STRUTHERS’ LIGAMENT AND SUPRACONDYLAR HUMERAL PROCESS: AN ANATOMICAL STUDY AND CLINICAL IMPLICATIONS

The objective of this study was to determine the frequency and anatomical characteristics of Struthers’ ligament and the supracondylar humeral process and evaluate the clinical implications in compressive neuropathy of the median nerve .

Method:

We dissected 60 arms from 30 cadavers (26 males and 4 females): 15 were previously preserved in formalin and glycerin and 15 were dissected fresh in the Anatomy Laboratory for this paper. The relationships between Struthers’ ligament and the median nerve and brachial artery and veins were documented with drawings and photos .

Results:

The supracondylar humeral process was not found in any of the 60 dissected arms. Struthers’ ligament was identified in six arms (two bilateral); in all cases high insertion of the pronator teres muscle was observed .

Conclusion:

Struthers’ ligament is an aponeurotic structure that may or may not be associated with the supracondylar humeral process, and is an important potential site of median nerve compression in the lower third of the arm. Level of Evidence IV, Case Series.

Keywords:
Ligaments; Nerve compression syndromes; Median nerve; Humerus

Authorship

Edie Benedito Caetano

Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde, Sorocaba, SP, Brazil.Pontifícia Universidade Católica de São PauloBrazilSorocaba, SP, Brazil Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde, Sorocaba, SP, Brazil.

João José Sabongi Neto

Conjunto Hospitalar de Sorocaba, Department of Hand Surgery, Sorocaba, SP, Brazil. Conjunto Hospitalar de SorocabaBrazilSorocaba, SP, Brazil Conjunto Hospitalar de Sorocaba, Department of Hand Surgery, Sorocaba, SP, Brazil.

Luiz Angelo Vieira

Maurício Ferreira Caetano

José Eduardo de Bona

Thais Mayor Simonatto

Correspondence: Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde. PUC-SP/FCMS. Rua Joubert Wey, 290. Sorocaba, SP, Brazil. 18030-070. ediecaetano@uol.com.br

All authors declare no potential conflict of interest related to this article

AUTHORS’ CONTRIBUTIONS:

Each author made significant individual contributions to this manuscript. EBC (0000-0003-4572-3854)*, LAV (0000-0003-4406-2492)*, and MBFC (0000-0003-0994-2128)* were the main contributors in drafting the manuscript. JEB (0000-0002-2416-7281)* and TMS (0000-0002-0654-5373)* conducted the bibliographical research. All authors participated in dissecting and photographing the cadavers. EBC and JJSN (0000-0002-0554-1426)* reviewed the manuscript, contributed to the intellectual concept, coordinated the study, and were responsible for directing the other participants. *ORCID (Open Researcher and Contributor ID).

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (6)

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Figure 1
A) In the right arm of one corpse, we identified high insertion of the pronator teres muscle (a) from which a cord-shaped ligament originated (b) and was positioned on the median nerve (c) and the brachial artery (d) inserting into the diaphysis of the humerus. B) On the left side, the ligament originated in the same place and was inserted proximally but had no relation to the median nerve or brachial artery. The pronator teres muscle (a); Struthers’ ligament (b); median nerve (c); brachial artery (d).

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Figure 2
A) The arcade of Struthers (a) is a musculoaponeurotic structure which extends from the medial intermuscular septum to the medial head of the triceps brachii muscle (b). It is positioned anterior to the ulnar nerve (c) and may compress this structure. B) A case similar to the situation in Figure 1B was recorded in the left arm of another cadaver. Pronator teres muscle (a). Struthers’ ligament (b). Median nerve (c). Brachial artery (d).

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Figure 3
A-B) In one cadaver, we identified a bilateral anatomical variation consisting of high insertion of the humeral head of the pronator teres muscle (a) which was inserted through a short ligament (b) in the diaphysis of the humerus causing pressure on the median nerve (c) and brachial artery (d), but no bone spike was seen.

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Figure 4
We identified two similar cases (A) in the right arm of a recently-deceased cadaver and (B) in the left arm of another cadaver preserved in formaldehyde and glycerin; the Struthers’ ligament was composed of a fibrous lamina (b) originating in the medial epicondyle and adjacent brachial fascia, moving upwards and passing over the median nerve (c) and brachial artery (d) to insert itself into the fascia of the brachial muscle and the humeral shaft. Pronator teres (a).

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Figure 5
A) Clinical case. In one cadaver, we identified a bilateral anatomical variation consisting of high insertion of the humeral head of the pronator teres muscle (a) which inserted via a short ligament (b) in the supracondylar process of the humerus, compressing the median nerve (c). B) Surgery showing the pronator teres muscle disinserted (a) from the supracondylar process of the humerus (b) and compressing the median nerve (c). Detail: supracondylar process (a) and median nerve (b).

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Figure 6
A) High insertion of the pronator teres muscle (a) associated with high origin of the anterior interosseous nerve (above the elbow joint) (b). Median nerve (c). B) The Struthers’ ligament (a) originated in the medial epicondyle (b) and moved proximally, fanning out and inserting into the brachial fascia and the internal brachial ligament and passing over the ulnar nerve (c) in precisely the place where the nerve passed from the anterior compartment to the posterior of the arm.

Figure 1 A) In the right arm of one corpse, we identified high insertion of the pronator teres muscle (a) from which a cord-shaped ligament originated (b) and was positioned on the median nerve (c) and the brachial artery (d) inserting into the diaphysis of the humerus. B) On the left side, the ligament originated in the same place and was inserted proximally but had no relation to the median nerve or brachial artery. The pronator teres muscle (a); Struthers’ ligament (b); median nerve (c); brachial artery (d).

Figure 2 A) The arcade of Struthers (a) is a musculoaponeurotic structure which extends from the medial intermuscular septum to the medial head of the triceps brachii muscle (b). It is positioned anterior to the ulnar nerve (c) and may compress this structure. B) A case similar to the situation in Figure 1B was recorded in the left arm of another cadaver. Pronator teres muscle (a). Struthers’ ligament (b). Median nerve (c). Brachial artery (d).

Figure 3 A-B) In one cadaver, we identified a bilateral anatomical variation consisting of high insertion of the humeral head of the pronator teres muscle (a) which was inserted through a short ligament (b) in the diaphysis of the humerus causing pressure on the median nerve (c) and brachial artery (d), but no bone spike was seen.

Figure 4 We identified two similar cases (A) in the right arm of a recently-deceased cadaver and (B) in the left arm of another cadaver preserved in formaldehyde and glycerin; the Struthers’ ligament was composed of a fibrous lamina (b) originating in the medial epicondyle and adjacent brachial fascia, moving upwards and passing over the median nerve (c) and brachial artery (d) to insert itself into the fascia of the brachial muscle and the humeral shaft. Pronator teres (a).

Figure 5 A) Clinical case. In one cadaver, we identified a bilateral anatomical variation consisting of high insertion of the humeral head of the pronator teres muscle (a) which inserted via a short ligament (b) in the supracondylar process of the humerus, compressing the median nerve (c). B) Surgery showing the pronator teres muscle disinserted (a) from the supracondylar process of the humerus (b) and compressing the median nerve (c). Detail: supracondylar process (a) and median nerve (b).

Figure 6 A) High insertion of the pronator teres muscle (a) associated with high origin of the anterior interosseous nerve (above the elbow joint) (b). Median nerve (c). B) The Struthers’ ligament (a) originated in the medial epicondyle (b) and moved proximally, fanning out and inserting into the brachial fascia and the internal brachial ligament and passing over the ulnar nerve (c) in precisely the place where the nerve passed from the anterior compartment to the posterior of the arm.

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STRUTHERS’ LIGAMENT AND SUPRACONDYLAR HUMERAL PROCESS: AN ANATOMICAL STUDY AND CLINICAL IMPLICATIONS

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[1] Correspondence: Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde. PUC-SP/FCMS. Rua Joubert Wey, 290. Sorocaba, SP, Brazil. 18030-070. ediecaetano@uol.com.br