Clinical Anatomy 11:239245 (1998)

Biometry of the Muscular Branches

of the Median Nerve to the Forearm
F. CANOVAS,1* PH. MOUILLERON,2

AND

F. BONNEL1

1Laboratoire

2Service

dAnatomie, 2 rue Ecole de Medecine, Montpellier, France

Orthopedie 3, Hopital Lapeyronie, Av du Doyen G. Giraud, Montpellier, France

The aim of this study was to determine the biometry of the muscular branches of the median
nerve to the forearm in ten embalmed upper limbs. We measured the length of the forearm and
the level of origin of each muscular branch of the median nerve to the forearm from the middle
of a line between the medial and lateral epicondyles. The level of origin of each branch was
then calculated as a percentage of the length of the forearm. Mean length of the forearm was
25 6 2.36 cm (range: 22-29 cm). Although the levels of origin of the proximal and distal nerves
to pronator teres, and of the nerves to palmaris longus, flexor carpi radialis and flexor digitorum
superficialis, were quite variable (coefficient of variation: CV . 48.61%), the level of origin of
the anterior interosseous nerve (CV 5 31.24%) and its branches (nerves to flexor pollicis
longus and flexor digitorum profundus, CV 5 20.06%) was less variable. These results suggest
that the anterior interosseous nerve of the forearm is probably the nerve to connect in muscular
free transfers in order to restore flexion of the fingers after damage to the flexor tendons to the
forearm. We observed Martin-Gruber communications in six out of ten dissections. Clin. Anat.
11:239245, 1998. r 1998 Wiley-Liss, Inc.
Key words: level of origin; Martin-Gruber communication

INTRODUCTION
Usually the median nerve gives off six branches to
muscles in the forearm: the proximal and distal nerves
to pronator teres (PPT and DPT); the nerves to
palmaris longus (PL), flexor carpi radialis (FCR), and
flexor digitorum superficialis (FDS); and the anterior
interosseous nerve of the forearm that provides the
innervation of the flexor pollicis longus (FPL), flexor
digitorum profundus (FDP), and pronator quadratus
(PQ). Biometric studies of muscular branches of the
median nerve are few (Bonnel, 1990; Linell, 1921;
Dangelo, 1958; Sunderland, 1978), yet free muscular
transfers to restore mobility of the fingers after trauma
to the forearm require a precise knowledge of the level
of origin of these branches. The purpose of our work
was to specify the biometry of these muscular branches
of the median nerve.

MATERIALS AND METHODS

Our study was based on the dissection of one upper
limb from each of ten cadavers, six female, four male,
aged 7085 years, preserved by intra-arterial injection
of a 10% glyceroformalin solution. Each forearm was

r 1998 Wiley-Liss, Inc.

dissected after shoulder disarticulation, with the elbow

in extension, the wrist in neutral position and the
forearm in pronation.
In each forearm, we removed the skin and fascias of
the flexor surface of the elbow, the forearm and the
wrist. The bicipital aponeurosis was divided. The
superficial head of the pronator teres was elevated and
the tendons of flexor carpi radialis and palmaris longus
divided in their distal one-third, after dissection of
their supplying nerves.
Nerves to the deep muscles of the forearm were
dissected after longitudinal splitting of the flexor
digitorum superficialis from the fibrous arch, and
following the anterior interosseous nerve of the forearm from proximal to distal.
We measured each of the following:
1. The length of the forearm, from the middle of a
line between the medial and lateral epicondyles
to the middle of a line between the radial and
ulnar styloid processes.
*Correspondence to: Dr. F. Canovas, Service Orthopedie 3, Hopital
Lapeyronie, Av du Doyen G. Giraud, 34000, Montpellier, France.
Received 25 April 1995; Revised 24 May 1996 and 27 March 1997

240

Canovas et al.

2. The level of origin of each muscular branch of

the median nerve, measured from the middle of
the interepicondylar line.
The level of origin of each branch was calculated as a
percentage ratio of the length of the forearm (Table 1).
The mean, standard deviation (SD), variance, median
and quantiles, and the coefficient of variation (CV)
were calculated for each muscular branch, using the
SAS system.

RESULTS
The mean length of the forearm was 25 6 2.36 cm
(range: 22-29 cm; CV 9.47%).
The patterns of branching and distribution of the
branches of the median nerve to the forearm muscles
in two specimens not included in the series are shown
in Figures 1a and 1b. The results in the series of 10
specimens are shown diagramatically in Figure 2.
Proximal Nerve to Pronator Teres (PPT)
This arose independently in eight of the ten specimens (Fig. 2 nos. 1, 3, 4, 5, 6, 8, 9, and 10), with the
distal nerve to pronator teres [DPT] in one (no. 7), and
with DPT and the nerve to flexor carpi radialis (FCR)
in one (no. 2). The mean percentage ratio of the
proximal nerve to pronator teres was 0.17 6 6.19%
(range: 213.2 to 18.69%; median 5 0.93%. A negative
value for the percentage ratio indicates the origin of
the nerve above the epicondyles in some cases). The
CV was 36.47%, indicating the great variability of its
level of origin.

Nerves to Flexor Muscles, From the Medial

Epicondyle
a. Distal nerve to pronator teres (DPT). This arose
independently in three cases (nos. 1, 9, 10), with
PPT in one (no. 7), with nerve to FCR in two
(nos. 3 and 6), with nerve to flexor digitorum
superficialis (FDS) in 2 (nos. 4 and 8), with
nerves to PPT and FCR in one (no. 2), and with
nerves to PL, FCR and FDS in one (no. 5). It
arose on average 2.4 cm below the epicondyles,
in one case at the level of the epicondyles, and in
nine cases below. The mean percentage ratio of
the distal nerve to pronator teres was 9.63 6
6.12% (range: 0 to 18.51%; median 5 9.56%).
The CV was 63.61%.
b. Nerve to palmaris longus (PL). This arose independently in one case (no. 2), with nerve to FDS
in three (nos. 1, 3, and 6), with nerve to FCR in
five (nos. 4, 7, 8, 9, and 10), and with nerves to
DPT, FCR and FDS in one (no. 5). It arose on
average 2.5 cm below the epicondyles. The
mean percentage ratio of the nerve to palmaris
longus was 10.08 6 4.90% (range: 4.5420.37%;
median 5 9.56%). The CV was 48.61%.
c. Nerve to flexor carpi radialis (FCR). This arose
independently in one case (no. 1), with DPT in
two (nos. 3 and 6), with nerve to PL in five (nos.
4, 7, 8, 9, and 10), with PPT and DPT in one (no.
2), and with nerves to DPT, PL, and FDS in one
(no. 5). It arose on average 2.5 cm below the
epicondyles, in one case at the level of the
epicondyles, and in nine cases below. The mean

TABLE 1. Level of Origin of the Muscular Branches of the Median Nerve in Each of Ten Specimens
(nos. 110), Measured in cm From the Interepicondylar Line and Expressed as a Percentage of the
Length of the Forearm (L, in cm). Negative Values Indicate Origin Above the Epicondyles, Zero,
Origin at the Epicondyles, and Positive Values, Origin Below the Epicondyles

1
2
3
4
5
6
7
8
9
10
Mean
S.D.

PPT

DPT

FCR

PL

FDS

AI

FPL

FDP

27
29
27
22
22
25
25
23.5
26.5
23
25
2.36

1.85
0
23.7
2.27
24.54
4
6
0
213.2
8.69
0.17
6.19

18.51
0
11.11
11.36
4.54
8
6
4.25
15.09
17.39
9.63
6.12

22.22
0
11.11
6.81
4.54
8
14
6.38
11.32
13.04
9.74
6.09

20.37
5.17
11.11
6.81
4.54
8
14
6.38
11.32
13.04
10.08
4.9

20.37
17.24
11.11
11.36
4.54
8
28
4.25
18.86
21.73
14.55
7.9

24.07
18.96
16.66
11.36
11.36
18
20
8.51
24.52
17.39
17.09
5.34

25.92
22.41
24.07
18.18
25
26
28
14.89
30.18
19.56
23.4
4.7

25.92
22.41
24.07
18.18
25
26
28
14.89
30.18
19.56
23.4
4.7

PPT: Proximal nerve to pronator teres; DPT: Distal nerve to pronator teres; FCR: Nerve to flexor carpi
radialis; PL: Nerve to palmaris longus; FDS: Nerve to flexor digitorum superficialis; AI: Anterior
interosseous nerve; FPL: Nerve to flexor pollicis longus; FDP: Nerve to flexor digitorum profundus.

Muscular Branches of the Median Nerve

percentage ratio of the nerve to flexor carpi

radialis was 9.74 6 6.09% (range: 022.22%;
median 5 9.56%). The CV was 62.51%.
d. Nerve to flexor digitorum superficialis (FDS).
This arose independently in four cases, two from
the median nerve (nos. 2 and 9) and two from the
anterior interosseous nerve (nos. 7 and 10); with
nerve to PL in three (nos. 1, 3 and 6), with DPT
in two (nos. 4 and 8), and with nerves to DPT,
FCR and PL in one (no. 5). It arose on average
3.5 cm below the epicondyles. The mean percentage ratio of the nerve to flexor digitorum
superficialis was 14.55 6 7.91% (range: 4.25
28%; median 5 14.3%). The CV was 54.38%.
Supplementary branches additional to the variants described above and arising from the median nerve in its distal part were found in two
cases (two branches in one case and three in
another).
Anterior Interosseous Nerve and Its Branches
a. Anterior interosseous nerve (AI). This arose on
average 4.3 cm below the epicondyles. The
mean percentage ratio was 17.09 6 5.34% (range:
8.5124.52%; median 5 17.7%). The CV was
31.24%.
b. Nerves to flexor pollicis longus (FPL) and flexor
digitorum profundus (FDP) arose on average 5.9
cm below the epicondyles. The mean percentage ratio was 23.42% 6 4.7% (range: 14.89
30.19%; median 5 24.53%). The CV was 20.06%.
The mean distance between the origin of AI and
its point of branching was 1.75 cm (0.5 cm in one,
1 cm in one, 1.5 cm in three, 2 cm in three, 2.5
cm in one and 3 cm in one). Along its pathway
between flexor digitorum profundus and flexor
pollicis longus, AI gave off 14 small branches to
each of these two muscles. These results indicated that the level of origin of the anterior
interosseous nerve and its branches was less
variable than the level of origin of the other
muscular branches.
Communications
Principal connections of the median nerve or its
branches were made with the ulnar nerve. Out of ten
dissections, we observed six Martin-Gruber communications distributed in three types: in four cases, between the anterior interosseous nerve of the forearm
and the ulnar nerve; in one case between the median
nerve and the ulnar nerve; and in one case between
branches of innervation of the flexor digitorum profun-

241

dus (from the anterior interosseous nerve) and the

ulnar nerve.

DISCUSSION
In the median nerve of the forearm one can distinguish three parts: a proximal part associated with the
origin of the nerves to the flexor muscles of the medial
epicondyle: pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis; an
intermediate part associated with the origin of the
anterior interosseous nerve of the forearm and supplying muscles of the deep layer of the forearm; and a
distal part associated with the palmar cutaneous nerve.
We have shown a great variation in the origin of the
branches to flexor muscles arising from the medial
epicondyle. There does not exist a definitive description of this innervation in the anatomy textbooks.
Sunderland (1978) made a biometric description of the
branches, but did not distinguish main branches from
smaller secondary branches. Only by histologic study
can one ascertain the nervous nature of these branches.
According to Sunderland (1978), the first branch of the
median nerve to the forearm was always that to the
pronator teres which received two to four branches in
14 cases out of 20. When the muscle received multiple
branches, the first was always that to the superficial
head of the muscle. It arose at a level between 7 cm
above the medial epicondyle and 2.3 cm below (above
the medial epicondyle in eight cases out of 20, at its
level in four cases and below in eight cases). In one
case out of 20, this proximal branch had a common
origin with the nerve to flexor carpi radialis.
Sunderland (1978) found the distal branches to
pronator teres to have their origins with another
muscular branch in seven cases out of 20. In our
dissections, the proximal nerve to pronator teres arose
in three cases out of ten above the epicondyles. Our
observations are comparable to those of Sunderland
(1978) but differ from those of Dangelo (1958).
For the nerve to flexor carpi radialis, we have
observed a great variation in origin: in nine cases out of
ten, it arose from a common trunk with one or more of
the other nerves of the flexor muscles of the medial
epicondyle and, in one case, from a single trunk.
Sunderland (1978) found the nerve to flexor carpi
radialis to be single in 18 cases and double in two
cases. In 19 cases out of 20, its origin, close to the
epicondyle, was a single trunk or connected with the
nerves to pronator teres, flexor digitorum superficialis
and flexor digitorum profundus. Its level of origin lay
between 1.5 cm above the medial epicondyle and 5 cm
below.

242

Canovas et al.

Fig. 1. a. Diagram and photograph of a dissection of the median nerve in the forearm, with its
main branches. b. Diagram and photograph of the median nerve and its branches in another
specimen. Note the multiple branches to flexor pollicis longus.

Authors vary in their description of nerves to flexor

digitorum superficialis muscle (Sunderland, 1978; Bonnel, 1990). It arose as a single trunk in four of our ten
cases, and in two out of 20 of Sunderland (1978), for
whom a frequent pattern was a main trunk and two to
seven branches. Rouviere (1984) described the flexor
digitorum superficialis as innervated by a branch
coming from one or two nervous trunks to flexor
muscles of the medial epicondyle, by one or two other
branches to its radial head and by a nerve arising in the
middle part of the forearm, and supplying the distal
belly of the deep part of the muscle, the inferior nerve
of the flexor digitorum superficialis.

The intermediate part of the median nerve corresponds to the territory of the anterior interosseous
nerve that innervates the deep muscles of the forearm:
flexor pollicis longus, flexor digitorum profundus and
pronator quadratus. The nomenclature of the anterior
interosseous nerve of the forearm is however disputed.
For some French authors (Testut, 1930; Lazorthes,
1955; Bouchet, 1983; Rouviere, 1984), the median
nerve gives off a trunk for muscles of the deep layer
that further divides into three branches, the nerves to
flexor pollicis longus and flexor digitorum profundus,
and the anterior interosseous nerve of the forearm that
innervates the pronator quadratus. On the other hand,

Muscular Branches of the Median Nerve

Figure 1.

for Anglo-Saxon authors (Hollinshead, 1958; Sunderland, 1978; Johnson, 1979; Backhouse, 1980), the
anterior interosseous nerve of the forearm takes its
origin from the median nerve and innervates along its
pathway flexor pollicis longus, flexor digitorum profundus and pronator quadratus. In our dissections, its
origin was between 2 and 6.5 cm below the epicondyles, mean: 4.3 cm. Its configuration was relatively
constant and the length of its branches varied little.
For Sunderland (1978), its origin lay on average 5.1 cm
(range: 2.3-8 cm) below the medial epicondyle and for
Linnel (1921), 5.24 cm. Sunderland (1978) found the
innervation of flexor digitorum profundus to be multiple in 17 out of 20 cases, with two to six branches.
The muscle was innervated by the anterior interosseous nerve of the forearm. In two cases, a supplementary branch arose directly from the median nerve. In 13
cases out of 20, the nerve had a common origin with
the nerve of the flexor pollicis longus, connecting with
nerves of flexor digitorum superficialis and flexor carpi

243

(Continued.)

radialis. The first branch divided at 3.1 cm-11.4 cm

below the medial epicondyle.
The flexor pollicis longus muscle was for Sunderland (1978) innervated by multiple branches in 17
cases out of 20, two to six branches coming from the
anterior interosseous nerve of the forearm. A supplementary branch arose from the median nerve in three
cases. Branches had a separate origin or stemmed from
nerves to flexor digitorum profundus and flexor digitorum superficialis muscles. The first branch arose
4-15 cm below the medial epicondyle.
Communication Between Median
and Ulnar Nerves
The principal connections in the forearm are with
the ulnar nerve. The connection between the anterior
interosseous nerve of the forearm and the muscular
branch of the ulnar nerve to flexor digitorum profundus is situated inside this muscle. Traditionally, the
two lateral heads of flexor digitorum profundus are

244

Canovas et al.

Fig. 2. Schematic drawing of the pattern of branching of the median nerve to forearm muscles (nos.
110). Note the variations in the origin of the branches which seldom match standard textbook
descriptions.

innervated by the median nerve and the two medial

heads by the ulnar nerve. Depending on the communication, the four heads of the flexor digitorum profundus can be innervated by the median nerve alone or
almost exclusively by the ulnar nerve. All variations
between these two extreme cases are possible, a
muscular head being able to receive a double innervation. The Martin-Gruber communication (Martin, 1763;
Gruber, 1870) connects the median nerve or its anterior interosseous branch to the ulnar nerve at the upper
part of the forearm. It is a frequent connection: 20% for

Gruber (1870), and 20-25% for Thane (1897) and

Piersol (1907).
In conclusion, our metrical results show that the
origin of the muscular branches of the median nerve as
well as the innervation by one or multiple branches for
a muscle was variable. The anterior interosseous nerve
of the forearm and its branches showed the least
variability. The anterior interosseous nerve of the
forearm arose on average 4.3 cm below the line
between the epicondyles, and its branches were given
off opposite the fibrous arch of the flexor digitorum

Muscular Branches of the Median Nerve

superficialis. Our observations suggest that the anterior interosseous nerve of the forearm is probably the
nerve to connect in muscular free transfers to restore
flexion of the fingers after damage to the flexor
tendons to the forearm by direct trauma, in the
syndrome of Volkman and following electrical burns.

REFERENCES
Backhouse, K.M. 1980 Innervation du bras et de la main. In
Traite de Chirurgie de la Main. Tome 1. Paris: Masson, pp.
309324.
Bonnel, F. and M. Mansat 1990 Nerf median. In Nerfs Peripheriques, Tome premier, Membre superieur. Paris: Masson,
pp. 110132.
Bouchet, A. and J. Cuilleret 1983 In Anatomie. Vol 3. Paris:
Simep, pp. 12951296.
Dangelo, J.G. 1958 Estudo anatomico da inervacao do m. pronator
teres. Anais Fac Med Univ Minas Gerais. 18:179181.
Gruber, W. 1870 Ueber die verbindung des nervus medianus
mit dem nervus ulnaris am unterarm des menschen und der
saugetiere. Arch. Anat. Physiol. 37:501522.

245

Hollinshead, W.H. 1958 In Anatomy for Surgeons: Vol 3. The

Back and the Limbs. Hoeber-Harper: pp. 419422.
Johnson, R.K., M. Spinner and M.M. Shrewsbury 1979 Median
nerve entrapment syndrome in the proximal forearm. J.
Hand Surg. 4:4851.
Lazorthes, G. 1955 In Le Syste`me Nerveux Peripherique.
Paris: Masson et Cie, pp. 217225.
Linell, E.A. 1921 The distribution of nerves in the upper limb,
with reference to variabilities and their clinical significance.
J. Anat. 55:7983.
Martin, R. 1763 Tal om nervus allmanna egenskaperi mannisikans kropp. Lars salvius. Stockholm. (cited from Mannerfelt
1968 J.B.J.S. 5B:152155).
Piersol, G.A. 1907 In Human Anatomy. G.A. Piersol (ed.).
Philadelphia and London: pp. 12981302.
Rouviere, H. and A. Delmas 1984 In Anatomie Humaine. Tome
3. Paris: Masson, pp. 187193.
Sunderland, S. 1978 In Nerves and Nerve Injuries. London and
New York: Churchill Livingstone, pp. 656690.
Testut, L. and A. Latarjet 1930 In Traite dAnatomie Humaine.
Vol. 3. Paris: G Doin et Cie, pp. 272280.
Thane, G.D. 1897 The Nerves. In Quains Elements of
Anatomy. Vol. 3. Part 2. New York and Bombay: Longmans,
Green and Co, pp. 301303.