Preserved Sensation of the Palmar Radial Hand by the Superficial Branch of the Radial Nerve Following Median Nerve Laceration: A Case Report
Sean M. Wade, MD1, DesRaj M. Clark, MD1, Matthew E. Miller, MD1, Jason M. Souza, MD1, Leon J. Nesti, MD, PhD2 and Scott M. Tintle, MD3, (1)Walter Reed National Military Medical Center, Bethesda, MD, (2)Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, (3)Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD
Introduction: Multiple variations of sensory innervation patterns in the hand exist and are well recognized in the literature. This report discusses the case of an active duty servicemember who was found to have the superficial branch of the radial nerve innervating his hand's classically described median nerve sensory distribution following a transection of the proximal median nerve resulting from a gunshot wound to the brachium sustained in combat.
Methods: The patient provided his consent to have his operative reports, clinical notes, and electrodiagnostic evaluations analyzed with the purpose of creating this case report. The scientific literature was rigorously reviewed for additional reports detailing aberrant hand innervation patterns in order to help create this case report.
Results: Initial operative exploration of the patient's right brachium following his ballistic injury demonstrated segmental injury to both the median and ulnar nerves. Sensory neurological exam of the injured upper extremity by a multi-disciplinary peripheral nerve care team demonstrated preserved sensation to the medial and lateral forearm and to the palmar and dorsal aspects of radial hand encompassing the base of the thenar eminence, thumb, index, and long fingers while sensation was absent along the remainder of the palmar surface of the hand extending along both the palmar and dorsal aspects of the small and ring fingers. The patient subsequently underwent ulnar nerve grafting in the brachium followed by multiple tendon transfers to reanimate and restore sensation his hand and wrist flexion. Based upon the very proximal location of the large median nerve defect, closely located to a brachial artery graft, and the aberrant preservation of sensation of the radial hand, the surgical team did not reconstruct the median nerve gap as it did not seem clinically necessary or worth the added risk. The patient eventually regained rudimentary flexion of the digits and wrist with sensory restoration to the medial forearm. He was able to remain on active duty following his reconstructive surgeries and
Discussion/Conclusion: These aberrant patterns can lead to diagnostic challenges and complicate the treatment of nerve-injured patients. Therefore, it is important to understand these variations in order to help avoid potential clinical errors in caring for these patients. To date, most descriptions of aberrant innervation patterns in the upper extremity involve interneural connections between branches of the median and ulnar nerves with a paucity of descriptions involving the radial nerve.
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