anterbrachium is the forearm,region between elbow and the wrist Sarris I, Gbel F, Gainer M, Vardakas DG, Vogt MT, Sotereanos DG. It is located in a depression on the anterior surface of the elbow joint. This case report presents the case of a 34-year-old Persian female with dysesthesia and pain in the medial side of the forearm immediately following a blunt trauma by mechanism of elbow external rotation. The three patients with brachial plexus catheters had these inserted using the bent needle technique of supraclavicular block,9and all had undergone major wrist, elbow, or forearm surgery during regional anesthesia, followed by regional analgesia using their catheters. In this case report study, we presented the case of a 34-year-old female with isolated MAC nerve injury after blunt trauma. 2004;25(4):2169. Upper trace: abnormal response obtained from the right side medial antebrachial cutaneous, peak latency 1.77milliseconds, amplitude 7.6V (more than 50% amplitude drop compared with the other side). Second, compartmentalization may occur because the layers of connective tissue within the tissue plane are not homogeneous, do not necessarily interconnect, and may hinder or prevent diffusion.8Therefore, injection at one point does not guarantee spread elsewhere. But anesthetizing the cutaneous distribution of the musculocutaneous nerve is best accomplished with a LAC nerve block. Note how the dye conforms to the shape of the surrounding rigid anatomychest wall, coracoid process, and subscapularis. Summary location: forearm The first deposits 5 mL local anesthetic just lateral to the border of the biceps tendon. It is also called the antecubital fossa because it lies anteriorly to the elbow (Latin cubitus) when in standard anatomical position. and transmitted securely. Fig. Reg Anesth Pain Med 2004; 29:24, Cornish PB, Leaper CJ, Hahn JL: Evaluation of spread of a bolus injection administered, Winnie AP, Radonjik R, Akkineni SR, Durrani Z: Factors influencing distribution of local anaesthetic into the brachial plexus sheath. Mild tenderness in the anteromedial part of the elbow was detected. The antebrachial fascia or deep fascia of the forearm is a thick connective tissue fascia investing the forearm muscles. The site is secure. Study now. Ma CX,Pan WR,Liu ZA,Zeng FQ,Qiu ZQ,Liu MY, Deep lymphatic anatomy of the upper limb: an anatomical study and clinical implications. Brachial artery suppliesoxygenated blood the forearm. We present a case of acute blunt trauma-induced injury to the MAC nerve that was diagnosed by a nerve conduction study. Indeed, the only indication for elbow approaches is to block forearm flexor and extensor muscles when the surgeon desires immobility of the fingers. The right elbow X-ray was normal. As a noun antebrachium is (anatomy) the forearm. What is the difference of antebrachium and the brachium? al ant-i-br-k-l. : relating to the antebrachium. PubMed Plast Reconstr Surg. Overview of the thoracic outlet syndromes and review of true neurogenic thoracic outlet syndrome. Reg Anaesth Pain Med 2003; 28:336, Lanz EL, Theiss D, Jankovic D: The extent of blockade following various techniques of brachial plexus block. Ballard T, Smith T. Anatomy, medial antebrachial cutaneous nerve. FIGURE 6. Sometimes nerve testing (EMG/NCS) may be needed to see how much the nerve and muscle are being affected. Complications of pseudoaneurysms can cause a serious threat to the afflicted limb and the patient's life. WebA home mechanic wants to raise the $280-\mathrm{kg}$ engine out of a car. statement and London, Longmans, Green, 1967, p 1227, Carlson GW: Surgical anatomy of the neck. On further evaluation, the medial antebrachial cutaneous nerve SNAP of the symptomatic side had a considerable amplitude drop (more than 50%) compared with the other side (as shown in Fig. 2020 Aug 13;5:173-193. doi: 10.1016/j.cnp.2020.07.005. The nerve becomes superficial as it penetrates the mid belly of the sternocleidomastoid muscle, thereafter forming three branches (Figure 3). Thomas K, Sajjad H, Bordoni B. Anatomy, shoulder and upper limb, medial brachial cutaneous nerve. Alireza Ashraf. She complained of difficulty in writing due to this annoying dysesthesia. The intercostobrachial is anesthetized by depositing 5 mL of local anesthetic subcutaneously superiorly and inferiorly along the axillary crease via a 1.5-in. Also, there was no significant psychological disorder or related family history. After 2days, the nature of the pain became dull. By using this website, you agree to our Bookshelf Patients should be informed to protect their insensate limb from external pressure or temperature extremes. The cubital fossa is an area of transition between the anatomical arm and the forearm. In conclusion, this study suggests that there may not be an enveloping and encasing soft tissue structure, or sheath, around the brachial plexus. The floor of the cubital fossa is formed proximally by the brachialis and distally by the supinator muscle. 2017;70(11):15828. Antebrachium Methods: Injury of the MAC nerve occasionally occurred due to iatrogenic reasons during the interventions. All authors read and approved the final manuscript. With the approval of the Nelson-Marlborough Ethics Committee (Nelson, New Zealand) and written informed consent, three patients with functioning brachial plexus catheters and two patients with functioning sciatic nerve catheters were enrolled in the study. The plexuses studied did not show that sex, color or side of the body had much if any influence upon the presence of variations, including some that have not been reported in the literature. Diagnostics (Basel). The major difference between the two systems lay beyond the limits of spread of the dye, where the anatomy was clearly different, i.e. Although spontaneous recovery of this nerve is possible, appropriate treatment could be administered promptly to assist the patient in early recovery. How many minutes does it take to drive 23 miles? by injecting 1 ml of 50% diluted 300 mg/ml Omnipaque (iohexol; Amersham Health Limited, Auckland, New Zealand) dye down the respective catheters and then performing a preliminary computerized tomography scan. Selective nerve blocks can sometimes be used also for pain treatment of minor trauma or surgery. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. It can also happen by falling onto a flexed elbow, but this accounts for less than 5% of cases.The displaced fracture fragments may impinge and damage the contents of the cubital fossa. Both systems showed substantial anterograde and retrograde flow from the catheter tip, with clear limits of outward spread determined by solid anatomical structures, and clear lines demarcating the limits of spread (figs. Anesth Analg 1979; 58:22534, Rodriguez J, Barcena M, Alvarez J: Restricted infraclavicular distribution of the local anesthetic solution after infraclavicular brachial plexus block. The concept of the brachial plexus sheath seems to describe the anatomy inaccurately. Provided by the Springer Nature SharedIt content-sharing initiative. The LAC and MAC nerve blocks can provide either primary anesthesia for superficial forearm operations or supplement an incomplete plexus block. Recent investigations have cast doubt on its nature and existence. Anterior 2: the probe was axially moved downwards There was no Tinels sign around the elbow region. Lower trace: normal response obtained from the left side medial antebrachial cutaneous, peak latency 1.55milliseconds, amplitude 26.9V. The management of patients seeking revisional body contouring procedures is discussed, particularly when performed on patients following massive weight loss, may require secondary intervention to treat residual contour abnormalities. Ann Vasc Surg. At this level, block of the ulnar nerve results in anesthesia of the little finger and motor block of the intrinsic muscles of the hand. Cite this article. PubMed Central Electromyogr Clin Neurophysiol. There was neither distortion nor displacement of the anatomical structures surrounding the nerves (figs. During the first stage, the basilic or brachial vein is anastomosed with the brachial artery in end-to-side fashion. Medial antebrachial cutaneous NCS changes closely paralleled median motor response changes. The position of the catheter tips was determined by a radiologist (C.L.) Enter two words to compare and contrast their definitions, origins, and synonyms to better understand how those words are related. For instance, the practitioner may rather choose the midhumeral brachial plexus block, where selective application of clonidine or low concentration of long-acting local anesthetics to the median and ulnar nerves prolongs analgesia without concomitant prolongation of motor block. Journal of patient safety. block of the supraclavicular nerve is accomplished with 510 mL of an intermediate- or long-acting local anesthetic, depending on analgesic requirements. Yildiz N, Ardic F. A rare cause of forearm pain: anterior branch of the medial antebrachial cutaneous nerve injury: a case report. FOIA FIGURE 3. For this reason, these blocks may be preferable to selective elbow or wrist blocks as a supplement to incomplete brachial plexus anesthesia involving volar forearm cutaneous distribution. actually distal to the brachium. The brachial plexus catheter tips lay just inferolateral to the coracoid process of the scapula, whereas the sciatic nerve catheter tips lay between the tip of the ischial tuberosity and the femur. The medial antebrachial cutaneous (MAC) nerve is a branch of the brachial plexus that carries fibers of C8T1 segments [1, 2]. J Plast Reconstr Aesthet Surg. She denied alcohol consumption or smoking. FE contributed to the editing of the manuscript. Accessibility 2011 Dec;35(6):807-15. doi: 10.5535/arm.2011.35.6.807. The median nerve and brachial artery lie medially between the brachialis and triceps muscles ( Figure 1 (Aa)). Is it helpful? It descends through the brachial fascia along with the basilic vein, brachial artery, and median and ulnar nerves [5]. Antebrachial vs Antebrachium Antebrachial vs Taxonomy Antibrachial vs Antebrachial Antecubital vs Antebrachial T1 radiculopathy: electrodiagnostic evaluation. 2014. https://doi.org/10.13070/rs.en.1.665. FIGURE 4. WebMedial Antebrachial Cutaneous Nerve Injury www.e-arm.org 915 relieved slightly. The MAC is blocked by injecting a half-ring of 57 mL local anesthetic about a quarter of the arms length above the medial elbow(Figure 7). Avoiding pressure on the funny bone can also help. On physical examination, she seemed well nourished with a blood pressure of 115/80mmHg, pulse rate of 75 beats per minute, and axillary temperature of 36.2C at the first outpatient visit. As an adjective antebrachial is relating to the forearm. Anesth Analg 1983; 62:558, Urmey WF, Talts KH, Sharrock NE: One hundred per cent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Because cutaneous nerve blocks of the upper extremity require only small amounts of local anesthetic, which are typically injected subcutaneously and not close to major vessels, they can be placed with standard American Society of Anesthesiologists (ASA) monitoring. 2017; [PubMed PMID: 29391938], Mukai K,Nakajima Y,Nakano T,Okuhira M,Kasashima A,Hayashi R,Yamashita M,Urai T,Nakatani T, Safety of Venipuncture Sites at the Cubital Fossa as Assessed by Ultrasonography. Anesthesiology 1958; 19:2814, Winnie AP, Collins VJ: The subclavian perivascular technique of brachial plexus anesthesia. antebrachial | antebrachium | Derived terms | Antebrachial is a derived term of antebrachium. Aiming to control the symptoms, we started conservative management for her. Although spontaneous recovery of this nerve may be possible, the delay in timely diagnosis can cause imposing unnecessary diagnostic work-ups to evaluate other differential diagnoses of forearm dysesthesia. When LAC and/or MAC nerve blocks are supplemental to a previous incomplete brachial plexus block, the additional 1520 mL of local anesthetic should be well tolerated by patients if injected 2030 minutes after the primary block. 2001;83(1):25. WebThe brachial catheter CTDS was performed from the top of the clavicle to 30 mm below the glenoid fossa, and the sciatic catheter CTDS was performed from the top of the sacroiliac On follow-up electrodiagnosis, after several sessions of physical therapy, the medial antebrachial cutaneous nerve sensory nerve action potential still had a significant amplitude difference. J Brachial Plex Peripher Nerve Inj. Pneumothorax can result from a needle that passes through the suprascapular notch and enters the pleural space. This case report presents the case of a 34-year-old Persian female with dysesthesia and pain in the medial side of the forearm immediately following a blunt trauma by mechanism of elbow external rotation. Within the roof runs the median cubital vein, which can be accessed for venipuncture (see clinical significance below). official website and that any information you provide is encrypted Student Research Committee, Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran, Department of Physical Medicine and Rehabilitation, Shiraz Geriatric Research Center, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Karimkhan Zand Street, Shiraz, 71348-44119, Iran, You can also search for this author in J Med Case Reports 17, 91 (2023). 2021. The medial antebrachial cutaneous nerve, along with the posterior and lateral antebrachial cutaneous nerves, is responsible for providing sensation to the skin of the forearm. Bethesda, MD 20894, Web Policies Before Although potential ulnar nerve entrapment can occur at multiple points along its course, for example, the Arcade of Struthers, the medial intermuscular septum, the medial epicondyle, the cubital tunnel, and the deep flexor pronator aponeurosis, the most common site of entrapment is the cubital tunnel. Different variations were reported in the anatomical course of this nerve [2, 6, 7]. In the literature, some reported causes of MAC nerve involvement include brachial plexopathy [8] and thoracic outlet syndrome [9]. 22-gauge needle is placed at this entry mark and directed caudad in the sagittal plane until it contacts the scapular spine, followed by injection of 10 mL of a long-acting local anesthetic. Neurogenic thoracic outlet syndrome shows predominant damage in the T1 distribution, whereas sternotomy-related brachial plexopathy shows predominant damage in the C8 distribution, suggesting that these lesions are localized at the level of the anterior primary rami of the cervical roots, and not in the lower trunk of the brachial plexus. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. The brachial pulse may be palpated in the cubital fossa just medial to the tendon. https://doi.org/10.1186/s13256-023-03797-1, DOI: https://doi.org/10.1186/s13256-023-03797-1. First, some surgical sites are partially innervated by sensory nerves that are not part of the brachial plexus or not consistently anesthetized with plexus blocks. CAS Terms and Conditions, Cookies policy. Webantebrachial | brachial | As adjectives the difference between antebrachial and brachial is that antebrachial is relating to the forearm while brachial is pertaining or belonging to the arm. The medial antebrachial cutaneous nerve (MACN) arises from the medial cord (78%) and the lower trunk (22%) of the brachial plexus. Race CM, Saldana MJ. If a peripheral nerve stimulator is used, the suprascapular nerve is identified by the motor response of external shoulder rotation. There are generally three instances in which the anesthesiologist desires to perform these selective nerve blocks. Selective nerve blocks at the elbow can be recommended for hand surgery when forearm motor block is desired and motor block of the proximal brachial plexus block is not desired. Suprascapular nerve block (SSNB) can be used as an adjunct to arthroscopic shoulder surgery and total shoulder arthroplasty. Proximal techniques of brachial plexus block are often superior to selective nerve block at the elbow because the latter are more difficult to perform, are more time-consuming and uncomfortable, and potentially carry a greater risk of complications. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Why Walden's rule not applicable to small size cations. Clinical, electrodiagnostic and imaging features of true neurogenic thoracic outlet syndrome: Experience at a tertiary referral center. Intraoperative Protective Mechanical Ventilation: Fact or Fiction? Techniques for anesthetizing the LAC and MAC nerves involveonly superficial injection of local anesthetic; thus the risk of nerve injury is very low. Tissue planes are fundamental to surgical dissection technique,12but perhaps they are not sufficiently emphasized in anesthetic practice, given the number of publications in the literature that describe them.5,6,1316. Most medical practitioners are aware of two patterns of venous returns in the cubital fossa. This study further examines the issue. For the purposes of the study, a functioning sciatic nerve catheter was defined as absence of cold sensation in the territories of the common peroneal and tibial nerves 1 h before CTDS. Acondition that involves pressure or stretching of the ulnar nervewhich can cause numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand. The concept of the axillary "sheath" has been a central tenet of brachial plexus regional anesthesia for many years. See more. It also forms the lateral intermuscular septum, which divides the forearm muscle into the anterior and posterior compartments together with the radius, ulna, and interosseous membrane. 2023 Jan 6;13:1077830. doi: 10.3389/fneur.2022.1077830. It may also be used for the insertion of a peripherally inserted central catheter. This segment of the brachial plexus gives rise to three lateral branches: dorsal scapular nerve , long thoracic nerve and intercostal nerve . Each trunk has a well-known scheme of origin from the roots of the brachial plexus: The superior trunk is formed by the roots of C5 and C6. This chapter describes how and when to anesthetize the most common of these nervesthe supraclavicular, the suprascapular, and the intercostobrachial. The catheters were inserted to a depth of 1011 cm from skin to catheter tip. Article Electrodiagnostic features of true neurogenic thoracic outlet syndrome. One of the most common sites for venipuncture is the superficial veins in the cubital fossa of upper limbs which include the cephalic, basilic, median cubital, and antebrachial veins and their tributaries. Journal of Neurosciences in Rural Practice, The medial antebrachial cutaneous nerve (MACN) is a branch of the brachial plexus with a great variation within its branches. For the purposes of the study, a functioning brachial plexus catheter block was defined as absence of cold sensation in the territories of the ulnar, median, radial, medial and lateral antebrachial cutaneous, and axillary nerves 1 h before CTDS. 2011;6(01):e389. J Brachial Plex Peripher Nerve Inj. The intercostobrachial nerve is anesthetized by subcutaneous injection of 35 mL local anesthetic along the axillary crease. Unable to load your collection due to an error, Unable to load your delegates due to an error. Other Comparisons: What's the difference? Dark areasadjacent to the nerves are adipose tissue. The anatomic differences distinguishing these disorders from each other, and from other lower trunk brachial plexopathies, have not been defined. Polcaro L, Charlick M, Daly DT. Three milliliters is deposited with a 22- to 25-gauge sharp needle into the mid belly of the sternocleidomastoid. PhilipB. Cornish, M.B., Ch.B., F.A.N.Z.C.A. BioMed research international. Blunt trauma can be one of the causes of medial antebrachial cutaneous nerve involvement. BMJ case reports. Because of the wide variations of these superficial veins, it has been reported that adverse effects such as bruising, hematoma, and sensory change occurred by mispuncture in various health care systems. The CTDS was performed on the second postoperative day. WebAs adjectives the difference between antecubital and antebrachial is that antecubital is pertaining to, or situated in the anterior part of the elbow (cubitus while antebrachial is The suprascapular nerve is blocked as it emerges from the suprascapular notch. Seror P. Forearm pain secondary to compression of the medial antebrachial cutaneous nerve at the elbow. Google Scholar. WebMethods: We compared the medial antebrachial cutaneous sensory nerve action potential amplitude with the median motor, ulnar motor, and ulnar sensory NCS amplitudes in 10 2002;18(08):66570. The medial antebrachial cutaneous sensory response is sensitive in the diagnosis of neurogenic thoracic outlet syndrome. The physical ability and perception of the elderly with a high risk of sarcopenia to cope with daily activities and the tools available from Affective Science are used to measure the detectable emotional change. Nerve conduction responses of both sides of the medial antebrachial cutaneous nerve. 2021. Their case report is of clinical importance in a multidisciplinary aspect and possible neurological consequences of the iatrogenic injury to the nerve and its branches and a short literature review on MACN anatomical variations is presented. The objective of this study was to identify electrodiagnostic and anatomic distinctions between true neurogenic thoracic outlet syndrome and median sternotomy-related brachial plexopathy, in reference to the pattern of abnormality of the medial antebrachial cutaneous sensory nerve conduction study (NCS) response. When considering the application of these various blocks, the reader is reminded that innervation of the upper extremity is often variable and overlapping. ( A) Axial section of sciatic nerve catheter. We and our partners use cookies to Store and/or access information on a device. FIGURE 9. Yildiz N. Medial antebrachial cutaneous neuropathy in a teacher: a case report. Reg Anesth 1997; 22:1067, Cornish PB: Supraclavicular regional anaesthesia revisited: The bent needle technique. The following observations relate to figures 14. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Epub 2019 Jul 19. Careers. The radial nerve supplies sensation to the dorsum of the forearm and hand (see Figures 1 and 2); it also innervates the musculature of the dorsal forearm. The .gov means its official. Complications of elbow arthroscopy. 2004 Oct;115(10):2316-22. doi: 10.1016/j.clinph.2004.04.023. Kelly EW, Morrey BF, ODriscoll SW. The ankle-brachial index test compares the blood pressure measured at the ankle with the blood pressure measured at the arm. National Library of Medicine It passes the elbow joint just medial to the brachial artery and in front of the brachialis muscle. Article Because of its superficial placement, complications of the intercostobrachial nerve block are virtually nonexistent. Lateral border is the medial border of the brachioradialis muscle. The bicipital aponeurosis forms a partial protective covering to the medial nerve, brachialartery and ulnar artery. CAS WebBrachial definition, belonging to the arm, foreleg, wing, pectoral fin, or other forelimb of a vertebrate. The light touch and pinprick sensation were impaired on the medial side of the right forearm. The axillary block is a peripheral nerve block performed in the axilla and anesthetizes the terminal branches of the brachial plexus ( figure 1 ). Neither adjuvant significantly increases duration if a long-acting local anesthetic such as bupivacaine or ropivacaine is chosen. Local anesthetic spread in an interscalene plexus block often blocks the cervical plexus and therefore it is adequate to block the supraclavicular nerve, but the nerve is frequently not anesthetized with a supraclavicular brachial plexus block. HSS J. Our data suggest that medial antebrachial cutaneous nerve fibers are closely associated anatomically at the T1 root level with median motor fibers innervating the thenar muscles. Search for other works by this author on: Reding M: Nouvelle mthode d'anesthsie rgionale du membre suprieur. Physical therapy, including nerve gliding exercises, was done that was relatively effective, especially on the ulnar nerve block at the elbow. Do you have pictures of Gracie Thompson from the movie Gracie's choice? Jung MJ, Byun HY, Lee CH, Moon SW, Oh M-K, Shin H. Medial antebrachial cutaneous nerve injury after brachial plexus block: two case reports. Blocking the LAC is accomplished with two local anesthetic injections placed along the intercondylar line. needle that is placed just medial to the brachial artery at the level of the epicondyles (see Figure 8). StatPearls. In the literature, MAC nerve involvement has been reported to have various mechanisms. The relevant anatomy will be covered with specific nerve block description. At the supraclavicular level, however, the elements of the plexustrunks, divisions, and cordsinterlace and interlink, and hence the connective tissues containing these nerves interconnect, a feature observed when they are dissected.8This interconnection would allow for a more even spread of injected solution, a phenomenon that is observed clinically.21This is distinctly different at the axillary level, where the terminal nerves do not interconnect and the connective tissues surrounding them create distinct compartments for each.16Fourth, side effect profiles may be explained by the interconnection, via tissue planes, of the anatomical compartments across which the nerves travel. 1. To the best of our knowledge, this is the first time that this nerve injury has been reported after acute blunt trauma. PhilipB. Cornish, Christopher Leaper; The Sheath of the Brachial Plexus: Fact or Fiction?. The medial antebrachial cutaneous nerve originates from the medial cord of the brachial plexus in continuation of the lower trunk. 2004;115(10):231622. The MAC nerve contains the fibers WebAntebrachial vs Antebrachium - What's the difference? It provides cutaneous innervation to the lateral (radial) half of the volar forearm. Part of Brachial Plexus Injury Associated with Median Sternotomy during Cardiac Surgery: Three Cases of C8 Radiculopathy Due to the Fracture of the First Rib. The brachial plexus instead lies in the tissue plane between the rigid anatomical structures that form the boundaries of the anatomical axilla.17This rigid anatomy and the tissue plane within its borders combine to contain and direct the flow of an injected solution. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Suprascapular nerve block is a valuable analgesic adjunct for shoulder arthroscopy performed with the patient under general anesthesia. For this study, six arm cadavers from three fresh cadavers were dissected and examined to find and study possible anatomical variations of the MACN. The medial antebrachial cutaneous nerve originates from the medial cord of the brachial plexus in continuation of the lower trunk. , upper extremity versus lower extremity (figs. The medial antebrachial cutaneous nerve arises from the brachial plexus and supplies the skin of the medial portion of the forearm. The lateral antebrachial cutaneous nerve arises from the musculocutaneous nerve and supplies sensory innervation to the radial aspect of the forearm. The horizontal black linein the coronal section indicates an axial section that is then displayed as directed by the solid black arrow. As such, it is not a component of the brachial plexus and is, therefore, not anesthetized by any brachial plexus approach. Biceps brachii / long head short head, tendon of biceps brachii, bicipital aponeurosis.
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