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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
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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
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
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)
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
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References
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