Response to “Direct Radial to Ulnar Nerve Transfer to Restore Intrinsic Muscle Function in Combined Proximal Median and Ulnar Nerve Injury: Case Report and Surgical Technique”

Abstract

We read with interest this recent article regarding motor renervation of the ulnar innervated intrinsic, using fascicles of the terminal branches of the posterior interosseous nerve in a patient with combined high median and ulnar palsy.1Phillips B.Z. Franco M.J. Yee A. Tung T.H. Mackinnon S.E. Fox I.K. Direct radial to ulnar nerve transfer to restore intrinsic muscle function in combined proximal median and ulnar nerve injury: case report and surgical technique.J Hand Surg Am. 2014; 39: 1358-1362Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar While we commend the authors for their innovative strategy and we would agree that distal motor renervation is beneficial in proximal peripheral nerve injuries, we remain confused by the strategy employed in this particular case. The authors’ comment “no functional loss occurred from denervation of the abductor pollicis longus.” However, it is not documented how thumb function was assessed. When high median and ulnar nerve palsy is reconstructed, we believe that a functioning anterior pollicis longus provides stability and aids thumb positioning to augment tendon transfers for opposition. In addition, we favor the extensor indicis proprius as an opposition donor tendon. The ulnar intrinsic function can be reliably restored using the extensor carpi radialis longus as a donor tendon. In this case, it is not clear what strategies the authors would use to reconstruct thumb function, having sacrificed 2 useful thumb motors for questionable improvement in the deep ulnar nerve function. Direct Radial to Ulnar Nerve Transfer to Restore Intrinsic Muscle Function in Combined Proximal Median and Ulnar Nerve Injury: Case Report and Surgical TechniqueJournal of Hand SurgeryVol. 39Issue 7PreviewA distal median to ulnar nerve transfer for timely restoration of critical intrinsic muscle function is possible in isolated ulnar nerve injuries but not for combined ulnar and median nerve injuries. We used a distal nerve transfer to restore ulnar intrinsic function in the case of a proximal combined median and ulnar nerve injury. Transfer of the nonessential radial nerve branches to the abductor pollicis longus, extensor pollicis brevis, and extensor indicis proprius to the motor branch of the ulnar nerve was performed in a direct end-to-end fashion via an interosseous tunnel. Full-Text PDF In Reply:Journal of Hand SurgeryVol. 40Issue 4PreviewWe appreciate the concerns of both this letter writer and that of another regarding the potential downgrading of thumb function in the interest of providing ulnar intrinsic function. The results are yet early in this particular case and it is indeed critical to find what functions are most necessary by further follow-up and careful assessment of outcomes. Full-Text PDF