Copyrighl 1986 by The Journal of Bone and Joint Surgery, Incorporated

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Anatomical Basis for Repair of Ulnar and MedianNerves in the Distal Part of the Forearm *t* by GroupFascicular Suture and Nerve-Grafting
BY JIMMY JOHN A. CHOW, M.D., LIEUTENANT WASHINGTON, AND COLONEL, DAVID MARTHA L. C. MEDICAL MEYER, JOHNSON, CORPS, UNITED STATES COLONEL, WASHINGTON, ARMY, MEDICAL D.C. ALLEN L. VAN BEEK, M.D., ARMY, BILOS, LIEUTENANT PH.D., CORPS, UNITED STATES

the

From Walter ReedArmyMedicalCenter, Washington, D.C., Uni~brmed Services University School of Medicine,Bethesda, Maryland, and Cook County Hospitaland Hektoen Institute of Medical Research,Chicago,Illinois ABSTRACT: The topography of the intraneural fascicular groups must be understood if the treatment of acute lacerations of the major nerves in the forearm is to be successful. Most lacerations in the upper extremity occur at the wrist and in the distal half of the forearm. With microsurgical longitudinal dissections and serial sections, we studied the intraneural topography of the fascicular groups of the median and ulnar nerves utilizing forty-five fresh frozen or refrigerated specimens. We devised a new technique of light photography to demonstrate the distinct boundaries of the fascicular groups. The intraneural fascicular groups provide the anatomical basis for the recommended surgical techniques of group fascicular repair and nerve-grafting. In 1945, Sunderland reported his classic study, "The Intraneural Topography of the Radial, Median and Ulnar Nerves"5, and in 1968 his book 6 Nerves and Nerve Injuries was published. Since then, his description of the intraneural fascicular pattern has been widely quoted and has been confirmed by the studies of Jabaley et al. and Williams. For our purposes, two points may be drawn from Sunderlands reports. I. The funicular pattern in both the ulnar and median nerves is continually modified along the length of each nerve by repeated divisions, anastomoses, and changes in the relative positions of the funiculi. The changes in position of individual funiculi may take place within a short expanse of the nerve, often in a segment of 2.5 millimeters or less. 2. The funiculi (also called fascicles or bundles) arrange themselves in definite groups that are usually identifiable along the course of the nerve for distances of several centimeters, especially in the distal portions of the two nerves. Sunderland reported that the bundles in the branches of each nerve course as separate and distinct groups within the nerve, and despite the changing patterns of the individual funiculi in cross section, the bundle groups, during their course in the nerve, are individually identifiable for variable, and often considerable, distances above the site of branching. ManycIinicians have cited our first point to support claims that a precise anatomical realignment of fascicles in the~ repair of lacerated peripheral nerves is impossible. Our second point generally has been overlooked, as it relates to surgical treatment. The present study was prompted by clinical observations by the principal one of us (J. A. C.) made at the Cook County Hospital between July I978 and June 1979. Of fiftysix cases of laceration of the major peripheral nerves of the .upper extremity, forty-one were lacerations of the median or ulnar nerve, or both, at the wrist or in the distal half of the forearm. These observations emphasized the significance of intraneural fascicular group topography in the tte-atment of acute lacerations of the major nerves at the wrist and distal half of the forearm. Also, the fascicular group arrangement is more constant distally in the major nerves of the upper and lower extremities. We decided to attempt to reconfirm Sunderlands observations on the intraneural topography of the median and ulnar nerves, with special attention to the fascicular groups, and to amplify his studies. Our purpose was to investigate the anatomical feasibility of suturing the groups of fascicles individually. Materials and Methods

-.l[S.

27,

We used forty-five fresh refrigerated or fresh frozen * Thisarticle wasaccepted publicationprior to July I, 1985.No specimens of the upper extremity, and in seventeen specifor conflict-of-interest statementwas requestedfromthe authors. + Theopinions asse,--r,i;.,~s coa~ained or hereinare the privateviews mens we did a microsurgical longitudinal dissection of the (::,.:i::.,.!ar groups o;: &~media~ ~ir<u" ,~rve~: Wetraced and

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CHOW ET AL.

ULNAR

15MM DORSAL
F~, 1-A Figs. I-A through l-D: Histological sections of the left ulnar nerve, one centimeter Fig. l-A: At a level fifteen millimeters proximal to the radial styloid process. apart (hematoxyii~ and eosin, 10),

of the medianand ulnar nerves in the proximaI part of the forearm were followed in the proximal direction, utilizing a similar microsurgical dissection technique, tn ten specimenswe madea series of sections at five-millimeter inter-

vals and studied themby a methodsimilar to that described by Sunderland~. Weused hematoxylin and eosin and Masson trichrome stains. Special attention was directed to the group fascicular patterns of the median and ulnar nerves

AIqAT~3~6~C-AL

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FOR REPAIR

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275

FI~, Th(rty-fi,~e millimeters proximal to the raOi~l s~yloid process.

scribed by VanBecketal, -~ in. 1979(Fig. 3). (Figs. t-A through I-D and 5), This empt~asis was different In, addition to the data obtainefi from t~e,~e fort~-fw~ ~:rom those of previously published anatomical stugies, whichfocused their attention on the individual fascicles of fresh specimens, additional information was obtained from dissection of sixty-si~ f~rmalin-fixed specimens f~m ca~!~enerves. Wealso devised a newpt~otographic technique to study davera to determine the locations and c~urses of the motor a series of consecutive segments of the median and ulnar fascic~lar groups of the ulnar nerve at the wrist and in the distal part of the forearm. nerves in sixteen specimens (Pigs. 2-A and 2-B). The lostitular group topography of tl-te median and alaar nerves Results was studied in two specimensutilizing a series of sections, from the edge of the palmto tt~e proximal part of the arm, Ulnar Nerve The ulnar nerve gives rise to three terminal branc/Tes by scanning electron microscopy. The technique was de-

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J. A. CHOWET AL.

FIG. 2-A Figs. 2-A and 2-B: Conventionalphotographs of cross-sectional surfaces of segmentsof the left ulnar nerve madewith a camera that had a bellows attachment (x 5). Fig. 2-A: Fifty millimeters proximalto the radial styloid process.

at the level of the proximaledge of the palm-- one muscular and twocutaneous(Fig. 4). The first is a branchthat supplies the hypothenar muscles and interosseus muscles. One cutaneous branch proceeds to the fourth web space as the common digital nerve, while the other supplies the hypoth-

enar skin and the ulnar side of the little finger. Thesethree branches can be followed proximally as three distinct fascicular groupsfor fifty millimeters from the radial styloid process (Figs. 1-A through l-D). The two sensory groups mergeat that level. Fromthe fifty-millimeter to the ninety-

frown~hesensor fascicular groui~~S!. 3

ANATOMICALBASIS FOR REPAIR OF ULNAR AND MEDIAN NERVES

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ULNAR

150MM

FIG. 3 Scanningelectron micrographof the left ulnar nerve, 150 millimeters proximalto the radial styloid process. Note the intraneural epineurium(arrows) and the fascicular group from the dorsal cutaneous branch located at the ulnar portion of the nerve.

hree fas ,loid ~ups tety-

millimeter level, the mergedsensory and the motorfascicles can be identified as two distinct fascicular groups separated by a firm condensationof connectivetissues (the intraneural epineurium) (Figs. 2-A and 2-B). At the ninety-millimeter level, these two groups merge. The motor fascicular group may therefore be identified as a distinct entity from the tip

of the radial styloid process to a point ninety millimeters proximal to the palm. In all but two of the 111 specimens that Werestudied, the motor fascicular group of the ulnar nerve at the distal part of the forearm was located at the ulnar-dorsal position or central dorsal position. In the exceptional two specimens,it was located at the radial-dorsal

nerve(left forearm). .GERY VOL. 68-A, NO. 2. FEBRUARY 1986

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CHOWET AL.

RADIAL

20MM

DORSAL

F~G. 5 Histological section of the right mediannerve at a level twenty millimeters proximalto the radial styloid process. Aindicates the radially located combinedmotorand sensory group. The motor fascicles to the thenar musclesare on the volar aspect of this group. B and C are the sensory fascicular groups from the common digital nerves of the second and third web spaces, respectively (hematoxylin and eosin, x 10).

position. At the level of the distal third of the forearm,the motorfascicular group constituted 30 to 35 per cent of the total fascicular cross-sectional area of the ulnar nerve. The dorsal cutaneous branch is separate from the main trunk of the ulnar nerve at, and distal to, the junction of the middle and distal thirds of the forearm (eighty to ninety millimeters from the palm). It was followed proximally as a separate fascicular group, running side by side with the combined fascicular group from the three terminal branches, from the ninety-millimeter level to the 250-millimeterlevel proximal to the palm (Fig. 3). In the proximal half of the forearm, the fascicular groups that ~correspondto the three terminal branchesat the proximal edge of the palm becomedistinct. However, at the elbow,the specific fascicular groups that form the motor branchesto the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus can be readily identified. They remainas distinct entities for approximately centimeters ten proximal to the elbow. Median Nerve

cles are in the volar-radial position. Themotorfascicles to the two radial lumbrical muscles are also located in the mixed sensory-motor fascicular group, situated ulnar to the motor fascicular group to the thenar muscles.Moredistally, in the palm, the motorbranch to the index lumbrical muscleaccompanies radial digital the nerve of the index finger. The motorbranch to the lumbrical muscle of the long finger accompaniesthe common digital nerve to the second webspace. The motor fascicles of the median ner*e at the distal end of the forearmconstitute only 10 per cent of the total fascicular cross-sectional area of the nerve. The palmar cutaneous branch is separate from the main part of the median nerve at approximately seventy millimeters proximalto the radial styloid process, and its sensory fascicular groupcan be traced proximallyas an entity to the 150-millimeter level; that is, to the middlethird of the forearnq.

At the level of the wrist and in the distal quarter of the forearm, three fascicular groups maybe identified in the median nerve, and they can be traced as separate entities Discussion for five to seven centimeters proximal to the proximaledge of the palm. At the ulnar side, there are two sensory fasBecause majornerves at the distal part of the forethe cicular groups (Fig.-5), which form the two common digital arm are lacerated so frdquently, a study of the topography nerves to the third and second web spaces. On the radial of the intraneural fascicular groupsat these levels has special side, there is one large fascicular groupconsisting of sensory clinical significance. andmo~#r --:~:,:cicies....... t~e :;e~sorv fascicles continue d{:;taI!y Our findings are basedon st. ~.die~ c;f f~>.~~efresh as &c cadi~.!~igitalnerve ~heindex :)f ~:ic.:2=.:~:

In the proximal half of the forearm, the fascicular groups that correspond to the terminal branches become indistinct, but the motorfascicular groups that terminate as branches to the muscles of the forearm maybe traced for about ten centimeters proximallyfrom the site of branching.

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the distinct entities of the fascicular groupsat serial levels (Figs. 2-A and 2-B). The surgical relevance of our findings should be emphasized because they provide an anatomical basis for group fascicular repair. In 1917, Langleyand Hashimoto,of Cambridge University, suggested the idea of separate suture of fascicular groups, and advised cutting open the inner, dense epineurial sheath (intraneural epineurium). The technique of group fascicular repair has been described by Van Beck 7 and Kleinert8 as well as by Sunderland (Fig. 6). Utilizing the operating microscope, one mayreadily identify, match, align, and repair the fascicular groups. Groupfascicular repair maybe conceptualized as inner

segmentof nerve is lost, the fascicles at the two nerve ends will not correspond, so that fascicle-to-fascicle repair by perineurially placed sutures is precluded. Undersuch conditions, one should be able to identify corresponding fascicular groups rather than individual fascicles at the nerve ends, and then microsurgical group fascicular repair will be possible because the fascicular groupsremainas identifiable entities for several centimeters proximalto the wrist. In the surgical treatment of acute lacerations of the major peripheral nerves, we advocate microsurgical group fascicular repair or microsurgicalepineurial repair with correct alignment of the fascicular groups. Wedo not advocate fascicular (perineurial) repair.

F~. 6 Groupfascicular repair.

"/

F~. 7 Groupfascicular nerve-grafting,

epineurial repair. The epineurium maybe divided into external epineuriumand intraneural epineurium. The external epineuriumsurrounds the entire nerve, while the intraneural epineurium separates and surrounds individual fascicular groups or individual fascicles (Figs. 1-B and 2-B). The epineurium,either external or intraneural, lends itself to separate suturing without injury to the encased fascicular groups. Utitizir~ the operating microscope, sutures maybe car.:g:~i!) ap?ii::< sizec.~.:.::: c~< thetascicuIar gr~>:ps. i~.>..~,t .,;

The fascicular group arrangementof major peripheral nerves is also important for the techniqueof interfascicular 34. nerve-grafting as described by Millesi and Millesi et al. Theypointed out that, using the operating microscope,nerve grafts can be utilized to bridge the gap betweenthe corresponding fascicular groups (Fig. 7). Webelieve that the relatively constant location of the motorfascicular group of the ulnar nerve at the distal part of ..~ f~;,:." ~-m >av:i,::.~ " i~~,~.:.~:...t. In all buttwoof i:.~ t~te i11 ~:;<>c:cic~~ens ,.~..~: .tudied, that fasciculargroup t!,:x~ ~, :: :~ : .::. "2t ~},: :i:: .,.," cer,.tral dorsalpositi.op., in in~r~ .ic rrmsck:s;;;. ~i:e ha~=,d, one should make special a

~ess surgical trauma resuita~.<a,.ri;~g. If a signii:~ ::~nt and

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J. A. CHOW AL. ET

effort duringnervesutureto correctlyidentify andalign this motorfascicular group. We recognize the value of the early work of 5 and Sunderland the later contributions Jabaleyet al. and of Williams, and most of the points that they made have been confirmed our study. Ourdissections constitute a larger in number specimensthan do the previously published reof ports, and we further highlight the privileged anatomical

fact of the moreconstant fascicular grouparrangement in the intraneural topography the ulnar and median of nerves at the distal part of the forearm, where majority acute the of lacerationsoccurclinically.
NOTE: Lieutenant Colonel is indebted Sir Sydney Chow to Sunderland proofreading for the manuscript to Dr. Michael and Jabaley, Brace Dr. Williams, Dr. Hanuo and Millesi advice for andencouragement thepreparation this work. authors during of The thank George Mr. Holborow. Mr. Gregory Holmes, PaulNiner,andMs. Mr. lngridLynch technical for assistance. also They thank G.Wind, for preparation theline drawings. Gary M.D., of

References
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2. 3. 4. 5. 6. 7. 8. 9. 10.

JABALEY, M. E.; WALLACE, W. H.; and HECKLER, R.: Internal Topography of Major Nerves of the Forearm and Hand: A Current View. I. F. Hand Surg., 5: 1-18, 1980. LANGLEY, N., and HASHIMOTO, Onthe Suture of Separate Nerve Bundles in a Nerve Trunk and on Internal Nerve Plexuses. J. Physiol., J. M.: 51: 318-346, 1917. : MILLESI,H.: Nerve Grafts -- Indications, Techniques and Prognosis. In Management Peripheral Nerve Problems, p. 417. Edited by G. E. of Omer, Jr., and MortonSpinner. Philadelphia, W. B. Saunders, 1980. MILLESI, MEISSL, and BERGER, The Interfascicular Nerve-Grafting of the Medianand Ulnar Nerves. J. Boneand Joint Surg., 54..A: H.; G.; A.: 727-750, June 1972. SUNDERLAND, SYDNEY: Intraneural Topographyof the Radial. Median and Ulnar Nerves. Brain, 68: 243-298, 1945. The SUNDERLAND, SYDNEY: Nerves and Nerve Injuries. Edinburgh, Churchill Livingstone, 1968. SUNDERLAND, SYDNEY: Nerves and Nerve Injuries. Ed. 2. Edinburgh, Churchill Livingstone. 1978. VAN BEEK,ALLEN, KLEINERT, E.: Practical Microneurorrhaphy. Orthop. Clin. North America, 8: 377-386, 1977. and H. VAN BEEK, L.; JACOBS, C.; and ZOOK, G.: Examinationof Peripheral Nerves with the ScanningElectron Microscope.Plast. and Reconstr. A. S. E. Surg., 63: 509-519, 1979. WILLIAMS, B.: Peripheral Nerve Injuries in Children. In Symposium Pediatric Plastic Surgery, pp. 266-282. Edited by D. A. Kernahan, H. H. on G. Thompson,and B. S. Bauer. St. Louis, C. V. Mosby, 1982.