Transdeltoid Approach to Axillary Nerve Repair: Anatomical Study and Case Series.

PURPOSE: In cases of isolated paralysis of the axillary nerve, dissection of the distal stump at the posterior deltoid border can be difficult because of scarring from an injury or previous surgery. To overcome this, we propose dissecting the anterior division of the axillary nerve (ADAN) using a deltoid-splitting approach. We investigated the anatomy of the ADAN as it pertains to the transdeltoid approach and report the clinical application of this approach in 9 patients with isolated axillary nerve injury. METHODS: The axillary nerve and its branches were dissected in 9 fresh cadaver specimens. In the clinical series, 1 patient with a lesion confined to the ADAN underwent nerve grafting. In the remaining 8 patients, the ADAN was repaired by transferring the triceps lower medial head and anconeus (TLMA) motor branch via a single-incision or double-incision posterior arm approach. RESULTS: The posterior division of the axillary nerve does not travel around the humerus. It innervated the posterior deltoid and teres minor muscles. At the posterior margin of the humerus, the ADAN ran adjacent to the teres minor tendon. The ADAN's trajectory on the lateral side of the humerus was 65 mm (SD ± 8 mm) from the midpoint of the acromion. One centimeter from the origin, the ADAN offered a prominent branch to the middle deltoid and wound around the humerus anteriorly at the surgical neck just distal to the infraspinatus tendon. A transdeltoid approach was feasible in all our patients. The TLMA was reached without any tension in the ADAN. Middle deltoid strength in 1 patient who had received a graft scored M3, while anterior and middle deltoid strength in the remaining patients who underwent nerve transfers scored M4. CONCLUSIONS: With axillary nerve lesions, reinnervation of the ADAN is a priority. The transdeltoid approach between the posterior and middle deltoid offers a direct and feasible approach to the ADAN. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Anatomy of Profunda Brachial Artery in the Axilla and Its Relationship With the Radial Nerve: Fresh-Cadaver Anatomical Study and Clinical Observations.

PURPOSE: Dissection of the radial nerve in the axilla and upper portion of and posterior aspect of arm may be necessary for brachial plexus reconstruction, in axillary nerve paralysis, and in radial nerve injuries. The radial nerve is in intimate contact with the profunda brachial artery (PBA). The authors sought to describe the relationship of the PBA with the radial nerve. MATERIALS AND METHODS: We dissected the PBA and the radial nerve bilaterally in 20 upper limbs from 10 fresh cadavers after subclavian artery injection with green latex. We studied the relationship of the PBA with the radial nerve, its branching patterns, and its diameters. In addition, we performed surgery on 5 patients with brachial plexus, radial, or axillary nerve injury in whom we dissected the PBA. RESULTS: The PBA was present in all dissections, originating from the brachial artery (n = 19 specimens) close to the latissimus dorsi tendon or from the subscapular artery (n = 1 specimen). In 15 dissections, the PBA bifurcated into an anterior (AB) and a posterior (PB) branch. In one dissection, the AB was absent. The AB traveled toward the triceps medial head. The PB flanked the radial nerve posteriorly and traveled around the humerus, with the radial nerve passing between the medial and the lateral head of the triceps. The AB and PB were longer than the PBA and measured on average 53 mm (SD ± 33 mm) and 39 mm (SD ± 26 mm), respectively. Intraoperatively, the radial nerve could be exposed in the upper arm by pulling the triceps medial head anteriorly together with the AB. The PB was lateral to the radial nerve in the posterior arm approach. CONCLUSIONS: In the upper arm, the radial nerve was not flanked by a single branch as postulated in anatomical textbooks but by 2 branches resulting from the bifurcation of the PBA. CLINICAL RELEVANCE: Awareness of PBA anatomy is essential during radial nerve dissection from the anterior or posterior arm approach.

Triceps and cutaneous radial nerve branches investigated via an axillary anterior arm approach: new findings in a fresh-cadaver anatomical study.

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.

A Method of Shoulder Spica Cast Application In Shoulder Muscle Transfer Patients In Supine Position.

Background Children with birth brachial plexus injury (BBPI) often require secondary surgery for the shoulder. The shoulder spica is necessary after shoulder muscle transfer surgery in babies with BBPI. However, its application can be difficult in the supine position under anesthesia. The authors describe a simple and cost-effective method of applying the shoulder spica cast without changing the supine position under anesthesia. Technique While still under anesthesia, the child is placed in a supine position and then elevated on the wooden bar. The POP roll is wrapped around in a cylindrical manner, starting from the level one inch above the anterior superior iliac spine. The contralateral shoulder is also incorporated into the cast. Conclusion The spica application technique described comprises commonly available materials, such as a wooden plank, pair of bolsters, plaster of Paris rolls, and dressing materials overcoming the need for customized apparatus or the operation table. The materials are easy to assemble and thereby applicable just about anywhere. The task also becomes less challenging for the anesthetic in the supine position. This technique is easily reproducible and cost-effective.

Peripheral Nerve Injury to the Lower Limb: Repair and Secondary Reconstruction.

This article is based on literature review of relevant articles as well as the authors' own experiences in treating peripheral nerve injuries of the lower limb. The article deals with causative factors of lower limb nerve injuries, various grading systems of the injuries, approaches to such injuries, and techniques to repair lower limb nerve injuries. It also enumerates several reasons to explain the poorer prognosis of peroneal nerve injuries and the possible distal nerve transfers in lower limb albeit with poorer outcomes.