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Surg Radiol Anat (2002) 24: 302–307

DOI 10.1007/s00276-002-0055-0

O R I GI N A L A R T IC L E

F. Duparc Æ R. Putz Æ C. Michot Æ J.-M. Muller
P. Fréger

The synovial fold of the humeroradial joint:
anatomical and histological features, and clinical
relevance in lateral epicondylalgia of the elbow
Received: 19 February 2002 / Accepted: 6 July 2002 / Published online: 12 October 2002
Ó Springer-Verlag 2002

Abstract The synovial fold of the humeroradial joint is laterodorsal and dorsal (n=6;), lateral to dorsal (n=5),
known, and sometimes considered as a meniscus that lateral (n=5), ventral (n=4) and circular (n=4). The
could be injured by chronic repeated trauma related to mean length was 21.4 mm (range from 9–51 mm). The
pronation and supination. The aims of this study were to mean width was 2.9 mm (range 1–10 mm), and the mean
determine the gross anatomy and histological structure maximal thickness 1.7 mm (range 1–4 mm). The histo-
of this fold, and to clarify its participation in the painful logical study showed two types of folds: a rigid struc-
lateral syndromes of the elbow. Fifty elbows from adult ture, with oriented fibrous tissue, triangular with a
cadavers were dissected. The capsule of the humerora- peripheral capsular base, covered on its two sides and
dial part of the elbow joint was resected with the annular along the free edge by a synovial layer; and a pliable
ligament. The presence of a synovial fold, and its loca- structure, formed of two synovial layers that surrounded
tion relative to the cranial edge of the annular ligament a thin fatty tissue, with a villous appearance of the free
divided into five sectors (ventral, ventrolateral, lateral, edge. No fibromyxoid structure, as in a real meniscus,
laterodorsal and dorsal) were noted; morphological pa- was observed. Some nerve fibers were seen in the folds.
rameters such as thickness, width and length were The five folds resected in operated patients were hyper-
measured. The histological examination determined the trophic, and showed an increased number of nerve
structure of the folds. Five synovial folds were resected fibers, along the capsule but also close to the synovial
during surgery for epicondylalgia in five patients who layer. Some painful syndromes of the lateral side of the
suffered from pain precisely at the level of the joint be- elbow are not related to tendinitis or to posterior int-
tween the capitulum and the fovea radialis, and were erosseous nerve compression, but have an intra-articular
also examined. A fold was present in 43 cases, and in origin. This study showed that the synovial fold is not a
two cases two folds were seen at the deep side of the meniscus, and may be involved in the etiology of lateral
junction between the capsule and the annular liga- epicondylalgia.
ment. The most frequent positions were: dorsal (n=11), The French version of this article is available in the form
of electronic supplementary material and can be obtained
by using the Springer Link server located at http://
dx.doi.org/10.1007/s00276-002-0055-0.
The French version of this article is available in the form of elec-
tronic supplementary material and can be obtained by using the
Springer Link server located at http://dx.doi.org/10.1007/s00276-
002-0055-0 La frange synoviale de l’articulation huméro-radiale:
F. Duparc (&) Æ J.-M. Muller Æ P. Fréger
aspects anatomiques et histologiques et corrélations
Laboratoire d’Anatomie, Faculté de Médecine Pharmacie cliniques dans les épicondylalgies latérales du coude
de Rouen, 22, boulevard Gambetta, 76183 Rouen cedex, France
E-mail: Fabrice.Duparc@chu-rouen.fr Résumé La frange synoviale de l’articulation huméro-
Tel.: +33-2-32888007
Fax: +33-2-32888312
radiale est connue et parfois considérée comme un
ménisque qui pourrait être lésé par des traumatismes
R. Putz chroniques répétés en pronation et supination. Les ob-
Ludwig-Maximilians-Universität, Medizinische Fakultät,
Lehrstuhl 1, Pettenkofferstrasse 11, 80336 Munich, Germany jectifs de cette étude étaient de préciser les aspects ana-
tomiques et histologiques de cette frange et de clarifier sa
C. Michot
Laboratoire d’Anatomie Pathologique,
participation dans les syndromes douloureux latéraux
Centre Hospitalier Universitaire de Rouen, du coude. Cinquante coudes de cadavres adultes ont été
1 rue de Germont, 76031 Rouen cedex 1, France disséqués. La capsule de l’articulation huméro-radiale

Les syndromes dou. categorized into one of five intervals: ventral. 2). The structure des franges. Cinq franges synoviales ont été position relative to the superior edge of the annular ligament was réséquées au cours d’intervention pour des épicondylal. latéral. 2 Frontal scan of the humeroradial joint. The étaient mesurées. or articular. (2) Is it histologically a real meniscus? (3) What is its placed between the capitulum (a) and the edge of the fovea radialis. 4. 3).7 mm (1–4).9 mm (1–10). La longueur moyenne était 21. Les cinq franges réséquées chez des patients opérés étaient hy- pertrophiées et montraient une augmentation du nom- bre de fibres nerveuses. 1). et ont fait l’objet de sured with a caliper: length of the fold along the superior edge of la même étude histologique. and the morphological parameters were mea- niveau de l’interligne huméro-radial. couverte sur ses deux faces et son bord libre par une couche synoviale. triangulaire à base capsulaire. possible role in the pathogenesis of lateral pain of the fixed to the capsule (b). the capsule loureux de la face latérale du coude ne sont pas toujours en relation avec une tendinite ou une compression du nerf interosseux postérieur. nervous (compression of the posterior interosseous nerve). Des fibres nerveuses ont été observées dans les franges. but the surgical findings show nu- merous variations in location. L’épaisseur. lateral. e. ventrale (4 cas) et circulaire (4 cas). latérale (5 cas). When it is present. 13] have hypothesized a chronic injury of the synovial fold that is located in the joint line between the capitulum and the fovea radialis. une structure souple. divisée Fifty elbows of adult embalmed cadavers. were dis- en 5 secteurs (ventral. with the annular ligament (b) left adjacent to au contact de la couche synoviale. sected. radial head . latéro-dorsale et dorsale (6 cas). f. low capsule of the humeroradial joint. 2. The shape was defined gies chez cinq patients qui souffraient précisément au as rigid or pliable.4 mm (9–51). Nous avons noté la présence d’une frange synoviale et sa position par Material and methods rapport au bord crânial du ligament annulaire. Les positions les plus fréquentes étaient: dorsale (11 cas). La largeur moyenne était 2. l’épaisseur moyenne était 1. shape. latéro. The aim of this study was to answer three questions: (1) What is the gross anatomical appearance of this fold? Fig. L’étude histologique précisait la presence or the absence of a synovial fold was noted (Fig. Some authors [1. latérale et dorsale (5 cas). above the superior edge of the annular elbow? ligament (d). 5. n’a été observée. et 2 fois deux franges étaient vues à la jonction entre la capsule et le ligament annulaire. faite de deux couches synoviales qui entouraient un fin tissu adipeux. free of scars. 303 était réséquée avec le ligament annulaire. mais peuvent avoir une origine articulaire. ventro- lateral. determined. Aucune structure fibro-myxoı̈de. with the annular ligament (Fig. from dorsal et dorsal). le long de la capsule mais aussi Fig. This classically described synovial fold is sometimes called a ‘‘meniscus’’. ventro-latéral. dorsal (Fig. dorsolateral. and structure of this fold. avec un aspect villeux du bord libre. The capsule of the humeroradial joint was resected. 1 The capsule (a) of the humeroradial joint was resected ventrally to dorsally. Une frange était présente dans 43 cas. comme un réel ménisque. Keywords Elbow Æ Humeroradial joint Æ Synovial fold Æ Epicondylalgia Æ Pain Introduction The etiology of painful syndromes of the lateral side of the elbow may be tendinous (epicondylitis). la largeur et la longueur ventral to dorsal insertions. the synovial fold (c) could be regarded as a ‘‘pseudo-meniscus’’. L’étude histologique a montré deux types de franges: une structure rigide avec du tissu fibreux orienté. Cette étude a montré que la frange synoviale n’est pas un ménisque et peut être à l’origine de syndromes douloureux d’épicondylalgie latérale.

dorsal Fig. It appeared as a rigid structure in 30 cases. Only two of the 14 cadavers examined bilaterally cally. ventral. 5 Position of the synovial folds to be sectioned (10 lm) for the histological examination the annular ligament. laterodorsal and dorsal (n=6). f. antero- and an inflammatory appearance. two separate folds were seen. the fold was bilateral Fig. sectioned (10 lm) (Fig. Immunohistochemical testing was performed using anti-S100 showed a symmetrical appearance between the right and protein (dilution 1/1500. 4. d. lateral and laterodorsal (n=2). including study of the nerve fibers. width (3) of the fold were measured laterodorsal (n=2) . double (n=2). In two elbows. underwent a histological exam. lateral and laterodorsal in two. ventrolateral to dorsal (n=4). 3. annular ligament was: circular in four cases. The position along the superior edge of the primary antibody. which we divided into five parts: 1. none was observed. 6). and lat- ination. erodorsal in two. 2. circular Fig.304 Fig. lateral (n=5). 5. Five recently removed synovial folds. lateral to dorsal in five. lateral to dorsal (n=5). oxidase kit (LSAB2. the height (2) (maximal thickness) and the (n=4). 6 The main shapes observed (n = number of cases) of the humeroradial synovial folds: a. followed by staining with a streptavidin-per. DAKO). lateral in five. lateral in two. ventrolateral (n=2). dorsal in 11. resected during surgery laterodorsal and dorsal in six. 4 The length (1). i. g. lateral. and as a pliable structure in 13. for painful humeroradial joint and showing an increased thickness anterolateral to dorsal in four. 4). e. width as the distance measured between the attachment at the deep side of the in 24 elbows of 12 cadavers. b. and present in only one elbow in one case. joints in one. The synovial folds were then fixed and stained (hematoxylin- eosin-safran). either the A synovial fold was found in 43 elbows (86%). height as the maximal thickness. 5). laterodorsal. DAKO). c. In 14 cadavers examined bilaterally. absent in both right and left capsule and the free margin (Fig. and examined histologi. In seven cases (14%). When a fat pad was present in the pos- Results terior aspect of the humeroulnar joint. h. one ventral and the second one dorsal or latero- dorsal (Fig. ventrolateral. j. The sections were incubated with left sides. dorsal (n=11). 3 The location of the fold was related to the superior edge of the annular ligament.

Nerve fibers were ob- served in the deep part of the synovial fold. The pliable type: a thin fibrous axis (a) is surrounded on two sides by the synovial layer The presence of a synovial fold in the humeroradial joint was inconstant in our study: 86% of the joints showed Fig. 305 synovial fold was posterior or posterolateral. No fibrochondroid tissue was found. 7). labelled black. No intra-articular septum was found. without a specific appearance of the synovial folds. Osteoarthritis of the capitulum and the fovea radialis was seen in six elbows. the thickness of the folds was increased in com- parison with the observed thickness of the cadaveric folds. presenting a slightly orien- tated pattern. The nerve fibers were numerous. along the collagen orientated fibers of the capsule. The synovial layer was thin and regular or slightly villous or plicate. and the synovial layer was thicker than in the cadavers. above the an. 8 Histology. Fig. or the synovial lining was in continuity. close to the capsule (Fig. In the five folds resected during the peroperative study. with fatty tissue (adipocytes) along the attachment on the capsule and developed in the fibrous tissue (Fig. and mainly placed close to small arteries deep part of the synovial fold. and were located and in the fibrous tissue closely to the synovial layer . (2) a rigid structure. The histological examination showed two main fea- tures: (1) a double-layered synovial pliable structure. 7 Histology. with a thin fibrous axis (Fig. 9 Nerve fibers (a and b). Fig. 9). 10). 8). Adipocytes were seen in greater numbers in the re- sected folds compared with the cadaveric folds. The synovial layer was often thicker than in the folds with a pliable structure. Adipocytes were seen along the attachment to the joint capsule. 10 Nerve fibers were numerous (a and b). with a thicker fibrous axis. and located close to the synovial layer (Fig. Discussion Incidence Fig. The rigid type showed a thick fibrous axis (a). parallel to the axis of the fold. which were present in only five cases. The fi- brous axis remained slightly orientated. were found in the nular ligament.

is not so separated by Isogai et al. [6] into three types according true because the stresses are mainly transmitted from the to its microscopic appearance: villous. or vea radialis. radialis is no longer in close contact with the capitulum. which covers a larger part of the radial they studied.3 mm). Our study may answer the question of whether the fold unar. as in a meniscus of the knee. hard and thicker – correspond to the dif- ferent shapes characterized by Isogai et al. which could be trans- lated as ‘‘humeroradialis labrum’’. and from the capitulotrochlear notch to Akagi and Nakamura [1] published the case of a 27- the medial crest of the ulnar edge of the radial head. head in embryos than in adults. [6]: circumference (length) Clinical relevance 25 mm (range 8. [6] as semil. and found degeneration of the orbicular sidered as a protective one. structure cannot be called a meniscus. 12]. [6] distinguished anterior and posterior positions of the fold relative to the superior edge of the Innervation annular ligament. only presence of nerve fibers close to the attachment on the four circular folds were seen among 43 (7%). The participation of the synovial fold in the origin of pain in the elbow joint is advocated by Isogai et al. directly compressed between the capitulum and the fo. soft and fine. This author performed an intra-articular procedure in 27 The role during pronation and supination may be con. it was either consistently found joint extended from the crest to the ulnar part of the [9. and six The innervation has not been studied previously. and pli- central part of the capitulum to the center of the fovea cate.2–4.306 one. and would have par- tially disappeared [3. No elbow in our 50 cases showed any septum. mimicking a . belt-like. These authors found four completely circular folds among 179 folds in adults (2. or Meniscus or not? a rigid fold. Isogai et al. In our sample. but in fact the fold is not ligament or a redundant synovial fold in 77% of cases. fringed. or not described [11].2%). The presence of a synovial layer on the two sides of the fold is not in favor of the role of a real meniscus placed between two ar- Anatomical position ticular surfaces in order to increase the congruence. In the classical description of the elbow joint in the degenerative lesions of the cartilage of the humeroradial textbooks of anatomy. falciforme’’. year-old man presenting a snapping elbow because of Murata et al.7 mm (range 0. of 86 patients. repeated injuries and in- flammation. The structure as a meniscus-like shape called a ‘‘bourrelet synovial fold does not cover these loading areas. This illustrates is a meniscus or a meniscus-like structure: the absence of the various appearances encountered as regards the size a fibrochondroid structure means this anatomical and thickness of the folds. radialis. and especially in the elderly as a result of degenerative Functional role changes induced by aging. [6] found The origin of the synovial fold of the humeroradial joint a synovial fold attached to the annular ligament–joint is thought to be the remaining part of the initial intra- capsule angle in all the 179 specimens and 40 embryos articular septum. the presence of thicker nerve fibers in a than the anterior synovial folds. The mechanical concept of dispersion of could only have affected the synovial layer. Paturet [8] described condylalgia. folds were generally longer and extended more laterally Furthermore.2-40.8 mm). Posterior capsule provides an explanation for a painful fold. which was loading forces. The among 40 folds in embryos (15%). when the fovea local anesthetic at the sore spot on the epicondyle [13]. petal-like or tongue-like. Paturet [8] considered that the fold was a synovial fold raised by a fold of the capsule. [6]. they also appeared superficial position in the folds resected in symptomatic wider and more deeply interposed in the humeroradial elbows may suggest participation of the fold in epi- joint than were the anterior folds. The morphological parameters were similar to the data presented by Isogai et al. and Testut [12] called Embryology it a ‘‘bourrelet huméro-radial’’. Rouvière and Delmas [10] and Paturet [8] explained that Intra-articular surgery must be considered for pa- the fold could occur in the joint and fill the humeroradial tients with incomplete pain relief after a test injection of space during extension of the elbow. thickness (height) 1. The intra-articular lesions were tears or lamination. Shape The shapes we described – a pliable fold. the fold in an anterior and lateral position. Poirier [9] described this fovea radialis and lastly to the fovea radialis. Isogai et al. 6]). in comparison with a scythe-shaped la- brum. [7] have shown that the development of chondroid metaplasia of the synovial fold.

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