Clinical Anatomy of the Elbow BMJ

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


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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


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

Documents

Clinical Anatomy of the Elbow BMJ