High Median Nerve Reconstruction with Vascularized Ulnar Nerve and Extensor Carpi Radialis Brevis Motor Branch to Anterior Interosseous Nerve Transfers.

Combined high median and ulnar nerve injuries present significant challenges due to the complexity of restoring sensory and motor functions with limited donor sites for tendon or nerve transfers. Traditional techniques such as cable grafting often fail to achieve satisfactory functional recovery, particularly in cases involving proximal injuries and large nerve gaps. We report a case of a 21-year-old man who sustained a gunshot wound to the right medial upper arm, injuring the median and ulnar nerves. Three months postinjury, the patient exhibited upper extremity weakness, with 0 of 5 finger and wrist flexion, 0 of 5 pronation, and dense numbness in both nerve distributions. Surgical exploration revealed large zones of injury and gaps in both the ulnar and median nerves. Reconstruction involved using the ulnar nerve as a pedicled vascularized ulnar nerve graft to reconstruct the median nerve gap and an extensor carpi radialis brevis (ECRB) to anterior interosseous nerve (AIN) transfer. The vascularized ulnar nerve graft was used to augment sensory, pronation, and wrist flexion recovery, whereas the ECRB to AIN transfer aimed to restore thumb and finger flexion. This combined approach leverages the vascularized graft's robust blood supply to improve axonal survival and growth and uses the ECRB to AIN transfer to target motor functions for grasp and pinch strength. This case highlights the potential of integrating advanced nerve repair techniques to optimize outcomes in complex nerve injuries, addressing the limitations of traditional methods, and provides a promising strategy for managing combined high median and ulnar nerve injuries.