Anterior Interosseous Nerve Transfer to the Motor Branch of the Ulnar Nerve for High Ulnar Nerve Injuries

Steven C. Haase, MD Kevin C. Chung, MD

Primary repair of a high ulnar nerve injury results in a uniformly poor outcome as a result of the great distance between the site of injury and the innervated muscles. In this study the authors present two cases of high ulnar nerve injuries in adults. Reconstruction was performed using the distal branch of the anterior interosseous nerve, which was transferred to the distal motor branch of the ulnar nerve. This resulted in timely return of function to the ulnar-innervated intrinsic muscles of the hand, which was documented further by electromyography. For high ulnar nerve injuries, this type of nerve transfer is a much better approach than the traditional primary neurorrhaphy.
Haase SC, Chung KC. Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries. Ann Plast Surg 2002;49:285290 From the Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical Center, Ann Arbor, MI. Received Nov 1, 2001, and in revised form Jan 25, 2002. Accepted for publication Jan 25, 2002. Address correspondence and reprint requests to Dr Chung, Section of Plastic Surgery, The University of Michigan Health System, 1500 E. Medical Center Drive, 2130 Taubman Center, Ann Arbor, MI 48109-0340.

anterior interosseous nerve to the motor branch of the ulnar nerve at the wrist should reduce greatly the delay in reinnervation of the intrinsic muscles and lead to an improved outcome. Our objectives were to demonstrate the usefulness of this innovative technique and to present the outcomes we observed, including electromyographic evaluation of the reconstruction.

Patient Reports
Patient 1 Patient 1 is a 41-year-old right-hand-dominant carpenter who was involved in a motor vehicle accident in which he sustained a complex right upper arm laceration. The ulnar nerve was divided 8 cm above the elbow, as was the medial head of the triceps muscle (Fig 1). The wound was closed initially at the referring hospital, and the patient was sent to our institution for denitive repair of the nerve injury. Within a week of injury, the patient was taken to surgery, at which time the ulnar nerve was transposed anteriorly and repaired. The anterior interosseous nerve was divided at its most distal point, where it entered the pronator quadratus muscle (Fig 2). Guyons canal was opened and the motor branch of the ulnar nerve was identied and traced proximally as far as possible, where it was divided. This motor branch was tunneled under the exor tendons and was coapted to the transected anterior interosseous nerve (Fig 3). Six months after surgery there was evidence of reinnervation of the intrinsic muscles of the hand (Fig 4). Most notable was the return of function of the interosseous (Fig 5), adductor pollicis, and abductor digiti quinti muscles. Nerve conduction studies were performed 11 months postoperatively. They revealed single motor unit recruitment in the intrinsic muscles of the hand
Copyright 2002 by Lippincott Williams & Wilkins, Inc. 285

In adults, repair of high ulnar nerve injuries those near or above the elbow has historically yielded unsatisfactory results, with minimal recovery of intrinsic muscle function and resultant claw hand deformity.1 This is true despite the most meticulous techniques, whether the repair is primary or secondary, and regardless of whether a nerve graft is used.2,3 Although sensation is restored most of the time, recovery of motor function in the intrinsic muscles of the hand is almost uniformly poor, especially in the adult patient. This is principally the result of the considerable distance between the site of injury and the muscle motor end plates to be reinnervated. During the several months required for the regenerating axons to traverse this gap, the denervated muscles undergo irreversible atrophy and brosis. We present 2 patients who illustrate an alternative method for reconstructing high ulnar nerve lesions. Transfer of the terminal branch of the
DOI: 10.1097/01.SAP.0000015429.34256.34

Annals of Plastic Surgery

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Fig 1. The end of the proximally divided ulnar nerve was held by a pickup.

Fig 2. The arrow points to the anterior interosseous nerve at its entrance into the pronator quadratus muscle. Note the accompanying anterior interosseous vessels.

innervated normally by the ulnar nerve, consistent with proximal-to-distal regrowth.

Discussion
Patient 2 Patient 2 is a 52-year-old man who was involved in a motor vehicle accident, during which he sustained partial degloving injury of the right arm. This wound was covered initially with a skin graft at another institution (Fig 6), and the patient was referred to our center for denitive reconstruction. Approximately 6 weeks after the initial injury, the patient was taken to surgery for repair of a 15-cm ulnar nerve gap with two strands of sural nerve graft (Fig 7). Distally, the anterior interosseous nerve was coapted to the motor branch of the ulnar nerve at the wrist, using a 7-cm sural nerve graft (Fig 8). The nerve graft was used because of a substantial amount of tension at the nerve coaptation site with primary repair. Because exion of the small nger was already noticeably weak, transfer of the exor digitorum profundus tendon of the small nger to the exor digitorum profundus tendon of the middle nger was performed. The elbow wound was covered with a gracilis muscle free ap. One year postoperatively, the patients function of his intrinsic muscles had returned almost completely. He was able to abduct and adduct the ngers of his right hand (Fig 9). He has regained protective sensation along the ulnar side of his hand. His elbow range of motion is normal (Fig 10).
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Ulnar nerve injuries at or above the level of the elbow generally have a poor functional outcome with traditional repair. Children with similar injuries have better outcomes, most likely because of the increased plasticity of their nervous systems.4 Regardless of age, muscle atrophy begins at the moment of denervation, and if the elapsed time to reinnervation is long, the atrophic changes in the muscle become irreversible. This explains why functional recovery gets worse as the delay between the time of injury and the time of reconstruction increases. Likewise, the more proximal the nerve lesion, the less likely that adequate recovery can occur once nerve regeneration traverses the increased distance to the end organ targets. Several investigators have sought to slow down or to stop this muscle atrophy by external or internal muscle stimulation during the denervated period.5 These kinds of muscle stimulators are largely experimental at this time. To obtain a more satisfactory outcome, tendon transfers have been considered an integral part of reconstructing high ulnar nerve lesions.6 Without tendon reconstruction, most patients are left with clawed, weak hands. We have undertaken an alternative method of reconstruction in isolated high ulnar nerve injuries. The terminal branch of the anterior interosseous nerve is a predominant

Haase and Chung: Anterior Interosseous Nerve Transfer

Fig 3. (A) The arrow points to the repair between the anterior interosseous nerve and the motor branch of the ulnar nerve. (B) Diagram illustrating the anterior interosseous nerve transfer to the motor branch of the ulnar nerve. N nerve; M muscle.

Fig 4. The right reconstructed hand has recovered intrinsic muscle function.

motor nerve that innervates the pronator quadratus muscle and sends a few sensory branches to the wrist joint. This nerve can be transferred to the distal motor branch of the ulnar nerve, thereby greatly reducing the necessary distance for axonal regeneration to the intrinsic muscles. This type of nerve transfer was brought to our attention by Mackinnon and Novak.7 A report also exists in the Chinese literature that used cadaveric analyses to demonstrate the feasibility of this approach.8 Several features of this transfer are attractive. The donor defect is essentially negligible. The intact pronator teres muscle is

Fig 5. The patient is able to abduct and adduct the ngers.

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Volume 49 / Number 3 / September 2002

Fig 6. Skin graft over the elbow wound.

Fig 7. Proximal ulnar nerve repair using two strands of sural nerve graft.

Fig 8. (A) The arrow points to the motor branch of the ulnar nerve. (B) The anterior interosseous to motor branch of the ulnar nerve was repaired using sural nerve graft (arrow).

sufcient to pronate the forearm. Because the transferred nerve is a pure motor nerve, there should be no competition by sensory bers for motor pathways during reinnervation. Reconstruction of this injury should provide for sensation in the ulnar nerve distribution as well. Fortunately, return of sensation is somewhat less problematic, because the sensory receptors do not depreciate to the extent that muscle atrophy occurs in motor units. Therefore, repair of the ulnar nerve by primary repair or nerve graft at the site of injury is still required to direct the sensory axons to their destination in the hand. Some groups have sought to shorten the recovery time for these nerve pathways as well, proposing a transfer of the median nerve sensory branch to the ulnar sensory nerve at the wrist.9 This approach may leave the patient with an insensate palm. We think that return of sensation down the
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Fig 9. The patient is able to abduct and adduct the ngers.

native pathways of the ulnar nerve, despite the delay, should sufce to provide at least protective sensation in most cases.

Haase and Chung: Anterior Interosseous Nerve Transfer

Fig 10. (A, B) Return of normal elbow exion with a healed gracilis free ap muscle.

Helpful adjuncts to this procedure are also illustrated in these patient reports. Transfer of the exor profundus tendon of the small nger and/or ring nger to that of the middle nger recovers function that is lost with denervation of the ulnar portion of that muscle belly. Reinnervation of the more proximal ulnar-innervated muscles (i.e., exor carpi ulnaris) should occur in a more traditional fashion after primary or secondary nerve repair at the elbow because the connections to these more proximal muscles may still be intact. Reports of similar nerve transfer techniques now exist in the literature. Transfer of a single motor fascicle from the ulnar nerve to the biceps muscle has restored elbow exion in patients with upper brachial plexus injuries.10 In an animal model, transfer of part of the ulnar nerve to a transected median nerve has restored considerable function without substantial donor decit.11 Certainly, the possibilities for future application of this concept are not yet fully explored. A valid criticism of this report is the inability to rule out any MartinGruber connections in these patients. However, anatomic studies have failed

to nd these connections in the distal forearm; all connections occurred more proximally.12 Although no nerve conduction studies were obtained preoperatively, our patients had no clinical evidence of intrinsic muscle function after the initial ulnar nerve transection. Even if subclinical connections had been present, they would be severed with the distal transection of the ulnar nerve at Guyons canal. Any reinnervation observed must be the result of regeneration through the nerve connection that we created. We succeeded in restoring intrinsic muscle function in 2 patients who would have had negligible recovery by traditional means. For high ulnar nerve injuries, the anterior interosseous nerve transfer to the deep motor branch of the ulnar nerve should be the preferred method for intrinsic muscle reinnervation.

References
1 Gaul JS. Intrinsic motor recoverya long-term study of ulnar nerve repair. J Hand Surg [Am] 1982;7A:502508 2 Barrios C, Amillo S, de Pablos J, et al. Secondary repair of ulnar nerve injury. Acta Orthop Scand 1989;61:46 49 289

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Volume 49 / Number 3 / September 2002 of median nerve and deep branch of ulnar nerve.] [In Chinese.] Chung-Kuo Hsiu Fu Chung Chien Wai Ko Tsa Chih 1997;11:335337 Battiston B, Lanzetta M. Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer. J Hand Surg [Am] 1999;24A:11851191 Sungpet A, Suphachatwong C, Kawinwonggowit V, et al. Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus. J Hand Surg [Br] 2000;25B:325328 Lutz BS, Chuang DCC, Chuang SS, et al. Nerve transfers to the median nerve using parts of the ulnar and radial nerves in the rabbit effects on motor recovery of the median nerve and donor nerve morbidity. J Hand Surg [Br] 2000;25B:329 335 Shu HS, Chantelot C, Oberlin C, et al. MartinGruber communicating branch: anatomical and histological study. Surg Radiol Anat 1999;21:115118

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Vastamki M, Kallio PK, Solonen KA. The results of secondary microsurgical repair of ulnar nerve injury. J Hand Surg [Br] 1993;18B:323326 Allan CH. Functional results of primary nerve repair. Hand Clin 2000;16:6772 Williams HB. A clinical pilot study to assess functional return following continuous muscle stimulation after nerve injury and repair in the upper extremity using a completely implantable electrical system. Microsurgery 1996;17:597 605 Trevett MC, Tuson C, de Jager LT, et al. The functional results of ulnar nerve repair: dening the indications for tendon transfer. J Hand Surg [Br] 1995;20B:444 446 Mackinnon SE, Novak CB. Nerve transfers: new options for reconstruction following nerve injury. Hand Clin 1999; 15:643 666 Wang Y, Zhu S, Zhang B. [Anatomical study and clinical application of transfer of pronator quadratus branch of anterior interosseous nerve in the repair of thenar branch

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