Elbow complex

INTRODUCTION
• The elbow complex includes the elbow joint
( Humeroulnar & Humeroradial joints) and the
Proximal & Distal radioulnar joint.
• The elbow joint is a modified or loose hinge
joint.
• One degree of freedom is possible at the elbow
permitting the motion is flexion & Extension
which occurs in the sagittal plane around coronal
axis.
• A slight bit of axial rotation & side - to – side
motion of the ulna occurs during flexion &
extension and that is why the elbow is
considered to be a modified or loose hinge joint.
• Two major ligaments & five muscles are directly
associated with the elbow joint.
• Three of the muscles are flexors that cross the
anterior aspect of the joint .The other two
muscles are extensors that cross the posterior
aspect of the joint.
• The proximal & distal radioulnar joints are linked
& function as one joint . The two joints acting
together produce rotation of the forearm & have
one degree of freedom of motion.
• The radioulnar joints are diarthrodial uniaxial
joints of the pivot type & permit rotation
( Supination & Pronation ) which occurs in
transverse plane around a vertical axis.
• Six ligaments & four muscles are associates with
these joints . Two muscles are for supination &
two for pronation.
Structure of humero - ulnar and
humero- radial joint
Articulating surfaces on the humerus
!The articulating surfaces on the anterior aspect of the
distal humerus are the hourglass-shaped trochlea and
the spherical capitulum .

! These structures are

situated between the medial and lateral humeral
epicondyles.

!The trochlea, which forms part of the humeroulnar

articulation, lies slightly anterior to the
humeral shaft.
!A groove called the trochlear groove spirals
obliquely around the trochlea and divides it into
medial and lateral portions.

! The medial portion of the

trochlea projects distally more than the lateral portion
and results in a valgus angulation of the forearm.

!The indentation in the humerus located just above

the trochlea is called the coronoid fossa and is
designed to receive the coronoid process of the ulna at
the end of elbow flexion range of motion (ROM).
!The capitulum, which is part of the humeroradial
articulation,
is located on the anterior lateral surface of the distal
humerus.

! A groove called capitulotrochlear groove

separates capitulum from trochlea.

!The indentation
located on the humerus just above the capitulum is
called the radial fossa and is designed to receive
the
head of the radius in elbow flexion.
! Posteriorly, the distal
humerus is indented by a deep fossa called the
olecranon
fossa, which is designed to receive the
olecranon process of the ulna at the end of elbow
extension ROM.
Articulating surface on ulna
!The articulating surfaces of the ulna and radius
correspond to the humeral articulating surfaces .

! The ulnar articulating surface of the humeroulnar joint

is a deep semicircular concave surface called the
trochlear notch.

! The proximal portion of the

notch is divided into two unequal parts by the trochlear
ridge, which corresponds to the trochlear groove on
the humerus.

!The ulnar coronoid process

forms the distal end of the notch, whereas the olecranon
process projects over the proximal end.
Articulating surface on radius
! The radial articulating surface of the
humeroradial
joint is composed of the proximal end of the
radius, known as the head of the radius .

!The radial head has a slightly cup-shaped concave

surface
called the fovea that is surrounded by a rim .

! The radial head’s convex rim fits into the

capitulotrochlear
Groove.
 Structure Of Elbow Joint( HU &
HR Articulation)
• Articulation between the ulna & humerus
at the humeroulnar joint occurs primarily
as a sliding motion of the ulnar trochlear
ridge on the humeral trochlear groove(in
flexion)
• Articulation between the radial head & the
capitulum at the humeroradial joint
involves sliding of the shallow concave
radial head over the convex surface of the
capitulum( in extension)
• JOINT CAPSULE : The HU & HR & The
superior radioulnar joint are enclosed in a
single joint capsule.
• The capsule is fairly large ,loose & weak
anteriorly & posteriorly and it contains
folds that are able to unfold to allow for a
full range of elbow motion.The capsule is
reinforced by the collateral ligaments.
•Anteriorly the capsule is attached just
above the coronoid fossa and radial fossa of
the humerus and to the ulna on the margin
of the coronoid process.

•Posteriorly, attatched to the upper edge of

the olecronon fossa.
• LIGAMENTS
• Collateral ligaments
: - Medial collateral
ligament- anterior, posterior,
transverse
:- Lateral collateral
ligament- lateral ulnar
collateral ligament, annular
ligament
 Function of MCL
• It is also called ulnar collateral ligament.
• Stabilize the elbow against valgus torque.
• Limit extension at the end of the elbow
extension ROM.
• Guides joint motion throughout flexion
ROM.
• Provides some resistance to longitudinal
distraction of joint surfaces.
 Function of LCL
• It is also called radial collateral ligament.
• Stabilize elbow against varus torque.
• Reinforce HR joint & assists in providing
some resistance to longitudinal distraction
of the articulating surfaces.
• Prevents subluxation of humeroulnar joint
.
MUSCLES :
• The major flexors of the elbow are the
brachialis, the biceps brachii, & the
brachioradialis.
• The brachialis muscle arises from the
anterior surface of the lower portion of the
humeral shaft & attaches by a thick
,broad tendon to the ulnar tuberosity &
coronoid process.
• The biceps brachii arises from two heads
one short & the other long.
• The short head arises as a thick ,flat
tendon from the coracoid process of the
scapula & the long head arises a narrow
tendon from scapula supraglenoid tubercle
& both head insert by way of the strong
flattened tendon on the on the rough
posterior area of the tuberosity of the
radius & other insert into the bicipital
aponeurosis
• The brachioradialis muscles arises from
the lateral supracondylar ridge of the
humerus & insert in to the distal end of the
radius just proximal to the radial styloid
process.
• The to extensors of the elbow are the
triceps & the anconeus.
• The triceps has three heads long,medial &
lateral.
• The long head arises from the infraglenoid
tubercle of the scapula by flattened tendon
that blends with the glenohumeral joint
capsule.
• The medial & lateral head cross the elbow
joint.
• Medial head arises f rom the entire
posterior surface of the humerus.
• Lateral head arises from only a narrow
ridge on the posterior humeral surface.
• Three heads insert via a common tendon
in the olecranon process.
• The anconeus is a small triangular muscle
that arises from the posterior surface of
the lateral epicondyle of the humerus &
extends medially to attach to the lateral
a s p e c t of t h e o l e c r a n o n p r o c e s s &
proximal of the posterior surface of the
ulna.
Functions of humero ulnar and
humero radial joints.
 Carrying Angle
• W h e n t h e u p p e r e x t r e m i t y i s in t h e
anatomic position ,the long axis of the
humerus and the long axis of the forearm
form an acute angle when the meet at the
elbow. The angulation in the frontal plane
is caused by the configuration of the
articulating surfaces at the humeroulnar
joint.
• The medial aspect of the trochlea extends
more distally than does the lateral aspect,
which shifts the medial aspect of the ulna
trochlear notch more distally and results in
a lateral deviation (or valgus angulation) of
the ulna in relation to the humerus. This
normal valgus angulation is called the
carrying angle or cubitus valgus.
• The average angle in full elbow extension
is about 15.
• An increase in the carrying angle beyond
the average is considered to be abnormal,
especially if it occurs unilaterally. A varus
angulation at the elbow is referred to as
cubitus varus and is usually abnormal.
• Normally, the carrying angle disappears
when the forearm is pronated and the
elbow is in full extension and when the
supinated forearm is flexed against the
humerus in full elbow flexion.`
 Mobility and Stability
• The number of factors determine the
amount of motion that is available at
the elbow joint.
• These includes
1. Type of motion
2. Position of the forearm
3. Position of shoulder
Type of motion

! The range of active flexion at

the elbow is usually less than the range of passive
motion, because the bulk of the contracting flexors
on the anterior surface of the humerus may interfere
with the approximation of the forearm with the
humerus.

! The active ROM for elbow flexion with the

forearm supinated is typically considered to be from
about 135 to 145, whereas the range for passive
flexion
is between 150 and 160.
!The position of the forearm
also affects the flexion ROM.

! When the forearm is either in pronation or midway

between supination and pronation, the ROM is less
than it is when the forearm is supinated.
!The position of the shoulder may affect
the ROM available to the elbow.

!Two joint muscles such as the biceps

brachii & triceps that cross both the shoulder
and elbow joints may limit ROM at the
elbow if a full ROM is attempted at both joint
simultaneously.
• Other factors that limit ROM and help
to provide stability for the elbow are-
! Configuration of joint surfaces
! Ligaments
! Joint capsule and muscles.
!In full extension, the humeroulnar joint is in a
close-packed position.

! In this position, bony contact of the

olecranon process in the olecranon fossa limits
the end of the extension range, and the
configuration of the joint structures helps
provide valgus and varus stability.
!Anterior portion of the joint capsule provides the
majority of the resistance to anterior displacement of
the distal humerus out of the olecranon fossa, whereas
the MCL and LCL contribute only slightly.

!Approximation of the coronoid process with the

coronoid fossa and of the rim of the radial head in the
radial fossa limits extremes of flexion.
Muscle Action
Elbow Flexors
Brachialis,Biceps brachii &
Brachioradialis
!The biceps brachii, is considered to be a
mobility muscle because of its insertion
close to the elbow joint axis.
!The MA of the biceps is rather small when
the elbow is in full extension,

! Therefore, when the elbow is fully extended,

the biceps is less effective as an elbow flexor
than when the elbow is flexed to 90.
The biceps brachii is active during unresisted
elbow flexion with the forearm supinated
and when the forearm is midprone position
in both concentric and eccentric contractions,

but it tends not to be active when the forearm

is pronated.
However, when the magnitude of the
resistance increases, the biceps is active in all
positions of the forearm
The brachialis is considered to be a mobility
muscle.
!According to EMG studies, the brachialis
muscle works in flexion of the elbow in all
positions of the forearm, with and without
resistance.
! It also is active in all types of contractions
(isometric, concentric, and eccentric) during slow
and fast motions.
!Also, the brachioradialis shows no activity during
slow, unresisted, concentric elbow flexion.

!The brachioradialis shows moderate activity if a

load is applied and the forearm is either in
midprone position or in full pronation.
Extensors
Triceps & Anconeus
!Activity of the long head
of the triceps is affected by changing shoulder joint
positions because the long head crosses both the shoulder
and the elbow.
!The long head’s ability to produce
torque may diminish when full elbow extension is
attempted with the shoulder in hyperextension.
! The medial and lateral heads of the triceps, being
one-joint muscles, are not affected by the position of
the shoulder.
!The medial head is active in unresisted active elbow extension, but all
three heads are active when heavy resistance is given to extension or
when quick extension of the elbow is attempted in the gravity assisted
Position.
 Radioulnar Joint
• The radius and ulna articulate with each
other at their proximal and distal ends at
synovial joints, called the proximal and
distal radioulnar joints. These articulations
are the pivot type of synovial joint that
produces pronation and supination.
Structure:
Superior Radioulnar Joint

!The articulating surfaces of the proximal

radioulnar joint include the ulnar radial
notch, the annular ligament, the capitulum
of the humerus, and the head of the radius.

!The radial notch is located on the lateral

aspect of the proximal ulna directly below
the trochlear
Notch.
!The surface of the radial notch is
concave and covered with articular cartilage.

! A circular ligament called the annular

ligament is attached to the anterior and
posterior edges of the notch.

! The annular ligament encircles the rim of

the radial head, which is also covered with
articular cartilage.
• Distal radioulnar joint

• Head of the ulna articulates with the

ulnar notch of radius.
RADIOULNAR ARTICULATION

Pronation of the forearm occurs as a result of the radius’s

crossing over the ulna at the superior radioulnar joint.

During pronation and supination, the rim of the head of the

radius spins within the osteoligamentous enclosure formed by
the radial notch and the annular ligament.

At the same time, the surface of the head spins on the

capitulum of the humerus.

At the distal radioulnar joint, the concave surface of the ulnar

notch of the radius slides around the ulnar head.
Ligaments – Radioulnar Joint

!The three ligaments associated with the proximal

radioulnar joint are the annular and quadrate liga-
ments and the oblique cord.
!The annular ligament is a strong band that
forms four fifths of a ring that encircles the radial
head.
! The inner surface of the ligament is covered with
cartilage and serves as a joint surface.
! The proximal border of the annular ligament
blends with the joint capsule, and the lateral aspect
is reinforced by fibers from the LCL.
!The quadrate ligament extends from the inferior edge of the
ulna’s radial notch to insert in the neck of the radius.

! The quadrate ligament reinforces the inferior aspect of the joint

capsule and helps maintain the radial head in apposition to the
radial notch.

!The quadrate ligament also limits the spin of the radial head in
supination and pronation.

!The oblique cord is a flat fascial band on the ventral forearm

that extends from an attachment just inferior to the radial notch on
the ulna to insert just below the bicipital tuberosity on the radius.

!it may assist in preventing separation of the radius and ulna.

 Muscles:-
• pronator teres, pronator quadratus,
• biceps brachii,and supinator.
Functions of radio – ulnar joint
Axis of Motion of supination-pronation

!The axis of motion for pronation and supination is a

longitudinal axis extending from the center of the
radial head to the center of the ulnar head.

! In supination, the radius and ulna lie parallel to one

another, whereas in pronation, the radius crosses over
the ulna
! There is very little motion of the ulna during
pronation and supination.
! The ulnar head moves distally and dorsally in
pronation and proximally and medially in supination.
Range of Motion pronation-supination

! Limitation of pronation when the elbow is extended may be

caused by passive tension in the biceps brachii.

Pronation in all elbow positions is limited by bony

approximation of the radius and ulna.

Supination is limited by passive tension in the palmar

radioulnar ligament and the oblique cord.

The quadrate ligament limits spin of the radial head in both

pronation and supination, and the annular ligament helps to
maintain stability of the proximal radioulnar joint by holding
the radius in close approximation to the radial notch.
Muscle action
Pronation
!Muscles of pronation are Pronator teres &
Pronator quadratus
!The pronators produce pronation by
exerting a pull on the radius, which causes
its shaft and distal end to turn over the ulna.

!The pronator teres contributes some of its

force toward stabilization of the proximal
radioulnar joint, helps maintain contact of the
radial head with the capitulum.
!The pronator quadratus, a one-joint muscle, is
unaffected by changing positions at the elbow.

!The pronator quadratus is active in unresisted and

resisted pronation and in slow or fast pronation. The
deep head of the pronator quadratus is active during
both resisted supination and resisted pronation.
!Muscle of supination are Supinator & Biceps brachii

!supinators, like the pronators, act by pulling the shaft and

distal end of the radius over the ulna.

! The supinator muscle may act alone during unresisted

slow supination in all positions of the elbow or forearm.

!The supinator also can act alone during unresisted fast

supination when the elbow is extended.

!activity of the biceps is always evident when supination is

performed against resistance and during fast supination when
the elbow is flexed to 90.
 Injury Around Elbow Joint
• Compression Injuries
• Distraction Injuries
• Tennis elbow/ lateral
epicondylitis
• Golfers elbow
• Varus/Valgus Injuries
Compression Injuries
!Falling on the hand when the elbow is in a close-packed
(extended) position may result in the transmission of forces
through the bones of the forearm to the elbow.

! If the forces are transmitted through the radius,a fracture of the

radial head may result from impact of the radial head on the
capitulum.

!If the force from the fall is transmitted to the ulna, a fracture of
either the coronoid or olecranon processes may occur from
impact of the ulna on the humerus.

! If neither the radius nor the ulna absorbs the excessive force by
fracturing, then the force may be transmitted to the humerus and
may result in a fracture of the supracondylar area.
!Muscle contractions also may cause high compression forces at
the elbow.

! Nerve compression, bony fracture, or

dislocation may also result from muscle contractions.

!forceful contractions of the flexor carpi ulnaris muscle may

compress the ulnar nerve as it passes through the cubital tunnel
between the medial
epicondyle of the humerus and olecranon process of the ulna.

!The result of these stresses can

cause an injury called cubital tunnel syndrome.
■ Distraction Injuries

! A tensile force of sufficient magnitude exerted on a

pronated and extended forearm may cause the radius to be
pulled inferiorly out of the annular ligament.
!This injury is common in young children younger than
5 years and rare in adults.
! Lifting a small child up into the air by one or both hands
or yanking a child by the one hand is the usual causative
mechanism, and
therefore the injury is referred to as either nursemaid’s
elbow or “pulled elbow”.
■ Varus/Valgus Injuries

!Distraction and compression forces are created if

either
one of the collateral ligaments is overstretched or
torn.
If one side of the joint is subjected to abnormal
tensile
stresses, the other side is subjected to abnormal
compressive
Forces.
!For example, the MCL is subjected to tensile
stress during “cock-up” portion of throwing a ball.
! The resulting medial instability may cause
an increase in the normal carrying angle and
excessive compression on the lateral aspect of the
joint so that the radial head impacts on the
capitulum.
!If the abnormal compression forces on the
articular cartilage are prolonged, these forces may
interfere with the blood supply of the cartilage and
result in avascular necrosis of the capitulum.
Tennis elbow

•Lateral epicondylitis
•Caused by repetitive wrist motion
•By the repeated forcefull contraction of the
wrist extensor mainly extensor carpi radialis
brevis
Golfers elbow

•Medial epicondylitis
•it is due to forcefull repeated contraction of
pronator teres, flexor carpi radialis and
occasionally flexor carpi ulnaris
 References
• Joint Structure and Function :A
Comprehensive Analysis by Pmela K.
Levangie , Cynthia C. Norkin, Fourth
Edition, Pg No-273-299.
• BasicBiomechanicsofthe
Musculoskeletal System by Margareta
Nordin , Victor H.Frankel,Pg No-342