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Anatomy and Evaluation of Anatomy and Evaluation of the Brachial Plexusthe Brachial Plexus
San Jose State UniversitySan Jose State University
Undergraduate Athletic Training Undergraduate Athletic Training Educational ProgramEducational Program
ContentsContents
Anatomy of the Brachial PlexusAnatomy of the Brachial Plexus
Mechanisms of Brachial Plexus Injury Mechanisms of Brachial Plexus Injury
and Pathologiesand Pathologies
Neurological Evaluation for the Brachial Neurological Evaluation for the Brachial Plexus and Related Special TestsPlexus and Related Special Tests
AnatomyAnatomy
LevelsLevels
RRootsoots
TTrunksrunks
DDivisionsivisions
CCordsords
BBranchesranches
RRealeal
AthleticAthletic TTrainers rainers
DDrinkrink
CColdold
BBeereer
Brachial Plexus Branches & Brachial Plexus Branches & Muscular InnervationsMuscular Innervations
Dorsal Scapular N.Dorsal Scapular N. Levator ScapulaeLevator Scapulae Rhomboid Major/MinorRhomboid Major/Minor
Lateral Pectoral N.Lateral Pectoral N. Pectoralis Major/MinorPectoralis Major/Minor
Suprascapular N.Suprascapular N. InfraspinatusInfraspinatus SupraspinatusSupraspinatus
Musculocutaneous N.Musculocutaneous N. Biceps BrachiiBiceps Brachii BrachialisBrachialis CoracobrachialisCoracobrachialis
Brachial Plexus Branches & Brachial Plexus Branches & Muscular InnervationsMuscular Innervations
Axillary N.Axillary N. DeltoidDeltoid Teres MinorTeres Minor
Upper Subscapular N.Upper Subscapular N. SubscapularisSubscapularis
Middle Subscapular or Middle Subscapular or Thoracodorsal N.Thoracodorsal N.
Latissimus DorsiLatissimus Dorsi
Lower Subscapular N.Lower Subscapular N. SubscapularisSubscapularis Teres MajorTeres Major
Brachial Plexus Branches & Brachial Plexus Branches & Muscular InnervationsMuscular Innervations
Median N.Median N. Abductor Pollicis Abductor Pollicis
Brevis/LongusBrevis/Longus Flexor Carpi RadialisFlexor Carpi Radialis Flexor Digitorum Flexor Digitorum
SuperficialisSuperficialis Flexor Digitorum Profundus Flexor Digitorum Profundus
(Lat. 2)(Lat. 2) Flexor Pollicis Brevis (Lat.) Flexor Pollicis Brevis (Lat.)
& Longus& Longus Lumbricales (Lat. 2)Lumbricales (Lat. 2) Opponens PollicisOpponens Pollicis Palmaris LongusPalmaris Longus Pronator QuadratusPronator Quadratus Pronator Teres *Pronator Teres *
Radial N.Radial N. Abductor Pollicis BrevisAbductor Pollicis Brevis AnconeusAnconeus BrachioradialisBrachioradialis Extensor Carpi Radialis Extensor Carpi Radialis
Brevis/LongusBrevis/Longus Extensor Carpi UlnarisExtensor Carpi Ulnaris Extensor Digiti MinimiExtensor Digiti Minimi Extensor Digitorum Extensor Digitorum
CommunisCommunis Extensor IndicisExtensor Indicis Extensor Pollicis Extensor Pollicis
Brevis/LongusBrevis/Longus SupinatorSupinator Triceps BrachiiTriceps Brachii
Brachial Plexus Branches & Brachial Plexus Branches & Muscular InnervationsMuscular Innervations
Ulnar N.Ulnar N. Abductor Digiti MinimiAbductor Digiti Minimi Adductor PollicisAdductor Pollicis Dorsal InterosseiDorsal Interossei Flexor Carpi UlnarisFlexor Carpi Ulnaris Flexor Digiti MinimiFlexor Digiti Minimi Flexor Digitorum Profundus Flexor Digitorum Profundus
(Med. 2)(Med. 2) Flexor Pollicis Brevis (Med.)Flexor Pollicis Brevis (Med.) Lumbricals (Med. 2)Lumbricals (Med. 2) Opponens Digiti MinimiOpponens Digiti Minimi Palmar InterosseiPalmar Interossei
Long Thoracic N.Long Thoracic N. Serratus AnteriorSerratus Anterior
Medial Pectoral N.Medial Pectoral N. Pectoralis MajorPectoralis Major
Medial Brachial Medial Brachial Cutaneous N. (sensory)Cutaneous N. (sensory)
Medial Antebrachial Medial Antebrachial Cutaneous N. (sensory)Cutaneous N. (sensory)
Mechanisms of Mechanisms of Injury to the Brachial PlexusInjury to the Brachial Plexus
Brachial Plexus Injury OverviewBrachial Plexus Injury Overview Sports most commonly associated with brachial Sports most commonly associated with brachial
plexus injuries include: football, baseball, plexus injuries include: football, baseball, basketball, volleyball, fencing, wrestling, and basketball, volleyball, fencing, wrestling, and gymnastics gymnastics
Nerve injuries can result from blunt force trauma, Nerve injuries can result from blunt force trauma, poor posture, or chronic repetitive stresspoor posture, or chronic repetitive stress
Patients generally present with pain and/or Patients generally present with pain and/or muscle weakness muscle weakness
Over time, some patients may experience Over time, some patients may experience muscle atrophymuscle atrophy
(Duralde, 2000)(Duralde, 2000)
Brachial Plexus Injury OverviewBrachial Plexus Injury Overview Before performing special tests, rule out fractures Before performing special tests, rule out fractures
and dislocationsand dislocations Brachial plexus injuries resolve quicker than spinal Brachial plexus injuries resolve quicker than spinal
cord injuriescord injuries
(Prentice, p.846)(Prentice, p.846)
Evaluation for return-to-play should take into Evaluation for return-to-play should take into consideration symptoms, resolution time, and prior consideration symptoms, resolution time, and prior injuries to this regioninjuries to this region
(Gorden, et al., 2003)(Gorden, et al., 2003) Evaluate athletes immediately after injury and again Evaluate athletes immediately after injury and again
after the game/practiceafter the game/practice
(Kuhlman & McKeag, 1998)(Kuhlman & McKeag, 1998)
Three Mechanisms of InjuryThree Mechanisms of Injury
PercussionPercussion
TractionTraction
Cervical Nerve CompressionCervical Nerve Compression
PercussionPercussion
Occurs with direct blow to the Occurs with direct blow to the supraclavicular fossa over Erb’s pointsupraclavicular fossa over Erb’s point
(Troub, 2001)(Troub, 2001)
Example: Cross-check to a hockey Example: Cross-check to a hockey playerplayer
TractionTraction
Occurs with a direct blow to the Occurs with a direct blow to the shoulder with the neck laterally flexed shoulder with the neck laterally flexed toward the unaffected shouldertoward the unaffected shoulder
(Troub, 2001)(Troub, 2001)
Example: Gymnast falls on beamExample: Gymnast falls on beam
Cervical Nerve CompressionCervical Nerve CompressionOccurs when the neck is flexed laterally Occurs when the neck is flexed laterally toward the patient’s affected shouldertoward the patient’s affected shoulder
Caused by compression or irritation of the Caused by compression or irritation of the nerves, resulting in point tenderness over nerves, resulting in point tenderness over involved vertebrae of affected nerve(s)involved vertebrae of affected nerve(s)
(Troub, 2001)(Troub, 2001)
Example: Football player tackles an Example: Football player tackles an opponentopponent
A. Traction B. Percussion C. Cervical Nerve Compression
Brachial Plexus PathologiesBrachial Plexus Pathologies
““Burners” or “Stingers”Burners” or “Stingers” Associated with traction and/or compressionAssociated with traction and/or compression
Thoracic Outlet SyndromeThoracic Outlet Syndrome
Burners or StingersBurners or Stingers Mechanisms of injury include cervical flexion Mechanisms of injury include cervical flexion
away from the limb and hyperextension of the away from the limb and hyperextension of the cervical spinecervical spine
May present with pain, numbness, burning, May present with pain, numbness, burning, and/or tingling from the shoulder to the fingersand/or tingling from the shoulder to the fingers
Possible loss of function in arm and hand for Possible loss of function in arm and hand for several minutes up to several daysseveral minutes up to several days
(Prentice, p.846)(Prentice, p.846)
Thoracic Outlet SyndromeThoracic Outlet Syndrome Caused by pressure on the brachial plexus Caused by pressure on the brachial plexus
and/or subclavian artery and/or veinand/or subclavian artery and/or vein
May present with numbness, paresthesia, pain, May present with numbness, paresthesia, pain, cool and pale skin, cyanosis or edema in upper cool and pale skin, cyanosis or edema in upper extremity, and swollen veinsextremity, and swollen veins
(Prentice, pp. 683-684)(Prentice, pp. 683-684)
Patient may also develop unilateral atrophy Patient may also develop unilateral atrophy and/or lowered shoulder on affected sideand/or lowered shoulder on affected side
(Duralde, 2000)(Duralde, 2000)
Three Grades of InjuryThree Grades of Injury
Grade 1 – Neuropraxia Grade 1 – Neuropraxia
Grade 2 – AxonotmesisGrade 2 – Axonotmesis
Grade 3 – NeurotmesisGrade 3 – Neurotmesis
Grade 1 - NeuropraxiaGrade 1 - NeuropraxiaResults in a disruption in the function of a Results in a disruption in the function of a
nerve that produces numbness and nerve that produces numbness and tinglingtingling
Most common grade within athleticsMost common grade within athletics
Symptoms usually resolve within several Symptoms usually resolve within several minutes minutes
(Duralde,2000)(Duralde,2000)
Grade 2 - AxonotmesisGrade 2 - AxonotmesisDamage to the nerve’s axon Damage to the nerve’s axon
Symptoms include numbness, tingling, Symptoms include numbness, tingling, and affected function (may last several and affected function (may last several days)days)
Long nerves have a greater healing time Long nerves have a greater healing time than short nerves than short nerves
Rare within athleticsRare within athletics (Duralde,2000)(Duralde,2000)
Grade 3 - NeurotmesisGrade 3 - Neurotmesis
Permanent nerve damage occursPermanent nerve damage occurs
Very rare within athleticsVery rare within athletics
““Occurs with high-energy trauma, Occurs with high-energy trauma, fractures, and penetrating injuries”fractures, and penetrating injuries”
(Duralde, 2000)(Duralde, 2000)
C5-C6 AffectedC5-C6 Affected
Motor Deficits: Motor Deficits:
Shoulder abduction, shoulder flexion, Shoulder abduction, shoulder flexion, elbow flexion, and wrist extensionelbow flexion, and wrist extension
Sensory Loss: Sensory Loss:
Lateral arm, 1Lateral arm, 1stst digit, and 2 digit, and 2ndnd digit digit
C7 AffectedC7 Affected
Motor Deficits: Motor Deficits:
Elbow extension weakness and wrist flexionElbow extension weakness and wrist flexion
Sensory Loss: Sensory Loss:
Pad of index fingerPad of index finger
C8-T1 Affected (very rare)C8-T1 Affected (very rare)
Motor Deficits: Motor Deficits:
Finger abduction/adduction and thumb Finger abduction/adduction and thumb flexors/extensorsflexors/extensors
Sensory Loss: Sensory Loss:
44thth digit, 5 digit, 5thth digit, medial forearm, and digit, medial forearm, and medial armmedial arm
C5-T1 AffectedC5-T1 Affected
Motor Deficits: Motor Deficits:
Scapular motion and entire armScapular motion and entire arm
Sensory Loss: Sensory Loss:
Entire arm, forearm, and handEntire arm, forearm, and hand
Process of EvaluationProcess of Evaluation
DermatomesDermatomesC5 – Lateral armC5 – Lateral arm
C6 – Lateral forearm, thumb, index fingerC6 – Lateral forearm, thumb, index finger
C7 – Posterior forearm, middle fingerC7 – Posterior forearm, middle finger
C8 – Medial forearm, ring and little fingerC8 – Medial forearm, ring and little finger
T1 – Medial armT1 – Medial arm
MyotomesMyotomesC5 – Shoulder abductionC5 – Shoulder abduction
C6 – Elbow flexion or wrist extensionC6 – Elbow flexion or wrist extension
C7 – Elbow extension or wrist flexionC7 – Elbow extension or wrist flexion
C8 – Grip strength, shake handsC8 – Grip strength, shake hands
T1 – Interossei, spread fingers and resist T1 – Interossei, spread fingers and resist finger adduction finger adduction
Peripheral Nerve TestsPeripheral Nerve Tests
Musculocutaneous N.Musculocutaneous N.• Sensory – Anterior Sensory – Anterior
armarm
• Motor – Elbow Motor – Elbow flexionflexion
Axillary N.Axillary N.• Sensory – Lateral Sensory – Lateral
armarm
• Motor – Shoulder Motor – Shoulder abductionabduction
Peripheral Nerve TestsPeripheral Nerve Tests
Radial N.Radial N.• Sensory – 1Sensory – 1stst Dorsal Dorsal
web spaceweb space• Motor – Wrist Motor – Wrist
extension and thumb extension and thumb extensionextension
Median N.Median N.• Sensory – Pad of Sensory – Pad of
Index fingerIndex finger• Motor – Thumb pinch Motor – Thumb pinch
and abductionand abduction
Ulnar N.Ulnar N.• Sensory – Pad of little Sensory – Pad of little
fingerfinger• Motor – Finger Motor – Finger
abductionabduction
Reflex TestsReflex TestsC5 – Biceps brachii reflex (anterior arm C5 – Biceps brachii reflex (anterior arm
near antecubital fossa)near antecubital fossa)
C6 – Brachioradialis reflex (lateral aspect C6 – Brachioradialis reflex (lateral aspect of forearm)of forearm)
C7 – Triceps brachii reflex (at insertion of C7 – Triceps brachii reflex (at insertion of tricep brachii)tricep brachii)
C8 and T1 do not have reflex testsC8 and T1 do not have reflex tests
Related Special Tests Related Special Tests
Brachial PlexusBrachial Plexus• Cervical Compression Cervical Compression
TestTest
• Cervical Distraction Cervical Distraction TestTest
• Spurling’s TestSpurling’s Test
• Brachial Plexus Brachial Plexus Traction TestTraction Test
Thoracic Outlet SyndromeThoracic Outlet Syndrome• Adson’s TestAdson’s Test
• Allen’s Test Allen’s Test
• Military Brace PositionMilitary Brace Position
ReferencesReferencesDuralde, X. A. (2000). Neurologic injuries in athlete’s shoulder. Duralde, X. A. (2000). Neurologic injuries in athlete’s shoulder. Journal Journal
of Athletic Training, 35(3)of Athletic Training, 35(3), pp.316-318., pp.316-318.
Gorden, J. A., Straub, S. J., Swanik, C. B., & Swanik, K. A. (2003). Gorden, J. A., Straub, S. J., Swanik, C. B., & Swanik, K. A. (2003). Effects of football collars on cervical hyperextension and lateral Effects of football collars on cervical hyperextension and lateral flexion. flexion. Journal of Athletic Training, 38(3)Journal of Athletic Training, 38(3), pp. 209-218., pp. 209-218.
Hoppenfeld, S. (1976). Physical Examination of the Spine & Extremities. Hoppenfeld, S. (1976). Physical Examination of the Spine & Extremities. Upper Saddle River: NJ: Prentice Hall. pp.93-127.Upper Saddle River: NJ: Prentice Hall. pp.93-127.
Kuhlman, G. S. & McKeag, D. B. (1999). The “burner”: A common nerve Kuhlman, G. S. & McKeag, D. B. (1999). The “burner”: A common nerve injury in contact sports. injury in contact sports. American Family Physician, 60(7)American Family Physician, 60(7). Retrieved . Retrieved April 5, 2006 from the American Academy of Family Physicians April 5, 2006 from the American Academy of Family Physicians database.database.
Martini, F. H., Timmons, M. J., & Tallitsch, R. B. (2003). Human Martini, F. H., Timmons, M. J., & Tallitsch, R. B. (2003). Human Anatomy. Upper Saddle River, NJ: Pearson Education, Inc.Anatomy. Upper Saddle River, NJ: Pearson Education, Inc.
Starkey, C. & Ryan, J. (2002). Evaluation of Orthopedic and Athletic Starkey, C. & Ryan, J. (2002). Evaluation of Orthopedic and Athletic Injuries. Philadelphia, PA: F. A. Davis Company.Injuries. Philadelphia, PA: F. A. Davis Company.
Troub, M. (2001). Brachial plexus injuries in athletics: Troub, M. (2001). Brachial plexus injuries in athletics: “Burners”. “Burners”. Northwest Texas Sports Medicine Clinic.Northwest Texas Sports Medicine Clinic. Retrieved March Retrieved March 5, 2006 from the Northwest Texas Sports Medicine Clinic website. 5, 2006 from the Northwest Texas Sports Medicine Clinic website.
Project ParticipantsProject Participants Presenters: Heather Terbeek, Hank House, Cesar Presenters: Heather Terbeek, Hank House, Cesar
Cardenas, and Rachel SorrisCardenas, and Rachel Sorris
Models: Becky Roark & Kevin GeigerModels: Becky Roark & Kevin Geiger
Researchers: Caitlin Wall, Heather Terbeek, Hank Researchers: Caitlin Wall, Heather Terbeek, Hank House, Cesar Cardenas, and Becky Roark House, Cesar Cardenas, and Becky Roark
Special Thanks to Our Faculty: Jeff Roberts, Special Thanks to Our Faculty: Jeff Roberts,
Dr. Leamor Kahanov, and Chris WardenDr. Leamor Kahanov, and Chris Warden