- Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, AL, USA
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Anatomical Sciences, St. George's University, Grenada
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, IN, USA
Aaron A. Cohen-Gadol
Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, IN, USA
DOI:10.4103/2152-7806.91139Copyright: © 2011 Tubbs RS. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Tubbs RS, Deep A, Shoja MM, Mortazavi MM, Loukas M, Cohen-Gadol AA. The arcade of Struthers: An anatomical study with potential neurosurgical significance. Surg Neurol Int 26-Dec-2011;2:184
How to cite this URL: Tubbs RS, Deep A, Shoja MM, Mortazavi MM, Loukas M, Cohen-Gadol AA. The arcade of Struthers: An anatomical study with potential neurosurgical significance. Surg Neurol Int 26-Dec-2011;2:184. Available from: http://sni.wpengine.com/surgicalint_articles/the-arcade-of-struthers-an-anatomical-study-with-potential-neurosurgical-significance/
Background:Significant controversy exists regarding the existence of the so-called arcade of Struthers and whether this structure is involved in some cases of proximal ulnar nerve entrapment. Therefore, the aim of the present study was to further elucidate this anatomy.
Methods:Fifteen cadavers (30 sides) underwent dissection of the medial arm with special attention to the course of the ulnar nerve and its relationships to the soft tissues of this region.
Results:We identified a thickening in the inferior medial arm that crosses the ulnar nerve and is consistent with the so-called arcade of Struthers in 86.7% of sides. On 57.7% of the sides, the arcade was found to be due to a thickening of the brachial fascia and was classified as a type I arcade. On 19.2% of the sides, the arcade was due to the internal brachial ligament and these were classified as type II arcades. On 23.1% of the sides, the arcade was due to a thickened medial intermuscular septum and these were classified as type III arcades. The mean length of the arcade was 4.3 cm and the distal end of the arcade was, on average, 6.8 cm above the medial epicondyle. Although the presence of an arcade of Struthers was slightly more common in female specimens, this did not reach statistical significance. However, arcades were found more often on right side (P
Conclusions:Based on our findings, the arcade of Struthers is an anatomical band of connective tissue in the medial distal arm that crosses the ulnar nerve. This structure was found in the majority of our specimens and may need to be evaluated in proximal ulnar neuropathies. We believe that past studies that have not observed the arcade and past studies with varied findings are due to the various definitions used for this anatomical structure. Using the classification system as demonstrated in the present study may make future communications regarding the arcade of Struthers more exact.
Keywords: Anatomy, entrapment, neurosurgery, peripheral nerve, ulnar nerve
Ulnar nerve entrapment constitutes the second most common nerve entrapment in the upper limb after median nerve entrapment in the carpal tunnel. The ulnar nerve originates from the medial cord of the brachial plexus and transmits fibers from C8 and T1 and sometimes C7 roots.[
With such controversy in the literature regarding the anatomy and even the presence of the arcade of Struthers, the aim of the present study was to further elucidate this morphology and its potential role in compression neuropathies of the ulnar nerve.
Fifteen adult cadavers (30 sides) underwent dissection of the medial arm with special attention given to the course of the ulnar nerve and its relationships to the soft tissues of this region. Nine specimens were from females and six were from males, with an age range at death of 39-85 years (mean 70 years). Ten specimens were formalin fixed and five specimens were unembalmed. With the cadavers in the supine position, forearms supinated, and the upper limbs abducted to 90°, the whole of the overlying skin of the medial arm was removed. The deeper fasciae were carefully dissected, observing for the relationship between these tissues and the ulnar nerve. If the so-called arcade of Struthers was observed, measurements and relationships of its anatomy were documented. Statistical analysis between sides and genders was performed using Statistica for Windows, with significance set at P < 0.05.
We identified a thickening in the inferior medial arm that crossed the ulnar nerve and was consistent with the so-called arcade of Struthers in 86.7% (26 of 30) of sides. For the remaining sides (13.3%), the ulnar nerve coursed through a non-thickened MIS. On 15 sides (57.7%), the arcade was found to be due to a thickening of the brachial fascia, and we classified these as type I arcades [Figure
The arcade of Struthers should not be confused with the ligament of Struthers first described by Sir John Struthers in 1854 as a fibrous band that extends from an anomalous supracondylar spur to the medial epicondyle of the humerus and that may compress the median nerve.[
The history of operative treatment for ulnar nerve entrapment caused by the arcade of Struthers dates back to the description by Kane et al.,[
“If the roof of the arcade has multiple ligaments, simple release of the arcade may not be enough. It is recommended that the ligaments, which pass deep to the ulnar nerve, including the internal brachial ligament, should be released at their insertions. This can be done without extending the skin incision, since the insertion of such ligaments is located at the same level as the arcade. If the ulnar nerve is found buried in the medial head of the triceps, the overlying muscular roof should be incised. Proximal extension of the skin incision may be needed to mobilize the ulnar nerve fully from the deep groove in the muscle.”
Regarding the internal BL, arcade of Struthers and MIS, Won et al.[
The arcade was described as a fibrous canal with an average length of 5.7 cm.[
Some authors have also implicated the arcade of Struthers in cases of failed cubital tunnel surgery.[
Regarding the classical description of the arcade of Struthers,[
We believe that an arcade of Struthers as described by multiple authors does exist, and based on our study, it exists in the majority of individuals. However, why some individuals become symptomatic and others do not is yet to be elucidated. As the ulnar nerve traverses this structure, this area may necessitate surgical evaluation for proximal ulnar neuropathies. This later notion is supported by case reports of patients with ulnar nerve palsy that improved following transection of this connective tissue. On the majority of sides, the arcade was found to be due to a thickening of the brachial fascia. Other arcades were formed by the internal BL and MIS. Each of these structures could be easily evaluated with a more proximal skin incision and exploration for routine decompressive procedures of the ulnar nerve at the medial epicondyle. Based on our study, this could be up to almost 20 cm proximal to the medical epicondyle. Therefore, in order to better localize the site of compression, adjuncts to surgical decompression could include electrophysiology and ultrasound.
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