1. Chinese Medical Journal 2008; 121(2):99-104 99
Repair of brachial plexus lower trunk injury by transferring
brachialis muscle branch of musculocutaneous nerve:
anatomic feasibility and clinical trials
ZHENG Xian-you, HOU Chun-lin, GU Yu-dong, SHI Qi-lin and GUAN Shi-bing
Keywords: brachialis muscle branch; median nerve; finger flexion; nerve transfer; brachial plexus injury
Background There are few effective methods for treating injuries to the lower trunk of brachial plexus, and the curative
effect is usually poor. The purpose of this study was to provide anatomic references for transferring the brachialis muscle
branch of musculocutaneous nerve (BMBMCN) for selective neurotization of finger flexion in brachial plexus lower trunk
injury, and to evaluate its clinical curative effects.
Methods Microanatomy and measurement were done on 50 limbs from 25 adult human cadavers to observe the origin,
branch, type of the BMBMCN and median nerve, as well as their adjacent structures. Internal topographic features of the
fascicular groups of the median nerve at the level of the BMBMCN were observed. In addition, the technique of BMBMCN
transfer for selective neurotization of finger flexion of the median nerve was designed and tested in 6 fresh adult human
cadavers. Acetylcholinesterase (AchE) staining of the BMBMCN and median nerve was done to observe the features of
the nerve fibers. This technique was clinically tried to restore digital flexion in 6 cases of adult brachial plexus lower trunk
injury. These cases were followed up for 3, 6, 9 and 12 months postoperatively. Recovery of function, grip strength, nerve
electrophysiology and muscle power of the affected limbs were observed and measured.
Results The brachialis muscle was totally innervated by the musculocutaneous nerve (MCN). Based on the Hunter’s
line, the level of the origin of the BMBMCN was (13.18±2.77)cm. AchE histochemical staining indicated that the
BMBMCN were totally made up of medullated nerve fibers. At the level of the BMBMCN, the median nerve consistently
collected into three fascicular groups as shown by microanatomy in combination with AchE stain. The posterior fascicular
group was mainly composed of anterior interosseous nerves and branches to the palmaris longus. The technique was
tested in six fresh cadavers successfully, except that stoma split occurred in one case. Five of the six cases recovered
digital flexion 12 months after operation, and at the same time grip strength, muscle power, and nerve electrophysiology
also recovered markedly.
Conclusions The technique of transferring the BMBMCN for selective neurotization of finger flexion is anatomically
safe and effective, with satisfactory clinical outcomes.
Chin Med J 2008;121(2):99-104
rachial plexus injury is a common and
frequently-occurring clinical problem, the incidence
of which has been on the rise in recent years. At present,
nerve transfer is the principal approach to repair brachial
Compared with injuries to the upper
trunk of brachial plexus, there are relatively few methods
for repairing injuries to the lower trunk, which mainly
include transferring intercostal nerve, phrenic nerve or
contralateral C7 nerve for the purpose of reconstructing
finger flexion, but the therapeutic outcome was
unsatisfactory and less than 50% of the cases could
resume muscle power above M3.3-5
There is therefore an
urgent need for seeking a novel operation modality to
help reconstruct finger flexion quickly and effectively. In
the present study, we conducted an intensive study on the
feasibility of transferring the brachialis muscle branch
with musculocutaneous nerve (BMBMCN) to repair the
median nerve and reconstruct finger flexion, based on
which we applied this technique to clinical cases and
observed the therapeutic outcome.
Used in this experimental study were 50 upper limbs
from 25 adult human cadavers fixed in 10% formalin and
12 upper limbs from 6 adult fresh human cadavers
(obtained from Department of Anatomy, Fudan
University, Shanghai, China).
A z-shaped longitudinal incision extending to the infra-
Department of Orthopedics, Changzheng Hospital, Second
Military Medical University, Shanghai 200003, China (Zheng XY,
Hou CL and Guan SB)
Department of Hand Surgery, Huashan Hospital, Fudan University,
Shanghai 200040, China (GU YD and Shi QL)
Correspondence to: Dr. GU Yu-dong, Department of Hand Surgery,
Huashan Hospital, Fudan University, Shanghai 200040, China (Tel
and Fax: 86-21-62489999. Email: firstname.lastname@example.org)
This study was supported by a grant from the Major State Basic
Research Development Program of China (973 Program, No.
2. Chin Med J 2008;121(2):99-104100
Figure 1. Incision.
Figure 2. Findings during the operation: BMBMCN (green arrow), lateral antebrachialcutaneous nerve (yellow arrow), and median nerve
Figure 3. Transferring of the BMBMCN (green arrow) to the posterior fascicular group of the median nerve (blue arrow) to reconstruct
the finger flexion.
Figure 4. The BMBMCN (green arrow) was anastomosised to the posterior fascicular group of the median nerve (blue arrow).
clavicular part was made to expose the cords and
branches of the brachial plexus located in the medial part
of the upper arm. After marking the natural position of
the median nerve, microdissection and measurement were
carried out carefully with assistance of the headset
surgical loupe (2.5 power).
(1) The origin, branch, and type of the BMBMCN and
median nerve, and their adjacent structures;
(2) Level of the BMBMCN origin on the basis of the
(3) Internal topographic features of the fascicular groups
of the median nerve at the level of BMBMCN separated
retrogradely from the trunk and its muscular branches of
the median nerve in the arm. 10% acetic acid solution
was applied to the nerve fibers in order to loosen the
connective tissue and for the convenience of observation;
(4) Acetylcholinesterase (AchE) staining of the BMBMCN
and median nerve at the level of BMBMCN of the 12
limbs from the 6 fresh cadavers to observe features of the
Mimic operation of transferring the BMBMCN for
selective neurotization of finger flexion was performed
on the 12 limbs from the 6 fresh cadavers. Postoperative
abduction, elevation, flexion, extension, external rotation
and internal rotation of the shoulders, and flexion and
extension of the elbows were tested passively to see
whether there was any collapse of the nerve stomas.
Every action was repeated at least three times.
A retrospective study was done on the cases of injuries to
the brachial plexus lower trunk from October 2001 to
August 2004. The subjects included 5 males and one
female whose age ranged from 28 to 49 years with a
mean of 35 years. The course of injury ranged from 3 to
20 months with a mean of 6.88 months. According to the
level and severity, the injuries were classified as simple
lower trunk injury in 2 cases, and middle trunk + lower
trunk complete injury in 4 cases including one with
combined partial upper trunk injury whose elbow flexion
had been normal but electromyographic study showed a
simple phase of the brachialis muscle.
A 10–15 cm long longitudinal incision was made in the
middle and inferior part of the medial upper arm. The
BMBMCN was found at 9–18 cm proximal to the
Hunter’s line, and was disconnected after local blockade
with 1% lidocaine. The dissociable length of the
BMBMCN was then measured. Furthermore, the median
nerve was detected in the medial of the musculocutaneous
nerve. The fascicular group selectively innervating finger
flexion of the median nerve was cut off after
disassociation beneath the myelin sheath. Finally, the
nerves were sutured by 6-8 stitches with 9-0 no-healing
suture with the assistance of a 10 power surgical
microscope (Figures 1–4).
Follow-up and measurements
The cases were followed up for 3, 6, 9 and 12 months
postoperatively for observation of (1) functional
recovery of the limbs, including impediment of elbow
flexion, impediment of two-point discrimination and
wrist flexion; (2) grip strength as measured by the
Biometrics 5.0 dynamometer, based on which the grip
recovery rate was calculated by comparing it with the
unaffected side. (3) nerve electrophysiological parameters,
including the latency phase (LAT), the maximum evoked
potential amplitude (AMP), motor nerve conduction
velocity (MNCV) of the median nerve, by using Dantec
2000M myo-electrophysiograph, based on which the
conduction recovery rate was calculated by comparing
them with the unaffected side; (4) muscle power of the
thumb and the index finger using Medical Research
Council (MRC) standard, based on which the fineness
rate was assessed. According to MRC standard, muscle
power of the thumbs and index fingers was measured 12
months after operation. Muscle power was classified as
excellent (above M4), good (M2–M3), and poor (below
The values obtained are expressed as mean ± standard
deviation (SD), and data were analyzed by the SPSS 12.0
3. Chinese Medical Journal 2008; 121(2):99-104 101
Figure 5. The results indicated the median nerve consistently collected into three fascicular groups at least in the level of the BMBMCN,
which were located at the anterior (thick green arrow), middle, and posterior (slender green arrow) parts of the median nerve trunk. The
schematic diagram in the bottom left had shown the cross-sectional features in the level of the BMBMCN (green part referred to motor
nerve fibers; and blue part referred to sensory nerve fibers.)
Figure 6. The natural position of the median nerve must be marked preoperatively (arrow referred to the posterior of the median nerve),
then the separation were performed.
Figure 7. After the separation of the median nerve, the posterior fascicular group (blue arrow) was cut to be prepare to anastomosise
with the BMBMCN (green arrow).
Figure 8. The BMBMCN (green arrow) was anastomosised to the posterior fascicular group of the median nerve (blue arrow. Yellow
arrow referred to the site of the anastomosis).
statistical software. The significance of the difference was
calculated by analysis of variance (ANOVA). A P value
<0.05 was considered statistically significant.
Origin, branch and adjacent structures of the nerves
The microanatomical study of the 50 limbs from the 25
adult human cadavers showed that the brachialis muscle
was totally innervated by the musculocutaneous nerve
and doubly innervated by the radial nerve in the
anteroinferior part of the brachialis muscle in about 22
cases (44%). The length of BMBMCN was (4.84±1.29)
cm, the diameter was (1.69±0.30) mm, and the number of
branches was (1.16±0.55). According to the type of
BMBMCN, there were three types as observed in our
study: type I of single branch in 45 limbs (90%), type II
of two branches in 3 limbs (6%), and type III of multiple
branches in 2 limbs (4%).
At the same time, microanatomy of the median nerve
indicated that there were 44 limbs (88%) of superior
position type, 4 limbs (8%) of inferior position type, and
2 limbs (4%) of simple-root type.
At the level of the BMBMCN origin, the distance
between the BMBMCN and the median nerve was about
(2.23±0.97)cm, so that anastomosis of them could be
Localization of BMBMCN
Based on the Hunter’s line, the level of the BMBMCN
origin ranged from 8.7 cm to 18.2 cm with a mean of
Internal topographic features of the median nerve
After retrograde separation, the internal topographic
features of the fascicular groups of the median nerve were
observed at the level of BMBMCN. The results indicated
the median nerves consistently collected at least into three
fascicular groups at the level of BMBMCN, which were
located at the anterior, middle, and posterior parts of the
median nerve trunk. The anterior fascicular group was
composed of the branches of the pronator teres and the
flexor carpi radialis; the posterior fascicular group was
composed mainly of the anterior interosseous nerve (the
branch of the long flexor muscle of thumb, the branch of
the proximal part of deep flexor muscle of fingers and the
branch of the quadrate pronator muscle), the branches of
the palmaris longus and the branch of the partial
superficial flexor muscle of fingers; and the middle
fascicular group was made up mostly of the sensory and
motion branches to the hand (the trunk of the median
nerve) and the branches of the partial flexor digitorum
superficialis (Figure 5).
Histochemical stain of AchE
AchE histochemical stain indicated that the BMBMCN
was totally made up of medullated nerve fibers, whose
stain area was confined to the axon, and the medullary
sheath was not AchE stained. According to AchE
histochemical stain of the median nerve at the level of
BMBMCN, the internal topographic features of the
fascicular groups of the median nerve were observed
using the Leica FW4000 imaging analysis system, which
geared to the microanatomic findings. The anterior and
posterior fascicular groups were mainly composed of
motor nerve fibers, and the middle fascicular group was
mostly made up of sensory nerve fibers.
Results of the mimic operation
Figures 6–8 show the procedure of the mimic operation
of transferring the BMBMCN for selective neurotization
of finger flexion in the 12 limbs from the 6 fresh cadavers.
All cases were successfully incised through a 10–15 cm
long incision without tension at the site of anastomosis, or
occurrence of secondary injuries to the nerves and vessels.
After operation, passive activity of the shoulders and
elbows was tested. Stoma split was observed in one case,
because the BMBMCN origin in this limb was located
16.2 cm above the Hunter’s line. This indicates the
4. Chin Med J 2008;121(2):99-104102
importance of secure postoperative external fixation.
The 6 cases were followed up for 12–28 months with a
mean of 16 months. No secondary injury to the nerves
and vessels occurred during the operation, and no
postoperative complication such as infection and
ulceration in the limbs was noticed.
Functional recovery of the affected limbs
No impediment of elbow flexion or change of two-point
discrimination in the thumbs and index fingers occurred
in any case. Digital flexion was recovered in 5 of the 6
cases 12 months after operation. For the patient who
failed to recover digital flexion within 18 postoperative
months, contralateral C7 was transferred to repair the
Recovery of grip strength
Grip strength recovered gradually with the lapse of time.
There was a significant difference in the recovery rate of
grip strength between the two groups using SNK method
(P <0.05, Table 1).
Nerve electrophysiological parameters recovered in
varying degrees with the lapse of time (Table 1). There
was no significant difference in the recovery rate of
evoked potential of the median nerve between 3- and
6-month groups (P>0.05). There was no significant
difference in the recovery rate of motor nerve conduction
of the median nerve between 3- and 6-month groups
(P>0.05). The differences were otherwise significant
(P<0.05) using SNK method.
Table 1. The recovery rate of the grip power and nerve
electrophysiological items after lower trunk
injury (%, mean ± SD)
Time (m) Grip strength LAT AMP MNCV
3rd 26.14±3.56 18.68±2.32 28.53±2.12*
6th 36.04±4.66 32.33±3.36 33.58±2.54*
9th 48.91±5.78 44.68±2.56 53.26±1.24 49.87±2.24
12th 66.04±3.21 63.89±4.12 70.32±3.66 60.23±5.03
All comparisons of the the grip strength recovery rate between every two groups
were statistically significant, P<0.05. As for the electrophysiological study,
significant differences were noted between the every two groups except for *the
evoked potential amplitude recovery rate between third month and group sixth
and the motor nerve conduction velocity recovery rate between third
month and sixth month (P>0.05). LAT, latency phase; AMP, amplitude; MNCV,
motor nerve conduction velocity.
Muscle power study
In this study, 5 cases were excellent, and one case was
Significance of the technique
At present, the principal approach to the treatment of
brachial plexus injury is nerve transfer. A new chapter has
been opened in the repair of brachial plexus injury since
Dr. GU YD created phrenic and contralateral C7 nerve
transfer and applied them in clinical practices.6,7
brachial plexus upper trunk injuries, there have been
many repairing methods aimed at reconstructing the
functions of the shoulders and elbows, including
traditional or video-assisted thoracoscopical phrenic
nerve, intercostal nerve, the fascicular groups of ulnar
nerve or median nerve transfer to MCN to reconstruct
elbow flexion; accessory nerve transfer to suprascapular
nerve to reconstruct shoulder abduction with the anterior
or posterior approach; and ipsilateral C7 nerve transfer to
the upper trunk to reconstruct shoulder abduction and
On the whole, there are numbers of
methods to choose for the repair of upper trunk injuries.
The curative effect is usually good, and 50%–84.6%
cases are able to recover muscle power above M3. But
there have been fewer methods for the repair of injuries to
the brachial plexus lower trunk, which mainly include
intercostal nerve, phrenic nerve or contralateral C7 nerve
transfer to reconstruct finger flexion. In addition, the
curative effect is poor, and fewer than 50% cases can
recover muscle power above M3. Patients with lower
trunk injury often lose most of their hand functions,
especially paralysis of the flexion muscle of the arm,
impairment of finger flexion, and incapacitation of the
intrinsic muscles of the hand. It is therefore urgent to seek
a new method of reconstructing finger flexion quickly
Gu YD et al advanced the idea of
constructing finger flexion by transferring the BMBMCN
from the upper trunk. But more deep-going study on the
anatomic feasibility of this technique is required, and
more clinical cases are needed to testify the clinical
feasibility and effectiveness of this technique.
Anatomic feasibility of the technique
Firstly, the components of the nerve fibers in the
BMBMCN and internal topographic features of the
fascicular groups of the median nerve at the level of
BMBMCN determine the effectiveness of the new
technique of transferring the BMBMCN for selective
neurotization of finger flexion in injury to the brachial
plexus lower trunk. This is one of the anatomic
foundations of the technique. On the one hand, the nerve
fibers in the BMBMCN are simply motor nerve fibers.
AchE histochemical stain revealed that the BMBMCN
were totally made up of medullated nerve fibers. So it is
beneficial to the enhancement of the curative effects by
transferring the BMBMCN as the power source of repair
due to decrease in the axonal mismatching rate of the
motor nerve fibers and reduction in irregular growth of
the fibers. On the other hand, the median nerves
consistently collect into three fascicular groups at the
level of BMBMCN. In their study of the internal
topographic features of the fascicular groups of the
median nerve in the arm, Zancolli et al18
found that there
was a distinguished boundary between the sensory
fascicles and the motor fascicles in the inferior parts of
the upper arm. Furthermore, the microanatomic
observation of this study revealed that the median nerves
consistently collect at least into three fascicular groups at
5. Chinese Medical Journal 2008; 121(2):99-104 103
the level of BMBMCN, which were located at the
anterior, middle, and posterior parts of the median nerve
trunk. Among them, the posterior fascicular group was
mainly composed of the anterior interosseous nerve, the
branch to the palmaris longus and the branch of the
partial superficial flexor muscle of fingers.19,20
Transferring the BMBMCN to the posterior fascicular
group of the median nerve with a distance of (2.23±0.97)
cm could reconstruct finger flexion definitely. In a word,
this study suggests that transferring the BMBMCN for
selective neurotization of finger flexion is an effective
and anatomically feasible technique.
Secondly, elbow flexion remains normal after BMBMCN
transfer. Less residual function impairment after the
procurement of posterior fascicular groups of the median
nerve ensures the safety of the new technique. This is
another anatomic foundation of the technique. On the one
hand, microanatomy revealed that the brachial muscle
was a secondary muscle for elbow flexion and was
compensated by the covered biceps muscle in the 2/3 of
the anteriomedial side and the brachioradial muscle in the
1/3 of the anteriolateral side.21
Moreover, this study
showed that 44% of the middle and inferior part of the
brachialis muscle was doubly innervated by the radial
nerve. So no significant influence on elbow flexion was
induced by BMBMCN transfer. On the other hand, our
cases demonstrated that less residual function impairment
after the procurement of posterior fascicular groups of the
median nerve. In this study, slight sensory defects in the
thumbs occurred in 2 cases within 3 months
postoperatively, but the impaired sensation did not
recover to the preoperative level until 6 months
postoperatively, suggesting that there was little
impairment to the residual function of the median nerve.
In short, our anatomical study indicates that the new
technique is safe.
Advantages and disadvantages of the technique
Our clinical study demonstrated the following advantages
of the technique: The procedure can be completed
conveniently and practicably by a single incision; the
nerves can be anastomosed at a go without tension, thus
promoting the curative effects of the technique; and the
obvious shortening of the distance between the donor
nerve and the recipient nerve allows for quick recovery of
finger flexion due to acceleration of nerve regeneration.
This study also indicates that the BMBMCN is an
effective and safe donor nerve due to less impairment to
This study also found some disadvantages of the
technique. First of all, it has strict indications, thus
limiting its clinical use. The precondition of this
technique is that there is no impairment to BMBMCN as
a donor nerve. In addition, it is unable to repair the
function of the internal muscle of the hand.
Operative cautions of the technique
Firstly, clinical studies have shown the indications of the
new technique, including single lower trunk injury or
proximal median nerve injury, especially in cases with a
long course of disease but without occurrence of
irreversible fibrosis in the innervated muscle. When
functional impairment or loss occurs in the upper or
middle trunk, the donor BMBMCN is likely to be
affected, and the outcome is usually poor. In this study,
there was one case where the brachial plexus lower trunk
was damaged completely and the upper and middle trunk
was injured incompletely, digital flexion failed to recover
within 18 months after operation possibly due to
preoperative injury to the donor BMBMCN or sensory
impairment of the hand.
Secondly, it plays a key role in maintaining the function
of median nerve. During the procurement of the posterior
fascicular group of the median nerve, the residual
function of the median nerve should be protected to the
best. Furthermore, functional preservation of the median
nerve helps recovery of digital flexion because it reduces
impairment to the sensation of the radial half in the
Thirdly, separation and electric stimulation can be used
during the operation to distinguish the BMBMCN and
lateral antebrachial cutaneous nerve of the BMN more
Fourthly, distinguishing the finger flexion fascicular
group of the median nerve during operation is of great
significance. The finger flexion fascicular group lies in
the posterior 1/3 part according to the preoperatively
marked natural position of the median nerve. The harvest
should be done with the assistance of the surgical
microscope and testified by SEP examination.
Finally, the study recommends postoperative external
fixation of elbow flexion by 90 degree to prevent stoma
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(Received January 23, 2007)
Edited by HAO Xiu-yuan