Ann Rehabil Med.  2019 Dec;43(6):635-641. 10.5535/arm.2019.43.6.635.

Safe Needle Insertion Locations for Motor Point Injection of the Triceps Brachii Muscle: A Pilot Cadaveric and Ultrasonography Study

• Koo HJ
• Park HJ
• Park GY
• Han Y
• Sohn D
• Im S

• KMID: 2468690
• DOI: http://doi.org/10.5535/arm.2019.43.6.635

Abstract

OBJECTIVE
To determine the location of the motor endplate zones (MoEPs) for the three heads of the triceps brachii muscles during cadaveric dissection and estimate the safe injection zone using ultrasonography.
METHODS
We studied 12 upper limbs of 6 fresh cadavers obtained from body donations to the medical school anatomy institution in Seoul, Korea. The locations of MoEPs were expressed as the percentage ratio of the vertical distance from the posterior acromion angle to the midpoint of the olecranon process. By using the same reference line as that used for cadaveric dissection, the safe injection zone away from the neurovascular bundle was identified in 6 healthy volunteers via ultrasonography. We identified the neurovascular bundle and its location with respect to the distal end of the humerus and measured its depth from the skin surface.
RESULTS
The MoEPs for the long, lateral, and medial heads were located at a median of 43.8%, 54.8%, and 60.4% of the length of the reference line in cadaver dissection. The safe injection zone of the medial head MoEPs corresponded to a depth of approximately 3.5 cm from the skin surface and 1.4 cm away from the humerus, as determined by sonography.
CONCLUSION
Correct identification of the motor points for each head of the triceps brachii would increase the precision and efficacy of motor point injections to manage elbow extensor spasticity.

Keyword

Cadaver; Ultrasonography; Muscle spasticity; Botulinum toxins

MeSH Terms

Acromion
Botulinum Toxins
Cadaver*
Elbow
Head
Healthy Volunteers
Humerus
Korea
Motor Endplate
Muscle Spasticity
Muscles
Needles*
Olecranon Process
Schools, Medical
Seoul
Skin
Ultrasonography*
Upper Extremity
Botulinum Toxins

Figure

• 

  Fig. 1. Diagrammatic drawing of relationship between reference line and three points of the triceps muscle. The distance from the vertical reference line to each point was recorded as an x value (cm) and the distance from the acromion angle to the point where perpendicular line crossed the vertical reference line was defined as a y value (%).

• 

  Fig. 2. Schematic drawing (A) of the location where the intramuscular endings are most densely located for each of the three heads of triceps brachii muscles and the branches of radial nerve in brachium innervating the triceps muscle (B). The branches of radial nerve at the motor entry point (MEP, star), proximal and distal limit point (PLP and DLP, white arrows) and where intramuscular nerve endings; the motor end plate zones (MoEP, circle) are most dense.

• 

  Fig. 3. Ultrasound scan, showing the MoEPs for the LoH (A), LaH (B), and MH (C) to be located at a median (interquartile range) depth of 2.0 cm (1.9–2.6 cm), 1.9 cm (1.5–2.5 cm), and 3.5 cm (3.0–3.8 cm) from the skin surface. The median distance between the central point of the muscle belly of the MH and the medial border of the humerus at the MoEP level (D1) was 1.4 cm (1.1–1.5 cm). The median distance between the central point of the muscle belly of the MH and vessel at the MoEP level (D2) was 1.0 cm (0.7–1.1 cm). MoEPs, motor endplate zones; LoH, long head; LaH, lateral head; MH, medial head; V, vessel (white arrow); D1, median distance between the central point of the muscle belly of the medial board and the medial border of the humerus; D2, median distance between the muscle belly of the MH and vessel.

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