ANATOMY OF UPPER LIMB BRACHIAL PLEXUS , NERVES + INJURIESBRACHIAL PLEXUS + INJURIES Components Roots + Trunks + divisions + Cords and branches . Roots anterior rami of C5 To T1 spinal nerves ( deep to the scalenus anterior ) Trunks Upper - middle - lower trunks . ~ Upper trunk : Formed by CS + C6 roots . seine, Tonks | Root ~ Middle trunk : Formed by C7 ONLY . ea ~ Lower trunk : Formed by C8 + T1 roots . Divisions — Each trunk divides into an- terior and posterior divisions . Cords Three cords :- Key branches ~ Lateral cord : formed by anterior divisions fee eee 7 a TW of the upper + middle trunks carey = Medial cord : Anterior division of lower 5, ravi nene trunk. - Posterior cord : formed by the posterior 4. Mean neve divisions of all three trunks . 5. Umar neve. Braches FROM ROOTS: ~ ~ Long thoracic nerve : nerve to serratus anetrior (C5, C6 and C7). ~ Dorsal scapular nerve : nerve to rhomboids (C5). cs Cords o n Long thoracie nerve Musculacutaneous Medial pectoral nerve Lateral root of median nerve Medial cutaneous nerve of arm Aaillary nerve Medial cutaneous nerve of forearm Radial neve Medial root of median nerve Median nerve Unnar nerveFROM TRUNKS : - - Suprascapular nerve : (C5, C6). - Nerve to subclavius : (C5, C6). FROM CORDS : - 1- FROM LATERAL CORD : - - Lateral pectoral nerve : (C5, C6 and C7). - Lateral root of median nerve : (C5, C6 and C7) - Musculocutaneous nerve : (C5, C6 and C7) 2- FROM MEDIAL CORD : - - Medial pectoral nerve : (C8 and 77). - Medial cutaneous nerve of the arm: (77). - Medial cutaneous nerve of the forearm : (C8 and 77). ~ Medial root of the median nerve : (C8 and 77). - Ulnar nerve : (C7, C8 and 771). 3~- FROM POSTERIOR CORD : - - Radial nerve: (C5, C6, C7, C8, T7). - Axillary nerve : (C5, C6). - Thoracodorsal nerve : (C6, C7, C8) - Upper subscapular nerve : (C5, C6). - Lower subscapular nerve: (C5, C6 ). Lesions Three cords : - ERB'S PARALYSIS ( UPPER PLEXUS INJURY ) ~ Caused by excessive increase in the angle be- y ‘tween the head and shoulder . / - Involved : Upper trunks ( C5 + C5 ) - Deformity : Policeman's tip hand OR waiter's tip hand . - Presentation of deformity : - + Arm hangs by the side . : + Adduction and medial rotation . Injury of the upper brachial plexus + Extension and pronation of forearm . BUT WHY THIS POSITION ? - Adduction of the arm : paralysis of ( Deltoid ) . ~ Medial rotation of the arm : paralysis of ( suprspinatus + ifraspinatus - teres minor ). ~ Elbow Extension : Paralysis of biceps . ~ Forearm pronation : Paralysis of biceps - Loss of sensation along the outer aspect of arm : affection of roots of C6. KLUMPKE'S PARALYSIS ( LOWER PLEXUS INJURY ) - Caused hyperabduction of the arm due to falling on outstretched hand OR aextended arm in breech presentation . - Involved : Lower trunks (C8 + T!)- Presentation of deformity : ~ oT + Claw hand : paralysis of wwist flexors and fin- gers (C6 , C7, C8) and all intrinsic muscles of the hand (8,71). + Loss of sensations aling the medial border of the forearm and hand : affection of T1 root . QQ + Horner's syndrome : Partila ptosis , miosis , an- hydrosis , enopthalmos ) : due to affection of A sympathetic fibers supplying the head and neck which leaves through the T1. 8 Injury of the lower brachial plexus The following structures are at risk of injury . ~ Infercostobrachial nerve . - Long thoracic nerve . ~ Thoracodorsal nerve . - Thoracodorsal arfery . Features of Erb’s and Klumpke's paralyses Nerve roots involved, Sand 06 Sand TL “Muscles paralyzed Deltoid, supraspinatus infraspinatus, biceps brachii, All intrinsic muscles ofthe hand. brachial, brachioradialis, supinator and extensor carpi ‘radialis longus Position of the upper limbyhand Policeman's tip/Porter’ tip/Waiter’s tip position Claw hand. Sensory loss (sometimes) ‘Along the outer aspect of the arm “Along the medial border of forearm and hand ‘Autonomic signs Absent Present (Horner's syndrome)NERVES - NERVE LESIONS AXILLARY NERVE Types Mixed nerve ve er = Root cs, C6. Origin Arises in the axilla as a small- — te er branch of the 2 terminal branches of the Infenor posterior cord of brachial plexus . Branches * Main trunk : Articular to shoulder joint . + Anterior division : To deltoid + cutaneous in- nervation to its lower part . + Posterior division : posterior part of deltoid + —_ "=-esnalon ee teres minor muscle . falfotdetoid + Upper lateral cutaneous branch of arm: sup- eee plis the skin over lower part of deloid + Upper cutancovs branch of ‘am to akin of lower lateral part of the arm. ee MUSCULOCUTANEOUS NERVE Types ‘Mixed nerve. “AXILLARY NERVE. Shouller joint Ancerior branch eres minor ae Root C6, C6, C7. Lateral Messi Origin Arises in the axilla as the larg- ee est branch of the lateral cord of the brachial plexus . ves Termination Ends by becoming the lateral cutaneous nerve of the forearm a orcas Branches + Muscular : coracobrachialis muscle - Biceps cae brachii - Brachialis muscle . wach aan + Cutaneous : Supplies the lateral 1/2 of the sawn anterior surface of the forearm down to the Brachial upper part of the ball of the thumb . + Articular : To the elbow joint SS + Communicating : With the median nerve . We Etbow joint Deep fascia Rare injury . if it injured can lead to the following : ~ ~ loss of strong flexion and supination . Lae canon reef ~ loss of biceps fendon reflex . ance ~ lass of sensation along the lateral aspect of ‘the forearm .RADIAL NERVE Types Mixed nerve. Root C5,6,7,8,71 ae Origin —_Arises in the axilla , As the largest Lateral a Medi branch of the posterior cord of the brachial plexus . a Termination In the cubital fossa where it divided in the lateral epicondyle into Superficial radial nerve and posterior interosseous nerve . AXILLA Posterior cutaneous nerve of arm Long head of triceps Profunda brachi artery Medial head of triceps Lateral head of triceps Lateral intermuscular septum ARM. Lower lateral cutaneous nerve of arm Brachial (sal lateral part Anconeus M pan) Brachioradialis Elbow joint Posterior cutaneous nen oftoream J LF Exensor carp radaislongus Deep terminal branch of radial nerve (posterior interosseous nerve) i Superficial terminal branch of radial nerve Supinator Extensor carpi (superficial radial nerve) radials brews censor digitorum Radial artery Enenor digit mini FOREARM fcensor carpi ina ‘Abductor polis longus oS Exensor polis brevis + Brachioradials Emeraor polis longus oe ‘ductor polis longus Inferior radio-uinarjoine extn Exensor polis breve een oon Barperpalige lon ‘Skin of lateral side of dorsum of hand and HAND Interal 3 digits except nail beds Branches Main trunk : - 1- Branches in the axilla and the upper arm : - Branch to the long head of triceps muscle . - Branch to medial head of triceps . - Posterior cutaneous nerve of the arm : Supplies the skin of the back of the arm. 2- Branches in the spiral groove : ~ ~ Branch to the lateral head of triceps . - Branch to the medial head of triceps . - Nerve to anconeus .~ Lower cutaneous branch of the arm : Supplies the skin of the lateral aspect of the arm from deltoid tuberosity down to the elbow . ~ Posterior cutaneous nerve of the forearm : Supplies the skin of the back of the forearm from the elbow to the wrist . 3 Branches in the lower 1/3 of the arm: ~ ~ Branch to the lateral part of brachialis muscle . ~ Branch to the brachioradialis muscle . - Branch to the extensor carpi radialis longus muscle . Branches of posterior interosseous nerve : - + Branches before piercing the supinator : - Extensor carpi radialis brevis . - supinator . Branches after emerging from supinator : - Extensor digitorum - Extensor digiti minimi ~ Extensor carpi ulnaris ~ Abductor pollicis longus ~ Extensor pollicis brevis - Extensor pollicis longus - Extensor indicis . Branches of the superficial radial nerve : - Lateral 2/3 of the dorsum of the hand . - Dorsum of the lateral 35 fingers up to the middle [ thumb to the distal phalanges } . Lesions 1- In the axilla and upper arm : ~ - paralysis of triceps muscle . - Paralysis of the wrist extensors : loss of extension of the wrist , weak fist , Paralysis of the fingers and thumb extensors . Fig Showing Sensory innervation of radial - Sensoy affection between the area between the 1* na and 2" metacarpal bone . 2- In the spiral groove : - - Wrist and fingers drop only [ The medial head of triceps is intact } . - Sensoy affection between the area between the * and 2” metacarpal bone . 3 - Posterior interosseous nerve : ~ = No elbow drop . = No wrist drop . - Only there is loss of fingers extension . 4- Injury to superficial radial nerve : - - No motor affection .MEDIAN NERVE ~~} Antririnterosscous nerve Pronator teres Fetor carpi radials Palmar longus ipo Pos ores Flexor digitorum superficial Flexor digitorum profundus (lateral haf) Pronator quadrats ‘Wrist and inferior radio-ulnarjint - Fesordigrorum supercias Flexor retnaculom Flexor carpi dials Palmar cutaneous branch (lateral of palmar skin) _Abocor pola breve: HAND. Flexor polis brevis ‘Opponens polis falar dial branches (acer 3 igi ncading Types Mixed nerve . ee Root 5, 0,2,0,-9% Origin Arises in the axilla by 2 roots : - A): Lateral root : From the lateral cord . B ) : Medial root : From the medial cord .Termination At the distal border of the flexor retinacuilum into lateral and medial terminal branches which supply the hand . Branches 1- In Axilla and arm : No branches . 2-In the forearm : ~ A): Muscular : ~ - Pronator teres muscle . - Flexor carpi radialis muscle . - Palmaris longus muscle . 4 4 - Flexor digitorum superficialis muscle . B ): Articular : - ~ To the elbow joint and superior radioulnar joint . C): Anterior interosseous nerve : - Gives Innervation to : - - Flexor pollicis longus - pronator quadratus - Lateral 1/2 flexor digitorum profundus . ~ Articular to : Wrist and inferior radioulnar joint . 0): Palmer cutaneous branch : - - Supplies the skin over the lateral 2/3 of the palm . 3- Branches in the hand: - + Lateral palmer digital branch : - A):3 Common palmer digital branches : - Fig Showing Area of sensory loss in hand ~ 2 of 3: passes to the sides of the thumb. ~The 3”: supplies the first lumbrical . 8 ): Recurrent muscular branch : - Supplies the thenar muscles [ Flexor pollicis longus - Abductor pollicis brevis - Opponens pol- licis ] + Medial terminal branch : Gives 2 common palmer branches ~ Lateral branch : Supplies the 2~'lumbrical , Then supplies the adjacent sides of the index and middle fingers . ~ Medial branch : Supply the adjacent sides of the middle and ring fingers . Fig Showing Effects of the median nerve injury Injuries A) Inaxilla or in the arm : ~ + Motor affection : - 11- Loss of pronation of the forearm : Paralysis of pronator teres + pronator quadratus . 2- Loss of flexion of proximal and middle phalanges of medial 4 fingers : Paralysis of flexor dig- itorum suprficialis . 3 Loss of flexion of distal phalanges of the index and middle fingers : Paralysis of lateral 1/2 of flexor digitorum profundus . + Deformity : - - Ape / Monkey hand deformity , Showing : ~ 1- Hyper-extension of the thumb : due to paralysis of the flexors . 2 - Adduction : Oue to paralysis of the abductors . 3- Flat thenar muscles : Due to atrophy the the muscles .+ Sensation : Loss of sensation from : - - Lateral 2/3 of the palm of the hand - Lateral 35 fingers anterior and the distal halves posterior . 8 ) Below the elbow joint : - + Motor affection : - - paralysis of : [ lumbrical - 2% lumbrical - flexor pollicis brevis - Abductor pollicis brevis - Op- ponens pollicis ]. + Deformity :- - Ape / Monkey hand deformity , Showing : - 1- Hyper-extension of the thumb : due to paralysis of the flexors . 2 - Adduction : Due to paralysis of the abductors . 3 - Flat thenar muscles : ue to atrophy the the muscles . + Sensation : Loss of sensation from : ~ ~ Lateral 2/3 of the palm of the hand ~ Lateral 35 fingers anterior and the distal halves posterior C) At the wrist joint : ( carpal tunnel syndrome ) . Fig Showing sensory affection of the median nerveULNAR NERVE Types Mixed nerve [ Motor + Sensory } . os ed Root €7,8,T1. Later Medi Origin —_Arises in the axilla as the larg- . est branch of the medial cord of brachial plex- us. Medial interonscir sept of an Media epicondye of humerus vines fl Flerordigtcrum profundus (medial half) FOREARM, esr carpi ulonis °° Bar cigancoaa branch (enecal of palmar sin) ‘Dorsal cutaneous branch (shi of medial side of dorsum Palmar brevis ‘othand are medal 1% fingers) or Deep terminal branch Palmar aepect of. ae medal 1 digits Superficial sr digit mini Adductor pois Abdictor digit minim Opponens digit mimi Fler poll brevis (often) 3 palmar inceossei 2 medial Lambvicals- 4 dorsal inceroseei Branches 1- In the axilla and arm : No branches . 2-In the forearm : - A): Muscular : Flexor carpi ulnaris + medial 1/2 of flexor digitorum profundus .+ Sensation :- ~ Palmer cutaneous branch : supply the skin of the medial 1/3 of ~~ the palm ~ Dorsal cutaneous branch : Supplies the medial 1/3 of the dor sum of the hand and the dorsum of the medial 1/5 fingers . ~~] 3 Branches in the hand : - AA) Superficial terminal branch :~ Fig showing Complete caw hand + Muscular : Palmaris brevis . +2 Palmer digital branch : - - Medial part : Passes to the medial side of the little Finger . Fig Showing Foment'’s sign to test the integrity of palmar interossei - Lateral part : Supplies the adjacent side of the ring and little fingers . B ) Deep terminal branch : - + Muscular : Abductor digiti minimi - flexor digitin minimi - Op- ponens digiti minimi . Lesions. + Motor manifestations : - Fig Showing Sensory loss in the hand - The affcetion is in the hand muscles . Following vinar nerve injury + Sensory manifestations : - - Loss of sensation from the palmer surfaces of the medial 15 fingers + Deformity : - ~ complete claw hand . Posterior cord of brachial Medial and lateral cords of brachial Medial coed of brachial plexus pleas pes Root value on on con Motor innervation Supplies allthe muscles on Supplies supplies the backof.am and forearm — athe muscles cn the front of — One-amd-balf mnsces ofthe forearm forearm except flexor carpi lnaris (flexor capi wlnaris and medi ha of and medial half of flexor digitorum the flexor digitorum profundus) profindus ~ all the intrinsic muscles of the hand, = muscle ofthenar eminence and first exept first two lambricals and two Iombeials ruses of thenar eminence Sensory innervation + Posterior surface of the Palmar aspect of lateral 23nd of hand, Palmar aspect of medi 1/3 of hand ‘rm and forearm and lateral 3 digits including their and medial 1 fingers ‘+ Dorsal aspect of lateral dorsal tips 2/3 of hand an lateral, Medligits fleas of sion» Wrist drop ‘+ Ape-thumb deformity (Simian’s + Claw-hand deformity (main en rif) + Absence of extension of hand) + Wasting of hypothenar eminence MD joint of gts || + Westingofthexar enieors _|> Absnace of sbectoa aad eduction + Loseofsensitiontoa + absence of abduction of thumb of fingers variable small area over» Pointing inex inger + Loss of sensation on the ulnar side of the oot ofthe thumb + Absence of opposition ofthumb the had and medial 1¥ digits + Loss of sensation onthe palmar aspect of lateral part of hand and lateral 34 digitsSUPRASCAPULAR NERVE Types Motor nerve Root From CS to C6 roots . Branches ~ Articular branches : GH joint and AC joint ~ Muscular branch : Supraspinatus and infraspinatus muscles LONG THORACIC NERVE Types = Motor nerve Root CS, C6, C7. Branches — Gives motor innervation for serratus anterior muscle . Injury —_ winged scapula , Making the patient press both hands flat against a wall . OBTURATOR NERVE Types —_Mllixed nerve . Root L2,L3 and L4 Branches Anterior branch : ~ = Muscular : Adductor longus , adductor brevis , Gracilis ~ Cutaneous : lower part of anteromedial aspect of the thigh . ~ Articular : to the hip joint . Posterior branch : - ~ Muscular : adductor brevis , Obturator externus , pubic part of adductor magnus ~ Articular : To knee joint