Brachialis to Anterior Interosseous Nerve Transfer with Extended Forearm Incision

Loss of flexor pollicis longus and radial profundus function results in a deficit of pinch and reduced grip strength in the hand. This palsy can be isolated or commonly included in a lower brachial plexus injury. The brachialis nerve is an available, synergistic, and powerful donor for transfer in these scenarios, especially in C7,8,T1 injuries and when other common donors are unavailable due to injury like the extensor carpi radialis brevis. In this case, the patient presented three months following a partial C7 and C8,T1 brachial plexus injury from a fall with no recovery on electrodiagnostic studies. The brachialis to anterior interosseous nerve transfer was elected with the supinator to flexor digitorum superficialis nerve transfer and lateral antebrachial cutaneous to ulnar sensory nerve transfer. This video details the specifics for the brachialis transfer with an extended incision into the forearm to confirm the proximal topography of the anterior interosseous fascicle in the median nerve. Additionally, this patient has an anomalous sensory nerve anastomosis from a brachialis nerve branch to the sensory component of the median nerve.

Standard:

Extended:

POSITION

Supine.

INCISION

Incision on the medial aspect of the arm that is medial/inferior to the palpation of the biceps/triceps groove, Brunner’s zig-zag incision over the elbow crease, and lazy-S incision over the proximal forearm.

REFERENCES

1. Murphy RK, Ray WZ, Mackinnon SE. Repair of a median nerve transection injury using multiple nerve transfers, with long-term functional recovery. J Neurosurg. 2012 Nov;117(5):886-9. PMID: 22978538.
2. Ray WZ, Yarbrough CK, Yee A, Mackinnon SE. Clinical outcomes following brachialis to anterior interosseous nerve transfers. J Neurosurg. 2012 Sep;117(3):604-9. PMID: 22817905.
3. Boyd KU, Nimigan AS, Mackinnon SE. Nerve reconstruction in the hand and upper extremity. Clin Plast Surg. 2011 Oct;38(4):643-60. Review. PMID: 22032591.
4. Tung TH, Mackinnon SE. Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am. 2010 Feb;35(2):332-41. Review. PMID: 20141906.
5. Brown JM, Shah MN, Mackinnon SE. Distal nerve transfers: a biology-based rationale. Neurosurg Focus. 2009 Feb;26(2):E12. Review. PMID: 19416056.

Disclosure: No authors have a financial interest in any of the products, devices, or drugs mentioned in this production or publication.