Archives of Orthopaedic
Arch Orthop Trauma Surg (1986) 105:313-315
Anatomical Variations of the Semilunar Notch in Elbow Dislocations
J Wadstr 6m, C Kinast, and K Pfeiffer
Departement ffir Chirurgie, Kantonsspital Basel, Switzerland
Summary The anatomical relations of the semilunar
notch of the ulna were studied in radiographs, taken
in a strict lateral view, from 100 patients with elbow
dislocations The results were compared with those
from a control group of 150 patients without disloca-
tion or other radiographic pathology We found that
the coronoid process and an angle (a) formed between
the axis of the ulna and a line going through the tip of
the coronoid process and the tip of the olecranon
were significantly smaller than those in the control
group (P = 0 02) The central angle of the semilunar
notch was significantly larger in the dislocation group
than in the control group (P = 0 009) The smaller
angle (a) and larger central angle in the dislocation
group are a result of a lower coronoid process, but
they are also due to the prominent tip of the olecra-
non The results suggest that the dislocation mecha-
nism is partly a hyperextension, with the tip of the
olecranon as the pivot point.
Zusammenfassung Die anatomischen Verhiltnisse
der Incisura semilunaris ulnae wurden im seitlichen
R 6ntgenbild bei 100 Patienten vermessen, die eine
traumatische Ellbogenluxation erlitten hatten Die
Me Bwerte von 150 Ellbogengelenken ohne voraus-
gegangene Verletzung dienten als Kontrollgruppe.
Die Hohe des Processus coronoideus und der Winkel
(a) gebildet von der Ulnaschaftachse und der Verbin-
dungslinie der Spitze des Processus coronoideus und
des Ellenhakens waren bei den Gelenken, die eine
Ellbogenluxation erlitten hatten, signifikant kleiner
(P = 0 02) als in der Kontrollgruppe Der Zentrums-
winkel der Incisura semilunaris war signifikant gro-
Offprint requests to: Dr Jonas Wadstrom, Department of Sur-
gery, University Hospital, S-751-85 Uppsala, Sweden
and Traumatic Surgery
© Springer-Verlag 1986
Ber (P=0 009) als in der Kontrollgruppe Der kleinere
Winkel (a) und der gr 6Bere Zentrumswinkel in der
Ellbogenluxationsgruppe k 6 nnen einerseits durch ei-
nen niedrigeren Processus coronoideus bedingt sein,
andererseits aber auch durch einen ausgepragten El-
lenhaken Diese Ergebnisse lassen an einen Hyper-
extensionsmechanismus beim Luxationsvorgang den-
ken Hierbei wiirde eine prominente Olecranon-
spitze als Hypomochleon fiir die Trochlea humeri
wirken, welche dann fiber einen relativ kleinen Pro-
cessus coronoideus gehebelt wird.
Anatomical, constitutional, and biomechanical as-
pects of elbow dislocations have been discussed in a
number of publications Some authors l3, 4, 6l claim
that the height of the coronoid process is important,
and that in cases of fractures involving more than
one-sixth of the semilunar notch a reconstruction
should be performed to prevent recurrent disloca-
tions l2 l A critical analysis of the literature shows
that the presented statements and conclusions are
based mostly on case reports of recurrent disloca-
tions Poigenfiirst and Iselin l8l performed a systema-
tic analysis of the radiological findings in 58 elbow
dislocations They concluded that there are antomi-
cal and constitutional factors predisposing elbow dis-
locations, such as a small central angle and varus or
valgus deformations, valgus leading to posterolateral
and varus to posteromedial luxation These predis-
posing factors are said to be within the normal range,
but there was no control group and normal was not
defined Arnold and Lindenau l1l are the only au-
thors who have compared the radiological findings in
314 J Wadstr 6m et al : Variations of Semilunar Notch in Elbow Dislocations

three patients with elbow dislocation with a control
group of 30 patients without dislocation or other
bone lesion They measured the central angle and
found it to be smaller in patients with dislocations.
Since it seems logical that elbow dislocations may
be due to certain predisposing anatomical factors -
though this has been poorly documented we ana-
lyzed the radiological findings in patients with elbow
dislocation and compared these with radiographs of
patients without dislocation or other bone lesions.
Patients and Methods

The radiographs of 100 elbow dislocations, without any bone

Fig 1 Measurement points of the semilunar notch P, Height
of the coronoid process; a, angle between the axis of the ulna
shaft and a line going through the tip of the coronoid process
and the tip of the olecranon; T, depth of the semilunar notch;
L, distance between the tip of the olecranon and the coronoid
process
lesion, were analyzed and compared with 150 radiographs of
patients without dislocations or other bone lesions The radio-
graphs were taken in a strict lateral view Radiographs not
taken in a strict lateral view were excluded On each radio-
graph the following measurements were performed.
(1) The height of the coronoid process P, measured from a
line A parallel to the longitudinal axis of the ulna and
tangential to the semilunar notch (see Fig 1)
(2) The angle (a) between the line A and a line B going
through the tip of the coronoid process (x) and the tip of
the olecranon (y) (see Fig 1)
(3) The distance L between the points (x) and (y)(see Fig 1)
(4) The depth of the semilunar notch T measured between the
line B and a line Bl drawn parallel to B and tangential to
the semilunar notch This point also defines the point
(z)(see Fig 1).
(5) The radius (r) of a circle going through the point (x), (y),
and (z)(see Fig 2)
(6) The central angle (b) of the arch defined by the circle and
the points (x) and (y)(see Fig 2)
The groups were comparable as to age and male/female
ratio (see Table 1) The statistical significance was calculated
with the Mann-Whitney U-test.

Results

The angle (a) and the height of the coronoid process

P were significantly smaller in the dislocation group
Fig 2 Manner in which the central angle (b) and the radius (r) (P = 0 02) The central angle (b) was significantly
were measured larger in the dislocation group (P = O 009) The
radius (r) and the coefficient of L/T did not signifi-
cantly differ between the two groups The values and
Table 1 Age and ratio of women to men in each group ranges are listed in Table 2.
Female/ Age
mtale (%) Range Median
(years) (years) Discussion
Control group 48/52 19-84 47
In Fig 3 two hypothetical shapes of the semilunar
Dislocation group 43/57 16-87 46
notch are shown D is constructed with a small angle

Table 2 Values and ranges of the height of the coronoid process (P), and of the width of angles (a) and
(b) in both groups
P (mm) b° a°
Range Median Range Median Range Median
Control group 13-29 18 154 °-216 ° 178 ° 14 °-36 ° 25°
° ° °
Dislocation group 10-28 18 152 °-214 184 8o-36 24 °
J Wadstr 6m et al : Variations of Semilunar Notch in Elbow Dislocations
D N
Fig 3 Two hypothetical shapes of the semilunar notch D is
constructed with extreme values of (a), (b), and P found in the
dislocation group N is constructed with extreme values of (a),
(b), and P found in the control group
(a), a large central angle (b), and a small P, as found
in patients with elbow dislocations N is constructed
with a large P, a large angle (a), and a small central
angle (b) as found in patients without dislocations.
Accordingly, and as postulated by other authors l1,
5, 9l, the significance of the coronoid process is evi-
dent In contradiction to what has been claimed ear-
lier l1, 5, 9l, the central angle was larger in the dislo-
cation group The reason for this somewhat surpris-
ing result is the prominent tip of the ulna, as can be
seen in Fig 3 Most patients with elbow dislocation
say that they fell on the outstretched arm It thus
seems plausible that elbow dislocation is partly the
result of hyperextension, with the tip of the olecra-
non as pivot point, and not only, as postulated by
315
other authors l4, 7 l, a combination of lateral rotation
and valgus strain.
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Received November 5, 1985