Mateusz Gładysz FESSH prep

FESSH prep Peripheral nerve injury Principles of nerve transfer; Oberlin and double fascicular transfers for elbow flexion; distal anterior interosseous to ulnar and median to radial transfers; supercharged end to side transfer

Nerve transfers: principles and classic donors

Last reviewed v1.0

FESSH-039Peripheral nerve injury●●○ intermediate

Regarding nerve transfers for upper-limb nerve injury:

  1. 1.A nerve transfer allows a single tension-free end-to-end coaptation close to the target without an interposition graft, so that a maximal number of motor axons can reach the motor end plates within the critical reinnervation period.

  2. 2.In the Oberlin transfer for C5–C6 avulsion, fascicles amounting to roughly 10 per cent of the ulnar nerve are coapted directly to the motor branch to biceps, without significant impairment of hand function.

  3. 3.Distal nerve transfer for a high ulnar nerve injury requires the sacrifice of forearm pronation, because the anterior interosseous nerve branch to pronator quadratus is used as the donor to the deep motor branch.

  4. 4.The supercharged end-to-side anterior interosseous-to-ulnar motor nerve transfer alone is intended as the definitive reconstruction for a complete (fifth-degree) transection of the ulnar nerve.

  5. 5.Distal transfers from the median nerve in the forearm have been described to restore wrist and finger extension after radial nerve palsy, as an alternative to interposition nerve grafting or tendon transfer.

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Question ID
FESSH-039
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. A nerve transfer allows a single tension-free end-to-end coaptation close to the target without an interposition graft, so that a maximal number of motor axons can reach the motor end plates within the critical reinnervation period.

    True

    Mackinnon and Novak set out the principle: good motor function after a motor nerve injury requires a maximal number of motor axons reaching the end plate within a critical time, and nerve transfers eliminate the need for a graft by allowing a direct end-to-end repair without tension. Grafting requires two coaptation sites and long regeneration distances for proximal injuries, whereas a transfer converts the injury into a distal one; Dahlin notes that considering nerve transfers in the treatment arsenal can shorten the time to reinnervation of muscle targets. The donor must be expendable, ideally synergistic, and close to the recipient.

    • Mackinnon SE, Novak CB. Nerve transfers. New options for reconstruction following nerve injury. Hand Clin. 1999;15(4):643-66, ix. PMID 10563268
    • Grinsell D, Keating CP. Peripheral nerve reconstruction after injury: a review of clinical and experimental therapies. Biomed Res Int. 2014;2014:698256. PMID 25276813
    • Dahlin LB. The role of timing in nerve reconstruction. Int Rev Neurobiol. 2013;109:151-64. PMID 24093611

  2. 2. In the Oberlin transfer for C5–C6 avulsion, fascicles amounting to roughly 10 per cent of the ulnar nerve are coapted directly to the motor branch to biceps, without significant impairment of hand function.

    True

    Oberlin's 1994 anatomical study and first four cases harvested ten percent of the bulk of the ulnar nerve for direct suture to the motor nerve of the biceps with no significant impairment of hand function. Mackinnon's double fascicular modification adds a median nerve fascicle to the brachialis branch: in six patients clinical reinnervation appeared at a mean of 5.5 months and elbow flexion recovered to a mean of MRC grade 4+ without functional or sensory donor morbidity, and in Ray's series of 29 cases 97% regained elbow flexion (M5 in eight, M4 in 15, M3 in four) with no deficit in the donor distributions.

    • Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am. 1994;19(2):232-7. PMID 8201186
    • Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am. 2005;30(5):978-85. PMID 16182054
    • Ray WZ, Pet MA, Yee A, Mackinnon SE. Double fascicular nerve transfer to the biceps and brachialis muscles after brachial plexus injury: clinical outcomes in a series of 29 cases. J Neurosurg. 2011;114(6):1520-8. PMID 21351836

  3. 3. Distal nerve transfer for a high ulnar nerve injury requires the sacrifice of forearm pronation, because the anterior interosseous nerve branch to pronator quadratus is used as the donor to the deep motor branch.

    False

    The terminal anterior interosseous nerve branch to pronator quadratus is the donor, but pronation is preserved by pronator teres. In Novak and Mackinnon's series all patients had reinnervation of the ulnar-innervated intrinsic muscles with improved lateral pinch and grip strength, and no functional deficit in tasks performed in pronation was reported. Brown's technical paper describes the three distal transfers used for a high ulnar injury: anterior interosseous nerve to the deep motor branch, the third web-space sensory contribution of the median nerve to the volar sensory component of the ulnar nerve, and end-to-side reinnervation of the dorsal cutaneous branch from the median sensory trunk.

    • Novak CB, Mackinnon SE. Distal anterior interosseous nerve transfer to the deep motor branch of the ulnar nerve for reconstruction of high ulnar nerve injuries. J Reconstr Microsurg. 2002;18(6):459-64. PMID 12177812
    • Brown JM, Yee A, Mackinnon SE. Distal median to ulnar nerve transfers to restore ulnar motor and sensory function within the hand: technical nuances. Neurosurgery. 2009;65(5):966-977; discussion 977-978. PMID 19834412

  4. 4. The supercharged end-to-side anterior interosseous-to-ulnar motor nerve transfer alone is intended as the definitive reconstruction for a complete (fifth-degree) transection of the ulnar nerve.

    False

    Barbour and Mackinnon describe the supercharged end-to-side (SETS) transfer as a procedure with broad utility for second- and third-degree axonotmetic injuries, to augment partial recovery and to babysit the motor end plates until the native parent axons regenerate to target; the donor is coapted end-to-side to the deep motor branch, preserving the distal ulnar motor pathway. Complete proximal transection does not exclude adjunctive SETS: Koriem and colleagues prospectively compared ulnar repair plus SETS in 11 patients with isolated repair in 10. SETS does not itself restore continuity across an unrepaired proximal transection and is therefore not a stand-alone definitive reconstruction of that injury. Functional motor recovery depends on the time to end-plate reinnervation and the number of regenerating axons that reach the target.

    • Barbour J, Yee A, Kahn LC, Mackinnon SE. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation. J Hand Surg Am. 2012;37(10):2150-9. PMID 23021177
    • Koriem E, El-Mahy MM, Atiyya AN, Diab RA. Comparison Between Supercharged Ulnar Nerve Repair by Anterior Interosseous Nerve Transfer and Isolated Ulnar Nerve Repair in Proximal Ulnar Nerve Injuries. The Journal of hand surgery. 2020;45(2):104-110. PMID 31866151

  5. 5. Distal transfers from the median nerve in the forearm have been described to restore wrist and finger extension after radial nerve palsy, as an alternative to interposition nerve grafting or tendon transfer.

    True

    Brown, Tung and Mackinnon describe the use of distal nerve transfers for restoration of radial nerve function in the forearm, in place of the traditional options of interposition grafting or tendon transfer, using expendable median-innervated donors coapted to the recipient branches for wrist and finger extension close to their targets. Brown and Mackinnon's review of transfers in the forearm and hand argues that distal transfers often give a reconstruction superior to traditional grafting, particularly for proximal injuries where a graft would require regeneration over a long distance and two coaptations. Tendon transfers remain the alternative when the delay exceeds the reinnervation window.

    • Brown JM, Tung TH, Mackinnon SE. Median to radial nerve transfer to restore wrist and finger extension: technical nuances. Neurosurgery. 2010;66(3 Suppl Operative):75-83; discussion 83. PMID 20124928
    • Brown JM, Mackinnon SE. Nerve transfers in the forearm and hand. Hand Clin. 2008;24(4):319-40, v. PMID 18928884