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Upper Extremity Compartmental Anatomy: Fabienne Robertson Nancy M

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Skeletal Radiol (2006) 35: 195–201 DOI 10.1007/s00256-005-0063-3 REVIEW ARTICLE Glen A. Toomayan Upper extremity compartmental anatomy: Fabienne Robertson Nancy M. Major clinical relevance to radiologists Brian E. Brigman Abstract Malignant tumors of the Violation of high-resistance compart- Received: 26 April 2005 Revised: 29 September 2005 upper extremity are uncommon, and mental barriers necessitates more Accepted: 13 October 2005 their care should be referred to extensive surgical resection. Biopsy Published online: 18 February 2006 specialized facilities with experience may be performed by the radiologist # ISS 2006 treating these lesions. The Musculo- using imaging guidance. Knowledge G. A. Toomayan . F. Robertson . skeletal Tumor Society (MSTS) stag- of compartmental anatomy allows the N. M. Major ing system is used by the surgeon to radiologist or surgeon to use an easily Department of Radiology, determine appropriate surgical excisable biopsy approach and Duke University Medical Center, P.O. Box 3808 management, assess prognosis, and prevent iatrogenic spread to unaf- Durham, NC 27710, USA communicate with other healthcare fected compartments. Case examples providers. Magnetic resonance are presented to illustrate the impor- . G. A. Toomayan (*) F. Robertson imaging (MRI) is employed pre- tance of compartmental anatomy in N. M. Major . B. E. Brigman ’ Division of Orthopaedic Surgery, operatively to identify a lesion s the management of benign and Department of Surgery, compartment of origin, determine malignant upper extremity tumors. Duke University Medical Center, extent of spread, and plan biopsy and P.O. Box 3808 resection approaches. Involvement of Keywords MRI . Tumor . Upper Durham, NC 27710, USA . e-mail: [email protected] neurovascular structures may result in extremity Compartmental anatomy Tel.: +919-684-7469 devastating loss of upper extremity Fax: +919-684-7138 function, requiring amputation. Introduction management have not been defined as clearly in the upper extremity as in the lower extremity [3]. Tumors of the upper extremity pose diagnostic and For the practicing radiologist, knowledge of upper therapeutic challenges not encountered with lower extrem- extremity compartmental anatomy helps to provide useful ity tumors. Upper extremity malignancies are less common pre-operative staging information to the surgeon. If called than lower extremity malignancies, limiting the experience upon to perform closed biopsy, the radiologist must of the radiologist, pathologist, and orthopaedic surgeon [1]. understand locations of compartments in order to use an The presence of small, highly specialized extrinsic hand easily excisable biopsy tract and prevent iatrogenic tumor muscles located close together and in proximity to critical spread [4]. Principles of extremity sarcoma staging and neurovascular structures makes diagnosis and surgical percutaneous biopsy of the suspicious lower extremity mass excision challenging [2]. Functional deficits that result have been reviewed previously, but briefly include travers- from surgical tumor excision or amputation can be ing the minimum number of compartments, avoiding particularly debilitating in the upper extremity, due to the neurovascular structures, and placing biopsy tracts along profound role the upper extremity plays in performing proposed limb salvage incision lines [5]. Any question activities of daily living. Lastly, definitions of compart- regarding the placement or route of an image-guided biopsy mental anatomy and the role they play in dictating surgical should be discussed with the surgeon ultimately responsible 196 for the surgical treatment of the lesion. This review focuses Table 1 Musculoskeletal Tumor Society (MSTS) sarcoma staging on defining compartmental anatomy of the upper extremity system and highlighting its usefulness in performing biopsies and Stage Grade Site Metastasis communicating important pre-operative information to the surgeon. IA Low (G1) Intracompartmental (T1) None (M0) IB Low (G1) Extracompartmental (T2) None (M0) IIA High (G2) Intracompartmental (T1) None (M0) Epidemiology IIB High (G2) Extracompartmental (T2) None (M0) III Low (G1)or Intracompartmental (T1)or Regional or Malignant tumors of bone and soft tissue are relatively rare. High (G2) Extracompartmental (T2) Distant (M1) In 2004, there were an estimated 2,440 new malignant bone Note: adapted from [12, 15] tumors and 8,680 new malignant soft-tissue tumors diagnosed in the United States [6]. Bone and soft-tissue tumors combined account for less than 1% of all newly to other providers in a concise, yet uniform and reliable diagnosed malignancies. Approximately twice as many fashion [11]. malignant bone and soft tissue neoplasms occur in the The radiologist may be consulted to help establish all lower extremity as compared to the upper extremity [7, 8]. three staging characteristics by interpreting pre-operative Many practitioners therefore have little experience manag- imaging studies and performing the biopsy. Magnetic ing patients with upper extremity malignancies. resonance imaging (MRI) is the imaging modality of Benign upper extremity tumors are more common than choice in staging extremity neoplasms, due to its ability to malignancies and include ganglion cysts, epidermoid image masses in multiple planes and provide excellent soft- inclusion cysts, giant cell tumors of tendon sheath, tissue resolution [11]. In interpreting a pre-operative, pre- lipomas, benign peripheral nerve sheath tumors, and biopsy imaging study, the radiologist must make note of the palmar nodules of Dupuytren’s contracture [9, 10]. Despite size and location of the tumor, as well as its relationship to the likelihood that an upper extremity tumor is benign, the critical neurovascular structures. As surgical excision of physician must approach all upper extremity tumors with any upper extremity neurovascular structures has great the suspicion of malignancy [11]. It is therefore recom- implications for the patient’s overall function, it is mended that the care of patients with these lesions be important to inform the surgeon of possible involvement undertaken by a team of surgeons, radiologists, and of or proximity to these critical structures [2]. Adequate pathologists with experience managing malignant upper pre-operative knowledge and planning may allow for extremity lesions. Often this requires referral to a microsurgical vascular or neural grafting or tendon-transfer specialized multi-disciplinary medical center. procedures to minimize any ultimate loss of function for the patient. The radiologist must also characterize the compartmen- Staging tal location of the tumor. Lesions staged as intracompart- mental (T1), or limited to within the compartment of origin, Bone and soft-tissue sarcomas arising from mesenchymal are surgically treated with wide local resection, whereas tissue are staged for surgery by the Musculoskeletal Tumor extracompartmental (T2) lesions, or those that have spread Society (MSTS) staging system [12]. This system has been beyond the compartment of origin, are generally treated preferred by surgeons, while medical oncologists generally with radical excision (excising the entire anatomic com- use the American Joint Committee on Cancer (AJCC) partment), which often necessitates amputation to achieve a staging system [11, 13]. The MSTS staging system better functional outcome [16]. characterizes musculoskeletal sarcomas other than Ewing’s Anatomic compartments are defined as anatomic regions sarcoma, leukemia, lymphoma, undifferentiated round cell bounded by high-resistance barriers to tumor spread, such tumors, and metastatic carcinoma, by grade (G), site (T), as fascial planes, articular cartilage, and cortical bone. and metastasis (M) (Table 1)[14, 15]. Grade is determined Compartmental definition is possible for 95% of muscu- by histopathology as benign, low-grade malignant, or high- loskeletal tumors, with the remaining tumors occurring in grade malignant. Site is characterized as intracompart- extrafascial planes or poorly compartmentalized spaces mental or extracompartmental. Metastasis is defined as [17]. Tumor spread may occur along neurovascular present or absent. The MSTS staging system is useful for structures in the upper extremity, some of which pass determining appropriate surgical management, providing between compartments [17]. A tumor which has spread prognostic stratification, and communicating information beyond its compartment of origin through a high-resistance 197 barrier will necessitate a more significant surgical proce- axillary artery and vein become the brachial artery and dure than one which is confined within one compartment. vein. These structures descend the arm medially in an Therefore, identification of compartmental location and extracompartmental location along with the median and spread by the radiologist is helpful for surgical planning. ulnar nerves (Fig. 1). As these neurovascular structures pass into the distal arm, the brachial artery and veins along with the median nerve penetrate the anterior compartment Arm Compartments and continue in a location between the biceps and brachialis muscles, while the ulnar nerve remains extra- For purposes of tumor staging, the arm is regarded as compartmental. The radial nerve occupies a position deep composed of three anatomic compartments as well as the within the posterior compartment, in close proximity to the extracompartmental axillary space [17]. The humerus, with posterior humerus
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