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.

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

Zobrazit více v PubMed

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

Hall JG. Arthrogryposis multiplex congenita: etiology, genetics, classification, diagnostic approach, and general aspects. J Pediatr Orthop B. 1997;6:159–166. doi: 10.1097/01202412-199707000-00002. PubMed DOI

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

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

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

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

Tobin GR. Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstr Surg. 1985;75:814–824. doi: 10.1097/00006534-198506000-00009. PubMed DOI

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

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

Betka I, Kacirkova J. On the vascularization of the M. Pectoralis major. Cs Otolaryng. 1988;37:188–190. PubMed

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

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

Holt SJ. Indigogenic staining methods for esterases. In: Danielli JF, editor. General cytochemical methods 1. New York: Academic Press; 1958. pp. 375–398. PubMed

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

Čihák R, Popelka S. Partial defects of the pectoralis major muscle. Acta Chir Orthop Traumat Cechoslovaka. 1961;28:185–194. PubMed

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

Doyle JR, James PM, Larsen LJ, Ashley RK. Restoration of elbow flexion in arthrogryposis multiplex congenita. J Hand Surg. 1980;5:149–152. doi: 10.1016/S0363-5023(80)80146-8. PubMed DOI

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

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

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

Carroll RE, Kleinman WB. Pectoralis major transplantation to restore elbow flexion to the paralytic limb. J Hand Surg. 1979;4:501–507. doi: 10.1016/S0363-5023(79)80001-5. PubMed DOI

Tsai T-M, Kalisman M, Burns J, Kleinert HE. Restoration of elbow flexion by pectoralis major and pectoralis minor transfer. J Hand Surg. 1983;8:186–190. doi: 10.1016/S0363-5023(83)80013-6. PubMed DOI

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

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

Smet HT. Pectoralis major flaps. In: Smet HT, editor. Tissue transfers in reconstructive surgery. New York: Raven Press; 1989. pp. 74–79.

Hidalgo DA. Free muscle transplantation. In: Shaw WW, Hidalgo DA, editors. Microsurgery in trauma. New York: Futura; 1987.

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

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

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