Clinical Anatomy 26:10281030 (2013)

ORIGINAL COMMUNICATION

Ulnar Nerve Innervation of the Medial Head of

the Triceps Brachii Muscle:
A Cadaveric Study
1

3


MARIOS LOUKAS,1,2* SHARATH S. BELLARY,1 NESLIHAN YUZBAS

IOGLU,
4
5
MOHAMMADALI M. SHOJA, R. SHANE TUBBS, AND ROBERT J. SPINNER6

Department of Anatomical Sciences, School of Medicine, St Georges University, Grenada, West Indies
2
Department of Anatomy, Medical School Varmia and Mazuria, Olsztyn, Poland
3
Department of Anatomy, Istanbul Medipol University School of Medicine, Istanbul, Turkey
4
Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
5
Childrens Hospital, Pediatric Neurosurgery, Birmingham, Alabama
6
Departments of Neurologic Surgery, Orthopedics, and Anatomy, Mayo Clinic, Rochester, Minnesota

Although the ulnar nerve is closely associated with the triceps brachii muscle,
the literature does not normally describe it as supplying this muscle. However,
recent research has examined the ulnar nerve in the upper arm and identied
branches supplying the medial head of the triceps brachii muscle. This study
aims to expand upon this research by describing the course and incidence
of these branches in a larger sample size. We examined 50 specimens in
25 cadavers. Ulnar innervation of the medial head of the triceps brachii was
identied in 14 specimens (28%). The mean distance of the ulnar nerve branch
midpoint was 26% along a line between the surgical neck and an epicondyle
line, with a range of 1139%. Innervation of the triceps brachii muscle by the
ulnar nerve has important clinical and surgical implications. Clin. Anat.
26:10281030, 2013. VC 2013 Wiley Periodicals, Inc.
Key words: ulnar nerve; triceps brachii; medial head of triceps

INTRODUCTION
Traditionally, the triceps brachii muscle has been
described as receiving its entire motor innervation from
the radial nerve, with the major contributions arising
from C6 and C8 nerve roots (Gu, 1997; Standring
et al., 2008). The branching pattern of the radial nerve
branches to the triceps brachii muscle, however, may
be variable (Guse and Ostrum 1995; Ozer et al., 2006;
Bekler et al., 2009). For example, radial nerve trifurcation has been observed at the lateral aspect of the humerus with one branch penetrating the medial head of
the triceps brachii muscle (Gerwin et al., 1996; Standring et al., 2008), though it is possible that such a
branch merely passes through the medial head on its
way to innervate the anconeus (Standring et al., 2008).
Additionally, a branch has been observed traveling parallel to the ulnar nerve (ulnar collateral branch of the
radial nerve) (Anson, 1963).
Recently, reports have described an ulnar innervation of the medial head of the triceps brachii muscle

C
V

2013 Wiley Periodicals, Inc.

(Bekler et al., 2009; Miguel-Perez et al., 2010). This

study aimed to expand our current understanding of
ulnar innervation of the medial head of the triceps
brachii muscle and determine the prevalence of this
variable anatomy.

MATERIALS AND METHODS

Twenty-ve human cadavers (50 limbs) were dissected during the gross anatomy course at the School
of Medicine at St. Georges University in Grenada,
*Correspondence to: Marios Loukas, Department of Anatomical
Sciences, St. Georges University, School of Medicine, Grenada,
West Indies. E-mail: mloukas@sgu.edu
Received 5 May 2011; Revised 20 March 2013; Accepted 22
April 2013
Published online 29 May 2013 in Wiley Online
(wileyonlinelibrary.com). DOI: 10.1002/ca.22270

Library

Ulnar Nerve Innervation of the Medial Head of the Triceps Brachii Muscle 1029
West Indies during 20072009. These cadavers (13
female, 12 male) ranged in age at the time of death
from 68 to 93 years with a mean age of 78 years. All
cadavers were xed with formalin/phenol/alcohol
solution. None of the cadavers revealed any evidence
of gross pathology, previous surgical procedures, or
traumatic lesions to the upper limbs.
The ulnar nerve was dissected from its origin from
the brachial plexus to its termination in the hand. Following a preliminary examination, images from all dissected specimens were recorded with a Nikon digital
camera (model: Nikon D40) and studied using a computer-assisted image analysis system (Lucia software
5.0 [2000, edition for Windows XP], made by Nikon
[Laboratory Imaging Ltd.]). The digital camera was
connected to an image processor (Nvidia GeForce
6800 GT) linked to a computer. Digitized images of
the radial and ulnar nerves, together with their surrounding structures, were stored in the Lucia program, (2048 3 1536 pixels). After applying a
standard 1 mm scale to all pictures, the program was
able to use this information to calculate pixel differences between two selected points, such as the origin
and termination of a given nerve, as previously
described (Loukas et al., 2008). The purpose of the
software was to allow easy and accurate translation of
pixel differences into metric measurements as previously described (Loukas et al., 2008).
Specically, the presence of an ulnar nerve
branch(es) to the triceps brachii muscle was determined, along with the location and morphology of the
branch and its innervation. The distance was measured from the origin of the ulnar branch (from the
ulnar nerve main trunk) to its point of termination
(the point of entrance into the medial head of triceps
brachii muscle). Subsequently, by using points of origin of the branch from the ulnar nerve, we calculated
the location of the ulnar branches innervating the triceps brachii muscle with reference to two anatomical
lines. The proximal reference point was dened as the
point on the surgical neck of the humerus where it
was crossed by a line perpendicular to the long axis of
the humerus. Similarly, the distal reference point was
the intersection of the above noted line with the interepicondylar line of the distal humerus. Having dened
these reference points, the ulnar branches were localized and their location was expressed in centimeters
and as a percentage of the distance between the
proximal and distal points. The purpose of converting
raw data to percentages was to allow for standardization against variation of the morphometric measurements of the arm. Finally, the ulnar branches were
transected at their midpoint and their diameter
measured.
Statistical analysis between sides and genders
was performed using Students t-test with statistical
signicance set at P < 0.05.

Fig. 1. The picture depicts the ulnar nerve at the distal portion of the humerus giving off several branches to
the medial head of the triceps. [Color gure can be
viewed in the online issue, which is available at
wileyonlinelibrary.com.]

(Fig. 1). Bilateral occurrence of these branches

occurred in three (2.15%) specimens. The remaining
specimens showed unilateral distribution of these ulnar
nerve branches. In all specimens, the ulnar nerve
pierced the medial intermuscular septum, inclining
medially as it descended anteriorly to the medial head
of the triceps brachii muscle to the interval between
the medial epicondyle and olecranon process. All nerve
branches from the ulnar nerve innervating the medial
head of the triceps brachii muscle were found to arise
after the ulnar nerve pierced the medial intermuscular
septum.
The mean distance of the ulnar nerve branch midpoint of the intersection point along the surgical neck
and the interepicondylar line of the distal humerus
was 26% or 7.28 cm (from distal to proximal), with a
range of 11% (3.1 cm) to 39% (10.9 cm) (Fig. 2).
The length of the ulnar nerve branches ranged from
1.2 to 4.5 mm, with a mean of 3.4 mm. The mean diameter of the ulnar nerve branches was 0.9 mm with
a range of 0.61.3 mm. No statistically signicant differences were noticed in the ulnar nerve branches
with regard to side or gender.

DISCUSSION
RESULTS
Ulnar nerve branches to the triceps brachii muscle
were found in 14 (28%) of the 50 dissected arms and
were always seen penetrating into the medial head

The ulnar nerve is normally described as a terminal

branch of the brachial plexus, specically from the
medial cord, with major contributions from C7, C8,
and T1 (Sunderland, 1978; Gu, 1997; Standring
et al., 2008). It is not thought to branch before

1030 Loukas et al.

important clinical and surgical ramications. Clinicians
may misinterpret data and come to wrong conclusions
based on the retention of triceps brachii muscle function following injury to the radial nerve or impingement of cervical nerve roots C7 and C8. Surgeons can
easily injure the ulnar nerve branch to the medial
head of the triceps brachii muscle during posterior
approaches to the elbow, for example, ulnar nerve
transposition. Potentially, a surgeon could utilize such
branches as part of a novel nerve transfer (neurotization) to restore function in a denervated muscle in the
upper limb. Such a nerve transfer procedure would
result in little postoperative dysfunction of the triceps
brachii muscle due to its robust innervation from the
radial nerve.

CONCLUSIONS
Contrary to standard information, the ulnar nerve
can innervate the medial head of the triceps brachii
muscle. This variant anatomy has important clinical
and surgical implications.

REFERENCES
Fig. 2. This picture depicts the mean distance of the
ulnar nerve branch midpoint along the intersection
between the surgical neck and the interepicondylar line of
the distal humerus. Having dened these reference
points, the ulnar branches were localized and their location was expressed in centimeters and as a percentage of
the distance between the proximal and distal points.
[Color gure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]

passing from distal to the medial epicondyle (Linell,

1921; Sunderland, 1978; Doyle and Botte, 2003;
Standring et al., 2008). Ulnar innervation to the triceps brachii muscle has recently been identied
(Bekler et al., 2009). Prior studies have, however,
been limited in sample size and in describing the precise location of such ulnar nerve branches. Bekler
et al. (2009) described the presence of this variation
in 11/18 specimens (61%), but did not elaborate on
this morphology. Miguel-Perez et al. (2010) described
this variation in a single cadaveric dissection. In this
study with a larger sample size, ulnar innervation of
the triceps brachii muscle was observed in 28% of
specimens. In all specimens, the ulnar nerve supplied
branches to the medial head of the triceps brachii
muscle after passing through the intermuscular septum proximal to the elbow joint. Our study aimed to
expand on this knowledge and provide insight into the
course of these ulnar nerve branches in order to promote awareness of this anatomic variation.
Ulnar innervation of the medial head of the triceps
brachii muscle independent of the radial nerve has

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