Sie sind auf Seite 1von 10

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

429

Anatomy and Biomechanics of the Elbow Joint

Silvia Martin, MD 1 Eugenia Sanchez, MD 2

1 Department of Radiology, Son Llatzer Hospital, Palma de Mallorca, Spain 2 Department of Radiology, Clínica Cemtro, Madrid, Spain

Semin Musculoskelet Radiol 2013;17:429 436.

Address for correspondence Eugenia Sánchez, MD, Department of Radiology, Clínica Cemtro, Madrid Spain (e-mail: eugenia.sanchez4@gmail.com).

Abstract Magnetic resonance (MR) imaging provides clinically useful information in assessing the elbow joint. Superior depiction of muscles, ligaments and tendons as well as the ability to directly visualize nerves, bone marrow and hyaline cartilage, are advantages of MR imaging relative to conventional imaging techniques. As the elbow is located super - cially, clinical examination is easier for the orthopedic surgeon and only a few cases need a diagnosis for the radiologist, for this reason the elbow joint is little known for the

radiologist. To better understand the injuries that occur in the elbow during the sport

Keywords

activities, we need a better understanding of the biomechanics of the joint. And for

understanding the biomechanics, it is necessary to know the exact anatomy of the

elbow joint and to be able to identify each anatomic structure in the different imaging

planes and pulse sequences. This is especially important in MR as the imaging tool that

elbow

anatomy

elbow MR

elbow ultrasound

elbow biomechanics

shows a highest soft tissue resolution among other imaging techniques.

Imaging of the elbow can be a challenge for the inexperienced radiologist. Because of its super cial location, clinical exami- nation of the elbow is relatively easier. Also, most of these lesions affect the bone and are possible to evaluate with plain lm. Most elbow injuries are diagnosed only with the ortho- pedic surgeons clinical examination and plain lm. A few cases need a diagnosis by the radiologist. Thus the elbow joint is little known to the radiologist.

Positioning and Imaging Technique

Because the elbow is located away from the center of the body, positioning can be dif cult. Imaging of the elbow with the patient supine, arm at the side, has been described. However, positioning the elbow at the periphery of the magnetic eld often results in a poor signal-to-noise ratio and may severely limit the effectiveness of spectral fat saturation techniques. In addition, the examination may be dif cult in large patients. We prefer patients in the prone position with the affected arm over the head (the so-called superman position) 1 ( Fig. 1 ). This position keeps the elbow near the isocenter of the magnet. However, this position is sometimes uncomfortable and leads to poor quality images. In a recently described new patient position, the patient lies prone with the arm over-

Issue Theme Sport Injuries of the Elbow and Fingers; Guest Editor, Mario Padrón, MD

head, the elbow at 90 degrees, and the forearm supinated (the acronym used is the FABS position: exed elbow, adducted shoulder, forearm supinated). 2 It is possible to study the elbow joint with ultrasound (US) that offers some advantages over magnetic resonance (MR) imaging. One of them is the ability to perform the examina- tion in a comfortable position for the patient. 3

Normal Anatomy

Descriptions of the elbow anatomy can be subdivided into the classic forms:

1. Elbow joint and bone

2. Joint capsule and articular recess

3. The ulnar collateral ligament and the radial collateral ligament

4. Tendons and muscles

5. Neurovascular structures

Elbow Joint and Bone

The elbow joint has three joints: the ulnohumeral, radio- capitellar, and proximal radioulnar joints located within a synovial-lined joint capsule. 4 The ulnohumeral joint, a hinge

Copyright © 2013 by Thieme Medical

Publishers, Inc., 333 Seventh Avenue, New 10.1055/s-0033-1361587.

York, NY 10001, USA. Tel: +1(212) 584-4662.

ISSN 1089-7860.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

430 Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez

and Biomechanics of the Elbow Joint Martin, Sánchez Fig.1 Patient in the prone position. joint, is

Fig.1 Patient in the prone position.

joint, is formed by the articulation of the ulnar trochlear notch with the central waist of the humeral trochlea. The radiocapitellar joint is formed by the articulation of the convex cartilage-covered capitellum with the concave surface of the radial head. The proximal radioulnar joint consists of the radial head, whose outer circumference articulates with the radial notch, a small depression along the lateral surface of the coronoid process of the ulna ( Fig. 2 ). It is important to know the normal bone anatomy of the elbow because MRI can diagnose occult fractures such as stress fractures, bone con- tusion, and a small epiphyseal avulsion that can be missed with plain lm.

Joint Capsule and Articular Recess

The elbow joint has a capacity of 24 to 30 mL and is delineated by its capsule and associated synovial lining. The anterior joint capsule and synovium inserts proximal to the coronoid and radial fossa at the anterior aspect of the humerus. The posterior joint capsule attaches to the humerus just proximal

joint capsule attaches to the humerus just proximal Fig. 2 The elbow joint consists of three

Fig. 2 The elbow joint consists of three joints: the ulnohumeral, radiocapitellar, and proximal radioulnar joints.

to the olecranon fossa. Between the synovium and capsule are anterior and posterior fat pads. 4 Three small masses of fat rest in the radial, coronoid, and olecranon fossa 5 ( Fig. 3 ). It is possible to assess these fat pads with US.

Fat Pad Sign

The anterior fat pad is a summation of radial and coronoid fat pads that are normally pressed into the shallow radial and coronoid fossa by the brachialis muscle. On a lateral radio- graph of the elbow with 90 degrees of exion, the anterior fat pad is normally seen as a faint radiolucent line parallel to the anterior distal humerus. The posterior fat pad is normally pressed into the deep olecranon fossa by the triceps tendon and invisible on a true lateral radiograph. 5 Distension of an intact joint capsule causes displacement of the fat pads. The anterior fat pad is displaced anteriorly and superiorly, and the posterior fat pad is displaced posteriorly and superiorly and becomes visible on the lateral radiograph of the elbow in 90 degrees of exion ( Fig. 4 ).

of the elbow in 90 degrees of fl exion ( ► Fig. 4 ). Fig. 3

Fig. 3 There are three small masses of fat in the ( a ) radial (arrowhead), ( b ) coronoid (arrowhead), and olecranon fossa (white arrow).

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez 431

and Biomechanics of the Elbow Joint Martin, Sánchez 431 Fig. 4 ( a ) Sagittal T2-weighted

Fig. 4 ( a ) Sagittal T2-weighted image. Distension of an intact joint capsule ca uses displacement of the fat pads. The anterior fat pad is displaced anteriorly and superiorly, and the posterior fat pad is displaced posteriorly and superiorly (black arrows). ( b ) Lateral radiographs of the elbow in 90 degrees of exion. The lateral radiograph shows the anterior fat pad displace d anteriorly and superiorly (arr owheads); the posterior fat pad becomes visible on the lateral radiograph of the elbow (black arro ws). This patient had a fracture o f the radial head (white arrow).

Collateral Ligaments of the Elbow

The ulnar and radial collateral ligaments are important joint- stabilizing structures.

The Ulnar Collateral Ligament

The ulnar collateral ligament consists of (1) the anterior bundle, which extends from the anterior aspect of the medial epicondyle to the med ial coronoid margin; (2) the posterior bundle, which extends from the posteroinferior aspect of the medial epicondyle to the medial olecranon margin; and (3) the transverse bundle, which extends from the coronoid process to the olecranon. 4 The most important stabilizing ligament is the anterior bundle. This bundle is the easier to visualize on coronal MR like a well-dened low signal intensity band. In most cases the posterior and transverse bundle is dif cult to identify on MR images

( Fig. 5 ). 6

It is possible to evaluate the anterior band of the ulnar collateral ligament with US. It is shown as a thin hypoechoic band deep to the common exor tendon. 3

The Radial Collateral Ligament

The radial collateral ligament consists of (1) the radial collat- eral ligament proper,which extends from the anteroinfe- rior aspect of the lateral epicondyle to diffusely insert in the annular ligament; (2) the lateral ulnar collateral ligament, which extends from the anteroinferior aspect of the lateral epicondyle to the supinator crest of the ulna; and (3) the annular ligament, which encircles the radial head and at- taches to the anterior and posterior margins of the radial notch of the ulna. 4,7 The most important stabilizing ligament is the lateral ulnar collateral ligament. The radial collateral ligament proper and lateral ulnar collateral ligament are best visualized in coronal MR images ( Fig. 6 ). On US the radial collateral ligament appears as a thin brillar structure with a slightly different course with respect to the extensor common tendon origin. 3

Tendons and Muscles

Elbow muscle anatomy is complex. There are at least 16 muscles in the elbow, and these muscles involve not only the elbow but also the shoulder and wrist. These muscles have different functions that include exion, extension, pronation, and supination. 8 We have arbitrarily subdivided the elbow into four quadrants consisting of anterior, lateral, medial, and posterior aspects. 3

Anterior Compartment

In the anterior compartment are two muscles: the biceps brachii muscle and the brachialis muscle. 1,3,7,8 The distal biceps tendon is a at tendon that inserts distally on the radial tuberosity. It appears round and shows low signal intensity on axial images (Fig. 7 ). Another structure, the bicipital apo- neurotic or lacertus brosus, descends medially to insert into the subcutaneous border of the upper ulna via the deep fascia of the forearm 2 (Fig. 7 ). The brachialis muscle is located deep

2 ( ► Fig. 7 ). The brachialis muscle is located deep Fig. 5 The anterior

Fig. 5 The anterior bundle of the ulnar collateral ligament (white arrows).

Seminars in Musculoskeletal Radiology Vol. 17 No. 5/2013

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

432 Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez

and Biomechanics of the Elbow Joint Martin, Sánchez Fig. 6 ( a ) The lateral ulnar

Fig. 6 ( a ) The lateral ulnar collateral ligament extends from the anteroinferio r aspect of the lateral epicondyle to the supinator crest of the ulna (white arrows). ( b ) The radial collateral ligament proper extends from the anteroinferior aspect of the lateral epicondyle to insert in the annular ligament (white arrows).

to the muscle biceps brachii and runs through the anterior joint capsule to insert into the cubital tuberosity.

Lateral Compartment

The muscles in this compartment form the common extensor tendon ( Fig. 8 ) 1,3,7,8 :

Extensor carpi radialis longus muscle

Extensor carpi radialis brevis muscle

Extensor digitorum longus muscle

Extensor carpi ulnaris muscle

Medial Compartment

The muscles in this compartment form the common exor tendon ( Fig. 8 ) 1,3,7,8 :

fl exor tendon ( ► Fig. 8 ) 1 , 3 , 7 , 8 :

Fig. 7 ( a ) The distal biceps inserts distally on th e radial tuberosity (black arrows). ( b ) It appears round and shows low signal intensity on axial images (black arrows). ( c ) The lacertus brosus is shown (black arrow).

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez 433

and Biomechanics of the Elbow Joint Martin, Sánchez 433 Fig. 8 ( a ) In the

Fig. 8 ( a ) In the lateral compartment are the muscles that form the common extensor tendon (arrowheads). ( b ) In the medial compartment are the muscles that form the common exor tendon (black arrows).

Pronator teres muscle

Flexor carpi radialis muscle

Palmaris longus muscle

Flexor carpi ulnaris muscle

Flexor digitorum super cialis muscle

Posterior Compartment

The two muscles in the posterior compartment are (1) the triceps brachii muscle that travels along the posterior aspect of the humerus and inserts into a broad tendon on the olecranon process of the ulna, and (2) the anconeus muscle. 1,3,7,8

Neurovascular Structures

Three major nerves traverse the elbow joint: the ulnar nerve, the median nerve, and the radial nerve. 3,9

The Ulnar Nerve

The ulnar nerve is the most consistently identi ed at the elbow. The nerve is clearly delineated posterior to the medial humeral epicondyle as it runs within a bro-osseus tunnel (cubital tunnel). This tunnel is bordered by the medial epicondyle (medial border), the olecranon (lateral border), the elbow capsule at the posterior aspect of ulnar collateral ligament (oor), and a retinaculum (roof) the Osborne fascia that continues distally with the aponeu- rotic arch, the arcuate ligament. On axial MR images, the ulnar nerve can usually be followed as it proceeds between the ulnar and humeral heads of the exor carpi ulnaris muscle ( Fig. 9 ). It is possible to evaluate the ulnar nerve with US. The ulnar nerve appears as an ovoid hypoechoic image close to the hyperechoic bony cortex of the medial epicondyle.

The Radial Nerve

Slightly above the elbow joint, the radial nerve is usually outlined within a strip of fat separating the brachialis, bra- chioradialis, and the extensor carpi radialis longus muscles.

The Median Nerve

The median nerve courses in the fascial planes between the pronator teres and brachialis muscles. The medial nerve is often barely distinguishable from the muscles because of the compactness of the muscles and the minimal amount of fat present at that level.

muscles and the minimal amount of fat present at that level. Fig. 9 The ulnar nerve

Fig. 9 The ulnar nerve runs within the cubital tunnel (cross).This tunnel is bordered by the medial epicondyle (black arrow), the olecranon (white arrow), and th e Osborne fascia (arrowhead).

Seminars in Musculoskeletal Radiology Vol. 17 No. 5/2013

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

434 Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez

and Biomechanics of the Elbow Joint Martin, Sánchez Fig. 10 The range of movement of the

Fig. 10

The range of movement of the elbow is from 0 degrees in extension to 150 degrees of exion.

Biomechanics of the Elbow

Biomechanics is the science that examines forces acting upon and within a biological structure and effects produced by such forces10 Biomechanics is a complex study of function and demands including structure, motor power and acceler- ation, and angular forces and loads. Regarding the elbow, the study of biomechanics includes the exion/extension motion, pronation/supination motion; motor power and acceleration related to the biceps brachialis, triceps brachioradialis, supi- nator and pronator teres muscles; structural shapes and interactions of the distal humerus/proximal radius/proximal ulna; and the forces related to a variety of demands, ranking from lifting to throwing. 11 The elbow is a trocho-ginglymus joint with three articu- lations (the ulnohumeral, radiocapitellar, and proximal radio- ulnar joints) that acts as a link between the shoulder and the hand, and possesses two degrees of freedom: exion-exten- sion and pronation-supination. 12 Elbow exion normally ranges from 0 degrees or slight hyperextension, to 150 degrees of exion ( Fig. 10 ). The radiocapitellar joint and proximal radioulnar joint provide 85 degrees of supination and 75 degrees of pronation. The axis passes through the center of the radial head and extends through the radial border of the distal ulna. There are 3 to 41 degrees of varus-valgus and axial laxity that occur with elbow exion. Maximal extension can be limited by impaction of the olecranon into the olecranon fossa anterior capsule and ligaments, and the exor muscle tightness. Maximal exion is limited by anterior muscle bulk, the impaction of the radial head and coronoid process into their corresponding fossa, and triceps muscle tightness. 12 The elbow in full extension and supination has a relative valgus alignment called a carrying angle that measures 10 to 15 degrees in men and 5 degrees greater in women

( Fig. 11 ). 11

The congruity of the articulations as well as the capsule, medial, and collateral ligament complexes, account for most of the stability of the joint. Muscles play a dynamic role in stabilizing the elbow. The primary stabilizer for varus stability is the articulation of the ulnohumeral joint. The medial collateral ligament is the

primary stabilizer versus valgus stress, and it is the most important stabilizer for the throwing motion. The elbow is used in many different activities such as throwing, tennis and golf swings, and volleyball, and there- fore most elbow complaints are related to sports. Most elbow injuries are as result of repetitive use, although traumatic injuries are also common. 13 Two stabilizer elements can found in the elbows joint:

passive stabilizers and bony stability.

Passive Stabilizers

Bony Stability

The interlocking highly congruous articular surfaces of the elbow joint make it an inherently stable joint. The radial head

joint make it an inherently stable joint. The radial head Fig. 11 forearm with the elbow

Fig. 11

forearm with the elbow in full extension measures between 10 and 20

The carrying angle made between the axes of the arm and the

degrees.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez 435

acts as a secondary stabilizer to valgus stress, but it also indirectly helps to stabilize against varus stress. Therefore, the radial head becomes important to valgus stability when the medial ulnar collateral ligament is injured. Force trans- mission across the radial head is greatest with the elbow in 0 to 30 degrees exion, and it is also increased when the forearm is placed into pronation. An et al showed that 75 to 85 degrees of varus stress was resisted by the proximal half of the olecranon, and 60 to 67% of varus stress was resisted by the coronoid (distal half of the sigmoid notch). 14 The olecranon engages the olecranon fossa of the humerus at 20 degrees, making the elbow inherently more stable against varus-valgus stress when in full exten- sion. The coronoid process plays an important role in pre- venting posterior dislocation. The coronoid is also essential to varus stability when the lateral collateral ligament is intact.

Capsuloligamentous Contribution

The medial collateral ligament complex consists of the ante- rior bundle, the posterior bundle, and the transverse ligament (ligament of Cooper/oblique bundle). Several biomechanical studies have established that the anterior medial collateral ligament (AMCL) bundle acts as the elbow s main stabilizer to valgus stress. The AMCL is the primary valgus stabilizer in the functional elbow range of motion, whereas the role of the posterior medial collateral ligament bundle is more impor- tant in higher degrees of exion. Speci cally, with a valgus load, the anterior band of the anterior bundle is taut from 0 to 85 degrees, whereas the posterior band is taut from 55 to 140 degrees of exion. The midportion of the anterior band maintains tension throughout the elbow range of motion. The lateral collateral ligament complex is composed of the radial collateral ligament, the lateral ulnar collateral ligament, the annular ligament, and the accessory lateral collateral ligament. It originates on the lateral epicondyle, slightly posterior to the axis of rotation of the elbow, allowing the ligament to remain taut throughout elbow range of motion. The annular ligament is the primary stabilizer of the proximal radioulnar joint. The anterior portion of the annular ligament is taut during supination, whereas the posterior portion becomes taut during pronation. 2 The accessory later- al collateral ligament is an inconstant structure that extends from the annular ligament to the supinator crest along the lateral aspect of the ulna. When present, it acts to further stabilize the annular ligament during varus stress. 15 Ligamentous injuries of the elbow may be related to a single traumatic event, as in elbow dislocation or varus extension stress injury to the radial collateral ligament, or to chronic repetitive trauma with valgus stress to the medial collateral ligament. Injury to the ulnar band of the radial collateral ligament has also been reported as a complication of common extensor tendon release for treatment of lateral epicondylitis.

Active Stabilizers

Only a few muscles work primarily to move the elbow. Any muscle that crosses the elbow joint does generate a joint reactive force and thereby helps to stabilize the joint by

compressing the articular surfaces. The four main muscle groups around the elbow are the anterior biceps group, the posterior triceps group, the lateral extensor-supination group, and the medial exor-pronator group. The primary elbow exors are the brachialis, biceps brachii, and brachior- adialis. Secondary elbow exors include the pronator teres, extensor carpi radialis longus, and the exor carpi radialis. The exor pronator group serves as a secondary stabilizer of the elbow joint, assisting the ulnar collateral ligament against valgus stress. The biceps is the most powerful supinator of the forearm while also assisting in elbow exion. Therefore, exion or exion-supination motions most often aggravate pain related to distal biceps tendinopathy. Rupture of the distal biceps tendon is most often secondary to sudden, forceful extension overload of the arm with the elbow in mild exion. This mechanism of trauma is most common in weightlifters and rugby players. Distal biceps musculotendinous ruptures are typically associated with trauma occurring on the glenohum- eral elevation with the elbow extended and the forearm in supination. Extension of the elbow is provided by the triceps and the anconeus. Pronation is powered by the pronator teres and pronator quadratus. Supination is powered mainly by the biceps, with assistance from the supinator, and to a lesser degree the nger and wrist extensors. The wrist extensor tendons assist in stabilizing the elbow against varus stress. Triceps tendon avulsion is most often secondary to acute trauma. The mechanisms of injury in- clude 1 decelerating counterforce during active extension as in a fall with an outstretched hand, 2 direct blow to the tendon, and 3 forceful eccentric contraction of the triceps muscle with the elbow exed. Relocation of the medial head of triceps tendon during elbow extension from the exed position is responsible for the painful snapping sensation typical of snapping triceps syndrome. 12 Certain occupations and activities expose the elbow to increased amounts of stress that can lead to traumatic or overuse-type injuries. Elbow biomechanics plays a very im- portant role in many throwing motions including the baseball pitch, the football pass, the javelin throw, and the windmill softball pitch. The elbow is also emphasized in other popular activities such as the tennis serve and golf swing. The amount of stress experienced across the elbow partially depends on the positioning of the hand, shoulder, and elbow. This is seen in the baseball pitch. Most of these injuries result from the accumulation of microtraumas from repetitive pitching. The six phases of pitching are windup, stride, arm cocking, arm acceleration, arm deceleration, and follow-through. Max- imal valgus torque is generated during the cocking and acceleration phases of throwing, in which torque peaks immediately before ball release. During arm cocking, large tensile forces are produced on the medial aspect of the elbow. The repetitive valgus loading of the elbow joint at this instant is most often associated with a possible injury to the ulnar collateral ligament. Morrey and An demonstrated that the ulnar collateral ligament contributes 54% of the resistance to valgus loading in the exed arm position. 16 It must

Seminars in Musculoskeletal Radiology Vol. 17 No. 5/2013

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

436 Anatomy and Biomechanics of the Elbow Joint Martin, Sánchez

combine with the elbow stabilizers and the elbow muscles to reduce the stress and to resist this valgus loading. Muscle contraction during this phase may reduce the stress seen on the ulnar collateral ligament by compressing the joint and adding stability. In high-level athletes, the repetitive stress of throwing can lead to predictable problems in the elbow due to valgus exten- sion overload. Medial tension injuries include medial ulnar collateral ligament sprain or rupture, ulnar neuritis, and ex- or-pronator tendinitis/rupture. Posterior impingement due to wedging of the olecranon into the fossa can lead to poster- omedial osteophyte formation and olecranon stress fracture. Lateral compression of the radiocapitellar joint can lead to osteoarthritis, fragmentation, and loose body formation. Valgus stress is placed on the elbow by activities such as throwing and golng. Phases of the throw are particularly high during late cocking and acceleration. Golfers place this area under stress during their swing. On repetitive varus stress, the musculotendinous complex may be subjected to eccentric loading and potential overuse as in lateral epicondylitis.

References

1 Sonin AH, Tutton SM, Fitzgerald SW, Peduto AJ. MR imaging of the adult elbow. Radiographics 1996;16(6):1323 1336

2 Chew ML, Giuffrè BM. Disorders of the distal biceps brachii tendon. Radiographics 2005;25(5):1227 1237

3 Martinoli C, Bianchi S, Zamorani MP, Zunzunegui JL, Derchi LE. Ultrasound of the elbow. Eur J Ultrasound 2001;14(1):21 27

4 Daniels DL, Mallisee TA, Erickson SJ, Boynton MD, Carrera GF. The elbow joint: osseous and ligamentous structures. Radiographics 1998;18(1):229 236

5 Goswami GK. The fat pad sign. Radiology 2002;222(2):419 420

6 Cotten A, Jacobson J, Brossmann J, et al. Collateral ligaments of the elbow: conventional MR imaging and MR arthrography with coronal oblique plane and elbow exion. Radiology 1997; 204(3):806 812

7 Murphy BJ. MR imaging of the elbow. Radiology 1992;184(2):

525 529

8 Bunnell DH, Fisher DA, Bassett LW, Gold RH, Ellman H. Elbow joint:

normal anatomy on MR images. Radiology 1987;165(2):527 531

9 Rosenberg ZS, Bencardino J, Beltran J. MR features of nerve disorders at the elbow. Magn Reson Imaging Clin N Am 1997; 5(3):545 565

10 Loftice J, Fleisig GS, Zheng N, Andrews JR. Biomechanics of the elbow in sports. Clin Sports Med 2004;23(4):519 530, vii viii

11 Hutchinson MR, Wynn S. Biomechanics and development of the elbow in the young throwing athlete. Clin Sports Med 2004;23(4):

531 544, viii

12 Alcid JG, Ahmad CS, Lee TQ. Elbow anatomy and structural biomechanics. Clin Sports Med 2004;23(4):503 517, vii

13 Pope TL Jr, Bloem HL, Beltran J, Morrison WB, Wilson DJ. Normal elbow. In: Imaging of the Musculoskeletal System, Vol 1. Phila- delphia, PA: Saunders; 2008:221

14 An KN, Morrey BF, Chao EY. The effect of parcial renoval of proximal ulna on elbow constraint. Clin Orthop 1986;209:

270 279

15 Soller DW. The elbow. In: Magnetic Resonance Imaging in Orthopaedics and Sports Medicine. 3rd ed., Vol 2. Baltimore, MD: Lippincott Williams & Wilkins; 2007:1463

16 Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am JS Sports Med 1983;11:315 319

download,oremailarticlesforindividualuse.

listservwithoutthecopyrightholder'sexpresswrittenpermission.However,usersmayprint,

PublishingInc.anditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoa

CopyrightofSeminarsinMusculoskeletalRadiologyisthepropertyofThiemeMedical

download,oremailarticlesforindividualuse.

listservwithoutthecopyrightholder'sexpresswrittenpermission.However,usersmayprint,

PublishingInc.anditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoa

CopyrightofSeminarsinMusculoskeletalRadiologyisthepropertyofThiemeMedical