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Page 8 of 12 Costa et al. Plast Aesthet Res 2020;7:32 I http://dx.doi.org/10.20517/2347-9264.2020.43

Figure 7. Nerve transfers in an end-to-end strategy to restore ulnar sensation. Protective sensation of the third web space is maintained
through end-to-side coaptation of the distal stump on the sensitive portion of the median nerve itself

The back of the hand supplied by the radial nerve is not critical. This has prompted some authors to suggest
end-to-side coaptation on the functioning median nerve and indeed, this has been performed in many
clinical scenarios [46-49] . Experimental data have also shown that the axons transmitted in these end-to-side
strategies provide maximum protective sensation [50,51] .

Recently, Somsak suggested an end-to-side transfer as a treatment for C5-C6 root avulsions. In addition
to the loss of sensation, such patients may experience pain on the dorsoradial aspect of the hand. An end-
to-side transfer between the superficial branch of the radial nerve to the ulnovolar portion of the median
[52]
nerve has shown promise in relieving pain and providing protective sensation .
Ulnar nerve
Sensory nerve transfers for isolated ulnar nerve injuries aim to reestablish protective sensation to the ulnar
[53]
border of the hand . In the literature, several methods have been proposed by different authors to utilize
the functioning median nerve in order to provide sensation to the distribution of the ulnar nerve.

In the event of a brachial plexus or high ulnar nerve injury, the nerve directed to the third web space can be
[22]
used to restore sensation to the ulnar border of the hand, which is more critical .

[54]
Brown et al. described end-to-end coaptation between the proximal stump of the nerve of the third web
space and the distal stump of the nerve for the fourth web space in the distal forearm.

Furthermore, the dorsal sensory branch of the ulnar nerve is coapted end-to-side to the sensory part of the
median nerve after making an epineural opening [Figure 7].

[55]
Flores reported an analogous approach, with the use of an end-to-side technique .
The sensitivity of the ulnar side of the hand can, in fact, be restored with end-to-side nerve transfers.
This can be done using the median branch to the third web space as a donor. Another possible technique
involves coaptation of the sensitive branches of the ulnar nerve with the functional median nerve at the
[16]
level of the forearm . These techniques allow restoration of the sensitivity of the ulnar border of the hand
without denervation of the territories supplied by the median nerve.

[56]
Oberlin et al. described coaptation in the distal forearm with an interpositional nerve graft between the
LACN and the dorsal branch of the ulnar nerve. Ruchelsman et al. described a revised technique, which
[57]
avoids the use of an interpositional graft through dissection for a longer LACN.