brachial plexus injury
TRANSCRIPT
SURGICAL ANATOMY OF BRACHIAL PLEXUS
Sudhir suggala
ANATOMY
A network of nerves starting from 5 nerve roots in upper spine & ending in nerves that control movement & sensation in the upper limb.
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.
Levels
Roots
Trunks
Divisions
Cords
Branches
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
NERVES FROM ROOTS .
DORSAL SCAPULAR N. C5
ARISES FROM C5 JUST LAT. TO LONG THORACIC
TRAV. POST TO Plx
INNERVATES LEV.SCAPULAE, RHOMBOIDES
Brachial Plexus
Netter 2nd ed
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
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
NERVES FROM TRUNKS
SUPRASCAPULAR N. C5,6 SENSORY TO SHOULDER JT. MOTOR TO SUPRASPINATUS AND
INFRASPINATUS
N.TO SUBCLAVIUS C5,6
DIVISONS
LIE DEEP TO CLAVICLE POSTERIOR DIV. OF UPPER AND MIDDLE
TRUNK LARGER 10% OF CASES NO POST. DIVISON OF
LOWER TRUNK
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
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.
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
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.
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.
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.
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.
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.
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
BLOOD SUPPLY
From subclavian & vertebral art. Vertebral art.- c5, c6. & more proximal
cervical nerves C8, T1,- br. From costocervical trunk.
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.
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
Anatomy
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.
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
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
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
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)
FUNCTIONAL DISTRIBUTION MOTOR
C5-SHOULDER ABDUCTION C6-WRIST EXTENSION C7-WRIST FLEXION AND FINGER
EXTENSION C8-FINGER FLEXION T1-FINGER ABDUCTION AND ADDUCTION
SENSATION
C5-LATERAL ARM C6-LAT.FOREARM ,THUMB,INDEX FINGER C7-MIDDLE FINGER C8-MEDIAL FOREARM,RING,SMALL
FINGER T1-MEDIAL ARM T2-AXILLA
TRANSITIONAL ZONE
BERTHOLD (1993):JUNC. b/w ROOTS AND SPINAL CORD
A CENTRAL-PERIPHERAL TRANSITIONAL ZONE
2 TYPES OF INTRADURAL INJURY-RUPTURE AND AVULSION
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 .
UPPER PLEXUS INJURY (ERB’S PARALYSIS)
LOWER PLEXUS INJURY(KLUMPKE’S PARALYSIS)
INJURY AT LEVEL OF ROOTS
CORDS INJURY
LATERAL POSTERIOR MEDIAL
NEOPLASTIC RADIATION
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