Dr .T.

The brachial plexus is formed by the union of the

anterior primary divisions (ventral rami) of the fifth
through eighth cervical nerves ( C5,C6,C7,C8 ) and
first thoracic (T1) nerve, with variable contributions
from C4 and T2.
It consists of roots, trunks, divisions, cords and
terminal branches.
The roots of the plexus (anterior primary rami of C5-
T1 nerves) are between the scalene muscles, the
trunks in the posterior triangle, the divisions behind
the clavicle, and the cords arranged around the
second part of axillary artery.
About 10% of plexuses are prefixed (from C4-C8) and
10% postfixed (from C6-T2).
COURSE
The nerves roots leave the intervertebral foramina and
course anterolaterally and inferiorly to lie between
the anterior and middle scalene muscles.

Between these muscles, these nerve roots unite to form

3 vertically arranged trunks- upper(C5,C6),
middle(C7), lower(C8,T1).
The prevertebral fascia invests the anterior and
middle scalene muscles and fuses laterally to enclose
the brachial plexus in a fascial sheath.

The trunks emerge from the interscalene space to lie

cephaloposterior to the subclavian artery as it courses
along the upper surface of the first rib.
As the trunks pass over the lateral border of the
first rib and under the clavicle, each divides into
anterior and posterior divisions.
The divisions pass posterior to the middle of the
clavicle to enter the axilla, surrounded by the
fascial sheath descended from the prevertebral
fascia.
Here they combine again to form three cords
which are named according to their relationship
to the second part of axillary artery.
Lateral cord- formed by the union of anterior
divisions of superior and middle trunks.
Medial cord- formed by the anterior division of
inferior trunk.
Posterior cord- formed by the posterior divisions of
all three trunks.
At the lateral border of pectoralis minor each
cord divides into the peripheral nerves of the
upper extremity.
Lateral cord- gives off lateral branch of Median
nerve; terminates as Musculocutaneous nerve.
Medial cord- gives off medial branch of Median
nerve and median cutaneous nerves of arm and
forearm; terminates as Ulnar nerve.
Posterior cord- gives off Axillary nerve; terminates
as Radial nerve.
Anterior scalene muscle: arises from the anterior
tubercles of transverse processes of the third , fourth,
fifth and sixth cervical vertebrae and is inserted into
the scalene tubercle on the inner border of the first
rib.
The muscle lies anterior to the brachial plexus, being
seperated from it below by the subclavian artery.
Its lateral border, if palpable, is a guide to the
position of the plexus.
Medial scalene muscle: arises from the posterior
tubercles of the six lowest cervical vertebrae, and is
inserted into the upper surface of the first rib behind
the groove made by the brachial plexus and the
subclavian artery. The plexus thus lies in front of the
muscle.
First rib: the first rib lies in an almost horizontal
plane, being inclined slightly downwards and
forwards.
It passes below the clavicle at about the junction of
its inner and middle thirds.
Head: the head has a single articular facet, which
articulates with the body of the first thoracic vertebra.
Tubercle: the tubercle articulates with the transverse
process of the same vertebra.
Upper surface: it has two articular grooves- an
anterior one for the subclavian vein and a posterior
one for the subclavian artery and the lowest trunk of
the brachial plexus. On the inner border, between the
grooves, is the scalene tubercle.
The subclavius muscle arises in front of the anterior
groove and the scalenus medius is inserted behind the
posterior groove.
Lower surface: the lower surface of the first rib
has no costal groove- the inner border embraces
the dome of the pleura and the outer border gives
origin to the first slip of the serratus anterior.
Subclavian artery: the subclavian artery extends
from its origin to the outer border of the first rib.
The right subclavian artery originates from the
innominate artery and the left from the aortic
arch.
A major portion of the brachial plexus is located
parallel and lateral to the third part of the
subclavian and first part of the axillary artery, just
above and below the clavicle, respectively.
The third part of the subclavian artery extends
from the outer border of the anterior scalene
muscle laterally and caudally to the outer border
of the first rib, where it becomes the first part of
the axillary artery.
The terminal part of the subclavian artery lies behind
the clavicle near its midpoint. At this level the inferior
trunk of the brachial plexus is posterior to the third
part of the third part of the subclavian artery. The
upper two trunks of the brachial plexus lie superior
and lateral to the subclavian artery.
Subclavian vein: the subclavian vein is separated
from the brachial plexus by the anterior scalene
muscle. As it is well protected by the clavicle, it is
unlikely to be punctured.
The brachial line: the brachial line runs in a
straight line from the transverse process of the
sixth cervical vertebra to the axillary artery in the
axilla. It runs inferolateral at 45 degrees from the
horizontal and slightly forwards at 15 degrees.
Branches of brachial plexus
Branches of the roots:
C5- dorsal scapular
C5,6- nerve to subclavius
C5,6,7- long thoracic nerve

The dorsal scapular nerve (C5) runs down deep to

levator scapulae and the two rhomboids, supplying all
three muscles.
Lying on serratus posterior superior, it forms
neurovascular bundle with the descending
scapular vessels alongside the vertebral border of
the scapula
The nerve to subclavius (C5,6) passes down over
the trunks of the plexus and in front of the
subclavian vein. It frequently contains contains
accessory phrenic fibres which join the phrenic
nerve in the superior mediastinum.
The long thoracic nerve (C5,6,7) ,forms on the first
digitation of the serratus anterior muscle and runs
vertically downwards just behind the midaxillary line,
deep to the fascia over the muscle.
Branches of the upper trunk:

The supraclavicular nerve (C5,6), prominent

beneath the fascial floor of the posterior triangle,
passes beneath the transverse scapular ligament
and round the lateral border of the scapular spine.
The nerve supplies supraspinatus, infraspinatous,
and the shoulder and acromioclavicular joints.
Branches of the lateral cord: (LML)

C5,6,7- lateral pectoral

C5,6,7- musculocutaneous
C5,6,7- lateral root of median
The lateral pectoral nerve (C5,6,7) passes through
the clavipectoral fascia and supplies the upper
fibres of the pectoralis major.
It also contributes to the supply of pectoralis
minor via a communicating branch.
The musculocutaneous
nerve (C5,6,7) supplies the
flexors of the arm-
coracobrachialis, biceps
brachii and brachialis.
Below the elbow, it is
known as the ‘ lateral
cutaneous nerve of the
forearm’ and gives the
cutaneous supply from
elbow to wrist by an
 anterior and a posterior branch along the radial
border of the forearm.

The lateral root of the median nerve (C5,6,7) is joined

by the medial root to form the main nerve.
Branches of the medial cord: (M4U)
C8,T1- medial pectoral
C8,T1- medial root of median
C8,T1- medial cutaneous nerve of arm
C8,T1- medial cutaneous nerve of forearm
C8,T1- ulnar
The medial pectoral nerve gives a branch to pectoralis
minor and then pierces it to supply the sternocostal
fibres of the pectoralis major.
The medial root of the
median nerve crosses the
axillary artery to join its
companion and form the
median nerve at the
lateral side of the artery.
The median cutaneous nerve of arm is the smallest
branch of the plexus. It supplies the skin on the
medial aspect of the arm.

The medial cutaneous nerve of the forearm supplies

the skin over the lower part of the arm and the medial
side of the forearm.
The ulnar nerve is the
largest branch of the
medial cord and supplies
most of the small
muscles of the hand.
Branches of the posterior cord:

C5,6- upper subscapular

C6,7,8- thoracodorsal
C5,6- lower subscapular
C5,6- axillary
C5,6,7,8,T1- radial
The upper and lower subscapular nerves supply the
respective parts of the subscapularis, with the lower
nerve also supplying teres major.
The thoracodorsal nerve supplies the latissimus dorsi.
It is thrown into prominence in the position of lateral
rotation and abduction of the humerus and is thus in
danger in surgeries on the lower axilla.
The axillary nerve divides
into anterior and posterior
branches after supplying
the shoulder joint. The
anterior branch supplies
the deltoid and a small
area of overlying skin. The
posterior branch supplies
the teres minor and
deltoid, and continues as
the ‘upper lateral
cutaneous nerve of the
arm’.
The radial nerve is the
continuation of the
posterior cord and is the
largest branch of the
brachial plexus.
In the arm, it supplies
the triceps and the skin
along the posterior
surface (‘posterior
cutaneous nerve of the
arm).