Anatomy and Evaluation of the Brachial Plexus San Jose State University Undergraduate Athletic Training Educational Program

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


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


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


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


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”


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


Elbow extension weakness and wrist flexionElbow extension weakness and wrist flexion


Pad of index fingerPad of index finger

C8-T1 Affected (very rare)C8-T1 Affected (very rare)


Finger abduction/adduction and thumb Finger abduction/adduction and thumb flexors/extensorsflexors/extensors


44thth digit, 5 digit, 5thth digit, medial forearm, and digit, medial forearm, and medial armmedial arm

C5-T1 AffectedC5-T1 Affected


Scapular motion and entire armScapular motion and entire arm


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

Documents

Anatomy and Evaluation of the Brachial Plexus San Jose State University Undergraduate Athletic Training Educational Program