These sections are not functionally different, but help explain the complex anatomy of brachial plexus. This technique provides excellent analgesia to the upper part of the arm, but in 50% of patients the lower branches of the cervical plexus are also blocked. A major branch of this plexus is the phrenic nerve, which arises from the anterior divisions of spinal nerves C3-C5. The ulnar artery enters the hand anteriorly to the flexor retinaculum and laterally to the ulnar nerve. The Trachea. The stretching mechanism can also be caused by falls onto the neck/shoulder or excessive traction on the arm, for example during sports (often known as “burner syndrome”), motorbiking accidents or attempts to reduce a shoulder dislocation. It involves excising the aneurysm and reconstructing the vessel wall using a vascular graft. Some patients report neuropathic pain affecting the arm, shoulder and neck. Anatomy of the Brachial Plexus. The brachial plexus is divided into five parts; roots, trunks, divisions, cords and branches (a good mnemonic for this is Read That Damn Cadaver Book). Other branches of the cervical plexus innervate the vertebral muscles, and provide cutaneous innervation to parts of the neck and scalp. Here is an awesome in-depth video review of the anatomy of the axilla from jono03 on YouTube, which begins with a thorough breakdown of the brachial plexus and a systematic approach to finding all the branches. On the left, it branches directly from the arch of aorta. The brachial plexus can be compressed between the anterior and middle scalene muscles , or against the 1 st rib or a cervical rib; typically, it is the lower cord which becomes irritated (resulting in symptoms affecting the ulnar … It then turns medially and travels between the heads of the adductor pollicis muscle. This manifests as numbness in the radial nerve distribution and a “wrist drop” deformity with very weak extension of the elbow, wrist and fingers. You can click to make it bigger! The key features are ipsilateral partial ptosis (drooping eyelid), miosis (constricted pupil), anhidrosis (loss of sweating on affected side of face), dilatation lag (slowly dilating pupil) and enophthalmos (eye appears sunken). These two arteries anastomose in the hand by forming two arches - the superficial palmar arch, and the deep palmar arch. Found an error? If you require a refresher on how to perform a neurological examination of the upper limb, you can check out our video guide here. he median nerve is most commonly damaged by compression within the carpal tunnel at the wrist, resulting in numbness of the median nerve distribution to the hand, wasting of the thenar eminence, The ulnar nerve supplies just two muscles in the anterior compartment of the forearm, wasting of the hypothenar eminence and intrinsic muscles of the hand, a, Start typing to see results or hit ESC to close, Paediatric Intravenous (IV) Fluid Prescribing, DNACPR Discussion and Documentation – OSCE Guide, Cervical Spine X-ray Interpretation – OSCE Guide, medical MCQ quiz platform at https://geekyquiz.com, Clinical Anatomy: Brachial Plexus Injuries, http://radiopaedia.org/cases/pancoast-tumour-5, The brachial plexus is a complex intercommunicating network of nerves formed by spinal nerves, The five spinal nerves quickly unite to form, The brachial plexus is easier to learn if you break it down into its, It is important to remember that C5 also gives fibres which join fibres from C3 and C4 to form the, There are no extra nerve branches arising from the divisions, None to the skin, but it is thought to play an important role in the sensation of chest wall pain, for example after mastectomy or breast implant insertion, and is, therefore, a target for regional nerve blocks, None to the skin, but may have a role in the sensation of chest wall pain following breast surgery. A collection of anatomy notes covering the key anatomy concepts that medical students need to learn. The medical information on this site is provided as an information resource only, and is not to beused or relied on for any diagnostic or treatment purposes. Thankfully, most patients do not suffer from significant loss of function in terms of day-to-day activities, but elderly people may struggle to pull themselves up from a sitting position, and young climbers or bodybuilders are likely to notice significantly reduced performance on the affected side. This means that it is well protected from ischaemia in cases of temporary or partial occlusion of the brachial artery. These cookies do not store any personal information. At the lower border of the teres major muscle, the axillary artery is renamed the brachial artery. The most common three you’ll need to know about are Erb’s palsy, Klumpke’s palsy and Horner’s syndrome. This results in shoulder movement weakness, which is best elicited on examination by asking the patient to place the dorsum of their hand on the opposite buttock to test extension, adduction and internal rotation. A collection of free medical student quizzes to put your medical and surgical knowledge to the test! The best definition is given by Bonniot: “The superior limit corresponds to the first roots where the first collateral of the lumbar brachial plexus: A network of nerve fibers, running from the spine, formed by the ventral rami of the lower four cervical and first thoracic nerve roots (C5–C8, T1). This is, in my opinion, the absolute best anatomy atlas out there. Special Tests. Vascular symptoms tend to be brought on or exacerbated by vigorous overhead activities, such as lifting or throwing. Radial nerve injury results in loss of innervation to the muscles of the posterior compartments of the arm and forearm. The radial and ulnar arteries are formed by the bifurcation of the brachial artery within the cubital fossa: These two arteries anastomose in the hand by forming two arches – the superficial palmar arch, and the deep palmar arch. The most significant ones include: You will be expected to know what each of the nerves of the brachial plexus actually does. It then shows a clear dissection of the distal brachial plexus with the isolation of the musculocutaneous, median and ulnar nerves – the fibres look so much nicer in real life than they do in prosections! We've also just launched an OSCE Flashcard Collection which contains over 800 cards. Use the information in this article to help you with the answers. This, of course, means that examiners absolutely LOVE testing you on it! by intercommunicating with the stellate ganglion of the, Anconeus (extends elbow, stabilises elbow joint), Extensor carpi radialis longus and brevis (extend and abduct wrist), Extensor carpi ulnaris (extend and adduct wrist). Example: brachial plexus. NeuroImages 2005, Radiopaedia.org – “Pancoast Tumour”; available from, Sinnatamby CS; “Last’s Anatomy, 12th Edition” – Churchill Livingstone 2011, Snell RS; “Clinical Anatomy by Regions, 9th Edition” – Lippincott Williams and Wilkins 2011. Direct trauma can result from clavicle fractures, gunshot wounds or stabbings. The syndrome is particularly associated with hepatitis E virus infection – occurring bilaterally in up to 10% of cases. They also pronate the forearm and abduct the wrist. ... Brachial plexus, its formation, branches and clinical anatomy including concised notes. The ventral rami exit through the neural foramina of the cervical vertebrae posterior to the vertebral artery. In such cases, the patient’s head continues to move. The most common cause is a traction injury during, The same mechanism can also be caused by a. The radial artery enters the hand dorsally, crossing the floor of the anatomical snuffbox. However, the clinician must be able to visualize the nerves of the brachial plexus as they travel from the cervical foramen, through the interscalene groove, and posteriorly to the midpoint of the clavicle, where they form terminal nerves at the level of the axilla. Subclavian vein compression can result in diffuse arm pain and swelling, venous distension and cyanosis. The hand has a rich arterial supply with many anastomoses between vessels. On the right, the subclavian artery arises from the brachiocephalic trunk. Fig 1 – Schematic demonstrating the arterial supply to the upper limb. Importantly, the artery can be divided into three parts based on its position relative to the pectoralis minor muscle: The main branches of the axillary artery include: Anterior and posterior circumflex arteries. Finally, the divisions merge into cords of the brachial plexus, that give off the terminal branches of the brachial plexus. the shoulder with fixation of the brachial plexus between the clavicle. There are many recognised anatomical variations to this structure, which may affect over 50% of people! The three branches from the posterior cord should also be easy to spot – you will see the two small subscapular nerves and the large thoracodorsal nerve between them, which forms a bundle with the thoracodorsal artery and vein to supply latissimus dorsi. Is our article missing some key information? The brachial artery is a continuation of the axillary artery past the lower border of the teres major. It descends down the neck, within the prevertebral fascia, to innervate the diaphragm. Usually severe or complex traction injuries sustained during difficult childbirth, High-speed road traffic accidents, resulting in violent stretching +/- tearing of all nerve roots, Acquired Horner’s syndrome may be due to a, Acquired pathology such as whiplash trauma, repetitive strain/sports injury. Some key points to take away from this diagram are: It is very easy to panic when given a diagram or prosection of the brachial plexus to label in exams. Anatomy. Note its relation to the median nerve as it descends the arm. The median nerve, therefore, supplies pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, the lateral two parts of flexor digitorum profundus, flexor pollicis longus and pronator quadratus. If C7 is involved, elbow and wrist extension will also be diminished and the wrist may be held in fixed flexion. This results in numbness in the ulnar distribution to the hand, wasting of the hypothenar eminence and intrinsic muscles of the hand, a “claw hand” deformity due to an inability to extend the ring and little fingers, and weak finger abduction and adduction. The long thoracic nerve often crops up in exam questions. The needle Compression of the medial, lateral and posterior cords of the brachial plexus can occur between the first rib and clavicle (known as thoracic outlet) and below pectoralis minor : Atlas of Anatomy, 2nd edition, Thieme (2012), p. 317; Friedrich Anderhuber, Franz Pera, Johannes Streicher: Waldeyer Anatomie des Menschen, 19th edition, De Gruyter (2012), p.493-495; W. Chaijaroonkhanarak et al. As an added bonus, he also shows you the axillary artery and its branches.
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