Advanced search

Online first
Review article
Published online: 2024-04-03

open access

View PDF Download PDF file
Page views 260
Article views/downloads 261
Get Citation

Connect on Social Media

Connect on Social Media

Possible anastomoses between the long branches of the brachial plexus and their clinical significance

Karolina Sujka1, Nicol Zielinska1, Richard Shane Tubbs234, Łukasz Olewnik1
DOI: 10.5603/fm.93685
Pubmed: 38567934

Abstract

The brachial plexus consists of nerves that supply the upper limb and some nerves of the back, torso, and neck. It is formed by the ventral rami of C5 to T1 (in some cases, C4 or T2 also contribute). The anterior rami of the spinal nerves unite to the roots, trunks, divisions, cords, and terminal branches that innervate muscles and skin. An example is associated with terminal branches of the long nerves. Knowledge of this variation is necessary for enabling surgeons, orthopedists, and neurologists to avoid injury during surgical exploration in the arm or axilla region, and for achieving correct diagnoses, because such variability can evoke nonspecific responses. Awareness of this anastomosis is also mandatory for anesthetists performing anesthesia in the upper limb region. The aim of this article is to describe anastomoses between long nerves from the brachial plexus and to consider their clinical significance.

Keywords: Brachial plexusmedial brachial cutaneous nervemedial antebrachial cutaneous nervemedian nervemusculocutaneous nerveradial nerveulnar nerve

Article available in PDF format

View PDF Download PDF file

References

  1. Moore KL, Agur MR, Dalley AF. Clinically oriented anatomy (7th ed). Lippincott Williams & Wilkins, Philadelphia 2013: 753–822.
  2. Standring S. Gray’s anatomy: the anatomical basis of clinical practice. Churchill Livingstone/Elsevier, Edinburgh 2008: 1417–1425.
  3. Hayashi M, Shionoya K, Hayashi S, et al. A novel classification of musculocutaneous nerve variations: The relationship between the communicating branch and transposed innervation of the brachial flexors to the median nerve. Ann Anat. 2017; 209: 45–50.
    CrossRefPubMed
  4. Jeon CH, Kee KH, Kim JiY, et al. Bilateral variations of musculocutaneous nerves with rare pattern in a Korean female cadaver. Anat Sci Int. 2013; 88(3): 167–170.
    CrossRefPubMed
  5. El Falougy H, Selmeciova P, Kubikova E, et al. The variable communicating branches between musculocutaneous and median nerves: a morphological study with clinical implications. Bratisl Lek Listy. 2013; 114(5): 290–294.
    CrossRefPubMed
  6. Radunovic M, Vukasanovic-Bozaric A, Radojevic N, et al. A new anatomical variation of the musculocutaneous and the median nerve anastomosis. Folia Morphol. 2013; 72(2): 176–179.
    CrossRefPubMed
  7. Bhanu PS, Sankar KD. Bilateral absence of musculocutaneous nerve with unusual branching pattern of lateral cord and median nerve of brachial plexus. Anat Cell Biol. 2012; 45(3): 207–210.
    CrossRefPubMed
  8. Venieratos D, Anagnostopoulou S. Classification of communications between the musculocutaneous and median nerves. Clin Anat. 1998; 11(5): 327–331, doi: 10.1002/(SICI)1098-2353(1998)11:5<327::AID-CA6>3.0.CO;2-M.
    PubMed
  9. Kirazlı Ö, Tatarlı N, Ceylan D, et al. A variation of the cords of the brachial plexus on the right and a communication between the musculocutaneous and median nerves on the left upper limb: a unique case. J Neurol Surg A Cent Eur Neurosurg. 2013; 74 Suppl 1: e176–e179.
    CrossRefPubMed
  10. Emamhadi M, Chabok SY, Samini F, et al. Anatomical variations of brachial plexus in adult cadavers; a descriptive study. Arch Bone Jt Surg. 2016; 4(3): 253–258.
    PubMed
  11. Orebaugh SL, Williams BA. Brachial plexus anatomy: normal and variant. ScientificWorldJournal. 2009; 9: 300–312.
    CrossRefPubMed
  12. Desai N, Merjavy P, Russon K. Anatomical Variation of the Brachial Plexus and Its Clinical Implications. https://resources.wfsahq.org/atotw/anatomical-variation-of-the-brachial-plexus-and-its-clinical-implications/.
  13. Yogesh As, Marathe Rr, Pandit Sv. Musculocutaneous nerve substituting for the distal part of radial nerve: A case report and its embryological basis. J Neurosci Rural Pract. 2011; 2(1): 74–76.
    CrossRefPubMed
  14. Bhattarai C, Poudel PP. Unusual variation in musculocutaneous nerves in Nepalese. Kathmandu Univ Med J (KUMJ). 2009; 7(28): 408–410.
    CrossRefPubMed
  15. Smith JL, Siddiqui SA, Ebraheim NA. Comprehensive summary of anastomoses between the median and ulnar nerves in the forearm and hand. J Hand Microsurg. 2019; 11(1): 1–5.
    CrossRefPubMed
  16. Das G. Communication between the branches of brachial plexus on arm: a cadaveric study. J Med Sci Clin Res. 2016; 4(9): 12309–12314.
    CrossRef
  17. Gupta M, Goyal N. Harjeet Anomalous communications in the branches of brachial plexus. J Anat Soc India. 2005; 54(1): 22–25.
  18. Kirik A, Mut SE, Daneyemez MK, et al. Anatomical variations of brachial plexus in fetal cadavers. Turk Neurosurg. 2017 [Epub ahead of print].
    CrossRefPubMed
  19. Unver Dogan N, Uysal II, Karabulut AK, et al. Brachial plexus variations in human fetuses. Neurosurgery. 2003; 53(3): 676–84; discussion 684.
    CrossRefPubMed
  20. Pattanshetti S, Jevoor PS, Shirol VS, et al. A study of the formation and branching pattern of brachial plexus and its variations in adult human cadavers of north Karnataka. J Sci Soc. 2012; 39(2): 70–77.
    CrossRef
  21. Mrvaljević M, Pajić S, Popović P, et al. Analysis of the anatomic variations of the brachial plexus and its branches at the level of formation and branching of its trunci. Facta Universitatis, Series: Medicine and Biology. 2018: 1–8.
    CrossRef
  22. Shrivastava T, Yadav Y, Garg L, et al. Median: musculocutaneous nerve communication. Int Med J. 2012; 19(3): 1–269.
    CrossRef
  23. Bergman RA, Thompson SA, Afifi AK, Saadeh FA. Compendium of human anatomic variation. Urban & Schwarzenberg, Baltimore 1988.
  24. Uzun A, Seelig LL. A variation in the formation of the median nerve: communicating branch between the musculocutaneous and median nerves in man. Folia Morphol. 2001; 60(2): 99–101.
    PubMed
  25. Ballesteros LE, Forero PL, Buitrago ER. Communication between the musculocutaneous and median nerves in the arm: an anatomical study and clinical implications. Rev Bras Ortop. 2015; 50(5): 567–572.
    CrossRefPubMed
  26. Maeda S, Kawai K, Koizumi M, et al. Morphological study of the communication between the musculocutaneous and median nerves. Anat Sci Int. 2009; 84(1-2): 34–40.
    CrossRefPubMed
  27. Caetano EB, Vieira LÂ, Cavalheiro CS, et al. Anatomic study of the nervous communication between the median and musculoucutaneous nerve. Acta Ortop Bras. 2016; 24(4): 200–203.
    CrossRefPubMed
  28. Iwamoto S, Kimura K, Takahashi Y, et al. Some aspects of the communicating branch between the musculocutaneous and median nerves in man. Okajimas Folia Anat Jpn. 1990; 67(1): 47–52.
    CrossRefPubMed
  29. Uyaroğlu FG. Anastomotic branch from the median nerve to the musculocutaneous nerve: a case report. Anatomy. 2008; 2: 63–66.
    CrossRef
  30. Chauhan R, Roy TS. Communication between the median and musculocutaneous nerve. A case report . J Anat Soc India. 2002; 51(1): 72–75.
  31. Felippe MM, Telles FL, Soares ACL, et al. Anastomosis between median nerve and ulnar nerve in the forearm. J Morphol Sci. 2012; 29(1): 23–26.
  32. Amoiridis G, Vlachonikolis IG. Verification of the median-to-ulnar and ulnar-to-median nerve motor fiber anastomosis in the forearm: an electrophysiological study. Clin Neurophysiol. 2003; 114(1): 94–98.
    CrossRefPubMed
  33. Ferrari GP, Gilbert A. The superficial anastomosis on the palm of the hand between the ulnar and median nerves. J Hand Surg Br. 1991; 16(5): 511–514.
    CrossRefPubMed
  34. Hopf HC. Forearm ulnar-to-median nerve anastomosis of sensory axons. Muscle Nerve. 1990; 13(7): 654–656.
    CrossRefPubMed
  35. Sirasanagandla SR, Patil J, Potu BK, et al. A rare anatomical variation of the Berrettini anastomosis and third common palmar digital branch of the median nerve. Anat Sci Int. 2013; 88(3): 163–166.
    CrossRefPubMed
  36. Rodriguez-Niedenführ M, Vazquez T, Parkin I, et al. Martin-Gruber anastomosis revisited. Clin Anat. 2002; 15(2): 129–134.
    CrossRefPubMed
  37. Bölükbaşi O, Turgut M, Akyol A. Ulnar to median nerve anastomosis in the palm (Riches-Cannieu anastomosis). Neurosurg Rev. 1999; 22(2-3): 138–139.
    CrossRefPubMed
  38. Race CM, Saldana MJ. Anatomic course of the medial cutaneous nerves of the arm. J Hand Surg Am. 1991; 16(1): 48–52.
    CrossRefPubMed
  39. Carlan D, Pratt J, Patterson JM, et al. The radial nerve in the brachium: an anatomic study in human cadavers. J Hand Surg Am. 2007; 32(8): 1177–1182.
    CrossRefPubMed
  40. Polatsch DB, Melone CP, Beldner S, et al. Ulnar nerve anatomy. Hand Clin. 2007; 23(3): 283–9, v.
    CrossRefPubMed
  41. Georgiev GP, Landzhov B, Olewnik Ł, et al. Unusual sensory innervation of the dorsal hand and why we should bear this variation in mind. Folia Morphol. 2023; 82(1): 194–197.
    CrossRefPubMed
  42. Huanmanop T, Agthong S, Luengchawapong K, et al. Anatomic characteristics and surgical implications of the superficial radial nerve. J Med Assoc Thai. 2007; 90(7): 1423–1429.
    PubMed
  43. Ikiz ZA, Uçerler H. Anatomic characteristics and clinical importance of the superficial branch of the radial nerve. Surg Radiol Anat. 2004; 26(6): 453–458.
    CrossRefPubMed
  44. Fukumoto K, Kojima T, Kinoshita Y, et al. An anatomic study of the innervation of the wrist joint and Wilhelm's technique for denervation. J Hand Surg Am. 1993; 18(3): 484–489.
    CrossRefPubMed
  45. Park BK, Bun HR, Hwang M, et al. Medial and lateral branches of the superficial radial nerve: cadaver and nerve conduction studies. Clin Neurophysiol. 2010; 121(2): 228–232.
    CrossRefPubMed
  46. Omokawa S, Ryu J, Tang JB, et al. Vascular and neural anatomy of the thenar area of the hand: its surgical applications. Plast Reconstr Surg. 1997; 99(1): 116–121.
    CrossRefPubMed
  47. Huanmanop T, Agthong S, Luengchawapong K, et al. Anatomic characteristics and surgical implications of the superficial radial nerve. J Med Assoc Thai. 2007; 90(7): 1423–1429.
    PubMed
  48. Tryfonidis M, Jass GK, Charalambous CP, et al. Superficial branch of the radial nerve piercing the brachioradialis tendon to become subcutaneous: an anatomical variation with clinical relevance. Hand Surg. 2004; 9(2): 191–195.
    CrossRefPubMed
  49. Thomas K, Sajjad H, Bordoni B. Anatomy, shoulder and upper limb, medial brachial cutaneous nerve. StatPearls [Internet], Treasure Island 2022.
  50. Chodewaratham P, Chentanez V, Agthong S, et al. Anatomy of posterior antebrachial cutaneous nerve related to the lateral epicondyle and interepicondylar line. Int J Morphol. 2016; 34(3): 953–957.
    CrossRef
  51. Li H, Zhu W, Wu S, et al. Anatomical analysis of antebrachial cutaneous nerve distribution pattern and its clinical implications for sensory reconstruction. PLoS One. 2019; 14(9): e0222335.
    CrossRefPubMed
  52. Grujičić R. Antebrachial cutaneous nerves. https://www.kenhub.com/en/library/anatomy/antebrachial-cutaneous-nerves.
  53. Stylianos K, Konstantinos G, Pavlos P, et al. Brachial branches of the medial antebrachial cutaneous nerve: A case report with its clinical significance and a short review of the literature. J Neurosci Rural Pract. 2016; 7(3): 443–446.
    CrossRefPubMed
  54. Marathe Rr, Mankar S, Joshi M, et al. Communication between radial nerve and medial cutaneous nerve of forearm. J Neurosci Rural Pract. 2010; 1(1): 49–50.
    CrossRefPubMed
  55. Ariyasinghe C, Hacking C, Luijkx T. Medial cutaneous nerve of the forearm. Radiopaedia.org. 2015.
    CrossRef
  56. Bonczar T, Walocha JA, Bonczar M, et al. Assessing the innervation of the dorsal wrist capsule using modified Sihler's staining. Folia Morphol. 2021; 80(1): 81–86.
    CrossRefPubMed
  57. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989; 14(2 Pt 1): 267–271.
    CrossRefPubMed
  58. Mahan MA, Spinner RJ. Clinical Importance of Anatomic Variation of the Nerves of the Upper Extremity. Nerves and Nerve Injuries. 2015: 589–605.
    CrossRef
  59. Ballard T, Black AC, Smith T. Anatomy, medial antebrachial cutaneous nerve. StatPearls [Internet], Treasure Island 2023.
  60. Guru A, Kumar N, Ravindra Shanthakumar S, et al. Anatomical study of the ulnar nerve variations at high humeral level and their possible clinical and diagnostic implications. Anat Res Int. 2015; 2015: 378063.
    CrossRefPubMed
  61. Ajayi NO, Lazarus L, Satyapal KS. Multiple variations of the branches of the brachial plexus with bilateral connections between ulnar and radial nerves. Int J Morphol. 2012; 30(2): 656–660.
    CrossRef
  62. Loukas M, Louis RG, Wartmann CT, et al. The clinical anatomy of the communications between the radial and ulnar nerves on the dorsal surface of the hand. Surg Radiol Anat. 2008; 30(2): 85–90.
    CrossRefPubMed
  63. Tellioglu AT, Sensöz O. The dorsal branch of the digital nerve: an anatomic study and clinical applications. Ann Plast Surg. 1998; 40(2): 145–148.
    PubMed
  64. Roy J, Henry BM, PĘkala PA, et al. Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Muscle Nerve. 2016; 54(1): 36–47.
    CrossRefPubMed
  65. Cavalheiro CS, Filho MR, Pedro G, et al. Clinical repercussions of martin-gruber anastomosis: anatomical study. Rev Bras Ortop. 2016; 51(2): 214–223.
    CrossRefPubMed
  66. Srinivasan R, Rhodes J. The median-ulnar anastomosis (Martin-Gruber) in normal and congenitally abnormal fetuses. Arch Neurol. 1981; 38(7): 418–419.
    CrossRefPubMed
  67. Rodriguez-Niedenführ M, Vazquez T, Parkin I, et al. Martin-Gruber anastomosis revisited. Clin Anat. 2002; 15(2): 129–134.
    CrossRefPubMed
  68. Lee KS, Oh CS, Chung IH, et al. An anatomic study of the Martin-Gruber anastomosis: electrodiagnostic implications. Muscle Nerve. 2005; 31(1): 95–97.
    CrossRefPubMed
  69. Chang YT, Chen CL, Lai CH. Marinacci anastomosis (reverse Martin-Gruber anastomosis): a case report. Medicine (Baltimore). 2021; 100(13): e25073.
    CrossRefPubMed
  70. Hodzic R, Hodzic M, Iljazovic E, et al. The incidence and characteristics of marinacci anastomosis: an anatomical study. Int J Innov Res Med Sci. 2020; 5(3).
    CrossRef
  71. Wakode SL, Ravi N. Marinacci anastomosis: a case report. Cureus. 2021; 13(10): e19034.
    CrossRefPubMed
  72. Caetano E, Vieira L, Neto JS, et al. Anastomose de Riché-Cannieu: estrutura, função e significância clínica. Rev Bras Ortop. 2019; 54(05): 564–571.
    CrossRef
  73. Kimura I, Ayyar DR, Lippmann SM. Electrophysiological verification of the ulnar to median nerve communications in the hand and forearm. Tohoku J Exp Med. 1983; 141(3): 269–274.
    CrossRefPubMed
  74. Boland RA, Krishnan AV, Kiernan MC. Riche-Cannieu anastomosis as an inherited trait. Clin Neurophysiol. 2007; 118(4): 770–775.
    CrossRefPubMed
  75. Ahadi T, Raissi GR, Yavari M, et al. Prevalence of ulnar-to-median nerve motor fiber anastomosis (Riché-Cannieu communicating branch) in hand: an electrophysiological study. Med J Islam Repub Iran. 2016; 30: 324.
    PubMed
  76. Szewczyk B, Polguj M, Paulsen F, et al. A proposal for a new classification of coracobrachialis muscle morphology. Surg Radiol Anat. 2021; 43(5): 679–688.
    CrossRefPubMed
  77. Sharma V, Ramesh Babu CS, Gupta V, et al. Variation of roots in the formation of median nerve. Int J Anat Res. 2018; 6(4.2): 5853–5860.
    CrossRef
  78. Master N, Gupta D. Analysis of the Morphological Variations between Musculocutaneous Nerve and Median Nerve-A cadaveric study. Indian J Clin Anat Physiol. 2016; 3(3): 326.
    CrossRef
  79. Sthapak E, Gajbe U, Singh BR. Study of communication between musculocutaneous and median nerves in man. J Anat Soc India. 2018: 27–44.
  80. Gelmi C, Pedrini F, Fermi M, et al. Communication between median and musculocutaneous nerve at the level of cubital fossa - A case report. Transl Res Anat. 2018; 11: 1–4.
    CrossRef
  81. Choi D, Rodríguez-Niedenführ M, Vázquez T, et al. Patterns of connections between the musculocutaneous and median nerves in the axilla and arm. Clin Anat. 2002; 15(1): 11–17.
    CrossRefPubMed
  82. Loukas M, Aqueelah H. Musculocutaneous and median nerve connections within, proximal and distal to the coracobrachialis muscle. Folia Morphol. 2005; 64(2): 101–108.
  83. Liu J, Zhong K, Lin D. Median nerve compression caused by superficial brachial artery: an unusual clinical case. J Int Med Res. 2020; 48(12): 300060520969043.
    CrossRefPubMed
  84. Pascual-Font A, Vazquez T, Marco F, et al. Ulnar nerve innervation of the triceps muscle: real or apparent? An anatomic study. Clin Orthop Relat Res. 2013; 471(6): 1887–1893.
    CrossRefPubMed
  85. Diz-Díaz J, Gómez-Muñoz E, Sañudo J, et al. Which is the function of a martin-gruber connection? Clin Anat. 2019; 32(4): 501–508.
    CrossRefPubMed
  86. Jones O. The Musculocutaneous Nerve. https://teachmeanatomy.info/upper-limb/nerves/musculocutaneous-nerve/.
  87. Ozello D. Two Minutes of Anatomy. https://www.youtube.com/watch?v=ZaKf-bf79sY.
  88. Jones O. The Ulnar Nerve. https://teachmeanatomy.info/upper-limb/nerves/ulnar-nerve/.
  89. Atherton DD, Fabre J, Anand P, et al. Relocation of painful neuromas in Zone III of the hand and forearm. J Hand Surg Eur Vol. 2008; 33(2): 155–162.
    CrossRefPubMed
  90. Health Jade Team. Radial Nerve. https://healthjade.com/radial-nerve/.

About cookies

Necessary cookies

Allways active

These cookies are necessary for the proper display and operation of the website. Blocking them may cause the website to malfunction.

Analytical cookies

As part of our website, we use analytical tools, such as Google Analytics, that allow us to verify website traffic. These tools may require the use of cookies.

Community cookies

These are cookies associated with the social networks we use. Accepting them will allow us to associate your visit to the site with our social media profiles.

Marketing cookies

These are cookies responsible for carrying out advertising and marketing activities - consenting to their use will allow us to target you with advertisements based on your previous activities within our website.

Copyright © 2023-2024 Via Medica Regulations Cookie policy Privacy Statement Legal Note