DOCSLIB.ORG

Nerve-Transfers-Lee

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Nerve-Transfers-Lee Review Article Nerve Transfers for the Upper Extremity: New Horizons in Nerve Reconstruction Abstract Steve K. Lee, MD Nerve transfers are key components of the surgeon’s Scott W. Wolfe, MD armamentarium in brachial plexus and complex nerve reconstruction. Advantages of nerve transfers are that nerve regeneration distances are shortened, pure motor or sensory nerve fascicles can be selected as donors, and nerve grafts are generally not required. Similar to the principle of tendon transfers, expendable donor nerves are transferred to denervated nerves with the goal of functional recovery. Transfers may be subdivided into intraplexal, extraplexal, and distal types; each has a unique role in From the Hospital for Special the reconstructive process. A thorough diagnostic workup and Surgery and Weill Cornell Medical intraoperative assessment help guide the surgeon in their use. College, New York, NY. Nerve transfers have made a positive impact on the outcomes of Dr. Lee or an immediate family nerve surgery and are essential tools in complex nerve member has received royalties from, is a member of a speakers’ bureau reconstruction. or has made paid presentations on behalf of, and serves as a paid consultant to or is an employee of Arthrex; serves as an unpaid lthough not a new concept, neurotization should be reserved to consultant to Synthes; has received Anerve transfers have become an describe the direct implantation of a research or institutional support from increasingly important technique in divided donor nerve into muscle, Arthrex, DePuy Mitek, Integra LifeSciences, Medartis, Axogen, and the strategic algorithm for nerve re- which has shown promise in an ani- 1,2 Checkpoint; and serves as a board construction. Pioneers such as mal model. member, owner, officer, or Flouren introduced the rooster committee member of the American plexus model in 1820, Balance de- Society for Surgery of the Hand. Indications and scribed the spinal accessory nerve Dr. Wolfe or an immediate family Contraindications member has received royalties from (SAN) transfer to the facial nerve in Extremity Medical; is a member of a 1903, Vulpius described use of the speakers’ bureau or has made paid A variety of indications exists for presentations on behalf of Small medial pectoral nerve in 1920, and nerve transfer, primarily when the Bone Innovations and TriMed; Seddon, the transfer of intercostal proximal nerve end is nonfunctional serves as a paid consultant to or is nerves (ICNs) in 1963.1 an employee of Extremity Medical or nerve reconstruction would re- and Small Bone Orthopedics; and The definition of nerve transfer is quire an excessively long nerve graft. serves as a board member, owner, the surgical coaptation of a healthy Nerve transfer may expedite reinner- officer, or committee member of the nerve donor to a denervated nerve. vation when traditional nerve graft- New York Society for Surgery of the Hand. The principle is similar to that of ing would exceed the expected via- tendon transfers in that a necessary bility of motor end plates and muscle J Am Acad Orthop Surg 2012;20: 3 506-517 distal function is recovered by sacri- (approximately 12 to 18 months). ficing another function that is less es- Nerve transfer may also be indicated http://dx.doi.org/10.5435/ JAAOS-20-08-506 sential to the patient. Synonyms for in patients in whom the zone of in- nerve transfer are nerve-to-nerve jury is very broad, with dense scar- Copyright 2012 by the American neurotization, heterotopic nerve su- Academy of Orthopaedic Surgeons. ring. Nerve transfer outside the zone ture, and nerve crossing. The term of injury is more surgically efficient 506 Journal of the American Academy of Orthopaedic Surgeons Steve K. Lee, MD, and Scott W. Wolfe, MD and outcomes, more predictable.4 nerve to the axillary nerve, a fascicle promised recipient nerve.7 End-to- In the upper extremity, nerve trans- of the ulnar nerve to the biceps mo- end transfer is preferable for all fer is most commonly used for recon- tor branch, a fascicle of the median transfers; reverse end-to-side trans- struction of brachial plexus injury. nerve to the brachialis motor branch, fers have not been demonstrated to Other indications include complex and triceps branches of the radial improve motor outcomes in humans injuries to peripheral nerves, espe- nerve to the axillary nerve and its but do show experimental promise.7,8 cially when associated with fractures branches. Extraplexal refers to do- End-to-side transfers have demon- and dislocations, lacerations, injuries nor nerves that originate outside the strated efficacy in sensory nerves.3,6 from projectiles, neoplasia, or, oc- plexus. Examples include the SAN to The most common upper extremity casionally, neuralgic amyotrophy the suprascapular nerve (SSN) and deficits that benefit from nerve trans- (Parsonage-Turner syndrome). the ICN or phrenic nerve to the mus- fer are elbow flexion and shoulder sta- Contraindications for nerve trans- culocutaneous nerve (MCN). bilization, abduction, and external ro- fer include the presence of a superior Distal transfer: Nerve transfer that tation. Other indications include reconstructive option, excessive time is at or distal to the elbow. scapular stabilization for winging, el- between injury and reinnervation (ie, Single versus dual transfer: Single bow extension, wrist extension, finger >18 months), or donor nerve motor transfer refers to the use of one nerve and thumb extension, finger flexion, strength of less than Medical Re- transfer to achieve one action. An and intrinsic hand function. Tables 1 to search Council grade M4. example of a single transfer is an ul- 3 describe intraplexal, extraplexal, and nar nerve fascicle to the biceps motor distal motor transfers. Sensory deficits branch to achieve elbow flexion. of the thumb, index, ring and small fin- Advantages of Nerve Dual transfer refers to the use of two ger and ulnar border of the hand are Transfer nerve transfers to achieve one action. treated by nerve transfers listed in Ta- An example is an ulnar nerve fascicle ble 4. Nerve transfer has the distinct ad- to the biceps motor branch and a Intraplexal donors include the fol- vantage over primary nerve repair median nerve fascicle to the brachia- lowing: ulnar nerve fascicle, median and long nerve grafting of shortening lis motor branch to achieve elbow nerve fascicle, medial pectoral nerve, the length that the nerve must regen- flexion. thoracodorsal nerve, triceps branches erate by bringing the donor nerve Direct nerve transfer: A direct nerve of the radial nerve, brachialis branch of closer to the target organ.3,5 With transfer connects the donor nerve to the MCN, and pectoral fascicle from nerve transfer, pure motor fascicles the recipient nerve without an inter- the middle trunk of C7. with maximal axonal counts are di- posed graft. If a tensionless nerve co- Extraplexal donors include the fol- rected to a recipient nerve. Opti- aptation is not possible, an interposi- lowing: SAN, ICNs, phrenic nerve, mally, nerves are directly transferred tion nerve graft must be used. and contralateral C7 nerve root. to the recipient nerve without an in- Motor versus sensory transfer: Distal transfer donors include the terposed nerve graft. As opposed to Transfers with the goal of recovering following: distal anterior interosse- tendon transfer, when nerve transfer motor or sensory function. Transfers ous nerve (AIN), radial nerve branch is successful, recovered function is performed to restore sensory func- to the extensor carpi radialis brevis, similar to the original muscle func- tion have the added benefit of de- supinator branches of the posterior tion because synchronous physio- creasing neuropathic pain.6 interosseous nerve (PIN), and radial logic motion may be achieved. With End-to-end, end-to-side, reverse end- nerve branch to the brachioradialis. quicker nerve recovery, more rapid to-side: End-to-end nerve transfer refers motor reeducation is also possible. to direct coaptation of the end of the donor nerve to the proximal end of the Common Transfers and Outcomes Nomenclature recipient nerve (Figure 1). End-to-side nerve transfer describes coaptation of Intraplexal versus extraplexal: Intra- the proximal end of the recipient nerve Intraplexal Transfers plexal refers to nerve transfers in to an epineural window in the side of Ulnar Nerve Fascicle to Biceps which the donor nerve originates in an intact and functioning donor nerve. Motor Branch the brachial plexus, including the ter- Reverse end-to-side is when the end of Transfer of the ulnar nerve fascicle to minal peripheral nerve branches a freshly divided donor nerve is the biceps motor branch, described above the elbow. Examples include coapted to an epineural window in the by Oberlin et al9 in 1994, critically the medial pectoral or thoracodorsal side of an intact but functionally com- altered the approach to modern August 2012, Vol 20, No 8 507 Nerve Transfers for the Upper Extremity: New Horizons in Nerve Reconstruction Figure 1 Illustrations of the types of nerve transfer. A, End-to-end. B, End-to-side. C, Reverse end-to-side. nerve transfers. In this transfer, one individual fascicle (Checkpoint Sur- or central part of the nerve;10 any or two fascicles of the ulnar nerve gical Stimulator; Checkpoint Surgi- fascicles that give no response are are transferred directly to the motor cal, Cleveland, OH) and observing presumed to be sensory, and those branch of the biceps. In our practice, the distal muscular contraction. A that cause flexor
Load more

Recommended publications
  • Cubital Tunnel Syndrome
    Cubital Tunnel Syndrome What many people call the “funny bone” really is a nerve. This ulnar nerve runs behind a bone in the elbow through a space Figure 1: Ulnar Nerve at elbow joint (inner side of elbow) called the “cubital tunnel” (Figure 1). Although “banging the funny bone” usually causes temporary symptoms, chronic pressure on or stretching of the nerve can affect the blood supply to the ulnar nerve, causing numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand. This is called “cubital tunnel syndrome.” Humerus Causes There are a few causes of this ulnar nerve problem. These include: Pressure. Because the nerve runs through that “funny bone” groove and has little padding over it, direct pressure (like leaning your arm on an arm rest) can compress the nerve, causing your arm and hand—especially the ring and small fingers—to Ulnar Nerve “fall asleep.” Stretch. Keeping the elbow bent for a long time can stretch Medial Epicondyle the nerve behind the elbow. This usually happens during sleep. Anatomy. Sometimes, the ulnar nerve does not stay in its place and snaps back and forth over a bony bump as the elbow is moved. Repetitive snapping can irritate the nerve. Sometimes, the soft tissues over the nerve become thicker or there is an Ulna “extra” muscle over the nerve that can keep the nerve from working correctly. Treatment Signs and Symptoms The first treatment is to avoid actions that cause symptoms. Cubital tunnel syndrome can cause pain, loss of sensation, Wrapping a pillow or towel around the elbow or wearing a splint and/or tingling.
    [Show full text]
  • Anatomical Variations of the Brachial Plexus Terminal Branches in Ethiopian Cadavers
    ORIGINAL COMMUNICATION Anatomy Journal of Africa. 2017. Vol 6 (1): 896 – 905. ANATOMICAL VARIATIONS OF THE BRACHIAL PLEXUS TERMINAL BRANCHES IN ETHIOPIAN CADAVERS Edengenet Guday Demis*, Asegedeche Bekele* Corresponding Author: Edengenet Guday Demis, 196, University of Gondar, Gondar, Ethiopia. Email: [email protected] ABSTRACT Anatomical variations are clinically significant, but many are inadequately described or quantified. Variations in anatomy of the brachial plexus are important to surgeons and anesthesiologists performing surgical procedures in the neck, axilla and upper limb regions. It is also important for radiologists who interpret plain and computerized imaging and anatomists to teach anatomy. This study aimed to describe the anatomical variations of the terminal branches of brachial plexus on 20 Ethiopian cadavers. The cadavers were examined bilaterally for the terminal branches of brachial plexus. From the 40 sides studied for the terminal branches of the brachial plexus; 28 sides were found without variation, 10 sides were found with median nerve variation, 2 sides were found with musculocutaneous nerve variation and 2 sides were found with axillary nerve variation. We conclude that variation in the median nerve was more common than variations in other terminal branches. Key words: INTRODUCTION The brachial plexus is usually formed by the may occur (Moore and Dalley, 1992, Standring fusion of the anterior primary rami of the C5-8 et al., 2005). and T1 spinal nerves. It supplies the muscles of the back and the upper limb. The C5 and C6 fuse Most nerves in the upper limb arise from the to form the upper trunk, the C7 continues as the brachial plexus; it begins in the neck and extends middle trunk and the C8 and T1 join to form the into the axilla.
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • Anastomotic Branch from the Median Nerve to the Musculocutaneous Nerve: a Case Report
    Case Report www.anatomy.org.tr Recieved: February 10, 2008; Accepted: April 22, 2008; Published online: October 31, 2008 doi:10.2399/ana.08.063 Anastomotic branch from the median nerve to the musculocutaneous nerve: a case report Feray Güleç Uyaro¤lu1, Gülgün Kayal›o¤lu2, Mete Ertürk2 1Department of Neurology, Ege University Faculty of Medicine, Izmir, Turkey 2Department of Anatomy, Ege University Faculty of Medicine, Izmir, Turkey Abstract Anomalies of the brachial plexus and its terminal branches are not uncommon. Communicating branch arising from the mus- culocutaneous nerve to the median nerve is a frequent variation, whereas the presence of an anastomotic branch arising from the median nerve and joining the musculocutaneous nerve is very rare. During routine dissection of cadaver upper limbs, we observed an anastomotic branch arising from the median nerve running distally to join with the branches of the musculocutaneous nerve in a left upper extremity. The anastomotic branch originated from the median nerve 11.23 cm prox- imal to the interepicondylar line. After running distally and coursing between the biceps brachii and the brachialis muscles, this anastomotic branch communicated with two branches of the musculocutaneous nerve separately. The presence of the communicating branches between these nerves should be considered during surgical interventions and clinical investigations of the arm. Key words: anatomy; brachial plexus; communicating branch; upper limb; variation Anatomy 2008; 2: 63-66, © 2008 TSACA Introduction neous nerve (C5, C6, and C7) connects with the median nerve in the arm.2,3 The musculocutaneous nerve is the Variations of the brachial plexus and its terminal continuation of the lateral cord of the brachial plexus.
    [Show full text]
  • 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.
    [Show full text]
  • Cubital Tunnel Syndrome)
    DISEASES & CONDITIONS Ulnar Nerve Entrapment at the Elbow (Cubital Tunnel Syndrome) Ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes compressed or irritated. The ulnar nerve is one of the three main nerves in your arm. It travels from your neck down into your hand, and can be constricted in several places along the way, such as beneath the collarbone or at the wrist. The most common place for compression of the nerve is behind the inside part of the elbow. Ulnar nerve compression at the elbow is called "cubital tunnel syndrome." Numbness and tingling in the hand and fingers are common symptoms of cubital tunnel syndrome. In most cases, symptoms can be managed with conservative treatments like changes in activities and bracing. If conservative methods do not improve your symptoms, or if the nerve compression is causing muscle weakness or damage in your hand, your doctor may recommend surgery. This illustration of the bones in the shoulder, arm, and hand shows the path of the ulnar nerve. Reproduced from Mundanthanam GJ, Anderson RB, Day C: Ulnar nerve palsy. Orthopaedic Knowledge Online 2009. Accessed August 2011. Anatomy At the elbow, the ulnar nerve travels through a tunnel of tissue (the cubital tunnel) that runs under a bump of bone at the inside of your elbow. This bony bump is called the medial epicondyle. The spot where the nerve runs under the medial epicondyle is commonly referred to as the "funny bone." At the funny bone the nerve is close to your skin, and bumping it causes a shock-like feeling.
    [Show full text]
  • 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
    [Show full text]
  • Anatomical, Clinical, and Electrodiagnostic Features of Radial Neuropathies
    Anatomical, Clinical, and Electrodiagnostic Features of Radial Neuropathies a, b Leo H. Wang, MD, PhD *, Michael D. Weiss, MD KEYWORDS Radial Posterior interosseous Neuropathy Electrodiagnostic study KEY POINTS The radial nerve subserves the extensor compartment of the arm. Radial nerve lesions are common because of the length and winding course of the nerve. The radial nerve is in direct contact with bone at the midpoint and distal third of the humerus, and therefore most vulnerable to compression or contusion from fractures. Electrodiagnostic studies are useful to localize and characterize the injury as axonal or demyelinating. Radial neuropathies at the midhumeral shaft tend to have good prognosis. INTRODUCTION The radial nerve is the principal nerve in the upper extremity that subserves the extensor compartments of the arm. It has a long and winding course rendering it vulnerable to injury. Radial neuropathies are commonly a consequence of acute trau- matic injury and only rarely caused by entrapment in the absence of such an injury. This article reviews the anatomy of the radial nerve, common sites of injury and their presentation, and the electrodiagnostic approach to localizing the lesion. ANATOMY OF THE RADIAL NERVE Course of the Radial Nerve The radial nerve subserves the extensors of the arms and fingers and the sensory nerves of the extensor surface of the arm.1–3 Because it serves the sensory and motor Disclosures: Dr Wang has no relevant disclosures. Dr Weiss is a consultant for CSL-Behring and a speaker for Grifols Inc. and Walgreens. He has research support from the Northeast ALS Consortium and ALS Therapy Alliance.
    [Show full text]
  • 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.
    [Show full text]
  • 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.
    [Show full text]
  • Brachial Plexus Posterior Cord Variability: a Case Report and Review
    CASE REPORT Brachial plexus posterior cord variability: a case report and review Edward O, Arachchi A, Christopher B Edward O, Arachchi A, Christopher B. Brachial plexus posterior cord anatomical variability. This case report details the anatomical variants discovered variability: a case report and review. Int J Anat Var. 2017;10(3):49-50. in the posterior cord of the brachial plexus in a routine cadaveric dissection at the University of Melbourne, Australia. Similar findings in the literature are reviewed ABSTRACT and the clinical significance of these findings is discussed. The formation and distribution of the brachial plexus is a source of great Key Words: Brachial plexus; Posterior cord; Axillary nerve; Anatomical variation INTRODUCTION he brachial plexus is the neural network that supplies motor and sensory Tinnervation to the upper limb. It is typically composed of anterior rami from C5 to T1 spinal segments, which subsequently unite to form superior, middle and inferior trunks. These trunks divide and reunite to form cords 1 surrounding the axillary artery, which terminate in branches of the plexus. The posterior cord is classically described as a union of the posterior divisions from the superior, middle and inferior trunks of the brachial plexus, with fibres from all five spinal segments. The upper subscapular, thoracodorsal and lower subscapular nerves propagate from the cord prior to the axillary and radial nerves forming terminal branches. Variability in the brachial plexus is frequently reported in the literature. It is C5 nerve root Suprascapular nerve important for clinicians to be aware of possible variations when considering Posterior division of C5-C6 injuries or disease of the upper limb.
    [Show full text]