1. brachial plexus & its applied anatomy[1]
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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

    • 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.
    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.
    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
    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.
    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
    • Dorsal scapular nerve-(c4-c5)- levator scapulae, rhomboids (MAJOR-MINOR)
    • Subclavian nerve(c5-c6)- subclavian muscle
    • Long thoracic nerve(c5-c7)- serratus anterior muscle
    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
    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-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-
    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
    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
    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