Brachial plexus

Where Ventral Rami Come From

Dorsal Root

Ventral Root

spinal nerve

Dorsal Ramus of spinal nerve

Ventral Ramus of spinal nerve

Parts of Brachial Plexus

• R = ROOTS (ventral rami)• T = TRUNKS• D = DIVISIONS• C = CORDS• B = BRANCHES

Relationship of cords of brachial plexus with axillary artery

PUT IT ALL TOGETHER…...

Branches of roots - Dorsal scapular nerve(C5) Long thoracic nerve (C5,C6,C7) muscular branches to longus colli & scaleni Branch to phrenic nerve

Branches of upper- Nerve to subclavius (C5,C6)

Trunk Suprascapular nerve (C5,C6)

BRANCHES OF SUPRACLAVICULAR PART OF BRACHIAL PLEXUS

BRANCHES OF INFRACLAVICULAR PART OF BRACHIAL PLEXUS

• Lateral cord Musculocutaneous nerve(C5,C6)

Lateral pectoral nerve (C5,C6)

Lateral root of median nerve (C5,C6)

• Medial cord Medial cutaneous nerve of arm (C8,T1) Medial cutaneous nerve of forearm(C8,T1)

Medial root of median nerve(C8,T1)

Medial pectoral nerve (C8,T1)

Ulnar nerve(C7,C8,T1)

• Posterior cord Upper subscapular nerve(C5,C6)

Lower subscapular nerve(C5,C6)

Nerve to latissimus dorsi (C6,C7,C8)

Axillary nerve(C5,C6)

Radial nerve(C5,C6,C8,T1)

BRANCHES OF ROOTS

DORSAL SCAPULAR NERVE

• Root value- C5• Supply – Rhomboid major & minor muscle

Posterior view

LONG THORACIC NERVERoot value- C5,C6,C7Supply – Serratus anterior muscle

BRANCHES OF UPPER TRUNK

NERVE TO SUBCLAVIUS Root value – C5,C6

SUPRASCAPULAR NERVERoot value – C5,C6

LATERAL PECTORAL NERVE

Root value- C5,C6,C7

MEDIAL PECTORAL NERVE

Root value- C8,T1

MUSCULOCUTANEOUS NERVE

Root value – C5,C6,C7

12-13

MEDIAN NERVE

MEDIAL CUTANEOUS NERVE OF ARMRoot value- C8,T1

MEDIAL CUTANEOUS NERVE OF FOREARMRoot value- C8,T1

12-15

ULNAR NERVE

Root value-(C7),C8,T1

UPPER SUBSCAPULARRoot value-C5,C6

LOWER SUBSCAPULARRoot value- C5,C6

NERVE TO LATISSIMUS DORSIRoot value-C6,C7,C8

AXILLARY NERVE

RADIAL NERVE

DERMATOMES OF UPPER LIMB

APPLIED ANATOMY

TENDON REFLEXES

• Biceps brachii tendon reflexe (C5,C6)

• Triceps tendon reflex (C6,C7,C8)

• Brachioradialis tendon reflex(C5,C6,C7)

LONG THORACIC NERVE

Causes - carrying Heavy load on shoulder Sudden pressure on shoulder from above

Deformity – Winging of scapula Overhead abduction not possible

ERB’S PARALYSIS

• Erb’s point

• Causes

• Nerve roots involved

• Muscles Paralysed

• Deformity

• Disability

LEFT SIDE PARALYSIS

Klumpke’s paralysis-

Site of injury

Cause of injury

Nerve roots involved

Muscles paralysed

Deformity

Disability

CLAW HAND HORNER SYNDROME

MUSCULOCUTANEOUS NERVE

• Cause• Muscle paralysed• Disability

SUPRASCAPULAR NERVE

• Cause• Muscle paralysed• Disability

AXILLARY NERVE• Causes crutch pressing upward into the

armpit, Downward shoulder dislocations fractures of the surgical neck of

the humerus. • Motor effects:

• Sensory effects:

• Deformity:

MEDIAN NERVE –

Cause-

Site of injury-

Muscles paralysed-

Deformity

Disability

RIGHT SIDE

ULNAR NERVE

Causes-

Axilla- crutch pressureArm- # of shaft of humerusElbow- # of medial epicondyleForearm- penetrating injuriesWrist- cut and stab wounds

Muscles paralysed-

Deformity

Disability

RADIAL NERVE

Cause-

Site of injury-

Muscles paralysed-

Deformity

Disability

DIAGNOSIS

• Relies mainly on clinical examination• No specific lab. Studies• CT myelography• MRI• Nerve conduction studies

TREATMENT

• Most injuries recover without any Rx• Rx is done in very highly specialized centers• Surgical optionsa. nerve transfersb. nerve graftc. muscle transfersd. neurolysis of scar around the brachial plexus in incomplete lesions.

BRACHIAL PLEXUS BLOCK

Supraclavicular approach Axillary approach

Roots join to form Trunks! (in neck)

Ventral Rami Trunks

• C5 Upper Trunk• C6• C7 Middle Trunk• C8• T1 Lower Trunk

Trunks Split to form Divisions! (in neck)• Trunks Divisions

• Upper AnteriorPosterior

• Middle Anterior

Posterior

• Lower Anterior Posterior

Divisions Join to form Cords! (in axilla)

U A P

M A P

L A P POSTERIOR CORD

LATERAL CORD

MEDIAL CORD

Trunks Divisions Cords

Musculocutaneous Nerve

• Motor components

• Sensory: Skin along lateral surface of forearm

Course

Effects:Motor: paralysis of the supraspinatus, infraspinatus, subclavius, biceps brachii, part of brachialis, coracobrachialis; deltoid teres minor. Sensroy: sensory loss on the lateral side of the arm. Deformity: waiter tip postiona. limb will hang by the side, b. medially rotated by sternocostal part of the pectoralis major; c. pronated forearm (biceps paralysis)

• Motor effects:paralysis of triceps Anconeus extensors of the wrist Extensors of fingers. Brachioradialis supinator muscle • Deformity: Wrist and finger drop

• Sensory effects : small area of sensation loss at arm and forearm sensory loss over lateral part of the dorsum of the hand (lat. 3.5 fingers without distal phalynges)

Test for ulnar nerve Card test

Froment’s sign

Egawa’s test

AXILLA

CONTENT• Axillary artery & its

branches• Axillary vein & its tributaries• Infraclavicular part of

brachial plexus• Axillary lymph nodes• Axillary fat

Carpal tunnel syndrome

Epidemiology

Signs &symptoms

Motor changes

Sensory changes

Vasomotor changes

Trophic changes

Tests done

Tinel sign Phalen’s maneavure

Radial Nerve Injury in axilla• Causes of injury

Motor effects:paralysis of triceps,anconeus extensors of the wrist Extensors of fingers. Brachioradialis supinator muscle • Deformity: Wrist and finger dropSensory effects -small area of sensation loss at arm andforearm sensory loss over lateral part of the dorsum of the

hand (lat. 3.5 fingers without distal phalynges)

Injuries at Spiral Groove

Caused by fracture shaft of humerus. • Motor effects: paralysis of extensors of the wrist Extensors of fingers

• Deformity: Wrist and finger drop

• Sensory effects: anesthesia is present over the dorsal surface of the hand (lat. 3.5 fingers)