|Year : 2022 | Volume
| Issue : 2 | Page : 101-104
A cadaveric study of deep branch of radial nerve at arcade of Frohse
R Sivachidambaram1, TH Dilipkumar2, A Stellamary1
1 Assistant professor, Department of Anatomy, Government Medical College, Pudukkottai, Tamil Nadu, India
2 Assistant professor, Department of Anatomy, Madras Medical College, Chennai, Tamil Nadu, India
|Date of Submission||13-Jan-2022|
|Date of Decision||29-Mar-2022|
|Date of Acceptance||30-Apr-2022|
|Date of Web Publication||26-May-2022|
No A3, 1st Floor, A- Block, Doctors Quarters, Government Medical College, Pudukkottai - 622 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: The arcade of Frohse (AF) is the most common site for compression of the deep branch of the radial nerve (DBRN). During the surgical fixation of proximal radial shaft fracture, there is a chance of accidental injury to DBRN near the arcade. The objective of the study was to describe the nature of AF, to provide the superficial surgical landmark for DBRN at AF, and to indicate the appropriate position of the forearm for the surgical approach in fracture proximal radial shaft surgery. Methodology: The present study was done on 50 upper extremities preserved in 10% formalin. The studied parameters were morphology of AF, forearm length, the distance between the lateral epicondyle and the DBRN at AF, arcade ratio and the distance of DBRN at AF to the biceps tendon in pronated and supinated forearm. Results: In 50 upper extremities, the AF was tendinous in 27 limbs (54%), musculotendinous in 19 limbs (38%), and membranous in 4 limbs (8%). The mean forearm length was 234.43 mm. The mean distance from the DBRN to the lateral epicondyle was 48.98 mm. The mean arcade ratio was 0.208 mm. At AF, the mean distance from DBRN to the biceps tendon in pronation and supination was 12.72 mm and 18.98 mm, respectively. Conclusion: The most common type of AF is tendinous type. The mean arcade ratio derived from our study was 0.208. It is suggested that the terminal supination of the forearm is the appropriate position for surgical reduction and fixation of proximal radial shaft fracture through the ventral (Henry's) approach.
Keywords: Arcade of Frohse, biceps tendon, deep branch of radial nerve, entrapment neuropathy, proximal radial shaft fracture
|How to cite this article:|
Sivachidambaram R, Dilipkumar T H, Stellamary A. A cadaveric study of deep branch of radial nerve at arcade of Frohse. Natl J Clin Anat 2022;11:101-4
|How to cite this URL:|
Sivachidambaram R, Dilipkumar T H, Stellamary A. A cadaveric study of deep branch of radial nerve at arcade of Frohse. Natl J Clin Anat [serial online] 2022 [cited 2022 Jul 1];11:101-4. Available from: http://www.njca.info/text.asp?2022/11/2/101/346073
| Introduction|| |
Entrapment neuropathies are the common painful condition of the upper extremities. In an epidemiological study, the incidence of radial nerve neuropathy was reported as 1.42 in 1 lakh population. The compression of the deep branch of the radial nerve (DBRN) causes pain in the lateral part of the elbow region, followed by the weakness of the forearm extensor compartment muscles. The supinator muscle has two laminas between which the DBRN passes. The upper margin of the superficial lamina of the supinator muscle is called the arcade of Frohse (AF). The DBRN passes through the AF to enter into the supinator tunnel.
Frohse and Frankel in 1908, first explained the morphology of AF. Later in 1968, Spinner suggested that unyielding tendinous arcade can injure the DBRN at the AF. Several authors have studied various structures that can compress the radial nerve along its course.,, However, the AF was reported as the most common site for entrapment of DBRN. Hence, the nature of AF and the surgical landmark of DBRN at the arcade are essential for the orthopedic surgeon to decompress the nerve in entrapment syndrome.
The DBRN is highly susceptible to iatrogenic injury near the AF during the surgical fixation of proximal radial shaft fracture. The surgery is performed either through a ventral approach (Henry's approach) or a dorsolateral approach (Thompson's approach) of the forearm. During the surgery, the proximal shaft of the radius needs to be exposed by detaching the supinator muscle without injury to the nerve under it., Hence, the appropriate positioning of the forearm can clear the nerve from the field of surgery which is necessary for the orthopedic surgeon to avoid iatrogenic injury to the DBRN.
The aims of our study were to describe the morphology of AF and to establish the useful superficial surgical landmark for DBRN at AF and to suggest the appropriate position of the forearm for surgical reduction and fixation of proximal radial shaft fracture through ventral (Henry's) approach of the forearm.
| Materials and Methods|| |
The present study was done in the Department of Anatomy, Government Medical College, Pudukkottai. This descriptive cross-sectional study was done by dissecting 50 formalin-fixed upper extremities (25 right and 25 left) from 25 cadavers. All the upper extremities from the well-preserved cadavers irrespective of gender, occupation were included in the study. The upper extremities with deformity, trauma, or signs of previous surgery were excluded from the study. Since it was a cadaveric study, ethical clearance was exempted for the same (letter dated December 6, 2021).
The formula used for the sample size calculation was n = (z2) standard deviation (SD) 2/(e)2 where Z-Level of confidence ‒ 95%–1.96%, SD is the SD of arcade ratio. In the previous literature, Ozturk et al. showed that arcade ratio SD was 0.047. Error accepted was 2%–0.02%, leading to a sample size of (n) of 22. We did the study in 50 upper extremities to get more precise value.
During the routine classroom dissection, the supinator muscle was identified and the DBRN was traced up to the AF. The morphology of AF was classified into four types as follows:, (1) tendinous type consists of dense white fibrous tissue, (2) musculotendinous type with both muscular and tendinous fibers, (3) muscular type formed only by the muscle fibers, and (4) membranous type resembles a thin whitish layer of the arcade.
The measurements include (a) the forearm length between the lateral epicondyle of the humerus and the radial styloid process, (b) the distance between the lateral epicondyle and the point of entry of DBRN at AF, and (c) at AF, the distance between the DBRN and the tendon of biceps in supination and pronation of the forearm [Table 1]. The arcade ratio was calculated by the distance between the lateral epicondyle to the DBRN at AF divided by the length of the forearm. The orthopedic surgeon can predict the superficial surgical landmark of DBRN at the arcade from the lateral epicondyle by multiplying the mean value of the arcade ratio with the patient's forearm length.
Statistical analyses such as mean, SD and range were calculated using IBM SPSS statistical software version 20.0 (IBM Corp, New York, USA).
| Results|| |
Of 50 upper extremities, the AF was tendinous in 27 limbs (54%), musculotendinous in 19 limbs (38%), and membranous in 4 limbs (8%) [Figure 1], [Figure 2], [Figure 3]. We did not find any muscular type of AF in our study. The measurement parameters were given in mean ± SD (mm). The mean length of the forearm was 234.43 ± 22.33 mm. The mean distance from the DBRN to the lateral epicondyle was 48.98 ± 7.35 mm. The mean arcade ratio was 0.208 ± 0.012 mm. At AF, the mean distance between the DBRN and the biceps tendon in pronation and supination was 12.72 ± 2.74 mm and 18.98 ± 3.43 mm, respectively [Figure 4]. All the above values are mentioned in [Table 2].
|Figure 1: AF is tendinous, AF: Arcade of Frohse, SM: Supinator muscle, DBRN: Deep branch of the radial nerve, SB: Superficial branch of the radial nerve|
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|Figure 2: AF is musculotendinous. AF: Arcade of Frohse, SM: Supinator muscle, DBRN: Deep branch of the radial nerve, SB: Superficial branch of the radial nerve|
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|Figure 3: AF is membranous. AF: Arcade of Frohse, SM: Supinator muscle, DBRN: Deep branch of the radial nerve, SB: Superficial branch of the radial nerve|
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|Figure 4: (A)-The length of the forearm, (B)-distance from the lateral epicondyle of the humerus to the point of entry of DBRN at AF, and (C)-distance of DBRN at AF to the biceps tendon, AF: Arcade of Frohse, SM: Supinator muscle, DBRN: Deep branch of the radial nerve, BT: Biceps tendon, LE: Lateral epicondyle, SB: Superficial branch of the radial nerve, SP: Radial styloid process|
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| Discussion|| |
The pain in the lateral part of the elbow is the most common symptom reported in the entrapment syndrome of DBRN. Most of the orthopedic surgeons diagnosed it as tennis elbow. However, in recent decades, several authors have studied the AF as one of the most common causes of lateral elbow pain due to the compression of DBRN under it. Frohse and Frankel studied that the AF is a normal tendinous arcade of the upper margin of the supinator muscle. Later, Spinner compared the morphology of arcades in newborn and adult limbs. He suggested that the absence of tendinous arcade in newborns and its presence in adult cadavers were due to repeated rotatory movements of the forearm. In Berton et al. and Riffaud et al. studies, the most common type of arcade reported was tendinous type (66% and 52%, respectively). In the present study, the AF was predominantly of tendinous type (54%), followed by musculotendinous (38%) and membranous type (8%) which is comparable with the similar results given by Berton et al.'s and Riffaud et al.'s study., However, in contrast to their study, the muscular type of arcade was not reported in our study.
Werner operated on 90 patients with lateral elbow pain at the point of entry of DBRN at the AF. He suggested that during pronation, the supinator and the tendinous arcade got more tensed, and it could injure the nerve passing under it. Of 90 patients he operated, 83 patients had nerve compression. Hence, such predominant tendinous nature of the arcade makes the DBRN more vulnerable to injury during the repeated rotatory movements of the forearm. Such movements are frequently seen in tennis players and orchestra conductors.
In entrapment syndrome, the superficial surgical landmark of DBRN at the AF is much important for the orthopedic surgeon to locate the nerve and decompress the nerve at the arcade. The surgeon can look for the tenderness in the lateral elbow region at the level of the arcade to diagnose the condition clinically. In our study, the average distance between the lateral epicondyle and the point of entry of DBRN at the AF was 48.98 mm. The same distance was reported as 46.23 mm in Ozturk et al.'s and 49.1 mm in Papadopoulos et al.'s studies. The mean arcade ratio in our study was 0.208, and the same was reported as 0.199 in Ozturk et al.'s study. The orthopedic surgeon can predict the location of the arcade and the nerve under it from the lateral epicondyle by multiplying the mean arcade ratio with the forearm length of the patient.
Most of the proximal radial shaft fracture requires surgical plating of fractured segments. The proximal part of the radius was accessed during the procedure by detaching the AF and the supinator muscle from its attachment. The surgery is usually done through a ventral approach (Henry's approach) or a dorsolateral approach (Thompson's approach) of the forearm to access the fracture segments. In both approaches, the DBRN passing through the arcade can be injured accidentally by the surgeon. The rotatory movement of the forearm along its axis moves the DBRN from the field of surgery. Hence, the forearm position is important for the surgeon to avoid accidental injury to the nerve.
In the present study, at AF, the mean distance between the DBRN and the distal biceps tendon in pronation and supination was 12.72 mm and 18.98 mm, respectively. The distance between the DBRN and the biceps tendon decreases in pronation and it increases in supination. Similar results were reported in Schwarz et al. with a shorter distance between the nerve and the tendon in pronation (14.1 mm) and a longer distance between them in supination (20.5 mm). Our study result indicated that the forearm's terminal supination moves the DBRN laterally from the biceps tendon, which is the appropriate position for the ventral approach (Henry) in proximal radial shaft fracture to avoid injury to the DBRN.
From our study results, the predominant tendinous type of AF is the normal anatomical feature seen in adult cadavers. However, in a patient with a specific occupation who needs repeated pronation and supination of the forearm are more prone for compressive neuropathy of DBRN under the tendinous arcade. The mean arcade ratio derived from our study can help the orthopedic surgeon locate the DBRN at the AF from the lateral epicondyle during the nerve decompression procedure. The surgeon can also look for tenderness in the superficial landmark for DBRN at the arcade to clinically diagnose entrapment neuropathy. The supination of the forearm for the ventral (Henry's) approach is the position suggested by our study during the plating of proximal radial shaft fracture to reduce the chance of iatrogenic DBRN injury.
| Conclusion|| |
The most common type of AF is tendinous type. The useful superficial surgical landmark for DBRN at AF from the lateral epicondyle is predicted by multiplying the mean arcade ratio with the forearm length of the patient. The mean arcade ratio derived from our study was 0.208. It is suggested that the terminal supination of the forearm is the appropriate position for surgical reduction and fixation of proximal radial shaft fracture through the ventral (Henry's) approach.
The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase humankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]