|Gray's||subject #84 321|
In primates, including humans, the elbow joint is the synovial hinge joint between the humerus in the upper arm and the radius and ulna in the forearm which allows the hand to be moved towards and away from the body. The superior radioulnar joint shares joint capsule with the elbow joint but plays no functional role at the elbow. The elbow region includes prominent landmarks such as the olecranon (the bony prominence at the very tip of the elbow), the elbow pit, and the lateral and medial epicondyles.
- 1 Structure
- 2 Clinical significance
- 3 Society and culture
- 4 In other animals
- 5 Additional images
- 6 Notes
- 7 References
- 8 See also
The elbow-joint comprises three different portions enveloped by a common joint capsule.
|Humeroulnar joint||trochlear notch of the ulna||trochlea of humerus||Is a simple hinge-joint, and allows of movements of flexion and extension only.|
|Humeroradial joint||head of the radius||capitulum of the humerus||Is a ball-and-socket joint.|
|Superior radioulnar joint||head of the radius||radial notch of the ulna||In any position of flexion or extension, the radius, carrying the hand with it, can be rotated in it. This movement includes pronation and supination.|
In humans, the main task of the elbow is to properly place the hand in space by shortening and lengthening the upper limb. While the superior radioulnar joint shares joint capsule with the elbow joint, it plays no functional role at the elbow.
With the elbow extended, the long axis of the humerus and that of the ulna coincide. At the same time, the articular surfaces on both bones are located in front of those axes and deviate from them at an angle of 45°. Additionally, the forearm muscles that originate at the elbow are grouped at the sides of the joint in order not to interfere with its movement. The wide angle of flexion at the elbow made possible by this arrangement — almost 180° — allows the bones to be brought almost in parallel to each other.
|Left elbow extended and flexed|
When the extended elbow is viewed from behind, the medial and lateral epicondyles and the olecranon — the three major landmarks of the elbow — lie on a horizontal line called the Hueter line. In the flexed elbow, on the other hand, they form an equilateral triangle, known as the Hueter triangle, when viewed from behind and lie on the arm's frontal plane when viewed from the side. The shape of this triangle is altered by dislocations and fractures so that the olecranon reaches above the Hueter line in extension and behind the frontal plane in flexion.
The trochlea of the humerus runs obliquely across the distal end of the humerus. The groove running across the trochlea is, in most people, vertical on the anterior side but spirals off on the posterior side. This results in the forearm being aligned to the upper arm during flexion, but forming an angle to the upper arm during extension — an angle known as the carrying angle. (See also Sexual dimorphism below.) Thus, the orientation of the transverse axis of the elbow joint varies during extension and flexion so that it is always perpendicular to the main axis of the forearm.
The ligaments on either side of the elbow are triangular bands which blend with the joint capsule. They are positioned so that they always lie across the transverse joint axis and are, therefore, always relatively tense and impose strict limitations on abduction, adduction, and axial rotation at the elbow.
The ulnar collateral ligament has its apex on the medial epicondyle. Its anterior band stretches from the anterior side of the medial epicondyle to the medial edge of the coronoid process, while the posterior band stretches from posterior side of the medial epicondyle to the medial side of the olecranon. These two bands are separated by a thinner intermediate part and their distal attachments are united by a transverse band below which the synovial membrane protrudes during joint movements. The anterior band is closely associated with the tendon of the superficial flexor muscles of the forearm, even being the origin of flexor digitorum superficialis. The ulnar nerve crosses the intermediate part as it enters the forearm.
The radial collateral ligament is attached to the lateral epicondyle below the common extensor tendon. Less distinct than the ulnar collateral ligament, this ligament blends with the annular ligament of the radius and its margins are attached near the radial notch of the ulna.
The elbow joint and the superior radioulnar joint are enclosed by a single fibrous capsule. The capsule is strengthened by ligaments at the sides but relatively weak in front and behind.
On the anterior side the capsule consists mainly of longitudinal fibres. However, some bundles among these fibers run obliquely, thicken and strengthen the capsule, and are referred to as the capsular ligament. Deep fibres of brachialis insert anteriorly into the capsule and act to pull it and the underlying membrane during flexion in order to prevent them from being pinched.
On the posterior side the capsule is thin and mainly composed of transverse fibres. A few of these fibres stretch across the olecranon fossa without attaching to it and form a transverse band with a free upper border. On the ulnar side, the capsule reaches down to the posterior part of the annular ligament. The posterior capsule is attached to the triceps tendon which prevents the capsule from being pinched during extension.
The synovial membrane of the elbow joint is very extensive. On the humerus, it extends up from the articular margins and covers the coronoid and radial fossae anteriorly and the olecranon fossa posteriorly. Distally, it is prolonged down to the neck of the radius and the superior radioulnar joint. It is supported by the quadrate ligament below the annular ligament where it also forms a fold which gives the head of the radius freedom of movement.
Several synovial folds project into the recesses of the joint. These folds or plicae are remnants of normal embryonic development and can be categorized as either anterior (anterior humeral recess) or posterior (olecranon recess). A crescent-shaped fold is commonly present between the head of the radius and the capitulum of the humerus. 
On the humerus there are extrasynovial fat pads adjacent to the three articular fossae. These pads fill the radial and coronoid fossa anteriorly during extension, and the olecranon fossa posteriorly during flexion. They are displaced when the fossae are occupied by the bony projections of the ulna and radius.
There are three main flexor muscles at the elbow:
- Brachialis acts exclusively as an elbow flexor and is one of the few muscles in the human body with a single function. It originates low on the anterior side of the humerus and is inserted into the tuberosity of the ulna.
- Brachioradialis acts essentially as an elbow flexor but also supinates during extreme pronation and pronates during extreme supination. It originates at the lateral supracondylar ridge distally on the humerus and is inserted distally on the radius at the styloid process.
- Biceps brachii is the main elbow flexor but, as a biarticular muscle, also plays important secondary roles as a stabiliser at the shoulder and as a supinator. It originates on the scapula with two tendons: That of the long head on the supraglenoid tubercle just above the shoulder joint and that of the short head on the coracoid process at the top of the scapula. Its main insertion is at the radial tuberosity on the radius.
Brachialis is the main muscle used when the elbow is flexed slowly. During rapid and forceful flexion all three muscles are brought into action assisted by the superficial forearm flexors originating at the medial side of the elbow. The efficiency of the flexor muscles increases dramatically as the elbow is brought into midflexion (flexed 90°) — biceps reaches its angle of maximum efficiency at 80–90° and brachialis at 100–110°.
Active flexion is limited to 145° by the contact between the anterior muscles of the upper arm and forearm, more so because they are hardened by contraction during flexion. Passive flexion (forearm is pushed against the upper arm with flexors relaxed) is limited to 160° by the bony projections on the radius and ulna as they reach to shallow depressions on the humerus; i.e. the head of radius being pressed against the radial fossa and the coronoid process being pressed against the coronoid fossa. Passive flexion is further limited by tension in the posterior capsular ligament and in triceps brachii. 
Elbow extension is simply bringing the forearm back to anatomical position. This action is performed by triceps brachii with a negligible assistance from anconeus. Triceps originates with two heads posteriorly on the humerus and with its long head on the scapula just below the shoulder joint. It is inserted posteriorly on the olecranon.
Triceps is maximally efficient with the elbow flexed 20–30°. As the angle of flexion increases, the position of the olecranon approaches the main axis of the humerus which decreases muscle efficiency. In full flexion, however, the triceps tendon is "rolled up" on the olecranon as on a pulley which compensates for the loss of efficiency. Because triceps' long head is biarticular (acts on two joints), its efficiency is also dependent on the position of the shoulder. 
Extension is limited by the olecranon reaching the olecranon fossa, tension in the anterior ligament, and resistance in flexor muscles. Forced extension results in a rupture in one of the limiting structures: olecranon fracture, torn capsule and ligaments, and, though the muscles are normally left unaffected, a bruised brachial artery. 
The arteries supplying the joint are derived from an extensive circulatory anastomosis between the brachial artery and its terminal branches. The superior and inferior ulnar collateral branches of the brachial artery and the radial and middle collateral branches of the profunda brachii artery descend from above to reconnect on the joint capsule, where they also connect with the anterior and posterior ulnar recurrent branches of the ulnar artery; the radial recurrent branch of the radial artery; and the interosseous recurrent branch of the common interosseous artery.
The blood is brought back by vessels from the radial, ulnar, and brachial veins. There are two sets of lymphatic nodes at the elbow, normally located above the medial epicondyle — the deep and superficial cubital nodes (also called epitrochlear nodes). The lymphatic drainage at the elbow is through the deep nodes at the bifurcation of the brachial artery, the superficial nodes drain the forearm and the ulnar side of the hand. The efferent lymph vessels from the elbow proceed to the lateral group of axillary lymph nodes.  
When the arm is extended, with the palm facing forward or up, the bones of the humerus and forearm are not perfectly aligned. The deviation from a straight line occurs in the direction of the thumb, and is referred to as the "carrying angle" (visible in the right half of the picture, right).
The carrying angle permits the arm to be swung without contacting the hips. Women on average have smaller shoulders and wider hips than men, which may necessitate a more acute carrying angle (i.e., less angle than that in male when measured from outside). There is, however, extensive overlap in the carrying angle between individual men and women, and a sex-bias has not been consistently observed in scientific studies. This could however be attributed to the very small sample sizes in those cited earlier studies. A more recent study based on a sample size of 333 individuals from both sexes concluded that carrying angle is a suitable secondary sexual characteristic.
The angle is greater in the dominant limb than the non-dominant limb of both sexes, suggesting that natural forces acting on the elbow modify the carrying angle. Developmental, aging and possibly racial influences add further to the variability of this parameter.
The types of disease most commonly seen at the elbow are due to injury.
Two of the most common injuries at the elbow are overuse injuries: tennis elbow and golfer's elbow. Golfer's elbow involves the tendon of the common flexor origin which originates at the medial epicondyle of the humerus (the "inside" of the elbow). Tennis elbow is the equivalent injury, but at the common extensor origin (the lateral epicondyle of the humerus).
There are three bones at the elbow joint, and any combination of these bones may be involved in a fracture of the elbow. Patients who are able to fully extend their arm at the elbow are unlikely to have a fracture (98% certainty) and an X-ray is not required as long as an olecranon fracture is ruled out. Acute fractures may not be easily visible on X-ray.
Elbow dislocations constitute 10% to 25% of all injuries to the elbow. The elbow is one of the most commonly dislocated joints in the body, with an average annual incidence of acute dislocation of 6 per 100,000 persons. Among injuries to the upper extremity, dislocation of the elbow is second only to a dislocated shoulder. A full dislocation of the elbow will require expert medical attention to re-align, and recovery can take approximately 8–14 weeks. A small amount of people (10% or less) report near full recovery and minimal permanent restriction, but a permanent restriction of 5–15% movement is common.
Infection of the elbow joint (septic arthritis) is uncommon. It may occur spontaneously, but may also occur in relation to surgery or infection elsewhere in the body (for example, endocarditis).
Elbow arthritis is usually seen in individuals with rheumatoid arthritis or after fractures that involve the joint itself. When the damage to the joint is severe, fascial arthroplasty or elbow joint replacement may be considered.
Society and culture
The now obsolete length unit ell relates closely to the elbow. This becomes especially visible when considering the Germanic origins of both words, Elle (ell, defined as the length of a male forearm from elbow to fingertips) and Ellbogen (elbow). It is unknown when or why the second "l" was dropped from English usage of the word.
In other animals
Though the elbow is similarly adapted for stability through a wide range of pronation-supination and flexion-extension in all extant hominoids, there are some minor differences. In arboreal hominoids such as orangutans, the large forearm muscles originating on the epicondyles of the humerus generate significant transverse forces on the elbow joint. The structure to resist these forces is a pronounced keel on the trochlear notch on the ulna, which is more flattened in, for example, humans and gorillas. In extant knuckle-walkers, on the other hand, the elbow has to deal with large vertical loads passing through extended forearms and the joint is therefore more expanded to provide larger articular surfaces perpendicular to those forces.
Derived traits in catarrhini (apes and Old World monkeys) elbows include the loss of the entepicondylar foramen (a hole in the distal humerus), a non-translatory (rotation-only) humeroulnar joint, and a more robust ulna with a shortened trochlear notch.
The proximal radioulnar joint is similarly derived in higher primates in the location and shape of the radial notch on the ulna; the primitive form being represented by New World monkeys, such as the howler monkey, and by fossil catarrhines, such as Aegyptopithecus. In these taxa, the oval head of the radius lies in front of the ulnar shaft so that the former overlaps the latter by half its width. With this forearm configuration, the ulna supports the radius and maximum stability is achieved when the forearm is fully pronated. 
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This article uses anatomical terminology; for an overview, see anatomical terminology.
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