Contents

Anatomy of the Brachial Plexus

Mechanisms of Brachial Plexus Injury and Pathologies

Neurological Evaluation for the Brachial Plexus and Related Special Tests

Levels
Roots Trunks Real

Athletic

Trainers

Divisions
Cords Branches

Drink
Cold Beer

Thats it!
C5 Roots
Dorsal Scapular n.

The Brachial Plexus

C6 C7 C8 T1
Long Thoracic n. N. to subclavius Suprascapular n.

Trunks Divisions

Upper

Middle

Lower

Posterior

Lateral

Cords

Lateral pectoral n.

Upper subscapular Lower subscapular Thoracodorsal

Medial Radial

Medial pectoral n. Medial cutan. n. of arm Medial cutan. n. forearm

Branches

Musculocutaneous

Axillary

Median

Ulnar

Brachial Plexus Branches & Muscular Innervations

Dorsal Scapular N.

Suprascapular N.

Levator Scapulae Rhomboid Major/Minor

Infraspinatus Supraspinatus

Musculocutaneous N.
Lateral Pectoral N.

Biceps Brachii Brachialis Coracobrachialis

Pectoralis Major/Minor

Brachial Plexus Branches & Muscular Innervations

Axillary N.

Deltoid
Teres Minor

Middle Subscapular or Thoracodorsal N.

Latissimus Dorsi

Upper Subscapular N.

Lower Subscapular N.

Subscapularis

Subscapularis Teres Major

Median N.

Brachial Plexus Branches & Muscular Innervations

Radial N.

Abductor Pollicis Brevis/Longus

Abductor Pollicis Brevis

Flexor Carpi Radialis

Flexor Digitorum Superficialis Flexor Digitorum Profundus (Lat. 2) Flexor Pollicis Brevis (Lat.) & Longus Lumbricales (Lat. 2) Opponens Pollicis Palmaris Longus Pronator Quadratus Pronator Teres *

Anconeus
Brachioradialis Extensor Carpi Radialis Brevis/Longus Extensor Carpi Ulnaris Extensor Digiti Minimi Extensor Digitorum Communis

Extensor Indicis
Extensor Pollicis Brevis/Longus Supinator Triceps Brachii

Brachial Plexus Branches & Muscular Innervations

Ulnar N.

Long Thoracic N.

Abductor Digiti Minimi Adductor Pollicis Dorsal Interossei Flexor Carpi Ulnaris Flexor Digiti Minimi Flexor Digitorum Profundus (Med. 2) Flexor Pollicis Brevis (Med.)

Serratus Anterior

Medial Pectoral N.

Pectoralis Major

Medial Brachial Cutaneous N. (sensory)

Lumbricals (Med. 2)
Opponens Digiti Minimi Palmar Interossei

Medial Antebrachial Cutaneous N. (sensory)

Mechanisms of Injury to the Brachial Plexus

Brachial Plexus Injury Overview Sports most commonly associated with brachial plexus
injuries include: football, baseball, basketball, volleyball, fencing, wrestling, and gymnastics Nerve injuries can result from blunt force trauma, poor posture, or chronic repetitive stress Patients generally present with pain and/or muscle weakness Over time, some patients may experience muscle atrophy
(Duralde, 2000)

Brachial Plexus Injury Overview Before performing special tests, rule out fractures and
dislocations Brachial plexus injuries resolve quicker than spinal cord injuries
(Prentice, p.846)

Evaluation for return-to-play should take into consideration symptoms, resolution time, and prior injuries to this region
(Gorden, et al., 2003)

Evaluate athletes immediately after injury and again after the game/practice
(Kuhlman & McKeag, 1998)

Three Mechanisms of Injury

Percussion

Traction
Cervical Nerve Compression

Percussion
Occurs with direct blow to the supraclavicular fossa over Erbs point
(Troub, 2001)

Example: Cross-check to a hockey player

Traction
Occurs with a direct blow to the shoulder with the neck laterally flexed toward the unaffected shoulder
(Troub, 2001)

Example: Gymnast falls on beam

Cervical Nerve Compression Occurs when the neck is flexed laterally toward the patients
affected shoulder Caused by compression or irritation of the nerves, resulting in point tenderness over involved vertebrae of affected nerve(s)

(Troub, 2001)

Example: Football player tackles an opponent

A. Traction B. Percussion C. Cervical Nerve Compression

Three Grades of Injury

Grade 1 Neuropraxia

Grade 2 Axonotmesis

Grade 3 Neurotmesis

Results in a disruption in the function of a nerve that produces numbness and tingling

Grade 1 - Neuropraxia

Most common grade within athletics

Symptoms usually resolve within several minutes

(Duralde,2000)

Grade 2 Axonotmesis Damage to the nerves axon

Symptoms include numbness, tingling, and affected function (may last several days)

Long nerves have a greater healing time than short nerves

Rare within athletics

(Duralde,2000)

Grade 3 - Neurotmesis

Permanent nerve damage occurs

Very rare within athletics

Occurs with high-energy trauma, fractures, and penetrating injuries

(Duralde, 2000)

C5-C6 Affected

Motor Deficits:

Shoulder abduction, shoulder flexion, elbow flexion, and wrist extension

Sensory Loss: Lateral arm, 1st digit, and 2nd digit

C7 Affected

Motor Deficits:

Elbow extension weakness and wrist flexion

Sensory Loss: Pad of index finger

C8-T1 Affected (very rare)

Motor Deficits:

Finger abduction/adduction and thumb flexors/extensors

Sensory Loss: 4th digit, 5th digit, medial forearm, and medial arm

C5-T1 Affected

Motor Deficits:

Scapular motion and entire arm

Sensory Loss: Entire arm, forearm, and hand

Process of Evaluation

Dermatomes C5 Lateral arm

C6 Lateral forearm, thumb, index finger

C7 Posterior forearm, middle finger

C8 Medial forearm, ring and little finger

T1 Medial arm

C5 Shoulder abduction

Myotomes

C6 Elbow flexion or wrist extension

C7 Elbow extension or wrist flexion

C8 Grip strength, shake hands

T1 Interossei, spread fingers and resist

finger adduction

Peripheral Nerve Tests

Axillary N. Sensory Lateral arm Motor Shoulder abduction Musculocutaneous N.

Sensory Anterior arm

Motor Elbow flexion

Peripheral Nerve Tests

Radial N. Sensory space 1st Dorsal web Median N. Sensory Pad of Index finger Motor Thumb pinch and abduction

Motor Wrist extension and thumb extension

Ulnar N. Sensory Pad of little finger Motor Finger abduction

Duralde, X. A. (2000). Neurologic injuries in athletes shoulder. Journal of Athletic Training, 35(3), pp.316-318. Gorden, J. A., Straub, S. J., Swanik, C. B., & Swanik, K. A. (2003). Effects of football collars on cervical hyperextension and lateral flexion. Journal of Athletic Training, 38(3), pp. 209-218. Hoppenfeld, S. (1976). Physical Examination of the Spine & Extremities. Upper Saddle River: NJ: Prentice Hall. pp.93-127. Kuhlman, G. S. & McKeag, D. B. (1999). The burner: A common nerve injury in contact sports. American Family Physician, 60(7). Retrieved April 5, 2006 from the American Academy of Family Physicians database. Martini, F. H., Timmons, M. J., & Tallitsch, R. B. (2003). Human Anatomy. Upper Saddle River, NJ: Pearson Education, Inc. Starkey, C. & Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries. Philadelphia, PA: F. A. Davis Company. Troub, M. (2001). Brachial plexus injuries in athletics: Burners. Northwest Texas Sports Medicine Clinic. Retrieved March 5, 2006 from the Northwest Texas Sports Medicine Clinic website.

References