825137

research-article2019
HANXXX10.1177/1558944718825137HandGlickel et al

Surgery Article
HAND

Anomalous Courses of the Palmar

1­–5
© The Author(s) 2019
Article reuse guidelines:
Cutaneous Branch of the Median Nerve sagepub.com/journals-permissions
DOI: 10.1177/1558944718825137
https://doi.org/10.1177/1558944718825137

in Relation to the Flexor Carpi Radialis hand.sagepub.com

Tendon for ORIF of Distal Radius Fractures

Steven Z. Glickel1, Sara M. Glynn1, Andy L. Chang2,

Jessie W. Janowski3, O. Alton Barron1, and Louis W. Catalano III1

Abstract
Background: The purpose of this study was to prospectively document the incidence of variations in the course of
palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor
carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR
sheath will be approximately 5%. Methods: All cases that met inclusion criteria between November 2013 and March 2018
were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each
surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the
relationship to the FCR sheath, and the course of the PCBMN were recorded. Results: In total, 101 distal radius fractures
were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There
were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath.
Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6
were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4
branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median
nerve. Conclusions: Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought
and can be expected in approximately 18.8% of patients.

Keywords: palmar cutaneous branch of the median nerve, anomalous, course, anatomy, branching

Background approach.8 The PCBMN has been studied primarily regard-

Distal radius fractures are among the most common fractures
in adults.1,2 Due to a more active aging population, the inci-
dence and severity of distal radius fractures are likely to
increase.3 Distal radius fractures require surgical intervention
if adequate reduction and stabilization cannot be achieved
with closed treatment. The standard treatment at this time for
most distal radius fractures is open reduction and internal fixa-
tion (ORIF) through a volar approach.4,5 The most common
volar approaches are the Henry approach and the flexor carpi
radialis (FCR) approach. The Henry approach uses the inter-
val between FCR and radial artery to access the deep compart-
ment of the forearm.6 This approach requires dissection of the
radial artery and its branches. The FCR approach avoids arte-
rial branches superficially and involves incising the FCR ten-
don sheath to access the deep compartment of the forearm.7
The palmar cutaneous branch of the median nerve
(PCBMN) is one of the structures at risk during the FCR
ing carpal tunnel surgery at the wrist because injury to the
nerve was previously a common complication of carpal tun-
nel surgery.9-15 The PCBMN branches from the radial side
of the median nerve approximately 4 to 8 cm proximal to
the wrist flexion crease and courses dorsal to the antebrach-
ial fascia alongside the ulnar aspect of FCR until it pierces
the fascia distally to lie on the flexor retinaculum.14-16
However, there are few reports of the incidence of
encountering the PCBMN during the FCR approach and
1
New York University, New York, NY, USA
2
Mount Sinai Hospital System, New York, NY, USA
3
Orthopedic Physicians Alaska, Anchorage, USA
Corresponding Author:
Steven Z. Glickel, Clinical Professor of Orthopaedic Surgery, New York
University, OrthoManhattan, 485 Madison Avenue, New York, NY
10022, USA.
Email: szghand@gmail.com
2 HAND 00(0)

relevant anatomic variations in the distal forearm in the lit-

erature. A recent study reported a 5.5% incidence of anoma-
lous PCBMN branches entering the FCR sheath during
volar plating for distal radius fractures.17 The incidence of
complex regional pain syndrome after ORIF of distal radius
fractures has been documented to be between 3% and
10%.18 It is believed by some that injury to the PCBMN
during the FCR approach may be responsible for some
cases of complex regional pain syndrome after distal radius
fracture fixation.10,19-21
The purpose of this study was to prospectively document
the incidence of anatomic variations in the course of the
PCBMN that may increase the risk of injury to the nerve
during the standard FCR approach. We hypothesized that
the incidence of anomalous branching of the PCBMN
around the FCR sheath will be approximately 5%.
Methods
Patients older than 18 years who presented with a distal
radius fracture requiring operative fixation were offered to
be included in the study. The operating surgeon made the
final decision regarding the need for operative intervention
using the FCR approach. Exclusion criteria included
patients who were younger than 18 years, open fractures
distorting anatomy (Gustilo-Anderson grade II or greater),
previous surgical approach to the volar wrist or distal fore-
arm, and previous significant trauma to the volar wrist or
distal forearm. This study had institutional review board
approval, and informed consent was given to all patients
who chose to participate in the study. Baseline demographic
patient information collected included patient age, sex, date
of surgery, hand dominance, and side of injury.
All surgeries were performed by 1 of 3 fellowship-
trained hand surgeons. All cases that met inclusion criteria
between November 2013 and March 2018 were included in
the study. Each surgeon performed the standard FCR
approach to the distal radius. The incision was made directly
over the palpable FCR tendon extending from the distal
wrist crease approximately 10 cm proximally. Dissection
was carried down to the volar FCR sheath. The sheath was
incised longitudinally along the radial aspect of the tendon.
The FCR tendon was retracted ulnarly and the floor of the
sheath exposed and examined for the presence of anoma-
lous branches of the PCBMN within the sheath. Any such
branches were retracted and protected, and the floor of the
sheath was incised. The flexor pollicus longus tendon was
retracted ulnarly to protect the median nerve and expose
pronator quadratus. During the exposure, inspection for the
PCBMN was performed, and if no PCBMN was identified,
the dissection was carried out ulnar to the FCR tendon.
Once the PCBMN was identified, it was dissected proxi-
mally to the branching point from the median nerve and
distally to the wrist crease.
Figure 1.  Palmar cutaneous branch of the median nerve
(PCBMN) found within the floor of the flexor carpi radialis sheath.
The blue dashed lines outline the PCBMN course.
The branching location from the median nerve, the rela-
tionship to the FCR sheath, and the course of the PCBMN
were recorded. Photographs were taken in most cases. The
course of the PCBMN was characterized by its relationship
to the FCR sheath (separate and parallel, within the sheath,
crossing the sheath). Notes were taken to describe the
course if the PCBMN did not follow one of these specific
branching patterns. The course of the PCBMN was defined
as anomalous if it did not branch radially from the median
nerve and if the course was parallel and superficial to the
FCR sheath. Simple statistical methods were used to calcu-
late averages and percentages.
Results
In total, 101 distal radius fractures met the inclusion criteria.
There were 20 men and 81 women. The average age of the
study cohort was 58.8 years (range = 18-86 years). Eighty-
two patients were right handed, and 45 patients had the
injury on their dominant hand. The PCBMN was unable to
be identified in 4 patients. Palmaris longus was present in 84
patients. The average branching point of PCBMN was 5.2
cm from the distal wrist crease (range = 3.3-9.0). Twenty-
six anomalous branching patterns of PCBMN were noted.
Of the 26 anomalous branching patterns, 19 crossed volar,
dorsal, or ran within the FCR sheath. Six PCBMN were
found within the FCR sheath (Figure 1), 1 penetrated the
FCR sheath (Figure 2), 6 crossed over the volar aspect of the
FCR sheath (Figure 3), and 6 were dorsal to the FCR tendon
sheath. When comparing the branching patterns of the
PCBMN from the median nerve, 4 branched from the volar
aspect of the median nerve, 2 branched from the ­dorsal
aspect of the median nerve, and 1 branched from the ulnar
aspect of the median nerve.
Glickel et al 3
Figure 2.  Palmar cutaneous branch of the median nerve
(PCBMN) penetrating the dorsal flexor carpi radialis sheath. The
blue dashed lines outline the PCBMN course.
Figure 3.  Palmar cutaneous branch of the median nerve
(PCBMN) crossing the volar aspect of the flexor carpi radialis
tendon distally from proximal-ulnar to distal-radial. The blue
dashed lines outline the PCBMN course.
Discussion
The course of the PCBMN and its variations at the wrist
have been extensively studied in the setting of carpal tunnel
release.22 From previous cadaveric studies, PCBMN
branches radially from the median nerve approximately 4 to
8 cm proximal to the wrist flexion crease. The nerve then
courses dorsal to the antebrachial fascia alongside the ulnar
aspect of FCR tendon, superficial to the sheath, until it
pierces the fascia distally to lie on the flexor retinaculum
before innervating the palm.10,12,14-16,22-24 Several variations
to this branching pattern of the PCBMN have also been
reported. The PCBMN has been described to cross volar to
the FCR and run on the radial side of the FCR,25 communi-
cate with the superficial branch of the radial nerve,16,23 and
branch from the ulnar aspect of the median nerve.26 In addi-
tion, Hobbs et al16 reported on 2 separate PCBMN arising
from the median nerve at different levels. In fact, anoma-
lous courses of the PCBMN may be underreported as the
PCBMN is generally not dissected out completely during
routine volar approaches to the distal forearm if not encoun-
tered.
Damage to the PCBMN can result in undesirable conse-
quences in otherwise routine forearm and wrist surgeries.
Injury can lead to decreased sensation in the thenar region
of the palm and painful neuromas and may even contribute
to complex regional pain syndrome.14,27 Injuries to the
PCBMN were common historically. Reported damage to
the PCBMN approached 1 out of 3 patients in one study.27
Carroll et al14 described cases of painful neuromas mistaken
for incomplete carpal tunnel release.
Despite these cadaveric studies of the PCBMN, few
studies have described the course of PCBMN in volar
approaches to the forearm for distal radius fractures. Nagle
et al25 reported on 1 patient who underwent a Russe
approach to the scaphoid with a PCBMN that branched 2
cm proximal to the wrist flexion crease and crossed volar to
the FCR sheath from proximal-ulnar to distal-radial. Jones
et al17 reported on 182 distal radius fractures treated with
volar plate fixation using the volar Henry approach. They
identified 10 patients with anomalous PCBMN that entered
the FCR sheath at various levels during the volar Henry
approach.
In the present study, we identified 26 abnormal branch-
ing patterns of PCBMN during the FCR approach for volar
plate fixation for distal radius fractures. There was an 18.8%
incidence of encountering the PCBMN volar, within, or
dorsal to the FCR sheath with this approach. The incidence
of encountering PCBMN around the FCR was more than
we hypothesized. It was also more than the incidence of
5.5% seen entering the FCR sheath reported by Jones et al.17
In contrast to their study, we explored the PCBMN to the
proximal branching point from the median nerve to its distal
arborization at the level of the distal palmar crease. We also
explored for the PCBMN if we did not find it during the
initial exposure. We believe that by doing so, we were able
to identify all possible anomalous branching patterns for the
PCBMN. This is the likely explanation for why we were
able to isolate a higher incidence of anomalous courses of
the PCBMN than what is reported in the literature.
On a technical note, we typically observed that the
PCBMN was in close proximity to small amounts of adi-
pose tissue during the dissection around the FCR tendon.
While exposing the FCR tendon, we suggest avoiding sharp
dissection with a knife where adipose tissue is present.
Instead, we suggest spreading with dissecting scissors to
avoid the possibility of inadvertently injuring the PCBMN.
Most branching patterns of the PCBMN are from the
radial aspect of the median nerve.10,11,16,17,23,25 However, in
our cohort of patients, we found a 6.9% incidence of volar,
dorsal, or ulnar branching of the PCBMN from the median
4 HAND 00(0)
nerve. We do not have a clear explanation for why we iden-
tified these anomalous branching patterns from the median
nerve compared with reported accounts in the literature.
Although unlikely, it is possible that trauma and hematoma
formation in distal radius fractures can possibly distort
PCBMN course. In contrast, the historic anatomic studies
were done in cadavers that were well preserved and trauma-
free.9,10,12-15,23 Despite these interesting findings, the branch-
ing pattern from the median nerve should not affect the
incidence of encountering the PCBMN during the routine
FCR approach to the distal radius. It is rare to encounter the
actual branching point from the median nerve as this is not
routinely exposed.
We were unable to identify the PCBMN in 4 patients.
This finding is not completely unique as the absence of the
PCBMN has been documented in the literature previously.28
The information from this study reaffirms that the FCR
approach remains relatively safe. However, variation in the
course of the PCBMN relative to the FCR sheath is more
than previously thought and can be expected in approxi-
mately 1 out of 5 patients. Surgeons should be aware of the
risk to the PCBMN during the FCR approach and should
use caution, especially around adipose tissue.
11. Siegel JL, Davlin LB, Aulicino PL. An anatomical variation
Ethical Approval
This study was approved by our institutional review board.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical stan-
dards of the responsible committee on human experimentation
(institutional and national) and with the Helsinki Declaration of
1975, as revised in 2008 (5).
Statement of Informed Consent
Informed consent was obtained from all individual participants
included in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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