The document discusses the brachial plexus, which is a network of nerves that supplies sensation and motor function to the upper extremity. It is formed from the lower cervical and upper thoracic spinal nerves. The document details the anatomy of the brachial plexus including its roots, trunks, divisions, cords and branches. It also discusses clinical conditions involving brachial plexus injury and techniques for brachial plexus nerve blocks such as interscalene and supraclavicular blocks.

1. Presentor -Dr. Amey Dixit
Moderator-Dr. A.K. Rathiya (M.D.)
Shyam Shah Medical College REWA(MP)
24 /12/2019

2.  The word “PLEXUS” means a network of nerves or vessels.
 The brachial plexus is an arrangement of nerve fibers formed by
intercommunications among the ventral rami of the lower four
cervical nerves (C 5 - C 8) and the first thoracic nerve (T 1).
 Brachial plexus is network of nerves that supply sensation and motor
function to upper extremity.
INTRODUCTION

3. RELATIONS
In the neck
The brachial plexus lies in the posterior triangle,
being covered by the skin ,platysma & deep fascia;
where it is crossed by the supraclavicular nerves,
the inferior belly of the omohyoid, the external
jugular vein, and the transverse cervical artery.
When it emerges between the Scalene anterior
and medius ; its upper part lies above the third
part of the subclavian artery, while the trunk
formed by the union of the 8th cervical and
1st thoracic, is placed behind the artery.

4. Behind the clavicle
At the lateral edge of the first rib, each trunk
forms anterior and posterior divisions that
pass posterior to the midpoint of the clavicle
to enter the axilla.
In the axilla
Within the axilla, these divisions form the
lateral, posterior and medial cords, named
for their relationship with the second part
of the axillary artery.
At the lateral border of the pectoralis minor,
the three cords divides into the peripheral
nerves of the upper extremity.

5. ANATOMY
Plexus consist of:-
Roots – C5-T1
Trunks – Upper ,middle and lower
Division- Anterior and posterior
Cords – Medial, posterior and lateral
Branches

6. Roots
The ventral rami of spinal nerves C5 to T1 are referred to as the roots of the plexus.
Trunks
– Shortly after emerging from the intervertebral foramina , roots unite to form
three trunks.
 The ventral ramus of C7 continues as the Middle Trunk.
 The ventral rami of C5 & C6 unite to form the Upper Trunk.
 The ventral rami of C 8 & T 1 unite to form the Lower Trunk.
Divisions
– Each trunk splits into an anterior division and a posterior division.
 The anterior divisions usually supply flexor muscles.
 The posterior divisions usually supply extensor muscles.

7. Cords
– The anterior divisions of the upper and middle trunks unite to form the
lateral cord.
– The anterior division of the lower trunk forms the medial cord.
– All 3 posterior divisions from each of the 3 cords unite to form the
posterior cord.

8. BRANCHES
From Nerve Root value Muscle Cutaneous
ROOTS Dorsal scapular
nerve
C5 Rhomboid and
levator scapulae
-
Long thoracic nerve/
Nerve of bell
C5 C6 C7 Serratus anterior -
Nerve to subclavicus C5 C6 Subclavius muscle -
UPPER TRUNK Suprascapular nerve C5 C6 Supraspinatus and
infraspinatus
-
LATERAL CORD Lateral pectoral
nerve
C5 C6 C7 Pectoralis major (by
communicating
with the medial
pectoral nerve)
-
Lateral root of
median nerve
C5 C6 C7 Fibres to the
median nerve
-
Musculocutaneous
nerve
C5 C6 C7 Coracobrachialis
Brachialis and
Biceps brachii
Lateral Cutaneous
nerve of the forearm

9. From Nerve Root value Muscle Cutaneous
MEDIAL CORD Medial pectoral
nerve
C8 T1 Pectoralis major and
pectoralis minor
Medial root of
median nerve
C8 T1 Fibers to the median
Nerve
Portions of hand not
served by ulnar or radial
Medial cutaneous
nerve of arm
C8 T1 - Front and medial skin of
the arm
Medial cutaneous
nerve of forearm
C8 T1 - Medial Skin Of The
Forearm
Ulnar nerve C8 T1 Flexor carpi ulnaris and
the medial half of the
flexor digitorum
profundus, intrinsic
hand muscles except
thenar eminence and
first and second
lumbricals (median).
The skin of the medial
side of the hand, medial
one and a half fingers on
the palmar side and
medial one and a half
fingers on the dorsal
side

10. From Nerve Root value Muscle Cutaneous
POSTERIOR CORD Upper subscapular
nerve
C5 C6 Subscapularis (upper
part)
-
Lower subscapular
nerve
C5 C6 Subscapularis (lower
part )
and Teres major
-
Thoracodorsal
nerve(Middle
subscapular nerve)
C6 C7 C8 Latissimus dorsi -
Radial nerve
(Largest branch of
brachial plexus)
C5 C6 C7 C8 T1 Triceps, anconeus, part
of the brachialis,
brachioradialis,
extensor carpi radialis
longus and all the
extensor muscles of the
posterior compartment
of the forearm
Posterior cutaneous
nerve of arm and
forearm, Lower lateral
cutaneous nerve of arm
Axillary nerve C5 C6 Deltoid and Teres
minor
Upper lateral cutaneous
nerve of arm

11. Cutaneous innervation
B
B

12. Innervation of the major bones
(osteotomes)

13. Variations
 Pre-fixed ( 28-62%) Post-fixed ( 16-73%)

14. Branches of the brachial plexus may be described as
supraclavicular part – roots
trunk
division
Infraclavicular part – cords
nerves

15. BRACHIAL PLEXUS INJURY
ERB’S PARALYSIS
 Injury to the upper trunk of brachial plexus
 Nerve root involved C5
C6
 Nerve involved Axillary nerve
Musculocutaneous nerve
 Causes of injury: Undue separation of the head from the shoulder, which is
commonly encountered in
1)birth injury 2) fall on shoulder

16.  Muscle paralysed Position of upper limb
Deltoid arm is adducted
Teres minor arm is medially rotated
Brachialis forearm is extended
Biceps forearm is pronated
commonly called "waiter's tip hand“
or “Police man tip hand”
 Appearance
Drooping, wasted shoulder pronated and extended limb hangs limply

17. KLUMPKE’S PARALYSIS
 Injury to lower trunk of brachial plexus
 Nerve root involved C8
T1
 Nerve involved Ulnar nerve mainly (dominant nerve of hand)
 Muscle paralyzed Intrinsic muscles of the hand (T1)
Ulnar flexors of the wrist and fingers (C8)

18.  Deformity Hyperextension at the metacarpophalangeal joints
Flexion at the interphalangeal joints.
“Claw hand”

19. CUBITAL TUNNEL SYNDROME
Compression of ulnar nerve between
two head of flexor carpi ulnaris
CARPAL TUNNEL SYNDROME
Compression of median nerve between
flexor retinaculum and ulnar bursa

20. THORACIC OUTLET SYNDROME
 The term ‘thoracic outlet syndrome’ (TOS) was originally coined in 1956
by RM Peet.
 Thoracic outlet syndrome is neurovascular symptoms in the upper
extremities due to pressure on the nerves and vessels by bony,
ligamentous or muscular structure in narrow space between clavicle
and 1st rib. (the thoracic outlet)
 The specific structures compressed are usually the nerves of the branchial
plexus and occasionally the subclavian artery or subclavian vein.

21. Depending on the site of injury and the injury component of the
neurovascular bundle 3 distinct syndromes
encountered-
I. Neurological syndrome (95%)
weakness of intrinsic hand muscles and
sensory abnormalities in C5-T1 distribution
II. Venous syndrome.(4%)
venous thrombosis of subclavian /
axillary vein
III. Arterial syndrome (1%)
ischemia of fingers and hands

22. BRACHIAL PLEXUS BLOCK
 Peripheral nerve blocks used for anaesthesia , post op analgesia
and diagnosis & treatment of chronic pain disorders.
 Blockade of the brachial plexus (C5-T1) at several locations allows
surgical anaesthesia of the upper extremity and shoulder.

23. HISTORY
 1880 – Halstead & Hall injected cocaine into peripheral sites.
 1912 – KulenKampff after experimenting on himself, used supraclavicular
technique.
 1922 – Gaston Labat used axillary block.
 1940 – Macintosh and Mushin modified KulenKampff block.
 1964 – Alon P Winnie described perivascular sheath and block.

24. TECHNIQUES FOR LOCALIZING NEURAL STRUCTURES
 Paresthesia technique
 Peripheral nerve stimulation
 Ultrasound-Guided regional anesthesia

25. BRACHIAL PLEXUS BLOCK TECHNIQUES
 Interscalene Block
 Supraclavicular Block
 Infraclavicular Block
 Axillary Block

26. INTERSCALENE BLOCK
 Described by Winnie in 1970
 Blockade occurs at the level of the superior
and middle trunks
 Blockade of inferior trunk is incomplete &
requires supplementation.
Indications-
 Surgery in shoulder ,upper arm
 Post op analgesia for total shoulder arthroplasty

27. Techniques-
PERIPHERAL NERVE STIMULATION OR PARESTHESIA
 Positioning- supine position with the head turned away from the side to be
blocked.
 Landmark-
White arrow- clavicle
Red arrow- posterior border of
sternocleidomastoid muscle
Blue arrow- external jugular vein
The scalene groove is often palpated just in
front or behind the external jugular vein.

28.  Maneuver to extenuate the posterior border of the sternocleidomastoid muscle
and external jugular vein by asking the patient to lift her head off of the table
while looking away from the side to be blocked.
Clavicular
head of
SCM
The needle is inserted between palpating
fingers at the level of C6 that are positioned in
the scalene groove (between anterior and
middle scalene muscle)
Needle is inserted between fingers in
interscalene groove with a slight caudad
direction,posterior to EJV

29.  Under sterile precautions and development of a skin wheal, a 22- to 25-gauge, 4-cm
needle is inserted perpendicular to the skin at a 45-degree caudad and slightly
posterior angle. The needle is advanced until paresthesia or nerve stimulator response
is elicited.
 If bone is encountered within 2 cm of the skin, it is likely to be a transverse process,
and the needle may be “walked” across this structure to locate the nerve.
 After negative aspiration, 10 to 30 mL of solution is injected incrementally, depending
on the desired extent of blockade.
 Contraction of the diaphragm indicates phrenic nerve stimulation and anterior needle
placement; the needle should be redirected posteriorly to locate the brachial plexus.

30. ULTRASOUND GUIDED
 Transducer position- Transverse on the neck, 3–4 cm superior to the
to the clavicle, over the external jugular vein.
 Identify carotid artery ,Once the artery has been identified, the transducer is moved slightly
laterally across the neck. The goal is to identify the anterior and middle scalene muscles and
the elements of the brachial plexus(trunk) as hypoechoic structure that is located between
them.
 The needle is then advanced either in an “out- of plane”
or an “in- plane” approach.
 After negative aspiration , local anaesthetic is infiltrated
into brachial plexus.
 Small volume is required.

31. Blockade distribution
FIGURE 3. Sensory distribution of the interscalene brachial
plexus block (in red).
The interscalene approach to brachial plexus blockade
results in reliable anesthesia of the shoulder and upper
arm (Figure 3). The supraclavicular branches of the
cervical plexus, supplying the skin over the acromion
and clavicle, are also blocked due to the proximal and
superficial spread of local anesthetic.
The inferior trunk (C8-T1) is usually spared unless the
injection occurs at a more distal level of the brachial
plexus.

32. Complications-
 Inadvertent epidural or intrathecal block
 Ipsilateral diaphragmatic paresis
 Severe hypotension and bradycardia
 Nerve damage or neuritis
 Intravascular injection
 Horner’s syndrome with dyspnea and hoarseness of voice
 Pneumothorax
 Hemothorax
 Hematoma and Infection

33. SUPRACLAVICULAR BLOCK
Location-
 The three trunks are clustered vertically over
the first rib cephaloposterior to the subclavian
artery. The neurovascular bundle lies inferior to
the clavicle at about its midpoint.
 Blockade occurs at the distal trunk–proximal
division level
Indications
 Operations on the elbow, forearm, and hand.

34. Technique
PERIPHERAL NERVE STIMULATON OR PARESTHESIA
 Positioning- in supine position with the head turned away from the side to be
blocked. The arm to be anesthetized is adducted, and the hand should be extended
along the side toward the ipsilateral knee as far as possible.
 In the classic technique, the midpoint of the clavicle is identified .The posterior
border of the sternocleidomastoid is felt. The palpating fingers can roll over the
belly of the anterior scalene muscle into the interscalene groove, where a mark
should be made approximately 1.5 to 2.0 cm posterior to the midpoint of the
clavicle. Palpation of the subclavian artery at this site confirms the landmark.

35.  After appropriate preparation and development of a skin wheal, the
anesthesiologist stands at the side of the patient facing the patient's head.
 A 22-gauge, 4-cm needle is directed in a caudad,
slightly medial, and posterior direction until a
paresthesia or motor response is elicited or the first
rib is encountered.
 If the first rib is encountered without elicitation of a paresthesia, the needle
can be systematically walked anteriorly and posteriorly along the rib until the
plexus or the subclavian artery is located.

36.  The needle can be withdrawn and reinserted in a more posterolateral direction,
which generally results in a paresthesia or motor response.
 This needle directs from the vicinity to:-
Upper trunk (shoulder twitch)
Middle trunk (biceps, triceps, pectoralis twitch)
Lower trunk (fingers twitch). GOAL
 On localization of the brachial plexus, aspiration for blood should be performed
before incremental injections of a total volume of 20 to 30 mL of solution.

37. ULTRASOUND GUIDED
Transducer position- Transverse on the neck, superior to
the clavicle at the midpoint
The brachial plexus is seen as a collection of hypoechoic
oval structures (bunch of grapes) posterior and
superficial to the artery.

38. Blockade distribution
FIGURE 1. Expected sensory distribution of the
supraclavicular brachial plexus block.
The supraclavicular approach to the brachial plexus blockade
results in anesthesia of the upper limb including often the
shoulder because all trunks and divisions can be anesthetized
from this location. The skin of the proximal part of the medial
side of the arm (intercostobrachial nerve, T2), however, is never
anesthetized by any technique of the brachial plexus block and,
when necessary, can be blocked by an additional subcutaneous
injection just distal to the axilla (Figure 1).

39. Complications
 Pneumothorax
 Phrenic nerve block (upto 30%)
 Horner's syndrome
 Neuropathy.

40. INFRACLAVICULAR BLOCK
Landmarks:
The boundaries of the infraclavicular fossa are :
Medially- first rib
Superiorly- clavicle and coracoid process
Anteriorly-pectoralis muscle
Laterally- humerus
 Blockade occurs at the level of the cords.
Indications- Hand, wrist, elbow and distal
arm surgery

41. Technique
PERIPHERAL NERVE STIMULATION OR PARESTHESIA
 Positioning- Supine position with the head facing opposite side.
The anesthesiologist also stands opposite side.
Keep the patient's arm abducted and flexed at the elbow.
The arm should be supported at the wrist to a clear, unobstructed
view and interpretation of twitches of the hand.
Technique of Palpation of coracoid
process
Palpation of medial head of clavicle

42. Classic approach
The needle is inserted 2 cm below the midpoint of the inferior clavicular
border & advanced laterally, using a nerve stimulator to identify the plexus.
An incremental injection of 20- 30 ml of solution ,after negative aspiration, is
sufficient.
 Coracoid technique
Consists of insertion of the needle 2 cm medial and 2 cm caudal to the
coracoid process, has also been described.

43. ULTRASOUND GUIDED
Transducer position - approximately parasagittal, just medial
to the coracoid process, inferior to the clavicle.
(Pericoracoid approach)
The three cords are located lateral , posterior and medial
to the artery and are seen as hyperechoic structure.
(Double bubble sign)
Local anaesthetic is injected posterolateral to artery
Complications
 Inadvertent intravascular injection
 Pneumothorax
L

44. Blockade distribution
FIGURE 1. Distribution of sensory blockade of the infraclavicular
brachial plexus block.
The infraclavicular approach to brachial plexus blockade
results in anesthesia of the upper limb below the shoulder.
If required, the skin of the medial aspect of the upper arm
(intercostobrachial nerve, T2) can be blocked by an
additional subcutaneous injection on the medial aspect of
the arm just distal to the axilla.

45. AXILLARY BLOCK
The axillary brachial plexus block was first
described by Halsted in 1884.
Blockade occurs at the level of the terminal
nerves.
Blockade of the musculocutaneous nerve is
not always produced with this approach.
Indications –
Surgery on the forearm and hand.
Elbow procedures are also successfully
performed with the axillary approach.

46. Landmarks-
 The axillary artery is the most important landmark; the nerves maintain a predictable
orientation to the artery.
 The median nerve is found superior to the artery, the ulnar nerve is inferior, and the
radial nerve is posterior and somewhat lateral.
 At this level, the musculocutaneous nerve has already left the sheath and lies in the
substance of the coracobrachialis muscle.
 The intercostobrachial nerve , is usually blocked by the skin wheal overlying the
artery.

47. Technique
PERIPHERAL NERVE STIMULATION OR PARESTHESIA
Positioning- The patient should be in the supine position with the arm to be
blocked placed at a right angle to the body and the elbow flexed to 90 degrees ,
the dorsum of the hand rests on the bed or pillow.
The axillary artery is then palpated as far as proximally as possible ,fixed against the
humerus by the index & middle fingers of the left hand , & a skin wheal is raised
directly over the artery at a point in the axilla approximating the skin crease.
Palpation of axillary artery

48.  A transarterial technique is used whereby the needle
pierces the artery and 40 to 50 ml of solution is injected
posterior to the artery. Alternatively, half of the solution
can be injected posterior and half injected anterior to the
artery.
 Classically, upon completion of the injection ,the arm should be adducted &
returned to the patient’s side to prevent the humeral head from obstructing
proximal flow of the local anaesthetic solution.
 However , maintaining the arm in abduction decreases onset time &
prolongs both sensory & motor block.

49. ULTRASOUND GUIDED
 Transducer position-: short axis to arm,
just distal to the pectoralis major insertion.
 Ultrasound guidance with visualization of
local anaesthetic spread around the 4 nerves
decreases block onset time & can reduce the
number of needle redirections.
ML
L
PP

50. Blockade distribution
FIGURE 3. Sensory distribution after axillary brachial plexus
block.
The axillary brachial plexus block results in anesthesia
of the upper limb from the mid-arm down to and
including the hand.

51. Complications
 Nerve injury
 Systemic toxicity
 Neuropathies
 Inadvertent intravascular injections

52. THANK YOU