SCIENTIFIC ARTICLE

Incidence of an Anomalous Course of the Palmar

Cutaneous Branch of the Median Nerve During Volar
Plate Fixation of Distal Radius Fractures
Christopher Jones, MD,* Pedro Beredjiklian, MD,* Jonas L. Matzon, MD,*
Nayoung Kim, BS,* Kevin Lutsky, MD*

Purpose Volar plating of distal radius fractures using an approach through the flexor carpi
radialis (FCR) sheath is commonplace. The palmar cutaneous branch of the median nerve
(PCB) is considered to run in a position adjacent to, but outside, the ulnar FCR sheath.
Anatomic studies have not identified anatomic abnormalities relevant to volar plating. The
purpose of this study was to determine the frequency of anomalous PCB branches entering the
FCR sheath during volar plating.
Methods This observational study involved 10 attending hand surgeons during a 7-month
period (July 2015eJanuary 2016). Surgeons assessed, documented, and reported any PCB
anomalies that were encountered during volar plating through a trans-FCR approach.
Results There were 182 volar plates applied that made up the study group. There were 10
cases (5.5%) of anomalous PCBs entering the FCR sheath. In 4 cases, the PCB pierced the
radial FCR sheath proximally, crossed beneath the tendon, and traveled distally on the ulnar
side. In 4 other cases, the PCB entered the FCR sheath proximally on the ulnar or central
aspect of the sheath and remained within the sheath, staying along the ulnar or dorsal side of
the tendon. In 1 case, the PCB pierced the ulnar distal aspect of the sheath and split into 2
branches. In 1 case, the PCB ran within the sheath along the radial aspect of the FCR.
Conclusions Anomalies in the course of the PCB are more common than often considered.
These variants are at risk during volar surgical approaches to the wrist that proceed through
the FCR sheath.
Clinical relevance Although dissecting along the radial side of the FCR sheath may protect the
PCB in most cases, care must be taken to identify anomalous branches (if present) and protect
them during surgery. (J Hand Surg Am. 2016;-(-):-e-. Copyright Ó 2016 by the
American Society for Surgery of the Hand. All rights reserved.)
Key words Distal radius fracture, palmar cutaneous branch, volar plate.

From the *Division of Hand & Upper Extremity Surgery, The Rothman Institute,
Philadelphia, PA.
Received for publication March 1, 2016; accepted in revised form May 18, 2016.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Kevin F. Lutsky, MD, Department of Hand & Upper Extremity
Surgery, The Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107;
e-mail: Kevin.lutsky@rothmaninstitute.com.
0363-5023/16/---0001$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2016.05.011
T
HE VOLAR HENRY APPROACH IS commonly used
for plate fixation of distal radius fractures. The
distal surgical interval between the flexor carpi
radialis (FCR) and the radial artery is generally
considered to be safe with regard to the palmar cuta-
neous branch of the median nerve (PCB), particularly
if the dissection remains along the radial aspect of
the FCR tendon sheath.1,2 This is largely based
on anatomic studies of the PCB that have demon-
strated that it generally courses adjacent to the palmaris

Ó 2016 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 PALMAR CUTANEOUS BRANCH ANOMALIES
longus, if present, or along the ulnar side of the FCR
sheath. In fact, not a single PCB crossed the FCR or
entered the FCR sheath in any of more than 200
specimens described in previously reported stud-
ies.3e10 However, in our experience with volar plating
of distal radius fractures, we have encountered varia-
tions in the course of the PCB, which have placed the
nerve at risk during the surgical approach.
The purpose of this study was to assess the fre-
quency with which variations in the course of the
PCB, resulting in the nerve crossing over or entering
the FCR sheath, are visualized during routine volar
plate fixation of distal radius fractures. Knowledge of
these variations is valuable for surgeons performing
procedures that use this exposure.
METHODS
All patients who underwent volar plate fixation of
distal radius fractures between July 2015 and January
2016 by 10 fellowship-trained orthopedic hand sur-
geons were included. This study had institutional
review board approval and was waived informed
consent in accordance to our institutional review
board institutional policy. During the study period,
the surgeons were asked to perform their standard
approach to the distal radius and to be vigilant for
atypical PCB branches in the surgical field.
A roster of patients who underwent distal radius
fixation during the study period was created using the
group’s billing records. Operative reports were
reviewed to ensure inclusion of only patients who had
undergone volar plate fixation, including patients
who underwent combined volar and dorsal ap-
proaches. Patients who underwent distal radius frac-
ture fixation during the study period were excluded if
they underwent an isolated alternate surgical
approach (eg, dorsal plate, spanning plate, or external
fixation). Open fractures were included, aside from 1
patient who sustained massive forearm trauma with a
near amputation. This individual was excluded
because of the distortion of the native anatomy.
All surgeons performed the volar approach of
Henry.2 A longitudinal incision was created along the
volar, radial aspect of the distal forearm. The FCR
tendon sheath was identified and divided on its radial
aspect. The tendon was retracted, and the floor of the
FCR sheath was incised along is radial aspect. The
finger and thumb flexors and the median nerve were
retracted ulnarly, which allowed exposure of the
pronator quadratus muscle. During this dissection,
careful attention was paid to identify any variant
PCBs. The median nerve proper was not dissected,
J Hand Surg Am.
and the course of the PCB was not explored unless it
was identified in the surgical dissection. The surgeons
notified the lead investigator of any PCB anomalies
encountered, documented the specific nerve course,
and took an intraoperative photograph. Participating
surgeons were reminded of the study during monthly
meetings.
RESULTS
There were 196 distal radius fractures treated during
the study period. Of them, 182 were treated with
volar plate fixation and met inclusion criteria,
whereas 14 were excluded. There were 3 open frac-
tures included, 2 of which were grade I and 1 was
grade IIIA. There were 43 men and 139 women with
an average age of 60 years (range, 21e92 years) in
the study group. We identified 10 patients (5.5%), 8
women and 2 men, with anomalous PCBs that
entered the FCR sheath. In 4 cases, the PCB pierced
the FCR sheath proximally on the radial side, crossed
beneath the FCR, and traveled distally on the ulnar
side of the sheath. In 4 other cases, the PCB entered
the FCR sheath proximally on the ulnar or central
aspect of the sheath and remained within the sheath,
staying along the ulnar or dorsal side of the tendon
(Fig. 1). In 1 case, the PCB pierced the ulnar distal
aspect of the sheath and split into 2 branches, one of
which proceeded radially across the sheath and the
other proceeded ulnar to the sheath (Fig. 2). In 1 case,
the PCB ran within the sheath along the radial aspect
of the FCR. There were no reports of intraoperative
PCB injury.
DISCUSSION
Much focus has been placed on PCB variations in the
palm because it pertains to the risk of injury during
carpal tunnel release surgery. Multiple anatomic
studies have documented variations including ulnar
takeoff,11 travel in different palmar soft tissue planes,8
communication with the superficial branch of the
radial nerve,9 high and low takeoffs with a course
ulnar to, or through, the palmaris longus tendon,8 and
a variety of arborization patterns.4 Many of these
studies included dissection into the forearm to deter-
mine the takeoff and course of the nerve as it
approached the wrist;4,7e10 yet none of these anatomic
studies describe the PCB crossing or entering the FCR
sheath. A single case report described the PCB
crossing over top of the FCR, 2 cm proximal to the
wrist flexion crease during the Russe approach for
treatment of a scaphoid nonunion.12 That report
raised the question as to whether the PCB could be
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 PALMAR CUTANEOUS BRANCH ANOMALIES
FIGURE 1: The PCB (arrow) is seen here entering the sheath,
and running centrally within the sheath along its dorsal aspect
before heading in an ulnar direction. The asterisk (*) indicates the
FCR tendon.
inadvertently injured during the volar Henry approach
to the distal radius, which uses a similar internervous
plane.2
Based on anatomic studies, the PCB most
commonly branches from the radial aspect of the
median nerve at an average of 4.1 cm (range,
1.0e25.1 cm) from the wrist flexion crease, coursing
below the antebrachial fascia at an average of 3.4 mm
ulnar to the FCR tendon.6,8,12 However, in our
experience performing volar plating of distal radius
fractures, we have encountered a PCB branch
crossing over or entering the FCR sheath in approx-
imately 1 of every 20 patients. We cannot definitively
determine why these branches were not previously
identified in anatomic studies. It is possible that the
anomalous branches were not seen because of the
relatively smaller sample size of each of those
studies. However, on the basis of our findings, these
branches do exist and we feel that our findings rein-
force the need to increase awareness of these poten-
tial anomalous nerve branches.
With the advent and success of volar plating of the
distal radius, the volar Henry approach has become
commonplace. This approach has been presumed to
be safe with respect to the PCB as long as the
dissection proceeds on the radial side of FCR sheath.
In fact, it is believed that the PCB need not even be
identified or explicitly protected.2 Although dissec-
tion along the radial aspect of the FCR would have
potentially prevented injury to 40% of our PCB
variants, the majority of our PCB variants would have
remained at risk using this approach.
In light of our study findings, we would expect the
incidence of reported PCB injury during distal radius
surgery to be higher.13e15 We are not aware of any
series documenting the incidence of PCB injury
during volar plating, or any reports of this specific
J Hand Surg Am.
3
FIGURE 2: The PCB is seen here entering the sheath (dotted line)
distally and splitting into 2 branches. One branch (arrow) pro-
ceeded radially across the sheath. The asterisk (*) indicates the
FCR tendon.
complication. It is not clear why this is the case.
However, several explanations are possible. It may be
that palmar numbness is underreported—patients
may be more concerned or focused on their post-
operative pain and less likely to notice palmar
numbness. It may also be that complications such as
complex regional pain syndrome (type 2), which has
been described with greater frequency than PCB
injury, may in some cases be due to damage to the
PCB, but not reported or recognized as such.
The main strength of this study is the large number
of distal radius fractures treated by volar plating that
were included. The primary limitation of our work is
the lack of PCB identification in each arm as would
be performed in a cadaver anatomic study. Because
we did not trace the nerve to its origin or endpoint
(doing so would have deviated from standard practice
and may have increased risk of injury), it is possible
that the anomalous nerve we encountered was an
accessory branch of the PCB, or other interconnect-
ing or anomalous nerve branch. If this were the case,
it may be that injury to this branch would be less
apparent clinically. However, these nerves pierced
the FCR sheath from deep to the fascia, ran in the
expected direction of the PCB and headed toward the
palm of the hand.
Although all surgeons were attentive to the pos-
sibility of variant branches, we did not identify and
dissect the PCB unless it was discovered during the
approach. Therefore it is possible that a variant
branch was present but not identified. We may not
have seen all variants or anomalous branching pat-
terns. If anything, this would mean that we may have
underestimated the incidence of this variant.
Given the frequency with which we found the PCB
entering or crossing the FCR sheath, the safety of the
Henry approach should be reconsidered. We recom-
mend that surgeons anticipate the potential for this
PCB variant when using the distal extent of the volar
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4 PALMAR CUTANEOUS BRANCH ANOMALIES
Henry approach, remain vigilant, and proceed care-
fully with dissection through the FCR sheath.
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