**3.2 Subscapularis (SS)**

Place the child supine. This muscle lies anterior to the scapula. So, mark the medial border of the scapula. At the proximal two-thirds and distal one-third junction of the medial border, the needle is inserted after slightly pushing the scapula posteriorly. The needle should advance laterally parallel to the scapular spine. Do not advance the needle anterior to avoid any pneumothorax. Once the needle reaches some distance, preferably near or less near to the center of the scapula. Somewhat needle movement may be appreciated if the arm is moved in external rotation (**Figure 11**).

#### **Figure 10.**

*Pectoralis major (PM): fingers elevating PM from anterior axilla, plus denotes entry point of a needle. Arrows depicting needle directions.*

*Anatomical Surface Guided Techniques for Botulinum Toxin Injection in Spastic Cerebral… DOI: http://dx.doi.org/10.5772/intechopen.107200*

#### **Figure 11.**

*Subscapularis (SS): plus at medial scapular border showing entry point for SS and arrow showing the direction of the needle.*

#### **3.3 Biceps**

Child supine or sitting, arm by the side of the body, in elbow slightly flexed with the forearm in full supination. Palpate the anterior acromion point. Draw a line from the mid-elbow flexion crease (biceps tendon) and anterior acromion. The midpoint of this line corresponds to the center of the biceps belly. Muscle positioning may seem more medially in severe upper limb spasticity, such as adducted and internally rotated shoulder, so always take care of rotations and positioning. Hold the biceps between the nondominant thumb and index finger. Inject at this point. Passive slight extension and flexion will elicit good needle movement (**Figure 12**).

#### **3.4 Brachialis (Br)**

Positioning as for Biceps, mark the proximal two-thirds and distal one-third junction. At this point, find the place between the lateral border of the biceps and the lateral head of the triceps. Repeated supination and pronation will help in finding out the entry point, which is the first point/groove, where there is no biceps movement seen. Insert the needle at this point and push it further medically parallel to the transverse plane (toward the humerus). Pay attention not to go posterior to avoid entering in triceps. With the forearm in pronation passively gently extend flex the elbow a bit eliciting good needle movement (**Figures 13a** and **b**).

(a)

(b)

**Figure 13.**

*a. Brachialis palpation: thumb in between lateral border of biceps and triceps. b. Brachialis (Br): B- biceps,Tlateral head of triceps, plus denotes injection entry point between B and T gap.*
