August 30, 2015

Theme III - Scientific Basis of

Clinical Practice

BRACHIAL PLEXUS

A plexus is a network of intersecting (intermingle but dont join) nerves. Ventral rami (not T2-T12) merge with one or more adjacent anterior rami to form major
somatic plexuses in which fibers intermingle and form a new set of multisegmental peripheral nerves, which contain fibers from multiple spinal nerves. Most
nerves in the upper limb arise from the brachial plexus, protected proximally by the cervico-axillary canal and the axillary sheath. It is a complex network of
merging and separating nerves, 5Rm3Ts6Dm3Cs3B, formed by the union of ventral rami C5-T1, which constitute the roots of the plexus. Almost all branches
(terminal outgrowths) arise in the axilla, after the plexus has crossed the first rib.

ROOTS

(emerge from
intervertebral foramina, pass
between anterior and middle
scalene with subclavian artery)

C5

C6

C7

C8

T1

Dorsal scapular
nerve arises
superiorly rhomboids
Long thoracic nerve leaves posteriorly serratus anterior

TRUNKS

(inferior trunk passes

through subclavian artery groove
posterior to scalene tubercle on
first rib)

Superior trunk
Subclavian nerve inferiorly - subclavius
Suprascapular nerve (runs through foramen of

Middle trunk

Inferior trunk
With subclavian artery,
traverses groove posterior to
scalene tubercle of first rib

superior transverse scapular ligament, then along spine

and winds around lateral border for i/spinatous)

supraspinatous, infraspinatous

DIVISIONS

(divisions pass
through cervicoaxillary canal,
under coracoid process, merging
to cords occurs infraclavicularly).
Anterior divisions supply flexor
compartments, posterior divisions
supply extensor compartments.

Anterior

(surround the axillary

artery posteriorly, medially, and
laterally)

Terminal branches are

MARMU:

Musculocutaneous
C5-C7
Axillary C5-C6
Radial all
Median all
Ulnar C7-T1

Anterior

Lateral cord - LML

CORDS

BRANCHES

Posterior

Lateral
pectoral
nerve
passes
costacoracoi
d membrane
to reach
deep
surface of
pectoral
muscles

Pectoralis
major,
pectoralis
minor

Musculocutane
ous nerve
pierces
coracobrachialis,
descends between
biceps brachii and
brachialis,
continues as
lateral cutaneous
nerve of forearm

Biceps brachii,
brachialis,
coracobrachialis

Posterior

Posterior cord - ULTRA

Lateral
branch of
median
nerve merges
with medial root
lateral to
axillary artery,
passes slightly
medially in
cubital fossa

Muscles of
anterior
compartmen
t, some of

Radial
nerve
passes
posteri
or to
humer
us in
radial
groove,

Post
compa
rtmen
t of

Upper
subscapul
ar nerve

Thoracodo
rsal nerve

passes
posteriorly
to enter
subscapular
fossa

runs
inferolateral
ly to apical
part of
latissimus
dorsi

Subscapula
ris

Latissimu
s dorsi

Posterio
r

Anterior

Medial cord - MMMMU

Lowe
r
subs
capu
lar
nerv
e

Axillar
y
nerve

Subs
capu
laris,
teres

Deltoi
d,
teres
minor,

Medial
branch
of the
median
nerve

Ulnar
nerve

merges
with
lateral
root

Muscles
of
anterior
compart

Flexor
carpi
ulnaris
, most

Med
ial
pec
tora
l,
me
dial
bra
chia
l/an
terb
rac
hial
cut

August 30, 2015

palm

Theme III - Scientific Basis of

Clinical Practice
forear
m,
skin

majo
r

should
er
joint

ment,
some of
palm

palm
muscle
s

ene
ous

August 30, 2015

Theme III - Scientific Basis of

Clinical Practice

Recall that injection of anaesthesia into or around the axillary sheath (proximal artery, vein, nerve) combined with an occlusive tourniquet produces
upper limb nerve block, in which sensation is blocked to all deep muscles of the upper limb and the skin distal to the elbow.
Brachial plexus injuries influence movements and cutaneous sensation in the upper limb, resulting in paralysis and anaesthesia. These
may be the result of disease/stretching/wounds in the lateral cervical region of the neck, or in the axilla itself. Signs and symptoms obviously depend
upon the region of the BP involved:
Paralysis test the patients ability to perform movements (complete paralysis
akinesia, incomplete paralysis weak movements)

Anaesthesia detect patients ability to feel pain

C5/C6 injuries Erbs palsy usually result from an excessive increase in neck/shoulder angle (person thrown from vehicle/horse, shoulder is
decelerated upon impact, whilst head/neck continue to move, shoulder dystocia perinatally) and may avulse the roots of the plexus from the SC.
May also result from chronic microtrauma (e.g. carrying heavy backpack), producing motor/sensory deficits in musculocutaneous + radial
nerves and muscle spasms.
Cord compression impingement of plexus cords between coracoid and pec minor tendon - from prolonged hyperabduction (manual tasks
over the head) result in pain radiating down arm, numbness, parasthesia, erythema, and weakness of hands. May be accompanied by
hyperabduction syndrome (compression also of axillary vessels), which manifests in ischemia of the upper limb and distension of superficial
veins.
o Waiters tip position arm adducted and medially rotated pronated, loss of sensation in lateral aspect of forearm.
Acute brachial plexus neuritis is idiopathic, and presents with acute onset of severe pain around the shoulder, followed by muscle weakness and
occasionally atrophy.

August 30, 2015

A, C Excessive increase in
neck/shoulder angle cause
B Waiters tip position

D, E Upper limb pulled

superiorly cause
F Claw hand

Theme III - Scientific Basis of

Clinical Practice