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Anatomy of the upper limb – brachial plexus
- 1. Dr. Patrick Reynolds F2 Trauma & Orthopaedics Brachial plexus Nerve supply of upper limb Common clinical syndromes and presentation
- 9. Musculocutaneous nerve •Supplied by C5, C6 and C7 •Formed by a branch of the lateral cord (superior and medial trunks) •Supplies “BBC” muscles - Biceps Brachii, Brachialis and Coracobrachialis •Gives off lateral cutaneous nerve of the forearm – important structure to identify in surgery around the ACF
- 11. Radial nerve •Supplied by C5-8, T1 (inconsistent) •Formed by a continuation of the posterior cord) •Supplies Extensor muscles and brachioradialis (extensor paradox) and abductor pollicis longus •Proximally runs around the spiral groove, dives deep through lateral intermuscular septum, runs anterolaterally around the radial head and reappears through the extensor compartment in the forearm
- 13. Median nerve •Supplied by C5-8, T1 (inconsistent) •Formed by a confluence of the medial and lateral cords •Supplies flexor compartment of forearm, three thenar muscles and two lumbricals of hand •Supplies deep compartment as the anterior interosseuous nerve •Anterior interosseous nerve supplies radial half of FDP, FPL and pronator quadratus, sensory to wrist and carpal tunnel
- 15. Ulnar nerve •Supplied by C7, C8 T1 •Direct continuation of medial cord (C8, T1) with contribution of (C7) fibres from axilla •Supplies some flexors on ulnar side, ulnar side of FDP, all intrinsic muscles, lumbricals & interossei of hand excluding LOAF •Runs posteriorly on humerus, pass through cubital tunnel
- 17. Ulnar claw hand Ulnar nerve lesion at wrist or just below elbow gives previous “claw” appearance Position caused by loss of lumbrical function (flex MCPJ, extend PIPJ) with unopposed effect of finger extensors Paradoxically a higher lesion of the ulnar nerves leads to less severe “clawing”, why? FDP on ulnar side receives ulnar nerve supply. Paralysis of ulnar FDP occurs in high lesions giving fingers a less flexed appearance Injury is more severe but appearance is better, hence “Paradox”
- 19. Erb’s Palsy
- 20. Erb’s Palsy Traction injury to C5, C6 often birth injury during difficult delivery Abductors and lateral rotators of shoulder and the supinators are paralysed Arm hangs by side, medially rotated, pronated with loss of sensation on the lateral side of arm and forearm
- 21. Klumpke’s paralysis Damage to the lowest roots (C8, T1) Can also be a birth injury during breech delivery where arms remain above head Small muscles of hand are most affected. Often get clawing Ulnar sensory loss Appearance as per claw hand
- 22. Useful mnemonics for hands LOAF – Intrinsic muscles supplied by median nerve lateral two lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis A OF A OF A – Thenar (lateral to medial-palmar surface): Abductor pollicis brevis Opponens pollicis Flexor pollicis brevis Adductor pollicis Hypothenar (lateral to medial-palmar surface): Opponens digiti minimi Flexor digiti minimi Abductor digiti minimi