906510

research-article2020
HANXXX10.1177/1558944720906510HANDNeto et al

Surgery Article
HAND

The 2-Dimensional and 3-Dimensional

2022, Vol. 17(1) 50­–54
© The Author(s) 2020
Article reuse guidelines:
Anatomy of the Adult Brachial Plexus sagepub.com/journals-permissions
DOI: 10.1177/1558944720906510
https://doi.org/10.1177/1558944720906510

Divisions and Cords journals.sagepub.com/home/HAN

Junot H. S. Neto1,2 , Bernardo C. Neto3,4, Andre B. D. Eiras1,

Renato H. S. Botelho1, Jose M. de M. Carmo1,3,
and Marco Aurélio R. F. Passos3

Abstract
Background: The objective of this work was to perform a critical review of the 2-dimensional and 3-dimensional anatomy
of the adult brachial plexus divisions and cords. Methods: Twelve adult brachial plexuses from fresh cadavers were
dissected. All were male and aged between 30 and 50 years. Only corpses without brachial plexus injuries were selected.
The purpose of the dissections was to identify the origin of the anterior and posterior divisions of the adult brachial plexus
in their respective trunks, as well as the positioning of the posterior, lateral, and medial cords. Results: The posterior
division of all trunks had a cranial and dorsal origin, while the anterior division of all trunks had a caudal and ventral origin.
The posterior cord was the most cranial of all, the lateral cord was central, and the medial cord was the most caudal
of all cords. The posterior division of the superior trunk was always between the suprascapular nerve and the anterior
division. Conclusions: Brachial plexus diagrams in most textbooks and papers are different from what was found in our
dissections. Contrary to the known diagram, the posterior divisions always had a cranial origin in the superior, middle, and
inferior trunks.

Keywords: anatomy, brachial plexus, adult, divisions, cords

Introduction division were incorrect. In contrast to Wilfred Harris,4

Uysal et al5 dissected 200 fetal brachial plexuses and dem-
The brachial plexus is formed by the ventral rami of the onstrated that the posterior divisions of the superior and
spinal nerves of C5, C6, C7, C8, and T1. It is divided into middle trunk had a caudal origin. So, for them, the anterior
5 anatomical sessions known as roots, trunks, divisions, division of the superior trunk will be situated between the
cords, and terminal branches. The superior trunk is formed suprascapular nerve and the posterior division. Kirik et al,6
by the union of C5 and C6 roots, C7 root continues as the and Albertoni et al7 also dissected fetal brachial plexus and
middle trunk, and the inferior trunk is formed by the union reached the same conclusions as Uysal et al.5
between C8 and T1 roots. Each trunk will give rise to a It was a surprise when we realized that a reference book
posterior and anterior division. The posterior division of all for hand surgery specialists8 had 2 different illustrations to
trunks forms the posterior cord, the anterior division of the describe the brachial plexus. The illustration of children’s
superior and middle trunk forms the lateral cord, and the
anterior division of the inferior trunk continues as the
medial cord.1 The brachial plexus can receive contributions 1
Pedro Ernesto University Hospital, State University of Rio de Janeiro,
from other roots as C4 in 22% of cases2 or T2 in 1% of Rio de Janeiro, Brazil
2
cases.3 Marcílio Dias Naval Hospital, Brazilian Navy, Rio de Janeiro, Brazil
3
State University of Rio de Janeiro, Brazil
Wilfred Harris4 dissected the brachial plexuses of 60 4
Fluminense Federal University, Rio de Janeiro, Brazil
adults and stated that the posterior division of the superior
trunk always had a cranial origin. It always lies between the Corresponding Author:
Junot H. S. Neto, Service of Hand Surgery and Microsurgery,
suprascapular nerve and the anterior division. In 1904, he
Department of Orthopedics and Traumatology, Pedro Ernesto
warned the scientific community that the illustrations of the University Hospital, Rio de Janeiro State University, Boulevard 28 de
brachial plexus in most books and articles with the anterior Setembro Avenue, 77—Vila Isabel, 20.551-030 Rio de Janeiro, Brazil.
division between the suprascapular nerve and the posterior Email: netojunotf@gmail.com
Neto et al 51

brachial plexus had similarities with the brachial plexus

described by Wilfred Harris,4 while the adult brachial
plexus illustration had similarities to the brachial plexus
described by Uysal et al,5 Kirik et al,6 and Albertoni et al.7
This disagreement in the literature led the authors to con-
duct this research.

Material and Methods

Twelve adult brachial plexuses from donated fresh cadavers
were dissected. All were male and aged between 30 and 50
years. Only corpses without brachial plexus injuries were
selected. The purpose of the dissections was to identify the
origin of the anterior and posterior divisions of the brachial
plexus in their respective trunks (superior, middle, and infe-
rior trunks), as well as the positioning of the posterior, lat-
eral, and medial cords.
The bodies were placed in a supine position; the arm was
adducted and traction applied in an inferior direction to
allow the posterior triangle to open out. We used the extended
access to the brachial plexus with a longitudinal supracla- Figure 1. Adult brachial plexus dissection. Red arrows: superior
vicular incision over the sternocleidomastoid border, a trans- trunk; yellow arrows: middle trunk; pink arrows: inferior trunk;
verse supraclavicular incision over the clavicle followed black arrows: posterior divisions; black circles: posterior cord;
inferiorly by the deltopectoral groove. The supraclavicular orange circles: lateral cord; white circles: medial cord.
plexus was approached first, to visualize the roots of the
plexus. The incision was made just deep to the skin to divide divisions had a caudal origin. The posterior cord was the
the platysma. Immediately deep to the platysma, the supra- most cranial, the lateral cord was central, and the medial
clavicular nerves were encountered. The deep fascia was cord was caudal.9,10 Leonardo da Vinci’s drawings had the
divided along the line of the incision, and a few fibers of the same anatomy as those found in our dissections.
clavicular head of the sternomastoid muscle were divided There is significant confusion in the literature regarding
distally. Below this muscle, the omohyoid was also divided. the anterior and posterior divisions of the superior trunk.
The fascial layer lying on top of the scaleni was incised, Part of this confusion can be caused by the way we draw
allowing the plexus to come into view. The infraclavicular and teach anatomy, perhaps because of the convenience of
incision was made through the skin, subcutaneous tissue, always drawing or representing the brachial plexus in the
and clavipectoral fascia up to the clavicle. The tendon of the same way as we see in most textbooks and papers.6,11-26
pectoralis minor was then identified, lifted, and divided to This confusion probably dates from the time of Vesalius
immediately exposing the entire length of the infraclavicular (1555), his illustration of the brachial plexus has the same
plexus. In all cases, we performed clavicle osteotomy. anatomy as published in most books and articles to date.27
There were differences in brachial plexus illustrations
described by Wilfred Harris4 and Uysal et al,5 Kirik et al,6
Results and Albertoni et al.7 However, it is essential to emphasize
The posterior division of all trunks had a cranial and dorsal that while Wilfred Harris4 dissected adult brachial plex-
origin, while the anterior division of all trunks had a caudal uses; Uysal et al,5 Kirik et al,6 and Albertoni et al.7 dis-
and ventral origin. The posterior cord was the most cranial sected fetal brachial plexuses. Possibly there are anatomical
of all; the lateral cord was central, and the medial cord was differences between the adult and fetal brachial plexus that
the most caudal of all cords. The posterior division of the justify 2 different illustrations. However, more studies
superior trunk was always between the suprascapular nerve need to be done to determine if there are anatomical differ-
and the anterior division (Figures 1-3). ences between the adult and child brachial plexus.
We were not the first to realize that brachial plexus
designs do not correctly represent the origin of the posterior
Discussion division of the superior trunk. An example of this was Wil-
Leonardo di Ser Piero da Vinci (Leonardo Da Vinci) was one fred Harris4 who alone fought against all the other thinkers
of the first to represent in modern illustrations the anatomy of his day to change this knowledge but was unsuccessful.
of the brachial plexus. In his illustrations, the posterior Several authors described the posterior division of the
­divisions of all trunks had a cranial origin, while all anterior ­superior trunk with a cranial origin like us.4,9,10,27-31 Some
52 HAND 17(1)

Figure 2. Two-dimensional illustration of the adult brachial plexus.

Figure 4. Three-dimensional illustration of trunks, divisions and

cords of adult brachial plexus. Black: superior trunk; blue: middle
trunk; white: inferior trunk; green: suprascapular nerve; orange:
Figure 3. Three-dimensional illustration of the superior posterior divisions; yellow: anterior divisions; red: posterior
trunk. Blue: superior trunk; green: suprascapular nerve; orange: cord; brown: lateral cord; pink: inferior cord.
posterior division; yellow: anterior division.
that none of them follow the known illustration of the bra-
authors were radical in their conclusions; Hanna,31 for chial plexus as the basis for surgery. They do not believe
example, stated that the illustrations of the brachial plexus that the illustrations represent the real anatomy, because
urgently need to be corrected because the posterior division they all know that the posterior division of the superior
of the superior trunk is always situated between the supra- trunk arises between the suprascapular nerve and the ante-
scapular nerve and the anterior division. We share this same rior division. We also share the opinion that brachial plexus
opinion; however, it was possible to identify in our dissec- illustrations do not represent the correct anatomy found in
tions that not only the posterior division of the superior the surgical field. We always found the origin of the poste-
trunk had a cranial origin, but all posterior divisions of the rior division of the superior trunk between the suprascapu-
adult brachial plexus had a cranial origin concerning their lar nerve and the anterior division (Figure 5). Moreover,
respective trunks (Figure 4). we always found all the posterior divisions of the adult bra-
Through personal communication with several surgeons chial plexus with a cranial origin concerning their respec-
familiar with the brachial plexus anatomy, we conclude tive trunks.
Neto et al 53

ORCID iD
Junot H. S. Neto https://orcid.org/0000-0001-9258-0708

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