Brachial plexus

The brachial plexus is formed by five roots, the union of the anterior divisions of the lower four cervical nerves and the greater part of the anterior division of the first thoracic nerve; the fourth cervical usually gives a branch to the fifth cervical, and the first thoracic frequently receives one from the second thoracic.

The plexus extends from the lower part of the side of the neck to the axilla.

The nerves which form it are nearly equal in size, but their mode of communication is subject to some variation. The following is, however, the most constant arrangement.

• The fifth and sixth cervical unite soon after their exit from the intervertebral foramina to form a trunk.
• The eighth cervical and first thoracic also unite to form one trunk, while the seventh cervical runs out alone.
• Three trunks—upper, middle, and lower—are thus formed, and, as they pass beneath the clavicle, each splits into an anterior and a posterior division.
• The anterior divisions of the upper and middle trunks unite to form a cord, which is situated on the lateral side of the second part of the axillary artery, and is called the lateral cord or fasciculus of the plexus. 
• The anterior division of the lower trunk passes down on the medial side of the axillary artery, and forms the medial cord or fasciculus of the brachial plexus. 
• The posterior divisions of all three trunks unite to form the posterior cord or fasciculus of the plexus, which is situated behind the second portion of the axillary artery.

Relations.—In the neck, the brachial plexus lies in the posterior triangle, being covered by the skin, Platysma, and deep fascia; it is crossed by the supraclavicular nerves, the inferior belly of the Omohyoideus, the external jugular vein, and the transverse cervical artery. It emerges between the Scaleni anterior and medius; its upper part lies above the third part of the subclavian artery, while the trunk formed by the union of the eighth cervical and first thoracic is placed behind the artery; the plexus next passes behind the clavicle, the Subclavius, and the transverse scapular vessels, and lies upon the first digitation of the Serratus anterior, and the Subscapularis. In the axilla it is placed lateral to the first portion of the axillary artery; it surrounds the second part of the artery, one cord lying medial to it, one lateral to it, and one behind it; at the lower part of the axilla it gives off its terminal branches to the upper limb.

Branches of Communication.—Close to their exit from the intervertebral foramina the fifth and sixth cervical nerves each receive a gray ramus communicans from the middle cervical ganglion of the sympathetic trunk, and the seventh and eighth cervical similar twigs from the inferior ganglion. The first thoracic nerve receives a gray ramus from, and contributes a white ramus to, the first thoracic ganglion. On the Scalenus anterior the phrenic nerve is joined by a branch from the fifth cervical.

Branches of Distribution.—The branches of distribution of the brachial plexus may be arranged into two groups, viz., those given off above and those below the clavicle:

Supraclavicular Branches:

• Dorsal Scapular : 5C
• Suprascapular: 5, 6 C
• Nerve to Subclavius: 5, 6 C
• Long thoracic: 5,6,7 C
• To Longus colli and Scaleni: 5,6,7,8 C

Infraclavicular Branches:

• Lateral cord
  • Musculocutaneous: 5, 6, 7 C
  • Lateral anterior thoracic: 5, 6, 7 C
  • Lateral head of median: 6, 7 C
   
• Medial cord
  • Medial anterior thoracic: 8 C, 1 T
  • Medial antibrachial cutaneous: 8 C, 1 T
  • Medial brachial cutaneous: 8 C, 1 T
  • Ulnar: 8 C, 1 T
  • Medial head of median: 8 C, 1 T
   
• Posterior cord:
  • Upper subscapular: 5, 6 C
  • Lower subscapular: 5, 6 C
  • Thoracodorsal: 5, 6, 7 C
  • Axillary: 5, 6 C
  • Radial: 6, 7, 8 C, 1 T