Aberrant Dual Origin of the Dorsal Scapular Nerve and Its Communication Anatomy Section with Long Thoracic Nerve: an Unusual Variation of the Brachial Plexus
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Brachial-Plexopathy.Pdf
Brachial Plexopathy, an overview Learning Objectives: The brachial plexus is the network of nerves that originate from cervical and upper thoracic nerve roots and eventually terminate as the named nerves that innervate the muscles and skin of the arm. Brachial plexopathies are not common in most practices, but a detailed knowledge of this plexus is important for distinguishing between brachial plexopathies, radiculopathies and mononeuropathies. It is impossible to write a paper on brachial plexopathies without addressing cervical radiculopathies and root avulsions as well. In this paper will review brachial plexus anatomy, clinical features of brachial plexopathies, differential diagnosis, specific nerve conduction techniques, appropriate protocols and case studies. The reader will gain insight to this uncommon nerve problem as well as the importance of the nerve conduction studies used to confirm the diagnosis of plexopathies. Anatomy of the Brachial Plexus: To assess the brachial plexus by localizing the lesion at the correct level, as well as the severity of the injury requires knowledge of the anatomy. An injury involves any condition that impairs the function of the brachial plexus. The plexus is derived of five roots, three trunks, two divisions, three cords, and five branches/nerves. Spinal roots join to form the spinal nerve. There are dorsal and ventral roots that emerge and carry motor and sensory fibers. Motor (efferent) carries messages from the brain and spinal cord to the peripheral nerves. This Dorsal Root Sensory (afferent) carries messages from the peripheral to the Ganglion is why spinal cord or both. A small ganglion containing cell bodies of sensory NCS’s sensory fibers lies on each posterior root. -
Branching Pattern of the Posterior Cord of the Brachial Plexus: a Natomy Section a Cadaveric Study
Original Article Branching Pattern of the Posterior Cord of the Brachial Plexus: natomy Section A A Cadaveric Study PRITI CHAUDHARY, RAJAN SINGLA, GURDEEP KALSEY, KAMAL ARORA ABSTRACT Results: normal branching pattern of the posterior cord was Introduction: Anatomical variations in different parts of the brachial encountered in 52 (86.67%) limbs, the remaining 8 (13.33%) being plexus have been described in humans by many authors, although variants in one form or the other. The upper subscapular nerve, these have not been extensively catalogued. These variations the thoracodorsal nerve and the axillary nerve were seen to arise are of clinical significance for the surgeons, radiologists and the normally in 91.66%, 96.66% and 98.33% of the limbs respectively. anatomists. The posterior division of the upper trunk being the parent of the variants of all these. The lower subscapular nerve had a normal In a study of 60 brachial plexuses which Material and Methods: origin in 96.66% of the limbs, with the axillary nerve being the belonged to 30 cadavers (male:female ratio = 28:02 ) obtained from parent in its variants, while the radial nerve had a normal origin the Department of Anatomy, Govt. Medical College, Amritsar, the in all of the limbs. Almost all the branches of the posterior cord brachial plexuses were exposed as per the standard guidelines. emanated distally on the left side as compared to the right side. The formation and the branching pattern of the posterior cord have been reported here. The upper subscapular, lower subscapular, Conclusion: The present study on adult human cadavers was an thoracodorsal and the axillary nerves usually arise from the posterior essential prerequisite for the initial built up of the data base at the cord of the brachial plexus. -
Anatomical Study of the Brachial Plexus in Human Fetuses and Its Relation with Neonatal Upper Limb Paralysis
ORIGINAL ARTICLE Anatomical study of the brachial plexus Official Publication of the Instituto Israelita de Ensino e Pesquisa Albert Einstein in human fetuses and its relation with neonatal upper limb paralysis ISSN: 1679-4508 | e-ISSN: 2317-6385 Estudo anatômico do plexo braquial de fetos humanos e sua relação com paralisias neonatais do membro superior Marcelo Rodrigues da Cunha1, Amanda Aparecida Magnusson Dias1, Jacqueline Mendes de Brito2, Cristiane da Silva Cruz1, Samantha Ketelyn Silva1 1 Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brazil. 2 Centro Universitário Padre Anchieta, Jundiaí, SP, Brazil. DOI: 10.31744/einstein_journal/2020AO5051 ❚ ABSTRACT Objective: To study the anatomy of the brachial plexus in fetuses and to evaluate differences in morphology during evolution, or to find anatomical situations that can be identified as the cause of obstetric paralysis. Methods: Nine fetuses (12 to 30 weeks of gestation) stored in formalin were used. The supraclavicular and infraclavicular parts of the brachial plexus were dissected. Results: In its early course, the brachial plexus had a cord-like shape when it passed through the scalene hiatus. Origin of the phrenic nerve in the brachial plexus was observed in only one fetus. In the deep infraclavicular and retropectoralis minor spaces, the nerve fibers of the brachial plexus were distributed in the axilla and medial bicipital groove, where they formed the nerve endings. Conclusion: The brachial plexus of human fetuses presents variations and relations with anatomical structures that must be considered during clinical and surgical procedures for neonatal paralysis of the upper limbs. How to cite this article: Cunha MR, Dias AA, Brito JM, Cruz CS, Silva Keywords: Brachial plexus/anatomy & histology; Fetus/abnormalities; Paralysis SK. -
Risk of Encountering Dorsal Scapular and Long Thoracic Nerves During Ultrasound-Guided Interscalene Brachial Plexus Block with Nerve Stimulator
Korean J Pain 2016 July; Vol. 29, No. 3: 179-184 pISSN 2005-9159 eISSN 2093-0569 http://dx.doi.org/10.3344/kjp.2016.29.3.179 | Original Article | Risk of Encountering Dorsal Scapular and Long Thoracic Nerves during Ultrasound-guided Interscalene Brachial Plexus Block with Nerve Stimulator Department of Anesthesiology and Pain Medicine, Wonkwang University College of Medicine, Wonkwang Institute of Science, Iksan, *Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea Yeon Dong Kim, Jae Yong Yu*, Junho Shim*, Hyun Joo Heo*, and Hyungtae Kim* Background: Recently, ultrasound has been commonly used. Ultrasound-guided interscalene brachial plexus block (IBPB) by posterior approach is more commonly used because anterior approach has been reported to have the risk of phrenic nerve injury. However, posterior approach also has the risk of causing nerve injury because there are risks of encountering dorsal scapular nerve (DSN) and long thoracic nerve (LTN). Therefore, the aim of this study was to evaluate the risk of encountering DSN and LTN during ultrasound-guided IBPB by posterior approach. Methods: A total of 70 patients who were scheduled for shoulder surgery were enrolled in this study. After deciding insertion site with ultrasound, awake ultrasound-guided IBPB with nerve stimulator by posterior approach was performed. Incidence of muscle twitches (rhomboids, levator scapulae, and serratus anterior muscles) and current intensity immediately before muscle twitches disappeared were recorded. Results: Of the total 70 cases, DSN was encountered in 44 cases (62.8%) and LTN was encountered in 15 cases (21.4%). Both nerves were encountered in 10 cases (14.3%). -
Muscle Attachment Sites in the Upper Limb
This document was created by Alex Yartsev ([email protected]); if I have used your data or images and forgot to reference you, please email me. Muscle Attachment Sites in the Upper Limb The Clavicle Pectoralis major Smooth superior surface of the shaft, under the platysma muscle Deltoid tubercle: Right clavicle attachment of the deltoid Deltoid Axillary nerve Acromial facet Trapezius Sternocleidomastoid and Trapezius innervated by the Spinal Accessory nerve Sternocleidomastoid Conoid tubercle, attachment of the conoid ligament which is the medial part of the Sternal facet coracoclavicular ligament Conoid ligament Costoclavicular ligament Acromial facet Impression for the Trapezoid line, attachment of the costoclavicular ligament Subclavian groove: Subclavius trapezoid ligament which binds the clavicle to site of attachment of the Innervated by Nerve to Subclavius which is the lateral part of the the first rib subclavius muscle coracoclavicular ligament Trapezoid ligament This document was created by Alex Yartsev ([email protected]); if I have used your data or images and forgot to reference you, please email me. The Scapula Trapezius Right scapula: posterior Levator scapulae Supraspinatus Deltoid Deltoid and Teres Minor are innervated by the Axillary nerve Rhomboid minor Levator Scapulae, Rhomboid minor and Rhomboid Major are innervated by the Dorsal Scapular Nerve Supraspinatus and Infraspinatus innervated by the Suprascapular nerve Infraspinatus Long head of triceps Rhomboid major Teres Minor Teres Major Teres Major -
Examination of the Shoulder Bruce S
Examination of the Shoulder Bruce S. Wolock, MD Towson Orthopaedic Associates 3 Joints, 1 Articulation 1. Sternoclavicular 2. Acromioclavicular 3. Glenohumeral 4. Scapulothoracic AC Separation Bony Landmarks 1. Suprasternal notch 2. Sternoclavicular joint 3. Coracoid 4. Acromioclavicular joint 5. Acromion 6. Greater tuberosity of the humerus 7. Bicipital groove 8. Scapular spine 9. Scapular borders-vertebral and lateral Sternoclavicular Dislocation Soft Tissues 1. Rotator Cuff 2. Subacromial bursa 3. Axilla 4. Muscles: a. Sternocleidomastoid b. Pectoralis major c. Biceps d. Deltoid Congenital Absence of Pectoralis Major Pectoralis Major Rupture Soft Tissues (con’t) e. Trapezius f. Rhomboid major and minor g. Latissimus dorsi h. Serratus anterior Range of Motion: Active and Passive 1. Abduction - 90 degrees 2. Adduction - 45 degrees 3. Extension - 45 degrees 4. Flexion - 180 degrees 5. Internal rotation – 90 degrees 6. External rotation – 45 degrees Muscle Testing 1. Flexion a. Primary - Anterior deltoid (axillary nerve, C5) - Coracobrachialis (musculocutaneous nerve, C5/6 b. Secondary - Pectoralis major - Biceps Biceps Rupture- Longhead Muscle Testing 2. Extension a. Primary - Latissimus dorsi (thoracodorsal nerve, C6/8) - Teres major (lower subscapular nerve, C5/6) - Posterior deltoid (axillary nerve, C5/6) b. Secondary - Teres minor - Triceps Abduction Primary a. Middle deltoid (axillary nerve, C5/6) b. Supraspinatus (suprascapular nerve, C5/6) Secondary a. Anterior and posterior deltoid b. Serratus anterior Deltoid Ruputure Axillary Nerve Palsy Adduction Primary a. Pectoralis major (medial and lateral pectoral nerves, C5-T1 b. Latissimus dorsi (thoracodorsal nerve, C6/8) Secondary a. Teres major b. Anterior deltoid External Rotation Primary a. Infraspinatus (suprascapular nerve, C5/6) b. Teres minor (axillary nerve, C5) Secondary a. -
The SPA Arrangement of the Branches of the Upper Trunk of the Brachial Plexus: a Correction of a Longstanding Misconception and a New Diagram of the Brachial Plexus
LABORATORY INVESTIGATION J Neurosurg 125:350–354, 2016 The SPA arrangement of the branches of the upper trunk of the brachial plexus: a correction of a longstanding misconception and a new diagram of the brachial plexus Amgad Hanna, MD Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin OBJECTIVE Brachial plexus (BP) diagrams in most textbooks and papers represent the branches and divisions of the upper trunk (UT) in the following sequence from cranial to caudal: suprascapular nerve, anterior division, and then posterior division. This concept contradicts what is seen in the operating room and is noticed by most peripheral nerve surgeons. This cadaveric study was conducted to look specifically at the exact pattern of branching of the upper trunk of the BP. METHODS Ten cadavers (20 BPs) were dissected. Both supra- and infraclavicular exposures were performed. The clavicle was retracted or resected to identify the divisions of the BP. A posterior approach was used in 2 cases. RESULTS In all dissections the origin of the posterior division was in a more cranial and dorsal plane in relation to the anterior division. In most dissections the supra scapular nerve branched off distally from the UT, giving it the appearance of a trifurcation, taking off just cranial and dorsal to the posterior division. The branching pattern of the UT consistently had the following sequential arrangement from cranial and posterior to caudal and anterior: suprascapular nerve (S), posterior division (P), and anterior division (A), hence the acronym SPA. CONCLUSIONS Supraclavicular exposure of the BP exposes only the trunks and divisions. Recognizing the “SPA” arrangement of the branches helps in identifying the correct targets for neurotization, especially given that these 3 branches are the most common targets for BP repair. -
Dorsal Scapular Nerve Neuropathy: a Narrative Review of the Literature Brad Muir, Bsc.(Hons), DC, FRCCSS(C)1
ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2017/128–144/$2.00/©JCCA 2017 Dorsal scapular nerve neuropathy: a narrative review of the literature Brad Muir, BSc.(Hons), DC, FRCCSS(C)1 Objective: The purpose of this paper is to elucidate Objectif : Ce document a pour objectif d’élucider this little known cause of upper back pain through a cette cause peu connue de douleur dans le haut du narrative review of the literature and to discuss the dos par un examen narratif de la littérature, ainsi que possible role of the dorsal scapular nerve (DSN) in de discuter du rôle possible du nerf scapulaire dorsal the etiopathology of other similar diagnoses in this (NSD) dans l’étiopathologie d’autres diagnostics area including cervicogenic dorsalgia (CD), notalgia semblables dans ce domaine, y compris la dorsalgie paresthetica (NP), SICK scapula and a posterolateral cervicogénique (DC), la notalgie paresthésique (NP), arm pain pattern. l’omoplate SICK et un schéma de douleur postéro- Background: Dorsal scapular nerve (DSN) latérale au bras. neuropathy has been a rarely thought of differential Contexte : La neuropathie du nerf scapulaire dorsal diagnosis for mid scapular, upper to mid back and (NSD) constitue un diagnostic différentiel rare pour la costovertebral pain. These are common conditions douleur mi-scapulaire, costo-vertébrale et au bas/haut presenting to chiropractic, physiotherapy, massage du dos. Il s’agit de troubles communs qui surgissent therapy and medical offices. dans les cabinets de chiropratique, de physiothérapie, de Methods: The methods used to gather articles for this massothérapie et de médecin. paper included: searching electronic databases; and Méthodologie : Les méthodes utilisées pour hand searching relevant references from journal articles rassembler les articles de ce document comprenaient la and textbook chapters. -
Pectoral Region and Axilla Doctors Notes Notes/Extra Explanation Editing File Objectives
Color Code Important Pectoral Region and Axilla Doctors Notes Notes/Extra explanation Editing File Objectives By the end of the lecture the students should be able to : Identify and describe the muscles of the pectoral region. I. Pectoralis major. II. Pectoralis minor. III. Subclavius. IV. Serratus anterior. Describe and demonstrate the boundaries and contents of the axilla. Describe the formation of the brachial plexus and its branches. The movements of the upper limb Note: differentiate between the different regions Flexion & extension of Flexion & extension of Flexion & extension of wrist = hand elbow = forearm shoulder = arm = humerus I. Pectoralis Major Origin 2 heads Clavicular head: From Medial ½ of the front of the clavicle. Sternocostal head: From; Sternum. Upper 6 costal cartilages. Aponeurosis of the external oblique muscle. Insertion Lateral lip of bicipital groove (humerus)* Costal cartilage (hyaline Nerve Supply Medial & lateral pectoral nerves. cartilage that connects the ribs to the sternum) Action Adduction and medial rotation of the arm. Recall what we took in foundation: Only the clavicular head helps in flexion of arm Muscles are attached to bones / (shoulder). ligaments / cartilage by 1) tendons * 3 muscles are attached at the bicipital groove: 2) aponeurosis Latissimus dorsi, pectoral major, teres major 3) raphe Extra Extra picture for understanding II. Pectoralis Minor Origin From 3rd ,4th, & 5th ribs close to their costal cartilages. Insertion Coracoid process (scapula)* 3 Nerve Supply Medial pectoral nerve. 4 Action 1. Depression of the shoulder. 5 2. Draw the ribs upward and outwards during deep inspiration. *Don’t confuse the coracoid process on the scapula with the coronoid process on the ulna Extra III. -
High-Resolution 3T MR Neurography of the Brachial Plexus and Its Branches, with Emphasis on 3D Imaging
REVIEW ARTICLE High-Resolution 3T MR Neurography of the Brachial Plexus and Its Branches, with Emphasis on 3D Imaging A. Chhabra, G.K. Thawait, T. Soldatos, R.S. Thakkar, F. Del Grande, M. Chalian, and J.A. Carrino ABSTRACT SUMMARY: With advancement in 3D imaging, better fat-suppression techniques, and superior coil designs for MR imaging and the increasing availability and use of 3T magnets, the visualization of the complexity of the brachial plexus has become facile. The relevant imaging findings are described for normal and pathologic conditions of the brachial plexus. These radiologic findings are supported by clinical and/or EMG/surgical data, and corresponding high-resolution MR neurography images are illustrated. Because the brachial plexus can be affected by a plethora of pathologies, resulting in often serious and disabling complications, a better radiologic insight has great potential in aiding physicians in rendering superior services to patients. ABBREVIATIONS: EMG ϭ electromyography; MIP ϭ maximum intensity projection; MRN ϭ MR neurography; SPACE ϭ sampling perfection with application- optimized contrasts by using different flip angle; STIR ϭ short tau inversion recovery, TOS ϭ thoracic outlet syndrome he brachial plexus is a network of nerve confluences and ram- nerve (C5-C7) to the serratus anterior muscle arise directly from Tifications, which combine to form the large terminal branches the nerve roots.1,2,5 that supply motor and sensory branches to the upper extremities. The clinical differentiation of brachial plexopathy from other Trunks and Their Anatomic Relations spine-related abnormalities often poses a considerable diagnostic The C5 and C6 nerve roots compose the upper trunk, C7 contin- challenge, and electrodiagnostic tests are difficult to perform due ues as the middle trunk, and C8 and T1 compose the lower trunk. -
Variations in the Formation of the Trunks of Brachial Plexus
Original article http://dx.doi.org/10.4322/jms.ao063614 Variations in the formation of the trunks of brachial plexus Aragão, JA.1,2*, Melo, LO.2, Barreto, ATF.2, Da Silva Leal, AT.2 and Reis, FP.1 1Departamento de Medicina, Universidade Tiradentes – UNIT, CEP 49010-390, Aracaju, SE, Brasil 2Departamento de Morfologia/Anatomia, Universidade Federal de Sergipe – UFS, CEP 49100-000, Aracaju, SE, Brasil *E-mail: [email protected] Abstract Background: The brachial plexus is a complex network of nerves that innervates the upper limbs. Variations in brachial plexus are common, as well as its relationships with other anatomical structures, gaining thus clinical and surgical importance. The aim of this study was to report variations in the formation of the trunks of brachial plexus. Material and Methods: Forty upper limbs from 20 human fetuses were used, fixed and kept in 10% formol solution. Fetal age was estimated from the hallux-calcaneus length and ranged from 20 to 37 weeks of gestation, with a mean of 25.63 weeks. The plexus were dissected without the aid of optical instruments, and the access route for dissection began 2 cm below the mastoid process, followed the posterior border of the sternocleidomastoid muscle until the medial third of the clavicle, and then went through the deltopectoral groove until the arm. Results: Of the 40 plexuses investigated, 37 (92.5%) had the usual trunk formation, and 3 (7.5%) showed variation in its formation. Among these, in 2 (5%) plexuses of a single fetus, the upper trunk was formed by the C5, C6 and C7 roots, the middle trunk by the C8 root, and the lower trunk by the T1 root, both on left and right sides. -
Electrodiagnosis of Brachial Plexopathies and Proximal Upper Extremity Neuropathies
Electrodiagnosis of Brachial Plexopathies and Proximal Upper Extremity Neuropathies Zachary Simmons, MD* KEYWORDS Brachial plexus Brachial plexopathy Axillary nerve Musculocutaneous nerve Suprascapular nerve Nerve conduction studies Electromyography KEY POINTS The brachial plexus provides all motor and sensory innervation of the upper extremity. The plexus is usually derived from the C5 through T1 anterior primary rami, which divide in various ways to form the upper, middle, and lower trunks; the lateral, posterior, and medial cords; and multiple terminal branches. Traction is the most common cause of brachial plexopathy, although compression, lacer- ations, ischemia, neoplasms, radiation, thoracic outlet syndrome, and neuralgic amyotro- phy may all produce brachial plexus lesions. Upper extremity mononeuropathies affecting the musculocutaneous, axillary, and supra- scapular motor nerves and the medial and lateral antebrachial cutaneous sensory nerves often occur in the context of more widespread brachial plexus damage, often from trauma or neuralgic amyotrophy but may occur in isolation. Extensive electrodiagnostic testing often is needed to properly localize lesions of the brachial plexus, frequently requiring testing of sensory nerves, which are not commonly used in the assessment of other types of lesions. INTRODUCTION Few anatomic structures are as daunting to medical students, residents, and prac- ticing physicians as the brachial plexus. Yet, detailed understanding of brachial plexus anatomy is central to electrodiagnosis because of the plexus’ role in supplying all motor and sensory innervation of the upper extremity and shoulder girdle. There also are several proximal upper extremity nerves, derived from the brachial plexus, Conflicts of Interest: None. Neuromuscular Program and ALS Center, Penn State Hershey Medical Center, Penn State College of Medicine, PA, USA * Department of Neurology, Penn State Hershey Medical Center, EC 037 30 Hope Drive, PO Box 859, Hershey, PA 17033.