Rev. bras. ortop. vol.50 número5

w w w . r b o . o r g . b r

Original

Article

Communication

between

the

musculocutaneous

and

median

nerves

in

the

arm:

an

anatomical

study

and

clinical

implications

Luis

Ernesto

Ballesteros

_,

_Pedro

_Luis

_Forero,

_Edna

_Rocío

_Buitrago

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received13July2014 Accepted21August2014

Availableonline27December2014

Keywords:

Mediannerve

Musculocutaneousnerve Communication

a

b

s

t

r

a

c

t

Objective:Todeterminethefrequencyandfeaturesofcommunicationbetweenthe muscu-locutaneousnerve(MCN)andmediannerve(MN)inasampleoftheColombianpopulation, andassessitsclinicalimplication.

Methods:Thearmsof53cadaverspecimensthathadbeensubjectedtonecropsyatthe NationalInstituteofForensicMedicine,inBucaramanga,Colombia,werestudied.The struc-turesoftheanteriorcompartmentofthearmweredissectedandcharacterizedregarding thepresenceofcommunicationbetweentheMCNandMN.

Results:Acommunicatingbranchwasfoundin21/106upperlimbs(19.8%),occurring bilat-erallyin10(47.6%)andunilaterallyin11(52.4%),withoutsignificantdifferenceregarding thesideofoccurrence(p=0.30).In17%ofthecases,therewasMCN-MNcommunication inwhichthecommunicatingbranchwasseenleavingtheMCNafterpiercingthe cora-cobrachialismuscle(TypeI).In2.8%,theconnectionwasfromtheMNtotheMCN(Type II).Thelengthofthecommunicatingbranchwas57.8±33.4mm.Thedistancesfromthe proximalanddistalpointsofthisbranchtothecoracoidprocesswere138±39.4mmand 188±48.3mm,respectively.Thecommunicatingbranchwaslocatedmostlyinthemiddle thirdofthearm.

Conclusions: ThefrequencyofMCN-MNcommunicationobservedinthepresentstudyisin themiddleoftherangeofwhatwasreportedinpreviousstudies.MCN-MNconnections needtobetakenintoaccountindiagnosingandmanagingperipheralnervelesionsofthe upperlimbs.

©2015PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.

∗ _{Correspondingauthor.}

E-mail:lballest56@yahoo.es(L.E.Ballesteros). http://dx.doi.org/10.1016/j.rboe.2014.08.009

Comunicac¸ão

entre

os

nervos

musculocutâneo

e

mediano

no

brac¸o:

estudo

anatômico

e

implicac¸ões

clínicas

Palavras-chave:

Nervomediano Nervomúsculo-cutâneo Comunicac¸ão

r

e

s

u

m

o

Objetivo: Determinar a frequência e características da comunicac¸ão entre os nervos músculo-cutâneo(MCN)emediano(MN)emumaamostrada populac¸ãocolombiana, e avaliarsuaimplicac¸ãoclínica.

Métodos: Osbrac¸osde53cadáveresforamavaliadosemnecropsianoNationalInstituteof ForensicMedicine,emBucaramanga,Colômbia.Asestruturasdocompartimentoanterior dobrac¸oforamdissecadasecaracterizadasemrelac¸ãoàpresenc¸adecomunicac¸ãoentre MCNeMN.

Resultados: Umramocomunicantefoiencontradoem21/106membrossuperiores(19.8%), ocorrendobilateralmenteem10(47,6%)eunilateralmenteem11(52,4%),semdiferenc¸a significativa emrelac¸ãoao ladoda ocorrência(p=0,30). Em17%doscasos, haviauma comunicac¸ãoentreMCN-MNnaqualoramocomunicanteeravistoemergindodoMCN apósperfuraromúsculocóraco-braquial(TipoI).Em2,8%doscasosaconexãofoidoMN paraoMCN(TipoII).Ocomprimentodoramocomunicantefoi57,8±33,4mm.As distân-ciasentreospontosproximaledistaldesteramoeoprocessocoracóidefoi138±39,4mme 188±48,3mm,respectivamente.Oramocomunicanteselocalizouprincipalmentenoterc¸o médiodobrac¸o.

Conclusão: Afrequênciadacomunicac¸ãoentreMCN-MNobservadanopresenteestudoestá namédiadaquelarelatadaemoutrostrabalhos.AsconexõesMCN-MNdevemserlevadas emconsiderac¸ãonodiagnósticoenomanejodaslesõesdosnervosperiféricosdosmembros superiores.

©2015PublicadoporElsevierEditoraLtda.emnomedaSociedadeBrasileirade OrtopediaeTraumatologia.

Introduction

Attheinfraclavicularlevel,thelateralfascicleofthebrachial plexususuallybifurcatesgivingorigin tothe musculocuta-neousnerve(MCN)andthelateralrootofthemediannerve (MN). However,duringtheembryologicaldevelopment pro-cessitispossiblethatbundlesoffiberscorrespondingtothe MNinitiallyruntogetherwithbundlesoffibersoftheMCN. TheMNrecoversthefibersrequiredtoperformitsmotorand sensorialfunctionsintheupperextremity,onlywhenthe bun-dlesoffiberswereconnectedwiththeirnerveoforigin(MN) attheproximalormid-thirdsofthearm.Althoughwithlow frequency,fibersoftheMCNhavealsobeenseentoinitially runalongoftheMNandlaterreestablishtheirconfiguration throughacommunicatingbranch.1–5

TheincidenceoftheMCN-MNcommunicationhasbeen reportedindiversepopulationgroupswithawide variabil-itybetween2.1and63.5%.5–8_{Themajorityofthestudiesonly}

reporttheMCN-MNcommunication.Maedaetal.3_and

Chiara-pattanakometal.6_{havereportedanoccurrenceof3–6.8%for}

the communicationfrom the MNtothe MCN. Information abouttheprevalenceofsideofMCN-MNcommunicationis low.Fewstudiesreportpredominanceoftheleftsideandof theunilateralexpressionofthiscommunicatingbranch.4,9,10

Severalwaystoclassifythiscommunicatingbranchhavebeen proposedbythewidevariabilityinitsexpression.3,7,8,10,11

KnowledgeoftheexistenceoftheMCN-MN communica-tioninthearmisclinicallyimportant;itallowsanadequate

evaluationandmanagementofupperlimbmotordisorders causedbyperipheralnerveinjuriesaswellasacorrectsurgical planningandapproachesofaxillaandarm.10,12–14_The

clini-calimplicationsofMCN-MNcommunicationsinthearmhave notbeendescribedindetailforotherpopulations.1,3,6,7,13,15–19

Taking into account that the ethnic factor is decisive for theemergenceofdiversemorphologicalexpressionsandthe absenceofthistypeofinformationfromtheMestizo popula-tion,whichispredominantinLatinAmerica,makesthisstudy highlyrelevantinfreshcadavericmaterial.

Methods

This descriptive study was designed to determine the frequency and morphologic features ofthe MCN-MN com-municationin106freshfrozenupperextremitiesof53male adultswhowereundergoingnecropsyattheNationalInstitute ofForensicMedicine.Thesamplemetthefollowinginclusion criteria:Mestizosubjectswithoutevidenceofdirecttraumaor conditionsinvolvingtheupperextremityandwhowerenot thesubjectsofforensicanalysis.

thearm.Then,theepineuralconnectivetissuewasremoved andboththeMCNandtheMNweredissectedfromtheir ori-ginstotheirrespectivemotorpoints,takingtheirtrajectories inthearmasareference.

TheexistenceofMCN-MNcommunicatingbranchesinthe armwasverifiedandtheirqualitativefeatureswererecorded inaccordancewiththeclassificationproposedbyMaedaetal.3

asfollows:Type Iwhen the communicationis observedat the mid or distalthirds ofthe arm. This classwas subdi-videdinto4subtypes.SubtypeIa:whenthecommunication arose from MCN in its intramuscular via into the coraco-brachialismuscle(CbM).SubtypeIb:whenthecommunicating branchexitsfromMCNbeforethebicepsmuscle(BM)branch. SubtypeIc:whenthecommunicationislocatedbetweenthe branchesgoingtoBMandbrachialismuscle(BrM).SubtypeId: whenthecommunicatingbranchexitsaftertheemergence ofBrMbranch. Similarly,theoccurrenceofcommunicating branches between the MN and the MCN was recorded as Type II with 2subtypes. SubtypeIIa: the branchfrom MN reached the segment between the origins of BM and BrM branches.SubtypeIIb:whenthecommunicatingbranchwas connectedwiththebranchtoBrM.Thelengthofthe commu-nicatingbranchaswellasthedistancesfromtheirproximal anddistalpointstotheacromionwasmeasured.Thelength ofthe arm from the anterior edgeof the acromion tothe bi-epicondylarlineoftheelbowwasmeasuredandthe seg-ment where the communicating branch was located was recorded.

Allmorphometricassessmentsweremadewithadigital caliper(Mitotuyo®_{)andthefindingswerephotographedwith}

a DSLR camera. All findings were digitized in Exceltables andthe statisticalanalyseswerecarriedout.Nominal vari-ablesaredescribedwithratios,whilecontinuousvariablesare describedwithmeansandstandarddeviations.Statistical evi-dencesweretestedwiththesquarechi(2)testandStudentt

testacceptinganalphaerrorofupto5%.Ap-value<0.05was consideredassignificant.

Results

TheMCN-MNcommunicatingbranchwaspresentin21/106 (19.8%) upper limbs evaluated, occurring bilaterally in 10 (47.6%); unilaterallyin 11(52.4%)without significant differ-enceatthesideofoccurrence(p=0.30).Tenwerelocatedat therightandelevenattheleft(p=0.30).

Type I communication was observed in 18 cases (17%) (Fig.1),wheretheMCN-MNcommunicatingbranchemerged afterMCNpiercedCbMandit wasconnectedtothe MNin anobliquetrajectory.ThecommunicationarosefromMCNin itsintramuscularviaintoCbM(subtypeIa)in2cases(11.1%); fromtheproximalsegmentofMCNbeforetothebranchtoBM (subtypeIb)in2cases(11.1%)(Fig.1A);fromthemid-segment oftheMCNbetweentheemergenceofthebranchestoBMand BrM(subtypeIc)in8specimens(44.5%)(Fig.1B),andin6cases (33.3%)thecommunicatingbrancharosefromthebranchto BrM(subtypeId)(Fig.1C).

Inthreespecimens(2.8%)thecommunicatingbranchwas foundfromMNinanobliquetrajectoryatthelevelofthe mid-thirdofthearmandthenitwasconnectedwiththeMCN(Type

DM

a

b

c

DM DM

CbM

CbM

CbM

BM

BM

BM

BrM MN

MCN

MCN

MN

MN UN

Fig.1–Communicationbetweenthemusculocutaneousandmediannerves.(a)MCN–MNcommunicationoriginatedfrom theproximalsegmentofmusculocutaneousnerve(SubtypeIb).Lateralviewofrightarm.DM–deltoidmuscle,CbM– coracobrachialismuscle,BM–bicepsmuscle,MN–mediannerve,UN–ulnarnerve,(*)communicatingbranch,(**)BM additionalhead;(b)MCN–MNcommunication,originatedafterthebranchtothebicepsmuscle(subtypeIc).Lateralviewof leftarm,DM–deltoidmuscle,CbM–coracobrachialismuscle,BM–bicepsmuscle,BrM–brachialismuscle,MCN–

Table1–Incidenceofmusculocutaneous–mediannervescommunicationindiversepopulationaccordingtoseveral authors.

Author,year Population Incidencen[%]

Samplesize MCN-MN MN-MCN Total

Kosugietal.,1992 Japanese 75 54.7 – 54.7

Yangetal.,1995 Singaporean 24 12.5 – 12.5

Eglsederetal.,1997 American 108 36 – 36

Chiarapattanakonetal.,1998 Thai 112 11.6 4.4 16

Venieratosetal.,1998 Greak 158 13.9 – 13.9

Choietal.,2002 British 276 26.4 – 26.4

Beheiry.2004 Egyptian 60 5 – 5

Loukasetal.,2005 American 258 46.1 – 46.1

Pachaetal.,2005 Spanish 46 28.3 – 28.3

Chitra,2007 Indian 50 26 – 26

Krishnamurthyetal.,2007 Indian 44 9.1 6.8 15.9

Bhattaraietal.,2009 Nepalesi 32 6.3 – 6.3

Guerri-Guttenbergetal.,2009 Argentinean 26 53.6 – 53.6

Maedaetal.,2009 Japanesi 453 18.8 12.8 41.5

Uysaletal.,2009 Turkish 140 10 – 10

Budhirajaetal.,2011 Indian 116 20.7 – 20.7

Kervanciogluetal.,2011 Turkish 20 25 – 25

Presentstudy Colombian 106 17 2.8 19.8

II).TypeIIawasfoundin2cases(1.9%)andTypeIIbinonecase (Fig.2).

Thedistancebetweentheacromionandtheproximalpoint ofthecommunicatingbranchwas138±39.4mm.The emer-gencepointofthecommunicatingbranchwasmoredistalat therightsidethanattheleftside(rightside145.7mm;leftside 1329mm).Thedistancefromthedistalpointofthe communi-catingbranchtotheacromionwas188±48.3mm.Thelength ofthearmmeasuredfromthelateraledgeoftheacromion

BrM BM

MCN

MN

Fig.2–Communicationbetweenthemedianand

musculocutaneousnerves.Lateralviewofrightarm.DM– deltoidmuscle,CbM–coracobrachialismuscle,BM–biceps muscle,MCN–musculocutaneousnerve,MN–median nerve,(*)communicatingbranch,(**)BMadditionalhead.

tothebi-epicondylarlineoftheelbowwas298±18.6mm. Fif-teen(71.4%)communicatingbrancheswereseentobelocated atthemidthirdand6(28.6%)brancheswereprojectedfrom theinferioraspectofthemidthirdtothemidpointofthelower thirdofthearm.Thelengthofthecommunicatingbranches was57.8±33.4mm,itwaslongerattherightside(61.9mm) than atthe leftside (53.4mm),but thisdifference wasnot statisticallysignificant(p=0.51).

Discussion

About the frequency of the MCN-MN communication our results(19.8%)areagreewiththemid-range(17–36%)reported bysomeauthors.7,16–18,20,21_{Thehighestincidenceshavebeen}

reported within a range of 37–54.7%.1,3,8,10 _{The low}

inci-dence ofthis communicationisnotorious(range5–16%)in severalstudiesconductedindiversepopulations5,7,9,15,19,22–24

(Table1).Thewidevariabilityspectrumreportedbydiverse authorsisprobablygivenbymultiplefactorssuchasthesize ofthesamples,themethodologyusedandtheancestral bio-logicfeaturesthatdeterminethevariableexpressionofthese structuresintheevaluatedpopulations.

Similarly, ourfindings are consistentwith theliterature concerningtothepredominanceoftheunilateraloccurrence over the bilateral occurrence,1,7,10,12,17,22 _{and the}

predomi-nanceoftheleftsidewithoutstatisticaldifference.5,7_Allprior

studies establish thesignificant predominance ofthe pres-ence ofasinglecommunicatingbranchwithintherangeof 90–93.2%andthepresenceoftwocommunicatingbranches withalowfrequency(6.8–10.7%).8,10,17,18,22,25

OurseriesdescribesthepresenceofTypeIMCN-MN com-munication.Thiscommunicationisreportedbymostauthors as the most common with an incidence of 45–72%.3,7,8,22

Similarly, the communicating branch that arose from the mid-segment of the MCN (subtype Ib) indicated by some authors3,6,15_{asthemostcommononeisinagreementwith}

stud-iesthatarepresentbeforetheMCNpiercestheCbM7,7,10,22

were not found in our study. It is probably due to differ-encesofresearcher’sinterpretationabouthowthelateraland medialfasciclesformtheMN.Mostauthorsonlyreferthatthe communicatingbranchgoesfromMCNtoMN5,9,10,15,16,18,22–25

howeverTypeIIcommunicationfromMNtoMCNwasfoundin ourstudyin2.8%accordingtoreportedinotherstudieswith anincidenceof4.4–12.8%,3,6,23_{wherebythecommunication}

betweenMCNandMNmayoccurbothways.

Thedistancesfrom the emergence and endingpoint of the communicating branch to the acromion in our series (138–188mm)areconsistentwiththefindingsofmostprior studiesaswellasthehighprevalenceofthecommunicating branch(50–100%)arisingafterMCNperforatesCbMthathas reportedatthemid-thirdand attheuppersegmentofthe lowerthirdofthearm.4–6

Mostresearcheshavemadequalitativedescriptionabout MCN-MN communication, and onlyfew priorstudies have reportedthelengthofthe communicatingbranch.10,17,20_In

ourseriesthelengthofthecommunicationbranch(57.8mm) isrelativelyhigherthan reportedbyChitraet al.17 _(45mm)

andLoukasetal.10_{(46mm)whereasElgsederandGoldman}20

reportaconsiderablyshorterlengthforthiscommunicating branch(18mm).

TheMCN-MNcommunicatingbranchwasassociatedtoan additionalheadofthe bicepsbrachii in23.8%casesinour study(Fig.2),ithasalsobeenhighlightedbyotherauthors.1,3,13

Duringtheplanning ofsurgicalproceduresinthearmit is importanttorememberthatapproximately1in4upperlimbs assessedmaypresentaMCN-MNcommunicationassociated withanadditionalheadofthebicepsbrachii.

TheMCNentrapmentisrare.Itcanoccurduetoan inade-quatepositioningofthearmduringsleep26,27_{becausetheCbM}

andBMactasanchorpointforMCN.Ifthissituation coex-istswithacommunicatingbranchwhereapartofMNpasses throughCbM,theclinicalsignscouldbesimilartothosefound inMNneuropathyinthehand.12,14_{ThediagnosisofMCN-MN}

communicationinthisclinical presentationby electromyo-graphicmethodscouldpreventunnecessaryreleases ofthe carpaltunnel.

TheMCN-MN communication should beconsidered for clinicalexaminationofnerveinjuries atthe axillaand the arm,aswellasinthesurgicalprocedurestothisregionlikethe neuromuscularflaps,peripheralnerverepairorevenforthe nerveblocksattheupperextremitiesinanestheticpractice. TheMCNor MNinjuriesproximalor distaltothe commu-nicatingbranchescoulddeterminebeneficial ordeleterious modifications inthe functionand movement of the upper extremity.10,15,24 _{TheMCN injuryproximal tothe MCN-MN}

communicationcanleadtoanunexpectedweaknessofthe forearmflexormusclesandthenarmuscleswithclinicalsigns like seen in a MNinjury at the level of the arm. Further-more,theMNinjuryproximaltotheMN-MCNcommunication can lead to a clinical presentation characterized by func-tionalpreservationofforearmandhandmusclesinnervated byMN.12

In the peripheral nerve surgery, especially in nerve transferstechniques,agoodknowledgeoftheMCN-MN com-munications is required. The MCN has been successfully

usedasareceivernervetotherecoveryofelbowflexion.28,29

Furthermore, the MCN motor branch to BrM has been used as donor to anterior interosseous nerve and poste-rior interosseousnervefor thetreatment oflower brachial plexusinjuries30,31_{aswellasinthetreatmentoftretraplegic}

patients.32_{Ourstudyisinagreementwithpreviousstudies}

aboutTypeIIcincidenceobservedinarangeof16.7–33.3%.3_If

theBrMmotorbranchisusedasdonorinnervetransfersand TypeIIccommunicationispresent,couldoccurcompromise oftheforearmpronation,wristandmiddlephalanxflexion and/orsensitivityoflateralfingersofthehand.

Conclusions

KnowledgeoftheexistenceoftheMCN-MNcommunication inthearmisclinicallyimportant;itallowsanadequate evalu-ationandmanagementofupperlimbmotordisorderscaused byperipheralnerveinjuriesaswellasacorrectsurgical plan-ningandapproachesofaxillaandarm.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

WewouldliketorecognizetheNationalInstituteofForensic Medicine,NortheasternColombianregion,forsupplyingthe anatomicalpiecesusedinthisstudy.

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