Topic 6: Nerve supply of the Upper Limb Flashcards
What is a plexus?
Complex plait of nerves originating from ventral rami of spinal nerves
–> ventral rami = anterior divisions of spinal nerves
What does a plexus do?
redistributes nerve fibres from several spinal levels BEFORE forming peripheral nerves
–> gives some redundancy of nerve supply
Parts of the Brachial plexus
- roots
- trunks
- divisions
- cords
- branches
What does the Brachial plexus supply
all muscles of the upper limb
Root values of the brachial plexus
C5-T1
TRUNKS
1. Upper
merges from the C5 &6 roots
TRUNKS
2. middle
comes from the root C7
TRUNKS
3. lower
merges from the root values C8 & T1
DIVISIONS
anterior & posterior divisions that come off trunks
CORDS
1. lateral cord
- lateral to axillary artery
- merge of the anterior divisions
CORDS
2. posterior cord
- posterior to the axillary artery
- merge of the posterior divisions
CORDS
3. Medial
- medial to the axillary artery
- originates just from the anterior division off the lower trunk
BRANCHES
- Musculocutaneous nerve
- axillary nerve
- radial nerve
- median nerve
- ulnar nerve
ORIENTATION
Where do the roots emerge between?
between scalene (neck) muscles (anterior & middle)
ORIENTATION
Where are the trunks?
superior to the clavicle
ORIENTATION
Cords
- inferior to the clavicle
- named by their position relative to axillary artery
Branches from the roots & distribution
1. Dorsal scapular
rhomboids
Branches from the roots & distribution
2. Long thoracic (C5-C7)
serratus anterior
Branches from the trunks & their dist
1. suprascapular nerve
supraspinatus, infraspinatus
Branches from the trunks & their dist
2. nerve to subclavius nerve
Subclavius
How many branches are there from cords?
14
branches from cords(not peripheral)
- upper subscapular
- lower subscapular
- thoracodorsal
- medial cutaneous nerve of arm
- medial cutaneous nerve of forearm
- medial pectoral
- lateral pectoral
Branches from the cords (peripheral)
- axillary
- radial & posterior interosseus branch (PIN - pins supinator)
- musculocutaneous
- median and its anterior interosseus branch
- ulnar
THE BIG FIVE
1. Musculocutaneous
First branch; only goes to anterior arm
THE BIG FIVE
2. Axillary nerve
Next; dives deep into axilla
THE BIG FIVE
3. Radial nerve
Next; dives deep between heads of triceps (find out which heads)
THE BIG FIVE
4. Median nerve
- formed by 2 cords (posterior & medial)
- runs straight down midline of anterior arm
THE BIG FIVE
5. Ulnar
most inferior branch formed by only one cord (medial)
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Axillary Nerve root value
C5,6
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Axillary Nerve motor distribution
deltoid, teres minor
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Axillary Nerve sensory distribution
skin over deltoid, shoulder jt
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Radial nerve root value
C5-T1
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Radial nerve motor distribution
all UL extensors, brachoradialis, supinator, AbdPL
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Radial nerve sensory distribution
- skin of the posterior arm, forearm and hand (lateral 3.5 digits), wrist & elbow jts
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Musculocutaneous root value
C5,6,7
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Musculocutaneous motor distribution
coracobrachialis, biceps brachii, brachialis
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Musculocutaneous sensory distribution
- skin of lateral forearm to base of thumb (via the lateral cutaneous nerve of the forearm), elbow jt
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Median nerve root value
C5-T1
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Median nerve motor distribution
FCR, PL, both pronators, FDS, FDP (lat), FPL, AbdPB, FPB, OppPoll, lat 2 lumbricals
HALF LOAF
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Median nerve sensory distribution
- skin of the lateral 3.5 digits and corresponding palm, wrist and elbow jts
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Ulnar nerve RV
C8-T1
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Ulnar nerve motor dist
FCU, FDP(medial), PB, AbdDM, FDM, OppDM, med 2 lumbricals, addPoll, all interossei
DISTRIBUTION OF THE BRANCHES OF THE BRACHIAL PLEXUS
Ulnar nerve sensory dist
skin of the medial 1.5 digits and corresponding palm, wrist jt
Where does the musculocutaneous nerve originate from?
the lateral cord (C5-C7)
Course of the musculocutaneous nerve
- starts lateral to axillary artery
- descends & pierces the corachobrachialis
- runs between biceps & brachialis
Branches of the musc nerve
lateral cutaneous nerve of forearm
Vulnerable sites
- not especially vulnerable to injury
- injuries @ birth could be a cause
Where does the axillary nerve originate from?
posterior cord (C5-6)
Course of the axillary nerve
- starts posterior to axillary artery
- dives deep into shoulder (quad space)
- supplies shoulder jt
- ant branch winds around neck of humerus to supply deltoid
- post branch to supply deltoid & teres minor
What does the ant branch of the axillary nerve supply
winds around neck of humerus to supply deltoid
What does post branch of axillary nerve supply?
deltoid & teres minor
Branches of the axillary nerve
superior/ upper lateral cutaneous nerve of arm (vaccine area)
Axillary nerve vulnerable to injury
shoulder dislocation (because wraps around humeral neck)
Where does the radial nerve originate from?
posterior cord (C5-T1)
Course of the radial nerve
- lies posterior to axillary artery
- ducks deep between lat & med heads of triceps brachii
- travels in radial groove on humerus
- enters anterior arm between brachioradialis & brachialis (cubital fossa)
- crosses elbow joint anteriorly & divides
Branches of radial nerve
1. deep branch radial/ posterior interosseus nerve
- pierces supinator
- then runs along posterior surface of interosseus membrane
- travels into posterior forearm & innervates everything
Branches of the radial nerve
2. superficial branch radial
only innervates skin & jts
Injury of the radial nerve
- fracture of humerus (radial groove)
- incorrect technique with crutches
- arcade of Frohse
- –> entrapment between supinator heads
Where does the median nerve originate from
- lateral cord (C5-C7)
- medial cord (C8-T1)
Where do median nerve cords unite?
anterior to axillary artery
Where does the median nerve travel?
deep to biceps brachii
what muscle does the median nerve travel on top of?
brachialis
What accessory structure does Median nerve travel deep to?
deep to bicipital aponeurosis in cubital fossa
What muscle does Med nerve run between
between heads of pronator teres
- then deep to FDS
what accessory structure does the median nerve travel deep to to enter the hand?
the flexor retinaculum via carpal tunnel
ulnar nerve originates from:
medial cord (root value C8-T1)
what muscle does the ulnar nerve travel anterior to?
triceps brachii
what landmarks does the ulnar nerve travel in between (near elbow)?
between the medial epicondyle of the humerus and the olecranon
how does the ulnar nerve enter the anterior forearm?
by passing through heads of FCU
what muscle does ulnar nerve run along lateral to ulnar artery?
FDP
how does the ulnar nerve enter the hand?
by passing anterior to flexor retinaculum just lateral to the pisiform
Branch of the median nerve
interosseous branch
where is the anterior interosseus branch of the median nerve formed?
cubital fossa
where does the anterior interosseous branch of the median nerve travel?
on anterior surface of interosseous membrane
injury of the median nerve:
- deep cuts to the forearm
- superficial cut at wrist
- entrapment between heads of pronator teres
- carpal tunnel syndrome
injury of ulnar nerve:
- at the groove behind the medial epicondyle
- superficial cut at wrist
- fall onto hand/ compression in Guyon’s canal (between hook of hamate & pisiform)
SMALLER BRANCHES
Branches from the cords
Lateral pectoral nerve
innervates pectoralis major
- from lateral cord
BRANCHES FROM THE CORDS
Upper subscapular
subscapularis
- posterior cord
BRANCHES FROM THE CORDS
Thoracodorsal
Lat dorsi
- posterior cord
BRANCHES FROM THE CORDS
Lower subscap
lower subscapularis & teres minor
- posterior cord
BRANCHES FROM CORDS - MEDIAL CORD
- medial pectoral nerve (pec minor & part of major)
- medial cutaneous nerve of Arm
- medial cutaneous nerve of forearm
BRANCHES FROM THE ROOTS
1. dorsal scapular
rhomboids
BRANCHES FROM THE ROOTS
2. long thoracic
serratus anterior
BRANCHES FROM THE TRUNKS
1. suprascapular
supraspinatus, infraspinatus (comes from superior trunk)
BRANCHES FROM THE TRUNKS
2. nerve to subclavius
subclavius (comes from superior trunk)
what is the nerve entering corachobrachialis?
musculocutaneous nerve
nerves of the “M”
- musculocutaneous
- median nerve
- ulnar nerve
what are the feet of the “m”
medial and lateral cords