You are on page 1of 52

MOB TCD

Clinical Anatomy of Elbow


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

MOB TCD

Injuries to Elbow and Wrist



Skin Bones Muscles, tendons Nerves Blood vessels

MOB TCD

Bones of Elbow

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

Medial or Ulnar Collateral Ligament


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

MOB TCD

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

MOB TCD

Medial Structures of Elbow

Common flexor origin, ulnar nerve

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

Posterior Relations

medial

olecranon bursitis

MOB TCD

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

MOB TCD

Lateral Elbow

MOB TCD

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

MOB TCD

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)

MOB TCD

Common Flexor Origin


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

MOB TCD

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

Anderson & Hall, 1995

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

Pain in Elbow and Wrist


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

MOB TCD

Test for Stability of Elbow


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

MOB TCD

Adult Elbow Injuries


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

MOB TCD

Elbow Pain
Loose bodies Pain Locking

MOB TCD

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

MOB TCD

Test for Medial Epicondylitis


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

MOB TCD

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

MOB TCD

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

MOB TCD

Lateral Epicondylitis; Pathology


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

MOB TCD

Lateral Epicondylitis
Racquet sports Backhand Throwing sports Golfers Musicians Labourers

Behr & Altchek, 1997

MOB TCD

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

MOB TCD

Elbow Nerve Compression


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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

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

MOB TCD

BMJ Publishing Group Limited (BMJ Group) 2012. All rights reserved.