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Current concepts in elbow kinematics and biomechanics

Jason Stein and Anand M. Murthi
Purpose of review
Recent advances in the diagnosis and treatment of elbow
disorders require that orthopedists develop a better
understanding of the elbow. This paper reviews the current
literature on elbow kinematics and biomechanics.
Recent findings
This review covers elbow anatomy and how this affects its
stability; elbow kinematics and biomechanics in sports,
including pediatric athletes; and a theoretical section on
basic kinematics.
Summary
Current literature on the osseous and ligamentous
stabilizers of the elbow will help surgeons better treat
elbow instability that occurs through trauma and sports.
Current understanding of the biomechanics of the elbow in
both adult and pediatric athletes will hopefully help prevent
and treat injuries in athletes. Finally, as understanding of
elbow kinematics becomes more sophisticated through
use of computer models, designs for elbow arthroplasty will
hopefully improve.
Keywords
elbow, kinematics, stability
Curr Opin Orthop 16:276—
—279. ª 2005 Lippincott Williams & Wilkins.
Department of Orthopaedics, Shoulder and Elbow Service, University of Maryland
School of Medicine, Baltimore, Maryland, USA
Correspondence to Anand M. Murthi, MD, University of Maryland, Department of
Orthopaedics, 2200 Kernan Drive, Baltimore, MD 21207, USA
Tel: 410 448 6416; fax: 410 448 6351; e-mail: amurthi@umoa.umm.edu
Current Opinion in Orthopaedics 2005, 16:276—
—279
ª 2005 Lippincott Williams & Wilkins.
1041-9918

Introduction
The elbow is a complex joint that connects the hand to
the shoulder and allows the hand to work in space. It
has a complex arrangement of osseous and ligamentous
interactions that contribute to its stability. The proximal
radius is cylindrical with a concave surface that articulates
with the capitellum. The greater sigmoid notch of the
olecranon articulates with the trochlea, which is shaped
like a spool. This is a hinge joint (ginglymus) that allows
flexion and extension. There is also an articulation between the ulna and radius, and this, along with the radiocapitellar joint, is a trochoid joint that allows axial rotation
and pivoting [1•].
The elbow capsule and ligaments add to the inherent osseous stability of the joint. The capsule surrounds all three
of the elbow’s articulations. Medially there is a complex of
ligaments that comprise the medial collateral ligament
complex. There are anterior, posterior, and transverse
(oblique/ligament of Cooper) bundles. Previous work
has established that the anterior bundle is the most important stabilizer for valgus torques [2–9]. This anterior
bundle can be divided into anterior and posterior bands.
The anterior is taught in extension and the posterior in
flexion due to the cam effect of the condyles [4]. The lateral collateral ligament complex is comprised of the radial
and ulnar collateral, annular, and accessory ligaments. This
complex is responsible for stabilizing the elbow against
varus stress and posterolateral instability.
These basic osseous and ligamentous stabilizers lead to an
inherently stable joint, and chronic joint instability after
simple dislocation is rare [10–12]. Serious trauma and
chronic injury due to athletic activities can lead to instability. Further delineation of the biomechanics and kinematics of the elbow will help us prevent and treat elbow
injuries in the future.

Elbow stability
With advances in techniques and hardware for open reduction and internal fixation of elbow fracture dislocations, interest in elbow stability has increased. The ‘terrible triad’
of the elbow — medial and lateral collateral injury, radial
head fracture, and coronoid fracture — lead to elbow instability. Several experiments were performed recently to further elucidate how these structures affect elbow stability.
Schneeberger et al. [13] designed an interesting study to
simulate how the radial head and coronoid process contribute to posterolateral instability. Their study compared
cadaveric elbows that had combinations of radial head
276

Kinematics and biomechanics Stein and Murthi 277

resection, coronoid resections of differing amounts, and
radial head replacements, either rigid or floating. The
authors discuss several results. After radial head resection,
there was a significant increase in rotatory laxity. We still
do not know whether this is clinically significant, but this
adds to the argument that radial head resection alone may
not be a completely benign operation. We also learned that
radial head resection and a 30% loss of the coronoid lead
to instability. This was overcome by radial head replacement. Resection of 50% or more of the coronoid caused
instability refractory to radial head replacement. Additional
reconstruction of the coronoid was necessary to reestablish elbow stability. The authors also noted that the rigid
radial head prosthesis was more stable than the floating
prosthesis, but we cannot be sure if this is clinically
significant.
Another study by Deutch et al. [14] examined posterolateral instability after radial head resection, coronoid resection (50%), and medial and lateral collateral ligament
injuries. They too found that radial head resection alone
led to laxity, as in the previous study. In their experiments,
radial head replacement could prevent subluxation after
radial head and coronoid resection. They also found that
transection of the medial ligaments did not significantly
increase instability but that transection of the lateral ligaments did. In fact, in their elbows with the ‘terrible triad’,
radial head replacement with lateral ligament reconstruction
restored stability without the need for coronoid reconstruction. They also reported that with radial head resection
and lateral ligamentous injury but an intact coronoid, lateral ligamentous reconstruction was sufficient to restore
stability, without radial head replacement.
A study by Beingessner et al. [15] compared the effect of
radial head replacement in the face of medial and lateral
collateral ligament injuries in a model that included dynamic muscle forces. They found that radial head replacement alone in the face of ligamentous injury did not
restore elbow kinematics to normal. Riet et al. [16] investigated the position of the radial head to determine
whether this has an effect on elbow kinematics. The radial
head is not a perfect circle. They found that by rotating
the radial head, small but statistical changes occurred in
the rotation of the ulna during range of motion. It is unknown whether this will have any clinical significance, but
further investigation may change the shape of radial head
prostheses and how methodically we implant them.
In addition to osseous and ligamentous restraints, the flexorpronator mass may play a critical role in elbow stability.
Park and Ahmad [17] performed an experiment in which
elbow kinematics were analyzed after medial collateral ligament complex release followed by physiologic loading of
the elbow. They determined that the flexor-pronator mass
helps to stabilize the elbow and that the flexor carpi

ulnaris is the most important, followed by the flexor digitorum superficialis and then the pronator teres.
Pediatric supracondylar humerus fractures are commonly
treated by the orthopedist and can lead to a cubitus varus
deformity. It has been thought that cubitus varus was only
a cosmetic deformity and had no long-term consequences
[18–20]. Recently, posterolateral instability in patients
with longstanding cubitus varus has been reported in
the literature [21–26]. Beuerlein et al. [27] performed
an experiment to test the effect of cubitus varus on lateral
collateral ligament strain and ulnohumeral joint widening.
Interestingly, they found that at 20! degrees of varus there
was significant joint space widening and a significant increase in ligament strain at 25!. This new information
may change the way orthopedists treat pediatric patients
with residual cubitus varus after supracondylar humerus
fractures.

Biomechanics and kinematics in sports
The most commonly studied sporting activity is baseball
pitching. The pitching motion can be divided into six
phases: wind-up, stride, arm cocking, arm acceleration,
arm deceleration, and follow through. During wind-up
the lower body is doing most of the work, the elbow is
flexed, and there is little muscle activity. The same is virtually true of the stride phase. The elbow begins extended
and ends flexed. During arm cocking a moderate flexion
torque is created. The shoulder externally rotates, creating a valgus torque on the elbow. Arm acceleration is the
phase from maximal shoulder external rotation to ball release. The elbow reaches its maximal extension velocities.
During arm deceleration the elbow experiences a flexion
moment arm and finally during follow through helps to
dissipate upper extremity energy to the rest of the body.
Many other sports have similar motions that we will not
cover here [28].
Pitchers and athletes in other sports experience chronic
valgus forces on their elbows that lead to predictable injuries to their elbows. Chronic valgus loads cause strain and
injury to the medial collateral ligament complex. This can
lead to pain and elbow instability. This causes medial
shearing of the posterior olecranon that can cause bone
spurs and loose bodies. Finally, the valgus load causes compressive loads on the radiocapitellar joint that can cause
degeneration [29].
Biomechanics in pediatric athletes have not received much
attention. Interestingly, there are predictable phases that
children go through as they develop a mature throwing
motion. First they learn to push, then cock, then step,
and then finally they learn to start perpendicular and
coordinate their motion to create more speed. During
the earlier parts of this development, injuries are fairly

278 Elbow

uncommon because this immature throwing style cannot
create enough torque to overcome or injure the elbow
[30,31].
Sabick et al. [32] recently preformed a study on 12-yearold pitchers. Using high-speed cameras they studied the
kinematics of these children’ s throwing motions. They
found that the basic motion of the pediatric athlete was
the same as for the adult. The only difference was in
the values of the amounts of torque generated. Interestingly, they were able to quantify that the athlete’s weight,
maximal shoulder internal rotation torque, maximal shoulder adduction torque, and maximal external rotation angle
of the shoulder were all factors that increased valgus load.
This led them to believe that if the athletes’ motion had
less shoulder external rotation, they might be less likely to
injure their elbow. They admit that this would probably
lead to lower pitching velocities and would therefore be
a difficult change to get pitchers to accept.

Miscellaneous topics
Much research has been done on gait analysis of the lower
extremity, but little attention has been focused on these
same characteristics for activities of daily living for the upper extremity. This information will help us design better
implants and design better computer models of the forces
and motions around the shoulder and elbow. Murray and
Johnson [33] performed an experiment that catalogued
the kinematics of some basic activities of the upper extremity and then used these data to calculate the forces
and motions around the shoulder and elbow. Interestingly,
the greatest amount of elbow flexion was required to reach
the back of the head and the greatest moment arm occurred during lifting a block to head height. They omitted
hygienic tasks from their study and this will need to be
elucidated in the future.
A long-term complication with elbow arthroplasty has
been stress at the bone–cement interface. In the past,
constrained prostheses were used and failed at this interface. Now less constrained devices are used, but exactly
how much freedom is necessary is unknown. Kasten
et al. [34] studied ulnar motion through pronation and supination and found that the ulna rotates 3.2!. This may
have significance for the design of future implants.
Finally, computer models of the elbow and other joints will
play a significant role in the future development of total
joint prostheses and possibly one day replace cadaveric or
in-vitro studies if they become accurate enough. Recently
Giesl et al. [35] developed a human elbow computer model
that demonstrates elbow stability from osseous and muscle forces at 90! of flexion. Although this has little clinical
relevance now, it is exciting to ponder what we may be
able to do with these simulations in the future.

Conclusion
The elbow is a complex joint with interactions between
osseous, ligamentous, and muscular units. It is an integral
joint in the upper extremity that connects the hand to the
shoulder and torso, allowing us to perform many of our activities of daily living and our athletic endeavors. Trauma
to this important joint can be a devastating injury, especially when it causes instability. Recent literature has
helped to elucidate the roles of the radial head and coronoid and collateral ligaments in elbow stability. These
experiments on cadaveric specimens also suggest what
types of repairs will be required to achieve stability, and
which ones we can forego. Interestingly, new literature
has challenged our belief that cubitus varus deformities
of the elbow were merely cosmetic deformities and that
these injuries may lead to instability. New kinematic data
on pediatric throwers suggest that, in order to prevent elbow injury, we might want to alter the mechanics of throwing in child athletes to limit the amount of external
rotation that they achieve. A database containing the kinematics of the upper extremity during daily activities will
help us to better design total joints and understand the
motions and forces required to perform these tasks. Finally,
new computer models may one day help us to perform experiments without the use of cadavers or in-vitro studies.

References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
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