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Pino PA, Wu KY, Rhee PC. Combined Hyperselective Neurectomy and Fractional Lengthening Technique for Triceps Spasticity. Tech Hand Up Extrem Surg 2024; 28:33-38. [PMID: 37747072 DOI: 10.1097/bth.0000000000000455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Triceps spasticity can occur in patients with upper motor neuron syndrome. It is often undetected when there is predominant elbow flexion spasticity and/or contracture. This condition can become apparent after surgery for elbow flexor spasticity, leading to impaired active elbow. Although triceps muscle-tendon lengthening procedures can be performed, these techniques do not directly address the issue of spasticity which is neurally mediated. This article presents a surgical technique for addressing triceps spasticity with a combined approach of hyperselective neurectomy of the medial head of the triceps and muscle-tendon lengthening of the long and lateral heads.
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Affiliation(s)
- Paula A Pino
- Department of Orthopedic Surgery
- Department of Orthopedic Surgery, Pontificia Universidad Catolica de Chile
- Upper Extremity Division, Instituto Teletón Santiago, Santiago, Chile
| | - Kitty Y Wu
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN
| | - Peter C Rhee
- Department of Orthopedic Surgery
- Clinical Investigation Facility, Travis Air Force Base, CA
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Traumatic injury to the axillary nerve associated with paralysis of triceps brachii: A case report. Turk J Phys Med Rehabil 2022; 68:550-554. [PMID: 36589354 PMCID: PMC9791698 DOI: 10.5606/tftrd.2022.10266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/28/2022] [Indexed: 12/12/2022] Open
Abstract
Although many textbooks reported the innervation of three heads of the triceps muscle with the radial nerve, some studies showed the axillary nerve supply to this muscle. Herein, we report a 21-year-old male patients with a traumatic injury to the axillary nerve associated with paralysis of his triceps muscle. Based on the electrophysiological findings, it could be reasonable to conclude that the main branch innervating all heads of the triceps muscle originated from the axillary nerve. It is vital to look for concomitant paralysis of the triceps in patients with an axillary nerve injury in terms of surgical management, prognosis, and nerve repair.
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Bertelli JA, Goklani MS, Patel N, Duarte ECW. Triceps and cutaneous radial nerve branches investigated via an axillary anterior arm approach: new findings in a fresh-cadaver anatomical study. J Neurosurg 2022; 136:1424-1433. [PMID: 34624848 DOI: 10.3171/2021.4.jns2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to describe the anatomy of the radial nerve and its branches when exposed through an axillary anterior arm approach. METHODS Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery. RESULTS Via the anterior arm approach, all triceps muscle heads could be dissected and individualized. The radial nerve overlaid the latissimus dorsi tendon, bounded by the axillar artery on its superior surface, then passed around the humerus, together with the lower lateral arm and posterior antebrachial cutaneous nerve, between the lateral and medial heads of the triceps. No triceps motor branch accompanied the radial nerve's trajectory. Over the latissimus dorsi tendon, an antero-inferior bundle, containing all radial nerve branches to the triceps, was consistently observed. In the majority of the dissections, a single branch to the long head and dual innervations for the lateral and medial heads were observed. The triceps long and proximal lateral head branches entered the triceps muscle close to the latissimus dorsi tendon. The second branch to the lateral head stemmed from the triceps lower head motor branch. The triceps medial head was innervated by the upper medial head motor branch, which followed the ulnar nerve to enter the medial head on its anterior surface. The distal branch to the triceps medial head also originated near the distal border of the latissimus dorsi tendon. After a short trajectory, a branch went out that penetrated the medial head on its posterior surface. The triceps lower medial head motor branch ended in the anconeus muscle, after traveling inside the triceps medial head. The lower lateral arm and posterior antebrachial cutaneous nerve followed the radial nerve within the torsion canal. The lower lateral brachial cutaneous nerve innervated the skin over the biceps, while the posterior antebrachial cutaneous nerve innervated the skin over the lateral epicondyle and posterior surface of the forearm. The average numbers of myelinated fibers were 926 in the long and 439 in the upper lateral head and 658 in the upper and 1137 in the lower medial head motor branches. CONCLUSIONS The new understanding of radial nerve anatomy delineated in this study should aid surgeons during reconstructive surgery to treat upper-limb paralysis.
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Affiliation(s)
- Jayme A Bertelli
- 1Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Mayur Sureshlal Goklani
- 2Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India
| | - Neehar Patel
- 3Department of Plastic Surgery, Wockhardt Hospital, The Umrao IMSR, Mumbai, Maharashtra, India; and
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Osorio M, Lewis S, Tse R. Multimodal Management and Triple Nerve Transfer for Optimal Recovery of Shoulder Function Following Neonatal Brachial Plexus Palsy: A Case Report. PM R 2019; 11:558-561. [PMID: 30831000 DOI: 10.1002/pmrj.12043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/27/2018] [Indexed: 11/11/2022]
Abstract
Neonatal brachial plexus palsy is a complex disorder that requires evaluation of the primary nerve injury and associated sequelae. There is no standardized approach to management, and many treatment options are available. We present a case of Erb palsy with a unique multidisciplinary approach to nonsurgical and surgical management. Inherent in the case is the complexity of decision-making, and we review the literature on treatment options and the rationale for the approach, which resulted in near normal functional recovery.
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Affiliation(s)
- Marisa Osorio
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA
| | - Sarah Lewis
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA
| | - Raymond Tse
- Department of Surgery, Division of Plastic Surgery, University of Washington, Seattle, WA.,Department of Surgery, Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA
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Chaware PN, Santoshi JA, Patel M, Ahmad M, Rathinam BAD. Surgical Implications of Innervation Pattern of the Triceps Muscle: A Cadaveric Study. J Hand Microsurg 2018; 10:139-142. [PMID: 30483020 DOI: 10.1055/s-0038-1660771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/01/2018] [Indexed: 10/28/2022] Open
Abstract
The innervation pattern of triceps is complex and not fully comprehended. Anomalous innervations of triceps have been described by various authors. We have attempted to delineate the nerve supply of the triceps and documented the anomalous innervations of its different heads. The brachial plexus and its major branches (in the region of the axilla and arm) and triceps were dissected in 36 embalmed cadaver upper limbs. Long head received one branch from radial nerve in 31 (86%) specimens. Four (11%) specimens received two branches including one that had dual innervation from the radial and axillary nerves, and one (3%) specimen had exclusive innervation from a branch of the axillary nerve. Medial head received two branches arising from the radial nerve in 34 (94%) specimens. One (3%) specimen received three branches from the radial nerve whereas one (3%) had dual supply from the radial and ulnar nerves. Lateral head received multiple branches exclusively from the radial nerve, ranging from 2 to 5, in all (100%) specimens. Knowledge of the variations in innervation of the triceps would not only help the surgeon to avoid inadvertent injury to any of the nerve branches but also offers new options for nerve and free functional muscle transfers.
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Affiliation(s)
| | - John Ashutosh Santoshi
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Manmohan Patel
- Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Mohtashim Ahmad
- Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bertha A D Rathinam
- Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Al-Qattan MM, Kattan AE, Al-Qahtany BS, Al-Qattan OM, Al-Qattan HM. Triceps nerve to deltoid nerve transfer after an unsatisfactory intra-plexus neurotization of the posterior division of the upper trunk. Int J Surg Case Rep 2017; 37:124-126. [PMID: 28666151 PMCID: PMC5491484 DOI: 10.1016/j.ijscr.2017.06.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/12/2017] [Accepted: 06/12/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Our literature review did not reveal any study on the results of triceps to deltoid nerve transfer done as a secondary procedure after an unsatisfactory primary intraplexus neurotization of the posterior division of the upper trunk. PRESENTATION OF CASES We report on three adults with C5-C6 brachial plexus injury who had an unsatisfactory deltoid function following primary intraplexus neurotization. Patients presented to our clinic late (14-16 months after injury). All patients had poor shoulder abduction (<40°) despite the presence of visible and palpable deltoid contractions. A triceps to deltoid nerve transfer resulted in an excellent shoulder abduction (> 150°) in all patients. DISCUSSION The primary surgery in our patients acted as a "baby-sitter" procedure; explaining the good results of the late secondary distal nerve transfer. CONCLUSION Good results may be obtained from a late distal nerve transfer for the deltoid muscle as long as there is partial innervation of the muscle.
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Affiliation(s)
- Mohammad M Al-Qattan
- Division of Plastic Surgery King Saud University, Riyadh, Saudi Arabia; Division of Plastic Surgery at National Hospital, Riyadh, Saudi Arabia.
| | - Abdullah E Kattan
- Division of Plastic Surgery King Saud University, Riyadh, Saudi Arabia; Division of Plastic Surgery at National Hospital, Riyadh, Saudi Arabia
| | - Bayan S Al-Qahtany
- Division of Plastic Surgery King Saud University, Riyadh, Saudi Arabia; Division of Plastic Surgery at National Hospital, Riyadh, Saudi Arabia
| | - Omar M Al-Qattan
- Division of Plastic Surgery King Saud University, Riyadh, Saudi Arabia; Division of Plastic Surgery at National Hospital, Riyadh, Saudi Arabia
| | - Heba M Al-Qattan
- Division of Plastic Surgery King Saud University, Riyadh, Saudi Arabia; Division of Plastic Surgery at National Hospital, Riyadh, Saudi Arabia
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CORR Insights ®: Variations in the Innervation of the Long Head of the Triceps Brachii: A Cadaveric Investigation. Clin Orthop Relat Res 2017; 475:251-252. [PMID: 27853936 PMCID: PMC5174075 DOI: 10.1007/s11999-016-5167-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 11/10/2016] [Indexed: 01/31/2023]
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Flores LP. Outcomes of Transferring a Healthy Motor Fascicle From the Radial Nerve to a Branch for the Triceps to Recover Elbow Extension in Partial Brachial Plexus Palsy. Neurosurgery 2016; 80:448-453. [DOI: 10.1093/neuros/nyw054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/11/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Triceps reinnervation is an important objective to pursue when repairing the brachial plexus for cases with upper roots injuries, and a number of different techniques have been developed in order to restore elbow extension in such cases.
OBJECTIVE: To demonstrate the surgical outcomes associated with the technique of transferring a single healthy motor fascicle from the radial nerve of the affected arm to a branch innervating 1 of the 3 heads of the triceps.
METHODS: A retrospective study of 13 adult patients sustaining an upper trunk syndrome associated with total elbow extension palsy who underwent the proposed technique as part of the surgical planning for reconstruction of the brachial plexus.
RESULTS: Outcomes scored as M4 for elbow extension were noted in 9 cases (70%), M3 in 3 (23%), and M1 in 1 subject (7%). No patient considered the postoperative strength for carpal or finger extension as impaired. There were no differences in outcomes by using a fascicle activating carpal or finger extension as donor, as well as regarding the use of the branch to the medial or lateral head of the triceps as the recipient.
CONCLUSION: The technique of transferring a healthy motor fascicle from the radial nerve of the affected side to one of its nonfunctional motor branches to the triceps is an effective and safe procedure for recovering elbow extension function in patients sustaining partial injuries of the brachial plexus.
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Tse R, Kozin SH, Malessy MJ, Clarke HM. International Federation of Societies for Surgery of the Hand Committee report: the role of nerve transfers in the treatment of neonatal brachial plexus palsy. J Hand Surg Am 2015; 40:1246-59. [PMID: 25936735 DOI: 10.1016/j.jhsa.2015.01.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/14/2015] [Accepted: 01/21/2015] [Indexed: 02/02/2023]
Abstract
Nerve transfers have gained popularity in the treatment of adult brachial plexus palsy; however, their role in the treatment of neonatal brachial plexus palsy (NBPP) remains unclear. Brachial plexus palsies in infants differ greatly from those in adults in the patterns of injury, potential for recovery, and influences of growth and development. This International Federation of Societies for Surgery of the Hand committee report on NBPP is based upon review of the current literature. We found no direct comparisons of nerve grafting to nerve transfer for primary reconstruction of NBPP. Although the results contained in individual reports that use each strategy for treatment of Erb palsy are similar, comparison of nerve transfer to nerve grafting is limited by inconsistencies in outcomes reported, by multiple confounding factors, and by small numbers of patients. Although the role of nerve transfers for primary reconstruction remains to be defined, nerve transfers have been found to be effective and useful in specific clinical circumstances including late presentation, isolated deficits, failed primary reconstruction, and multiple nerve root avulsions. In the case of NBPP more severe than Erb palsy, nerve transfers alone are inadequate to address all of the deficits and should only be considered as adjuncts if maximal re-innervation is to be achieved. Surgeons who commit to care of infants with NBPP need to avoid an over-reliance on nerve transfers and should also have the capability and inclination for brachial plexus exploration and nerve graft reconstruction.
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Affiliation(s)
- Raymond Tse
- Division of Plastic Surgery, Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA.
| | - Scott H Kozin
- Department of Orthopaedic Surgery, Shriners Hospitals for Children, Temple University, Philadelphia, PA
| | - Martijn J Malessy
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Howard M Clarke
- Division of Plastic Surgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
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