Unusual nerve supply of biceps from ulnar nerve and median nerve and a third head of biceps

ABSTRACTVariations in branching pattern of the brachial plexus are common and have been reported by several investigators. Of the four main nerves traversing the arm, namely median, ulnar, radial and musculocutaneous, the ulnar and median nerve do not give any branches to muscles of the arm. Ulnar nerve after taking origin from medial cord of brachial plexus runs distally through axilla on medial side of axillary artery till middle of arm, where it pierces the medial intermuscular septum and enters the posterior compartment of arm. Ulnar nerve enters forearm between two heads of flexor carpi ulnaris from where it continues further. It supplies flexor carpi ulnaris , flexor digitorum profundus and several intrinsic muscles of hand . We recently observed dual supply of biceps muscle from ulnar and median nerves in arm. Musculocutaneous nerve was absent. Although communications between nerves in arm is rare, the communication between median nerve and musculocutaneous nerve were described from the 19th century which could explain innervation of biceps from median nerve. But no accurate description of ulnar nerve supplying biceps could be found in literature. Knowledge of anatomical variation of these nerves at level of upper arm is essential in light of the frequency with which surgery is performed to transfer nerve fascicles from ulnar nerve to biceps in case of brachial plexus injuries. We also observed third head of biceps, our aim is to describe the exact topography of this variation and to discuss its morphological.

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Absence of Musculocutaneous Nerve: Embryological Basis

Asian Journal of Medical Sciences ◽

10.3126/ajms.v3i2.6626 ◽

2013 ◽

Vol 3 (2) ◽

pp. 21-24

Author(s):

Arvind Kumar Pankaj ◽

CS Ramesh Babu ◽

Archana Rani ◽

Anita Rani ◽

Jyoti Chopra ◽

...

Keyword(s):

Brachial Plexus ◽

Median Nerve ◽

Ulnar Nerve ◽

Lateral Root ◽

Axillary Artery ◽

Musculocutaneous Nerve ◽

Medical Sciences ◽

Lateral Cord ◽

Pectoral Nerve ◽

Male Cadaver

Variation of brachial plexus characterized by the absence of musculocutaneous nerve in right arm was found during routine dissection of a 54 year old male cadaver. After giving lateral pectoral nerve, rest of the lateral cord continued as lateral root of median nerve. An unusual branch was arising from lateral cord which crossed the axillary artery anteriorly and then divided into two branches. One of these branches joined ulnar nerve and other medial root of median nerve. All the muscles of front of arm were supplied by branches of median nerve. These variations are important for the anesthetists, surgeons, neurologists during surgery and for anatomists during dissection in the region of axilla. DOI: http://dx.doi.org/10.3126/ajms.v3i2.6626 Asian Journal of Medical Sciences 3(2012) 21-24

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Formation, trajectory and distribution variants of the median nerve of the fetus

ARS Medica Tomitana ◽

10.1515/arsm-2017-0025 ◽

2017 ◽

Vol 23 (3) ◽

pp. 142-149

Author(s):

I. S. Tudorache ◽

P. Bordei ◽

D. M. Iliescu

Keyword(s):

Median Nerve ◽

Ulnar Nerve ◽

Upper Limb ◽

Lateral Root ◽

Axillary Artery ◽

Single Case ◽

Musculocutaneous Nerve ◽

Single Nerve ◽

Nerve Fascicle ◽

Medial Nerve

AbstractOur study was performed by dissection on a number of 54 nervous trunks of the median nerve of the fetus. We found that the median nerve is always formed from two roots, their joining being at different levels of the upper limb, between the axilla and the elbow. The axilla nerve trunk was formed at the level of the axillary region, in 38.89% of the cases, in 22.22% of the cases the union was made at the middle part of the arm, and in 38.89% of the cases in the elbow. The lateral root of the medial nerve was formed in 55.56% of cases from a single nerve fascicle, in 44.44% of cases consisting of two nerve fascicles. The medial root was formed in 61.11% of cases from a single nerve fascicle, in 38.89% of the cases being made up of two nerve fascicles. In 27.78% of cases, the medial root passed behind the axillary artery. Regarding the volume of the two roots, we found that in 44.44% of the cases, the lateral root was more voluminous, in 27.78% of cases, the median root was larger and in 27.78% of cases, the two roots were approximately equal. We have encountered situations where a ramification for the forearms muscles emerged from the lateral root. Occasionally, a ram for the brachial muscle was detached from the medial root, and from the lateral root a ram for the biceps muscle, both muscles receiving branches also from the musculocutaneous nerve. We have encountered a single case where the median nerve inches the anterior muscles of the arm, missing the musculocutaneous nerve. In cases of low joining of the roots, we have encountered cases where a lateral root formed a ram for forearm muscles. The anastomoses between the two median nerve roots can sometimes be located just above their union or anterior to the lower portion of the axillary artery. In one case, we encountered between the two roots, above their union, the existence of three oblique anastomoses, the two upper ones from the lateral to the medial root, and the third from the medial root to the lateral root. Common are anastomoses between the roots of the roots and the root on the opposite side. The most common are the anastomosis between the medial fascicle of the lateral root and the medial root of the median nerve. In one case, we encountered a double overlap between the musculocutaneous nerve and the lateral nerve root. In one case, we encountered a strong anastomosis between the medial nerve fascicle of the medial root and the radial nerve. Common and at all levels of the upper limb are the anastomoses between the median and ulnar nerves. In the case of a low union of the two median roots, we encountered anastomoses between a root of the root and the ulnar nerve, or between a root and the ulnar nerve. I encountered a single case with an anastomosis, Martin- Gruber, which was previously passing through the ulnar and interos-like arteries and from which the anterior forearm muscles were detached.

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Infraclavicular brachial plexus stretch injury

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.5 ◽

2004 ◽

Vol 16 (5) ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

Daniel H. Kim ◽

Judith A. Murovic ◽

Robert L. Tiel ◽

David G. Kline

Keyword(s):

Brachial Plexus ◽

Median Nerve ◽

Ulnar Nerve ◽

Axillary Artery ◽

Vascular Injuries ◽

State University ◽

Associated Injuries ◽

Stretch Injury ◽

Louisiana State University ◽

Acceptable Outcome

Object The authors report the surgery-related results obtained in 143 patients with stretch-induced infraclavicular brachial plexus injuries (BPIs). The entire series comprised 1019 operative BPIs managed at the Louisiana State University Health Sciences Center between 1968 and 1998. Methods Infraclavicular lesions represented 143 (28%) of the total of 509 stretch injuries involving both the infra-and supraclavicular brachial plexus, of which 366 (72%) were supraclavicular lesions. The operative approach is thoroughly outlined, and common patterns and combinations of involvement of nerves peculiar to the infraclavicular area are presented. Overall, the results of suture and graft repair were favorable for the lateral and posterior cord and their outflows. Repair of medial cord–median nerve also yielded acceptable results. The results of medial cord and medial cord–ulnar nerve, however, were poor. The incidence of associated injuries in the infraclavicular as opposed to the supraclavicular area, including shoulder dislocation and fracture and humeral fractures as well as vascular injuries including axillary artery injury was higher. Results of a literature search supported the finding that vascular injuries were increased due to the juxtaposition of vessels among the brachial plexus elements. Conclusions Thus, although less common than their supraclavicular counterpart, infraclavicular stretch injury lesions when they occur are technically more difficult to treat and are associated with a higher incidence of vascular and dislocation/fraction injuries. Favorable results were obtained for lateral and posterior cord lesions and their outflows, with acceptable outcome after medial cord–median nerve stretch injury repair. The results of medial cord and medial cord to ulnar nerve, however, were poor.

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Physiological and clinical advantages of median nerve fascicle transfer to the musculocutaneous nerve following brachial plexus root avulsion injury

Journal of Neurosurgery ◽

10.3171/jns.2006.105.6.830 ◽

2006 ◽

Vol 105 (6) ◽

pp. 830-834 ◽

Cited By ~ 27

Author(s):

Rahul K. Nath ◽

Andrew B. Lyons ◽

Gabriel Bietz

Keyword(s):

Brachial Plexus ◽

Median Nerve ◽

Ulnar Nerve ◽

Muscle Function ◽

Functional Restoration ◽

Musculocutaneous Nerve ◽

World Health ◽

Biceps Muscle ◽

Root Avulsion ◽

Nerve Fascicle

Object Loss of biceps muscle function is a significant disability after brachial plexus root avulsion injuries. Nerve grafting techniques to reestablish anatomical and functional continuity between the spinal cord and the avulsed root have not proven successful. Using nerve transfers for functional restoration of root avulsion injuries appears to be effective and has physiological advantages for reducing regeneration distances. Since the early 1990s, the Oberlin technique of transferring ulnar nerve fascicles to the motor branch of the musculocutaneous nerve has been the preferred operative technique for reinnervation and restoration of biceps muscle function. In the current study the authors examine the efficacy of an alternative technique using median nerve fascicles transferred to the musculocutaneous nerve to reinnervate the biceps muscle. Methods Forty consecutive patients with combined C5–6 brachial plexus root avulsions were evaluated pre- and postoperatively according to the British Medical Research Council Motor Grading Scale. Personal interviews concerning quality of life (QOL) after surgery were conducted and scored based on standards set by the World Health Organization. All patients showed some degree of improvement in biceps muscle function. Thirty-six (90%) of the 40 patients regained movement against gravity. The patients had a 77% improvement in overall QOL after the surgery; most notably, 92% of the patients reported their lack of need for medication and 75% a significant lessening of postoperative pain. Redirection of part of the healthy median nerve resulted in no measurable functional deficits, and only 28 patients reported minor sensory disturbances in the first web space for an average of 3 months after surgery. Conclusions Median nerve fascicle transfer resulted in a significant improvement in biceps muscle function with an acceptable level of morbidity and should be considered an effective, and in many cases preferable, alternative to ulnar nerve fascicle transfer.

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Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.19 ◽

2004 ◽

Vol 16 (5) ◽

pp. 313-318

Author(s):

Thomas H. Tung ◽

Christine B. Novak ◽

Susan E. Mackinnon

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Nerve Transfers ◽

Brachialis Muscle ◽

Nerve Fascicle ◽

The Mean ◽

Mean Time ◽

Flexion Strength

Object In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve. Methods The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG). The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient. Conclusions The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.

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Peripheral Nervous SystemUpper Extremity

10.1093/med/9780199845712.003.0028 ◽

2013 ◽

Author(s):

Adam Fisch

Keyword(s):

Nervous System ◽

Brachial Plexus ◽

Median Nerve ◽

Peripheral Nervous System ◽

Ulnar Nerve ◽

Radial Nerve ◽

Upper Extremities ◽

Cervical Plexus

Chapter 3 discusses how to draw the peripheral nervous system (upper extremities), including the brachial plexus, median nerve, ulnar nerve, radial nerve, and the cervical plexus.

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Cadaveric Study of Anatomical Variations in the Musculocutaneous Nerve and in the Median Nerve

Journal of Morphological Sciences ◽

10.1055/s-0039-1688799 ◽

2019 ◽

Vol 36 (02) ◽

pp. 122-125

Author(s):

Abhilasha Priya ◽

Chandni Gupta ◽

Antony Sylvan D'souza

Keyword(s):

Brachial Plexus ◽

Median Nerve ◽

Peripheral Nerves ◽

Anatomical Variations ◽

Musculocutaneous Nerve ◽

Branching Pattern ◽

Kasturba Medical College ◽

Upper Limbs ◽

Medical College ◽

Lateral Cord

Introduction The musculocutaneous nerve and the median nerve are branches from the lateral cord of the brachial plexus with a root value of C5, C6, and C7. The medial root of the median nerve is a branch of the medial cord. The present study aims at observing any variations in these peripheral nerves, so that this knowledge can be utilized by surgeons, anesthesiologists, and orthopedicians during surgical procedures and nerve block. Materials and Methods The present study was carried on 30 adult embalmed cadavers (60 upper limbs) in the department of anatomy of the Kasturba Medical College , Manipal, India. The infraclavicular part of the brachial plexus was dissected, and any anatomical variations in the formation and in the branching pattern of the musculocutaneous nerve and of the median nerve were noted and photographs were taken. Results The median nerve was noted to be formed from 3 roots in 8 out of 60 dissected upper limbs (13.33%). The musculocutaneous nerve was absent in 5% of the dissected limbs, and communications between these 2 nerves were noted in 13.33% of the dissected limbs. Conclusions Noted variations of the nerves may be of help to surgeons operating in the axillas and in the arms.

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Reinnervation of the biceps in C5–7 brachial plexus avulsion injuries: results after distal bypass surgery

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.7 ◽

2004 ◽

Vol 16 (5) ◽

pp. 1-4 ◽

Cited By ~ 21

Author(s):

Stefano Ferraresi ◽

Debora Garozzo ◽

Paolo Buffatti

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Hand Function ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Biceps Muscle ◽

Nerve Transfers ◽

Significant Difference ◽

Normal Hand ◽

Nerve Dysfunction

Object The authors report various techniques, and their results, after performing median and ulnar nerve transfers to reanimate the biceps muscle in C5–7 avulsion-related brachial plexus injuries (BPIs). Methods Forty-three adult patients with BPIs of the upper-middle plexus underwent reinnervation of the biceps muscle; neurotization of the musculocutaneous nerve was performed using fascicles from the ulnar nerve (39 cases) and the median nerve (four cases). The different techniques included sectioning, rerouting, and direct suturing of the entire musculocutaneous nerve (35 cases); direct reinnervation of the motor branches of the musculocutaneous nerve (three cases); and reinnervation using small grafts to the motor fascicles that enter the biceps muscle (five cases). Elbow flexion recovery ranged from M2 to M4+, according to the patient's age and the level of integrity of the hand. No surgery-related failure occurred. No significant difference in outcome was related to any of the technical variants. In patients younger than age 45 years and exhibiting a normal hand function a score of M4 or better was always achieved. On average, reinnervation occurred 6 months after surgery. There was no clinical evidence of donor nerve dysfunction. Conclusions When accurate selection criteria are met, the results after this type of neurotization have proved excellent.

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Uncommon course of the ulnar artery through the pronator teres muscle

Journal of Nepal Medical Association ◽

10.31729/jnma.2722 ◽

1970 ◽

Vol 52 (195) ◽

pp. 946-948

Author(s):

Katerina Vymazalová ◽

Lenka Vargová ◽

Marek Joukal

Keyword(s):

Median Nerve ◽

Anatomical Variation ◽

Ulnar Artery ◽

Predisposing Factor ◽

Anatomical Structures ◽

Pronator Teres ◽

Flexor Carpi Ulnaris ◽

Cubital Fossa ◽

The Right ◽

Flexor Digitorum

In this paper, we describe a very rare variant in the course of the ulnar artery that we encountered in dissecting the right upper limb of a 74-year-old man. The ulnar artery arose standardly from the brachial artery in the cubital fossa. However, its ensuing course differed from the norm. The artery entered together with the ulnar vein and median nerve into the pronator canal (between the humeral and ulnar heads of the pronator teres). Further, the ulnar artery descended classically to the ulnar side of the forearm between the flexor carpi ulnaris and flexor digitorum superficialis. Knowledge of this variation in the course of the ulnar artery may have significance in clinical practice because accumulation of anatomical structures in the pronator canal could be a predisposing factor for the compression of nerve or blood vessels. Keywords: anatomical variation; median nerve; pronator canal; pronator teres muscle; ulnar artery.

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Report of a Transligamentous Ulnar Nerve Sensory Branch

Hand ◽

10.1177/1558944719831338 ◽

2019 ◽

Vol 15 (1) ◽

pp. NP11-NP13

Author(s):

Christina R. Vargas ◽

Kyle J. Chepla

Keyword(s):

Median Nerve ◽

Ulnar Nerve ◽

Carpal Tunnel ◽

Carpal Tunnel Release ◽

Anatomical Variation ◽

Dominant Male ◽

Transverse Carpal Ligament ◽

Anatomical Variant ◽

Motor Branch ◽

Right Hand

Background: Several anatomical variations of the median nerve recurrent motor branch have been described. No previous reports have described the anatomical variation of the ulnar nerve with respect to transverse carpal ligament. In this article, we present a patient with symptomatic compression of the ulnar nerve found to occur outside the Guyon canal due to a transligamentous course through the distal transverse carpal ligament. Methods: A 59-year-old, right-hand-dominant male patient presented with right hand pain, subjective weakness, and numbness in both the ulnar and the median nerve distributions. Electromyography revealed moderate demyelinating sensorimotor median neuropathy at the wrist and distal ulnar sensory neuropathy. At the time of planned carpal tunnel and Guyon canal release, a transligamentous ulnar nerve sensory common branch to the fourth webspace was encountered and safely released. Results: There were no surgical complications. The patient’s symptoms of numbness in the median and ulnar nerve distribution clinically improved at his first postoperative visit. Conclusions: We have identified a case of transligamentous ulnar nerve sensory branch encountered during carpal tunnel release. To our knowledge, this has not been previously reported. While the incidence of this variant is unknown, hand surgeons should be aware of this anatomical variant as its location puts it at risk of iatrogenic injury during open and endoscopic carpal tunnel release.

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