Formation
Parts of BP
Distribution - Nerve Supply ? areas
Anatomical Variations
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Applied AnatomyDr.Ravi 2/1/2022
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Spinal Nerves
Spinal nerves attach to the
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spinal cord via rootsDorsal root
Has only sensory neurons
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Attached to cord via rootletsDorsal root ganglion
Ventral root
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Has only motor neuronsNo ganglion - all cel bodies
of motor neurons found in
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gray matter of spinal cordDr.Ravi 2/1/2022
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Spinal Nerves
31 pair
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each contains thousands of nerve fibersAl are mixed nerves have both sensory and motor
neurons
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Connect to the spinal cordExit from SC ? Supplying the muscles & structures
of the body
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Dr.Ravi 2/1/2022
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Spinal Nerves8 pairs of cervical nerves from
C1 to C8
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12 pairs of thoracic nerves
from T1-T12
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5 pairs of lumbar nerves fromL1 to L5
5 pairs of sacral nerves from
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S1 to S5
1 pair of coccygeal nerves
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located at C zero (Co)Dr.Ravi 2/1/2022
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Formation of RamiRami are lateral branches of a
spinal nerve
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Rami contain both sensory and
motor neurons
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Two major groupsDorsal ramus
Neurons innervate the
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dorsal regions of the
body
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Ventral ramusLarger
Neurons innervate the
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ventral regions of thebody
Braid together to form
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plexuses (plexi)
Dr.Ravi 2/1/2022
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6Nerve Plexuses
Nerve plexus
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A nerve plexus is nothing more than a
system or network of connected nerve
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fibers that link spinal nerves with specificareas of the body . A network of ventral
rami.
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Ventral rami (except T2-T12)
Branch and join with one another
Form nerve plexuses
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In cervical, brachial, lumbar, and sacral
re
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gioN n
o splexus formed in thoracic region of s.c.
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Dr.Ravi 2/1/2022
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BranchesDorsal Ramus
of
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Neurons within muscles of trunk and back
Spinal
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NervesVentral Ramus (VR)
Braid together to form plexuses
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Cervical plexus - VR of C1-C4
Brachial plexus - VR of C5-T1
Lumbar plexus - VR of L1-L4
Sacral plexus - VR of L4-S4
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Coccygeal plexus -VR of S4&S5Communicating Rami: communicate
with sympathetic chain of ganglia
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Covered in ANS unit
12-8
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Dr.Ravi 2/1/20228
Brachial Plexus - Origin
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Formed by ventral rami of spinal
nerves C5-T1
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Five ventral rami formRoots / Trunks that separate into
Divisions that then form
Cords that give rise to Branches
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Major nerves
Axil ary
Radial
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MusculocutaneousUlnar
Median
Dr.Ravi 2/1/2022
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Brachial Plexus
15 cms long ,spinal column to
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axil a.
Brachial plexus is responsible for
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cutaneous (sensory) andmuscular (motor) innervation of
the entire upper limb & pectoral
girdle.
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It proceeds through the neck, theaxil a and into the arm.
Dr.Ravi 2/1/2022
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10
Dr.Ravi 2/1/2022
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11Relations - BP
In neck- posterior triangle,
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being covered by skin,
Platysma, & deep fascia; where
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it is crossed by supraclavicularnerves, inferior belly of
Omohyoid, external jugular vein,
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& transverse cervical artery.
Dr.Ravi 2/1/2022
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12Relations - BP
When it emerges between
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Scalene anterior &
medius
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--* its upper part liesabove 3rd part of
subclavian artery,
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* while trunk formed by
union of C8 & T1 is
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placed behind artery.Dr.Ravi 2/1/2022
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Relations - BPPlexus next passes behind clavicle,
Subclavius, & transverse scapular vessels, &
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lies upon 1st digitation of Serratus anterior, &
Subscapularis.
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Dr.Ravi 2/1/202214
Relations
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In axilla it is placed
lateral to first portion of
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axillary artery; itsurrounds 2nd part of
artery, one cord lying
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medial to it, one lateral to
it, and one behind it; at
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lower part of the axilla itgives off its terminal
branches to upper limb.
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Dr.Ravi 2/1/2022
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Anatomy CORD & BRANCH DIVISIONTRUNK
ROOT
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Dorsal scapular N.
C4
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Suprascapular N.C5
UT
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Lateral pectoral
C6
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ADRD
N.subclavius
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PD
AL CO
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AC
PDD
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7
MT
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LATERPD
C8
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PD
MUSCULO CUTANEOUS
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DT
L
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AD
T
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AL ROOTA
1
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XILLARY
LATER
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N. to latissimusRADIAL NERVE POSTERIOR COR
M
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dorsi
T2
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EDIAL ROOTMEDIAL COR
U. Subscapular
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Long thoracic
L. Subscapular
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MCF MCA Medial pectoralMEDIAN NERVE
ULNAR NERVE
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Dr.Ravi 2/1/2022
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Brachial Plexus BranchesDr.Ravi 2/1/2022
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Brachial Plexus BranchesBranches of the Roots
?Long thoracic nerve(C5,C6,C7)
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?Dorsal scapular nerve(C5)?N. to longus colli & scaleni
Branches of Trunks
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?Suprascapular nerve(C5,C6)
?Nerve to subclavius(C5,C6)
Branches of Lateral Cord
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?Lateral Pectoral (C5-C7)
?Musculocutaneous (C5-C7)
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?Lateral root of Median Nerve (C5-C7)Dr.Ravi 2/1/2022
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Brachial Plexus Branches
Branches of Medial Cord
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?Medial pectoral(C8-T1)?Medial cutaneous nerve of arm(C8-T1)
?Medial cutaneous nerve of forearm(C8-T1)
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?Ulnar nerve(C7,C8,T1)
?Medial root of median nerve(C8-T1)
Branches of Posterior Cord
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?Upper subscapular (C5,C6)
?Thoracodorsal (C6-C8)
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?Lower subscapular (C5,C6)?Axil ary (C5,C6)
?Radial (C5-C8,T1)
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Dr.Ravi 2/1/2022
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Muscles supplied by Brachial plexusDr.Ravi 2/1/2022
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Mode of Brachial Plexus Injuries
? Road traffic accident
? Penetrating injuries
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? Surgical complications? Birth Injuries
? Domestic violence and accidents
Dr.Ravi 2/1/2022
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Traumatic Brachial Plexopathies
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Penetrating injury
? Infraclavicular plexus commonly affected
? Knife, gun shot etc
? Less common incident
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? direct contact, hematoma pseudoaneurysmDr.Ravi 2/1/2022
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Traumatic Brachial Plexopathies
Closed traction injuries
? Supraclavicular injuries- forced
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separation of head and shoulder
? Infraclavicular injuries- forced
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separation of arm from the torso (hyperabduction)
? Root avulsion- more serious
? Ventral roots are more prone to injury-
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lesser calibers ,thinner dural sac
Dr.Ravi 2/1/2022
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23Tractional Brachial Plexus
Injury
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Dr.Ravi 2/1/2022
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Obstetric Brachial PlexopathiesFive pattern of injuries
C5,C6(Erb's palsy)
C5-T1 with some finger flexion sparing
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C5-T1 with flail arm and Horner's syndromeC5-T1 with Horner (Klumpke's palsy)
Dr.Ravi 2/1/2022
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PlexopathiesDr.Ravi 2/1/2022
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Erb's Paralysis
? Injury of upper trunk at Erb's point, caused by traction
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on arm at birth or due to accident? Nerve root avulsion from cord, involved C5 & C6 causing
paralysis of deltoid, biceps, brachialis, brachioradialis &
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supinator muscles? Abduction, lateral rotation of arm & flexion &
supination of forearm lost
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? Waiter's tip position (Adduction & medial rotation of
arm, extension of elbow and pronation of forearm)
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Dr.Ravi 2/1/202228
?Sensory loss over
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the arm
Waiter's tip deformity
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Dr.Ravi 2/1/202229
Upper brachial plexus Erb-Duchenne palsy
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? Results from excessive displacement of the head to the opposite side and
depression of the shoulder on the same side
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Difficult labourMotorcycle fal
Malposition of the upper
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limb on the operation table
? Abrasions on the face and
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shoulder show how thismotorcyclist pulled his entire
plexus apart
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Dr.Ravi 2/1/2022
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Upper brachial plexus Erb-Duchenne palsyThe lesion produced is similar to that produced by a stab or bul et wound in the
neck affecting the superior trunk of the brachial plexus
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Superior trunk
Neck wound
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? Affects C5 & C6 roots or the superiortrunk
? suprascapular nerve, nerve to subclavius,
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musculocutaneous, and axil ary nerves
are affected
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Dr.Ravi 2/1/202231
Upper brachial plexus Erb-Duchenne palsy
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? Abduction, lateral rotation, and
flexion at the shoulder are
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affected? limb hangs by side adducted and
medially rotated by unopposed
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pectoralis major
? forearm extended and pronated
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because action of biceps is lost? Affects C5 & C6 roots or the superior
trunk
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? suprascapular nerve, nerve to subclavius,
musculocutaneous, and axil ary nerves
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are affectedWaiter's tip position
Dr.Ravi 2/1/2022
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Klumpke's Paralysis
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? Injury of lower trunk? Caused due to hyper abduction of arm (extended arm
in a breech delivery, a fal on a outstretched arm)
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? C8,T1 & some time C7 are involved? Intrinsic muscles of hand & flexors of wrist(C6,C7,C8)
& fingers (C8,T1) are affected
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? Claw hand deformity & anesthesia along the ulnarborder of the forearm & hand
? Horner's syndrome (injury to sympathetic fibers to
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head & neck)
Dr.Ravi 2/1/2022
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33Lower brachial
plexus
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Klumpke palsy
results from excessive
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? or when a personabduction of the arm
falls from a height
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as in during labor
grasping something
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to save himself? Cervical rib
Note the transverse process of C7
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Dr.Ravi 2/1/2022
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Lower brachial plexus Klumpke palsyAffects C8&T1
Claw hand
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? Small muscles of the hand are
affected
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Note wasting of dorsal interosseiDr.Ravi 2/1/2022
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Klumpke's Paralysis
Horner's syndrome
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Ptosis, myosis,enophthalmos andloss of ciliospinal reflex
Claw hand deformity
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Dr.Ravi 2/1/2022
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Supraclavicular Brachial PlexopathiesBurner syndrome (stinger syndrome)
? Forceful separation of head & shoulder ( lateral neck
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extension & shoulder depression after a blunt force tohead & neck)
? Presented with unilateral sharp burning pain in neck
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radiating to arm? Classical C6 distribution,C5 may also affected
? Male sports person
? Permanent neurological dysfunction is rare
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Dr.Ravi 2/1/2022
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Burner syndrome (Stinger syndrome)Dr.Ravi 2/1/2022
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Winging of Scapula
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? Serratus anterior stabilizes the
scapula
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? Winging occurs due toweakness in serratus anterior
? Injury to the nerve to serratus
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anterior ( long thoracic nerve)
? Injury occurs during surgery or
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due to infection? Pushing and/or punching
defect
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Dr.Ravi 2/1/2022
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Winging scapula:?Injury to the long thoracic nerve
?Resulting from the blows on the
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posterior triangle of the neck
?Serratus anterior muscle paralysed
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?Inability to protract & rotate the scapuladuring the abduction of the arm above the
head
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?Medial border and inferior angle of the
scapula elevated
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Dr.Ravi 2/1/202240
Supraclavicular Brachial Plexopathies
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Rucksack palsy ( cadet palsy, pack
palsy)
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? Classical presentation ?painweakness associated with wearing a
backpack
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? Sensory involvement and most aredue to demyelinating conduction
block (neuropraxia) of brachial plexus
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Dr.Ravi 2/1/202241
Cervical rib
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Dr.Ravi 2/1/2022
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True neurogenic thoracic outlet
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syndromeDr.Ravi 2/1/2022
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Thoracic outlet syndrome
? Compression of subclavian artery
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and lower trunk of brachialplexus in the area of the clavicle.
? This can happen when there is an
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extra cervical rib? There may be pain in neck &
shoulders, & numbess in the last 3
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fingers & inner forearm.? radial pulse may be easily
obliterated by movements of the
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arm, particularly with armextended & abducted at shoulder.
Dr.Ravi 2/1/2022
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44True neurogenic thoracic outlet syndrome
? Brachial plexus fibers compromised
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by a translucent band extending
from rudimentary cervical rib to 1st
rib
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? C8 and T1 fibers are mostly affected? Presented with pain, paresthesia in
the neck shoulder and along the
medial border of hand
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? Weakness of the muscles in the
hand
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? symptom & sign of vascularcompromise
Dr.Ravi 2/1/2022
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True neurogenic thoracic outlet syndrome
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Adson's Maneuver Allen's TestManagement-Surgical lysis of fibrous band or resection of
cervical rib
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Dr.Ravi 2/1/202246
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Supraclavicular Brachial PlexopathiesPancoast Syndrome
? Superior lobe carcinoma of
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lung, mainly NSCC? Compression of T1 as only
pleura separates lung from
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T1? Shoulder pain radiating in an
ulnar distribution down the
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armPancost tumor MRI
? Shoulder pain worse at night
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? Associated with Hornersyndrome
Dr.Ravi 2/1/2022
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47
Pancoast Tumor
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CT Chest- Pancoast Tumor Invading T1Dr.Ravi 2/1/2022
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Infraclavicular Brachial Plexopathies
? Crutch palsy: radial nerve compression
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? Midshaft clavicular fracture: medial cordinjury
Dr.Ravi 2/1/2022
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Nonspecific Brachial Plexopathies
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Neuralgic Amyotrophy? Frequently involves long thoracic, axil ary and
supraclavicular nerves
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? Presenting feature: abrupt shoulder or upperarm pain, often nocturnal onset
? Pain abates after 7-10 days
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? 50% associated with infectionDr.Ravi 2/1/2022
50
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1. The middle trunk of the brachial plexus isformed by anterior rami of which spinal
cord segments?
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a. C7b. C6 and C7
c. C6
d. C5 and C6
e. C7 and T1
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Dr.Ravi 2/1/2022
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2. Postoperative examination revealed that themedial border and inferior angle of the left
scapula became unusually prominent
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(projected posteriorly) when the arm was
carried forward in the sagittal plane,
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especially if the patient pushed withoutstretched arm against heavy resistance
(e.g., a wall). What muscle must have been
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denervated during the axil ary dissection?
A. Levator scapulae
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b. Pectoralis majorc. Rhomboideus major
d. Serratus anterior
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e. Subscapularis
Dr.Ravi 2/1/2022
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523. A person sustains a left brachial plexus injury in an auto accident.
After initial recovery the following is observed:
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1) the diaphragm functions normally,
2) there is no winging of the scapula,
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3) abduction cannot be initiated, but if the arm is helped throughfirst 45 degrees of abduction, patient can fully abduct arm.
From this amount of information and your knowledge of
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formation of the brachial plexus where would you expect
injury to be:
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a. Axil ary nerveb. Posterior cord
c. Roots of plexus
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d. Superior trunk
e. Suprascapular nerve
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Dr.Ravi 2/1/202253
4. In a case of Erb's palsy, where roots C5
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and C6 of the brachial plexus are avulsed
(torn out) which muscle is paralyzed?
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A. Latissimus dorsib. Pectoralis minor
c. Supraspinatus
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d. Trapezius
e. Triceps brachii
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Dr.Ravi 2/1/202254