Transferring the Motor Branch of the Opponens Pollicis to the Terminal Division of the Deep Branch of the Ulnar Nerve for Pinch Reconstruction

Published:October 23, 2018DOI:


      With ulnar nerve injuries, paralysis of the first dorsal interosseous (FDI) and the adductor pollicis (ADP) muscles weakens pinch. The likelihood that these muscles will be reinnervated following ulnar nerve repair around the elbow is very low. To overcome this obstacle, we propose a more distal repair: transferring the opponens pollicis motor branch (OPB) to the terminal division of the deep branch of the ulnar nerve (TDDBUN).


      We dissected 10 embalmed hands to study the anatomy of the thenar branches of the median nerve and TDDBUN. We also operated on 3 patients with recent ulnar nerve injuries around the elbow, suturing the ulnar nerve and transferring the OPB to the TDDBUN. Before and after surgery, we measured grasp, key pinch, and pinch-to-zoom strength using dynamometers. Pinch-to-zoom gesture consists of moving the index finger and thumb pulp toward each other for zooming out of an image on screen. Patients were followed for at least 15 months.


      The thenar branch of the median nerve innervated the abductor pollicis brevis and opponens pollicis in all specimens, but only half the superficial head of the flexor pollicis brevis. The TDDBUN gave off a single motor branch to the transverse head of the ADP, 1 or 2 branches to the oblique head, and a final branch to the FDI. The ratio of myelinated fibers between the OPB and the TDDBUN was 3:5. Relative to the normal side, pinch-to-zoom strength was mostly affected by the ulnar nerve lesion, with strength decreased by 80% to 90%. After surgery, we observed reinnervation of the FDI and an 80% to 90% improvement in pinch-to-zoom strength.


      Transferring the OPB to the TDDBUN provided reinnervation of the FDI and ADP, thereby contributing to pinch strength improvement.

      Type of study/level of evidence

      Therapeutic V.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Mannerfelt L.
        Studies on the hand in ulnar nerve paralysis. A clinical-experimental investigation in normal and anomalous innervation.
        Acta Orthop Scand. 1966; Suppl 87: 1+
        • Draeger R.W.
        • Stern P.J.
        The inverted pyramid sign and other eponymous signs of ulnar nerve palsy.
        J Hand Surg Am. 2014; 39: 2517-2520
        • Smith R.J.
        Extensor carpi radialis brevis tendon transfer for thumb adduction—a study of power pinch.
        J Hand Surg Am. 1983; 8: 4-15
        • Gaul Jr., J.S.
        Intrinsic motor recovery—a long-term study of ulnar nerve repair.
        J Hand Surg Am. 1982; 7: 502-508
        • Post R.
        • de Boer K.S.
        • Malessy M.J.
        Outcome following nerve repair of high isolated clean sharp injuries of the ulnar nerve.
        PLoS ONE. 2012; 7e47928
        • Roganovic Z.
        Missile-caused ulnar nerve injuries: outcomes of 128 repairs.
        Neurosurgery. 2004; 55: 1120-1129
        • Trevett M.C.
        • Tuson C.
        • de Jager L.T.
        • Juon J.-M.
        The functional results of ulnar nerve repair.
        J Hand Surg Eur. 2016; 20: 444-446
        • Uraloğlu M.
        • Orbay H.
        • Açar H.B.
        • Sensöz M.
        Flexor pollicis brevis adductorplasty: an alternative method in ulnar nerve paralysis.
        Ann Plast Surg. 2006; 57: 110-114
        • Novak C.B.
        • Mackinnon S.E.
        Distal anterior interosseous nerve transfer to the deep motor branch of the ulnar nerve for reconstruction of high ulnar nerve injuries.
        J Reconstr Microsurg. 2002; 18: 459-464
        • Haase S.C.
        • Chung K.C.
        Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries.
        Ann Plast Surg. 2002; 49: 285-290
        • Flores L.
        Comparative study of nerve grafting versus distal nerve transfer for treatment of proximal injuries of the ulnar nerve.
        J Reconstr Microsurg. 2015; 31: 647-653
        • Battiston B.
        • Lanzetta M.
        Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer.
        J Hand Surg Am. 1999; 24: 1185-1191
        • Sallam A.A.
        • Mohamed S.E.
        • Mohamed A.I.
        Nerve Transfer versus nerve graft for reconstruction of high ulnar nerve injuries.
        J Hand Surg Am. 2017; 42: 265-273
        • Schenck T.L.
        • Stewart J.
        • Lin S.
        • Aichler M.
        • Machens H.G.
        • Giunta R.E.
        Anatomical and histomorphometric observations on the transfer of the anterior interosseous nerve to the deep branch of the ulnar nerve.
        J Hand Surg Eur. 2015; 40: 591-596
        • Sunderland S.
        • Hughes E.
        Metrical and non-metrical features of the muscular branches of the ulnar nerve.
        J Comp Neurol. 1946; 85: 113-125
        • Bertelli J.A.
        • Ghizoni M.F.
        Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus.
        J Neurosurg Spine. 2016; 24: 990-995
        • Mathiowetz V.
        • Kashman N.
        • Volland G.
        • Weber K.
        • Dowe M.
        • Rogers S.
        Grip and pinch strength: normative data for adults.
        Arch Phys Med Rehabil. 1985; 66: 69-74
        • Kapandji A.
        Clinical test of apposition and counter-apposition of the thumb [in French].
        Ann Chir Main. 1986; 5: 67-73
        • Olave E.
        • Prates J.C.
        • Del Sol M.
        • Sarmento A.
        • Gabrielli C.
        Distribution patterns of the muscular branch of the median nerve in the thenar region.
        J Anat. 1995; 186: 441-446
        • Stopford J.S.
        The variation in distribution of the cutaneous nerves of the hand and digits.
        J Anat. 1918; 53: 14-25
        • Munford J.
        • Morecraft R.
        • Blair W.F.
        Anatomy of the thenar branch of the median nerve.
        J Hand Surg Am. 1987; 12: 361-365
        • Xie P.
        • Jiang Y.
        • Zhang X.
        • Yang S.
        The study of intramuscular nerve distribution patterns and relative spindle abundance of the thenar and hypothenar muscles in human hand.
        PLoS One. 2012; 7e51538
        • Hughes L.A.
        • Clarke H.M.
        Normal arborization of the deep branch of the ulnar nerve into the interossei and lumbricals.
        J Hand Surg Am. 1995; 20: 10-14
        • Atkins S.E.
        • Logan B.
        • McGrouther D.A.
        The deep (motor) branch of the ulnar nerve: a detailed examination of its course and the clinical significance of its damage.
        J Hand Surg Eur. 2009; 34: 47-57
        • Bertelli J.A.
        • Kechele P.R.
        • Santos M.A.
        • Besen B.A.M.P.
        • Duarte H.
        Anatomical feasibility of transferring supinator motor branches to the posterior interosseous nerve in C7-T1 brachial plexus palsies. Laboratory investigation.
        J Neurosurg. 2009; 111: 326-331
        • Brandsma J.W.
        • Schreuders T.A.R.
        • Birke J.A.
        • Angelika P.
        • Oostendorp R.
        Manual muscle strength testing: intraobserver and interobserver reliabilities for the intrinsic muscles of the hand.
        J Hand Ther. 2012; 8: 185-190
        • Schreuders T.A.R.
        • Roebroeck M.E.
        • Jaquet J.-B.
        • Hovius S.E.R.
        • Stam H.J.
        Measuring the strength of the intrinsic muscles of the hand in patients with ulnar and median nerve injuries: reliability of the Rotterdam Intrinsic Hand Myometer (RIHM).
        J Hand Surg Am. 2004; 29: 318-324
        • Schreuders T.A.R.
        • Roebroeck M.E.
        • Jaquet J.-B.
        • Hovius S.E.R.
        • Stam H.J.
        Long-term outcome of muscle strength in ulnar and median nerve injury: comparing manual muscle strength testing, grip and pinch strength dynamometers and a new intrinsic muscle strength dynamometer.
        J Rehabil Med. 2004; 36: 273-278
        • Kozin S.H.
        • Porter S.
        • Clark P.
        • Thoder J.J.
        The contribution of the intrinsic muscles to grip and pinch strength.
        J Hand Surg Am. 1999; 24: 64-72
        • Yancosek K.E.
        • Mullineaux D.R.
        Stability of handwriting performance following injury-induced hand-dominance transfer in adults: a pilot study.
        J Rehabil Res Dev. 2011; 48: 59-68
        • Goetz T.J.
        • Costa J.A.
        • Slobogean G.
        • Patel S.
        • Mulpuri K.
        • Travlos A.
        contribution of flexor pollicis longus to pinch strength: an in vivo study.
        J Hand Surg Am. 2012; 37: 2304-2309
        • Kim J.
        • Cho D.
        • Lee K.
        • Lee B.
        A real-time pinch-to-zoom motion detection by means of a surface EMG-based human-computer interface.
        Sensors. 2015; 15: 394-407
        • Gracia-Ibáñez V.
        • Sancho-Bru J.L.
        • Vergara M.
        Relevance of grasp types to assess functionality for personal autonomy.
        J Hand Ther. 2018; 31: 102-110
        • Duchenne G.-B.
        Physiologie des Mouvements Démontrée à l'Aide de l‘Experimentation Électrique et de l’Observation Clinique.
        JB Balliere et Fils, Paris1867: 84-87
        • Gupta S.
        • Michelsen-Jost H.
        Anatomy and function of the thenar muscles.
        Hand Clin. 2012; 28: 1-7
        • Johanson M.E.
        • Skinner S.R.
        • Lamoreux L.W.
        Phasic relationships of the intrinsic and extrinsic thumb musculature.
        Clin Orthop Relat Res. 1996; 322: 120-130
        • Bertelli J.A.
        • Soldado F.
        • Rodrígues-Baeza A.
        • Ghizoni M.F.
        Transfer of the motor branch of the abductor digiti quinti for thenar muscle reinnervation in high median nerve injuries.
        J Hand Surg Am. 2018; 43: 8-15