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Anatomy Atlases: Illustrated Encyclopedia of Human Anatomic Variation: Opus III: Nervous System: Plexuses: Median Nerve

Illustrated Encyclopedia of Human Anatomic Variation: Opus III: Nervous System: Plexuses

Median Nerve

Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD

Peer Review Status: Internally Peer Reviewed


The following variations in the formation, course, and distribution of this nerve have been reported. The combination from the first thoracic nerve to the formation of the median nerve may be missing.

Either the outer (lateral) or the inner (medial) branch (from the lateral and medial cords) of the nerve may consist of two nerve bundles.

The site of union between the lateral and medial branches is quite variable and has been found as far down as the elbow.

The two branches may enclose the axillary vein as well as the axillary artery.

The median nerve or either of its branches may pass behind the axillary artery instead of in front of it; the nerve may also pass behind the brachial artery.

The lateral branch of the nerve sometimes arises in the middle of the arm, behind the axillary artery, and joins the medial branch.

The median nerve usually passes between the two heads of pronator teres. It may also pass superficial or deep to the two heads or may pierce the humeral head. The nerve may lie on the superficial surface of flexor digitorum superficialis instead of deep to it. In some cases, the median splits, forming a cleft in the forearm and allowing the passage of the ulnar artery or one of its branches, the superficial long head of the flexor pollicis, or an extra palmaris longus muscle to pass through. The divided nerve may pass through the carpal tunnel in separate compartments.

Communications have been described between the median and ulnar nerves in the arm, forearm, or hand. Up to 90% of all subjects studied are reported to have median-ulnar nerve anastomoses, 10% of which are bilateral. In other studies (e.g., Thomson, J. Anat. 69:159-164) 15% (63 of 406 arms) is a commonly given value. In the Thomson study, communications between the anterior interosseous ocurred in 8% (33 cases); between the median and ulnar trunks in 3% (12 cases); between the muscular branches of median and ulnar in 4% (16 cases) and by a superficial branch between the median and ulnar in 0.5% (2 cases). They are more frequently reported on the right side. These median-ulnar anastomoses may carry nerve fibers to muscles of the hand that are commonly supplied by the ulnar nerve. Opponens pollicis may be supplied by both the ulnar and median nerves (30% of cases). The superficial head of the short flexor of the thumb (flexor pollicis brevis) is very frequently (83% of cases) supplied by both the median and ulnar nerves, and in about 25% of cases by the ulnar alone.

Martin-Gruber anastomoses occur in cases where motor axons usually destined for the ulnar nerve continue from the medial cord into the median nerve. These anastomoses were mentioned by Verchère as the work of Rolando Martin, in De nerv. corp. hum., Holmiae et Lipsiae, 1781, secto secunda, p. 216; by Gruber, in Arch. für Anat., 1870, p. 501; by Letiévant, in Soc. chir., Paris, 1867 et in Traité des sections nerveuses., Paris, 1873, p. 45, by Frantz Glénard, by Audibert et Savy, in the Bull. de la Soc. des conf. anat. de Lyon, and by Henle, in his classic treatise Handb. der Nervenlehre, 1879, p. 549.

The anterior interosseous branch of the median nerve to m. abductor indicis and to the first dorsal interosseous muscles (3% of individuals) have been described. The third, fourth, and fifth common digital branches of the median may arise in the proximal forearm and enter the hand independently. The anterior and posterior interosseous nerves may communicate at the lower end of the interosseous space.

The median may communicate with the musculocutaneous nerve. In 50% of individuals, the part of flexor digitorum profundus to the index and middle fingers is supplied by the median nerve while the part to the ring and little finger is supplied by the ulnar. The median nerve may encroach on the part of the muscle supplied by the ulnar nerve. Only rarely does the ulnar nerve encroach to supply the middle finger (medial distal edge) part of flexor digitorum profundus.

The median nerve may innervate, in part, biceps brachii and brachialis muscles.

Occasionally, the median nerve (and brachial artery) passes through a channel formed by a supracondylar process and ligament, where it (they) may become compressed, producing clinical symptoms.

A median nerve was found entering the belly of flexor digitorum superficialis, on its lateral side, and emerging from its tendon (to the index finger) about 25 mm above the wrist joint.

The median nerve may pass into the hand within the flexor retinaculum, where it may also give rise to the motor recurrent branch. The recurrent branch may also arise above or pass through the retinaculum to reach the thenar muscles.

Classification of Median Nerve Anomalies in the Carpal Tunnel (from the wrist flexor crease to the superficial palmar arch.) (from Amadio)

Type

Approximate incidence in 275 carpal tunnel releases.

High Division

3

Open branching

2

Closed loop

<1

Motor Branch

19

Transretinacular

15

Multiple

2

Multiple and Transretinacular

2

Palmar Cutaneous Branch

2.5

Transretinacular

2.5

Multiple

0

Multiple and Transretinacular

0

Median-ulnar sensory ramus (arising on median nerve proximal to superficial arch)

1

Unclassified

0

The median nerve may be perforated by the median artery, when present.

Riche-Cannieu anastomoses (between the median and ulnar nerves in the palm of the hand) may exist in 70% of individuals. Martin-Gruber (median-ulnar nerves) anastomoses in the forearm have a reported frequency of 15%. It should be remembered that the "anastomoses" occur between the median, ulnar, radial, and musculocutaneous nerves, as well as between other nerves. These are errors in the pathway (course) of some, inappropriately placed nerve fibers. In order for these nerve fibers to get to their proper end-point, the bundle of nerves fibers leave the inappropriate trunk and join the proper nerve trunk. Both Martin-Gruber and Riche-Cannieu "anastomoses" are examples of nature's correction of nerve fibers located in inappropriate nerve pathways. Certainly a mystery, these "anastomoses". On a broader and larger scale, the brachial plexus and sacral plexuses are other examples of neuronal sorting.

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Image 31G Image 31H Image 31I Image 31J Image 32A

Image 32B Image 32C Image 32D Image 32E Image 32F

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Image 45 Image 46 Image 47 Image 48 Image 49

Image 50 Image 51 Image 52A Image 52B Image 53A Image 53B

Image 54 Image 57 Image 60 Image 62A Image 96


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