2. DR. SUNDIP CHARMODE
INTRODUCTION
• Network of Nerves
• Originates in Neck and enters Axilla.
• Proximal part – posterior to subclavian artery
• Distal part – surrounds axillary artery
• The Brachial plexus supplies the upper limb.
3. DR. SUNDIP CHARMODE
FORMATION
• It is formed by the Ventral Primary Rami of Lower Four
Cervical Nerves and First Thoracic Nerve (C5, C6, C7, C8,
T1)
7. DR. SUNDIP CHARMODE
ROOTS
• They are basically five in number C5-T1 - Supra-clavicular
part
• They emerge downwards and laterally between Scalenus
Anterior and Scalenus Medius.
• They are constituted by the Anterior Primary Rami of spinal
nerves C5 – C8 and T1, with contributions from the Anterior
primary rami of C4 and T2.
8. DR. SUNDIP CHARMODE
ROOTS
• The C5 and C6 roots receive Grey Rami Communicans from
Middle Cervical Sympathetic ganglia.
• The C7 and C8 roots receive Grey Rami Communicans
from Inferior Cervical Sympathetic ganglia.
• The T1 root receive Grey Rami Communicans from first
thoracic Sympathetic ganglia.
9. DR. SUNDIP CHARMODE
SYMPATHETIC INNERVATION
• They carry Post-ganglionic Sympathetic fibers onto roots
for distribution to the periphery.
• Arteries of skeletal muscles are dilated by sympathetic
activity.
• For skin, they are vasomotor, sudomotor and pilomotor.
12. DR. SUNDIP CHARMODE
POST FIXED PLEXUS
• The contribution of T1 is large
• T2 is always present
• C4 is absent
• C5 is reduced in size.
13. DR. SUNDIP CHARMODE
TRUNKS
• They are Three in number – Supra-clavicular part
• Present in Posterior triangle of neck
• Roots C5 and C6 join to form Upper trunk
• Roots C7 continue as Middle trunk
• Roots C8 and T1 join to form Lower trunk
14. DR. SUNDIP CHARMODE
DIVISIONS
• Retro Clavicular Part - Before the Axilla
• Each trunk divides into Ventral and Dorsal divisions which
ultimately supply Anterior (Flexor) and Posterior (Extensor)
compartments of the limb.
• These divisions join to form cords.
15. DR. SUNDIP CHARMODE
CORDS
• Infra Clavicular Part - Three in number
• Anterior division of Upper and Middle trunk join to form
Lateral cord
• Anterior division of Lower trunk continues as Medial cord
• Posterior divisions of Upper, Middle and Lower trunk join to
form Posterior cord.
18. DR. SUNDIP CHARMODE
SUPRA CLAVICULAR BRANCHES
• From the Roots:
• Dorsal Scapular nerve – C5
• A branch to join the Phrenic nerve – C4, C5
• Long Thoracic nerve – C5, C6, C7
• Muscular branches to Longus Colli and Scaleni – (C5 –C8)
19. DR. SUNDIP CHARMODE
DORSAL SCAPULAR
NERVE
• Nerve to Rhomboids
• It carries fibers from C5
• It supplies Rhomboids Major and Minor
muscles and Levator scapulae
• Causes Retraction of Scapula.
20. DR. SUNDIP CHARMODE
DORSAL SCAPULAR NERVE
• Course:
• The nerve passes back and downwards by piercing Scalenus
Medius muscle.
• It is accompanied by Descending Scapular artery
• Injury to Nerve – Laterally rotated scapula with upward
rotation. (Lateral winging of scapula)
23. DR. SUNDIP CHARMODE
LONG THORACIC NERVE/
NERVE TO SERRATUS ANTERIOR
• It arises from Dorsal aspects of C5, C6 and C7 roots.
• C5 and C6 roots pierce Scalenus Medius and pass down
behind Brachial plexus between Scalenus Ant. and Medius.
• They unite and enter the axilla behind the 1st part of Axillary
artery.
• At this point, C7 unites to form the trunk of nerve.
26. DR. SUNDIP CHARMODE
LONG THORACIC NERVE / NERVE OF BELL
• It passes just posterior to the mid-axillary line for 22-24 cm
to reach Serratus Anterior muscle.
• Lies closely adherent to the muscle and supply segmentally.
• Injury leads to Medial Winging of Scapula.
28. DR. SUNDIP CHARMODE
SUPRA CLAVICULAR BRANCHES
• From the Trunks: Two branches from the Upper trunk only:
• Nerve to Subclavius - C5, C6
• Suprascapular nerve – C5, C6
29. DR. SUNDIP CHARMODE
NERVE TO SUBCLAVIUS
• Arises from Upper trunk at Erb’s point and conveys fibers
from C5 and C6.
• Descends in front of Brachial plexus and 3rd part of
Subclavian artery and supply Subclavius muscle from
behind.
• May give rise to Accessory Phrenic nerve.
31. DR. SUNDIP CHARMODE
SUPRASCAPULAR NERVE
• It is a large branch of upper trunk (C5, C6) at Erb’s point.
• It passes backwards above the clavicle, deep to trapezius
muscle.
• It enters through Suprascapular foramen to supply
Supraspinatus muscle.
34. DR. SUNDIP CHARMODE
SUPRASCAPULAR NERVE
• It supplies :
1. Supraspinatus muscle
2. Infraspinatus muscle
3. Articular twig to Capsule of shoulder joint
4. Articular twig to Acromio-clavicular joint
35. DR. SUNDIP CHARMODE
INFRA CLAVICULAR BRANCHES
• From Lateral cord (Three branches)
1. Lateral Pectoral Nerve
2. Musculo-cutaneous Nerve
3. Lateral Root of Median Nerve
36. DR. SUNDIP CHARMODE
INFRA CLAVICULAR BRANCHES
• From Medial cord (Five branches)
1. Medial Pectoral Nerve
2. Medial Cutaneous Nerve of Forearm
3. Medial Cutaneous Nerve of Arm
4. Medial Root of Median Nerve
5. Ulnar Nerve
37. DR. SUNDIP CHARMODE
INFRA CLAVICULAR BRANCHES
• From Posterior cord (Five branches)
1. Upper Subscapular Nerve
2. Lower Subscapular Nerve
3. Thoraco-dorsal Nerve
4. Axillary Nerve
5. Radial Nerve
38. DR. SUNDIP CHARMODE
LATERAL PECTORAL NERVE
• Branch of Lateral cord conveying fibers from C5, C6 and
C7.
• It makes a loop of communication with Medial pectoral nerve
anterior to the 1st part of axillary artery.
• It pierces Clavipectoral fascia and supplies Pectoral
muscles.
39. DR. SUNDIP CHARMODE
Below the elbow, it continues as Lateral cutaneous nerve of
forearm and supplies skin over the antero-lateral region of
forearm till the base of thenar eminence.
41. DR. SUNDIP CHARMODE
MUSCULO-CUTANEOUS NERVE
• Branch of Lateral cord conveying fibers from C5, C6 and C7.
• The nerve supplies Coracobrachialis, Short head of Biceps
brachii and Medial half of Brachialis.
• Gives twig to elbow joint.
• It continues beyond elbow as Lateral cutaneous nerve of
forearm and supplies skin over the Antero-lateral region of
forearm till the base of thenar eminence.
43. DR. SUNDIP CHARMODE
MEDIAN ROOT OF MEDIAN NERVE
• This root carry fibers of C8, T1.
• It joins with the Lateral root of Median nerve and forms the
Median nerve
44. DR. SUNDIP CHARMODE
MEDIAL PECTORAL NERVE
• First branch of medial cord conveys C8, T1 fibers
• It passes forwards between axillary artery and vein and joins
Lateral pectoral nerve to form a loop.
• It supplies both the Pectorals.
45. DR. SUNDIP CHARMODE
Below the elbow, it continues as Lateral cutaneous nerve of
forearm and supplies skin over the antero-lateral region of
forearm till the base of thenar eminence.
47. DR. SUNDIP CHARMODE
MEDIAL CUTANEOUS NERVE OF ARM
• Smallest branch of medial cord conveying C8, T1 fibers.
• Lies on the Medial side of Axillary vein.
• Receives communication from Intercosto-brachial nerve.
• Supplies skin over the Medial side of the distal third of the
arm.
49. DR. SUNDIP CHARMODE
MEDIAL CUTANEOUS NERVE OF FOREARM
• Branch of medial cord conveying C8, T1 fibers.
• Lies between the 3rd part of Axillary artery and Axillary vein.
• Divides into two branches Anterior and Posterior.
• Supplies skin over the Lower part of the Arm and Antero-
medial surface of forearm up to the wrist.
51. DR. SUNDIP CHARMODE
ULNAR NERVE
• Branch of Medial cord carrying C7, C8 and T1 fibers.
• C7 fibers reach by a communicating branch from Lateral root of
median nerve.
• In Axilla it lies between Axillary artery and vein.
• It supplies :
• Flexor Carpi Ulnaris
• Medial half of Flexor Digitorum Profundus
• 15 intrinsic muscles of palm.
55. DR. SUNDIP CHARMODE
LOWER SUBSCAPULAR NERVE
• Branch of Posterior cord with C5, C6 fibers
• Supplies Lower part of Subscapularis muscle and Teres major
57. DR. SUNDIP CHARMODE
THORACO-DORSAL NERVE
• It is a fairly large branch of Posterior cord carrying C6 to C8.
• Arises between Upper and Lower subscapular nerves
• Descends along with Subscapular artery
• Supplies Latissimus Dorsii muscle.
59. DR. SUNDIP CHARMODE
AXILLARY NERVE
• It is a branch of Posterior cord carrying C5, C6.
• Winds round surgical neck of Humerus along with Posterior
Circumflex Humeral Vessels.
• Supplies Deltoid
61. DR. SUNDIP CHARMODE
RADIAL NERVE
• Largest branch of Posterior cord carrying C5-C8 and T1
fibers.
• Supplies :
• All three heads of triceps
• 12 muscles on the back of forearm.
63. DR. SUNDIP CHARMODE
CLINICAL CORRELATION OF BRACHIAL PLEXUS
1. Erb’s paralysis
2. Klumpke’s paralysis
3. Horner syndrome
4. Vasomotor changes
5. Trophic changes
6. Winging of Scapula
64. DR. SUNDIP CHARMODE
ERB’S PARALYSIS
• Site of injury – Erb’s point in Upper trunk of brachial plexus
• Cause of injury- Undue separation of head from the
shoulder :
• Fall on shoulder
• Birth injury
• During anesthesia
• Nerve roots involved – Mainly C5 and partly C6
66. DR. SUNDIP CHARMODE
ERB’S PARALYSIS
• Deformity and Position of limb :
• Arm – Hangs by the side, Adducted, Medially rotated
• Forearm – Extended and Pronated
• Policeman’s tip hand/Waiter’s tip hand/Porter’s tip hand
67. DR. SUNDIP CHARMODE
Disability : Following
movements are lost
• Abduction and Lateral Rotation of arm at
shoulder joint
• Flexion and supination of forearm
• Biceps and Supinator jerks are lost
• Sensations over a small area over lower
part of deltoid are lost
68. DR. SUNDIP CHARMODE
KLUMPKE’S PARALYSIS
• Site of injury – Lower trunk of brachial plexus
• Cause of injury- Undue abduction of the arm as in
clutching something with the hands after :
• Fall from the height
• Birth injury
• Nerve roots involved – Mainly T1 and partly C8
69. DR. SUNDIP CHARMODE
KLUMPKE’S PARALYSIS
• Muscles paralyzed –
• Intrinsic muscles of hand (T1)
• Ulnar flexors of the wrist and fingers (C8)
• Deformity and Position of limb :
• Claw’s hand – Hyperextension at M-P joints and
flexion at I-P joints
• Disability :
• Biceps and supinator jerks are lost
• Complete claw hand
• Cutaneous anesthesia and analgesia
70. DR. SUNDIP CHARMODE
HORNER’S SYNDROME
• If T1 is injured proximal to the White rami communicans to
first thoracic sympathetic ganglion then there is:
• Ptosis
• Miosis
• Anhidrosis
• Enophthalmos
• Loss of Cilio-spinal reflex
• Loss of sympathetic supply to head and neck.
71. DR. SUNDIP CHARMODE
VASOMOTOR CHANGES
• Skin with sensory loss - Warmer due to arteriolar dilatation
• Skin is dry due to absence of sweating – loss of sympathetic
activity
72. DR. SUNDIP CHARMODE
TROPHIC CHANGES
• Dry and scaly skin – long standing case of paralysis
• Nails crack easily
• Atrophy of pulp of fingers
