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The Double Anastomotic Innervation of Thenar Muscles

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The Double Anastomotic Innervation of Thenar Muscles J. Anat. (1971), 109, 3, pp. 461-466 461 With 3 figures Printed in Great Britain The double anastomotic innervation of thenar muscles DAN HARNESS AND ELIEZER SEKELES Department of Anatomy The Hebrew University-Hadassah Medical School Jerusalem, Israel, P.O.B. 1172 (Accepted 27 April 1971) INTRODUCTION Terminal anastomoses between motor nerves may provide muscles with double motor innervation, and are important for the motor innervation of the hand, in particular the thenar muscles. We were interested in the anastomosis between the recurrent branch of the median nerve' and the deep branch of the ulnar nerve, first described by Cannieu in 1896 and Riche in 1897. Preliminary dissections showed a much higher percentage of anastomoses than previously reported, thus motivating the present study. Cannieu (1897) and Riche (1897) reported that the anastomosis occurred between a ramus of the recurrent branch of the median nerve supplying the superficial head of the flexor pollicis brevis, and the anastomotic ramus of the deep branch of the ulnar nerve supplying the deep head of the flexor pollicis brevis (Fig. 1). The anast- omotic branch appears between the two heads of the adductor pollicis and then circles round the tendon of the flexor pollicis longus on its lateral side, forming an ansa. According to the classification of Paturet (1958) the anastomosis of Cannieu and Riche is of the simple type, i.e. the anastomotic fibres pass transversely or ansiformly to become enclosed by a common sheath. Hovelacque (1927) noted the following variations: (1) According to Chevrier (1904) it can be a separate branch of the median nerve to the superficial head of the flexor pollicis brevis which sends a ramus to the anast- omosis. In this case, the anastomosis can be located either on the surface of, or deep in, the flexor pollicis brevis (Fig. 2a). (2) The anastomosis can be with one of the two digital branches of the thumb coming from the median nerve. In this case, the anastomosis is located medial to the tendon of the flexor pollicis longus and sometimes double or triple anastomoses can be found (Figs. 2b, 3). Riche, quoted by Hovelacque (1927), mentions two other possibilities: (3) Anastomosis between one of the branches of the digital nerve of the thumb and the branch to the adductor pollicis, coming from the deep branch of the ulnar nerve. This anastomosis is also medial to the tendon of the flexor pollicis longus and is located deep in the adductor pollicis, in which case there is no ulnar innervation to the deep head of the flexor pollicis brevis (Fig. 2c). 1 This branch, called 'recurrent' by Grant and Basmajian (1965), is the one described in Gray's Anatomy (34th ed., 1967) as the muscular branch of the median nerve in the palm of the hand. 462 DAN HARNESS AND ELIEZER SEKELES (4) The anastomosis passes through the first lumbrical, which then receives its innervation from the deep branch of the ulnar nerve (Fig. 2d). MATERIALS AND METHODS Thirty-five hands, obtained from adult cadavers of both sexes and of different ages, were dissected. The cadavers had been exposed to the routine preservation method usual in our laboratory (Sekeles & Gitlin, 1970). In 19 cases this procedure was carried out at least 6 months previously while the 16 other cases were preserved only two days prior to dissection. Median nerve Superficial and deep heads of flexor Ulnar nerve pollicis brevis Flexor retinaculum 'Recurrent' branch Deep branch of Anastomosis - ulnar nerve Branch to deepBrnht head of f l head ofe flexor xreraor ~~~~~~~~adductor pollicist pollicis brevis I ,,\AAI I I Oblique and transverse heads of adductor pollicis Tendon of flexor pollicis longus Fig. 1. Schematic representation of the various structures in the palm concerned with the formation of the Cannieu and Riche anastomosis. Dissection. The median nerve was traced into the palm, and its branches there were identified. We found it advisable to dissect on the ulnar side of the nerve in order to protect the recurrent branch, which originates on its radial side. The re- current branch was identified and isolated along its entire path in the thenar eminence. The deep branch of the ulnar nerve was then exposed and followed from its origin, lateral and distal to the pisiform, through the origin of the hypothenar muscles, continuing posterior to the flexor tendons of the fingers until it entered the adductor pollicis and gave rise to the anastomotic branch. The anastomotic branch was then carefully followed on the anterior surface of, or through, the adductor pollicis until, passing near the deep head of the flexor pollicis brevis, it either en- circled the tendon of the flexor pollicis longus or passed medial to it, to join the anastomotic branch of the median nerve. RESULTS In 27 of the 35 hands that we dissected an anastomosis was detected; 13 of these 27 anastomoses were in accordance with the description of Cannieu (1897) in that the anastomotic ansa circled round the lateral side of the tendon of Innervation of thenar muscles 463 flexor pollicis longus (Fig. 1). In the other 14 hands all the variations mentioned above were detected; in all these the anastomosis lay medial to the tendon of the flexor pollicis longus (Figs. 2, 3). In all 16 cases which were dissected in a fresh state an anastomosis was found. It was observed that the larger the deep branch of the ulnar nerve, the larger was the anastomotic ansa. (a) (b) 3 (C) (d) 3 Fig. 2. Schematic representation of the variations in the Cannieu and Riche anastomosis. 1, Median nerve; 2, ulnar nerve; 3, deep branch of ulnar nerve; 4, branch to deep head of flexor pollicis brevis; 5, branch to adductor pollicis; 6, digital branch to thumb; 7, recurrent branch; 8, separate branch of median nerve to the superficial head of flexor pollicis brevis; 9, digital branch to index finger. A, Anastomosis. DISCUSSION Except in French anatomy books, such as those of Hovelacque (1927), Paturet (1958), Poirier (1901), Rouviere (1948), and in some others, such as Kaplan (1953) and Villiger (1924), no special attention has been paid to the anastomosis of Cannieu and Riche. Cannieu (1897) reported an anastomosis between the recurrent branch of the 464 DAN HARNESS AND ELIEZER SEKELES median nerve and the deep branch of the ulnar nerve in 3 out of the 20 hands which he dissected. His report does not mention the possibility of double innervation to the muscles of the thenar eminence. Other dissections dealt in detail with the double innervation of thenar muscles but did not describe the path taken by the nerves to reach the muscle. Thus, Brooks (1886) had already found, in 19 out of 31 hands, double innervation of the flexor pollicis brevis. Day & Napier (1961) found double innervation of the deep head of the flexor pollicis brevis in 5 out of 24 hands, and, in 7 out of 30 hands, of the super- ficial head of the same muscle. When they performed the dissection according to Brooks' method, Day & Napier (1961) found double innervation of both the deep and superficial heads of the flexor pollicis brevis in 20 % of cases. Fig. 3. A photograph ofa dissected hand, showing an anastomosis between the deep branch of the ulnar nerve and the digital branch of the thumb coming from the median nerve (see Fig. 2b). For the purpose of photography the flexor retinaculum was cut, the tendons of flexor muscles and lumbricals removed, and the median nerve reflected over to the radial side revealing its posterior aspect. A, Anastomosis. 1, Median nerve; 2, deep branch ofulnar nerve; 3, digital branch to the thumb; 4, digital branch to index finger; 5, other digital branches of median nerve; 6(a) oblique head of adductor pollicis, (b) transverse head of adductor pollicis; 7, flexor retinaculum (cut). Electromyographical examinations, alone or combined with percutaneous stimula- tion, have contributed to knowledge of the double innervation of thenar muscles. Sala (1958) reported double innervation of the flexor pollicis brevis in three hands out of every four examined. Forrest & Basmajian (1965) and Forrest (1967) found that the superficial head of the flexor pollicis brevis, as described by Cruveilhier Innervation of thenar muscles 465 (1834),' received double innervation by ulnar and median branches in 17 out of 25 cases. Clinical reports have emphasized the importance of double innervation of the thenar muscles in complete paralysis of the median or ulnar nerves. Highet (1943) reported that out of 45 patients with complete division of the ulnar or median nerves he found only 5 with degeneration or complete paralysis of the flexor pollicis brevis. This muscle, according to Basmajian (1967) and others, is responsible for powerful opposition. Bunnell (1949) stated that opposition is not lost after complete severance of the median nerve because of the innervation by the ulnar nerve. Murphey, Kirklin & Finlayson (1946) and Clifton (1948), although speaking of an anomalous innerva- tion, did report cases of complete function of the hand and thumb after interruption of the ulnar and median nerves, respectively. Rowntree (1949) attempted to analyse the innervation of the individual muscles of the thumb, and found that in 226 hands the ulnar nerve supplied flexor pollicis brevis partially in 15 %, and completely in 32%. The existence of a terminal anastomosis in the depth of the thenar eminence, in 27 out of the 35 hands dissected by us (77 %) suggests that this anastomosis serves as a path by which nerve fibres of median and ulnar origin may effect a double innervation of the muscle. Forrest's supposition (1967) that 'Muscles situated in close proximity to anastomotic branches, and supplied by them, will possess a double innervation', may be supported by our findings, as is his conclusion that terminal motor anastomoses between the median and ulnar nerves might be more frequent than has hitherto been admitted.
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