Journal Pre-proof

The absent musculocutaneous nerve: A systematic review

Dawn D. Hunter, Matthew J. Zdilla

PII: S2214-854X(20)30031-5
DOI: https://doi.org/10.1016/j.tria.2020.100092
Reference: TRIA 100092

To appear in: Translational Research in Anatomy

Received Date: 23 July 2020

Revised Date: 22 September 2020
Accepted Date: 23 September 2020

Please cite this article as: D.D. Hunter, M.J. Zdilla, The absent musculocutaneous nerve: A systematic
review, Translational Research in Anatomy (2020), doi: https://doi.org/10.1016/j.tria.2020.100092.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2020 Published by Elsevier GmbH.

Author Contributions:

Dawn D. Hunter – Research design, systematic review of literature, manuscript preparation,

critical revision, and final approval of manuscript

Matthew J. Zdilla – Research design, systematic review of literature, manuscript preparation,

critical revision, and final approval of manuscript

of
ro
-p
re
lP
na
ur
Jo
Title of Article: The absent musculocutaneous nerve: A systematic review

Running Title: The absent musculocutaneous nerve

Article Category: Systematic Review

Author Names and Institution Affiliations: Dawn D. Hunter, Ph.D.1, Matthew J. Zdilla,
D.C.1,2,3*

1. Department of Pathology, Anatomy, and Laboratory Medicine (PALM), West Virginia

University School of Medicine, Robert C. Byrd Health Sciences Center, Morgantown,

of
West Virginia, USA.
2. Department of Natural Sciences and Mathematics, West Liberty University, West

ro
Liberty, West Virginia, USA.
-p
3. Department of Graduate Health Sciences, West Liberty University, West Liberty, West
Virginia, USA.
re
lP

*Correspondence to: Dr. Matthew J. Zdilla, Department of Pathology, Anatomy, and Laboratory
Medicine (PALM), West Virginia University School of Medicine, Robert C. Byrd Health
na

Sciences Center, Morgantown, West Virginia, 26506 (USA)

Tel.: +1-304-293-0598; Fax: +1-304-293-8159; E-mail: matthew.zdilla@hsc.wvu.edu

ur

Author ORCIDs:
Jo

Dawn D Hunter: 0000-0002-7187-9222

Matthew J Zdilla: 0000-0002-2578-1128

Conflicts of Interest: The authors have no conflicts of interest to report.

Financial Disclosure: The authors have no financial contributions.

1
Abstract:

The musculocutaneous nerve is occasionally absent in humans. Accordingly, there may be

unforeseen clinical implications regarding the atypical innervation of the musculature otherwise
supplied by the musculocutaneous nerve. Case reports and prevalence studies have detailed the
absence of the musculocutaneous nerve; however, a systematic review has not been conducted.
Therefore, this report utilized Preferred Reporting Items for Systematic Reviews and Meta-
analysis (PRISMA) guidelines to identify 24 manuscripts for qualitative synthesis, including 16
cases and eight cross-sectional studies detailing 482 limbs from 241 individuals. The prevalence

of
of the absence of the musculocutaneous nerve among limbs ranged from 1.66% (1:60 limbs) to
13.33% (4:30 limbs). However, females were under-represented among reports—only 8.7%

ro
(21:241) of the population studied. The review identified that in the absence of the
-p
musculocutaneous nerve, the biceps brachii, brachialis, and, when present, accessory head of the
biceps brachii were almost always innervated by branches of the median nerve. The
re
coracobrachialis was innervated by branches from, most commonly, the lateral cord and less
lP

commonly, the lateral root of the median nerve or a recurrent branch from the median nerve. In a
typical median nerve injury, clinical manifestations would include motor and sensory deficits in
na

the wrist and hand. However, a high median nerve injury occurring in the absence of a
musculocutaneous nerve would have an atypical clinical presentation—specifically, weakness in
ur

shoulder and elbow flexion, weakness in supination, and also cutaneous sensory loss to the
Jo

lateral forearm in addition to the typical median nerve palsy affecting the wrist and hand.

Keywords: anatomy; anatomical variation; brachial plexus; median nerve; systematic review

2
1. Introduction:

The musculocutaneous nerve (C5-C7) arises from the lateral cord of the brachial plexus and
provides motor innervation to the coracobrachialis, biceps brachii, and brachialis as well as
sensory innervation to the lateral forearm by way of the lateral cutaneous nerve of the forearm
[1, 2]. The aforementioned musculature primarily provides arm flexion, arm adduction, forearm
flexion, and supination.

The median nerve (C5-T1) typically arises from two roots: a lateral root (C5-C7) and a medial

of
root (C8-T1). The median nerve, as opposed to the musculocutaneous nerve, has no somatomotor
or somatosensory function in the arm. Rather, the median nerve is generally responsible for

ro
responsible for the innervation of the forearm pronators and flexors, aside from flexor carpi
-p
ulnaris and the ulnar aspect of flexor digitorum profundus, as well as innervating some intrinsic
musculature of the hand, in addition to much of the skin of the palm and fingers. Accordingly,
re
median nerve damage manifests in varied loss of pronation, finger and wrist flexion, as well as
lP

sensory deficits in the hand, but no change in the movement or sensation of the arm.
na

Embryological studies suggest that the musculocutaneous nerve is derived from the median
nerve [1]. Indeed, a communicating branch may be found between the musculocutaneous and
ur

median nerves [3]. However, in some individuals the musculocutaneous nerve is absent, thus
Jo

representing a failure of separation from the median nerve. If the musculocutaneous nerve is
absent, the musculature of the arm would require innervation from a surrogate nerve— likely, the
median nerve due to location, embryological relationship, and overlap in ventral rami
contributions. In the case where a median nerve acted as a surrogate for an absent
musculocutaneous nerve, an injury to the proximal median nerve would lead to palsy of arm
flexion, arm adduction, forearm flexion, and supination in addition to loss of cutaneous sensation
from the lateral antebrachium, in addition to widespread loss of function in the typical median
nerve distribution.

Musculocutaneous nerve absence is supposedly a rare anatomical variation; however, a

systematic review, specific to reports detailing the absence of the musculocutaneous nerve, has

3
never been conducted. Therefore, this report provides a systematic review of the literature
detailing the absence of the musculocutaneous nerve.

2. Materials and Methods:

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines
were utilized to perform the systematic review [4]. The Anatomical Quality Assessment
(AQUA) tool was utilized to assess the risks of bias [5, 6].

2.1. Systematic Review Search Strategy:

of
The MEDLINE database was searched via the PubMed search engine. The following search

ro
terms were utilized: “musculocutaneous nerve” in varied combinations with “absent,” “absence,”
“missing,” “aplasia,” and “aplastic.” These terms were searched in both the title and abstract of
-p
MEDLINE records. Therefore, the script utilized in the search therefore read as follows:
re
((((((musculocutaneous nerve[Title/Abstract]) AND aplastic[Title/Abstract])) OR
lP

((musculocutaneous nerve[Title/Abstract]) AND aplasia[Title/Abstract])) OR

((musculocutaneous nerve[Title/Abstract]) AND missing[Title/Abstract])) OR
na

((musculocutaneous nerve[Title/Abstract]) AND absence[Title/Abstract])) OR

((musculocutaneous nerve[Title/Abstract]) AND absent[Title/Abstract]).
ur

The authors read the titles and abstracts of all studies in tandem from two separate computers.
Jo

There was no blinding of any details of MEDLINE records (e.g., journal titles, author names,
author affiliations, dates, etc.). The search was performed for all articles ab initio until 10 May
2019.

2.2. Systematic Review Study Selection Criteria:

Anatomical studies of humans that contained information about the musculocutaneous nerve
were included. Studies describing non-human species, studies describing clinical circumstances
(e.g., trauma, surgery), and studies of genetic diseases were excluded. Furthermore, studies in
which manuscripts were written in non-English languages were excluded. There were no filters
used for date.

4
3. Results:
3.1. Study Selection:
The MEDLINE search identified 63 records. Of the 63 records, there were seven duplicated
records that were removed. Therefore, 56 records were screened and subsequently assessed for
eligibility. A total of 32 articles were excluded as result of the eligibility screening. Accordingly,
a total of 24 records were included in the qualitative synthesis (Fig. 1).

3.2. Description of the Studies:

of
The majority of studies included in the review were those of case reports (15:24: 62.5%).

ro
Otherwise, the search revealed one correspondence article describing a case (1:24: 4.2%), and
eight cross-sectional studies (8:24; 33.3%). A summary of studies detailing the absence of the
-p
musculocutaneous nerve is found in Table 1 [7-30].
re
lP

Of the 16 cases (including the correspondence article) reviewed, 7 documented a unilateral left-
sided absence, 5 documented a right-sided absence, and 4 revealed a bilateral absence. Further,
na

13 of the 15 case reports (86.7%) described the absence of the musculocutaneous nerve in males.
The two case reports (13.3%) describing absence in females reported bilateral absences. The
ur

correspondence article by Nakatani et al. [30] described the absence of the musculocutaneous
nerve in the left limb of a male. Considering the correspondence article as the summary of an
Jo

isolated case alongside the compilation of case reports— 14 of 16 (87.5%) descriptions of cases
identified the absence of the musculocutaneous nerve in males and 2 of 16 (12.5%) identified
absence of the nerve in females.

The eight cross-sectional studies included a total of 482 limbs from 241 individuals. The
prevalence of the absence of the musculocutaneous nerve among limbs ranged from 1.66% (1:60
limbs) to 13.33% (4:30 limbs) [10, 24]. However, the study that documented the greatest
prevalence of 13.33% (4:30 limbs) was performed on a sample consisting of only 15 cadavers of
unspecified sex [10]. The largest population study included a study sample of 116 limbs,
revealing the second-highest prevalence of absence in 11.21% of limbs (13:116 limbs) [13].
However, it is important to note that, in the aforementioned study, 98 of the 116 limbs were from

5
males [13]. Furthermore, the study with the third-largest prevalence of 8.33% of limbs (2:24
limbs), was performed among a sample of 22 male limbs and only 2 female limbs (11 males and
one female cadaveric sample) [27]. Indeed, every study that assessed prevalence had at least
double the sample of males than females (Table 2)[8, 10, 12, 13, 18, 24, 26, 27]. The distribution
of females represented in studies ranged from 2.4% (1:41) to 33.3% (10:30). Overall, the
prevalence of females represented among studies was 8.7% (21:241). Therefore, females should
be considered under-represented, relative to males, with regard to study of musculocutaneous
nerve absence.

of
Of the eight cross-sectional studies, seven provided information regarding laterality. Only one of

ro
the seven cross-sectional studies which addressed laterality noted a bilateral absence [10].

-p
The absence of the musculocutaneous nerve was found among varied geographic and racial
re
populations including those described as Indian [7], Japanese [30], black [27], white [27], and
lP

Caucasian [22]. Additionally, absence of the musculocutaneous nerve was identified in both fetal
and adult populations [18].
na
ur

4. Discussion:
This report is the first systematic review to provide detailed examination of reports noting an
Jo

absence of the musculocutaneous nerve. The prevalence of the absence of the musculocutaneous
nerve among limbs ranged from 1.66% (1:60 limbs) to 13.33% (4:30 limbs). This review adds
novel insights to the body of literature regarding brachial plexus variations. Specifically, this
information identifies common patterns with regard to the lateral cord and median nerve serving
as surrogates in the absence of the musculocutaneous nerve. The aforementioned variant
innervation patterns have important clinical implications particularly in the event of a proximal
median nerve lesion.

4.1. Muscular Innervations in the Absence of the Musculocutaneous Nerve:

The coracobrachialis, which typically receives innervation from the musculocutaneous nerve,
received varied innervations in the absence of the musculocutaneous nerve. The coracobrachialis

6
was supplied by branches from, most commonly, the lateral cord. Less commonly, the
coracobrachialis, received innervation from the lateral root of the median nerve or a recurrent
branch from the median nerve. Further, the systematic review revealed reports that suggested
that the motor branches to the coracobrachials were small and friable [16, 20].

In the absence of the musculocutaneous nerve, the biceps brachii and brachialis typically
received innervation from the median nerve. However, the biceps brachii and brachialis have
also been reported to receive innervation from the lateral root of the median nerve [26].
Likewise, reports identifying the nerve supply to the skin of the lateral forearm noted that the

of
lateral forearm was supplied by branches arising from the median nerve.

ro
Some concurrent variations were noted in the absence of the musculocutaneous nerve. An
-p
accessory head of the biceps brachii was documented in 3 of the 14 case reports (21.4% of
re
reports).
lP

4.2. Regarding Sex:

na

The review identified clear bias with regard to subject demographic sampling, namely with
regard to sex. Every study that assessed prevalence had at least double the sample of males than
ur

females (Table 2) [8, 10, 12, 13, 18, 24, 26, 27]. Further, only 2 of the 15 cases (13.3%) were
those describing the absence of the musculocutaneous nerve in females. Both of the cases
Jo

describing absence in females described bilateral absences. The bilateral absence of the
musculocutaneous nerve in a male has, however, been described by Ihunwo et al [29].

It is unclear if there is variation in the prevalence or presentation of musculocutaneous absence

between males and females due to sampling bias. The sampling bias is also suggestive of the
possibility of reporting bias regarding cases. Future studies should therefore be performed with
the inclusion of greater proportions of females than have been included in prior studies.

4.3. Regarding Attendant Variations:

7
The third head of the biceps brachii has been reported to occur with varied frequencies between
14.2% and 26% [31, 32]. These prevalences are consistent with the 21.4% (3:14) of case reports
from this systematic review that have documented accessory biceps brachii muscles. The
alignment between the prevalence of cases identified in this study and that of prior reports
regarding the prevalence of accessory biceps brachii heads, suggests that the accessory heads of
the biceps identified in this review were not likely related to the absence of the
musculocutaneous nerve. However, this review emphasizes that such accessory musculature may
be innervated by the median nerve in the absence of a musculocutaneous nerve.

of
4.4. Clinical Implications:

ro
In a typical median nerve injury, clinical manifestations would include motor and sensory
deficits in the forearm and hand. However, a high median nerve injury, occurring in the absence
-p
of a musculocutaneous nerve would have an atypical clinical presentation— the additional loss
re
of shoulder and elbow flexion with cutaneous sensory loss to the lateral forearm. Furthermore,
lP

the clinical presentation would include weakness in supination (from biceps brachii palsy) in
attion to the loss of pronation that would otherwise be expected in a high median nerve injury.
na

Proximal injuries to the median nerve could occur, for example, in the case of a fractured
ur

humerus [33-35]. Furthermore, in humerus fracture fixation, whether by the anterolateral of

medial approach, identification of the median and musculocutaneous nerve need to be identified
Jo

intraoperatively [24, 36, 37]. The absence of the musculocutaneous nerve could, therefore, lead
to surgical confusion during fracture fixation.

Further confusion may be encountered with regard to nerve transfer surgeries in the
reconstruction of musculocutaneous nerve and its branches. Examples of such nerve transfer
candidates include the spinal accessory nerve, intercostal nerve, medial pectoral nerve, ulnar
nerve, and, perhaps especially noteworthy, the median nerve [38-45].

This study was limited to only one database and, though reproducible and verifiable, is not an
exhaustive systematic review of the literature.

8
In summary, this review has identified that several variations in surrogate innervation may exist
in the setting of an absent musculocutaneous nerve. Such variations have been reported with
varied prevalence. The anatomical variations of nerve structures occurring in the absence of the
musculocutaneous nerve have clinical implications; therefore, physicians should be aware of the
variant anatomy associated with the absence of the musculocutaneous nerve. Accordingly, this
systematic review provides a helpful knowledge base regarding the absence of the
musculocutaneous nerve.

Declatation of Competing Interest:

of
ro
The authors declare that they have no competing interest

Author Contributions: -p
re
Dawn D. Hunter – Research design, systematic review of literature, manuscript preparation,
critical revision, and final approval of manuscript
lP

Matthew J. Zdilla – Research design, systematic review of literature, manuscript preparation,

na

critical revision, and final approval of manuscript

ur
Jo

9
References:

[1] M.A. Mahan, R.J. Spinner, Nerves of the upper extremity, in: R.S. Tubbs, M.M. Shoja, M.
Loukas (Eds.), Bergman’s comprehensive encyclopedia of human anatomic variation, John
Wiley & Sons, Inc., Hoboken, 2016, p.1081.
[2] E. Clarke, G. Wysiadecki, R. Haładaj, J. Skrzat, Fusion between the median and
musculocutaneous nerve: A case study. Folia Med. Cracov. 59 (2019), 45–52.
https://doi.org/10.24425/fmc.2019.131135.

[3] C.A.E. Gelmi, F.A. Pedrini, M. Fermi, G.A. Mariani, L.I. Cocco, A.M. Billi, Communication
between median and musculocutaneous nerve at the level of cubital fossa - A case report. Trans.

of
Res. Anat. 11 (2018 June) 1-4. https://doi.org/10.1016/j.tria.2018.04.001.

ro
[4] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, PRISMA Group, Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 6 (2009 Jul)
-p
e1000097. https://doi.org/10.1371/journal.pmed.1000097.
[5] B.M. Henry, K.A. Tomaszewski, J.A. Walocha, Methods of Evidence-Based Anatomy: a
re
guide to conducting systematic reviews and meta-analysis of anatomical studies. Ann. Anat. 205
(2016 May) 16-21. https://doi:10.1016/j.aanat.2015.12.002.
lP

[6] B.M. Henry, K.A. Tomaszewski, P.K. Ramakrishnan, J. Roy, J. Vikse, M. Loukas, R.S.
Tubbs, J.A. Walocha, Development of the anatomical quality assessment (AQUA) tool for the
na

quality assessment of anatomical studies included in meta-analyses and systematic reviews. Clin.
Anat. 30 (2017 Jan) 6–13. https://doi.org/10.1002/ca.22799.
ur

[7] K. Raza, S. Singh, N. Rani, R. Mishra, K. Mehta, S. Kaler, Anomalous Innervation of the
Median Nerve in the Arm in the Absence of the Musculocutaneous Nerve. Sultan Qaboos Univ.
Jo

Med. J. 17 (2017 Feb) e106-e108. https://doi.org/10.18295/squmj.2016.17.01.019.

[8] A.A. Padur, N. Kumar, S.R. Shanthakumar, S.D. Shetty, G.S. Prabhu, J. Patil, Unusual and
Unique Variant Branches of Lateral Cord of Brachial Plexus and its Clinical Implications- A
Cadaveric Study. J. Clin. Diagn. Res. 10 (2016 Apr) AC01-4.
https://doi.org/10.7860/JCDR/2016/15244.7482.
[9] A. Sarkar, A. Saha, Bilateral absence of musculocutaneous nerve: a case report. J. Clin.
Diagn. Res. 8 (2014 Sep) AD06-7. https://doi.org/10.7860/JCDR/2014/8779.4903.
[10] P. Kaur, R. Kumar, A. Jain, Variations in innervation of muscles in anterior compartment of
arm - a cadaveric study. J. Clin. Diagn. Res. 8 (2014 May) AC01-3.
https://doi.org/10.7860/JCDR/2014/8818.4316.
[11] P.S. Bhanu, K.D. Sankar, Bilateral absence of musculocutaneous nerve with unusual
branching pattern of lateral cord and median nerve of brachial plexus. Anat. Cell Biol. 45 (2012
Sep) 207-210. https://doi.org/10.5115/acb.2012.45.3.207.

10
[12] A.Y. Nasr, Morphology and clinical significance of the distribution of the median nerve
within the arm of human cadavers. Neurosciences (Riyadh). 17 (2012 Oct) 336-344.
[13] V. Budhiraja, R. Rastogi, A.K. Asthana, P. Sinha, A. Krishna, V. Trivedi, Concurrent
variations of median and musculocutaneous nerves and their clinical correlation--a cadaveric
study. Ital. J. Anat. Embryol. 116 (2011) 67-72.
[14] M.P. Parchand, S.T. Patil, Absence of musculocutaneous nerve with variations in course
and distribution of the median nerve. Anat. Sci. Int. 88 (2013 Jan) 58-60.
[15] V. Tomar, S. Wadhwa, Asymmetric bilateral variations in the musculocutaneous and
median nerves with high branching of brachial artery. Acta Medica (Hradec Kralove) 55 (2012)
189-192. https://doi.org/10.14712/18059694.2015.45.
[16] R. Pacholczak, W. Klimek-Piotrowska, J.A. Walocha, Absence of the musculocutaneous

of
nerve associated with a supernumerary head of biceps brachii: a case report. Surg. Radiol. Anat.
33 (2011 Aug) 551-554. https://doi.org/10.1007/s00276-010-0771-9.

ro
[17] A. Yogesh, M. Joshi, V. Chimurkar, R. Marathe, Unilateral variant motor innervations of
-p
flexure muscles of arm. J. Neurosci. Rural Pract. 1 (2010) 51-53. https://doi.org/10.4103/0976-
3147.63107.
re
[18] R.A. Guerri-Guttenberg, M. Ingolotti, Classifying musculocutaneous nerve variations. Clin.
Anat. 22 (2009 Sep) 671-683.
lP

[19] V.R. Vollala, S. Nagabhooshana, S.M. Bhat, B.K. Potu, V. Rodrigues, N. Pamidi, Multiple
arterial, neural and muscular variations in upper limb of a single cadaver. Rom. J. Morphol.
na

Embryol. 50 (2009) 129-135.

[20] J.H. Fregnani, M.I. Macéa, C.S. Pereira, M.D. Barros, J.R. Macéa, Absence of the
ur

musculocutaneous nerve: a rare anatomical variation with possible clinical-surgical implications.

Sao Paulo Med. J. 2008;126 (2008 Sep) 288-290. https://doi.org/10.1590/s1516-
31802008000500009.
Jo

[21] S. Wadhwa, N. Vasudeva, J.M. Kaul, A rare constellation of multiple upper limb anomalies.
Folia Morphol. 67 (2008 Nov) 236-239.
[22] S.M. Abuel-Makarem, A.F. Ibrahim, H.H. Darwish, Absence of musculocutaneous nerve
associated with a third head of biceps brachii muscle and entrapment of ulnar nerve.
Neurosciences (Riyadh). 12 (2007) 340-342.
[23] M.E. Aydin, A. Kale, M. Edizer, C. Kopuz, M.T. Demir, U. Corumlu, Absence of the
musculocutaneous nerve together with unusual innervation of the median nerve. Folia Morphol.
65 (2006 Aug) 228-231.
[24] E.E. Beheiry, Anatomical variations of the median nerve distribution and communication in
the arm. Folia Morphol. 63 (2004 Aug) 313-318.
[25] W.C. Song, H.S. Jung, H.J. Kim, C. Shin, B.Y. Lee, K.S. Koh, A variation of the
musculocutaneous nerve absent. Yonsei Med. J. 44 (2003 Dec) 1110-1113.
https://doi.org/10.3349/ymj.2003.44.6.1110.

11
[26] M.H. Badawoud, Study of the anatomical variations of the musculocutaneous nerve.
Neurosciences (Riyadh). 8 (2003 Oct) 218-221.
[27] P.V. Prasada Rao, S.C. Chaudhary, Absence of musculocutaneous nerve: two case reports.
Clin. Anat. 14 (2001) 31-35. https://doi.org/10.1002/1098-2353(200101)14:1<31::AID-
CA1005>3.0.CO;2-Y.
[28] E. Gümüsburun, E. Adigüzel, A variation of the brachial plexus characterized by the
absence of the musculocutaneous nerve: a case report. Surg. Radiol. Anat. 22 (2000) 63-65.
https://doi.org/10.1007/s00276-000-0063-x.
[29] A.O. Ihunwo, S.P. Osinde, A.U. Mukhtar, Distribution of median nerve to muscles of the
anterior compartment of the arm. Cent. Afr. J. Med. 43 (1997 Dec) 359-360.
[30] T. Nakatani, S. Tanaka, S. Mizukami, Absence of the musculocutaneous nerve with

of
innervation of coracobrachialis, biceps brachii, brachialis and the lateral border of the forearm by
branches from the lateral cord of the brachial plexus. J. Anat. 191 (1997 Oct) 459-460.

ro
https://doi.org/10.1046/j.1469-7580.1997.19130459.x.
-p
[31] K. Akita, A. Nimura, Arm muscles, in: R.S. Tubbs, M.M. Shoja, M. Loukas, (Eds.),
Bergman’s comprehensive encyclopedia of human anatomic variation, John Wiley & Sons, Inc.,
re
Hoboken, 2016, p. 293.
[32] L.A. Schwerdtfeger, M.A. Pascoe, T. Clapp, (2018) High incidence of a third head of biceps
lP

brachii in females. Trans. Res. Anat. 12 (2018 Sep) 25-27.

https://doi.org/10.1016/j.tria.2018.08.001.
na

[33] E. Apergis, D. Aktipis, A. Giota, G. Kastanis, G. Nteimentes, A. Papanikolaou, Median

nerve palsy after humeral shaft fracture: case report. J. Trauma 45 (1998 Oct) 825-826.
https://doi.org/10.1097/00005373-199810000-00040.
ur

[34] A. Tanagho, T. Elgamal, S. Ansara, Anterior interosseous nerve palsy as a complication of

Jo

proximal humerus fracture. Orthopedics. 36 (2013 Oct) e1330-e1332.

https://doi.org/10.3928/01477447-20130920-29.

[35] R. Rohilla, R. Singla, N.K. Magu, R. Singh, A. Devgun, R. Mukhopadhyay, P. Gogna,

Combined radial and median nerve injury in diaphyseal fracture of humerus: a case report. Chin.
J. Traumatol. 16 (2013) 365-367.
[36] A.K. Henry, Exposure of the humerus and femoral shaft. Br. J. Surg. 12 (1925) 84.
[37] S. Lu, J. Wu, S. Xu, B. Fu, J. Dong, Y. Yang, G. Wang, M. Xin, Q. Li, T.C. He, F. Wang,
D. Zhou, Medial approach to treat humeral mid-shaft fractures: a retrospective study. J. Orthop.
Surg. Res. 11 (2016 Mar) 32. https://doi.org/10.1186/s13018-016-0366-1.
[38] S.E. Mackinnon, A.L. Dellon, Surgery of the peripheral nerve. Thieme Medical Publishers,
New York, 1991, pp. 423–454.

12
[39] D.C. Chuang, M.C. Yeh, F.C. Wei, Intercostal nerve transfer of the musculocutaneous nerve
in avulsed brachial plexus injuries: evaluation of 66 patients. J. Hand Surg. Am. 17 (1992 Sep)
822–828. https://doi.org/10.1016/0363-5023(92)90451-t.

[40] K.E. Brandt, S.E. Mackinnon, A technique for maximizing biceps recovery in brachial
plexus reconstruction. J. Hand Surg. Am. 18 (1993 Jul) 726–733. https://doi.org/10.1016/0363-
5023(93)90328-Z.

[41] C. Oberlin, D. Béal, S. Leechavengvongs, A. Salon, M.C. Dauge, J.J. Sarcy, Nerve transfer
to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus:
anatomical study and report of four cases. J. Hand Surg. Am. 19 (1994 Mar) 232-237.
doi:10.1016/0363-5023(94)90011-6.

of
[42] G.A. Merrell, K.A. Barrie, D.L. Katz, S.W. Wolfe, Results of nerve transfer techniques for
restoration of shoulder and elbow function in the context of a meta-analysis of the English

ro
literature. J. Hand Surg. Am. 26 (2001 Mar), 303–314. https://doi.org/10.1053/jhsu.2001.21518.

-p
[43] P. Songcharoen, S. Wongtrakul, R.J. Spinner, Brachial plexus injuries in the adult. nerve
transfers: the Siriraj Hospital experience. Hand Clin. 21 (2005 Feb) 83–89.
re
https://doi.org/10.1016/j.hcl.2004.10.002.
lP

[44] S.E. Mackinnon, C.B. Novak, T.M. Myckatyn, T.H. Tung, Results of reinnervation of the
biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J. Hand Surg.
Am. 30 (2005 Sep) 978–985. https://doi.org/10.1016/j.jhsa.2005.05.014.
na

[45] R.S. Rohde, S.W. Wolfe, Nerve transfers for adult traumatic brachial plexus palsy (brachial
plexus nerve transfer). H.S.S. J. 3 (2007 Feb) 77–82. https://doi.org/10.1007/s11420-006-9027-y.
ur
Jo

13
Figure Legends:

Fig. 1: PRISMA flow chart summarizing the search process and results.

of
ro
-p
re
lP
na
ur
Jo

14
Table 1: Summary of studies detailing the absence of the musculocutaneous nerve
Author(s) and
Type of Study/Sample
Publication Dates
Raza et al., 2017 [7] Case report
“Elderly,” Male Cadaver
• Unilateral - left side
• Race: Indian
Padur et al., 2016 [8] Cadaveric study
82 upper limbs (41 cadavers)
40 males/1 female
Summary Data – Absent
Musculocutaneous Nerve
The biceps brachii and brachialis
were supplied by branches of
median nerve.
The coracobrachialis was supplied
by a branch originating from lateral
root of median nerve.
The coracobrachialis, biceps brachii
and brachialis were supplied by
branches of median nerve.

of
Two cadavers with absent
musculocutaneous nerves.

ro
1. Unilateral - left side
2. Unilateral - right side
• Race: not specified
Sarkar and Saha, 2014 Case report
[9] Male Cadaver
-p The coracobrachialis, biceps brachii
and brachialis were supplied by
re
• Bilateral branches of median nerve; except on
• Race: not specified the left side, coracobrachialis was
lP

supplied by branch of lateral cord.

Kaur et al., 2014 [10] Cadaveric study The coracobrachialis, biceps brachii
na

30 upper limbs (15 cadavers) and brachialis were innervated by

Three cadavers with absent branches of median nerve.
musculocutaneous nerves
ur

(4:30, 13.3% of limbs).

1. Bilateral
Jo

2. Unilateral – right side

3. Unilateral – right side
• Sex and Race: not
specified
Bhanu and Sankar, Case report
2012 [11] 43-year-old, Female cadaver
• Bilateral
• Race: not specified
Nasr, 2012 [12] Cadaveric study
60 upper limbs (30 cadavers)
40 limbs from males
20 limbs from females
Two cadavers with absent
The biceps brachii and brachialis
were innervated by branches of the
median nerve before giving rise to
the lateral cutaneous nerve of the
forearm, bilaterally. The
coracobrachialis was innervated by a
branch of the lateral cord,
bilaterally.
The coracobrachialis, biceps brachii,
and brachialis were supplied by
branches of the median nerve.
In the male left upper limb (i.e.,
 musculocutaneous nerves contralateral limb), the median nerve
(2:60, 3.3% of limbs). gave muscular branches to the flexor
1. Male muscles of the forearm proximal to
Unilateral – right side the cubital fossa.
• Race: not specified
2. Female
Unilateral – left side
• Race: not specified

Budhiraja et al., 2011 Cadaveric study The biceps brachii and brachialis
[13] 116 upper limbs (58 cadavers) were innervated by branches of the
and ages between 36-73 years median nerve before giving rise to
98 limbs from males the lateral cutaneous nerve of the

of
18 limbs from females forearm. The coracobrachialis was
Thirteen cadavers with absent innervated by a branch of the lateral

ro
musculocutaneous nerves cord.
(13:116, 11.21% of limbs).
-p
• Laterality: not specified
• Race: not specified
re
Parchand and Patil, Case report The coracobrachialis, both heads of
lP

2013 [14] 62-year-old, Male cadaver biceps biceps brachii, and brachialis
• Unilateral – left side were supplied by branches of the
• Race: not specified median nerve. The lateral cutaneous
na

nerve of the forearm was also a

branch of the median nerve.
Tomar and Wadwha, Case report The biceps brachii was supplied by
ur

2012 [15] 65-year-old, Male cadaver branch of median nerve. The

• Unilateteral -right side innervation of brachialis was not
Jo

• Race: not specified specifically mentioned. The

coracobrachialis was supplied by a
nerve from the lateral cord.The
median nerve gave the lateral
cutaneous nerve of the forearm.

Contralaterally, the
musculocutaneous nerve pierced the
coracobrachialis without supplying
it (rather, it was supplied by a
recurrent branch of the median
nerve). A communicating branch
existed between the
musculocutaneous and median
nerves at the level of the
coracobrachialis insertion. Also, the
brachial artery bifurcated in the

Pacholczak et al., Case report
2011 [16] 54-year-old, Male cadaver
• Unilateral – right side
• Race: not specified
proximal arm.
The lateral cord pierced the
coracobrachialis (though unclear
regarding the innervation of the
coracobrachialis) to become the
lateral root of the median nerve. The
lateral root of the median nerve then
continued to innervate the brachialis
as well as a three-headed biceps
brachii before supplying the forearm
as the lateral cutaneous nerve of the
forearm. The lateral root then joined

of
medial root at the midpoint of the
arm to become the median nerve.

ro
The contralateral arm was
unremarkable.
Yogesh et al., 2010
[17]
Case report
-p
58-year-old, Male cadaver
The coracobrachialis, biceps brachii,
and brachialis were supplied by
re
• Unilateral – left side branches of the median nerve. The
• Race: not specified lateral cutaneous nerve of the
lP

forearm was also a branch of the

median nerve.
Guerri-Guttenberg and Cadaveric study In both the fetus and adult, the
na

Ingolotti, 2009 [18] 56 upper limbs median nerve supplied the

30 fetal upper limbs (15 coracobrachialis, biceps brachii,
fetal cadavers) brachialis, and became the lateral
ur

26 adult upper limbs (13 cutaneous nerve of the forearm.

adult cadavers)
Jo

Musculocutaneous nerves
absent in two limbs
(2:56.3.6%) of the total limbs;
1:30 fetal limbs; 1:26 adult
limbs)
1. Unilateral – left sidea)
(23-week-old fetus)
• Race: not specified
2. Unilateral – left side a)
(adult)
• Race: not specified
Vollala et al., 2009 Case report The coracobrachialis muscle was
[19] 45-year-old, Male cadaver supplied by the lateral root of the
• Unilateral – right side median nerve. The biceps brachii
• Race: not specified and brachialis muscles were
supplied by the median nerve. Also,
one of the muscular branches of the
 median nerve continued as the
lateral cutaneous nerve of the
forearm.

Additional variations in the right

extremity included a superficial
ulnar artery, persistent median
artery, variant superficial palmar
arch, a third head for biceps brachii,
an accessory head for flexor pollicis
longus, and a variant insertion of
pectoralis major.

of
The contralateral upper extremity
was unremarkable.

ro
Fregnani et al., 2008 Case report The coracobrachialis, biceps brachii,
[20] Male cadaver (unspecified age) and brachialis muscles were
-p
• Unilateral – right side
• Age: not specified
supplied by the median nerve. The
branch to the coracobrachialis was
re
• Race: not specified small and fragile and could not be
preserved during dissection. Also,
lP

one of the muscular branches gave

the lateral cutaneous nerve of the
forearm.
na

No other nerve of artery variations

were seen. The cephalic vein was a
ur

tributary of the external jugular vein

rather than the axillary vein.
Jo

Wadhwa et al., 2008 Case report
[21] 70-year-old, Male cadaver
• Unilateral – right side
• Race: not specified
Branches from the lateral cord
supplied the coracobrachialis, biceps
brachii, brachialis muscles, and gave
rise to the lateral cutaneous nerve of
the forearm.

The brachial artery bifurcated into

superficial and deep branches in the
upper third of the arm.

The contralateral upper extremity

Abuel-Makarem et al., Case report
2007 [22] 60-to-65-year-old, Male
cadaver
• Unilateral – left side
• Race: “Caucasian”
was unremarkable.
The lateral cord supplied the
coracobrachialis and communicated
with the medial root of the median
nerve twice. The lateral cord then
supplied the long and short heads of

Aydin et al., 2006 [23] Case report
58-year-old, Male cadaver
• Unilateral – left side
• Race: not specified
ro
Beheiry, 2004 [24] Cadaveric study
60 upper limbs (30 cadavers)
Ages between 30-67 years
-p
One cadaver (65-year-old,
Male) with absent
re
musculocutaneous nerve (1:60,
1.66% of limbs)
lP
• Unilateral – left side
• Race: not specified
na
ur
Song et al., 2003 [25] Case Report
28-year-old, Male cadaver
Jo
• Unilateral – left side
• Race: not specified
Badawoud, 2003 [26] Cadaveric study
54 upper limbs (27 adult
cadavers)
One cadaver with absent
musculocutaneous nerve (1:54,
1.9%)
1. Unilateral – right side
• Race: not specified
the biceps brachii as well as the
brachialis. The lateral root then
joined the medial root to form the
median nerve which innervated a
third head of the biceps brachii and
continued as the lateral cutaneous
nerve of the forearm. Also, the ulnar
nerve traveled within the substance
of the medial head of the triceps.
The median nerve supplied branches
to the coracobrachialis, biceps
brachii, and brachialis muscles and
then formed the lateral cutaneous
of
nerve of the forearm.
The coracobrachialis was supplied
by a branch from the lateral cord. A
branch from the lateral root of the
median nerve supplied the short and
long heads of the biceps brachii.
Another branch of the median nerve
supplied the brachialis and gave the
lateral cutaneous nerve of the
forearm. There were no vascular
anomalies.
The contralateral upper extremity
was unremarkable.
The coracobrachialis was innervated
by the lateral cord. Branches from
the median nerve innervated the
biceps brachii and brachialis
muscles and gave an addition
branch, lateral cutaneous nerve of
the forearm.
The long thoracic nerve only
included fibers from C6 and C7. No
vascular variations.
The coracobrachialis, biceps brachii,
and brachialis muscles received their
nerve supply from the lateral root of
the median nerve.
Prasada Rao and Cadaveric study
Chaudhary, 2001 [27] 24 upper limbs (12 cadavers)
22 limbs from males
2 limbs from a female
Two cadavers with absent
musculocutaneous nerves
(2:24, 8.33%)
1. 89-year-old male
Unilateral – right side
• Race: white
2. 50-year-old male
Unilateral – left side
• Race: black
In the 89-year-old, the lateral cord
gave a branch to the
coracobrachialis muscle. A branch
of the median nerve supplied the
biceps brachii and brachialis
muscles and gave the lateral
cutaneous nerve of the forearm.
In the 50-year-old, the
coracobrachialis receive innervation
from branches arising from both the
lateral cord and median nerve. The
median nerve innervated the biceps

of
brachii and brachialis muscles and
gave the lateral cutaneous nerve of

ro
the forearm.
Gümüsburun and Case report The coracobrachialis muscle was
Adigüzel, 2000 [28]
• Bilateral
-p
72-year-old, Female cadaver innervated by branches of lateral
cord. The biceps brachii and
re
• Race: not specified brachialis muscles were innervated
by branches of median nerve. The
lP

lateral cutaneous nerve of the

forearm was a branch off of the
median nerve.
na

Ihunwo et al., 1998 Case Report The coracobrachialis, biceps brachii,

[29] Adult male and brachialis muscles were
• Bilateral innervated by branches of median
ur

• Race: not specified nerve.

Jo

Nakatani et al., 1998 Correspondence The coracobrachialis, both heads of

[30] 59-year old, Male cadaver biceps, and brachialis muscles were
• Unilateral - left side innervated by the lateral cord. The
• Race: Japanese lateral cutaneous nerve of the
forearm was a branch from the
lateral cord and a small contribution
from the medial root of the median
nerve.
a)
: Not explicitly reported but appreciated from images found in the manuscript.
Table 2: Representation of sex among prevalence studies.
Sex
Author(s) and Sample
n Female Male
Publication Dates Type
Ratio % Ratio %
Cadavers 41 1:41 2.4 40:41 97.6
Padur et al., 2016 [8]
Limbs 82 2:82 2.4 80:82 97.6
a) a) a) a)
Cadavers 15
Kaur et al., 2014 [10] a) a) a) a)
Limbs 30
Cadavers 30 10:30 33.3 20:30 66.7
Nasr, 2012 [12]
Limbs 60 20:60 33.3 40:60 66.7
Budhiraja et al., 2011 Cadavers 58 9:58 15.5 49:58 84.5
[13] Limbs 116 18:116 15.5 98:116 15.5

of
a) a) a) a)
Guerri-Guttenberg and Cadavers 28
a) a) a) a)
Ingolotti, 2009 [18] Limbs 56

ro
a) a) a) a)
Cadavers 30
Beheiry, 2004 [24] a) a) a) a)
Limbs 60
Badawoud, 2003 [26]
Cadavers
Limbs
27
54
-p a)
a)
a)
a)
a)
a)
a)
a)
re
Prasada Rao and Cadavers 12 1:12 8.3 11:12 91.7
Chaudhary, 2001 [27]
Limbs 24 2:24 8.3 22:24 91.7
lP

Cadavers 241 21:141 14.9 120:141 85.1

Pooled Data
Limbs 482 42:282 14.9 240:282 85.1
na

a)
: Not reported in the study
ur
Jo
Jo
ur
na
lP
re
-p
ro
of
Highlights:
• Absent musculocutaneous nerve, median nerve acts as principle surrogate
• Absent musculocutaneous nerve, coracobrachialis usually innervated by lateral cord
• Females are under-represented population in study of musculocutaneous nerve absence

of
ro
-p
re
lP
na
ur
Jo
Conflicts of Interest: None
The authors declare no conflicts of interest.

of
ro
-p
re
lP
na
ur
Jo
Ethical Statement: Not applicable

of
ro
-p
re
lP
na
ur
Jo
Financial Disclosure: The authors have no financial contributions.

of
ro
-p
re
lP
na
ur
Jo