Clinical Anatomy 24:168178 (2011)

ORIGINAL COMMUNICATION

Patterns of Motor Branching of the

Musculocutaneous Nerve in Human Fetuses and
Clinical Signicance
PIRAYE KERVANCIOGLU,1* MUSTAFA ORHAN,1

AND

NIHAL KILINC2

Anatomy Department, Gaziantep University Medical Faculty, Turkey

Pathology Department, Canakkale Onsekiz Mart University Medical Faculty, Turkey

The purpose of this morphologic study is to investigate the course and the
branching pattern of motor branches of musculocutaneous nerve (MCN) in
human fetuses. Twenty upper limbs (10 right, 10 left) of spontaneously aborted
formalin-xed fetuses were dissected under a stereomicroscope to determine
motor branches for the biceps brachii and brachialis and the communicating
branches between the MCN and median nerve (MN). The MCN entered the proximal and middle part of coracobrachialis in 13/20 and 5/20 of arms, respectively,
and the remaining 2/20 did not pierce coracobrachialis. The communication
between MCN and MN was observed in 5/20 of the arms and detected only in the
distal part of the coracobrachialis. The most frequently observed innervation is
the type wherein a single branch to biceps brachii, which bifurcated for supplying
the short and long heads (12/20). For the innervation of brachialis, the most frequent type was a single branch from the main trunk of the MCN (15/20). During
the dissections, the distance between the acromion and the emerging point of
the motor branches was measured. The mean distance between the acromion
and the emerging point of the all motor branches for biceps brachii in all types of
specimens was 33.8 6 6.1% of acromion-lateral epicondyle length and for brachialis was 50.6 6 11.5% of acromion-lateral epicondyle length. The data of the
MCN variations in the human fetus may be useful for the clinicians and pediatric
surgery. Clin. Anat. 24:168178, 2011. V 2011 Wiley-Liss, Inc.
C

Key words: fetal morphology; upper limb; musculocutaneous nerve; nerve

variations

INTRODUCTION
The musculocutaneous nerve (MCN) is responsible
for innervation of the exor musculature of the elbow
and for the skin sensitivity on the lateral surface of
the forearm. Its bers being derived from ventral
branches of the C5, C6, and C7 spinal nerves. The
MCN arises from the lateral cord of the brachial
plexus, opposite the lower border of pectoralis
minor. It pierces the corachobrachialis and then
passes obliquely between the biceps brachii and brachialis to innervate all three of these muscles. Close
to the elbow, it pierces the deep fascia and reaches
surface of the forearm and continued as the lateral
antebrachial cutaneous nerve (Moore, 1992; Standring et al., 2005).
C 2011
V

Wiley-Liss, Inc.

The course and the branching pattern of the MCN as

well as variations of the communicating branches
between MCN and median nerve (MN) have been morphologically investigated in adult cadavers (Linell,
1921; Yang et al., 1995; Venieratos and Anagnostopoulou, 1998; Choi et al., 2002; Loukas and Aqueelah,
*Correspondence to: Piraye Kervancioglu, Department of
Anatomy, The University of Gaziantep, Medical Faculty, University
Avenue 27310, Sehitkamil/Gaziantep, Turkey.
E-mail: pkervancioglu@gantep.edu.tr
Received 2 July 2010; Revised 29 September 2010; Accepted 5
October 2010
Published online 22 January 2011 in Wiley Online Library
(wileyonlinelibrary.com). DOI 10.1002/ca.21095

Anatomy of Musculocutaneous Nerve in Fetuses

TABLE 1. Number of Dissected of Arms According
to the Gestational Weeks
Gestational age (weeks)
16
19
23
26
28
30
36

Number (arms)
2
4
4
2
4
2
2

2005; Pacha Vicente et al., 2005; Guerri-Guttenberg

and Ingolotti, 2009). However, there are only a few
studies on the MCN in fetuses (Linell, 1921; KwolczakMcGrath et al., 2008; Guerri-Guttenberg and Ingolotti,
2009; Uysal et al., 2009). As Kwolczak-McGrath et al.
(2008) emphasized that the body proportions of newborns and infants are rather similar to a fetus than an
adult, studying the course of the MCN and the exit
points of the motor branches for biceps brachii and brachialis in fetuses will be helpful for clinicians and surgeons. The branching pattern of MCN has been considered important for surgical procedures; several studies
have been reported about this topic in recent years
(Loukas and Aqueelah, 2005; Pacha Vicente et al.,
2005; Kwolczak-McGrath et al., 2008; Guerri-Guttenberg and Ingolotti, 2009; Uysal et al., 2009). Park et
al. (2007) noted that accurate localization of the motor
points of the biceps brachii or brachialis is necessary
for injection of the neurolytic agents into these points
for an effective treatment of spasticity of the elbow
exors. It would also be useful for safe surgery in the
surgical treatment of recurrent anterior instability of
the shoulder by coracoid transfer (Latarjets procedure). Understanding the anatomy of the communications between MCN and MN is critical in surgical repair
to the plexus and assessment of MN and MCN dysfunction (Choi et al., 2002; Loukas and Aqueelah, 2005).

MATERIALS AND METHODS

The examinations were carried out on 20 upper
limbs of 10% formalin-xed fetuses of both the sexes
(six male and four female) from spontaneously aborted
human fetuses with no macroscopic abnormalities. The
fetuses were from the collection of the Department of
Human Anatomy, Medical Faculty of Gaziantep University. The material was collected and examined in accordance with Turkish legislation. The procedures followed were in accordance with the ethical standards of
the Committee on Human Experimentation of the Faculty, which are based on the Helsinki Declaration in
2008. Their ages ranged from 16 to 36 weeks of gestation (Table 1). The fetal age was established by measurements of individual crown-rump length.
Both sides of the upper limbs of the each fetus
were dissected from the axillary fossa to elbow joint.
Dissections were carried out under a stereomicroscope (83 magnications, Leica S4E) and photographed. During the dissection, we observed the
penetrating point of MCN to coracobrachialis and the
communicating branches between MCN and MN with
respect to the point of entrance of the MCN to the

169

coracobrachialis. The course and branching patterns

of MCN were determined and classied. We used the
classication of the branching patterns of MCN to
biceps brachii and brachialis, which has been previously described by Yang et al. (1995). The following
distances were then measured in each limb: (i) the
acromion-lateral epicondyle distance, (ii) the distance from acromion to emergence of nerves supplying biceps brachii, and (iii) the distance from acromion to emergence of nerves supplying brachialis.
We recorded these measurements at 458 of shoulder
abduction and the elbow in 908 of exion in the neutral rotation position of the arm. Measurements were
performed with a caliper with 0.05-mm accuracy.

RESULTS
In 13 (65%) of the arms, the MCN entered from
the proximal 1/3 part of coracobrachialis (Fig. 1a),
whereas in ve (25%) of the arms, it entered the
middle 1/3 part (Fig. 1b). In two of the arms (10%),
the MCN did not enter coracobrachialis but gives the
motor branches to it (Fig. 2).
The communicating branch between MCN and MN
was present in ve of 20 arms (25%). All the communicating branches were single, unilateral, and localized distal to penetrate point of the MCN to the coracobrachialis. The direction of the communications was
always from the MCN to the MN (Figs. 3 and 4).
In two of the arms, after giving the motor branches
of biceps brachii and brachialis, the MCN pierced the
common belly of biceps brachii and continued as the
lateral antebrachial cutaneous nerve (Fig. 4).
The MCN giving the motor branch to the coracobrachialis before entering it was found only bilaterally of
the arms of a fetus (2/20 of arms, 10%) (Fig. 5).
Yang et al. (1995) determined three types of
branching patterns for biceps brachii and two types
for brachialis. Additionally, we found different types
of branching patterns and described one branching
type for biceps brachii (Type IV) and two branching
type for brachialis (Types III and IV) (Fig. 6).

Patterns of Motor Branches Innervating

Biceps Brachii
In Type I, one single branch left the main trunk of the
MCN distal to the coracobrachialis and subsequently
split into two branches to supply, one each, the long
and the short heads of the biceps brachii. We observed
13 (65%) specimens with Type I pattern (Fig. 7a).
In Type II, there were two independent branches,
each one to a separate head of the muscle, the proximal innervating the short head of the biceps brachii
and the distal the long head. One (5%) specimen
with Type II pattern was observed (Fig. 7b).
In Type III, there were also two independent
branches: a proximal dividing into two branches,
each to a different head of the biceps brachii, and a
distal branch innervating the common belly of biceps
brachii. We observed four (20%) specimens with
Type III pattern (Fig. 7c).
In Type IV, two branches that did not left the main
trunk of the MCN with a common root but branched

170

Kervancioglu et al.

Fig. 1. MCN entered from the proximal 1/3 part of coracobrachialis (right side)
(a) and MCN entered from the middle 1/3 part of coracobrachialis (right side) (b). bb,
biceps brachii; arrow, musculocutaneous nerve; nvb, neurovascular bundle; p-m-d,
1/3 proximal-middle-distal part of coracobrachialis. [Color gure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

out at the same point than each innervates a different

head of the biceps brachii. Two (10%) specimens
were observed with Type IV pattern (Fig. 7d).

Patterns of Motor Branches Innervating

Brachialis
Type I: A single branch from the MCN innervating
brachialis was observed. We found 15 (75%) specimens with Type I pattern (Fig. 8a).
Type II: Two primary branches from the MCN
innervating brachialis were observed. One (5%)
specimen was found with Type II pattern (Fig. 8b).
Type III: A single branch from the MCN, which
then bifurcated to innervate brachialis, was observed.

We found two (10%) specimens with Type III pattern

(Fig. 8c).
Type IV: Three branches from the MCN innervating brachialis were observed. One in the proximal
branched out alone, but the two in the distal
branched out at the same point of MCN without a
common root. Two (10%) specimens were found
with Type IV pattern (Fig. 8d).

Localization of Motor Branches of MCN to

Biceps Brachii According to the Reference
Line Between Acromion-Lateral Epicondyle
The mean acromion-lateral epicondyle length was
43.5 6 7.66 mm. The mean distance between the

Anatomy of Musculocutaneous Nerve in Fetuses

Fig. 2. The course of musculocutaneous nerve (mcn) without entering coracobrachialis (cb) (left side). bb, biceps brachii; mn, median nerve; un, ulnar nerve;
arrow, nerve branch of mcn to cb. [Color gure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]

Fig. 3. The communication (arrow) between musculocutaneous nerve (mcn) and

median nerve (mn). cb, coracobrachialis; ba, brachial artery (left side). [Color gure
can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

171

172

Kervancioglu et al.

Fig. 4. After giving the motor branches of biceps brachii (bb) and brachialis, the musculocutaneous nerve
(mcn) pierced the common belly of biceps brachii (black
arrow) (left side). mn, median nerve; un, ulnar nerve; ba,

brachial artery; bv, brachial vein; white arrow, motor

branch to brachialis; white arrowhead, communication
between MCN and MN. [Color gure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

Fig. 5. The musculocutaneous nerve (mcn) giving motor branch (arrow) before
entering coracobrachialis (cb) (right side). bb, biceps brachii; mn, median nerve;
un, ulnar nerve; ba, brachial artery. [Color gure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]

Anatomy of Musculocutaneous Nerve in Fetuses

Fig. 6. The branching pattern of MCN to biceps brachii and brachialis. SH, short head of biceps brachii; LH,
long head of biceps brachii; CB, common belly of biceps
brachii.

acromion and the emerging point of the all motor

branches in all types of specimens was 15.3 6 4.8
mm (33.8 6 6.1% of acromion-lateral epicondyle
length). The mean distance between the acromion
and the emerging point of the proximal branches
and distal branches can be seen in Table 2.

Localization of Motor Branches of MCN to

Brachialis According to the Reference Line
Between Acromion-Lateral Epicondyle
The mean distance between the acromion and the
emerging point of the all motor branches in all types
of specimens was 21.7 6 5.4 mm (50.6 6 11.5% of
acromion-lateral epicondyle length). The mean distance between the acromion and the emerging point
of the proximal branches and distal branches can be
seen in Table 3.

DISCUSSION
The signicance of the branching patterns and variations of the peripheral nerves for clinical and surgical
applications has been widely documented. Oberlin et
al. (1994) described a technique of nerve transfer for
restoration of elbow exion in traumatic C5-6 avulsion
of the brachial plexus in adults. They sutured some of
the fascicles of the ulnar nerve to the motor branches

173

of MCN to the biceps brachii. Noaman et al. (2004)

applied Oberlins nerve transfer in Erbs birth palsy
and mentioned that clinicians must be aware of the
numerous variations of the course, branching patterns, and communications of the MCN. Heise et al.
(2004) reported that early prognostic assessment of
obstetrical brachial plexopathies would facilitate
rational selection of infants for brachial plexus surgery; so, they performed bilateral motor nerve conduction studies of the MCN to compare the amplitude
of compound muscle action potentials. Murphy and
Chan (2000) emphasized that to provide upper limb
regional anesthesia effectively and efciently, the
physician must be clear on the sensory and motor
innervations to the site of surgery for improving success and limiting complications.
The communicating branch between the MCN and
MN is by far the most frequent of all the variations
that may be observed in the formation and course of
the nerves of the brachial plexus (Venieratos and
Anagnostopoulou, 1998). These communicating
branches are usually explained as the bers that
failed to continue within the lateral root of the MN
and continued with MCN but joined the MN later with
the communicating branches (Prasada Rao and
Chaudhary, 2000; Standring et al., 2005). In the
present study, the communicating branch from MCN
to MN was found in ve of 20 arms (25%). To compare the incidence of communicating branch from
MCN to MN within the number of dissected arms was
listed in Table 4. In our ndings, all the communicating branches were unilateral and localized distal to
the entrance point of the MCN to the coracobrachialis. The direction of the communications was always
from the MCN to MN. We did not found a communication with two branches, whereas Pacha Vicente et
al. (2005) found it in 2.2%.
The knowledge of the incidence and variations of
the communicating branches is important for clinicians and especially for surgeons. In cases of MCN
variations with a communicating branch from MCN to
MN is present, proximal injuries of the MCN would
also involve MNs bers. This knowledge is important
for evaluating post-traumatic weakness of forearm
exors and thenar muscles, because the injury of
the communicating branches may give rise to weakness of the muscles, which is to be known innervating with MN as in classic anatomy knowledge. This
may lead difculty to identify the injured nerve. Russell (2006) reported that the lateral component of
the MN from the lateral cord provides mostly sensory
axons from C6 and C7. In some persons, this component is very small, with the majority of the MNs C6
and C7 bers running instead in the MCN only to be
returned to the MN via a communication. So, proximal injury of the MCN may also cause a loss of sensation in the dermatomes of the MN. In the diagnosis
of carpal tunnel syndrome, this communication must
be considered to avoid unnecessary release of the
carpal tunnel. Also, this communication is especially
important during surgical operation of the arm as it
could damage during the retraction for anterior
approach to a humerus fracture (Choi et al., 2002;
Chitra, 2007). Venieratos and Anagnostopoulou
(1998) noted that the anterior surgical approach to

174

Kervancioglu et al.

Fig. 7. The branching pattern of MCN to biceps brachii. a: Type I (right side). b: Type II (left side). c: Type
III (left side). d: Type IV (left side). cb, coracobrachialis;
bb, biceps brachii; mcn, musculocutaneous nerve; nvb,
neurovascular bundle; mn, median nerve; black arrow,

nerve branch to short head of biceps brachii; black

arrowhead, nerve bracnh to long head of biceps brachii;
white arrow, nerve branch to common belly of biceps brachii. [Color gure can be viewed in the online issue, which
is available at wileyonlinelibrary.com.]

the shoulder joint may be complicated by the presence of this communicating branch.
Venieratos and Anagnostopoulou (1998) reported
three types of communications between MCN and
MN considering the entrance point of the MCN to the
coracobrachialis as the reference point. In Type 1,
the communication was proximal to the entrance
point, in Type 2, the communication was distal to the
entrance point, and in Type 3, the nerve and the
communicating branch did not pierce the muscle.
The communicating branches in the proximal to the
entrance point were reported 33% by Choi et al.
(2002), 41% by Venieratos and Anagnostopoulou
(1998), 70% by Chitra (2007), and 84.6% by
Guerri-Guttenberg and Ingolotti (2009). They were
distal in 30% (Chitra, 2007), 45% (Venieratos and
Anagnostopoulou, 1998), 65% (Choi et al., 2002),
and 7.7% (Guerri-Guttenberg and Ingolotti, 2009).
Uysal et al. (2003) reported a distal communication
in two out of 200 limbs of fetuses. In the present
study, all the communicating branches observed
between the MCN and MN were in the distal to the
entrance point and were classied as Type 2 accord-

ing to the classication made by Venieratos and Anagnostopoulou (1998).

Different frequencies have been reported about
the relations of the MCN within coracobrachialis. The
studies and the reported percentages of the specimens, which the MCN did not pierce coracobrachialis,
are as follows: Eglseder and Goldman (1997)
29.6%, Choi et al. (2002) 4.7%, Pacha Vicente et al.
(2005) 6.5%, and Uysal et al. (2009) 3%. Nonetheless, Ozturk et al. (2005) reported that in all 42
extremities, the MCN had no variations, originated
from the lateral cord of the brachial plexus and
entered the coracobrachialis. Uysal et al. (2009)
reported that the MCN entered the superior part of
coracobrachialis in 43% of specimens, the middle
part in 37%, and the inferior part in 17%. In our
study, in 65% of arms, the MCN entered from the
proximal 1/3 part of coracobrachialis, in 25% of
arms, it entered the middle 1/3 part and no sample
that the MCN enter distal 1/3 part of coracobrachialis, and in the remaining 10% of the arms, the MCN
did not enter coracobrachialis. Uysal et al. (2009)
noted that the high percentage of entrance point of

Anatomy of Musculocutaneous Nerve in Fetuses

175

Fig. 8. The branching pattern of MCN to brachialis. a: Type I (left side). b:

Type II (right side). c: Type III (right side). d: Type IV (left side). cb, coracobrachialis; b, brachialis; mcn, musculocutaneous nerve; nvb, neurovascular bundle;
mn, median nerve; arrow, nerve branch to brachialis. [Color gure can be viewed in
the online issue, which is available at wileyonlinelibrary.com.]

MCN in the upper and middle parts of the coracobrachialis suggests that trauma of these regions would
cause MCN damage in a high percentage.
The coracobrachialis arises from the tip of the
coracoid process of the scapula and inserts into
the middle third of the humeral body. Transfer of
the coracoid process to the scapular neck is used

for the treatment of recurrent anterior instability of

the shoulder (Latarjet procedure). Helfet (1958)
reported a case that paraesthesia developed after
coracoid transfer procedure and rst mentioned the
clinical importance of the entry of the MCN into the
coracobrachialis at a high level. Therefore, the surgeon should remember these variations in levels of

TABLE 2. Localization of Motor Nerves to Biceps Brachii

Motor nerves
supplying biceps
brachii
All motor branches
Type I, IV, and
proximal branch of
Type II and III
Distal branch of
Type II and III
a

Average distance from acromion to

emergence of nerves supplying
biceps (mm) (6SD)

Average distance from acromion

to emergence of nerves supplying
biceps brachii as percentage of
acromion-lateral epicondyle
lengtha (6SD) (%)

15.3 6 4.8
14.4 6 3.5

33.8 6 6.1
33.2 6 5.7

19.2 6 7.4

37.7 6 6.7

The mean acromion-lateral epicondyle length: 43.5 6 7.66 mm.

176

Kervancioglu et al.

TABLE 3. Localization of Motor Nerves to Brachialis

Motor nerves supplying brachialis

All motor branches
Type I, III, and proximal
branch of Type II, IV
Distal branch of Type II, IV
a

Average distance from acromion

to emergence of nerves supplying
brachialis (mm) (6SD)

Average distance
from acromion to emergence
of brachialis nerves as
percentage of acromion-lateral
epicondyle lengtha (6SD)

21.7 6 5.4
21.6 6 5.7

50.6 6 11.5
50.5 6 11.8

22.4 6 3.5

55.5 6 9.2

The mean acromion-lateral epicondyle length: 43.5 6 7.66 mm.

the entries of these nerves into the coracobrachialis

while applying this procedure.
The MCN sending motor branch to the coracobrachialis before entering it was found only bilaterally of
the arms of a fetus (2/20 of arms, 10%) by us. Kerr
(1918) reported that these branches arose from the
MCN in 54 out of the 109 plexuses. Ozturk et al.
(2005) found these branches from MCN to the coracobrachialis in all 42 extremities. MCN has been
studied in several studies, but in most of them, these
branches have not been mentioned. The muscle has
drawn attention with its potential use for contouring
the infraclavicular area (Parry et al., 1988) or covering the axillary vessels specically in reconstructive
postmastectomy operations (Hobar et al., 1990).
A number of variations with varying frequency in
the course and branching pattern of the MCN have
been reported, and the clinical importance of the
motor branches of biceps brachii and brachialis in
brachial plexus surgery has been widely documented
(Yang et al., 1995; Choi et al., 2002; Pacha Vicente
et al., 2005). We used the classication of the
branching pattern to the biceps brachii described by
Yang et al. (1995), but we found a different type of
branching pattern and added Type IV branching type
for biceps brachii. Yang et al. (1995) determined two
types of branching patterns for brachialis (Type I
and Type II), but we were able to identify four types
of branching patterns (Type III and Type IV). The
ndings of previous studies on branching patterns of

MCN to biceps brachii and brachialis and the results

of the present study are compared in Table 5. The
information of branching pattern of MCN to the
motor branches of the biceps brachii and brachialis
can be used by surgeons who elect to do nerve
transfers or nerve grafts for restoration of elbow
exion in brachial plexus injuries. Nerve transfer
consists of suturing normal nerve axons to the distal
end of an injured nerve.
Information on the location of the motor branches
to the biceps brachii and brachialis was documented
in the previous studies (Yang et al., 1995; Chiarapattanakom et al., 1998; Pacha Vicente et al., 2005;
Kwolczak-McGrath et al., 2008). In the present
study, we followed the methodology described by
Pacha Vicente et al. (2005) that the point where the
motor branch arose from the main MCN trunk has
been recorded, and the measurements were taken
along the axis between the tip of the acromion process and the lateral epicondyle of the humerus as
reference points. In some studies, different methodologies are used; for example, they measured the
point where the nerve enters the muscle (Egleseder
and Goldman, 1997; Park et al., 2007) or used the
medial epicondyle of the humerus and the coracoid
process of the scapula as reference points for measurements (Yang et al., 1995, Chiarapattanakom
et al., 1998).
We expressed our results as a percentage of the
acromion-lateral epicondyle length like Pacha Vicente

TABLE 4. Incidence of Communication Between Musculocutaneous and Median Nerves

Study
Eglseder and Goldman (1997)
Venieratos and Anagnostopoulou (1998)
Prasada Rao and Chaudhary (2000)
Aktan et al. (2001)
Choi et al. (2002)
Pacha Vicente et al. (2005)
Loukas and Aqueelah (2005)
Chitra (2007)
Uysal et al. (2003)
Kwolczak-McGrath et al. (2008)
Uysal et al. (2009)
Guerri-Guttenberg and Ingolotti (2009)
Our study
a

F: fetus study, others are adult study.

Number of
dissected arms

Number of
communications

Incidence of
communication (%)

108
158
24
48
276
46
258
50
200 (F)a
40 (F)a
140 (F)a
26
30 (F)a
56 (total)
20 (F)a

39
22
8
5
58
13
119
13
2
8
14
12
20
32
5

36
13.9
33
10.4
21
28.3
46
26
1
20
10
42.2
66.6
57
25

Anatomy of Musculocutaneous Nerve in Fetuses

177

TABLE 5. Comparing the Branching Patterns of MCN to Biceps Brachii and Brachialis in Literature
Biceps brachii

Yang et al. (1995)

Chiarapattanakom
et al. (1998)
Pacha Vicente
et al. (2005)
Kwolczak-McGrath
et al. (2008)
Present study

Type I
(%)

Type II
(%)

83.4
62

8.3
33

8.3
5

95.8
92

60.5

27.9

11.6

72.1

47.5

42.5

10

20

10

65

Type III
(%)

Brachialis

et al. (2005) and Kwolczak-McGrath et al. (2008).

We think that as our study group consist of the
fetuses whose arm lengths are considerably variable
according to gestational age, it will be more signicant for clinicians to compare the results as a percentage of a reference length, especially surgeons
who elect to operate pediatrics patients. KwolczakMcGrath et al. (2008) also studied with fetuses and
expressed their results as a percentage of the acromion-lateral epicondyle length. We compared our
results with Pacha Vicente et al. (2005) and Kwolczak-McGrath et al. (2008). Pacha Vicente et al.
(2005) reported the mean distance between the
acromion and the emerging point of rst branch to
the biceps brachii regardless of the branching type
was 42.5% of the acromion-lateral epicondyle
length. Kwolczak-McGrath et al. (2008) reported
36.3%, while in our study it was 33.2%. For the
branch to the brachialis, the mean distance regardless of the branching pattern as reported by Pacha
Vicente et al. (2005) was 58.7% and by KwolczakMcGrath et al. (2008) was 60.91%, while it was
50.6% in our study. In respect of our study, the
point where the motor branches of the biceps brachii
was located at approximately proximal one-third of a
reference line from the acromion to the lateral epicondyle. In the brachialis, the location of the motor
points was likely to be half of the reference line.
Our results may help surgeons and anesthetist to
localize the motor nerves of biceps brachii and brachialis in relation to anatomic surface landmarks for
motor point blocks, nerve reconstructions, or nerve
transfers.
Although many morphological studies have been
carried out on MCN in adults, there are few data
available on the course of MCN in fetuses. Studying
and publishing of the nerve courses in the limbs of
the fetuses will provide the knowledge for surgeons
to avoid from some malpractices and may help the
clinicians to explain the clinical neurophysiology of
some complex cases.

REFERENCES
Aktan ZA, Ozturk L, Bilge O, Ozer MA, Pinar YA. 2001. A cadaveric
study of the anatomic variations of the brachial plexus nerves in
the axillar region and arm. Turk J Med Sci 31:147150.

Type IV
(%)

Type I
(%)

Type II
(%)

Type III
(%)

Type IV
(%)

4.2
8

27.9

100

75

10

10

Chiarapattanakom P, Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. 1998. Anatomy and internal topography of the musculocutaneous nerve: The nerves to the biceps
and brachialis muscle. J Hand Surg Am 23:250255.
Chitra R. 2007. Various types of intercommunications between musculocutaneous and median nerves: An analytical study. Ann Indian Acad Neurol 10:100104.
Choi D, Rodriguez-Niedenfuhr M, Vazquez T, Parkin I, Sanudo
JR. 2002. Patterns of connections between the musculocutaneous and median nerves in the axilla and arm. Clin Anat
15:1117.
Eglseder WA Jr, Goldman M. 1997. Anatomic variations of the musculocutaneous nerve in the arm. Am J Orthop 26:777780.
Guerri-Guttenberg RA, Ingolotti M. 2009. Classifying musculocutaneous nerve variations. Clin Anat 22:671683.
Heise CO, Lorenzetti L, Marchese AJ, Gherpelli JL. 2004. Motor conduction studies for prognostic assessment of obstetrical plexopathy. Muscle Nerve 30:451455.
Helfet AJ. 1958. Coracoid transplantation for recurring dislocation of
the shoulder. J Bone Joint Surg Br 40:198202.
Hobar PC, Rohrich RJ, Mickel TJ. 1990. The coracobrachialis muscle
ap for coverage of exposed axillary vessels: A salvage procedure. Plast Reconstr Surg 85:801804.
Kerr AT. 1918. The brachial plexus of nerves in man, the variations
in its formation and branches. Am J Anat 23:285395.
Kwolczak-McGrath A, Kolesnik A, Ciszek B. 2008. Anatomy of
branches of the musculocutaneous nerve to the biceps and brachialis in human fetuses. Clin Anat 21:142146.
Linell E. 1921. The distribution of nerves in the upper limb, with reference to variabilities and their clinical signicance. J Anat
55:79112.
Loukas M, Aqueelah H. 2005. Musculocutaneous and median nerve
connections within, proximal and distal to the coracobrachialis
muscle. Folia Morphol (Warsz) 64:101108.
Moore KL. 1992. Clinically Oriented Anatomy. 3rd Ed. Baltimore:
Williams and Wilkins. p 553554.
Murphy DB, Chan VW. 2000. Upper extremity blocks for day surgery. Tech Reg Anesth Pain Manag 4:1929.
Noaman HH, Shiha AE, Bahm J. 2004. Oberlins ulnar nerve transfer
to the biceps motor nerve in obstetric brachial plexus palsy:
Indications, and good and bad results. Microsurgery 24:182
187.
Oberlin C, Be
al D, Leechavengvongs S, Salon A, Dauge MC,
Sarcy JJ. 1994. Nerve transfer to biceps muscle using a part
of ulnar nerve for C5-C6 avulsion of the brachial plexus: Anatomical study and report of four cases. J Hand Surg Am
19:232237.
Ozturk A, Bayraktar B, Taskara N, Kale AC, Kutlu C, Cecen A. 2005.
Morphometric study of the nerves entering into the coracobrachialis muscle. Surg Radiol Anat 27:308311.
Pacha Vicente D, Forcada Calvet P, Carrera Burgaya A, Llusa
Pe
rez
M. 2005. Innervation of biceps brachii and brachialis: Anatomical
and surgical approach. Clin Anat 18:186194.

178

Kervancioglu et al.

Park BK, Shin YB, Ko HY, Park JH, Baek SY. 2007. Anatomic motor
point localization of the biceps brachii and brachialis muscles. J
Korean Med Sci 22:459462.
Parry SW, Ward JW, Mathes SJ. 1988. Vascular anatomy of the
upper extremity muscles. Plast Reconstr Surg 81:358365.
Prasada Rao PV, Chaudhary SC. 2000. Communication of the musculocutaneous nerve with the median nerve. East Afr Med J
77:498503.
Russell SM. 2006. Examination of the Peripheral Nerve Injuries. An
Anatomical Approach. New York: Thieme. p 12.
Standring S, Ellis H, Healy J, Johnson D, Williams A. 2005. Grays
Anatomy. 39th Ed. Oxford: Churchill Livingstone. p 846849.
Uysal II, Seker M, Karabulut AK, Buyukmumcu M, Ziylan T. 2003.

Brachial plexus variations in human fetuses. Neurosurgery

53:676684.
Uysal II, Karabulut AK, Buyukmumcu M, Unver Dogan N, Salbacak A. 2009. The course and variations of the branches of the
musculocutaneous nerve in human fetuses. Clin Anat 22:337
345.
Venieratos D, Anagnostopoulou S. 1998. Classication of communications between the musculocutaneous and median nerves. Clin
Anat 11:327331.
Yang ZX, Pho RW, Kour AK, Pereira BP. 1995. The musculocutaneous nerve and its branches to the biceps and brachialis muscles.
J Hand Surg Am 20:671675.