International Journal of Neuroscience, 2014; 124(7): 542546

Copyright 2014 Informa Healthcare USA, Inc.

ISSN: 0020-7454 print / 1543-5245 online
DOI: 10.3109/00207454.2013.858336

CASE REPORT

Ulnar neuropathy with prominent proximal Martin-Gruber

anastomosis
Ahmet Z. Burakgazi,1 Mary Russo,2 Elham Bayat,2 and Perry K. Richardson2
1

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Neuroscience Section, Department of Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA;
Department of Neurology, George Washington University, Washington, DC, USA
Martin-Gruber anastomosis (MGA) is the most common nerve anastomosis in the upper extremities and it
crosses from the median nerve to the ulnar nerve. Proximal MGA is an under recognized anastomosis between
the ulnar and median nerves at or above the elbow and should not be missed during nerve conduction studies.
We presented two patients with ulnar neuropathy mimicking findings including numbness and tingling of the 4th
and 5th digits and mild weakness of intrinsic hand muscles. However, both cases had an apparently remarkable
conduction block between the below- and above-elbow sites that was disproportionate to their clinical findings.
To explain this discrepancy, a large MGA was detected with stimulation of the median nerve at the elbow. Thus,
proximal MGA should be considered in ulnar neuropathy at the elbow when apparent conduction block or/and
discrepancy between clinical and electrodiagnostic findings is found.
KEYWORDS: proximal Martin-Gruber anastomosis, ulnar neuropathy, nerve conduction studies

Ulnar neuropathy at the elbow is the second most common mononeuropathy in electrodiagnostic laboratories,
after carpal tunnel syndrome [13]. The clinical findings
include weakness of interossei muscles and decreased
sensation in the ulnar nerve distribution. The electrodiagnostic findings include a presence of a significant drop
in ulnar motor amplitude with above elbow stimulation
along with slowing of conduction velocity (CV) or
abnormal temporal dispersion. However, a discrepancy
can rarely be seen between clinical and electrodiagnostic
findings [1,3,4]. These discrepancies can be apparent
conduction block (CB) without slowing of CV with
above elbow stimulation of the ulnar nerve, or apparent
CB between below- and above-elbow stimulation of
the ulnar nerve without consistent clinical findings [3,
58]. Thus, if one detects a significant discrepancy
between the clinical and electrodiagnostic findings,
an alternative explanation should be investigated
[3,6,911].
Typical Martin-Gruber anastomosis (MGA) is a
crossover between median and ulnar nerves in the forearm. Proximal MGA is an under recognized anastomosis between the ulnar and median nerves at or above the
Received 10 August 2013; revised 20 October 2013; accepted 20 October 2013
Correspondence: Ahmet Z. Burakgazi, MD, Carilion Clinic, 3 Riverside
Circle, Roanoke, VA 24016, USA. E-mail: drburakgazi@yahoo.com

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elbow and should not be missed during nerve conduction studies (NCS) [9,10,12]. Its electrodiagnostic detection may be misinterpreted as evidence of conduction
block when there may be none, and thus misinterpreted
as evidence of ulnar neuropathy in a normal individual
[9,10,13]. This may lead to inappropriate intervention.
Herein, we present two cases of ulnar neuropathy with
prominent MGA to emphasize the importance of proximal MGA assessment in patients with ulnar neuropathy
when electrodiagnostic findings are not consistent with
clinical findings [2,5,9,10].

Case Reports
Patient 1
A 60-year-old male with a history of diabetes presented
with pain and numbness in the fingers, particularly the
digits 4th and 5th for two months, with nocturnal paresthesia of the hand, more on the right side for several
months. The patient also described right hand weakness, difficulties in grasping and fine motor activities,
and tenderness over the medial aspect of the elbow. He
denied neck pain radiating to his upper extremity. However, the numbness and pain in his forearm and ulnar
side of the hand could radiate up to his shoulder.

Ulnar Neuropathy with Prominent MGA

The physical examination showed his cranial nerves

were intact, 5/5 strength was in the shoulder girdle,
proximal upper arms, and forearm muscles except for
4/5 strength was in the interossei muscle (4/5) and abductor pollicis brevis (APB) muscles; sensation to light
touch, pin prick, vibration was intact except there was a
decreased sensation on the ulnar side of the hands bilaterally and at the tip of the first three fingers; deep tendon
reflexes were intact; Babinski response was absent; and
his coordination and gait examination were within normal limits.

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there was a proximal MGA, a response upon stimulation of the median nerve at the elbow was detected. The
stimulation sites and a schematic depiction of proximal
MGA is shown in Figure 1.

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Patient 2
A 45-year-old male with no significant past medical history presented with right 4th and 5th digit numbness
for 68 months. The patient did not have any remarkable weakness in his hands. He denied neck pain and
had mild tenderness over the medial aspect of the elbow
that radiated to the shoulder and hand.
The physical examination demonstrated that CN
were within normal limits; 5/5 strength in upper and
lower limb muscles; sensation to light touch and pin
prick was decreased on the ulnar side of the right hand;
deep tendon reflexes were intact; Babinski response was
absent; and his coordination and gait examination were
within normal range.

Nerve conduction studies

Technique
Ulnar motor NCS were performed with disc electrodes.
G1 was placed over the muscle belly of abductor digiti
minimi (ADM) and first interossei muscles (FDI), G2
was placed at the lateral base of fifth digit for ADM or
at the base of second digit for FDI; and G0 was placed
on the dorsum of hand, in between S1 and G1. The current was gradually increased to the point that the CMAP
no longer increased in side in order to obtain supramaximal stimulation. The elbow was in a flexed position
during ulnar motor nerve stimulation. The ulnar nerve
was stimulated at three points: S1: 68 cm proximal to
G1 over the ulnar nerve at the wrist; S2: 46 cm distal
to the ulnar groove (BG); and S3: 1012 cm proximal
to the below elbow site of stimulation (AG). Using an
inching technique with 2-cm increments, the amplitude
change was found to occur between 46 cm distal to
the medial epicondyle. Proximal MGA was suspected in
cases when a decrement in ulnar motor nerve amplitude
was >0.5% or >0.30.4 MV with AG stimulation compared with BG stimulation [2,3,9,10]. To confirm the
median to ulnar crossover, the disc electrodes were kept
on the ulnar-innervated muscles and the median nerve
was stimulated at the elbow, over the brachial pulse. If

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Figure 1. Depiction of proximal MGA. (Please see Figures 2

and 3 for descriptions of A, B, C, D, F, G, H, 1, 2, 3, 4, 6, 7, 8.)

FDI: First Dorsal Interosseus; APB: Abductor Pollicis Brevis.
Med. Epic: Medial Epicondyle.

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A. Z. Burakgazi et al.

Patient 1
NCS revealed absent right ulnar digital cutaneous sensory nerve action potentials (SNAPs), decreased amplitude of left ulnar sensory SNAP, and decreased amplitude of right median SNAP with delayed latency. The
right and left ulnar/first dorsal interosseous (FDI) motor
NCS showed a decline in compound motor action potential (CMAP) amplitude (98% and 55%, respectively)
across the elbow segment, with slowed CV. Then disc
electrodes were kept on the FDI and median nerves were
stimulated at the elbow. 4.7 mV and 8.7 mV CMAP
amplitudes were obtained from ADM and FDI muscles with median nerve stimulation at the elbow, respectively (Figure 2A and 2B). The response and decrement
was attributed to a large proximal MGA. The right median/thenar motor NCS showed mildly prolonged latency. The median nerve CMAP amplitude recording
from abductor pollicis brevis (ABP) was 11.2 mV with
wrist stimulation and 9.3 mV with elbow stimulation.

Concentric needle electromyography of the right upper

limb showed chronic denervation in the FDI muscle.
This patient was diagnosed with ulnar neuropathy and
carpal tunnel syndrome.
Patient 2
Nerve conduction studies showed decreased amplitude
of the right ulnar sensory nerve action potential. The
right ulnar/FDI motor NCS showed a decline in CMAP
amplitude (92%) across the elbow segment with normal
conduction velocity. A 10.2 mV and 12.2 mV CMAP
amplitude response was obtained from ADM and FDI
muscles with median nerve stimulation at the elbow, respectively (Figure 3A and 3B). The response and decrement was attributed to a large proximal MGA. The median nerve CMAP amplitude recording from APB was
15.9 mV with wrist stimulation and 15.3 mV with elbow
stimulation. Concentric needle electromyography of the
right upper limb was within normal limits.

Figure 2. Demonstration of prominent MGA from ADM (Figure 2A) and from FDI (Figure 2B) muscles in

Patient#1. (A): Ulnar nerve stimulation site at the wrist recording over ADM; (B): Ulnar nerve stimulation site
below the elbow recording over ADM; (C): Ulnar nerve stimulation site above the elbow recording over ADM;
(D): Median nerve stimulation site at the elbow while recording over ADM; (E): Ulnar nerve stimulation site
at the wrist recording over FDI; (F): Ulnar nerve stimulation site below the elbow recording over FDI; (G):
Ulnar nerve stimulation site above the elbow recording over FDI; (H): Median nerve stimulation site at the
elbow while recording over FDI.

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Ulnar Neuropathy with Prominent MGA

545

Figure 3. Demonstration of prominent MGA from ADM (Figure 3A) and from FDI (Figure 3B) muscles in

Patient#2. (1): Ulnar nerve stimulation site at the wrist recording over ADM; (2): Ulnar nerve stimulation site
below the elbow recording over ADM; (3): Ulnar nerve stimulation site above the elbow recording over ADM;
(4): Median nerve stimulation site at the elbow while recording over ADM; (5): Ulnar nerve stimulation site
at the wrist recording over FDI; (6): Ulnar nerve stimulation site below the elbow recording over FDI; (7):
Ulnar nerve stimulation site above the elbow recording over FDI; (8): Median nerve stimulation at the elbow
while recording over FDI.

Discussion
MGA is the most common nerve anastomosis in the
upper extremities and is seen around 15%30% of
normal individuals [2,4,5,12]. The incidence of MGA
for normal individuals has been reported as 11%24%
in various cadaveric studies [1315], and 15%39% in
previous nerve conduction reports [5,8,16]. MGA may
arise from the main trunk of the median nerve or from
one of its branches, particularly anterior interosseous
nerve. The crossed over median nerve fibers merge
with the distal ulnar nerve to innervate ulnar nerve
innervated muscles [5,10,14].
There are four well-defined types of MGA [5] localizing in forearm: (1) Type 1 is the most common type
(approximately 90% of cases) and arises between anterior interosseous and ulnar nerves, (2) Type 2 arises
between the median and ulnar nerve trunks, (3) Type

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3 arises between branches innervating the flexor digitorum profundus muscles, and (4) Type 4 is anastomic
branch from the median or anterior interosseous nerve
joining the ulnar nerve at two different points[5,13,14].
Proximal MGA is an under-recognized anastomosis
between ulnar and median nerves at or above the elbow
[5,10,13]. An accompanying ulnar neuropathy can be
detected based on the clinical findings including weakness of intrinsic hand muscles and decreased sensation
on the ulnar nerve distribution and the electrodiagnostic findings including slowing in conduction velocity and
abnormal ulnar sensory nerve action potential response
[5,10,11]. Marras et al. [10] reported a patient with
proximal MGA mimicking ulnar neuropathy at the elbow. Whitaker et al. [9] detected proximal MGA in
three patients over a period of 2 years. In our cases,
the patients had ulnar neuropathy mimicking findings
including numbness and tingling of the 4th and 5th

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A. Z. Burakgazi et al.

digits and mild weakness of intrinsic hand muscles.

However, both cases had an apparently remarkable conduction block between the below- and above-elbow sites
that was disproportionate to their clinical findings. It
should be considered that there is a potential for misinterpretation with understimulation at the above site of
stimulation and overstimulation at the median nerve at
the elbow. Thus, stimulation should be increased gradually and carefully to avoid this misinterpretation. To explain this discrepancy, a large MGA was detected with
stimulation of the median nerve at the elbow. This inconsistency was explained with the presence of a prominent proximal MGA.
In conclusion, proximal MGA should be considered
in ulnar neuropathy at the elbow when apparent conduction block or/and discrepancy between clinical and
electrodiagnostic findings is found.

Declaration of Interest
The authors report no conflict of interest. The authors
alone are responsible for the content and writing of this
paper.

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