Beruflich Dokumente
Kultur Dokumente
PMID: 12960925
Received: 2002.06.20
Accepted: 2003.02.28
Published: 2003.09.08
Authors Contribution:
A Study Design
B Data Collection
C Statistical Analysis
D Data Interpretation
E Manuscript Preparation
F Literature Search
G Funds Collection
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Basic Research
Summary
Background:
We aimed to determine the presence of median and ulnar nerve communication in the forearm by anatomical and electrophysiological examinations in the Anatolian population.
Material/Methods:
30 forearms from 15 preserved cadavers (2 females, 13 males, 4265 years of age) were carefully dissected to observe median and ulnar nerve communication. We also performed median
and ulnar nerve motor conduction studies by recording the thenar, hypothenar and first dorsal
interosseous (FDI) muscles, stimulating both nerves at distal and proximal points, and the
recordings were compared in 60 forearms (30 subjects, 17 female, 13 male, 3467 years of age).
Results:
Conclusions:
In this study group, the ratio of MGC was revealed as 3.3% and 6.6%, in the electrophysiological and anatomical examination, respectively. Knowledge of this crossover is of crucial importance in the clinical evaluation of nerve injuries of the median and ulnar nerves, as well as in
accurate interpretation of nerve conduction velocity of these nerves, especially in association
with carpal tunnel syndrome. Anatomical and electrophysiological classifications of MartinGruber communication are reviewed.
key words:
Full-text PDF:
Word count:
Tables:
Figures:
References:
Authors address:
http://www.MedSciMonit.com/pub/vol_9/no_9/2866.pdf
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3
47
Levent Sarikcioglu, Department of Anatomy, Faculty of Medicine, Akdeniz University, 07070 Antalya, Turkey,
email: levent@med.akdeniz.edu.tr or sarikcioglul@yahoo.com
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BACKGROUND
Median-ulnar communication in the forearm was first
described by the Swedish anatomist Martin [1] in 1763,
and later by Gruber [2] in 1870. This communication is
now known as the Martin-Gruber communication
(MGC). The incidence of MGC ranges from 5% to 34%.
The vast majority of these connections cross over from
median to ulnar nerve. Sometimes, one communicating
branch may link from ulnar to median nerve, which is
known as reversed MGC, ulnar-to-median communication, or Marinacci communication [3].
MGC is traditionally diagnosed based upon changes in
the amplitude of the compound muscle action potential
(CMAP) in routine nerve conduction studies [4].
Knowledge of this crossover is of crucial importance in
the clinical evaluation of nerve injuries of median and
ulnar nerves, as well as in accurate interpretation of the
nerve conduction velocity of these nerves, especially in
association with carpal tunnel syndrome [5]. The presence of the MGC in patients with carpal tunnel syndrome results in a partial or total sparing of thenar
muscles from denervation and the paradoxical recording of normal proximal latencies in the median nerve
when the distal latency is prolonged [6].
In the present study, we aimed to determine the presence of median and ulnar nerve communication in the
forearm by anatomical and electrophysiological examinations in an Anatolian population.
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Table 1. MGC classifications. (Abbreviation: MN: median nerve UN: ulnar nerve, AIN: anterior interosseous nerve).
Srinivasan
Rodriguezand Rhoden Nakashima
Niedenfuhr
[39]
[24]
[22, 44]
Hirasawa
[45]
Thomson
[46]
AIN and UN
Oblique
anastomosis
Class I
Type I, II, VI
Type Ia
MN and UN
Oblique
anastomosis
Class II
Type III
Type Ib
Communication between
Pattern I
(Type Ic),
Pattern II
Pattern I
(Type Ia, Ib)
Type I
Type II
Type II
Preston [7],
Oh [8],
Kimura [9]
Type I
Type II
Type III
Class III
Type II
Type III
Type III
Type IV
Type IV, V
Type III
(combination
of Type Ia, Ib
and II)
RESULTS
that obtained with wrist stimulation. CMAP results
recorded from the hypothenar muscles in routine ulnar
studies are normal. To demonstrate an MGC in this
situation, the ulnar nerve was stimulated at the wrist
and below the elbow while recording the thenar muscles, looking for a drop in CMAP amplitude between
wrist and below-the-elbow.
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Table 2. Documented occurrence of MGC from the latest literature. (Abbreviations: : no data could be found, ?: unknown percentage (case report)).
Author
Gruber F [2]
Mannerfelt L [26]
Rosen AD [20]
Kimura et al [27]
Kimura et al [27]
Vasickova Z [28]
Streib EW [29]
Gessini et al. [30]
Snirvasaan R and Rhoden J [24]
Ropert A and Metral S [31]
Kimura et al. [19]
Brandsma et al. [32]
Kayamori R [5]
Uncini et al. [33]
Hoph HC [34]
Valls-Sole J [35]
Uchida Y and Sugioka Y [36]
Uchida Y and Sugioka Y [36]
Amoiridis G [37]
Amoiridis G [37]
Hoogbergen MM and Kauer JM [38]
Nakashima T [39]
Okuno Y and Kasai T [40]
Sander et al. [4]
Taams KO [16]
Taams KO [16]
Chantelot et al. [41]
Budak F and Gonenc Z
Shu et al.
Gumusburun E and Adiguzel E [42]
Stancic et al. [43]
Simonetti S [13]
Rodriguez-Niedenfuhr et al [22]
Rodriguez-Niedenfuhr et al [44]
Erdem et al. [15]
Present study
Present study
Year
1870
1966
1973
1976
1976
1977
1979
1981
1981
1981
1983
1986
1987
1988
1990
1991
1992
1992
1992
1992
1992
1993
1994
1997
1997
1997
1999
1999
1999
2000
2000
2001
2002
2002
2002
%
15.2
15.0
5
17
39.6
?
?
15.5
?
1.3
?
14
?
?
?
17
16
32
?
21.3
?
?
23
?
17.5
23.6
?
?
57
13.6
13.1
27
6.6
3.3
(see Table 1). In the other case, it was between the median
nerve and the ulnar nerve (Type Ib) (see Table 1). By
electrophysiological recordings, we found MGC in 2 of 60
forearms (3.3%) examined in vivo. One of these had type I
MGC (Figure 2) and the other had type II (Figure 3).
There were no subjects who had type III MGC.
The MGCs were found on the right side in both
anatomical and electrophysiological examinations.
DISCUSSION
The literature contains descriptions of well-documented
MGCs and their frequencies (Table 2). The high incidence of a similar connection in monkeys and apes suggests that these communications are of phylogenetic significance [10].
The incidence of MGC is reported to range from 5% to
34% [11]. Horiguchi et al. [12] reported 25% frequency
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Subjects
38/250
6/41
5/96
57/328
/303
42/106
1
1
31/200
4
2/150
2
83/600
2
1
1
8/47
14/87
32/100
1
28/108
3
1
14/112
1
19/108
17/72
1
1
24/42
19/140
31/236
27/100
2/30
2/60
in anatomical examination, and 18.5% in electrophysiological examination. Simonetti [13] found a much higher incidence (57%) in electrophysiologic examination.
The frequency of occurrence in the Anatolian population was reported by Budak and Gonenc [14] to be
17.5%, and 27% by Erdem et al. [15]. In the present
study, while anatomical examination showed MGC in 2
of 30 (6.6%) upper extremities, electrophysiological
examination revealed 2 MGCs in 60 subjects (3.3%). We
found MGC less frequently than reported in the available literature. We believe that these differing frequencies in the Anatolian population should be corrected by
studies with larger samples.
It has been suggested that unilateral MGC occurs more
often in the right side than the left [16]. In our cases,
MGCs were also found on the right side in both anatomical and electrophysiological examination.
CONCLUSIONS
In this study group, the frequency of occurrence of
MGC was found to be 3.3% and 6.6% in electrophysiological and anatomical examination, respectively. By
recognizing the existence of different types of connections, mistakes in diagnosis of peripheral nerve lesions
in the forearm can be avoided. The possible existence of
these connections is also important for surgical and electrophysiological procedures, especially in association
with carpal tunnel syndrome.
REFERENCES:
1. Martin F: Tal om nervers allmanna agenskaler i manniskans kropp.
ed Stockholm: L. Salvius; 1763
2. Gruber W: ber die verbindung des nervus medianus mit dem
nervus ulnaris am unterarme des menschen und der saugethiere.
Arch Anat Physiol Med Leipzig, 1870; 37: 501-522 (cited by
Srinivasan and Rhodes)
3. Marinacci A: The problem of unusual anomalous innervation of
hand muscles: the value of electrodiagnosis in its evaluation. Bull
Los Angeles Neurol Soc, 1964; 29: 133-142
4. Sander HW, Quinto C, Chokroverty S: Median-ulnar anastomosis
to thenar, hypothenar, and first dorsal interosseous muscles: collision technique confirmation. Muscle Nerve, 1997; 20: 1460-2
5. Kayamori R: Electrodiagnosis in Martin-Gruber anastomosis.
Nippon Seikeigeka Gakkai Zasshi, 1987; 61: 1367-72
6. Iyer V, Fenichel GM: Normal median nerve proximal latency in
carpal tunnel syndrome: a clue to coexisting Martin-Gruber anastomosis. J Neurol Neurosurg Psychiatry, 1976; 39: 449-52
7. Preston DC, Shapiro BE: Electromyography and Neuromuscular
Disorders: Clinical-Electrophysiologic Correlations. ed Boston:
Butterworth-Heinemann; 1998
8. Oh S: Clinical Electromyography: Nerve Conduction Studies. 2nd
ed. Baltimore: Williams & Wilkins; 1993
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1999; 21: 115-8
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Surg [Am], 1992; 17: 47-53
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International K.K.; 1996
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crossover in Martin-Gruber anastomosis. Muscle Nerve, 2001; 24:
380-6
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extremities (an electrophysiological study). Electromyogr Clin
Neurophysiol, 1999; 39: 231-4
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anatomical study. J Hand Surg [Br], 1997; 22: 328-30
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26. Mannerfelt L: Studies on the hand in ulnar nerve paralysis. A clinical-experimental investigation in normal and anomalous innervation. Acta Orthop Scand, 1966; 87: 1
27. Kimura J, Murphy MJ, Varda DJ: Electrophysiological study of
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