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Here is a complete clinical example of the Brachial Plexus, drawn from Gray's Anatomy for Students, S. Das Manual on Clinical Surgery, and the Harriet Lane Handbook.

Brachial Plexus - Structure & Clinical Examples

Anatomy at a Glance

The brachial plexus is formed by the anterior rami of C5-C8 and T1. It originates in the neck, passes over rib I, and enters the axilla. Its parts from medial to lateral are:
LevelComponents
RootsC5, C6, C7, C8, T1 (anterior rami)
TrunksSuperior (C5+C6), Middle (C7), Inferior (C8+T1)
DivisionsEach trunk splits into anterior + posterior
CordsLateral, Medial, Posterior (named by position relative to axillary artery)
Terminal nervesMusculocutaneous, Median, Radial, Ulnar, Axillary
Brachial Plexus diagram showing Roots, Trunks, Divisions, Cords, and Terminal nerves with anatomical relationships
Fig. 7.53 - Brachial Plexus: (A) Schematic showing branches, (B) Relationships to the axillary artery - Gray's Anatomy for Students

Clinical Example 1: Erb-Duchenne Palsy (Upper Brachial Plexus Injury)

Roots injured: C5 and C6
Mechanism:
  • Adult: fall of weight on shoulder, motorcycle accident (head forcefully moved away from shoulder)
  • Neonate: difficult labour - angle between shoulder and neck is forced open
Muscles paralysed: Deltoid, biceps, brachialis, brachioradialis, supinator
Classic posture - "Policeman taking a tip" / "Waiter's tip" deformity:
  • Arm: adducted, internally rotated
  • Elbow: extended
  • Forearm: pronated
  • Wrist: flexed
Sensory loss: Outer arm and upper lateral forearm
Prognosis: Best prognosis of all brachial plexus injuries; accounts for ~90% of birth-related cases.

Clinical Example 2: Klumpke's Palsy (Lower Brachial Plexus Injury)

Roots injured: C8 and T1
Mechanism:
  • Forceful hyperabduction of the shoulder (e.g., breech delivery with arms above head, a person falling and grabbing onto an object overhead)
Muscles paralysed: Intrinsic muscles of the hand (interossei, lumbricals, thenar, hypothenar)
Clinical findings:
  • Claw hand (hyperextension at MCPs, flexion at IPs)
  • Features of combined median + ulnar nerve palsy
  • Sensory loss: medial forearm, hand, and inner 1.5 fingers
Associated finding - Horner's syndrome (if T1 root is avulsed):
  • Ptosis (drooping eyelid)
  • Enophthalmos (sunken eye)
  • Miosis (constricted pupil)
  • Anhidrosis (no sweating on ipsilateral face)
Prognosis: Poor; less than 2% of birth brachial plexus cases.

Summary Table (from Harriet Lane Handbook)

InjuryRootsClinical FeaturesPrognosis
Erb-DuchenneC5-C6 (±C4)Adduction + internal rotation arm; forearm pronated; wrist flexedBest (90% of cases)
Total palsyC5-T1 (±C4)Entire arm involved; Horner syndrome if T1Intermediate (8-9%)
KlumpkeC7-T1Flaccid hand; Horner syndrome if T1Worst (<2%)

Memory Aid

  • ERB = Upper (C5-C6) = "wAITER's tip" - arm hangs limp in internal rotation, looks like a waiter asking for a tip
  • KLUMPKE = Lower (C8-T1) = "CLAW hand" - intrinsic hand muscles lost + Horner's syndrome
Sources: Gray's Anatomy for Students, p. 858-859 | S. Das Manual on Clinical Surgery, 13th Ed., p. 140 | Harriet Lane Handbook, 23rd Ed.
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