Skip to main content

Advertisement

SpringerLink
Log in

Anatomic localization of motor entry points and accurate regions for botulinum toxin injection in the flexor digitorum superficialis

  • Original Article
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Purpose

The aim of this study was to determine the motor entry points (MEPs) and the precise intramuscular nerve distribution of the flexor digitorum superficialis (FDS) and to provide accurate injection regions for botulinum toxin.

Methods

This study was performed on 46 fresh cadaveric arms with exposed intramuscular innervation of the FDS. For each main motor branch of the FDS, MEPs, where the nerve branch first pierced the muscle belly, and the proximal and distal limit points (PLPs and DLPs, respectively) of the terminal intramuscular nerve endings were located. These data were expressed as relative percentages and absolute distances in relation to the coordinate system, which defined the line between medial and lateral epicondyle of the humerus (ME and LE, respectively) as y-axis and the midpoint of ME and LE as origin. MEP distributions were analyzed using distances measured in tenths of the x and y axes.

Results

Two main branches innervated the FDS in 27 cases, the distal main branches of the FDS were classified into three types by origin. For proximal main branches, MEPs were located at x = 19.7% and y = 18.5%, whereas PLPs were located at x = 16.4%, and DLPs were located at x = 37.7%. For distal main branches, corresponding values were 31.6, 5.5, 50.9, and 73.1%.

Conclusions

The parameters provided by this study should increase the efficacy and precision of neuromuscular botulinum toxin blockades administered to treat finger spasticity.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. An XC, Lee JH, Im S, Lee MS, Hwang K, Kim HW, Han SH (2010) Anatomic localization of motor entry points and intramuscular nerve endings in the hamstring muscles. Surg Radiol Anat 32:529–537

    Article  PubMed  CAS  Google Scholar 

  2. Autti-Ramo I, Larsen A, Peltonen J, Taimo A, von Wendt L (2000) Botulinum toxin injection as an adjunct when planning hand surgery in children with spastic hemiplegia. Neuropediatrics 31:4–8

    Article  PubMed  CAS  Google Scholar 

  3. Bensmail D, Robertson J, Fermanian C, Roby-Brami A (2010) Botulinum toxin to treat upper-limb spasticity in hemiparetic patients: grasp strategies and kinematics of reach-to-grasp movements. Neurorehabil Neural Repair 24:141–151

    Article  PubMed  Google Scholar 

  4. Bickerton LE, Agur AM, Ashby P (1997) Flexor digitorum superficialis: locations of individual muscle bellies for botulinum toxin injections. Muscle Nerve 20:1041–1043

    Article  PubMed  CAS  Google Scholar 

  5. Brashear A, Gordon MF, Elovic E, Kassicieh VD, Marciniak C, Do M, Lee CH, Jenkins S, Turkel C (2002) Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J Med 347:395–400

    Article  PubMed  CAS  Google Scholar 

  6. Canovas F, Mouilleron P, Bonnel F (1998) Biometry of the muscular branches of the median nerve to the forearm. Clin Anat 11:239–245

    Article  PubMed  CAS  Google Scholar 

  7. Chantelot C, Feugas C, Guillem P, Chapnikoff D, Remy F, Fontaine C (1999) Innervation of the medial epicondylar muscles: an anatomic study in 50 cases. Surg Radiol Anat 21:165–168

    Article  PubMed  CAS  Google Scholar 

  8. Chen G, Jiang H, Liu AT, Zhang JL, Lin ZH, Dang RS, Yu DZ, Li WP, Liu BL (2010) Neurovascular details about forearm muscles: applications in their clinical use in functional muscular transfer. Surg Radiol Anat 32:3–8

    Article  PubMed  Google Scholar 

  9. Gunther SF, DiPasquale D, Martin R (1992) The internal anatomy of the median nerve in the region of the elbow. J Hand Surg Am 17:648–656

    Article  PubMed  CAS  Google Scholar 

  10. Harrison TP, Sadnicka A, Eastwood DM (2007) Motor points for the neuromuscular blockade of the subscapularis muscle. Arch Phys Med Rehabil 88:295–297

    Article  PubMed  Google Scholar 

  11. Henzel MK, Munin MC, Niyonkuru C, Skidmore ER, Weber DJ, Zafonte RD (2010) Comparison of surface and ultrasound localization to identify forearm flexor muscles for botulinum toxin injections. PM R 2:642–646

    PubMed  Google Scholar 

  12. Lagalla G, Danni M, Reiter F, Ceravolo MG, Provinciali L (2000) Post-stroke spasticity management with repeated botulinum toxin injections in the upper limb. Am J Phys Med Rehabil 79:377–384 (quiz 391–394)

    Google Scholar 

  13. Lai SM, Studenski S, Duncan PW, Perera S (2002) Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke 33:1840–1844

    Article  PubMed  Google Scholar 

  14. Lee JH, Kim HW, Im S, An X, Lee MS, Lee UY, Han SH (2009) Localization of motor entry points and terminal intramuscular nerve endings of the musculocutaneous nerve to biceps and brachialis muscles. Surg Radiol Anat 32:213–220

    Article  PubMed  Google Scholar 

  15. Lee JH, Lee BN, Han SH, An XC, Chung RH (2011) The effective zone of botulinum toxin A injections in the sternocleidomastoid muscle. Surg Radiol Anat. doi:10.1007/s00276-010-0729-y

  16. Lepage D, Parratte B, Tatu L, Vuiller F, Monnier G (2005) Extra- and intramuscular nerve supply of the muscles of the anterior antebrachial compartment: applications for selective neurotomy and for botulinum toxin injection. Surg Radiol Anat 27:420–430

    Article  PubMed  CAS  Google Scholar 

  17. Marur T, Akkin SM, Alp M, Demirci S, Yalçin L, Ogüt T, Akgün I (2005) The muscular branching patterns of the ulnar nerve to the flexor carpi ulnaris and flexor digitorum profundus muscles. Surg Radiol Anat 27:322–326

    Article  PubMed  Google Scholar 

  18. Munin MC, Navalgund BK, Levitt DA, Breisinger TP, Zafonte RD (2004) Novel approach to the application of botulinum toxin to the flexor digitorum superficialis muscle in acquired brain injury. Brain Inj 18:403–407

    Article  PubMed  Google Scholar 

  19. Pandyan AD, Cameron M, Powell J, Stott DJ, Granat MH (2003) Contractures in the post-stroke wrist: a pilot study of its time course of development and its association with upper limb recovery. Clin Rehabil 17:88–95

    Article  PubMed  CAS  Google Scholar 

  20. Parratte B, Tatu L, Vuillier F, Diop M, Monnier G (2002) Intramuscular distribution of nerves in the human triceps surae muscle: anatomical bases for treatment of spastic drop foot with botulinum toxin. Surg Radiol Anat 24:91–96

    Article  PubMed  CAS  Google Scholar 

  21. Richard SS (2004) Clinical anatomy. In: Upper limb, 4th edn. Lippincott Williams & Wilkins, Baltimore, 132 pp

  22. Roberts C, Crystal R, Eastwood DM (2006) Optimal injection points for the neuromuscular blockade of forearm flexor muscles: a cadaveric study. J Pediatr Orthop B 15:351–355

    Article  PubMed  Google Scholar 

  23. Simpson DM (2000) Treatment of spasticity with botulinum toxin. Muscle Nerve 23:447–449

    Article  PubMed  CAS  Google Scholar 

  24. Sun SF, Hsu CW, Sun HP, Hwang CW, Yang CL, Wang JL (2010) Combined botulinum toxin type A with modified constraint-induced movement therapy for chronic stroke patients with upper extremity spasticity: a randomized controlled study. Neurorehabil Neural Repair 24:34–41

    Article  PubMed  Google Scholar 

  25. Tung TH, Mackinnon SE (2001) Flexor digitorum superficialis nerve transfer to restore pronation: two case reports and anatomic study. J Hand Surg Am 26:1065–1072

    Article  PubMed  CAS  Google Scholar 

  26. Twitchell TE (1951) The restoration of motor function following hemiplegia in man. Brain 74:443–480

    Article  PubMed  CAS  Google Scholar 

  27. Unver Dogan N, Uysal II, Karabulut AK, Fazliogullari Z (2010) The motor branches of median and ulnar nerves that innervate superficial flexor muscles: a study in human fetuses. Surg Radiol Anat 32:225–233

    Article  PubMed  Google Scholar 

  28. Zuber M, Sebald M, Bathien N, de Recondo J, Rondot P (1993) Botulinum antibodies in dystonic patients treated with type A botulinum toxin: frequency and significance. Neurology 43:1715–1718

    PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of General Surgery, First Hospital, University of Jilin, Changchun, China

    J. F. Ye

  2. Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, 505, Banpo-dong, Seocho-gu, Seoul, 137701, Republic of Korea

    J. F. Ye, J. H. Lee, X. C. An & Seung-Ho Han

  3. Department of Nuclear Medicine, First Hospital, University of Jilin, Changchun, China

    C. H. Lin

  4. Department of Spine Surgery, Affiliated Hospital of Qingdao University Medical College, Qingdao, China

    B. Yue

Authors
  1. J. F. Ye
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. H. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. X. C. An
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. C. H. Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. B. Yue
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Seung-Ho Han
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Seung-Ho Han.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ye, J.F., Lee, J.H., An, X.C. et al. Anatomic localization of motor entry points and accurate regions for botulinum toxin injection in the flexor digitorum superficialis. Surg Radiol Anat 33, 601–607 (2011). https://doi.org/10.1007/s00276-011-0779-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-011-0779-9

Keywords

Search

Navigation