Download rajiv gandhi university of health sciences, karnataka, bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,
BANGALORE.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
TO BE SUBMITTED IN DUPLICATE
1.
NAME OF THE
DR. DIVYA.C
CANDIDATE AND
D/0 P V CHANDRASHEKAR REDDY,
ADDRESS
# 251, 3RD FLOOR,
13TH CROSS, 11TH MAIN,
WILSON GARDEN,
BANGALORE- 560027
2.
3.
NAME OF THE
M. S. RAMAIAH MEDICAL COLLEGE
INSTITUTION
BANGALORE - 560054
COURSE OF THE STUDY
AND SUBJECT
4.
5.
M.D ANATOMY
DATE OF ADMISSION TO
THE COURSE
27- 05- 2010
TITLE OF THE TOPIC
AN ANATOMICAL STUDY OF INNERVATION
OF THE THREE HEADS OF TRICEPS BRACHII
6. BRIEF RESUME OF INTENDED WORK.
6.1. INTRODUCTION AND NEED FOR THE STUDY:
The extensor compartment of the arm is occupied by triceps muscle, through which runs
the radial nerve and profunda brachii artery. Triceps arises by three heads namely long head,
lateral head and medial head1.
The long head arises by a flattened tendon from the infraglenoid tubercle of scapula,
blending above with the gleno-humeral capsule. Its muscular fibres descend medial to lateral
head and superficial to medial head and join them to form a common tendon. The lateral head
arises from a narrow, linear, oblique ridge on posterior surface of humeral shaft and from the
lateral intermuscular septum. These fibres also converge to the common tendon. Medial head
which is overlapped posteriorly by the lateral and long heads has an extensive origin from the
entire posterior surface of the humeral shaft, medial side of the radial groove, medial border of
humerus, medial intermuscular septum and lower part of the lateral intermuscular septum. Some
muscular fibres reach the olecranon directly and the rest converge to the common tendon.
The tendon of triceps begins near the middle of the muscle. It has two laminae. One
superficial in lower half of the muscle and other in its substance. After receiving the muscle
fibres, the two layers unite above the elbow and are attached for the most part to upper surface of
olecranon.
Innervation - Triceps is innervated by radial nerve, C6, C7 and C8 with separate branches for
each head1,2.
Radial nerve arises from posterior cord C5, C6, C7, C8 (T1) of the brachial plexus. It descends
from the axilla and along with profunda brachii artery it inclines dorsally passing through the
triangular space below the lower border of teres major, between long head of triceps and
humerus. Here it gives a branch which supplies long head of triceps and a muscular branch to
the medial head, which is a long slender filament and lies close to ulnar neve as far as the distal
third of arm. It is often termed as ulnar collateral nerve. Radial nerve then spirals obliquely
across back of the humerus, lying first between lateral and medial head of triceps and then in a
shallow groove deep to the lateral head. A large posterior branch arises from the radial nerve as it
lies in humeral groove. It divides to supply medial and lateral heads of triceps. The nerve to
medial head is long and descends in medial head of triceps and partially supplies it and passes
behind the elbow to end in anconeus1.
The presence of a separately innervated muscle unit of triceps may have possible surgical
importance and can be used for motor reconstruction.
Axillary nerve, ulnar nerve and ulnar collateral branch of the radial nerve are previously
unrecognized sources of triceps brachii innervation. Additional study will be directed towards
exploring these branches as potential sources for reinnervation of denervated muscle by direct
nerve transfer without nerve grafting for management of brachial plexus injuries and biceps
brachii denervation and eventually for reinnervation of other muscles in the arm and forearm3,4.
6.2. REVIEW OF LITERATURE:
The pattern of triceps innervation is complex and as yet and has not been fully
elucidated. Anatomy textbooks report that the motor branch of long head of triceps brachii arises
from the radial nerve1,2. A retrospective clinical study of traumatic injuries of the axillary nerve
with associated paralysis of the long head of triceps suggests that the motor branch of the long
head of triceps may arise from the axillary nerve5. On the basis of cadaver specimen dissection
and in vivo motor nerve stimulation, 65% of motor branch of the long head of triceps seems to
originate from the axillary nerve3.
New advances in peripheral nerve surgery such as neurotization of muscle by direct
suture of the nerve end to muscle or transfer of healthy motor nerve branches to motor nerve end
of a denervated muscle is used for motor reconstruction. Triceps muscle and its main motor
nerve namely the radial nerve have multiple connection modalities. Each of the motor branches
to triceps might be used as a donor for nerve transplantation. The motor branch to long head of
triceps should be used preferentially when the intention is to establish triceps innervation 6.
Motor function of deltoid muscle in patients with complete C5-6 root injury (upper brachial
plexus injury) can be restored by transferring the nerve to the long head of triceps to the anterior
branch of axillary nerve through a posterior approach7.
The contribution of an ulnar nerve branch of motor function to triceps was observed in
many surgical procedures that needed ulnar nerve dissection proximal to elbow. The ulnar
innervated part of medial head of triceps muscle may be used like an independent motor unit for
motor reconstructions4.
In elbow surgeries the posterior side of elbow joint are approached through triceps
splitting and triceps reflection. Although splitting of fibres of triceps proximally increases the
exposure of the posterior humerus, innervation of the lateral portion of the medial head of triceps
and anconeus muscle may be jeopardized. Therefore, surgeons interested in elbow surgery
should revise the course of the nerve to medial head of triceps and anconeus and try to choose a
more conservative posterior surgical approach8.
6. 3. OBJECTIVE OF THE STUDY:
1. To establish the anatomy of motor branches to triceps brachii.
2. To determine the exact origin of motor branch of the long head of triceps brachii.
3. To explore a possible contribution of the ulnar nerve to motor innervation of the medial
head of the triceps.
7. MATERIALS AND METHODS:
7.1. SOURCE OF DATA: Materials for this study will be randomly selected 52 upper limbs of
formalin embalmed cadavers from the department of anatomy.
Study design: Cross sectional study.
Study area: M.S.Ramaiah Medical College, Bangalore.
Study subject: The study will be performed on 52 upper limbs of formalin embalmed cadavers
from department of anatomy, M S Ramaiah Medical College.
Sample size: 52, estimated using nMaster software, based on the study- “Does the motor branch
of the long head of triceps brachii arise from the radial nerve?”. Considering the nerve supply to
long head of triceps is from axillary nerve in 65% of specimens in the above study. Here the
alpha error considered is 5% and relative precision is 20%.
7.2. METHOD OF COLLECTION OF DATA:
Method of collection of data is by standard dissection method of posterior compartment
of the arm in 52 formalin embalmed cadavers.
Using a standard medial skin incision at the back of the arm, subcutaneous tissue will be
removed. Deep fascia will be removed to expose the triceps muscle which fills the posterior
compartment. Superiorly, the medially placed long head of triceps which arises from
infraglenoid tubercle of scapula will be separated from the lateral head which has a linear origin
from the posterior surfaces of humerus.
The nerve supply to each head of triceps will be traced and carefully followed to the
source of each nerve branch.
Inclusion Criteria: Formalin embalmed upper limb specimens irrespective of age, sex or race.
Exclusion Criteria: Upper limbs showing gross asymmetry, any injury to nerve supplying the
triceps, or any surgical procedures done at brachial plexus will be excluded as unsuitable.
Statistical Analysis: The descriptive study statistics of motor branches of three heads of triceps
will be analysed and expressed in percentage.
7.3. Does the study require any investigations or interventions to be conducted on patients
or other humans or animals?
No
7.4. Has ethical clearance been obtained from your institution?
Yes
8. LIST OF REFERENCES
1. Standring, Gray’s anatomy, 38th edition, Upper arm, ELBS. Elsevier, Churchill, Livingstone,
2005; 855.
2. Last R.J, Anatomy Regional and Applied, The Arm, 7th edition. ELBS. Edinburgh. Churchill
Livingstone, 1984; 76.
3. De Seze M.P, Rezzouk J, et.al. Does the motor branch of the long head of the triceps brachii
arise from radial nerve? Journal of surgical radiological anatomy. 2004; 26: 459-461.
4. Halil Bekler, Valerie M.Wolfe, et.al. A cadaveric study of ulnar nerve innervation of the
medial head of triceps brachii. Clinical orthopaedics and related research. 2009; 467: 235-238.
5. Rezzouk J, Durandeau A. Long head of the triceps brachii in axillary nerve injury : anatomy
and clinical aspects. Revue de chirurgic orthopedique et reparatrice de’l appareil moteur. 2002;
88: 561-564.
6. Bertelli J A, Santos M A, et.al. Triceps motor branch as donar or reciever in nerve transfer.
Neurosurgery. 2007; 6: 333-338.
7.Witooncahart K, et.al. Nerve transfer to deltoid muscle using nerve to long head of triceps. Part
1- an anatomical feasibility study 1. Journal of hand surgery. 2003; 28: 628-632.
8. Ozer H, Acar H I , et.al. Course of the innervation supply of medial head of triceps and
anconeus muscle at the posterior aspect of humerus (anatomical study). Archieves of orthopaedic
and trauma surgery. 2006; 126: 549-553.
9
SIGNATURE OF THE CANDIDATE
The study of innervation of triceps brachii is
valuable aid for anatomical studies. Separately
innervated muscle unit may have surgical
10
REMARKS OF THE GUIDE
importance and can be used for motor
reconstruction.
This study will facilitate in surgical procedures
and nerve grafting.
11
NAME AND DESIGNATION OF
DR. SHESHGIRI.C. M.S.
SENIOR PROFESSOR AND HEAD
11.1 GUIDE
DEPARTMENT OF ANATOMY
M.S.RAMAIAH MEDICAL COLLEGE
BANGALORE.
11.2
SIGNATURE
11.3 CO GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT
DR. SHESHGIRI.C. M.S.
SENIOR PROFESSOR AND HEAD
DEPARTMENT OF ANATOMY
M.S.RAMAIAH MEDICAL COLLEGE
BANGALORE.
11.6
SIGNATURE
12.1
REMARKS OF PRINCIPAL AND DR. KUMAR S.
DEAN
M.D.
PRINCIPAL AND DEAN,
M.S.
RAMAIAH
MEDICAL
COLLEGE,
TEACHING AND MEMORIAL HOSPITALS,
BANGALORE.
12.2
SIGNATURE