Title: Extensor Carpi Radialis Brevis to Anterior Interosseous Nerve Transfer.
Published: 4/11/2011, Updated: 4/11/2011.

Author(s): Susan E. Mackinnon MD, Andrew Yee BS.
Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO.

The senior author’s preferred nerve transfer to reinnervate anterior interosseous nerve (AIN) function is the brachialis to anterior interosseous nerve transfer. However, in cases with major brachial plexus injuries, the brachialis nerve will not be available as a donor nerve due to its C5,6 root origination. In these cases, the nerve to the extensor carpi radialis brevis (ECRB) is an excellent donor nerve substitute when available. The ECRB to AIN nerve transfer is an easier and quicker transfer when compared to the brachialis to AIN nerve transfer due to a few different technical points. These technical points include that the ECRB to AIN nerve transfer does not require interfascicular dissection and the nerve transfer is closer to the AIN motor targets than the brachialis transfer. The surgical exposure for the ECRB to the AIN nerve transfer occurs in the proximal-forearm, at the level of the median nerve, where the AIN branches and is easily identified lateral to the median nerve. In comparison, the brachialis to AIN nerve transfer occurs in the mid-arm and requires intrafascicular dissection of the median in order to mobilize the recipient AIN fascicle for transfer. In summary, for severe brachial plexus injuries, the ECRB nerve is an excellent donor nerve choice to reinnervate AIN function when the brachialis nerve is not available.

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  Figure 1 - Identification of Median Nerve Branches 265.8 KB
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  Figure 2 – Identification of Radial Nerve Branches 269.0 KB
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  Figure 3 – Isolating the Donor and Recipient Nerve 301.2 KB
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  Figure 4 – ECRB to AIN Nerve Transfer 293.0 KB

PROCEDURE: Extensor Carpi Radialis Brevis to Anterior Interosseous Nerve Transfer.

Donor Nerve: Extensor carpi radialis brevis nerve branch of the radial nerve.
Recipient Nerve: Anterior interosseous nerve of the median nerve.
Nerve Coaptation: End-to-end.

Incision Description:

• A lazy-S volar incision is made in the proximal-forearm, about 12cm in length.

Sugical Steps:
Exposure and Dissection:

1. Incise skin and dissect through subcutaneous tissue.

Median Nerve Decompression and Exposure:

2. In the distal portion of the incision, the radial vessels are identified and the radial sensory nerve is identified. The pronator teres tendon is located between these two structures.
3. A step-lengthening tenotomy of the pronator teres tendon is performed at this level.
4. Moving proximally in the forearm, the median nerve is identified just medial to the radial vessels.
5. The deep head of the pronator teres is divided to expose the median nerve.

Extensor Carpi Radialis Brevis to Anterior Interosseous Nerve Transfer:

6. The anterior interosseous nerve is identified as the major branch coming off of the median nerve on the radial side.
7. There is a cleavage plain between the anterior interosseous nerve and the median nerve that allows for the proximal neurolysis of the anterior interosseous nerve for additional length.
8. The anterior interosseous nerve is stimulated to confirm that it is not functioning.
9. The nerve to the extensor carpi radialis brevis (ECRB) is then identified by following the radial sensory nerve proximally and observing the nerve branch takeoff of the smaller nerve to the ECRB. This nerve is stimulated to confirm function.
10. The donor nerve, ECRB, is divided distally.
11. The ECRB nerve is transposed towards the anterior interosseous nerve (AIN).
12. The recipient nerve, AIN, is divided proximally.
13. The nerve repair is completed with no tension on the repair through full range of movement of the extremity.