Brachial Plexus

ANATOMY OF THE
BRACHIAL PLEXUS
BY
DR OJEWALE A.O
1
BRACHIAL PLEXUS
 The brachial plexus is the plexus of nerves

formed by the anterior (ventral) rami of
lower four cervical and the first thoracic
(i.e., C5, C6, C7, C8, and T1) spinal
nerves with little contribution from C4 to T2
spinal nerves.
2
Components of the brachial plexus
• It consists of four
components: (a)
roots, (b) trunks,
(c) divisions, and
(d) cords. The
roots and trunks
are located in the
neck, divisions
behind the clavicle
and the cords in
the axilla. 3
 Roots:
• The roots (five) are constituted of anterior
primary rami of C5 to T1 spinal nerves. They
are located in neck, deep to scalenus anterior
muscle.
 Trunks
• The trunks (three) are formed as follows:
• The C5 and C6 roots join to form the upper
trunk; the C7 root alone forms the middle
trunk and, C8 and T1 roots join to form the
lower trunk. They lie in the neck occupying the
cleft between scalenus medius behind and the 4
 Divisions
• Each trunk divides into anterior and
posterior divisions. They lie behind the
clavicle.
 Cords
• The cords (three) are formed as follows:
the anterior divisions of the upper and
middle trunks unite to form the lateral
cord and the anterior division of the
lower trunk continues as the medial cord.
The posterior divisions of the three
trunks unite to form the posterior cord.5
6
Branches of the brachial plexus
 A. From roots
• Long thoracic nerve/nerve to serratus
anterior (C5, C6, and C7).
• Dorsal scapular nerve/nerve to
rhomboids (C5).
• In addition to the long thoracic nerve and
dorsal scapular nerve, branches are given
by the roots to supply scalene muscles
and longus colli (C5, C6, C7, and C8) and
there is contribution to phrenic nerve (C5).
7
 B. From trunks:
• Suprascapular nerve (C5 and C6)
• Nerve to subclavius (C5 and C6)
 The branches arising from roots and trunks
are supraclavicular branches of brachial
plexus.
 C. From cords
 From lateral cord
• Lateral pectoral nerve (C5, C6, and C7).
• Lateral root of median nerve (C5, C6, and
C7).
• Musculocutaneous nerve (C5, C6, and C7).8
Cont’d
 From medial cord:
• Medial pectoral nerve (C8 and T1).
• Medial cutaneous nerve of arm (T1).
• Medial cutaneous nerve of forearm (C8
and T1).
• Medial root of median nerve (C8 and T1).
• Ulnar nerve (C7, C8, and T1)
9
Cont’d
 From posterior cord:

• Radial nerve (C5, C6, C7, C8, and T1).
• Axillary nerve (C5 and C6).
• Thoraco-dorsal nerve/nerve to latissimus
dorsi (C6, C7, and C8).
• Upper subscapular nerve (C5 and C6).
• Lower subscapular nerve (C5 and C6).
10
APPLIED ANATOMY
• Erb’s point: It is the region of upper
trunk of brachial plexus where six
nerves meet as follows: 5th and 6th
cervical roots join to form the upper
trunk, which gives off two nerves—
suprascapular and nerve to subclavius,
and then divides into anterior and
posterior divisions.
11
• Erb’s paralysis (upper plexus injury): It is
caused by the excessive increase in the
angle between the head and shoulder,
which may occur by fall from the back of
horse and landing on shoulder or traction of
the arm during birth of a child.
• This involves upper trunk (C5 and C6 roots)
and leads to a typical deformity of the limb
called policeman’s tip hand/porter’s tip
hand/waiter's tip hand. In this deformity, the
arm hangs by the side, adducted and
medially rotated, and forearm is extended
and pronated. 12
Injury of the upper brachial plexus leading to excessive
increase in the angle between the head and shoulder: A, fall
from the height and landing on a shoulder; B, Traction of the
arm and hyperextension of the neck.
13
• The detailed account of clinical features of
Erb’s paralysis is as follows:
• Adduction of arm due to paralysis deltoid
muscle.
• Medial rotation of arm due to paralysis
supraspinatus, infraspinatus, and teres minor
muscles.
• Extension of elbow, due to paralysis of biceps
brachii.
• Pronation of forearm due to paralysis of biceps
brachii.
14
• Loss of sensation (minimal) along the
outer aspect of arm due to involvement of
roots of C6 spinal nerve.
• Klumpke’s paralysis (lower plexus
injury):It is caused by the hyperabduction
of the arm, which may occur when one
falls on an outstretched hand or an arm is
pulled into machinery or during delivery
(extended arm in a breech presentation).
The nerve roots involved in this injury are
C8 and T1 and sometimes C7.
15
 The clinical features of Klumpke’s paralysis
are as follows:
• Claw hand, due to paralysis of the flexors of
the wrist and fingers (C6, C7, and C8), and
all intrinsic muscles of the hand (C8 and T1).
• Loss of sensations along the medial border
of the forearm and hand (T1).
• Horner’s syndrome,(characterized by
partial ptosis, miosis, anhydrosis, and
enophthalmos) due to involvement of
sympathetic fibres supplying head and neck,
which leave the spinal cord through T1.
16
Injury of the lower brachial plexus leading to excessive
increase in the angle between the trunk and shoulder: A,
sudden upward pull of the arm; B, arm pulled during delivery.
17
• Surgical approach to axilla: The axilla is
approached surgically through the skin of
the floor of axilla for the excision of axillary
lymph nodes to treat the cancer of the
breast. The structures at risk during this
procedure are (a) intercostobrachial nerve,
(b) long thoracic nerve, (c) thoraco-dorsal
nerve, and (d) thoraco-dorsal artery.
18
Features of Erb’s and
Klumpke’s paralyses
Erb’s paralysis Klumpke’s paralysis
Nerve roots involved C5 and C6 C8 and T1
Muscles paralyzed Deltoid, supraspinatus All intrinsic muscles of the
infraspinatus, biceps brachii, hand
brachialis, brachioradialis,
supinator and extensor carpi
radialis longus
Position of the upper Policeman’s tip/Porter’s Claw hand

limb/hand tip/Waiter’s tip position
Sensory loss (sometimes) Along the outer aspect of the Along the medial border of
arm forearm and hand
Autonomic signs Absent Present (Horner’s syndrome)
19

Brachial Plexus

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ANATOMY OF THE

 The brachial plexus is the plexus of nerves

 From posterior cord:

Position of the upper Policeman’s tip/Porter’s Claw hand

Autonomic signs Absent Present (Horner’s syndrome)

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