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Clinical Anatomy of Elbow

Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

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Injuries to Elbow and Wrist

Skin Bones Muscles, tendons Nerves Blood vessels

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Bones of Elbow

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Elbow Joint
Synovial hinge joint One degree of freedom Uniaxial The articular surfaces are the trochlea and the capitulum of the humerus The trochlear notch of the ulna The superior aspect of the head of the radius

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Elbow Joint
When the elbow is extended, medial epicondyle, olecranon and lateral epicondyle are in a straight line When flexed, they form a triangle

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Capsule of Elbow Joint

Capsule surrounds the joint Anteriorly to the margins of the coronoid and radial fossae of the humerus Medially and laterally just beyond the articular margin Excluding the medial and lateral epicondyles to which the common flexor and extensor origins are attached

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Capsule of Elbow Joint

Capsule surrounds the joint Posteriorly to the margins of the olecranon fossa Inferiolaterally it is inserted into the annular ligament of the superior radioulnar joint

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Synovial Membrane
Lines the capsule and nonarticular structures inside the capsule Continuous inferiorly with synovial membrane of superior radio-ulnar joints Annular ligament covered with articular cartilage

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Synovial Membrane
Between the capsule and synovial membrane are three other pads of fat The largest, at the olecranon fossa, is pressed into it by triceps during flexion Two, at the coronoid and radial fossae, are pressed in by brachialis during extension They are all slightly displaced in contrary movements

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Synovial Membrane
Smaller synovial-covered tags of fat project into the joint near constrictions flanking the trochlear notch, covering small non-articular areas of bone

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Medial or Ulnar Collateral Ligament

Thick triangular ligament attached superiorly to the medial epicondyle Its anterior band is attached distally to the tubercle on the upper medial margin of the coronoid process The posterior band is attached to the medial margin of the olecranon A thinner portion, the oblique band, unites both bands

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Medial or Ulnar Collateral Ligament

The ulnar nerve lies on the medial ligament The anterior band may be ruptured in throwing events

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Lateral or Radial Collateral Ligament

The ligament is attached to the lateral epicondyle Fans out to be attached to the upper border of the annular ligament The annular ligament is attached to the margins of the radial notch of the ulna It is part of the articulation of the superior radioulnar joint Covered with articular cartilage

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Medial Structures of Elbow

Common flexor origin, ulnar nerve

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Anterior Relations
Brachialis lies on capsule Medial to lateral Common flexor origin Median nerve Brachial artery covered by bicipital aponeurosis Biceps Radial nerve Superficial Deep branch is posterior interosseus nerve

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Posterior Relations
Triceps Anconeus Olecranon bursa Ulnar nerve posterior to medial epicondyle Common extensor origin

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Extensor Tendons
Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis* Extensor digitorum communis Extensor digiti minimi Extensor carpi ulnaris

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Posterior Relations

medial

olecranon bursitis

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Posterolateral
Below lateral epicondyle Head of radius Behind the extensors of the forearm Posterior interosseous nerve

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Lateral Elbow

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Movements of Elbow Joint

Flexion and extension Semiflexion is least pack position Flexion of the elbow is limited by: Impact of the radial head in the radial fossa Coranoid process against the coronoid fossa Tension of posterior part of capsule Tension of triceps Apposition (contact) between soft tissues of forearm and upper arm

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Flexion of Elbow
Main flexors Brachialis, musculocutaneous (C5,6) Biceps, musculocutaneous (C5,6) Weak flexors Common flexor origin, median (C6,7) Except flexor carpi ulnaris, ulnar nerve (C6,7) Brachioradialis, radial (C5,6)

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Common Flexor Origin

Pronator teres Flexor carpi radialis Flexor digitorum superficialis Palmaris longus Median nerve (C6,7) Flexor carpi ulnaris Ulnar nerve (C6,7)

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Elbow
Biceps brachii Brachialis Pronator teres Supinator posterior Musculocutaneous C5,6 Musculocutaneous C5,6 Median C6,7 Interosseous C5,6

Anderson & Hall, 1995

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Extension of Elbow
Triceps is the main extensor Weak are extensors from common extensor origin Nerve supply radial (C7,8) Extension of the elbow is limited by: Impingement of the olecranon of the ulna on the olecranon fossa of the humerus Tension of the anterior arm muscles and collateral ligaments

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Biceps Brachii
Crosses shoulder, elbow and superior radioulnar A long head arising from the supraglenoid tubercle The adjoining portion of the labrum within the capsule of the shoulder joint It passes above the head of the humerus Leaves the joint below the transverse ligament, which acts as a retinaculum

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Biceps Brachii
It is surrounded by synovial membrane, which extends inferiorly to the lower margin of the teres major, i.e. the posterior fold of the axilla Short head arises from the coracoid process with the coracobrachialis

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Biceps Brachii
The two heads unite to form a fleshy belly, which becomes a tendon, inserted into the posterior aspect of the radial tuberosity The bicipital aponeurosis extends from its medial margin, passing anterior to the brachial artery and the median nerve, fuses with deep fascia of the forearm and the medial margin of the ulna A bursa separates it from the radius Nerve supply is musculocutaneous nerve C5,6,7

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Action of Biceps Muscle

Helps to stabilise and flex the shoulder Its role as a dynamic stabiliser of the glenohumeral joint is particularly important in the late cocking phase of throwing Flexes the elbow The most powerful supinator of the forearm when the elbow is flexed The action of the biceps is weak at the shoulder and powerful at the elbow

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Brachialis Muscle
Arises from the anterior aspect of the shaft of the humerus below the deltoid tuberosity It is inserted into the anterior aspect of the coranoid process of the ulna and the capsule of the elbow joint It lies directly anterior to the elbow joint and is only a flexor of the elbow The musculocutaneous nerve C5,6,7 supplies it

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Coracobrachialis Muscle
It arises from the coracoid process, together with the short head of the biceps brachii Inserts into the middle of the medial surface of the humerus Helps to flex and adduct the arm at the shoulder joint

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Coracobrachialis Muscle
The coracobrachialis muscle also helps to stabilise the shoulder joint A persistent lower head may remain as supra-trochlear spur or Ligament of Struthers, attached to the medial epicondyle of the humerus May compress the median nerve or the brachial artery Musculo-cutaneous nerve C5,6,7

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Pain in Elbow and Wrist

Must rule out referred pain from cervical spine Upper thoracic spines Increased neural tension

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Test for Stability of Elbow

Varus and valgus stresses 0 and 30 degrees of flexion
Behr & Altchek, 1997

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Adult Elbow Injuries

Fractures Distal humerus Radial head and radial neck Olecranon Dislocations Simple Fracture, dislocation
Behr & Altchek, 1997

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Elbow Pain
Loose bodies Pain Locking

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Medial Elbow Pain

Referred pain Medial epicondylitis Medial collateral ligament injury Ulnar nerve injury Avulsion of medial epicondyle Apophysitis Degenerative changes of medial elbow
Brukner & Khan, 1997

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Test for Medial Epicondylitis

Stabilise flexed elbow Palpate medial epicondyle Slowly supinate the forearm Extend wrist and elbow, while patient resists
Anderson & Hall, 1995

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Lateral Elbow Pain

Lateral epicondylitis (tennis elbow) Entrapment of the radial nerve Degenerative changes of the radio-humeral joint Posterolateral rotatory instability Cervical spine problems
Behr & Altchek, 1997

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Lateral Epicondylitis
Extensor carpi radialis brevis in most cases Anterior edge of extensor digitorum communis 30% Less frequently Extensor carpi radialis longus Extensor carpi ulnaris
Nirschl, 1993

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Lateral Epicondylitis; Pathology

Tendonosis 1. Repetitive microtrauma 2. Angioplastic hyperplasia 3. Fibrosis 4. Granulation tissue 5. Mucoid degeneration
Nirschl, 1993

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Lateral Epicondylitis
Racquet sports Backhand Throwing sports Golfers Musicians Labourers

Behr & Altchek, 1997

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Test for Lateral Epicondylitis

Stabilise flexed elbow Resisted extension and radial deviation of wrist Passive stretching of wrist extensors Resisted extension of extensor digitorum communis of middle finger with wrist extended

Anderson & Hall, 1995

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Elbow Nerve Compression

Radial tunnel syndrome Posterior interosseous nerve syndrome Cubital tunnel syndrome Pronator syndrome Anterior interosseous nerve syndrome
Behr & Altchek, 1997

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Test for Ulnar Neuritis

Tap ulnar nerve on posteromedial aspect of medial epicondyle Completely flex elbow and hold for five minutes Positive = tingling along nerve
Anderson & Hall ,995

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Elbow Effusion
Fullness in the triangular area bounded by The radial head The lateral epicondyle The tip of the olecranon
Behr & Altchek, 1997

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Pediatric Elbow Injuries

Fractures lateral condyle and olecranon Physeal fractures of radial head Supracondylar fracture and fracture of radial neck Little League elbow Osteochondritis dissecans of capitellum
Behr & Altchek, 1997

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Pediatric Elbow Injuries

Traction apophysitis Little League elbow Due to repeated stress on medial epicondyle by contraction of the flexor pronator group Valgus loads during late cocking and acceleration stages of throwing
Behr & Altchek, 1997

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Elbow Dislocation

Osteochondritis Dissecans of Capitellum

Avascular necrosis of subchondral bone Repetitive trauma to blood supply in dominant arm in athletic children >8 years Female gymnasts Male baseball
Pappas, 1982

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