BRACHIAL PLEXUS

Prof.Dr. U.Murali.M.S;MBA
Dept.Of Surgery
D Y Patil Medical College
Mauritius.

Contents of Discussion

Spinal Nerves
Nerve Plexus
BP Origin & Relations
Formation
Parts of BP
Distribution - Nerve Supply areas
Anatomical Variations
Applied Anatomy

Spinal Nerves

Spinal nerves attach to the

spinal cord via roots

Dorsal root

Has only sensory neurons

Attached to cord via rootlets
Dorsal root ganglion

Ventral root

Has only motor neurons

No ganglion - all cell bodies
of motor neurons found in
gray matter of spinal cord

Spinal Nerves

31 pair

each contains thousands of nerve fibers

All are mixed nerves have both sensory and motor
neurons

Connect to the spinal cord

Exit from SC Supplying the muscles & structures

of the body

Spinal Nerves
8 pairs of cervical
nerves from C1 to C8
12 pairs of thoracic
nerves from T1-T12
5 pairs of lumbar nerves
from L1 to L5
5 pairs of sacral nerves
from S1 to S5
1 pair of coccygeal
nerves located at C zero
(Co)

Formation of Rami

Rami are lateral branches of a

spinal nerve

Rami contain both sensory and

motor neurons
Two major groups
Dorsal ramus
Neurons innervate the
dorsal regions of the body
Ventral ramus
Larger
Neurons innervate the
ventral regions of the
body
Braid together to form
plexuses (plexi)

12-6

Nerve Plexuses

Nerve plexus

A nerve plexus is nothing more than a

system or network of connected nerve fibers
that link spinal nerves with specific areas of
the body . A network of ventral rami.

Ventral rami (except T2-T12)

Branch and join with one another

Form nerve plexuses
In cervical, brachial, lumbar, and sacral regions
No plexus formed in thoracic region of s.c.

12-7

Branches
of
Spinal
Nerves

Dorsal Ramus

Neurons within muscles of trunk and back

Ventral Ramus (VR)

Braid together to form plexuses

Communicating Rami: communicate

with sympathetic chain of ganglia

12-8

Cervical plexus - VR of C1-C4

Brachial plexus - VR of C5-T1
Lumbar plexus - VR of L1-L4
Sacral plexus - VR of L4-S4
Coccygeal plexus -VR of S4&S5

Covered in ANS unit

Brachial Plexus - Origin

Formed by ventral rami of spinal

nerves C5-T1
Five ventral rami form

12-9

Roots / Trunks that separate into

Divisions that then form
Cords that give rise to Branches

Major nerves
Axillary
Radial
Musculocutaneous
Ulnar
Median

Brachial Plexus

15 cms long ,spinal column to

axilla.

Brachial plexus is responsible for

cutaneous (sensory) and muscular
(motor) innervation of the entire
upper limb & pectoral girdle.

It proceeds through the neck, the

axilla and into the arm.

Relations - BP

In the neck, the brachial plexus

lies in the posterior triangle,
being covered by the skin,
Platysma, and deep fascia; where
it is crossed by the
supraclavicular nerves, the
inferior belly of the Omohyoid,
the external jugular vein, and the
transverse cervical artery.

Relations - BP

When it emerges
between the Scalene
anterior and medius
--* its upper part lies
above the third part of
the subclavian artery,
* while the trunk
formed by the union of
C8 & T1 is placed
behind the artery.

Relations - BP

The plexus next passes behind the clavicle,

the Subclavius, and the transverse scapular
vessels, and lies upon the first digitation of the
Serratus anterior, and the Subscapularis.

Relations

In the axilla it is placed

lateral to the first portion
of the axillary artery; it
surrounds the second part
of the artery, one cord
lying medial to it, one
lateral to it, and one
behind it; at the lower part
of the axilla it gives off its
terminal branches to the
upper limb.

FORMATION OF THE BRACHIAL

PLEXUS

PUT IT ALL TOGETHER...

ROOTS

Originates froms C5-C8 and most of T1

Receives gray rami communicates from the
symphathetic trunk.
Carry postganglionic symphathetic fibers onto
root for distribution of periphery.
Root and trunk enter posterior triangle of
neck by passing between anterior scalene
and middle scalene muscles and lies
between superior and posterior to subclavian
artery.

TRUNKS

C5,C6 roots pass down wards between

Scalenus medius and Scalenus anterior
muscles and unite to form SUPERIOR
TRUNK
C7 root pass between Scalenus muscles and
at laeral border of scalenus anterior emreges
as MIDDLE TRUNK
C8, T1 roots unite behind a fascial sheet
(sibsons fascia) and beneath the subclavian
artery form LOWER TRUNK

DIVISION

Lateral to the 1st rib , where three trunks are

located behind the axillary artery ,they separate
into 3 anterior and 3 posterior divisions
The 3 anterior division form parts of brachial
plexus that ultimately give rise to peripheral
nerves associated with the anterior compartment
of arm or forearm.
The 3 posterior division combine to form parts of
the brachial plexus that give rise to nerves
associated with the posterior compartments.

CORDS

3 posterior divisions unite to form posterior

cord
Anterior divisions of upper and ,middle trunks
(C5-C7) unite to form lateral cord
Anterior division of lower trunk forms medial
cord(C8-T1)
Cords named after their relation with AA &
passes through the thoracic outlet and give off
major branches

BRANCHES - Roots

From the Roots

Dorsal Scapular nerve

Derived from C5 root
Motor nerve to the
Rhomboideus major and
minor muscles

Roots

Long Thoracic nerve

Derived from C 5,6,7
Innervates the serratus
anterior muscle

BRANCHES OF UPPER
TRUNK
NERVE TO SUBCLAVIUS
Root value C5,C6
SUPRASCAPULAR
NERVE
Root value C5,C6

Branches LC & MC
LATERAL PECTORAL NERVE MEDIAL PECTORAL NERVE
Root value- C5,C6,C7

Root value- C8,T1

Lateral Cord

Direct branches:
Lateral pectoral nerve: C5-7
To clavicular head of pectoralis
major muscle

Terminal nerves:
Musculocutaneous: C5-7
Lateral root of median
nerve: C5-7

Medial Cord: Direct Branches

Medial pectoral nerve:

C8-T1
To sternal head of pectoralis
major muscle and pectoralis
minor muscle.

Medial cutaneous nerve to

arm
Medial cutaneous nerve to
forearm

MEDIAL
CUTANEOUS
NERVE OF
ARM
Root value- C8,T1
MEDIAL
CUTANEOUS
NERVE OF
FOREARM
Root value C8,T1

Medial Cord: Terminal Nerves

Ulnar C8-T1
Medial root of
median nerve C8-T1

ULNAR NERVE

Posterior Cord Direct Branches

Upper subscapular nerve

C5-6
To subscapularis muscle

Thoracodorsal nerve:
C6-7
To latissimus dorsi muscle

Lower subscapular nerve:

C5-6
To subscapularis and
teres major muscles

UPPER
SUBSCAPULAR
Root value-C5,C6
LOWER
SUBSCAPULAR
Root value- C5,C6
NERVE TO
LATISSIMUS DORSI
Root value-C6,C7,C8

Posterior Cord Terminal Nerves

Axillary nerve: C5-6

Motor: To deltoid and teres
minor muscles.

Sensory: Skin on arm over

deltoid muscle:

AXILLARY NERVE

Posterior Cord Terminal Nerves

Radial nerve: C5-T1

Motor:
Posterior compartments of
arm and forearm.
Brachioradialis muscle

Sensory:
Back of arm, forearm, hand

RADIAL NERVE

Cutaneous distribution

Anatomic Variations

The plexus may include anterior rami from C4 or

T2 and these are designated as
Pre fixed- C4 added
Post fixed- T2 added.
The connective tissue sheath that invests the
plexus especially in the axillary region has a
convoluted and septated structure that can lead
to non uniform distribution of local anaesthetics .

The musculocutaneous nerve may fuse to or have

communications with the median nerve , which
can result in its absence from within the
coracobrachialis muscle.

Communication between median and ulnar nerves

is common in the forearm with the median nerve
replacing the innervations to various muscles
normally supplied by the ulnar nerve.

Variations with respect to vessels within the arm

may be present like double axillary veins , high
origin of radial artery and double brachial arteries.

The interscalene groove may have variations in

the relationship between the plexus roots and
trunks and the muscles.
For eg.- the C5 or C6 roots may traverse
through or anterior to the anterior scalene
muscles.
In many specimens no inferior trunk exists , a
single cord or a pair of cords may develop. In
some cases no discrete posterior cord forms ,
with the posterior divisions diverging to form
terminal branches.

APPLIED ANATOMY

Brachial Plexus Injury

Obstetric palsy - Injury to all or portion of a child

brachial plexus occurring at that time of the
delivery.

Excessive lateral traction on the head so that the

head is pulled away from the shoulder.

Divide into :

Erbs Duchenne Palsy

Klumpkees Palsy

Erbsparalysis
C5 -C6
Birth injury / Trauma
Arm hangs by the side
+ Rotate medially
Forearm pronated +
extended
Flexed wrist + fingers
Deltoid/supraspinatus/
infraspinatus/biceps/
brachialis
. LOS in arm

Erbs Palsy Nerves Affected

LEFT SIDE PARALYSIS

Klumpkesparalysis

C8 T1
Traction injuries / Fall
* Intrinsic muscles of the hand +
long flexors of the wrist & hand
paralysed
Claw hand = extension at MPJ +
flexion at IPJ ( wrist & hand )
* Forearm supinated
* LOS medial side - am
Cervical rib can cause paralysis
similar to Klumpkesparalysis with
post-fixed T2 contribution

BRACHIAL PLEXUS BLOCK

Supraclavicular approach

Axillary approach

Begin with a letter Y, an I and a Y.

Add a strike and a spare

Draw arches.

Draw horizontal lines to separate the parts.

Roots
Trunks
Divisions

Cords
Branches

Begin labeling.
C5
Roots
Trunks

C6

C7

Upper

C8

T1

Middle

Lower

Medial

Posterior

Cords

Lateral

Divisions

Branches

Musculocutaneous

SLOW

Axillary

Median

Radial

Ulnar

Add details . . .
Branches off the posterior cord spell ULTRA
C5
C6
C7
C8
Roots
Trunks

Upper

T1

Middle

Lower

Upper subscapular
Lower subscapular
Thoracodorsal

Medial

Posterior

Cords

Lateral

Divisions

Branches

Musculocutaneous

SLOW
SLOW

Axillary

Median

Radial

Ulnar

3M comes off the medial cord.

C5

C6

C7

C8

T1

Roots
Trunks

Middle

Upper

Lower

Upper subscapular
Lower subscapular
Thoracodorsal

Medial

Posterior

Cords

Lateral

Divisions

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

Branches

Musculocutaneous

SLOW
SLOW

Axillary

Median

Radial

Ulnar

The lateral pectoral n. comes off the lateral cord.

C5

C6

C7

C8

T1

Roots
Trunks

Upper

Middle

Lower

Upper subscapular
Lower subscapular
Thoracodorsal

Medial

Lateral pectoral n.

Posterior

Cords

Lateral

Divisions

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

Branches

Musculocutaneous

Axillary

Median

Radial

Ulnar

There are 4 supraclavicular branches.

C5

C6

C7

C8

T1

Roots

Long
Thoracic n.

Dorsal Scapular n.

Trunks

Upper

N. to subclavius
Suprascapular n.

Middle

Lower

Upper subscapular
Lower subscapular
Thoracodorsal

Medial

Lateral pectoral n.

Posterior

Cords

Lateral

Divisions

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

Branches

Musculocutaneous

SLOW

Axillary

Median

Radial

Ulnar

Thats it!

The Brachial Plexus

C5

C6

C7

C8

T1

Roots

Long
Thoracic n.

Dorsal Scapular n.

Trunks

Upper

N. to subclavius
Suprascapular n.

Middle

Lower

Upper subscapular
Lower subscapular
Thoracodorsal

Medial

Lateral pectoral n.

Posterior

Cords

Lateral

Divisions

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

Branches

Musculocutaneous

Axillary

Median

Radial

Ulnar