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Anatomy and Evaluation of the Brachial Plexus

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Title: Anatomy and Evaluation of the Brachial Plexus


1
Anatomy and Evaluation of the Brachial Plexus
  • San Jose State University
  • Undergraduate Athletic Training Educational
    Program

2
Contents
  • Anatomy of the Brachial Plexus
  • Mechanisms of Brachial Plexus Injury
  • and Pathologies
  • Neurological Evaluation for the Brachial Plexus
    and Related Special Tests

3
Anatomy
4
Levels
  • Roots
  • Trunks
  • Divisions
  • Cords
  • Branches
  • Real
  • Athletic Trainers
  • Drink
  • Cold
  • Beer

5
(No Transcript)
6
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

7
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

8
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

9
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)

10
Mechanisms of Injury to the Brachial Plexus
11
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)

12
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)

13
Three Mechanisms of Injury
  • Percussion
  • Traction
  • Cervical Nerve Compression

14
Percussion
  • Occurs with direct blow to the supraclavicular
    fossa over Erbs point
  • (Troub, 2001)
  • Example Cross-check to a hockey player

15
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

16
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

17
  • Traction
  • B. Percussion
  • C. Cervical Nerve Compression

18
Brachial Plexus Pathologies
  • Burners or Stingers
  • Associated with traction and/or compression
  • Thoracic Outlet Syndrome

19
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)

20
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)

21
Three Grades of Injury
  • Grade 1 Neuropraxia
  • Grade 2 Axonotmesis
  • Grade 3 Neurotmesis

22
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)

23
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)

24
Grade 3 - Neurotmesis
  • Permanent nerve damage occurs
  • Very rare within athletics
  • Occurs with high-energy trauma, fractures, and
    penetrating injuries
  • (Duralde, 2000)

25
C5-C6 Affected
  • Motor Deficits
  • Shoulder abduction, shoulder flexion, elbow
    flexion, and wrist extension
  • Sensory Loss
  • Lateral arm, 1st digit, and 2nd digit

26
C7 Affected
  • Motor Deficits
  • Elbow extension weakness and wrist flexion
  • Sensory Loss
  • Pad of index finger

27
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

28
C5-T1 Affected
  • Motor Deficits
  • Scapular motion and entire arm
  • Sensory Loss
  • Entire arm, forearm, and hand

29
Process of Evaluation
30
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

31
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

32
Peripheral Nerve Tests
  • Musculocutaneous N.
  • Sensory Anterior arm
  • Motor Elbow flexion
  • Axillary N.
  • Sensory Lateral arm
  • Motor Shoulder abduction

33
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

34
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

35
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

36
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.

37
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
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