Clinical anatomy of the elbow


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  • Clinical anatomy of the elbow

    1. 1. MOB TCD Clinical Anatomy of Elbow Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin
    2. 2. MOB TCD Injuries to Elbow and Wrist • • • • • Skin Bones Muscles, tendons Nerves Blood vessels
    3. 3. MOB TCD Bones of Elbow
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. 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
    8. 8. 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
    9. 9. 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
    10. 10. 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
    11. 11. 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
    12. 12. MOB TCD Medial or Ulnar Collateral Ligament • The ulnar nerve lies on the medial ligament • The anterior band may be ruptured in throwing events
    13. 13. 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
    14. 14. MOB TCD Medial Structures of Elbow Common flexor origin, ulnar nerve
    15. 15. 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
    16. 16. MOB TCD Posterior Relations • • • • Triceps Anconeus Olecranon bursa Ulnar nerve posterior to medial epicondyle • Common extensor origin
    17. 17. MOB TCD Extensor Tendons • • • • • • Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis* Extensor digitorum communis Extensor digiti minimi Extensor carpi ulnaris
    18. 18. MOB TCD Posterior Relations medial olecranon bursitis
    19. 19. MOB TCD Posterolateral • • • • Below lateral epicondyle Head of radius Behind the extensors of the forearm Posterior interosseous nerve
    20. 20. MOB TCD Lateral Elbow
    21. 21. 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
    22. 22. 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)
    23. 23. 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)
    24. 24. MOB TCD Elbow • • • • Biceps brachii Brachialis Pronator teres Supinator posterior Anderson & Hall, 1995 Musculocutaneous C5,6 Musculocutaneous C5,6 Median C6,7 Interosseous C5,6
    25. 25. 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
    26. 26. 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
    27. 27. 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
    28. 28. 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
    29. 29. 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
    30. 30. 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
    31. 31. 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
    32. 32. 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
    33. 33. MOB TCD Pain in Elbow and Wrist • Must rule out referred pain from cervical spine • Upper thoracic spines • Increased neural tension
    34. 34. MOB TCD Test for Stability of Elbow • Varus and valgus stresses • 0 and 30 degrees of flexion Behr & Altchek, 1997
    35. 35. MOB TCD Adult Elbow Injuries Fractures • Distal humerus • Radial head and radial neck • Olecranon Dislocations • Simple • Fracture, dislocation Behr & Altchek, 1997
    36. 36. MOB TCD Elbow Pain • Loose bodies • Pain • Locking
    37. 37. 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
    38. 38. 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
    39. 39. 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
    40. 40. 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
    41. 41. MOB TCD Lateral Epicondylitis; Pathology Tendonosis 1. Repetitive microtrauma 2. Angioplastic hyperplasia 3. Fibrosis 4. Granulation tissue 5. Mucoid degeneration Nirschl, 1993
    42. 42. MOB TCD Lateral Epicondylitis • • • • • • Racquet sports Backhand Throwing sports Golfers Musicians Labourers Behr & Altchek, 1997
    43. 43. 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
    44. 44. MOB TCD Elbow Nerve Compression • Radial tunnel syndrome • Posterior interosseous nerve syndrome • Cubital tunnel syndrome • Pronator syndrome • Anterior interosseous nerve syndrome Behr & Altchek, 1997
    45. 45. 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
    46. 46. 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
    47. 47. 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
    48. 48. 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
    49. 49. MOB TCD Elbow Dislocation
    50. 50. 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
    51. 51. “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”