1
DEVELOPMENTAL AND GROSS
ANATOMY OF THE ELBOW
TODD GUYETTE
MARK DRAKOS
STEPHEN FEALY
JOSHUA HATCH
STEPHEN J. O’BRIEN
The elbow joint is a non–weight-bearing lever between the
shoulder and the hand. In this chapter, we focus on the
gross anatomy of the elbow joint including phylogeny and
developmental anatomy.
PHYLOGENY
Evolutionary development of the adult forelimb can be
traced from primitive fish. The fish’s paired lateral longitu-
dinal folds gave rise to the pectoral and pelvic fins, the
predecessors of the modern-day upper and lower limbs.
As fish evolved into amphibians and gradually left the
water environment, the elbow underwent several major
changes to structurally adapt to waterless gravity. The pely-
cosaurs of the late Paleozoic Era (235 to 255 million years
ago) were among the first identifiable reptilian land crea-
tures (1). To support the torso, these early quadrupeds
walked with their forelimbs. Proximal forelimbs, which cor-
respond to the present-day humerus, were held virtually
fixed in the horizontal plane. The distal forelimb, which
corresponds to the present-day ulna and radius, was flexed
at a 90-degree angle in the sagittal plane. This rendered
elbow flexion primarily for lateral movements. Forward ac-
celeration was manifested by rotation of the humerus via
its long axis and extension of the elbow joint. Although
structural stability dominated the architectural blueprint for
early reptiles, evolution gradually dispensed more mobility
and flexibility into their elbow designs.
Department of Sports Medicine and Shoulder Service, Hospital for Special
Surgery, New York, New York 10021.
T. Guyette and S. J. O’Brien: Also Division of Orthopedic Surgery, Weill
Medical College of Cornell University, New York, NY 10021.
M. Drakos: Also State University of New York at Stony Brook, Stony
Brook, NY 11794.
Early mammals developed a trochlea at the distal hu-
merus through the addition of an intercondylar ridge. De-
velopment of the capitellum provided another cartilaginous
surface for articulation, thus permitting pronation/supina-
tion of the elbow joint.
In bipedal mammals, the function of the elbow is to
work in concordance with the shoulder joint to deftly and
precisely move the hand in space. The wide range of motion
of the shoulder joint has evolved at the price of shoulder
joint stability. Thus, shoulder range of motion has allowed
the elbow to successfully adapt to become a non–weight-
bearing joint with vestigial aspects of its ancestral structural
stability without sacrificing the ability of the arm to position
the hand in space (2).
Humerus
The humerus has undergone several morphological changes
during its evolution. The head of the humerus has moved
proximally underneath the torso, as well as from the hori-
zontal plane to a more vertical resting orientation. In addi-
tion, the distal humeral shaft underwent an episode of tor-
sion relative to the proximal humerus thereby making the
humeral head internally rotated relative to the epicondyles.
The extent of this rotation resulted in a 30-degree shift of
the humeral head relative to the humeral epicondyles in the
sagittal plane.
The Radius
Evolution of the radius has centered on an increasing ability
for multiplanar motion. Most of these changes have oc-
curred proximally at the radiohumeral and radioulnar artic-
ulations where a more circular cross section and stability
provided by ligamentous attachments rather than osseous
integration has allowed for greater supination and prona-
tion.
2 The Athlete’s Elbow
The Ulna
The proximal ulna is responsible for the osseous contribu-
tion of elbow stability. The proximal ulna has a thick olecra-
non process and a trochlear notch that acts as a hinge mecha-
nism for the elbow joint. Historically, this articulation was
built for structural integrity and had a more limited range
of motion. Bending of this joint was primarily in the lateral
plane. Subsequently, the ancient trochlear groove had fewer
degrees of freedom than the modern elbow.
Flexors of the Forearm
In more primitive mammals, the biceps had a single origin
on the supraglenoid tubercle of the glenoid and assisted in
limb elevation. However, because of torsional changes, the
biceps now has two heads: one at the supraglenoid tubercle
of the glenoid fossa and the other on the coracoid process
of the scapula. This limits the biceps brachii to elevation
only when the arm is externally rotated. The modern biceps
brachii takes part in supination, which its predecessors did
not. The brachioradialis differentiated to a higher order
muscle and is called upon when strength or speed is needed.
The pronator teres muscle is responsible for pronation, a
motion that was absent in the earliest ancestors.
Extensors of the Forearm
The triceps hasn’t undergone any significant evolutionary
morphological changes, but the long head of the triceps has
been steadily decreasing in size and girth (3). The function
of the anconeus muscle has been widely debated (4–6). The
anconeus has been shown to be active during extension and
to a lesser extent pronation/supination, and its evolutionary
course is unclear.
Dermatome
Neural groove
Myotome
Sclerotome
Somite
Notochord
A B
DEVELOPMENTAL ANATOMY
Weeks 3 to 8 of human development are referred to as the
embryonic period. During this time, mitotic division, cou-
pled with differentiation, creates an embryo that takes on
a human form. By the end of the embryonic period, the
differentiation process is virtually complete. This is the time
at which the embryo is exquisitely sensitive to teratogens
that may produce limb malformations.
The fetal period begins with week 9 and continues
through to birth. Bone undergoes a dynamic remodeling
and maturing process as the limbs develop in a precise ar-
rangement around the proximal skeleton. The collagen con-
tent of bone and ligament increases, vascularization is ex-
panded, and bursae and tendons migrate to their final
destinations.
Embryonic Period
The embryo is composed of three germinal layers that are
the precursors of all adult tissues: the ectoderm, endoderm,
and mesoderm. Each layer in the trilaminar embryonic disk
differentiates and migrates to form specific tissues. With
regard to limb development, the ectoderm, which is respon-
sible for nervous tissue, and the mesoderm, which is the
precursor of muscle, bone, cartilage, and connective tissues,
are of most interest.
The neural ectoderm folds to become the neural tube,
the future site of the brain and spinal cord during the third
week of gestation (Fig. 1.1A). The neural tube also gives
rise to all the preganglionic autonomic fibers and all the
nerves that innervate striated muscle. The neural crest cells
migrate from their central position in the embryo to become
the peripheral ganglia, afferent nerve fibers, and the support
cells of the peripheral nervous system. The intraembryonic
mesoderm gives rise to the dura mater and the connective
FIGURE 1.1. Stages in the develop-
ment of the somite. A: Mesoderm
cells arrange around a small cavity
while the ectodermal cells involute
forming the neural groove. B: The
cells of the somite lose their epithelial
arrangement and migrate to three
distinct regions forming the sclero-
tome, myotome, and dermatome.
(Modified from Sadler TW, Langmans
medical embryology, 8th ed. Philadel-
phia: Lippincott, Williams & Wilkins,
Dorsal aorta 2000, Fig. 5.11, with permission.)

tissue of the peripheral nerve fibers, namely the endoneu-
rium, perineurium, and epineurium.
A thick plate of mesoderm arises laterally to the neural
tube on both sides, forming a paraxial mesoderm that be-
comes organized into segments called somitomeres. These
form a linear sequence craniocaudally. The somitomeres
further differentiate and segment into somites at about day
20, with new somites emerging at a rate of three per day
eventually. The most caudal somites gradually become reab-
sorbed yielding 35 maturing somites.
Somites further differentiate into the following three
components: (a) dermatome (dermal components), (b)
myotome (muscular components), and (c) sclerotome (car-
tilaginous and osseous components) (Fig. 1.1B). The upper
limb appears first in the embryo at the beginning of week
4. The limb is comprised of an inner layer of mesoderm
surrounded by ectoderm. The ectoderm in the limb tip is
referred to as the apical ectodermal ridge, which directs the
elongation and direction of limb growth. The mesoderm
forms hyaline cartilage that develops a primary ossification
center at the center of the bone—the diaphysis. All long
bones form via this process.
Macroscopically, outpouchings are seen at the end of
week 4 on the ventrolateral side of the cervical spine oppo-
site C-6 (Fig. 1.2A). The upper limbs maintain a growth
advantage over the lower limbs, starting and finishing their
development earlier. Pairs of somites from C3-8 and T1-2
contribute to the developing upper limb. At this point, the
embryo is approximately 5 to 6 mm long and the upper
limb bud begins to undergo neovascularization.
During week 5, the buds become rounded outpouchings
1. Developmental and Gross Anatomy 3
that curve ventromedially. In the proximal bud, spinal
nerves C4-T1 begin to permeate. Mesenchyme surrounding
the central axis of the bud condenses (Fig. 1.2C), demon-
strating the first signs of proximal bones (Fig. 1.2D). The
distal bud’s shape becomes more distinct and is now called a
hand plate. The vasculature, a continuation of the subclavian
artery, continues to bore into the bud and—now referred
to as the axis artery—concludes with a terminal plexus of
vessels.
During week 6, the embryo grows to approximately 8
to 11 mm. The condensation of mesenchymal cells about
the central axis now reveals a discernible ulna, radius, and
humerus (Fig. 1.2E). Cartilage develops in the humerus,
and muscle mass in the proximal limb can be visualized.
The hand plate shows the earliest signs of a carpus, metacar-
pus, and distal digital phalanx. The brachial plexus begins
to appear. Nerve fibers have segmented, and dorsal fibers
and ventral fibers have pierced the bud to form the embry-
onic radial nerve and the embryonic ulnar nerve, respec-
tively. At this time, they extend to the elbow joint. The
terminal vascular plexus continues to migrate into the arm.
The first tributaries are the median and posterior interos-
seous arteries at the level of the embryonic elbow, followed
by the ulnar and radial arteries arising from their respective
sides of the axis artery.
At week 7, the embryo is 11 to 17 mm long and upper
extremity joints are easily identified. Primary ossification
centers are distinguished in the humerus, ulna, and radius.
Discrete anterior and posterior muscle condensations differ-
entiate into the biceps brachii and triceps brachii, respec-
tively. Finger rays become clearly distinguishable. At this
FIGURE 1.2. Developmental sequence
of the upper extremity. A: Out-
pouchings are seen at the end of week
4 at the level of C-6. B: Clasp of the ecto-
dermal covering and apical ectodermal
ridge. C: Primordial mesenchyme occu-
pies the center of the limb bud. D: Dur-
ing week 6, proximodistally centers of
chondrification appear. E: At the end of
6 weeks, the ulna and radius are discerni-
ble. At week 7, finger rays begin to be-
come distinguishable with further chon-
drification of proximal bones.
4 The Athlete’s Elbow
point, the ulnar and radial nerves extend to the hand plate.
Different growth rates stimulate bending of the elbow and
consequently flexion of the forearm. There is an accelerated
growth pattern of the ventral elbow, forcing the dorsal side
to stretch to accommodate growth.
At the end of the embryonic period in week 8, the em-
bryo is 25 to 31 mm long. The upper limbs rotate laterally
approximately 90 degrees so that the elbow points caudally
in the sagittal plane (Fig. 1.3) (7). In this orientation, the
palms are turned downward. It is because of this rotation
that the dermatome patterns in the adult are markedly dis-
similar with those in the embryo. The fingers separate dur-
ing this stage and upper limb movement begins. The ulna
and radius continue to ossify. The head of the radius as-
sumes its characteristic concave form and the annular liga-
ment of the radius is created. The axis artery persists as the
axillary, brachial, and posterior interosseous artery.
Collateral ligaments, a joint capsule, and cavitations be-
tween all three bones allow for the formation of a single
joint cavity at the end of the embryonic period.
Fetal Period
The fetal period, characterized by rapid growth, begins with
week 9 and concludes with birth. During this period, expan-
sion of the body is accelerated relative to the head. Limbs
reach their final prenatal length by the twelfth week. Ossifi-
cation of the ulna, radius, and humerus proceeds rapidly
between the thirteenth and sixteenth weeks. The primary
ossification centers of the diaphysis as well as the secondary
epiphyseal ossification centers arise between the seventh and
twelfth weeks.
FIGURE 1.3. Rotational changes. At week 8,
the upper limbs rotate approximately 90 de-
grees so that the elbows point caudally in the
sagittal plane.
In the fourth month (weeks 13 to 16), ossification
throughout the skeleton is extensive. Coordinated limb
movements occur in the fetus but cannot be felt by the
mother. In the fifth month, these coordinated limb move-
ments can be detected and are known as quickening. In the
seventh month, limb changes are confined and size changes
occur. Within the eighth month, the skin becomes pink
and smooth. Bone marrow has become the major site of
hematopoiesis. In the infant, all bone marrow generates
blood cells, but in the adult, it becomes the function of the
proximal skeleton primarily.
Postnatal Development
The postnatal development of the upper limb is focused
on the development of secondary ossification centers (8).
Ossification of the distal humerus occurs in a predictable
manner, with boys ossifying 2 to 24 months later than girls
depending on the site (Fig. 1.4). The radial head ossification
center appears at 4 and 5 years of age and fuses to the radial
shaft at 14 to 15 years and 15 to 17 years for girls and boys,
respectively. The secondary ossification center of the radial
head appears initially elliptical, but flattens with maturity.
Occasionally, it is bipartite and mistaken for epiphyseal frac-
tures. The olecranon process ossifies through two separate
centers. At birth, the first ossification center lies midway
between the olecranon tip and coronoid process. This is
joined by a second ossification center at 8 and 10 years of
age for girls and boys, respectively. Fusion to the ulnar shaft
occurs at the same age as radial head fusion for both girls
and boys. This second ossification center has been described
to persist into adult life.


5-8 yrs
 7-9 yrs

8-11 yrs
 9-13 yrs
12-14 yrs
 13-16 yrs

1-11 m
7-11 yrs
 1-26 m  8-13 yrs

10+ yrs
 12+ yrs
A B
ADULT ANATOMY
The elbow functions as a hinge joint, or ginglymus. The
humeroulnar joint is responsible for movement in the fron-
tal plane, flexion, and extension. Supination and pronation
occurs primarily at the radioulnar joint. Elbow joint stability
is conferred by the bony congruity of the humerus, ulna,
and radius, as well as by contributions from associated liga-
ments and muscles.
Surface Anatomy
The cubital fossa is visible anteriorly on the forearm, bor-
dered by the pronator teres medially and brachioradialis
laterally (Fig. 1.5). The fossa has a roof of deep fascia be-
tween these two muscles that is reinforced by the bicipital
aponeurosis. The antecubital fossa skin crease noted anteri-
orly passes between the epicondylar axis of the distal hu-
merus and thus lies at the level of the radial head, approxi-
mately 1 cm distal to the joint line (9).
The median cubital vein is the most frequent site for
obtaining a blood sample and is easily identified in the su-
perficial fascia of the cubital fossa. It can be readily seen if
one flexes the pronated forearm against resistance. The floor
of the cubital fossa is marked by the supinator laterally and
brachialis medially. The fossa contains the biceps brachii
tendon, the brachial artery, and median nerve from lateral
to medial. The brachial artery bifurcates at the inferior angle
of the fossa into the radial and ulnar arteries.
The medial bicipital sulcus is the interval between the
biceps brachii and the triceps brachii. It is located on the
medial aspect of the arm and is particularly visible when
1. Developmental and Gross Anatomy 5

14+ yrs
 17+ yrs
FIGURE 1.4. Ossification of the distal hu-
merus. A: Age of appearance of ossification
centers. B: Fusion of ossification centers
to humeral shaft. (Modified with permis-

10+ yrs
sion from Rockwood and Green: Fractures.
 12+ yrs
CD-ROM, Philadelphia: Lippincott, 1997, Fig.
10-13.)
the forearm is flexed against resistance. The brachial artery
lies deep to the medial bicipital furrow. A brachial pulse
can be felt by compressing just above the elbow and by
applying pressure medial to the furrow. The basilic vein is
also in the medial bicipital sulcus superficially. The lateral
bicipital sulcus is the interval between the biceps brachii
and the brachialis and is an important landmark for surgical
exposures. The cephalic vein runs along the anterior edge
of the brachioradialis muscle within this sulcus.
With the elbow held in extension, the bony prominences
of the olecranon is colinear with the medial and lateral epi-
condyles of the humerus (Fig. 1.6). With elbow flexion, the
olecranon is rotated proximally forming an isosceles trian-
gle. The posterior aspect of the radiohumeral joint is palpa-
ble as a horizontal groove lateral to the olecranon when
the forearm is extended. During flexion of the elbow with
concurrent pronation and supination of the forearm, the
radial head can be palpated approximately 1 cm distal to
the lateral epicondyle. The triangle formed by the radial
head, lateral epicondyle, and olecranon is a zone free of
major transgressing nerves and vessels and is thus used for
percutaneous access to the joint. The ulnar nerve lies on
the posterior surface of the medial epicondyle above the
elbow and can be palpated through the thin subcutaneous
tissue.
Osteology
Humerus
The humerus is a long tubular bone completing the shoul-
der proximally and the elbow distally (Fig. 1.7). The ossifi-
cation is somewhat complex. There is one diaphyseal center
6 The Athlete’s Elbow

FIGURE 1.5. Anterior surface landmarks. (From Olson T: A.D.A.M. student atlas of anatomy.
Philadelphia: Lippincott, Williams & Wilkins, 1996, Fig. 6.1, with permission.)

in the center of the shaft, three individual epiphyseal centers
for the head, trochlea, and capitellum, and apophyseal cen-
ters for the epicondyles. The distal humerus consists of two
condyles, each covered with articular (hyaline) cartilage.
The condyles are the trochlea and the capitellum, which
provide the surfaces for articulation with the ulna and the
radius, respectively. Proximal to the trochlea, the medial
epicondyle provides the source of attachment for the ante-
rior condensations of muscles that make up the flexors and
pronators of the forearm. Proximal to the capitellum is the
lateral condyle, which although not as prominent as the
medial epicondyle serves as the site for forearm extensor and
supinator muscular attachment. Both condyles are flexed
anteriorly approximately 30 degrees relative to the shaft;
thus, on lateral radiographs, the epicondylar axis is in line
䉳
FIGURE 1.6. Posterior surface landmarks. (From Olson T: A.D.A.M. student atlas of anatomy.
Philadelphia: Lippincott, Williams & Wilkins, 1996, Fig. 6.2, with permission.)
1. Developmental and Gross Anatomy 7
FIGURE 1.7. Anterior osseous anatomy. (From Agur
AMR and Lee ML: Grant’s atlas of anatomy, 10th ed.
Philadelphia: Lippincott, Williams & Wilkins, 1999,
Fig. 6.1A, with permission.)
with the anterior humeral cortex. The discrepancy in size
of the medial and lateral condyles is responsible for the 6-
to 8-degree valgus tilt of the distal humerus (10). This, in
addition to the 4 degrees of valgus of the greater sigmoid
notch, creates the clinically observed carrying angle of 13
to 16 degrees in women and 11 to 14 degrees in men (11).
It is thought that women developed this larger carrying
angle to account for the genetic predisposition of wider hips
and to allow the extended arm to clear them (2).
Proximal to the capitellum, on the lateral humerus, lies
the radial fossa. This accommodates the radial head during
forearm flexion. The coronoid fossa resides medial to the
radial fossa in the middle of the distal anterior humerus,
providing an analogous function for the coronoid process
during forearm flexion. The olecranon fossa lies posteriorly
8 The Athlete’s Elbow
in the midline of the distal humerus, accommodating the
olecranon process during extension. These fossae are bor-
dered by a rigid lateral supracondylar column and a less
robust medial supracondylar column. This discrepancy be-
tween the medial and lateral columns is important during
arthroplasty of the elbow, as the medial column is frequently
fractured during broaching with the elbow trials.
An important landmark for lateral surgical exposures is
the prominent lateral supracondylar ridge that separates the
brachioradialis from the extensor carpi radialis longus
(ECRL) anteriorly and brachioradialis from the triceps
brachii posteriorly. Proximal to the medial epicondyle along
the medial bicipital sulcus, a supracondylar process is ob-
served in 1% to 3% of individuals (12). Anomalous liga-
mentous attachments to this process from the medial epi-
condyle may be observed in these individuals. This
supracondylar process may serve as an insertion of the cora-
cobrachialis muscle and as an anomalous origin of the pro-
nator teres muscle. This aberrant process has been associated
with fractures and entrapment of the median and ulnar
nerves.
Ulna
The ulna is an asymmetrical bone that is thick proximally,
tapering midshaft to form a triangular cross section, and
finally ending with a cylindrical cross section at the wrist
(Fig. 1.8). The ulna possesses one diaphyseal ossification
center in the shaft and two epiphyseal ossification centers:
one each for the distal ulnar head and the proximal portion
of the olecranon process. The greater sigmoid notch of the
proximal ulna, comprising a 190-degree arc, articulates with
the trochlea of the humerus in a pulley-like fashion. The
sigmoid notch consists of the coronoid process distally with
its articular and cortical surface where the brachialis muscle
and the oblique cord insert, and the olecranon proximally
where triceps brachii muscle inserts.
FIGURE 1.8. Posterior osseous anatomy. (From Agur AMR
and Lee ML: Grant’s atlas of anatomy, 10th ed. Philadelphia:
Lippincott, Williams & Wilkins, 1999, Fig. 6.1B, with permis-
sion.)

The medial aspect of the coronoid process acts as the
origin for the medial part of pronator teres, flexor pollicis
longus, flexor digitorum profundus, and flexor digitorum
superficialis. Additionally, the anterior portion of the medial
collateral ligament of the elbow inserts onto this region of
the coronoid process. The lateral surface of the coronoid
process consists of a radial notch oriented perpendicularly
to the longitudinal axis and serving as a site for articulation
with the radial head. The radial head is stabilized by the
annular ligament of the radius that surrounds the head and
attaches to the anterior and posterior margins of the notch.
From the inferior border of this notch extends a depression,
distally to which originates the supinator muscle. The me-
dial collateral ligament inserts onto a tuberosity on a proxi-
mal cast of this depression and serves to resist varus stresses
(13).
Radius
The radius has an elliptical cross section distally and tapers
proximally to become cylindrical. It has three ossification
centers: one each in the diaphysis of the shaft, head, and
distal styloid process. The radial head has a proximal con-
cavity for articulation with the capitellum, securely fixed by
the annular ligament. In infants and young children, the
radial head is largely cartilaginous and consequently de-
formable. A distal pull on the forearm can cause a herniation
of the premature radial head through an inferior opening
in the annular ligament; this is known as nursemaid’s elbow
(14).
The anterior face of the radial tuberosity is covered by
a radiobicipital bursa that protects the biceps tendon during
pronation. The biceps brachii tendon attaches to the rough
posteromedial surface of the radial tuberosity and thus plays
a role in both flexion and supination of the forearm. Judi-
cious reconstruction of distal biceps tendon ruptures to its
anatomic insertion has been shown in the literature to be
important in maintaining both functions of the biceps
brachii.
The interosseous membrane runs between the medial
crests of the radius and the lateral crests of the ulna. It
facilitates force transmission from the radius to the ulna for
forces that would drive the radius proximally.
Articulation
The elbow is a hinge-like joint made up of the humeroulnar
and radiohumeral joints. These joints are located in the
same synovial cavity with the proximal radioulnar joint. The
humeral trochlea acts as a pulley for the trochlear notch of
the ulna and permits flexion and extension about a trans-
verse axis. During this motion, the radial head glides along
the articular surface of the capitellum without influencing
the tract of motion. Flexion of the elbow is limited by con-
tact of the soft tissue structures of the forearm, most notably
1. Developmental and Gross Anatomy 9
the biceps brachii muscle. Extension of the forearm is lim-
ited by the olecranon process of the ulna, which contacts
the olecranon fossa of the humerus. The normal range of
motion of the elbow is 135 degrees for flexion and extension
(15). Rotation and varus/valgus forces at the elbow are lim-
ited by the elbow’s inherent bony stability, with a significant
restraint to varus/valgus loads arising from the collateral
ligaments.
The radioulnar joint participates in supination and pro-
nation. The axis of rotation is an imaginary line that runs
from the center of the radial head through the styloid pro-
cess of the ulna. During this motion, the ulna remains fixed
with the radius rotating internally during pronation and
externally during supination. Pronation is limited by soft
tissues on the anterior surface of the radius and ulna; supina-
tion is largely limited by the ligaments between the ulna
and carpal bones. The normal range for these are 80 degrees
of supination and 80 degrees of pronation (15). These two
distinct types of motion classify the elbow as a trochogingly-
moid joint (Fig. 1.9).
Humeral Articulations
Elbow flexion is constrained by the trochlea, a hyperbolic
surface that articulates with the semilunar (trochlear) notch
of the ulna. Articular cartilage covers an arch of 300 to 330
degrees on its anterior, distal, and posterior aspects and is
responsible for absorbing compressive forces (16,17). This
allows for a tongue-and-groove, captive-type interface with
the proximal ulna. The trochlea is not a symmetrical surface
and allows for about 5 degrees of internal rotation in early
flexion and 5 degrees of external rotation in terminal flexion
(10). The medial lip is somewhat larger and protrudes more
distally than the lateral lip. The two lips are partitioned
by a helical groove that traverses in an anterolateral to a
posteromedial manner.
The capitellum of the distal humerus is spherical and is
covered with a thick articular cartilage of about 2 mm in
depth. The posterior medial capitellum is marked by a
prominent tubercle separating the capitellum from the lat-
eral lip of the trochlea, with which the radial head articulates
throughout the entire range of flexion. The orientation of
the articular surface of the distal humerus is rotated anteri-
orly approximately 30 degrees with respect to the longitudi-
nal axis of the humerus. The center of the arc formed by
the trochlea and capitellum is on a line coplanar to the
anterior distal cortex of the humerus. Thus, a 5- to 7-degree
internal rotation is observed of the distal humeral articular
surface with respect to the midline of the humeral epicon-
dyles. In the frontal plane, there is approximately a 6-degree
valgus tilt of the condyles with respect to the longitudinal
axis of the humerus. This articular surface accounts for more
than 50% of elbow stability in extension and more than
70% of elbow stability when the elbow is flexed 90 degrees
(18).
10 The Athlete’s Elbow
FIGURE 1.9. Elbow osseous articulating anatomy. (From Agur AMR and Lee ML: Grant’s atlas
of anatomy, 10th ed. Philadelphia: Lippincott, Williams & Wilkins, 1999, Fig. 6.18A and B, with
permission.)
Proximal Radius Articulations
Articular cartilage covers the radial depression anteriorly
within the radial head. This concavity has an arc of about
40 degrees (17). In addition, 240 degrees of the outside
circumference of the radial head articulates with the ulna.
The lesser trochlear notch forms an arc of about 60 to 80
degrees, delegating the remaining 160 to 180 degrees to
pronation and supination (19). The radial head is largely
covered with articular cartilage except for the anterolateral
one third of the circumference of the head. This part of the
radial head also lacks subchondral bone and does not have
the same structural integrity as the covered areas. It is the
most often fractured area of the radial head. The head and
neck of the radius form a 15-degree varus angle with the
distal portion of the radius relative to the distal midline
(20).
Proximal Ulna Articulations
Like the other surfaces in the elbow joint, the trochlear
notch does not have a uniform supply of articular cartilage
covering the bone. Fatty tissue divides the anterior coronoid
articular cartilage from the posterior olecranon articular car-
tilage. The trochlear notch is divided medially and laterally
by a ridge that produces four quadrants of proximal ulnar
articular cartilage.
The sigmoid notch opening is situated approximately
30 degrees posteriorly to the longitudinal axis of the ulna
corresponding to the 30-degree inferior rotation of the distal
humerus and allowing for stability (11). Anteriorly, there
is a 1- to 6-degree rotation of the shaft lateral to the articulat-
ing surface contributing to the carrying angle (16). Laterally,
the notch forms a 190-degree arc that is elliptical in nature
(19). This dictates an anteroposterior articulation for flexion
and explains the lack of articular cartilage on midpoint of
the sigmoid notch as well as its relative low density of struc-
tural bone. The lesser sigmoid notch situated distally and
laterally to the coronoid process is comprised of a concavity
with an articulation arc of 70 degrees (21). It articulates
with the radial head and is virtually perpendicular to the
greater notch, allowing for head rotation at a right angle
with respect to the transverse axis of flexion and extension.
The primary plain radiographic views to capture the os-
teology of the elbow are the anteroposterior and lateral views
(Figs. 1.10 and 1.11). In the anteroposterior view, the elbow
is extended and supinated so that the joint is in the same

FIGURE 1.10. Anteroposterior plain radiograph of the elbow.
plane, perpendicular to the beam. The radial head, radial
tuberosity, medial epicondyle, lateral epicondyle, the hu-
meral condyles, and the olecranon can be readily discerned
via this view. One can assess the radiohumeral and the hu-
meroulnar articular surfaces as well as the joint spaces.
The lateral view orients the elbow so that the beam is
perpendicular to the longitudinal axis of the humerus, al-
though it does not show a true lateral view of the joint.
The coronoid process and the olecranon, which are not
easily visualized in the anteroposterior view, are more readily
distinguished on the lateral view. In addition, three views
of the radial head via pronation, supination, and the neutral
position can be obtained.
Synovial Membrane
The synovium serves to limit flexion and extension in addi-
tion to lining the joint capsule. It attaches proximally to
the coronoid and radial fossae and inserts anteriorly and
posteriorly to the proximal margin of the olecranon fossa.
It traverses the joint distally and inserts onto the annular
ligament and radial neck to form the sacciform recess. A
fatty deposit (fat pad) may be observed between the syno-
vium and capsule both anteriorly and posteriorly (Fig.
1.12).
1. Developmental and Gross Anatomy 11
FIGURE 1.11. Lateral plain radiograph of the elbow.
Bursae
Seven bursae have been described in the elbow (Fig. 1.12).
Clinically important is the superficial bursa between the
olecranon process and superficial fascia. This bursa does not
exist in newborns and appears at approximately 7 years of
age. Two more deep bursae appear on the posterior surface
of the elbow: a deep intratendinous bursa in the triceps
brachii and an occasional deep subtendinous bursa between
the triceps tendon and the olecranon. A bursa deep to the
anconeus on the ulna has been reported in about 12% of
individuals (22).
Subcutaneous bursae on the lateral epicondyle have been
described as well. A radioulnar bursa lies deep to the com-
mon extensor tendons distally on the lateral epicondyle, but
superficial to the capsule. This particular bursa has been
implicated in lateral epicondylitis. A radiobicipital bursa
separates the biceps brachii tendon from the radial tuberos-
ity and functions to permit smooth gliding of these struc-
tures during rotary movements of the forearm. There are
also bursae present in the deep cubital fossa lying between
the lateral edge of the biceps brachii tendon, the ulna, and
brachialis in 20% of individuals. Finally, a bursa between
the ulnar nerve, the medial epicondyle, and the margin of
the triceps brachii is uncommon but has also been observed.
Development of these bursae may be directly attributed
to repeated stresses about the elbow. In children younger
than 7 years, no bursae have been reported. However, begin-
ning at 10 years of age, bursae appear and grow steadily in
size and girth (23). It is thought that a correlation exists
between the age at which a child has entered school and
begins to write with his or her arms in a flexed position
and the resulting friction and stresses that induce bursae
formation in the child (23,24).
12 The Athlete’s Elbow

FIGURE 1.12. Bursae and synovium of the el-

bow. (From Agur AMR and Lee MJ: Grant’s
atlas of anatomy, 10th ed. Philadelphia: Lip-
pincott, Williams & Wilkins, 1999, Fig. 6.46,
with permission.)

Ligaments Medial Collateral Ligament Complex

The elbow joint is stable because of the congruous anatomy.
The ligaments of the elbow consist of medial and lateral
collateral ligament complexes, providing stability to the
elbow in various degrees of flexion to varus, valgus, and
rotatory forces.
The medial collateral ligament complex is composed of the
anterior oblique, the posterior oblique, and the transverse
ligaments (Fig. 1.13) (13). The medial collateral ligament
complex is the primary stabilizer of the elbow joint to valgus
stress. The anterior bundle is the most discrete component,

FIGURE 1.13. Ligaments of the medial elbow. (From Agur AMR and Lee MJ: Grant’s atlas of
anatomy, 10th ed. Philadelphia: Lippincott, Williams & Wilkins, 1999, Fig. 6.51A, with permis-
sion.)

and it is composed of anterior and posterior bands that
tighten in reciprocal fashion as the elbow is flexed and ex-
tended. The posterior bundle is a thickening of the posterior
capsule and is well defined only when the elbow is placed
in about 90 degrees of flexion. The transverse ligament ap-
pears to contribute little or nothing to elbow stability be-
cause its fibers span the medial border of the semilunar
notch from the coronoid to the olecranon.
The origin of the medial collateral ligament is from the
anteroinferior surface of the epicondyle (13,25) The ulnar
nerve lies in the posterior aspect of the medial epicondyle
and does not lie near the origin of the medial collateral
ligament. This relationship is important, as decompression
by medial epicondylectomy must not interfere with the liga-
ment origin. Excision of the medial epicondyle should be
limited to 20% of the width of the epicondyle in the coronal
plane to avoid violating the origin of the ligaments, which
could destabilize the elbow (26).
The anterior oblique ligament is the primary stabilizer
of the elbow, resisting valgus stress between 20 and 120
degrees of elbow flexion (21,27,28). It is a strong well-
defined structure arising from the anteroinferior surface of
the medial epicondyle and inserts into the sublimus tubercle
adjacent to the joint surface. The anterior bundle inserts an
average of 18 mm posterior to the tip of the coronoid.
The anterior bundle is divided into two bands. The ante-
rior and posterior bands have distinct biomechanical roles.
The anterior band is the primary restraint to valgus stress
at 30, 60, and 90 degrees of flexion and a coprimary restraint
at 120 degrees of flexion (29). This portion of the anterior
FIGURE 1.14. Ligaments of the lateral elbow. (From Agur AMR and Lee MJ: Grant’s atlas of
anatomy, 10th ed. Philadelphia: Lippincott, Williams & Wilkins, 1999, Fig. 6.51B, with permission.)
1. Developmental and Gross Anatomy 13
oblique ligament is more prone to injury when the elbow
is in extension. The posterior band functions as a secondary
restraint to valgus stress with the elbow held at 120 degrees
of flexion (30).
The mean length of the anterior portion of the medial
collateral ligament is 27.1 4.3 mm. The mean length of
the posterior portion of the ligament is 24.2 4.3 mm.
The mean widths of the anterior and posterior portions are
4.7 1.2 mm and 5.3 1.1 mm, respectively (13).
The humeral attachment of the medial collateral liga-
ment arises from the anteroinferior surface of the medial
epicondyle. The humeral origins of both the anterior and
the posterior bundles are posterior to the axis of motion
and are more taut in flexion than in extension. The anterior
bundle increases 18% in length from full extension to 120
degrees of flexion. The posterior bundle of the medial collat-
eral ligament is even more posterior to the axis of motion
than the anterior bundle and has been shown to increase
an average of 39% within the same range of motion.
Lateral Collateral Ligament Complex
The lateral collateral ligament complex is composed of the
lateral collateral, the lateral ulnar collateral, and the annular
ligament (Fig. 1.14). The descriptions of the ligamentous
constraints on the lateral side, unlike those on the medial
side, have varied considerably in the literature (31,32).
Whereas the medial collateral ligament complex is com-
posed of discreet bands, the lateral complex consists more
of a complex of ligamentous fibers. The main function of
14 The Athlete’s Elbow
the complex is to provide external rotational and varus sta-
bility to the elbow joint as the elbow flexes. As the elbow
flexes, the effects of the lateral collateral complex gradually
increase toward 110 degrees of joint flexion. The complex
also been shown to serve as a base for radial head stability.
Incompetence of this complex has been implicated in the
development of posterolateral rotatory instability (33–35).
Posterolateral elbow joint instability results in radial head
subluxation posteriorly. The pivot shift test, by which a
forced valgus and external rotation force is applied to the
forearm, results in subluxation of the radial head and a re-
production of the patients symptoms.
The lateral collateral ligament or radial collateral liga-
ment is a poorly demarcated fan-shaped structure. The ori-
gin of the lateral collateral ligament is from the entire infe-
rior surface of the lateral epicondyle, which is near the axis
of rotation. Proximally, the fibers of the lateral collateral
ligament and the lateral ulnar collateral ligament cannot be
separated. The ligament extends into the annular ligament
in a fan-shaped expansion. The lateral collateral and annular
ligaments continue to form a broad conjoined insertion
onto the proximal aspect of the ulna. The lateral ligament
is intimately associated with the common extensor muscles
along its superficial surface and the lateral joint capsule
along the deep surface. The length of the ligament measures
approximately 20 mm with a width of approximately 8 mm.
The ligament remains taut throughout flexion and exten-
sion, which suggests that the origin of the ligament is close
to the axis of rotation (13).
The lateral ulnar collateral ligament is the posterior por-
tion of the lateral collateral ligament. The fibers proximal
to the annular ligament are inseparable from the lateral liga-
ment proximal to the annular ligament. The fibers of the
ligament pass through the intermediary stratum of the an-
nular ligament where they become discrete fibers. These
fibers then insert distally on the proximal part of the supina-
tor crest, blending with the fibers from the inferior margin
of the annular ligament. The fibers become noticeable with
varus or external rotational forces. The ligament, because
of being near the axis of rotation, remains taut throughout
the range of elbow flexion extension with little change in
the distance between the ligament origin and insertion.
The annular ligament is a strong band of tissue that at-
taches to the anterior and posterior margins of the lesser
sigmoid notch. The ligament at its anterior insertion be-
comes taut during supination, and the posterior insertion
becomes taut at the extremes of pronation. The funnel shape
of the ligament assists in stabilizing the proximal radius
throughout the range of prosupination. The radial part of
the collateral ligament blends with the annular ligament
and is an important stabilizer of the radial head. Indirectly,
through the annular ligament, this structure also stabilizes
the humeroulnar joint.
Anatomic sectioning studies have attempted to deter-
mine the function of the individual ligaments (32). Studies
have shown that the maximal elbow joint laxity in forced
varus and external rotation caused by sectioning of the lat-
eral ligaments occurs between 90 and 110 degrees of joint
flexion. However, the literature varies as to the key compo-
nent to lateral stability. The ulnar part of the lateral collat-
eral ligament has been shown in some studies to be the
essential component to lateral stability. However, other
studies have found it impossible to separate the fibers of
the two lateral ligaments proximal to the annular ligament
and have designated the lateral ligament as the primary com-
ponent to lateral stability. Problems in comparison are due
to different locations used for ligament transections. How-
ever, it has been the teaching that the lateral ulnar collateral
ligament is the primary lateral stabilizer of the elbow.
The accessory lateral collateral ligament, the quadrate
ligament, and the oblique cord are other structures that
occasionally are discussed as being part of the lateral collat-
eral ligament complex. The accessory collateral ligament has
fibers blended with the inferior margin of the annular liga-
ment and is presumed to assist in stabilizing the annular
ligament during varus stress. The quadrate ligament is a
thin fibrous tissue covering the capsule between the inferior
margin and the annular ligament and the ulna. The function
of the quadrate ligament is to assist in stabilizing the proxi-
mal radial ulnar joint in full supination and pronation (36).
The oblique cord is formed by the fascia overlying the deep
head of the supinator and extends from the lateral side of
the tuberosity of the ulna to the radius below the radial
tuberosity. The function of the oblique cord is not known
(37).
Muscles
Early in development, genetic regulation and the microenvi-
ronment direct the migration of somites into the upper limb
to differentiate into mature musculature. There exists an
anterior condensation that becomes the flexors and prona-
tors of the forearm, as well as a posterior condensation that
differentiates into the extensors and supinators of the
forearm.
Major Flexors of the Forearm
The major flexors of the forearm include the biceps brachii,
brachioradialis, brachialis, and pronator teres (Figs. 1.15
and 1.16).
Biceps Brachii
The biceps brachii has two muscle bellies, covers the brachi-
alis muscle in the distal arm, and is visible on the anterior
arm. The long head arises from the supraglenoid tubercle
via the shoulder capsule and the bicipital sulcus of the hu-
meral head. The short head originates on the coracoid pro-
cess of the scapula. Both heads join to give rise to a tendon
that inserts onto the posterior and medial surface of the

radial tuberosity. This tendon also sends an expansion, the
bicipital aponeurosis, medially into the deep fascia on the
proximal forearm. It is the major flexor of the forearm but
also supinates the forearm due to its medial insertion on
the radial tuberosity. The muscle’s function as a flexor is
maximized during supination due to the tract of the long
head in the bicipital groove. The biceps brachii is innervated
by the musculocutaneous nerve.
Brachialis
The brachialis lies deep to the biceps brachii in the distal
arm. It has the largest cross section of any of the flexors,
1. Developmental and Gross Anatomy 15
FIGURE 1.15. Anterior elbow superficial anat-
omy. (From Olson T: A.D.A.M. student atlas of anatomy.
Philadelphia: Lippincott, Williams & Wilkins, 1996,
Fig. 6.41, with permission.)
although it maintains a significant mechanical disadvantage
because it crosses the elbow joint close to the axis of rotation.
The brachialis arises from the lateral surface of the humeral
shaft below the deltoid tuberosity and inserts onto the coro-
noid process of the ulna and adjacent ulnar shaft. The bra-
chialis is innervated by the musculocutaneous nerve.
Brachioradialis
The brachioradialis is located on the lateral aspect of the
arm and forearm. It has the greatest mechanical advantage
of any of the forearm flexors. The origin of the brachioradi-
alis is on the upper two thirds of the humeral lateral supra-
16 The Athlete’s Elbow
condylar ridge with its insertion on the proximal margin of
the radial styloid process. The brachioradialis functions as
a forearm flexor when strength is needed and a supinator
with the arm pronated. Innervation of the brachioradialis
is from the radial nerve.
Pronator Teres
The pronator teres has two muscle bellies and is the major
pronator of the forearm. The superficial head arises from
the medial supracondylar ridge of the humerus just above
the medial epicondyle while the deep head originates on
FIGURE 1.16. Anterior elbow deep anat-
omy. (From Olson T: A.D.A.M. student atlas
of anatomy. Philadelphia: Lippincott, Wil-
liams & Wilkins, 1996, Fig. 6.43, with per-
mission.)
the ulna just medial to the insertion of the brachialis and
onto the lateral surface of the radius at approximately mid-
shaft. In addition to pronation, the pronator teres aids the
brachialis in forearm flexion, particularly when the forearm
must be kept pronated. The median nerve is responsible for
innervation.
Major Extensors of the Forearm
The major extensors of the forearm are triceps brachii and
anconeus (Figs. 1.17 and 1.18).

FIGURE 1.17. Posterior elbow superficial anatomy. (From Olson
T: A.D.A.M. student atlas of anatomy. Philadelphia: Lippincott,
Williams & Wilkins, 1996, Fig. 6.49, with permission.)
Triceps Brachii
Triceps Brachii, the major extensor of the forearm, com-
poses the entire posterior musculature of the arm and con-
sists of three heads. The long head arises from the infragle-
noid tubercle. The lateral head arises from a narrow linear
region lateral to the radial groove of the humerus while the
medial head arises from the entire posterior surface of the
humeral shaft medial to and inferior to the radial groove.
The three heads join and insert onto a common tendinous
insertion on the olecranon process of the ulna. The lateral
and medial heads are used predominantly whenever active
extension of the forearm is needed. The long head is used
particularly when strength or speed is needed and acts to
extend the arm at the glenohumeral joint. The triceps
brachii is innervated by the radial nerve.
Anconeus
This diminutive muscle originates from the posterior hu-
merus just superior to the capitellum and inserts onto the
proximal half of the ulna. Electrophysiology studies have
demonstrated that the anconeus is active during elbow ex-
tension, although the mechanical contribution is small. In
1. Developmental and Gross Anatomy 17
addition, this muscle has been shown to be active during
pronation and supination of the forearm. Innervation is via
the radial nerve.
Major Pronators of the Forearm
The major pronators of the forearm consist of pronator teres
and pronator quadratus. Pronator teres has already been
discussed in the section on flexors. Functionally, the teres
is used to assist the pronator quadratus whenever strength
or speed of pronation is necessary or when the forearm flexes
and pronates simultaneously.
Pronator Quadratus
Pronator quadratus is a pure pronator of the forearm and
is stimulated whenever active pronation occurs. It arises
from the anterior surface of the distal radius and inserts
onto the anteromedial surface of the ulna. It is innervated
by the anterior interosseous nerve, which is a branch of the
median nerve.
Major Supinators of the Forearm
Biceps brachii and the supinator muscle make up the major
supinators of the forearm. Biceps brachii has already been
discussed in the section on flexors and remains the major
contributor of supination strength and speed. Because of
the roughly equal antagonist strengths of pronator quadra-
tus and supinator, with the additional strength of biceps
brachii, one can supinate with a much greater force than
one can pronate. The combination of this with the vast
majority of individuals being right handed has led to the
modern engineering of screws that can be tightened by supi-
nation of the right forearm.
Supinator
The supinator is a pure supinator of the forearm. It is a
relatively flat muscle characterized by sparse tendinous tis-
sue. It arises form the lateral epicondyle of the humerus,
the lateral collateral ligament, and the supinator crest of the
ulna with its insertion onto the upper one third of the radial
shaft. The supinator is used during active supination, al-
though it is much weaker than biceps brachii. Innervation
is derived from the deep radial nerve.
Other Muscles That Cross the Elbow
Muscles that cross the elbow but not already discussed in
the mechanical categories include the flexor carpi radialis
(FCR), flexor carpi ulnaris (FCU), palmaris longus, ECRL,
extensor carpi radialis brevis (ECRB), and extensor carpi
ulnaris (ECU) (Figs. 1.15–1.18).
The FCR, FCU, and palmaris longus all originate from
a common flexor tendon that originates on the medial epi-
condyle of the humerus, as well as insert onto various bones
and ligaments of the wrist. Due to their variations in inser-
18 The Athlete’s Elbow
tion sites, the FCU acts as a wrist adductor and flexor, the
palmaris longus functions solely as a wrist flexor, and the
FCR functions as a wrist abductor and flexor and assists in
elbow flexion (38). Additionally, with the elbow in flexion,
the FCR has been observed to assist in forearm pronation
and the FCU has been described as a weak extensor of the
forearm. Contracting together, the FCR and FCU act syner-
gistically to flex the wrist. Whereas the FCR and palmaris
longus are innervated by the median nerve, the FCU is
innervated by the ulnar nerve. The palmaris longus is a
frequently harvested tissue for grafts, although it is absent
in 11% to 12% of the population (39).
The ECRL arises from the lateral supracondylar ridge
of the humerus while the ECRB and ECU originate via a
common extensor tendon from the lateral epicondyle of the
humerus. All three insert onto various bones and ligaments
of the wrist. The extensor carpi radialis muscles are responsi-
ble for wrist extension and abduction while the ECU assists
in extension and wrist adduction. Thus, these muscles act
synergistically to give pure wrist extension. The ECRL, by
virtue of its orientation, may play a function in elbow flex-
ion. The ECRL is innervated by the radial nerve and the
ECRB has been described with innervation by the deep or
superficial radial nerve depending on anatomic variants.
The ECU is innervated by the deep radial nerve.
The orientation of the forearm musculature, as well as
the posterior interosseous nerve, can be estimated topically
using the methods described by Henry (Fig. 1.19) (40).
Anteriorly, the opposite hand is placed on the medial aspect
FIGURE 1.18. Posterior elbow deep anatomy. (From Olson T:
A.D.A.M. student atlas of anatomy. Philadelphia: Lippincott,
Williams & Wilkins, 1996, Fig. 6.50, with permission.)
of the forearm with the ring finger running distally just
inside the lateral border. This finger then approximates the
route of the FCU. Similarly, the middle finger approximates
palmaris longus, the index approximates FCR, and the
thumb approximates pronator teres. Posteriorly, the oppo-
site hand is placed on the lateral aspect of the forearm with
the ring finger running distally at the junction of the radial
head and neck. This finger then approximates extensor dig-
iti communis. Similarly, the middle finger approximates
extensor digiti minimi, the index finger approximates ECU,
and the thumb approximates anconeus. In addition, the
posterior interosseous nerve runs deep to the pulp of the
index finger.
Nerves
Early in embryonic development, the human upper limb
develops as a protuberance primarily innervated by the C5-
T1 spinal segments. As an extension of the ventrolateral
body wall, the upper limb is innervated solely by the ventral
rami of spinal nerves. Visceral structures such as the smooth
muscle in the blood vessels are innervated by the sympa-
thetic postganglionic axons that join with the ventral rami
and penetrate the limb from T-2 and T-3 spinal segments.
After the C5-T1 ventral rami exit the vertebral column
and give off tributaries to the neck muscles, they participate
in a complex exchange known as the brachial plexus (Fig.
1.20). Initially, the rami combine to form three trunks: the
C-5 and C-6 rami form the superior trunk, the C-7 rami
 1. Developmental and Gross Anatomy 19

Pr
on
at
or
Fle te
xo re
rc s
ar
pi
ra
Pa dia
lm lis
ari
s lon
gu
s

Fle
xor
car
pi
uln
ari
s
Palmaris longus tendon

FIGURE 1.19. Anterior surface of the right forearm and wrist showing how to locate the position
of superficial muscles. (From Moore K and Dadley AF: Clinically oriented anatomy, 4th ed. Phila-
delphia: Lippincott, Williams & Wilkins, 1999, p. 763, with permission.)

FIGURE 1.20. Brachial plexus. (From Olson T: A.D.A.M. student atlas of anatomy. Philadelphia:
Lippincott, Williams & Wilkins, 1996, with permission.)
20 The Athlete’s Elbow
forms the middle trunk, and the C-8 and T-1 rami form
the inferior trunk. In general, the higher spinal segments
innervate the proximal limb structures and the lower seg-
ments innervate the distal limb. Thus, the shoulder is pre-
dominantly innervated by C-5 and C-6, the arm by C5-7,
the forearm by C6-8, and the hand by C8-T1.
After the three trunks have formed, the superior and
middle trunk merge to create the lateral cord. The middle
trunk continues distally with tributaries from the superior
and inferior trunk to establish the posterior cord. The infe-
rior trunk persists as the medial cord. Distal to this ex-
change, the lateral cord continues as the musculocutaneous
nerve. Proximal to the origin of this nerve, the lateral cord
gives off a branch that meets with another branch from the
medial cord, giving rise to the median nerve. The medial
cord persists distal to this bifurcation to yield the ulnar
nerve. The posterior cord persists after giving off several
tributaries as the radial nerve. Developmentally, ventral
muscle is innervated by branches from the medial and lateral
cords of the brachial plexus. Many nerves of the shoulder
are given off before the formation of the four primary upper
limb nerves. In addition, two cutaneous nerves of the upper
limb also branch proximally yet provide sensory informa-
tion from the arm and forearm. However, all other sources
of nervous tissue in the upper limb arise from the musculo-
cutaneous, median, radial, and ulnar nerves.
Musculocutaneous Nerve
The musculocutaneous nerve is a terminal branch of the
lateral cord and is comprised of C5-8 nerve roots (Fig. 1.21).
It heads distally, penetrating the coracobrachialis muscle
where it remains deep. Distally, it emerges in the plane
separating the biceps brachii and the brachialis where it
follows the cephalic vein into the forearm. Here, it gives
off a lateral cutaneous nerve of the forearm that supplies
the sensory innervation for the lateral aspect of the forearm
(Figs. 1.24 and 1.25). The musculocutaneous innervates the
coracobrachialis, biceps brachii, and brachialis muscles. If
the nerve is damaged, flexion and supination of the forearm
will be particularly weak because of the absence of the pow-
erful biceps brachii. It has been shown that 62% of the
population demonstrate this branching pattern, yet com-
mon anomalies include two separate branches from the
musculocutaneous nerve that innervates the biceps (33%)
and three branches to the biceps in 5% (41).
Although it is rare that the musculocutaneous nerve is
injured alone, to test this nerve, the examiner should ask
the patient to flex the supinated forearm against resistance.
Median Nerve
The median nerve is the terminal branch of the lateral and
medial cord originating from C5-T1 nerve roots (Fig. 1.21).
The nerve immediately crosses the anterior aspect of the
brachial artery and then assumes a position adjacent to it
as it descends the arm. The nerve follows this tract into the
cubital fossa where it lies medial to both the brachial artery
and the tendon of biceps brachii. The nerve then penetrates
between the two heads of pronator teres and gives off the
anterior interosseous nerve. The median nerve continues
distally through the forearm in the plane between the flexor
digitorum superficialis muscle and the flexor digitorum pro-
fundus muscles. Just proximal to the wrist, the median nerve
is exposed between the flexor digitorum superficialis and
the FCR. The nerve is still deep and is just lateral to the
palmaris longus tendon. Here, it heads into the carpal tun-
nel toward the hand where it gives off the motor recurrent
nerve.
The median nerve supplies the pronator teres, palmaris
longus, FCR, and flexor digitorum superficialis. The ante-
rior interosseous branch of the median is responsible for
the flexor pollicis longus, the pronator quadratus, and the
lateral two digits of the flexor digitorum profundus. The
motor recurrent branch of the median is responsible for
abductor pollicis brevis, the superficial head of flexor pollicis
brevis, the opponens pollicis, and the lateral two lumbricals.
The sensory distribution of the median includes the lateral
two thirds of the hand, the first three and one half digits
ventrally, and the first three and one half tips of the digits
dorsally (Fig. 1.24). Neither the anterior interosseous nor
the motor recurrent has a cutaneous distribution.
If the median nerve becomes damaged proximal to the
elbow, weak wrist flexion with ulnar deviation is observed
due to the unopposed effects of the FCU. Additionally,
there is weak flexion of the digits and opposition and flexion
of the thumb interphalangeal joint is not possible. At rest,
the thumb assumes an adducted and laterally rotated posi-
tion.
To test the median nerve, the patient is requested to
make a circle by opposing the pads of the thumb and the
little finger. The examiner then applies a force to the proxi-
mal phalanx of the thumb to resist this motion of the
thumb. This is a test of the thenar eminence muscles, which
the median nerve supplies. The tip of the index finger is
used to test for sensory function. Usually, this area is the
least likely to exhibit nerve variations.
Ulnar Nerve
The ulnar nerve is the most medial terminating branch of
the brachial plexus derived from nerve roots C-8 and T-1
and occasionally C-7 (Fig. 1.22) (42). Initially it runs adja-
cent to the brachial artery in the bicipital sulcus of the me-
dial aspect of the arm. The nerve runs distally and a little
posteriorly to take its place on the posterior surface of the
medial epicondyle. The space posterior to the medial epi-
condyle, where the ulnar nerve runs, is referred to as the
cubital tunnel. The roof of this tunnel is called the cubital
tunnel retinaculum (43). At this location, the ulnar nerve is
1. Developmental and Gross Anatomy 21

FIGURE 1.21. Musculocutaneous and median

nerves. (From Agur AMR and Lee MJ: Grant’s
atlas of anatomy, 10th ed. Philadelphia: Lip-
pincott, Williams & Wilkins, 1999, Fig. 6.8A,
with permission.)
22 The Athlete’s Elbow

FIGURE 1.22. Ulnar nerve. (From Agur AMR

and Lee MJ: Grant’s atlas of anatomy, 10th ed.
Philadelphia: Lippincott, Williams & Wilkins,
1999, Fig. 6.8B, with permission.)

significantly exposed during flexion and accounts for the
radiating pain when one strikes his or her ‘‘funny bone.’’
Asymptomatic instability may also be present in the ulnar
nerve at this point in about 16% of individuals in whom
the nerve can dislocate over the medial epicondyle during
flexion (44). It then penetrates the forearm between the
ulnar and the humeral heads of the FCU, descending in
the forearm deep to the FCU. At the wrist, it gives off a
superficial branch and a deep branch, both of which con-
tinue into the hand.
The ulnar nerve innervates the FCU and the two medial
digitations of flexor digitorum profundus. Its tributary, the
superficial ulnar nerve, innervates palmaris brevis. Its other
branch, the deep ulnar nerve, innervates abductor digiti
minimi, flexor digiti minimi brevis, opponens digiti min-
imi, the medial two lumbricals, the palmar interossei, ad-
ductor pollicis, and the deep head of the flexor pollicis bre-
vis. The sensory distribution includes the medial half of the
dorsal hand and the medial one third of the palm. The
superficial ulnar nerve is responsible for the sensory distribu-
tion of the ventral aspect of the little finger as well as half
the ventral ring finger (Fig. 1.24). The deep ulnar nerve
has no sensory distribution.
Damage to the ulnar nerve at the wrist joint leads to a
flexion of the ring and fifth fingers known as the ‘‘ulnar
claw.’’ This is accompanied by atrophy of the hypothenar
eminence because of denervation of the hypothenar and
interossei muscles. If the injury of the ulnar nerve occurs
proximal to the elbow, the distal symptoms are similar with-
out claw deformity, as the flexor digitorum profundus is
denervated.
To test the ulnar nerve, the patient is asked to abduct
the fingers against resistance from the examiner. This tests
the abductor digiti minimi and the dorsal interossei, which
are innervated by the ulnar nerve. The sensory test consists
of a skin prick on the tip of the fifth finger.
Radial Nerve
The radial nerve is the posterior terminal branch of the
brachial plexus. It is derived from C6-8 with variable contri-
butions from C-5 and T-1 (Fig. 1.23). The nerve travels
distally to the radial groove of the humerus where it runs
adjacent to the profunda brachii artery. It then continues
distally down the lateral humerus to the plane between bra-
chialis and brachioradialis. Here, it divides into a superficial
and deep radial nerve. The superficial radial nerve traverses
the anterior aspect of the elbow and runs in the forearm
deep to the brachioradialis. The nerve becomes superficial
to the posterior aspect of the brachioradialis tendon and
extends into the wrist where it divides into dorsal digital
branches. The deep radial nerve crosses the anterior surface
of the elbow deep to brachioradialis. It curves around the
lateral radius near the neck where it penetrates the supinator
and emerges posteriorly. Here, it gives out branches to su-
1. Developmental and Gross Anatomy 23
perficial extensor musculature. Distal to the radial bifurca-
tion, another tributary, the posterior interosseous nerve, de-
scends along the posterior border of the interosseous
membrane.
The radial nerve innervates the triceps brachii, anconeus,
brachioradialis, and ECRL. The ECRB is innervated either
by the superficial or by the deep radial nerve. The deep
radial nerve innervates the supinator, extensor digitorum,
extensor digiti minimi, and ECU. The posterior interos-
seous nerve innervates the extensor pollicis brevis, abductor
pollicis longus, extensor pollicis longus, and extensor in-
dicis. The radial nerve provides the sensory supply for the
posterior lateral aspect of the arm and the posterior aspect
of the forearm (Figs. 1.24 and 1.25). The superficial radial
nerve is responsible for the cutaneous distribution on the
posterior lateral surface of the hand. Neither the deep radial
nerve nor the posterior interosseous nerve has a sensory
supply.
There are several distinct symptoms indicative of radial
nerve damage. Radial nerve damage at or distal to the
radial groove preserves function of the triceps brachii and
extension of the elbow. Deep radial nerve injury at the
neck of the radius preserves brachioradialis as well as
extensor carpi radialis function. Wrist flexion, however,
is accompanied by abduction due to unopposed action
of the extensor carpi radialis. To test the motor function
of this nerve, the patient is requested to extend the
forearm, wrist, and fingers against resistance. Prick the
skin overlying first dorsal interosseous muscle on the back
of the hand to test sensory function.
Blood Vessels and Lymphatics
Arteries
The axillary artery is a direct continuation of the subclavian
artery, which begins distal to the lateral border of the first
rib. The axillary artery becomes the brachial artery as it
crosses the inferior border of the teres major tendon. It
terminally bifurcates in the distal cubital fossa and becomes
the radial and ulnar arteries.
Brachial Artery and Its Tributaries
The brachial artery is the continuation of the axillary artery
at the lower border of the teres major tendon (Fig. 1.26).
It descends on the medial surface of the humerus and can
be palpated in the distal medial bicipital sulcus by palpating
between the biceps brachii and triceps brachii muscles. The
brachial artery has five major tributaries: the profunda
brachii, the superior ulnar collateral, the inferior ulnar col-
lateral, the radial, and the ulnar artery. The profunda brachii
is given off immediately below teres major and passes onto
the posterior surface of the humerus with the radial nerve
via the radial groove. The profunda brachii then descends
between the lateral and medial heads of the triceps and ends
24 The Athlete’s Elbow

FIGURE 1.23. Axillary and radial

nerve. (From Agur AMR and Lee MJ:
Grant’s atlas of anatomy, 10th ed. Phil-
adelphia: Lippincott, Williams & Wil-
kins, 1999, Fig. 6.8D, with permission.)
 1. Developmental and Gross Anatomy 25

FIGURE 1.24. Cutaneous nerves of the anterior arm. (From Olson T: A.D.A.M. student atlas of
anatomy. Philadelphia: Lippincott, Williams & Wilkins, 1996, Fig. 6.17, with permission.)

FIGURE 1.25. Cutaneous nerves of the posterior arm. (From Olson T: A.D.A.M. student atlas of
anatomy. Philadelphia: Lippincott, Williams & Wilkins, 1996, Fig. 6.19, with permission.)
26 The Athlete’s Elbow

FIGURE 1.26. Arterial system of the arm. (From Olson

T: A.D.A.M. student atlas of anatomy. Philadelphia: Lip-
pincott, Williams & Wilkins, 1996, Fig. 6.13 anterior view,
with permission.)

as several tributaries that contribute to several anastomoses nous. At that point, it runs between the brachioradialis and
about the elbow. The intraosseous structures of the elbow the FCR to the wrist where it travels through the anatomic
joint are supplied by branches from local extraosseous arter- snuffbox and gives off further tributaries. The radial artery
ies (Fig. 1.27) (46). The vascular patterns within the cartila- gives off two major tributaries, the radial recurrent and the
ginous structures about the elbow also have distinct arrange- superficial radial arteries, providing the predominant source
ments. Within the epiphyseal cartilages of the trochlea, of the elbow vasculature. The radial recurrent branches dis-
capitellum, and the epicondyles, the vasculature assumes a
centripetal nature, whereas within the epiphyseal cartilage
between the capitellum and trochlea, the pattern is longitu-
dinal. This predisposes the latter to avascular necrosis (47).
The superior ulnar collateral artery is given off immediately
distal to the profunda brachii and descends on the lateral
side of the brachial artery and humerus adjacent to the ulnar
nerve. The superior ulnar collateral, similar to the profunda
brachii, terminates in tributaries that contribute to anasto-
moses about the elbow. The inferior ulnar collateral is given
off proximally to the medial epicondyle. It descends adja-
cent to the distal ulnar nerve and terminates in anastomoses
about the elbow. Within the cubital fossa, the brachial artery
runs alongside the median nerve and the biceps brachii ten-
don. The brachial artery divides into two terminal branches
as the ulnar and radial arteries at the anterior surface just
below the cubital fossa at the neck of the radius.

Radial Artery
The radial artery is the lateral terminal branch of the bra-
chial artery. It gives off tributaries including those supplying
FIGURE 1.27. Deep venous system of the arm. (From Olson T:
blood to the hand. The radial artery runs deep to the anterior A.D.A.M. student atlas of anatomy. Philadelphia: Lippincott, Wil-
edge of the brachioradialis until that muscle becomes tendi- liams & Wilkins, 1996, Fig. 6.15 anterior view, with permission.)
 1. Developmental and Gross Anatomy 27

tally to the origin of the radial nerve and runs laterally and
then proximally across the anterior surface of the elbow joint
to anastomose with the profunda brachii artery.

Ulnar Artery
The ulnar artery is the medial terminal branch of the bra-
chial artery. It runs deep to the pronator teres and the ulnar
origin of flexor digitorum profundus. It then descends in
the forearm deep to the FCU until it reaches the wrist where
it gives off tributaries to the hand vasculature. The ulnar
recurrent artery arises just distal to the origin of the ulnar
artery on the medial side. It divides into anterior and poste-
rior branches that both turn proximally to anastomose with
the ulnar collateral artery. The common interosseous artery
arises distal to the ulnar recurrent artery and then descends
briefly before bifurcating into anterior and posterior
branches. The anterior interosseous artery descends through
the forearm on the anterior surface of the interosseous mem-
brane between the flexor digitorum profundus and flexor
pollicis longus. It gives rise to the median artery, which runs
adjacent to the median nerve to the hand. The posterior
interosseous artery dives to the posterior surface of the inter-
osseous membrane to reach the deep posterior compartment
of the forearm where it runs distal to the wrist. The posterior
interosseous artery gives rise to the internal recurrent artery,
which dives to the deep posterior compartment, but then
heads proximally to anastomose with the profunda brachii FIGURE 1.28. Superficial venous system of the arm. (From Olson
artery. T: A.D.A.M. student atlas of anatomy. Philadelphia: Lippincott,
Williams & Wilkins, 1996, Fig. 6.16 anterior view, with permis-
In a small percentage of individuals, the ulnar artery sion.)
reaches the deep surface of the FCU by traversing the prona-
tor teres superficially instead of deeply. In these rare occur-
rences, the superficial ulnar artery can be palpated if not cia of the cubital fossa. The median cubital vein arises just
seen in the cubital fossa. distal to the elbow as a tributary of the cephalic vein and
runs proximally and medially to join the basilic vein just
above the elbow. It is the favorite site for intravenous injec-
Veins tions and withdrawing venous blood. It lies in the medial
part of the cubital fossa. The median antecubital vein drains
The major arteries of the upper limb have a deep vein run- blood from the ventral wrist and then runs proximally up
ning adjacent to them. In the arm, two deep brachial veins the forearm to empty into the median cubital vein.
travel proximally to form an axillary vein, which then emp-
ties into the subclavian vein (Fig. 1.27). Lymphatics
There is a corresponding dense network of veins in the The lymphatic drainage of the upper extremity is divided
upper limb to return the blood from the extensive arterial into superficial and deep systems. In the hand and forearm,
anastomoses. There are four major superficial veins: the ce- the superficial lymphatic vessels travel with the superficial
phalic vein, the basilic vein, the median cubital vein, and veins. Vessels that start dorsally at the wrist wrap anteriorly
the median antebrachial vein (Fig. 1.28). The cephalic vein as they progress proximally, with the medial vessels follow-
rises from the radial side of the wrist receiving blood from ing the basilic vein and the lateral lymphatics the cephalic
the dorsal side of the hand. It runs proximally along the vein. Although lymphatic drainage from the superficial sys-
lateral border of the limb and empties into the axillary vein. tem eventually converges upon the anterior and lateral axil-
The basilic vein begins on the medial side of the wrist drain- lary lymph node system, some of the lymphatics from the
ing from the dorsum of the hand as well. It runs proximally ulnar three digits and ulnar forearm pass through epitro-
along the medial side of the arm and then superficially in chanteric lymph nodes noted about the medial epicondyle.
the medial bicipital sulcus. The basilic vein dives deep to The deep lymphatic system, less developed than the superfi-
take its spot adjacent to the brachial artery at midarm. The cial, follows the main neurovascular bundles (radial, ulnar,
median cubital vein provides an anastomotic connection interosseous, and brachial) to the anterior and lateral axillary
between the cephalic and basilic veins in the superficial fas- lymph nodes.