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7/28/2019 Clinical Anatomy of the Elbow BMJ
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MOB TCD
Professor Emeritus Moira OBrienFRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
Clinical Anatomy of Elbow
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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 thetrochlea and the capitulum ofthe humerus
The trochlear notch of the ulna
The superior aspect of thehead of the radius
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When the elbow is extended,medial epicondyle,
olecranon and
lateral epicondyle
are in a straight line
When flexed, they form a
triangle
Elbow Joint
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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 justbeyond the articular margin
Excluding the medial and
lateral epicondyles to which
the common flexor andextensor 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 non-articular structures inside the
capsule
Continuous inferiorly with
synovial membrane of superiorradio-ulnar joints
Annular ligament covered with
articular cartilage
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Between the capsule andsynovial membrane are threeother pads of fat
The largest, at the olecranonfossa, is pressed into it by
triceps during flexion Two, at the coronoid and
radial fossae, are pressed inby brachialis during extension
They are all slightly displacedin contrary movements
Synovial MembraneMOB TCD
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Synovial Membrane
Smaller synovial-coveredtags of fat project into thejoint near constrictionsflanking the trochlear notch,covering small non-articular
areas of bone
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Medial or Ulnar Collateral Ligament
Thick triangular ligamentattached superiorly to themedial epicondyle
Its anterior band is attacheddistally to the tubercle on
the upper medial margin ofthe coronoid process
The posterior band isattached to the medialmargin of theolecranon
A thinner portion, theoblique band, unites bothbands
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Medial or Ulnar Collateral Ligament
The ulnar nerve lies on themedial ligament
The anterior band may beruptured in throwing events
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Lateral or Radial Collateral Ligament
The ligament is attached tothe lateral epicondyle
Fans out to be attached tothe upper border of theannular ligament
The annular ligamentisattached to the margins ofthe radial notch of the ulna
It is part of the articulation ofthe superior radioulnar joint
Covered with articularcartilage
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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 bybicipital 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
olecranon bursitismedial
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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 ElbowMOB TCD
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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 Coranoidprocess 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 Musculocutaneous C5,6 Brachialis Musculocutaneous C5,6
Pronator teres Median C6,7
Supinator posterior 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 islimited 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 andsuperior radioulnar
A long headarising from the
supraglenoid tubercle
The adjoining portion of thelabrum 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 bysynovial membrane,
which extends
inferiorly to the lower
margin of the teres
major, i.e. theposterior fold of the
axilla
Short headarises from the coracoid
process with the coracobrachialis
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The two heads unite to form afleshy 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
Biceps BrachiiMOB TCD
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Action of Biceps Muscle
Helps to stabilise and flex theshoulder
Its role as a dynamicstabiliser of the gleno-humeral joint is particularly
important in the late cockingphase of throwing
Flexes the elbow
The most powerful supinatorof the forearm when the
elbow is flexed The action of the biceps is
weak at the shoulder andpowerful at the elbow
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Brachialis Muscle
Arises from the anterior aspectof the shaft of the humerus
below the deltoid tuberosity
It is inserted into the anterior
aspect of the coranoidprocess
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 coracoidprocess, together with the
short head of the biceps
brachii
Inserts into the middle of themedial surface of the
humerus
Helps to flex and adduct the
arm at the shoulder joint
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Coracobrachialis Muscle
The coracobrachialis muscle alsohelps 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 nerveor the brachial artery
Musculo-cutaneous nerve C5,6,7
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Pain in Elbow and Wrist
Must rule out referred painfrom 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 flexionBehr & Altchek, 1997
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Adult Elbow Injuries
Fractures
Distal humerus Radial head and radial neck
Olecranon
Dislocations
Simple Fracture, dislocationBehr & 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 ofmedial 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 (tenniselbow)
Entrapment of the radial nerve
Degenerative changes of the
radio-humeral joint Posterolateral rotatory instability
Cervical spine problemsBehr & Altchek, 1997
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Lateral Epicondylitis
Extensor carpi radialis brevis inmost cases
Anterior edge of extensordigitorum communis 30%
Less frequently
Extensor carpi radialis longus
Extensor carpi ulnarisNirschl, 1993
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Lateral Epicondylitis; Pathology
Tendonosis1. Repetitive microtrauma
2.Angioplastic hyperplasia
3. Fibrosis
4. Granulation tissue
5. Mucoid degenerationNirschl, 1993
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Racquet sports
Backhand
Throwing sports
Golfers
Musicians LabourersBehr & Altchek, 1997
Lateral Epicondylitis
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Stabilise flexed elbow
Resisted extension and radial deviation of wrist
Passive stretching of wrist extensors
Resisted extension of extensor digitorum communis ofmiddle finger with wrist extended
Anderson & Hall, 1995
Test for Lateral Epicondylitis
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Elbow Nerve Compression
Radial tunnel syndrome Posterior interosseous nerve
syndrome
Cubital tunnel syndrome
Pronator syndrome Anterior interosseous nerve
syndromeBehr & Altchek, 1997
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Test for Ulnar Neuritis
Tap ulnar nerve on posteromedial aspect of medialepicondyle
Completely flex elbow and hold for five minutes
Positive = tingling along nerveAnderson & Hall ,995
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Elbow Effusion
Fullness in the triangular areabounded by
The radial head
The lateral epicondyle
The tip of the olecranonBehr & 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
Osteochondritisdissecans of capitellum
Behr & Altchek, 1997
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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 throwingBehr & Altchek, 1997
Pediatric Elbow Injuries
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Elbow Dislocation
Osteochondritis DissecansMOB TCD
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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 baseballPappas, 1982
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BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.
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