BRACHIAL PLEXUS

SUBMITTED BY :MEGHA PUNJ BPT IIIyr

ACKNOWLEDGEMENT I Megha punj of BPT IIIyr here by express my gratitude toward Dr. MEENAKSHI SINGH for her advice and guidance throughout the project .She supplied me with material and without her this project would not have reached completion.

BRACHIAL PLEXUS

DEFINITION

The Brachial plexus is a union of the lower four cervical ventral rami and a greater part of the first thoracic ventral rami.

Contribution to plexus varies from Cervical fourth rami and thoracic rami.

TYPES OF BRACHIAL PLEXUS

Types of brachial plexus depends contribution to plexus from Cervical fourth rami and thoracic rami:-

PREFIXED TYPE OF PLEXUS

When the branch from cervical fourth rami is large, that from thoracic second is frequently absent and the branch from thoracic first is reduced.

POST TYPE OF PLEXUS FIXED

If the contribution from the Cervical fourth rami is small or absent, the contribution of cervical fifth rami is reduced but that of thoracic first is larger and one from thoracic second is always present. This type arrangement is known as Post fixed type of plexus

PARTS OF BRACHIAL PLEXUS

The brachial plexus have following parts: ROOTS TRUNK DIVISION OF TRUNK CORDS BRANCHES

COMMONEST ARRANGEMENT OF BRACHIAL PLEXUS

The fifth and sixth rami unite at the lateral border of the Scalenus medius and forms UPPER TRUNK. The eight cervical and first thoracic rami join behind Scalenus anterior and forms LOWER TRUNK. The seventh cervical forms MIDDLE TRUNK. These three trunks incline laterally; just above or behind the clavicle, each bifurcates into ANTERIOR and POSTERIOR DIVISION.

FORMATION OF CORDS OF BRACHIAL PLEXUS

The Anterior division of the UPPER and MIDDLE TRUNK forms the LATERAL CORD, it lies lateral to the axillary artery. The Anterior division of LOWER TRUNK forms the MEDIAL CORD it lies medial to the axillary artery. Posterior division of all the three trunks forms the POSTERIOR CORD; it lies posterior to the axillary artery.

RELATIONS OF BRACHIAL PLEXUS RELATION IN NECK

In the neck the plexus lie in the POSTERIOR RIANGLE of the neck in the angle between the clavicle and lower posterior border of Sternocledomatoid, covered by Platysma, deep fascia and skin through which it is palpable.

The lower trunk lies posterior to subclavian artery.

The plexus passes posterior to the medial two third of clavicle.

RELATION IN THE AXILLA

The lateral and posterior cords are lateral to the first part of axillary artery, the medial cord being behind it. In the lower axilla the cords divide into nerves for upper limb. Branches of lateral cord are lateral, of medial cord are medial and posterior cord are posterior to the axillary artery.

RELATION OF BRACHIAL PLEXUS IN NECK AND AXILLA

BRANCHES OF BRACHIAL PLEXUS

Branches of brachial plexus are divided into two divisions these are : SUPRACLAVICULAR BRANCHES From roots and trunks. INFRACLAVICULAR BRANCHES. From lateral cord, medial cord and from posterior cord.

Supraclavicular branches from the ROOTS: BRANCHES TO SCALENII AND LONGUS COLLI: ORIGIN
From lower cervical ventral ramii.

COURSE
Supply near and around the exit from the intervertebral foramina

DORSAL SCAPULAR NERVE ORIGIN

Nerve comes out from 5 cervical ventral ramus

COURSE
Pierce scalenus medius and supplies the rhomboids muscle

LONG THORACIC NERVE ORIGIN

Formed by roots from the fifth to seventh cervical rami.

COURSE
The upper two roots pierce the scalenus medius. The nerve descends dorsal to the brachial plexus and the first part of axillary artery. The nerve continues downwards to lower border of serratus anterior supplying branches of each digitation.

BRANCHES FROM TRUNKS NERVE TO SUBCLAVIOUS ORIGIN Near the junction of fifth and sixth cervical ventral rami. COURSE This branch descends anterior to the plexus and the third part of subclavian artery and is usually connected to phrenic nerve.it passes above to the subclavian vein to supply subclavious.

SUPRASCAPULAR NERVE ORIGIN

Arise from the junction of fifth and sixth cervical ventral rami.

COURSE
This runs laterally deep to the trapezius and omohyoid, enters the supraspinous foosa through the suprascapular notch inferior to the superior transverse scapular ligament. Then nerve runs deep to the supraspinatus and curves round the lateral border of the scapular spine with the suprascapular artery to reach the infraspinous fossa, here it gives 2 branches to supraspinatus and articular rami.

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INFRACLAVICULAR BRANCH THESE ARE THE BRAHCHES FROM THE 3 CORDS OF BRACHIAL PLEXUS. BRANCHES FROM THE LATERAL CORD LATERAL PECTORAL NERVE. ORIGIN
Arise from the anterior division of the upper and middle trunk from lateral cord.

COURSE
It crosses anterior to the axillary artery and vein, pierces the clavipectoral fascia and supplies the deep surface of the pectoralis major and also supplies some part of pectoralis minor muscle.

MUSCULOCUTANEOUS NERVE ORIGIN

Arise from the lateral cord of plexus i.e.from the fifth to seventh cervical ventral rami.

COURSE
It pierces the coracobracrachialis and descends laterally between the biceps and brachialis to the lateral side of arm.

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Just below the elbow it pierces the deep fascia lateral to the tendon of biceps, continuing as the LATERAL CUTANEOUS NERVE OF FOREARM Branches to biceps and brachialis leave after the musculocutaneous pierces the coracobrachialis the branch to the brachialis supplies the elbow joint.

The nerve also supplies a small branch to the humerus, entering with the nutrient artery. This passes deep to the cephalic vein, descending along the radial border of the forearm and wrist, supplying the skin of forearms anterolateral surface.

BRANCHES FROM THE MEDIAL CORD MEDIAL PECTORAL NERVE ORIGIN

It is derived from the eight cervical and first thoracic ventral rami.

COURSE
It curves forward between the axillary artery and vein; anterior to the artery it joins a ramus of the lateral pectoral nerve, entering the deep surface of the Pectoralis minor to supply it.

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MEDIAL CUTANEOUS NERVE OF ARM ORIGIN

This arises from medial cord and contains fibres from the eight cervical and first thoracic ventral rami.

COURSE
It traverses the axilla, crossing anterior or posterior to the axillary vein, to which it is then medial, and communicating with the intercostobrachial nerve. It descends medial to the brachial artery and basilica vein to a point midway in the upper arm. Here it pierces the deep fascia to supply a medial area in the arms distal third, extending on to its anterior and posterior aspects. Some rami reach the skin anterior to the medial epicondyle, others over the olecranon. It connects with the posterior medial cutaneous nerve of forearm.

MEDIAL CUTANEOUS NERVE OF FOREARM ORIGIN

It arises from the medial cord; this is derived from the eighth cervical and first thoracic ventral rami.

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COURSE
At first it is between the axillary artery and vein and supplies a ramus piercing the deep fascia to supply the skin over biceps, almost to the elbow. The nerve descends medial to the brachial artery, pierces the deep fascia with the basilica vein midway in the arm and divides into anterior and posterior branches. The larger branch usually passes in front of, occasionally behind, the medial cubital vein, descending anteromedial in the forearm to supply the skin as far as the wrist and connecting with the palner cutaneous branch of ulnar nerve. The posterior branch descends obliquely medial to basilica vein, anterior to the medial epicondyle, and curves round to the back of forearm, descending on its medial border to the wrist, supplying the skin. It connects with the medial cutaneous nerve of arm, posterior cutaneous nerve of forearm, dorsal branch of ulnar nerve.

ULNAR NERVE ORIGIN

Arises from the medial cord of the brachial plexus.

COURSE
It gives no cutaneous or motor branches in the axilla or in the arm.

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 As it enters the forearm from behind the medial epicondyle, it supplies the flexor carpi ulnaris and medial half of the flexor digitorum profundus.

In the distal third of the forearm ,it gives off its palmar and posterior cutaneous branches.

The palmar cutaneous branch supplies the skin over the hypothenar eminence; the posterior branch supplies the skin over the medial third of the dorsum of the hand and the medial one and a half fingers. Not uncommonly, the posterior branch supplies two and one half instead of one and a half fingers. It does not supply the skin over the distal part of the dorsum of these fingers. Having entered the palm by passing in front of the flexor retinaculum, the superficial branch of the ulnar nerve supplies the skin of the palmar surface of medial one and a half fingers,including there nail beds. The deep branch supplies all the muscles of the hand except the muscles of the thenar eminence and the two lumbricals, which are supplied by the medial nerve.

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BRANCHES FROM POSTERIOR CORD SUPERIOR SUBSCAPULAR NERVE ORIGIN

Arise from the posterior cord of brachial plexus.

COURSE
It enters the subscapulais at a high level and is frequently double.

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INFERIOR SUBSCAPULAR NERVE ORIGIN

Arise from posterior cord of brachial plexus.

COURSE
It supplies the lower part of the subscapularis, ending in teres major, which is sometimes supplied by separate branch.

THORACODORSAL NERVE ORIGIN

Posterior cord of brachial plexus.

COURSE
Arises between the subscapular nerves and accompanies the subscapular artery along the posterior axillary wall to supply latissmus dorsi, reaching its distal border.

AXILLARY (CIRCUMFLEX HUMERAL) NERVE ORIGIN

Arise from posterior cord and its fibres being derived from the fifth and sixth cervical ventral rami.

COURSE
The nerve finally divides into anterior and posterior branches. The anterior branch, with the posterior circumflex humeral vessel, curves round the humeral neck, deep to the deltoid ,to

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its anterior border, supplying it and giving few cutaneous branches. The posterior branch supplies the teres minor and the posterior part of the deltoid. The posterior branch pierces the deep fascia low on the posterior border of the deltoid, continuing as the UPPER LATERAL CUTANEOUS NERVE OF ARM and supplying the skin over the lower part of deltoid and upper part of the long head of triceps. The axillary trunk supplies a branch to the shoulder joint below the subscapularis.

RADIAL NERVE ORIGIN

Arise from the posterior cord of the brachial plexus. COURSE In the axilla it gives off three branches :a) The posterior cutaneous nerve of the arm, which supplies the skin on the back of the arm down to the elbow. b) The nerve to the long head of the triceps. c) The nerve to the medial head of the triceps.

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In the spiral groove of the humerus it gives off four branches:a) The lower lateral cutaneous nerve of the arm which supplies the lateral surface of the arm down to the elbow. b) The posterior cutaneous nerve of the forearm, which supplies the skin down the middle of the back of the forearm as far as the wrist. c) The nerve to the lateral head of the triceps,and d) The nerve to the medial head of the triceps and anconeous. In the anterior compartment of the arm above the lateral epicondyle it gives off three branches:a)The nerve to a small part of the brachialis. b)The nerve to the brachioradialis and c)The nerve to the extensor carpi radialis longus. In the cubital fossa it gives off the deep branch of the radial nerve and continues as the superficial radial nerve. The deep branch supplies the extensor carpi radialis brevis and the supinator in the cubital foosa and all the extensor muscles un the posterior compartment of the forearm. The superficial radial nerve is sensory and supplies the skin over the dorsal surface of the lateral three and a half proximal to the nail beds.

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LESIONS OF BRACHIAL PLEXUS

Lesions of brachial plexus commonly affect either the upper part of the plexus, that is the C5, C6 roots and the upper trunk, and these are usually traumatic;or the lower part of the brachial plexus, that is the C8 AND T1 roots and the lower trunk, when lesions may be caused by trauma but may also be produced by malignant infiltration or a thoracic outlet syndrome. Severe lesions may cause injury to the whole plexus.

UPPER PLEXUS INJURY RUCKSACK PARALYSIS

Rucksack palsy is due to a traction on upper trunk of the brachial plexus from heavy and maladjusted rucksacks. Since axonal continuity is preserved recovery is usually complete. Severe traction injuries may occur in motorcycle accidents with lateral flexion of head away from downward displacement of shoulder, , causing a traction injury of the upper part of plexus. The whole plexus may be involved in these injuries and sometimes the nerve roots are avulsed from the cervical spinal cord.

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Undue separation of the head and shoulder i.e. lateral flexion of the head away from downward displacement of shoulder.

CLINICAL PICTURE
There is gross wasting and weakness of shoulder girdle muscles as C5 is affected with inability to abduct the arm, and with marked weakness of elbow flexor and wrist extensors.

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ERBS PARALYSIS ERBS POINT: - The region of the upper trunk of the
brachial plexus where six nerves meet is known as ERBS POINT. Following are the six nerves meeting at a common point :1 2 3 4 5 6 SUBSCAPULAR NERVE MUSCULOCUTANEOUS NERVE AXILLARY NERVE RADIAL NERVE MEDIAN NERVE ULNAR NERVE

Injury at this point is results in Erbs paralysis.

CAUSES 1-Undue separation of the head from the shoulder.

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2-Fall on the shoulder. 3-During anesthesia. 4-Birth injury

Midsaggital view of infant in utero. The infants left shoulder is caught behind the mothers sacrum. The brachial plexus is stretched and damaged as the head is pulled out hence the erbs point is damaged.
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NERVE ROOT INVOLVED

Mainly C5 and partly C6 nerve roots are involved.

MUSCLE PARALYSED Mainly biceps, deltoid ,brachialis and brachioradialis. Partly supraspinatus, infraspinatus and supinator. DEFORMITY ARM-Hangs by the side; it is adducted and medially rotated. FOREARM-Extended and pronated.

The deformity is known as POLICE MAN TIP HAND OR PORTERS TIP HAND.

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DISABILITY The following movements are lost:# Abduction and lateral rotation of the forearm is lost. # Flexion and supination of forearm. # Biceps and supinator jerks are lost. # Sensations are lost over a small area over the lower part of the deltoid.

TREATMENT

The treatment of the erbs paralysis is done by providing the subject with SHOULDER SPLINT.

LOWER PLEXUS INJURY Damage to the lower part of the plexus may result from extension of an apical carcinoma or from metastatic spread, often from carcinoma of breast.
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All the muscles supplied by the corresponding nerve are effected and treatment is done on the basis of the extend of the nerve injury and the muscles involved.

INJURY TO THE LOWER PART OF THE PLEXUS AND MUSCLES INVOLVED

CLINICAL PICTURE

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# There is slowly progressive weakness usually starting in the small hand muscles(T1)and spreading to involve the finger flexors(C8). # Usually a painful condition and pain may be severe. # There is a sensory loss on the medial aspect of forearm(T1) extending into medial aspect of hand to little finger(C8). THORACIC OUTLET SYNDROME THORACIC OUTLET-A outlet formed anteriorly by the sternocledomastoid and posterior by the trapezeus and base by the clavical.

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DEFINATION- The lower trunk of the brachial plexus(C8, T1) may become angulated over a cervical rib together with subclavian artery and results in thoracic outlet syndrome. CLINICAL PICTUREPatients may present with vascular symptoms due to kinking of the subclavian artery. There may be presence of some neurological deficit (this is more likely in patients with small rudimentary ribs which extend into a fibrous band which joins the first rib anteriorly) There is slow insidious onset of wasting of the small hand muscles, often starting on the lateral side with involvement of the thenar eminence and first dorsal interosseous. There will be pain and paresthesia in theb medial aspect of the forearm extending to the little finger,which is often aggravated by carrying shopping or suitcases. A bruit may be heard over the subclavian artery and the radial pulse may be easily obliterated by movements of the arm, particularly with the arm extended abducted at the shoulder. TREATMENT Surgical removal of the rib is done to decrease the angulations and thus stretch.

HORNER SYNDROME
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Horner syndrome occurs if there is involvement of the cervical sympathetic ganglia and the subclavian artery. A similar syndrome may occur following radiotherapy for breast carcinoma, but this is usually painless. Thoracic surgery involving a sternal split may cause traction on the brachial plexus and usually affects the lower part of the plexus. KLUMPKES PARALYSIS SITE OF INJURY-Lower part of the brachial plexus. CAUSE OF INJURY- Undue abduction of the arm,as in clutching something with hands after a fall from a height or sometimes in birth injury. NERVE ROOT INVOLVED- Mainly T1 and partly C8. MUSCLE PARALYSED-Intrinsic muscles of the hand(T1). Ulnar flexors of the wrist and fingers(C8). DEFORMITY- Claw hand due to the unsupported action of the long flexors and extensors of the fingers.Ia a claw hand there is hyperextention at the metacarpophalangeal joints and flexion at interphalangeal joints DISABILITY- Claw hand # Cutaneous anesthesia and analgesia in a narrow zone along the ulnar border of the forearm and hand.
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# Horner syndrome. # Vasomoter changes:-The skin areas with sensory loss is warmer due to arteriolar dilation. It is also drier due to absence of sweating as there is loss of sympathetic activity. # Topical changes:- Long standing case of paralysis leads to dry and scaly skin .The nails easily crack with atrophy of the pulp of the fingers.

NEURALGIC AMYOTROPHY This is a demylinating neuropathy which principally affects branches of the brachial plexus ,so that a characterstic feature is the dense involvement of some muscles within a myotome while others in the same myotome are not affected . FOR EG:- If there is involvement of the suprascapular nerve causes marked weakness of supraspinatus and infraspinatus ,but deltoid may be normal. SUPRACLAVICULAR BRANCHS LONG THORACIC NERVE Supplies the serratus anterior muscle and cause of injury is due to injury to scapula clinical presentation.
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Winging of scapula occurs. ie; undue prominence of medical border of scapula during pushing and punching activities. Individual is unable to perform pushing and punching movement and loss of overhead abductions.

WINGED SCAPULA (B) SUPRASCAPULAR NERVE Caused by damage to Scapula through trauma. Clinical presentation. Pain in shoulder, wasting of muscles supplied by the nerve ie Supraspinatus and Infraspinatus muscles. INFRACLAVICULAR BRANCHES.

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(A) MUSCULOCUTANEOUS NERVE. CAUSE :- Damage is caused by injury to upper arm or proximal humeral fractures. CLINICAL FEATURES. # Marked weakness of elbow flexion. # Sensory impairements lateral cutaneous nerve of forearm. #Pain and paresthesia aggervated by elbow extension.
(B)

AXILLARY NERVE.

CAUSE Crutches Shoulder dislocation Injections . CLINICAL FEATURES Wasting and weakness of deltoid, sensory loss on outer aspect of arm. Difficulty in initation of the abduction move in. 1. MEDIAN NERVE. Pronator & long wrist flexors and finger flexors are paralysed. Clinical Presentation.
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Forearm is supinated , wrist fiexion is weak and wrist is kept in adduction. CARPAL TUNNEL SYNDROME Tunnel formed by the anterior concave surface of carpal bones. CONTENT Flexor tendons, sheaths and median nerve CAUSE (a) Compression of median nerve within the terminal. (b) Compression occurs due to thickening of the flexor sheath or arthritic changes in the carpal bone. CLINICAL FEATURES Burning pain, pins, and, needle, sensation in lateral 31/2 fingers and weakness of thenar eminence. ULNAR NERVE

INJURY AT ELBOW CAUSES # Medial epicondyle fracture. # Supracondular fracture. MOTOR CHANGES

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(i) (ii) (iii) (iv)

(v)

Inability to flex little and ring finger and also inability to adduct the finger. Medial border of forearm is flattened. MCP digits are hyperextended due to paralyses of lumbricals and flexion at interphalangeal digits due to same reason. This is known as CLAW HAND .

SENSORY CHANGES

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Loss of sensation over medial anterior and posterior aspect of medial 11/2 finger. VASOMOTOR CHANGES Affected area is warmer and drier due to asteriolar dilation, absence of sweating due to loss of sympathetic activity.

INJURY AT WRIST MOTOR CHANGES Small hand muscles are paralysed, claw hand deformity occurs. SENSORY, VASOMOTOR CHANGES SAME RADIAL NERVE MOTOR- Triceps, anconeus, long wrist extensors paralysed wrist drop occur. SENSORY- Loss of sensation, post aspect of forearm dorsal surface of hand, lateral 31/2 finger. MANAGEMENT

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COCCUP SPLINT BIBLIOGRAPHY GRAYS ANATOMY B.D. CHAURASIA INTERNET

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