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1. brachial plexus & its applied anatomy[1]
 

1. brachial plexus & its applied anatomy[1]

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    1. brachial plexus & its applied anatomy[1] 1. brachial plexus & its applied anatomy[1] Presentation Transcript

    • BRACHIAL PLEXUS
    • PRESENTED BY,
      PUVANESWARI
      THENMOLI
      ROHINIE
      THARSHINI
    • BRACHIAL PLEXUS
      • Formed by anterior(ventral) rami of C5 to C8, and most of the anterior ramus of T1.
      • Originates from neck, passes laterally and inferiorly over rib I, and enters axilla.
      • The part of brachial plexus from medial to laterally are roots, trunks, divisions, and cords.
      • Proximal part is posterior to subclavian artery
      • Distal part is surrounds by axilliary artery.
    • ROOTS
      Originates froms C5-C8 and most of T1
      Receives grays rami communicates from the symphatetic trunk.
      Carry postganglionic symphatetic 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 scalenusmedius and scalenus anterior muscles and unite to form SUPERIOR TRUNK
      C7 root pass between scalenus muscles and at laeral border of scalenus anterior emeges as MIDDLE TRUNK
      C8, T1 roots unite behind a fascial sheet (sibson”s 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 passes through the thoracic outlet and give off major branches
    • BRANCHES OF ROOTS
      • Dorsal scapular nerve-(c4-c5)- levator scapulae, rhomboids (MAJOR-MINOR)
      • Subclavian nerve(c5-c6)- subclavian muscle
      • Long thoracic nerve(c5-c7)- serratus anterior muscle
    • PECTORAL NERVE
      Lateral anterior thoracic nerve(c5-c7) arises from anterior divisions of upper, middle trunks
      Medial anterior thoracic nerve(c8-T1) branch of medial cord
      Anterior thoracic nerves(c5-T1) supplies pectoralis major, pectoralis minor
    • BRANCHES FROM CORD
      Lateral cord-1)musculocutaneous nerve(c5-c7)
      FUNCTION:sensory for skin on lateral side of forearm
      2)lateral head of median nerve(c5-c7)
      FUNCTION: motor nerve for ,Pectoralis major
    • MEDIAL CORD.
      Medial cord-1)med.ant.thoracic nerve(c8-T1)
      FUNCTION: Pectoralos major and minor
      2)med. Cut. Nerve of arm(c8-T1)
      FUNCTION: Skin on medial side of distal one-third of arm
      3)med.cut. Nerve of forearm(c8-T1)
      FUNCTION: Skin of medial side of forearm
      4)ulnar nerve(c7-T1)
      FUNCTION: supply all intrinsic muscle of hand(except
      thenar muscles and 2 lateral lembricals),also
      carpiulnaris and median half of flexor
      digitorumprofundus in forearm.
      5)med. Head of median nerve(c8-T1)
    • POSTERIOR CORD
      Posterior cord-
      1)subscapular nerve(upper,lower)(c5-c7)
      2)thoraco dorsal nerve(c5-c7)
      3)axillary nerve(c5-c6)
      4)radial nerve(c5-c8)
    • Lesions of brachial plexus
      Usually incomplete
      Muscle paralysis
      Muscle atrophy
      Loss of tendon reflexes
      Sensory changes
      Clinical deficit involving >one spinal/peripheral nerve
    • Total plexus palsy
      • Usually due to severe trauma
      • Entire arm is paralysed
      • All arm”s musculature may undergo rapid atrophy
      • Complete anesthesia of arm distal to a line extending obliquely from tip of shoulder to medial arm half way to elbow
      • Entire upper limb is areflexic
    • Upper plexus paralysis
      Erb –duchenne palsy results from the damage to c5,c6 roots/upper trunk
      Causes- forceful separation of head and shoulder,pressure on shoulder, fire arm recoil, birth injury, and idiopathic plexitis
      Paralysis of deltoid, biceps, brachioradialis, brachialis, and occasionally supra spinatus,infraspinatus and sub scapularis
      Iimb is internally rotated, adducted, fore arm is extended and pronated,palm facing out and back ward-police man”s tip position
      shoulder abduction(deltoid, supraspinatus);elbow flexion(biceps, brachioradialis, brachialis);ext.rotation of arm(infraspinatus);fore arm supination (biceps) are impaired
      Very proximal lesions can cause weakness of rhomboids,levator scapulae, serratusanterior,and scalene muscles
      Sensation is usually intact, some sensory loss may occur over the outer surface of upper arm
      Biceps, brachioradialis reflexes are depressed or absent
    • Lower plexus paralysis
      Dejerine-klumpke -follows injury to c8,T1 roots
      Results from trauma; arm traction in abducted position,surgical procedures for lung tumour , mass lesion like aneurysm of aortic arch
      Weakness of wrist flexion, finger flexion, and intrinsic muscles of hand resulting in claw hand deformity
      Sensation may be lost in medial arm ,medial fore arm ,ulnar aspect of hand
      Finger flexor reflex is lost/depressed(c8-T1)
      When T1 root is involved, sympathetic fibers destined for superior cevical ganglion are inturrupted;ipsilatralhorner syndrome develops(ptosis, miosis,anhydrosis)
    • Lesions of posterior cord
      Subscapular, thoraco dorsal, axillary, and radial nerves are involved
      Sub scapular nerve- paresis of teresmajor,subscapularis(internal rotators of humerus)
      Thoraco dorsal nerve- lattismusdorsi paresis
      Axillary injury manifest as deltoid(arm abduction) and teres minor(lateral rotation of shoulder)paresis and sensory loss over lateral arm
      Radial injury results in paresis of elbow extension ,wrist extension ,fore arm supination and finger extension, sensory loss over entire extensor surface of arm and fore arm and on the back of the hand and dorsum of first four fingers
    • Lesions of lateral cord
      Surgical/local trauma
      Musculocutaneous nerve, lateral head of median nerve are involved
      Paralysis of biceps, brachialis and coracobrachialis,which control elbow flexion and fore arm supination-musculocutaneous nerve
      Paresis of muscles supplied by median nerve except intrinsic hand muscles-pronatorteres, flexocarpiradialis,flexordigitorumsuperficialis;(flexor nerve of wrist)
      Biceps reflex is absent
      Sensory loss may occur lateral fore arm
    • Lesions of medial cord
      Weakness of muscles supplied by ulnar nerve and medial head of median nerve
      ulnar muscles involved are flexor carpiulnaris, flexor digitorumlll and lV and ulnar intrinsic hand muscles
      Median muscles involved are abductor pollicisbrevis, superficial head of flexor pollicisbrevis, opponenspollicis, 1st and 2ndlumbricals
      With proximal lesions med. Ant. Tho. Nerve may be injured ,paresis of pectoralis
      Finger flexor reflex is depressed
      Sensory loss over medial arm and fore arm
    • Traumatic plexopathy
      1)direct trauma
      2)secondary injury from damage to structures around the shoulder and neck, such as fractures of clavicle and first rib
      3)iatrogenic injury as in nerve blocks
      Early management-weakness and sensory loss depending on part involved
      if portions of plexus have been sharply transected early repair can be done
      in open injuries ,disrupted nerve elements can be tagged for later repair , damage to vessels and lung require immediate intervention
    • Metastatic plexopathy
      Lung and breast carcinoma most common
      Lymphoma ,sarcoma, melanoma less common
      Tumor metastasis spread through lymphatics , most commonly involved is adjacent to lateral group of axillary lymph nodes,which are close to lower plexus
      Severe pain is hallmark of disease
      Signs referable to lower plexus and its divisions
      > ½ patients have horner”s syndrome
      Few may have lymphedema of hands
      Pancoast syndrome in non small cell bronchogenic carcinoma
    • Pancoast syndrome
      Superior pulmonary sulcus tumor
      Arises from the pleural surface of apex of lung
      Grows into para vertebral space and posterior chest wall
      Invades C8 ,T1 spinal nerves , sympathetic chain, stellate ganglion, necks of 1st 3 ribs, transverse processes and borders of the vertebral bodies of C7 through T3
      Eventually invade spinal canal and compress the spinal cord
      Severe shoulder pain radiating to head and neck ,axilla, chest, and arm
      Pain and paresthesias of the medial aspect of arm and 4th 5th digits,
      Weakness with atrophy of intrinsic hand muscles
    • Metastatic plexopathy
      Treatment-
      1)Radiotherapy
      2)chemotherapy
      3)opioids , NSAIDs , AEDs , transcutaneous stimulation, para sympathetic blockade, and dorsal rhijotomy
      4) Surgical resection if possible
    • Idiopathic brachial plexopathy
      Arm pain , weakness
      All age groups ,3rd- 7th decades
      Men involved in vigorous activities
      Precipitating event in > ½ URI ,flu like illness , immunisation , surgery, stress or post partum
    • Erb’sparalysis
      •C5 -C6
      •Birth injury
      •Arm hangs by the side+Rotatemedially
      •Forearm pronated+ extended
      •Flexed wrist + fingers
      •deltoid –supraspinatus–infraspinatus–biceps -brachialis
    • Klumpke’sparalysis
      •C8 –T1
      •Intrinsic muscles of the hand + long flexors of the hand ------paralysis
      •Claw hand = extension at MPJ + flexion at IPJ
      •Cervical rib can cause paralysis similar to Klumpke’sparalysis with post-fixed T2 contribution
    • Winging of the scapula
      •Injury to the long thoracic nerve
      •Paralysis of serratusanterior muscle
    • Clinical features
      Abrupt onset of pain in shoulder, scapular area, trepezius ridge, upper arm, fore arm ,hand;pain lasts for hours to wks and abates gradually
      Weakness develops simultaneously progress for 2-3 wks
      O/E weakness of shoulder girdle muscles both upper &lower plexus involved
      Arm kept in position of adduction at shoulder and flexion at elbow
      Discrete lesions of individual nerves can occur
      Can also involve cranial nerves VII and X , phrenic nerves
      Sensory loss is less common ,outer surface of upper arm , fore arm
      1/3 rd are bilateral
      In small no. of patients diaphragm paralysis can occur
    • DIAGONOSTIC
      cervical radiculopathy- persistent pain , neck stiffness, pain persists as weakness develops, EMG increased insertional activity and fibrillation potentials
      neoplasticplexopathy- unremittingly painful, lower plexus mostly involved
      motor neuron disease- sensation is usually spared
    • Diagnostic tests
      Confirm diagnosis and r/o other conditions
      Reduced amplitudes of SNAPs , CMAPs
      MRI of plexus – to exclude structural lesions , high T2 signal intensity , fatty atrophy of involved muscles
      Elevated liver enjymes in patients with b/l disease and phrenic nerve involvement
      Anti ganglioside anti bodies in some
      CSF priein elevation, and oligoclonal bands in few
      Pathogenesis- ischemic /auto immune mechanism suggested
    • Treatment
      Opioid analgesics for pain
      2 wks course of oral prednisone is tried
      Immobilisation of arm in sling
      With onset of paralysis , exercises can prevent contractures
      Natural course of disease is benign
      36% recovered by one year
      76% by the end of 2 yrs
      89% b y the end of 3 yrs
    • THANK
      YOU!