Anatomy and Evaluation of the Brachial Plexus

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Anatomy and Evaluation of the Brachial Plexus

• San Jose State University
• Undergraduate Athletic Training Educational
  Program

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Contents

• Anatomy of the Brachial Plexus
• Mechanisms of Brachial Plexus Injury
• and Pathologies
• Neurological Evaluation for the Brachial Plexus
  and Related Special Tests

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Anatomy
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Levels

• Roots
• Trunks
• Divisions
• Cords
• Branches

• Real
• Athletic Trainers
• Drink
• Cold
• Beer

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Brachial Plexus Branches Muscular Innervations

• Suprascapular N.
• Infraspinatus
• Supraspinatus
• Musculocutaneous N.
• Biceps Brachii
• Brachialis
• Coracobrachialis

• Dorsal Scapular N.
• Levator Scapulae
• Rhomboid Major/Minor
• Lateral Pectoral N.
• Pectoralis Major/Minor

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Brachial Plexus Branches Muscular Innervations

• Axillary N.
• Deltoid
• Teres Minor
• Upper Subscapular N.
• Subscapularis

• Middle Subscapular or Thoracodorsal N.
• Latissimus Dorsi
• Lower Subscapular N.
• Subscapularis
• Teres Major

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Brachial Plexus Branches Muscular Innervations

• Median N.
• Abductor Pollicis Brevis/Longus
• Flexor Carpi Radialis
• Flexor Digitorum Superficialis
• Flexor Digitorum Profundus (Lat. 2)
• Flexor Pollicis Brevis (Lat.) Longus
• Lumbricales (Lat. 2)
• Opponens Pollicis
• Palmaris Longus
• Pronator Quadratus
• Pronator Teres

• Radial N.
• Abductor Pollicis Brevis
• Anconeus
• Brachioradialis
• Extensor Carpi Radialis Brevis/Longus
• Extensor Carpi Ulnaris
• Extensor Digiti Minimi
• Extensor Digitorum Communis
• Extensor Indicis
• Extensor Pollicis Brevis/Longus
• Supinator
• Triceps Brachii

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Brachial Plexus Branches Muscular Innervations

• Ulnar N.
• Abductor Digiti Minimi
• Adductor Pollicis
• Dorsal Interossei
• Flexor Carpi Ulnaris
• Flexor Digiti Minimi
• Flexor Digitorum Profundus (Med. 2)
• Flexor Pollicis Brevis (Med.)
• Lumbricals (Med. 2)
• Opponens Digiti Minimi
• Palmar Interossei

• Long Thoracic N.
• Serratus Anterior
• Medial Pectoral N.
• Pectoralis Major
• Medial Brachial Cutaneous N. (sensory)
• Medial Antebrachial Cutaneous N. (sensory)

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Mechanisms of Injury to the Brachial Plexus
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Brachial Plexus Injury Overview

• Sports most commonly associated with brachial
  plexus injuries include football, baseball,
  basketball, volleyball, fencing, wrestling, and
  gymnastics
• Nerve injuries can result from blunt force
  trauma, poor posture, or chronic repetitive
  stress
• Patients generally present with pain and/or
  muscle weakness
• Over time, some patients may experience muscle
  atrophy
• (Duralde, 2000)

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Brachial Plexus Injury Overview

• Before performing special tests, rule out
  fractures and dislocations
• Brachial plexus injuries resolve quicker than
  spinal cord injuries
• (Prentice, p.846)
• Evaluation for return-to-play should take into
  consideration symptoms, resolution time, and
  prior injuries to this region
• (Gorden, et al., 2003)
• Evaluate athletes immediately after injury and
  again after the game/practice
• (Kuhlman McKeag, 1998)

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Three Mechanisms of Injury

• Percussion
• Traction
• Cervical Nerve Compression

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Percussion

• Occurs with direct blow to the supraclavicular
  fossa over Erbs point
• (Troub, 2001)
• Example Cross-check to a hockey player

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Traction

• Occurs with a direct blow to the shoulder with
  the neck laterally flexed toward the unaffected
  shoulder
• (Troub, 2001)
• Example Gymnast falls on beam

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Cervical Nerve Compression

• Occurs when the neck is flexed laterally toward
  the patients affected shoulder
• Caused by compression or irritation of the
  nerves, resulting in point tenderness over
  involved vertebrae of affected nerve(s)
• (Troub, 2001)
• Example Football player tackles an opponent

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• Traction
• B. Percussion
• C. Cervical Nerve Compression

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Brachial Plexus Pathologies

• Burners or Stingers
• Associated with traction and/or compression
• Thoracic Outlet Syndrome

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Burners or Stingers

• Mechanisms of injury include cervical flexion
  away from the limb and hyperextension of the
  cervical spine
• May present with pain, numbness, burning, and/or
  tingling from the shoulder to the fingers
• Possible loss of function in arm and hand for
  several minutes up to several days
• (Prentice, p.846)

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Thoracic Outlet Syndrome

• Caused by pressure on the brachial plexus and/or
  subclavian artery and/or vein
• May present with numbness, paresthesia, pain,
  cool and pale skin, cyanosis or edema in upper
  extremity, and swollen veins
• (Prentice, pp. 683-684)
• Patient may also develop unilateral atrophy
  and/or lowered shoulder on affected side
• (Duralde, 2000)

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Three Grades of Injury

• Grade 1 Neuropraxia
• Grade 2 Axonotmesis
• Grade 3 Neurotmesis

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Grade 1 - Neuropraxia

• Results in a disruption in the function of a
  nerve that produces numbness and tingling
• Most common grade within athletics
• Symptoms usually resolve within several minutes
• (Duralde,2000)

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Grade 2 - Axonotmesis

• Damage to the nerves axon
• Symptoms include numbness, tingling, and affected
  function (may last several days)
• Long nerves have a greater healing time than
  short nerves
• Rare within athletics
• (Duralde,2000)

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Grade 3 - Neurotmesis

• Permanent nerve damage occurs
• Very rare within athletics
• Occurs with high-energy trauma, fractures, and
  penetrating injuries
• (Duralde, 2000)

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C5-C6 Affected

• Motor Deficits
• Shoulder abduction, shoulder flexion, elbow
  flexion, and wrist extension
• Sensory Loss
• Lateral arm, 1st digit, and 2nd digit

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C7 Affected

• Motor Deficits
• Elbow extension weakness and wrist flexion
• Sensory Loss
• Pad of index finger

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C8-T1 Affected (very rare)

• Motor Deficits
• Finger abduction/adduction and thumb
  flexors/extensors
• Sensory Loss
• 4th digit, 5th digit, medial forearm, and medial
  arm

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C5-T1 Affected

• Motor Deficits
• Scapular motion and entire arm
• Sensory Loss
• Entire arm, forearm, and hand

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Process of Evaluation
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Dermatomes

• C5 Lateral arm
• C6 Lateral forearm, thumb, index finger
• C7 Posterior forearm, middle finger
• C8 Medial forearm, ring and little finger
• T1 Medial arm

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Myotomes

• C5 Shoulder abduction
• C6 Elbow flexion or wrist extension
• C7 Elbow extension or wrist flexion
• C8 Grip strength, shake hands
• T1 Interossei, spread fingers and resist
  finger adduction

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Peripheral Nerve Tests

• Musculocutaneous N.
• Sensory Anterior arm
• Motor Elbow flexion

• Axillary N.
• Sensory Lateral arm
• Motor Shoulder abduction

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Peripheral Nerve Tests

• Median N.
• Sensory Pad of Index finger
• Motor Thumb pinch and abduction
• Ulnar N.
• Sensory Pad of little finger
• Motor Finger abduction

• Radial N.
• Sensory 1st Dorsal web space
• Motor Wrist extension and thumb extension

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Reflex Tests

• C5 Biceps brachii reflex (anterior arm near
  antecubital fossa)
• C6 Brachioradialis reflex (lateral aspect of
  forearm)
• C7 Triceps brachii reflex (at insertion of
  tricep brachii)
• C8 and T1 do not have reflex tests

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Related Special Tests

• Thoracic Outlet Syndrome
• Adsons Test
• Allens Test
• Military Brace Position

• Brachial Plexus
• Cervical Compression Test
• Cervical Distraction Test
• Spurlings Test
• Brachial Plexus Traction Test

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References

• Duralde, X. A. (2000). Neurologic injuries in
  athletes shoulder. Journal of Athletic Training,
  35(3), pp.316-318.
• Gorden, J. A., Straub, S. J., Swanik, C. B.,
  Swanik, K. A. (2003). Effects of football collars
  on cervical hyperextension and lateral flexion.
  Journal of Athletic Training, 38(3), pp. 209-218.
• Hoppenfeld, S. (1976). Physical Examination of
  the Spine Extremities. Upper Saddle River NJ
  Prentice Hall. pp.93-127.
• Kuhlman, G. S. McKeag, D. B. (1999). The
  burner A common nerve injury in contact
  sports. American Family Physician, 60(7).
  Retrieved April 5, 2006 from the American Academy
  of Family Physicians database.
• Martini, F. H., Timmons, M. J., Tallitsch, R.
  B. (2003). Human Anatomy. Upper Saddle River, NJ
  Pearson Education, Inc.
• Starkey, C. Ryan, J. (2002). Evaluation of
  Orthopedic and Athletic Injuries. Philadelphia,
  PA F. A. Davis Company.
• Troub, M. (2001). Brachial plexus injuries in
  athletics Burners. Northwest Texas Sports
  Medicine Clinic. Retrieved March 5, 2006 from the
  Northwest Texas Sports Medicine Clinic website.

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Project Participants

• Presenters Heather Terbeek, Hank House, Cesar
  Cardenas, and Rachel Sorris
• Models Becky Roark Kevin Geiger
• Researchers Caitlin Wall, Heather Terbeek, Hank
  House, Cesar Cardenas, and Becky Roark
• Special Thanks to Our Faculty Jeff Roberts,
• Dr. Leamor Kahanov, and Chris Warden