Clinical anatomy of the elbow

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2. MOB TCD
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
Clinical Anatomy of Elbow

3. Injuries to Elbow and Wrist
•Skin
•Bones
•Muscles, tendons
•Nerves
•Blood vessels
MOB TCD

4. Bones of Elbow
MOB TCD

5. 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

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

7. 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

8. 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

9. Synovial Membrane
•Lines the capsule and non-
articular structures inside the
capsule
•Continuous inferiorly with
synovial membrane of superior
radio-ulnar joints
•Annular ligament covered with
articular cartilage
MOB TCD

10. •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
Synovial Membrane
MOB TCD

11. 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

12. 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

13. Medial or Ulnar Collateral Ligament
•The ulnar nerve lies on the
medial ligament
•The anterior band may be
ruptured in throwing events
MOB TCD

14. 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

15. Medial Structures of Elbow
Common flexor origin, ulnar nerve
MOB TCD

16. 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

17. Posterior Relations
•Triceps
•Anconeus
•Olecranon bursa
•Ulnar nerve posterior to medial
epicondyle
•Common extensor origin
MOB TCD

18. Extensor Tendons
•Brachioradialis
•Extensor carpi radialis longus
•Extensor carpi radialis brevis*
•Extensor digitorum communis
•Extensor digiti minimi
•Extensor carpi ulnaris
MOB TCD

19. Posterior Relations
olecranon bursitis
medial
MOB TCD

20. Posterolateral
•Below lateral epicondyle
•Head of radius
•Behind the extensors of the forearm
•Posterior interosseous nerve
MOB TCD

21. Lateral Elbow
MOB TCD

22. 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

23. 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

24. 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

25. Elbow
•Biceps brachii Musculocutaneous C5,6
•Brachialis Musculocutaneous C5,6
•Pronator teres Median C6,7
•Supinator posteriorInterosseous C5,6
Anderson & Hall, 1995
MOB TCD

26. 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

27. 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

28. 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

29. •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
Biceps Brachii
MOB TCD

30. Action of Biceps Muscle
•Helps to stabilise and flex the
shoulder
•Its role as a dynamic
stabiliser of the gleno-
humeral 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

31. 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

32. 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

33. 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

34. Pain in Elbow and Wrist
•Must rule out referred pain
from cervical spine
•Upper thoracic spines
•Increased neural tension
MOB TCD

35. Test for Stability of Elbow
•Varus and valgus stresses
•0 and 30 degrees of flexion
Behr & Altchek, 1997
MOB TCD

36. Adult Elbow Injuries
Fractures
•Distal humerus
•Radial head and radial neck
•Olecranon
Dislocations
•Simple
•Fracture, dislocation
Behr & Altchek, 1997
MOB TCD

37. Elbow Pain
•Loose bodies
•Pain
•Locking
MOB TCD

38. 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

39. 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

40. 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

41. 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

42. Lateral Epicondylitis; Pathology
Tendonosis
1.Repetitive microtrauma
2.Angioplastic hyperplasia
3.Fibrosis
4.Granulation tissue
5.Mucoid degeneration
Nirschl, 1993
MOB TCD

43. •Racquet sports
•Backhand
•Throwing sports
•Golfers
•Musicians
•Labourers
Behr & Altchek, 1997
Lateral Epicondylitis
MOB TCD

44. •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
Test for Lateral Epicondylitis
MOB TCD

45. Elbow Nerve Compression
•Radial tunnel syndrome
•Posterior interosseous nerve
syndrome
•Cubital tunnel syndrome
•Pronator syndrome
•Anterior interosseous nerve
syndrome
Behr & Altchek, 1997
MOB TCD

46. 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

47. 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

48. 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

49. •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
Pediatric Elbow Injuries
MOB TCD

50. Elbow Dislocation
MOB TCD

51. 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

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