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Contents
1 Structure
1.1 Roots
1.2 Trunks
1.3 Divisions
1.4 Cords
1.5 Branches The right brachial plexus with its short branches,
1.6 Diagram viewed from in front.
1.7 Specific branches
Details
2 Function
3 Clinical significance From C5, C6, C7, C8, T1
3.1 Injury Innervates Sensory and motor innervation to the
3.1.1 Definition
upper limb
3.1.2 Motorcycle accidents
3.1.3 Sports Injuries Identifiers
3.1.4 Penetrating wounds Latin plexus brachialis
3.1.5 Injuries during birth
3.2 Tumors MeSH A08.800.800.720.050
3.3 Imaging Dorlands p_24/12647576
3.4 In anaesthetics
/Elsevier
4 Additional images
5 References TA A14.2.03.001
6 Bibliography FMA 5906
7 External links
Anatomical terms of neuroanatomy
Structure
The brachial plexus is divided into five roots, three trunks, six divisions, three anterior and three posterior, three cords,
and five branches. There are five "terminal" branches and numerous other "pre-terminal" or "collateral" branches,
such as the subscapular nerve, the thoracodorsal nerve, and the long thoracic nerve,[1] that leave the plexus at various
points along its length.[2] A common structure used to identify part of the brachial plexus in cadaver dissections is the
M or W shape made by the musculocutaneous nerve, lateral cord, median nerve, medial cord, and ulnar nerve.
Roots
The five roots are the five anterior rami of the spinal nerves, after they have given off their segmental supply to the
muscles of the neck. The brachial plexus emerges at five different levels; C5, C6, C7, C8, and T1. C5 and C6 merge to
establish the upper trunk, C7 continuously forms the middle trunk, and C8 and T1 merge to establish the lower trunk.
Prefixed or postfixed formations in some cases involve C4 or T2, respectively. The dorsal scapular nerve comes from
the superior trunk[2] and innervates the rhomboid muscles which retract the scapula. The subclavian nerve originates
in both C5 and C6 and innervates the subclavius, a muscle that involves lifting the first ribs during respiration. The
long thoracic nerve arises from C5, C6, and C7. This nerve innervates the serratus anterior, which draws the scapula
laterally and is the prime mover in all forward-reaching and pushing actions.
Trunks
Divisions
Cords
These six divisions regroup to become the three cords or large fiber bundles. The cords are named by their position
with respect to the axillary artery.
The posterior cord is formed from the three posterior divisions of the trunks (C5-C8, T1)
The lateral cord is formed from the anterior divisions of the upper and middle trunks (C5-C7)
The medial cord is simply a continuation of the anterior division of the lower trunk (C8, T1)
Branches
The branches are listed below. Most branch from the cords, but a few branch (indicated in italics) directly from earlier
structures. The five on the left are considered "terminal branches". These terminal branches are the musculocutaneous
nerve, the axillary nerve, the radial nerve, the median nerve, and the ulnar nerve. Due to both emerging from the
lateral cord the musculocutaneous nerve and the median nerve are well connected. The musculocutaneous nerve has
even been shown to send a branch to the median nerve further connecting them.[1] There have been several variations
reported in the branching pattern but these are very rare.[3]
Diagram
Anatomical illustration of the brachial plexus with areas of roots, trunks, divisions and cords marked. Clicking on names of branches will link
to their Wikipedia entry.
Diagrammatic representation of the brachial plexus using colour The brachial plexus, including all branches of
to illustrate the contributions of each nerve root to the branches. the C5-T1 ventral primary rami. Includes
mnemonics for learning the plexus's
connections and branches.
Specific branches
Bold indicates primary spinal root component of nerve. Italics indicate spinal roots that frequently, but not always,
contribute to the nerve.
From Nerve Roots[4] Muscles Cutaneous
dorsal scapular
roots C4, C5 rhomboid muscles and levator scapulae -
nerve
branch to phrenic
roots C5 Diaphragm -
nerve
upper suprascapular
C5, C6 supraspinatus and infraspinatus -
trunk nerve
lateral lateral pectoral C5, C6, pectoralis major and pectoralis minor (by
-
cord nerve C7 communicating with themedial pectoral nerve)
thoracodorsal
posterior nerve (middle C6, C7,
latissimus dorsi -
cord subscapular C8
nerve)
anterior branch: deltoid and a small area of posterior branch becomessuperior lateral
posterior overlying skin cutaneous nerve of armInnervates the skin of
axillary nerve C5, C6
cord posterior branch: teres minor and deltoid the lateral shoulder and arm: shoulder
muscles joint.[2]
medial cutaneous
medial
nerve of the C8, T1 - medial skin of the forearm
cord
forearm
The terminal branches of the brachial plexus (musculocutaneous n., axillary n., radial n., median n., and ulnar n.) all
have specific sensory, motor and proprioceptive functions.[5][6]
musculocutaneous
Skin of the anterolateral forearm Brachialis, biceps brachii, coracobrachialis
nerve
Posterior aspect of the lateral forearm and Triceps brachii, brachioradialis, anconeus, extensor muscles of the
radial nerve
wrist; posterior arm posterior arm and forearm
Skin of palm and medial side of hand and Hypothenar eminence, some forearm flexors, thumb adductor
,
ulnar nerve
digits 3-5 lumbricals 3-4, interosseous muscles
Clinical significance
Injury
Brachial plexus injury affects cutaneous sensations and movements in the upper limb. They can be caused by
stretching, diseases, and wounds to the lateral cervical region (posterior triangle) of the neck or the axilla. Depending
on the location of the injury, the signs and symptoms can range from complete paralysis to anesthesia. Testing the
patient's ability to perform movements and comparing it to their normal side is a method to assess the degree of
paralysis. A common brachial plexus injury is from a hard landing where the shoulder widely separates from the neck
(such as in the case of motorcycle accidents or falling from a tree). These stretches can cause ruptures to the superior
portions of the brachial plexus or avulse the roots from the spinal cord. Upper brachial plexus injuries are frequent in
newborns when excessive stretching of the neck occurs during delivery. Studies have shown a relationship between
birth weight and brachial plexus injuries; however, the number of cesarean deliveries necessary to prevent a single
injury is high at most birth weights.[8] For the upper brachial plexus injuries, paralysis occurs in those muscles
supplied by C5 and C6 like the deltoid, biceps, brachialis, and brachioradialis. A loss of sensation in the lateral aspect
of the upper limb is also common with such injuries. An inferior brachial plexus injury is far less common, but can
occur when a person grasps something to break a fall or a baby's upper limb is pulled excessively during delivery. In
this case, the short muscles of the hand would be affected and cause the inability to form a full fist position.[9]
To differentiate between pre ganglionic and post ganglionic injury, clinical examination requires that the physician
keep the following points in mind. Pre ganglionic injuries cause loss of sensation above the level of the clavicle, pain
in an otherwise insensate hand, ipsilateral Horner's syndrome, and loss of function of muscles supplied by branches
arising directly from rootsi.e., long thoracic nerve palsy leading to winging of scapula and elevation of ipsilateral
diaphragm due to phrenic nerve palsy.
Acute brachial plexus neuritis is a neurological disorder that is characterized by the onset of severe pain in the
shoulder region. Additionally, the compression of cords can cause pain radiating down the arm, numbness, paresthesia,
erythema, and weakness of the hands. This kind of injury is common for people who have prolonged hyperabduction
of the arm when they are performing tasks above their head.
Definition
Brachial plexus injuries are injuries that affect the nerves that carry signals from the spine to the shoulder.[10] This can
Brachial plexus injuries are injuries that affect the nerves that carry signals from the spine to the shoulder.[10] This can
be caused by the shoulder being pushed down and the head being pulled up, which stretches or tears the nerves.
Injuries associated with malpositioning commonly affect the brachial plexus nerves, rather than other peripheral nerve
groups.[11][12] Due to the brachial plexus nerves being very sensitive to position, there are very limited ways of
preventing such injuries. The most common victims of brachial plexus injuries consist of victims of motor vehicle
accidents and newborns.
Motorcycle accidents
Motorcyclists who are involved in accidents are very susceptible to brachial plexus injuries due to the nature of the
collision. "Brachial plexus injuries were identified in 54 of 4538 patients presenting to a regional trauma facility
Motor vehicle accidents were the most frequent cause overall."[13]
Many of these patients were forced to undergo reconstructive surgery. During physical therapy, the position of the
brachial plexus became very important to avoid further damage.[14] "The risk can be reduced by thorough release of
the tissues from the inferior surface of the clavicle before mobilization of the fracture fragments."[8] By wearing
protective gear, like a helmet, a motorcyclist can help prevent nerve damage after collisions.
Sports Injuries
Brachial Plexus injuries can occur during the delivery of newborns when after the delivery of the head, the anterior
shoulder of the infant cannot pass below the pubic symphysis without manipulation. This manipulation can cause the
baby's shoulder to stretch, which can damage the brachial plexus to varying degrees.[17] This type of injury is referred
to as shoulder dystocia. Shoulder dystocia can cause obstetric brachial plexus palsy (OBPP), which is the actual injury
to the brachial plexus. The incidence of OBPP in the United States is 1.5 per 1000 births, while it is lower in the
United Kingdom and the Republic of Ireland (0.42 per 1000 births).[18] While there are no known risk factors for
OBPP, if a newborn does have shoulder dystocia it increases their risk for OBPP 100-fold. Nerve damage has been
connected to birth weight with larger newborns being more susceptible to the injury but it also has to do with the
delivery methods. Although very hard to prevent during live birth, doctors must be able to deliver a newborn with
precise and gentle movements to decrease chances of injuring the child.
Tumors
Tumors that may occur in the brachial plexus are schwannomas, neurofibromas and malignant peripheral nerve sheath
tumors.
Imaging
Imaging of the Brachial Plexus can be done effectively by using a higher magnetic strength MRI Scanner like 1.5 T or
more. It is impossible to evaluate the brachial plexuses with plain Xray, CT and ultrasound scanning can manage to
view the plexuses to an extent; hence MRI is preferred in imaging brachial plexus over other imaging modalities due
to its multiplanar capability and the tissue contrast difference between brachial plexus and adjacent vessels. The
plexuses are best imaged in coronal and sagittal planes, but axial images give an idea about the nerve roots. Generally,
T1 WI and T2 WI images are used in various planes for the imaging; but new sequences like MR Myelolography,
Fiesta 3D and T2 cube are also used in addition to the basic sequences to gather more information to evaluate the
anatomy more.
In anaesthetics
Additional images
Mind map showing The axillary artery and Nerves in the Cutaneous nerves of
branches of brachial its branches. infraclavicular portion right upper extremity.
plexus of the right brachial
plexus in the axillary
fossa.
References
1. Kawai, H; Kawabata, H (2000). Brachial Plexus Palsy. Singapore: World Scientific. pp. 6, 20.
ISBN 9810231393.
2. Saladin, Kenneth (2015). Anatomy and Physiology (7 ed.). New York: McGraw Hill. pp. 489491.
ISBN 9789814646437.
3. Goel, Shivi; Rustagi, SM; Kumar, A; Mehta, V; Suri, RK (Mar 13, 2014). "Multiple unilateral variations in
medial and lateral cords of brachial plexus and their branches" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
3968270). Anatomy & Cell Biology. 47 (1): 7780. PMC 3968270 (https://www.ncbi.nlm.nih.gov/pmc/articles/P
MC3968270) . PMID 24693486 (https://www.ncbi.nlm.nih.gov/pubmed/24693486).
doi:10.5115/acb.2014.47.1.77 (https://doi.org/10.5115%2Facb.2014.47.1.77).
4. Moore, K.L.; Agur, A.M. (2007). Essential Clinical Anatomy (3rd ed.). Baltimore: Lippincott Williams &
Wilkins. pp. 4301. ISBN 978-0-7817-6274-8.
5. Saladin, Kenneth (2007). Anatomy and Physiology: The Unity of Form and Function. New York, NY: McGraw-
Hill. p. 491. ISBN 9789814646437.
6. "Axillary Brachial Plexus Block" (http://www.nysora.com/techniques/nerve-stimulator-and-surface-based-ra-tec
hniques/upper-extremitya/3260-axillary-brachial-plexus-block.html). www.nysora.com. New York School of
Regional Anesthesia. 20/09/2013. Check date values in: |date= (help)
7. Moore, K.L.; Agur, A.M. (2007). Essential Clinical Anatomy (3rd ed.). Baltimore: Lippincott Williams &
Wilkins. pp. 4345. ISBN 978-0-7817-6274-8.
8. Ecker, Jeffrey L.; Greenberg, James A.; Norwitz, Errol R.; Nadel, Allan S.; Repke, John T. (1997). "Birth
Weight as a Predictor of Brachial Plexus Injury". Obstetrics & Gynecology. 89 (5): 64347. PMID 9166293 (htt
ps://www.ncbi.nlm.nih.gov/pubmed/9166293). doi:10.1016/S0029-7844(97)00007-0 (https://doi.org/10.1016%2
FS0029-7844%2897%2900007-0).
9. Moore, Keith (2006). Clinically Oriented Anatomy. Philadelphia: Lippincott Williams & Wilkins. pp. 77881.
ISBN 0-7817-3639-0.
10. http://www.mayoclinic.com/health/brachial-plexus-injury/DS00897/Brachial
11. Cooper, DE; Jenkins, RS; Bready, L; Rockwood Jr, CA (1988). "The prevention of injuries of the brachial
plexus secondary to malposition of the patient during surgery". Clinical orthopaedics and related research
(228): 3341. PMID 3342585 (https://www.ncbi.nlm.nih.gov/pubmed/3342585). doi:10.1097/00003086-
198803000-00005 (https://doi.org/10.1097%2F00003086-198803000-00005).
12. Jeyaseelan, L.; Singh, V. K.; Ghosh, S.; Sinisi, M.; Fox, M. (2013). "Iatropathic brachial plexus injury: A
complication of delayed fixation of clavicle fractures". The Bone & Joint Journal. 95B (1): 10610.
PMID 23307682 (https://www.ncbi.nlm.nih.gov/pubmed/23307682). doi:10.1302/0301-620X.95B1.29625 (http
s://doi.org/10.1302%2F0301-620X.95B1.29625).
13. Midha, Rajiv (1997). "Epidemiology of Brachial Plexus Injuries in a Multitrauma Population" (http://meta.wkhe
alth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0148-396X&volume=40&issue
=6&spage=1182). Neurosurgery. 40 (6): 11828; discussion 11889. PMID 9179891 (https://www.ncbi.nlm.nih.
gov/pubmed/9179891). doi:10.1097/00006123-199706000-00014 (https://doi.org/10.1097%2F00006123-19970
6000-00014).
14. http://www.webmd.com/pain-management/tc/physical-therapy-topic-overview
15. Elias, Ilan. "Recurrent burner syndrome due to presumed cervical spine osteoblastoma in a collision sport
athlete - a case report" (http://www.biomedcentral.com/1749-7221/2/13). Journal of Brachial Plexus and
Peripheral Nerve Injury. Retrieved 12/2/15. Check date values in: |access-date= (help)
16. Cunnane, M (2011). "A retrospective study looking at the incidence of 'stinger' injuries in professional rugby
union players" (http://bjsm.bmj.com/content/45/15/A19.1.abstract). British Journal of Sports Medicine. 45: A19.
doi:10.1136/bjsports-2011-090606.60 (https://doi.org/10.1136%2Fbjsports-2011-090606.60). Retrieved 12/2/15.
Check date values in: |access-date= (help)
17. "Brachial Plexus Injuries Information Page: National Institute of Neurological Disorders and Stroke (NINDS)"
(http://www.ninds.nih.gov/disorders/brachial_plexus/brachial_plexus.htm). www.ninds.nih.gov. Retrieved
2016-11-28.
18. Doumouchtsis, Stergios K.; Arulkumaran, Sabaratnam (2009-09-01). "Are all brachial plexus injuries caused by
shoulder dystocia?". Obstetrical & Gynecological Survey. 64 (9): 615623. ISSN 1533-9866 (https://www.worl
dcat.org/issn/1533-9866). PMID 19691859 (https://www.ncbi.nlm.nih.gov/pubmed/19691859).
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Bibliography
Saladin, Kenneth (2014). Anatomy and Physiology (7th ed.). McGraw-Hill Education. p. 491.
Kishner, Stephen. "Brachial Plexus Anatomy". Medscape. WebMD. Retrieved 29 Nov 2015.
External links
Schematic diagram of Brachial plexus
Brachial Plexus Injury/Illustration, Cincinnati Children's Hospital Medical Center
Brachial Plexus: Schema by Frank H. Netter
Learn the Brachial Plexus in Five Minutes or Less by Daniel S. Romm, M.D. and Dennis A. Chu Chu, M.D. [1]
Video of the dissected axilla and Brachial Plexus