THE ELBOW

ANATOMY

• The Elbow is a hinge joint

made up of
• Humerus
• Ulna
• Radius
• Has 3 articulations:
• Humeroulnar Joint
• Radioulnar Joint
• Proximal Radioulnar Joint
ANATOMY – Distal Humerus
ANATOMY – Proximal Radius and
Ulna
ANATOMY - Stabilizers

• Elbow stability is provided by the soft tissue

structures surrounding the joint as well as by
bony articulations of the joint itself.
• The soft tissue restraints can be divided into
both static and dynamic stabilizers.
• The static stabilizers:
• joint capsule
• LCL
• MCL
ANATOMY – Joint Capsule

• The fibrous capsule is broad

and thin anteriorly.
• Proximally - attached to the
front of the medial epicondyle
and humerus above the
coronoid and radial fossa.
• Distally - attached to the edge
of the ulnar coronoid process
and anular ligament.
ANATOMY – Joint Capsule

• Medially – blends into the

ulnar collateral lligament and
it may be augmented by
fibers from brachialis
• Laterally – blends with radial
collateral ligament.
 ANATOMY – Joint Capsule

• Posteriorly, the capsule is even thinner

and is related to the tendon of triceps
and anconeus.
• Proximally - attached to the
superoposterior aspect of the humeral
capitulum, the posterior aspect of the
medial epicondyle and the olecranon
fossa. Only the lowest part of the
olecranon fossa is devoid of a capsular
attachment.
ANATOMY – Joint Capsule

• Inferomedially - reaches the superior

and lateral margins of the olecranon
and is
• Laterally - continuous with the
superior radio-ulnar capsule deep to
the annular ligament.
Anatomy - LCL

• The LCL has three components

:
• Radial collateral ligament
• Annular ligament
• Lateral ulnar collateral
ligament.
• It is the primary varus and
posterolateral rotational
stabilizer of the elbow
 Anatomy - LCL

• The radial head is surrounded by the

annular ligament which attaches to the
anterior and posterior margins of the
radial notch of the proximal ulna.
• The radial collateral ligament arises from
the lateral epicondyle and blends with
the annular ligament.
Anatomy - LCL

• The lateral ulnar collateral

ligament is posterior to the radial
collateral ligament and attaches
to the crista supinatoris of the
proximal ulna, just distal to the
annular ligament.
 Anatomy - MCL

• MCL consists of the anterior and

posterior bundles.
• The anterior bundle is the key valgus
stabilizer of the elbow, arising from
the anteriorinferior aspect of the
medial epicondyle to insert on the
sublime tubercle of the proximal
ulna.
Anatomy - MCL

• The posterior bundle provides a

secondary restraint to valgus load
and also resists ulnar rotation.
Anatomy – Dynamic Restraints

• The dynamic restraints:

• Biceps
• Brachialis
• Triceps
• provide compressive stability
to the elbow due to their
joint reactive forces
• important when the static
stabilizers have been injured
Anatomy – Dynamic Restraints

• The common extensor muscles(ECRB, EDC, EDQ,

ECU) arises from the lateral condyle provide varus
stability

• The common flexor muscles (FCR, PL, FCU, FDS)

arises from the medial epicondyle and provide valgus
stability.
 ANATOMY – Radial Nerve

Radial Nerve
• ventral roots of spinal
nerves C5, C6, C7, C8 & T1.
• emerges from the radial
groove on the lateral
aspect of the humerus.
• At this point, it pierces the
lateral intermuscular
septum and enters the
anterior compartment of
the arm.
 Anatomy – Ulnar Nerve

Ulnar Nerve
Arises from C8-T1 nerve
roots and descends on the
posteromedial aspect of the
humerus.
It runs inferior to the
posteromedial aspects of the
humerus, passing behind the
medial epicondyle (in the cubital
tunnel)
 Anatomy – Median Nerve
Median Nerve
• C5-C7(lateral cord) and C8 & T1
(medial cord).
• Initially lateral to the artery and
lies anterior to the elbow joint; it
then crosses anteriorly to run
medial to the artery in the distal
arm and into the cubital fossa.
Anatomy – Median Nerve

• In the cubital fossa the median

nerve passes medial to the brachial
artery, in front of the point of
insertion of the brachialis muscle
and deep to the biceps.
• The median nerve gives off an
articular branch in the upper arm as
it passes the elbow joint. A branch
to pronator teres may arise from
the median nerve immediately
proximal to the elbow joint.
RANGE OF MOTION

• Flexion
135 degrees – 150
degrees
• Extension
• 0 degrees- 5
degrees
(hyperextension)
RANGE OF MOTION

• Pronation
• 75 – 90 degrees
• Supination
• 85 – 90 degrees
ELBOW INJURIES
 Anterior Elbow Injuries

Distal Biceps Rupture

• Traumatic avulsion of distal biceps
tendon from bicipital tuberosity of
the proximal radius.
• Eccentric extension load applied to
flexed,supinated forearm.
 Anterior Elbow Injuries

Distal Biceps Rupture

• Atypical injury; 97% of biceps
ruptures are proximal, only 3% of
biceps ruptures occur at elbow;
almost all occur in males, most
commonly in 5th to 6th decades of
life; thought to be associated with
preexisting tendon
injury/degeneration or steroid use.
• Tenderness to palpation in
antecubital fossa, regional
ecchymosis, palpable tendon defect
in complete tears
 Posterior Elbow Injuries

Triceps Tendonitis
• Inflammation of the triceps tendon at its insertion on the
olecranon process of the ulna.
• Overuse injury from repetitive extension/ hyperextension
of the elbow.
• Most commonly occurs in baseball players and weightlifters;
patients report pain focal to the triceps insertion on the
olecranon; usually no acute trauma identified.
 Posterior Elbow Injuries

• Normal range of motion and neurovascular exam; triceps

tendon is tender to palpation at, or just proximal to, its
insertion site; no palpable defects; focal pain with
resisted elbow extension.
• Plain x-ray usually normal, but lateral view can reveal
traction osteophyte or calcific deposit in terminal
tendon; MRI can be useful to distinguish between
inflammation and partial triceps tendon tear.
• RICE, NSAIDs
Posterior Elbow Injuries

Triceps Rupture/Olecranon Avulsion

• Traumatic avulsion of the triceps
tendon from its insertion on the
olecranon process of the ulna, or
avulsion of the olecranon process
from the ulna with triceps tendon
attached.
• Most commonly occurs from fall on
outstretched hand with
deceleration load applied to an
actively contracting triceps; also
reported in weightlifters and in
direct trauma.
 Posterior Elbow Injuries

• Rare injury; twice as common in

males than females; occurs in
patients of all ages, including
adolescents with an incompletely
fused olecranon physis; can be
associated with steroid use,
metabolic bone disorders, and
renal osteodystrophy.
Posterior Elbow Injuries

• Tenderness to palpation along

olecranon and distal triceps;
regional ecchymosis and
edema; palpable defect of
triceps tendon or step-off at
olecranon; weak elbow
extension/ inability to hold
elbow extended against
gravity; modified Thompson
test
Posterior Elbow Injuries

• Clinical diagnosis; “flake sign”

(small bony avulsion fragment
from olecranon process) noted
in 80% of these injuries; can use
MRI or ultrasound to aid in
diagnosis if unclear.
• Nonoperative treatment
indicated only in the elderly or
in patients with partial tears;
nonoperative management
consists of splint immobilization
with the elbow in 30 degrees of
flexion for approximately 4
weeks; treatment of choice is
surgical repair within 2 weeks
of
 Posterior Elbow Injuries

Olecranon Impingement Syndrome

• Also known as hyperextension valgus overload syndrome
or “boxer’s elbow”; mechanical abutment of olecranon
process against posterior soft tissues or the olecranon fossa
that occurs with terminal extension of the elbow.
• Overuse syndrome caused by repetitive extension
overloading; can occur in a stable elbow (football linemen,
gymnasts, weightlifters) or can be seen in athletes with
chronic attenuation of the ulnar collateral ligament
(overhead throwers) causing the olecranon process to
impinge against the medial wall of the olecranon fossa.
 Posterior Elbow Injuries

• Can produce posterior elbow pain, crepitus, and other

mechanical symptoms (such as locking or catching);
overhead throwers often complain of premature fatigue,
loss of velocity, or loss of control.
• Athletes may have some loss of terminal extension;
posterior elbow pain with valgus stress in terminal
extension; possible laxity of ulnar collateral ligament (UCL)
with valgus stress; can have palpable loose bodies.
 Posterior Elbow Injuries
• Plain x-rays can reveal loose bodies, hypertrophic bone
formation/osteophytes in humeral fossae, calcifi cation of
the UCL, medial epicondyle avulsion fractures or can be
normal; MRI can help to further assess the status of the
articular cartilage and highlights areas of soft tissue edema
and attenuation.
• RICE, NSAIDs, Rehab
• Olecranon Bursitis
• Also known as “miner’s elbow,” or
“student’s elbow”;
• inflammation of the bursa overlying
the olecranon process
• of the ulna; can be acute or chronic,
septic or aseptic
• Typically occurs because of direct
(often mild) trauma to the posterior
elbow; may be secondary to asingle
direct blow, or to repetitive trauma
to the superfi cial tissues; septic
bursitis often occurs through
contamination of a skin wound or via
surrounding dermatitis.
• Acute or gradual onset of swelling;
acute/septic cases can be painful,
whereas chronic cases are often
painless; most common in football
and hockey players; high association
with play on artificial turf.
• Focal posterior elbow swelling;
mobile, fluctuant mass that can wax
and wane in size; can have
associated erythema or drainage in
septic cases; surrounding forearm
edema usually seen in cases of
septic bursitis only; no restriction in
range of motion; normal
neurovascular exam.
• X-rays show calcification of the bursa or
olecranon spur; aspiration can be
performed in acute and chronic cases;
fluid should be sent for cell count and
differential, Gram stain/culture, and
crystal analysis; aseptic fluid has a low
white blood cell count with a high
percentage of monocytes (80%); gouty
crystals not uncommon; Staphylococcus
aureus most common cause of septic
bursitis.
• RICE, NSAIDs, corticosteroid, with a
compressive dressing for 2 to 3 weeks
• septic bursitis should be drained/excised
with administration of intravenous
antibiotics (1 to 3 weeks), followed by 2
weeks of oral antibiotics; chronic aseptic
cases can also be treated with excision of
the bursal sac.
 Medial Elbow Injuries
• Also known as “golfer’s elbow”
• inflammation/degenerative change
of the flexor-pronator mass at its
origin on the medial epicondyle.
• Stress/overuse injury of the
flexor-pronator mass that occurs
with repetitive wrist flexion or
forearm pronation.
 Medial Elbow Injuries

• Pain at the medial epicondyle;

symptoms are often mild and
intermittent; occurs less
commonly than lateral
epicondylitis;
• seen in pitchers, golfers,
bowlers, weightlifters and
football players;
• can be associated with ulnar
neuropathy and, less commonly,
triceps tendonitis and loose
body formation.
Medial Elbow Injuries

• Usually full ROM without

associated crepitus; pain at the
medial epicondyle
discomfort/weakness
exacerbated by resisted wrist
flexion and/or pronation
performed in full extension;
• Some patients have a positive
Tinel’s with percussion
• Radiographs typically normal,
though calcifications in the
flexor-pronator mass occasionally
present;
 Medial Elbow Injuries

• EMG/NCSwill be normal (even in

cases with positive Tinel’s in the
region);
• MRI can be used to confirm the
diagnosis in patients with possible
conflicting sources of pain
• Majority of patients will respond
to conservative activity
modification, counterforce elbow
bracing, NSAIDs, icing, and a
physical therapy program,
corticosteroids
Medial Elbow Injuries

Ulnar Nerve Compression

Syndrome
• Also known as cubital tunnel
syndrome; compression of the
ulnar nerve as it crosses the elbow
joint.
• trauma, cubitus valgus deformity,
or subluxing ulnar nerve at the
medial epicondyle.
• seen in weightlifters
concentrating on triceps. onset is
insidious.
Medial Elbow Injuries

• Insidious onset of aching medial

elbow/forearm pain, numbness
at ring/small fi ngers, and grip
weakness; ROM not limited
• Tinel’s sign over cubital tunnel;
positive ulnar nerve
compression test; subluxation
of ulnar nerve with elbow
flexion; positive Froment’s test;
grip weakness; weak flexor
digitorum profundus (FDP) to
small finger.
Medial Elbow Injuries

• EMG/NCV : slowing of
conduction velocity acrosselbow
(20% to 25%).
• X-rays: usually normal, but may
have osteophytes or cubitus
valgus deformity.
• NSAIDs, modification of
training, night-time splinting,
elbow pads;
Lateral Elbow Injuries

Lateral Epicondylitis
• Also known as “tennis elbow”;
degenerative tears in extensor
carpi radialis brevis (ECRB) origin
with pain at lateral epicondyle.
• Repetitive contraction of wrist
extensors leads to extensor
tendon degeneration.
• 10x more frequent than medial
epicondylitis; increased risk with
racket sports, age above 40, poor
technique, dominant arm; pain
with lifting objects; initially pain
subsides with rest.
 Lateral Elbow Injuries
• Tenderness to palpation over
lateral epicondyle and ECRB; pain
with resisted wrist and long finger
extension; pain with resisted
supination
• Clinical diagnosis. X-rays are
usually normal (22% calcific
changes); MRI may show
inflammation of the ECRB.
Lateral Elbow Injuries

• RICE, NSAIDs, physical therapy, and counterforce

bracing.
• Corticosteroid injection
• Excision of ECRB tendon.
• Racket sport athletes should analyze stroke
mechanics and racket grip size as part of treatment.
Lateral Elbow Injuries

Radiocapitellar Chondrosis
• Damage to the articular cartilage of
the radius and capitellum secondary
to compressive forced from valgus
stress.
• Valgus stress of throwing and racket
sports imparts strong tensile forces
to medial collateral ligament and
strong compressive forces to lateral
joint of elbow, leading to overload
forces against the articular cartilage.
May also occur following sudden,
extreme compressive event or radial
head fracture.
Lateral Elbow Injuries

• Throwing athletes; painful swelling

at lateral elbow with throwing;
catching and locking.
• Tender radiocapitellar joint, lateral
swelling, crepitus and increased pain
with forearm pronation-supination;
decreased range of motion; assess
medial collateral ligament integrity.
• X-ray: loss of radiocapitellar joint
space; marginal osteophytes, loose
bodies MRI: loss of articular
cartilage.
Lateral Elbow Injuries

• Rest, NSAIDs, physical therapy

• graduated activity dictated by pain
• corticosteroid injection
• joint debridement through lateral
arthrotomy or arthroscopy with
removal of marginal osteophytes
and loose bodies
• radial head excision versus
replacement – late stages
Lateral Elbow Injuries

• Focal lesion in adolescents

consisting of a separation of
both articular cartilage and
subchondral bone
• Repetitive microtrauma to
capitellum from high valgus
stresses leads to chondral
injury and subchondral
fractures; fractures become
necrotic and are gradually
resorbed, while overlying
cartilage remains viable; if
cartilage remains intact,
bone defect may fill in; if
cartilage loses integrity,
loose body may develop.
Lateral Elbow Injuries

• History of activity-related lateral elbow pain in

adolescent/young adult
• males in throwing sports, females in gymnastics;
dominant arm; history of repetitive, painful overuse;
pain resolves with rest or in off-season; occasional
clicking/locking.
• Tenderness of radiocapitellar joint; swelling; lack of full
extension; crepitus, clicking, popping with range of
motion (suspect loose body)
• positive radiocapitellar compression test
Lateral Elbow Injuries

• X-rays: radiolucency and rarefaction of the capitellum,

with flattening of the articular surface, possible loose
bodies;
• MRI: early low-signal changes on T1 images; T2 images
helpful for denoting intervening fluid in lesion
consistent with fragment separation.
• For intact articular cartilage, period of rest with activity
restriction (3 to 6 weeks), with physical therapy and
gradual return to activities at 3 months, full activity by
6 months; follow with serial x-rays.
• If fragment is displaced, recommended treatment is
excision of unstable articular fragment and drilling of
capitellar defect; surgery indicated for loose bodies
Lateral Elbow Injuries

Posterior Interosseous Nerve

Compression Syndrome
• Also known as radial tunnel
syndrome; entrapment neuropathy
of posterior interosseous branch of
radial nerve.
• Hypoxemia of the posterior
interosseous nerve, leading to
paresthesia, secondary to
compression under fibrous arch of
supinator (arcade of Frosche) or
more distally in supinator muscle.
Lateral Elbow Injuries

• Arching lateral elbow pain from lateral epicondyle,

radiating into dorsal forearm (arcade of Frosche);
aggravated by pronation-supination activities;
extensor weakness of wrist and fingers; no
numbness.
• Tinel’s 8 cm distal to lateral epicondyle; pain with
resisted pronation/supination; pain with long finger
extension; weakness of wrist extensors and extensor
digitorum communis (EDC); no sensory loss.
Lateral Elbow Injuries

• Primarily a clinical diagnosis; x-rays : osteophyte at

radiocapitellar joint (rare); EMG/NCV: rarely
confirmatory for posterior interosseous nerve
compression.
• Rest, training schedule modification, dorsiflexion
wrist splint, physical therapy for stretching and
strengthening; surgical decompression in
recalcitrant cases.