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Neural Perforasomes of the Upper Extremity

Koehler, Steven M., M.D.; Matson, Andrew P., M.D.; Ruch, David S., M.D.; Mithani, Suhail K., M.D.

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1539–1546
doi: 10.1097/PRS.0000000000004984
Hand/Peripheral Nerve: Original Articles

Background: In the setting of the rapid advancement of integumentary vascular knowledge, the authors hypothesized that the extrinsic blood supply to the major peripheral nerves of the upper extremity could be categorized into discrete neural “perforasomes.”

Methods: Total limb perfusion of the arterial system was performed with gelatin–red lead oxide in cadaveric upper limbs. The perforating vessels to the radial, median, and ulnar nerves were identified, confirmed with fluoroscopy, and dissected. Distances to major anatomical landmarks of the upper extremity were measured. Additional cadaveric limbs’ nerves were dissected and source arteries were selectively cannulated and injected to assess specific contribution to extrinsic nerve perfusion. The perfusion of each nerve was then calculated among all specimens.

Results: The radial, median, and ulnar nerve perforators were mapped. The corresponding neural perforasomes were mapped. The distal portions of the superficial radial nerve and the posterior interosseous nerve demonstrated a lack of staining. Similarly, at the carpal tunnel and at the proximal 25 percent of the median nerve (corresponding to the pronator teres), the nerve lacked vascular staining. At the Guyon canal and the flexor carpi ulnaris, the ulnar nerve demonstrated a lack of vascular staining.

Conclusions: Peripheral nerves can be divided into neural perforasomes with limited overlap. The extrinsic perfusion of peripheral nerves is highly segmental. Absent stains within the nerves correspond to common sites of compression: carpal tunnel and pronator teres for the median nerve, supinator for the posterior interosseous nerve, and the Guyon canal and the flexor carpi ulnaris for the ulnar nerve.

Brooklyn, N.Y.; and Durham, N.C.

From the Department of Orthopaedic Surgery, SUNY Downstate Medical Center; and the Division of Hand and Upper Extremity, Department of Orthopaedic Surgery, Duke University.

Received for publication November 16, 2017; accepted May 16, 2018.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Steven M. Koehler, M.D., Department of Orthopaedic Surgery, SUNY Downstate Medical Center, 450 Clarkson Avenue, MSC 30, Brooklyn, N.Y. 11203,

©2018American Society of Plastic Surgeons