DOI: http://dx.doi.org/10.

1590/1413-785220162402149097
Original Article

INTRAMUSCULAR MARTIN-GRUBER ANASTOMOSIS

Edie Benedito Caetano1, Luiz Ângelo Vieira1, Mauricio Ferreira Caetano1, Cristina Schmitt Cavalheiro1, Mauro Razuk Filho1,
João José Sabongi Neto1
1. Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde, Campus Sorocaba, Sorocaba, SP, Brazil.

ABSTRACT and the ulnar nerve. Conclusion: The purpose of intramuscular

Objective: This paper reports the incidence, origin, course and Martin-Gruber anastomosis, which we found in 5% of dissected
anatomical relationships of intramuscular Martin-Gruber anas- limbs, is to supply the flexor digitorum profundus muscle and it
tomosis. Methods: Anatomical dissection of 100 limbs from is unlikely to have any influence on the innervation of the intrinsic
50 adults cadavers was performed. The intramuscular Martin- muscles of the hand. Level of Evidence IV, Cases Series.
-Gruber anastomosis was found in five forearms, three in the
right and two in the left side, one was bilateral. All communi- Keywords: Arteriovenous anastomosis. Nervous system mal-
cation were located between the anterior interosseous nerve formations. Median nerve. Ulnar nerve.

Citation: Caetano EB, Vieira LA, Caetano MF, Cavalheiro CS, Razuk Filho M, Sabongi Neto JJ. Intramuscular martin-gruber anastomosis. Acta Ortop Bras. [online].
2016;24(2):94-7. Available from URL: http://www.scielo.br/aob.

INTRODUction (17%), Uchida e Sugioka5 (17%), Amoiridis6 (32%), Nakashi-

The nerve communication between the median and ulnar ner- ma7 (21.3%), Shu et al.8 (23.6%), Rodriguez-Niedenfuhr9
ves is an anatomical variation that can occur in different loca- (13.6%), Erdem et al.10 (27%), Sarikcioglu et al.,11 Prates
tions in the upper limb. The nerve communication between the et al.12 (7.8%), Lee et al.13 (39%), Kazaros et al.14 (10%),
median and ulnar nerves may occur in the forearm (“Martin- Almeida et al.,15 and Felippe et al.16 (10%). Most of these
-Gruber” anastomosis), between the thenar motor branch of authors consider that this anastomosis involves axons lea-
the median nerve and the deep motor branch of the ulnar ving the main trunk of the median nerve or anterior interos-
nerve in the palm of the hand (“Cannieu and Riché” anasto- seous nerve, crossing the forearm to join the main trunk of the
mosis), between the sensory branches of both nerves, also ulnar nerve, causing changes in the innervation of the intrinsic
in the palm of the hand (“Berretini” anastomosis). Anatomical muscles of the hand. However, the existence of intramuscular
and electrophysiological studies suggest that these commu- anastomosis was only reported by Verchere,17 Nakashima,7
nications have important clinical and surgical implications. and Rodriguez-Niedenfuhr.9
Several case reports on isolated injuries of the median and In this study we report the Martin-Gruber anastomosis in
ulnar nerves showed differences from the classic pattern of 27 limbs. Of these connections, five occurred within the
innervation of these muscles suggested by anatomy treaties. muscle mass of the deep flexor digitorum (intramuscular
The knowledge of anatomical variations in the innervation of anastomosis). This article presents exclusively the anatomi-
these muscles is important for diagnosis and treatment of cal details with the intramuscular connection resulting from
nerve damage and compression syndromes. these dissections.
The Swedish anatomist Martin1, in 1763, was the first to con-
MATERIALs and meThODs
sider the possibility of a connection between the fascicles of
the median and ulnar nerves in the forearm. In the following One hundred forearms of 50 adult cadavers from the Anatomy
century, in 1870, Gruber2 dissected 250 forearms and found discipline, Faculdade de Ciencias Médidas e da Saúde da Pon-
38 nerve connections. Since then, this neural communication tíficia Universidade Católica de São Paulo (Sorocaba campus),
is known as Martin-Gruber anastomosis. SP, Brazil, were dissected to perform this study. Forty six cada-
The incidence of Martin-Gruber anastomosis was described vers were male and four were female. The age ranged from 28
by Gruber2 as (15.2%), Thomson3 (15.5%), Kimura et al.4 to 77 years old, 27 were white and 23 non-white. The pieces

All the authors declare that there is no potential conflict of interest referring to this article.

Work developed at Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde, Campus Sorocaba, Sorocaba, SP, Brazil.
Correspondence: Rua Mooca, 271 Jardim Paulistano, 18040-700 Sorocaba, SP, Brazil. ediecaetano@uol.com.br

Article received in 04/28/2015, approved in 08/31/2015.

Acta Ortop Bras. 2016;24(2):94-7
94
were previously prepared with 10% formaldehyde and glycerine
solution. Forearms deformed by trauma and malformations
were excluded from the sample.
The dissection was performed through a midline incision around
the forearm and a lower third of the arm, two flaps including skin
and subcutaneous tissue were folded to the radial and ulnar
sides, respectively, and the same was done for the forearm
fascia exposing, thus, all muscles.
All muscles of the forearm were dissected; innervation and the
presence of nerve communication between the nerves of the
forearm was analyzed. All anatomical variations found were
recorded, noted and photographed. A Keeler 2.5X magnifying
glass (Germany) was used for magnification. Besides investi-
gation of “Martin-Gruber” nerve communication, the relation
of Gantzer muscle with the anterior interosseous nerve and
the median nerve, as well as the anatomical variations of the Figure 2. (A) Median nerve; (B) Ulnar nerve; (C) Intramuscular Martin-Gruber
forearm muscles were analyzed. This study was approved by Anastomosis; (D) Flexor digitorum profundus muscle.
the Ethics Committee of Faculdade de Ciências Médicas e da
Saúde, Pontíficia Universidade Católica de São Paulo (CAAE n°
43267715.2.0000.5373).

RESULTS
We observed Martin-Gruber anastomosis in 27 of 100 fore-
arms dissected, and in five limbs the nerve connection was
reported inside the muscle mass of the deep flexor digitorum
(intramuscular anastomosis). Regarding topographical situa-
tion, intramuscular communications occurred in the proximal
third of the forearm, three on the right antimere and two on the
left, and one of these was bilateral.
In five pieces nerve fascicles originated from the anterior inte-
rosseous nerve in a variable location at distal direction, variation
of obliquity, posterior to the ulnar artery, penetrating the muscle
mass of the deep flexor digitorum, communicating with the
ulnar nerve inside the muscle. We found that from this nerve
connection there were fascicles directed to the deep flexor Figure 3. (A) Median nerve; (B) Ulnar nerve; (C) Intramuscular Martin-Gruber
Anastomosis; (D) Flexor digitorum profundus muscle.
digitorum muscle. (Figures 1-5)

Figure 1. (A) Median nerve; (B) Ulnar nerve; (C) Intramuscular Martin-Gruber Figure 4. (A) Median nerve; (B) Ulnar nerve; (C) Intramuscular Martin-Gruber
Anastomosis; (D) Flexor digitorum profundus muscle. Anastomosis; (D) Flexor digitorum profundus muscle.

Acta Ortop Bras. 2016;24(2):94-7

95
 We classified these 27 nerve connections in six types. In five of
them (total of 22 pieces), we observed that these communica-
tions could alter the normal pattern of innervation of the intrinsic
muscles. However, it is very unlikely that the changes in the in-
trinsic hand muscles may occur in intramuscular anastomoses,
which purpose, in our interpretation, was exclusively to innervate
the flexor digitorum profundus muscle.
The existence of the intramuscular anastomosis was only men-
tioned by Verchere17 and Nakashima,7 the latter reported the
intramuscular connection in six of 30 dissected cases (20%),
and this author believed that these nerve fascicles were desti-
ned to the flexor digitorum profundus muscle. Almeida et al.,15
analyzing the type of anastomotic presentation, found that two
of five anastomoses originated from the muscular branches of
the flexor digitorum profundus muscle, but did not inform whe-
Figure 5. (A) Median nerve; (B) Ulnar nerve; (C) Intramuscular Martin-Gruber ther these communications have occurred inside the muscle
Anastomosis; (D) Flexor digitorum profundus muscle. mass. Thomson,3 Lee et al.13 and Piagkou et al.20 mentioned,
while ranking Martin-Gruber anastomosis, that these nerve
DISCUSsion connections can only innervate the flexor digitorum profun-
dus muscle, but did not mention that this communication
The clinical implication of classical Martin-Gruber anastomosis
takes place inside the muscle mass. Rodriguez-Niedenfuhr9
is to enable the transfer of nerve fascicles between the median described in details the intramuscular connection stating that
and ulnar nerves and, thereby, to alter the normal pattern of in- its presence is extremely rare because it was recorded only
nervation of the intrinsic muscles of the hand. Thomson,3 Kimura in 1.3% of 236 dissected limbs and reported that intramus-
et al.,4 Uchida e Sugioka,5 Shu et al.,8 Rodriguez-Niedenfuhr,9 cular connection was represented by a single branch that
Sarikcioglu et al.,11 Lee et al.,13 Kazaros et al.,14 and Felippe originated from the anterior interosseous nerve, penetrated
et al.16 considered that this anastomosis involves axons leaving the muscle mass of the flexor digitorum profundus muscle
the main trunk of the median nerve, or anterior interosseous without providing any nerve contribution to this muscle, and
nerve, crossing the forearm to join the main trunk of the ulnar communicated with the ulnar nerve. They report that the in-
nerve, causing innervation changes in the intrinsic hand muscles. tramuscular course of the nerve communication can be a
Martin-Gruber anastomosis has significant clinical importance potential nerve compression site which would be a clinical
for understanding certain injuries of the median and ulnar ner- implication of this connection. Our findings agree with those of
ves and compression syndromes. Two cases described the- Nakashima,7 however differ completely from the description of
reafter demonstrate this importance. Sraj et al.18 reported the Rodriguez-Niedenfuhr,9 because we consider that the purpose
case of a patient who had every symptoms of carpal tunnel of intramuscular communication was to innervate the flexor
syndrome, however, provocative Tinel signal test and Phalen digitorum profundus muscle, as in the five cases we reported
test were negative. The patient presented obvious signs of ulnar with enough evidence, penetration of muscle mass fascicles
nerve compression at the elbow. The nervous stimulus at the of the flexor digitorum profundus muscle.
epitrochlea-olecranon groove triggered the typical symptoms of
carpal tunnel syndrome, which indicates the transfer of sensitive CONCLUSion
(afferent) nerve fascicles of the ulnar nerve to the median nerve. The knowledge of anatomical variations regarding hand inner-
Streib 19 reported the case of a 77 year-old patient complaining vation has a significant importance, particularly when conside-
of hand weakness. Electrical stimulation has demonstrated that ring physical examination, prognosis, diagnosis and surgical
the response of the muscles in the thenar region had amplitude treatment. If these variations are not valued, mistakes and con-
greater than 50% when the median nerve was stimulated in the sequences are inevitable. We believe, however, that intramus-
wrist in relation to the elbow. The opposite occurred regarding cular nerve communications, reported in 5% of 100 members
the ulnar nerve, amplitude was 50% higher in the elbow. There dissected, are intended only to innervate the flexor digitorum
is no doubt that in this case nerve communication occurred at profundus muscle and it is unlikely to have any influence on the
the forearm (Martin-Gruber anastomosis). innervation of intrinsic muscles of the hand.

AUTOR’S CONTRIBUTIONS: Each author contributed individually and significantly to the development of this study. EBC (0000-0003-4572-3854)*
and LAV (0000-0003-4406-2492)* contributed to dissections and orientation of the work, as well as to the final review of the manuscript. CSC (0000-
0003-3239-8474)* and MRF (0000-0002-2313-471X)* were the main contributors on writing the manuscript, performing bibliographic review and
assessing the results. MFC (0000-0003-0994-2128)* and JJSN (0000-0002-0554-1426)* contributed to the intellectual concept of the study. *ORCID
(Open Research and Contributor ID).

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