ANATOMY OF ELBOW AND

FOREARM WITH APPLIED

ASPECTS

Presentation by :- Dr S Adithya Karthik

Moderator :- Dr Chunchesh K D
Chairperson :- Dr Ambrish S
 ELBOW JOINT

• Hinge variety of synovial joint between the distal end of humerus and proximal
ends of radius and ulna
• Elbow complex includes:-
1. Humeroradial
2. Humeroulnar
3. Superior radioulnar joint
 ARTICULAR PART OF DISTAL
HUMERUS(ANTERIOR)

• Lower end of humerus forms the condyle which is expanded from side to side, and has
articular and non articular part
• Articular part includes the following:-
1. Capitulum- rounded projection which articulates with head of humerus
2. Trochlea- pulley shaped surface which articulates with trochlear notch of ulna. The medial
edge of trochlea projects down 6mm more than lateral edge which results in formation of
the carrying angle
3. Coronoid fossa- depression above anterior aspect of trochlea, which accommodates
coronoid process of ulna when elbow flexed.
4. Radial fossa- depression above anterior aspect of capitulum which accommodates head of
radius when elbow flexed
CAPITULUM AND TROCHLEA
 NON ARTICULAR PART OF DISTAL
HUMERUS

1. Medial epicondyle- Prominent bony projection on medial side at distal end.

It is subcutaneous and easily felt on medial side of elbow
2. Lateral epicondyle- smaller than medial epicondyle, Anterolateral part has
muscular impression(for anconeus)
3. Lateral supracondylar ridge- sharp lateral margin above distal end
4. Medial supracondylar ridge- sharp medial margin over distal end
5. Olecranon fossa lies just above posterior aspect of trochlea, which
accommodates olecranon process of ulna when elbow extended
 LIGAMENTS OF ELBOW JOINT

1. Capsular ligament-
• Superiorly, attached to lower end of humerus in such a way that capitulum,
trochlea, radial fossa, coronoid fossa and olecranon fossa are intracapsular
• Inferomedially, attached to margin of trochlear notch of ulna except laterally
• Inferolaterally, attached to annular ligament of superior radioulnar joint
 CAPSULAR LIGAMENT OF ELBOW
JOINT

• Attached to lower end along a line that reaches upper limits of radial and
coronoid fossae anteriorly
• Reaches upper limit of olecranon fossa posteriorly
• All these fossae lie within joint cavity
• Medially, line of attachment passes between medial epicondyle and trochlea
• Laterally, passes between lateral epicondyle and capitulum
 LIGAMENTS OF ELBOW JOINT

2. Ulnar collateral ligament- triangular in shape with apex attached to medial

epicondyle of humerus, and base to ulna. It has thick anterior and posterior bands
which are attached to coronoid and olecranon processes respectively. Their lower
ends are joined to each other by an oblique band, This ligament is crossed by
ulnar nerve.
 LIGAMENTS OF ELBOW JOINT

• 3. Radial collateral ligament- fan shaped band extending from lateral

epicondyle to annular ligament
 RELATIONS OF ELBOW JOINT

• Anteriorly- Brachialis, median nerve, brachial artery and tendon of biceps

brachii
• Posteriorly- Triceps brachii and anconeus
• Medially- Ulnar nerve, flexor carpi ulnaris and common flexors
• Laterally- Supinator, extensor carpi radialis brevis and other common
extensors
 BLOOD SUPPLY OF ELBOW

• Anterior(ventral) and posterior(dorsal) descending branches of profunda

brachii artery
• Radial recurrent artery(ventral)
• Interosseous recurrent artery from posterior interosseous(ventral)
• Inferior ulnar collateral(dorsal)
• Anterior ulnar recurrent(dorsal)
• Posterior ulnar recurrent(ventral)
BLOOD SUPPLY OF ELBOW
 MUSCLE ATTACHMENTS(VENTRAL)

1. Brachialis arises from lower halves of anteromedial and anterolateral

surfaces of shaft of humerus
2. Brachioradialis arises from upper 2/3rd of lateral supracondylar ridge
3. Extensor carpi radialis longus arises from lower 1/3 rd of medial
supracondylar ridge
4. Superficial flexor muscles of forearm arise by a common origin from
anterior aspect of medial epicondyle, which is called common flexor origin
5. Superficial extensor muscles of forearm and supinator have a common
origin from lateral epicondyle, which is called common extensor origin
 MUSCLE ATTACHMENTS(DORSAL)

1. Anconeus- arises from posterior part of lateral epicondyle

2. Lateral head of triceps brachii arises from oblique ridge on upper part of
posterior surface above radial groove, while Medial head arises from
posterior surface below radial groove.
 CARRYING ANGLE

• Transverse axis of elbow is directed medially and downwards

• Extended forearm is not in straight line with arm and makes an angle of 13
degrees with it, which is known as Carrying angle
• Factors responsible:-
1. Medial flange of trochlea is 6mm deeper than lateral flange
2. Superior articular surface of coronoid process of ulna is placed oblique
 CARRYING ANGLE

• Carrying angle disappears upon full

flexion of forearm, and during pronation
of forearm.
• The angle is 10°-15° in males and >15° in
females.
 3 BONY POINTS OF ELBOW

• 3 bony points form an equilateral triangle in flexed elbow and are in 1 line in
extended elbow.
• Disruption in this relationship is seen in medial epicondyle #, lateral
epicondyle # and posterior elbow dislocation
 CLINICAL IMPORTANCE

1. Supracondylar fracture of humerus is common, especially in young age, It is

usually a result of fall on outstretched hand. The lower fragment is mostly
displaced backwards, so that elbow is unduly prominent. This fracture can
also cause injury to median nerve, and can lead to Volkmann’s ischemic
contracture caused by occlusion of brachial artery
2. Head of humerus commonly dislocates anteroinferiorly
3. Ulnar nerve can get injured in case of medial condyle # of humerus
 CLINICAL IMPORTANCE

1. Dislocation of elbow is usually posterior and is associated with fracture of

coronoid process. 3 bony point relationship is lost
2. Pulled elbow= subluxation of radial head occurs in children when forearm is
suddenly pulled in pronation. Head of radius slips out of the annular
ligament
3. Tennis elbow= lateral epicondylitis, occurs due to abrupt pronation with
fully extended elbow due to either
• Sprain of radial collateral ligament
• Tearing of fibres of extensor carpi radialis
 CLINICAL IMPORTANCE

1. Student’s elbow= bursitis over s/c posterior surface of olecranon process,

because of sustained pressure on elbow
2. Golfer’s elbow= microtrauma of medial epicondyle of humerus, occurring
commonly in golf players due to the common flexor origin undergoing
repetitive strain
 CLINICAL IMPORTANCE

Backwards Supracondylar fracture-

• Backwards supracondylar fracture(common) where lower fragment displaced
backward.
• Mechanism- fall on hand with bent elbow, forearm fully pronated. Injury to
brachial artery and 3 main nerves is possible.
• Rx- Immediate reduction, with elbow joint flexed in collar and cuff in such a
position that radial pulse is well palpated
 CLINICAL IMPORTANCE

Forward supracondylar fracture

• Lower fragment displaced anteriorly
• Mechanism- Fall on stretched outstretched hand with fully extended elbow
• Complications- Malunion, Cubitus valgus or varus, Myositis ossificans, Injury
to brachial vessels, Volkmann’s ischemic contracture and injury to nerves
 CLINICAL IMPORTANCE

T and Y shaped fractures

• Splitting of 2 condyles with olecranon driven upwards
• Elbow remains flexed supported by other hand and movements painfully
restricted
• Mechanism- Falls on point of elbow
 CLINICAL IMPORTANCE

Fracture neck of radius(children)

• Epiphyseal separation with triangular metaphysis attached to it
• Mechanism- Fall on outstretched hand with elbow in valgus position
• Head of radius tilted forward, outward and laterally
• Pronation and supination painfully restricted
 CLINICAL IMPORTANCE

Fracture head of radius

• Mechanism- Fall on outstretched hand with elbow in valgus position, so that
radial head is crushed against capitulum
• Painfully restricted pronation and supination of forearm, slightly painful
flexion and extension
• X ray- Vertical split in radial head or lateral displacement of major portion of
radial head, or comminuted fracture with multiple fragments
 CLINICAL IMPORTANCE

Fracture of olecranon process

• Mechanism- Direct fall on point of elbow
• Fracture line is at narrowest point of olecranon where it joins with shaft of ulna
• X ray and palpation- Gap between olecranon fragments
 CLINICAL IMPORTANCE

Posterior dislocation of elbow

• Mechanism- Fall on outstretched hand with elbow slightly flexed
• Differentiated from supracondylar # by
1. Patient is adult
2. Palpation- abnormal posterior displacement of olecranon process
3. Absence of abnormal mobility and crepitus
4. Shortening of forearm
 CLINICAL IMPORTANCE

Monteggia fracture and dislocation

• Fracture and displacement of upper 1/3rd of Ulna(anterior) with dislocation of
radial head(anterior)
• Mechanism- Fall on outstretched hand with forcible pronation of forearm
• Movement of elbow joint completely restricted
Reverse Monteggia fracture and dislocation
• Fracture and displacement of upper 1/3rd of ulna(posterior) with dislocation of
radial head(posterior)
 INSPECTION OF ELBOW JOINT

FRONT
• Attitude-
1. Position of joint- Whether extended or flexed, pronated or supinated. In
most injuries, elbow is held in flexion.
2. Carrying angle- Increased in cubitus valgus and decreased in cubitus varus
 INSPECTION OF ELBOW JOINT

BEHIND
• Attitude
1. Position of olecranon noted- Undue prominence may signify posterior
dislocation of elbow or supracondylar # (in children)
2. In a large no. of supracondylar fractures, lower fragment can also be
displaced laterally or medially
 INSPECTION OF ELBOW JOINT

SIDE
• Attitude- Note if there is any anteroposterior broadening of elbow, as evident in
supracondylar fracture and post. dislocation
 INSPECTION OF ELBOW JOINT

• SWELLING- Usually, an injury to elbow results in tremendous amount of

swelling, making diagnosis difficult without Xray
1. Localised swelling near head of radius- Due to fracture at this site
2. Swelling wholly confined to posterior aspect of elbow is probably due to
fracture of olecranon process
 INSPECTION OF ELBOW JOINT

DEFORMITY- Usually obvious sign of traumatic injury to bone

• Abnormal swelling in upper part of ulna maybe Monteggia #
• Abnormal protrusion of olecranon process backwards maybe Post. Dislocation
in adults or Supracondylar # in children
 PALPATION OF ELBOW JOINT

Components of palpation, in different areas to be systemically examined:-

1. Localised Bony Tenderness
2. Local Bony irregularity(deformity)
3. Displacemnt
4. Abnormal mobility of fragments
5. Crepitus
 PALPATION OF ELBOW JOINT

• Lower 1/3rd of humerus

1. Supracondylar fracture(in children)
2. T and Y shaped supracondylar fractures(adults)

Both epicondyles palpated for normal position

Abnormal mobility+ Crepitus tested by moving distal fragment against stabilised
proximal fragment(gently)
Abnormal broadening of lower humerus tested, along with distorted condyles to
diagnose T and Y shaped fractures
 PALPATION OF ELBOW JOINT

• Upper end of radius

1. Fracture head of radius(adults)
2. Fracture neck of radius(children)
3. Dislocation of head of radius(Monteggia)

Head of radius is palpated distal to lateral condyle when forearm is

pronated/supinated and elbow flexed
In case of radial head #, tenderness during rotation of radius
 PALPATION OF ELBOW JOINT

• Upper part of Ulna

1. Fracture of upper end of ulna with displacement
2. Monteggia #

Upper end of ulna is subcutaneous on the medial aspect, and can be palpated
easily for deformity or tenderness
 PALPATION OF ELBOW JOINT

• Olecranon
1. Posterior dislocation of elbow
2. Supracondylar fracture
3. Olecranon fracture

Local bony tenderness and irregularity suggests olecranon crack #

Abnormal projection of elbow posteriorly suggests the 1 st 2 conditions
 PALPATION OF ELBOW

• Relative positions of 3 bony points

1. Posterior dislocation of elbow
2. T and Y shaped # of condyles

The 2 epicondyles of humerus are palpated with thumb and middle finger, and tip of
olecranon process palpated with index finger
Comparison of 3 bony points with normal side is compulsory
Wide seperation of epicondyles= T and Y shaped #
Post dislocation of olecranon= Post. Elbow dislocation
 MEASUREMENTS AROUND ELBOW

• Forearm should be held at right angle to arm so that epicondyles become

prominent
1. Length of arm measured from angle of acromion to lateral
epicondyle(Shortened in supracondylar#)
2. Length of forearm measured from measured from lateral epicondyle of
humerus to tip of radial styloid process(Shortened in post. dislocation of
elbow)
3. 3 bony points marked with pencil and sides of triangle measured
 MOVEMENTS OF ELBOW

• Flexion
• Extension
• Supination
• Pronation

Unhindered movements suggest no bony injury

Injury to upper radius- pain during pronation and supination
All other injuries- pain and limitation of flexion and extension
 SURFACE LANDMARKS OF FOREARM

• Head of radius- Palpated in a depression on posterolateral aspect of extended

elbow, distal to lateral epicondyle
• Radial styloid process- Projects 1 cm lower than ulnar styloid, and can be felt
proximal to anatomical snuff box
• Head of ulna- Surface elevation on medial part of osterior surface of wrist
when hand is pronated
• Ulnar styloid- Posteromedial aspect of wrist, 1 cm proximal to radial styloid
process
 RADIUS

• Upper end-
1. Head is disc shaped and covered with hyaline cartilage, which articulates
with capitulum of humerus. It fits into a socket formed by radial notch of
ulna and annular ligament, thus forming superior radioulnar joint
2. Neck is enclosed by narrow lower margin of annular ligament
3. Tuberosity lies just below medial part of neck
 RADIUS

• Shaft
1. Anterior border
2. Posterior border
3. Medial/Interosseous border- with interosseous membrane attached to lower
3/4th
4. Anterior surface- Between anterior and interossesous borders
5. Posterior surface- Between posterior and interosseous borders
6. Lateral surface- Between anterior and posterior borders
 RADIUS

• Lower end
1. Anterior surface- thick prominent ridge
2. Posterior surface- 4 grooves for the extensor tendons
3. Medial surface- Ulnar notch for head of ulna
4. Lateral surface- Prolonged to form radial styloid process
5. Inferior surface- Articulates with scaphoid and lunate bones
 RADIUS(MUSCLE ATTACHMENTS)

1. Biceps- Inserted into posterior part of radial tuberosity

2. Supinator- Inserted into upper part of lateral surface
3. Pronator teres- Inserted into middle of lateral surface
4. Brachioradialis- Inserted into lowest part of lateral surface above styloid
process
5. Pronator quadratus- inserted into lower part of anterior surface nad lower
medial end
 RADIUS(MUSCLE ORIGINS)

1. Radial head of flexor digitorum superficialis- from anterior oblique line

2. Flexor pollicis longus- from upper 2/3rd of anterior surface
3. Abductor pollicis longus- from posterior surface
4. Extensor pollicis brevis- from posterior surface
 ULNA

• Upper end
1. Olecranon process- projects upwards from shaft with superior, anterior,
posterior, medial and lateral surfaces
2. Coronoid process- projects forward from shaft with superior, anterior,
medial and lateral surfaces
3. Trochlear notch- forms articular surface that articulates with trochlea of
humerus to form elbow joint
4. Radial notch- articulates with head of radius to form superior radioulnar
joint
 ULNA

• Shaft
1. Lateral/Interosseous border
2. Anterior border
3. Posterior border
4. Anterior surface- between anterior and interosseous borders
5. Medial surface- between anterior and posterior borders
6. Posterior surface- between posterior and interosseous borders
 ULNA

• Lower end
1. Head of ulna- articulates with radius to form distal radioulnar joint
2. Ulnar styloid process- projects downwards from posteromedial lower end of
ulna
 ULNA(MUSCLE ATTACHMENTS)

• Triceps brachii- inserted into posterior part of superior surface of olecranon

• Brachialis- inserted into anterior surface of coronoid process including
tuberosity of ulna
• Anconeus- inserted into lateral aspect of olecranon process and upper 1/4 th of
posterior surface of shaft
 ULNA(MUSCLE ORIGINS)
1. Supinator- arises from supinator crest
2. Flexor digitorum superficialis- From tubercle at medial margin of coronoid process
3. Pronator teres- from medial margin of coronoid process
4. Flexor digitorum profundus- from upper 3/4th of anterior and medial surfaces of shaft, medial surfaces of
coronoid and olecranon process, posterior border of shaft through aponeurosis
5. Flexor carpi ulnaris- from medial side of olecranon process
6. Pronator quadratus- from lower part of anterior surface
7. Extensor carpi ulnaris- from posterior border
MUSCLES OF FRONT OF FOREARM
MUSCLES OF BACK OF FOREARM
MUSCLES OF FRONT/BACK OF
FOREARM
BLOOD SUPPLY OF FOREARM
NERVES OF FOREARM
 CLINICAL IMPORTANCE

Colle’s fracture-
• Fracture of radius 2cm proximal to its distal end
• Distal fragment displaced upwards and backwards, with radial styloid
displaced proximal to ulnar styloid
• If distal fragment displaced anteriorly, It is known as Smith’s fracture
 CLINICAL IMPORTANCE

Madelung’s deformity
• Dorsal subluxation of distal end of ulna due to retarded growth of lower end of
radius
 REFERENCES

• B D Chaurasia’s textbook of human anatomy

• S Das’ practical manual of surgery
• Netter’s anatomy atlas(online)
• Orthobullets(online)
• Radiopedia(online)
• Miscellaneous pictures(online)
THANK YOU