Determinar a frequência e as características anatômicas do ligamento de Struthers e do processo supracondilar do úmero e avaliar sua implicação clínica na neuropatia compressiva do nervo mediano.

Método::

Foram dissecados 60 membros superiores de 30 cadáveres de adultos, 26 do sexo masculino e quatro do sexo feminino, 15 previamente preservados em formol e glicerina e 15 dissecados a fresco no Laboratório de Anatomia. A relação do ligamento de Struthers com o nervo mediano e a artéria e veias braquiais, foi documentada com desenhos e fotografias.

Resultados:

O processo supracondilar do úmero não foi encontrado em nenhum dos 60 braços dissecados. O ligamento de Struthers foi identificado em seis membros (dois bilaterais); em todos havia inserção alta do músculo pronador redondo.

Conclusão:

O ligamento de Struthers é uma estrutura aponeurótica que pode estar ou não associada ao processo supracondilar do úmero e representa local de possível compressão do nervo mediano no terço inferior do braço. Nível de Evidência IV, Série de Casos.

Descritores:
Ligamentos; Síndromes de compressão nervosa; Nervo mediano; Úmero

Autoria

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).

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Figuras

Figuras (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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[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