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Abord antrieur du coude

Christian Dumontier, Cyril Clerico


Service de chirurgie plastique, reconstructrice et esthtique,
chirurgie de la main, Nice

Avec laide du laboratoire danatomie, Nice

Cours DIU de la main du grand Sud

Anatomie de la face antrieure du coude

Plan osto-articulaire: articulation du coude


Plan musculaire: brachialis et biceps brachialis,
pitrochlens, picondyliens
Plan cutan
ET surtout, toutes les structures qui traversent le
coude pour aller lAVB et la Main +++

Larticulation du coude

Humrus avec deux condyles et deux apophyses


Ulna et radius

Nommez les lments numrots

Comment sappelle cette anomalie ?


A quelle structure est-elle associe ?
A quelle pathologie est-elle associe

A Aydinlioglu; FN Gumrukcuoglu; N Koyun. The prevalence of supracondyloid process in the living: a radiographic study
West Indian Med. L.2010; 59(5)

Processus supracondylien, frquence 1%, bilatral 50%, femme


> homme
Ligament de Struthers ( arcade de Struthers)
Compression nerf mdian, artre brachiale, nerf ulnaire

Une seule capsule !


Capacit minimale autour
de 65 de flexion

Les muscles

Brachialis

Biceps et son expansion

Epitrochlens

be important in stabilizing the tendons distally. The superficial layer originated from the anterior radial aspect of the long
head of the biceps just proximal to the commencement of the
distal biceps tendon. This superficial layer macroscopically
T H E J O U R N A L O Fwas
B Othe
N Ethickest
& J Olayer
I N T in
S UallRspecimens,
G E R Y J Band
J S .itOpassed
RG
I S T A L B I C E P S TE N D O N A N A T O MY :
in aDdistal
direction
VOand
L U Mulnar
E 89-A
N Uanterior
M B E R to
5 the
Mmusculotendinous
A Y 2007
AjuncC A D A VE R I C S T U D Y
tion of the short head. In some specimens, a rudimentary
middle layer, which acted as a mesentery, was present. It was
the only layer to attach to the short head. This middle layer
passed in an ulnar direction to merge anteriorly with the
su- the elbow extended, and between the proximal part of
with
perficial layer. The deep layer originated from the deep radial
thebi-radius and the biceps tendons during pronation of the
side of the musculotendinous area of the long head of the
Fig. 3
ceps. This layer passed in an ulnar direction deep to the
tenforearm.
Cross section of the two tendons (the short head [SH] and the long
don of the short head to merge with the other two layers.
These three layers merged and continued distally, super- The insertion of the long head was at a point farthest
head [LH]). The three layers of the aponeurosis stabilize the tendon of
the short head.
ficial to the ulnar flexor muscles of the forearm. Thereaway
were from the rotation of the radius, potentially providing

1048

Lacertus Fibrosus

a greater lever arm to increase supination power (Fig. 7).


Conversely, the tendon of the short head was attached more
distally, providing it with the potential for greater flexion
power.

Fig. 4

Cross section of the forearm 2 cm distal to


the elbow. The aponeurosis (blue) completely
encircles the forearm flexor muscles and has

Discussion
e demonstrated that, in most individuals, the biceps
muscles are two independent muscle bellies of the two
heads, with two separate tendon areas. The remaining individuals had several interdigitations between both muscle bellies
and again two easily defined tendons. No biomechanical or
histological investigations were performed, and this is a potential limitation of the study.
The distinct pattern found in the majority of patients
was described recently in a case report4. The authors reported

Expansion mdiale du biceps

tethering points into the muscle mass. BT =


biceps tendon, and LF = the two attachment
sites of the lacertus fibrosus.

Rle mcanique: Il stabilise le tendon distal du


biceps et rpartit les contraintes
Fig. 7

The line of the humeral shaft is demonstrated (LH = long head and

SH = short head).

La contraction du biceps/ou des picondyliens


entrane une mdialisation des picondyliens
Change leur bras de levier et les place dans laxe
de lavant-bras performances mcaniques

Zone 3: Postaponeurosis
The two tendons continued distal to the aponeurosis and inserted into the proximal part of the radius. In both groups, the
tendon of the long head passed deep to the tendon of the short
head to insert more proximally. The insertion of the tendon of
the long head was oval in shape, occupying most of the radial
tuberosity. The tendon of the short head curved anterior to
the tendon of the long head, to insert in a fan-like fashion into
the distal portion of the radial tuberosity, and extended distal
to it (Fig. 5). The attachments of the two distal tendons were
surrounded by the bicipitoradial bursa (Fig. 6). This bursa
completely encircled the distal tendons in all specimens. The
bursa could be easily distended by injection of 7 mL of saline
solution or latex on its deep radial side. The bursal membrane
continued around the ulnar side of the tendons, where it was
adherent to the tendon and would not distend. The bursa was
attached proximally to the biceps tendon on the radial aspect.
From this point, it draped down over the tendons, adhering to
both tendons on the ulnar aspect. The bursa was attached
along the proximal deep edge of the tendon of the long head
to create a teardrop shape. Thus, the bursa lay between the
groove in the brachialis muscle and the distal biceps tendons

Fig. 8

Chez le cheval, le lacertus fibrosus relie le biceps lECRL ce qui lui


permet de tenir debout quand il dort

As the forearm muscles contract, the flexor muscle mass migrates


proximally, increasing its cross-sectional area (a). This tenses the aponeurosis, pulling the biceps tendons medially (b). This increased force
on the biceps tendon may be an important factor in the etiology of biceps tendon rupture.

Les structures qui traversent


le coude

Dehors

Bas

v. basilique

v. cphalique

Les nerfs sous-cutans

N. cutan mdial antbrachial


Branche de C8T1
Longe artre axillaire par en dedans
Perce le fascia avec la veine
basilique (en avant delle) et se
divise en deux branches
La branche antrieure, la plus
grosse est en avant de la veine
basilique mdiane
La branche postrieure croise le
plan interne entre +6 et - 6 cm
par rapport lpitrochle (
voie dabord du nerf ulnaire)

n cutan latral antbrachial


1 cm en dehors du tendon du
biceps au pli du coude
Au contact en pronation

supination

pronation

Basset, Nunley. Compression of the musculocutaneous nerve at the elbow. JBJS Am 1982;
64A:1050-2.
Davidson, Basset, Nunley. Musculocutaneous nerve entrapment revisited. J Shoulder Elbow
1998; 7:250-5.

n. mdian et a. brachiale
Gouttire bicipitale interne
A. brachiale se divise en a. radiale et a. ulnaire qui
donne rapidement la. interosseuse commune
nerf mdian chemine sous trois zones de compression
potentielles

Zones de compression du mdian au


coude
Lacertus fibrosus
Deux chefs du pronator
teres
Arcade du Flexor
digitorum superficialis
Zones musculaires et/
ou tendineuses
compression dynamique

Pronator teres
Deux chefs (picondylien
mdial et ulnaire)
Nombreuses variations (nerf
mdian dessus-dessousentre les deux chefs)

Arcade du flexor digitorum


superficialis

Deux chefs
Zone de naissance du nerf
interosseux antrieur

Nerf radial au coude


Nerf mixte, nat de C5C6C7C8
Tronc 2aire postrieur
Gouttire de torsion humrale
Perfore la cloison
intermusculaire 6-12 cm audessus de linterligne
Division 2-3 cm de part et
dautre de linterligne

n. radial

Au contact de la capsule articulaire,


en avant du milieu du capitulum

n. radial

Se divise au coude en ses


deux branches, antrieure
sensitive, et postrieure,
motrice qui passe entre les
chefs du supinator

Le tunnel radial
Dfini par Roles & Maudles
en 1972
Depuis linterligne
Jusqu lentre dans le
supinator
Dont le bord suprieur peut
tre fibreux (arcade de
Frhse)

Zones potentielles de compression du nerf radial

Faisceaux fibreux en avant de larticulation HR


Plexus artrio-veineux (A.R.Radiale)
ECRB
Arcade de FROHSE +++
Partie distale Court Supinateur

Supinator
Enroul autour du radius
2 faisceaux
Pfd transversal
Sous la cavit sigmode du
cubitus
Face antero-ext col radius
Supf oblique
picondyle (fx moyen LLE)
Face ant. radius
Entre la br. post radiale

M
S

ARCADE
DE FROHSE
Epaississement fibreux de la partie
proximale du faisceau superficiel
Aspect normal musculaire ou
fibreux fin
Transformation fibreuse
Variante anatomique
Avec lge
Absente chez le Ftus
Plus frquente chez ladulte
Suite surmenage rptitif

Br
Sensitive
Br
Sensitive

Br
Br
Motrice
Motrice

Exercice possible
La section puis rinsertion du
tendon distal du biceps au coude
et les rapports anatomiques

Pourquoi en parler ?

La rupture distale est une lsion non rare:

Frquence estime: 1,2 / 100,000 patients (scaphode


25/10,0000, Fx radius 260/100,000)

Dsinsertion distale du tendon de la tubrosit (< 5 cas de


rupture tendon-muscle)

Grewal (AAOS 2011): 90 lsions randomises 1 voie vs 2


voies :

19 neurapraxie transitoires vs 3 (1 voie vs 2 voies)

Biceps brachii musculus

Actions: Flchit le coude et permet la supination de lAVB


(dboucher une bouteille)

Si rupture: perte de force en flexion ( 15%), et surtout en


supination ( 40%)

Nombreuses
variations
Fig. 1

Le biceps brachial est le muscle prsentant le plus de


variations du corps humain (Macalister, 1875) depuis une
agnsie 7 chefs diffrents (3 chefs, 13,1%, variation la plus
frquente - Rodriguez-Niedenfh-175 cadavres)

Two individual muscle bellies with an equal number of branches from the musculocutaneous
nerve.

inating from the coracoid process of the scapula and a long


head originating from the superior lip of the glenoid. In ten
specimens (Group 1), these two muscle bellies continued
along their entire length as separate muscles (Fig. 1). The two
muscle bellies were surrounded by loose epimysial tissue. The
short head remained on the ulnar side of the arm throughout

its course. The long head ran parallel to


radial side of the arm.
The remaining seven specimens (G
ing amounts of interdigitation of musc
distal third of the muscle bellies. The m
tion occurred 5 cm proximal to the di

Lincidence de ces variations dpendrait de lethnie (Asvat et


al. 1993)

Les variations proximales, les plus frquentes, sont en


rapport avec des anomalies du mdian ou du musculocutan
Fig. 2

The long head (LH) and short head (SH) showing the crescentic shape of the tendon of the long
head, which stabilizes and contains the tendon of the short head.

Sassmannshausen JBJS 2004

Eames et al. JBJS 2007

Athwal, Steinmann, and Rispoli / Distal Biceps Tendon Anatomy

1227

Nombreuses
variations

Figure 2. The long- and short-head biceps tendon insertions are illustrated (A). The mean footprint area of the long head of the
tendon was 48 mm2 and of the short head of the tendon was 60 mm2. A cadaveric specimen (B) demonstrates the separation
between the short and long heads of the distal tendons (white arrow) with near complete rupture of the short head of the distal
tendon (black arrow).

Sparation du tendon distal


dans 40% des cas,

lesced enough that precise calculation of the individual footprints was difficult and therefore thought to
be imprecise and was abandoned.
The lacertus fibrosus was examined and found to
originate from the proximal aspect of the short head
of the distal tendon (Fig. 1) in all 15 specimens.
Tendon Insertion
In all specimens, the biceps tendon insertion was
located along the extreme ulnar margin of the bicipital tuberosity (Fig. 3). The tendon is ribbon-shaped
just proximal to its insertion; however, as it approaches the tuberosity the tendon thickens in width
and length creating a true footprint on the tuberosity. The average distance from the articular margin
of the radial head to the start of the biceps tendon
insertion in all specimens was 23 mm (range, 18 27
mm); the average distance in the male specimens was
25 mm (range, 22 to 27 mm) and in the female specimens was 22 mm (range, 18 25 mm). The average
length of the biceps tendon insertion on the tuberosity
was 21 mm (range, 1725 mm) and the average width
was 7 mm (range, 6 10 mm). The average length and

Tendon bifide dans 25%

Hypovascularisation tendon
distal

width of the biceps insertion in the male specimens


were 22 mm and 8 mm, respectively, and in the
female specimens were 20 mm and 7 mm, respectively. The average area of the biceps tendon insertion (footprint) in all specimens was 108 mm2 (range,
81135 mm2). The average area in the male and
female specimens was 112 mm2 and 104 mm2, respectively.
In 10 specimens the exact dimensions and area of
the short- and long-head tendon insertions could be
calculated. The short-head tendon insertion on the
bicipital tuberosity averaged 12 mm in length, 7 mm
in width and 60 mm2 in area. The long-head tendon
insertion on the bicipital tuberosity averaged 9 mm in
length, 7 mm in width and 48 mm2 in area.

Discussion
The purpose of this anatomic project was to provide
quantitative data on the dimensions and area of the
biceps tendon insertion on the radius and to identify
local landmarks to assist with correct tendon orientation. The clinical importance of re-creating normal
distal biceps tendon orientation is unknown; how-

Poudel, PP; Bhattarai, C (2009). "Study on the supernumerary heads of biceps brachii muscle in Nepalese" Nepal Med
Coll J 11 (2): 9698.
Dirim, B; Brouha, SS; Pretterklieber, ML; Wolff, KS; Frank, A; Pathria, MN; Chung, CB (2008). "Terminal Bifurcation of the
Biceps Brachii Muscle and Tendon: Anatomic Considerations and Clinical Implications". American Journal of
Roentgenology 191 (6): W248-W255
Fogg QA, et al. The distal biceps brachii tendon anatomy revisited from a surgical perspective. Clin Anat 2009;22;346-51

Insertion
distale
Mazzocca et al 125

J Shoulder Elbow Surg


Volume 16, Number 1

Table I External osteology measurements

Sur la tubrosit bicipitale


22-24 mm de long 12-15 mm de large
30 de supination p/r
plan coronal
Nombreuses variations de
formes
Measurement

Distance from
radial head to
BT (mm)
BT width (mm)
BT length (mm)
Diameter of radius
distal to BT (mm)
Width of radius at
BT (mm)
Styloid angle ()
Radial head
diameter (mm)
Radial neck-shaft
angle ()
Radial length (mm)

Mean ! SD

Minimum

25 ! 3
15 ! 2
22 ! 3

19
10
16

30
19
30

17 ! 2

13

22

17 ! 2
123 ! 10

12
98

23
142

Figure 2 A Faxitron image of a proximal radius demonstrates the


angular orientation of the bicipital tuberosity (solid red line) and
the leading and trailing edges of the biceps brachii tendon insertion
(dashed red lines). The anterior posterior reference (green) is established by a line passing through the center of the radius and a posterior cortical trough marking the midsagittal plane of the radius.

Maximum

23 ! 2

18

28

7!3
24 ! 2

0
20

14
27

BT, Bicipital tuberosity.

Plus large chez les


nanderthaliens

Figure 3 This diagram shows the biceps brachii tendon insertion.


The tendon footprint envelops the bicipital tuberosity extending ulnar to the apex towards the top of the diagram.

insertion and biceps tuberosity in the transverse plane


of the forearm. The Faxitron and axial CT images both
demonstrate that the bicipital tuberosity lies in more
pronation
J Shoulder Elbow
Surg (65! and 68! ) than is commonly held. In
addition, Figure
shows ridge
that thetype.
biceps ten5 Medium
Volume 16, Number
1Faxitron imaging
don footprint generally lies over the apex of the tuberosity, with the geometric center of the tendon inserting
in less pronation (50! ); that is, anterior to, the apex.
Although these alone are interesting anatomic facts,
Table I External osteology measurements
they have direct surgical importance for repair of distal biceps tendon avulsions. Further, the wide range of
Measurementtuberosity
Mean
! SD and
Minimum
Maximum
orientations
tendon insertion
sites demonstrate the significant individual variation that exists
Distance from in local anatomy.
radial head to
BT (mm)
25 ! 3
19
30
BT width (mm)
15 ! 2
10
19
BT length (mm)
22 ! 3
16
30
Diameter of radius
distal to BT (mm)
17 ! 2
13
22
Width of radius at
BT (mm)
17 ! 2
12
23
Styloid angle ()
123 ! 10
98
142
Radial head
diameter (mm)
23 ! 2
18
28

Figure 4 This Faxitron image shows a proximal radius with a bicipital tuberosity that lies in more than 90! pronation from anterior.
When this anatomic variation is found intraoperatively, the tendon
insertion cannot be restored anatomically with current single-incision techniques.

The biceps tendon ruptures from its insertion in


a clean manner, precisely at the tendo-osseous junction. This may occur because of its local histologic
makeup6 or may be due to mechanical impingement.10 Intraoperatively, the surgeon is faced with
the task of creating an anatomic repair to the site of
original tendon attachment. The most widely used
operative techniques include the 2-incision method
of Boyd and Anderson, or some variation thereof,1,7,
9,12,13,18,20,24
or a 1-incision technique using suture
anchors,4,21,30 an endobutton,2,16,28 or an interference screw.17 The anatomy characterized by this
study has direct implications for the procedures
followed in each of these operative techniques.
The 2-incision technique as introduced by Boyd
and Anderson,7 later modified by Morrey et al,24
makes an anterior incision in the cubital region to
expose the biceps tendon. A second incision is
made posteriorly through the common extensor mass
while the forearm is maximally pronated to expose
the tuberosity. A high-speed burr or osteotome is
used to create a cortical window in theMazzocca
tuberosity.24 et
Drill holes are placed along the margin of the cavitated tuberosity, and the sutures in the tendon are
passed through the holes and tied.
A substantial reduction in the biceps tendon supination moment arm may occur with cavitation of the
tuberosity. In our study, the mean distances from the
radial center to the apex of the tuberosity, to the center
of tendon insertion, and to the diaphyseal cortex were
11.6, 10.5, and 7.1 mm, respectively. By these measures, the average distance from the center of the

al 125

VO L U M E 89-A N U M B E R 5 M A Y 2007

A C A D A VE R I C S T U D Y

Insertion distale

Linsertion est en arrire


de la tubrosit, avec
une bourse sreuse en
regard de la crte axiale
antrieure

Fig. 5

Insertion footprint of the long head (LH) and the short head (SH) into the proximal part of the
radius.

several strong fascial adhesions to the ulnar flexor muscles,


tethering the aponeurosis. The aponeurosis also continued radially to the forearm flexor muscles as well as the median
nerve and brachial artery. The aponeurosis was attached to
both the radial and ulnar aspects of the proximal part of the
ulna, completely encircling the forearm flexor muscles (Fig.
4). It inserted into the antebrachial fascia and reinforced it.

There were several perforating holes in the radial side of the


aponeurosis for the recurrent radial vessels.
The two distal tendons in the majority of the specimens
(Group 1) were able to move separately from one another in a
sliding action. The tendons in Group 2 followed the same line
as those in the other group, but they did not have the ability to
glide independently.

Figure 2 A Faxitron image of a proximal radius demonstrates the


angular orientation of the bicipital tuberosity (solid red line) and
the leading and trailing edges of the biceps brachii tendon insertion
(dashed red lines). The anterior posterior reference (green) is established by a line passing through the center of the radius and a posterior cortical trough marking the midsagittal plane of the radius.

Figure 4 This F
ital tuberosity t
When this ana
insertion canno
sion techniques

Figure 2. The long- and short-head biceps tendon insertions are illustrated (A). The mean footprint area of the long head of the
tendon was 48 mm2 and of the short head of the tendon was 60 mm2. A cadaveric specimen (B) demonstrates the separation
The
bice
between the short and long heads of the distal tendons (white arrow) with near complete rupture of the short head of
the distal
a clean man
tendon (black arrow).

lesced enough that precise calculation of the individual footprints was difficult and therefore thought to
be impreciseFig.and
was abandoned.
6
The bicipitoradial
bursa was
injected with
latex.
The lacertus
fibrosus
examined
and found to
originate from the proximal aspect of the short head
of the distal tendon (Fig. 1) in all 15 specimens.

tion. This m
makeup6 o
width of the biceps insertion in the male specimens
10
Intr
ment.
were 22 mm and 8 mm, respectively, and in the
of c
female specimens were 20 mm and 7the
mm,task
respecten
tively. The average area of the biceps original
tendon inser2
tion (footprint) in all specimens was 108operative
mm (range, te
2
81135 mm ). The average area in the
male and
of Boyd
and
2
2

9,12,13,18,20
female specimens was 112 mm and 104
mm , reTendon Insertion
4,21
spectively.
anchors,
In all specimens, the biceps tendon insertion was
In 10 specimens the exact dimensions and area of
ence screw
located along the extreme ulnar margin of the bicipthe short- and long-head tendon insertions could be
study onhas
ital tuberosity (Fig. 3). The tendon is ribbon-shaped
calculated. The short-head tendon insertion
the
Figure 3 however,
This diagram
biceps brachii
tendon
insertion.
just proximal to its insertion;
as itshows
ap- thebicipital
in
tuberosity averaged 12 mm in followed
length, 7 mm
envelops
bicipital
tuberosity
extending
ul2
proaches the tuberosityThe
thetendon
tendon footprint
thickens in
width the in
width and 60 mm in area. The long-head
Thetendon
2-inc
nar
to
the
apex
towards
the
top
of
the
diagram.
and length creating a true footprint on the tuberinsertion on the bicipital tuberosity averaged
mm in
and 9Anders
2
osity. The average distance from the articular margin
length, 7 mm in width and 48 mm in area.

Athwal GS, et al. The distal biceps tendon: Footprint and relevant clinical
anatomy. J Hand Surg Am 2007;32:1225-9

Rapports vasculonerveux

Avec le nerf mdian

Avec la. brachiale

Avec le nerf radial

La branche profonde - plus


proche de la tubrosit
radiale

La plus petite distance : 19 mm

Quelle voie dabord ?

En S italique (brachiale et
antbrachiale)

Transversale (assistance
endoscopique)

En L invers