Struthers' ligament and traumatic median nerve injury: case illustration.

J neurosurg May 13, 2016 1 submitted September 17, 2015. accepted March 11, 2016. include when citing Published online May 13, 2016; DOI: 10.3171/2016.3.JNS152159. correspondence Helene T. Khuong, Department of Neurological Sciences, Division of Neurosurgery, CHU de Quebec–Universite Laval, 1401 18th St., Quebec, QC G1J 1Z4, Canada. email: helene-thida.khuong.1@ulaval.ca. A 31-year-old right-handed man sustained a penetrating injury to the medial aspect of his right arm that resulted in brachial artery laceration. He underwent a brachioradial artery bypass. At the time of surgery, neither the right median nerve nor the ulnar artery was found in its usual location in the vicinity of the brachial artery. The patient was referred 5 months later with a clinical and electrophysiological picture of complete median nerve injury. MRI showed right median nerve discontinuity, with a proximal stump neuroma in the humeral supracondylar area. A linear structure joining a supracondylar spur to the medial epicondyle was identified as Struthers’ ligament, with the median nerve deviating away from the brachial artery (Fig. 1 left). Median nerve reconstruction using autologous sural nerve graft was offered. Intraoperatively, the median nerve was found medial to its normal course and trapped under a rigid band (Fig. 1 right). The Struthers’ ligament was resected to release the median nerve and perform a tension-free graft reconstruction toward the distal stump (Fig. 1 right). This case illustrates that, although rare, the presence of Struthers’ ligament can be associated with significant neurovascular variations.1,2 Originally described in 1848,5 Struthers’ ligament is estimated to be found in 1%–2% of individuals, but its prevalence may vary according to the studied population.3 Struthers’ ligament is well recognized as a cause of median nerve entrapment.4 To the best of our knowledge, this is the first report of its influence on the management of a traumatic nerve injury.