An anatomical investigation of rare upper limb neuropathies due to the Struthers’ ligament or arcade: a meta-analysis
Abstract
Background: The Struthers’ ligament (SL) is a fibrous band that originates fromthe supracondylar humeral process and inserts into the medial humeral epicondyle, potentially compressing both the median nerve and brachial artery. The controversial Struthers’ arcade (SA) is a musculotendinous band found in the distal end of the arm that might compress the ulnar nerve. This study aimed to evaluate the pooled prevalence estimate of the SL and SA, and their anatomical features. Materials and methods: A meticulous search of major electronic medical databases was carried out regarding both structures. Applicable articles (and all relevant references) were analysed. Data from the eligible articles was extracted and evaluated. The quality and the potential risk of bias in the included studies were assessed using the AQUA tool. Results: The arcade was reported in 13 studies (510 arms), whereas the ligament in 6 studies (513 arms). The overall pooled prevalence estimate of the ligament was 1.8%, and 52.6% for the arcade. Most frequently, the ulnar nerve was covered by a tendinous arcade (42.2%). In all cases, the ligament inserted into the medial humeral epicondyle, but had various origins. Only 1 study reported compression of the median nerve by the ligament, whilst another contradicted this view. Conclusions: Although the SL is rare, and the SA is a valid anatomical entity (though with a variable presentation), clinically meaningful neurovascular entrapments caused by these structures are infrequent. Nonetheless, a better understanding of each may be beneficial for the best patient outcomes.
Keywords: Struthers’ arcadeStruthers’ ligamentmeta-analysis
References
- Al-Naib I. Humeral supracondylar spur and Struthers' ligament. A rare cause of neurovascular entrapment in the upper limb. Int Orthop. 1994; 18(6): 393–394.
- Al-Qattan MM, Murray KA. The Arcade of Struthers: An Anatomical Study. J Hand Surg. 1991; 16(3): 311–314.
- Al-Qattan MM, Husband JB. Median nerve compression by the supracondylar process: a case report. J Hand Surg Br. 1991; 16(1): 101–103.
- Andreisek G, Crook DW, Burg D, et al. Peripheral neuropathies of the median, radial, and ulnar nerves: MR imaging features. Radiographics. 2006; 26(5): 1267–1287.
- Aydinlioglu A, Cirak B, Akpinar F, et al. Bilateral median nerve compression at the level of Struthers' ligament. Case report. J Neurosurg. 2000; 92(4): 693–696.
- Ay S, Bektas U, Yilmaz C, et al. An unusual supracondylar process syndrome. J Hand Surg Am. 2002; 27(5): 913–915.
- Bartels RH, Grotenhuis JA, Kauer JMG. The arcade of Struthers: an anatomical study. Acta Neurochir (Wien). 2003; 145(4): 295–300.
- Bilecenoglu B, Uz A, Karalezli N. Possible anatomic structures causing entrapment neuropathies of the median nerve: an anatomic study. Acta Orthop Belg. 2005; 71(2): 169–176.
- Blakeborough A, Chennells PM, Cape J. Case report: cellist's elbow?--vascular entrapment in association with the ligament of Struthers. Clin Radiol. 1994; 49(12): 902–904.
- Bradshaw DY, Shefner JM. Ulnar neuropathy at the elbow. Neurol Clin. 1999; 17(3): 447–461.
- Caetano EB, Sabongi JJ, Vieira LA, et al. Struthers' ligament and supracondylar humeral process: an anatomical study and clinical implications. Acta Ortop Bras. 2017; 25(4): 137–142.
- Caetano EB, Sabongi Neto JJ, Vieira LA, et al. The arcade of Struthers: an anatomical study and clinical implications. Rev Bras Ortop. 2017; 52(3): 331–336.
- Camerlinck M, Vanhoenacker FM, Kiekens G. Ultrasound demonstration of Struthers' ligament. J Clin Ultrasound. 2010; 38(9): 499–502.
- Campbell WW, Landau ME. Controversial entrapment neuropathies. Neurosurg Clin N Am. 2008; 19(4): 597–608, vi.
- Caputo AE, Watson HK. Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome. J Hand Surg Am. 2000; 25(3): 544–551.
- Dellon A. Musculotendinous variations about the medial humeral epicondyle. J Br Soc Surg Hand. 1986; 11(2): 175–181.
- Dellon A, Mackinnon S. Musculoaponeurotic variations along the course of the median nerve in the proximal forearm. J Hand Surg. 1987; 12(3): 359–363.
- Eversman W. Entrapment and compression neuropathies. In: Green D, editor. Operative hand surgery, Vol. 2. Churchill Livingstone, New York 1993: 1341–1385.
- Gessini L, Jandolo B, Pietrangeli A. Entrapment neuropathies of the median nerve at and above the elbow. Surg Neurol. 1983; 19(2): 112–116.
- Gonzalez MH, Lotfi P, Bendre A, et al. The ulnar nerve at the elbow and its local branching: an anatomic study. J Hand Surg Br. 2001; 26(2): 142–144.
- Gunther SF, DiPasquale D, Martin R. Struthers’ ligament and associated median nerve variations in a cadaveric specimen. Yale J Biol Med. 1993; 66(3): 203–208.
- Henry BM, Tomaszewski KA, Walocha JA. Methods of Evidence-Based Anatomy: a guide to conducting systematic reviews and meta-analysis of anatomical studies. Ann Anat. 2016; 205: 16–21.
- Henry BM, Tomaszewski KA, Ramakrishnan PK, et al. Development of the anatomical quality assessment (AQUA) tool for the quality assessment of anatomical studies included in meta-analyses and systematic reviews. Clin Anat. 2017; 30(1): 6–13.
- Kane E, Kaplan EB, Spinner M. [Observations of the course of the ulnar nerve in the arm]. Ann Chir. 1973; 27(5): 487–496.
- Kleinman WB. Revision ulnar neuroplasty. Hand Clin. 1994; 10(3): 461–477.
- Laha RK, Dujovny M, DeCastro SC. Entrapment of median nerve by supracondylar process of the humerus. Case report. J Neurosurg. 1977; 46(2): 252–255.
- Mirza A, Mirza JB, Lee BK, et al. An anatomical basis for endoscopic cubital tunnel release and associated clinical outcomes. J Hand Surg Am. 2014; 39(7): 1363–1369.
- Ochiai N, Hayashi T, Ninomiya S. High ulnar nerve palsy caused by the arcade of struthers. J Hand Surg. 2016; 17(6): 629–631.
- Popinchalk SP, Schaffer AA. Physical examination of upper extremity compressive neuropathies. Orthop Clin North Am. 2012; 43(4): 417–430.
- Poujade T, Hanouz N, Lecoq B, et al. Ultrasound-guided surgical treatment for ulnar nerve entrapment: a cadaver study. Chir Main. 2014; 33(4): 256–262.
- Rogers MR, Bergfield TG, Aulicino PL. The failed ulnar nerve transposition. Etiology and treatment. Clin Orthop Relat Res. 1991(269): 193–200.
- Siqueira MG, Martins RS. The controversial arcade of Struthers. Surg Neurol. 2005; 64 (Suppl 1): S17–S20.
- Smith RV, Fisher RG. Struthers ligament: a source of median nerve compression above the elbow. Case report. J Neurosurg. 1973; 38(6): 778–779.
- Spinner M, Kaplan EB. The relationship of the ulnar nerve to the medial intermuscular septum in the arm and its clinical significance. Hand. 1976; 8(3): 239–242.
- Suranyi L. Median nerve compression by Struthers ligament. J Neurol Neurosurg Psychiatry. 1983; 46(11): 1047–1049.
- Taylor GI, Cichowitz A, Ang SG, et al. Comparative anatomical study of the gracilis and coracobrachialis muscles: implications for facial reanimation. Plast Reconstr Surg. 2003; 112(1): 20–30.
- Tiyaworanan P, Jianmongkol S, Thammaroj T. Anatomical study of arcade of Struthers. Hand Surg. 2010; 15(3): 157–159.
- Tubbs RS, Deep A, Shoja MM, et al. The arcade of Struthers: An anatomical study with potential neurosurgical significance. Surg Neurol Int. 2011; 2: 184.
- von Schroeder HP, Scheker LR. Redefining the "Arcade of Struthers". J Hand Surg Am. 2003; 28(6): 1018–1021.
- Wehrli L, Oberlin C. The internal brachial ligament versus the arcade of Struthers: an anatomical study. Plast Reconstr Surg. 2005; 115(2): 471–477.
- Yoshida A, Okutsu I, Hamanaka I. Minimally invasive endoscopic ulnar nerve assessment and surgery for cubital tunnel syndrome patients—Relation between endoscopic nerve findings and clinical symptoms. Asia-Pacific J Sport Med Arthrosc Rehabil Technol. 2014; 1(3): 96–101.
- Zhong S, Zhong Z, Yu Yu, et al. Ultrasonic observation and clinical application of arcade of struthers in the Mid-Arm. World Neurosurg. 2016; 91: 560–566.e1.
