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Deltoid, teres minor, and supraspinatus
4%
164/3939
Deltoid, teres minor, and teres major
175/3939
Teres minor and teres major
2%
61/3939
Deltoid and teres major
10%
384/3939
Deltoid and teres minor
79%
3124/3939
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This patient sustained an axillary nerve injury during a large anterior exposure to the shoulder. The patient is offered a Leechavengvongs radial to axillary nerve transfer, as this will potentially restore the lost axillary nerve function to the deltoid and teres minor. The axillary nerve branches off of the posterior cord (along with the radial nerve) of the brachial plexus, travels just inferior to the subscapularis, then winds posterior and travels through the quadrangular space with the posterior circumflex humeral artery. The anterior branch innervates the anterior half of the deltoid, while the posterior branch innervates the posterior portion of the deltoid and the teres minor. This posterior branch also supplies the lateral cutaneous nerve of the arm. Axillary nerve injury is an uncommon but potentially debilitating complication of shoulder surgery. Physical exam would be significant for partial or complete deltoid paralysis, which would be most evident with tested shoulder abduction while in internal rotation. In internal rotation, the supraspinatus is rotated anteriorly and thereby contributes less to abduction. The Leechavengvongs procedure involves the transfer of one branch of the radial nerve (to medial, lateral, or long head of the triceps) to the axillary nerve. The goal is to get as much excursion of the radial nerve as possible and transferring the branch as proximally as possible on the axillary nerve. Bertelli et al. report on 9 patients who underwent transfers of the branch of the radial nerve to the medial head of the triceps to the axillary nerve for chronic axillary nerve palsy. The authors found that all patients recovered deltoid function, abduction strength improved to 60% of normal, and endurance improved to 65% of normal. The authors advocate using the branch to the medial head of the triceps as it is longer than the other branches of the radial nerve so as to offer more excursion and it is expendable. Price et al. determined the relationship of the axillary nerve to the shoulder joint capsule in a cadaveric analysis. The teres minor branch was the closest to the glenoid rim. The axillary nerve is in the closest proximity to the glenoid rim at the 6 o'clock position, 12.4mm. The authors underscore the importance of familiarity with the anatomy of the axillary nerve during shoulder procedures. Incorrect Answers: Answer 1: The supraspinatus is innervated by the suprascapular nerve. Answers 2-4: The teres major is innervated by the lower subscapular nerve.
4.4
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