, Volume 4, Issue 1, pp 92–97 | Cite as

Motor Nerve Transfers to Restore Extrinsic Median Nerve Function: Case Report

  • Eugene C. Hsiao
  • Ida K. Fox
  • Thomas H. Tung
  • Susan E. Mackinnon


Active pronation is important for many activities of daily living. Loss of median nerve function including pronation is a rare sequela of humerus fracture. Tendon transfers to restore pronation are reserved for the obstetrical brachial plexus palsy patient. Transfer of expendable motor nerves is a treatment modality that can be used to restore active pronation. Nerve transfers are advantageous in that they do not require prolonged immobilization postoperatively, avoid operating within the zone of injury, reinnervate muscles in their native location prior to degeneration of the motor end plates, and result in minimal donor deficit. We report a case of lost median nerve function after a humerus fracture. Pronation was restored with transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres branch of the median nerve. Anterior interosseous nerve function was restored with transfer of the supinator branch to the anterior interosseous nerve. Clinically evident motor function was seen at 4 months postoperatively and continued to improve for the following 18 months. The patient has 4+/5 pronator teres, 4+/5 flexor pollicis longus, and 4−/5 index finger flexor digitorum profundus function. The transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres and supinator branch of the radial nerve to the anterior interosseous nerve is a novel, previously unreported method to restore extrinsic median nerve function.


Nerve transfers Pronation Nerve injury Median nerve 


  1. 1.
    Abrams RA, Ziets RJ, Lieber RL, et al. Anatomy of the radial nerve motor branches in the forearm. J Hand Surg Am 1997;22:232–7. doi: 10.1016/S0363-5023(97)80157-8.PubMedCrossRefGoogle Scholar
  2. 2.
    Apergis E, Aktipis D, Giota A, et al. Median nerve palsy after humeral shaft fracture: case report. J Trauma 1998;45:825–6. doi: 10.1097/00005373-199810000-00040.PubMedCrossRefGoogle Scholar
  3. 3.
    Bertelli JA. Brachialis muscle transfer to the forearm muscles in obstetric brachial plexus palsy. J Hand Surg Br 2006;31:261–5. doi: 10.1016/j.jhsb.2005.11.001.PubMedCrossRefGoogle Scholar
  4. 4.
    Bunnell S. Opposition of the thumb. J Bone Jt Surg Am 1938;20:269–84.Google Scholar
  5. 5.
    Camitz H. Uber die Behandlung der Oppositionslahmung. Acta Chir Scand. 1929;65:77–81.Google Scholar
  6. 6.
    Chuang DC, Ma HS, Borud LJ, et al. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. Plast Reconstr Surg 2002;109:1934–46. doi: 10.1097/00006534-200205000-00025.PubMedCrossRefGoogle Scholar
  7. 7.
    Davis T. Median nerve palsy. In: Green DP, editor. Operative hand surgery. Philadelphia, PA: Churchill Livingstone; 2005. p. 1131–59.Google Scholar
  8. 8.
    Haugstvedt JR, Berger RA, Berglund LJ. A mechanical study of the moment-forces of the supinators and pronators of the forearm. Acta Orthop Scand 2001;72:629–34. doi: 10.1080/000164701317269076.PubMedCrossRefGoogle Scholar
  9. 9.
    Huber E. Hilfsoperation bei median Uhlahmung. Dtsch Arch Klin Med 1921;136:271.Google Scholar
  10. 10.
    Kapandji A. Biomechanics of pronation and supination of the forearm. Hand Clin 2001;17:111–22.PubMedGoogle Scholar
  11. 11.
    Mackinnon SE, Novak CB. Nerve transfers: new options for reconstruction following nerve injury. Hand Clin 1999;15:643–66.PubMedGoogle Scholar
  12. 12.
    Mackinnon SE, Novak CB, Myckatyn TM, et al. Results of re-innervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am 2005;30:978–85. doi: 10.1016/j.jhsa.2005.05.014.PubMedCrossRefGoogle Scholar
  13. 13.
    Mackinnon SE, Roque B, Tung TH. Median to radial nerve transfer for treatment of radial nerve palsy. Case report. J Neurosurg 2007;107:666–71. doi: 10.3171/JNS-07/09/0666.PubMedCrossRefGoogle Scholar
  14. 14.
    Manske PR, McCarroll HR Jr, Hale R. Biceps tendon rerouting and percutaneous osteoclasis in the treatment of supination deformity in obstetrical palsy. J Hand Surg Am 1980;5:153–9.PubMedGoogle Scholar
  15. 15.
    Novak CB, Mackinnon SE. Distal anterior interosseous nerve transfer to the deep motor branch of the ulnar nerve for reconstruction of high ulnar nerve injuries. J Reconstr Microsurg 2002;18:459–64. doi: 10.1055/s-2002-33326.PubMedCrossRefGoogle Scholar
  16. 16.
    Novak CB, Mackinnon SE. Surgical treatment of a long thoracic nerve palsy. Ann Thorac Surg 2002;73:1643–5. doi: 10.1016/S0003-4975(01)03372-0.PubMedCrossRefGoogle Scholar
  17. 17.
    Novak CB, Mackinnon SE. Treatment of a proximal accessory nerve injury with nerve transfer. Laryngoscope 2004;114:1482–84. doi: 10.1097/00005537-200408000-00030.PubMedCrossRefGoogle Scholar
  18. 18.
    Ozkan T, Aydin A, Ozer K, et al. A surgical technique for pediatric forearm pronation: brachioradialis rerouting with interosseous membrane release. J Hand Surg Am 2004;29:22–7. doi: 10.1016/j.jhsa.2003.10.002.PubMedCrossRefGoogle Scholar
  19. 19.
    Royle ND. An operation for paralysis of the thumb intrinsic muscles of the thumb. JAMA 1938;111:612–3.Google Scholar
  20. 20.
    Seddon H, Medaware P, Smith H. Rate of regeneration of peripheral nerves in man. J Physiol 1943;102:191–215.PubMedGoogle Scholar
  21. 21.
    Thompson TC. A modified operation for opponens paralysis. J Bone Jt Surg Am 1942;26:632–40.Google Scholar
  22. 22.
    Timm WN, O'Driscoll SW, Johnson ME, et al. Functional comparison of pronation and supination strengths. J Hand Ther 1993;6:190–3.PubMedGoogle Scholar
  23. 23.
    Tung TH, Mackinnon SE. Flexor digitorum superficialis nerve transfer to restore pronation: two case reports and anatomic study. J Hand Surg Am 2001;26:1065–72. doi: 10.1053/jhsu.2001.28427.PubMedCrossRefGoogle Scholar
  24. 24.
    Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 2003;98:313–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Tung TH, Weber RV, Mackinnon SE. Nerve transfers for the upper and lower extremities. Oper Tech Orthop 2004;14:213–22. doi: 10.1053/j.oto.2004.06.002.CrossRefGoogle Scholar
  26. 26.
    Weber RV, Mackinnon SE. Nerve transfer in the upper extremity. J Am Soc Surg Hand 2004;4:200–13. doi: 10.1016/j.jassh.2004.06.011.CrossRefGoogle Scholar

Copyright information

© American Association for Hand Surgery 2008

Authors and Affiliations

  • Eugene C. Hsiao
    • 1
  • Ida K. Fox
    • 1
  • Thomas H. Tung
    • 1
  • Susan E. Mackinnon
    • 1
  1. 1.Department of Surgery, Division of Plastic and Reconstructive Surgery, School of MedicineWashington UniversitySaint LouisUSA

Personalised recommendations