ABSTRACT

Platinum-based anticancer agents have revolutionized oncological treatments globally. However, their therapeutic efficacy is often accompanied by systemic toxicity. Carboplatin, recognized for its relatively lower toxicity profile than cisplatin, still presents off-target toxicities, including dose-dependent cardiotoxicity, neurotoxicity, and myelosuppression. In this study, we demonstrate a delivery strategy of carboplatin to mitigate its off-target toxicity by leveraging the potential of zwitterionic nanocarrier, H-dot. The designed carboplatin/H-dot complex (Car/H-dot) exhibits rapid drug release kinetics and notable accumulation in proximity to tumor sites, indicative of amplified tumor targeting precision. Intriguingly, the Car/H-dot shows remarkable efficacy in eliminating tumors across insulinoma animal models. Encouragingly, concerns linked to carboplatin-induced cardiotoxicity are effectively alleviated by adopting the Car/H-dot nanotherapeutic approach. This pioneering investigation not only underscores the viability of H-dot as an organic nanocarrier for platinum drugs but also emphasizes its pivotal role in ameliorating associated toxicities. Thus, this study heralds a promising advancement in refining the therapeutic landscape of platinum-based chemotherapy.

PMID:37895146 | PMC:PMC10607179 | DOI:10.3390/ijms242015466

11:09

PubMed articles on: Cardio-Oncology

Prospective, Multicenter Phase II Trial of Non-Pegylated Liposomal Doxorubicin Combined with Ifosfamide in First-Line Treatment of Advanced/Metastatic Soft Tissue Sarcomas

Cancers (Basel). 2023 Oct 18;15(20):5036. doi: 10.3390/cancers15205036.

 

ABSTRACT

Cardiotoxicity is a well-known adverse effect of cancer-related therapy that has a significant influence on patient outcomes and quality of life. The use of antineoplastic drugs to treat colorectal cancers (CRCs) is associated with a number of undesirable side effects including cardiac complications. For both sexes, CRC ranks second and accounts for four out of every ten cancer deaths. According to the reports, almost 39% of patients with colorectal cancer who underwent first-line chemotherapy suffered cardiovascular impairment. Although 5-fluorouracil is still the backbone of chemotherapy regimen for colorectal, gastric, and breast cancers, cardiotoxicity caused by 5-fluorouracil might affect anywhere from 1.5% to 18% of patients. The precise mechanisms underlying cardiotoxicity associated with CRC treatment are complex and may involve the modulation of various signaling pathways crucial for maintaining cardiac health including TKI ErbB2 or NRG-1, VEGF, PDGF, BRAF/Ras/Raf/MEK/ERK, and the PI3/ERK/AMPK/mTOR pathway, resulting in oxidative stress, mitochondrial dysfunction, inflammation, and apoptosis, ultimately damaging cardiac tissue. Thus, the identification and management of cardiotoxicity associated with CRC drug therapy while minimizing the negative impact have become increasingly important. The purpose of this review is to catalog the potential cardiotoxicities caused by anticancer drugs and targeted therapy used to treat colorectal cancer as well as strategies focused on early diagnosing, prevention, and treatment of cardiotoxicity associated with anticancer drugs used in CRC therapy.

PMID:37895912 | PMC:PMC10610064 | DOI:10.3390/ph16101441

11:09

PubMed articles on: Cardio-Oncology

Multimodality Cardiovascular Imaging of Cardiotoxicity Due to Cancer Therapy

Life (Basel). 2023 Oct 23;13(10):2103. doi: 10.3390/life13102103.

ABSTRACT

Cancer therapies have revolutionized patient survival rates, yet they come with the risk of cardiotoxicity, necessitating effective monitoring and management. The existing guidelines offer a limited empirical basis for practical approaches in various clinical scenarios. This article explores the intricate relationship between cancer therapy and the cardiovascular system, highlighting the role of advanced multimodality imaging in monitoring patients before, during, and after cancer treatment. This review outlines the cardiovascular effects of different cancer therapy classes, offering a comprehensive understanding of their dose- and time-dependent impacts. This paper delves into diverse imaging modalities such as echocardiography, cardiac magnetic resonance imaging, cardiac computed tomography, and nuclear imaging, detailing their strengths and limitations in various conditions due to cancer treatment, such as cardiac dysfunction, myocarditis, coronary artery disease, Takotsubo cardiomyopathy, pulmonary hypertension, arterial hypertension, valvular heart diseases, and heart failure with preserved ejection fraction. Moreover, it underscores the significance of long-term follow-up for cancer survivors and discusses future directions.

PMID:37895484 | PMC:PMC10608651 | DOI:10.3390/life13102103

11:09

PubMed articles on: Cardio-Oncology

H-Dot Mediated Nanotherapeutics Mitigate Systemic Toxicity of Platinum-Based Anticancer Drugs

Int J Mol Sci. 2023 Oct 23;24(20):15466. doi: 10.3390/ijms242015466.

 

ABSTRACT

BACKGROUND: Certain antineoplastic therapies are associated with an increased risk of cardiomyopathy and heart failure (HF). Sodium-glucose cotransporter-2 (SGLT2) inhibitors improve outcomes in patients with HF.

OBJECTIVES: This study aims to examine the efficacy of SGLT2 inhibitors in patients with cancer therapy-related cardiac dysfunction (CTRCD) or HF.

METHODS: The authors conducted a retrospective cohort analysis of deidentified, aggregate patient data from the TriNetX research network. Patients aged ≥18 years with a history of type 2 diabetes mellitus, cancer, and exposure to potentially cardiotoxic antineoplastic therapies, with a subsequent diagnosis of cardiomyopathy or HF between January 1, 2013, and April 30, 2020, were identified. Patients with ischemic heart disease were excluded. Patients receiving guideline-directed medical therapy were divided into 2 groups based on SGLT2 inhibitor use. After propensity score matching, odds ratios (ORs) and Cox proportional HRs were used to compare outcomes over a 2-year follow-up period.

RESULTS: The study cohort included 1,280 patients with CTRCD/HF (n = 640 per group; mean age: 67.6 years; 41.6% female; 68% White). Patients on SGLT2 inhibitors in addition to conventional guideline-directed medical therapy had a lower risk of acute HF exacerbation (OR: 0.483 [95% CI: 0.36-0.65]; P < 0.001) and all-cause mortality (OR: 0.296 [95% CI: 0.22-0.40]; P = 0.001). All-cause hospitalizations or emergency department visits (OR: 0.479; 95% CI: 0.383-0.599; P < 0.001), atrial fibrillation/flutter (OR: 0.397 [95% CI: 0.213-0.737]; P = 0.003), acute kidney injury (OR: 0.486 [95% CI: 0.382-0.619]; P < 0.001), and need for renal replacement therapy (OR: 0.398 [95% CI: 0.189-0.839]; P = 0.012) were also less frequent in patients on SGLT2 inhibitors.

CONCLUSIONS: SGLT2 inhibitor use is associated with improved outcomes in patients with CTRCD/HF.

PMID:37897456 | DOI:10.1016/j.jchf.2023.08.026

11:09

PubMed articles on: Cardio-Oncology

Recent Perspectives on Cardiovascular Toxicity Associated with Colorectal Cancer Drug Therapy

Pharmaceuticals (Basel). 2023 Oct 11;16(10):1441. doi: 10.3390/ph16101441.

ABSTRACT

INTRODUCTION: Limited data exist on the risk of venous and arterial thromboembolisms (VTE and ATE) in patients receiving cetuximab plus chemotherapy. We aimed to determine the thromboembolic risk of patients with recurrent/metastatic colorectal cancer (CRC) treated with cetuximab plus chemotherapy compared to chemotherapy alone.

METHODS: This population-based study used nationwide claims data from the Health Insurance Review and Assessment Service of South Korea from 2013 to 2020. Patients with recurrent/metastatic CRC treated with first-line oxaliplatin- or irinotecan-based doublets with or without cetuximab and no secondary prevention for VTE and ATE were included. Primary outcomes were the occurrence of any thromboembolic events, VTE, and ATE, which were determined using the cumulative incidence method incorporating death as a competing event.

RESULTS: We identified 19,723 patients (cetuximab plus chemotherapy, N = 7630; chemotherapy alone, N = 12,093). The cumulative incidence of any thromboembolic events in patients with cetuximab plus chemotherapy was significantly higher than in those receiving chemotherapy alone (6-month, 5.62 % vs. 3.58 %, P < 0.0001). The rates of VTE (6-month, 5.11 % vs. 3.28 %, P < 0.0001) and ATE (6-month, 0.53 % vs. 0.32 %, P = 0.0218) were also higher in patients receiving cetuximab plus chemotherapy. In multivariable analysis, cetuximab plus chemotherapy was independently associated with developing any thromboembolic events (hazard ratio [HR], 1.63; 95 % confidence interval [CI], 1.42-1.87), VTE (HR, 1.62; 95 % CI, 1.40-1.87), and ATE (HR, 1.77; 95 % CI, 1.16-2.71).

CONCLUSIONS: Cetuximab with irinotecan- or oxaliplatin-based doublet chemotherapy was associated with an increased risk of any thromboembolic events, VTE, and ATE; further studies are warranted to examine the underlying mechanisms.

PMID:37804738 | DOI:10.1016/j.thromres.2023.10.005

07:12

PubMed articles on: Cardio-Oncology

07:12

PubMed articles on: Cardio-Oncology

07:12

PubMed articles on: Cardio-Oncology

07:12

PubMed articles on: Cancer & VTE/PE

Guidelines in Practice: Prevention of Venous Thromboembolism

07:12

PubMed articles on: Cancer & VTE/PE

Episodic Cocaine Use as a Cause of Venous Thromboembolism and Acute Liver Injury

07:12

PubMed articles on: Cardio-Oncology

07:12

PubMed articles on: Cardio-Oncology

07:12

PubMed articles on: Cancer & VTE/PE

Risk and timing of venous thromboembolism after surgery for lung cancer: a nationwide cohort study

07:12

PubMed articles on: Cancer & VTE/PE

07:12

PubMed articles on: Cancer & VTE/PE

07:12

PubMed articles on: Cancer & VTE/PE

07:12

PubMed articles on: Cancer & VTE/PE

07:12

PubMed articles on: Cancer & VTE/PE

11:09

Cardiotoxicity News

PubMed articles on: Cardio-Oncology

SGLT2 Inhibitor Use and Risk of Clinical Events in Patients With Cancer Therapy-Related Cardiac Dysfunction

JACC Heart Fail. 2023 Oct 12:S2213-1779(23)00596-6. doi: 10.1016/j.jchf.2023.08.026. Online ahead of print.

 

ABSTRACT

INTRODUCTION: Previous studies suggest that quality improvement initiatives focused on hospital-acquired venous thromboembolism have a positive impact on prescribing rates of venous thromboembolism prophylaxis, especially those that incorporate computerized changes.

METHODS: We conducted a quality improvement project to determine whether education and computerized prescriber order entry system changes affect venous thromboembolism prophylaxis compliance rates in hospitalized medical patients at a Comprehensive Cancer Center. Between 1 January 2021 and 31 January 2023, 37,739 non-surgical, adult patient encounters with a length of stay > 48 h were analyzed in our study. From 18 December 2021 to 8 March 2022, provider education was delivered to the three largest admitting services, and computerized prescriber order entry changes were implemented incorporating a mandatory requirement to either order venous thromboembolism prophylaxis or document a contraindication for all patients at moderate venous thromboembolism risk.

RESULTS: Monthly venous thromboembolism prophylaxis compliance rates, as defined by the Centers for Medicare and Medicaid Services VTE-1 metric, increased from a mean of 74% to 93% after the interventions. This change was driven primarily by an increased utilization of mechanical venous thromboembolism prophylaxis from 37% to 53%.

CONCLUSION: Our study demonstrated that a multi-faceted intervention incorporating provider education and computerized prescriber order entry system changes can significantly increase venous thromboembolism prophylaxis compliance rates in cancer patients.

PMID:37801550 | DOI:10.1177/10781552231205779

07:12

PubMed articles on: Cancer & VTE/PE

Increased risk of venous and arterial thromboembolism in patients with colorectal cancer receiving cetuximab-based combination chemotherapy: A population-based study in Korea

Thromb Res. 2023 Oct 4;231:50-57. doi: 10.1016/j.thromres.2023.10.005. Online ahead of print.

 

ABSTRACT

BACKGROUND: Guidelines recommend extended venous thromboembolism (VTE) prophylaxis for high-risk populations undergoing major abdominal cancer operations. Few studies have evaluated extended VTE prophylaxis in the Medicare population who are at higher risk due to age.

METHODS: We performed a retrospective study using a 20% random sample of Medicare claims, 2012-2017. Patients ≥65 years with an abdominal cancer undergoing resection were included. Primary outcome was the proportion of patients receiving new extended VTE prophylaxis prescriptions at discharge. Secondary outcomes included postdischarge VTE and hemorrhagic events.

RESULTS: The study included 72 983 patients with a mean age of 75. Overall, 8.9% of patients received extended VTE prophylaxis. This proportion increased (7.2% in 2012, 10.6% in 2017; p < 0.001). Incidence of postdischarge hemorrhagic events was 1.0% in patients receiving extended VTE prophylaxis and 0.8% in those who did not. The incidence of postdischarge VTE events was 5.2% in patients receiving extended VTE prophylaxis and 2.4% in those who did not.

CONCLUSION: Adherence to guideline-recommended extended VTE prophylaxis in high-risk patients undergoing major abdominal cancer operations is low. The higher rate of VTE in the prophylaxis group may suggest we captured some therapeutic anticoagulation, which would mean the actual rate of thromboprophylaxis is lower than reported herein.

PMID:37800390 | DOI:10.1002/jso.27473

07:11

PubMed articles on: Cancer & VTE/PE

Pulmonary Embolism Treatment Evolution: A Comparative Analysis of Pulmonary Embolism Response Team Management at a Single Institution

Am J Cardiol. 2023 Oct 14;208:171-172. doi: 10.1016/j.amjcard.2023.09.003. Online ahead of print.

NO ABSTRACT

PMID:37844520 | DOI:10.1016/j.amjcard.2023.09.003

07:12

PubMed articles on: Cancer & VTE/PE

A multifaceted quality improvement intervention on venous thromboembolism prophylaxis compliance in hospitalized medical patients at a comprehensive cancer center

J Oncol Pharm Pract. 2023 Oct 6:10781552231205779. doi: 10.1177/10781552231205779. Online ahead of print.

 

ABSTRACT

Atrial fibrillation (AF) can increase thrombosis, especially arterial thrombosis, and some studies show that AF patients have a higher risk of developing pulmonary embolism (PE). The objective of our study is to investigate whether there is a direct causal effect of AF on PE. A two-sample Mendelian randomization (MR) approach was utilized to determine whether there is a causal relationship between AF and PE. European population-based consortia provided statistical data on the associations between Single Nucleotide Polymorphisms (SNPs) and relevant traits. The AF dataset was obtained from genome-wide association studies (GWAS) comprising 60,620 cases and 970,216 controls, while a GWAS of 1846 cases and 461,164 controls identified genetic variations associated with PE. Estimation of the causal effect was mainly performed using the random effects inverse-variance weighted method (IVW). Additionally, other tests such as MR-Egger intercept, MR-PRESSO, Cochran's Q test, "Leave-one-out," and funnel plots were conducted to assess the extent of pleiotropy and heterogeneity. Using 70 SNPs, there was no evidence to suggest an association between genetically predicted AF and risk of PE with multiplicative random-effects IVW MR analysis (odds ratio = 1.0003, 95% confidence interval: 0.9998-1.0008, P = 0.20). A null association was also observed in other methods. MR-Egger regression and MR-PRESSO respectively showed no evidence of directional (intercept, - 2.25; P = 0.94) and horizontal(P-value in the global heterogeneity test = 0.99) pleiotropic effect across the genetic variants. No substantial evidence was found to support the causal role of AF in the development of PE. Causal effect of atrial fibrillation on pulmonary embolism: a Mendelian randomization study. AF atrial fibrillation, PE pulmonary embolism, GWAS genome-wide association studies, SNPs single nucleotide polymorphisms, OR odds ratio, CI confidence interval.

PMID:37839022 | DOI:10.1007/s11239-023-02903-w

07:11

PubMed articles on: Cancer & VTE/PE

Persistent underuse of extended venous thromboembolism prophylaxis in patients undergoing major abdominal cancer operations

J Surg Oncol. 2023 Oct 6. doi: 10.1002/jso.27473. Online ahead of print.

 

ABSTRACT

BACKGROUND Cerebral ischemia and hemorrhages were reported to be the main complications of polycythemia vera (PV). The relationship between PV and increased risk of the cerebrovascular events has been established. Some patients with secondary polycythemia have thromboembolic events comparable to those of PV. However, secondary polycythemia that leads to cerebrovascular events is uncommon. CASE REPORT A 35-year-old man without any prior medical history presented with mild clinical acute ischemic stroke and polycythemia. The patient then showed worsening neurological deficits that were later attributed to the concurrent cerebral venous thrombosis, which led to malignant cerebral infarction with hemorrhagic transformation, and subarachnoid hemorrhage. His polycythemia appeared to be secondary to bacterial infection. The treatments for the secondary polycythemia were first phlebotomy and intravenous hydration, followed by intravenous broad-spectrum antibiotics. PV was excluded because the JAK2 V617F mutation was absent, the patient's peripheral blood smear suggested secondary polycythemia due to bacterial infection, and there were improvements in hemoglobin, erythrocyte count, and hematocrit after intravenous antibiotics. At the 1-month follow-up, he was moderately dependent, and hemoglobin, erythrocyte count, and hematocrit were within normal limits, without receiving any further phlebotomy or cytoreductive agents. CONCLUSIONS This case highlights the plausible causation of secondary polycythemia that could lead to concomitant cerebral thrombosis and hemorrhagic events. The diagnosis of cerebral venous thrombosis should be considered in a patient who presents with headache, focal neurological deficits, polycythemia, and normal head computed tomography scan.

PMID:37838828 | PMC:PMC10584197 | DOI:10.12659/AJCR.941507

07:11

PubMed articles on: Cancer & VTE/PE

Causal effect of atrial fibrillation on pulmonary embolism: a mendelian randomization study

J Thromb Thrombolysis. 2023 Oct 15. doi: 10.1007/s11239-023-02903-w. Online ahead of print.

 

ABSTRACT

PURPOSE: Pulmonary embolism (PE) is a significant contributor to mortality in patients with cancer. Although anticoagulation serves as the cornerstone of treatment for cancer-associated PE, it has not been emphasized in real-world settings. The aim of this study was to examine the impact of suboptimal anticoagulant treatment on the prognosis of cancer-associated PE.

METHODS: A cohort of 356 individuals newly diagnosed with acute PE were enrolled. The primary outcome of the study was recurrent venous thromboembolism (VTE), and the secondary outcomes were all-cause mortality and major bleeding (consisting of a reduction in the hemoglobin level by at least 20 g/L, transfusion of at least 2 units of blood, or symptomatic bleeding in a critical area or organ or fatal bleeding).

FINDINGS: Of the total participants, 156 (43.8%) were diagnosed with cancer. A comparison between the cancer and noncancer groups revealed that patients with cancer were more frequently asymptomatic (41.0% vs 4.5%; P < 0.001), less likely to have right ventricular dysfunction (4.5% vs 14.0%; P = 0.001), received less anticoagulant treatment during hospitalization (85.3% vs 98.5%; P < 0.001), and had a shorter duration of anticoagulation (5.02 [7.40] months vs 14.19 [10.65] months; P < 0.001). In addition, patients with cancer were found to be at a higher risk of recurrent VTE (17.3% vs 4.0%; P < 0.001) and all-cause mortality (23.7% vs 10.5%; P = 0.001). Multiple Cox regression analysis indicated that discontinuation of anticoagulation at 3 months was a significant risk factor for recurrent VTE in the cancer group (HR, 15.815; 95% CI, 3.047-82.079; P = 0.001).

IMPLICATIONS: The brief duration of anticoagulation therapy and elevated likelihood of recurrent VTE serve as cautionary indicators for the need to enhance awareness of standardized anticoagulant treatment for cancer-associated PE. The ultimate goal is to enhance patient prognosis and quality of life.

PMID:37838562 | DOI:10.1016/j.clinthera.2023.09.014

07:11

PubMed articles on: Cancer & VTE/PE

Concomitant Cerebral Venous Thrombosis and Intracranial Hemorrhages in Presentation of a Patient with Secondary Polycythemia: A Case Report

Am J Case Rep. 2023 Oct 15;24:e941507. doi: 10.12659/AJCR.941507.

 

ABSTRACT

Low molecular weight heparins (LMWH) and anti-Xa direct oral anti-coagulants (DOACs) are recommended for the long-term treatment of cancer-associated thrombosis (CAT) based on well-documented randomised controlled trials. Anti-Xa DOACs are viewed as a first choice for the treatment of patients with CAT. A large number of drug-drug interactions have been reported between DOACs and chemotherapy drugs, modifying circulating levels of DOAC leading to fears of increased bleeding risks or thrombotic recurrence. Progresses in anti-neoplastic therapies have improved the prognosis and the survival, thus increasing the prevalence of frail patients with cancer. However, since frailties tend to be excluded from large trials due to multiple co-morbidities, current guidelines are not fully applicable to this population. The management of these frail patients with CAT is particularly complex and requires a risk assessment on a case-by-case basis with specific focus on cancer, patient-related risk factors and drug-drug interactions. In this brief review we have identified age, co-morbidities and co-medications as key factors of frailty that require careful attention and we have developed a therapeutic decision algorithm to help clinicians optimising the use of anti-coagulants in patients with cancer with CAT, especially in case of anti-Xa DOACs concomitant medications. With the evaluation of the bleeding risk according to the type of cancer, and anticipating drug-drug interactions intensity, taking into account patient frailties allows the optimisation of the anti-coagulant choice. A systematic collaboration between oncologists, vascular pathology specialists and pharmacists is warranted to ensure an optimal patient management. Clinical studies are needed to determine the real impact of these interactions.

PMID:37824026 | PMC:PMC10582124 | DOI:10.1007/s40262-023-01298-4

07:11

PubMed articles on: Cancer & VTE/PE

Risk factors for bleeding in cancer patients treated with conventional dose followed by low dose apixaban for venous thromboembolism

Thromb Haemost. 2023 Oct 10. doi: 10.1055/a-2188-8773. Online ahead of print.

ABSTRACT

BACKGROUND: Incidence of and risk factors for bleeding in cancer patients with venous thromboembolism (VTE) treated with apixaban are poorly described.

METHODS: We analyzed data from the prospective CAP study where 298 cancer patients with any type of VTE received 5 mg apixaban twice daily for 6 months, and then 2.5 mg apixaban twice daily for 30 months. For most analyses major bleedings and clinically relevant non-major bleedings were merged to "clinically relevant bleedings". Risk factors were estimated by odds ratios (OR) and 95% confidence intervals (CI).

RESULTS: The incidence of clinically relevant bleedings was 38% per person year during the first 6 months of treatment, 21% per person year from 7 to 12 months, and between 4% and 8% per person year from 13 to 36 months. Clinically relevant bleedings were associated with age above 74 years (OR 2.0, 95% CI 1.0-4.1), BMI below 21.7 (OR 2.3, 95% CI 1.1-4.8), and hemoglobin at baseline below 10.5 for females (OR 2.8, 95% CI 1.1-7.3) and 11.1 for males (OR 3.3, 95% CI 1.3-8.4) during the first 6 months. Gastrointestinal (GI) or urogenital cancer were not associated with clinically relevant bleedings compared with other cancers. Among patients with luminal GI-cancer, non-resected cancer had increased risk of bleeding (OR 3.4, 95% CI 1.0-11.6) compared with resected GI-cancer.

CONCLUSION: It was very few bleedings while patients were on low-dose apixaban. Factors associated with bleeding in patients treated with full-dose apixaban were high age, low BMI, and low hemoglobin, and probably non-resected luminal GI-cancer.

PMID:37816388 | DOI:10.1055/a-2188-8773

07:11

PubMed articles on: Cancer & VTE/PE

A Novel Model to Prevent Venous Thromboembolism in Patients with Lung Cancer

07:11

PubMed articles on: Cancer & VTE/PE

Comparison of Direct Oral Anticoagulants versus Low Molecular Weight Heparin in Primary and Metastatic Brain Cancers: A Meta-Analysis and Systematic Review

07:11

PubMed articles on: Cancer & VTE/PE

Intensify Standardized Anticoagulation for Cancer-Associated Pulmonary Embolism: From Single-Center Real-World Data

Clin Ther. 2023 Oct 12:S0149-2918(23)00378-8. doi: 10.1016/j.clinthera.2023.09.014. Online ahead of print.

 

32 Systems Anatomy

FIGURE 1.21. (continued) E: Proximal radioulnar joint, with radial head removed, showing

annular ligament. F: Proximal ulna, with proximal radius removed to show annular ligament and

radial notch. G: Right elbow, anterior aspect, showing synovial membrane. The capsule has been

removed and the articular cavity distended. H: Right elbow, posterior aspect, showing synovial

membrane. The capsule has been removed and the articular cavity distended.

E F

G H

and 1.21A,E, and F). The notch is narrow, oblong, and

lined with articular cartilage. The notch articulates with the

circumferential rim of the radial head. The anterior and

posterior margins of the radial notch provide the attachment areas for the annular ligament.

Shaft (Body) of the Ulna

The shaft (or body) of the ulna is triangular in cross-section

in the proximal two-thirds, but becomes round in the distal

third. Longitudinally, the proximal half of the shaft is

slightly convex dorsally and concave anteriorly. The distal

half (and sometimes central portion) becomes longitudinally straight. The distal half of the shaft may be slightly

concave laterally and convex medially. In cross-section, the

triangular shape presents an anterior, posterior, and medial

surface, as well as an anterior border, posterior border, and

interosseous border (each of which is located at the apex of

the triangular cross-sectional shape). The interosseous ligament is attached along the interosseous border apex of the

triangle, and there is no true lateral surface in this region of

the bone. More distally, the bone becomes progressively circular in cross-section. The shaft flares slightly distally as it

enlarges into the ulnar head.

The three borders of the ulnar shaft are the anterior,

posterior, and interosseous borders. The anterior border of

the ulna begins proximal at the prominent medial angle of

the coronoid process and extends distally along the

anteromedial aspect of the shaft to terminate anterior and

medial to the styloid process of the head of the ulna. The

anterior border is best defined in its proximal portion, and

becomes rounder, smoother, and less clearly defined in the

central distal portion as the shaft becomes progressively

circular in circumference distally. In this central portion of

the anterior border, the ulna provides a large surface origin for the flexor digitorum profundus muscle (see Fig.

1.17). The distal one-fourth of the anterior border is

referred to as the pronator ridge and provides origin for the

pronator quadratus (4).

The posterior border of the ulna begins proximally at the

apex of the triangular subcutaneous surface of the olecranon

(see Fig. 1.18). The posterior border extends distally along

the mid-posterior portion of the shaft, to terminate posterior to the styloid process. The posterior border is well

defined along its proximal one-third to three-fourths; however, as the ulna becomes more circular in cross-section distally, the distal portion of the posterior border is more

rounded, smooth, and poorly defined. In the well defined

proximal portion, the posterior border of the ulna gives rise

to the attachments of an aponeurosis, which provides a

common origin for the flexor carpi ulnaris, the extensor

carpi ulnaris, and the flexor digitorum profundus (see Fig.

1.18). The posterior border separates the medial and posterior surfaces of the ulna.

The interosseous border of the ulna is well defined and

can be somewhat sharp in its central portion (see Figs 1.17

to 1.20). The interosseous border actually extends along the

lateral margin of the ulna, beginning at the radial notch and

curving slightly anteriorly as it extends distally. A proximal

portion of the interosseous border is referred to as the

supinator crest, providing a ridge for the attachment of a

portion of the supinator muscle. In the distal one-fourth of

the shaft, the interosseous border is less well defined. The

interosseous ligament attaches along the interosseous border and is thickest at its attachment in the central portion

of the interosseous border. The interosseous ligament provides a partition that separates the anterior and posterior

surfaces of the ulna.

 

The olecranon is the large, thick curved portion of the

proximal ulna. The most proximal portion of the olecranon

is angled slightly forward or distally to form a prominent lip

that passes into the olecranon fossa of the humerus when

the elbow is extended. The base of the olecranon is slightly

constricted where it joins the shaft of the ulna, forming the

narrowest part of the proximal ulna. The posterior surface

of the olecranon is triangular and smooth. This prominent

area, easily palpable through the skin, is covered by the olecranon bursa. The superior (or most proximal) surface of

the olecranon is somewhat quadrilateral in shape and has a

rough surface for the insertion of the triceps tendon. The

anterior surface of the olecranon is concave and smooth,

and is lined with articular cartilage to form the proximal

portion of the trochlear notch. There usually is a nonarticular zone in the mid-portion of the articular surface (see

later discussion of trochlear notch). The elbow joint capsule

attaches to the anterior aspect of the superior surface of the

olecranon. The medial portion of the olecranon provides

attachment for the oblique and posterior parts of the ulnar

collateral ligament. The medial aspect of the olecranon also

provides an area for the origin of a portion of the flexor

carpi ulnaris muscle. The posteromedial portion also provides a part of the origin of the flexor digitorum superficialis. The lateral portion of the olecranon provides the

insertion of the anconeus muscle (see Fig. 1.18).

28 Systems Anatomy

FIGURE 1.17. Right ulna and radius, anterior aspect, showing

muscle origins (red) and insertions (blue).

The coronoid process is a triangular eminence that projects from the anterior surface of the ulna, roughly at the

junction of the shaft with the proximal portion (see Fig.

1.19). Its base arises from the proximal and anterior part

of the shaft. The superior surface of the coronoid process

is smooth and concave, and forms the inferior portion of

the trochlear notch. Its inferior surface is concave and

rough. At the junction of the coronoid with the shaft of

the ulna is a thickened, rough eminence, the tuberosity of

the ulna. This tuberosity provides the attachment area for

the brachialis as well as the oblique cord of the radius. The

lateral surface of the coronoid contains the radial notch,

1 Skeletal Anatomy 29

FIGURE 1.18. Right ulna and radius, posterior aspect, showing

muscle origins (red) and insertions (blue).

FIGURE 1.19. Right ulna and radius, anterior aspect.

which is a narrow, rounded, oblong depression lined with

articular cartilage. The radial notch articulates with the

rim of the radial head during forearm supination and

pronation. The medial surface of the coronoid process

provides the area of attachment of the anterior and

oblique portions of the ulnar collateral ligament. At the

anterior portion of the medial surface of the coronoid is a

small, rounded eminence for the origin of three humeroulnar heads of the flexor digitorum superficialis. Posterior to this eminence, a slight ridge extends from the

medial aspect of the coronoid distally. Along this ridge

arise the proximal portions of the insertions of the flexor

digitorum profundus, along with the ulnar head of the

pronator teres. In addition, a small ulnar head of the

flexor pollicis longus may arise from the distal part of the

coronoid process (see Fig. 1.of attachment of the anterior and

oblique portions of the ulnar collateral ligament. At the

anterior portion of the medial surface of the coronoid is a

small, rounded eminence for the origin of three humeroulnar heads of the flexor digitorum superficialis. Posterior to this eminence, a slight ridge extends from the

medial aspect of the coronoid distally. Along this ridge

arise the proximal portions of the insertions of the flexor

digitorum profundus, along with the ulnar head of the

pronator teres. In addition, a small ulnar head of the

flexor pollicis longus may arise from the distal part of the

coronoid process (see Fig. 1.17).

30 Systems Anatomy

FIGURE 1.20. Right ulna and radius, posterior aspect.

The trochlear notch of the ulna is a large concave depression that is semilunar in shape and formed by the coronoid

process and the olecranon (see Figs. 1.19 and 1.21A,E, and

F). The trochlear notch, covered anteriorly by articular cartilage, provides the articular surface for the trochlea of the

humerus. The articular surface of the trochlear notch has an

area near its mid-portion that contains a central transverse

area that usually is deficient in articular cartilage. This area

subdivides the articular surface into a proximal portion (on

the anterior surface of the olecranon) and a distal portion

(on the anterosuperior surface of the coronoid). At this

mid-portion of the trochlear notch, the borders are slightly

indented near its middle, creating a narrow portion in the

proximal ulna.

The radial notch of the ulna is the articular depression

on the lateral aspect of the coronoid process (see Figs. 1.19,

1 Skeletal Anatomy 31

FIGURE 1.21. A: Proximal right ulna, lateral aspect. B: Right elbow, medial aspect, showing capsular attachment and medial ligaments. C: Right elbow, lateral aspect, showing capsular attachment and lateral ligaments. D: Right elbow, sagittal section. E: Proximal radioulnar joint, with

radial head removed, showing annular ligament.

(continued on next page)

A B

C D

 

ULNA

Derivation and Terminology

The ulna derives its name from the Latin word meaning “the

arm” or “the elbow” (1,3). The plural of ulna is ulnae (1).

Ossification Centers and Accessory Bones

The ulna has three ossification centers: one in the shaft

(body), one in the proximal portion (proximal extremity),

and one in the distal end (distal extremity). The mid-portion of the shaft is the first ossification center to appear,

becoming visible at approximately the eighth week of fetal

life (Figs. 1.15 and 1.16). The ossification centers then

extend through the major part of the shaft. At birth, the

distal portions and the major part of the olecranon remain

cartilaginous. Between the fifth and sixth years, a center in

the central portion of the ulnar head appears and soon

extends into the styloid process. At approximately the

tenth year, a center appears in the olecranon near its outer

portion. Most of the ossification of the olecranon actually

develops from proximal extension from the center of the

shaft (2,4,5).

Several accessory bones can be associated with the distal

ulna. These accessory bones, if present, usually are the result

of secondary or additional ossification centers that do not

fuse with the distal ulnar or associated carpal bones. Accessory bones associated with the distal ulna include the os triangulare (os intermedium antebrachii, os triquetrum secundarium), the os ulnostyloideum, and the os pisiforme

secundarium (ulnare antebrachii, metapisoid) (see Fig.

1.27B) (44–46). The os triangulare is located distal to the

head of the ulna, between the ulnar head, lunate, and triquetrum. The os ulnostyloideum is located in the vicinity

of the ulnar styloid. The os pisiforme secundarium is

located between the distal ulna and pisiform, close to the

proximal edge of the pisiform.

1 Skeletal Anatomy 27

FIGURE 1.15. Illustration of ulna, showing the three centers of

ossification. There is one center in the shaft (body), one in the

proximal portion (proximal extremity), and one in the distal end

(distal extremity).

FIGURE 1.16. Illustration of proximal and distal ulna in a young

adult, showing epiphyseal lines.

Accessory bones also can occur from other causes such as

trauma (46) or heterotopic ossification of synovial tags (47).

Therefore, anomalous, irregular ossicles or small, rounded

bones of abnormal size or shape may be encountered that

do not fit a specific described accessory bone or location.

Osteology of the Ulna

The ulna is located in the medial aspect of the forearm lying

parallel to the radius when the forearm is supinated. It is a

true long bone with a triangular cross-section proximally

that becomes rounded distally. The ulna consists of a shaft

with thick cortical bone and a long, narrow medullary canal

(Figs. 1.17 to 1.20). The cortex of the ulna is thickest along

the interosseous border and dorsal surface. In the proximal

and distal ends of the ulna, the cortical bone becomes thinner, and the medullary canal is replaced with cancellous

bone. The cortical bone remains relatively thick along the

posterior portion of the olecranon.

The ulna is anatomically divided into three main portions: the proximal end (proximal portion, proximal

extremity), the shaft (body), and the distal end (distal portion, distal extremity) (Fig. 1.21; see Figs. 1.19 and 1.20).

The proximal end contains the hook-shaped olecranon and

the coronoid process to form the medial hinge-like portion

of the elbow. The shaft consists of the major portion of the

body between the proximal and distal portions. The distal

end consists of the head and styloid process. In general, the

ulna becomes progressively smaller and thinner from proximal to distal.

Proximal Ulna

The proximal end of the ulna consists of the olecranon, the

coronoid process, the trochlear notch, and the radial notch

(see Fig. 1.21A–F).

 

Supracondylar Process

In approximately 1% of upper extremities, there is a downward-curved, hook-shaped process of bone that emanates

from the medial cortex approximately 5 cm proximal to the

medial epicondyle. It can be associated with a connecting

fibrous band (ligament of Struthers), which can be a proximal extension of the pronator teres. The median nerve may

pass deep to the supracondylar process and ligament, and

may be subject to compression, resulting in median neuropathy. The brachial artery also may pass deep to the ligament (28,40–43).

Lateral Epicondylitis

Lateral epicondylitis commonly is referred to as tennis

elbow. It is thought to consist of either chronic inflammation, partial tear, or “overuse injury” of the common extensor origin. Chronic or repetitive wrist or digital extension

often is associated with the onset of symptoms. The extensor carpi radialis brevis often is implicated as the main muscle involved. Although management usually is conservative

(activity modification, antiinflammatory medications,

splinting, cortisone injections), severe and refractory cases

can be managed with operative exploration and release,

debridement, or repair of the extensor carpi radialis brevis

origin or other involved muscle.

Medial Epicondylitis

Medial epicondylitis commonly is referred to as golfer’s

elbow. Similar to lateral epicondylitis, it is though to consist

of either chronic inflammation, partial tear, or overuse

injury of the common flexor pronator muscle origin.

26 Systems Anatomy

Chronic or repetitive wrist or digital flexion often is associated with symptoms.

Osteochondrosis

Osteochondrosis (osteochondritis dissecans, osteonecrosis)

of the capitellum of the humerus is referred to as Panner’s

disease.