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Elbow Anatomy

Francesc Malagelada

a , Miquel Dalmau-Pastor b , Jordi Vega c and Pau Golanó b,d a

Barts and The London NHS Trust, London, UK

b of Arthroscopic and Surgical Anatomy, L'Hospitalet de Llobregat, Barcelona, Spain c

Hospital Quiron, Barcelona, Spain

d Department of Orthopaedic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

Abstract

The elbow is a complex joint that consists of three different articulations: humeroulnar, humeroradial, and proximal radioulnar. During certain activities it can be subjected to signicant loads, especially in racquet or throwing sports. The ligamentous complexes of the elbow are involved in the pathoanatomy of throwing athletes or in elbow dislocations and instability. The elbow is crossed by important nerves and vessels for the function of the upper extremity and is the origin of theexor-pronator and extensor-supinator musculatures of the forearm. A sound knowl- edge of the elbow anatomy is essential to diagnose and treat elbow sports injuries. The aim of this chapter is to present a review of the elbow anatomy to assist the surgeon or sports medicine physician in the diagnosis and treatment of the athletic population.

Introduction

The elbow is a complex joint consisting of three articulations: the humeroulnar, the humeroradial,

and the proximal radioulnar joints. Although it is not a weight-bearing joint, it can be subjected to

high loads when practicing racket or throwing sports, or in gymnastics. As a consequence of these

continued sport activities, stability structures of the elbow can result affected. Elbow stability is

provided by static and dynamic constraints. Static constraints or passive elbow stabilizers include the osteoarticular anatomy, the medial and lateral collateral ligament complexes, and the capsule. Dynamic constraints or active elbow stabilizers are the muscles that cross the elbow joint. A thorough knowledge of the anatomy is essential to diagnose and treat any conditions in the elbow. Along with the necessary skills, anatomy is the key to consistent results in open and arthroscopic surgery. The aim of this chapter is to provide the surgeon or sports medicine physician with a visual review of the elbow anatomy.

Surface Anatomy

The elbow is a supercial joint, and therefore, many anatomical landmarks can be palpated around its surface. Understanding of surface anatomy is necessary to perform an effective physical

Pau Golano has deceased

*Email: paugolano@gmail.com *Email: pgolano@ub.edu

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examination and in surgical and nonsurgical management. Prior to arthroscopic portal placement, some of these landmarks should be marked, including the ulnar nerve (Byram et al.2013). In anatomical position (extension and supination of the elbow), the cubital fossa and its bound- aries are easily observed in the anterior area. The brachioradialis muscle forms the lateral border, whereas the medial is formed by the pronator teres muscle distally and the tendon of the biceps

the insertion of the biceps brachii tendon. A change in muscle contour, or proximal retraction of the

muscle, may indicate a distal biceps brachii tendon rupture (Hsu et al.2012). The median nerve is Itisfeltasacord-like structure. Nexttoitthepulseofthebrachialartery isevident astheyfollowthe same course together. Theexor-pronator musculature is palpable emerging from its origin at the

medial epicondyle. Both the cephalic vein laterally and the basilic vein medially are usually visible

in athletic subjects. Posteriorly, the olecranon is easily localized at the center of the joint. When the elbow is at 90 of exion, the medial and lateral epicondyles form an inverted triangle with the olecranon (Fig.2). On

Fig. 1Anatomical dissection of the cubital fossa and its boundaries.1Biceps brachii muscle,2biceps brachii tendon,

3lacertusbrosus,4brachialis muscle,5brachioradialis muscle,6extensor carpi radialis longus,7extensor carpi

radialis brevis,8pronator teres,9exor carpi radialis,10palmaris longus11exor carpi ulnaris,12musculocutaneous

nerve,13communicating venous branch (cut) between the supercial veins and humeral veins,14median nerve,15

humeral artery.#Pau Golano

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the medial aspect of the elbow, the ulnar nerve can be palpated distal to the medial epicondyle at the

level of its groove. It should also be checked for mobility since it can become subluxated during exion of the elbow and reduced in extension (Novak et al.2012). On the lateral aspect, the lateral epicondyle and the extensor-supinator musculature are palpable. Another group of muscles, the mobile wad of three (Henry1970) (brachioradialis, extensor carpi radialis brevis, and extensor carpi

radialis longus), are located anterior to the extensor-supinator mass. At a distance of 2 cm distally

from the lateral epicondyle, the humeroradial joint and the radial head are felt especially when pronosupinating the forearm. A posterolateral soft spot formed between the lateral epicondyle, the olecranon, and the radial head is a landmark for placement of the direct lateral arthroscopic portal. Through this portal irrigationuid is introduced into the joint to distend the anterior compartment and create a safe anterior working area for arthroscopy. Furthermore, this posterior soft spot should be palpated for fullness, indicating elbow joint effusion or hemarthrosis (Hsu et al.2012) (Fig.3). Other commonly used portals during elbow arthroscopy are summarized in Table1with distances to anatomic landmarks and structures at risk (Rosenberg and Loebenberg2007).

Osteology

The elbow can be simplied to a hinge joint (ginglymus) between the distal humerus and proximal ulna and radius (Fig.4). In reality, it consists of three different joints: the humeroulnar and the

Fig. 2Elbow viewed from posterior. (a) With the elbow extended, the medial and lateral epicondyles and the tip of the

olecranon are alienated. (b) With the elbowexed to 90 , these three bony landmarks form an equilateral triangle. The

relationship between these three bony landmarks is altered with displaced intra-articular distal humerus fractures or

during elbow dislocations.#Pau Golano

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humeroradial (ginglymoid motion inexion and extension) and the proximal radioulnar joint (trochoid motion in pronation and supination). Combined these articulations create a trochleo- ginglymoid joint (Prasad et al.2003). This conguration makes the elbow fairly constrained and one of the most congruous and stable joints of the body (Fig.5). The ulna and the radius are connected by the forearm interosseous membrane which highly contributes to the stability of the proximal and distal radioulnar joints. The normal range of motion of the elbow is approximately 0 of extension and 140 ofexion. A functional range of motion for activities of the daily living has been described to be of 30-130 andthe functional arcofthrowingrangesfrom20 to130 .Thenormalsupinationandpronationare both of approximately 80 (Morrey et al.1981) (Fig.6). lateral supracondylar columns transition to the medial and lateral epicondyles and terminate at the two humeral condyles with their articular surfaces. The outermost aspect of these columns com- prises the medial and lateral supracondylar ridges, respectively. The medial condyle has the spool- shapedtrochleawhicharticulateswiththeproximalulnaandiscoveredbyarticularcartilage overan arc of 300 . The more prominent medial epicondyle is an attachment point for the ulnar collateral ligament complex and theexor-pronator musculature. The lateral condyle has the hemispheric- shaped capitulum which articulates with the radial head (Miyasaka1999; Morrey and An2000). Lateral and proximal to the capitulum is the lateral epicondyle, an origin point for the lateral collateral ligament complex and the supinator-extensor musculature (Fig.7). Just proximal to the condyles, there are three fossas that are uncovered of articular cartilage but play an important role in the range of movement. Anteriorly, the coronoid and radial fossa accommodate the coronoid process of the ulna and radial head, respectively, during elbowexion

Fig. 3(a) Lateral view of the elbow showing the surface anatomy of the soft spot formed between the lateral

epicondyle, the olecranon, and the radial head. (b) Anatomical dissection showing the relationship of the soft spot

and the wrist extensors muscle group.1Biceps brachii muscle,2brachialis muscle,3triceps brachii muscle,4lateral

intermuscular septum,5brachioradialis muscle,6extensor carpi radialis longus muscle,7extensor carpi radialis brevis

muscle,8extensor digitorum muscle,9anconeus muscle,10extensor digiti minimi.#Pau Golano

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(Fig.7). Posteriorly, the olecranon fossa accommodates the olecranon in full elbow extension. If an occupying lesion is present in these areas,exion and extension of the elbow will be reduced. The humeral trochlea articulates with the ulnar notch (or incisura semilunaris) of the proximal ulna. This notch opens at an angle of 30 posteriorly with respect to the long axis of the ulna. The medial ridge of the trochlea is more prominent than the lateral ridge, causing a valgus tilt of 6-8 at the articulation (Miyasaka1999). The capitulum articulates with the concave surface of the radial angulated30 posteriorangleofthe ulnar notch to allow full extension (Fig.7). The carrying angle is dened by the angle between the long axis of the humerus and ulna measured in full extension. This averages 11-14 in males and 13-16 in females. This valgus angle is commonly greater than 15 in throwing athletes (King et al.1969; Morrey and An2000). The proximal radius includes the cylindrical radial head and neck (Figs.8and9). The radial head articulates with both the radial notch of the ulna and the humerus at the capitulum and at the of 280 of the rim. This leaves the remaining 80 of the anterolateral rim devoid of cartilage. The radial neck length is of 13 mm (range 9-19mm). The radial head is angulated 55 (range 45-65º).

Table 1Elbow arthroscopic portals. + Distances showed in mm correspond to the average distance. Note that portals

are safer when the elbow is flexed

Portal Purpose Location Structures at risk +

Direct lateralDistension/viewing Soft spot (triangle between olecranon, radial head, and lateral epicondyle)Posterior antebrachial cutaneous nerve

Proximal

medialWorking/highow irrigation2 cm proximal to medial epicondyle. Slightly anteriorto theintermuscular septumMedian nerve (12.4 mm distended/7.6 mm non distended)

Ulnar nerve (12 mm)

Medial antebrachial

cutaneous nerve (6 mm at 90
exion) AnterolateralViewing 1 cm distal and 1 cm anterior to lateral epicondyle. In a sulcus between radial head and capitulumRadial nerve (3 mm at 90 exion)

Preference to the safer

proximal lateralPosterior antebrachial cutaneous nerve (2 mm at 90
exion)

Proximal

lateralViewing 2 cm proximal and 1 cm anterior to the lateral epicondyleLateral antebrachial cutaneous nerve (6.1 mm)

Radial nerve (9.9 mm at

90
/4.9 mm in extension) AnteromedialViewing 2 cm anterior and 2 cm distal to the medial epicondyleMedial antebrachial cutaneous nerve (1 mm)

Median nerve (7 mm

exed/2 mm extended) PosterolateralViewing 3 cm proximal to olecranon, superior and posterior to the lateral epicondyleMedial and posterior antebrachial cutaneous nerves (25 mm)

Straight

posteriorWorking (removal of posterior osteophytes or synovectomy)3 cm medial to the posterolateral portal Posterior antebrachial cutaneous nerve (23 mm)

Ulnar nerve (25 mm)

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This radial torsion is calculated by comparing a line drawn on the radial head, perpendicular to the radial notch, to a line drawn between the center of the radial styloid process and the center of the ulnar notch. Likewise the radial head is angulated when compared to the diaphysis as shown by a proximal diaphysis-neck angle of 17 (range 6-28º). These considerations are important when

Fig. 5Elbow bones and its joints showing the most important anatomical details. (a) Anterior view, (b) posterior view.

1Humeral diaphysis,2lateral supracondylar ridge,3medial supracondylar ridge,4radial fossa,5coronoid fossa,

6olecranon fossa,7lateral epicondyle,8medial epicondyle,9capitulum,10trochlea,11trochleocapitellar groove,12

radial diaphysis,13radial head,14radial neck,15radial tuberosity,16ulnar diaphysis,17coronoid process,18

olecranon,19ulnar tuberosity.#Pau Golano

Fig. 4Anterior view of the elbow bones and its joints: humeroulnar, the humeroradial, and the proximal radioulnar

joints. The bones have been colored digitally with Adobe Photoshop. Withred colorthe humerus, withblue colorthe

radius, and withgreen color, the ulna.#Pau Golano

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restoring radial anatomy in cases of radial head fractures or prosthetic replacements (Van Riet

et al.2004). The radial neck connects the radial head to the shaft. At the medial and distal aspect of

the neck, the radial tuberosity can be found; it is a bony prominence that serves as the insertion point

of the biceps tendon. The proximal ulna consists of the olecranon and the ellipsoid anterior surface of the ulnar notch. The notch is covered by articular cartilage except for the mid portion which is usually covered by the ulnar notch is the coronoid process which is the insertion site for the brachialis muscle tendon and the anterior bundle of the medial collateral ligament. At the medial aspect of the coronoid process, the sublime tubercle is a bony prominence that serves as the insertion site for the medial collateral ligament. At the lateral aspect of the coronoid process, the supinator crest is a rather elongated bony prominence that serves as the attachment for the lateral ulnar collateral ligament process is an important restraint for elbow stability.

Capsule

The joint capsule surrounds all three articulations of the elbow joint. The anterior and posterior portions are thinner than the medial and lateral thickenings, which form the collateral ligamentous

posterior capsule is taut inexion (King et al.1993). It provides most of its stabilizing effects when

the elbow is extended (Deutch et al.2003) (Fig.11). Thecapacityofthenormal capsularelbow jointhas beenestimated tobejustover20ml(Fig.12). It has been described to be greater in cases of chronic instability and decreased in the presence of joint contractures (O'Driscoll et al.1990). The maximum volume capacity of the capsule is of

Fig. 6Range of motion of the elbow joint. (a) Flexion-extension movement, provided by the humeroulnar and the

humeroradial (ginglymoid). (b) Pronation-supination movement, provided by proximal radioulnar joint (trochoid).#

Pau Golano

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25-30mlinadults occurring at80

ofexion (Alcid etal.2004).Thisenables topredict theposition of greatest comfort when effusion or hemarthroses are present. Gray and Morrey in their anatomic studies provided detailed description of the elbow capsule (Gray1918; Morrey and An2000). The anterior capsule inserts proximally above the coronoid and radial fossas. Distally itisattached totheanterior marginofthe coronoidprocess medially andtothe annular ligament laterally. Fibrous bands have been described within the capsule: three anteriorly and three distinct bands posteriorly. Anteriorly, they have been termed according to its location as

anterior lateral, anterior medial oblique, and anterior transverse bands. The posterior capsule inserts

proximally above the olecranon fossa, and distally at the annular ligament and the tip of the olecranon. Most of the olecranon is therefore an extracapsular structure. The three capsular bands described posteriorly are the posterior lateral oblique, posterior medial oblique, and posterior

Fig. 7Humerus bone. (a) Anterior view, (b) posterior view, (c) lateral view, (d) medial view.1Humeral diaphysis,

2lateral supracondylar ridge,3medial supracondylar ridge,4radial fossa,5coronoid fossa,6olecranon fossa,7lateral

epicondyle,8medial epicondyle,9capitulum,10trochlea,11trochleocapitellar groove,12sulcus for ulnar nerve.

#Pau Golano

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Fig. 8Radius bone. (a) Anterior view, (b) posterior view.1Radial diaphysis,2radial head,3radial neck,4radial

tuberosity.#Pau Golano

Fig. 9Anterior view of the proximal radioulnar joint.1Ulnar diaphysis,2olecranon,3tip of the olecranon,4coronoid

process,5tip of the coronoid process,6ulnar notch,7the ulnar notch is divided by a transverse portion composed of

fatty tissue into a anterior portion made up of the coronoid process and the posterior olecranon,8sublime tubercle,

9radial notch,10ulnar tuberosity,11radial diaphysis,12radial head,13radial neck,14radial tuberosity,15typical

osteochondral lesion of the radial head at the level of trochleocapitellar groove.#Pau Golano

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transverse bands. They are considered to reinforce the capsule (Reichel and Morales2013) (Figs.11 and12). On the inner aspect of the capsule, some synovial folds can be distinguished. Specially consistent aretwolateralfolds, oneundertheannularligament andasecondonebetweentheheadoftheradius and capitulum which adopts a meniscoid structure and may assist in humeroradial joint motion (Bozkurt et al.2005; Sanal et al.2009) (Fig.13).

Ligaments

The medial and lateral collateral ligament complexes are primary elbow stabilizers (Bryce and Armstrong2008). The classical anatomy described below is found in the majority of cases but

Fig. 10Ulna bone. (a) Anterior. (b) Lateral view. (c) Posterior view. (d) Medial view.1ulnar diaphysis,2olecranon,

3tip of the olecranon,4coronoid process,5tip of the coronoid process,6ulnar notch,7the ulnar notch is divided by a

transverse portion composed of fatty tissue into a anterior portion made up of the coronoid process and the posterior

olecranon,8radial notch,9ulnar tuberosity,10supinator crest,11sublime tubercle.#Pau Golano

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Fig. 12Anterior view of the elbow joint capsule. The synovial space waslled with blue latex.1Medial epicondyle,

2lateral epicondyle,3synovial recess under the annular ligament,4radial tuberosity,5biceps brachii tendon (cut)at

the level of its insertion in the radial tuberosity,6coronoid process,7anterior medial obliquebrous band,8anterior

transverse band,9lateral collateral ligament,10annular ligament,11medial collateral ligament,12subsynovial fat pads.

#Pau Golano

Fig. 11(a)Anteriorviewoftheelbowjointcapsule.(b)Posteriorviewoftheelbowjointcapsule(elbowinextension).(c)

Posterior view of the elbow joint capsule (elbow in 90 offlexion).1Lateral epicondyle,2medial epicondyle,3synovial

recess under the annular ligament,4biceps brachii tendon (cut) at the level of its insertion in the radial

tuberosity,5olecranon,6lateral collateral ligament,7annular ligament,8medial collateral ligament,9coronoid process.

#Pau Golano

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variations have been described in the anatomy of both the medial and lateral collateral ligament complexes (Beckett et al.2000).

Medial Collateral Ligament Complex

The medial collateral ligament complex (MCL) consists of three bundles with different points of origin and insertion forming a triangular shape: the anterior, posterior, and transverse (Fig.14). Because of the multiplicity of the bundles and their functions, the MCL has been compared to the isthemostsignicantcomponent oftheMCL,beingthemainstabilizertovalgusstress oftheelbow (Morrey and An1985; Regan et al.1991; Callaway et al.1997; Miyake et al.2012). Its origin is at

5 mm anterior and inferior to the tip of the medial epicondyle and inserts on the sublime tubercle,

18 mm distal to the coronoid tip, along the medial aspect of the coronoid process (Cage et al.1995;

is of 27 mm (Morrey and An1983,O'Driscoll et al.1992b). The anterior bundle can be further divided into anterior and posterior bands (Morrey and An1985; Callaway et al.1997; Floris et al.1998). Some authors have included a third deep middle band (Fuss1991; Ochi et al.1999). Macroscopic observation denes a visible ridge that demarcates the border between the anterior and

the posterior band (Floris et al.1998). Histological study conrms that the insertion is not limited to

the sublime tubercle, but that somebers course over it to insert further distally on the proximal and

medial ulna (Dugas et al.2007). Neither the anterior nor posterior bands are isometric (Morrey and to 120 (Safran et al.2005). The anterior band is taut in extension and relaxes inexion. The posterior bandis taut atintermediate positions andrelaxed inextension. This isdueto the ligament's origin being slightly posterior to the axis of rotation inexion and extension. The middle band has been described as being isometric throughout all the elbow range of motion. Therefore, it has been suggested as the"guiding band"for ligament reconstruction (Fuss1991). Multiple techniques and modications in bone tunnel placement have been described (Thompson et al.2001; Armstrong et al.2002; Bowers et al.2010; Slullitel and Andres2010; Duggan et al.2011; Morrey2012; McGraw et al.2013). The main principles are currently directed to offer

Fig. 13Sagittal section of the elbow at the level of the humeroradial joint.1Capitulum,2radial head,3radial neck,

4synovial fold which adopts a meniscoid structure.#Pau Golano

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excellent exposure, avoid detachment of theexor-pronator mass, and reconstruct the isometric bers of the"guiding band"(Safran et al.2005). The anterior bundle, as the primary restraint to valgus stress of the elbow from 30 to 120 of elbowexion (i.e., functional range of motion), has

been the focus of multiple studies in order to assist in surgical reconstruction techniques (Munshi M

tunnel placement. Despite some controversy, it has been reported that the ligament attachments or footprints correspond to two osseous landmarks: the humeral epicondyle and the ulnar sublime tubercle (Figs.14and15). The footprint of the anterior bundle has been described in more detail, as it is considered the main medial ligamentous stabilizer. The surface areas of the humeral and ulnar 2 ,respectively (Dugasetal.2007).Themean width of the anterior bundle footprint on the ulna has been reported to be 5.8 mm (range 5 to 7 mm) (Floris et al.1998). Some authors have described a longer ulnar attachment that extends distally along the ulna (Farrow et al.2011) (Fig.16). However, in cases of complete ligament tear, anatomic

Fig. 14Medial view of the elbow bones in 90

ofexion. (a) Bone main anatomic details. (b) Drawing of the medial

collateral ligament complex and annular ligament (Adobe Photoshop).1Medial supracondylar ridge,2medial

epicondyle,3trochlea,4coronoid fossa,5capitulum,6radial head,7radial neck,8radial tuberosity,9olecranon,10

coronoid process,11ulnar tuberosity,12sublime tubercle,13humeroradial joint,14proximal radioulnar joint,15

humeroulnar joint,16anterior bundle of the medial collateral ligament,17posterior bundle of the medial collateral

ligament,18transverse bundle of the medial collateral ligament,19annular ligament.#Pau Golano

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Fig. 15Medial osteoarticular view of the elbow showing the morphology of the medial collateral ligament during the

range of motion.(a) Elbow in extension,(b)elbow at 90 ofexion, (c) elbow in maximalexion.1Medialepicondyle,

2sublime tubercle,3anterior bundle of the medial collateral ligament,4transverse bundle of the medial collateral

ligament,5posterior bundle of the medial collateral ligament,6annular ligament,7biceps brachii tendon (cut) at the

level of its insertion in the radial tuberosity,8oblique cord,9interosseous membrane.#Pau Golano

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Fig. 16Medial osteoarticular view of the elbow showing the longer ulnar footprint of the anterior bundle according to

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