The patient came to the clinic 04-February-2020 telling that he suffered motorcycle accident 07-August-2019. The left upper limb was severely injured in several places and he had at that time several fractures. Debridement of the wounds and exploration of the nerves with reduction and fixation of the fractures were performed accordingly.

On examination: The patient has complete non-function of the left median and ulnar nerves at the mid third right arm with ugly scars and painful bulb at the mid third right arm under the running scar. The radial, MCN were functioning properly.

The patient was sent for EMG and ECS of both left median and ulnar nerves, which was performed 05-February-2020 confirming non-function of these nerves at the mid third left arm.

Incision over the projection of the left brachial artery and identification of the supposed to be the median nerve. IT was swinging to the direction of the left ulnar nerve.  Further dissection medially for the supposed to be the median nerve. Only thee branches of the MCN were found and stimulation confirmed it. The left ulnar nerve was exposed at its projection in its bony groove at the elbow level and transposition was performed. IT was directed proximally to the ugly scar at the projection of the supposed to be the proximal ulnar nerve. It became clear that this proximal part was the median nerve. Dissection medially for the ulnar nerve showed that it was distracted above and medially with an onion at its end. So as to expose the distal end of the median nerve, it was necessary to go down to healthy tissues and the nerve was identified. The median nerve was followed proximally and it was in good anatomical structure until it reached the elbow were it disappeared in the scar behind the tendon of the biceps muscle attachment. It became clear that in the first surgery the surgeon was attempting to make bride between the proximal median nerve with distal ulnar nerve. The left sural nerve was harvested and only three segments were possible to obtain. The scarous afibrillary parts of the nerves were dissected and removed until a good fibrillary ends came to vision. The left median nerve was possible to anastamose directly using 4 zero nylon after mobilizing it distally scarifying during the some of the motor branches and keeping other major ones, with the position of the elbow in flexion. The transposed ulnar nerve was necessary to performed 3 twigs of the sural nerve to bridge the gap.  Using MultiGen the nerves before resection and scar removal were not responding even to 5 Volts. Routine closure of the wounds with back slap to keep the elbow in flexed position.

Smooth postoperative recovery. The patient was sent to the ward.

The performed surgery was performed to preserve the soft tissues of the left upper limb and surgery for the nerves was not performed in proper way.

The surgeon at first surgery tried to anastamose the median nerve to the ulnar, which made confusion about the anatomy.

Direct anastamoses of the median nerve will give better results than the anastomosed ulnar using the sural grafts.

Please revise the anatomy before doing such surgery, so as not to confuse the second surgeon in redo surgery.