Brachial Plexus Anatomy: Normal and Variant

Effective brachial plexus blockade requires a thorough understanding of the anatomy of the plexus, as well as an appreciation of anatomic variations that may occur. This review summarizes relevant anatomy of the plexus, along with variations and anomalies that may affect nerve blocks conducted at these levels. The Medline, Cochrane Library, and PubMed electronic databases were searched in order to compile reports related to the anatomy of the brachial plexus using the following free terms: "brachial plexus", "median nerve", "ulnar nerve", "radial nerve", "axillary nerve", and "musculocutanous nerve". Each of these was then paired with the MESH terms "anatomy", "nerve block", "anomaly", "variation", and "ultrasound". Resulting articles were hand searched for additional relevant literature. A total of 68 searches were conducted, with a total of 377 possible articles for inclusion. Of these, 57 were found to provide substantive information for this review. The normal anatomy of the brachial plexus is briefly reviewed, with an emphasis on those features revealed by use of imaging technologies. Anomalies of the anatomy that might affect the conduct of the various brachial plexus blocks are noted. Brachial plexus blockade has been effectively utilized as a component of anesthesia for upper extremity surgery for a century. Over that period, our understanding of anatomy and its variations has improved significantly. The ability to explore anatomy at the bedside, with real-time ultrasonography, has improved our appreciation of brachial plexus anatomy as well.