INTRODUCTION

• Wilhelm Erb is well known for his early contributions to the

field of neurology and was an eminent physician of his
time. One area described by him and that still bears his
name is Erb's point. This point located just superior to
the clavicle was used by Erb to transcutaneously elicit
contractions of various proximal arm muscles with
electrical stimulation. Many have mistakenly
interchanged the terms "Erb's point" and "nerve point"
when describing the point of emergence of the
cutaneous branches of the cervical plexus near the
posterior border of the sternocleidomastoid muscle
•
• Before discussing the erb’s point in detail lets discuss the
anatomic structures related to this poi first.
 CERVICAL PLEXUS
FORMATION

The cervical plexus is formed by the ventral rami of the

upper six cervical nerves.
It lies at the level of the first four vertebrae, deep to the
internal jugular vein, and the sternocleidomastoid muscle, in
front of the scalenus medius and levator scapulae.

BRANCHES:- Branches of the plexus may be divided into two

sets :
1.SUPERFICIAL BRANCHES consisting of those perforating the
cervical fascia and supply the integument.
These are further subdivided into –
ASCENDING BRANCHES
DESCENDING BRANCHES

1.DEEP BRANCHES are distributed to the muscles.

These are further subdivided into –
MEDIAL BRANCHES
LATERAL BRANCHES
 SUPERFICIAL ASCENDING
BRANCHES
1.LESSER OCCIPITAL
2.GREATER AURICULAR
3.TRANSVERSE (ANTERIOR) CUTANEOUS
4.
THE LESSER OCCIPITAL NERVE:-
Arises from the second cervical nerve.
It sends off an auricular branch which supplies the skin of the upper
third of the crania
surface of the auricle, and also it communicates with the posterior
auricular branch of the
facial nerve.
1.
THE GREATER AURICULAR NERVE:-
It’s the largest of the ascending branches.
It arises from the second and third cervical nerves.
When it passes on to the parotid it further divides into:-
üANTERIOR BRANCH which is distributed to the skin of the face over the
parotid gland, and communicates within the substance of the gland with
the facial nerve.
üPOSTERIOR BRANCH which supplies the skin over the mastoid process and
on the back of the auricle.
Some fibers also pierce the auricle, to supply the lobule and the
auricle.
THE TRANSVERSE (ANTERIOR) CUTANEOUS NERVES
Arises from the second and the third cervical nerves.
It divides beneath the platysma into the following branches –

ASCENDING BRANCHES - pass upwards to the submandibular

region, and forms a plexus with the cervical branch of the
facial nerve, beneath the platysma, those branches which pierce
the muscle supply the upper and the front parts of the neck.

DESCENDING BRANCHES - pierce the platysma , and are

distributed to the skin of the side and front of the neck as
low as the sternum.
 SUPERFICIAL DESCENDING
BRANCHES

SUPRACLAVICULAR NERVES:-
These nerves arise from the third and the fourth cervical nerves,
and at the level of
the clavicle divide into the following branches –

1.MEDIAN SUPRACLAVICULAR NERVES –

Supply the skin as far as the median plane and as low down
as the second rib, and supply one or two filaments to the
sternoclavicular joint.
1.
2. INTERMEDIATE SUPRACLAVICULAR NERVES –
Supply the skin over the pectoralis major and deltoid upto
the level of the second rib.
1.
3. LATERAL SUPRACLAVICULAR NERVES –
Supply the skin of the upper and posterior parts of the
shoulder.

1.
 DEEP BRANCHES – MEDIAL SERIES
These include the following communicating and muscular branches:-
COMMUNICATING BRANCHES consists of filaments which pass from the
loop between first and second cervical nerves to the
üHypoglossal (which further has three branches)
•meningeal
•superior root of ansa cervicalis
• nerve to thyrohyoid and geniohyoid
üvagus
üsympathetic

MUSCULAR BRANCHES to –
üRectus capitis lateralis
üRectus capitis anterior
üLongus capitis
üLongus colli
üInferior root of ansa cervicalis
üphrenic
 DEEP BRANCHES – LATERAL
SERIES

These include the following communicating and muscular branches:-

COMMUNICATING BRANCH with Accessory nerve in the substance of the

sternocleidomastoid , in the posterior triangle and under the cover of
the trapezius

MUSCULAR BRANCHES to –
Sternocleidomastoid
trapezius
Levator scapulae
Scalenus medius
 ERB’S
POINT
ERB’S POINT or PUNCTUM NERVOSUM is a site at the lateral root of the
brachial plexus.

It is a landmark of the brachial plexus on the upper trunk, located

about 1 inch (2.5 cm) above the clavicle at about the level of
sixth cervical vertebra.

It is formed by the union of the C5 and C6 nerve roots, which later

converge.

At the nerve trunk, branches of the suprascapular nerves and the

nerve to the subclavius also merge.

The merged nerve divides into the anterior and posterior division of
C5 and C6.
 LOCATION OF ERB’S
POINT

A crucial landmark in the POSTERIOR TRIANGLE OF THE NECK is the erb’s

point.

The SPINAL ACCESSORY

GREATER AURICULAR
LESSER OCCIPITAL &
TRANSVERSE CERVICAL NERVES
All pass within 2 cm above or below this location.

The approximate location of the erb’s point is on the posterior border

of the sternocliedomastoid muscle, midway between its attachments to
the mastoid process and the sternum and clavicle.

The point is approximately the location of an angle between the

posterolateral border of the sternocleidomastoid muscle and the
clavicle.
 IMPORTANCE OF ERB’S
POINT

At the erb’s point , the cutaneous branches of the cervical plexus

emerge from behind the posterior border of the
sternocleidomastoid muscle.

Anesthesia of skin of the neck and upper chestcan be attained by

blocking the cutaneous nerves as they emerge at ths point.
 ERB’S PALSY
• Erb's palsy (Erb-Duchenne Palsy) is a paralysis of the
arm caused by injury to the upper group of the arm's
main nerves, specifically the upper trunk C5-C6 is
severed. These form part of the brachial plexus,
comprising the ventral rami of spinal nerves C5-C8, and
T1. These injuries arise most commonly, but not
exclusively, from shoulder dystocia during a difficult
birth. Depending on the nature of the damage, the
paralysis can either resolve on its own over a period of
months, necessitate rehabilitative therapy, or require
surgery.
 STERNOCLEIDOMASTOID
MUSCLE
Also known as the sternomastoid It’s a paired muscle in the superficial
layer of the anterior portion of neck.
It passes obliquely down across the side of the neck and forms a
prominent landmark especially when contracted.

ORIGIN –
Below the sternocleidomastoid has two heads :-
MEDIAL HEAD – which is a rounded tendinous fasciculus, attached to the
upper part of the anterior surface of the manubrium sterni.
It passes upwards, laterally, and backwards.
LATERAL HEAD – is composed up of a muscular and fibrous fasiculi.
It passes almost vertically upwards from the upper surface of the
medial surface of the clavicle.
The two heads are separated by a triangular interval.

INSERTION –
Above the muscle is inserted by a strong tendon into the lateral
surface of the mastoid process( from its apex to its superior border ),
and by a thin apponeurosis into the superior nuchal line.
The clavicular fibers are chiefly attached to the mastoid process
The sternal fibers are more oblique and superficial and extend onto the
occiput.
 ANTERIOR AND POSTERIOR TRIANGLES
OF THE NECK

Boundaries of the anterior triangle:-

üIN FRONT – by the median line of the neck

üABOVE – base of the mandible, and a line continuing this
from the angle of
ü the mandible to the sternocliedomastoid.
üBEHIND – anterior border of sternocleidomastoid
üAPEX - of the triangle is at the upper border of
sternum.
ü
Boundaries of the posterior triangle:-

IN FRONT – posterior border of sternocleidomastoid.

BELOW – middle third of the clavicle.
BEHIND – anterior margin of trapezius.
APEX – corresponds to the meeting of sternocleidomastoid
and trpezius on
the occipital bone.