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This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

Bony Anatomy¶

• The elbow is a trocho-ginglymoid joint consisting of medial and lateral articulations that provide bony stability [3].
• The medial ulnohumeral joint is formed by the articulation of the trochlea with the ulna within the greater sigmoid notch [3].
• The ulnohumeral joint exhibits highly congruent anatomy through almost 180° of articular contact, excluding the bare area of the greater sigmoid notch which is devoid of cartilage [3].
• The coronoid process possesses medial and lateral facets that buttress the trochlea anteriorly [3].
• The sublime tubercle, located just distal and medial to the coronoid, serves as the attachment site for the anterior bundle of the medial ulnar collateral ligament [3].
• The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle and forms the attachment site for the flexor pronator mass [3].
• The lateral radiocapitellar joint is formed by the articulation of the capitellum and the radial head [3].
• The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [3].
• The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [3].
• The radial head articulates with both the capitellum and the lesser sigmoid notch of the ulna [3].
• The lateral epicondyle is the origin of the lateral extensor musculature [3].
• The lateral ulnar collateral ligamentous complex originates at the geometric center of the radiocapitellar articulation, just distal to the lateral epicondyle [3].
• The distal humeral articulation is angled 30° from the longitudinal axis [3].
• The anterior humeral line should pass through the center of the axis of rotation [3].
• The axis of rotation is angulated 5° to 7° in the coronal plane relative to the epicondylar axis, with the medial side positioned more distally than the lateral side [3].
• The coronal angulation of the axis of rotation accounts for the change from a valgus carrying angle to a more varus position as the elbow flexes [3].
• There is a high correlation in the size of the radius and capitellum between sides in the same individual [3].
• The olecranon provides a broad attachment site for the triceps muscle [3].
• The ulna bends approximately 8° medially at 8 cm from the tip of the olecranon [3].
• The proximal ulna has a slight anterior bow [3].
• The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [3].

Ligaments¶

• The medial ulnar collateral ligaments are areas of capsular thickening that provide stability to the medial side of the elbow joint [3].
• The lateral ulnar collateral ligament complex includes the radial collateral ligament and the lateral ulnar collateral ligament [3].
• The annular ligament attaches proximal and deep to the lateral ulnar collateral ligamentous complex but is intimately associated with it [3].

Clinical Examination¶

• Physical examination of the elbow focuses on functional anatomy because the joint places the hand in space and allows it to be brought to the torso, head, or mouth [20].
• Fundamental elements of the elbow examination include inspection, palpation, range of motion, strength, stability, and special tests [20].
• The history is the most valuable tool to guide the clinical examination of the elbow [20].
• Location, quality or type, context, duration, and severity of elbow pain are important for understanding pathology and focusing the physical examination [20].
• Determining the symptom trajectory (whether pain is getting better, worse, or remaining constant) is helpful when considering intervention [20].

Imaging¶

• Ultrasonographic imaging of the elbow includes techniques for imaging normal anatomic structures [21].
• Magnetic resonance evaluation of the elbow includes assessment of ligament complexes [21].
• Common findings on 3-Tesla elbow MRI in asymptomatic professional baseball pitchers include collateral ligament thickening and ulnar nerve abnormalities [21].
• MR imaging of the elbow evaluates osseous and soft-tissue anatomy as well as acute lesions and overuse injury [21].
• Radiographic and MR appearance of the elbow can be correlated to provide insight into imaging findings [21].
• MRI findings of structural changes in the elbow in overhead throwers are described in the context of clinical presentation [21].
• UCL injury patterns are illustrated with MRI [21].
• MR evaluation of instability patterns emphasizes the soft-tissue lesions resulting from dislocation [21].
• Normal and variant anatomy of the elbow can be identified on magnetic resonance imaging [21].
• Elbow magnetic resonance imaging variants and pitfalls are documented in the literature [21].

Osteoarthritis¶

• Symptomatic primary osteoarthritis of the elbow affects 2% of the population [18].
• The average age of presentation for primary elbow osteoarthritis is 50 years, with a range of 20 to 70 years [18].
• Men are affected by primary elbow osteoarthritis more often than women at a 4:1 ratio [18].
• Hand dominance and strenuous manual labor are associated with primary osteoarthritis of the elbow [18].
• Secondary causes of elbow osteoarthritis include trauma, osteochondritis dissecans, and synovial osteochondromatosis [18].
• Elbow osteoarthritis is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [18].
• Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension [18].
• Advanced elbow osteoarthritis rarely presents with joint space narrowing [18].
• Osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [18].
• Patients with elbow osteoarthritis typically present with loss of terminal extension and flexion and painful catching, clicking, or locking [18].
• Pain in elbow osteoarthritis is typically noted at the end ranges of motion rather than through the midrange [18].
• Night pain is not typical of elbow osteoarthritis; if present, an inflammatory cause should be considered [18].
• Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [18].
• Radiographs for elbow osteoarthritis typically show osteophyte formation at the coronoid process, coronoid fossa, radial fossa, radial head, olecranon tip, and olecranon fossa [18].
• Joint spaces at the ulnohumeral joint are usually preserved in elbow osteoarthritis [18].
• Joint spaces at the radiocapitellar joint are mildly narrowed in elbow osteoarthritis [18].
• Radiographs typically underestimate the number of loose bodies present in elbow osteoarthritis [18].
• CT may be useful for surgical planning of elbow osteoarthritis by allowing detailed assessment of osteophytes and loose bodies [18].
• Nonsurgical treatment for elbow osteoarthritis includes rest, NSAIDs, corticosteroid injections, and activity modification [18].
• Surgical indications for elbow osteoarthritis include failure to respond to nonsurgical interventions, loss of motion interfering with activities of daily living, and painful locking or catching [18].
• Joint-sparing procedures such as débridement, excision of osteophytes, capsular release, and removal of loose bodies are preferred for elbow osteoarthritis [18].
• Total elbow arthroplasty is rarely indicated for elbow osteoarthritis and is not indicated for patients younger than 65 years or physically active patients due to concerns about implant longevity [18].
• The Outerbridge-Kashiwagi arthroplasty involves trephination of the olecranon fossa and removal of osteophytes [18].
• Limitations of the Outerbridge-Kashiwagi procedure include incomplete anterior release and incomplete anterior osteophyte removal [18].
• Contraindications for arthroscopic treatment of elbow osteoarthritis include severe contracture and periarticular heterotopic ossification [18].
• Relative contraindications for arthroscopic treatment of elbow osteoarthritis include prior ulnar nerve transposition and prior extensive open procedures [18].
• Ulnar nerve transposition and release of the posterior bundle of the medial collateral ligament should be considered for patients with less than 90° to 100° of elbow flexion undergoing elbow osteoarthritis surgery [18].
• Deep infections in the elbow are more common than in other joints treated arthroscopically, occurring in 0.8% to 2.2% of cases [18].
• Transient nerve palsies complicate 1% to 3% of arthroscopic elbow procedures, with radial and ulnar nerves being the most commonly affected [18].
• During arthroscopic elbow surgery, joint distention moves the capsule away from bone, but the distance between neurovascular structures and the capsule remains unchanged [18].
• Neurovascular structures at risk during portal placement, débridement, and capsular release include the median nerve (anteromedial), ulnar nerve (posteromedial), and radial nerve (adjacent to the anterolateral capsule) [18].
• The brachialis muscle protects the median nerve and brachial artery during capsular procedures [18].
• The olecranon fossa is an oval structure that is wider in the medial to lateral dimension [18].
• Olecranon osteophytosis extends medially and laterally, not just at the tip, requiring resection along the medial and lateral aspects to allow maximal extension [18].
• Coronoid osteophytosis extends medially, not just at the tip, requiring medial resection if necessary to maximize restoration of flexion range of motion [18].

Surgical Positioning¶

• Patient positioning for elbow arthroscopy is based primarily on surgeon preference [1].
• Classically, elbow arthroscopy was performed supine with the surgical arm draped across the chest over a bolster [1].
• The modern concept of arm suspension from the supine position, keeping the arm in 90° of shoulder abduction and 90° of elbow flexion, was introduced in 1985 [1].
• Advantages of the supine position for elbow arthroscopy include simplified airway access, familiar orientation, and ease of conversion to an open procedure [1].
• Disadvantages of the supine position for elbow arthroscopy include elbow instability during the procedure and difficult access to the posterior compartment [1].
• The modified supine position suspends the arm over the chest with the elbow in 90° of flexion while the forearm, wrist, and hand are secured in a mechanical holder [1].
• The modified supine position facilitates easy arm adjustment, providing access to both the anterior and posterior compartments of the elbow [1].
• The modified supine position decreases the risk of injury to anterior neurovascular structures by allowing them to drop away from the anterior capsule [1].
• In the lateral decubitus position for elbow arthroscopy, the patient is positioned laterally on a beanbag with the surgical arm flexed to 90° and suspended over a well-padded post [1].
• Joint distraction in the lateral decubitus position is provided by a weight attached to the hand [1].
• Advantages of the lateral decubitus position include improved arm stability, posterior elbow access, and relatively easy airway management [1].
• Disadvantages of the lateral decubitus position include orientation challenges from reversed anatomic landmarks and difficult access to the anterior compartment [1].
• In the prone position for elbow arthroscopy, the arm is suspended off the table in an arm holder with the arm in 90° of shoulder abduction and the elbow in 90° of flexion [1].
• Advantages of the prone position include natural traction, easy access to the posterior compartment, and a theoretically increased space between vascular structures and the anterior capsule [1].
• Disadvantages of the prone position include the necessity for general anesthesia, difficult airway access, reversed anatomy, and poor access to the anterior compartment [1].
• It is crucial to assess the elbow for access to each compartment and portal sites before starting arthroscopic procedures [1].
• Pressure on the antecubital fossa should be avoided during elbow arthroscopy to decrease the risk of injury to anterior neurovascular structures [1].
• A tourniquet is placed as proximal on the arm as possible and can be insufflated as needed during elbow arthroscopy [1].

Radial Nerve Approach¶

• The radial nerve is exposed in the axilla and proximal third of the arm by an incision for the distal part of the brachial plexus, carried distally more posteriorly than necessary for ulnar and median nerves [4].
• The neurovascular bundle is exposed between the triceps posteriorly and the biceps, brachialis, and coracobrachialis anteriorly [4].
• The radial nerve is exposed by retracting laterally the ulnar nerve, brachial artery and vein, and median nerve [4].
• The radial nerve gives branches to the long head and then to the medial head of the triceps before winding around the humerus [4].
• To expose the radial nerve on the posterior and lateral aspects of the humeral shaft, an incision begins along the posterior border of the distal third of the deltoid between the deltoid and long head of the triceps [4].
• The radial nerve is at its most superficial position proximal to the elbow by incising the fascia between the brachialis and brachioradialis [4].
• The radial nerve can be exposed proximally by incising the fascia and retracting the lateral head of the triceps laterally to the point where it winds around the humerus [4].
• The radial nerve sends branches to the brachioradialis 5 or 6 cm proximal to the elbow [4].
• The radial nerve sends branches to the extensor carpi radialis longus and brevis a little more distally than the brachioradialis branches [4].
• At the elbow, the radial nerve divides into the superficial and deep radial (posterior interosseous) nerves [4].
• The superficial radial nerve is entirely sensory but should be protected to avoid painful neuromas [4].
• The deep radial nerve is often injured, and such an injury is quite disabling [4].
• The deep radial nerve is exposed by following it beneath the brachioradialis into the supinator muscle [4].
• If the injury is at or distal to the supinator, the nerve is exposed by incising the fascia between the extensor carpi radialis longus and brevis and the extensor digitorum communis [4].
• The superficial part of the supinator is incised at a right angle to the direction of its fibers to complete the exposure of the entire deep radial nerve [4].

Chronic Elbow Dislocation Treatment¶

• The Speed technique for open reduction of old unreduced elbow dislocation involves an incision over the posterolateral aspect of the elbow, beginning in the midline 10 cm proximal to the olecranon [5].
• The incision continues distally to just proximal to the tip of the olecranon, then slightly laterally over the lateral humeral condyle and radial head, and continues farther distally for 5 cm on the forearm [5].
• The ulnar nerve is located and dissected up from its bed along the groove in the medial humeral condyle and carefully retracted [5].
• The aponeurosis of the triceps is reflected distally to form a flap of tissue attached to the olecranon [5].
• An incision is made in the midline of the arm through the fibers of the triceps muscle 7.5 cm proximal to the joint, distally to the olecranon, then curving around the lateral edge of the olecranon to the distal end of the skin incision [5].
• All muscle attachments are freed subperiosteally from the distal humerus, both anteriorly and posteriorly [5].
• The attachments of the joint capsule and collateral ligaments around the condyles of the humerus are released [5].
• Callus on the posterior surface of the humerus and in the olecranon fossa is removed along with any scar tissue [5].
• The radial head is exposed and the trochlear notch of the ulna is cleared after completely freeing the distal humerus [5].
• The forearm is rotated and gentle pressure is applied to the anterior surface of the capitellum to bring the radial head anteriorly into its normal position [5].
• If the radial head cannot be reduced easily, soft tissues are dissected more widely instead of applying force that may injure the articular surfaces [5].
• After the radial head is reduced, the coronoid process is slipped distally and then anteriorly over the trochlea to repeat the reduction [5].
• The joint is carried through a full range of motion after reduction [5].
• If the elbow is unstable, it is transfixed with one or two small Steinmann pins or Kirschner wires with the elbow at 90 degrees [5].
• The pins are cut off and the proximal portion is bent to prevent migration [5].
• The periosteum and triceps are sutured over the posterior surface of the humerus and the fascia over the radial head [5].
• The tongue of the triceps aponeurosis is sutured into its normal position or at a slightly more distal level [5].
• The wound is decompressed with a suction drain [5].
• Postoperatively, the arm is immobilized in a posterior splint at 90 degrees [5].
• The drain is removed after 24 hours [5].
• The pins are removed

Osseous Anatomy¶

General Structure¶

• The elbow is a trocho-ginglymoid joint with complex bony anatomy consisting of medial and lateral articulations that afford bony stability [3].
• The axis of rotation is 5° to 7° angulated in the coronal plane to the epicondylar axis, with the medial side more distal than the lateral side [3].
• This coronal angulation accounts for the change in a valgus carrying angle to a more varus position as the elbow is flexed [3].
• There is a high correlation between sides for the sizes of the radius and capitellum in the same individual, which is useful for surgical planning when the capitellum or radius has been destroyed [3].

Medial Compartment¶

• The trochlea articulates with the ulna within the greater sigmoid notch to create the ulnohumeral, hinged or trochoid, portion of the elbow joint [3].
• There is highly congruent anatomy through almost 180° of articular contact between the trochlea and ulna [3].
• The greater sigmoid notch of the ulna contains a bare area devoid of cartilage [3].
• The coronoid has a medial and lateral facet which buttresses the trochlea anteriorly [3].
• The sublime tubercle is located just distal and medial to the coronoid and provides the attachment site for the anterior bundle of the medial ulnar collateral ligament (MUCL) [3].
• The medial epicondyle forms the attachment site for the origins of the flexor pronator mass [3].
• The medial epicondyle is larger and more posteriorly oriented than the lateral epicondyle [3].

Lateral Compartment¶

• The capitellum and radial head form the radiocapitellar joint [3].
• The radius is held in close approximation to the ulna at the proximal radioulnar joint (PRUJ) by the annular ligament [3].
• The area of the ulna which articulates with the margin of the radial head at the PRUJ is known as the lesser sigmoid notch [3].
• The radial head articulates with both the capitellum and the lesser sigmoid notch [3].
• The lateral epicondyle is less prominent than the medial epicondyle and is the origin of the lateral extensor musculature [3].
• The origin of the lateral ulnar collateral ligamentous (LUCL) complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [3].
• The radial tuberosity exhibits a 15° of angular tilt from the long axis of the radius through the radial head and neck [3].

Posterior Compartment¶

• The olecranon allows for a broad attachment site of the triceps [3].
• The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon [3].
• There is a slight anterior bow to the proximal ulna [3].

Pediatric Ossification¶

• The capitellum ossification center appears at age 1 year in both girls and boys [26].
• The proximal radius ossification center appears at age 4–5 years in girls and 5–6 years in boys [26].
• The medial epicondyle ossification center appears at age 5–6 years in girls and 7–8 years in boys [26].
• The trochlea ossification center appears at age 8–9 years in girls and 10–11 years in boys [26].
• The olecranon ossification center appears at age 9 years in girls and 11 years in boys [26].
• The lateral epicondyle ossification center appears at age 10 years in girls and 11–12 years in boys [26].
• A rough guide for ossification is that the capitellum appears at age 1 year, and in girls, 2 years should be added for each additional ossification center except the proximal radius [26].
• There is a 2-year delay for boys for all ossification centers except the capitellum [26].
• Normally, a 12° valgus angle of the proximal radius exists [26].
• The proximal radius should be directed toward the capitellum on all radiographs [26].

Ligaments and Joint Capsule¶

Anatomy and Composition¶

• The static stabilizers of the elbow include the joint capsule, lateral collateral ligaments (LCLs), and medial collateral ligaments (MCLs) [32].
• The normal elbow joint capsule is thin but contributes to stability with the elbow in full extension and flexion [32].
• The LCL complex consists of three components: the radial collateral ligament, annular ligament, and lateral ulnar collateral ligament [32].
• The radial collateral ligament arises from the lateral epicondyle and blends with the annular ligament [32].
• The annular ligament attaches to the anterior and posterior margins of the radial notch of the proximal ulna [32].
• The lateral ulnar collateral ligament is located posterior to the radial collateral ligament and attaches to the crista supinatoris of the proximal ulna, just distal to the annular ligament [32].
• The MCL consists of anterior and posterior bundles [32].
• The anterior bundle of the MCL arises from the anterior-inferior aspect of the medial epicondyle and inserts on the sublime tubercle of the proximal ulna [32].
• The posterior bundle of the MCL provides a secondary restraint to valgus load and resists ulnar rotation [32].
• The anterior bundle of the MCL attaches to the sublime tubercle, which is located just distal and medial to the coronoid [3].
• The LUCL complex originates at the geometric center of the radiocapitellar articulation, just distal to the lateral epicondyle [3].
• The LUCL proper has a ligamentous attachment site on the ulna [3].
• The annular ligament attaches proximal and deep to the LUCL complex but is intimately associated with it [3].

Biomechanical Function¶

• The LCL is the primary varus and posterolateral rotational stabilizer of the elbow [32].
• The lateral ulnar collateral ligament is the primary elbow stabilizer to posterolateral elbow rotatory instability [22].
• The anterior band of the medial collateral ligament is the primary valgus stabilizer in elbow flexion [22].
• Pronation stabilizes the LCL-deficient elbow, while supination decreases stability in this setting [32].
• The common extensor muscles provide varus stability to the elbow [32].
• The common flexor muscles provide valgus stability to the elbow [32].
• The biceps, brachialis, and triceps provide compressive stability to the elbow due to joint reactive forces, particularly when static stabilizers are injured [32].
• Surrounding muscle stabilizers may mask clinical valgus instability in 50% of cases [30].
• The flexor carpi ulnaris (FCU) is the primary dynamic stabilizer for valgus stability, and the flexor digitorum superficialis (FDS) is a secondary stabilizer [30].

Injury Patterns and Pathology¶

• Patients with simple elbow dislocations routinely have disruption of both the MCL, LCL, and elbow capsule [32].
• In simple elbow dislocations, injury to the lateral common extensor origin is typically more extensive than injury to the medial common flexor origin [32].
• Residual instability after elbow dislocation is usually due to incompetence of the LCL in the majority of patients, as most activities of daily living exert a varus force on the elbow [32].
• The MCL is the most important stabilizer of the elbow joint only in patients who routinely load their elbow in valgus, such as throwing athletes [32].
• Posterolateral rotatory instability is caused by incompetence of the LUCL [30].
• Varus posteromedial rotatory instability is an increasingly recognized but poorly understood entity caused by fracture of the anteromedial coronoid process [30].
• Valgus instability etiology includes acute elbow trauma or chronic repetitive loading and attenuation of the MCL [30].
• In baseball players, the late cocking and acceleration phases of throwing place the highest stress on the MCL [30].
• Valgus extension overload presents with pain during the deceleration phase as the elbow reaches terminal extension [30].
• Osteophytes of the posteromedial olecranon process can block full extension in valgus extension overload [30].
• Ulnar neuritis or cubital tunnel syndrome is associated pathology with MCL tears [30].
• MRI evaluation of the MCL shows a T sign with leakage of intraarticular contrast material at the undersurface of the ligament at its distal insertion on the sublime tubercle in partial tears [30].
• MRI shows discontinuity of the ligament with surrounding edema and hemorrhage in complete MCL tears [30].
• MRI detects LUCL pathology in approximately 50% of cases of posterolateral rotatory instability [30].

Surgical Repair and Reconstruction¶

• LCL repair can be performed using transosseous bone tunnels or suture anchors [34].
• For LCL repair, a single drill hole is placed at the center of the flexion-extension axis located at the center of the arc of curvature of the capitellum [34].
• Two drill holes are placed on the posterior column of the lateral supracondylar ridge in patients with good bone, or one anteriorly and one posteriorly to the supracondylar ridge in patients with poorer quality bone [34].
• Locking Krackow stitches are placed in the LCL, and a second suture is placed in the extensor fascia during LCL repair [34].
• LCL repair sutures are tensioned while maintaining the forearm in pronation and the elbow at 90 degrees of flexion [34].
• Overtensioning of the lateral ligaments should be avoided if the MCL is deficient, as medial gaping of the elbow can occur [34].
• MCL repair is performed using drill holes located at the anterior-inferior aspect of the medial epicondyle and two holes more proximally [34].
• Suture anchors can be employed for MCL repair [34].
• Acute MCL injury is treated with primary ligamentous repair or reattachment with suture anchors [30].
• Partial tears or avulsion-type injuries that felt a "pop" are better candidates for primary repair than complete tears in a chronic setting [30].
• Chronic valgus instability in competitive overhead-throwing athletes is treated with MCL reconstruction using tendon autograft [30].
• Chronic posterolateral rotatory instability is treated with reconstruction of the LUCL using tendon autograft [30].
• Varus posteromedial rotatory instability is treated with ORIF of the coronoid with a buttress plate and assessment of MCL insertion [30].

Rehabilitation and Postoperative Care¶

• If the MCL is intact and the LCL requires protection, the forearm should be rehabilitated in pronation, with prosupination performed only at 90 degrees or greater of flexion [28].
• Varus positioning of the arm should be avoided in patients with LCL injuries and repairs [28].
• If the MCL has been injured but not repaired and the LCL is competent, flexion-extension of the elbow should be performed with the forearm maintained in supination [28].
• If both the MCL and LCL have been injured, active range of motion should be initiated with the forearm in a neutral position [28].
• Extension is allowed only to the extent that allows congruent tracking intraoperatively, with further extension permitted as muscle tone and stability improve [28].
• Passive stretching of the elbow is not performed until ligament healing is progressing, typically beginning 6 weeks postoperatively [28].
• Light strengthening may be started 6 weeks postoperatively, with a formal strengthening program initiated at 3 months [28].
• Active motion is preferred over passive motion as it tends to stabilize the elbow [28].
• The elbow should not be immobilized for longer than 2 weeks to avoid excessive stiffness [28].
• A safe arc of motion should be defined fluoroscopically under anesthesia to guide early motion protocols [28].
• In LCL-repaired and MCL-intact elbows, the forearm is kept in pronation to increase stability because pronation decreases stress on the LCL [30].
• In LCL-repaired but MCL-deficient elbows, the forearm is kept in supination to increase stability because supination decreases stress on the MCL [30].
• In elbows where both LCL and MCL are repaired, the forearm is kept in neutral [30].

Muscles and Tendons¶

Tendinous Anatomy and Entheses¶

• There are two types of entheses, or tendinous attachments, to bone: fibrous and fibrocartilaginous [37].
• Fibrous attachments are more fleshy, broad, and indirect, typically arising from the metaphysis or diaphysis of long bones [37].
• Muscles with fibrous entheses around the elbow include the origin of the pronator teres on the medial side, extensor carpi radialis longus and brachioradialis on the lateral aspect, and the origin of the brachialis and deep head triceps from the metadiaphysis of the humerus [37].
• Fibrocartilaginous entheses are associated with direct attachment and a grossly recognizable tendon unit, typically attaching to the epiphysis or apophysis [37].
• Muscles with fibrocartilaginous entheses include the common flexor and extensor tendons, distal biceps and triceps tendons, and the insertion of the brachialis tendon [37].

Medial Muscles and Tendons¶

• On the medial side, flexor tendons originate off the medial epicondyle from proximal to distal and superficial to deep, including the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and the humeral head of the flexor digitorum superficialis [37].
• These medial flexor tendons coalesce to form a common flexor tendon group that is not easily separated because the tendon fibers interdigitate at their origins [37].
• The humeral origin of the pronator teres is located just anterior and proximal to the insertion of the flexors off the medial epicondyle and along the anterior aspect of the supracondylar ridge [37].
• The deep ulnar head of the pronator teres and the humeral origin of the pronator teres form a tunnel through which the median nerve and brachial artery travel below the level of the lacertus fibrosus [37].
• The median nerve and brachial artery pierce a fibrous septum between the flexor digitorum superficialis and the ulnar head of the pronator teres [37].
• The brachial artery divides into the radial artery above and the ulnar artery below the ulnar head of the pronator teres muscle in the proximal forearm just distal to the articulation [37].

Anterior Muscles and Tendons¶

• The brachialis muscle originates from the medial intermuscular septum to the lateral intermuscular septum and medial and lateral supracondylar ridges of the humerus [37].
• The brachialis muscle travels across the elbow to insert broadly upon the distal aspect of the coronoid on the proximal ulna anteriorly [37].
• The biceps brachii is composed of a long and short head which fuse to form a common distal biceps tendon that inserts as a crescentic attachment to the radial tuberosity [37].
• The distal biceps tendon spirals 90°, with the long head inserting more proximal and posterior on the radial tuberosity and the short head inserting more anterior and distally [37].

Lateral Muscles and Tendons¶

• On the lateral aspect of the elbow, the common extensor tendon originates at the lateral epicondyle and is composed of the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris [37].
• The lateral common extensor tendons coalesce to form a common tendon that is not easily separated at its origin from the lateral epicondyle [37].
• The extensor carpi radialis longus muscle originates just proximal to the extensor carpi radialis brevis along the lateral column and intermuscular septum [37].
• The brachioradialis muscle originates proximal to the extensor carpi radialis longus in the distal third of the humerus [37].

Posterior Muscles and Tendons¶

• The anconeus muscle originates from the posterior part of the humerus just proximal to the capitellum and posterior joint capsule [37].
• The anconeus muscle inserts broadly along the posterior aspect of the ulna and is the first muscle palpable off the radial side of the ulna [37].
• The triceps tendon inserts onto the olecranon process with discrete heads separate from the capsule [37].
• The medial head of the triceps inserts deep to and separately from the lateral and long heads on the olecranon [37].

Radial Nerve Anatomy and Course¶

• The radial nerve is one of two terminal branches of the posterior cord of the brachial plexus and splits away from the axillary nerve just proximal to the quadrangular space [9].
• The radial nerve lies behind the axillary artery and brachial artery anterior to the long head of the triceps muscle [9].
• The radial nerve courses laterally and posteriorly deep to the long head of the triceps and lies deep to the lateral head and superficial to the medial head of the triceps near the spiral groove [9].
• After innervating the triceps, the radial nerve pierces the lateral intermuscular septum and enters the anterior compartment of the arm approximately 10 cm proximal to the lateral epicondyle [9].
• The anconeus muscle is innervated proximal to the joint, followed by the brachioradialis muscle and the extensor carpi radialis longus [9].
• The radial nerve enters the forearm anterior to the lateral epicondyle between the brachioradialis and brachialis and divides into its superficial and deep branches just anterior to the capitellum [9].
• The takeoff of the deep branch of the radial nerve marks the leading edge of the radial tunnel [9].
• The extensor carpi radialis brevis is generally innervated distal to the elbow joint, and supinator branches exit from the nerve just distal to the extensor carpi radialis brevis branches [9].
• Proximal to the supinator, potential sites of entrapment within the radial tunnel include fibrous bands originating from the lateral epicondyle, a vascular leash (the "leash of Henry") arising from the radial recurrent artery, and the leading fibrous edge of the extensor carpi radialis brevis [9].
• Distal to the extensor carpi radialis brevis is the tendinous leading edge of the supinator, also known as the arcade of Fröhse [9].
• The deep branch of the radial nerve passes under the arcade of Fröhse with two small branches to the two heads of the supinator on either side [9].
• Fibrous bands within the supinator muscle or hypertrophy of the superficial head may cause compression at the arcade of Fröhse [9].
• After the distal edge of the supinator, the emerging posterior interosseous nerve quickly divides into two branches [9].
• The superficial branch of the posterior interosseous nerve innervates the extensor carpi ulnaris, extensor digitorum communis, and extensor digiti quinti muscles [9].
• The deep branch of the posterior interosseous nerve innervates the abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and extensor indicis proprius muscle [9].

Ulnar Nerve Anatomy and Surgical Exposure¶

• The ulnar nerve is identified in its groove posterior to the medial epicondyle [11].
• The flexor carpi ulnaris can be freed from its humeral origin on the epicondyle to expose the ulnar nerve further [11].
• The ulnar nerve passes from the anterior to the posterior compartment at the arcade of Struthers [11].
• In the global approach to the elbow, the cubital tunnel is opened, the ulnar nerve is isolated, and it is transposed anteriorly if the medial aspect of the elbow is to be exposed [24].
• The ulnar nerve should be protected throughout the procedure with a Penrose drain during the global approach [24].

Operative Techniques Involving Muscles and Tendons¶

• In the Speed technique for chronic elbow dislocation, an incision is made over the posterolateral aspect of the elbow beginning 10 cm proximal to the olecranon [5].
• The triceps aponeurosis is reflected distally to form a flap of tissue attached to the olecranon during the Speed technique [5].
• An incision is made in the midline of the arm through the fibers of the triceps muscle 7.5 cm proximal to the joint, curving around the lateral edge of the olecranon during the Speed technique [5].
• Muscle attachments are freed subperiosteally from the distal humerus, both anteriorly and posteriorly, during the Speed technique [5].
• The triceps aponeurosis is sutured into its normal position or at a slightly more distal level after reduction in the Speed technique [5].
• In the modified Steindler procedure, flexor-pronator muscles arising from the medial epicondyle are transposed to a more proximal and anterior position on the humerus to increase their moment arm for elbow flexion [25].
• The muscles transferred in the modified Steindler procedure include the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis [25].
• Donor muscles for the Steindler transfer must have normal or nearly normal power (BMRC grades 4 to 5) [25].
• In the Mayer and Green modification of the Steindler procedure, the entire medial epicondyle is transferred and moved to the anterior aspect of the humerus [25].
• The attachment of the medial epicondyle and flexor-pronator group is fixed to the anterior aspect of the humerus with a 3.5-mm screw and washer in the modified Steindler procedure [25].
• Screw fixation in the modified Steindler procedure is augmented with two additional suture anchors inserted into the humerus around the drill hole [25].
• The anchor sutures are tied to the flexor pronator origin with the elbow flexed 130 degrees and the forearm supinated in the modified Steindler procedure [25].
• In the interposition arthroplasty technique, an incision is made 15 to 20 cm long on the posterior aspect of the arm and forearm just medial to the midline of the limb [12].
• The broad aponeurosis of the triceps muscle is exposed by elevating the deep fascia laterally 2 to 3 cm in the interposition arthroplasty technique [12].
• The periosteum is stripped from the distal third of the posterior surface of the humerus to expose the radial head and olecranon in the interposition arthroplasty technique [12].
• In the posterolateral approach of the global elbow technique, the Kocher interval is developed between the anconeus and extensor carpi ulnaris muscle to expose the elbow capsule and lateral epicondyle [24].
• To expose the olecranon fossa and posterior aspect of the distal humerus in the posterolateral approach, the anconeus and triceps are reflected medially [24].
• To expose the radial head in the posterolateral approach, the common extensor origin is elevated anteriorly from the underlying capsule, lateral ulnar collateral ligament, and lateral epicondyle [24].
• The interval between the extensor digitorum communis and extensor carpi radialis longus and brevis is developed to the level of the deep radial nerve where it enters the supinator at the arcade of Fröhse in the posterolateral approach [24].
• The supinator muscle is released from the supinator crest of the ulna and retracted along with the posterior interosseous nerve to expose the proximal radius in the posterolateral approach [24].
• In the posteromedial approach of the global elbow technique, the flexor carpi ulnaris and flexor digitorum profundus muscles are released subperiosteally from their ulnar origins [24].
• The flexor carpi ulnaris and flexor digitorum profundus muscles are retracted anteriorly to expose the coronoid process, the anterior bundle of the medial ligament complex, and anterior joint capsule in the posteromedial approach [24].
• In the approach to the radial nerve, the nerve is exposed in the axilla and proximal third of the arm by an incision for the distal part of the brachial plexus [4].
• The radial nerve is exposed between the triceps posteriorly and the biceps, brachialis, and coracobrachialis anteriorly [4].
• The radial nerve winds around the humerus at the point where it is traced distally in the approach to the radial nerve [4].
• The radial nerve sends branches to the brachioradialis 5 or 6 cm proximal to the elbow and to the extensor carpi radialis longus and brevis a little more distally [4].
• The radial nerve divides into the superficial and deep radial (posterior interosseous) nerves at the elbow [4].
• The deep radial nerve is exposed through the distal part of the incision beginning 8 to 10 cm proximal to the elbow and continuing to the middle of the dorsum of the forearm [4].
• The deep radial nerve is followed beneath the brachioradialis into the supinator muscle [4].
• In the flexorplasty of the elbow (Mayer and Green modification), the flexor muscle mass is freed and mobilized distally away from the joint capsule and the ulna as far as the motor branches of the median nerve and ulnar nerve will permit [7].
• The biceps muscle, brachial vessels, and median nerve are retracted laterally, and the atrophied brachial muscle is split longitudinally during flexorplasty [7].
• The periosteum is incised and stripped to expose the anterior aspect of the distal end of the humerus during flexorplasty [7].
• The elbow is flexed to 120 degrees to determine the site of attachment of the transfer, usually 2 inches proximal to the elbow, during flexorplasty [7].
• A hole is made on the anterior surface of the humerus and enlarged with progressively larger diamond-head hand drills to receive the transferred muscle during flexorplasty [7].
• The action of the transfer as a pronator of the forearm is decreased by transferring it laterally on the humerus during flexorplasty [7].
• Two tunnels are made from the lateral and medial cortices of the humerus and connected to the larger hole for passing the suture during flexorplasty [7].
• The common flexors and origin are firmly secured in the larger hole, and the periosteum is closed with interrupted sutures over the transferred tendon to reinforce its anchorage during flexorplasty [7].
• A long-arm cast is applied with the elbow in acute flexion and the forearm in full supination after flexorplasty [7].

Rehabilitation and Postoperative Care¶

• Elbow flexion and extension exercises involve bending the elbow so fingers touch the shoulder, then straightening the elbow as much as possible [2].
• Forearm rotation exercises involve standing with good posture, elbow bent to 90°, rotating the palm up to face the ceiling, then turning the palm down to face the floor [2].
• Wrist extension and flexion exercises involve extending the wrist backwards as far as possible, then flexing the wrist forwards as far as possible [2].
• Supporting the upper limb with the contra-lateral arm reduces load on the upper quadrant, reducing the risk of compensatory muscle strategies in the early post-operative shoulder [2].
• After ulnar nerve transposition, the elbow is immobilized at a 90-degree angle for 3 weeks [11].
• Physical therapy is started and continued after ulnar nerve transposition to prevent secondary changes in the muscles of the hand [11].
• After endoscopic cubital tunnel release, the wound is protected in a soft bulky dressing, and early range of motion is allowed as tolerated [14].
• After the Speed technique for chronic elbow dislocation, the arm is immobilized in a posterior splint at 90 degrees [5].
• The drain is removed after 24 hours following the Speed technique [5].
• Pins are removed approximately 14 days after surgery following the Speed technique [5].
• The splint is removed several times a day for gentle, active motion exercises following the Speed technique [5].
• When a moderate range of strong active motion has been regained, the splint may be discarded during the day but should be worn at night for 2 or 3 more months following the Speed technique [5].
• After the modified Steindler procedure, the elbow is maintained in 100 degrees of flexion until union of the medial epicondyle fragment, generally by 6 to 8 weeks [25].
• Passive flexion of the elbow, wrist, and fingers commences just after the operation following the modified Steindler procedure [25].
• Active flexion of the wrist and fingers with the elbow in full flexion is started in the third week following the modified Steindler procedure [25].
• Extension of the elbow, wrist, and fingers is allowed from the seventh week after surgery following the modified Steindler procedure [25].
• Postoperative rehabilitation and muscle reeducation take several months following the modified Steindler procedure, with the goal of full active elbow flexion and a

Neurovascular Anatomy¶

Radial Nerve¶

• The radial nerve is one of two terminal branches of the posterior cord of the brachial plexus [9].
• The radial nerve splits away from the axillary nerve just proximal to the quadrangular space [9].
• The radial nerve lies behind the axillary artery and brachial artery and anterior to the long head of the triceps muscle [9].
• The radial nerve courses laterally and posteriorly deep to the long head of the triceps [9].
• Near the spiral groove, the radial nerve lies deep to the lateral head and superficial to the medial head of the triceps [9].
• The radial nerve pierces the lateral intermuscular septum and enters the anterior compartment of the arm approximately 10 cm proximal to the lateral epicondyle [9].
• The anconeus muscle is innervated by the radial nerve proximal to the joint [9].
• The brachioradialis muscle is innervated by the radial nerve following the anconeus [9].
• The extensor carpi radialis longus is innervated by the radial nerve following the brachioradialis [9].
• The radial nerve enters the forearm anterior to the lateral epicondyle between the brachioradialis and brachialis [9].
• The radial nerve divides into its superficial and deep branches just anterior to the capitellum [9].
• The extensor carpi radialis brevis is generally innervated distal to the elbow joint [9].
• Supinator branches exit from the radial nerve just distal to the extensor carpi radialis brevis branches [9].
• Proximal to the supinator, fibrous bands originating from the lateral epicondyle and coursing superficial to the radial head are a potential site of entrapment within the radial tunnel [9].
• A vascular leash arising from the radial recurrent artery and arching over the nerve, known as the "leash of Henry," is a potential site of entrapment within the radial tunnel [9].
• The leading fibrous edge of the extensor carpi radialis brevis is a potential site of entrapment within the radial tunnel [9].
• Distal to the extensor carpi radialis brevis, the tendinous leading edge of the supinator, known as the arcade of Fröhse, is a potential site of entrapment [9].
• The deep branch of the posterior interosseous nerve innervates the abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and extensor indicis proprius muscles [9].
• The topography of the posterior interosseous nerve mirrors the digits, with branches to the thumb extensors on the radial side, to the extensor digitorum communis centrally located, and to the extensor carpi ulnaris ulnarly [9].
• The superficial radial nerve is entirely sensory [4].
• The deep radial nerve is also known as the posterior interosseous nerve [4].
• Approximately 5 or 6 cm proximal to the elbow, the radial nerve sends branches to the brachioradialis [4].
• A little more distally than the brachioradialis branches, the radial nerve sends branches to the extensor carpi radialis longus and brevis [4].
• At the elbow, the radial nerve divides into the superficial and deep radial nerves [4].

Ulnar Nerve¶

• The ulnar nerve is located in its groove posterior to the medial epicondyle [11].
• The superior ulnar collateral artery runs with the ulnar nerve and often requires division at the level just distal to the medial epicondyle during transposition [11].
• The medial antebrachial cutaneous nerve lies along the fascia usually about 3 cm distal to the medial epicondyle [40].
• Osbourne’s ligament is the thickened fascia between the medial epicondyle and olecranon overlying the ulnar nerve [40].
• The ulnar nerve is protected by the deep and superficial fascia between the two heads of the flexor carpi ulnaris distally [40].
• The arcade of Struthers and the medial intermuscular septum are proximal structures that can constrict the ulnar nerve [40].
• Large veins are present anterior to and piercing the medial intermuscular septum in the supracondylar area [11].

Median Nerve¶

• The median nerve is located just medial to the brachial artery and vein [27].
• The median nerve is intimate with the brachial artery and vein and can be found just distal to the cubital crease, adjacent to or within the flexor pronator muscle mass [27].
• The bicipital aponeurosis (lacertus fibrosus) may act as a compressive band across the flexor muscle in pronation [27].
• The tendon of the superficial head of the pronator teres is a potential compressive structure for the median nerve [27].
• The proximal tendinous attachment of the deep head of the pronator teres arches around the median nerve and attaches to the ulna [27].
• The proximal tendinous arch of the flexor digitorum superficialis is a potential compressive structure for the median nerve [27].
• Two crossing vascular leashes typically compress the median nerve distally [27].
• A ligament of Struthers may be identified proximal to the elbow crease and can compress the median nerve [27].
• The anterior interosseous nerve is a fascicle of the median nerve [27].
• The median nerve and brachial artery are located deep to the biceps brachii tendon and brachioradialis muscle in the proximal forearm [7].

Biomechanics and Function¶

Ligamentous Anatomy and Biomechanics¶

• The medial ulnar collateral ligament (MUCL) is comprised of the anterior bundle, posterior, and transverse ligament [10].
• The anterior bundle is the strongest component of the MUCL complex and serves as the primary restraint to valgus stress [10].
• The anterior bundle of the MUCL is subdivided into anterior and posterior bands that provide reciprocal function, with the anterior band tight in extension and the posterior band tight in flexion [10].
• The lateral ulnar collateral ligament (LUCL) origin center is located 10.7 mm from the lateral epicondyle [10].
• The LUCL insertion is located 3.3 mm from the apex of the supinator crest [10].
• The MUCL is commonly injured in overhead throwing athletes [10].
• Kinematic analysis of the MUCL allows for selective reconstruction based on the mechanism of injury and the dominant fibers affected [10].

Joint Kinematics and Motion¶

• The elbow's complex bony and ligamentous anatomy determines the biomechanical characteristics important for diagnosing instability patterns [10].
• There is a high correlation between the long outer diameter of the radial head and the vertical height of the capitellum [10].
• There is a high correlation between the long outer diameter of the radial head and the anterior width of the capitellum [10].
• The relationship between radial head size and capitellum size shows no significant difference between right and left elbows [10].
• The distal triceps tendon has three distinct insertional areas to the olecranon corresponding to the posterior capsular insertion, the deep muscular portion, and the superficial tendinous portion [10].
• The deep muscular head of the triceps corresponds to the medial head of the triceps [10].
• The tendinous portion of the triceps insertion corresponds to the long and lateral heads [10].
• The width of the triceps insertion is 2.6 cm [10].
• The triceps insertion is located 1.1 cm from the tip of the olecranon [10].

Throwing Biomechanics and Injury Mechanisms¶

• Valgus-hyperextension overloading of the elbow during throwing causes repetitive microtrauma and shear stresses to the medial elbow [8].
• The structures subjected to shear stress during throwing include the medial epicondyle physis, ulnar collateral ligament (UCL), and flexor pronator origin [8].
• Forces are highest on the medial elbow during the late cocking and early acceleration phases of throwing [8].
• Little Leaguer’s elbow is associated with throwing curveballs or an infielder bent-elbow throw involving a whipping mechanism [8].
• Children with Little Leaguer’s elbow often experience pain on the compressed radial side of the joint in addition to the distracted ulnar side [8].
• Chronic conditions associated with throwing injuries may produce an increased carrying angle or a flexion contracture [8].

Rehabilitation and Functional Loading¶

• Supporting the upper limb with the contra-lateral arm reduces load on the upper quadrant [2].
• Reducing load on the upper quadrant decreases the risk of compensatory muscle strategies in the early post-operative shoulder [2].
• Plank exercises recruit core musculature at levels consistent with strengthening [35].
• Plank performed on the floor recruits latissimus dorsi at lower levels than plank performed on a gym ball [35].
• Lack of core muscle endurance has been postulated as a potential factor in shoulder pathology in overhead and contact athletes [35].

Common Sites of Injury¶

Medial Elbow (Little Leaguer's Elbow)¶

• Little Leaguer’s elbow is a generic term for any injury to a child’s elbow accompanied by pain along the medial aspect of the proximal forearm or elbow [8].
• Little Leaguer’s elbow is a progressive problem resulting from repetitive microtrauma related to excessive stresses experienced by the immature skeleton during overhead athletics [8].
• Valgus-hyperextension overloading of the elbow during throwing causes repetitive microtrauma and shear stresses to the medial epicondyle physis, ulnar collateral ligament (UCL), and flexor pronator origin [8].
• The syndrome is associated with throwing curveballs or with an infielder bent-elbow throw that involves a whipping mechanism used to gain adequate speed [8].
• In younger patients, the diagnosis is more likely to be an apophysitis or an avulsion injury rather than a UCL sprain [8].
• Patients often first experience pain after and then during a game, which may be mild at first but eventually inhibits throwing [8].
• Forces are highest on the medial elbow during late cocking and early acceleration phases of throwing [8].
• Less common presentations include acute avulsion of the medial epicondyle [8].
• Patients may initially report decreased throwing distance or accuracy, progressing to a loss of throwing velocity as the injury advances [8].
• Chronic conditions may produce an increased carrying angle or a flexion contracture [8].
• Point tenderness is noted over the medial epicondyle, sublime tubercle, or flexor mass [8].
• Stability testing involves the moving valgus stress test, where valgus stress is applied with the arm in varied degrees of flexion and extension [8].
• Stability testing involves the milking maneuver, which applies valgus stress with forearm supination and >90° elbow flexion [8].
• Bilateral AP, lateral, and oblique radiographs of the elbow should be obtained to compare with the unaffected side for irregular physis appearance or displacement [8].
• Fragmentation of the medial epicondyle, trochlea, olecranon, or capitellum may be present on imaging [8].
• Medial epicondyle hypertrophy or radial head hypertrophy may be present on imaging [8].
• Advanced imaging with MRI is indicated in cases of possible UCL injury or when radiographs and physical examination are inconclusive [8].
• Magnetic resonance (MR) arthrogram may be helpful for diagnosis of UCL injury [8].
• Medial epicondylitis is managed initially with 4 to 6 weeks of rest [8].
• Valgus extension overload and posterior stress syndromes typically can be managed with rest or activity and throwing modifications depending on severity of symptoms [8].
• Alterations in the athlete’s form, motion, and playing habits as well as adherence to recommended pitch and inning counts are advised when return to throwing is initiated [8].
• Intra-articular steroid injection may be used to control inflammation [8].
• Surgical indications include failure to respond to nonsurgical treatment [8].
• Surgical indications include instability of the elbow with avulsion fracture or fragmentation of the medial epicondyle [8].
• UCL reconstruction with auto- or allograft is performed when indicated for UCL insufficiency [8].
• Open reduction and internal fixation (ORIF) is performed for medial epicondyle avulsion fractures displaced more than 5 mm [8].
• Consideration for ORIF is given for less displaced avulsion fractures in competitive throwers, although definitive research is lacking [8].
• Arthroscopic débridement of posterolateral synovium and olecranon osteophytes is performed for recalcitrant posterior symptoms of valgus extension overload [8].
• Complications of surgery include ulnar nerve neuropathy, loss of motion, infection, continued pain, and inability to return to play at the same level [8].
• Aggressive débridement of the olecranon or osteophytes may result in instability [8].
• For surgery not involving ligaments, rehabilitation involves minimal immobilization with early ROM, strengthening, and pain modalities [8].
• For ligament reconstructions, rehabilitation involves a short course of immobilization followed by protected ROM [8].
• Prevention involves educating coaches, parents, and athletes on pitch counts and proper mechanics of throwing [8].
• The term Little League elbow has been used to describe a multitude of lesions about the elbow, usually medial epicondylar apophysitis/avulsion, osteochondritis dissecans (OCD) of the capitellum, but also Panner disease and stress lesions of the olecranon apophysis and radial head epiphysis [29].
• These overuse syndromes can be seen in any overhead athlete [29].
• Patients usually have localized pain that is activity related [29].
• Radiographs may be normal or reveal characteristic changes consistent with osteonecrosis or epiphysiolysis [29].
• Treatment consists of nonsteroidal antiinflammatory drugs (NSAIDs) and activity modification [29].
• Young athletes may require immobilization to ensure compliance with rigid activity restrictions [29].
• Once symptoms have abated, a carefully designed, well-controlled return to athletics should be implemented [29].
• Persistent symptoms or instability may require surgical intervention [29].

Lateral Elbow and Radial Head¶

• Radial head fractures are the most common fractures of the elbow with an estimated incidence of 2.5 to 2.9 per 10,000 people per year [23].
• Radial head fractures are more common in women than in men and most frequently occur between the ages of 20 and 60 years [23].
• Undisplaced and minimally displaced radial head fractures typically occur as isolated injuries [23].
• More displaced and comminuted radial head fractures commonly have associated injuries to the collateral ligaments and may have associated fractures of the coronoid, capitellum, or proximal ulna [23].
• In high-energy trauma, dislocations of the elbow and/or forearm can also occur with radial head fractures [23].
• Disruption of the interosseous membrane and distal radial ulnar joint ligaments may result in axial instability of the forearm, termed the Essex–Lopresti lesion [23].
• The majority of radial head and neck fractures are minimally displaced and are isolated injuries [23].
• These fractures typically have a good functional outcome with nonsurgical treatment [23].
• Most radial head fractures occur as the result of low-energy mechanisms such as a trip and fall on an outstretched hand [23].
• Sporting activities as well as motor vehicle collisions cause higher energy fractures typically with greater displacement and a higher incidence of concomitant injuries [23].
• A valgus load causes impaction of the radial head into the capitellum, commonly with rupture of the MCL [23].
• Posterolateral rotatory subluxation of the radial head with respect to the capitellum causes a partial articular shear fracture of the anterior portion of the radial head often with rupture of the LCL [23].
• An axial forearm load causes impaction of the radial head into the capitellum with more severe trauma producing a fracture of the coronoid or rupture of the interosseous membrane and distal radioulnar joint ligaments, known as the Essex–Lopresti injury [23].
• Tears of the LCLs and/or MCLs are most commonly associated with radial head fractures [23].
• Dislocations of the elbow and fractures of the coronoid, capitellum, olecranon, and proximal ulna are also frequent associations with radial head fractures [23].
• Rupture of the interosseous membrane while uncommon is best diagnosed and treated early as late reconstruction is challenging and often unsatisfactory [23].
• Patients present with complaints of pain, swelling, and stiffness of the elbow and forearm [23].
• Ecchymosis may develop several days later [23].
• Tenderness laterally over the radial head is expected [23].
• Tenderness over the lateral epicondyle may indicate the presence of an associated LCL injury [23].
• Tenderness over the medial epicondyle or sublime tubercle may suggest MCL disruption [23].
• The alignment of the elbow is assessed to rule out an associated dislocation or Monteggia fracture-dislocation [23].
• A careful examination of range of motion is performed since loss of forearm rotation is one of the primary indications for surgical intervention in the setting of displaced fractures [23].
• If pain precludes a proper evaluation of forearm rotation, the surgeon can aspirate the hemarthrosis and inject local anesthetic or reevaluate the patient several days later when they are more comfortable [23].
• A loss of terminal extension is expected as a consequence of the hemarthrosis which accompanies all radial head fractures [23].
• The presence of clicking or crepitus with forearm rotation should be noted [23].
• The shoulder and wrist are examined for associated injuries [23].
• The distal radial ulnar joint should be palpated and balloted for both tenderness and instability [23].

Elbow Dislocations¶

• Simple elbow dislocations are typically the result of a fall on an outstretched hand [17].
• O'Driscoll et al. described a valgus, axial, and posterolateral force that results in the typical posterolateral dislocation of the elbow joint [17].
• The soft tissue injury is thought to begin on the lateral side of the elbow with disruption of the LCL and then proceeds through the capsule to the medial side with the medial collateral ligament (MCL) being injured last [17].
• The MCL may remain intact in some injuries [17].
• Less commonly, simple dislocation may be the result of a varus, axial, and posteromedial force where the injury proceeds from medial to lateral [17].
• This varus mechanism typically results in a small anteromedial coronoid fracture [17].
• Magnetic resonance imaging (MRI) and video studies have shown that complete ligamentous tears are more common on the medial side of the elbow with the lateral ligaments being preserved in some cases [17].
• These studies suggest that the sequence of failure may begin on the medial side of the elbow with acute valgus instability in an extended elbow [17].
• This mechanism may explain why some elbows are very stable after reduction since the LCL complex is sometimes preserved [17].
• By definition, simple elbow dislocations are not associated with fractures [17].
• Simple elbow dislocations are typically accompanied by significant disruption of the collateral ligaments, elbow capsule, and forearm flexor and extensor muscle origins [17].
• Although rare, injury to the brachial artery has been described in closed simple dislocations [17].
• Nerve palsies are possible in simple elbow dislocations [17].
• The ulnar nerve is the most commonly injured nerve following elbow dislocation [17].
• Entrapment of the median nerve in the joint after reduction has been described [17].
• Patients typically present with an obvious deformity and pain about the affected elbow [17].
• Some patients may self-reduce or spontaneously reduce and will present with pain, swelling, and ecchymosis but no deformity [17].
• With the elbow flexed to 90 degrees, the medial and lateral epicondyles and the olecranon process should form an isosceles triangle [17].
• If the isosceles triangle is not formed, the elbow is likely dislocated or subluxated [17].
• The elbow should be evaluated for open wounds [17].
• A complete peripheral neurologic examination should be performed for both motor and sensory functions [17].
• Radial and ulnar pulses should be compared with the opposite side [17].
• If pulses are decreased, arm–arm indices are useful to help determine if there is a vascular injury [17].
• Anteroposterior, lateral, and oblique radiographs are used to diagnose elbow dislocation and help to rule out associated fractures [17].
• Computed tomography (CT) scanning is rarely needed but can be useful if there is a questionable associated fracture [17].
• MRI is not needed unless there is concern for ulnar nerve entrapment in the joint [17].
• Simple elbow dislocations are often described based on the direction of dislocation [17].
• The majority of dislocations are posterior or posterolateral [17].
• Anterior, medial, lateral, and divergent dislocations are possible [17].
• Dislocations can be classified as acute, subacute (less than 6 weeks), or chronic [17].

Varus Posteromedial Instability¶

• Varus posteromedial instability (VPMI) may occur after a fall on an outstretched hand that applies a varus thrust to the elbow [19].
• A combined sagittal coronoid fracture and LUCL injury are the essential lesions of VPMI [19].
• The instability occurs as the distal humerus subluxates into the proximal ulnar lesion [19].
• When this occurs, the proximal ulna rotates in a posterior and varus direction producing incongruency [19].
• On the lateral aspect of the elbow, traction tears the lateral ligaments occur, usually without bony injury [19].
• Decreased range of motion, painful arc of motion, and, sometimes, crepitus are noted on examination for VPMI [19].
• AP radiographs will show a loss of articular congruency of the medial joint line and/or a sagittal coronoid fracture in VPMI [19].
• Opening of the radiocapitellar articulation is common indicating injury to the lateral ligaments [19].
• Radial head fractures are not seen with this injury pattern [19].
• This absence of radial head fractures distinguishes VPMI from a terrible triad injury [19].
• CT is the best study to define the orientation and size of the coronoid fracture [19].
• Early recognition of the instability pattern and treatment is needed to avoid rapid onset of posttraumatic arthritis [19].
• Treatment of VPMI consists of repair of the lateral collateral ligament and restoration of the proximal ulnar joint surface and/or open reduction and internal fixation of the coronoid fracture [19].
• Anteromedial coronoid fractures that are small, minimally displaced, and demonstrate no evidence of elbow subluxation may be treated nonoperatively [19].
• Outcomes are improved with anatomic reduction and secure coronoid fixation [19].
• Varus malalignment of the anteromedial facet or varus subluxation of the elbow lead to arthritic changes and poor functional results [19].

General Elbow Constraints and Dislocation Mechanics¶

• The three primary static constraints of the elbow are the ulnohumeral bony articulation, the anterior bundle of the MCL, and the LCL complex (including the LUCL) [19].
• The three secondary static constraints of the elbow are the capsule, the radial head, and the common flexor and extensor tendon origins [19].
• The dynamic constraints are the muscles that cross the elbow joint (the anconeus, triceps, and brachialis); these muscles apply compressive force [19].
• In posterolateral dislocations, the classic mechanism of injury is thought to be a combination of axial load, external rotation of the forearm (supination), and valgus force (valgus posterolateral) [19].
• A progressive circular disruption of the soft tissues occurs in posterolateral dislocations [19].
• Most elbow dislocations are successfully treated by brief immobilization followed by early protected range of motion therapy [19].
• The joint must be reduced concentrically, and treatment should not stop until satisfactory reduction is achieved [19].
• In posterior dislocations, the elbow is typically more unstable in extension [19].
• Therefore, the elbow should be immobilized in at least 90° of flexion [19].
• If the LCL is disrupted and the MCL is intact, the elbow will be more stable with the forearm in pronation [19].
• If the LCL and the MCL are disrupted, pronation of the forearm may draw attention to the medial injury, and the forearm should be positioned in neutral to off-load the lateral- and medial-side injuries [19].
• Loss of extension is the most common complication following the treatment of simple elbow dislocations [19].
• PLRI is primarily an ulnohumeral instability problem [19].
• Chronic PLRI is best treated by reconstructing the LUCL [19].
• VPMI is characterized by anteromedial facet fracture (sagittal plane fracture with MCL insertion) and LUCL tear [19].
• VPMI is treated surgically by repairing the anteromedial facet of the coronoid and, usually, repairing the LUCL [19].

Neurovascular Anatomy in Injury Context¶

• The native ulnar nerve runs along the medial triceps, around the medial epicondyle within the cubital tunnel, and then beneath the flexor carpi ulnaris fascia [13].
• The ulnar nerve may have been scarred in or transposed anteriorly during previous surgeries [13].
• Every attempt should be made to understand the ulnar nerve location by interrogating operative reports, physical examination, and by ultrasound if needed [13].
• If left in situ, the ulnar nerve needs to be identified and protected throughout the case [13].
• If previously transposed, it is practice to leave it within its bed requiring less dissection and lowering the risk of devascularization and injury [13].
• If not transposed originally, a subcutaneous transposition is preferred at the conclusion of the case to lower the risk of neuropathy and simplify future approaches [13].
• The radial nerve runs from medial to lateral along the posterior aspect

Surgical Anatomy¶

Nerve Anatomy and Protection¶

• The radial nerve runs from medial to lateral along the posterior aspect of the humeral cortex in the middle third of the diaphysis for a 6-cm segment [13].
• The radial nerve crosses the lateral intermuscular septum from posterior to anterior approximately 14 cm proximal to the lateral epicondyle [13].
• The radial nerve is highly vulnerable in revision arthroplasty and fracture care due to decreased surgeon familiarity and its intimate relationship with the humeral shaft [13].
• The radial nerve is at risk during reaming in the case of a cortical breech or during cementing as cement extrusion onto the nerve can cause thermal necrosis [13].
• Radial nerve necrosis has been documented during ultrasonic cement removal [13].
• In the revision setting, the radial nerve has been found intraosseous [13].
• Throckmorton et al. reported a 2.7% (7/258) incidence of radial nerve palsy in humeral component revision [13].
• Of the radial nerve palsies reported by Throckmorton et al., 43% (3/7) regained function [13].
• Causes of radial nerve palsy in the Throckmorton et al. series included thermal necrosis from extruded PMMA, neuropraxia, and tourniquet palsy [13].
• Thermal necrosis from extruded PMMA resulted in 0 out of 7 patients regaining function in the Throckmorton et al. series [13].
• The ulnar nerve should be identified so that it can be protected during olecranon fracture surgery, but it is not necessary to dissect it free of the cubital tunnel [15].
• The ulnar nerve should be identified so that it can be protected during posterior Monteggia fracture surgery, but it is not necessary to mobilize it [41].
• The ulnar nerve should be isolated and retracted during elbow arthrodesis [42].
• Care must be taken not to damage the ulnar nerve when inserting the axis pin for external fixation [36].
• Imaging is employed to ensure external fixation pins are not placed too deep to avoid injury to the ulnar nerve [36].
• If the ulnar nerve is left in situ, it needs to be identified and protected throughout the case [13].
• If the ulnar nerve was previously transposed, it is practice to leave it within its bed requiring less dissection and lowering the risk of devascularization and injury [13].
• If the ulnar nerve was not transposed originally, a subcutaneous transposition is preferred at the conclusion of the case to lower the risk of neuropathy and simplify future approaches [13].
• Anterior subcutaneous transposition is preferred at the conclusion of revision TEA to simplify and improve the safety of future approaches [39].
• Avoid drilling through the medial cortex to avoid ulnar nerve injury when inserting a guidewire for internal joint stabilization [16].

Muscular and Ligamentous Anatomy¶

• The Kocher approach is used between the ECU and anconeus when the LCL is ruptured [6].
• A common extensor tendon-splitting approach is preferred when the lateral ulnar collateral ligament is intact [6].
• A Kocher approach between the anconeus and the extensor carpi ulnaris is preferred if the lateral collateral ligament is disrupted to facilitate ligament repair [6].
• A more anterior approach splitting the common extensor tendon at the mid-portion of the radial head is preferred when the ligaments are intact [6].
• The interval between the ECU and FCU is developed and the subcutaneous border of the ulna is exposed during olecranon fracture surgery [15].
• On the ulnar side, the FCU is elevated from the olecranon to visualize the joint during olecranon fracture surgery [15].
• On the radial side, the anconeus fascia is incised and the muscle can be elevated from the olecranon fragment for further visualization during olecranon fracture surgery [15].
• The approach to internal joint stabilization involves the extensor carpi radialis brevis and extensor digitorum communis (Kaplan interval), which splits the common extensors 50:50 [16].
• The origin of the extensor carpi radialis longus, brachialis, and anterior capsule is elevated from the anterior humerus to improve access to the elbow during internal joint stabilization [16].
• The avulsed origin of the lateral collateral ligament and the common extensors will be reattached at the end of the internal joint stabilization procedure [16].
• The flexor pronator mass can be further elevated off the ulna to aid exposure during medial elbow approaches [38].
• The ECU and anconeus are elevated radially as required to expose the joint and shaft on the radial side during posterior Monteggia fracture surgery [41].
• The FCU may be elevated laterally to expose the joint and shaft on the ulnar side during posterior Monteggia fracture surgery [41].
• The broad aponeurosis of the triceps muscle is exposed by elevating the deep fascia laterally 2 to 3 cm during interposition arthroplasty [12].
• The triceps tendon is split medially and laterally and raised proximally as a flap, along with the attached fragment of the olecranon, during Staples arthrodesis [42].

Bony Anatomy and Joint Mechanics¶

• The proximal medial portal for elbow arthroscopy is 2 cm proximal to and 1-2 cm anterior to the medial epicondyle [1].
• The transtriceps portal is visible posteriorly in the modified supine position for elbow arthroscopy [1].
• The axis of ulno-humeral rotation is defined by two points: the lateral point at the geometric center of the dome of the capitellum and the medial point on the medial trochlear expansion [16].
• The distal end of the humerus is fashioned into one condyle convex from anteriorly to posteriorly during interposition arthroplasty [12].
• The distal humerus is shaped into an inverted V to achieve some mediolateral stability during interposition arthroplasty [12].
• The trochlear notch of the ulna is deepened and lengthened, and the head of the radius is cut away to the level of the distal part of this notch during interposition arthroplasty [12].
• The radial head is sectioned perpendicular to the neck at the junction of the radial head and neck during open radial head excision [6].
• The stump of the proximal radius must not impinge with the lesser sigmoid notch of ulna during forearm rotation after radial head excision [6].
• The olecranon is osteotomized and wedged into the posterior distal humerus in the Hallock technique for elbow arthrodesis [42].
• The distal posterior surface of the humerus is cut down to a flat surface in line with the surface of the remaining proximal end of the ulna during Staples arthrodesis [42].
• The anatomy about the elbow is complex and three-dimensional appreciation is required for complex revision surgery [13].
• Unlinked prosthesis requires retention of the condyles and collateral ligaments similar to fracture about the native elbow [13].
• Maintenance or repair of extensor mechanism is paramount in surgical management of periprosthetic fractures about total elbow arthroplasty [13].

Surgical Approaches and Intervals¶

• A direct lateral or a posterior skin incision is utilized for open radial head excision [6].
• A posterior incision is longer but is more cosmetic, avoids cutaneous nerves, and allows for an extensile approach to repair other structures if required [6].
• Dissection must be maintained anterior to the mid-axis of the radial head to avoid iatrogenic lateral instability during radial head excision [6].
• The forearm is maintained in pronation while approaching the radial head and neck to protect the posterior interosseous nerve during radial head excision [6].
• Further exposure for radial head excision can be achieved by detaching the anterior portion of the radial collateral ligament off the lateral epicondyle and the extensor carpi radialis longus and brevis off the lateral supracondylar ridge [6].
• Do not dissect distal to the biceps tuberosity without visualizing the posterior interosseous nerve during radial head excision [6].
• A posterior midline incision is made and full-thickness medial and lateral fasciocutaneous flaps are raised for olecranon fracture surgery [15].
• The skin incision is placed just radial to the tip of the olecranon for better coverage of hardware during olecranon fracture surgery [15].
• A posterior midline incision is employed and a full-thickness lateral flap is elevated on the deep fascia for open reduction and internal fixation of simple elbow dislocation [38].
• A fascial incision is made through the Kocher interval between the anconeus and extensor carpi ulnaris (ECU) for exposure of the LCL if not visible from injury [38].
• A posterior midline incision is made and full-thickness medial and lateral fasciocutaneous flaps are raised for posterior Monteggia fracture surgery [41].
• The skin incision is curved radially around the tip of the olecranon for better coverage of hardware during posterior Monteggia fracture surgery [41].
• The interval between the ECU and FCU is developed for exposure of the ulnar shaft during posterior Monteggia fracture surgery [41].
• The trochlea, capitellum, and radial head are exposed by retracting the olecranon fragment proximally during posterior Monteggia fracture surgery [41].
• The region of the lateral ligament complex origin on the lateral epicondyle of the humerus is palpated with a blunt instrument under the fascia during posterior Monteggia fracture surgery [41].
• An incision 15 to 20 cm long on the posterior aspect of the arm and forearm just medial to the midline of the limb is made for interposition arthroplasty [12].
• The Kocher interval is entered and dissection is carried along the lateral head of the triceps, taking care not to proceed so proximally as to endanger the radial nerve, during interposition arthroplasty [12].
• A triceps-splitting midline approach can be used to approach the joint during interposition arthroplasty [12].
• The periosteum is stripped from the distal third of the posterior surface of the humerus, retracted medially and laterally, to expose the radial head and olecranon during interposition arthroplasty [12].
• The elbow is approached through a posterior longitudinal incision for Staples arthrodesis [42].

References¶

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