1. SURGICAL ANATOMY OF
BRACHIAL PLEXUS
Sudhir suggala

2. ANATOMY
 A network of nerves starting from 5 nerve
roots in upper spine & ending in nerves that
control movement & sensation in the upper
limb.

3. ANATOMY contd…
 Located where neck joins shoulder behind
clavicle & between spine & upper arm just
distal to axilla.
 5 roots ant.primary rami after giving
segmental supply to prevertebral muscles
&scalene muscles.

4. Levels
 Roots
 Trunks
 Divisions
 Cords
 Branches

7. ROOTS
 THE ORIGIN NERVES ARE THE ANT.
PRIMARY RAMI OF5th TO 8th CERVICAL
VERTEBRAE AND T1.
 ROOTS EMERGE FROM THE
TRANSVERSE PROCESSES OF
CERVICAL VERTEBRAE IMMED. POST. TO
VERTEBRAL ARTERY
 T1:VULNERABLE IN FRACTURE AND
DISLOCATION OF FIRST RIB

8. NERVES FROM ROOTS .
 DORSAL SCAPULAR N. C5
 ARISES FROM C5 JUST LAT. TO LONG
THORACIC
 TRAV. POST TO Plx
 INNERVATES LEV.SCAPULAE, RHOMBOIDES

9. Brachial Plexus
Netter 2nd ed

11. ROOTS contd…
 LONG THORACIC N. OF BELL
C567
 IMMED. AFTER THEY ORIG. FROM
INTERVERTEBRAL FORAMEN
 ALSO PIERCES S.MED. AS IT PASSES
POST TO Plx

13. TRUNKS
 IN THE POST. TRIANGLE OF NECK
 C56: UPPER/SUPERIOR TRUNK
 C7; MIDDLE TRUNK
 C8 T1: LOWER/INFERIOR TRUNK
 TRUNKS LIE IN FRONT OF ONE
ANOTHER
 RELATION b/w C5 AND PHRENIC NERVE

15. NERVES FROM TRUNKS
 SUPRASCAPULAR N. C5,6
 SENSORY TO SHOULDER JT.
 MOTOR TO SUPRASPINATUS AND
INFRASPINATUS
 N.TO SUBCLAVIUS C5,6

16. DIVISONS
 LIE DEEP TO CLAVICLE
 POSTERIOR DIV. OF UPPER AND MIDDLE
TRUNK LARGER
 10% OF CASES NO POST. DIVISON OF
LOWER TRUNK

17. CORDS
 NAMED LAT. ,POST. AND MEDIAL ACC.
TO RELATION WITH AXILLARY ARTERY
 LATERAL CORD: ANT. DIV OF UPPER &
MIDDLE TRUNK
 MEDIAL CORD: ANT. DIV. OF LOWER
TRUNK
 POSTERIOR CORD:POST./DORSAL
DIVISONS OF ALL 3 TRUNKS

18. FROM LAT.CORD
 Lateral pectoral nerve- c5,c6,c7
 Pierce clavipectoral fascia.
 Communicate with medial pectoral across front
of 1st part of axillary art.
 Br. To P.major & P.minor
 No cut. Br.

19. FROM LAT. CORD contd…
 Musculocutaneous nr.-c5,c6,c7
 To biceps & brachialis.
 Becomes lateral cut. Nr. Of forearm.
 Lateral root of median nr.-c5,c6,c7
 Continuation of lat.cord

20. FROM MEDIAL CORD
Medial pectoral nr.- behind 1st part of ax.art
Perforates p.minor
No cut.br.
Medial root of median nr-. Crosses ax. Art to join lat root.
Medial cut.nr. Of arm – smallest & most medial.
Medial cut. Nr. Of forearm –
Large nr.
Runs down bet ax.art & ax. Vein in front of ulnar nr.
Ulnar nr.- largest br. C7 C8 T1
To most of the hand muscles.

21. FROM POST CORD contd…
 Radial nr. – c5,c6,c7,c8,T1
 Cont.of post cord
 Largest in the whole plexus
 Gives post cut nr. Of forearm.

22. FROM POST.CORD
 Upper subscapular- c5,c6
 Small nr.
 Enters upper part of subscapularis.
 Thoracodorsal – c6,c7,c8
 nr.to lat. Dorsi.
 A large nerve.
 Runs down post.ax. Wall.

23. FROM POST CORD contd…
 Lower subscapular –c5,c6
 To lower part of subscapularis
 Ends in teres major.
 Axillary nr. – c5,c6
 Circumflex nr.
 A large terminal br.
 No supply in axilla.
 Br.to shoulder jt.
 Ant. & post div.

24. FROM POST CORD contd…
 Radial nr. – c5,c6,c7,c8,T1
 Cont.of post cord
 Largest in the whole plexus
 Gives post cut nr. Of forearm.

25. VARIATIONS
 GREATEST VARIATION IN FORMATION
OCCURS IN LATERAL CORD
 10% OF CASES MUSCULOCUT. N. MAY
ARISE AS 2-3 BRANCHES
 LATERAL ROOT OF MEDIAN N. MAY
ARISE AS 2-3 BRANCHES

26. BLOOD SUPPLY
 From subclavian & vertebral art.
 Vertebral art.- c5, c6. & more proximal
cervical nerves
 C8, T1,- br. From costocervical trunk.

27. MICRO ANATOMY
 120,000-150,000 Myelinated fibres
 C5 &T1-least no. of myelin.fibres
 C8 –largest no. of myelin.fibres.
 Proportion of motor fibres highest in c5, then
c8 & least in c7 & t1.
 Sensory greatest in c7, then c6, then c8.
 Segregation of nr fibres well established
proximally.

28. PREFIXATION & POSTFIXATION
 PREFIXED: CONTRIBUTION FROM C4 IS
LARGE ,T2 IS OFTEN ABSENT
 POSTFIXED: CONTRIBUTION FROM T1
IS LARGE, T2 IS ALWAYS PRESENT,C4 IS
ABSENT,C5 IS REDUCED IN SIZE

31. Anatomy

32. BRACHIAL PLEXUS SHEATH
 C.t. of prevertebral fascia
 Blends with fascia of biceps & brachialis.
 C.t. septae compartmentalize components of
the sheath.
 Controversies – septae may limit spread of
solutions during BP block.

33. Brachial Plexus Branches &
Muscular Innervations
Dorsal Scapular N.
 Levator Scapulae
 Rhomboid Major/Minor
Lateral Pectoral N.
 Pectoralis Major/Minor
Suprascapular N.
 Infraspinatus
 Supraspinatus
Musculocutaneous N.
 Biceps Brachii
 Brachialis
 Coracobrachialis

34. Brachial Plexus Branches &
Muscular Innervations
Axillary N.
 Deltoid
 Teres Minor
Upper Subscapular N.
 Subscapularis
Middle Subscapular or
Thoracodorsal N.
 Latissimus Dorsi
Lower Subscapular N.
 Subscapularis
 Teres Major

35. Brachial Plexus Branches &
Muscular Innervations
Median N.
 Abductor Pollicis
Brevis/Longus
 Flexor Carpi Radialis
 Flexor Digitorum Superficialis
 Flexor Digitorum Profundus
(Lat. 2)
 Flexor Pollicis Brevis (Lat.) &
Longus
 Lumbricales (Lat. 2)
 Opponens Pollicis
 Palmaris Longus
 Pronator Quadratus
 Pronator Teres *
Radial N.
 Abductor Pollicis Brevis
 Anconeus
 Brachioradialis
 Extensor Carpi Radialis
Brevis/Longus
 Extensor Carpi Ulnaris
 Extensor Digiti Minimi
 Extensor Digitorum Communis
 Extensor Indicis
 Extensor Pollicis
Brevis/Longus
 Supinator
 Triceps Brachii

36. Brachial Plexus Branches &
Muscular Innervations
Ulnar N.
 Abductor Digiti Minimi
 Adductor Pollicis
 Dorsal Interossei
 Flexor Carpi Ulnaris
 Flexor Digiti Minimi
 Flexor Digitorum Profundus
(Med. 2)
 Flexor Pollicis Brevis (Med.)
 Lumbricals (Med. 2)
 Opponens Digiti Minimi
 Palmar Interossei
Long Thoracic N.
 Serratus Anterior
Medial Pectoral N.
 Pectoralis Major
Medial Brachial Cutaneous N.
(sensory)
Medial Antebrachial
Cutaneous N. (sensory)

37. FUNCTIONAL DISTRIBUTION MOTOR
 C5-SHOULDER ABDUCTION
 C6-WRIST EXTENSION
 C7-WRIST FLEXION AND FINGER
EXTENSION
 C8-FINGER FLEXION
 T1-FINGER ABDUCTION AND ADDUCTION

39. SENSATION
 C5-LATERAL ARM
 C6-LAT.FOREARM ,THUMB,INDEX
FINGER
 C7-MIDDLE FINGER
 C8-MEDIAL FOREARM,RING,SMALL
FINGER
 T1-MEDIAL ARM
 T2-AXILLA

48. TRANSITIONAL ZONE
 BERTHOLD (1993):JUNC. b/w ROOTS AND
SPINAL CORD
 A CENTRAL-PERIPHERAL TRANSITIONAL
ZONE
 2 TYPES OF INTRADURAL INJURY-
RUPTURE AND AVULSION

49. RUPTURE & AVULSION
 INTRADURAL RUPTURE IS TEARING OF
ROOTLETS AT OR PERIPHERAL TO T.Z
 AVULSION IS ROOTLETS ARE TORN
FROM SPINAL CORD ITSELF AND INJURY
IS CENTRAL TO TRANSITIONAL ZONE .

59.  UPPER PLEXUS INJURY (ERB’S
PARALYSIS)
 LOWER PLEXUS INJURY(KLUMPKE’S
PARALYSIS)
 INJURY AT LEVEL OF ROOTS

60. CORDS INJURY
 LATERAL
 POSTERIOR
 MEDIAL

61. NEOPLASTIC RADIATION

62. THANK YOU