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Reconstruction of elbow flexion in arthrogryposis multiplex congenita type I. Part I: surgical anatomy and vascular and nerve supply of the pectoralis major muscle as a basis for muscle transfer

  • Original Clinical Article
  • Published:
Journal of Children's Orthopaedics

Abstract

Purpose

The anatomy and neurovascular supply of the pectoralis major muscle was studied in order to establish the safe and functional muscle transfer for the reconstruction of elbow flexion in patients with arthrogryposis multiplex congenita (AMC).

Methods

Twenty pectoralis major muscles were dissected in 11 adult cadavers. The distribution of the motor end plates was studied in five pectoralis major muscles in foetuses by the detection of esterases.

Results

The pectoralis major muscle consists of clavicular, manubrial, sternocostal, costal and abdominal parts. Each part has a distinct vascular and nerve supply. The motor nerves arise from the medial and lateral pectoral nerves. The motor end plates are localised in one zone in the clavicular and manubrial parts and in two oblique zones in the distal parts of the muscle. In 15 cases, each of the muscle parts were supplied by one nerve branch. In four cases, six nerves were distinguished and the clavicular part was supplied by two nerves. In one case, four nerves were found, with the clavicular and manubrial parts supplied by one common nerve. Three branches (13 cases) or two arterial branches (seven cases) supplied the muscle, arising from thoracoacromial and lateral thoracic arteries, respectively. The superior branch supplied the clavicular and manubrial parts, whereas the dominant pectoral branch supplied the manubrial, sternocostal and costal parts of the muscle. The inferior branch of the lateral thoracic artery supplied the abdominal part in 13 cases. In seven cases, the inferior branch failed and the abdominal part was supplied from the dominant branch.

Conclusion

This study presents guidelines for the transfer of the distal parts of the pectoralis major muscle for the reconstruction of elbow flexion. The sternocostal, costal and abdominal parts of the muscle can be released as a unit from the chest wall after dissection between the second and third rib and be transferred to the brachium. They are sufficiently supplied from the dominant pectoral branch of the thoracoacromial artery in all cases and inconstantly from the inferior branch of the lateral thoracic artery and from three motor nerves.

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References

  1. Atkins RM, Bell MJ, Sharrard WJW (1985) Pectoralis major transfer for paralysis of elbow flexion in children. J Bone Joint Surg Br 67(4):640–644

    Google Scholar 

  2. Hall JG (1997) Arthrogryposis multiplex congenita: etiology, genetics, classification, diagnostic approach, and general aspects. J Pediatr Orthop B 6:159–166

    Article  Google Scholar 

  3. Manktelow RT, McKee NH, Vettese T (1980) An anatomical study of the pectoralis major muscle as related to functioning free muscle transplantation. Plast Reconstr Surg 65(5):610–615. doi:10.1097/00006534-198005000-00012

    Article  Google Scholar 

  4. Moosman DA (1980) Anatomy of the pectoral nerves and their preservation in modified mastectomy. Am J Surg 139:883–886. doi:10.1016/0002-9610(80)90403-1

    Article  Google Scholar 

  5. Freeman JL, Walker EP, Wilson JSP, Shaw HJ (1981) The vascular anatomy of the pectoralis major myocutaneous flap. Br J Plast Surg 34:3–10. doi:10.1016/0007-1226(81)90086-2

    Article  Google Scholar 

  6. Wei WI, Lam KH, Wong J (1984) The true pectoralis major myocutaneous island flap: an anatomical study. Br J Plast Surg 37:568–573. doi:10.1016/0007-1226(84)90151-6

    Article  Google Scholar 

  7. Tobin GR (1985) Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstr Surg 75:814–824

    Article  Google Scholar 

  8. Chaffaï MA, Mansat M (1988) Anatomic basis for the construction of a musculotendinous flap derived from the pectoralis major muscle. Surg Radiol Anat 10:273–282. doi:10.1007/BF02107898

    Article  Google Scholar 

  9. Nakajima K, Ide Y, Abe S, Okada M, Kikuchi A, Ide Y (1997) Anatomical study of the pectoral branch of thoracoacromial artery. Bull Tokyo Dent Coll 38:207–215

    Google Scholar 

  10. Betka I, Kacirkova J (1988) On the vascularization of the M. Pectoralis major. Cs Otolaryng 37:188–190, in Czech

    Google Scholar 

  11. Yang D, Marshall G, Morris SF (2003) Variability in the vascularity of the pectoralis major muscle. J Otolaryngol 32:12–15. doi:10.2310/7070.2003.35357

    Article  Google Scholar 

  12. Clark JMP (1946) Reconstruction of biceps brachii by pectoral muscle transplantation. Br J Surg 34:180–181. doi:10.1002/bjs.18003413408

    Article  Google Scholar 

  13. Holt SJ (1958) Indigogenic staining methods for esterases. In: Danielli JF (ed) General cytochemical methods 1. Academic Press, New York, pp 375–398

    Google Scholar 

  14. Čihák R (1959) Musculus pectoralis major und seine Komponenten in der Ontogenese des Menschen. Morfologie VII 2:174–191

    Google Scholar 

  15. Čihák R, Popelka S (1961) Partial defects of the pectoralis major muscle. Acta Chir Orthop Traumat Cechoslovaka 28:185–194, in Czech

    Google Scholar 

  16. Warwick R, Williams PL (eds) (1973) Gray’s anatomy, 35th edn, Longman, Edinburgh, pp 535–536

  17. Doyle JR, James PM, Larsen LJ, Ashley RK (1980) Restoration of elbow flexion in arthrogryposis multiplex congenita. J Hand Surg 5:149–152

    Article  Google Scholar 

  18. Lloyd-Roberts GC, Lettin AWF (1970) Arthrogryposis multiplex congenita. J Bone Joint Surg Br 52:494–508

    Google Scholar 

  19. Steindler A (1939) Tendon transplantation in the upper extremity. Am J Surg 44:260–271. doi:10.1016/S0002-9610(39)90954-2

    Article  Google Scholar 

  20. Zancolli E, Mitre H (1973) Latissimus dorsi transfer to restore elbow flexion. An appraisal of eight cases. J Bone Joint Surg Am 55:1265–1275

    Google Scholar 

  21. Carroll RE, Kleinman WB (1979) Pectoralis major transplantation to restore elbow flexion to the paralytic limb. J Hand Surg 4:501–507

    Article  Google Scholar 

  22. Tsai T-M, Kalisman M, Burns J, Kleinert HE (1983) Restoration of elbow flexion by pectoralis major and pectoralis minor transfer. J Hand Surg 8:186–190

    Article  Google Scholar 

  23. Van Heest A, Waters PM, Simmons BP (1998) Surgical treatment of arthrogryposis of the elbow. J Hand Surg 23:1063–1070. doi:10.1016/S0363-5023(98)80017-8

    Article  Google Scholar 

  24. Lahoti O, Bell MJ (2005) Transfer of pectoralis major in arthrogryposis to restore elbow flexion: deteriorating results in the long term. J Bone Joint Surg Br 87:858–860. doi:10.1302/0301-620X.87B6.15506

    Article  Google Scholar 

  25. Smet HT (1989) Pectoralis major flaps. In: Smet HT (ed) Tissue transfers in reconstructive surgery. Raven Press, New York, pp 74–79

    Google Scholar 

  26. Hidalgo DA (1987) Free muscle transplantation. In: Shaw WW, Hidalgo DA (eds) Microsurgery in trauma. Futura, New York

    Google Scholar 

  27. Cöers C, Woolf AL (1959) The innervation of muscle. A biopsy study. Blackwell, Oxford, pp 1–40

    Google Scholar 

  28. Pára F, Pařízek J (1973) Mapping of motor endplates zones in human muscles. In: Nesvadba Z (ed) Proceedings of the 3rd Symposium on Neuromuscular Disorders, Balnea, Prague, pp 28–36

  29. Schwarzacher HG (1959) Über die Länge und Anordnung der Muskelfasern in menschlichen Skeletmuskeln. Acta Anat (Basel) 37:217–231. doi:10.1159/000141469

    Article  Google Scholar 

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Acknowledgements

This study was sponsored by grant funds of the Ministry of Health of the Czech Republic IGA MZ CR no. 4162–3 “Muscle transfers on the upper extremity in treatment of arthrogryposis multiplex. Anatomical, electromyographic and clinical study.”

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Authors and Affiliations

  1. 1st Medical Faculty of Charles University Prague, Orthopaedic Hospital IPVZ, University Hospital Na Bulovce, Budinova 2, 18081, Prague 8, Czech Republic

    Jiri Chomiak & Pavel Dungl

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  1. Jiri Chomiak
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  2. Pavel Dungl
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Correspondence to Jiri Chomiak.

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Chomiak, J., Dungl, P. Reconstruction of elbow flexion in arthrogryposis multiplex congenita type I. Part I: surgical anatomy and vascular and nerve supply of the pectoralis major muscle as a basis for muscle transfer. J Child Orthop 2, 357–364 (2008). https://doi.org/10.1007/s11832-008-0130-0

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  • DOI: https://doi.org/10.1007/s11832-008-0130-0

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