Nerve Transfer to Deltoid Muscle

Using the Nerve to the Long Head

of the Triceps, Part I: An
Anatomic Feasibility Study
Kiat Witoonchart, MD, Somsak Leechavengvongs, MD,
Chairoj Uerpairojkit, MD, Phairat Thuvasethakul, MD,
Vudthipong Wongnopsuwan, MD, Bangkok, Thailand
Purpose: To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle
in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to
the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach.
Methods: The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The
number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral
space were noted. The length and diameter of the nerves to the long head and to the lateral head
of triceps at the level of triangular space were recorded. The distances from the acromion angle to
the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long
head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy
specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from
6 fresh cadavers for histomorphometric evaluation.
Results: The average length of the anterior branch of the axillary nerve in this study, measured from
the quadrilateral space to the innervating site, was 44.5 mm (range, 26 62 mm), and the average
length of the nerve to the long head of triceps, measured from its origin to the innervating site, was
68.5 mm (range, 30 69 mm). The average diameter of the anterior branches of the axillary nerve
and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average
number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the
long head of the triceps was 1,233.
Conclusions: Using the acromial angle as the landmark, the combined length of the two 2 nerves was
longer than the distance between them. The diameter, the number of axons, and the anatomic
proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the
anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior
approach for the management of upper brachial plexus injuries. (J Hand Surg 2003;28A:628 632.
Copyright 2003 by the American Society for Surgery of the Hand.)
Key words: Nerve transfer, axillary nerve, nerve to the long head of the triceps, brachial plexus
injury, deltoid paralysis.

From the Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Bangkok, Thailand.
Received for publication February 3, 2003; accepted in revised form April 17, 2003.
No benefits in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article.
Reprint requests: Kiat Witoonchart, MD, Institute of Orthopaedics, Lerdsin General Hospital, Silom Rd, Bangkok 10500, Thailand.
Copyright 2003 by the American Society for Surgery of the Hand
0363-5023/03/28A04-0013$30.00/0
doi:10.1016/S0363-5023(03)00200-4

628

The Journal of Hand Surgery

Witoonchart et al / Nerve Transfer to Deltoid Muscle

Loss of biceps and deltoid function is common in

complete C5 and C6 root injuries (upper brachial
plexus injury). For restoration of biceps function
recent evidence suggests that the result of direct
nerve transfers, such as the medial pectoral nerve or
parts of the ulnar nerve,1 6 seems to be superior to
that of traditional nerve transfer of intercostals, spinal accessory nerve, contralateral C7, or phrenic
nerve. All of them are far from the target muscle/
nerve and require the use of a long nerve graft. The
rate of functional restoration of the deltoid is low in
patients treated with nerve transfer to the axillary
nerve.79 One major factor in the failure of reinnervation is reduction of the nerve fibers that reinnervate
the deltoid muscle when nerve transfer is done at a
proximal level through anterior approach.10
In search of a better outcome we conducted a
feasibility study for restoration of deltoid function by
transferring the nerve to the long head of the triceps,
which contains mainly motor fibers, to the anterior
branch of the axillary nerve through the posterior
approach. From an anatomical standpoint this would
be reasonable because the nerve to the long head of
the triceps is close to the deltoid muscle.

Materials and Methods

This study was performed on shoulder girdles of 36
formalin-embalmed cadavers and 6 fresh cadavers.
All cadavers were placed in the prone position. The
skin and subcutaneous tissues were removed while
preserving the cutaneous nerves around the posterior
border of the deltoid muscle. The origin of the posterior deltoid muscle on the scapular spine was detached and the muscle was turned down. The quadrilateral space was approached and the branches of
the axillary nerve were located and traced distally to
their sites of innervation. The number, diameter, and
length of the branches of the axillary nerve at the
level of the quadrilateral space were recorded. The
interval between the lateral and the long heads of the
triceps was located at the level of the triangular space
to expose the radial nerve. Then the nerves to the
long head and to the lateral head of triceps were
identified and traced proximally to their origins from
the radial nerve. The length and diameter of both
branches were recorded. The distances from the acromion angle to the bifurcation of the anterior and
posterior branches of the axillary nerve, to the origin
of the nerve to the long head, and to the origin of the
nerve to the lateral head of the triceps were recorded
as well.
Nerve biopsy specimens of the axillary nerve and

629

the nerve to the long head of the triceps were obtained from each of the fresh cadavers for histomorphometric evaluation. They were immersed immediately in a 2.5% solution of glutaraldehyde buffered
with cacodylate, postfixed with 2% osmium tetroxide, and embedded in epoxy resin. Semi-thin sections
of 1.5 m were obtained by using an ultramicrotome.
The sections were stained with 1% para-phenylenediamine in absolute alcohol and examined under a
light microscope. The morphometric measurements
of all sections were taken by using a semiautomatic
image analyzing system. Gross morphometric measurements were obtained at a 100 magnification.
To minimize operator-dependent errors only one investigator (V.W.) analyzed the cross-sections.

Results
Anatomic Dissections
The axillary nerve at the level of the quadrilateral
space was clearly divided into 2 groups of branches:
1 to 3 anterior branches and one posterior branch
(Fig. 1). In our study there was one anterior branch in
36 shoulders (50.0%), 2 branches in 28 shoulders
(38.9%), and 3 branches in 8 shoulders (11.1%). The
anterior branch(es) wound around the humeral neck
anteriorly before supplying the deltoid. The posterior
branch was more superficial and divided into the
superior lateral brachial cutaneous nerve and a
branch to the posterior deltoid muscle. The posterior
branch also provided branches that supplied the teres
minor. There also were fibers from the posterior
branch to the posterior deltoid in 51 shoulders
(70.8%).
For the radial nerve, the nerve to the long head of
the triceps was the first branch, and the nerve to the
lateral head of the triceps emerged distally.
The results of the measurements are given in Table
1. The distance from the bifurcation of the anterior
branch of the axillary nerve to the origin of the nerve
to the long head of the triceps measured by using the
acromion angle as the reference point was always
shorter than the combined length of the 2 nerves.

Histomorphometric Evaluation
The results are summarized in Table 1. The average
number of myelinated nerve fibers of the anterior
branch of the axillary nerve was 2,704 with an average of 5.4 fascicles. The nerve to the long head of the
triceps contained 1,233 myelinated nerve fibers with
an average of 3.6 fascicles.

630

The Journal of Hand Surgery / Vol. 28A No. 4 July 2003

Figure 1. Schematic drawing of the posterior aspect of a right shoulder showing the axillary nerve and its branches and the nerve
to the long head of the triceps. (1) The nerve to the long head of the triceps. (2) The nerve to the lateral head of the triceps. (3)
The anterior branch of the axillary nerve. (4) The posterior branch of the axillary nerve. (5) Teres minor muscle. (6) The long head
of the triceps. (7) Teres major muscle. (8) The lateral head of the triceps. (9) Deltoid muscle (cut).

Discussion
Nerve transfer is a well-established method in brachial plexus reconstruction.
It generally has been accepted that the 2 main
priorities in nerve transfer are elbow flexion and arm

abduction.10 Recent studies suggest that whenever

possible direct nerve transfer of collateral branches
(such as the medial pectoral nerve, the thorocodorsal
nerve, or a part of the ulnar nerve in cases involving
upper brachial plexus) to retain biceps muscle yields

Table 1. Results of Measurements

Nerve
Anterior
branch of
axillary
nerve
Nerve to the
long head of
the triceps
Nerve to the
lateral head
of the triceps

Average No. of
Fibers (Range)

Average
No. of
Fascicles
(Range)

Average
Diameter
(Range)

Average Level*
(Range)

Average Length
(Range)

2,704
(1,6843,778)

5.4
(47)

2.2 mm
(1.82.5)

67 mm
(4789)

44.5 mm
(2662)

1,233
(6721,824)

3.6
(25)

1.2 mm
(1.01.6)

91 mm
(6598)

68.5 mm
(30110)

1.2 mm
(1.11.6)

132.5 mm
(121150)

43.5 mm
(2870)

*Measured from the acromion angle.

Witoonchart et al / Nerve Transfer to Deltoid Muscle

better results.4 6,11 The deltoid muscle usually cannot attain a level of function comparable with that of
the biceps muscle. This may be caused by the dilution of the donor nerve fibers entering the deltoid
muscle when the nerve transfer is done at a proximal
level through the anterior approach.10
Previous studies on the anatomy of the axillary
nerve focused mostly on the safety of the nerve
during shoulder surgery.12,13 Few studies have concentrated on nerve repair or nerve transfer of the
axillary nerve.10,14 Aszmann and Dellon14 studied
the internal topography of the axillary nerve focusing
on the motor fascicles of the deltoid muscle. They
reported that the nerve fascicles to the deltoid muscle
could be identified in a superolateral position as a
separate entity 4.5 cm proximal to the quadrilateral
space. Zhao et al10 studied the morphologic and
internal topography of the axillary nerve to provide
anatomic data for selective nerve transfer of the
deltoid muscle. They divided the axillary nerve into
3 segments. In zone 1, proximal to the subscapularis,
the axillary nerve has a single nerve trunk and nerve
fascicles to the deltoid muscle are identified at its
lateral part. In zone 2, in front of the subscapularis,
the nerve can be distinguished into the medial and
lateral fascicular groups. In zone 3, distal to the
subscapularis muscle, the nerve divides itself into
one anterior and one posterior branch, which are the
continuations of the lateral and medial fascicular
groups, respectively. The anterior branch contains all
fibers that innervate the anterior and middle deltoid
muscle and, in 57.5% of their cases, the posterior
deltoid muscle. The posterior branch contains fibers
that supply the posterior deltoid in 90% of cases.
Nerve fibers to the teres minor and cutaneous sensory
fibers also are found in the posterior branch. Zhao et
al10 suggested that nerve transfer be performed in
zone 2 to the lateral fascicular group of the axillary
nerve through a transaxillary approach. They did not
recommend a posterior approach in zone 3 because
they thought that the patient would have to be placed
in the lateral or prone position and that a nerve graft
would be necessary for donor nerves to reach the
anastomotic site.
In our study the posterior branch contained nerve
fibers to the teres minor and to the cutaneous sensory
fibers and 70.8% to the posterior part of the deltoid
muscle. Although using the anterior branch of the
axillary nerve as a recipient will not always result in
reinnervation of the posterior part of the deltoid,
previous studies of electromyographic and mechanical data suggest that the posterior part of the deltoid

631

Figure 2. Right shoulder from the posterior aspect. Schematic drawing of nerve transfer to the axillary nerve using the
nerve to the long head of the triceps. (1) The nerve to the long
head of the triceps. (2) The anterior branch of the axillary
nerve. (3) The posterior branch of the axillary nerve. (4) Teres
minor muscle. (5) Teres major muscle. (6) The long head of
the triceps. (7) The lateral head of the triceps. (8) Deltoid
muscle (cut).

played no role during elevation in the plane of scapula.15 Therefore using the anterior branch as a recipient nerve should not compromise the abductor
power gained. This transfer technique definitely will
avoid, however, the misdirection of the regenerated
axons into the superior lateral brachial cutaneous
nerve and teres minor, which results in decrease of
the motor fibers that reinnervate the deltoid muscle.
When a nerve transfer is performed the functional
gain should be greater than the functional loss. If the
nerve to the long head of the triceps is transferred the
functional loss will be minimal and is compensated
easily by the remaining 2 heads of triceps and the
teres muscle group. Travill16 showed that among the
3 heads of the triceps the long head played the least
important role whereas the medial and the lateral
heads showed a considerable amount of activity during elbow extension. The long head of the triceps has
been transferred as a pedicled musculocutaneous flap
and also can be used for a free functioning muscle
transfer.1720 Our study showed that this nerve could
directly reach the level of the anterior branch of the
axillary nerve without nerve grafting (Fig. 2). In
clinical cases this approach could be performed with

632

The Journal of Hand Surgery / Vol. 28A No. 4 July 2003

the patient in a supine position using a sandbag

beneath the affected upper extremity. A possible but
less desirable approach would be to use the nerve to
the lateral head of the triceps because of its more
distal location and its higher donor morbidity. The
histomorphometric data revealed that the anterior
branch of the axillary nerve contains approximately
2,704 myelinated axons. The nerve to the long head
of the triceps contains approximately 1,233 myelinated axons. It has been suggested that normal muscle
force can be achieved with a minimum of 30% of the
original motor neuron pool.21 From our study, using
the nerve to the long head of the triceps, 45.5% of the
original motor neuron pool can be reinnervated and
that should lead to a good recovery of the deltoid
muscle.
Transfer of the nerve to the long head of the triceps
to the anterior branch of the axillary nerve could be
an alternative method for reconstruction of the deltoid muscle in upper brachial plexus injury. This
procedure has a number of advantages: motor function is re-established with the use of a relatively pure
motor nerve, no nerve grafting is required, the mean
diameter and the number of axons of the donor and
recipient nerves are matched, and the donor morbidity is low and easily compensated.

6.

7.
8.

9.

10.

11.

12.

13.

14.

The authors would like to thank the Department of Anatomy and

Department of Forensic Medicine, Faculty of Medicine, Chulalongkorn
University, Bangkok, Thailand, for allowing access to anatomical specimens.

15.

References

16.

1. Brandt KE, Mackinnon SE. A technique for maximizing

biceps recovery in brachial plexus reconstruction. J Hand
Surg 1993;18A:726 733.
2. Samardzic M, Rasulic L, Grujicic D, Milicic B. Results of
nerve transfers to the musculocutaneous and axillary nerves.
Neurosurgery 2000;46:93103.
3. Samardzic M, Grujicic D, Rasulic I, Bacetic D. Transfer of
the medial pectoral nerve: myth or reality? Neurosurgery
2002;50:12771282.
4. Oberlin C, Beal D, Leechavengvongs S, Salon A, Dauge
MC, Sarcy JJ. Nerve transfer to biceps muscle using a part
of ulnar nerve for C5-C6 avulsion of the brachial plexus:
anatomical study and report of four cases. J Hand Surg
1994;19A:232237.
5. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Ketmalasiri W. Nerve transfer to biceps mus-

17.
18.

19.

20.

21.

cle using a part of the ulnar nerve in brachial plexus injury

(upper arm type): a report of 32 cases. J Hand Surg 1998;
23A:711716.
Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the
biceps and brachialis branches to improve elbow flexion
strength after brachial plexus injuries. J Neurosurg 2003;98:
313318.
Gu Y-D, Ma M-K. Use of the phrenic nerve for brachial
plexus reconstruction. Clin Orthop 1996;323:119 121.
Narakas AO. Neurotization in the treatment of brachial
plexus injuries. In: Gelberman RH, ed. Operative nerve
repair and reconstruction. Philadelphia: JB Lippincott, 1991:
1329 1358.
Lurje A. Concerning surgical treatment of traumatic injury
of the upper division of the brachial plexus (Erbs-type).
Ann Surg 1948;127:317326.
Zhao X, Hung LK, Zang GM, Lao J. Applied anatomy of the
axillary nerve for selective neurotization of the deltoid muscle. Clin Orthop 2001;390:244 251.
Novak CB, Mackinnon SE, Tung THH. Patient outcome
following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion. Br J Plast Surg
2002;55:416 419.
Loomer R, Graham B. Anatomy of the axillary nerve and its
relation to inferior capsular shift. Clin Orthop 1989;243:
100 105.
Vathana P, Chiarapattanakom P, Ratanalaka R, Vorasatit P.
The relationship of the axillary nerve and the acromion.
J Med Assoc Thai 1998;81:953956.
Aszmann OC, Dellon AL. The internal topography of the
axillary nerve: an anatomic and histologic study as it relates
to microsurgery. J Reconstr Microsurg 1996;12:359 363.
Comtet JJ, Herzberg G, Anaasan I. Biomechanics of the
shoulder and the scapulothoracic girdle. In: Tubiana R, ed.
The hand. Philadelphia: WB Saunders, 1993, Vol. 4:99 111.
Travill AA. Electromyographic study of the extensor apparatus of the forearm. Anat Rec 1962;144:373376.
Hallock GG. The triceps muscle flap for axillary contracture
release. Ann Plast Surg 1993;30:359 362.
Hartrampf CR Jr, Elliot LF, Feldman S. A triceps musculocutaneous flap for chest-wall defects. J Reconstr Microsurg
1990;86:502509.
Lim AYT, Pereira BP, Kumar VP. The long head of the
triceps brachii as a free functioning muscle transfer. Plast
Reconstr Surg 2001;107:1746 1752.
Sundine MJ, Malkani AL. The use of the long head of triceps
interposition muscle flap for treatment of massive rotator
cuff tears. Plast Reconstr Surg 2002;110:1266 1272.
Totosy De Zepetnek JE, Zung HV, Erdebil S, Gordon T.
Innervation ratio is an important determinant of force in
normal and reinnervated rat tibialis anterior muscles. J Neurophysiol 1992;67:13851392.