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Morrey’s
The Elbow and
ItsDisorders
Morrey’s
The Elbow and
Its Disorders
FIFTH EDITION
Bernard F. Morrey, MD Joaquin Sanchez-Sotelo, MD, PhD
Professor Professor
Department of Orthopedic Surgery Department of Orthopedic Surgery
Mayo Clinic Mayo Clinic College of Medicine
Rochester, Minnesota; Consultant
Professor of Orthopedics Division of Adult Reconstruction
University of Texas Health Science Center Department of Orthopedic Surgery
San Antonio, Texas Mayo Clinic
Rochester, Minnesota
Mark E. Morrey, MD, MSc

Assistant Professor of Orthopedics
Department of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
Anatomic dissections: Manuel Llusá-Pérez, MD, PhD, and José R. Ballesteros-Betancourt, MD
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
MORREY’S THE ELBOW AND ITS DISORDERS, FIFTH EDITION ISBN: 978-0-323-34169-1
Copyright © 2018 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc.
All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
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and contraindications. It is the responsibility of practitioners, relying on their own experience and
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individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
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contained in the material herein.
Previous editions copyrighted 2009, 2000, 1993, 1985 by The Mayo Clinic Foundation.
Library of Congress Cataloging-in-Publication Data
Names: Morrey, Bernard F., 1943- editor. | Sanchez-Sotelo, Joaquin, editor. | Morrey, Mark E., editor.
Title: Morrey’s the elbow and its disorders / [edited by] Bernard F. Morrey, Joaquin Sanchez-Sotelo,
Mark E. Morrey.
Other titles: Elbow and its disorders.
Description: Fifth edition. | Philadelphia, PA : Elsevier, [2018] | Preceded by Elbow and its disorders /
[edited by] Bernard F. Morrey, Joaquin Sanchez-Sotelo. 4th ed. c2009. | Includes bibliographical references
and index.
Identifiers: LCCN 2017013655 | ISBN 9780323341691 (hardcover : alk. paper)
Subjects: | MESH: Elbow Joint | Elbow Joint—injuries | Joint Diseases
Classification: LCC RD686 | NLM WE 820 | DDC 617.472044—dc23 LC record available at https://lccn.loc
.gov/2017013655
Senior Content Strategist: Kristine Jones

Senior Content Development Specialist: Ann Ruzycka Anderson
Publishing Services Manager: Catherine Jackson
Book Production Specialist: Kristine Feeherty
Design Direction: Bridget Hoette
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

The first Morrey’s The Elbow and Its Disorders is dedicated to my wife, Carla.
Carla has patiently supported me through the “all-nighters” of the first edition
in 1983 to my editing chapters while on our 50th wedding anniversary trip in
2016. I cannot thank her enough for simultaneously rearing our family while
encouraging me through all aspects of my career.
It is only fitting that the first “eponified” edition of this title be dedicated to
the one person who has had a major role in all the previous editions.
For her love and steadfast support I am forever grateful.
B.F.M.
CONTRIBUTORS
Joshua M. Abzug, MD Andrew T. Assenmacher, MD Allen T. Bishop, MD
Associate Professor ProMedica Health System Professor of Orthopedic and Neurologic
Departments of Orthopedics and Pediatrics Toledo, Ohio Surgery
University of Maryland School of Medicine Monroe, Michigan Mayo Clinic College of Medicine
Baltimore, Maryland Consultant, Division of Hand Surgery
George S. Athwal, MD, FRCSC Department of Orthopedic Surgery
Julie E. Adams, MD Professor of Surgery Mayo Clinic
Associate Professor Orthopedic Surgery Roth McFarlane Hand and Upper Limb Rochester, Minnesota
Mayo Clinic and Mayo Clinic Health System Centre
Rochester, Minnesota St. Joseph’s Health Care Jeremy Bruce, MD
Austin, Minnesota University of Western Ontario Chattanooga, Tennessee
London, Ontario, Canada
Christopher S. Ahmad, MD Travis C. Burns, MD
Head Team Physician New York Yankees Yaser M. Baghdadi, MD Lieutenant Colonel, United States Marine
Chief, Sports Medicine Service Surgical Resident Corps
Center for Shoulder, Elbow and Sports Cleveland Clinic Orthopedic Surgeon, San Antonio Military
Medicine Weston, Florida Medical Center
New York Presbyterian/Columbia University Fort Sam Houston, Texas
Medical Center Champ L. Baker, Jr., MD
New York, New York Hughston Clinic Christopher L. Camp, MD
Columbus, Georgia Sports Medicine Center
Shahryar Ahmadi, MD, FRCSC Mayo Clinic Department of Orthopedics
Assistant Professor of Orthopaedics Champ L. Baker III, MD Rochester, Minnesota
Director, Shoulder and Elbow Surgery Hughston Clinic
Department of Orthopaedics Columbus, Georgia Brian T. Carlsen, MD
University of Arkansas for Medical Sciences Associate Professor
Little Rock, Arkansas José R. Ballesteros-Betancourt, MD Plastic and Orthopedic Surgery
Department of Orthopaedic Surgery and Mayo Clinic
Eloy Dario Tabeayo Alvarez, MD Traumatology Rochester, Minnesota
Shoulder and Elbow Unit Hospital Clínic Barcelona;
Department of Orthopedic Surgery Faculty of Medicine Andrea Celli, MD
Hospital Universitario La Paz University of Barcelona Shoulder and Elbow Unit
Madrid, Spain Macro and Micro-Dissection and Surgical Hesperia Hospital
Anatomy Laboratory, Human Anatomy Modena, Italy
Kai-Nan An, PhD and Embryology Department
Professor Emeritus Barcelona, Spain Charalambos P. Charalambous, MBChB,
Mayo Clinic College of Medicine MSc, MD, FRCS (Tr & Orth)
Rochester, Minnesota Raul Barco, MD, PhD Honorary Professor
Shoulder and Elbow Unit Consultant in Trauma and Orthopaedics
James R. Andrews, MD Department of Orthopedic Surgery School of Medicine
The Andrews Institute Hospital Universitario La Paz University of Central Lancashire
Gulf Breeze, Florida Madrid, Spain Preston, United Kingdom;
Department of Trauma and Orthopaedics
Karen L. Andrews, MD Jonathan D. Barlow, MD, MS Blackpool Teaching Hospitals NHS Trust
Associate Professor Assistant Professor Blackpool, United Kingdom
Physical Medicine and Rehabilitation Department of Orthopedics
Mayo Clinic Division of Shoulder Surgery Neal Chen, MD
Rochester, Minnesota The Ohio State University Wexner Medical Assistant Professor
Center Sports Medicine Harvard Medical School;
Samuel Antuña, MD, PhD, FEBOT Columbus, Ohio Massachusetts General Hospital
Chief, Shoulder and Elbow Unit Department of Orthopaedic Surgery
Orthopedic Surgery Joseph M. Bestic, MD Boston, Massachusetts
Hospital Universitario La Paz; Assistant Professor of Radiology
Orthopaedic Department Diagnostic Radiology Emilie Cheung, MD
Hospital La Paz Mayo Clinic Associate Professor
Madrid, Spain Jacksonville, Florida Orthopedic Surgery
Stanford University
Palo Alto, California
vi
Contributors vii
Akin Cil, MD Neal S. ElAttrache, MD Justin L. Hodgins, MD

Franklin D. Dickson Associate Professor of Associate Clinical Professor Orthopaedic Surgeon
Orthopaedics Department of Orthopaedics Rouge Valley Health System
University of Missouri-Kansas City Keck School of Medicine Toronto, Ontario, Canada
Truman Medical Centers University of Southern California;
Kansas City, Missouri Director, Sports Medicine Terese T. Horlocker, MD
Fellowship, Kerlan-Jobe Orthopaedic Clinic Professor of Anesthesiology and
John E. Conway, MD Los Angeles, California Orthopaedics
Team Orthopedic Consultant Department of Anesthesiology
Texas Christian University and University of Bassem T. Elhassan, MD Mayo Clinic
Texas at Arlington Mayo Clinic Rochester, Minnesota
Medical Director Rochester, Minnesota
Texas Health Ben Hogan Sports Medicine Jeffery S. Hughes, MBBS, FRACS
Orthopedic Specialty Associates Larry D. Field, MD Orthopaedic Consultant
Texas Health Physicians Group Orthopaedic Physician North Shore Private Hospital
Fort Worth, Texas Mississippi Sports Medicine and Sydney, Australia
Orthopaedic Center
Roger Cornwall, MD Jackson, Mississippi Carrie Y. Inwards, MD
Associate Professor Professor of Pathology
Department of Orthopaedic Surgery and Antonio M. Foruria, MD, PhD Department of Laboratory Medicine
Department of Developmental Biology Shoulder and Elbow Reconstructive Surgery Division of Anatomic Pathology
Cincinnati Children’s Hospital Medical Unit Mayo Clinic College of Medicine
Center Head, Orthopedic Surgery Department Rochester, Minnesota
Cincinnati, Ohio Fundación Jiménez Díaz University Hospital
Associate Professor of Orthopedics In-Ho Jeon, MD, PhD
Omkar H. Dave, MD Surgery Department Professor
Omkar Dave MD PLLC Autonoma University Department of Orthopaedic Surgery
Orthopedic Surgery, Sports Medicine, and Madrid, Spain Asan Medical Centre, School of Medicine,
Arthroscopy University of Ulsan
Houston, Texas Hillary W. Garner, MD Seoul, South Korea
Assistant Professor
Joshua S. Dines, MD Department of Radiology Srinath Kamineni, MD, FRCS-Orth
Sports Medicine and Shoulder Service Mayo Clinic Professor of Bioengineering
Hospital for Special Surgery Jacksonville, Florida Brunel University School of Engineering
New York, New York and Design;
Robert U. Hartzler, MD, MS Consultant Elbow, Shoulder, Upper Limb
Karan Dua, MD Assistant Clinical Professor Surgeon, and Clinical Lead
Research Fellow University of the Incarnate Word School of Upper Limb Unit
Department of Orthopaedics Osteopathic Medicine Cromwell Hospital
University of Maryland Shoulder and Elbow Surgeon London, United Kingdom
Baltimore, Maryland The San Antonio Orthopaedic Group
San Antonio, Texas Graham J.W. King, MD, MSc, FRCSC
Thomas R. Duquin, MD Professor
Assistant Professor John W. Hinchey, MD Department of Surgery
Department of Orthopaedics Assistant Chief of Orthopaedic Surgery Western University;
University at Buffalo Shoulder & Elbow Fellowship, VA Site Director
Buffalo, New York Director St. Joseph’s Health Centre
South Texas Veterans’ Health Care System; Roth McFarlane Hand and Upper Limb
Anil K. Dutta, MD Adjunct Associate Professor, Orthopaedic Centre
Associate Professor Surgery London, Ontario, Canada
Orthopedic Surgery University of Texas Health Science Center at
University of Texas Health Science Center at San Antonio Jeffrey C. King, MD
San Antonio San Antonio, Texas Clinical Associate Professor
San Antonio, Texas Western Michigan University
E. Rhett Hobgood, MD Homer Stryker MD School of Medicine
Eric W. Edmonds, MD Mississippi Sports Medicine and Kalamazoo, Michigan
Associate Professor of Orthopaedic Surgery Orthopaedic Center
University of California San Diego; Jackson, Mississippi
Director, 360 Sports Medicine
Rady Children’s Hospital San Diego
San Diego, California
viii Contributors
Joyce S.B. Koh, MD Robert L. Lennon, DO Steven L. Moran, MD

Senior Consultant Orthopaedic Surgeon Associate Professor of Anesthesiology Professor and Chair of Plastic Surgery
Department of Orthopaedic Surgery Mayo Medical School; Professor of Orthopedic Surgery
Singapore General Hospital Supplemental Consultant Mayo Clinic
Singhealth Regional Health System Mayo Clinic Rochester, Minnesota
Singapore Rochester, Minnesota
Bernard F. Morrey, MD
Sandra L. Kopp, MD Kevin J. Little, MD Professor
Assistant Professor of Anesthesiology Director, Pediatric Hand and Upper Department of Orthopedic Surgery
Mayo Clinic Extremity Center Mayo Clinic
Rochester, Minnesota Cincinnati Children’s Hospital Medical Rochester, Minnesota;
Center; Professor of Orthopedics
Young W. Kwon, MD, PhD Associate Professor of Orthopaedic Surgery University of Texas Health Science Center
Associate Professor of Orthopaedic Surgery University of Cincinnati School of Medicine San Antonio, Texas
Department of Orthopaedic Surgery Cincinnati, Ohio
New York University School of Medicine Mark E. Morrey, MD, MSc
New York, New York Manuel Llusá-Pérez, MD, PhD Assistant Professor of Orthopedics
Professor of Human Anatomy and Department of Orthopedic Surgery
Mikko Larsen, MD, PhD Embryology Mayo Clinic College of Medicine
Consultant Plastic Surgeon Barcelona Medical School Rochester, Minnesota
Department of Plastic Surgery Department of Anatomy;
Launceston General Hospital Head of Trauma Unit Michael R. Moynagh, MBBAOBCh,
Launceston, Tasmania, Australia Hospital Clinic, Barcelona FFRRCSI, MRCSI
Trauma and Orthopaedics Assistant Professor of Radiology
Susan G. Larson, MS, PhD Barcelona, Spain Department of Radiology
Professor Mayo Clinic
Department of Anatomical Sciences Harvinder S. Luthra, MD Rochester, Minnesota
Stony Brook University School of Medicine John Finn Professor of Medicine
Stony Brook, New York Division of Rheumatology Robert Nirschl, MD, MS
Mayo Clinic Founder Chairman Emeritus
Lisa Lattanza, MD Rochester, Minnesota Nirschl Orthopaedic Center;
Professor of Orthopaedic Surgery Senior Orthopaedic Surgeon Emeritus,
Chief, Division of Hand, Elbow and Upper Alex A. Malone, MBBS, FRCS (Tr & Virginia Hospital Center
Extremity Surgery Orth), FRACS Arlington, Virginia;
Orthopaedic Surgery Senior Clinical Lecturer Clinical Associate
University of California San Francisco Department of Orthopaedic Surgery and Professor Emeritus
San Francisco, California; Musculoskeletal Medicine Georgetown University Medical Center
Consultant Surgeon University of Otago Washington, DC
Pediatric Orthopaedic Surgery Christchurch, New Zealand
Shriners Hospital of Northern California Michael J. O’Brien, MD
Sacramento, California Pierre Mansat, MD, PhD Assistant Professor of Orthopaedics
Professor of Orthopedics and Traumatology Department of Orthopaedic Surgery
Thomas Lawrence, MD, MSc, Department of Orthopedics and Tulane University School of Medicine
FRCS(T&O) Traumatology New Orleans, Louisiana
Consultant Shoulder and Elbow Surgeon University Hospital of Toulouse
Trauma and Orthopaedics Toulouse, France Shawn W. O’Driscoll, MD, PhD
University Hospital Coventry and Professor of Orthopedic Surgery
Warwickshire Thomas G. Mason, MD Mayo Clinic
Coventry, United Kingdom Rheumatology Rochester, Minnesota
Mayo Clinic
Brian P. Lee, MD Rochester, Minnesota Panayiotis J. Papagelopoulos, MD, DSc
Consultant Orthopaedic Surgeon Professor and Chairman
Orthopaedic Associates Amy L. McIntosh, MD First Department of Orthopaedics
Mount Elizabeth Hospital; Associate Professor of Orthopedic Surgery Athens University Medical School
Visiting Consultant Texas Scottish Rite Hospital for Children Attikon University General Hospital
Department of Orthopaedic Surgery Dallas, Texas Athens, Greece
Singapore General Hospital
Singapore Robert Nelson Mead, MD, MBA
Tulane University School of Medicine
New Orleans, Louisiana
Contributors ix
Rick Papandrea, MD Felix H. “Buddy” Savoie III, MD Jarrod R. Smith, MD

Partner Ray J. Haddad Professor and Chair of President
Orthopedic Associates of Wisconsin Orthopaedic Surgery Smith Orthopedics & Sports Medicine, PSC
Pewaukee, Wisconsin; Tulane University School of Medicine Ashland, Kentucky
Assistant Clinical Professor New Orleans, Louisiana
Orthopaedic Surgery Jay Smith, MD
Medical College of Wisconsin Olga D. Savvidou, MD Professor of Physical Medicine &
Milwaukee, Wisconsin Associate Professor Rehabilitation
First Department of Orthopaedics Departments of Physical Medicine and
Hamlet A. Peterson, MD, MS Athens University Medical School Rehabilitation
Emeritus Professor of Orthopedic Surgery Attikon University General Hospital Radiology and Anatomy
Mayo Medical School; Athens, Greece Mayo Clinic College of Medicine
Emeritus Consultant in Orthopedic Surgery Rochester, Minnesota
Emeritus Chair Pediatric Orthopedics Erin M. Scanlon, MD
Mayo Clinic Rheumatology Jeremy S. Somerson, MD
Rochester, Minnesota Mayo Clinic Assistant Professor
Rochester, Minnesota Department of Orthopaedic Surgery and
Samantha Lee Piper, MD Rehabilitation
Orthopedic Hand and Upper Extremity Alberto G. Schneeberger, MD University of Texas Medical Branch
Surgery Consultant Galveston, Texas
Southern California Permanente Medical Privatdozent at University of Zurich
Group Endoclinic Zurich, Klinik Hirslanden Robert J. Spinner, MD
San Diego, California Zurich, Switzerland Chairman
Department of Neurologic Surgery
Adam M. Pourcho, DO Benjamin W. Sears, MD Burton M. Onofrio Professor of
Instructor of Sports Medicine Orthopaedic Surgeon Neurosurgery
Physical Medicine and Rehabilitation Western Orthopaedics Professor of Orthopedics and Anatomy
Swedish Medical Group Denver, Colorado Mayo Clinic School of Medicine
Seattle, Washington Rochester, Minnesota
Adam J. Seidl, MD
Matthew L. Ramsey, MD Assistant Professor Anthony A. Stans, MD
Professor Orthopedic Surgery Chair, Division of Pediatric Orthopedics
Orthopaedic Surgery University of Colorado Department of Orthopedic Surgery
Thomas Jefferson University and Rothman Aurora, Colorado Mayo Clinic
Institute Rochester, Minnesota
Philadelphia, Pennsylvania William J. Shaughnessy, MS, MD
Pediatric Orthopedics and Scoliosis Surgery Scott P. Steinmann, MD
Nicholas G. Rhodes, MD Department of Orthopedic Surgery Professor of Orthopedic Surgery
Senior Associate Consultant Mayo Clinic Mayo Clinic and Mayo Clinic Health System
Department of Radiology Rochester, Minnesota Rochester, Minnesota
Mayo Clinic Austin, Minnesota
Rochester, Minnesota Alexander Y. Shin, MD
Professor of Orthopedic and Neurologic Matthew T. Stepanovich, MD
David Ring, MD, PhD Surgery Clinical Fellow
Associate Dean for Comprehensive Care Mayo Clinic College of Medicine Pediatric Orthopaedic and Scoliosis
Professor of Surgery and Perioperative Care Consultant, Division of Hand Surgery Fellowship
The University of Texas at Austin–Dell Department of Orthopedic Surgery Rady Children’s Hospital San Diego
Medical School Mayo Clinic San Diego, California
Austin, Texas Rochester, Minnesota
Philipp N. Streubel, MD
Joaquin Sanchez-Sotelo, MD, PhD Thomas C. Shives, MD Assistant Professor
Professor Professor Orthopaedic Surgery
Department of Orthopedic Surgery Department of Orthopedic Surgery University of Nebraska Medical Center
Mayo Clinic College of Medicine Mayo Clinic Omaha, Nebraska
Consultant Rochester, Minnesota
Division of Adult Reconstruction Jo Suenghwan, MD, PhD
Department of Orthopedic Surgery Juan P. Simone, MD Assistant Professor
Mayo Clinic Shoulder and Elbow Surgeon Department of Orthopaedics
Rochester, Minnesota Orthopedic Surgery Chosun University
Hospital Alemán Gwangju, South Korea
Buenos Aires, Argentina
x Contributors
Andrew R. Thoreson, MS Roger P. van Riet, MD, PhD Jacqueline S. Weisbein, DO

Biomechanics Laboratory Elbow Surgeon Partner and Medical Director
Division of Orthopedic Research Professor of Orthopaedic Surgery Napa Pain Institute
Rochester, Minnesota Fellowship Director Napa, California
President of the Belgian Elbow and
Thomas W. (Quin) Throckmorton, MD Shoulder Society Daniel E. Wessell, MD, PhD
Professor Department of Orthopaedic Surgery and Department of Radiology
Shoulder and Elbow Surgery Traumatology Mayo Clinic
University of Tennessee Campbell Clinic AZ Monica Jacksonville, Florida
Department of Orthopaedic Surgery University of Antwerp
Memphis, Tennessee Antwerp, Belgium Ken Yamaguchi, MD
Sam and Marilyn Fox Distinguished
Nho V. Tran, MD Ilya Voloshin, MD Professor of Orthopaedic Surgery
Associate Professor of Plastic Surgery Professor of Orthopaedics Chief, Shoulder and Elbow Service
Mayo Clinic Director, Shoulder and Elbow Division Washington University School of Medicine
Rochester, Minnesota Department of Orthopaedics St. Louis, Missouri
University of Rochester Medical Center
Ann E. Van Heest, MD Rochester, New York Dan A. Zlotolow, MD
Professor Associate Professor of Orthopaedics
Department of Orthopedic Surgery Carley Vuillermin, MBBS, FRACS Temple University School of Medicine;
University of Minnesota; Instructor in Orthopaedic Surgery Attending Physician
Gillette Children’s Specialty Healthcare Harvard Medical School; Shriners Hospital for Children
Shriners Hospital for Children—Twin Cities Staff Orthopaedic Surgeon Philadelphia, Pennsylvania
Minneapolis, Minnesota Department of Orthopaedic Surgery
Boston Children’s Hospital
Boston, Massachusetts
P R E FA C E
The fifth edition of The Elbow and Its Disorders is very special to me As is well known, there is a tremendous challenge in providing
personally for several reasons. First, this now represents over 30 years relevance through various types of communication. Today’s standards
since the first edition appeared, sharing our interest in diagnosis and are characterized by instantaneous access to the most current informa-
treatment of this “forgotten joint.” More importantly, this edition tion available in an electronic format. This edition, therefore, makes a
introduces once again Dr. Joaquin Sanchez-Sotelo as a co-editor and significant effort to maintain the tradition of this title as being the
also introduces for the first time my son, Mark Morrey, as a co-editor. definitive reference and containing clinical, relevant information
Future editions will be hallmarked by their innovative contributions regarding elbow disease and its management. But, importantly, it has
and exceptional ability to communicate and teach. This edition is also also made a considerable effort to utilize the advances realized with
hallmarked by the decision of the publisher, Elsevier, to rename The complementary video clips and electronic navigation. As has always
Elbow and Its Disorders henceforth eponymously as Morrey’s The Elbow been the case, we are forever in the debt of our many colleagues
and Its Disorders. I, of course, am extremely humbled by this decision worldwide who have shared their interesting cases with us and have
and am not only grateful to the publishers but also to my colleague, allowed us to publish some of their material. It is our sincere hope and
Dr. Sanchez-Sotelo, and to Mark, in whom I have the utmost confi- expectation that this fifth edition will be the best and most relevant yet.
dence will not only continue the publication of this material into the
future but will improve on the quality and relevance as well. Bernard F. Morrey, MD
xi
AC K N OW L E D G M E N T S
It is most appropriate to recognize with appreciation my many ortho- supportive and patient. One of the unsung heroes through all of these
pedic colleagues worldwide who have supported and encouraged me years has been my manuscript secretary, Donna Riemersma, who never
through the five editions of The Elbow and Its Disorders. In fact, the ceases to amaze me with her calmness and patience.
beautiful anatomic dissections featured in this edition are the contri- I must again thank Carla and the kids, Mike, Matt, Mark, and
bution of Dr. Manuel Llusá-Pérez, Dr. José R. Ballesteros-Betancourt, Maggie; thanks for your understanding and unfaltering support,
and their colleagues from Spain. The tremendous support provided by even as this project has extended a bit beyond what was originally
Drs. Sanchez-Sotelo and Mark Morrey for their contributions as well anticipated.
as their advice and encouragement is evident throughout the text. I Finally, my colleague, Joaquin, and my son and colleague, Mark,
particularly wish to recognize Dr. Shawn O’Driscoll, who has been my have not only been a great asset in the preparation of this edition but
partner and colleague for most of my career. The orthopedic com- have also assumed the task of taking this project into the future. I could
munity owes him a tremendous debt of gratitude for his numerous not have left this challenge in more capable hands. I have no doubt
contributions to elbow surgery. I especially appreciate his desire to that they will not just sustain the quality but will make it measurably
challenge existing thought and dogma and continue to push for a better and continue to adapt to the changing times and expectations.
better understanding of disease mechanisms and physical diagnosis. I As always, this will be done in the future as in the past, with the monical
am thankful to Elsevier, who has determined to “eponify” this title. The focus of improving patient care. Godspeed.
support of the publisher has been unwavering, and the editorial and
production crew of Elsevier has been not just professional but also Bernard F. Morrey, MD
xii
VIDEO CONTENTS
PART I Fundamentals and General Considerations 48 Hinged External Fixators of the Elbow
48-1 Application of the Dynamic Joint Distractor
4 History and Physical Examination of the Elbow
4-1 Ulnar Nerve Subluxation
4-2 Resisted Terminal Extension PART V Complications of Trauma and
4-3 Arm Bar Examination Elbow Stiffness
4-4 Localizing the Interval Between the Brachial Radialis and
Extensor Carpi Radialis Longus for Palpation of the 49 Persistent Elbow Instability
Posterior Interosseous Nerve 49-1 Reconstructive Options for Persistent Elbow Instability
4-5 Percussion of the Lateral Antebrachial Cutaneous Nerve 49-2 Allograft Reconstruction of the Coronoid
4-6 Posterior Plica Examination
4-7 Tennis Elbow Shear Test 50 Nonunion and Malunion of Distal Humerus Fractures
4-8 Range of Motion Examination 50-1 Open Reduction and Internal Fixation for Distal Humerus
4-9 Radiocapitellar Load Test Nonunion
4-10 Posterior Lateral Rotatory Drawer Test
4-11 Elbow Examination Under Anesthesia With Fluoroscopy 54 Extrinsic Contracture: Lateral and Medial
4-12 Moving Valgus Stress Test Column Procedures
4-13 Gravity-Assisted Varus Posterior Medial Rotatory 54-1 Open Contracture Release: Medial and Lateral Column
Instability Grind Test
55 Elbow Stiffness: Arthroscopic Contracture Release
55-1 Arthroscopic Osteocapsular Arthroplasty for
PART II Elbow Arthroscopy Primary Osteoarthritis
20 Arthroscopic Management of Elbow Plica and

Loose Bodies PART VI Sports and Soft Tissue Injuries
20-1 Elbow Plicae and Loose Bodies
60 Percutaneous Ultrasound Tenotomy Treatment of
22 Arthroscopic Management of Osteochondritis Epicondylitis
Dissecans of the Capitellum 60-1 Percutaneous Ultrasonic Tenotomy
22-1 Microfracture of Contained Osteochondritis
Dissecans Lesion 63 Elbow Tendinopathies: Acute Distal Biceps Tendon
Ruptures
63-1 Mayo Two-Incision Biceps Tendon Repair
PART III The Child and Adolescent Elbow
67 Articular Injuries in the Athlete
33 Osteochondritis Dissecans 67-1 Capitellar Osteochondritis Dissecans Lesion Treated
33-1 Treatment of Osteochondritis Desiccans With Microfracture
Elbow Lesions
33-2 Osteochondral Allograft Transfer for Osteochondritis
Dissecans PART VIII Joint Replacement Arthroplasty
87 Radiocapitellar Prosthetic Arthroplasty for Isolated
PART IV Acute Trauma Radiocapitellar Arthritis
87-1 UNI_Elbow Radio-Capitellum Replacement
39 Prosthetic Radial Head Replacement
39-1 rHead LATERAL Implant 90 Linked Elbow Arthroplasty: Rationale, Design
39-2 rHead RECON Bipolar Replacement Concept, and Surgical Technique
39-3 rHead Extended Stem Replacement 90-1 Coonrad-Morrey Total Elbow Arthroplasty
90-2 Highlights of the Zimmer Nexel Total Elbow Surgical
43 Coronoid Fractures Procedure
43-1 Lateral Approach to the Elbow for Radial Head Fixation
or Replacement and Coronoid Fixation 92 Distal Humeral Fractures
92-1 Total Elbow Arthroplasty for Distal Humerus Fractures
45 Distal Humerus Fractures: Fractures of the Columns
With Articular Involvement 93 Total Elbow Arthroplasty for Distal
45-1 Open Reduction and Internal Fixation for Distal Humerus Humerus Nonunion
Fractures 93-1 Total Elbow Arthroplasty for Distal Humerus Nonunions
xvi
Video Contents xvii
PART IX Complications and Salvage PART X Nonprosthetic Alternatives and

of Failed Arthroplasty Salvage Procedures
104 Isolated Polyethylene Wear and Elbow Replacement 110 Synovectomy of the Elbow
104-1 Fluoroscopic Examination for Bushing Wear 110-1 Arthroscopic Synovectomy of the Elbow
108 Revision of Failed Total Elbow Arthroplasty With 113 Anconeus Interposition Arthroplasty
Osseous Deficiency: Impaction Grafting 113-1 Anconeus Interposition Arthroplasty
108-1 Revision Techniques for Total Elbow Arthroplasty
114 Interposition Arthroplasty of the Elbow
109 Revision of Failed Total Elbow Arthroplasty With 114-1 Interposition Arthroplasty With Achilles Tendon Allograft
Osseous Deficiency: Humeral Replacement and and the Application of the Dynamic Joint Distractor
Allograft Prosthetic Composite Reconstruction
109-1 Allograft Prosthetic Composite Reconstruction
Morrey’s
The Elbow and
ItsDisorders
1
Phylogeny
Alex A. Malone and Susan G. Larson
INTRODUCTION Early mammals from the Triassic (210 to 160 mya) and Jurassic
(160 to 130 mya) periods also had radial and ulnar condyles. However,
The human elbow forms the link between brachium and forearm, the radial condyle was more protuberant than the ulnar, and the ulnar
controlling length of reach and orientation of the hand, and is one condyle was more linear and obliquely oriented (see Fig. 1.1). The two
of our most distinctive anatomic regions. An appreciation of elbow condyles were separated by an intercondylar groove. The ulnar notch
phylogeny complements anatomic knowledge in three ways: (1) it had articular surfaces for both the ulnar and the radial condyles, each
demonstrates how the elbow has evolved to facilitate specific functional matching the configuration of the corresponding humeral surface. The
demands, such as suspensory locomotion and dexterous manipulation; oblique orientation of the humeroulnar joint resembled a spiral con-
(2) it explains the functional significance of each morphologic feature; figuration, which helped to keep forearm movement in a sagittal plane
and (3) it assists in predicting the consequences of loss of such features as the humerus underwent a compound motion involving adduction,
through disease, injury, or treatment. elevation, and rotation during propulsion.
Most of the characteristic features of the human elbow significantly The trochleariform distal humeral articular surface in modern
predate the appearance of modern Homo sapiens. In fact, current mammals largely came about by widening the intercondylar groove
evidence suggests that this morphology can be traced back to the and the development of a ridge within it (see Fig. 1.1, bear). The
common ancestor of humans and apes, extant approximately 15 to 20 articular surface on the proximal ulna is oblique in orientation, and
million years ago (mya). the distal half retains an articulation with the ulnar condyle. This spiral
trochlear configuration allows the forearm to move in a sagittal plane
while maintaining the stability of ulnohumeral contact through the
EVOLUTION OF THE VERTEBRATE ELBOW cam effect of the ulnar condyle during humeral rotation.
The distal humerus of pelycosaurs, the late Paleozoic (255 to 235 mya) Most small noncursorial mammals have maintained the spiral
reptiles that probably gave rise to more advanced mammal-like reptiles, configuration of the trochlear articular surface observed in early
possessed a bulbous capitellum laterally and medially. The articulation mammals. In larger and more cursorial mammals, the trochlea displays
with the ulna was formed by two distinct surfaces: a slightly concave various ridges and is narrower to improve stability, although at the
ventral surface and a more flat dorsal surface (Fig. 1.1).11 The proximal expense of joint mobility. Only in the hominoid primates, which
articular surface of the ulna was similarly divided into two surfaces include humans, chimpanzees, gorillas, orangutans, and gibbons, is the
separated by a low ridge. Reconstruction of the forelimb of these medial aspect of the distal humeral articular surface truly trochleari-
reptiles suggests that they walked with limbs splayed out to the side. form. In the next section, we discuss the functional significance of the
The humerus was held more or less horizontal, the elbow flexed to 90 unique aspects of the hominoid elbow joint.
degrees, and the forearm was sagittally oriented. Forward motion was
brought about by rotation of the humerus around its long axis, which COMPARATIVE PRIMATE ANATOMY OF
propelled the body forward relative to the fixed forefoot. Elbow flexion
and extension probably were useful only in side-to-side motions. The
THE ELBOW REGION
ulnohumeral joint, with its dual articular surfaces, was well suited to Much of what follows is taken from the detailed studies of Rose.20,21
resist the valgus/varus stress produced by humeral rotation, and the The humeral trochlea may be cylindrical, conical, or trochleariform in
proximal end of the radius was flat and triangular, precluding prono- nonhuman primates.21 The trochlea is conical in some prosimians, but
supination. It appears, therefore, that stability rather than mobility was a cylindrical trochlea seems to be the most common shape and is
the major functional characteristic of the elbow of these late Paleozoic observed in most prosimians and New World monkeys. The trochlea
reptiles. is also cylindrical in most Old World monkeys but with a pronounced
Cynodonts, the more immediate ancestors of mammals from the medial flange or keel that is best developed anterodistally (Fig. 1.2).
Permo-Triassic period (235 to 160 mya), had their limbs underneath Only in apes and humans is the trochlea truly trochleariform, possess-
their bodies rather than at the sides. The distal humeral articular ing medial and lateral ridges all around the trochlear margins, which
surface consisted of radial and ulnar condyles separated by a shallow contribute to the stability of the ulnohumeral joint, substituting for
groove (see Fig. 1.1). The proximal ulnar articular surface was an the radiohumeral joint, which is freed for pronosupination throughout
elongate spoon shape for articulation with the humeroulnar condyle. the flexion range.11,20 In most species, the articular surface of the
The lateral flange on the ulna for articulation with the radius was sepa- trochlea expands posteriorly to the area behind the capitellum. In
rated from this surface by a low ridge. This ridge articulated with the larger monkeys, the lateral edge of the posterior trochlear surface
groove between the radial and ulnar condyles, displaying some features projects to form a keel that extends up the lateral wall of the olecranon
in common with the “tongue and groove” (trochleariform) type of fossa (see Fig. 1.2). In hominoids, this keel is a continuation of the
humeroulnar articulation characteristic of many modern mammals. lateral trochlear ridge and helps form a sharp lateral margin of the
2
CHAPTER 1 Phylogeny 3
PHYLOGENY
Hominoid primate Graviportal mammal Cursorial mammal

(chimpanzee) (elephant) (gazelle)
Partly terrestrial
mammal (bear)
Generalized mammal
(tree shrew) Prototherian
Cretaceous
~100 mya
Jurassic mammal ~155 mya
Late Triassic mammal ~215 mya
Cynodont Early Triassic ~250 mya
Pelycosaur Late Paleozoic ~300 mya

FIG 1.1 The major evolutionary stages in the development of the elbow joint from pelycosaurs to advanced
mammals. The distal ends of the humeri are shown on the left, and the corresponding radius and ulna are
on the right. The form of the pelycosaur elbow was designed to maximize stability. Subsequent evolutionary
stages show accommodations to increasing mobility. (Adapted from Jenkins FA Jr: The functional anatomy
and evolution of the mammalian humeroulnar articulation, Am J Anat 137:281, 1973.)
olecranon fossa, providing resistance to varus and internal rotation in The great apes (chimpanzees, gorillas, and orangutans) and the
extension.20,21 lesser apes (gibbons) move about in a much less stereotypical fashion
The trochlear notch of the ulna generally mirrors the shape of the than do monkeys. To accommodate this more varied form of limb use,
humeral trochlea. In humans and apes, the notch has medial and the hominoid humeroulnar joint, with its deeply socketed articular
lateral surfaces separated by a ridge that articulates with the trochlear surfaces and well-developed medial and lateral trochlear ridges all
groove (Fig. 1.3).20,21 around the joint margins, is designed to provide maximum stability
The differences seen in the configuration of the humeroulnar joint throughout the flexion-extension range.20–22 The use of overhead
across primate species reflect contrasting requirements for stabiliza- suspensory postures and locomotion in apes has led to the evolution
tion with different forms of limb use. In most monkeys, the humer- of the capacity for complete elbow extension. Apes even keep their
oulnar joint is in its most stable configuration in a partially flexed elbows extended during quadrupedal locomotion. The ideal joint
position owing to the development of the medial trochlear keel antero- configuration for resistance of transarticular stress with fully extended
distally and the lateral keel posteriorly.20 elbows during quadrupedal postures would be to have a trochlear
It is not surprising that this position of maximum stability is the notch that was proximally directed. It could then act as a cradle to
one assumed by the forelimb during the weight-bearing phase of support the humerus during locomotion. However, a proximal orien-
quadrupedal locomotion. The anterior orientation of the trochlear tation of the trochlear notch would severely limit elbow flexion by
notch is a direct adaptation to weight bearing with a partially flexed impingement of the coronoid process within its fossa. The antero-
limb. However, such an orientation does limit elbow extension to some proximal orientation of the trochlear notch in apes thus represents
degree. a compromise that safely supports the humerus on the ulna in
4 PART I Fundamentals and General Considerations
BABOON CHIMPANZEE HUMAN
Anterior
Zona conoidea Lateral trochlear ridge
Distal
Posterior keel
Posterior
FIG 1.2 Distal humerus of a baboon, a chimpanzee, and a human from anterior, distal, and posterior aspects.
The lateral trochlear ridge is well developed in both the human and the chimpanzee but is largely nonexistent
in the baboon. The baboon humerus displays prominent flanges anteromedially and posterolaterally. The
lateral epicondyle is placed higher in the chimpanzee than in the human and displays a more strongly
developed supracondylar crest.
BABOON CHIMPANZEE HUMAN extended elbow positions during locomotion without unduly sacrific-
Long
ing elbow flexion.1
olecranon On the lateral side of the elbow, the articular surface on the capitel-
process lum extends farther posteriorly in apes and humans than in monkeys,
allowing the radius to move with the ulna into full extension of the
elbow. In addition, the capitellum of apes and humans is uniformly
rounded, reflecting versatility rather than stereotypy in forelimb usage
(Fig. 1.4).
Heavily
The gutter-like region between the trochlea and capitellum—the
buttressed
coronoid zona conoidea—is a relatively flat plane that terminates distally in most
process monkeys. In the hominoids, it continues posteriorly (see Fig. 1.1).20,21
The zona conoidea articulates with the bevel of the radial head, and
differences in its configuration reflect differences in the shape of the
radial head.
FIG 1.3 Proximal ulna of a baboon, a chimpanzee, and a human. The The radial head of hominoid primates is nearly circular, and the
trochlear notch is wider in the chimpanzee and the human and displays peripheral rim is symmetrical and beveled all around the circumfer-
a prominent ridge for articulation with the trochlear groove. In addition, ence of the radial head for articulation with the zona conoidea (Fig.
the radial notch faces laterally in the chimp and human, unlike in the 1.5). This configuration provides good contact to resist dislocation of
baboon, in which it faces more anteriorly. the radial head from the humerus under the varied loading regimes
BABOON CHIMPANZEE HUMAN Supination Pronation
Flaring
supracondylar Monkey
crest
Low and
weakly
High developed
lateral lateral
epicondyle epicondyle
FIG 1.4 Distal humerus of a baboon, a chimpanzee, and a human from Ape
the lateral aspect. The articular surface of the capitellum extends farther
onto the posterior surface of the bone (small arrows) in humans and
chimpanzees to permit full extension at the humeroradial joint.
Supination Pronation L M
FIG 1.5 Diagrammatic anterior views of the right humeroradial joint of
a monkey and an ape in the prone and supine positions. In the monkey,
the lateral bevel of the radial head comes into maximum congruence
Monkey with the zona conoidea (hatched area) in the prone position, thereby
creating a maximally stable joint configuration. In the ape, the rim of
the more symmetrical radial head maintains good contact with the
recessed zona conoidea in all positions of pronosupination. This con-
Lateral tributes to a configuration emphasizing universal stability at the ape
lip elbow rather than a position of particular stability, as seen in the
monkey. (Adapted from Rose MD: Another look at the anthropoid
elbow, J Hum Evol 17:193, 1988.)
Ape of the ulna in most monkeys and prosimians faces either anterolater-
ally or directly anteriorly, whereas in hominoids, it faces more later-
ally.20,21 The configuration observed in apes and humans emphasizes
a broad range of pronosupination with a nearly equal degree of stabil-
ity in all positions.20,21
In general terms, most of the differences in elbow joint morphology
between quadrupedal monkeys and the apes can be related to the
L M
development of a position of particular stability in monkeys versus
FIG 1.6 Diagrammatic view of the radioulnar joint in pronation and more universal stability in apes.
supination in a monkey and an ape. A section through the radius and A few additional features of the human elbow are shared with apes,
ulna in the region of the radial notch is superimposed on an outline of
such as a more distal biceps tuberosity (longer radial neck) relative to
the distal humerus. In the monkey, the radial notch faces anterolater-
ally, whereas in the ape, it faces more directly laterally. The radial head
their body size.21 In apes, this is probably related to the demands for
of the monkey with its lateral lip comes into maximum congruence in powerful elbow flexion to raise the center of mass of the body during
the pronated position, conferring maximum stability in this position. The climbing and suspensory postures and locomotion. Although the
ape radioulnar joint, on the other hand, displays no such position of radial tuberosity faces more or less anteriorly in most primates, it faces
particular stability and instead emphasizes mobility. (Adapted from more medially in apes and humans, reflecting their greater range of
Rose MD: Another look at the anthropoid elbow, J Hum Evol 17:193, pronosupination.17 Extreme supination is an important component of
1988.) suspensory locomotion in apes, and the medially placed tuberosity
provides maximum supination torque near full supination.14,30 Apes
and humans share a relatively short lever arm for triceps compared
experienced by the hominoid elbow and can stabilize the radial head with that of most other primates, which is generally attributed to the
in all positions of pronosupination.20,21 demands for rapid elbow extension during suspensory locomotion.
In most monkeys and prosimians, the radial head is ovoid and Finally, apes and humans are distinguished from other primate species
the proximal radioulnar joint articulation is restricted to the anterior in possessing a biomechanical carrying angle at the elbow. Sarmiento22
and medial surfaces; as a result, the joint becomes close packed for has argued that the evolution of a carrying angle in apes is related to
stability in pronation (Fig. 1.6). In apes and humans, on the other the need to bring the center of mass of the body beneath the support-
hand, this articular surface extends almost all the way around the ing hand during suspensory locomotion in a manner similar to that
head, implying a greater range of pronosupination.20 The radial notch in which the valgus knee of humans brings the foot nearer the center
epicondyle and a less well-developed supracondylar crest than is seen

in the apes, reflecting diminished leverage of the wrist extensors and
brachioradialis.23–25 Humans have no bowing of the ulna that is related
to enhancing the leverage of the forearm pronators and supinators in
apes.1 Finally, a diminution in the prominence of the trochlear ridges
and steep lateral margin of the olecranon fossa in humans can be
related to the overall reduction in stresses at the human elbow and the
concomitant relaxation on the demands for strong stabilization in all
positions.20,21
When exactly did the basic pattern for the hominoid elbow arise,
and how old is the morphology of the modern human elbow? For
answers to these questions we must turn to the fossil record.
FOSSIL EVIDENCE
cg Dendropithecus macinnesi, Limnopithecus legetet, and Proconsul heseloni
(all from Africa) are among the earliest known hominoid species dated
to the early part of the Miocene epoch (23 to 16 mya) for which
postcranial material is known. Overall, the distal humeri of the first
two of these forms resemble generalized New World monkeys such as
Cebus (capuchin monkeys). The trochlea does not display a prominent
lateral ridge, and the zona conoidea is relatively flat. The trochlear
notch faces anteriorly, and the head of the radius is oval in outline with
a well-developed lateral lip. These features generally are considered to
be primitive for higher primates (monkeys, apes, and humans).8,9,20
P. heseloni, on the other hand, does display some features charac-
FIG 1.7 Frontal view of an arm-swinging gibbon showing the skeletal teristic of extant hominoids. It has a globular capitellum, well-developed
structure of the forelimb. The carrying angle of the elbow brings the medial and lateral trochlear ridges, and a deep zona conoidea forming
center of mass (i.e., center of gravity [cg]) more nearly directly under the medial wall of a recessed gutter between the capitellum and
the supporting hand. (Adapted from Sarmiento EE: Functional Differ- trochlea.20 In general, the elbow region of Proconsul resembles that of
ences in the Skeleton of Wild and Captive Orang-Utans and Their extant hominoids in features related to general stability and range of
Adaptive Significance. Ph.D. Thesis, New York University, 1985.) pronosupination, yet full pronation remains a position of particular
stability.20
The limited fossil material that is available from the late Miocene
epoch (16 to 5 mya) suggests that many hominoid species, including
of mass of the body during the single limb support phase of walking members of the genera Dryopithecus (from Europe), Sivapithecus
(Fig. 1.7). (from Europe and Asia), and Oreopithecus (from Europe), displayed
All of these features have been retained in humans because of the features characteristic of the modern hominoid elbow. Although it
their continued advantages for tool use and other behaviors. Powerful is possible that these features arose in parallel in different genera, the
flexion is clearly important. The continued importance of the carrying more parsimonious explanation is that they inherited this morphology
angle is perhaps less obvious, but one advantage that it does offer is from an early to middle Miocene common ancestor, possibly similar
that flexion of the elbow is accompanied by adduction of the forearm, to P. heseloni.16,29,31 Assuming that the characteristic features of the
thus bringing the hands more in front of the body, where most hominoid elbow are shared derived traits—that is, traits inherited from
manipulatory activities are undertaken. a single common ancestor—we can say that the elbow morphology of
The morphology of the modern human elbow is not identical modern apes and humans can be dated to roughly 15 to 20 mya.
to that of the ape elbow, however. In some cases, the differences are The majority of paleoanthropologists agree that humans are most
simply a matter of degree. For example, although both apes and closely related to the African apes (chimpanzees and gorillas) and that
humans are distinguished from other primates in the medial orienta- the two lineages arose in the late Miocene or earliest Pliocene period
tion of the radial tuberosity, it is more extreme in position in the (between 10 and 4 mya).8 The earliest known fossils of the human
ape; in the human it is typically slightly anterior to true medial. In lineage (hominids) date from the early Pliocene era, approximately 4
addition, although the olecranon is short in both humans and apes to 5 mya. There are three genera of these earliest hominids currently
compared with most monkeys, it is slightly longer in humans than in recognized, Ardipithecus, Paranthropus, and Australopithecus. The latter
apes and also shaped to maintain this length throughout the range of is the best known and most widespread genus, and includes the famous
flexion—both of which are advantageous for powerful manipulatory “Lucy” skeleton from Hadar, Ethiopia (Australopithecus afarensis).7,12
activities.6 The genus Homo, to which our own species belongs, first appeared
Other differences between the elbow morphology of humans and about 2.5 to 2 mya in East Africa with its earliest member species,
that of apes can be related to the fact that the human forelimb has no Homo habilis.
role in locomotion. These differences include a less robust coronoid All of the hominids from the Pliocene period were bipedal, although
process and a relatively narrower, proximally oriented trochlear notch some probably spent significant time climbing trees.23–26,28 The devel-
in humans, indicating relative stability in flexion rather than the need opment of bipedalism freed the upper extremity from the requirements
to support the weight of the body during quadrupedal locomotion in of locomotion, placing greater emphasis on increasing mobility. The
extension.1,13 Humans possess a smaller and more distally placed lateral ability to supinate and pronate was an immense advantage to hominids
PHYLOGENY
AL 288-1m KNM-ER 739 Gombore IB 7594

FIG 1.8 Distal humerus of Plio-Pleistocene hominids. Gombore IB 7594 represents early Homo on the basis
of the moderate development of the lateral trochlear ridge and low position of the lateral epicondyle. AL
288-1m (part of the “Lucy” skeleton, Australopithecus afarensis) displays a more prominent lateral trochlear
ridge, a recessed, gutter-like zona conoidea, a high position of the lateral epicondyle, and a well-developed
supracondylar crest. Therefore, it resembles living apes in many features of its elbow morphology. KNM-ER
739 has been attributed to Paranthropus boisei and, like AL 288-1m, has a lateral epicondyle that is positioned
above the articular surfaces. However, it is more like Homo, with the moderate development of the lateral
trochlear ridge.
in caring for their young, defending themselves, and gathering food. It genus Homo are similar to those of modern humans in having a
was also critical in efficient tool handling, which developed approxi- prominent interosseous border, a supinator crest, and a well-marked
mately 2 mya, at about the same time as H. habilis, although there is hollow for the play of the tuberosity of the radius.4,5,15 It appears,
debate about which species of early hominid was responsible for therefore, that many of the characteristics that distinguish the human
making them.27 elbow from that of the ape can be found in the earliest members of
Several distal humeri are known from these early hominid species. our genus.
All of the early hominid distal humeri lack the steep lateral margin of In overview, the combination of comparative anatomy and the
the olecranon fossa that is characteristic of chimpanzees and gorillas. fossil record indicates that the modern human elbow owes its begin-
However, they do show a considerable amount of morphologic varia- nings to our hominoid ancestry. Current evidence suggests that many
tion in other characteristics (Fig. 1.8). On the basis of the contour of of the characteristic features of the human distal humerus and proxi-
the distal end of the humeral shaft, the placement of the epicondyles, mal radius and ulna can be projected back approximately 15 to 20 mya
and the configuration of the articular surface, the fossil distal humeri to a common ancestor of extant apes and humans. Functional analysis
have been divided into two groups. The first group is characterized suggests that this morphologic structure arose in hominoid primates
by a weakly projecting lateral epicondyle that is placed low, at about in response to the need for stabilization throughout the flexion-
the level of the capitellum, and by a moderately developed lateral extension and pronosupination ranges of motion to permit a more
trochlear ridge.23,24 These are features shared with modern humans, versatile form of forelimb use. This morphology was still largely intact
and consequently, this group generally is referred to as early Homo. following the evolution of upright posture and bipedal locomotion in
The second group includes the Australopithecus and Paranthropus the earliest known hominids. However, as the forelimb became less and
species and is characterized by a well-developed lateral epicondyle that less involved in locomotion, the hominid elbow underwent additional
is high relative to the capitellum. These features are similar to those modifications, relaxing some of the emphasis on stabilization and
of modern apes. increasing performance throughout the range of movement. The fossil
A number of fragments of early hominid proximal radii have been record indicates that the distinct form of the modern human elbow
recovered representing each of the currently recognized species. The probably first appeared about 2 mya in our ancestor H. habilis. This
proximal radial fragments that have been attributed to early Homo morphology has changed only subtly during all subsequent stages of
display a much narrower bevel around the capitellar fovea than that of human evolution.
the modern apes and the earlier hominin group. This provides for
articulation with a more shallow zona conoidea and a more vertical
ACKNOWLEDGMENTS
and uniformly wide surface on the side of the head for articulation
with the ulna, favoring pronosupination over stability. Other primitive SGL would like to thank Jack Stern and John Fleagle for helpful com-
hominoid features include thick cortices, a relatively long and angu- ments on earlier versions of this chapter and Luci Betti-Nash for the
lated radial neck (lower neck shaft angle), and a more anteromedially preparation of figures.
(rather than medially) placed biceps tuberosity. Many of these features
are still present in a small percentage of modern humans, limiting the
functional conclusions that can be drawn and suggesting a mosaic REFERENCES
pattern of evolution.18,19 1. Aiello LC, Dean MC: An introduction to human evolutionary anatomy,
Some early hominid ulnae that have been recovered appear London, 1990, Academic Press.
to retain many primitive features, including a longer, more curved 2. Churchill SE, Pearson OM, Grine FE, et al: Morphological affinities of the
shaft, greater mediolateral width proximally, and a nonprominent proximal ulna from Klasies River main site: archaic or modern? J Hum
interosseous border.1,2,10 However, early human ulnae attributed to the Evol 31:213, 1996.
3. Deleted in review. 18. Patel BA: The hominoid proximal radius: re-interpreting locomotor
4. Day MH: Functional interpretations of the morphology of postcranial behaviors in early hominins. J Hum Evol 48:415, 2005.
remains of early African hominids. In Jolly CJ, editor: Early hominids of 19. Pearson OM, Grine FE: Re-analysis of the hominid radii from Cave of
Africa, London, 1978, Duckworth, p 311. Hearths and Klasies River Mouth, South Africa. J Hum Evol 32:577,
5. Day MH, Leakey REF: New evidence for the genus Homo from East 1997.
Rudolf, Kenya III. Am J Phys Anthropol 39:367, 1974. 20. Rose MD: Another look at the anthropoid elbow. J Hum Evol 17:193,
6. Drapeau MS: Functional anatomy of the olecranon process in hominoids 1988.
and Plio-Pleistocene hominins. Am J Phys Anthropol 124:297, 2004. 21. Rose MD: Functional anatomy of the elbow and forearm in primates. In
7. Drapeau MS, Ward CV, Kimbel WH, et al: Associated cranial and forelimb Gebo D, editor: Postcranial adaptation in nonhuman primates, DeKalb, IL,
remains attributed to Australopithecus afarensis from Hadar, Ethiopia. 1993, Northern Illinois Press, p 70.
J Hum Evol 48:593, 2005. 22. Sarmiento EE: Functional differences in the skeleton of wild and captive
8. Fleagle JG: Primate adaptation and evolution, ed 2, New York, 1999, orang-utans and their adaptive significance, Ph.D. Thesis, 1985, New York
Academic Press. University.
9. Harrison T: The phylogenetic relationships of the early catarrhine 23. Senut B: Humeral outlines in some hominoid primates and in
primates: a review of the current evidence. J Hum Evol 16:41, 1987. Plio-Pleistocene hominids. Am J Phys Anthropol 56:275, 1981.
10. Howell FC, Wood BA: Early hominid ulna from the Omo Basin, Ethiopia. 24. Senut B: Outlines of the distal humerus in hominoid primates:
Nature 249:174, 1974. application to some Plio-Pleistocene hominids. In Chiarelli AB,
11. Jenkins FA, Jr: The functional anatomy and evolution of the mammalian Corruccini R, editors: Primate evolutionary biology, Berlin, 1981, Springer
humeroulnar articulation. Am J Anat 137:281, 1973. Verlag, p 81.
12. Johanson DC, Lovejoy CO, Kimbel WH, et al: Morphology of the 25. Senut B, Tardieu C: Functional aspects of Plio-Pleistocene hominid limb
Pliocene partial hominid skeleton (A.L. 288-1) from the Hadar bones: implications for taxonomy and phylogeny. In Delson E, editor:
Formation, Ethiopia. Am J Phys Anthropol 57:403, 1982. Ancestors: the hard evidence, New York, 1985, A. Liss, p 193.
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51:39, 1979. 21:215, 1991.
2
Anatomy of the Elbow Joint
Bernard F. Morrey, Manuel Llusá-Pérez, and José R. Ballesteros-Betancourt
This chapter discusses the normal anatomy of the elbow region. Medial to the trochlea, the prominent medial epicondyle serves as
Abnormal and surgical anatomy is addressed in subsequent chapters a source of attachment of the medial ulnar collateral ligament and the
of this book dealing with the pertinent condition. flexor-pronator group of muscles. Laterally, the lateral epicondyle is
located just proximal to the capitellum and is much less prominent
than the medial epicondyle. The lateral ulnar collateral ligament and
TOPICAL ANATOMY AND GENERAL SURVEY
the supinator-extensor muscle group originate from the flat, irregular
The contours of the biceps muscle and antecubital fossa are easily surface of the lateral epicondyle.
observed anteriorly. Laterally, the avascular interval between the Anteriorly, the radial and coronoid fossae accommodate the radial
brachioradialis and the triceps, the so-called column, is an important head and coronoid process during flexion. Posteriorly, the olecranon
palpable landmark for surgical exposures (Fig. 2.1). Laterally, the fossa receives the tip of the olecranon.
tip of the olecranon, the lateral epicondyle, and the radial head In approximately 90% of individuals,85 a thin membrane of
also form an equilateral triangle and provide an important landmark bone separates the olecranon and coronoid fossae. The medial supra-
for joint aspiration and elbow arthroscopy (see Chapters 39 and condylar column is smaller than the lateral and explains the vulner-
80). The flexion crease of the elbow is in line with the medial and ability of the medial column to fracture caused by trauma and some
lateral epicondyles and thus actually reflects the joint axis and is 1 to surgical procedures.56 The posterior aspect of the lateral supracondy-
2 cm proximal to the joint line when the elbow is extended (Fig. 2.2). lar column is flat, allowing ease of application of contoured plates for
The inverted triangular depression on the anterior aspect of the fractures involving this structure. The prominent lateral supracondy-
extremity distal to the epicondyles is called the cubital (or antecubital) lar ridge serves as a site of attachment for the brachioradialis and
fossa. extensor carpi radialis longus muscles anteriorly and for the triceps
The superficial cephalic and basilic veins are the most prominent posteriorly (Fig. 2.6). It is also an important landmark for many
superficial major contributions of the anterior venous system and lateral surgical approaches, especially for the “column procedure” (see
communicate by way of the median cephalic and median basilic veins Chapters 11 and 54).
to form an “M” pattern over the cubital fossa (Fig. 2.3).2 Proximal to the medial epicondyle, approximately 5 to 7 cm along
The extensor forearm musculature originates from the lateral epi- the medial intramuscular septum, a supracondylar process may be
condyle and was termed the mobile wad by Henry.37 This forms the observed in 1% to 3% of individuals.44,48,80 A fibrous band termed the
lateral margin of the antecubital fossa and the lateral contour of the ligament of Struthers sometimes originates from this process and
forearm and comprises the brachioradialis and the extensor carpi attaches to the medial epicondyle.38 When present, this spur serves as
radialis longus and brevis muscles. The muscles comprising the an anomalous insertion of the coracobrachialis muscle and an origin
contour of the medial anterior forearm include the pronator teres, of the pronator teres muscle.34 Various pathologic processes have been
flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. Henry associated with the supracondylar process, including fracture44 and
has demonstrated that their relationship and location can be approxi- median4 and ulnar nerve38 entrapment (see Chapter 72).
mated by placing the opposing thumb and the index, long, and ring
fingers over the anterior medial forearm. The dorsum of the forearm Radius
is contoured by the lateral extensor musculature, consisting of the The radial head articulates with the capitellum. It exhibits a cylindrical
anconeus, extensor carpi ulnaris, extensor digitorum quinti, and exten- symmetrical shape with a depression in the midportion to accom-
sor digitorum communis. modate the capitellum. The osseous contour of the radial head, on the
Dermal innervation about the proximal elbow is quite variable, other hand, actually is more elliptical in shape, with a major and minor
being provided by the lower lateral cutaneous (C5, C6) and medial axis. The disk-shaped head is secured to the ulna by the annular liga-
cutaneous (radial nerve, C8, T1, and T2) nerves of the arm. The ment (Fig. 2.7). Distal to the radial head, the bone tapers to form the
forearm skin is innervated by the medial (C8, T1), lateral (musculo- radial neck, which, along with the head, is vulnerable to fracture.82 The
cutaneous, C5, C6), and posterior (radial nerve, C6–C8) cutaneous radial tuberosity marks the distal aspect of the neck and has two dis-
nerves of the forearm (Fig. 2.4).19 tinct parts (Fig. 2.8). The anterior surface is covered by a bicipitoradial
bursa protecting the biceps tendon during full pronation. However, it
OSTEOLOGY is the rough posterior aspect that provides the site of attachment of
the biceps tendon. During full pronation the tuberosity is in a dorsal
Humerus position; this allows repair of a ruptured biceps tendon through a
The distal humerus consists of an arch formed by two condyles that posterior approach11 (see Chapter 63) and is helpful to determine axial
support the articular elements of the trochlea and capitellum (Fig. 2.5). alignment of proximal radial fractures.26 In addition to the bicipital
9
A B
FIG 2.1 The palpable landmarks of the tip of the olecranon and the medial and lateral epicondyles are col-
linear with the elbow extended (A) and form an inverted triangle posteriorly when the elbow is flexed 90
degrees (B).
FIG 2.2 A line placed over the flexion crease (A) is actually situated approximately 1 cm above the elbow
joint line (B).
CHAPTER 2 Anatomy of the Elbow Joint 11
Fascia brachii
V. basilica humeri
V. cephalica humeri
N. cutaneus
M. biceps brachii
M. pronator teres
Lacertus fibrosus
M. flexor carpi radialis
V. mediana cephalica
V. mediana basilica
N. cutaneous M. pronator teres

antibrachii lateralis
V. mediana antibrachii V. basilica antibrachii
V. cephalica antibrachii
Ramus anastomoticus
M. flexor carpi radialis
Fascia antibrachii
FIG 2.3 The superficial venous pattern of the anterior aspect of the elbow demonstrates a rather charac-
teristic inverted M pattern formed by the median cephalic and median basilic veins. M., Musculus; N., nervus;
V., vena. (Redrawn from Anson BJ, McVay CB: Surgical anatomy, vol. 2, 5th ed. Philadelphia, 1971, WB
Saunders.)
Lateral supraclavicular
(C3 and 4)
Axillary (C5 and 6)
Lateral supraclavicular
(C3 and 4)
Medial cutaneous of
arm (T1 and 2) and Medial cutaneous of
intercostobrachial (T2) arm and Axillary (C5 and 6)
intercostobrachial
Lower lateral
(T1 and 2)
cutaneous of arm Posterior cutaneous
(radial, C5 and 6) of arm (radial)
Lateral cutaneous Lower lateral

of forearm cutaneous of arm
(musculocutaneous, Medial cutaneous (radial)
C5 and 6) of forearm
Radial Medial cutaneous

(C7 and 8) of forearm (C8, T1) Posterior cutaneous Radial
of forearm (radial)
Lateral cutaneous
Ulnar (C7 and 8) of forearm
(musculocutaneous)
Median (C6, 7, and 8)
Ulnar
A B Median
FIG 2.4 Typical distribution of the cutaneous nerves of the anterior (A) and posterior (B) aspects of the upper
limb. (Redrawn from Cunningham DJ: In Romanes GJ, editor: Textbook of anatomy, 12th ed. New York,
1981, Oxford University Press.)
6˚
A B
FIG 2.5 (A) The bony landmarks of the anterior aspect of the distal humerus. Note the 6-degree valgus
angulation of the flexion axis and long axis of the humerus. (B) The prominent medial and lateral supracondylar
bony columns as well as other landmarks of the posterior aspect of the distal humerus.
FIG 2.7 The elliptical radial head is stabilized to the lesser sigmoid
notch of the ulna. Note the symmetrical, circular portion that articulates
with the capitellum.
as the insertion site of the medial ulnar collateral ligament. The

triceps tendon attaches to the posterior aspect of the olecranon
FIG 2.6 Typical supracondylar process located approximately 5 cm process.
proximal to the medial epicondyle with its characteristic configuration. On the lateral aspect of the coronoid process, the lesser semilunar
or radial notch articulates with the radial head and is oriented roughly
perpendicular to the long axis of the bone. Distal to this, the supinator
radial bursa, several other potential bursae have also been described crest serves as the site of attachment to the supinator muscle. On this
about the elbow (Fig. 2.9). crest, a tuberosity occurs that is the site of insertion of the lateral ulnar
collateral ligament.51,56,65
Ulna
The proximal ulna provides the greater sigmoid notch (incisura ELBOW JOINT STRUCTURE
semilunaris), which serves as the major articulation of the elbow that
is responsible for its inherent stability (Fig. 2.10). The cortical surface Articulation
of the coronoid process serves as the site of insertion of the brachialis The elbow joint articulation is classified as a trochoginglymoid joint.76
muscle and of the oblique cord. Medially, the sublime tubercle serves The ulnohumeral joint resembles a hinge (ginglymus), allowing flexion
and extension. The radiohumeral and proximal radioulnar joint allows

axial rotation or a pivoting (trochoid) type of motion (Chapter 3).
15° Humerus
The trochlea is the hyperboloid, pulley-like surface that articulates
with the semilunar notch of the ulna covered by articular cartilage
through an arc of 300 degrees41,72,76 (Fig. 2.11). The medial contour is
larger and projects more distally than does the lateral portion of the
trochlea (see Fig. 2.5). The two surfaces are separated by a groove that
courses in a helical manner from an anterolateral to a posteromedial
direction.
The capitellum is almost spheroidal in shape and is covered with
hyaline cartilage, which is approximately 2 mm thick anteriorly. A
groove separates the capitellum from the trochlea, and the rim of the
radial head articulates with this groove throughout the arc of flexion
and during pronation and supination.
In the lateral plane, the orientation of the articular surface of the
distal humerus is rotated approximately 30 degrees anteriorly with
respect to the long axis of the humerus (Fig. 2.12). The center of the
concentric arc formed by the trochlea and capitellum defines the
flexion axis and is on a line that is coplanar to the anterior distal cortex
of the humerus.58 In the transverse plane, the articular surface and axis
of rotation are rotated outward approximately 5 degrees referable to
the epicondylar line (Fig. 2.13), and in the frontal plane, it is tilted
approximately 6 degrees in valgus42,46,79 (see Fig. 2.5).
Proximal Radius
Hyaline cartilage covers the depression of the radial head, which
has an angular arc of about 40 degrees,76 as well as approximately 240
FIG 2.8 Proximal aspect of the radius demonstrating the articular degrees of articular cartilage that articulates with the ulna, hence
margin for articulation with the lesser sigmoid notch, the radial neck, approximately 120 degrees of the radial circumference is not articular
and tuberosity. The neck angulates about 15 degrees away from the and amenable to open reduction internal fixation (ORIF) for fracture15
tuberosity.
Radiohumeral B.
Supinator B.
Cubital interosseus B.
Bicipital radial B.
FIG 2.9 A deep view of the anterior aspect of the joint revealing the submuscular bursa (B.) present about
the elbow joint.
Guiding ridge Greater sigmoid notch

Coronoid
Transverse groove Radial notch
of greater Supinator crest
sigmoid notch and tuberosity
Tubercle Olecranon
Ulnar tuberosity B
A
FIG 2.10 (A) Anterior aspect of the proximal ulna demonstrating the greater sigmoid fossa with the central
groove. (B) Lateral view with landmarks.
30°
FIG 2.11 Sagittal section through the elbow region, demonstrating the
high degree of congruity and articular arc of the distal humerus. Note
the limited capacity of the capsule.
FIG 2.12 Lateral view of the humerus shows the 30-degree anterior
rotation of the articular condyles with respect to the long axis of the
humerus.
(see Fig. 2.7). The lesser sigmoid fossa forms an arc of approximately
60 to 80 degrees,41,76 leaving an excursion of about 180 degrees for
pronation and supination. The anterolateral third of the circumference In the lateral plane, the sigmoid notch forms an arc of about 190
of the radial head is void of cartilage. This part of the radial head lacks degrees.73 The contour is not a true hemicircle but rather is ellipsoid.
subchondral bone and thus is not as strong as the part that supports This explains the articular void in the midportion.84
the articular cartilage; this part has been demonstrated to be the The orientation of the articulation is approximately 30 degrees
portion most often fractured.82 The head and neck are not colinear posterior to the long axis of the bone (Fig. 2.15). This matches the
with the rest of the bone and form an angle of approximately 15 30-degree anterior angulation of the distal humerus, providing stabil-
degrees with the shaft of the radius, directed away from the radial ity in full extension. In the frontal plane, the shaft is angulated from
tuberosity28 (see Fig. 2.8). about 1 to 6 degrees42,46,72 lateral to the articulation (Fig. 2.16). This
angle contributes, in part, to the variation of the carrying angle, which
Proximal Ulna is discussed in Chapter 3.
In most individuals, a transverse portion of nonarticular cartilage The lesser sigmoid notch consists of a depression with an arc of
divides the greater sigmoid notch into an anterior portion comprising about 70 degrees and is situated just distal to the lateral aspect of the
the coronoid and the posterior olecranon (Fig. 2.14). coronoid and articulates with the radial head.
Axis B
A 5° Epicondylar line
E
FIG 2.13 Axial view of the distal humerus shows the isometric trochlea
as well as the anterior position of the capitellum. The trochlear capitellar
groove separates the trochlea from the capitellum. The flexion axis,
AB, is about 5 degrees anteriorly rotated compared to the epicondylar
line, AE.
FIG 2.14 The relative percentage of hyaline cartilage distribution at the

proximal ulna; a transverse portion of nonarticular cartilage divides the
greater sigmoid notch into an anterior portion comprising the coronoid
and the posterior portion with the olecranon.
4˚
30°
FIG 2.15 The greater sigmoid notch opens posteriorly with respect to
the long axis of the ulna. This matches the 30-degree anterior rotation
of the distal humerus, as shown in Fig. 2.12.
Carrying Angle
The so-called carrying angle is the angle formed by the long axes of
the humerus and the ulna with the elbow fully extended (Fig. 2.17). In
men, the mean carrying angle is 11 to 14 degrees, and in women, it is
13 to 16 degrees.3,42,68 Furthermore, the carrying angle is approximately
1 degree greater in the dominant than nondominant side.89
Joint Capsule
The anterior capsule inserts proximally above the coronoid and radial
fossae (Fig. 2.18). Distally, the capsule attaches to the anterior margin
FIG 2.16 There is a slight (approximately 4 degrees) valgus angulation
of the coronoid medially as well as to the annular ligament laterally.
of the shaft of the ulna with respect to the greater sigmoid notch.
Posteriorly, the capsule attaches just above the olecranon fossa, distally
along the supracondylar bony columns. Distally, attachment is along
the medial and lateral articular margin of the sigmoid notch. The In so doing, it crosses the joint obliquely over the radial head and neck
greatest capacity of the elbow, 25 to 30 mL,69 occurs at about 80 degrees and inserts into the anterior distal capsule near the lesser sigmoid
of flexion.40,69 notch (Fig. 2.19). While a normal structure, it can become thickened
The anterior capsule is normally a thin transparent structure, but and in so doing produces the well-recognized symptom complex rec-
significant strength is provided by transverse and obliquely directed ognized as a snapping elbow. It has also been implicated in tennis
fibrous bands.22,56 elbow–like symptoms in those without the classic snapping sensation
Plica synovalis. A fold of the anterior capsule, the plica synovalis, (see Chapter 59).
is invariably present but is of variable prominence. Duparc credits The anterior capsule is, of course, taut in extension but becomes
Testut with the original description in 1928,24 but the clinical relevance lax in flexion. The joint capsule is innervated by highly variable
as the cause of a snapping elbow is credited to Miyazaki et al. in 1958.54 branches from all major nerves crossing the joint, including the
It courses from proximal to distal and obliquely from lateral to medial. contribution from the musculoskeletal nerve (Fig. 2.20).29
21 16 10 5 0
FIG 2.17 The carrying angle is formed by the variable relationship of the orientation of the humeral articula-
tion referable to the long axis of the humerus and the valgus angular relationship of the greater sigmoid
fossa referable to the long axis of the ulna. (Redrawn from Lanz T, Wachsmuth W: Praktische Anatomie.
Springer, 1959, Berlin [in German].)
A B
FIG 2.18 Dye distends the capsule. Note the extension of the capsule in the sacciform recess of the radial
head and the complex network of fibrous support to the capsule (A). Distribution of the synovial membrane
from the posterior aspect, demonstrating the presence of the synovial recess under the annular ligament
and about the proximal ulna (B).
Ligaments
The collateral ligaments of the elbow are formed by specialized thick-
enings of the medial and lateral capsules.
Medial Collateral Ligament Complex

The medial collateral ligament consists of three parts: anterior, poste-
rior, and transverse segments (Fig. 2.21). The anterior bundle is the
most discrete component, the posterior portion being a thickening of
the posterior capsule, and is well defined only in about 90 degrees of
flexion. The transverse component (ligament of Cooper) appears to
contribute little or nothing to elbow stability.
The ligament originates from a broad anteroinferior surface of
the epicondyle.64 The ulnar nerve rests on the posterior aspect of the
medial epicondyle but is not intimately related to the fibers of
the anterior bundle of the medial collateral ligament itself. This
has obvious implications with regard to the treatment of ulnar nerve
decompression by medial epicondylar ostectomy. A more obliquely
oriented excision might be most appropriate to both decompress the
ulnar nerve and preserve the collateral ligament origin. On the lateral
projection, the origin of the anterior bundle of the medial collateral
ligament is precisely at the axis of rotation at the anterior, inferior
margins of the medial epicondyle62 (Fig. 2.22). The posterior bundle
inserts along the midportion of the medial margin of the semilunar
notch. The width of the anterior bundle is approximately 4 to 5 mm
compared with 5 to 6 mm at the midportion of the fan-shaped poste-
rior segment.55 Recently ultrasound assessment has proved helpful in
further documenting the dimensions of these structures.61
FIG 2.19 The radial synovial plica (arrow) originates from the proximal The function of the ligamentous structures is discussed in
lateral capsule and courses distally and medially, enveloping a portion
detail in the following. Clinically and experimentally, the anterior
of the radial head.
bundle is clearly the major portion of the medial ligament complex59
Musculocutaneous
Median
Radial Ulnar
To anconeus
Left anterior Left posterior
FIG 2.20 A typical distribution of the contributions of the musculocutaneous radial median and ulnar nerves
to the joint capsule. (Redrawn from Gardner E: The innervation of the elbow joint, Anat Rec 102:161, 1948.)
Anterior bundle
Posterior bundle
Transverse ligament
FIG 2.21 The classic orientation of the medial collateral ligament, including the anterior and posterior
bundles, and the transverse ligament. This last structure contributes relatively little to elbow stability.
FIG 2.23 Dissection demonstrating the “Y” orientation of the lateral

collateral ligament complex.
Radial collateral ligament. This structure originates from the

lateral epicondyle and is actually a complex of several components
(Fig. 2.24). Its superficial aspect provides a source of origin for a
FIG 2.22 The origin of the medial complex is at the axis of rotation, portion of the supinator muscle. The length averages approximately
which is located at the anterior inferior aspect of the medial epicondyle.
20 mm with a width of approximately 8 mm. This portion of the liga-
This is the projected center of the trochlea.
ment is almost uniformly taut throughout the normal range of flexion
and extension, indicating that the origin of the ligament is very near
the axis of flexion.
and has been divided into anterior, posterior, and deep medial Annular ligament. A strong band of tissue originating and insert-
subcomponents.62 ing on the anterior and posterior margins of the lesser sigmoid notch
forms the annular ligament and maintains the radial head in contact
Lateral Ligament Complex with the ulna. The ligament is tapered distally to give the shape of a
Unlike the medial collateral ligament complex, with its rather consis- funnel and contributes about four fifths of the fibroosseous ring.51 The
tent pattern, the lateral ligaments of the elbow joint are less discrete, structure is not as simple as it appears because fibers arc medially and
and individual variation is common.30,31,40,74 Our investigation has laterally to secure the annular ligament to the ulna.71 A synovial reflec-
suggested that several components make up the lateral ligament tion extends distal to the lower margin of the annular ligament,
complex: (1) the radial collateral ligament; (2) the annular ligament; forming the sacciform recess. The radial head is not a pure circular
(3) a variably present accessory lateral collateral ligament; and (4) the disk75; thus, it has been observed that the anterior insertion becomes
lateral ulnar collateral ligament. These observations have now been taut during supination and the posterior aspect becomes taut during
confirmed by others. The current thinking is to consider the complex extremes of pronation.89
to be roughly in a “Y” shape, the arms of which attach to the anterior Lateral ulnar collateral ligament. In 1985, Morrey and An
and posterior aspects of the semilunar notch12,71 (Fig. 2.23). first described the so-called lateral ulnar collateral ligament.56 Before
Annular ligament
Radial Accessory collateral ligament
collateral
ligament
Lateral ulnar collateral ligament
FIG 2.24 Schematic representation of the radial collateral ligament

FIG 2.25 The lateral ulnar collateral ligament complex has a humeral
complex showing several portions, one of which, termed the radial
origin at the axis of rotation and inserts into the tubercle of the supinator
collateral ligament, extends from the humerus to the annular ligament.
crest (arrow). Due to its site of origin on the flexion axis (circle) it is taut
This is the portion that is implicated in clinical instability.27
both in extension and in flexion.
instability of the joint, it was shown to be deficient.63,64 As such, it is

considered the essential lateral stabilizer of the elbow joint (Fig. 2.25).
Accessory lateral collateral ligament. This definition has been
applied by Martin to the ulnar insertion of discrete fibers on the
tubercle of the supinator as described previously. Others have termed
this the lateral arm of the “Y” ligament.71 Proximally, the fibers
tend to blend with the inferior margin of the annular ligament
(see Fig. 2.23). We consider this a variant of the lateral ulnar collateral
ligament.
Quadrate ligament. A thin, fibrous layer covering the capsule
between the inferior margin, the annular ligament, and the ulna is
referred to as the quadrate ligament19,20,59 or the ligament of Denucé75
(Fig. 2.26). Spinner and Kaplan have demonstrated a functional role
for the structure, describing the anterior part as a stabilizer of the
proximal radial ulnar joint during full supination.75 The weaker pos-
terior attachment stabilizes the joint in full pronation.
Oblique cord. The oblique cord is a small and inconstant bundle
of fibrous tissue formed by the fascia overlying the deep head of the
supinator and extending from the lateral side of the tuberosity of
the ulna to the radius just below the radial tuberosity (see Fig. 2.26).
FIG 2.26 The quadrate ligament is a specialized thickening of the The morphologic significance is debatable,52,75 and the structure is not
inferior capsule that bridges the anterior inferior aspect of the annular considered to be of great functional consequence.9,31 At this point, we
ligament and the anterior capsule at the coronoid (arrow). The oblique continue to consider this structure as a curiosity.
cord originates from the lateral tuberosity of the ulna and attaches to Bursae. The bursae were first described in detail by Monro in
the radius distal to the tuberosity (open arrow). 1788.55 With subsequent elaboration, Lanz recognized seven bursae,
including three associated with the triceps.51 On the posterior aspect
of the elbow, the superficial olecranon bursa, which develops around
this, however, Martin had described a lateral ligament complex age 7 years,17 is situated between the olecranon process and the subcu-
mentioning fibers inserting from the tubercle of the supinator crest taneous tissue and is well known33 (Fig. 2.27). A deep subtendinous
to the humerus. This structure subsequently has been demonstrated bursa is present as the triceps inserts on the tip of the olecranon. An
to be invariably present and critically important clinically and was occasional deep subtendinous bursa has been described but may rep-
formally named the lateral ulnar collateral ligament.65 It originates resent a degenerative process. A bursa has also been described deep
from the lateral epicondyle and blends with the fibers of the annular to the anconeus muscle in approximately 12% of subjects by Henle,36
ligament, arching superficial and distal to it. The insertion is at the but we have not appreciated such a structure during more than 1000
tubercle of the crest of the supinator on the ulna. Although the origin exposures of this region. On the medial and lateral aspects of the joint,
blends with the origin of the lateral collateral ligament complex the subcutaneous medial epicondylar bursa is frequently present, and
occupying the posterior portion, the insertion is more discrete at the the lateral subcutaneous epicondylar bursa occasionally has been
tubercle (see Fig. 2.25). The function of this ligament is to provide observed. The radiohumeral bursa lies deep to the common extensor
stability to the ulnohumeral joint; in cases of posterolateral rotatory tendon, below the extensor carpi radialis brevis and superficial to the
Medial epicondylar B.
Lat. epicondylar B.
Ulnar n. B.
Subanconeus B.
Subtendinous B.
Sub ext. carpi
Intratendinous B.
radialis brevis B.
(Radiohumeral B.)
Olecranon B.
FIG 2.27 Posterior view of the elbow demonstrating the superficial and deep bursae (B.) that are present
about this joint. n, Nerve.
radiohumeral joint capsule. This entity has been implicated by several interosseous recurrent artery at the posterior aspect of the elbow.
authors16,66 in the etiology of lateral epicondylitis but is probably not The radial collateral artery penetrates the lateral intermuscular septum
a major factor. The constant bicipitoradial bursa separates the biceps and accompanies the radial nerve into the antecubital space, where it
tendon from the tuberosity of the radius (see Fig. 2.9). Less commonly anastomoses with the radial recurrent artery at the level of the lateral
appreciated is the deep cubital interosseous bursa lying between the epicondyle.
lateral aspect of the biceps tendon and the ulna, brachialis, and supina- The detailed vascular anatomy of the elbow region has been nicely
tor fascia. This bursa is said to be present in approximately 20% of described in great detail by Yamaguchi et al.88 The major branches
individuals.74 The clinical significance of the relevant bursae about the of the brachial artery are the superior and inferior ulnar collateral
elbow is detailed in Chapter 74. arteries, which originate medial and distal to the profunda brachial
artery. The superior ulnar collateral artery is given off just distal
VESSELS to the midportion of the brachium, penetrates the medial intermus-
cular septum, and accompanies the ulnar nerve to the medial epicon-
Brachial Artery and Its Branches dyle, where it terminates by anastomosing with the posterior ulnar
The cross-sectional relationship of the vessels, nerves, muscles, and recurrent artery and variably with the inferior ulnar collateral artery
bones is shown in Fig. 2.28.27 The brachial artery descends in the arm, (Fig. 2.31).
crossing in front of the intramuscular septum to lie anterior to the The inferior ulnar collateral artery arises from the medial aspect of
medial aspect of the brachialis muscle. The median nerve crosses in the brachial artery about 4 cm proximal to the medial epicondyle. It
front of and medial to the artery at this point, near the middle of the continues distally for a short course, dividing into and anastomosing
arm (Fig. 2.29). The artery continues distally at the medial margin of with branches of the anterior ulnar recurrent artery, and it supplies a
the biceps muscle and enters the antecubital space medial to the biceps portion of the pronator teres muscle.
tendon and lateral to the nerve (Fig. 2.30). At the level of the radial
head, it gives off its terminal branches, the ulnar and radial arteries, Radial Artery
which continue into the forearm. The radial artery typically originates at the level of the radial head,
The brachial artery usually is accompanied by medial and lateral emerges from the antecubital space between the brachioradialis and
brachial veins. Proximally, in addition to its numerous muscular and the pronator teres muscle, and continues down the forearm under the
cutaneous branches, the large, deep brachial artery courses posteriorly brachioradialis muscle. A more proximal origin occurs in up to 15%
and laterally to bifurcate into the medial and radial collateral arteries. of individuals.53 The radial recurrent artery originates laterally from
The medial collateral artery continues posteriorly, supplying the the radial artery just distal to its origin. It ascends laterally on the
medial head of the triceps and ultimately anastomosing with the supinator muscle to anastomose with the radial collateral artery at the
57
57
58
59 59
60
61 61
A B
Brachial a. and vv.
Biceps brachii m.
Brachialis m. Median n.
Radial n. Basilic v.
Ulnar n.
Brachioradialis m.
Medial intermuscular septum
Ext. carpi radialis longus m.
Lat. intermuscular Triceps brachii m.
septum
C (57) Humerus
Medial antebrachial cutan. n.
Pronator teres m.
Flexor carpi radialis m.
Basilic v.
Ext. carpi radialis
longus and brevis mm. Flexor digitorum superficialis m.
Ulnar collateral lig.
Dorsal antebrachial
Ulnar n.
D (59) cutan. n.
Flexor carpi ulnaris m.
Tendon of common ext. digitorum, Flexor digitorum profundus m.
carpi ulnaris, and digiti minimi mm. Anconeus m.
Pronator teres m.
Radial a. and v. Tendon of biceps brachii m.
Lat. antebrachial cutan. n. Medial antebrachial cutan. n.
Superficial radial n.
Flexor carpi radialis m.
Brachioradialis m. Palmaris longus m.
Ext. carpi radialis Common interosseous a. and median n.
longus and brevis mm.
Flexor digitorum superficialis m.
Antebrachii fascia
Ulnar n.
Radius
Flexor carpi ulnaris m.
Deep radial n.
Ulnar a. and v.
Common ext. digitorum m.
Flexor digitorum profundus m.
E (61) Ext. digiti minimi m. Ulna
Ext. carpi ulnaris m. Interosseous membrane
Supinator m. Anconeus m.
FIG 2.28 Cross-sectional relationships of the muscles (A) and the neurovascular bundles (B). (C) The region
above the elbow joint. (D) View taken across the elbow joint. (E) View just distal to the articulation. a., Artery;
cutan., cutaneous; Ext., extensor; Lat., lateral; lig., ligament; m., muscle; mm., muscles; n., nerve; v., vein;
vv., veins. (Redrawn from Eycleshymer AC, Schoemaker DM: A cross-section anatomy, New York, 1930, D.
Appleton and Co.)
Brachialis Biceps and lacertus fibrosus

Radial n. Median n.
Brachioradialis Brachial a.
Pronator teres, humeral head
Radial recurrent a.
Flexor carpi radialis and palmaris longus
Deep and superficial
branches of radial n. Pronator teres, ulnar head
Supinator Ulnar n.
Ant. and post. ulnar recurrent aa.
Extensor carpi radialis longus
Ulnar a.
Flexor digitorum sublimis Common interosseous a.
Pronator teres Posterior and anterior
interosseous aa.
Radial a. Anterior interosseous n.
Flexor carpi ulnaris
Flexor pollicis longus
Flexor digitorum profundus
Dorsal branch of ulnar n.
Ulnar a. and n.
Volar interosseous a. and n.
Pronator quadratus Median n.
Abductor pollicis longus
FIG 2.29 Anterior aspect of the elbow region demonstrating the intricate relationships among the muscles,
nerves, and vessels. a., Artery; aa., arteries; n., nerve. (Redrawn from Hollinshead WH: The back and limbs.
In Hollinshead WH, editor: Anatomy for surgeons, vol. 3. New York, 1969, Harper & Row, p 379.)
level of the lateral epicondyle, to which it provides circulation. For interosseous branches. The interosseous recurrent artery originates
better visualization, the radial recurrent artery sometimes is sacrificed from the posterior interosseous branch. This artery runs proximally
with the anterior elbow exposure. through the supinator muscle to anastomose with the vascular network
of the olecranon (see Fig. 2.31).
Ulnar Artery
The larger of the two terminal branches of the brachial artery is the
NERVES
ulnar artery. There is relatively little variation in its origin, which is
usually at the level of the radial head. The artery traverses the pronator Specific clinical and pertinent anatomic aspects of the nerves in the
teres between its two heads and continues distally and medially behind region of the elbow are discussed in subsequent chapters as appropri-
the flexor digitorum superficialis muscle. It emerges medially to con- ate. A general survey of the common anatomic patterns is given here
tinue down the medial aspect of the forearm under the cover of the (see Fig. 2.28).
flexor carpi ulnaris. Two recurrent branches originate just distal to
the origin of the ulnar artery. The anterior ulnar recurrent artery Musculocutaneous Nerve
ascends deep to the humeral head of the pronator teres and deep to The musculocutaneous nerve originates from C5–C8 nerve roots and
the medial aspect of the brachialis muscle to anastomose with the is a continuation of the lateral cord. It innervates the major elbow
descending superior and inferior ulnar collateral arteries. The poste- flexors, the biceps and brachialis, and continues through the brachial
rior ulnar recurrent artery originates with or just distal to the smaller fascia lateral to the biceps tendon, terminating as the lateral ante-
anterior ulnar recurrent artery and passes proximal and posterior brachial cutaneous nerve (Fig. 2.32). The motor branch enters the
between the superficial and deep flexors posterior to the medial epi- biceps and the brachialis approximately 15 and 20 cm below the tip of
condyle. This artery continues proximally with the ulnar nerve under the acromion, respectively.47
the flexor carpi ulnaris to anastomose with the superior ulnar collat-
eral artery. Additional extensive communication with the inferior Median Nerve
ulnar and middle collateral branches constitutes the rete articulare Arising from the C5–C8 and T1 nerve roots, the median nerve enters
cubiti (see Fig. 2.30). the anterior aspect of the brachium, crossing in front of the brachial
The common interosseous artery is a large vessel originating 2.5 cm artery as it passes across the intermuscular septum. It follows a straight
distal to the origin of the ulnar artery. It passes posteriorly and distally course into the medial aspect of the antecubital fossa, medial to the
between the flexor pollicis longus and the flexor digitorum profundus biceps tendon and the brachial artery. It then passes under the bicipital
just distal to the oblique cord, dividing into anterior and posterior aponeurosis. The first motor branch is provided to the pronator teres,
RC
MC
SUC
SUC
IUC
B
RR
C
IU
RR
PUR
PUR
IR
R
FIG 2.31 Illustration of the posterior collateral circulation of the
elbow. There are perforating vessels on the posterior aspect of the
lateral epicondyle, in the olecranon fossa, and on the medial aspect
of the trochlea. The tip of the olecranon is supplied by perforators
from the posterior arcade in the olecranon fossa. The superior ulnar
FIG 2.30 Illustration of the anterior extraosseous vascular anatomy collateral artery (SUC) is seen terminating in the posterior arcade.
demonstrating the medial arcade and the relationship of the radial IR, Interosseous recurrent artery; IUC, inferior ulnar collateral artery;
recurrent artery (RR) to the proximal aspect of the radius. The inferior MC, middle collateral artery; PUR, posterior ulnar recurrent artery;
ulnar collateral artery (IUC) provides perforators to the supracondylar RC, radial collateral artery; RR, radial recurrent artery. (Redrawn
region, medial aspect of the trochlea, and medial epicondyle before it from Yamaguchi K, Sweet FA, Bindra R, et al.: The extraosseous and
courses posteriorly to anastomose with the superior ulnar collateral intraosseous arterial anatomy of the adult elbow, J Bone Joint Surg
(SUC) and posterior ulnar recurrent (PUR) arteries. The radial recurrent 79A:1655, 1997.)
artery provides an osseous perforator to the radius as it travels proxi-
mally and posterior. B, Brachial artery; R, radial artery. (Redrawn from
Yamaguchi K, Sweet FA, Bindra R, et al.: The extraosseous and intraos-
seous arterial anatomy of the adult elbow, J Bone Joint Surg 79A:1654, in the humerus that bears its name. Before entering the anterior
1997.) aspect of the arm, it gives off motor branches to the medial and lateral
head of the triceps, accompanied by the deep branch of the brachial
artery. It then emerges inferiorly and laterally to penetrate the lateral
intermuscular septum. The nerve is at risk of injury from surgery or
through which it passes.2,39 It enters the forearm and continues distally fracture at this site. Two recent studies have placed the position of the
under the flexor digitorum superficialis within the fascial sheath of this radial nerve as 54% of the acromion/ulnar distance21 or 1.7% of the
muscle. transcondylar distance.87 After penetrating the lateral intermuscular
There are no branches of the median nerve in the arm (Fig. 2.33). septum in the distal third of the arm, it descends anterior to the
In the cubital fossa, a few small articular branches are given off before lateral epicondyle behind the brachioradialis. It innervates the bra-
the motor branches to the pronator teres, the flexor carpi radialis, the chioradialis with a single branch to this muscle. In the antecubital
palmaris longus, and the flexor digitorum superficialis. Because all space, the nerve divides into the superficial and deep branches. The
branches arise medially, medial retraction of the nerve during exposure superficial branch is a continuation of the radial nerve and extends
of the anterior aspect of the elbow is a safe technique. into the forearm to innervate the middorsal cutaneous aspect of the
The anterior interosseous nerve innervates the flexor pollicis longus forearm (Fig. 2.34).
and the lateral portion of the flexor digitorum profundus. It arises The motor branches of the radial nerve are given off to the triceps
from the median nerve near the inferior border of the pronator teres above the spiral groove except for the branch to the medial head of the
and travels along the anterior aspect of the interosseous membrane in triceps, which originates at the entry to the spiral groove. This branch
the company of the anterior interosseous artery. continues distally through the medial head to terminate as a muscular
branch to the anconeus. This accounts for the variability of the anco-
Radial Nerve neus when rotated or reflected from its origin.10,43,67
The radial nerve is a continuation of the posterior cord and originates In the antecubital space, the recurrent radial nerve curves around
from the C6, C7, and C8 nerve roots with variable contributions of the posterolateral aspect of the radius, passing deep to the supinator
the C5 and T1 roots. In the midportion of the arm, the nerve courses muscle, which it innervates. During its course through the supinator
laterally just distal to the deltoid insertion to occupy the spiral groove muscle, the nerve lies over a bare area, which is distal to and opposite
Musculocutaneous nerve
Coracobrachialis Median nerve
Long head of biceps
Short head of biceps

Lat. cutaneous
Pronator teres
nerve of forearm Brachialis (C6, C7) Palmaris longus
Flexor carpi radialis (C7-T1)
(C6-C8)
Flexor digitorum Communicating branch
superficialis (C6-T1) with ulnar nerve
Flexor pollicis longus
(C6-C8)
Pronator quadratus Flexor digitorum profundus
(C6-T1) (C8, T1)
Opponens pollicis
(C7, C8?, T1)
Abductor pollicis brevis
(C6, C7, C8?)
Flexor pollicis brevis
(C6-C8)
Lumbricals 1 and 2
FIG 2.32 The musculocutaneous nerve innervates the flexors of the (C7-T1)
elbow and continues distal to the joint as the lateral cutaneous nerve FIG 2.33 The median nerve innervates the flexor pronator group of
of the forearm. Lat., Lateral. (Redrawn from Langman J, Woerdeman muscles about the elbow, but there are no branches above the joint.
MW: Atlas of medical anatomy, Philadelphia, 1976, WB Saunders.) (Redrawn from Langman J, Woerdeman MW: Atlas of medical anatomy,
Philadelphia, 1976, WB Saunders.)
from the radial tuberosity.22 The nerve is believed to be at risk at this

site in cases of fracture of the proximal radius.78 It emerges from the the ulnar nerve. Furthermore, the structure flattens with elbow flexion,
muscle as the posterior interosseous nerve, and the recurrent branch thus decreasing the capacity of the cubital tunnel (Fig. 2.36).63 This
innervates the extensor digitorum minimi, the extensor carpi ulnaris, accounts for the clinical observation of ulnar nerve paresthesia with
and, occasionally, the anconeus. The posterior interosseous nerve is elbow flexion. Similarly, elbow instability can cause traction injury to
accompanied by the posterior interosseous artery and sends further the nerve.50
muscle branches distally to supply the abductor pollicis longus, the A few small capsular twigs are given to the elbow joint in this
extensor pollicis longus, the extensor pollicis brevis, and the extensor region.8 As the nerve enters the forearm between the two heads of the
indicis on the dorsum of the forearm. The nerve is subject to compres- flexor carpi ulnaris, it gives off a single nerve to the ulnar origin of the
sion as it passes through the supinator muscle14 or from synovial pronator and one to the epicondylar head of the flexor carpi ulnaris.
proliferation.25,28 Compression and entrapment problems are described Distally, the nerve sends a motor branch to the ulnar half of the flexor
in detail in Chapter 72. digitorum profundus. Two cutaneous nerves arise from the ulnar nerve
in the distal half of the forearm and innervate the skin of the wrist and
Ulnar Nerve the two ulnar digits of the hand.
The ulnar nerve is derived from the medial cord of the brachial plexus
from roots C8 and T1. In the midarm, it passes posteriorly through
MUSCLES
the medial intermuscular septum and continues distally anterior to the
septum and under the medial margin of the triceps. It is accompanied Relevant features of the origin, insertion, and function of the muscles
by the superior ulnar collateral branch of the brachial artery and the of the elbow region are covered in other chapters dealing with surgical
ulnar collateral branch of the radial artery. Although supposedly there exposure, functional examination, and biomechanics. This informa-
are no branches of this nerve in the brachium, an occasional motor tion also is discussed in various chapters when dealing with specific
branch to the triceps is encountered (Fig. 2.35). The ulnar nerve passes pathology. The following description will serve as a basic overview.
into the cubital tunnel under the medial epicondyle and rests against
the posterior portion of the medial collateral ligament, where a groove Elbow Flexors
in the ligament accommodates this structure. The roof of the cubital Biceps
tunnel has recently been defined and termed the cubital tunnel reti- The biceps covers the brachialis muscle in the distal arm and passes
naculum.63 Retinacular absence accounts for congenital subluxation of into the cubital fossa as the biceps tendon, which attaches to the
Radial nerve
Triceps (C6-C8, T1)
Post. cutaneous nerve of arm

Post. cutaneous nerve of forearm
Anconeus Brachioradialis (C5, C6)
Deep branch Extensor carpi radialis longus
of radial nerve and brevis (C6-C8)
Superficial branch of
radial nerve
Extensor pollicis longus
Extensor carpi ulnaris (C6?, C7, C8)
(C6?, C7, C8)
(C6?, C7, C8)
Extensor digitorum
(C6, C7, C8) Extensor pollicis brevis
FIG 2.34 The muscles innervated by the right radial nerve. Post., Posterior. (Redrawn from Langman J,
Woerdeman MW: Atlas of medical anatomy, Philadelphia, 1976, WB Saunders.)
posterior aspect of the radial tuberosity (Fig. 2.37). The constant The muscle is innervated by the musculocutaneous nerve. The
bicipitoradial bursa separates the tendon from the anterior aspect of lateral portion of the muscle covers the radial nerve as it spirals
the tuberosity, and the cubital bursa has been described as separating around the distal humerus. The median nerve and brachial artery are
the tendon from the ulna and the muscles covering the radius (see Fig. superficial to the brachialis and lie behind the biceps in the distal
2.9). The bicipital aponeurosis, or lacertus fibrosus, is a broad, thin humerus.
band of tissue that is a continuation of the anterior medial and distal
muscle fasciae. It runs obliquely to cover the median nerve and brachial Brachioradialis
artery and inserts into the deep fasciae of the forearm and possibly into The brachioradialis has a lengthy origin along the lateral supracondylar
the ulna as well.18 bony column that extends proximally to the level of the junction of
The biceps is a major flexor of the elbow that has a large cross- the midhumerus and distal humerus (see Fig. 2.38). The origin sepa-
sectional area but an intermediate mechanical advantage because it rates the lateral head of the triceps and the brachialis muscle. The
passes relatively close to the axis of rotation. In the pronated position, lateral border of the cubital fossa is formed by this muscle, which
the biceps is a strong supinator.6 The distal insertion may undergo crosses the elbow joint with the greatest mechanical advantage of any
spontaneous rupture,57,77 and this condition is discussed in detail later elbow flexor. It progresses distally to insert into the base of the radial
(Chapter 63). styloid (Fig. 2.39). The muscle protects and is innervated by the radial
nerve (C5, C6) as it emerges from the spiral groove. Its major function
Brachialis is elbow flexion. Rarely, the muscle may be ruptured.35
This muscle has the largest cross-sectional area of any of the elbow
flexors but suffers from a poor mechanical advantage because it crosses Extensor Carpi Radialis Longus
so close to the axis of rotation. The origin consists of the entire anterior The extensor carpi radialis longus originates from the supracondylar
distal half of the humerus, and it extends medially and laterally to the bony column joint just below the origin of the brachioradialis (see Fig.
respective intermuscular septa (Fig. 2.38). The muscle crosses the 2.39). The origin of this muscle is identified as the first fleshy fibers
anterior capsule, with some fibers inserting into the capsule that are observed proximal to the common extensor tendon. As it continues
said to help retract the capsule during elbow flexion. The major attach- into the midportion of the dorsum of the forearm, it becomes largely
ment is to the coronoid process about 2 mm distal from its articular tendinous and inserts into the dorsal base of the second metacarpal.
margin. More than 95% of the cross-sectional area is muscle tissue at Innervated by the radial nerve (C6, C7), the motor branches arise just
the elbow joint,49 a relationship that may account for the high incidence distal to those of the brachioradialis muscle.
of trauma to this muscle and the development of myositis ossificans In addition to wrist extension, its orientation suggests that this
with elbow dislocation.83 muscle might function as an elbow flexor.
Ulnar nerve
Flexor digitorum
profundus (C8, T1)
Median nerve Communicating branch

(C8, T1)
Deep head of flexor Triceps m.
pollicis (C6-C8) Abductor
flexor
Adductor pollicis Digiti minimi opponens
(C7, C8, T1) (C7, C8?, T1)
Flexion
Lumbricals (C7-C8, T1)
Palmar and dorsal Ulnar n.
interossei
OI
(C7?, C8, T1) ME
FIG 2.35 Muscles innervated by the right ulnar nerve. There are no B CTR
muscular branches of this nerve above the elbow joint. (Redrawn from
FIG 2.36 With flexion the cubital tunnel flattens, compressing the
Langman J, Woerdeman MW: Atlas of medical anatomy, Philadelphia,
ulnar nerve (A and B). CTR, Cubital tunnel retinaculum; m., muscle;
1976, WB Saunders.)
ME, medial epicondyle; n., nerve; OI, olecranon. (Redrawn from
O’Driscoll SW, Horii E, Carmichael SW, Morrey BF: The cubital tunnel
and ulnar neuropathy, J Bone Joint Surg 73B:613, 1991.)
Clinically, the origin of this muscle and its relationship with that
of the extensor carpi radialis brevis have been implicated in the patho-
logic anatomy of tennis elbow by Nirschl (Chapter 59). of the extensor surface of the forearm (see Fig. 2.39). The muscle
extends and abducts the fingers. According to Wright, the muscle can
Extensor Carpi Radialis Brevis assist in elbow flexion when the forearm is pronated. This observation
The extensor carpi radialis brevis originates from the lateral superior is not, however, supported by our cross-sectional studies.1 Innervation
aspect of the lateral epicondyle (see Fig. 2.38). Its origin is the most is from the deep branch of the radial nerve, with contributions from
lateral of the extensor group and is covered by the extensor carpi the sixth through eighth cervical nerves.
radialis longus. This relationship is important as the most commonly
implicated site of lateral epicondylitis. The extensor digitorum com- Extensor Carpi Ulnaris
munis originates from the common extensor tendon and is just medial The extensor carpi ulnaris originates from two heads, one above and
or ulnar to the extensor carpi radialis brevis. At its humeral origin, the the other below the elbow joint. The humeral origin is the most
fibers of the extensor digitorum communis and brevis are grossly and medial of the common extensor group (Fig. 2.40; see also Fig. 2.38).
histologically indistinguishable from one another32 (see Fig. 2.39). The The ulnar attachment is along the aponeurosis of the anconeus and
longus and brevis share the same extensor compartment as they cross at the superior border of this muscle. It is a valuable landmark for
the wrist under the extensor retinaculum. The brevis inserts into the exposures of the lateral elbow joint. The insertion is on the dorsal
dorsal base of the third metacarpal. The function of the extensor carpi base of the fifth metacarpal after crossing the wrist in its own com-
radialis brevis is pure wrist extension, with little or no radial or ulnar partment under the extensor retinaculum. The extensor carpi ulnaris
deviation.1 The extensor carpi radialis brevis is innervated by fibers of is a wrist extensor and ulnar deviator. Fibers of the sixth through
the sixth and seventh cervical nerves. The motor branch arises from eighth cervical nerve routes innervate the muscle from branches of
the radial nerve in the region of its division into deep and superficial the deep radial nerve.
branches.
Supinator
Extensor Digitorum Communis This flat muscle is characterized by the virtual absence of tendinous
Originating from the anterior distal aspect of the lateral epicondyle, tissue and a complex origin and insertion. It originates from three sites
the extensor digitorum communis accounts for most of the contour above and below the elbow joint: (1) the lateral anterior aspect of the
Trapezius Clavicular portion

Acromion
of pectoralis major
Groove for
cephalic vein
Deltoid
Sternocostal portion
of pectoralis major
Subscapularis
Coracobrachialis
Deltoid tuberosity Serratus anterior
Teres major and
latissimus dorsi
Brachialis Short head of biceps brachii
Long head of biceps brachii
Lat. head of triceps
Lat. intermuscular
septum
Brachioradialis
Tendon of biceps brachii

Extensor carpi
radialis longus Bicipital aponeurosis
Pronator teres
FIG 2.37 Anterior aspect of the arm and elbow region demonstrating the major flexors of the joint, the
brachialis, and the biceps muscles. (Redrawn from Langman J, Woerdeman MW: Atlas of medical anatomy,
Philadelphia, 1976, WB Saunders.)
Supraspinatus lateral epicondyle; (2) the lateral collateral ligament; and (3) the proxi-
mal anterior crest of the ulna along the crista supinatoris. The form of
the muscle is approximately that of a rhomboid because it runs
Subscapularis obliquely, distally, and radially to wrap around and insert diffusely on
the proximal radius, beginning lateral and proximal to the radial
Latissimus tuberosity and continuing distal to the insertion of the pronator teres
dorsi
Pectoralis major at the junction of the proximal and middle third of the radius (see Fig.
Teres major 2.40). It is important to note that the radial nerve passes through the
supinator to gain access to the extensor surface of the forearm. This
anatomic feature is clinically significant with regard to exposure of the
Deltoid Coracobrachialis lateral aspect of the elbow joint and the proximal radius and in certain
entrapment syndromes.75
The muscle obviously supinates the forearm but is a weaker supina-
tor than the biceps.38 Unlike the biceps, however, the effectiveness of
the supinator is not altered by the position of elbow flexion. The
Brachialis innervation is derived from the muscular branch given off by the radial
Brachioradialis nerve just before and during its course through the muscle with nerve
Origins fibers derived primarily from the sixth cervical root.
Insertions
Elbow Extensors
Triceps Brachii
Extensor carpi Pronator The entire posterior musculature of the arm is composed of the
radialis longus teres triceps brachii (see Fig. 2.34). The long head has a discrete origin
from the infraglenoid tuberosity of the scapula. The lateral head
Common originates in a linear fashion from the proximal lateral intramuscular
Common extensor flexor septum on the posterior surface of the humerus. The medial head
tendon tendon
originates from the entire distal half of the posteromedial surface
FIG 2.38 Anterior humeral origin and insertion of muscles that control of the humerus bounded laterally by the radial groove and medially
flexion of the elbow joint. by the intramuscular septum. Thus, each head originates distal to the
Biceps brachii
Triceps brachii Brachialis
Olecranon Brachioradialis
Lateral epicondyle Extensor carpi radialis brevis

of humerus
Extensor digitorum
Extensor digiti minimi

Extensor carpi ulnaris Extensor pollicis brevis
Tendons of extensor carpi

Head of ulna
radialis longus and brevis
Styloid process
of radius
FIG 2.39 The musculature of the posterolateral aspect of the right forearm. (Redrawn from Langman J,
Woerdeman MW: Atlas of medical anatomy, Philadelphia, 1976, WB Saunders.)
other, with progressively larger areas of origin. The long and lateral This may have some functional relevance of stabilizing the fat pad to
heads are superficial to the deep medial head, blending in the midline help cushion the elbow as it comes into full extension.86
of the humerus to form a common muscle that then tapers into
the triceps tendon and attaches to the tip of the olecranon with Anconeus
Sharpey’s fibers.13 The tendon usually is separated from the olecranon This muscle has little tendinous tissue because it originates from a
by the subtendinous olecranon bursa. The distal 40% of the triceps rather broad site on the posterior aspect of the lateral epicondyle and
mechanism consists of a layer of fascia that blends with the triceps from the lateral triceps fascia and inserts into the lateral dorsal surface
distally. of the proximal ulna (see Fig. 2.40). It is innervated by the terminal
Innervated by the radial nerve, the long and lateral heads are branch of the nerve to the medial head of the triceps. Curiously, the
supplied by branches that arise proximal to the entrance of the radial function of this muscle has been the subject of considerable specula-
nerve into the groove. The medial head is innervated distal to the tion. Possibly the most accurate description of function is that proposed
groove with a branch that enters proximally and passes through the by Basmajian and Griffin and by DaHora, who suggest that its primary
entire medial head to terminate by innervating the anconeus, an role is that of a joint stabilizer.5,20 The muscle covers the lateral portion
anatomic feature of considerable importance when considering some of the annular ligament and the radial head. For the surgeon, the major
approaches (e.g., Kocher, Bryan-Morrey, Boyd, and Pankovitch) to the significance of this muscle is its position as a key landmark in various
joint. lateral and posterolateral exposures and is emerging for usefulness in
The function of the triceps is to extend the elbow. Lesions of the reconstruction of the lateral elbow.
nerve in the midportion of the humerus usually do not prevent triceps
function that is provided by the more proximally innervated lateral Flexor Pronator Muscle Group
and long heads. Pronator Teres
This is the most proximal muscle of the flexor pronator group. There
Subanconeus Muscle are two heads of origin: the largest arises from the anterosuperior
The attachment of some muscle fibers of the medial head of the triceps aspect of the medial epicondyle and the second from the coronoid
to the posteromedial capsule has been termed the subanconeus muscle. process of the ulna, an attachment absent in approximately 10% of
Triceps brachii
Brachioradialis
Olecranon
Lateral epicondyle
Anconeus Extensor carpi radialis longus
Supinator
Posterior border of ulna
Extensor carpi radialis brevis
Extensor carpi ulnaris

Radius
Extensor pollicis longus Abductor pollicis longus
Extensor indicis Extensor pollicis brevis
Styloid process of ulna Tendons of extensor radialis

longus and brevis
Dorsal interossei
Extensor indicis
Tendon of extensor
digitorum
FIG 2.40 The extensor aspect of the forearm demonstrating the deep muscle layer after the extensor
digitorum and extensor digiti minimi have been removed. (Redrawn from Langman J, Woerdeman MW:
Atlas of medical anatomy, Philadelphia, 1976, WB Saunders.)
individuals39 (see Fig. 2.32). The two origins of the pronator muscle ulnaris (see Fig. 2.38). It becomes tendinous in the proximal portion
provide an arch through which the median nerve passes to gain access of the forearm and inserts into and becomes continuous with the
to the forearm. This anatomic characteristic is a significant feature in palmar aponeurosis. It is absent from approximately 10% of extremi-
the etiology of median nerve entrapment syndrome and is discussed ties.70 Its major function is as a donor tendon for reconstructive
in detail in Chapter 72. The common muscle belly proceeds radially surgery, and it is innervated by a branch of the median nerve.
and distally under the brachioradialis, inserting at the junction of the
proximal and middle portions of the radius by a discrete broad tendi- Flexor Carpi Ulnaris
nous insertion into a tuberosity on the lateral aspect of the bone. The flexor carpi ulnaris is the most posterior of the common flexor
Obviously, a strong pronator of the forearm, it is also considered a tendons originating from the medial epicondyle (see Figs. 2.33 and
weak flexor of the elbow joint.1,7,81 The muscle is usually innervated by 2.38). A second and larger source of origin is from the medial border
two motor branches from the median nerve before the nerve leaves the of the coronoid and the proximal medial aspect of the ulna. The ulnar
cubital fossa. nerve enters and innervates (T7–T8 and T1) the muscle between these
two sites of origin with two or three motor branches given off just after
Flexor Carpi Radialis the nerve has entered the muscle. These are the first motor branches
The flexor carpi radialis originates just inferior to the origin of the of the ulnar nerve, and therefore they are useful in localizing the level
pronator teres and the common flexor tendon at the anteroinferior of an ulnar nerve lesion. The muscle continues distally to insert into
aspect of the medial epicondyle (see Fig. 2.38). It continues distally and the pisiform, where the tendon is easily palpable, because it serves as
radially to the wrist, where it can be easily palpated before it inserts into a wrist flexor and ulnar deviator. With an origin posterior to the axis
the base of the second and sometimes the third metacarpal. Proximally, of rotation, weak elbow extension also may be provided by the flexor
the muscle belly partially covers the pronator teres and palmaris longus carpi ulnaris.1
muscles and shares a common origin from the intermuscular septum,
which it shares with these muscles. The innervation is from one or two Flexor Digitorum Superficialis
twigs of the median nerve (C6, C7), and its chief function is as a wrist This muscle is deep to those originating from the common flexor
flexor. At the elbow no significant flexion moment is present.1,23 tendon but superficial to the flexor digitorum profundus; thus, it is
considered the intermediate muscle layer. This broad muscle has a
Palmaris Longus complex origin (Fig. 2.41).45 Medially, it arises from the medial epi-
This muscle, when present, arises from the medial epicondyle, and condyle by way of the common flexor tendon and possibly from the
from the septa it shares with the flexor carpi radialis and flexor carpi ulnar collateral ligament and the medial aspect of the coronoid.38 The
Brachial artery
Median nerve
Triceps brachii
Aponeurosis of biceps brachii

Pronator teres
(cut)
Brachioradialis Brachialis
Ulnar artery
Radial artery
Pronator teres (cut) Humeral head

Radial head flexor digitorum superficialis
Superficial branch of radial nerve
Extensor carpi radialis longus Flexor pollicis longus

Ulnar artery and nerve
Extensor pollicis brevis
Flexor digitorum profundus
Flexor carpi radialis (cut) Median nerve
Flexor retinaculum
Deep layer of flexor retinaculum
Tendon of flexor digitorum profundus
FIG 2.41 The flexor digitorum superficialis is demonstrated after the palmaris longus and flexor carpi radialis
have been removed. The pronator teres has been transected and reflected. The important relationships of
the nerves and arteries should be noted. (Redrawn from Langman J, Woerdeman MW: Atlas of medical
anatomy, Philadelphia, 1976, WB Saunders.)
lateral head is smaller and thinner and arises from the proximal two 9. Bert JM, Linscheid RL, McElfresh EC: Rotatory contracture of the
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by one into the arms of gendarmes below. The palaces along the
Riva were a broad ribbon of color with a binding of black coats and
hats. The wall of San Giorgio fronting the barracks was fringed with
the yellow legs and edged with the white fatigue caps of two
regiments. Even over the roofs and tower of the church itself specks
of sight-seers were spattered here and there, as if the joyous wind in
some mad frolic had caught them up in very glee, and as suddenly
showered them on cornice, sill, and dome.
Beyond all this, away out on the lagoon, toward the islands, the red-
sailed fishing-boats hurried in for the finish, their canvas aflame
against the deepening blue. Over all the sunlight danced and blazed
and shimmered, gilding and bronzing the roof-jewels of San Marco,
flashing from oar blade, brass, and ferro, silvering the pigeons
whirling deliriously in the intoxicating air, making glad and gay and
happy every soul who breathed the breath of this joyous Venetian
day.
None of all this was lost upon the Professor. He stood in the bow
drinking in the scene, sweeping his glass round like a weather-vane,
straining his eyes up the Giudecca to catch the first glimpse of the
coming boats, picking out faces under flaunting parasols, and waving
aloft his yellow rag when some gondola swept by flying Pietro’s
colors, or some boat-load of friends saluted in passing.
Suddenly there came down on the shifting wind, from far up the
Giudecca, a sound like the distant baying of a pack of hounds, and
as suddenly died away. Then the roar of a thousand throats, caught
up by a thousand more about us, broke on the air, as a boatman,
perched on a masthead, waved his hat.
“Here they come! Viva Pietro! Viva Pasquale!—Castellani!—Nicoletti!
—Pietro!”
The dense mass rose and fell in undulations, like a great carpet
being shaken, its colors tossing in the sunlight. Between the thicket
of ferros, away down the silver ribbon, my eye caught two little
specks of yellow capping two white figures. Behind these, almost in
line, were two similar dots of blue; farther away other dots, hardly
distinguishable, on the horizon line.
The gale became a tempest—the roar was deafening; women waved
their shawls in the air; men, swinging their hats, shouted themselves
hoarse. The yellow specks developed into handkerchiefs bound to
the heads of Pietro and his brother Marco; the blues were those of
Pasquale and his mate.
Then, as we strain our eyes, the two tails of the sea-monster twist
and clash together, closing in upon the string of rowers as they
disappear in the dip behind San Giorgio, only to reappear in full
sight, Pietro half a length ahead, straining every sinew, his superb
arms swinging like a flail, his lithe body swaying in splendid,
springing curves, the water rushing from his oar blade, his brother
bending aft in perfect rhythm.
“Pietro! Pietro!” came the cry, shrill and clear, drowning all other
sounds, and a great field of yellow burst into flower all over the
lagoon, from San Giorgio to the Garden. The people went wild. If
before there had been only a tempest, now there was a cyclone. The
waves of blue and yellow surged alternately above the heads of the
throng as Pasquale or Pietro gained or lost a foot. The Professor
grew red and pale by turns, his voice broken to a whisper with
continued cheering, the yellow rag streaming above his head, all the
blood of his ancestors blazing in his face.
The contesting boats surged closer. You could now see the rise and
fall of Pietro’s superb chest, the steel-like grip of his hands, and
could outline the curves of his thighs and back. The ends of the
yellow handkerchief, bound close about his head, were flying in the
wind. His stroke was long and sweeping, his full weight on the oar;
Pasquale’s stroke was short and quick, like the thrust of a spur.
Now they are abreast. Pietro’s eyes are blazing—Pasquale’s teeth
are set. Both crews are doing their utmost. The yells are demoniac.
Even the women are beside themselves with excitement.
Suddenly, when within five hundred yards of the goal, Pasquale
turns his head to his mate; there is an answering cry, and then, as if
some unseen power had lent its strength, Pasquale’s boat shoots
half a length ahead, slackens, falls back, gains again, now an inch,
now a foot, now clear of Pietro’s bow, and on, on, lashing the water,
surging forward, springing with every gain, cheered by a thousand
throats, past the red tower of San Giorgio, past the channel of spiles
off the Garden, past the red buoy near the great warship,—one
quick, sustained, blistering stroke,—until the judge’s flag drops from
his hand, and the great race is won.
“A true knight, a gentleman every inch of him,” called out the
Professor, forgetting that he had staked all his soldi on Pietro. “Fairly
won, Pasquale.”
In the whirl of the victory, I had forgotten Pietro, my gondolier of the
morning. The poor fellow was sitting in the bow of his boat, his head
in his hands, wiping his forehead and throat, the tears streaming
down his cheeks. His brother sat beside him. In the gladness and
disappointment of the hour, no one of the crowd around him seemed
to think of the hero of five minutes before. Not so Giorgio, who was
beside himself with grief over Pietro’s defeat, and who had not taken
his eyes from his face. In an instant more he sprang forward, calling
out, “No! no! Brava Pietro!” Espero joining in as if with a common
impulse, and both forcing their gondolas close to Pietro’s.
A moment more and Giorgio was over the rail of Pietro’s boat,
patting his back, stroking his head, comforting him as you would
think only a woman could—but then you do not know Giorgio. Pietro
lifted up his face and looked into Giorgio’s eyes with an expression
so woe-begone, and full of such intense suffering, that Giorgio
instinctively flung his arm around the great, splendid fellow’s neck.
Then came a few broken words, a tender caressing stroke of
Giorgio’s hand, a drawing of Pietro’s head down on his breast as if it
had been a girl’s, and then, still comforting him—telling him over and
over again how superbly he had rowed, how the next time he would
win, how he had made a grand second—
Giorgio bent his head—and kissed him.
When Pietro, a moment later, pulled himself together and stood erect
in his boat, with eyes still wet, the look on his face was as firm and
determined as ever.
Nobody laughed. It did not shock the crowd; nobody thought Giorgio
unmanly or foolish, or Pietro silly or effeminate. The infernal Anglo-
Saxon custom of always wearing a mask of reserve, if your heart
breaks, has never reached these people.
As for the Professor, who looked on quietly, I think—yes, I am quite
sure—that a little jewel of a tear squeezed itself up through his
punctilious, precise, ever exact and courteous body, and glistened
long enough on his eyelids to wet their lashes. Then the bright sun
and the joyous wind caught it away. Dear old relic of a by-gone time!
How gentle a heart beats under your well-brushed, threadbare coat!
SOME VENETIAN CAFFÈS
VERY one in Venice has his own particular caffè, according
to his own particular needs, sympathies, or tastes. All the
artists, architects, and musicians meet at Florian’s; all the
Venetians go to the Quadri; the Germans and late
Austrians, to the Bauer-Grünwald; the stay-over-nights, to the
Oriental on the Riva; the stevedores, to the Veneta Marina below the
Arsenal; and my dear friend Luigi and his fellow-tramps, to a little
hole in the wall on the Via Garibaldi.
A LITTLE HOLE IN THE WALL ON THE VIA GARIBALDI

These caffès are scattered everywhere, from the Public Garden to
the Mestre bridge; all kinds of caffès for all kinds of people—rich, not
so rich, poor, poorer, and the very poorest. Many of them serve only
a cup of coffee, two little flat lumps of sugar, a hard, brown roll, and a
glass of water—always a glass of water. Some add a few syrups and
cordials, with a siphon of seltzer. Others indulge in the cheaper
wines of the country, Brindisi, Chianti, and the like, and are then
known as wine-shops. Very few serve any spirits, except a spoonful
of cognac with the coffee. Water is the universal beverage, and in
summer this is cooled by ice and enriched by simple syrups of
peach, orange, and raspberry. Spirits are rarely taken and
intemperance is practically unknown. In an experience of many
years, I have not seen ten drunken men,—never one drunken
woman,—and then only in September, when the strong wine from
Brindisi is brought in bulk and sold over the boat’s rail, literally by the
bucket, to whoever will buy.
In the ristoranti—caffès, in our sense—is served an array of eatables
that would puzzle the most expert of gourmands. There will be
macaroni, of course, in all forms, and risotto in a dozen different
ways, and soups with weird, uncanny little devil-fish floating about in
them, and salads of every conceivable green thing that can be
chopped up in a bowl and drowned in olive oil; besides an
assortment of cheeses with individualities of perfume that beggar
any similar collection outside of Holland.
Some of these caffès are so much a part of Venice and Venetian life,
that you are led to believe that they were founded by the early Doges
and are coëval with the Campanile or the Library. Somebody, of
course, must know when they first began setting out tables on the
piazza in front of Florian’s, or at the Quadri opposite, or yet again at
the Caffè al Cavallo, near San Giovanni e Paulo, and at scores of
others; but I confess I do not. If you ask the head waiter, who really
ought to know (for he must have been born in one of the upper
rooms—he certainly never leaves the lower ones), he shrugs his
shoulders in a hopeless way and sheds the inquiry with a despairing
gesture, quite as if you had asked who laid out San Marco, or who
drove the piles under Saint Theodore.
There is, I am convinced, no real, permanent, steady proprietor in
any of these caffès—none that one ever sees. There must be, of
course, somebody who assumes ownership, and who for a time
really believes that he has a proprietary interest in the chairs and
tables about him. After a while, however, he gets old and dies, and is
buried over in Campo Santo, and even his name is forgotten. When
this happens, and it is eminently proper that it should, another tenant
takes possession, quite as the pigeons do of an empty carving over
the door of the king’s palace.
But the caffè keeps on: the same old marble-top tables; the same old
glass-covered pictures, with the impossible Turkish houris listening
to the improbable gentleman in baggy trousers; the same serving-
counter, with the row of cordials in glass bottles with silver stoppers.
The same waiters, too, hurry about—they live on for centuries—
wearing the same coats and neckties, and carrying the same
napkins. I myself have never seen a dead waiter, and, now I happen
to think of it, I have never heard of one.
The head waiter is, of course, supreme. He it is who adds up on his
fingers the sum of your extravagances, who takes your money and
dives down into his own pocket for the change. He and his assistants
are constantly running in and out, vanishing down subterranean
stairs, or disappearing through swinging doors, with the agility of
Harlequin; you never know where or why, until they pop out again,
whirling trays held high over their heads, or bearing in both hands
huge waiters loaded with dishes.
The habitués of these caffès are as interesting as the caffès
themselves. The Professor comes, of course; you always know
where to find him. And the youthful Contessa! She of the uncertain
age, with hair bleached to a light law-calf, and a rose-colored veil!
And here comes, too, every distinguished or notorious person of high
or low degree at the moment in Venice; you have only to take a chair
at Florian’s and be patient—they are sure to appear before the music
is over. There is the sister of the Archduke, with the straight-backed,
pipe-stem-legged officer acting as gentleman-in-waiting; and he
does wait, standing bolt upright like a sergeant on dress parade,
sometimes an hour, for her to sit down. There is the Spanish
Grandee, with a palace for the season (an upper floor with an
entrance on a side canal), whose gondoliers wear flaming scarlet,
with a crest embossed on brass dinner-plates for arm ornaments;
one of these liveried attendants always dogs the Grandee to the
caffè, so as to be ready to pull his chair out when his Excellency sits
down. Then there are the Royal Academician, in gray tweed
knickerbockers, traveling incognito with two friends; the fragments of
an American linen-duster brigade, with red guide-books and faces, in
charge of a special agent; besides scores of others of every
nationality and rank. They are all at Florian’s some time during the
day.
You will see there, too, if you are familiar with the inside workings of
a favorite caffè, an underground life of intrigue or mystery, in which
Gustavo or Florio has a hand—often upon a billet-doux concealed
within the folds of a napkin; not to mention the harmless distribution,
once in a while, of smuggled cigarettes fresh from Cairo.
Poor Gustavo! The government brought him to book not long ago.
For many years he had supplied his patrons, and with delicious
Egyptians, too! One night Gustavo disappeared, escorted by two
gendarmes from the Department of Justice. Next morning the judge
said: “Whereas, according to the accounts kept by the Department of
Customs, the duties and expenses due the king on the cigarettes
unlawfully sold by the prisoner for years past aggregate two
thousand three hundred and ten lire; and whereas, the savings of the
prisoner for ten years past, and at the moment deposited to his
individual credit in the Banco Napoli, amount to exactly two thousand
three hundred and ten lire; therefore, it is ordered, that a sight draft
for the exact amount be drawn in favor of the king.” This would
entitle Gustavo to the pure air of the piazza; otherwise?—well,
otherwise not. Within a week Gustavo was again whirling his tray—a
little grayer, perhaps, and a little wiser; certainly poorer. Thus does a
tyrannical government oppress its people!
These caffès of the piazza, with their iced carafes, white napkins,
and little silver coffee-pots, are the caffès of the rich.
The caffè of the poor is sometimes afloat. No matter how early you
are out in the morning, this floating caffè—the cook-boat—has its fire
lighted, and the savory smell of its cuisine drifts over the lagoon, long
before your gondola rounds the Dogana. When you come alongside
you find a charcoal brazier heating a pan of savory fish and a large
pot of coffee, and near by a basketful of rolls, fresh and warm, from a
still earlier baker. There are peaches, too, and a hamper of figs. The
cook-boat is tended by two men; one cooks and serves, and the
other rows, standing in the stern, looking anxiously for customers,
and calling out in stentorian tones that all the delicacies of the
season are now being fried, broiled, and toasted, and that for the
infinitesimal sum of ten soldi you can breakfast like a doge.
If you are just out of the lagoon, your blood tingling with the touch of
the sea, your face aglow with your early morning bath, answer the
cry of one of these floating kitchens, and eat a breakfast with the
rising sun lighting your forehead and the cool breath of the lagoon
across your cheek. It may be the salt air and the early plunge that
make the coffee so savory, the fish and rolls so delicious, and the
fruit so refreshing; or it may be because the fish were wriggling in the
bottom of the boat half an hour earlier, the coffee only at the first
boiling, and the fruit, bought from a passing boat, still damp with the
night’s dew!
The caffè of the poorest is wherever there is a crowd. It generally
stands on three iron legs under one of the trees down the Via
Garibaldi, or over by the landing of the Dogana, or beneath the
shade of some awning, or up a back court. The old fellow who bends
over the hot earthen dish, supported on these legs, slowly stirring a
mess of kidneys or an indescribable stew, is cook, head waiter, and
proprietor all in one. Every now and then he fishes out some delicate
tidbit—a miniature octopus, perhaps (called fulpe), a little sea-horror,
all legs and claws, which he sprawls out on a bit of brown paper and
lays on the palm of your left hand, assuming, clearly, that you have
all the knives and forks that you need, on your right.
Once in a while a good Bohemian discovers some out-of-the-way
place up a canal or through a twisted calle that delights him with its
cuisine, its cellar, or its cosiness, and forever after he preëmpts it as
his caffè. I know half a dozen such discoveries—one somewhere
near San Giorgio degli Schiavoni, where the men play bowls in a
long, narrow alley, under wide-spreading trees, cramped up between
high buildings; and another, off the Merceria, where the officers
smoke and lounge; and still another, quite my own—the Caffè
Calcina. This last is on the Rio San Vio, and looks out on the
Giudecca, just below San Rosario. You would never suspect it of
being a caffè at all, until you had dodged under the little roof of the
porch to escape the heat, and opening the side door found yourself
in a small, plainly furnished room with little marble-top tables, each
decorated with a Siamese-twin salt-cellar holding a pinch of salt and
of pepper. Even then it is a very common sort of caffè, and not at all
the place you would care to breakfast in twice; that is, not until you
had followed the demure waiter through a narrow passage and out
into a square patio splashed with yellow-green light and cooled by
overlacing vines. Then you realize that this same square patch of
ground is one of the few restful spots of the wide earth.
It is all open to the sky except for a great arbor of grape leaves
covering the whole area, beneath which, on the cool, moist ground,
stand half a dozen little tables covered with snow-white cloths. At
one side is a shelter, from behind which come certain mysterious
noises of fries and broils. All about are big, green-painted boxes of
japonicas, while at one end the oleanders thrust their top branches
through the overhanging leaves of the arbor, waving their blossoms
defiantly in the blazing sun. Beneath this grateful shelter you sit and
loaf and invite your soul, and your best friend, too, if he happens to
be that sort of a man.
After having congratulated yourself on your discovery and having
become a daily habitué of the delightful patio, you find that you have
really discovered the Grand Canal or the Rialto bridge. To your great
surprise, the Caffè Calcina has been the favorite resort of good
Bohemians for nearly a century. You learn that Turner painted his
sunset sketches from its upper windows, and that dozens of more
modern English painters have lived in the rooms above; that Whistler
and Rico and scores of others have broken bread and had
toothsome omelets under its vines; and, more precious than all, that
Ruskin and Browning have shared many a bottle of honest Chianti
with these same oleanders above their heads, and this, too, in the
years when the Sage of Brantwood was teaching the world to love
his Venice, and the great poet was singing songs that will last as
long as the language.
ON THE HOTEL STEPS
F you drink your early coffee as I do, in the garden under the
oleanders, overlooking the water-landing of the hotel, and
linger long enough over your fruit, you will conclude before
many days that a large part of the life of Venice can be
seen from the hotel steps. You may behold the great row of gondolas
at the traghetto near by, ranged side by side, awaiting their turn, and
here and there, tied to the spiles outside the line, the more fortunate
boats whose owners serve some sight-seer by the week, or some
native padrone by the month, and are thus free of the daily routine of
the traghetto, and free, too, from our old friend Joseph’s summoning
voice.
You will be delighted at the good-humor and good-fellowship which
animate this group of gondoliers; their ringing songs and hearty
laughter; their constant care of the boats, their daily sponging and
polishing; and now and then, I regret to say, your ears will be
assailed by a quarrel, so fierce, so loud, and so full of vindictive
energy, that you will start from your seat in instant expectation of the
gleam of a stiletto, until by long experience you learn how harmless
are both the bark and bite of a gondolier, and how necessary as a
safety-valve, to accused and accuser as well, is the unlimited air-
space of the Grand Canal.
You will also come into closer contact with Joseph, prince among
porters, and patron saint of this Traghetto of Santa Salute. There is
another Saint, of course, shaded by its trellised vines, framed in
tawdry gilt, protected from the weather by a wooden hood, and
lighted at night by a dim lamp hanging before it—but, for all that,
Joseph is supreme as protector, refuge, and friend.
Joseph, indeed, is more than this. He is the patron saint and father
confessor of every wayfarer, of whatever tongue. Should a copper-
colored gentleman mount the steps of the hotel landing, attired in
calico trousers, a short jacket of pea-green silk, and six yards of bath
toweling about his head, Joseph instantly addresses him in broken
Hindostanee, sending his rattan chairs and paper boxes to a room
overlooking the shady court, and placing a boy on the rug outside,
ready to spring when the copper-colored gentleman claps his hands.
Does another distinguished foreigner descend from the gondola,
attended by two valets with a block-tin trunk, half a score of hat-
boxes, bags, and bundles, four umbrellas, and a dozen sticks,
Joseph at once accosts him in most excellent English, and has
ordered a green-painted tub rolled into his room before he has had
time to reach the door of his apartment. If another equally
distinguished traveler steps on the marble slab, wearing a Bond
Street ulster, a slouch hat, and a ready-made summer suit, with
yellow shoes, and carrying an Alpine staff (so useful in Venice)
branded with illegible letters chasing each other spirally up and down
the wooden handle, Joseph takes his measure at a glance. He
knows it is his first trip “en Cook,” and that he will want the earth, and
instantly decides that so far as concerns himself he shall have it,
including a small, round, convenient little portable which he
immediately places behind the door to save the marble hearth. So
with the titled Frenchman, wife, maid, and canary bird; the haughty
Austrian, his sword in a buckskin bag; the stolid German with the
stout helpmate and one satchel, or the Spaniard with two friends and
no baggage at all.
Joseph knows them all—their conditions, wants, economics,
meannesses, escapades, and subterfuges. Does he not remember
how you haggled over the price of your room, and the row you made
when your shoes were mixed up with the old gentleman’s on the
floor above? Does he not open the door in the small hours, when
you slink in, the bell sounding like a tocsin at your touch? Is he not
rubbing his eyes and carrying the candle that lights you down to the
corridor door, the only exit from the hotel after midnight, when you
had hoped to escape by the garden, and dare not look up at the
balcony above?
Here also you will often meet the Professor. Indeed, he is
breakfasting with me in this same garden this very morning. It is the
first time I have seen him since the memorable day of the regatta,
when Pasquale won the prize and the old fellow lost his soldi.
He has laid aside his outing costume—the short jacket, beribboned
hat, and huge field-glass—and is gracing my table clothed in what he
is pleased to call his “garb of tuition,” worn to-day because of a pupil
who expects him at nine o’clock; “a horrid old German woman from
Prague,” he calls her. This garb is the same old frock-coat of many
summers, the well-ironed silk hat, and the limp glove dangling from
his hand or laid like a crumpled leaf on the cloth beside him. The
coat, held snug to the waist by a single button, always bulges out
over the chest, the two frogs serving as pockets. From these depths,
near the waist-line, the Professor now and then drags up a great silk
handkerchief, either red or black as the week’s wash may permit, for
I have never known of his owning more than two!
To-day, below the bulge of this too large handkerchief swells yet
another enlargement, to which my guest, tapping it significantly with
his finger-tips, refers in a most mysterious way as “a very great
secret,” but without unbosoming to me either its cause or its mystery.
When the cigarettes are lighted he drops his hand deep into his one-
buttoned coat, unloads the handkerchief, and takes out a little
volume bound in vellum, a book he had promised me for weeks. This
solves the mystery and effaces the bulge.
One of the delights of knowing the Professor well is to see him
handle a book that he loves. He has a peculiar way of smoothing the
sides before opening it, as one would a child’s hand, and of always
turning the leaves as though he were afraid of hurting the back,
caressing them one by one with his fingers, quite as a bird plumes its
feathers. And he is always bringing a new book to light; one of his
charming idiosyncrasies is the hunting about in odd corners for just
such odd volumes.
“Out of print now, my dear fellow. You can’t buy it for money. This is
the only copy in Venice that I could borrow for love. See the chapters
on these very fellows—these gondoliers,” pointing to the traghetto.
“Sometimes, when I hear their quarrels, I wonder if they ever
remember that their guild is as old as the days of the Doges, a fossil
survival, unique, perhaps, in the history of this or of any other
country.”
While the Professor nibbles at the crescents and sips his coffee,
pausing now and then to read me passages taken at random from
the little volume in his hands, I watch the procession of gondolas
from the traghetto, like a row of cabs taking their turn, as Joseph’s “a
una” or “due” rings out over the water. One after another they steal
noiselessly up and touch the water-steps, Joseph helping each party
into its boat: the German Baroness with the two poodles and a silk
parasol; the poor fellow from the Engadine, with the rugs and an
extra overcoat, his mother’s arm about him—not many more
sunshiny days for him; the bevy of joyous young girls in summer
dresses and sailor hats, and the two college boys in white flannels,
the chaperone in the next boat. “Ah, these sweet young Americans,
these naïve countrywomen of yours!” whispers the Professor; “how
exquisitely bold!” Last, the painter, with his trap and a big canvas,
which he lifts in as carefully as if it had a broken rib, and then turns
quickly face in; “an old dodge,” you say to yourself; “unfinished, of
course!”
Presently a tall, finely formed gondolier in dark blue, with a red sash,
whirls the ferro of his boat close to the landing-steps, and a graceful,
dignified woman, past middle life, but still showing traces of great
beauty, steps in, and sinks upon the soft cushions.
The Professor rises like a grand duke receiving a princess, brings
one arm to a salute, places the other over his heart, and makes a
bow that carries the conviction of profound respect and loyalty in its
every curve. The lady acknowledges it with a gracious bend of her
head, and a smile which shows her appreciation of its sincerity.
“An English lady of rank who spends her Octobers here,” says the
Professor, when he regains his seat. He had remained standing until
the gondola had disappeared—such old-time observances are part
of his religion.
“Did you notice her gondolier? That is Giovanni, the famous
oarsman. Let me tell you the most delicious story! Oh, the childish
simplicity of these men! You would say, would you not, that he was
about forty years of age? You saw, too, how broad and big he was?
Well, mon ami, not only is he the strongest oarsman in Venice, but
he has proved it, for he has won the annual regatta, the great one on
the Grand Canal, for five consecutive summers! This, you know,
gives him the title of ‘Emperor.’ Now, there is a most charming
Signora whom he has served for years,—she always spends her
summers here,—whom, I assure you, Giovanni idolizes, and over
whom he watches exactly as if she were both his child and his
queen. Well, one day last year,” here the Professor’s face cracked
into lines of suppressed mirth, “Giovanni asked for a day’s leave,
and went over to Mestre to bid good-by to some friends en route for
Milan. The Brindisi wine—the vina forte—oh, that devilish wine! you
know it!—had just reached Mestre. It only comes in September, and
lasts but a few weeks. Of course Giovanni must have his grand
outing, and three days later Signor Giovanni-the-Strong presented
himself again at the door of the apartment of his Signora, sober, but
limp as a rag. The Signora, grand dame as she was, refused to see
him, sending word by her maid that she would not hear a word from
him until the next day. Now, what do you think this great strong fellow
did? He went home, threw himself on the bed, turned his face to the
wall, and for half the night cried like a baby! Think of it! like a baby!
His wife could not get him to eat a mouthful.
“The next day, of course, the Signora forgave him. There was
nothing else to be done, for, as she said to me afterwards, ‘What?
Venice without Giovanni! Mon Dieu!’”
The Professor throws away the end of his last cigarette and begins
gathering up his hat and the one unmated, lonely glove. No living
soul ever yet saw him put this on. Sometimes he thrusts in his two
fingers, as if fully intending to bury his entire hand, and then you see
an expression of doubt and hesitancy cross his face, denoting a
change of mind, as he crumples it carelessly, or pushes it into his
coat-tail pocket to keep company with its fictitious mate.
At this moment Espero raises his head out of his gondola
immediately beneath us. Everything is ready, he says: the sketch
trap, extra canvas, fresh siphon of seltzer, ice, fiasco of Chianti,
Gorgonzola, all but the rolls, which he will get at the baker’s on our
way over to the Giudecca, where I am to work on the sketch begun
yesterday.
“Ah, that horrid old German woman from Prague!” sighs the
Professor. “If I could only go with you!”
OPEN-AIR MARKETS
OMETIMES, in early autumn, on the lagoon behind the
Redentore, you may overtake a curious craft, half barge,
half gondola, rowed by a stooping figure in cowl and frock.
Against the glow of the fading twilight this quaint figure, standing in
the stern of his flower-laden boat, swaying to the rhythm of his oar,
will recall so vividly the time when that other
“Dumb old servitor ... went upward with the flood,”
that you cannot help straining your eyes in a vain search for the fair
face of the lily maid of Astolat hidden among the blossoms. Upon
looking closer you discover that it is only the gardener of the convent
grounds, on his way to the market above the Rialto.
PONTE PAGLIA ... NEXT THE BRIDGE OF SIGHS

If you continue on, crossing the Giudecca, or if you happen to be
coming from Murano or the Lido, you will pass dozens of other
boats, loaded to the water’s edge with baskets upon baskets of
peaches, melons, and figs, or great heaps of green vegetables,
dashed here and there with piles of blood-red tomatoes. All these
boats are pointing their bows towards the Ponte Paglia, the bridge
on the Riva between the Doges’ Palace and the prison, the one next
the Bridge of Sighs. Here, in the afternoons preceding market days,
they unship their masts or rearrange their cargoes, taking off the top
baskets if too high to clear the arch. Ponte Paglia is the best point of
entrance from the Grand Canal, because it is the beginning of that
short cut, through a series of smaller canals, to the fruit market
above the Rialto bridge. The market opens at daybreak.
Many of these boats come from Malamocco, on the south, a small
island this side of Chioggia, and from beyond the island known as
the Madonna of the Seaweed, named after a curious figure sheltered
by a copper umbrella. Many of them come from Torcello, that most
ancient of the Venetian settlements, and from the fruit-raising country
back of it, for all Torcello is one great orchard, with every landing-
wharf piled full of its products. Here you can taste a fig so delicately
ripe that it fairly melts in your mouth, and so sensitive that it withers
and turns black almost with the handling. Here are rose-pink
peaches the size of small melons, and golden melons the size of
peaches. Here are pomegranates that burst open from very
lusciousness, and white grapes that hang in masses, and melons
and plums in heaps, and all sorts of queer little round things that you
never taste but once, and never want to taste again.
These fruit gardens and orchards in the suburbs of Venice express
the very waste and wantonness of the climate. There is no order in
setting out the fruit, no plan in growing, no system in gathering. The
trees thrive wherever they happen to have taken root—here a peach,
here a pear, there a pomegranate. The vines climb the trunks and
limbs, or swing off to tottering poles and crumbling walls. The
watermelons lie flat on their backs in the blazing sun, flaunting their
big leaves in your face, their tangled creepers in everybody’s way
and under everybody’s feet. The peaches cling in matted clusters,
and the figs and plums weigh down the drooping branches.
If you happen to have a lira about you, and own besides a bushel
basket, you can exchange the coin for that measure of peaches. Two
lire will load your gondola half full of melons; three lire will pack it
with grapes; four lire—well, you must get a larger boat.
When the boats are loaded at the orchards and poled through the
grass-lined canals, reaching the open water of the lagoon, escaping
the swarms of naked boys begging backsheesh of fruit from their
cargoes, you will notice that each craft stops at a square box,
covered by an awning and decorated with a flag, anchored out in the
channel, or moored to a cluster of spiles. This is the Dogana of the
lagoon, and every basket, crate, and box must be inspected and
counted by the official in the flat cap with the tarnished gilt band, who
commands this box of a boat, for each individual peach, plum, and
pear must help pay its share of the public debt.
This floating custom-house is one of many beads, strung at intervals
a mile apart, completely encircling Venice. It is safe to say that
nothing that crows, bleats, or clucks, nothing that feeds, clothes, or is
eaten, ever breaks through this charmed circle without leaving some
portion of its value behind. This creditor takes its pound of flesh the
moment it is due, and has never been known to wait.
Where the deep-water channels are shifting, and there is a
possibility of some more knowing and perhaps less honest market
craft slipping past in the night, a government deputy silently steals
over the shallow lagoon in a rowboat, sleeping in his blanket, his
hand on his musket, and rousing at the faintest sound of rowlock or
sail. Almost hourly one of these night-hawks overhauls other strollers
of the lagoon in the by-passages outside the city limits—some
smuggler, with cargo carefully covered, or perhaps a pair of lovers in
a gondola with too closely drawn tenda. There is no warning sound
to the unwary; only the gurgle of a slowly-moving oar, then the
muzzle of a breech-loader thrust in one’s eyes, behind which frowns
an ugly, determined face, peering from out the folds of a heavy boat-
cloak. It is the deputy’s way of asking for smuggled cigarettes, but it
is so convincing a way as to admit of no discussion. Ever afterward
the unfortunate victim, if he be of honest intent, cannot only detect a
police-boat from a fishing yawl, but remembers also to keep a light
burning in his lamp-socket forward, as evidence of his honesty.
When the cargoes of the market boats are inspected, the duties
paid, and the passage made under Ponte Paglia, or through the
many nameless canals if the approach is made from the Campo
Santo side of the city, the boats swarm up to the fruit market above
the Rialto, rounding up one after another, and discharging their
contents like trucks at a station, the men piling the baskets in great
mounds on the broad stone quay.
THE FRUIT MARKET ABOVE THE RIALTO

After the inhabitants have pounced upon these heaps and mounds
and pyramids of baskets and crates, and have carried them away,
the market is swept and scoured as clean as a china plate, not even
a peach-pit being left to tell the tale of the morning. Then this greater
market shrinks into the smaller one, the little fruit market of the
Rialto, which is never closed, day or night.
This little market, or, rather, the broad street forming its area,—broad
for this part of Venice,—is always piled high with the products of

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Morreyâ€™s The Elbow and Its

Disorders - eBook PDF

Mark E. Morrey, MD, MSc

Library of Congress Cataloging-in-Publication Data

Senior Content Strategist: Kristine Jones

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Akin Cil, MD Neal S. ElAttrache, MD Justin L. Hodgins, MD

Joyce S.B. Koh, MD Robert L. Lennon, DO Steven L. Moran, MD

Rick Papandrea, MD Felix H. “Buddy” Savoie III, MD Jarrod R. Smith, MD

Andrew R. Thoreson, MS Roger P. van Riet, MD, PhD Jacqueline S. Weisbein, DO

20 Arthroscopic Management of Elbow Plica and

PART IX Complications and Salvage PART X Nonprosthetic Alternatives and

Hominoid primate Graviportal mammal Cursorial mammal

Jurassic mammal ~155 mya

Late Triassic mammal ~215 mya

Cynodont Early Triassic ~250 mya

Pelycosaur Late Paleozoic ~300 mya

BABOON CHIMPANZEE HUMAN

Zona conoidea Lateral trochlear ridge

BABOON CHIMPANZEE HUMAN Supination Pronation

epicondyle and a less well-developed supracondylar crest than is seen

AL 288-1m KNM-ER 739 Gombore IB 7594

N. cutaneous M. pronator teres

V. mediana antibrachii V. basilica antibrachii

Lateral cutaneous Lower lateral

Radial Medial cutaneous

as the insertion site of the medial ulnar collateral ligament. The

and extension. The radiohumeral and proximal radioulnar joint allows

Guiding ridge Greater sigmoid notch

FIG 2.14 The relative percentage of hyaline cartilage distribution at the

Medial Collateral Ligament Complex

Left anterior Left posterior

FIG 2.23 Dissection demonstrating the “Y” orientation of the lateral

Radial collateral ligament. This structure originates from the

Lateral ulnar collateral ligament

FIG 2.24 Schematic representation of the radial collateral ligament

instability of the joint, it was shown to be deficient.63,64 As such, it is

Brachialis Biceps and lacertus fibrosus

Dorsal branch of ulnar n.

Coracobrachialis Median nerve

Long head of biceps

Short head of biceps

from the radial tuberosity.22 The nerve is believed to be at risk at this

Triceps (C6-C8, T1)

Post. cutaneous nerve of arm

Median nerve Communicating branch

Flexor carpi ulnaris

Trapezius Clavicular portion

Tendon of biceps brachii

Triceps brachii Brachialis

Lateral epicondyle Extensor carpi radialis brevis

Extensor digiti minimi

Extensor carpi ulnaris Extensor pollicis brevis

Tendons of extensor carpi

Flexor carpi ulnaris

Extensor pollicis longus Abductor pollicis longus

Extensor indicis Extensor pollicis brevis

Styloid process of ulna Tendons of extensor radialis

Aponeurosis of biceps brachii

Pronator teres (cut) Humeral head

Superficial branch of radial nerve

Extensor carpi radialis longus Flexor pollicis longus

Flexor carpi ulnaris

Tendon of flexor digitorum profundus