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BackgroundUnderstanding muscle and tendon anatomy is of tremendous importance to achieve optimal surgical execution and results in tendon transfers around the shoulder. The aim of this study was to introduce and describe an additional distal muscle slip of the teres major (TM).MethodsSixteen fresh-frozen cadaver shoulders were dissected with the deltopectoral approach. The ventral latissimus dorsi (LD) tendon was harvested, and the shoulders were analyzed for the presence/absence of a distal teres major slip (dTMs) and its dimensions and relationship with the TM and LD tendons.ResultsThe dTMs was identified in 12 shoulders (75%). It was always distal to the TM tendon and visible during the deltopectoral approach. There was a clear separation between the TM proximally and dTMs tendon distally. At the humeral insertion, both tendons had a common epimyseal sheet around the teres major and inserted continuously at the humerus. The mean width of the dTMs tendon at the insertion was 13 ± 4 mm (range, 7–22 mm). The total lengths of the dTMs tendon and LD tendon were 40 ± 7 mm (range, 25–57 mm) and 69 ± 7 mm (range, 57–79 mm), respectively (p ConclusionsThis is the first macroscopic description of an additional distal slip of the teres major muscle. The dTMs has a separate (distal) but continuous (mediolateral) insertion at the humerus within a common epimyseal sheet around the TM. The dTMs tendon is visible during the deltopectoral approach and can therefore provide a lead structure, particularly in ventral LD transfers with the deltopectoral approach.

ResumoAvaliar os resultados de uma série de 28 casos de paralisia obstétrica alta tratadas com a técnica Sever-L'Episcopo modificada por Hoffer, entre 2003 e 2016. As crianças (idade média, quatro anos e sete meses) com contratura em adução e rotação interna do ombro sem deformidades ósseas secundárias (Mallet classe II) foram submetidas ao alongamento do músculo peitoral e tenotomia do músculo subescapular associada à transferência do latissimus dorsi e músculo redondo maior para o músculo infraespinhal, movendo-se para a função de rotadores externos e elevadores. O seguimento médio foi de 3 anos e 10 meses. Ao final do estudo, 24 pacientes obtiveram excelentes escores de avaliação funcional, principalmente de abdução e rotação externa, passando de Mallet classe II para classe IV. Quatro pacientes ainda demonstraram algum grau de limitação de movimento global, passando da classe II para a classe III. Independentemente do ganho funcional final, todos os pacientes foram capazes de realizar tarefas que antes eram difíceis. Os dados deste estudo sugerem que a cirurgia de Hoffer é um método eficaz no tratamento das sequelas de paralisia obstétrica alta sem deformidades ósseas secundárias.

Objective: To determine the effects of dry needling (DN) in active myofascial trigger points in the teres major muscle compared to an untreated control group in pain during throwing actions, shoulder range of motion (ROM), strength, and extensibility of the tissues in professional handball (HB) athletes. Methods: A randomised, single-blinded, controlled clinical trial was designed. Thirty HB athletes with shoulder pain were randomly assigned to the DN group (n = 15) or control group (n = 15). The DN group received a single session of ultrasound-guided DN technique in the teres major muscle. The control group received no intervention. Pain intensity during throwing actions (Numeric Pain Rating Score), shoulder ROM (inclinometer), isometric strength (hand-held dynamometer), and extensibility (inclinometer) were measured before and after treatment. Results: DN group showed statistically significant improvements with large effect sizes for pain intensity (p &lt, 0.001, E.S: 1.3), internal rotation ROM (p &lt, E.S: 3.0) and extensibility (p &lt, E.S: 2.9) compared to the control group. No statistically significant differences were found for isometric strength (p &gt, 0.05). Conclusion: A single session of DN in the teres major muscle was effective for improving pain intensity during throwing actions, internal rotation ROM and extensibility in HB athletes with shoulder pain.

Muscle coordination plays an important role in glenohumeral stability. The rotator cuff and the long head of the biceps are considered the primary dynamic stabilizers muscles. However, the fact that a subgroup of patients with a massive tear in the rotator cuff were able to keep a normal function, should make us question this traditional view. We hypothesize that the teres major which is also a monoarticular scapulohumeral muscle, although it is not part of the conjoined tendon of the rotator cuff, can play a role in glenohumeral stability by a direct support of the humeral head generated by the particular posteroanterior location of this muscle under the humeral head and which, as far as we know, has not been written up previously. This particular effect could appear while the arm is being lifted and the humeral head could be leaning on against the teres major muscle belly underneath it. An anatomical a radiological study was carried out to substantiate our hypothesis. Two cadaver specimens were used for the anatomical study. Frist body was studied through conventional dissection. The second body was analysed through sectional anatomy. Then a radiological study was carried out using magnetic resonance imaging in a healthy male volunteer. Both anatomically and radiologically, the anteroinferior surface of the humeral head was showed firmly resting against the muscle belly of the teres major, to the point of misshaping it from 110 degrees of arm elevation with external rotation. The specific contribution of this effect to the glenohumeral stability needs to be confirmed by further studies and can help us to prevent the high incidence of glenohumeral dislocations. info:eu-repo/semantics/publishedVersion

The quadrangular space is a space in the axilla bounded by the inferior margin of the teres minor muscle, the superior margin of the teres major muscle, the lateral margin of the long head of the triceps brachii muscle and the surgical neck of the humerus, medially. The axillary nerve (C5-C6) and the posterior circumflex humeral artery and veins pass through this space in order to supply their territories. The subscapularis muscle is situated into the scapular fossa and inserts itself into the lesser tubercle of the humerus, thus helping stabilize the shoulder joint. A supernumerary muscle known as accessory subscapularis muscle originates from the anterior surface of the muscle and usually inserts itself into the shoulder joint. It is a rare variation with few reports of its existence and incidence. We present a case of the accessory subscapularis muscle in a male cadaver fixated with a 10% formalin solution. The muscle passed anteriorly to the axillary nerve, thus, predisposing an individual to quadrangular space compression syndrome. We perform a review of the literature and address its clinical, anthropological and anatomical significance.

Teres major muscle (TM) and latissimus dorsi muscle (LD) are frequently used in muscle transfers around the shoulder girdle. Some authors have suggested harvesting techniques in which the muscle is detached in continuity with a bone segment. Information on the bony attachment footprint of these muscles is lacking. The purpose of this study was to investigate the region of attachment of the TM to facilitate safe and complete harvesting with a bone segment where it is indicated, and to determine the relationship of the TM footprint with that of the LD. Twenty‐eight upper extremities of 14 human cadavers (six female, eight male) were investigated during the students’ dissection course in the winter term 2012. The attachment footprints were photographed and the images were processed with imageJ Version 1.46r. The TM attachment footprint at the crest of the lesser tubercle had an average dimension of 187 ± 89 mm2. It was 49.6 ± 7.9 mm long and 7.4 ± 2.5 mm wide. The bony attachment of the LD within the bicipital groove, just below the tendon of the long head of the biceps muscle, had an area of 94 ± 37 mm2. It was 36.5 ± 8 mm long and 3.7 ± 1.2 mm wide. Both muscles were separated by 4.4 ± 1.7 mm and their attachments overlapped in the craniocaudal direction by 24.4 ± 12.4 mm. Earlier studies have investigated the dimensions of the muscles’ tendons close to the attachment not the bony attachment itself. The dimension of the attachment of the TM was larger than that of the LD. The ratio between the footprint areas was approximately 2:1. This information should be considered by surgeons undertaking transfers, which include a bony segment of the muscle insertion.

Rotator cuff tears are frequently treated in daily clinical practice. However, there have been few reports of tears around the shoulder involving the latissimus dorsi and teres major muscles. The author reports the rare case of an isolated tear of the teres major muscle with symptom onset during ordinary sports activities without a clear traumatic mechanism. The patient received conservative treatment, and satisfactory results were obtained. [ Orthopedics . 2019; 42(2):e276–e278.]

OBJECTIVE: Despite the increasing awareness of the contribution of myofascial dysfunctions to upper limb pain in breast cancer survivors, reliability of the identification of myofascial trigger points (MTPs) in this population has not yet been investigated. Therefore, the aim of the present study was to investigate the interrater reliability of the identification of MTPs by palpation at the upper limb region in breast cancer survivors with upper limb pain. DESIGN: Interrater reliability study. SETTING: University Hospitals Leuven, Belgium. SUBJECTS: Thirty breast cancer survivors with pain at the upper limb region. METHODS: Nine muscles (upper trapezius, levator scapulae, infraspinatus, supraspinatus, teres major and minor, subscapularis, pectoralis major, and scalene muscles) at the operated side were examined. The weighted kappa (WK) coefficient and Absolute Agreement with 95% confidence intervals were calculated. RESULTS: Moderate agreement was found for all examined upper limb muscles (WK = 0.41-0.60), except for the trapezius muscle, for which the agreement was almost perfect (WK = 0.83), and the supraspinatus muscle (WK = 0.23), for which the agreement was only fair. CONCLUSIONS: For most muscles, moderate interrater reliability for the identification of MTPs by palpation in breast cancer survivors with upper limb pain was found. Therefore, we concluded that the identification of MTPs by palpation may add to the diagnosis of the myofascial pain syndrome in breast cancer survivors. ispartof: PAIN MEDICINE vol:19 issue:8 pages:1650-1656 ispartof: location:England status: published

Background Massive irreparable rotator cuff tears in both the primary and the revision setting are challenging problems. There remains controversy over the ideal treatment methods for these patients. In the case of an irreparable posterosuperior rotator cuff tear, tendon transfers1-12 have emerged as a reliable option, with a durable outcome. The most commonly used tendon transfer options are the latissimus dorsi (LD)1-6and the lower trapezius (LT)12. Description The LD transfer is performed by first harvesting the LT tendon from the humeral shaft. It is critical to release the many adhesions to the muscle belly as well as to separate it from the teres major muscle. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor. The tendon is anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity. The LT transfer is performed by harvesting the LT muscle and tendon off its insertion on the medial aspect of the scapular spine. It should be mobilized to maximize excursion by releasing adhesions. An Achilles tendon allograft is anchored into the anterior aspect of the greater tuberosity arthroscopically. The Achilles tendon is then secured to the LT tendon. Alternatives In addition to tendon transfer, options include:Partial or complete attempted repair13-17.Augmentation or bridging with allografts18-23.Superior capsular reconstruction24.Subacromial balloon25. Rationale There remains a paucity of literature comparing tendon transfers with alternatives. However, when considering a tendon transfer, certain principles are critical in order to achieve an optimal outcome:The recipient and transferred tendons must have similar musculotendinous excursion.The recipient and transferred tendons should have similar lines of pull.One tendon (the transferred) should be designed to replace 1 function (of the recipient).The function of the transferred tendon and muscle should be expendable without substantial donor site morbidity.The strength of the transferred muscle must be at least grade 4.When deciding between the LT and LD transfer, certain considerations should be taken into account. The LD transfer has a proven history of successfully treating massive irreparable posterosuperior rotator cuff tears in studies with long-term follow-up1-6. Alternatively, although the LT transfer has only recently gained popularity, it has the advantage of "in-phase" muscle function, since the trapezius naturally contracts during shoulder external rotation. Furthermore, its line of pull almost completely mimics the infraspinatus.

The teres major and latissimus dorsi muscles (TM, LD) are considered to be the so-called brother muscles. Actually, being similar to the TM, an uppermost part of the LD usually arises from the scapular plate. In embryos of 11 mm CRL, anlagen of the TM and LD appeared to be fused to provide a single mass at an angle between the axillary and radial nerves. However, splitting had already finished in not only the TM and LD but also the other muscles at and around the shoulder in specimens of 14 mm CRL. Thus, muscle splitting at the region appeared to occur simultaneously at a short stage of 12-13 mm CRL.The TM and LD carried a common tendon still at 6 weeks (14-16 mm CRL), but their muscle bellies were separated clearly. A concept of brother muscles might be applied to the TM and LD according to a bias from the gross and comparative anatomy, not from the embryological view.

Isolated lesions to the teres major muscle are rare. They generally occur in patients participating in sports such as baseball, tennis, or boxing. We report the case of a sports patient who suffered an isolated injury to the teres major while water skiing. The clinical presentation was confirmed by MRI. Conservative treatment was chosen and consisted of brief analgesic immobilization, followed by rehabilitative treatment. The rapid recovery of this patient with normal isokinetic strength evaluation at 6 months was interesting for objectifying full muscle recovery. Our results and the data from the literature suggest that functional rather than surgical treatment is preferable in isolated lesions to the teres major muscle.

Objectives: The aim of this study was to observe the effect of Embedding therapy on frozen shoulder. Methods: 57 patients with frozen shoulder were treated with Embedding therapy. It was performed once a day, once per a week. 15~20 Embedding thread were used in one time Embedding therapy. The total number of Embedding therapy was 10. Trapezius muscle including the Gyeonjeong (GB21), Deltoid muscle including the Nosu (SI10), Supraspinatus muscle including the Byeongpung (SI12), Infraspinatus muscle including the Cheonjong (SI11) and gokwon(SI13), Lavator scapular muscle including the Gyeonjunsu (SI15), Rhomboides major muscle including the Pungmun (BL12), Rhomboides minor muscle including the Daejeo (BL11) and Teres major muscle including the Gyeonjeong (SI19). VAS scale, SPADI scale and ROM were compared between before and after treatment to evaluate the effect of Embedding therapy. Results: VAS scale decreased significantly (p=0.003). SPADI Scale decreased significantly (pain (p=0.006), disability(p=0.005)). ROM angle range increased significantly(flexion (p=0.005), extension(p=0.005), abduction(p=0.003), adduction(p=0.003), external rotation (p=0.005), internalrotation(p=0.005)). 29.8% patients were very much satisfied, 62.0% patients were satisfied and 8.0% patients were answered so so about Embedding therapy. Conclusion: The Embedding therapy could be effective to improve symptoms of frozen shoulder.

Information in recent literature on the teres major muscle (TM) is limited and, at times, contradictory. Exact information on its neurovascular supply is clinically relevant for its use in a free or pedicled muscle transfer in reconstructive shoulder surgery. Therefore, the aim of this study was to analyze the TM topographically, especially its neurovascular supply and its macroscopic appearance.Thirty upper extremities of 15 human cadavers (7 female and 8 male cadavers) were investigated during the students' dissection course of our anatomic department in the winter term of 2012.The lower subscapular nerve (LSN) innervated the TM in 86.6% of shoulders. In 13.3%, the thoracodorsal nerve (TDN) supplied the muscle. The LSN's branch was 49.8 ± 11.8 mm long. The TDN's branch was 83.5 ± 9.8 mm long. The entry of the neurovascular pedicle was located almost in the center part of the muscle. The arterial branch was 33.6 ± 7.3 mm long.In general, the LSN innervates the TM. However, in 10% to 20% of shoulders, the TDN innervates this muscle. The branch of the TDN supplying the TM is longer than the branch of the LSN. In a muscle transfer, the vessels are the predictable limiting factor for translation because they are shorter than the nerve. The artery, nerve, and vein enter the muscle in a close relationship (2 cm). It is useful to describe the entry point as an area of 2 cm in diameter around the middle of the TM.

Objective: the purpose of the present study was to analyze the concurrent validity and reliability of a force platform clinical COBS Feedback® for the estimation of the height of vertical jumps. Design: a cross-sectional correlational and comparative study. Setting: University Human Movement and Physiotherapy Laboratory. Participants: healthy university students (14 female and 13 male) aged between 18 and 25 years old (mean = 20.074 ±1.542). Main Outcome Measures: vertical jump heights, technical error and grade of agreement between methods of measurement. Results: after the 27 subjects performed a total of 135 vertical jumps on COBS Feedback®platform while simultaneously being recorded with a high-speed camera-based method, the intraclass correlation coefficient showed an almost perfect concordance between the two methods (ICC = 0.916, CI95%= 0.882 to 0.940, p

Background The posterolateral and medial aspect of the arm is supplied by the axillary (AXN) and intercostobrachial nerves (ICBN), which are not anaesthetised by an axillary brachial plexus block (ABPB). Blockade of the AXN and the ICBN has been reported in the quadrangular space (QS) posteriorly or by serratus plane block, respectively. An anterior ultrasound-guided approach to block the AXN and ICBN would be desirable to complete an ABPB at a single insertion site. Methods After a preliminary dissection study in six cadavers, ultrasound-guided AXN and ICBN injection was performed in 46 Thiel embalmed cadavers bilaterally. Key sonographic landmarks to identify the AXN in the QS are the humerus, teres major muscle, and subscapular muscle. With the same probe position, the ICBN was identified in the subfascial axillary space. Then, 2 ml latex was injected at each nerve and confirmed by dissection. Results Muscular and bony landmarks were identified in all cadavers. The AXN was seen in 99% in the QS or at the inferolateral margin of the subscapular muscle and surrounded by latex in 96% of cases. Latex spread to the axillary fossa, within the subscapular muscle, or to the radial nerve was noted in 8% of the injections. The ICBN was seen and surrounded by latex in 100% of cases. Conclusions We describe a reliable ultrasonographic approach to visualise the AXN and ICBN anteriorly from the conventional ABPB approach as confirmed in this cadaver study.

There are many articles reporting anomalies of various blood vessels of upper extremity. In the present article, we are reporting a case of high division of brachial artery into medial and lateral branches, 9.5 cm distal to the lower border of teres major muscle. It was also observed that the two branches are crossing over near the lower part of front of arm and the lateral branch continued into the cubital fossa and trifurcated at the proximal border of pronator teres muscle. We have discussed the anatomy, embryological basis, and clinical implications of these variations along with relevant literature review. The importance of knowledge about these variations in therapeutic and diagnostic interventions is discussed.

Isolated lesions to the teres major muscle are extremely rare. These injuries have been report in cases reports only due to the rarity of these injuries. I report the case of an amateur volleyball player who suffered an isolated injury to the teres major while volleyball for recreational purposes. The clinical presentation was confirmed by clinical examination and MRI scanning. Conservative treatment was chosen and consisted of brief immobilization and analgesics, followed by rehabilitative treatment. The patient recovered quickly from a conservative regime of physiotherapy and analgesics. The results and the data from the literature suggest that non-operative rather than surgical treatment is preferable in isolated lesions to the teres major muscle.

Variations in the arteries of the upper limb are commonly seen. Most of these variations are seen as variant division of axillary artery and as high origin of radial or ulnar artery. In the present case a higher division of brachial artery was seen, with the artery dividing in the arm just distal to teres major muscle into its terminal branches, the radial artery laterally and ulnar artery medially, the artery had passed superficial to the median nerve before its division. The other branches, profunda brachii and superior ulnar collateral arteries arose from brachial artery whereas the inferior ulnar collateral artery arose from the ulnar artery. Knowledge of such variations is important in view of their clinical significance and they need to be considered prior to surgical procedures.

WOS: 000398816300004 The axillary artery is the main artery supplying the shoulder region and is clinically important. In the present case we report an arterial variation of the left upper extremity of a 65 year-old female cadaver. The radial artery arose from the axillary artery 2.5 cm below the anterior humeral circumflex artery and above the teres major muscle. It first coursed along the medial aspect of the arm, then it passed laterally between the biceps brachii and the brachialis muscle. Reaching the upper part of the elbow, it coursed medial to the brachioradialis muscle. It did not give off any branches in either the arm or in the forearm regions. It contributed to the formation of the superficial palmar arch in the palm of the hand. Further, the brachial artery entered the cubital fossa and divided into ulnar and common interosseous arteries. The right upper extremity had a normal arterial branching pattern. Being aware of the variations of the axillary artery may help to prevent diagnostic errors and avoid complications during the surgery of the region. (C) 2017 Association for Research into Arterial Structure and Physiology. Published by Elsevier B.V. All rights reserved.

Isolated injuries to the teres major muscle occur in competitive sporting activities such as baseball pitching, hockey and tennis. We report a similar event of a physically fit man sustaining an isolated teres major rupture while waterskiing. Non-operative management was chosen, with pain resolution and no appreciable functional limitations at follow up. Because teres major muscle injury was suspected at the time of imaging, we present a dedicated imaging protocol to optimize assessment for teres major injury.

Purpose To evaluate the relative axonal match between potential donor and recipient nerves, so that maximal reinnervation potential may be reached with the least chance of donor site morbidity. Methods In 10 fresh-frozen cadaveric specimens, the main trunk and anterior, posterior, sensory and teres minor branches of the axillary nerve were identified, as were the radial nerve branches to the long, medial, and lateral heads of the triceps. The swing distances of the triceps fascicular nerve branches and the axillary nerve branches relative to the inferior border of the teres major muscle were recorded. Histomorphological analysis and axon counts were performed on sections of each branch. Results The median number of axons in the main axillary trunk was 7,887, with 4,052, 1,242, and 1,161 axons in the anterior, posterior, and teres minor branches, respectively. All specimens had a single long head triceps branch (median, 2,302 axons), a range of 1 to 3 branches to the medial head of the triceps (composite axon count, 2,198 axons), and 1 to 3 branches to the lateral head of the triceps (composite average, 1,462 axons). The medial and lateral head branches had sufficient swing distance to reach the anterior branch of the axillary nerve in all 10 specimens, with only 4 specimens having adequate long head branch swing distances. Conclusions It is anatomically feasible to transfer multiple branches of the radial nerve supplying the medial, lateral, and sometimes, long head of the triceps to all branches of the axillary nerve in an attempt to reinnervate the deltoid and teres minor muscles. Clinical relevance Understanding the axon counts of the different possible transfer combinations will improve operative flexibility and enable peripheral nerve surgeons to reinnervate for both abduction and external rotation with the highest donor/recipient axon count ratios.

The objectives of the study are to demonstrate the innervation patterns of the triceps muscles and the most suitable branch of the radial nerve for nerve transfer to restore the motor function of the deltoid muscle in patients with complete C5-C6 root injury. Seventy-nine arms (40 left arms and 39 right arms) from 46 embalmed cadavers (24 male and 22 female) were included in the study. The nerves to the triceps were dissected from the triceps muscles (long head, lateral head, and medial head). The lengths of the branches were measured from the main trunk. The distance from the inferior margin of the teres major muscle to the origin of the nerve to the long head, lateral head, and medial head of the triceps were recorded as well. The first branch was the nerve to the long head of the triceps in 79 arms (100%). The second branch was the nerve to the upper medial head in 30 arms (38%), nerve to the medial head in 8 arms (10.1%), nerve to the upper lateral head in 35 arms (44.3%) and nerve to the lateral head in 6 arms (7.6%). The patterns of branches to the triceps were classified according to our dissections. The nerve to the long head of the triceps was constant as the first branch of the nerve to the triceps branch of the radial nerve in the vicinity of the inferior margin of the teres major muscle.

SummaryIce hockey is a sport renowned for its numerous injuries; different studies report between 13.8 and 20 lesions per 1000 athlete exposures. Exactly 65.5% of these injuries occur during games, compared to 34.5% during training sessions. And 35.1% of all injuries involve the lower extremity and 29.7% the upper extremity (results drawn from games and training combined). Determining whether muscle injuries are extrinsic (contusions) or intrinsic (tears) is of utmost importance since the former generally require simple follow-up, whereas the latter necessitates further investigations, appropriate treatment and often prolonged absence from sports for the injured athlete. To our knowledge, no publication to date has reported isolated damage of the teres major muscle in Ice Hockey players. Seven cases were reported amongst baseball pitchers. Two cases presented after a waterskiing traction accident and a further case has been described in a tennis player. In the present study, we report two cases of isolated teres major tear in ice hockey players. These two athletes were both professional players competing at the highest level in the Swiss Ice Hockey League.

Hypothesis The combination of suprascapular nerve block (SSNB) and axillary nerve block (ANB) has been reported to provide safe and effective analgesia for arthroscopic shoulder surgery. This study was designed to identify anatomic landmarks of the suprascapular nerve (SSN) and axillary nerve (AN) and to evaluate the effects of SSNB and ANB using the identified landmarks. Materials and Methods This study included 52 cadaveric shoulders and 30 patients in the anatomic and clinical studies, respectively. After the exact location of the SSN and AN was identified from the cadavers, the clinical study at the end of the operation and at 8, 16, 24, 32, 40, and 48 hours postoperatively was performed in 2 groups: without both SSNB and ANB (group I) and with both SSNB and ANB (group II). Results The SSN was located at a length of one-half (2/5-3/5, 88%) from the anterior tip of the acromion to the superior angle of the scapula and at a length of two-fifths (1/3-1/2, 100%) from the anterior tip of the acromion to the medial border of the spine. The AN was located at a length of three-fifths (2/5-4/5, 98%) from the acromial angle to the inferior insertion of the teres major muscle. The depth from the skin was 3.20 ± 0.58 cm for the SSN and 2.07 ± 0.45 cm for the AN. The clinical study showed that the total amount of analgesic for patient-controlled anesthesia was markedly decreased at the end of the operation and at 8 hours postoperatively in group II compared with group I. Conclusions The SSNB and ANB were considered to provide safe and effective analgesia in terms of early postoperative pain in arthroscopic shoulder surgery.

We present a new surgical technique for a pedicled teres major muscle transfer to improve shoulder abduction and flexion in children with sequelae of obstetric brachial plexus palsy. In addition, we provide the clinical outcome in the first 17 operated children.

Objective Thoracomyoplasty after prior posterolateral thoracotomy (PLT) remains a challenge for the thoracic surgeon. Thoracodorsal artery division after PLT impairs the vascularization supply of the latissimus dorsi muscle (LDM) resulting in muscle mass reduction due to distal atrophy. This makes adequate filling of residual empyema space and/or surgical closure of bronchial stump insufficiency more difficult, and they require alternative surgical procedures. We present an alternative approach using a four-muscle flap technique to include the infraspinatus, the subscapularis and the teres major muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing residual empyema space and bronchial stump insufficiency. Methods Between 2002 and 2008 we performed the technique in 7 patients with residual empyema space. Three patients had post-tuberculosis syndrome, 2 had postpneumectomy empyema, and 2 had chronic parapneumonic empyema. Three cases were combined with a bronchopleural fistula. All patients underwent a two-stage procedure. First, open window thoracostomy was performed followed by definitive surgical treatment after 3-6 months. In all cases with bronchial insufficiency the stump was covered with a subscapularis muscle flap. The infraspinatus and the teres muscle group were used in combination with a local thoracoplasty. Results Mean age was 68 +/- 7.9 years. Time from open window thoracostomy to thoracomyoplasty averaged 4 +/- 1.3 months. The number of resected ribs ranged between 4 and 8. Mean postoperative stay in the ICU was 3 +/- 2.9 days. The thoracic drains were removed after 5 +/- 2.3 days. Total hospital stay was 15 +/- 7.6 days. No hospital mortality was noted. Minor postoperative complications occurred in 2 cases. Shoulder function without pain allowed abduction up to 90 degrees. Function was decreased by 16 +/- 9 degrees compared to preoperative evaluation. No severe progressive scoliosis was noted. Conclusions Division of the LDM and its vascular supply after posterolateral thoracotomy results in a reduction of muscle mass. The shoulder girdle muscles offer an adequate alternative to fill residual empyema space with acceptable long-term results and restriction in shoulder motion. In all cases with bronchial fistula, bronchial stump closure with a pedicled subscapular muscle was an effective alternative operative technique.

Descriptive cadaveric laboratory study.To identify the fiber type composition of the rotator cuff and teres major muscles in human subjects.The rotator cuff is commonly injured in athletics and is a major focus of sports medicine. Although the anatomy and architecture of each muscle have been described in great detail, these muscles have never been fiber typed using immunohistochemistry or gel electrophoresis. Fiber typing is important in modeling function, exercise training, and rehabilitation.We harvested tissue samples for all 4 rotator cuff muscles, as well as the teres major muscle from cadavers. Tissues were frozen in liquid nitrogen and sectioned. Cryosections were labeled with commercially available antibodies against fast and slow isoforms of myosin heavy chain (MHC). We also harvested fresh (unembalmed) tissue from deceased subjects and labeled tissue sections with antibodies against fast or slow MHC and wheat germ agglutinin. Gel electrophoresis followed by silver staining was also used to identify and quantify MHC isoforms in fresh tissue samples.All of the muscles were of mixed fiber type composition. As a whole, 44% of rotator cuff fibers labeled positively for slow MHC, with slow MHC content of 54% in supraspinatus, 41% in infraspinatus, 49% in teres minor, 38% in subscapularis, and 40% in teres major. Mixed MHC isoform distribution was confirmed by SDS-PAGE, which also indicated that the IIa and IIx isoforms were roughly equally present across the muscles.Human rotator cuff muscles, at least in older subjects, have a mixed fiber type. Because we only examined older subjects, we must limit our interpretation to this population.

Summary Background Breast cancer is the most common malignancy in women. Although scarring is recognized as contributing to limited shoulder movements, compromised tissue gliding in a wider range of fascial and connective tissue structures is under-recognized. Aim To report on soft tissue patterns in patients with upper limb dysfunction after modified radical mastectomy. Methods Tissue gliding was assessed in the neck, chest wall, abdomen, axilla and upper arm. Scarring, areas and directions of tightness were mapped on upper body charts. Results Eighteen shoulders were evaluated. All patients had combinations of restrictive tissue gliding and shoulder movements. Four dominant restrictive areas were identified—surgical scarring, axillary tightness radiating into the upper arm, lateral chest wall and posterior tightness over the teres major muscle. Discussion Breast cancer treatment results in tissues losing their shearing and gliding ability. Mapped restrictive tissue gliding clearly shows wider than reported restrictions. This pattern needs further research and investigation.

Conventional wheelchair is not effective for people with disabilities, because it requires a great power in pedaling wheelchair. To solve the problem, there is electric wheelchair with a joystick control. However it is also not effective, when users have limitations such as defects of the fingers. Given these circumstances, this research proposes an electric wheelchair with controlled by electromyography (EMG) which is placed on the arm muscles. The arm muscle signal which has an electric potential difference will be read by EMG sensors. Then the data will converted from analog to digital by Arduino. This Electric wheelchair use 4-channel electrodes for sampling muscle signal. Where, the wheelchair will move forward when the biceps muscle is active, moving backward when the teres major muscle active. The wheelchair will turn to the right when the muscles wirst flexor active and turn left when the muscles wirst extensor active. Then the wheelchair will stop when the four muscles are used active simultaneously.

The humerus is primarily affected in approximately 10 % of patients by primary bone tumors. Furthermore, the proximal humerus is a preferred location of metastatic invasion for breast carcinoma and renal cell carcinoma. Limb salvage surgery is indicated for these patients if a functional limb remains after tumor resection and if the patient’s general condition permits surgery. For the shoulder, the majority of resections involve a type I or V according to Malawer’s classification. Restoration of shoulder function after proximal humeral resection for oncological reasons is still a challenge. In most oncological cases, resection of the rotator cuff is necessary to obtain eradication of the tumor. For these patients, reverse shoulder arthroplasty can provide durable midterm function. The location of the tumor determines whether a reversed arthroplasty in combination with a transfer of the latissimus dorsi and teres major muscle can be used to overcome the problem of insufficient external rotation strength after rotator cuff resection.

Importance We present what we believe to be the first case series in which the teres major muscle is used as a free flap in head and neck reconstruction. Objectives To describe our experience with the teres major muscle in free flap reconstruction of head and neck defects and to identify advantages of this approach. Design, Setting, and Participants A retrospective review was performed at 2 tertiary care centers between February 1, 2007, and June 30, 2012. Data analysis was conducted from July 31, 2014, through December 1, 2014. Intervention Teres major muscle free flap for use in head and neck reconstruction. Main Outcomes and Measures Indications for use, complications, and outcomes including donor site morbidity. Results The teres major free flap was used in 11 patients as a component of chimeric subscapular system free flaps for a variety of complex head and neck defects. The teres major muscle was used to fill soft-tissue defects of the neck, face, and nasal cavity; it provided substantial soft-tissue volume but was less bulky than the latissimus dorsi muscle. The teres major muscle was also used to provide protection for vascular anastomoses and/or great vessels and to enhance soft-tissue coverage of the mandibular reconstruction plate. In addition, the muscle was selected as a substrate for skin grafting where inadequate neck skin remained. Flap survival occurred in 10 of 11 flaps (91%). Two flaps (18%) demonstrated venous congestion that was managed successfully. Two patients (18%) developed minor recipient-site complications (submental fistula and infection with recurrent wound dehiscence and plate exposure). All donor sites healed well, with chronic, mild shoulder pain noted in 2 patients (18%) and no postoperative seromas observed in any patient. Conclusions and Relevance Addition of the teres major muscle to a subscapular system free flap is an option for reconstruction of a variety of complex head and neck defects, particularly when a moderate amount of soft tissue is required. In select cases, the teres major muscle may have advantages over the latissimus dorsi muscle.

The red panda (Ailurus fulgens) is distributed primarily in the Himalayas and southern China. It is classified as a vulnerable species by the International Union for Conservation of Nature. The aim of this study was to describe the normal osteology and radiographic anatomy of the thoracic limb of the red panda. Radiography of the right thoracic limb was performed in seven captive adult red pandas. Radiographic findings were correlated with bone specimens from three adult animals. The scapula was wide craniocaudally and presented with a large area for the origin of the teres major muscle. The square-shaped major tubercle did not extend proximal to the head of the humerus. The medial epicondyle was prominent. A supracondylar foramen was present. The radial tuberosity and sesamoid bone for the abductor digiti I longus were prominent. The accessory carpal bone was directed palmarolaterally. Metacarpal bones were widely spread. The thoracic limb morphology of the red panda evidenced by osteology and radiography indicated flexibility of the thoracic limb joints and well-developed flexor and supinator muscles, which are important in arboreal quadrupedal locomotion. Knowledge gained during this study may prove useful in identifying skeletal material or remains and diagnosing musculoskeletal diseases and injuries of the thoracic limb.

The teres major (TerMa) muscle has a clinical significance for tendon transfer procedures in patients with massive rotator cuff tears. Individually, it originates from the dorsum of the inferior angle of scapula and inserts into the medial lip of bicepital groove of the humerus. Functionally, TerMa in cooperation with latissimus dorsi (LD) adducts arm, medially rotates arm, and assists in arm extension. The variation of TerMa insertion is very rare. In the shoulder and axillary regions of a 33-year-old Thai male cadaver, the variant insertion of the right TerMa was found. The muscle fibers of TerMa are directly attached at the supero-medial border of LD tendon. Notably, there was no terminal tendon of TerMa. To explain an unusual movement of the arm, this rare variation of the TerMa insertion is necessary to be recognized. This case report is very important for surgeons to preoperatively consider using the terminal tendon of TerMa for tendon transfer in treating patients with irreparable cuff tears.

Eleven fresh-frozen cadaver shoulders were dissected to define the anatomy of the teres major muscle and tendon and to determine the muscle's potential for use as a tendon transfer to the humeral head. Of the 11 specimens, 7 had Mathes type II circulation. The primary and secondary pedicles, from the circumflex scapular artery, entered the muscle 4.1 cm and 0.5 cm from the scapula, respectively. The lower subscapular nerve entered 4.1 cm from the scapula. Mean tendon and muscle lengths were 2.0 and 11.8 cm, respectively. As a unipolar transfer, the tendon reached the greater tuberosity in all but 1 specimen. The bipolar transfer offered numerous theoretical possibilities. We believe that the teres major has an appropriate vascular supply and adequate length to make it suitable for tendon transfer to the humeral head.

The axillary artery, a continuation of the subclavian artery, begins at the first rib's outer border and ending normally at the inferior border of the Teres major muscle and continuing further distally as Brachial artery. The axillary artery has several branches that supplies axillary region. Several variations about the Axillary artery and it's branches were have been reported. In this case, from the second part of this artery, we found a common trunk between Lateral thoracic and Subscapular arteries. Other branches of subscapular also has been separated from this trunk.

Variations in the venous pattern of the arm are common. In this case report, we are presenting the variations of the brachial vein and the basilic vein. During the routine dissections which were done by medical undergraduate students, we observed some variations in the veins of the upper limb. In the current case, there was only one brachial vein which accompanied the brachial artery. The basilic vein originated from the medial side of the dorsal venous network, ascended along the medial side of the forearm and joined the brachial vein to form the axillary vein at the distal border of the teres major muscle. The basilic vein and the brachial vein joined with one another in the middle of the arm to form a unique venous chiasma. A large number of invasive procedures are carried out by using the veins of the upper limb, particularly in and distal to the axillary region. This type of a venous chiasma may lead to complications in these procedures.

Background: In massive rotator cuff tears a teres major (TMj) tendon transfer to the insertion of the supraspinatus (SSp) reverses its adduction moment arm into abduction which is supposed to be an adequate salvage procedure. Analysis of muscle function to find biomechanical ground of such success is scarce. Methods: We compared pre- and postoperative clinical outcome of TMj transfer, i.e. Range of Motion, pain, Constant Shoulder scores and arm force. TMj activation was evaluated in 14 patients suffering massive cuff tears using activation ratios to describe the desired 'in-phase' and undesired 'out-of-phase' contribution to the external arm moment. Additionally, we analyzed activation of the latissimus dorsi (LD) and the medial part of the deltoids (DE). The activation ratios were compared to controls and TMj activation ratios were related to clinical outcome. Findings: TMj tendon transfer improved arm function. Pre-operatively, we observed 'out-of-phase' abduction activation of TMj and LD. After transfer patients activated TMj according to its new anatomical position. 'Out-of-phase' LD abduction activation persisted. The clinical improvements coincided with changes in activation ratio of TMj. Interpretation: 'Out-of-phase' TMj adductor activation is associated with compromised arm function in patients with irreparable cuff tears. After transfer, TMj is activated in correspondence with its new anatomical function, which was supportive for the improved arm function. (C) 2009 Elsevier Ltd. All rights reserved.

The purpose of this study was to investigate whether the stretch-shortening cycle (SSC) contraction is integrated in neuromuscular activation in upper body muscles during double poling in cross-country skiing. Thirteen elite skiers performed double poling roller-skiing at increasing treadmill velocities of 9, 15, 21, 27 km h(-1) and their individual maximal velocity. Elbow angle, axial pole force and surface EMG in the triceps brachii, pectoralis major, latissimus dorsi and teres major muscle were recorded. Increases in peak pole force, rate of force development and elbow flexion angular velocities were identified (P < 0.05). The mean MVC-normalized EMG amplitudes increased during the pre-activation phase before pole plant, elbow flexion and the reflex-mediated phase between 30 and 120 ms after pole plant due to velocity increases (P < 0.05). It is thus suggested that elite cross-country skiers use SSC during double poling, particularly in the triceps muscle in order to generate high forces.

Information regarding branches of the brachial plexus can be of utility to the surgeon for neurotization procedures following injury. Sixty-two adult cadaveric upper extremities were dissected and the subscapular nerves identified and measured. The upper subscapular nerve originated from the posterior cord in 97% of the cases and in 3% of the cases directly from the axillary nerve. The upper subscapular nerve originated as a single nerve in 90.3% of the cases, as two independent nerve trunks in 8% of the cases and as three independent nerve trunks in 1.6% of the cases. The thoracodorsal nerve originated from the posterior cord in 98.5% of the cases and in 1.5% of the cases directly from the proximal segment of the radial nerve. The thoracodorsal nerve always originated as a single nerve from the brachial plexus. The lower subscapular nerve originated from the posterior cord in 79% of the cases and in 21% of the cases directly from the proximal segment of the axillary nerve. The lower subscapular nerve originated as a single nerve in 93.6% of the cases and as two independent nerve trunks in 6.4% of the cases. The mean length of the lower subscapular nerve from its origin until it provided its branch into the subscapularis muscle was 3.5 cm and the mean distance from this branch until its termination into the teres major muscle was 6 cm. The mean diameter of this nerve was 1.9 mm. The mean length of the upper subscapular nerve from its origin to its termination into the subscapularis muscle was 5 cm and the mean diameter of the nerve was 2.3 mm. The mean length of the thoracodorsal nerve from its origin to its termination into the latissimus dorsi muscle was 13.7 cm. The mean diameter of this nerve was 2.6 mm. Our hopes are that these data will prove useful to the surgeon in surgical planning for potential neurotization procedures of the brachial plexus.

The teres major can be seen as an additional head of the latissimus dorsi muscle for three-dimensional movement of the arm. It gained importance in pedicled muscle transfers for the treatment of plexus palsies and shoulder instability. Its supplying vessels belong to the subscapular system. According to the literature, the muscle was transferred only once as a free microvascular but nonfunctional graft.Eleven flaps from fresh cadavers were dissected and perfused with radiopaque media. The detailed macroscopic and microangiographic anatomy was investigated to determine its potential use as a free functional muscle flap.Three different access routes are possible. The mean length of the flap was 158 mm, and the distal and proximal tendinous widths were 24 mm and 52 mm, respectively. A Taylor type 1 nerve and Mathes type 2 vessel distribution was found in all specimens. The main pedicle is situated in the middle third of the superomedial border of the flap and derives almost exclusively from the circumflex scapular artery. Radioangiograms indicate possible splitting of the muscle in the transverse and longitudinal directions. The nerve could always be isolated to a considerable length (66 mm) before reaching the posterior cord.This anatomical study indicates that the teres major can be seen as a separate entity in the subscapular system and can be transferred as a free flap either alone or in combination. According to what is known from pedicled transfers, the donor-site morbidity should be low if the latissimus dorsi is left intact.

Background Massive rotator cuff tears impose restraints on overhand arm functionality and are often accompanied by pain. After musculotendinous Teres Major transfer, overhand arm function is generally restored and pain is reduced. The assumed mechanical abduction insufficiency and Teres Major muscle function adaptation will be experimentally verified. Methods Principal Teres Major muscle activation (surface IEMG averaged over 3 s) is recorded for 12–24 isometric and isotonic force directions perpendicular to the 60° forward flexed humerus in three conditions: prior to surgery ( n = 6 patients), prior to surgery and after subacromial anaesthetic ( n = 6) and post-surgery ( n = 3). Principal direction and on-, offset directions were estimated. Findings Teres Major activation adapts both to pathological and post surgery conditions: the normal activation during adduction changes into activation during forward flexion or abduction. Glenohumeral stabilisation, not abduction torque, seems to be the explanation for post surgery Teres Major transfer success. Interpretations The pathological absence of Supraspinatus and Infraspinatus forces during forward flexion result in increased upward glenohumeral instability. The superior translations are compensated for by Teres Major activity during forward flexion. This translation-‘force’ function conflicts with the adduction-generating rotation-‘torque’ function. This may explain the pain-induced reduction of arm elevation in these patients. Musculotendinous transfer solves the force–torque conflict by changing the moment arm of the Teres Major from adduction to abduction. Teres Major can now both compensate for the loss of Supraspinatus and Infraspinatus forces needed for glenohumeral stabilisation and contribute to forward flexion of the arm.

Obstetric palsy is the injury of the brachial plexus during delivery. Although many infants with plexopathy recover with minor or no residual functional deficits, some children don't regain sufficient limb function because of functional limitations, bony deformities and joint contractures. Shoulder is the most frequently affected joint with internal rotation contracture causing limitation of abduction, external rotation. The treatment comprises muscle release procedures such as posterior subscapularis sliding or anterior subscapularis tendon lengthening and muscle transfers to restore the missing external rotation and abduction function.We evaluated whether the preoperative abduction degree affects functional outcome. Between 1998 and 2002, 46 children were operated on to restore shoulder abduction and external rotation. The average age at surgery was 7.6 years and average follow up was 40.8 months. We compared the postoperative results of the patients who had preoperative abduction less than 90 degrees (Group I: n = 37) with the patients who had preoperative abduction greater than 90 degrees (Group II: n = 9), in terms of abduction and external rotation function with angle measurements and Mallet classification. We inquired whether patients in Group I needed another muscle transfer along with latissimus dorsi and teres major transfers.In Group I the average abduction improved from 62.5 degrees to 131.4 degrees (a 68.9 degrees +/- 22.9 degrees gain) and the average external rotation improved from 21.4 degrees to 82.6 degrees (a 61.1 degrees +/- 23 degrees gain). In Group II the average abduction improved from 99.4 degrees to 140 degrees (a 40.5 degrees +/- 16 degrees gain) and the average external rotation improved from 33.2 degrees to 82.7 degrees (a 49.5 degrees +/- 23.9 degrees gain). Although there was a significant difference between Group I and II for preoperative abduction (p = 0.000) and abduction gain in degrees (p = 0.001), the difference between postoperative values of both groups was not significant (p = 0.268). There was also no significant difference between the two groups in the preoperative external rotation, the external rotation gain and the postoperative external rotation (p = 0.163, p = 0.181 and p = 0.803, respectively).Obstetric palsy patients with shoulder sequela who had a preoperative abduction less than 90 degrees hadas good functional results using latissimus dorsi, teres major muscle transfer and subscapularis muscle release as the patients who hada preoperative abduction greater than 90 degrees.

Rotator cuff tears following shoulder dislocation are the most common cause of prolonged shoulder pain. However, 9 to 18% of patients who have anterior dislocation actually suffer from prolonged pain due to axillary nerve injury [1]. The axillary nerve (C5, C6) is a branch of the posterior cord of the brachial plexus and exits the axilla to enter the quadrilateral space. This space is bounded by the teres minor muscle superiorly, the teres major muscle inferiorly, the long head of the triceps muscle medially, and the surgical neck of the humerus laterally. The anterior branch of the axillary nerve supplies the anterior deltoid muscle and overlying skin, while the posterior branch supplies the teres minor muscle, the posterior deltoid muscle, the skin overlying the distal deltoid muscle, and proximal triceps [2]. In an anterior shoulder dislocation, axillary nerve injury presumably occurs because of inferior displacement of the humeral head causing compression of the quadrilateral space [1]. Clinical symptoms of axillary nerve injury include vague shoulder pain, decreased strength on abduction, and abnormal sensation in the cutaneous distribution of the axillary nerve. The definitive diagnostic test used to confirm the clinical diagnosis of axillary nerve injury is electromyography (EMG). However, EMG is painful and operatordependent. MR imaging, on the other hand, is a noninvasive technique that can help provide a diagnosis, especially when other diagnoses besides axillary nerve injury are being considered [3]. Anatomical distribution of the signal changes on MR distinguishes nerve injury from direct traumatic injury of muscles. With axillary nerve injury, some or all of the muscles supplied by the axillary nerve will be affected, depending on the location of the injury along the path of the axillary nerve [1]. MR signal from acute denervation within the first 24 h may manifest as increased short tau inversion recovery (STIR) signal and as increased apparent diffusion coefficient (ADC) [4, 5]. Absence of edema of overlying soft tissues allows distinction of acute denervation from acute traumatic muscle injury. Subacute muscle denervation causes uniform muscle edema in approximately 2–4 weeks. Shifting of water from the intracellular to the extracellular space causes increased MR signal in the fluid-sensitive The case presentation can be found at doi:10.1007/s00256-009-0846-z.

We found a left superficial ulnar artery in the cadaver of a Japanese woman. This anomalous vessel originated from the brachial artery at a site 55 mm distal to the inferior border of the teres major muscle and medial to the median nerve, ran downward and medially superficial to the forearm flexor muscles, and then downward to enter the hand. It formed superficial and deep palmar arches with the radial artery. The clinical importance of the anomalous ulnar artery is discussed.