+ Brachial Plexus By Harvi & Manpreet

+ What is it? Network of nerve fibres that supply the skin and muscles of the upper limb – sensory & motor Begins in the root of the neck and passes through the axilla to enter the upper arm Purpose = damage to a spinal nerve means that the entire limb does not become paralysed and there is not total sensory loss Relatively common region to have traumatic injuries from various mechanisms

+ Axilla Anatomy Region that is superior to the armpit – connects the upper limb and neck Filled with fat and includes the tail of spence Contains lymph node groups which drain the anterior & posterior thoracic wall, breast and upper limb 1 = anterior axillary fold [pectoralis major & minor] 2 = posterior axillary fold [latissmus dorsi & teres major]

+ Axillary Lymph Groups & Vasculature

+ Brachial Plexus Components BranchesCords Divisions Trunks Roots Neck Upper Limb C5 C6 C7 C8 T1 UMLUML Lat. Post. Med. Musculocutaneous (C5-7) Median (C5-T1) Radial (C5- T1) Ulnar (C8,T1) Axillary (C5,6) A PA P P A

+ Brachial Plexus Specific Nerve Injuries Loss of anterior arm compartments Loss of deltoid & teres major Loss of most anterior forearm compartment muscles, thenar muscles and lumbricals 1&2 Loss of posterior arm & forearm compartments Loss of most small muscles of hand Ulnar Nerve Median Nerve Radial Nerve Musculocutaneous Nerve Axillary Nerve

+ Other Important Nerves Long thoracic nerve – damage causes scapula winging…can get from a stab injury in the axilla, surgery to upper limb & pancoast tumour Suprascapular nerve – damage causes loss of lateral shoulder rotation and shoulder instability as it supplies supraspinatus & infraspinatus

+ Case One: A patient has been diagnosed with a Pancoast Tumour, what signs would you expect to see in the upper limbs?

+ Pancoast Tumour Pancoast Tumour: Pancoast tumors are tumors that form at the extreme apex (very top) of either the right or left lung. Can compress the C8-T1 nerves (especially T1) T1 route goes in the nerves to the hands and supplies the small muscles of the hand. If this is damaged then there will be less usage of the small muscles which can lead to muscle wastage. It can also lead to reduced dexterity and dropping of items.

+ Case Two: A patient has a fallen from a tree and landed shoulder first to the ground, they then present to you like this. What is it?

+ Erb’s Palsy C5 & C6 Erb’s = upper root brachial plexus injury How? Stab to the neck Forceps Births Motorbike accidents What will be damaged? Axillary, suprascapular, dorsal scapular, lateral pectoral, musculocutaneous nerves What will it look like? Medially rotated shoulder = loss of supra- & infraspinatus & unopposed medial rotation action from sternal head of pec major Limp & loss of shoulder contour = loss of deltoid Pronated forearm = loss of biceps brachii Partial wrist drop/flexion at rest = Loss of extensor carpi radialis Anaesthesia over C5 & C6 dermatomes

+ A 4 year old child is brought in by her parents who say she has a clawing hand at rest, what is it?

+ Klumpke’s Palsy C8 & T1 How? Grabbing something whilst falling, Pancoast tumor What will be damaged? Wasting of ALL small muscles of the hand What will it look like? Clawing of digits 2-5 on rest Anaesthesia – medial elbow, forearm and arm

+ Common Nerve Injuries NerveRootCause of DamageResult of Damage MusculocutaneousC5,C6,C7Direct damage is rare Loss of anterior arm muscles Axillary NerveC5,C6 Dislocation of shoulder Fractured surgical neck humerous Loss of deltoid and teres minor Median NerveC5-T1 Stab to medial arm Loss of most anterior forearm muscles, thenar muscles and lumbricals 1 & 2. Radial NerveC5-T1 Fractured humeral shaft through spinal groove Dislocated/fracture head of radius Loss of posterior arm and forearm muscles Ulnar NerveC8-T1 Fracture of medial humeral epicondyle Loss of small muscles of hand.

+ Common Nerve Roots Triceps: C7 & C8 Brachioradialis (C5-C6 elbow flexor) Radial Wrist Extensor (C5-C6) Posterolateral dermatomes (C5-C6) Digit Extensors (C7-C8)

+ Questions? Thank you!