Section One  The basics
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Anatomy of the brachial plexus
Neal Chen, MD, Lynda J.-S. Yang, MD, PhD, Kevin C. Chung, MD, MS
SUMMARY BOX
1. The brachial plexus can be organized into 5 zones:
spinal nerve roots, trunks, divisions, cords and
terminal branches.
2. C5-6 nerve roots form the upper trunk, C7 nerve root
forms the middle trunk and C8-T1 nerve roots form
the lower trunk.
3. The anterior divisions of the upper and middle trunks
form the lateral cord, the posterior divisions of all the
trunks form the posterior cord, and the anterior
division of the lower trunk forms the medial cord.
4. The lateral cord and the medial cord forms the
median nerve.
5. The lateral cord terminates into the
musculocutaneous nerve, and the medial cord
terminates into the ulnar nerve.
Introduction
The brachial plexus is a beautiful, intricate, and
complex structure that comprises connections of
the spinal nerves to their terminal branches in the
upper extremity. There are multiple descriptions
through which this neurological conduit can be
decoded: (1) schematic anatomy, (2) surgical
anatomy and its relationships with surrounding
tissues, and (3) descriptions of its anatomical
variations.
Each of these 3 descriptions has advantages
and shortcomings. Surgical anatomy is helpful in
describing the relationships with nearby structures
and can serve as a guide to approaching the brachial
plexus, but this description does not address
intraplexal anatomy directly and can overlook
important internal variations. Schematic anatomy
provides a framework with which function of the
© 2012, Elsevier Inc
DOI: 10.1016/B978-1-4377-0575-1.00001-0
CHAPTER 1 
6. The posterior cord terminates into the axillary nerve
and the radial nerve.
7. The omohyoid muscle separates the posterior triangle
into a superior, omotrapezial triangle and an inferior,
omoclavicular triangle.
8. The upper and middle trunks and their divisions
generally lie in the omotrapezial triangle, whereas the
lower trunk lies in the omoclavicular triangle
9. The upper, middle, and lower trunks ramify into their
respective divisions posterior to the clavicle.
10. The divisions form cords around the axillary artery,
and each cord is named based on its relationship to
the artery.
plexus can be understood and lesions within the
plexus can be identified. However, schematic
anatomy can be misleading, especially when there
are anatomic variations. Finally, the description
of anatomic variability is comprehensive, but
unwieldy. The goal of this chapter is to capitalize
on the advantages of each of these approaches to
provide an understandable yet thorough treatment
of brachial plexus anatomy.
Historical perspective
At the end of the 19th century, understanding of
the brachial plexus relied on large treatises describ-
ing collections of anatomic dissections.1 The
strength of these descriptions was fortified by
the number of dissections available; however, the
quality of these dissections remains uncertain. A
 Section One  The basics
number of the anatomic specimens were dissected
by medical students, and the accuracy, especially
of anatomic variations, is debatable. Many of these
descriptions describe copious variations in how
the trunks of the plexus coalesce, either into one
solid cord, 2 cords, or multiple cords. Many of
these early descriptions have not withstood the
test of time.
During the same period, a number of works
began to codify what was believed to be a “true
form” of the plexus. Kerr, Walsh, and Harris2-4
described a series of personally performed or scru-
tinized dissections that suggested there was far less
anatomic variation than previously believed. Con-
vergence of these descriptions of the brachial plexus
has allowed a more schematic presentation from
which a general foundation can be constructed.
As the understanding of the brachial plexus
became more complete, what remained unclear was
which cervical roots contributed to it. Some authors
believed the plexus was pre-fixed (the plexus origi-
nated more cranially than normal and included the
C4 nerve root) or that the plexus was post-fixed (the
plexus originated more caudally to include the T2
nerve root).1 Other authors believed that instead of
having a more cranial or caudal origin, the brachial
plexus had a broader or a less broad origin. An even
more complex problem was the topographic
mapping of nerves within the brachial plexus. A
number of authors have pursued microscopic, fas-
cicular dissection of the plexus in order to advance
our understanding of the connections within this
complex structure.5
Advances in developmental biology have yielded
some insights into how the plexus is formed and
why contributions to the plexus are not entirely
consistent. Molecular events result in vertebrate seg-
mentation, and from these vertebrate segments,
neural crest cells migrate from the axis to the
periphery. Although these processes are not fully
understood, evidence is accumulating that these
molecular events ultimately dictate the final mor-
phology of the brachial plexus.
Primate anatomy also provides some insight into
the human brachial plexus. Comparative anatomy
suggests an increasing pattern of progressive organi-
zation. In lower primates, the artery lies superficial
to the brachial plexus and has a larger degree of
variation. In higher primates, the artery also lies
superficial to the brachial plexus, but there is a
tendency toward a more organized, consistent bra-
chial plexus. In humans, the axillary artery lies deep
4
to the anterior divisions to become intimate with
the cords (which are named by their relationship
to the axillary artery), and the brachial plexus main-
tains a highly organized and consistent structure
throughout its course.
Schematic anatomy
The standard schematic diagram used to describe
the brachial plexus uses 5 zones: (1) spinal nerve
roots, (2) trunks, (3) divisions, (4) cords, and (5)
terminal branches.6 The C5 to T1 nerve roots typi-
cally contribute to the brachial plexus. The C5
and C6 roots coalesce to form the upper trunk,
the C7 root forms the middle trunk, and the C8
and T1 roots coalesce to form the lower trunk.
Each trunk divides into an anterior and posterior
division. All 3 posterior divisions join to form the
posterior cord. The anterior divisions from the
upper and middle trunk form the lateral cord,
and the anterior division from the lower trunk
forms the medial cord. The posterior cord ulti-
mately branches into the terminal branches of the
axillary and radial nerves. The lateral cord and
medial cord each produce a branch that contributes
to form the median nerve. In addition to its con-
tribution to the median nerve, the lateral cord
terminates in the musculocutaneous nerve, and
the medial cord terminates in the ulnar nerve
(Figure 1.1).
A number of terminal branches (nerves) arise
from various zones of the basic structure; knowing
these branches and their function facilitates locali-
zation of a potential lesion. For instance, the dorsal
scapular nerve arises quite proximally from C5, and
the long thoracic nerve arises from the nerve roots
of C5 to C7; lack of function of either nerve implies
a proximal injury of the brachial plexus at the level
of the nerve roots. Similarly, the phrenic nerve
arises from C3, C4, and C5; diaphragmatic paralysis
is also consistent with a proximal lesion of the
brachial plexus. The upper trunk gives origin to the
suprascapular nerve; lack of supraspinatus and
infraspinatus function in the context of deltoid and
biceps weakness implies a lesion affecting the upper
trunk. More distally, the lateral cord gives rise to the
lateral pectoral nerve; the posterior cord gives rise
to the upper subscapular nerve, the thoracodorsal
nerve, and the lower subscapular nerve; the medial
cord gives rise to the medial pectoral nerve, the
medial brachial cutaneous nerve, and the medial

ROOTS
TRUNKS
Long thoracic
nerve
Dorsal
scapular
Suprascapular
nerve
C5 nerve
C6
C7
C8
T1
Medial pectoral nerve
Medial brachial cutanous nerve
Medial antebrachial cutanous nerve
Figure 1.1  Schematic diagram of the brachial plexus.
antebrachial cutaneous nerve (Figure 1.1). Similar
logic can be applied to these nerves to determine
the site of injury within the brachial plexus.
This basic schematic anatomy provides a crucial
foundation from which to understand surgical ana-
tomic relationships, and provides a benchmark
against which to measure anatomic variations.
Surgical anatomy (relationship
of the brachial plexus to
surrounding structures)
As described above, the brachial plexus has 5
roots (C5-T1), 3 trunks (upper, middle, and
lower), 6 divisions (2 divisions, anterior and pos-
terior, per trunk), 3 cords (lateral, posterior,
and medial) and 5 main terminal nerve branches
Anatomy of the brachial plexus 1
DIVISIONS
CORDS
Lateral pectoral
nerve
BRANCHES
Musculocutaneous nerve
Axillary nerve
Radial nerve
Median nerve
Ulnar nerve
Lower subscapular nerve
Thoracodorsal nerve
Upper subscapular nerve
(musculocutaneous, radial, axillary, median, and
ulnar). Grossly, the brachial plexus emerges in the
posterior triangle of the neck (bordered by the ster-
nocleidomastoid and trapezius muscles, clavicle,
and occiput). The neck is commonly conceptual-
ized as a set of triangles bounded by identifiable
structures. The sternocleidomastoid muscle divides
the neck into an anterior and posterior triangle. The
omohyoid muscle separates the posterior triangle
into a superior, omotrapezial triangle and an infe-
rior, omoclavicular triangle. The upper and middle
trunks and their divisions generally lie in the omo-
trapezial triangle, whereas the lower trunk lies in
the omoclavicular triangle (Figure 1.2).
Note that the spinal accessory nerve emerges pos-
terior to the sternocleidomastoid muscle, 2/3 of the
way up from the sternum to the mastoid, and
travels relatively superficially toward the trapezius.
5
 Section One  The basics
Sternocleidomastoid
Omohyoid
Posterior triangle
Omoclavicular triangle
Figure 1.2  Triangles of the neck.
More specifically, the trunks of the brachial plexus
emerge within the interscalene triangle bordered
by the anterior scalene, middle scalene, and the
clavicle.
The subclavian artery also travels through the
interscalene triangle, whereas the subclavian vein
travels anterior to the anterior scalene. The anterior
scalene attaches to the anterior tubercle of the
transverse process of the vertebrae and the clavicle,
and the middle scalene attaches to the posterior
tubercle of the transverse process; the anterior
tubercle of C6 is particularly bulbous (Chassaignac’s
tubercle) and can be used as an intraoperative
marker.
Proximal anatomical relationships
The dorsal rootlet (sensory) and ventral rootlet
(motor) converge to form a spinal nerve root. These
2 structures converge approximately at the level of
neural foramen (Figure 1.3). The cell bodies of the
axons of the sensory rootlet reside in the dorsal root
ganglion (outside of the spinal cord), whereas cell
bodies of the motor rootlet lie within the anterior
horn of the spinal cord. Knowledge of this anatomy
not only facilitates intraoperative surgical planning
but also the understanding of preoperative electro-
diagnostic studies.
The nerve root is enveloped by the epineurium,
which is confluent with the dura. The nerve roots
6
Sympathetic
nerve Spinal cord
Dorsal root Ventral rootlet
ganglion Dorsal rootlet
Ventral rami
Dorsal rami
Omotrapezial
triangle
Trapezius Figure 1.3  Axial representation of the spinal column
demonstrating the ventral and dorsal rootlets converging into
spinal nerve roots and their relationship to the sympathetic
ganglia.
contributing to the trunks exit from their neural
foramina and run along the bony groove between
the anterior and posterior tubercles of the vertebrae.
These bony “chutes” are well-formed for the nerves
comprising the upper trunk (C5, C6), and more
abbreviated for the nerves comprising the lower
trunk. In addition, there is less connective tissue
binding the lower nerve roots to the bony chutes
when compared to the upper nerve roots. Conse-
quently, the lower nerve roots (C8, T1) are prone
to preganglionic (avulsion) injury, whereas nerves
comprising the upper trunk tend to sustain post-
ganglionic injury.
As the spinal nerves emerge from the neural
foramina, they receive rami from the sympathetic
ganglia (Figure 1.3). Typically, the C5 and C6
nerves receive contributions from the middle cervi-
cal ganglion, C7 and C8 nerves receive contribu-
tions from the inferior cervical ganglion, and the
first thoracic nerve receives a contribution from its
associated ganglion. These contributions occur
distal to the dorsal root ganglion. Understanding
the relationship of the brachial plexus with the
sympathetic ganglia allows the examiner to deduct
the presence of a proximal C8, T1 lesion in the
presence of Horner’s sign (ptosis, meiosis, and
anhydrosis).
The nerve roots of C5 through C7 emerge from
the vertebral foramina and separate into anterior
(innervates the upper extremity) and posterior
primary rami (innervates the paraspinal muscles
and posterior vertebral elements). The anterior
rami lie in a groove in the transverse process that is

Vertebral artery
Spinal nerve
Figure 1.4  Relationship of the spinal nerve roots to the
vertebral artery at the level of the neural foramen.
posterior to the vertebral artery (Figure 1.4). The
anterior rami usually emerge between the anterior
and middle scalene muscles to form the upper
trunk.
The nerve roots of C8 and T1 are retroclavicular.
The 1st and 2nd rib lie posteriorly and the pleura
lies inferior to these roots. C8 traverses superiorly,
and T1 passes inferior to the 1st rib. Proceeding
distally, the nerve roots coalesce to form the lower
trunk on the superior surface of the 1st rib. The
lower trunk then emerges between the anterior and
middle scalene muscles.
Furthermore, the brachial plexus is comprised of
the nerve structures by which the central nervous
system communicates with the upper extremity.
The brachial plexus is intimately associated with
prominent vasculature. In the supraclavicular
region, the subclavian vessels are in close proximity
with the lower roots/lower trunk. In the infracla-
vicular region, the cords surround the axillary
artery, and in the arm, the median nerve travels with
the brachial artery.
Distal anatomical relationships
The upper, middle, and lower trunks ramify into
their respective divisions posterior to the clavicle.
The divisions form cords around the axillary artery.
Each cord is named based on its relationship to the
artery. The space around the plexus is in the form
of a pyramid: the posterior wall around the distal
plexus is formed by the subscapularis, teres major,
and latissimus dorsi muscles; the anterior wall is
formed by the pectoralis major, pectoralis minor,
and the clavipectoral fascia; and the medial wall is
Anatomy of the brachial plexus 1
formed by the upper ribs and the serratus anterior.
The anterior and posterior walls converge along the
medial humerus.
Surgical approaches
to the brachial plexus
Anterior approach
Supraclavicular exposure
The supraclavicular brachial plexus is exposed in
the posterior triangle of the neck. The patient is
supine with a roll under the scapulae, and the head
turned toward the opposite direction with the neck
in gentle extension. If there is a need to acquire a
sural nerve graft, a roll is also placed under the
buttock to internally rotate and flex the ipsilateral
leg. The lower part of the face, neck, shoulder, entire
chest, and leg are prepped for surgery.
A curvilinear incision extending from the sterno-
cleidomastoid muscle to the trapezius muscle is
made approximately 1.5 cm above the clavicle.7
The platysma is incised perpendicular to its fibers,
and a generous subplatysmal dissection is per-
formed. The external jugular vein is often encoun-
tered and must be retracted or ligated when
necessary. The position of the spinal accessory nerve
is relatively superficial as it courses from the poste-
rior aspect of the sternocleidomastoid muscle (2/3
of the distance from the sternum to the mastoid)
toward its insertion into the trapezius muscle
(Figures 1.5, 1.6). Identification of the spinal acces-
sory nerve along its course is crucial to preserve
trapezius function and to use its branches as poten-
tial donors for nerve transfer. An intraoperative
nerve stimulator can be used to identify and confirm
this nerve.
The lateral margin of the sternocleidomastoid
muscle is identified, with its sternal and clavicular
heads. The lateral aspect of the clavicular head is
released to facilitate exposure (Figure 1.7). The
supraclavicular nerves (sensory nerves branches of
the ansa cervicalis, C2-C4) are identified along their
superficial cranial-caudal course. These nerves are
likewise preserved for anatomical landmarks and
as potential donors for nerve graft material. The
supraclavicular nerves are followed proximally
until the C4 spinal nerve root is identified. From
the C4 spinal nerve root, a branch from this nerve
can be followed to the phrenic nerve, which is
derived from C3, C4 and C5. The phrenic nerve is
7
 Section One  The basics

Middle scalene

Posterior triangle Phrenic nerve Supraclavicular

Anterior nerve
scalene
Brachial plexus

Sternocleidomastoid
Clavicle
Clavicle
Omohyoid
(cut and reflected)

Transverse cervical
vessels
Figure 1.7  Supraclavicular exposure of the posterior triangle of
Figure 1.5  Supraclavicular exposure of the brachial plexus/ the neck demonstrating a supraclavicular nerve and the phrenic
posterior triangle of the neck. nerve.

The lateral edge of the anterior scalene muscle is

Omohyoid Supraclavicular nerve
Sternocleidomastoid
(cut and rotated)
Clavicle
Figure 1.6  Exposure of the posterior triangle of the neck
demonstrating the omohyoid and supraclavicular nerves.
dissected along its length on the anterior aspect of
the anterior scalene muscle. One should carefully
mobilize the phrenic nerve to preserve function of
the diaphragm. Periodic stimulation of the nerve
with an intraoperative nerve stimulator will confirm
intraoperative integrity of the nerve.
identified. The scalene fat pad is released from this
border in a cranial-to-caudal direction, then in a
medial-to-lateral direction to reflect the fat pad lat-
erally. When releasing the fat pad deep in this
region during exposure of the left supraclavicular
brachial plexus, one should preserve or ligate the
thoracic duct to avoid chyle leakage. The omohyoid
muscle is identified along its course toward the
suprascapular notch, and it can be tagged and
divided. Note that preserving this muscle to identify
the suprascapular notch can facilitate identification
of the suprascapular nerve (see below), especially in
patients whose anatomy is distorted by trauma.
The phrenic nerve courses lateral-to-medial
toward the diaphragm, whereas the contents of the
plexus and surrounding nerves course from medial-
to-lateral. As the phrenic nerve approaches the
lateral edge of the anterior scalene, the C5 spinal
nerve root emerges (Figure 1.8). Following the C5
root distally leads to the upper trunk, and following
the upper trunk proximally will lead to the C6
spinal nerve root. The C6 spinal nerve root is
located caudal and dorsal to the C5 spinal nerve
root. The anterior tubercle of C6 is very prominent
(Chassaignac’s tubercle). The C7, C8, and T1 spinal
nerve roots are sequentially more caudal and dorsal.
The transverse cervical artery and vein cross the C7
spinal nerve root and can be ligated. Following the
C7 spinal nerve distally will reveal the middle

8

C5
Middle scalene
C6
C7
Upper trank
C8
T1 Suprascapular
nerve
Posterior
division
Subclavian artery Anterior division
Figure 1.8  Supraclavicular exposure of the brachial plexus and
its relationship to the subclavian artery.
trunk. The C8 and T1 spinal nerves combine quickly
to form the lower trunk, which is adjacent to the
subclavian vessels (Figure 1.8). Roots of the lower
trunk surround the first rib; therefore, care should
be taken to avoid injury to the pleura. Should more
proximal exposure of the nerve roots be necessary,
the lateral edge of the anterior scalene muscle and
the bony “chutes” conducting the spinal nerve roots
can be resected. Occasionally, clear fluid may be
observed during proximal exposure of the spinal
nerve roots, indicating the presence of a pseudo-
meningocele and a likely avulsed root.
The next step is to identify the suprascapular
nerve and the divisions of the upper trunk. The
upper trunk can be seen to “split” into 3 separate
structures (lateral to medial): the suprascapular
nerve, the posterior division, and the anterior divi-
sion. Exposure of divisions of the brachial plexus
can often be accomplished with downward retrac-
tion of the clavicle. Distally, the dorsal scapular
artery and the suprascapular artery and vein lie at
the level of the divisions of the plexus, which may
be ligated as necessary for exposure. The clavicle can
either be preserved and mobilized with traction or
is cut. If an osteotomy is preferred, a clavicle plate
Anatomy of the brachial plexus 1
Lateral cord
Axillary artery
Pectoralis
minor (cut)
Medial cord
Ulnar nerve Median nerve
Figure 1.9  Infraclavicular exposure of the brachial plexus.
should be applied initially and removed, and then
the bone is cut to facilitate closure.
Infraclavicular exposure
The infraclavicular brachial plexus is exposed
through the deltopectoral groove. The patient is
placed in the supine position, and a linear incision
is made from the clavicle toward the axilla, in line
with the deltopectoral groove. The cephalic vein is
visualized within the groove, and it can be retracted
laterally or ligated. If needed, a portion of the pec-
toralis muscle can be detached from the inferior
surface of the clavicle and from the humerus. The
cuff of tendon from the humerus is tagged to facili-
tate later repair.
Once the interval is opened, the conjoint tendon
can be identified originating from the coracoid,
which consists of the short head of the biceps
and coracobrachialis. Attachment of the pectoralis
minor can be identified with the muscle proceeding
medially; blunt dissection will separate the pecto-
ralis minor from the surrounding tissues. This can
be either transected and released or tagged for later
repair. It is convenient to place sutures into the
tendon on either side of the divided tendon for
retraction and reapproximation.
9
 Section One  The basics
Brachial artery
Coracobrachialis
Ulnar nerve Musculocutaneous
nerve
Medial Biceps
antebrachial (retracted)
cutaneous
nerve
Median nerve
Figure 1.10  Exposure of the nervous anatomy in the medial
aspect of the arm.
Division of the pectoralis minor will reveal the
infraclavicular brachial plexus lying immediately
underneath (Figure 1.9). When the arm is at or
lower than the plane of the shoulder, the most
superficial structures are the lateral cord with its
lateral branch leading to the musculocutaneous
nerve and its medial branch leading to the median
nerve. The medial cord may be identified medial
and slightly posterior to the axillary artery, and the
lateral branch of the medial cord will lead to the
median nerve (the medial branch continues down
the arm as the ulnar nerve) (Figure 1.10). Exposure
of the posterior cord and its axillary and radial
nerve branches is best accomplished in the region
lateral to the axillary artery.
Posterior approach
The posterior approach is rarely used but can
be applied to resection of proximal lower brachial
plexus tumors or revision brachial plexus surgery.8
The patient is positioned prone with the shoulder
flexed and adducted to maximize scapular
10
protr­action. The head is turned toward the opera-
tive side to maximize access to the intervertebral
foramina.
A curvilinear incision approximately 2 finger-
breadths medial to the medial border of the
scapula is made, extending from the superior to
inferior angle. The trapezius is released, then the
medial musculature— rhomboid major, rhomboid
minor, and levator scapulae—is transected trans-
tendinously. If possible, a cuff of distal tendon
should be preserved for repair. Care should be
taken to preserve the dorsal scapular nerve and cir-
cumflex scapular artery.
The posterior and middle scalenes are released. If
needed, a portion or the entire first rib can be
resected extraperiosteally and the facets can be par-
tially resected to gain access to the nerve roots.
Approach to the medial arm
The approach to the medial arm can be performed
through an incision along the medial border of
the biceps tendon. The axillary artery, median
nerve, and ulnar nerve, as well as the medial
brachial and medial antebrachial nerves, lie rela-
tively superficially in the arm. In the mid-arm,
the median nerve lies anterior to the artery and
the ulnar nerve lies medial to the artery. In the
distal humerus, the ulnar nerve pierces the inter-
muscular septum to proceed into the posterior
compartment; whereas in the anterior compart-
ment, the artery proceeds radial to the median
nerve. When dissected more deeply, one will find
the musculocutaneous nerve supplies the biceps
and half of the brachialis, and the median nerve
supplies the other half of the brachialis. The mus-
culocutaneous nerve lies in the interval between
the biceps and brachialis, terminating into the
lateral antebrachial cutaneous nerve (Figure 1.10).
Anatomic variability
Brachial plexus variations
The greatest anatomic variation of the plexus occurs
with regard to the actual spinal roots that contrib-
ute to the brachial plexus. The typical schematic
anatomy describes the brachial plexus as originat-
ing from C5 to T1; however, the brachial plexus
may receive contributions from C4 or T2. Some
authors have defined a “pre-fixed” plexus as one
that receives a substantive contribution from C4

C4
C5
C6
C7
C8
T1
Figure 1.11  Schematic diagram of the Pre-fixed brachial plexus.
C5
C6
C7
C8
T1
T2
Figure 1.12  Schematic diagram of the Post-fixed brachial
plexus.
and a “post-fixed” plexus as one that receives a
substantive contribution from T2 (Figures 1.11,
1.12). The occurrence rate for these aberrant
contributions remains unclear. Estimates range
from 15% to 75% and defining the exact prevalence
requires further study.
A relatively common variation occurs when the
lateral cord contributes to the ulnar nerve. This vari-
ation has been reported in up to 43% of cases. A
second variation may occur when contribution of
the lateral cord to the median nerve is insignificant.
Oftentimes when this occurs, there is a distal con-
tribution of the musculocutaneous nerve to the
median nerve.
There is some debate whether the posterior cord
is in fact a true structure or whether it is just the
radial and axillary nerves arising proximally and
independently in the plexus and running together
Anatomy of the brachial plexus 1
posterior to the axillary artery. Some dissections
have noted an entirely independent course of the 2
nerves in 20% of specimens.
Brachial plexus/axillary artery variability
The relationship of the brachial plexus to the axil-
lary artery varies widely as well. Miller9 extensively
studied 480 specimens and found 8% of cases dem-
onstrating aberrant anatomy. She described 5 types
of aberrant findings:
1. The brachial artery or a branch of the brachial
artery is superficial to the median nerve.
2. The median nerve is divided by a branch of
the artery.
3. A structure of the plexus is modified by an
aberrant axillary artery.
4. A cord of the plexus is divided by an arterial
branch.
5. The nerves communicate around the axillary
artery or its branches.
Ultimately, these types of aberrant findings are
variations of the axillary artery or a portion of the
axillary artery traversing the brachial plexus more
superficially.
Terminal branch variability
There is significant variation from the standard
diagram used to describe the origin of terminal
branches of the brachial plexus. In approximately
65% of cases, Ballesteros et al.10 found aberrant
origins of the long thoracic, upper subscapular, and
inferior subscapular nerves. Dorsal subscapular
nerves varied in 50% of cases, and the suprascapu-
lar and thoracodorsal had variant origin in approxi-
mately 20% of cases.
Conclusions
Brachial plexus injuries can be devastating to the
patient’s normal functional status, and the long-
term implications of these injuries are often not
immediately understood by the patients or their
families. The challenging achievement of optimal
functional outcomes relies upon the basic sche-
matic and functional anatomic knowledge. The
treating practitioner must apply anatomical knowl-
edge to the clinical presentation and the appropri-
ate use of ancillary radiographic and electrodiagnostic
11
 Section One  The basics
studies to determine the proper course and timing
of surgical treatment. With increased awareness of
the condition and its anatomical basis, the outlook
for patients suffering severe brachial plexus injures
will continue to improve.
References
1. Leffert RD. Brachial plexus injuries. New York:
Churchill Livingstone; 1985. p. ix.
2. Kerr AT. The brachial plexus of nerves in man, the
variations in its formation and branches. Am J Anat
1918;23:285–395.
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