Medial Antebrachial Cutaneous Research Articles

The Management of Persistent and Recurrent Cubital Tunnel Syndrome.

Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy in the upper extremity. There are considerable diagnostic and therapeutic challenges associated with treating patients after a failed primary procedure for CuTS. Distinguishing cases of recurrence versus persistence and identifying concomitant pathology can guide treatment. Conditions that mimic CuTS must be carefully ruled out and coexisting dysfunction of the medial antebrachial cutaneous nerve needs to be addressed. Results of revision procedures are not as reliable as primary procedures for CuTS; however, improvements in pain and paresthesias are noted in approximately 75% of patients. Nerve wraps represent a promising adjuvant treatment option, but long-term outcome data are lacking. External neurolysis and anterior transposition after failed CuTS procedures are supported by case series; multicenter, prospective randomized trials are needed to guide treatment further and improve outcomes.

Arthroscopic Release of the Pronator-Flexor Origin for Medial Epicondylitis

We performed arthroscopic surgery for medial epicondylitis and evaluated pain relief, self-assessed functional outcome, and complications after the procedure. The patients included 2 males and 2 females with a mean age of 48.3 years. The average length of follow-up was 16.2 months. The pronator-flexor origin was partially released from the medial epicondyle in all elbows. In 2 cases, débridement of calcinosis in the pronator-flexor origin was also performed. In 2 of the 5 elbows, active flexion was preoperatively limited to 100 degrees, but the range of flexion recovered to the same as that on the contralateral side by the final follow-up. Postoperative valgus instability was not observed. The average scores using a visual analog scale for pain at rest and during activity improved from 5.8±4.4 to 0.3±0.6 and from 8.3±1.9 to 2.3±2.2, respectively. The mean DASH score improved from 59.1±24.3 to 7.5±10.3. According to Nirschl and Pettrone grading system, the outcomes were excellent for 3 elbows and good for 2 elbows. Medial antebrachial cutaneous nerve irritation occurred in 1 elbow, but finally resolved. Arthroscopic partial release and débridement of the common pronator-flexor origin is effective and safe procedure for recalcitrant medial epicondylitis.

Neurodynamic evaluation and nerve conduction studies in patients with forward head posture.

Forward head posture (FHP) is one of the most frequently seen problems. The aim of this study was to evaluate the neurodynamic tests and peripheral nerve conductions of upper extremity in patients with FHP. The study population included 100 patients with upper extremity and neck problems and 34 healthy individuals as a control group. Craniovertebral angle measurement was used to determine forward head posture. Stretch tests for radial, ulnar and median nerves were performed. Nerve conductions of bilateral median, radial, ulnar and medial antebrachial cutaneous (MAC) nerves were examined in all patients included in the study. The most significant nerve conduction differences in moderate-to-severe FHP patients were a decrease in the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP) amplitudes of median nerves, a decrease in the SNAP amplitude of ulnar nerves, a delay in the F response latency of ulnar nerves and prolongation in the SNAP latency of the MAC nerve. FHP makes patients more prone to peripheral entrapments.

The 7 Structures Distal to the Elbow That Are Critical to Successful Anterior Transposition of the Ulnar Nerve.

Background: Ulnar nerve transposition (UNT) surgery is performed for the treatment of cubital tunnel syndrome. Improperly performed UNT can create iatrogenic pain and neuropathy. The aim of this study is to identify anatomical structures distal to the medial epicondyle that should be recognized by all surgeons performing UNT to prevent postoperative neuropathy. Methods: Ten cadaveric specimens were dissected with attention to the ulnar nerve. Intramuscular UNT surgery was simulated in each. Distal to the medial epicondyle, any anatomical structure prohibiting transposition of the ulnar nerve to a straight-line course across the flexor-pronator mass was noted and its distance from the medial epicondyle was measured. Results: Seven structures were found distal to the medial epicondyle whose recognition is critical to ensuring a successful anterior transposition of the ulnar nerve: (1) Branches of the medial antebrachial cutaneous (MABC) nerve; (2) Osborne's fascia; (3) branches from the ulnar nerve to the flexor carpi ulnaris (FCU); (4) crossing vascular branches from the ulnar artery to the FCU; (5) the distal medial intermuscular septum between the FCU and flexor digitorum superficialis (FDS); (6) the combined muscular origins of the flexor-pronator muscles; and (7) the investing fascia of the FDS. Measurements are given for each structure. Conclusions: Poor outcomes and unnecessary revision surgeries for cubital tunnel syndrome can be avoided with intraoperative attention to 7 structures distal to the medial epicondyle. Surgeons should expect to dissect up to 12 cm distal to the medial epicondyle to adequately address these and prevent kinking of the nerve in transposition.

B-10. Electrodiagnostic studies in entrapment neuropathy

Electrodiagnosis of entrapment neuropathy at the upper limb is important to determine the treatment procedure. The median sensory nerve conduction studies and median nerve motor nerve distal latency have conventionally been performed for the diagnosis of carpal tunnel syndrome (CTS), but their sensitivities are not always sufficient. As a result of our research in 104 hands with CTS symptoms, both the ring finger test and second lumbrical–interossei comparison test had especially high sensitivity (92%), and this result supports the practice parameters recommended by the Japanese Society of Neurological Therapeutics. Exact localization of the lesion by electrodiagnosis in patients with ulnar neuropathy at the elbow (UNE) is often difficult because other disorders may mimic its symptoms (e.g., cervical lesion, brachial plexopathy, and Guyon’s canal syndrome). In one of our studies, sensitivity of the ulnar nerve motor nerve conduction velocity across the elbow lacked accuracy (54%). Meanwhile, the short-segment incremental study had the highest sensitivity (82%), maintaining high specificity (95%). In extreme UNEs, the combination of sensory nerve conduction studies evoked from the dorsal ulnar cutaneous branch and the medial antebrachial cutaneous nerve may be helpful in the exclusion of other disorders.

The anatomy of forearm free flap phalloplasty for transgender surgery.

Transgender surgeries are becoming more frequent and visual interpretation of anatomy is essential for both surgeons and patients. Since the forearm free flap phalloplasty was introduced in 1984, it has been known to provide reliable cosmetic and functional results for transitioning men compared with phalloplasty by different flaps. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. The forearm free flap consists of the anterior forearm skin, subcutaneous tissue, fascia containing the radial artery as the perforator and its venae comitantes, cephalic and basilic veins, and lateral and medial antebrachial cutaneous nerves are demonstrated in relation to the surgically derived flap. Song's forearm free flap phalloplasty requires two surgical stages with a three-month interval between the stages: prelamination of a neourethra and construction of a neophallus. The neophallus created by forearm flap phalloplasty is reported to achieve acceptable aesthetical and psychological satisfaction, appropriate size and shape, and satisfying sexual intercourse. Despite increasing experiences in gender confirming surgery with modifications made by many authors, urethral complications including fistula and/or stricture formation are the leading causes of reoperation. The poor esthetic outcome of the forearm donor site and a decrease in rigidity of the neophallus are the main limitations. Illustrations of anatomy help inform surgical choice and understanding of risks and benefits by patients. The anatomy of the free forearm flap phalloplasty supports creation of a neophallus for transsexual anatomy revision. Clin. Anat. 31:145-151, 2018. © 2017 Wiley Periodicals, Inc.

Vascular branches from cutaneous nerve of the forearm and hand: Application to better understanding raynaud's disease.

Cutaneous nerves have branches called vascular branches (VBs) that reach arteries. VBs are thought to be involved in arterial constriction, and this is the rationale for periarterial sympathectomy as a treatment option for Raynaud's disease. However, the branching patterns and distribution areas of the VBs remain largely unclear. The aim of the present study was to investigate the anatomical structures of the VBs of the cutaneous nerves. Forty hands and forearms were examined to assess the branching patterns and distribution areas of the VBs of the superficial branch of the radial nerve (SBRN), the lateral antebrachial cutaneous nerve (LACN), the medial antebrachial cutaneous nerve (MACN), and the palmar cutaneous branch of the ulnar nerve (PCUN). VBs reaching the radial and ulnar arteries were observed in all specimens. The branching patterns were classified into six types. The mean distance between the radial styloid process and the point where the VBs reached the radial artery was 34.3 ± 4.8 mm in the SBRN and 38.5 ± 15.8 mm in the LACN. The mean distance between the ulnar styloid process and the point where the VBs reached the ulnar artery was 60.3 ± 25.9 mm in the MACN and 43.8 ± 26.0 mm in the PCUN. This study showed that the VBs of the cutaneous nerves have diverse branching patterns. The VBs of the SBRN had a more limited distribution areas than those of the other nerves. Clin. Anat. 31:734-741, 2018. © 2017 Wiley Periodicals, Inc.

Rapid neurophysiological screening for sensory ganglionopathy: A novel approach.

Background and AimPure sensory neuropathies involving the dorsal root ganglia are commonly referred to as sensory ganglionopathies (SG). Causes of SG can be inherited (as seen in Friedreich's ataxia) or acquired (e.g. immune‐mediated or paraneoplastic). Diagnostic criteria for confirming SG have been published and consist of a combination of clinical and neurophysiological parameters. The aim of our study was to develop a neurophysiological method for rapid screening for diagnosis of SG.MethodsFor each subject we obtained the sensory nerve action potentials (SNAPs) of five nerves (median, ulnar, radial, sural and superficial peroneal) bilaterally. In the presence of an entrapment neuropathy we obtained the SNAP of the medial antebrachial cutaneous nerves bilaterally. We estimated the number of pairs of nerves showing a SNAP asymmetry of >50% (difference of SNAPs/ lower SNAP).ResultsSixty‐eight subjects, 34 patients with SG and 34 age and sex‐matched controls, participated in the study. Among all subjects using a receiver operating characteristic (ROC) curve analysis, the area under the curve was 0.984 (95% CI, 0.960–1.000; SE, 0.012; p < .001). In order to detect SG, presence of SNAP asymmetry of >50% in 2 pairs of nerves, not explained by an entrapment neuropathy, shows a sensitivity of 97.1%, a specificity of 94.1%, a positive predictive value of 94.3% and a negative predictive value of 97.0ConclusionThe number of pairs of nerves showing a SNAP asymmetry of >50% may be used as a novel rapid screening tool of patients with SG.

Clinical effects of repair of wounds in fingers after electrical burn with wrist perforator free flaps

Objective: To explore the clinical effects of repair of wounds in the fingers after electrical burn with wrist perforator free flaps. Methods: Twelve patients (13 fingers) with electrical burn were hospitalized in our burn ward from January 2016 to January 2017. After radical debridement, the size of wounds ranged from 5.0 cm×2.0 cm to 10.0 cm×7.0 cm. Wounds with size below or equal to 6.0 cm ×2.5 cm were repaired with free flaps based on the superficial palmar branch of radial artery, with flap area ranging from 2.5 cm×2.2 cm to 6.0 cm×4.5 cm. The superficial palmar branch of radial artery, subcutaneous vein, and palmar cutaneous branch of the median nerve underwent end-to-end anastomosis with digital proper artery, dorsal superficial vein, and digital proper nerve in the finger, respectively. The donor sites were sutured directly. Wounds with size larger than 6.0 cm×2.5 cm were repaired with free flaps based on the dorsal carpal branch of ulnar artery, with flap area ranging from 4.5 cm×3.0 cm to 12.0 cm×8.5 cm. The dorsal carpal branch of ulnar artery, subcutaneous vein, and medial antebrachial cutaneous nerve underwent end-to-end anastomosis with digital proper artery, dorsal superficial vein, and digital proper nerve in the finger, respectively. The donor sites were sutured directly or covered by full-thickness skin graft from abdomen. Results: Five free flaps based on the superficial palmar branch of radial artery and 8 free flaps based on the dorsal carpal branch of ulnar artery were used in the patients. In one week after surgery, 12 flaps survived completely, while one free flap based on the dorsal carpal branch of ulnar artery suffered from slight infection, after depressing change, it survived in the end. After the follow-up of half a year, the flaps were full in shape and the distance of two-point discrimination of ranged from 4.0 to 7.0 mm. The fingers showed good functional recovery and no deformity. The grade of function of the fingers was excellent in 10 cases and good in 3 cases. There were small incision scars in donor sites. Conclusions: The wrist perforator free flap is safe and reliable for repairing electrical burn wound of finger. The wounded finger shows good appearance and function after operation.

Restoration of active pick-up function in patients with total brachial plexus avulsion injuries.

IV.

Anatomy of the medial antebrachial cutaneous nerve and its significance in ulnar nerve surgery: An anatomical study

During cubital tunnel surgery, the medial antebrachial cutaneous nerve (MACN) may be injured, causing painful scars, neuromas, hypaesthesia or hyperalgesia. As the literature on the anatomy of crossing branches in this area is contradictory, this study aimed to re-examine the anatomy of the MACN in this region. Forty upper limbs were dissected. We looked specifically from 5cm proximal to 6cm distal to the medial epicondyle (ME) and documented the number of crossing branches and the distances between the crossing points and the ME; we also measured the length of each limb. The most common location for crossing branches was 2cm distal to the ME. Twenty-seven branches (∼23%) were found proximal to or at the level of the ME, and 91 branches (∼77%) were distal to it. The average distance between the proximal crossing points and the ME was 1.7cm, the mean number of crossing branches was 0.7 and at least one crossing branch per limb was found in 16/40 cases. For the distal crossing points, the average distance to the ME was 2.9cm, the mean number of crossing branches was 2.3 and at least one crossing branch per limb was found in all cases. There was no correlation between the limb lengths and the number of crossing branches. Because the incidence of posterior branches of the MACN crossing the course of the ulnar nerve is 100%, it is important to take the anatomy of the MACN into consideration when undertaking ulnar nerve surgery.

Rates of Complications and Secondary Surgeries After In Situ Cubital Tunnel Release Compared With Ulnar Nerve Transposition: A Retrospective Review

The purpose of this study was to contrast the rate and types of complications and secondary surgeries for in situ cubital tunnel release and ulnar nerve transposition. A retrospective cohort study was performed by query of hospital billing records for all patients who underwent cubital tunnel surgery from August 2008 to July 2013, yielding 421 patients. Exclusion criteria were acute trauma, revision surgery, neoplasm, age younger than 18 years, incomplete records, and postoperative follow-up less than 3 months. Of the remaining 234 patients, 147 patients underwent 157 in situ cubital tunnel releases and 87 patients underwent 90 ulnar nerve transpositions. In 157 in situ cubital tunnel releases, there were 6 complications (3.8%), including 3 cases (1.9%) of ulnar nerve instability, 2 cases (1.3%) of postoperative infection, and 1 case (0.6%) of a postoperative seroma. In 90 ulnar nerve transpositions, there were 2 complications (2.2%), including 1 case (1.1%) of postoperative infection and 1 case (1.1%) of medial antebrachial cutaneous nerve injury. The secondary surgery rate was 5.7% overall, 2.5% for insitu cubital tunnel release, and 11.1% for ulnar nerve transposition. Chronic kidney disease was associated with complication after cubital tunnel surgery. Prior trauma to the elbow and ulnar nerve transposition were associated with secondary surgery. The short-term complication rates of cubital tunnel surgery are low (3.2%), but higher for patients with chronic kidney disease. The secondary surgery rate after cubital tunnel surgery was 5.7% overall, but higher for patients with prior elbow trauma and for patients undergoing ulnar nerve transposition. Therapeutic IV.

Comparison of the anesthetic effect of ultrasound-guided brachial plexus block by different approaches in distal radius surgery

Objective To compare the anaesthetic effect of ultrasound-guided brachial plexus block by different approaches (interscalene, axillary, supraclavicular) in distal radius surgery. Methods Ninety adult patients undergoing elective surgery for distal radius fracture open reduction and internal fixation, distal radius fracture after implant removal surgery distal radius fracture, were randomly divided into interscalene group(group A), axillary group(group B) and supraclavicular group (group C) for brachial plexus block under ultrasound-guided(n=30). The performance time and complications were recorded. Besides, the onset time and block execution time of median nerve, ulnar nerve, radial nerve, lateral medial cutaneous nerve, forearm medial cutaneous nerve were evaluated. Results There is no significant difference in performance time(P>0.05) and the onset time of pain block in median nerve, radial nerve, lateral medial cutaneous nerve (P>0.05). As for ulnar nerve and medial antebrachial cutaneous nerve, there were no difference in onset time of pain block between group A[(21±6) min] and group C[(20±5) min] (P>0.05), but they were longer than group B[(8±5) min] (P 0.05), but they were longer than group B[(10±6) min] (P<0.05). The complete suceess rate of group B(90%) were higher than other two groups. We found that two patients in group A and one patient in group C were complicated with phrenic nerve block and one patient in group B showed little tolerance of tourniquet. Conclusions Ultrasound-guided axillary brachial plexus block in the distal radius surgery is recommended because of better blockage of ulnar nerve and medial antebrachial cutaneous nerve and fewer complications. Key words: Ultrasound; Brachial plexus block; Distal radius

A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report

BackgroundAlthough open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment.Case presentationWe report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. ConclusionsWe believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.

Dislocation of the Medial Antebrachial Cutaneous Nerve and the Ulnar Nerve in Painful Snapping Elbow

Dislocation of the Medial Antebrachial Cutaneous Nerve and the Ulnar Nerve in Painful Snapping Elbow

Mini-Open In Situ Cubital Tunnel Release

Cubital tunnel syndrome is the second most common nerve entrapment syndrome of the upper extremity. Patients typically present with numbness and paresthesias in the ring and small fingers, elbow pain, and intrinsic weakness. There are several surgical treatment options, including in situ decompression, medial epicondylectomy, subcutaneous transposition, and submuscular transposition. Potential complications include incomplete release, hematoma formation, and medial antebrachial cutaneous nerve injury. Recently, many authors have described an endoscopic cubital tunnel release that is performed through a smaller incision, is less invasive, and results in a faster recovery time. We describe a simple mini-open in situ release for ulnar nerve compression at the elbow. A 1 cm incision just posterior to the medial epicondyle is made and blunt dissection is utilized. The ulnar nerve is released on its posterior aspect under direct visualization. A Langenbeck retractor and Jameson tenotomy scissors are used to release the nerve proximally. The superficial and deep flexor carpi ulnaris fascia are released distally. This mini-open technique uses a smaller incision than the endoscopic technique, without the added cost of the endoscopic equipment.

Endoscopy-assisted subfascial anterior transposition of the ulnar nerve for the treatment of cubital tunnel syndrome

Many techniques have been described to relieve the compression and reduce subluxation of the ulnar nerve following surgery. The subfascial anterior transposition of the ulnar nerve (SfATUN) is one described technique, but involves a long scar, risk of injury to the medial antebrachial cutaneous nerve, and possible nerve ischemia from anterior transposition. We assessed a more refined approach of endoscopy-assisted SfATUN for the treatment of cubital tunnel syndrome. A consecutive case series of 21 patients (15 males and 6 females) with evidence of nerve subluxation after ulnar nerve decompression were operated using an endoscopy-assisted SfATUN. Each patient was assessed with pre- and postoperative nerve conduction studies, McGowan grading, and recovery of grip strength. The average age of patients was 54 years (range 23-74 years), and they were followed up for a mean of 9 months (range 3-22 months). Preoperative McGowan grades were eight grade II and 13 grade III. Eighteen of the 21 patients showed improvement, including improvement by two McGowen grades in 8 patients and improvement by one grade in 10 patients. Three grade III patients did not show improvement in grading after surgery. A proportion of 90% of patients showed significant improvements in motor nerve conduction velocity of the ulnar nerve across the elbow (p<0.001), and all showed some improvement in grip strength (p<0.001). One patient underwent redo neurolysis. A combination of endoscopy-assisted SfATUN allows for decompression transposition and reduced strain on the ulnar nerve through a small scar. This is now our standard approach for cubital tunnel syndrome and the "unstable" nerve.

Contralateral C7 Transfer via Both Vascularized Ulnar Nerve and Medial Antebrachial Cutaneous Nerve With the Ulnar Artery Anastomosed to the Arteria transversa Colli to Repair Brachial Plexus Avulsion

Background: Contralateral C7 nerve transfer to the median nerve has been used in an attempt to restore finger flexion in patients with total brachial plexus avulsion injury. However, the results have not been satisfactory mainly because of the requirement to use a long bridging nerve graft, which causes an extended nerve regeneration process and irreversible muscle atrophy. A new procedure involving contralateral C7 nerve transfer via both vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery anastomosed to the arteria transversa colli is presented here. Methods: It was performed in 25 patients with total brachial plexus avulsion injury. Contralateral C7 nerve root was coapted to the distal end of the ipsilateral vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery is anastomosed to the arteria transversa colli. The ulnar nerve was secured to the median nerve, and medial antebrachial cutaneous nerve was used to repair musculocutaneous nerve. Electromyography and ultrasonography were used to evaluate the early recovery. Recovery of finger, wrist, and elbow flexion was evaluated with the use of the modified British Medical Research Council muscle grading system. Results: Electromyography showed the early recovery by 3 months postoperatively, and smooth blood flow at the anastomotic stoma can be seen through ultrasound. The mean follow-up period (and standard deviation) was 20 ± 6 months. Motor function with a grade of M3+ or greater was attained in 60% of the patients for elbow flexion, 64% of the patients for finger flexion, 53% of the patients for thumb flexion, and 72% of the patients for wrist flexion. Conclusions: Contralateral C7 nerve transfer via both vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery anastomosed to the arteria transversa colli speeds up the nerve regeneration in patients with total brachial plexus avulsion injury and improve the utilization of contralateral C7 fiber. There was satisfactory recovery of finger flexion and wrist flexion in this series.

How to Avoid Damaging the Terminal Branches of the Medial Antebrachial Cutaneous Nerve and the Medial Brachial Cutaneous Nerve During Operations Involving the Medial Elbow?

Objective: Medial elbow incision is obligatory for cubital tunnel syndrome surgical treatment. However, the terminal branches of both the medial antebrachial cutaneous nerve (MACN) and the medial brachial cutaneous nerve (MBCN) are likely to be harmed using the current incision technique. The aim of this study was to seek a new incision to avoid damaging the branches of MACN and MBCN during the operation for cubital tunnel syndrome. Methods: Ten fresh frozen cadaver upper extremities and 20 clinical cases (elbows) were analyzed. A conventional incision and a new incision were used in the cadaveric specimens and the clinical cases, respectively. The medial epicondyle was set as the reference landmark to quantify the location of the terminal branches, with the elbow at full extension. The numbers of the terminal branches and their locations were noted for MACN and MBCN, and the locations of the posterior branch of the MACN were recorded in the elbow medial incision. Results: The average numbers of MACN’s posterior terminal branches were 2.6 ± 1.6 and 4.4 ± 2.4 in the cadaveric specimens and clinical cases, respectively. The average number of MBCN’s terminal branches was 2 ± 0.87 in the cadaveric specimens. The MACN’s posterior terminal branches were located at 19 and 45 mm, respectively, measuring from the medial epicondyle. And the posterior branch of MACN was always located in between the medial epicondyle and the basilic vein, and the average distance was 10 ± 6 mm to the medial epicondyle. We could preserve all the MBCN’s terminal branches in the new incision. The MACN’s posterior terminal branches could be perfectly exposed by the use of the antegrade dissection technique, finding the MACN’s posterior branch in advance. Conclusions: The new elbow medial incision technique could reduce the risk of injuring the terminal branches from the MBCN. The medial epicondyle and the basilic vein are reliable anatomical landmarks to identify the posterior branch of the MACN. An antegrade method of dissection can effectively identify and avoid the injury to the terminal branches of the MACN in the elbow medial incision.

Nerve transfer for sensory reconstruction of C8-T1 dermatomes in tetraplegia.

Absence of sensation in C8-T1 dermatome is a common finding in midcervical spinal cord injury. The goal was to restore sensation on the C8-T1 dermatomes by transferring sensory nerves with afferents on C5-C6 roots. A mean 10 months post spinal cord injury, we operated on 10 upper limbs from 5 tetraplegics averaging 23 years old. Cutaneous branches of the median nerve were transferred to the palm to the ulnar proper digital nerve of the little finger. In two patients, the lateral antebrachial cutaneous nerve was also transferred to the medial antebrachial cutaneous nerve. At a mean 20 months after surgery, on the ulnar side of the hand and little finger, all patients were able to perceive 19.3 g Semmes-Weinstein monofilament pressure. Nociception was restored on the medial side of the elbow, forearm, and hand. Faulty location was a common finding, but not as a major complaint. Sensory nerve transfers should be incorporated into the reconstruction of the upper limb in tetraplegics. © 2015 Wiley Periodicals, Inc. Microsurgery 36:637-641, 2016.