to impaired biceps

brachii, brachialis, coracobrachialis.

 Axillary nerve leading to paralyzed deltoid and teres

minor.
 RESPECTIVE ROLES OF MUSCLES
DAMAGED IN UPPER LESION OF BRACHIAL
PLEXUS

 SUPRASPINATUS= Abductor of shoulder

 INFRAASPINATUS == Lateral Rotator of shoulder
 Subclavius = Depression of clavicle
 Coracobrachialis= Flexor of shoulder
 Biceps brachii= Supinator of forearm+ flexor of
elbow+weak flexor of shoulder
 Brachialis= flexor of elbow
 Deltoid= Abductor of shoulder
 Teres minor = Lateral rotator of shoulder

Due to impairement in above mentioned roles of muscles,

 Limb remains ADDUCTED due to loss of abduction
function by supraspinatus and deltoid.
 Limb hangs limply by side.
 Forearm remains PRONATED due to loss of supination
function by Biceps brachii.
All these conditions result in a waiter waiting for a tip like
posture hence termed as WAITER’S TIP POSTURE”.
Median nerve injury
In case of the median nerve involvement, the
injury causes a palsy that results in a hand
deformity called APE HAND.

*The forearm rests in supine position.

*Ulnar deviation= adduction

It manifests as an inability to abduct the
thumb. It is due to paralysis of flexor carpi
radialis while the strength of flexor carpi
ulnaris is intact.

*loss of sensation in the lateral 3½ fingers.

*Weak wrist flexion

*Index finger and middle finger to some

extent tends to remain straight while the ring
and little finger can flex during fist making.
This indicates paralysis of first two
lumbricals.
LONG THORACIC NERVE INJURY

The long thoracic nerve enters serratus anterior on it’s superficial

side rather than deep side of muscle’s belly so it is in a position of
greater potential danger to trauma. Injury to this nerve will
lead to paralysis of serratus anterior muscle which results
in ;

Inability to rotate scapula during abduction of arm above

right angle so the scapula is no longer kept closely
applied to chest wall and protrude posteriorly in a
condition called WINGED SCAPULA
Ulnar nerve injury

An injury of the ulnar nerve causes a characteristic hand deformity

called the claw hand, which is a result of the paralysis of intrinsic
hand muscles innervated by this nerve.
The claw hand deformity is characterized by

*HYPEREXTENDED METACARPOPHARYNGEAL JOINT

*FLEXED INTERPHARYNGEAL JOINTS

Both these effects are more obvious in FOURTH AND FIFTH fingers
owing to paralysis of fourth and fifth lumbricals and interosseus
muscles supplied by ulnar nerve. Since first and second lumbricals
are supplied by median nerve so claw hand deformity is not obvious
in first two fingers.(index+middle finger)
RADIAL NERVE INJURY
The radial nerve is commonly damaged in AXILLA
or RADIAL GROOVE.
Injuries to the radial nerve will result in paralysis
of muscles supplying posterior compartment of
forearm. This leads to a condition called WRIST
DROP.

The Wrist remains in a flexed position and patient

is incapable of extending wrist against gravity.

Sensory loss in case of radial nerve damage

includes LITTLE/VARIABLE loss of
sensation/anaesthesia in:
*Lateral part of dorsum of hand
*lateral three and a half fingers

Important: Total or complete loss of sensation

does not occur because the dorsum of hand and
posterior compartment of forearm has an overlap
of other adjacent sensory innervations too.
AXILLARY NERVE DAMAGE
Since this nerve passes deeply from the axilla
through quadrangular space , it is very
vulnerable to injuries and traumas from
downward displacement of humeral head
dislocations & fractures of surgical neck of
humerus.

*It leads to paralysis of Deltoid muscle & it is

wasted over time.

*Paralysis of teres minor is NOT clinically

significant.

*Impairment of cutaneous branches of axillary

nerve including upper lateral cutaneous nerve
results in anaesthesia in Lower half of deltoid
muscle.
 MNEMONIC

Here is a helpful mnemonic to help you

remember some of the above nerve injuries
and associated hand lesions.

DR. CUMA
Drop = Radial nerve

Claw = Ulnar nerve

Median nerve = Ape (Apostle's) hand

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