The Elbow Complex

Dr Youssef masharawi

Dr Youssef masharawi

Anterior view of the course of the median nerve. Note the path of the nerve between the two heads of the pronator teres muscle

Dr Youssef masharawi

 Anterior view of the course of the radial nerve. Note the position of the deep branch of the radial nerve (posterior interosseous nerve) as it passes through the arcade of Frohse at the proximal margin of the superficial head of the supinator muscle .
4 Dr Youssef masharawi

Dr Youssef masharawi

1. Radiohumeral joint
Arthrology Synovial pivot/hinge joint. Ligaments Radial collateral ligament Annular ligament Kinetics Joint is designed primarily for flexion and extension but must allow the radial head to spin during pronation and supination. the head of the radius is in full contact in full flexion as the head of the radius enters the radial fossa of the humerus. Only half of the head makes contact on full extension. Innervation Abundant from the radial nerve and its branches, musculocutaneous and some supply from median nerve.
Dr Youssef masharawi

2. Humeroulnar joint
Arthrology Synovial hinge joint. Ligaments Medial collateral ligament Arcuate ligament Kinetics Considered a hinge joint; flexion and extension sagittal motion. Innervation Supplied by the ulnar nerve, median nerve, musculocutaneous and radial nerves.
7 Dr Youssef masharawi

3. Superior Radioulnar joint

Arthrology Synovial pivot joint. Ligaments Annular ligament Quadrate ligament Kinetics The adult radial head is oval in shape allowing the axis of the radius to displace laterally during pronation; Also during pronation the radius rotates, and the radial head tilts laterally and distally. Innervation Branches of median, ulnar, musculocutaneous and readial nerves.
8 Dr Youssef masharawi

Valgus stability
In extension, valgus stability is provided by the medial collateral ligament, anterior capsule and bony articulation. In flexion 54% of the stability is provided by the MCL alone. The anterior oblique portion of the MCL is thought to be a particularly important stabilizer.
9 Dr Youssef masharawi

Varus stability
In extension, varus stability is provided by the capsule (32%), the bony articulation (54%) and the lateral collateral ligament (14%). In flexion more stability is provided by the articulation (78%). In distraction most of the resistance was capsular (78%). Disruption of the lateral collateral ligament complex post dislocation or after chronic varus microtrauma . Elbow not often subject to varus stress. Straight varus instability is not as apparent as the posterolateral rotatory instability that always accompanies disruption of the LCL.

10

Dr Youssef masharawi

Posterolateral stability
Fall onto outstretched hand producing a valgus stress with hypersupination under axial compression. Disrupts the LCL (ulnar band) first with spontaneous reduction of subluxation, further stress disrupting medial ligament complex (posterior band first then anterior band) and the anterior capsule. Stages of disruption range from subluxation to complete dislocation. Other causes include: Lateral release for tennis elbow (LUCL disruption), radial head excision.
11 Dr Youssef masharawi

Carrying angle: Initially it was defined as the angle formed by the long axis of the humerus and the long axis of the ulna. An average angle of 10-15 degrees for men and slightly higher for women was described. This angle has since been measured using the humerus or the ulna as the fixed reference system. A third system is more dynamic and measures the abduction/adduction angle of the ulna with respect to the humerus. In this case the carrying angle progressively decreases with flexion.
12 Dr Youssef masharawi

Activities Commonly Associated with Overuse Elbow Injuries

Posterior dislocation: Posterolateral rotatory instability Racquet sports: Pronator syndrome, triceps tendinosis, olecranon stress fracture, lateral tennis elbow, radial tunnel syndrome, golfer's elbow, ulnar nerve entrapment Rowing: Radial tunnel syndrome Skiing: Ulnar nerve entrapment Swimming: Radial tunnel syndrome Weight lifting: Biceps tendinosis, triceps tendinosis, anterior capsule strain, radial tunnel syndrome, ulnar nerve entrapment
13 Dr Youssef masharawi

Causes of Overuse Elbow Pain

Anterior elbow: Biceps tendinosis Pronator syndrome Anterior capsule strain Posterior elbow: Triceps tendinosis Olecranon impingement Olecranon stress fracture Olecranon bursitis
14 Dr Youssef masharawi

Causes of Overuse Elbow Pain

Lateral elbow: Lateral tennis elbow Radial tunnel syndrome Radiocapitellar chondromalacia Posterolateral rotatory instability Medial elbow: Medial tennis elbow (golfer's elbow) Ulnar collateral ligament sprain Ulnar nerve entrapment
15 Dr Youssef masharawi

 A complete examination of the elbow includes the neck, shoulder and wrist. The most common overuse injury of the elbow is lateral tennis elbow.

16

Dr Youssef masharawi

17

Dr Youssef masharawi

18

Dr Youssef masharawi

Normal tendon structure

parallel collagen fibers attached to the bone)

19

Dr Youssef masharawi

Tendinopathy.
Due to damage, some of the normal collagen fibers have been replaced by scar tissue, which has similar structure but is not as strong .

20

Dr Youssef masharawi

Tendonitis.
Secondary to the damage within the tendon substance, inflammatory changes have developed around the tendon. Anti-inflammatory medication (including tablets and cortisone injections) can help relieve pain, but do not help heal the tendon damage .
21 Dr Youssef masharawi

Healing tendon.
The scar tissue within the tendon is starting to reorganize and preserve some structural strength. The best way to make this happen is to repeatedly load the tendon below its threshold of damage. Overload is dangerous, but complete rest means that the healing won't occur either .
22 Dr Youssef masharawi

The goal of any tendino-pathy is a healed tendon, where new collagen fibers have grown and the tendon is now as strong as the original and is no longer painful. The tendon is usually a little wider and less elastic, but highly functional. In the vast majority of tendinopathy cases, healing like this is possible .

23

Dr Youssef masharawi