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Brachial Plexus Dr. Sama-ul-Haque Dr. Nivin Sharaf Slide 2 The brachial plexus is a somatic nerve plexus formed by intercommunications among the ventral rami of the lower four cervical nerves ( C 5 - C 8) and the first thoracic nerve (T 1). The plexus is responsible for the motor innervation to all of the muscles of the upper limb with the exception of the trapezius and levator scapula.), and the sensory innervation of the upper limb except an area just above the point of the shoulder (supplied by supraclavicular nerves) and the dorsal scapular area which is supplied by cutaneous branches of dorsal rami. BRACHILAL PLEXUS Slide 3 Spinal Nerve Slide 4 FORMATION OF THE BRACHIAL PLEXUS Roots The ventral rami of spinal nerves C5 to T1 are referred to as the roots of the plexus. Trunks Shortly after emerging from the intervertebral foramina, these 5 roots unite to form three trunks. The ventral rami of C5 & C6 unite to form the Upper Trunk. The ventral ramus of C 7 continues as the Middle Trunk. The ventral rami of C 8 & T 1 unite to form the Lower Trunk. Divisions Each trunk splits into an anterior division and a posterior division. The anterior divisions usually supply flexor muscles The posterior divisions usually supply extensor muscles Slide 5 Location of Brachial plexus Slide 6 Relations of Brachial plexus Slide 7 FORMATION OF THE BRACHIAL PLEXUS CONT. Cords The anterior divisions of the upper and middle trunks unite to form the lateral cord. The anterior division of the lower trunk forms the medial cord. All 3 posterior divisions from each of the 3 cords all unite to form the posterior cord. The cords are named according to their position relative to the axillary artery Terminal branches: Musculo Cutaneous Ulnar n. Median n. Axillary n. Radial n. Slide 8 Slide 9 Relations of Brachial plexus Slide 10 Brachial Plexus Slide 11 Relation with Axillary Artery Slide 12 Postfixed Brachial Plexus Slide 13 Brachial Plexus Injuries The brachial plexus lies in the posterior triangle of the neck between the scalenus anterior and scalenus medius muscles. At the root of the neck, it lies behind the clavicle. The most common injury is severe traction with the arm in abduction e.g. after a motor cycle accident. Partial paralysis may also result from shoulder dislocation. Direct injury to the brachial plexus can result from a stab or gunshot wound. : Slide 14 Brachial Plexus Injuries In Adults: Sports most commonly associated: Football, baseball, basketball, volleyball, wrestling, and gymnastics. Nerve injuries can result from: Blunt force trauma, poor posture or chronic repetitive stress. Slide 15 Brachial Plexus Injuries Patients generally present with pain and/or muscle weakness. Some patients may experience muscle atrophy. Slide 16 Brachial Plexus Injuries Result: Anesthesia Paralysis 1. Complete 2. Incomplete Slide 17 Erb- Duchenne palsy Injury to Superior part of Plexus. Occurrence: Due to excessive increase in the angle between neck and the shoulder. Roots Involved: C5 and C6 Muscles Involved: Shoulder Arm Slide 18 Slide 19 Slide 20 Vacuum Extractor delivery Slide 21 Forceps delivery Slide 22 Falling on Shoulder Slide 23 Slide 24 Excessive Stretching Slide 25 Slide 26 Direct Blow Slide 27 Slide 28 Slide 29 What is Waiters tip or Porters tip position? Slide 30 Erb- Duchenne palsy Clinical Appearance: Motor Loss: Adducted Shoulder Medially Rotated Arm Extended Elbow Sensory Loss: Lateral aspect of Upper Limb (uncommon) Slide 31 Slide 32 Waiters tip position Characteristic position - adduction and internal rotation of the arm with forearm pronated Forearm extension normal Biceps reflex absent Slide 33 Slide 34 Waiters tip palsy Erb's palsy is caused by damage to the brachial plexus during delivery of the neonate. This is mostly limited to the 5th and 6th cervical nerves Slide 35 Slide 36 klumpke paralysis or Palsy Injury to Inferior part of Plexus. Occurrence: Excessive abduction of arm. Less common then Injury to Superior part of Plexus. Roots Involved: C8 and T1 Slide 37 klumpke paralysis or Palsy Clinical Appearance: Motor Loss: Small muscles of Hand Sensory Loss: Medial aspect of Upper Limb Slide 38 Person grasping something to prevent a fall Slide 39 Babys upper limb is pulled excessively during delivery Slide 40 Claw Hand Aetiology: brachial plexus lesion (C8- T1),Ulnar, and/ or Median nerve injury This occurs when all fingers are clawed. It is the result of hyperextension at the metacarpophalangeal joints and flexion of the interphalangeal joints. Slide 41 Claw Hand Slide 42 Cervical Rib Involves Inferior part of Plexus Slide 43 References http://www.upstate.edu/cdb/education/gr ossanat/limbs2.shtmlhttp://www.upstate.edu/cdb/education/gr ossanat/limbs2.shtml www.medicalstudent.com www.netteranatomy.com Slide 44 Thank You