Patterns of median nerve branching in the cubital fossa: implications for nerve transfers to restore motor function in a paralyzed upper limb

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  • 1 Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil;
  • 2 Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil;
  • 3 Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India;
  • 4 Pediatric Hand Surgery and Microsurgery Unit, Barcelona University Children's Hospital HM Nens, HM Hospitales, Barcelona, Spain;
  • 5 Pediatric Hand Surgery and Microsurgery Unit, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; and
  • 6 Department of Anatomy, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
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OBJECTIVE

The purpose of this study was to describe the anatomy of donor and recipient median nerve motor branches for nerve transfer surgery within the cubital fossa.

METHODS

Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery.

RESULTS

In the cubital fossa, the first branch was always the proximal branch of the pronator teres (PPT), whereas the last one was the anterior interosseous nerve (AIN) and the distal motor branch of the flexor digitorum superficialis (DFDS) on a consistent basis. The PT muscle was also innervated by a distal branch (DPT), which emerged from the anterior side of the median nerve and provided innervation to its deep head. The palmaris longus (PL) motor branch was always the second branch after the PPT, emerging as a single branch together with the flexor carpi radialis (FCR) or the proximal branch of the flexor digitorum superficialis. The FCR motor branch was prone to variations. It originated proximally with the PL branch (35%) or distally with the AIN (35%), and less frequently from the DPT. In 40% of dissections, the FDS was innervated by a single branch (i.e., the DFDS) originating close to the AIN. In 60% of cases, a proximal branch originated together with the PL or FCR. The AIN emerged from the posterior side of the median nerve and had a diameter of 2.3 mm, twice that of other branches. When dissections were performed between the PT and FCR muscles at the FDS arcade, we observed the AIN lying lateral and the DFDS medial to the median nerve. After crossing the FDS arcade, the AIN divided into: 1) a lateral branch to the flexor pollicis longus (FPL), which bifurcated to reach the anterior and posterior surfaces of the FPL; 2) a medial branch, which bifurcated to reach the flexor digitorum profundus (FDP); and 3) a long middle branch to the pronator quadratus. The average numbers of myelinated fibers within each median nerve branch were as follows (values expressed as the mean ± SD): PPT 646 ± 249; DPT 599 ± 150; PL 259 ± 105; FCR 541 ± 199; proximal FDS 435 ± 158; DFDS 376 ± 150; FPL 480 ± 309; first branch to the FDP 397 ± 12; and second branch to the FDP 369 ± 33.

CONCLUSIONS

The median nerve's branching pattern in the cubital fossa is predictable. The most important variation involves the FCR motor branch. These anatomical findings aid during nerve transfer surgery to restore function when paralysis results from injury to the radial or median nerves, brachial plexus, or spinal cord.

ABBREVIATIONS AIN = anterior interosseous nerve; DFDS = distal motor branch of the FDS; DPT = distal branch of the PT; FCR = flexor carpi radialis; FDP = flexor digitorum profundus; FDS = flexor digitorum superficialis; FDSA = FDS arcade; FPL = flexor pollicis longus; ME = medial epicondyle; PFDS = proximal FDS; PL = palmaris longus; PPT = proximal branch of the PT; PQ = pronator quadratus; PT = pronator teres.

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Contributor Notes

Correspondence Jayme A. Bertelli: Governador Celso Ramos Hospital, Florianópolis, SC, Brazil. drbertelli@gmail.com.

INCLUDE WHEN CITING Published online March 19, 2021; DOI: 10.3171/2020.9.JNS202742.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Brown JM, Tung THH, Mackinnon SE. Median to radial nerve transfer to restore wrist and finger extension: technical nuances. Neurosurgery. 2010;66(3 Suppl Operative):7583.

    • Search Google Scholar
    • Export Citation
  • 2

    Moore AM, Franco M, Tung TH. Motor and sensory nerve transfers in the forearm and hand. Plast Reconstr Surg. 2014;134(4):721730.

  • 3

    Ray WZ, Chang J, Hawasli A, . Motor nerve transfers: a comprehensive review. Neurosurgery. 2016;78(1):126.

  • 4

    Chantelot C, Feugas C, Guillem P, . Innervation of the medial epicondylar muscles: an anatomic study in 50 cases. Surg Radiol Anat. 1999;21(3):165168.

    • Search Google Scholar
    • Export Citation
  • 5

    Parot C, Leclercq C. Anatomical study of the motor branches of the median nerve to the forearm and guidelines for selective neurectomy. Surg Radiol Anat. 2016;38(5):597604.

    • Search Google Scholar
    • Export Citation
  • 6

    Tung TH, Mackinnon SE. Flexor digitorum superficialis nerve transfer to restore pronation: two case reports and anatomic study. J Hand Surg Am. 2001;26(6):10651072.

    • Search Google Scholar
    • Export Citation
  • 7

    Bertelli JA. Transfer of the radial nerve branch to the extensor carpi radialis brevis to the anterior interosseous nerve to reconstruct thumb and finger flexion. J Hand Surg Am. 2015;40(2):323328.e2.

    • Search Google Scholar
    • Export Citation
  • 8

    Bertelli JA, Ghizoni MF. Nerve transfers for restoration of finger flexion in patients with tetraplegia. J Neurosurg Spine. 2017;26(1):5561.

    • Search Google Scholar
    • Export Citation
  • 9

    Bertelli JA, Nehete S, Winkelmann Duarte EC, . Distal pronator teres motor branch transfer for wrist extension restoration in radial nerve paralysis. J Neurosurg. 2021;134(1):251257.

    • Search Google Scholar
    • Export Citation
  • 10

    Tubbs RS, Custis JW, Salter EG, . Quantitation of and superficial surgical landmarks for the anterior interosseous nerve. J Neurosurg. 2006;104(5):787791.

    • Search Google Scholar
    • Export Citation
  • 11

    Gunther SF, DiPasquale D, Martin R. The internal anatomy of the median nerve in the region of the elbow. J Hand Surg Am. 1992;17(4):648656.

    • Search Google Scholar
    • Export Citation
  • 12

    Unver Dogan N, Uysal II, Karabulut AK, Fazliogullari Z. The motor branches of median and ulnar nerves that innervate superficial flexor muscles: a study in human fetuses. Surg Radiol Anat. 2010;32(3):225233.

    • Search Google Scholar
    • Export Citation
  • 13

    Yang J, Jia X, Yu C, Gu Y. Pronator teres branch transfer to the anterior interosseous nerve for treating C8T1 brachial plexus avulsion: an anatomic study and case report. Neurosurgery. 2014;75(4):375379.

    • Search Google Scholar
    • Export Citation
  • 14

    Caetano EB, Vieira LA, Sabongi RG, . Transfer of nerve branches of the flexor carpi radialis to the posterior interosseous nerve. Acta Ortop Bras. 2018;26(4):222226.

    • Search Google Scholar
    • Export Citation
  • 15

    Caetano EB, Vieira LA, Cavalheiro CS, . Anatomical study of the transfer of flexor digitorum superficialis nerve branch of median nerve to restore wrist extension and forearm pronation. Einstein (Sao Paulo). 2019;17(3):eAO4489.

    • Search Google Scholar
    • Export Citation
  • 16

    Bertelli JA. Brachial plexus palsy. J Neurosurg. 2010;113(1):153154.

  • 17

    Bertelli JA. Nerve versus tendon transfer for radial nerve paralysis reconstruction. J Hand Surg Am. 2020;45(5):418426.

  • 18

    Bertelli JA, Ghizoni MF. Transfer of a flexor digitorum superficialis motor branch for wrist extension reconstruction in C5-C8 root injuries of the brachial plexus: a case series. Microsurgery. 2013;33(1):3942.

    • Search Google Scholar
    • Export Citation
  • 19

    Bertelli JA, Mendes Lehm VL, Tacca CP, . Transfer of the distal terminal motor branch of the extensor carpi radialis brevis to the nerve of the flexor pollicis longus: an anatomic study and clinical application in a tetraplegic patient. Neurosurgery. 2012;70(4):10111016.

    • Search Google Scholar
    • Export Citation
  • 20

    Bertelli JA, Nehete S, Winkelmann Duarte EC, Ghizoni MF. Transfer of the distal anterior interosseous nerve for thumb motion reconstruction in radial nerve paralysis. J Hand Surg Am. 2020;45(9):877.e1–877.e10.

    • Search Google Scholar
    • Export Citation
  • 21

    Bertelli JA, Tacca CP, Winkelmann Duarte EC, . Transfer of the pronator quadratus motor branch for wrist extension reconstruction in brachial plexus palsy. Plast Reconstr Surg. 2012;130(6):12691278.

    • Search Google Scholar
    • Export Citation
  • 22

    Davidge KM, Yee A, Kahn LC, Mackinnon SE. Median to radial nerve transfers for restoration of wrist, finger, and thumb extension. J Hand Surg Am. 2013;38(9):18121827.

    • Search Google Scholar
    • Export Citation
  • 23

    Emamhadi M, Andalib S. The first experience of triple nerve transfer in proximal radial nerve palsy. World Neurosurg. 2018;109:351355.

    • Search Google Scholar
    • Export Citation
  • 24

    Sallam AA, El-Deeb MS, Imam MA. Useful functional outcome can be achieved after motor nerve transfers in management of the paralytic hand. An observational study. HSS J. 2016;12(1):27.

    • Search Google Scholar
    • Export Citation
  • 25

    Emamhadi M, Andalib S. Double nerve transfer for restoration of hand grasp and release in C7 tetraplegia following complete cervical spinal cord injury. Acta Neurochir (Wien). 2018;160(11):22192224.

    • Search Google Scholar
    • Export Citation
  • 26

    Hsiao EC, Fox IK, Tung TH, Mackinnon SE. Motor nerve transfers to restore extrinsic median nerve function: case report. 2009;4(1):9297.

    • Search Google Scholar
    • Export Citation
  • 27

    García-López A, Sebastian P, Martinez F, Perea D. Transfer of the nerve to the brachioradialis muscle to the anterior interosseous nerve for treatment for lower brachial plexus lesions: case report. J Hand Surg Am. 2011;36(3):394397.

    • Search Google Scholar
    • Export Citation
  • 28

    García-López A, Navarro R, Martinez F, Rojas A. Nerve transfers from branches to the flexor carpi radialis and pronator teres to reconstruct the radial nerve. J Hand Surg Am. 2014;39(1):5056.

    • Search Google Scholar
    • Export Citation
  • 29

    Larson EL, Santosa KB, Mackinnon SE, Snyder-Warwick AK. Median to radial nerve transfer after traumatic radial nerve avulsion in a pediatric patient. J Neurosurg Pediatr. 2019;24(2):209214.

    • Search Google Scholar
    • Export Citation
  • 30

    Li Z, Reynolds M, Satteson E, . Double distal intraneural fascicular nerve transfers for lower brachial plexus injuries. J Hand Surg Am. 2016;41(4):e15e19.

    • Search Google Scholar
    • Export Citation
  • 31

    Maarrawi J, Mertens P, Luaute J, . Long-term functional results of selective peripheral neurotomy for the treatment of spastic upper limb: prospective study in 31 patients. J Neurosurg. 2006;104(2):215225.

    • Search Google Scholar
    • Export Citation
  • 32

    Murphy RK, Ray WZ, Mackinnon SE. Repair of a median nerve transection injury using multiple nerve transfers, with long-term functional recovery. J Neurosurg. 2012;117(5):886889.

    • Search Google Scholar
    • Export Citation
  • 33

    Palazzi S, Palazzi JL, Caceres JP. Neurotization with the brachialis muscle motor nerve. Microsurgery. 2006;26(4):330333.

  • 34

    Ray WZ, Mackinnon SE. Clinical outcomes following median to radial nerve transfers. J Hand Surg Am. 2011;36(2):201208.

  • 35

    Ray WZ, Yarbrough CK, Yee A, Mackinnon SE. Clinical outcomes following brachialis to anterior interosseous nerve transfers. J Neurosurg. 2012;117(3):604609.

    • Search Google Scholar
    • Export Citation
  • 36

    Sananpanich K, Kraisarin J, Siriwittayakorn W, . Double motor nerve transfer for all finger flexion in cervical spinal cord injury: an anatomical study and a clinical report. J Hand Surg Am. 2018;43(10):920926.

    • Search Google Scholar
    • Export Citation
  • 37

    Soldado F, Bertelli JA, Ghizoni MF. High median nerve injury: motor and sensory nerve transfers to restore function. Hand Clin. 2016;32(2):209217.

    • Search Google Scholar
    • Export Citation
  • 38

    Soldado F, Ghizoni MF, Bertelli J. Reconstruction of a C7–T1 brachial plexus lower root injury by transferring multiple nerves and a free gracilis muscle: case report. Microsurgery. 2020;40(6):696699.

    • Search Google Scholar
    • Export Citation
  • 39

    Ukrit A, Leechavengvongs S, Malungpaishrope K, . Nerve transfer for wrist extension using nerve to flexor digitorum superficialis in cervical 5, 6, and 7 root avulsions: anatomic study and report of two cases. J Hand Surg Am. 2009;34(9):16591666.

    • Search Google Scholar
    • Export Citation
  • 40

    van Zyl N, Hahn JB, Cooper CA, . Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report. J Hand Surg Am. 2014;39(9):17791783.

    • Search Google Scholar
    • Export Citation
  • 41

    Zheng XY, Hou CL, Gu YD, . Repair of brachial plexus lower trunk injury by transferring brachialis muscle branch of musculocutaneous nerve: anatomic feasibility and clinical trials. Chin Med J (Engl). 2008;121(2):99104.

    • Search Google Scholar
    • Export Citation
  • 42

    Yang F, Zhang X, Xie X, . Intramuscular nerve distribution patterns of anterior forearm muscles in children: a guide for botulinum toxin injection. Am J Transl Res. 2016;8(12):54855493.

    • Search Google Scholar
    • Export Citation

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