Skip to main content

Advertisement

SpringerLink
Log in

Motor branches of the ulnar nerve to the forearm: an anatomical study and guidelines for selective neurectomy

  • Original Article
  • Published:
Surgical and Radiologic Anatomy Aims and scope Submit manuscript

Abstract

Purpose

Precise knowledge of motor nerve branches is critical to plan selective neurectomies for the treatment of spastic limbs. Our objective is to describe the muscular branching pattern of the ulnar nerve in the forearm and suggest an ideal surgical approach for selective neurectomy of the flexor carpi ulnaris.

Methods

The ulnar nerve was dissected under loop magnification in 20 upper limbs of fresh frozen cadavers and its branches to the flexor carpi ulnaris muscle (FCU) and to the flexor digitorum profundus muscle (FDP) were quantified. We measured their diameter, length and distance between their origin and the medial epicondyle. The point where the ulnar artery joined the nerve was observed. The position in which the ulnar nerve gave off each branch was noted (ulnar, posterior or radial) and the Martin-Gruber connection, when present, had its origin observed and its diameter measured.

Results

The ulnar nerve gave off two to five muscular branches, among which, one to four to the FCU and one or two to the FDP. In all cases, the first branch was to the FCU. It arose on average 1.4 cm distal to the epicondyle, but in four specimens it arose above or at the level of the medial epicondyle (2.0 cm above in one case, 1.5 cm above in two cases, and at the level of the medial epicondyle in one). The first branch to the FDP arose on average 5.0 cm distal to the medial epicondyle. All the branches to FDP but one arose from the radial aspect of the ulnar nerve. A Martin-Gruber connection was present in nine cases. All motor branches arose in the proximal half of the forearm and the ulnar nerve did not give off branches distal to the point where it was joined by the ulnar artery.

Conclusions

The number of motor branches of the ulnar nerve to the FCU varies from 2 to 4. An ideal approach for selective neurectomy of the FCU should start 4 cm above the medial epicondyle, and extend distally to 50 % of the length of the forearm or just to the point where the ulnar artery joins the nerve.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Backhouse KM (1981) Nerve supply in the arm and hand. In: Tubiana R (ed) The hand, vol l. WB Saunders Company, Philadelphia, pp 275–290

    Google Scholar 

  2. Bergman RA, Afifi AK, Miyauchi R (2006) Ulnar nerve. http://www.anatomyatlases.org/AnatomicVariants/NervousSystem/Text/UlnarNerve.shtml. Accessed 9 Oct 2012

  3. Bhadra N, Keith MW, Peckham PH (1999) Variations in innervation of the flexor digitorum profundus muscle. J Hand Surg 24:700–703

    Article  CAS  Google Scholar 

  4. Botte MJ (2003) Nerve anatomy. In: Doyle JR, Botte MJ (eds) Surgical anatomy of the hand and upper extremity. Lippincott Williams Wilkins, Philadelphia, pp 185–236

    Google Scholar 

  5. Brunelli G, Brunelli F (1983) Partial selective denervation in spastic palsies (hyponeurotization). Microsurgery 4:221–224

    Article  CAS  PubMed  Google Scholar 

  6. Cambon-Binder A, Leclercq C (2014) Anatomical study of the musculocutaneous nerve branching pattern: application for selective neurectomy in the treatment of elbow flexors spasticity. Surg Radiol Anat. doi:10.1007/s00276-014-1371-x

    PubMed  Google Scholar 

  7. Carlson MG (2011) Cerebral Palsy. In: Wolf SW, Hotchkiss RN, Pederson WC, Kozin SH (eds) Green’s operative hand surgery, 6th edn. Elsevier, Philadelphia, pp 1139–1172

    Chapter  Google Scholar 

  8. Contreras MG, Warner MA, Charboneau WJ, Cahill DR (1998) Anatomy of the ulnar nerve at the elbow: potential relationship of acute ulnar neuropathy to gender differences. Clin Anat 11:372–378

    Article  CAS  PubMed  Google Scholar 

  9. Decq P, Filipeti P, Cubillos A, Slavov V, Lefaucheur JP, Nguyen JP (2000) Soleus neurotomy for treatment of the spastic equinus foot. Neurosurgery 47:1154–1161

    Article  CAS  PubMed  Google Scholar 

  10. Garland DE, Thompson R, Waters RL (1980) Musculocutaneous neurectomy for spastic elbow flexion in non-functional upper extremities in adults. J Bone Joint Surg Am 62:108–112

    CAS  PubMed  Google Scholar 

  11. Gonzalez MH, Lofti P, Bendre A, Mandelbroyt Y, Lieska N (2001) The ulnar nerve at the elbow. J Hand Surg (Br) 26:142–144

    Article  CAS  Google Scholar 

  12. Gruber W (1870) Uber die Verbindung des Nervus medianus mit dem Nervus ulnaris am Unterarme des Menschen und der Sangethiere. Arch Anat Phisiol Wissen Med 37:501–522

    Google Scholar 

  13. Gutmann L (1993) AAEM minimonograph 2: important anomalous innervations of the extremities. Muscle Nerve 16:339–347

    Article  CAS  PubMed  Google Scholar 

  14. Keenan MA, Todderud EP, Henderson R, Botte M (1987) Management of intrinsic spasticity in the hand with phenol injection or neurectomy of the motor branch of the ulnar nerve. J Hand Surg Am. 12:734–739

    Article  CAS  PubMed  Google Scholar 

  15. Leclercq C (2003) General assessment of the spastic upper limb. Hand Clin 19:557–564

    Article  PubMed  Google Scholar 

  16. Leibovic SJ, Hasting H (1992) Martin-Gruber revisited. J Hand Surg (Am) 17:47–53

    Article  CAS  Google Scholar 

  17. Lepage D, Parratte B, Tatu L, Vuiller F, Monnier G (2005) Extra- and intramuscular nerve supply of the muscles of the anterior antebrachial compartment: applications for selective neurotomy and for botulinum toxin injection. Surg Radiol Anat 27:420–430

    Article  CAS  PubMed  Google Scholar 

  18. Marur T, Akkin SM, Alp M, Demirci S, Yalçin L, Ogüt T, Akgün I (2005) The muscular branching patterns of the ulnar nerve to the flexor carpi ulnaris and flexor digitorum profundus muscles. Surg Radiol Anat 27:322–326

    Article  PubMed  Google Scholar 

  19. Nakashima T (1993) An anatomic study on the Martin-Gruber anastomosis. Surg Radiol Anat 15:193–195

    Article  CAS  PubMed  Google Scholar 

  20. Oh CS, Won HS, Lee KS, Chung IH, Kim SM (2009) Anatomic variation of the innervation of the flexor digitorum profundus muscle and its clinical implications. Muscle Nerve 39:498–502

    Article  PubMed  Google Scholar 

  21. Puligopu AK, Purohit AK (2011) Outcome of selective motor fasciculotomy in the treatment of upper limb spasticity. J Pediatr Neurosci. 6:118–125

    Article  Google Scholar 

  22. Rodriguez-Niedenführ M, Vazquez T, Parkin I, Logan B, Sañudo JR (2002) Martin-Gruber anastomosis revisited. Clin Anat 15:129–134

    Article  PubMed  Google Scholar 

  23. Shu HS, Chantelot C, Oberlin Alnot JY, Shao H (1997) Martin-Gruber communicating branch: anatomical and histological study. Surg Radiol Anat 21:115–118

    Article  Google Scholar 

  24. Srinivasan R, Rhodes J (1981) The median-ulnar anastomosis (Martin-Gruber) in normal and congenitally abnormal fetuses. Arch Neurol 38:418–419

    Article  CAS  PubMed  Google Scholar 

  25. Stoffel A (1913) Treatment of spastic contractures. Amer J Orthop Surg 10:611–644

    Google Scholar 

  26. Sunderland S (1945) The innervation of the flexor digitorum profundus and lumbrical muscles. Anat Rec 93:317–321

    Article  CAS  PubMed  Google Scholar 

  27. Sunderland S, Hughes ESR (1946) Metrical and non-metrical features of the muscular branches of the ulnar nerve. J Comp Neurol 85:113–123

    Article  CAS  PubMed  Google Scholar 

  28. Taams KO (1997) Martin-Gruber connections in South Africa. An anatomical study. J Hand Surg (Br) 22:328–330

    Article  CAS  Google Scholar 

  29. Tonkin MA (1995) The upper limb in cerebral palsy. Curr Orthop 9:149–155

    Article  Google Scholar 

  30. Tubbs RS, Custis JW, Salter EG, Blount JP, Oakes WJ, Wellons JC 3rd (2006) Quantitation of and landmarks for the muscular branches of the ulnar nerve to the forearm for application in peripheral nerve neurotization procedures. J Neurosurg 4:800–803

    Article  Google Scholar 

  31. Unver Dogan N, Uysal II, Karabulut AK, Fazliogullari Z (2010) The motor branches of median and ulnar nerves that innervate superficial flexor muscles: a study in human fetuses. Surg Radiol Anat 32:225–233

    Article  PubMed  Google Scholar 

  32. Watchmaker GP, Lee G, Mackinnon SE (1994) Intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition. J Hand Surg (Am) 19:915–922

    Article  CAS  Google Scholar 

  33. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ (1999) Gray’s anatomy, 38th edn. Churchill Livingstone, Edinburgh, pp 1270–1272

    Google Scholar 

Download references

Acknowledgments

We thank the staff of the anatomy laboratory of the Ecole de Chirurgie du Fer à Moulin for its help. (AP-HP, École de Chirurgie, F-75005 Paris, France).

Conflict of interest

The authors have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Hand and Microsurgery Division, Hospital das Clínicas da Faculdade de Medicina - University of São Paulo, Rua Dr Ovídio Pires de Campos, Sao Paulo, SP, 05403-010, Brazil

    Renata Paulos

  2. Institut de la Main, Clinique Jouvenet, 6 square Jouvenet, 75016, Paris, France

    Caroline Leclercq

Authors
  1. Renata Paulos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Caroline Leclercq
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Renata Paulos.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Paulos, R., Leclercq, C. Motor branches of the ulnar nerve to the forearm: an anatomical study and guidelines for selective neurectomy. Surg Radiol Anat 37, 1043–1048 (2015). https://doi.org/10.1007/s00276-015-1448-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-015-1448-1

Keywords

Search

Navigation