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SHORT REPORT

Key words: Riche-Cannieu anastomosis MUSCLE & NERVE

18:12&122 1995

RICHE-CANNIEU ANASTOMOSIS WITH PARTIAL TRANSECTION OF THE

SALVATORE RUSSOMANO, MD, GERALD J. HERBISON, MD, ARVIND BALIGA, MD, STANLEY R. JACOBS, MD, and JOHN MOORE, MD

T h e Riche5-Cannieu' anastomosis occurs in the palm between the recurrent branch of the median nerve and the deep branch of the ulnar nerve (Fig. l).' Despite equal clinical relevance, the RicheCannieu anastomosis has been comparatively overlooked. The purpose of this short report is to present a detailed electrophysiologic study of a Riche-Cannieu anastomosis associated with a severe partial laceration of the median nerve at the elbow.
CASE REPORT History.

opponens pollicis (OP) was 4/5. There was decreased light touch and pinprick in digits 1, 2, 3, and half of 4. Deep tendon reflexes of the biceps, wrist extensors, and triceps were normal. Electromyography of the left pronator teres, pronator quadratus, and medianinnervated FDP I1 and I11 revealed continuous fibrillations in all sites tested. There was no voluntary motor unit activity noted in these muscles. The left APB revealed many fibrillations in most sites tested. The motor unit potentials were of normal configuration with decreased recruitment.
Electromyography. Conduction studies. The left median nerve motor conduction (MNC) with surface electrodes revealed a prolonged latency of 4.9 ms (normal 4.3 ms) and a decreased distal amplitude of 193 FV (all amplitudes measured baseline to negative peak). Proximal conductions ruled out4 forearm crossover of the median to ulnar nerve or the ulnar to median. Palmar stimulation with the pickup surface electrode over the thenar muscles revealed an amplitude of 6 mV in the absence of any palpable contraction of the first dorsal interosseous (FDI). Musculocutaneous nerve stimulation at the anterior axillary fold resulted in vigorous contraction of the biceps with no evoked response over the APB. This ruled out anamolous innervation of the thenar muscles by the musculocutaneous nerve.4 The results of the clinical examination in combination with the initial EMG/NCS findings suggested partial preservation of the typically median innervated thenar musculature below the wrist. A more detailed electrophysiologic investigation was then conducted to explore the possibility of anomalous hand innervation, specifically the RicheCannieu anastomosis. Voluntary thumb abduction followed by ulnar nerve stimulation at the wrist revealed a silent period3 of motor unit activity of the APB and OP. Intramuscular and near-nerve

A 31-year-old male with a history of excessive alcohol use sustained a stab wound to his abdomen and left anticubital area. At the time of surgery, the median nerve was noted to be partially severed (approximately 75% as estimated by the surgeon). Repair of the left median nerve at the anticubital level was performed by approximating the lacerated portions with four sutures. One month postinjury, he underwent electrophysiologic testing. T h e impression of the surgeon was that abduction of the thumb was from partial preservation of the median nerve axons.
Physical Examination. Manual muscle testing demonstrated no muscle contraction ( 0 6 ) of his pronators (teres [PT] and quadratus [PG]), flexor digitorum profundus digits I1 (FPD 11) and I11 (FPD 111), and flexor pollicis longus (FPL). The strength of the abductor pollicis brevis (APB) and

From the Departments of Rehabilitation Medicine (Drs. Russomano, Herbison, Baliga, and Jacobs) and Surgery (Dr. Moore), Jefferson Medical College, Thomas Jefferson University, Philadelphia. Pennsylvania Address reprint requests to Gerald J Herbison, MD, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University, 1 1 Walnut Street, Room 617Curtis, Philadelphia, PA 19107 05 Accepted for publication August 1, 1994.

CCC 0 48-639x/951010120-03 1 0 1 9 John Wiley & Sons, Inc 95

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FIGURE 1. The Rich-Cannieu anastomosis between the deep ulnar nerve and the recurrent branch of the median nerve (by permission of the author" and publisher, Nauwelaets, Brussels).

needle electrodes were chosen to avoid errors of conduction.2 Monopolar needle electrodes were placed in the APB and FDI with the reference taped on the interphalangeal joint of the thumb. Needle stimulation in the palm 4 cm distal to the wrist crease revealed a 30-mV response in the APB and no response in the FDI, thus isolating the exact area of the Riche-Cannieu anastomosis. Stimulation of the ulnar nerve at the wrist revealed a 20-mV response in t h e APB. O n e percent lidocaine was used to block the Riche-Cannieu anastomosis 4 cm distal to the wrist crease on a line between the flexor carpi radialis and palmaris longus tendons. Repeated ulnar nerve stimulation at the wrist revealed a 90% reduction in the amplitude of the APB and OP muscles with almost complete loss of voluntary thumb abduction and opposition. A monopolar needle electrode in the FDI revealed an approximately 30-mV response. This confirmed that the Riche-Cannieu anastomosis was blocked and not the deep branch of the ulnar nerve (Fig. 1).
Discussion. Standard nerve conduction studies of the left median nerve (amplitude 193 pV) suggested significant axonal loss, with partial preservation of median nerve axons, but could not explain the well-preserved strength in thumb abduction and opposition. The normal evoked response (6 mV) recorded over the thenar muscles with palmar stimulation, in the absence of any contraction of the first dorsal interosseous, suggested preservation of some of the innervation to the APB and OP. This finding supported a Riche-Cannieu anastomotic nerve supply of the APB and OP. Even in the absence of any first dorsal interosseous contraction, however, this surface recorded re-

sponse could be secondary to a volume-conducted response from activation of the ulnar nerve (deep branch) to other ulnar innervated hand intrinsic muscles. T o evaluate this possibility we utilized antidromic stimulation with suppression of voluntary contraction as described by Kimura.3 During abductor pollicis brevis muscle contraction, in the absence of any contraction of the first dorsal interosseous muscle, ulnar stimulation at the wrist suppressed the voluntary motor unit potentials initiated by the patient's attempt at thumb abduction. Thus, despite continued effort, the action potential activity recorded over the thumb abductors was transiently suppressed following electrical stimulation of the ulnar nerve innervating the abductor pollicis brevis muscle. This further suggested that the voluntary activation of the thumb abductors was achieved by the ulnar nerve, via the RicheCannieu anastomosis, and stimulation of the ulnar nerve antidromically suppressed the voluntary contraction of the thumb abductors.3 Although there was no FDI muscle contraction, this silent period could have been secondary to contraction of other ulnar innervated hand intrinsics. To further support the presence of the Riche-Cannieu anastomosis (Fig. 1)2monopolar needle electrodes were used to isolate the recordings from the FDI and APB/OP. We isolated the anticipated area of the Riche-Cannieu anastomosis by palmar stimulation and recorded the responses in the APB and FDI. Block of the suspected Riche-Cannieu anastomosis, where it joined the recurrent branch of the median nerve, revealed a 95% reduction in amplitude of the APB and loss of voluntary thumb abduction with maintained FDI amplitude and normal voluntary MUP activity of the FDI with ulnar nerve stimulation at the wrist. These results following anesthetic nerve block ruled out any contribution to the amplitude of the APB due to volume conduction from the FDI and presumably from the adductor pollicis and ulnar-innervated flexor pollicis brevis. In conclusion, this patient had Riche-Cannieu anastomasis because: (1) the surgical findings did not explain the preservation of thumb abduction; (2) the very low voltage response from the wrist to the thenar muscles did not explain the preserved strength of the thumb abduction; (3) thumb abduction voluntary motor unit activity was suppressed by ulnar nerve stimulation; and (4) anesthetic blockade of the ulnar-to-median anastomosis in the hand 4 cm distal to the wrist crease almost completely abolished thumb abduction and the evoked response in the abductor pollicis brevis

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while preserving the evoked response to the first dorsal interosseous with stimulation of the median nerve at the wrist.
REFERENCES 1. Cannieu JMA: Note sur une anastomose entre le branche profunde du cubital et al median. Bull Soc Anat Physzol Brodeawc 1897; 18:339-349.

2. Dumitru D, Walsh NE, Weber CF: Electrophysiologic study of the Riche-Cannieu anomaly. Electromyogr Clin Neurophysiol 1988:28:27-31. 3. Kimura'J: Electrodiagnosis in Disemes of Nerve and Mzlscle: Principles and Practice (2nd ed). Philadelphia, F.A. Davis, 1989. DD 365-366. 4. Oh SJ; 'Clinical EMG: Nerve Conduction Studies. Baltimore, University Park Press, 1984, pp 293-309. 5. Riche P: Le nerf cubitale et les muscles de l'eminence. Bull Mem Soc Anat Paris 1897;5:251.

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