Injuries in Baseball, edited by James R. Andrews, Bertram Zarins, and Kevin E. Will<, Lippincott-Raven Publishers, Philadelphia © 1998. CHAPTER 17 . Functional Anatomy of the Elbow Mary Lloyd Ireland, Yvonne E. Satterwhite, Craig C. McKirgan, Michael Stroyan, and Kevin E. Wilk - - - FUNCTIONAL ANATOMY OF THE ELBOW trochlea's central depression, the trochlear groove, is bound on either side by two unequal, convex segments of Arthrology of the Elbow Complex bone. The groove is obliquely oriented from anterior to posterior and contributes to the valgus carrying angle of The elbow is a biomechanically complex joint com­ the elbow. The carrying angle is measured in the frontal posed of the humeroulnar, humeroradial, and proximal plane by the long axes of the humerus and ulna with the radioulnar articulations. Capsular and ligamentous struc­ elbow extended (normal range in males 11 ° to 14° and tures provide restraints to motion and stress in addition to females 13° to 16°) (3,4). The distal end of the humerus is that achieved by the inherent stability of congruous bony rotated anteriorly 30 degrees with respect to the shaft of contours. The elbow is shown diagrammatically from the ulna. In the frontal plane, the medial column of anterior (Fig. IA) and medial (Fig. lB) perspectives. trochlea is longer than the lateral. This difference creates a valgus tilt of approximately 6° measured by the distal humerus to the long axis of the humerus. Immediately Humeroulnar Joint proximal to the articular surfaces of the distal humerus lie two fossae- the coronoid anteriorly and the olecranon The humeroulnar joint is a uniaxial, diarthrodial mod­ posteriorly. These fossae receive the olecranon tip and the ified hinge joint. Motion ranges from 0° to 150° and coronoid of the proximal ulna, respectively, as the elbow occurs through a rotational axis in the center of the troch­ courses from full extension into flexion. lea, in the coronal plane. At the extremes of flexion and The anterior portion of the proximal ulna, the greater extension, limited degrees of internal and external rota­ sigmoid notch, has a longitudinally oriented guiding ridge tion are present (1). that articulates with the apex of the trochlear groove. Dia­ The distal humerus has two components-the trochlea grammatically shown is the proximal ulna anteriorly (Fig. medially and the capitellum laterally. Diagrams show the 3A) and medially (Fig. 3B). On either side of this ridge is distal humerus anterior (Fig. 2A), posterior (Fig. 2B), and a concave region, referred to as the "trochlear notch," axial (Fig. 2C) planes. The trochlea is spool-shaped and is articulating with the convex surface of the trochlea of the covered with articular cartilage from the edge of the ole­ humerus. The greater sigmoid notch is angulated 30° pos­ cranon fossa posteriorly to the coronoid fossa anteriorly, a teriorly with respect to the ulnar shaft, thus lying parallel surface area covering approximately 300° to 330° (2). The to the trochlea. This orientation and structural congruency permits maximum humeroulnar motion and enhances the bony stability of the elbow, particularly in full extension. ML Ireland and YE Satterwhite: Kentucky Sports Medicine The medial humeral epicondyle serves as the origin of Clinic, Lexington, KY 40517. the flexor-pronator muscle group and the medial ulnar CC McKirgan: Center for Orthopaedics and Sports Medicine, collateral ligament (5). The medial supracondylar ridge Indiana University of Pennsylvania, Indiana, PA 15701. lies just superior to the medial epicondyle and is occa­ M Stroyan: FITRAC, Marysville, MD. KE Wilk: HealthSouth Sports Medicine and Rehabilitation Cen­ sionally the site of origin of an additional medial promi­ ter, Birmingham, AL 35205; Program in Physical Therapy, Mar­ nence, the supracondylar process, from which the liga­ quette University, Milwaukee, WI. ment of Struthers may arise and extend distally to attach 199 200 I I NJURIES IN B ASEBALL Coronoid Fossa Med ial Epicondyle '-~~'f---Tro c hlear Groove Trochlea A Coronoid Process B FIG. 1. (A) Bony configuration of the elbow is shown anteriorly of the articulations. Radial ulnar, radial humeral, proximal radial ulnar is shown anteriorly and medially from the side. (B) The coronoid fossa and olecranon fossa allow for bony contact in flexion and extension. The smooth articulation of the dis­ tal humerus, capitellum, and spool-like trochlea, radial head, and proximal ulna are necessary for nor­ mal function and range of motion of the elbow. The distal humerus is shown anteriorly with the capitel­ lum laterally, trochlea medially. (Illustrated by Rich Pennell, CMI , Medical Illustrator, Medical Center Arts & Graphics, 509 Health Sciences Learning Center, 760 Rose Street Lexington, KY 40536-0232.) A Trochlear Groove B FIG. 2. (A) The lateral epicondyles and coronoid fossa and (B) posteriorly with the olecranon fossa, and (C) axially showing the articular aspect of the distal humerus. (Illus­ trated by Rich Pennell, CMI, Medical Illustrator, Medical Cen­ ter Arts & Graphics, 509 Health Sciences Learning Center, c Lateral Lip 760 Rose Street Lexington, KY 40536-0232.) F UNCTIONAL ANATOMY OF THE ELBOW I 20 I Guiding Ridge Transverse Groove of Greater Sigmoid Notch A B FIG. 3. (A) The proximal ulna is shown with the guiding ridge of the sigmoid notch, coronoid process, and ulna tuberosity from the anterior view, and (B) from the medial aspei:::t the coronoid process, greater sigmoid notch olecranon. (Illustrated by Rich Pennell, CMI, Medical Illustrator, Medical Center Arts & Graphics, 509 Health Sciences Learning Center, 760 Rose Street Lexington, KY 40536-0232.) to the medial epicondyle (6). This anomalous structure is gin does not extend as far as that of the adjacent present in approximately 1% of the population. trochlea. The capitellotrochlear groove separates the capitellum from the trochlea and guides the rim of the radial head in flexion and extension. The radial fossa is Humeroradial Joint a depression on the anterior aspect of the humerus, just proximal to the capitellum, into which the radius seats The humeroradial joint is a uniaxial diarthrodial joint when the elbow is fully flexed. Lateral to the radial functioning as a hinge and pivot. As a hinge in coronal fossa is the lateral humeral epicondyle, a bony eminence axis, flexion/extension movements occur at the humer­ extending superiorly into the lateral supracondylar ridge oulnar joint. The humeroradial joint pivots about a longi­ and providing origin for the extensor supinator muscle tudinal axis to permit rotational movements at the proxi­ mass. mal radioulnar joint. The articular surface of the radial head is a concave The humeroradial joint is created by the capitellum depression that is slightly oval, not fully cylindrical, in and the articular surface of the radial head. The capitel­ shape. The anterior view of the proximal radius is shown lum is an anterior half of a sphere whose posterior mar- (Fig. 4). Its head and surrounding rim narrow distally to form the radial neck. The radial head and neck angulate approximately 15 ° from the shaft of the radius (7). The Radial Head~- -i;ri\-Articular Margin radial head plays only a small role as a secondary , 'v·111 1·., ~ restraint to valgus stress to the elbow unless the ulnar Radial Neck '\ ~ '\~. collateral ligament has been compromised. The bicipital '1)-,~ ~ /~ tuberosity lies just distal to the radial neck and serves as ". ;~ ~\\ the insertion site for the biceps tendon. r;:;, r Radial Tuberosity ~i:i1 ) ri~ rt~~ ~1~ Proximal Radioulnar Joint The proximal radioulnar joint is a uniaxial, diarthrodial ~~ joint that functions in concert with the distal radioulnar ~~~\ joint to produce forearm supination and pronation. Rota­ ! ~ ~;' ~ tion occurs in the transverse plane around a longitudinal axis and normally encompasses a range of up to 180°. The FIG. 4. The proximal radius is shown with radial head, neck, joint is comprised of the convex medial rim of the radial articular margin, as well as radial tuberosity. (Illustrated by Rich Pennell, CMI, Medical Illustrator, Medical Center Arts & head and the concave lesser sigmoid notch (radial notch) Graphics, 509 Health Sciences Learning Center, 760 Rose of the ulna. During rotational movements, there is mini­ Street Lexington, KY 40536-0232.) mal motion of the ulna. The radial head rotates within a ---------- 202 I INJURIES IN BASEBALL ring formed by the annular ligament and the lesser sig­ posterior to the center axis of the elbow rotation, and moid notch while the radial shaft crosses over the ulnar attaches to the sublime tubercle medial to the coronoid. shaft with pronation and uncrosses with supination. The ligament's eccentric position, posterior to the rota­ tional axis, creates a cam effect, with ligament tension varying, depending on the degree of elbow flexion. His­ Ligamentous Anatomy tologically, two layers of the ligament have been identi­ fied. The medial joint capsule has a superficial and deep The capsuloligamentous anatomy of the elbow may be layer. The anterior oblique ligament has a thick deep por­ divided into anterior, posterior, medial, and lateral struc­ tion that lies within the two layers of the joint capsule and tures. The anterior capsule extends proximally to the a thin superficial portion, which is external to the joint radial and coronoid fossae and attaches distally to the capsule's superficial layer and may be confluent with the coronoid. With the elbow extended, the anterior capsule overlying flexor muscles (8). Functionally, the anterior becomes taut and provides resistance to distraction and oblique has been divided into three groups of fibers or hyperextension forces. The posterior capsule attaches bands: anterior, middle, and posterior. Each group has an proximally to the olecranon fossa and distally into -the arc through which the majority of its fibers are taut. This olecranon tip. Posteriorly, the capsule tightens with elbow arc changes slightly if varus or valgus stress is imposed flexion, but contributes only minimally to overall elbow upon the elbow joint (9).