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Use of the anterior branch of the medial antebrachial cutaneous nerve as

a graft for the repair of defects of the digital nerve
JA Nunley, MR Ugino, RD Goldner, N Regan and JR Urbaniak
J Bone Joint Surg Am. 1989;71:563-567.

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Use of the Anterior Branch of the Medial Antebrachial

Cutaneous Nerve as a Graft for the Repair
of Defects of the Digital Nerve*
BY JAMES A. NUNLEY, M.D.t, MICHAEL R. UGINO, M.D., RICHARD D. GOLDNER, M.D.t,
NANCY REGAN, O.T.R./L.t, AND JAMES R. URBANIAK, M.D.t, DURHAM, NORTH CAROLINA

From the Division of Orthopaedic Surgery. Duke Unis’ersits Medical Center, Durham

ABSTRACT: Using the anterior branch of the medial dons. Greene and Steichen used the dorsal cutaneous branch
antebrachial cutaneous nerve, grafting was performed of the ulnar nerve but, as with the use of the lateral ante-
on twenty-one digital nerves. The goal of the procedure brachial cutaneous nerve, sensibility was lost from already
was to repair a traumatic defect of greater than one compromised hands.
centimeter in the digital nerves of fourteen patients. The Because of the unsatisfactory results with the use of
patients were followed for twenty-four to eighty-nine other nerves, we report our experience with the use of the
months (average, fifty-seven months). All but one nerve anterior division of the medial antebrachial cutaneous nerve
graft restored the ability to distinguish between sharp as a donor graft for the repair of a digital nerve.
and dull stimuli, and all but three restored two-point
discrimination of between five and fifteen millimeters The Medial Antebrachial Cutaneous Nerve
(average, nine millimeters). No painful neuromas de- The medial antebrachial cutaneous nerve is a branch
veloped at the donor site. from the medial cord of the brachial plexus that consists of
sensory fibers from the first thoracic level5. The nerve ac-
Primary repair of a lacerated digital nerve usually yields companies the basilic vein down the arm and pierces the
a good result. Usually there is a return of sensibility, and deep fascia in the middle of the proximal part of the arm.
a neuroma does not form”. Often, however, the area of The nerve then splits into anterior and posterior branches
damage is so wide that end-to-end coaptation of the digital in the distal third of the arm. The anterior branch supplies
nerves is not possible or is possible only with extensive the anteromedial surface of the forearm, while the posterior
proximal and distal mobilization of the nerves and acute terminal branch provides sensation to the postero-ulnar sur-
flexion of the digit. As Terzis et al. Berger
, and Millesi, face.
and Millesi et al.78 demonstrated, neurorrhaphies that are
performed under tension generally yield poor results. It is Methods and Materials
for this reason that we believe that gaps in digital nerves Between December 1977 and August 1982, at the Duke
should be managed with nerve grafts. University Medical Center, fourteen patients had grafting
Many cutaneous nerves have served as donor grafts for of twenty-one traumatic defects of a digital nerve, using the
the repairofdigital nerves. Seddon used the proximal branch medial antebrachial cutaneous nerve as the donor graft.
of the medial antebrachial cutaneous nerve, but he was There were six female and eight male patients, and the ages
disappointed in the results. The sural nerve was used both ranged from sixteen to fifty-one years old. In one patient,
by Bunnell and by Buncke, but the disadvantage of using the nerve-grafting was done immediately after injury, while
that nerve is that additional anesthesia and an incision in in the others it was delayed for two to eleven months after
the lower extremity are needed. Wilgis and Maxwell, injury (Table I). Grafting was done in all of the five digits
McFarlane and Mayer. and Tenny and Lewis used the lateral of the hand when the gap in the digital nerve was greater
antebrachial cutaneous nerve, but some patients lost sen- than one centimeter or if excessive tension or acute digital
sibility in the thumb. Wilgis and Maxwell also used the flexion was needed to oppose the ends of the nerve after
terminal portion of the posterior interosseous nerve, but this excision of the neuroma and glioma.
necessitated an extensive exposure beneath the extensor ten-
Surgical Procedure
* No benefits in any form have been received or will be received from With a pneumatic tourniquet applied well proximal to
a commercial party related directly or indirectly to the subject ofthis article.
No funds were received in support of this study.
the elbow, the severed ends ofthe digital nerves are exposed
t Division of Orthopaedic Surgery. Duke University Medical Center. both proximally and distally and are serially incised under
Durham. North Carolina 277 10. Please address requests for reprints to Dr.
Nunley. P.O. Box 2919.
the operating microscope until healthy fascicles are iden-
: 1910 Blanding Street. Columbia. South Carolina 29201. tified proximally and the sheath looks normal distally. The

VOL. 71-A, NO. 4. APRIL 1989 563

564 J. A. NUNLEY ET AL.

TABLE I
DATA ON PATIENTS

Site of Discrim.
Time Interval Length Repair Two- Result of between
Age at from Injury of (Digital Nerve. Point Semmes-Weinstein Sharp and Length of
Case Operation to Operation Graft Digit) Discrim. Filament Test* Dull Stimuli Follow-up
(Yrs.) (Mos.) (cm) (mm) (Mos.)

1 51 5 4 (Y Radial, 1st 12 3.84-4.31 Good 77

shaped) Ulnar, 1st 8 3.22-3.61 Good
2 26 9 3 Ulnar,4th 8 Good 36
3 21 2 3.5 Ulnar 1st 12 3.22-3.61 Good 24
4 29 0 Unknown Ulnar, 1st None 3.84-4.31 Good 42
Radial. 1st None 3.84-4.31 Good
5 46 9 Unknown Ulnar, 1st None 4.56-6.65 Poor 89
6 35 10 3 Radial, 4th 5 Good 63
7 16 3 2.5 Ulnar, 3rd 7 Good 64
8 17 5 2.0 Ulnar, 2nd 6 Good 56
9 33 8 2.5 Ulnar, 1st 5 3.22-3.61 Good 62
10 30 4 3 Radial, 5th 15 3.22-3.61 Good 86
3 Ulnar, 1st 15 3.22-3.61 Good
11 26 4 2 Radial, 1st 9 Good 53
2 Ulnar, 1st 6 Good
12 32 3 1.5 Radial, 3rd 6 1.65-2.83 Good 44
1.5 Ulnar,4th 5 1.65-2.83 Good
13 28 11 2 Ulnar, 2nd 15 3.22-3.61 Good 48
14 22 4 1.5 Radial, 1st 7 3.22-3.61 Good 50
2.5 Ulnar, 1st 9 3.22-3.61 Good
2.5 Radial, 2nd 11 3.84-4.31 Good

*Log1o force, 0. 1 milligram.

digit is then maximally extended and the neural gap is mea- tension). The anterior branch of the medial antebrachial
sured. cutaneous nerve is found in the subcutaneous tissue. An
The donor graft from the medial antebrachial cutaneous appropriate length of nerve is harvested, the tourniquet is
nerve is obtained by making a longitudinal incision in the released, and hemostasis is obtained. The wound in the
skin two centimeters anterior and two to three centimeters forearm is closed using absorbable suture in the subcuta-
distal to the medial epicondyle (two fingerbreadths cephalad neous tissue and subcuticular nylon suture in the skin.
and distal to the medial epicondyle with the elbow in ex- Using an operating microscope, the graft is sutured to

5.0

4.5

4.0 S

3.5

. S.
3.0

2.5 S #{149} S

-a 2.0 S. #{149}

-t 1.5
. ..

e i.o

0.5

0.0
_1_ 2 3 4 6 7 8 9 U 12 13 14 16 17 18 19
10 15 20

2 point discrimination (In mm)

FIG. 1
The length of the graft correlated with the return of two-point discrimination.

THE JOURNAL OF BONE AND JOINT SURGERY

 USE OF THE ANTERIOR BRANCH OF THE MEDIAL ANTEBRACHIAL CUTANEOUS NERVE 565

both severed ends of the digital nerve with two or three Results

peripheral epineural sutures of 9-0 nylon. The wound in the Twenty-one digital nerves were grafted in the fourteen
digit is closed, and a bulky splint is applied to the hand. patients. The minimum length of follow-up was twenty-four
Postoperatively, motion is allowed on the basis of what is months; the longest, eighty-nine months; the average, fifty-
appropriate after concomitant digital procedures. seven months; and the median, fifty-six months.
Postoperatively, the patients were routinely examined
for the return of sensibility. At the latest assessment, the Sensibility
ability to distinguish between sharp and dull stimuli and All but one patient regained the ability to distinguish
static two-point discrimination were determined and between sharp and dull stimuli to the digit. Three of the
Semmes-Weinstein monofilament testing was done9 0. 3 twenty-one nerve grafts resulted in five millimeters of two-
The ability to distinguish between sharp and dull stimuli point discrimination; nine, six to ten millimeters; six, eleven

15

14

z
-z F-

0
z

: 10

55 55 .
5..

0/0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 if 17 18 19 20
5 10 15 20

2 poInt discrimination (in nun)

FIG. 2
The interval between the time of the injury and the time of the operation correlated with the return of two-point discrimination.

was tested for each nerve with the point and hub of a sterile to sixteen millimeters; and three, no two-point discrimi-
20-gauge needle. A good score meant that eighteen of nation (Fable I).
twenty tests were positive and a poor score meant that less Only fifteen ofthe grafted digital nerves were examined
than eighteen were positive. Weber two-point discrimination with Semmes-Weinstein filaments. Two nerves were normal
was determined according to the method of Moberg. ( I .65 to 2.83), eight provided diminished light touch (3.22
If the patient had a normal, apparently uninjured nerve to 3.61), four provided diminished protective sensation
on the opposite side of the finger, this normal nerve was (3.84 to 4.3 1), and one provided no protective sensation
anesthetized with infiltration of a local anesthetic solution. (4.56 to 6.65) (Table I).
The sensory testing was then repeated for the grafted digital There was no correlation between the length of the
nerve. In addition, the donor site in the forearm was assessed graft (range, 1 .5 to 4.0 centimeters) and the recovery of
to determine whether a painful neuroma had formed, the sensibility (Fig. 1). There also was no definite correlation
degree ofany hypersensitivity, and the size ofthe anesthetic between the length of time from injury to the repair and the
area. return of two-point discrimination (Fig. 2).

VOL. 71-A, NO. 4. APRIL 1989

566 J. A. NUNLEY ET AL.

digital nerve in the digit, eight of eleven grafts provided six

millimeters of two-point discrimination. Greene and

::-. .
Steichen
grafted
reported that, of fifteen
with the dorsal cutaneous
digital
branch
nerves that were
of the ulnar nerve,
one failed to provide any two-point discrimination and the
others provided an average of 9.5 millimeters of two-point
discrimination. However, Greene and Steichen pointed out
that ‘nerve
‘ block of the uninjured digital nerve in the same
finger was not performed as crossover innervation was not
considered to be significant”.
After an average of fifty-seven months, the results in
our series of twenty-one digital nerves that were grafted
with the anterior branch ofthe medial antebrachial cutaneous
nerve were comparable with those of the cited studies. Eigh-
teen grafts resulted in two-point discrimination of five to
fifteen millimeters. The average two-point discrimination
FIG. 3 was nine millimeters, a finding similar to that of Greene
The site of the incision in the forearm for the removal of a three-
centimeter-long graft from the medial antebrachial cutaneous nerve. The
and Steichen, and our results did not change when the con-
cross-hatched area shows the zone of hypoesthesia that will result from tralateral digital nerve was locally anesthetized.
the procedure.
We agree with the functional assessments of Buncke
and of Wilgis and Maxwell, who characterized normal static
Deject at (lie Donor Site two-point discrimination as two to six millimeters, fair as
No patient complained of discomfort or paresthesia at seven to ten millimeters, and poor as more than ten milli-
the donor site. In many patients. the hypoesthesia dimin- meters. In the combined series of Buncke, McFarlane and
ished in some areas in the donor forearm as progressive Mayer, Wilgis and Maxwell, and Greene and Steichen,
cross-over coverage from adjacent sensory nerves occurred, which consisted of forty-one nerve grafts, there were thir-
but no patient had completely normal sensibility in the fore- teen (32 per cent) normal results, twelve (29 per cent) fair
arm. Figure 3 illustrates a typical area of hypoesthesia. results, and sixteen (39 per cent) poor results for two-point
discrimination. Our twenty-one nerve grafts compare fa-
Discussion vorably, with six (29 per cent) normal results, six (29 per
When Seddon used the medial antebrachial cutaneous cent) fair results, and nine (42 per cent) poor results.
nerve for grafting digital nerves, the result was satisfactory There are several advantages to using the anterior
in only eleven of twenty-six digits. He attributed the Un- branch of the medial antebrachial cutaneous nerve as a donor
satisfactory results to poor vascularity ofthe digits. Mc- graft: ( 1) unlike the situation with the use of the sural nerve,
Farlane and Mayer used the lateral antebrachial cutaneous all of the incisions are made in the upper extremity, so
nerve as a graft in thirteen patients and stated that the fu-‘ ‘ regional anesthesia can be used; (2) unlike the situation with
nicular content is somewhat less than that of the sural nerve, the use of the lateral antebrachial cutaneous nerve or the
but in shape and diameter it more nearly approximates a dorsal cutaneous branch of the ulnar nerve, after which
digital nerve’ ‘ . However, their report did not include mea- sensibility may be lost from either the thumb or the small
surements on cadavera or histological measurements. finger, sensibility is not lost anywhere in the hand; and 3)
McFarlane and Mayer followed their patients for seven to unlike the situation with use of the posterior interosseus
twenty-three months. Two patients did not regain two-point nerve, for which the dissection is more complicated and
discrimination, and the remaining eleven had between seven deep to the extensor retinaculum, the medial antebrachial
and twenty millimeters. cutaneous nerve, which is subcutaneous, is easy to isolate.
Buncke used the sural nerve in two patients and re- In conclusion, we found the medial antebrachial cu-
ported that one obtained five millimeters of two-point dis- taneous nerve to be an excellent donor graft for the repair
crimination and the other, twenty millimeters. Wilgis and of digital nerves. After a long-term follow-up, the results
Maxwell used the sural nerve, the lateral antebrachial cu- were comparable with those of other grafts, and there were
taneous nerve. and the terminal portion of the posterior no adverse effects at the donor site. However, before the
interosseous nerve for grafts of lesions distal to the distal operation is done, the patient should understand that there
interphalangeal joint. After anesthetic block of the other will be a scar on the forearm.

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4. GREENE, T. L. , and STEICHEN, J. B. : Digital Nerve Grafting Using the Dorsal Sensory Branch of the Ulnar Nerve. J. Hand Surg. , 10-B: 37-40.
1985.

THE JOURNAL OF BONE AND JOINT SURGERY

 USE OF THE ANTERIOR BRANCH OF THE MEDIAL ANTEBRACHIAL CUTANEOUS NERVE 567
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