- Email: [email protected]
Historic origin of the “Arcade of Struthers”
Historic Origin of the “Arcade of Struthers” Ramon De Jesus, MD, Baltimore, MD, A. Lee Dellon, MD, Baltimore, MD, Tucson, AZ
John Struthers wrote in 1848 and 1854 about sites of compression of the median nerve from axilla to elbow. He is best known for describing the rare median nerve entrapment by a ligament from a supracondylar process extending to the medial humeral epicondyle. In 1973, observation of ulnar nerve entrapment associated with a midshaft humeral fracture and subsequent anatomic dissections led to the creation of the term “Arcade of Struthers.” Review of Struthers’ original writings fails to identify either the use of word “arcade” or description of ulnar nerve compression. Review of published anatomic dissections identifies variations in the origin of the medial head of the triceps, not described by Struthers, that may cause failure of an anterior transposition of the ulnar nerve. Continued use of the term “Arcade of Struthers” is historically incorrect. (J Hand Surg 2003;28A:528-531. Copyright © 2003 by the American Society for Surgery of the Hand.) Key words: Struthers, ligament, ulnar nerve entrapment, Froshe.
Sir John Struthers, as noted by Al-Qattan and Murray,1 was born in Dunfermline, Scotland, the son of a flax merchant. He graduated from Edinburgh University in 1845 and from 1846 to 1863 taught at Edinburgh University. He became Professor of Anatomy at Aberdeen University in 1863. His interest in comparative anatomy led him to study whales,1 as well as the embryology of the cat humerus,2,3 which identified the formation of the supracondylar process that bears his name. He also dissected this area in the dog and the lion, neither of which had a supracondylar process, but which, along with the “Quadrumana, Rodentia, Edentata, Marsupialia, and more From the Institute for Peripheral Nerve Surgery, Baltimore, MD; the Division of Plastic Surgery and Department of Neurosurgery, Johns Hopkins University, Baltimore, MD; and the Department of Surgery, University of Arizona, Tucson, AZ. Received for publication October 23, 2002; accepted in revised form January 27, 2003. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: A. Lee Dellon, MD, Institute for Peripheral Nerve Surgery, Suite 370, 3333 N. Calvert St, Baltimore, MD 21218. Copyright © 2003 by the American Society for Surgery of the Hand 0363-5023/03/28A03-0027$30.00/0 doi:10.1053/jhsu.2003.50071
528
The Journal of Hand Surgery
especially the Carnivora. . .have an opening in the humerus through which the median nerve and humeral artery pass, that opening being formed by an arched process crossing obliquely the inner surface of the bone, close above the internal condyle.”2,3 Although Struthers popularized the supracondylar process that bears his name he never used the word “arcade” in his publications nor did he describe ulnar nerve entrapment in any of his publications.2– 4 Rather Struthers described variations of the brachial artery4 and therefore of the ulnar artery origin and he described median nerve entrapment at the elbow (Fig. 1).4 In articles written in 1848 and 1854, Struthers credits Tiedemann in 1822 as first depicting this “process and ligament” (Tabulee Arteriarum, Plate xv. [figure number] 3), and Knox in 1841 (Edinburgh Med. and Surg. Journal, p.125) as first describing this arrangement in the “left arm of a stout muscular middle-aged man.”2,3 Struthers goes on to add, “Another instance of this arrangement is recorded by Mr. R. Quain in his recent work on the arteries, and is represented in Plate xxxvi. [figure number] 3.” How then did the term “Arcade of Struthers” come to exist? The May 1973 issue of the Annales de Chirurgie
De Jesus and Dellon / Struthers Did Not Describe an Arcade
529
internal brachial ligament were first described by Struthers in 1854 [p 491].
This report was the first to use the words “arcade.” Kane et al5 published a drawing (their figure number 7) that showed the “Arcade of Struthers” (Fig. 2). The caption of their figure states, composite drawing adapted from Struthers (1848) original plate of the supracondyloid process in the right arm. The solid line section of the drawing demonstrates the ‘Ligament of Struthers,’ a tendinous band arising from the supracondyloid process of the humerus and attaching to the junction of the medial epicondyle. This is the structure to which Struthers name has been applied as an eponym. The dotted area, added to the original drawing of Struthers represents detail of the level of the arcade of Struthers and the internal brachial ligament [p 491].
Figure 1. Original drawing from Struther’s 1848 publication of a left humerus with a supracondylar process.4
(Appendix A; this appendix can be viewed at the Journal’s Web site, www.jhandsurg.org) included an article by Kane et al5 entitled “Observations of the course of the ulnar artery in the arm”; an English translation of the article accompanied the French text. The article described a 7-year-old girl who had an ulnar nerve palsy that persisted for 6 months after a midshaft humerus fracture that on surgical exploration revealed the ulnar nerve to be entrapped in the fracture site. This finding led the investigators to dissect 20 adult limbs. They reported,5 In the course of our dissections, initially what appeared to be a tendinous attachment of part of the medial head of the triceps in the lower third of the humerus was actually the internal brachial ligament. It was in close proximity to the ulnar nerve in course. A careful dissection of this area revealed that the internal brachial ligament formed an arcade for passage of the ulnar nerve. The arcade was found in 14 of 20 specimens. When well-formed it was located in the distal third of the arm. In 2 additional specimens a modification of the arcade was seen in the mid-third. The arcade and the
In their subsequent publications6 – 8 a 1972 drawing, signed by the illustrator whose name can be read as Goldberg, is reproduced and is made to appear as if it were from the original Struthers’ article (Fig. 3). In subsequent writing by other investigators1,9,10 this structure has been referred to as the “Arcade of Struthers” and has been included in the etiology of ulnar nerve entrapment at the elbow. An article published by Vesley and Killian,9 entitled “Arcades of Struthers,” represents a report in a state medical journal that probably arose from a resident’s (Killian’s) presentation at rounds or a regional meeting. That publication is a review of Struther’s work and seriously misrepresents Struthers. Although Struther’s work is related to the brachial artery and although Vesley and Killian’s9 table (table number 1 in their report) clearly describes “median nerve-brachial artery arcades incidence,” subsequent interpretation from the title of their report suggests its use to be related to the “arcade” that compresses the ulnar nerve. Indeed, listed at the end of their table Vesley and Killian9 include “Ulnar Arcade Incidence” and list it as 1 in 105 subjects. This number cannot be substantiated from any readings of Struther’s works. As further evidence of their misrepresentation of Struther’s work, their Arcade VIII is listed to occur “very frequently,” when in fact this is the Ligament of Struthers, and occurs rarely. Their figure number 9, which purports to show the ulnar arcade, the arcade that compresses the ulnar nerve, clearly is taken from the drawing of Goldberg in Spinner’s original article and not from anything drawn or written by Struthers. In fact, it is directly drawn from figure number 1 of the Spinner and Kaplan publica-
530
The Journal of Hand Surgery / Vol. 28A No. 3 May 2003
Figure 2. Drawing by Goldberg from 1972 that appeared in a 1973 article by Kane et al5 on the course of the ulnar nerve in the arm. Note that Goldberg’s is a composite drawing including a reversed original from Struthers plus the dotted area, added to the original to represent details of the arcade of Struthers.5
tion that they list as reference 2 in their own bibliography.9 They have misquoted the authorship of that report, however, which they have listed as Kaplan ER and Spinner N, instead of Spinner M and Kaplan EB.7 Since that time the term “Arcade of Struthers” has come into common usage by hand surgeons. The supracondylar process of the humerus, described by Struthers in 1848, is uncommon (Fig. 1).4 In more than 2 decades of upper-extremity surgery the senior author (A.L.D.) has observed just one incomplete process and not one ligament has been found to compress the median nerve. In contrast monkeys and baboons have the ulnar nerve completely covered by the medial head of the triceps muscle.11 In humans, this covering is represented by the relatively rare epitrochlearis anconeus muscle and a more common accessory origin of the medial head of the triceps muscle.13 Much more common is the partially or completely subluxing ulnar nerve with little if any
restraining covering structure. Clearly the anatomy of the musculoskeletal arrangement and therefore of the nerves is evolving as the upper extremity continues to adapt over time to needs that are less arboreal. On the other hand the accessory origin of the medial head of the triceps from the medial intermuscular septum does exist. Kane et al5 found it in 14 of the 20 limbs they dissected (70%). Dellon11 found it in 16 of 64 limbs (24%). Al-Qattan and Murray1 found it in 17 of 25 limbs (68%). Although this structure can be involved in the etiology of ulnar nerve compression at the elbow, requiring the surgeon to inspect all structures proximal to the point of transposition of the ulnar nerve across the humerus, it was not the structure described by Struthers and continued use of the term “Arcade of Struthers” to describe it is historically incorrect. Use of the term arcade to call attention to sites at which a peripheral nerve might become entrapped was done once before by Spinner. In 1968 in an article entitled “The Arcade of Frohse and its relationship to posterior interosseous nerve paralysis,” Spinner12 wrote, “Through this arcade, described by Frohse, the posterior interosseous nerve passes to enter the plane between the two heads of the supinator muscle.” Spinner noted the presence of this ar-
Figure 3. Figure from subsequent publications showing the Arcade of Struthers.6 – 8
De Jesus and Dellon / Struthers Did Not Describe an Arcade
cade in 30% of his 25 adult limb dissections. In Spinner’s figure number 2, the fibrous region of the supinator is depicted as an arch. In their 1908 book Froshe and Frankel13 depicted, in the illustrations of Max Froshe, the author’s brother, no true fibrous arch and did not use any German word that could be interpreted as an arcade (translation courtesy of Oskar Aszmann, MD, University of Vienna Department of Plastic Surgery, Austria, 2003). Again subsequent to Spinner’s 1968 report, compression of the posterior interosseous nerve in the forearm is noted to occur at the Arcade of Froshe.10
References 1. Al-Qattan MM, Murray KA. The Arcade of Struthers: an anatomical study. J Hand Surg 1991;16B:311–314. 2. Struthers J. On some points in the abnormal anatomy of the arm. Br Foreign Med-Chir Rev 1854;14:170 –179. 3. Struthers J. Anatomic and physiologic observations, part I. Edinburgh: Sutherland and Knox, 1854:3– 6, 193–230. 4. Struthers J. On a peculiarity of the humerus and humeral artery. Monthly J Med Sci 1848;8:264 –267.
531
5. Kane E, Kaplan EB, Spinner M. Sur le trajet du nerf cubital au niveau du bras [Observations of the course of the ulnar nerve in the arm]. Ann Chir 1973;27:487– 496. 6. Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop 1974;104:46 – 67. 7. Spinner M, Kaplan EB. The relationship of the ulnar nerve to the medial intermuscular septum in the arm and its clinical significance. Hand 1976;8:239 –242. 8. Spinner M. Injuries to the major branches of peripheral nerves of the forearm, 2nd ed. Philadelphia: WB Saunders Co., 1978:230 –235. 9. Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc Alabama 1983;5233–37. 10. Eversmann WW. Entrapment and compressive neuropathy. In Green DP, ed. Operative Hand Surgery, 2nd ed. New York: Churchill Livingstone, 1988:1444, 1446. 11. Dellon AL. Musculotendinous variations about the medial humeral epicondyle. J Hand Surg 1986;11B:175–181. 12. Spinner M. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J Bone Joint Surg 1968;50B:809 – 812. 13. Froshe F, Frankel M. Die muskeln des menschlichen Ares. Jena 1908.
Appendix A. Table of Contents, May 1973 Issue of Annales De Chirurgie Les positions d’immobilisation de la main par R. Tubiana Plaies recentes des tendons flechisseurs au doigt par J. Duparc, J.Y., Alnot, J.Y. Nordin et. L. Pidhorz Sensibilite et sensations au nieau de le main (Sensibility of the hand as opposed to sensation in the hand) par G.E. Omer Sur le trajet du nerf cubital au niveau du bras (Observations of the course of the ulnar nerve in the arm) par E. Kane, E.B. Kaplan, et M. Spinner Restauration fe la sensibilite au niveau de la main par transfert d’un transplant cutane hetero-digital muni de, son pedicule vasculo-nerveux. Etude critque des resultats par J. Duparc et F. Roux Les lambeaux cutanes palmaires en ilot par R. Tubiana Macrodactylie et fibrolipomes du median (phacomatoses) par C. Gournet
459–466 467–478 479–485 487–496
497–502 503–509 511–518
John Struthers wrote in 1848 and 1854 about sites of compression of the median nerve from axilla to elbow. He is best known for describing the rare median nerve entrapment by a ligament from a supracondylar process extending to the medial humeral epicondyle. In 1973, observation of ulnar nerve entrapment associated with a midshaft humeral fracture and subsequent anatomic dissections led to the creation of the term “Arcade of Struthers.” Review of Struthers’ original writings fails to identify either the use of word “arcade” or description of ulnar nerve compression. Review of published anatomic dissections identifies variations in the origin of the medial head of the triceps, not described by Struthers, that may cause failure of an anterior transposition of the ulnar nerve. Continued use of the term “Arcade of Struthers” is historically incorrect. (J Hand Surg 2003;28A:528-531. Copyright © 2003 by the American Society for Surgery of the Hand.) Key words: Struthers, ligament, ulnar nerve entrapment, Froshe.
Sir John Struthers, as noted by Al-Qattan and Murray,1 was born in Dunfermline, Scotland, the son of a flax merchant. He graduated from Edinburgh University in 1845 and from 1846 to 1863 taught at Edinburgh University. He became Professor of Anatomy at Aberdeen University in 1863. His interest in comparative anatomy led him to study whales,1 as well as the embryology of the cat humerus,2,3 which identified the formation of the supracondylar process that bears his name. He also dissected this area in the dog and the lion, neither of which had a supracondylar process, but which, along with the “Quadrumana, Rodentia, Edentata, Marsupialia, and more From the Institute for Peripheral Nerve Surgery, Baltimore, MD; the Division of Plastic Surgery and Department of Neurosurgery, Johns Hopkins University, Baltimore, MD; and the Department of Surgery, University of Arizona, Tucson, AZ. Received for publication October 23, 2002; accepted in revised form January 27, 2003. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: A. Lee Dellon, MD, Institute for Peripheral Nerve Surgery, Suite 370, 3333 N. Calvert St, Baltimore, MD 21218. Copyright © 2003 by the American Society for Surgery of the Hand 0363-5023/03/28A03-0027$30.00/0 doi:10.1053/jhsu.2003.50071
528
The Journal of Hand Surgery
especially the Carnivora. . .have an opening in the humerus through which the median nerve and humeral artery pass, that opening being formed by an arched process crossing obliquely the inner surface of the bone, close above the internal condyle.”2,3 Although Struthers popularized the supracondylar process that bears his name he never used the word “arcade” in his publications nor did he describe ulnar nerve entrapment in any of his publications.2– 4 Rather Struthers described variations of the brachial artery4 and therefore of the ulnar artery origin and he described median nerve entrapment at the elbow (Fig. 1).4 In articles written in 1848 and 1854, Struthers credits Tiedemann in 1822 as first depicting this “process and ligament” (Tabulee Arteriarum, Plate xv. [figure number] 3), and Knox in 1841 (Edinburgh Med. and Surg. Journal, p.125) as first describing this arrangement in the “left arm of a stout muscular middle-aged man.”2,3 Struthers goes on to add, “Another instance of this arrangement is recorded by Mr. R. Quain in his recent work on the arteries, and is represented in Plate xxxvi. [figure number] 3.” How then did the term “Arcade of Struthers” come to exist? The May 1973 issue of the Annales de Chirurgie
De Jesus and Dellon / Struthers Did Not Describe an Arcade
529
internal brachial ligament were first described by Struthers in 1854 [p 491].
This report was the first to use the words “arcade.” Kane et al5 published a drawing (their figure number 7) that showed the “Arcade of Struthers” (Fig. 2). The caption of their figure states, composite drawing adapted from Struthers (1848) original plate of the supracondyloid process in the right arm. The solid line section of the drawing demonstrates the ‘Ligament of Struthers,’ a tendinous band arising from the supracondyloid process of the humerus and attaching to the junction of the medial epicondyle. This is the structure to which Struthers name has been applied as an eponym. The dotted area, added to the original drawing of Struthers represents detail of the level of the arcade of Struthers and the internal brachial ligament [p 491].
Figure 1. Original drawing from Struther’s 1848 publication of a left humerus with a supracondylar process.4
(Appendix A; this appendix can be viewed at the Journal’s Web site, www.jhandsurg.org) included an article by Kane et al5 entitled “Observations of the course of the ulnar artery in the arm”; an English translation of the article accompanied the French text. The article described a 7-year-old girl who had an ulnar nerve palsy that persisted for 6 months after a midshaft humerus fracture that on surgical exploration revealed the ulnar nerve to be entrapped in the fracture site. This finding led the investigators to dissect 20 adult limbs. They reported,5 In the course of our dissections, initially what appeared to be a tendinous attachment of part of the medial head of the triceps in the lower third of the humerus was actually the internal brachial ligament. It was in close proximity to the ulnar nerve in course. A careful dissection of this area revealed that the internal brachial ligament formed an arcade for passage of the ulnar nerve. The arcade was found in 14 of 20 specimens. When well-formed it was located in the distal third of the arm. In 2 additional specimens a modification of the arcade was seen in the mid-third. The arcade and the
In their subsequent publications6 – 8 a 1972 drawing, signed by the illustrator whose name can be read as Goldberg, is reproduced and is made to appear as if it were from the original Struthers’ article (Fig. 3). In subsequent writing by other investigators1,9,10 this structure has been referred to as the “Arcade of Struthers” and has been included in the etiology of ulnar nerve entrapment at the elbow. An article published by Vesley and Killian,9 entitled “Arcades of Struthers,” represents a report in a state medical journal that probably arose from a resident’s (Killian’s) presentation at rounds or a regional meeting. That publication is a review of Struther’s work and seriously misrepresents Struthers. Although Struther’s work is related to the brachial artery and although Vesley and Killian’s9 table (table number 1 in their report) clearly describes “median nerve-brachial artery arcades incidence,” subsequent interpretation from the title of their report suggests its use to be related to the “arcade” that compresses the ulnar nerve. Indeed, listed at the end of their table Vesley and Killian9 include “Ulnar Arcade Incidence” and list it as 1 in 105 subjects. This number cannot be substantiated from any readings of Struther’s works. As further evidence of their misrepresentation of Struther’s work, their Arcade VIII is listed to occur “very frequently,” when in fact this is the Ligament of Struthers, and occurs rarely. Their figure number 9, which purports to show the ulnar arcade, the arcade that compresses the ulnar nerve, clearly is taken from the drawing of Goldberg in Spinner’s original article and not from anything drawn or written by Struthers. In fact, it is directly drawn from figure number 1 of the Spinner and Kaplan publica-
530
The Journal of Hand Surgery / Vol. 28A No. 3 May 2003
Figure 2. Drawing by Goldberg from 1972 that appeared in a 1973 article by Kane et al5 on the course of the ulnar nerve in the arm. Note that Goldberg’s is a composite drawing including a reversed original from Struthers plus the dotted area, added to the original to represent details of the arcade of Struthers.5
tion that they list as reference 2 in their own bibliography.9 They have misquoted the authorship of that report, however, which they have listed as Kaplan ER and Spinner N, instead of Spinner M and Kaplan EB.7 Since that time the term “Arcade of Struthers” has come into common usage by hand surgeons. The supracondylar process of the humerus, described by Struthers in 1848, is uncommon (Fig. 1).4 In more than 2 decades of upper-extremity surgery the senior author (A.L.D.) has observed just one incomplete process and not one ligament has been found to compress the median nerve. In contrast monkeys and baboons have the ulnar nerve completely covered by the medial head of the triceps muscle.11 In humans, this covering is represented by the relatively rare epitrochlearis anconeus muscle and a more common accessory origin of the medial head of the triceps muscle.13 Much more common is the partially or completely subluxing ulnar nerve with little if any
restraining covering structure. Clearly the anatomy of the musculoskeletal arrangement and therefore of the nerves is evolving as the upper extremity continues to adapt over time to needs that are less arboreal. On the other hand the accessory origin of the medial head of the triceps from the medial intermuscular septum does exist. Kane et al5 found it in 14 of the 20 limbs they dissected (70%). Dellon11 found it in 16 of 64 limbs (24%). Al-Qattan and Murray1 found it in 17 of 25 limbs (68%). Although this structure can be involved in the etiology of ulnar nerve compression at the elbow, requiring the surgeon to inspect all structures proximal to the point of transposition of the ulnar nerve across the humerus, it was not the structure described by Struthers and continued use of the term “Arcade of Struthers” to describe it is historically incorrect. Use of the term arcade to call attention to sites at which a peripheral nerve might become entrapped was done once before by Spinner. In 1968 in an article entitled “The Arcade of Frohse and its relationship to posterior interosseous nerve paralysis,” Spinner12 wrote, “Through this arcade, described by Frohse, the posterior interosseous nerve passes to enter the plane between the two heads of the supinator muscle.” Spinner noted the presence of this ar-
Figure 3. Figure from subsequent publications showing the Arcade of Struthers.6 – 8
De Jesus and Dellon / Struthers Did Not Describe an Arcade
cade in 30% of his 25 adult limb dissections. In Spinner’s figure number 2, the fibrous region of the supinator is depicted as an arch. In their 1908 book Froshe and Frankel13 depicted, in the illustrations of Max Froshe, the author’s brother, no true fibrous arch and did not use any German word that could be interpreted as an arcade (translation courtesy of Oskar Aszmann, MD, University of Vienna Department of Plastic Surgery, Austria, 2003). Again subsequent to Spinner’s 1968 report, compression of the posterior interosseous nerve in the forearm is noted to occur at the Arcade of Froshe.10
References 1. Al-Qattan MM, Murray KA. The Arcade of Struthers: an anatomical study. J Hand Surg 1991;16B:311–314. 2. Struthers J. On some points in the abnormal anatomy of the arm. Br Foreign Med-Chir Rev 1854;14:170 –179. 3. Struthers J. Anatomic and physiologic observations, part I. Edinburgh: Sutherland and Knox, 1854:3– 6, 193–230. 4. Struthers J. On a peculiarity of the humerus and humeral artery. Monthly J Med Sci 1848;8:264 –267.
531
5. Kane E, Kaplan EB, Spinner M. Sur le trajet du nerf cubital au niveau du bras [Observations of the course of the ulnar nerve in the arm]. Ann Chir 1973;27:487– 496. 6. Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop 1974;104:46 – 67. 7. Spinner M, Kaplan EB. The relationship of the ulnar nerve to the medial intermuscular septum in the arm and its clinical significance. Hand 1976;8:239 –242. 8. Spinner M. Injuries to the major branches of peripheral nerves of the forearm, 2nd ed. Philadelphia: WB Saunders Co., 1978:230 –235. 9. Vesley DG, Killian JT. Arcades of Struthers. J Med Assoc Alabama 1983;5233–37. 10. Eversmann WW. Entrapment and compressive neuropathy. In Green DP, ed. Operative Hand Surgery, 2nd ed. New York: Churchill Livingstone, 1988:1444, 1446. 11. Dellon AL. Musculotendinous variations about the medial humeral epicondyle. J Hand Surg 1986;11B:175–181. 12. Spinner M. The arcade of Frohse and its relationship to posterior interosseous nerve paralysis. J Bone Joint Surg 1968;50B:809 – 812. 13. Froshe F, Frankel M. Die muskeln des menschlichen Ares. Jena 1908.
Appendix A. Table of Contents, May 1973 Issue of Annales De Chirurgie Les positions d’immobilisation de la main par R. Tubiana Plaies recentes des tendons flechisseurs au doigt par J. Duparc, J.Y., Alnot, J.Y. Nordin et. L. Pidhorz Sensibilite et sensations au nieau de le main (Sensibility of the hand as opposed to sensation in the hand) par G.E. Omer Sur le trajet du nerf cubital au niveau du bras (Observations of the course of the ulnar nerve in the arm) par E. Kane, E.B. Kaplan, et M. Spinner Restauration fe la sensibilite au niveau de la main par transfert d’un transplant cutane hetero-digital muni de, son pedicule vasculo-nerveux. Etude critque des resultats par J. Duparc et F. Roux Les lambeaux cutanes palmaires en ilot par R. Tubiana Macrodactylie et fibrolipomes du median (phacomatoses) par C. Gournet
459–466 467–478 479–485 487–496
497–502 503–509 511–518