Anatomy of the
Nerves of the Upper Limb
Department of human Anatomy and Embryology
Faculty of Medicine
Mansoura National University, Egypt
Contact Information: Anatomy Department Team
Official Email
Mobile (Optional)
Intended Learning Outcomes (ILOs)
1. Identify the arrangement, site of each part and
branches of the brachial plexus.
2. Enumerate the nerves of the upper limb.
3. List the origin, course and branches of the nerves
of the upper limb.
4. Recognize the nerve injuries of the upper limb
including mechanism of injury and presenting
deformities.
Agenda
1. What is the arrangement of the brachial plexus?
2. What is the site of each part of the brachial plexus?
3. What are the branches of the brachial plexus?
4. What is the origin, course and branches of the
nerves of the upper limb?
5. What are the mechanisms of injury of the nerves of
the upper limb?
6. What deformities are the result of the injuries of
the nerves of the upper limb?
Brachial Plexus
Definition: A network of nerves
supplying the upper limb arising
from the ventral rami of the
lower 4 cervical nerves and the
1st thoracic nerve (C5-T1).
Formation: It is divided into five
stages: Roots
Trunks
Divisions
Cords
Branches
Brachial Plexus
I. Roots: 5 In the neck
❑ Formed by the ventral rami of
C5, C6, C7, C8 and T1 spinal nerves.
II. Trunks: 3 In the neck
❑ Upper (Superior) trunk:
Formed by the union of C5 & C6 roots.
❑ Middle trunk:
Formed by the C7 root.
❑ Lower (Inferior) trunk:
Formed by the union of C8 & T1 roots.
III. Divisions: 6 Behind the clavicle.
❑ Each trunk divides into Anterior & Posterior
divisions.
Brachial Plexus
IV. Cords: 3 In the axilla
(Named according to their relation to the axillary artery)
❑ Lateral Cord:
Formed by the union of the anterior
divisions of the upper and middle trunks
❑ Medial Cord:
Formed by the anterior division of the lower
trunk.
❑ Posterior Cord:
Formed by the union of the posterior
divisions of the all 3 trunks
Brachial Plexus
V. Branches: 17 in total
• 2 From the Roots:
✓ Dorsal scapular nerve (C5)
(Nerve to Rhomboids)
✓ Long Thoracic Nerve (C5, C6, C7)
(Nerve to Serratus Anterior)
• 2 From the Trunks (Upper Trunk)
✓ Suprascapular nerve (C5, C6)
✓ Nerve to Subclavius (C5, C6)
• None from the divisions
• 13 From the Cords
❑ 3 From the Lateral Cord
❑ 5 From the Medial Cord
❑ 5 From the Posterior Cord
Axillary (Circumflex) Nerve
Origin: Posterior cord of Brachial Plexus (C5 & C6) in the axilla
Course: Important regions
❑ Pass through the quadrangular space along with the posterior
circumflex humeral artery & vein
❑ Winds Around the surgical neck of the humerus and divides into
its terminal branches
Long head
of triceps
Termination: Divides into 2 terminal branches:
Anterior & Posterior
Axillary (Circumflex) Nerve
Branches:
Muscular:Teres minor, Deltoid
Cutanous: Skin over deltoid, Upper lat. Cutanous n of
arm Anterior branch
of axillary nerve
Articular: shoulder joint
Cutaneous
branches
Nerve to
teres minor Upper lateral
cutaneous nerve
Posterior branch of the arm
of axillary nerve
Axillary (Circumflex) Nerve
Injury:
• Mechanism:
❑ Fracture of the surgical neck of the humerus
❑ shoulder dislocation
• Affection:
❑ Loss of sensation over the skin covering
deltoid muscle
❑ Paralysis of:
❑ Teres minor &
❑ Deltoid muscles
❑ Inability to abduct the arm (Shoulder
joint) from 15° to 90°.
❑ Deformity → Flat shoulder.
Long Thoracic Nerve Nerve
Origin: Roots the brachial plexus (Ventral Rami of C5, 6, 7)
Other names: Nerve to serratus anterior, nerve of Bell.
Function: Supplies Serratus Anterior Muscle
Injury:
❑Mechanism:
Commonly injured during Mastectomy.
❑Deformity: Winging of the scapula
With protrusion of the
medial border of the scapula
Musculocutaneous Nerve
Origin: Lateral Cord of the brachial plexus (C5, 6,)
Course: Important relations
❑ Pierces Coracobrachialis then
❑ Continues downwards between biceps brachii and brachialis
Termination: Continues as the lateral cutaneous nerve of the forearm
Branches:
1- Muscular branches to the muscles of the front of the arm.
- Brachialis: Medial half only.
- Biceps brachii.
- Coracobrachialis.
2- Articular: to the elbow joint.
3- Cutaneous: the lateral cutaneous nerve of the forearm.
Musculocutaneous Nerve
1. Sensory loss: loss of cutaneous sensation over the
lateral aspect of the forearm and the ball of the thumb.
2. Paralysis of voluntary muscles supplied:
➢ Paralysis of biceps brachii muscle: WEAK flexion at elbow
joint.
➢ Paralysis of coracobrachialis and medial part of brachialis.
3. Wasting of paralyzed muscle.
Median Nerve
Origin: Formed by 2 roots:
❑ Medial root from medial cord of brachial plexus
❑ Lateral root from lateral cord of brachial plexus
Root Value: c6, 7, 8,T1
Course:
❑ In the arm:
❑ Has triple relation to the brachial artery:
❑ Lateral then Anterior then Medial
❑ In the cubital fossa: Lies medial to the brachial artery
❑ In the forearm:
❑ Enters the forearm between the 2 heads of:
❑ Pronator teres
Median Nerve
Median
nerve
Course:
❑ In the forearm (Continued):
❑ Gives palmar cutaneous branch before
entering the carpal tunnel.
❑ In the hand:
❑ Enters the hand deep to the flexor
retinaculum (FR) (in the carpal tunnel). FDS
FCR
FR
Palmar
cut.
Br.
Median Nerve
Branches:
❑ In the axilla & arm: No branches
❑ In the forearm:
❑ Muscular: To muscles of the superficial compartment of
the anterior forearm EXCEPT Flexor Carpi Ulnaris.
❑ Anterior Interosseous nerve: To muscles of the deep
compartment of the anterior forearm EXCEPT ulnar
(medial) half of flexor digitorum profundus.
❑ Palmar cutaneous branch: Supplies the skin of the
lateral 2/3 of the palm.
❑ In the hand:
❑ Muscular: To thenar eminence (except adductor pollicis)
& lateral 2 lumbricals
❑ Cutaneous: To Palmar aspect of lateral 3.5 fingers &
skin over the dorsal aspect of their distal phalanges
Median Nerve
Branches:
❑ In the axilla & arm: No branches
❑ In the forearm:
❑ Muscular: To muscles of the superficial compartment of the
anterior forearm EXCEPT Flexor Carpi Ulnaris.
❑ Anterior Interosseous nerve: To muscles of the deep
compartment of the anterior forearm EXCEPT ulnar (medial)
half of flexor digitorum profundus.
❑ Palmar cutaneous branch: Supplies the skin of the lateral
2/3 of the palm.
❑ In the hand: Palm Dorsum
❑ Muscular: To thenar eminence (except adductor pollicis) &
lateral 2 lumbricals
❑ Cutaneous: To Palmar aspect of lateral 3.5 fingers &
skin
N.B. Inover the dorsal
Carpal aspectSyndrome:
Tunnel of their distal The
phalanges
palmar cutaneous branch is spared
Median Nerve
Injury:
❑ Deformity: Ape-hand deformity.
❑ 1. Sensory loss:
❑ Loss of cutaneous sensation over the lateral two-thirds of the palm of the
hand & palmar surface of the lateral three and half fingers.
❑ 2. Paralysis of muscles supplied:
❑ Paralysis of all the muscles of the front of forearm supplied by the median
nerve or by its anterior interosseous branch except the flexor carpi
ulnaris and the medial half of the flexor digitorum profundus muscles
which are supplied by the ulnar nerve.
❑ 3. Wasting of paralyzed muscle:
Ape-Hand
Ulnar Nerve
Origin: Medial Cord of the brachial plexus (C8 & T1)
Course:
❑ It then descends on the back of the medial epicondyle of the humerus.
❑ It enters the forearm by passing between the 2 heads of flexor carpi ulnaris.
❑ It enters the hand superficial to the flexor retinaculum lateral to pisiform
bone.
Termination: Divides into superficial & deep branches
Ulnar Nerve
Branches:
❑ In the axilla & arm: No branches
❑ In the forearm:
❑ Muscular: To Flexor carpi ulnaris and medial half of
Flexor Digitorum profundus.
❑ Articular: To the elbow joint.
❑ Palmar cutaneous branch: Supplies the palmar Flexor Digitorum
aspect of the medial 1/3 of the palm. Profundus
❑ Dorsal cutaneous branch: Supplies the dorsal
aspect of the medial 1/3 of the palm & dorsum of the
medial 1.5 fingers
❑ In the hand:
❑ Muscular: To all other muscles of the hand EXCEPT
thenar eminence and lateral 2 lumbricals
❑ Cutaneous: To Palmar aspect of medial 1.5 fingers
Ulnar Nerve
Injury:
❑ Deformity: Partial Claw hand.
1. Sensory loss:
❑ Loss of cutaneous sensation over both palmar and dorsal
surfaces of the medial third of the hand.&1,5 fingers.
2. Paralysis of voluntary muscles supplied:
❑ Medial 2 lumbricals paralysis → hyperextension of the MCP
joint and flexion of the IP joint of the little & ring fingers.
3. Wasting of paralyzed muscle.
Partial Claw Hand
Radial Nerve
Origin: From the posterior cord of the brachial plexus
Root Value: C5, 6, 7, 8,T1
Course:
❑ Passes through the lower triangular space (between the long
and medial heads of triceps).
❑ Runs with the profunda vessels in the spiral (radial) groove
❑ At the front of the arm it descends in the groove between the
brachialis and brachioradialis to the front of the elbow.
Radial Nerve
Branches:
❑ In the Axilla:
• Muscular:
❖ triceps. Radial nerve
• Cutaneous: Posterior cutaneous nerve of the arm. Inferior
❑ In the Spiral Groove: lateral
• Muscular: triceps and anconeus cutaneous
nerve of arm
❖ Cutaneous:
❑ Posterior cutaneous nerve of the forearm.
Radial Nerve
Branches:
❑ On the front of the arm:
• Muscular:
❖ To lateral ½ of brachialis
❖ Brachioradialis
❖ Extensor carpi radialis longus
• Articular: To the elbow joint.
Termination:
At the cubital fossa opposite the lateral epicondyle,
Divides into 2 terminal branches:
❑ Superficial (Sensory) branch
❑ Deep (Motor) branch:
called Posterior interosseous nerve
Posterior Interosseous nerve
Origin: From the radial nerve in front of the lateral epicondyle
Posterior
interosseous
branch of
radial nerve
Branches:
1- Muscular To all muscles of the back of the forearm EXCEPT:
Superficial
Anconeus, Brachioradialis & Extensor Carpi Radialis Longus branch of
2- Articular: to the inferior radioulnar & Wrist & intercarpal joints. radial nerve
3- Cutaneous: NONE.
N.B. Posterior interosseous nerve is PURELY MOTOR
Superficial Radial Nerve
Origin: From the radial nerve in front of the lateral epicondyle
.
Termination: on the dorsum of the hand by dividing
into 5 dorsal digital nerves supplying the lateral 3.5 fingers.
Radial Nerve
Injury:
❑ Deformity: Elbow, Wrist and Fingers drop.
❑ Mechanism: Saturday night palsy, crutch palsy,
fracture of midshaft of the humerus
1. Sensory loss:
❑ Loss of cutaneous sensation over the posterior and lateral surfaces
of the lower part of the arm and forearm.
❑ Loss of cutaneous sensation over the lateral two-thirds of the dorsal
surface of the hand and the dorsal surface of the lateral three and Saturday night palsy
half fingers (except the nails).
2. Paralysis of voluntary muscles supplied:
❑ Paralysis of all the extensor muscles of the wrist joint and fingers:
wrist drop and fingers drop.
3. Wasting of paralyzed muscles.
Wrist and finger drop
Injury of Brachial Plexus
Upper Trunk: Erb’s Duchenne Palsy
• Mechanism:
❑ Traction on the head during delivery
❑ Fall with Increased angle between neck & Shoulder
• Roots affected: C5 & C6
• Deformity: Waiter’s tip position
Injury of Brachial Plexus
Lower Trunk: Klumpke’s Palsy
• Mechanism:
❑ Pull on the upper limb during delivery.
❑ Upward Traction & Abduction of upper limb.
❑ Cervical rib: compressing the lower trunk.
• Roots affected: C8 & T1
• Deformity: Complete Claw Hand
❑ Hyperextension of MCP joints
❑ Flexion of IP joints
Complete
Claw
Hand
Quiz
Which deformity results from injury to the lower
trunk of the brachial plexus?
A) Complete Claw hand
B) Partial Claw hand
C) Waiter’s tip position
D) Flat shoulder
E) Ape-hand deformity
Answer: A
Quiz
Identify the Deformity & the nerve Injured
Waiter’s tip Complete Partial Ape hand Wrist & Finger drop Winging of scapula
position claw hand claw hand
Upper trunk Lower trunk Ulnar Long thoracic
Median Radial
of brachial of brachial nerve Nerve
nerve nerve
plexus plexus
