Signature: Med Sci Monit, 2003; 9(9): BR351-356

PMID: 12960925

Received: 2002.06.20
Accepted: 2003.02.28
Published: 2003.09.08

Authors Contribution:
A Study Design
B Data Collection
C Statistical Analysis
D Data Interpretation
E Manuscript Preparation
F Literature Search
G Funds Collection

WWW.MEDSCI MONIT.COM

Basic Research

Median and ulnar nerve communication in the

forearm: an anatomical and electrophysiological study
Levent Sarikcioglu1 abdef, Muzaffer Sindel1 ade, Sibel Ozkaynak2 be, Hulya Aydin2 be
1
2

Department of Anatomy, Akdeniz University Faculty of Medicine, Antalya, Turkey

Department of Neurology, Akdeniz University Faculty of Medicine, Antalya, Turkey

Source of support: none.

Summary
Background:

We aimed to determine the presence of median and ulnar nerve communication in the forearm by anatomical and electrophysiological examinations in the Anatolian population.

Material/Methods:

30 forearms from 15 preserved cadavers (2 females, 13 males, 4265 years of age) were carefully dissected to observe median and ulnar nerve communication. We also performed median
and ulnar nerve motor conduction studies by recording the thenar, hypothenar and first dorsal
interosseous (FDI) muscles, stimulating both nerves at distal and proximal points, and the
recordings were compared in 60 forearms (30 subjects, 17 female, 13 male, 3467 years of age).

Results:

Martin-Gruber communication was observed in 2 of 30 forearms (15 cases) by anatomical

examination, in 2 of 60 forearms (30 cases) by electrophysiological examination. No Marinacci
communication was found in either anatomical or electrophysiological examinations.

Conclusions:

In this study group, the ratio of MGC was revealed as 3.3% and 6.6%, in the electrophysiological and anatomical examination, respectively. Knowledge of this crossover is of crucial importance in the clinical evaluation of nerve injuries of the median and ulnar nerves, as well as in
accurate interpretation of nerve conduction velocity of these nerves, especially in association
with carpal tunnel syndrome. Anatomical and electrophysiological classifications of MartinGruber communication are reviewed.

key words:
Full-text PDF:
Word count:
Tables:
Figures:
References:

Authors address:

median nerve ulnar nerve Martin-Gruber communication

http://www.MedSciMonit.com/pub/vol_9/no_9/2866.pdf
1628
2
3
47

Levent Sarikcioglu, Department of Anatomy, Faculty of Medicine, Akdeniz University, 07070 Antalya, Turkey,
email: levent@med.akdeniz.edu.tr or sarikcioglul@yahoo.com

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BACKGROUND
Median-ulnar communication in the forearm was first
described by the Swedish anatomist Martin [1] in 1763,
and later by Gruber [2] in 1870. This communication is
now known as the Martin-Gruber communication
(MGC). The incidence of MGC ranges from 5% to 34%.
The vast majority of these connections cross over from
median to ulnar nerve. Sometimes, one communicating
branch may link from ulnar to median nerve, which is
known as reversed MGC, ulnar-to-median communication, or Marinacci communication [3].
MGC is traditionally diagnosed based upon changes in
the amplitude of the compound muscle action potential
(CMAP) in routine nerve conduction studies [4].
Knowledge of this crossover is of crucial importance in
the clinical evaluation of nerve injuries of median and
ulnar nerves, as well as in accurate interpretation of the
nerve conduction velocity of these nerves, especially in
association with carpal tunnel syndrome [5]. The presence of the MGC in patients with carpal tunnel syndrome results in a partial or total sparing of thenar
muscles from denervation and the paradoxical recording of normal proximal latencies in the median nerve
when the distal latency is prolonged [6].
In the present study, we aimed to determine the presence of median and ulnar nerve communication in the
forearm by anatomical and electrophysiological examinations in an Anatolian population.

Figure 1. A right forearm with MGC between anterior interosseous

nerve and ulnar nerve. MN median nerve, UN Ulnar
nerve, * MGC, arrow anterior interosseous nerve.

MATERIAL AND METHODS

nerve was stimulated at the wrist and antecubital fossa

while recording the ADM, looking for a CMAP when
stimulating at the antecubital fossa that was not present
when stimulating at the wrist.

30 forearms from 15 preserved cadavers (2 females, 13

males, 4265 ages) were carefully dissected to expose
the median and ulnar nerves. Connections between
these two nerves were noted and photographed. 30
patients admitted to the Department of Neurology were
also included in the present study. Informed consent
was obtained, and all performed procedures were
reviewed and approved by the Akdeniz University Ethical Committee. 60 forearms from these subjects were
examined electrophysiologicaly. We performed median
and ulnar nerve motor conduction studies by recording
the thenar, hypothenar and first dorsal interosseous
(FDI) muscles, stimulating both nerves at distal and
proximal points.
The techniques used to recognize the types of MGC
during routine nerve conduction studies can be summarized as follows:
Routine ulnar nerve motor conduction study
We used this routine neurophysiological recording to
recognize MGC type I [79]. In this abnormal innervation, when the abductor digiti minimi muscle (ADM) is
recorded and the ulnar nerve is stimulated at the wrist
and below the elbow, the amplitude of the ulnar compound muscle action potential (CMAP) with below-theelbow stimulation is lower than with wrist stimulation.
To demonstrate a MGC in this situation, the median

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Ulnar nerve motor conduction study by recording

the FDI
Crossover of median-to-ulnar fibers supplying the FDI
is the most common type of MGC, and has been called
type II [79]. However, this communication is frequently not recognized because routine ulnar motor studies,
recording the hypothenar muscles, and routine median
motor studies, recording the thenar muscles, are both
normal. This type of MGC occurs as a drop in amplitude between the wrist and below-the-elbow stimulation
sites, when ulnar motor studies are performed recording from the FDI. To demonstrate an MGC in this situation, the median nerve was stimulated at the wrist and
antecubital fossa while recording the FDI, looking for a
higher amplitude potential when stimulating at the
antecubital fossa as compared to the wrist.
Routine median nerve motor conduction study
In type III MGC, a crossover of median-to-ulnar fibers
supplying the thenar muscles may occur [79]. In this
abnormal innervation, when the thenar muscles are
recorded and the median nerve is stimulated at the
wrist and antecubital fossa, the median CMAP amplitude with antecubital fossa stimulation is higher than

Med Sci Monit, 2003; 9(9): BR351-356

Sarkicioglu L et al Median and ulnar nerve communication in the forearm

BR

Table 1. MGC classifications. (Abbreviation: MN: median nerve UN: ulnar nerve, AIN: anterior interosseous nerve).
Srinivasan
Rodriguezand Rhoden Nakashima
Niedenfuhr
[39]
[24]
[22, 44]

Hirasawa
[45]

Thomson
[46]

AIN and UN

Oblique
anastomosis

Class I

Type I, II, VI

Type Ia

MN and UN

Oblique
anastomosis

Class II

Type III

Type Ib

Communication between

MN and UN innervating hypothenar

muscles
MN and UN innervating the first
dorsal interosseous muscle
MN and UN innervating thenar
muscles
Muscular branch to flexor digitorum
Looped
profundus muscle
anastomosis
AIN and UN, muscular branches
flexor digitorum profundus muscle
originated from the connection
Combination or other
Combined
anastomosis

Pattern I
(Type Ic),
Pattern II
Pattern I
(Type Ia, Ib)

Shu H [47] Shu HS [10]

Type I

Type I

Type II

Type II

Preston [7],
Oh [8],
Kimura [9]

Type I
Type II
Type III
Class III

Type II

Type III

Type III

Type IV

Type IV, V

Figure 2. In Type I MGC, compound muscle action potentials (CMAP)

are obtained from the abductor digiti minimi muscle by stimulating median and ulnar nerves at distal and proximal sites.
Stimulating the ulnar nerve at the wrist and below the elbow,
the ulnar CMAP amplitude with below-elbow stimulation is
lower than with wrist stimulation. During stimulation of median nerve, there is no potential with wrist stimulation, whereas
a CMAP is present with antecubital fossa stimulation.

Type III
(combination
of Type Ia, Ib
and II)

Type V (two Type IVa, IVb

anastomotic (combination
branch)
of Type I, II,
III)

Figure 3. In Type II MGC, compound muscle action potentials (CMAP)

are obtained from the first dorsal interosseous muscle by
stimulating median and ulnar nerves at distal and proximal
sites. There is a drop in CMAP amplitude between the wrist
and below-elbow stimulation sites, when ulnar motor studies
are performed. During median nerve stimulation, however, a
higher amplitude CMAP is obtained when stimulating at antecubital fossa as compared to the wrist.

RESULTS
that obtained with wrist stimulation. CMAP results
recorded from the hypothenar muscles in routine ulnar
studies are normal. To demonstrate an MGC in this
situation, the ulnar nerve was stimulated at the wrist
and below the elbow while recording the thenar muscles, looking for a drop in CMAP amplitude between
wrist and below-the-elbow.

In our study, the frequency of occurrence of MGC as

determined by anatomical examination was 6.6% (in 2 of
30 upper extremities) (Figure 1). In each of the two upper
extremities, one MGC was encountered. In one of these
connections, the communicating branch was between the
interosseous anterior nerve and the ulnar nerve (Type Ia)

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Med Sci Monit, 2003; 9(9): BR351-356

Table 2. Documented occurrence of MGC from the latest literature. (Abbreviations: : no data could be found, ?: unknown percentage (case report)).
Author
Gruber F [2]
Mannerfelt L [26]
Rosen AD [20]
Kimura et al [27]
Kimura et al [27]
Vasickova Z [28]
Streib EW [29]
Gessini et al. [30]
Snirvasaan R and Rhoden J [24]
Ropert A and Metral S [31]
Kimura et al. [19]
Brandsma et al. [32]
Kayamori R [5]
Uncini et al. [33]
Hoph HC [34]
Valls-Sole J [35]
Uchida Y and Sugioka Y [36]
Uchida Y and Sugioka Y [36]
Amoiridis G [37]
Amoiridis G [37]
Hoogbergen MM and Kauer JM [38]
Nakashima T [39]
Okuno Y and Kasai T [40]
Sander et al. [4]
Taams KO [16]
Taams KO [16]
Chantelot et al. [41]
Budak F and Gonenc Z
Shu et al.
Gumusburun E and Adiguzel E [42]
Stancic et al. [43]
Simonetti S [13]
Rodriguez-Niedenfuhr et al [22]
Rodriguez-Niedenfuhr et al [44]
Erdem et al. [15]
Present study
Present study

Year
1870
1966
1973
1976
1976
1977
1979
1981
1981
1981
1983
1986
1987
1988
1990
1991
1992
1992
1992
1992
1992
1993
1994
1997
1997
1997
1999
1999
1999
2000
2000
2001
2002
2002
2002

%
15.2
15.0
5
17

39.6
?
?
15.5
?
1.3
?
14
?
?
?
17
16
32

?
21.3
?
?
23

?
17.5
23.6
?
?
57
13.6
13.1
27
6.6
3.3

(see Table 1). In the other case, it was between the median
nerve and the ulnar nerve (Type Ib) (see Table 1). By
electrophysiological recordings, we found MGC in 2 of 60
forearms (3.3%) examined in vivo. One of these had type I
MGC (Figure 2) and the other had type II (Figure 3).
There were no subjects who had type III MGC.
The MGCs were found on the right side in both
anatomical and electrophysiological examinations.

DISCUSSION
The literature contains descriptions of well-documented
MGCs and their frequencies (Table 2). The high incidence of a similar connection in monkeys and apes suggests that these communications are of phylogenetic significance [10].
The incidence of MGC is reported to range from 5% to
34% [11]. Horiguchi et al. [12] reported 25% frequency

BR354

Subjects
38/250
6/41
5/96
57/328
/303
42/106
1
1
31/200
4
2/150
2
83/600
2
1
1
8/47
14/87
32/100

1
28/108
3
1
14/112
1
19/108
17/72
1
1
24/42
19/140
31/236
27/100
2/30
2/60

Median to ulnar communication

Median to ulnar communication
Median to ulnar communication
Median to ulnar communication
Ulnar to median communication
Median to ulnar communication
Ulnar to median communication (case report)
Median to ulnar communication (case report)
Median to ulnar communication
Median to ulnar communication (case reports)
Ulnar to median communication
Median to ulnar communication (case reports)
Median to ulnar communication
Median to ulnar communication (case reports)
Ulnar to median communication (case report)
MGC in a patient with cubital tunnel syndrome
MGC in patients with cubital tunnel syndrome
MGC in patients without cubital tunnel syndrome
Median to ulnar communication
Ulnar to median communication
Ulnar to median communication (case report)
Median to ulnar communication
Median to ulnar communication (case reports)
Median to ulnar communication (case report)
Median to ulnar communication
Ulnar to median communication
Median to ulnar communication (case report)
Median to ulnar communication
Median to ulnar communication
Median to ulnar communication (case report)
Ulnar to median communication (case report)
Median to ulnar communication
Median to ulnar communication
Median to ulnar communication
Median to ulnar communication
Median to ulnar communication (anatomical examination)
Median to ulnar communication (electrophysiological examination)

in anatomical examination, and 18.5% in electrophysiological examination. Simonetti [13] found a much higher incidence (57%) in electrophysiologic examination.
The frequency of occurrence in the Anatolian population was reported by Budak and Gonenc [14] to be
17.5%, and 27% by Erdem et al. [15]. In the present
study, while anatomical examination showed MGC in 2
of 30 (6.6%) upper extremities, electrophysiological
examination revealed 2 MGCs in 60 subjects (3.3%). We
found MGC less frequently than reported in the available literature. We believe that these differing frequencies in the Anatolian population should be corrected by
studies with larger samples.
It has been suggested that unilateral MGC occurs more
often in the right side than the left [16]. In our cases,
MGCs were also found on the right side in both anatomical and electrophysiological examination.

Med Sci Monit, 2003; 9(9): BR351-356

Crutchfield and Gutmann [17], and Piza-Katzer [18]

found communication in the family members of persons
who showed this anomalous connection, and suggested
that there is familiar inheritance, probably autosomal
dominant. In the present study, we did not study familiar occurrence.
Occurrence frequency for ulnar-to-median nerve communication (Marinacci communication) was reported as
1.3% by Kimura et al. [19], 5% by Rosen [20], and 16.7%
by Golovchinsky [21]. In the present study, we did not
find any ulnar-to-median communication.
There is no consensus in the literature about the classification of MGCs. Numerous classifications have been proposed. Hirasawas, Nakashimas, Thompsons, Shus,
Srinivasans, and Rodriguez-Niedenfuhrs classifications
were based on anatomical dissections; Prestons, Ohs,
and Kimuras, on electrophysiological examinations; and
Shus, on histological examinations. A summary of these
classification schemes is shown in Table 1. RodriguezNiedenfuhr et al. [22] classified the MGC as pattern I
and II. Pattern I comprised cases with one communicating branch, and pattern II with two. Additionally,
according to their classification, Pattern I was subdivided
into three types, Ia, Ib, and Ic, depending on the level of
the communication from the median nerve.
When anatomical classifications were examined, the
most common communication paths are between median-ulnar nerve and the anterior interosseous-ulnar
nerve. We would argue that these common pathways
should be used, and others can be classified as combinations or simply other. Additionally, for electrophysiological classification, we accepted the suggestions made
by Preston and Shapiro [7], Oh [8] and Kimura [9].
According to electrophysiological recordings, MGC has
been classified into three groups [79]. In type I, there
is a crossover from median to ulnar nerve supplying the
hypothenar muscles. A crossover from median to ulnar
nerve supplying the first dorsal interosseous muscle is
the most common type of MGC, and has been called
type II. In type III MGCs, the crossover from median
nerve to ulnar nerve supplies the thenar muscles.
According to Van Dijk and Bouma [23], stimulation of
the proximal or distal ends of the communication does
not excite the same number of nerve fibers. The ulnar
nerve gains fibers, so the CMAP following distal stimulation will have a higher amplitude than following proximal stimulation. The number of fibers crossing over will
affect the magnitude of the difference. In MGC, one
nerves loss must be another nerves gain. Van Dijk and
Bouma [23] used this phenomenon and proposed a
detailed calculation. According to these formulae, normal conduction will result in values close to zero, while
MGC results in a large positive value. In our cases, we
found positive values. We confirmed the calculation
described by van Dijk and Bouma [23].
As suggested by Curtis and Ranschburg (cited by
Srinivasan and Rhodes [24]), the communication could

Sarkicioglu L et al Median and ulnar nerve communication in the forearm

carry either motor or sensory impulses, depending on

the pattern of the communication. But it is predominantly motor in nature, and has been found to innervate the first dorsal interosseous muscle in most
instances, less frequently the thenar and hypothenar
muscles. Involvement of sensory axons has been reported in one case by Santoro et al. [25]. The connection
was described as going from the median nerve to the
ulnar nerve. Such directionality referred to the apparent direction of the fibers; if a branch was noted to
course from median nerve proximally to the ulnar
nerve distally, it was assumed to be afferent. Yet nerves
such as cervical ansa demonstrate that the direction of
the electrical signal cannot always be inferred from the
local course of the nerve; signals can travel in a direction that may appear backward from strictly gross
anatomical considerations. Additionally, nerves have
efferent and afferent fibers. One cannot define the
source and destination of electrical signals if one does
not know whether the fibers are afferent or efferent.

CONCLUSIONS
In this study group, the frequency of occurrence of
MGC was found to be 3.3% and 6.6% in electrophysiological and anatomical examination, respectively. By
recognizing the existence of different types of connections, mistakes in diagnosis of peripheral nerve lesions
in the forearm can be avoided. The possible existence of
these connections is also important for surgical and electrophysiological procedures, especially in association
with carpal tunnel syndrome.

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