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Morrey’s
The Elbow and
ItsDisorders
 Morrey’s
The Elbow and
Its Disorders

FIFTH EDITION
Bernard F. Morrey, MD
Professor
Department of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota;
Professor of Orthopedics
University of Texas Health Science Center
San Antonio, Texas
Joaquin Sanchez-Sotelo, MD, PhD
Professor
Department of Orthopedic Surgery
Mayo Clinic College of Medicine
Consultant
Division of Adult Reconstruction
Department of Orthopedic Surgery
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
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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
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With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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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
Department of Orthopaedic Surgery
Singapore General Hospital
Singhealth Regional Health System
Singapore
Sandra L. Kopp, MD
Assistant Professor of Anesthesiology
Mayo Clinic
Rochester, Minnesota
Young W. Kwon, MD, PhD
Associate Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
New York University School of Medicine
New York, New York
Mikko Larsen, MD, PhD
Consultant Plastic Surgeon
Department of Plastic Surgery
Launceston General Hospital
Launceston, Tasmania, Australia
Susan G. Larson, MS, PhD
Professor
Department of Anatomical Sciences
Stony Brook University School of Medicine
Stony Brook, New York
Lisa Lattanza, MD
Professor of Orthopaedic Surgery
Chief, Division of Hand, Elbow and Upper
Extremity Surgery
Orthopaedic Surgery
University of California San Francisco
San Francisco, California;
Consultant Surgeon
Pediatric Orthopaedic Surgery
Shriners Hospital of Northern California
Sacramento, California
Thomas Lawrence, MD, MSc,
FRCS(T&O)
Consultant Shoulder and Elbow Surgeon
Trauma and Orthopaedics
University Hospital Coventry and
Warwickshire
Coventry, United Kingdom
Brian P. Lee, MD
Consultant Orthopaedic Surgeon
Orthopaedic Associates
Mount Elizabeth Hospital;
Visiting Consultant
Department of Orthopaedic Surgery
Singapore General Hospital
Singapore
Associate Professor of Anesthesiology
Mayo Medical School;
Supplemental Consultant
Mayo Clinic
Rochester, Minnesota
Kevin J. Little, MD
Director, Pediatric Hand and Upper
Extremity Center
Cincinnati Children’s Hospital Medical
Center;
Associate Professor of Orthopaedic Surgery
University of Cincinnati School of Medicine
Cincinnati, Ohio
Manuel Llusá-Pérez, MD, PhD
Professor of Human Anatomy and
Embryology
Barcelona Medical School
Department of Anatomy;
Head of Trauma Unit
Hospital Clinic, Barcelona
Trauma and Orthopaedics
Barcelona, Spain
Harvinder S. Luthra, MD
John Finn Professor of Medicine
Division of Rheumatology
Mayo Clinic
Rochester, Minnesota
Alex A. Malone, MBBS, FRCS (Tr &
Orth), FRACS
Senior Clinical Lecturer
Department of Orthopaedic Surgery and
Musculoskeletal Medicine
University of Otago
Christchurch, New Zealand
Pierre Mansat, MD, PhD
Professor of Orthopedics and Traumatology
Department of Orthopedics and
Traumatology
University Hospital of Toulouse
Toulouse, France
Thomas G. Mason, MD
Rheumatology
Mayo Clinic
Rochester, Minnesota
Amy L. McIntosh, MD
Associate Professor of Orthopedic Surgery
Texas Scottish Rite Hospital for Children
Dallas, Texas
Robert Nelson Mead, MD, MBA
Tulane University School of Medicine
New Orleans, Louisiana
Professor and Chair of Plastic Surgery
Professor of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
Bernard F. Morrey, MD
Professor
Department of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota;
Professor of Orthopedics
University of Texas Health Science Center
San Antonio, Texas
Mark E. Morrey, MD, MSc
Assistant Professor of Orthopedics
Department of Orthopedic Surgery
Mayo Clinic College of Medicine
Rochester, Minnesota
Michael R. Moynagh, MBBAOBCh,
FFRRCSI, MRCSI
Assistant Professor of Radiology
Department of Radiology
Mayo Clinic
Rochester, Minnesota
Robert Nirschl, MD, MS
Founder Chairman Emeritus
Nirschl Orthopaedic Center;
Senior Orthopaedic Surgeon Emeritus,
Virginia Hospital Center
Arlington, Virginia;
Clinical Associate
Professor Emeritus
Georgetown University Medical Center
Washington, DC
Michael J. O’Brien, MD
Assistant Professor of Orthopaedics
Department of Orthopaedic Surgery
Tulane University School of Medicine
New Orleans, Louisiana
Shawn W. O’Driscoll, MD, PhD
Professor of Orthopedic Surgery
Mayo Clinic
Rochester, Minnesota
Panayiotis J. Papagelopoulos, MD, DSc
Professor and Chairman
First Department of Orthopaedics
Athens University Medical School
Attikon University General Hospital
Athens, Greece
 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
Biomechanics Laboratory
Division of Orthopedic Research
Rochester, Minnesota
Thomas W. (Quin) Throckmorton, MD
Professor
Shoulder and Elbow Surgery
University of Tennessee Campbell Clinic
Department of Orthopaedic Surgery
Memphis, Tennessee
Nho V. Tran, MD
Associate Professor of Plastic Surgery
Mayo Clinic
Rochester, Minnesota
Ann E. Van Heest, MD
Professor
Department of Orthopedic Surgery
University of Minnesota;
Gillette Children’s Specialty Healthcare
Shriners Hospital for Children—Twin Cities
Minneapolis, Minnesota
Roger P. van Riet, MD, PhD
Elbow Surgeon
Professor of Orthopaedic Surgery
Fellowship Director
President of the Belgian Elbow and
Shoulder Society
Department of Orthopaedic Surgery and
Traumatology
AZ Monica
University of Antwerp
Antwerp, Belgium
Ilya Voloshin, MD
Professor of Orthopaedics
Director, Shoulder and Elbow Division
Department of Orthopaedics
University of Rochester Medical Center
Rochester, New York
Carley Vuillermin, MBBS, FRACS
Instructor in Orthopaedic Surgery
Harvard Medical School;
Staff Orthopaedic Surgeon
Department of Orthopaedic Surgery
Boston Children’s Hospital
Boston, Massachusetts
Jacqueline S. Weisbein, DO
Partner and Medical Director
Napa Pain Institute
Napa, California
Daniel E. Wessell, MD, PhD
Department of Radiology
Mayo Clinic
Jacksonville, Florida
Ken Yamaguchi, MD
Sam and Marilyn Fox Distinguished
Professor of Orthopaedic Surgery
Chief, Shoulder and Elbow Service
Washington University School of Medicine
St. Louis, Missouri
Dan A. Zlotolow, MD
Associate Professor of Orthopaedics
Temple University School of Medicine;
Attending Physician
Shriners Hospital for Children
Philadelphia, Pennsylvania

The fifth edition of The Elbow and Its Disorders is very special to me
personally for several reasons. First, this now represents over 30 years
since the first edition appeared, sharing our interest in diagnosis and
treatment of this “forgotten joint.” More importantly, this edition
introduces once again Dr. Joaquin Sanchez-Sotelo as a co-editor and
also introduces for the first time my son, Mark Morrey, as a co-editor.
Future editions will be hallmarked by their innovative contributions
and exceptional ability to communicate and teach. This edition is also
hallmarked by the decision of the publisher, Elsevier, to rename The
Elbow and Its Disorders henceforth eponymously as Morrey’s The Elbow
and Its Disorders. I, of course, am extremely humbled by this decision
and am not only grateful to the publishers but also to my colleague,
Dr. Sanchez-Sotelo, and to Mark, in whom I have the utmost confi-
dence will not only continue the publication of this material into the
future but will improve on the quality and relevance as well.
P R E FA C E
As is well known, there is a tremendous challenge in providing
relevance through various types of communication. Today’s standards
are characterized by instantaneous access to the most current informa-
tion available in an electronic format. This edition, therefore, makes a
significant effort to maintain the tradition of this title as being the
definitive reference and containing clinical, relevant information
regarding elbow disease and its management. But, importantly, it has
also made a considerable effort to utilize the advances realized with
complementary video clips and electronic navigation. As has always
been the case, we are forever in the debt of our many colleagues
worldwide who have shared their interesting cases with us and have
allowed us to publish some of their material. It is our sincere hope and
expectation that this fifth edition will be the best and most relevant yet.
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-
pedic colleagues worldwide who have supported and encouraged me
through the five editions of The Elbow and Its Disorders. In fact, the
beautiful anatomic dissections featured in this edition are the contri-
bution of Dr. Manuel Llusá-Pérez, Dr. José R. Ballesteros-Betancourt,
and their colleagues from Spain. The tremendous support provided by
Drs. Sanchez-Sotelo and Mark Morrey for their contributions as well
as their advice and encouragement is evident throughout the text. I
particularly wish to recognize Dr. Shawn O’Driscoll, who has been my
partner and colleague for most of my career. The orthopedic com-
munity owes him a tremendous debt of gratitude for his numerous
contributions to elbow surgery. I especially appreciate his desire to
challenge existing thought and dogma and continue to push for a
better understanding of disease mechanisms and physical diagnosis. I
am thankful to Elsevier, who has determined to “eponify” this title. The
support of the publisher has been unwavering, and the editorial and
production crew of Elsevier has been not just professional but also
xii
supportive and patient. One of the unsung heroes through all of these
years has been my manuscript secretary, Donna Riemersma, who never
ceases to amaze me with her calmness and patience.
I must again thank Carla and the kids, Mike, Matt, Mark, and
Maggie; thanks for your understanding and unfaltering support,
even as this project has extended a bit beyond what was originally
anticipated.
Finally, my colleague, Joaquin, and my son and colleague, Mark,
have not only been a great asset in the preparation of this edition but
have also assumed the task of taking this project into the future. I could
not have left this challenge in more capable hands. I have no doubt
that they will not just sustain the quality but will make it measurably
better and continue to adapt to the changing times and expectations.
As always, this will be done in the future as in the past, with the monical
focus of improving patient care. Godspeed.
Bernard F. Morrey, MD
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
20-1 Elbow Plicae and Loose Bodies
22 Arthroscopic Management of Osteochondritis
Dissecans of the Capitellum
22-1 Microfracture of Contained Osteochondritis
Dissecans Lesion
PART III The Child and Adolescent Elbow
33 Osteochondritis Dissecans
33-1 Treatment of Osteochondritis Desiccans
Elbow Lesions
33-2 Osteochondral Allograft Transfer for Osteochondritis
Dissecans
PART IV Acute Trauma
39 Prosthetic Radial Head Replacement
39-1 rHead LATERAL Implant
39-2 rHead RECON Bipolar Replacement
39-3 rHead Extended Stem Replacement
43 Coronoid Fractures
43-1 Lateral Approach to the Elbow for Radial Head Fixation
or Replacement and Coronoid Fixation
45 Distal Humerus Fractures: Fractures of the Columns
With Articular Involvement
45-1 Open Reduction and Internal Fixation for Distal Humerus
Fractures
PART VI Sports and Soft Tissue Injuries
60 Percutaneous Ultrasound Tenotomy Treatment of
Epicondylitis
60-1 Percutaneous Ultrasonic Tenotomy
63 Elbow Tendinopathies: Acute Distal Biceps Tendon
Ruptures
63-1 Mayo Two-Incision Biceps Tendon Repair
67 Articular Injuries in the Athlete
67-1 Capitellar Osteochondritis Dissecans Lesion Treated
With Microfracture
PART VIII Joint Replacement Arthroplasty
87 Radiocapitellar Prosthetic Arthroplasty for Isolated
Radiocapitellar Arthritis
87-1 UNI_Elbow Radio-Capitellum Replacement
90 Linked Elbow Arthroplasty: Rationale, Design
Concept, and Surgical Technique
90-1 Coonrad-Morrey Total Elbow Arthroplasty
90-2 Highlights of the Zimmer Nexel Total Elbow Surgical
Procedure
92 Distal Humeral Fractures
92-1 Total Elbow Arthroplasty for Distal Humerus Fractures
93 Total Elbow Arthroplasty for Distal
Humerus Nonunion
93-1 Total Elbow Arthroplasty for Distal Humerus Nonunions

xvi

PART IX Complications and Salvage
of Failed Arthroplasty
104 Isolated Polyethylene Wear and Elbow Replacement
104-1 Fluoroscopic Examination for Bushing Wear
108 Revision of Failed Total Elbow Arthroplasty With
Osseous Deficiency: Impaction Grafting
108-1 Revision Techniques for Total Elbow Arthroplasty
109 Revision of Failed Total Elbow Arthroplasty With
Osseous Deficiency: Humeral Replacement and
Allograft Prosthetic Composite Reconstruction
109-1 Allograft Prosthetic Composite Reconstruction
Video Contents xvii
PART X Nonprosthetic Alternatives and
Salvage Procedures
110 Synovectomy of the Elbow
110-1 Arthroscopic Synovectomy of the Elbow
113 Anconeus Interposition Arthroplasty
113-1 Anconeus Interposition Arthroplasty
114 Interposition Arthroplasty of the Elbow
114-1 Interposition Arthroplasty With Achilles Tendon Allograft
and the Application of the Dynamic Joint Distractor
Morrey’s
The Elbow and
ItsDisorders
 1
Phylogeny
Alex A. Malone and Susan G. Larson
INTRODUCTION
The human elbow forms the link between brachium and forearm,
controlling length of reach and orientation of the hand, and is one
of our most distinctive anatomic regions. An appreciation of elbow
phylogeny complements anatomic knowledge in three ways: (1) it
demonstrates how the elbow has evolved to facilitate specific functional
demands, such as suspensory locomotion and dexterous manipulation;
(2) it explains the functional significance of each morphologic feature;
and (3) it assists in predicting the consequences of loss of such features
through disease, injury, or treatment.
Most of the characteristic features of the human elbow significantly
predate the appearance of modern Homo sapiens. In fact, current
evidence suggests that this morphology can be traced back to the
common ancestor of humans and apes, extant approximately 15 to 20
million years ago (mya).
EVOLUTION OF THE VERTEBRATE ELBOW
The distal humerus of pelycosaurs, the late Paleozoic (255 to 235 mya)
reptiles that probably gave rise to more advanced mammal-like reptiles,
possessed a bulbous capitellum laterally and medially. The articulation
with the ulna was formed by two distinct surfaces: a slightly concave
ventral surface and a more flat dorsal surface (Fig. 1.1).11 The proximal
articular surface of the ulna was similarly divided into two surfaces
separated by a low ridge. Reconstruction of the forelimb of these
reptiles suggests that they walked with limbs splayed out to the side.
The humerus was held more or less horizontal, the elbow flexed to 90
degrees, and the forearm was sagittally oriented. Forward motion was
brought about by rotation of the humerus around its long axis, which
propelled the body forward relative to the fixed forefoot. Elbow flexion
and extension probably were useful only in side-to-side motions. The
ulnohumeral joint, with its dual articular surfaces, was well suited to
resist the valgus/varus stress produced by humeral rotation, and the
proximal end of the radius was flat and triangular, precluding prono-
supination. It appears, therefore, that stability rather than mobility was
the major functional characteristic of the elbow of these late Paleozoic
reptiles.
Cynodonts, the more immediate ancestors of mammals from the
Permo-Triassic period (235 to 160 mya), had their limbs underneath
their bodies rather than at the sides. The distal humeral articular
surface consisted of radial and ulnar condyles separated by a shallow
groove (see Fig. 1.1). The proximal ulnar articular surface was an
elongate spoon shape for articulation with the humeroulnar condyle.
The lateral flange on the ulna for articulation with the radius was sepa-
rated from this surface by a low ridge. This ridge articulated with the
groove between the radial and ulnar condyles, displaying some features
in common with the “tongue and groove” (trochleariform) type of
humeroulnar articulation characteristic of many modern mammals.
2
Early mammals from the Triassic (210 to 160 mya) and Jurassic
(160 to 130 mya) periods also had radial and ulnar condyles. However,
the radial condyle was more protuberant than the ulnar, and the ulnar
condyle was more linear and obliquely oriented (see Fig. 1.1). The two
condyles were separated by an intercondylar groove. The ulnar notch
had articular surfaces for both the ulnar and the radial condyles, each
matching the configuration of the corresponding humeral surface. The
oblique orientation of the humeroulnar joint resembled a spiral con-
figuration, which helped to keep forearm movement in a sagittal plane
as the humerus underwent a compound motion involving adduction,
elevation, and rotation during propulsion.
The trochleariform distal humeral articular surface in modern
mammals largely came about by widening the intercondylar groove
and the development of a ridge within it (see Fig. 1.1, bear). The
articular surface on the proximal ulna is oblique in orientation, and
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
cam effect of the ulnar condyle during humeral rotation.
Most small noncursorial mammals have maintained the spiral
configuration of the trochlear articular surface observed in early
mammals. In larger and more cursorial mammals, the trochlea displays
various ridges and is narrower to improve stability, although at the
expense of joint mobility. Only in the hominoid primates, which
include humans, chimpanzees, gorillas, orangutans, and gibbons, is the
medial aspect of the distal humeral articular surface truly trochleari-
form. In the next section, we discuss the functional significance of the
unique aspects of the hominoid elbow joint.
COMPARATIVE PRIMATE ANATOMY OF
THE ELBOW REGION
Much of what follows is taken from the detailed studies of Rose.20,21
The humeral trochlea may be cylindrical, conical, or trochleariform in
nonhuman primates.21 The trochlea is conical in some prosimians, but
a cylindrical trochlea seems to be the most common shape and is
observed in most prosimians and New World monkeys. The trochlea
is also cylindrical in most Old World monkeys but with a pronounced
medial flange or keel that is best developed anterodistally (Fig. 1.2).
Only in apes and humans is the trochlea truly trochleariform, possess-
ing medial and lateral ridges all around the trochlear margins, which
contribute to the stability of the ulnohumeral joint, substituting for
the radiohumeral joint, which is freed for pronosupination throughout
the flexion range.11,20 In most species, the articular surface of the
trochlea expands posteriorly to the area behind the capitellum. In
larger monkeys, the lateral edge of the posterior trochlear surface
projects to form a keel that extends up the lateral wall of the olecranon
fossa (see Fig. 1.2). In hominoids, this keel is a continuation of the
lateral trochlear ridge and helps form a sharp lateral margin of the
 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
extension.20,21
The trochlear notch of the ulna generally mirrors the shape of the
humeral trochlea. In humans and apes, the notch has medial and
lateral surfaces separated by a ridge that articulates with the trochlear
groove (Fig. 1.3).20,21
The differences seen in the configuration of the humeroulnar joint
across primate species reflect contrasting requirements for stabiliza-
tion with different forms of limb use. In most monkeys, the humer-
oulnar joint is in its most stable configuration in a partially flexed
position owing to the development of the medial trochlear keel antero-
distally and the lateral keel posteriorly.20
It is not surprising that this position of maximum stability is the
one assumed by the forelimb during the weight-bearing phase of
quadrupedal locomotion. The anterior orientation of the trochlear
notch is a direct adaptation to weight bearing with a partially flexed
limb. However, such an orientation does limit elbow extension to some
degree.
The great apes (chimpanzees, gorillas, and orangutans) and the
lesser apes (gibbons) move about in a much less stereotypical fashion
than do monkeys. To accommodate this more varied form of limb use,
the hominoid humeroulnar joint, with its deeply socketed articular
surfaces and well-developed medial and lateral trochlear ridges all
around the joint margins, is designed to provide maximum stability
throughout the flexion-extension range.20–22 The use of overhead
suspensory postures and locomotion in apes has led to the evolution
of the capacity for complete elbow extension. Apes even keep their
elbows extended during quadrupedal locomotion. The ideal joint
configuration for resistance of transarticular stress with fully extended
elbows during quadrupedal postures would be to have a trochlear
notch that was proximally directed. It could then act as a cradle to
support the humerus during locomotion. However, a proximal orien-
tation of the trochlear notch would severely limit elbow flexion by
impingement of the coronoid process within its fossa. The antero-
proximal orientation of the trochlear notch in apes thus represents
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
 CHAPTER 1 Phylogeny 5

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
L M
FIG 1.6 Diagrammatic view of the radioulnar joint in pronation and
supination in a monkey and an ape. A section through the radius and
ulna in the region of the radial notch is superimposed on an outline of
the distal humerus. In the monkey, the radial notch faces anterolater-
ally, whereas in the ape, it faces more directly laterally. The radial head
of the monkey with its lateral lip comes into maximum congruence in
the pronated position, conferring maximum stability in this position. The
ape radioulnar joint, on the other hand, displays no such position of
particular stability and instead emphasizes mobility. (Adapted from
Rose MD: Another look at the anthropoid elbow, J Hum Evol 17:193,
1988.)
experienced by the hominoid elbow and can stabilize the radial head
in all positions of pronosupination.20,21
In most monkeys and prosimians, the radial head is ovoid and
the proximal radioulnar joint articulation is restricted to the anterior
and medial surfaces; as a result, the joint becomes close packed for
stability in pronation (Fig. 1.6). In apes and humans, on the other
hand, this articular surface extends almost all the way around the
head, implying a greater range of pronosupination.20 The radial notch
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
development of a position of particular stability in monkeys versus
more universal stability in apes.
A few additional features of the human elbow are shared with apes,
such as a more distal biceps tuberosity (longer radial neck) relative to
their body size.21 In apes, this is probably related to the demands for
powerful elbow flexion to raise the center of mass of the body during
climbing and suspensory postures and locomotion. Although the
radial tuberosity faces more or less anteriorly in most primates, it faces
more medially in apes and humans, reflecting their greater range of
pronosupination.17 Extreme supination is an important component of
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
with that of most other primates, which is generally attributed to the
demands for rapid elbow extension during suspensory locomotion.
Finally, apes and humans are distinguished from other primate species
in possessing a biomechanical carrying angle at the elbow. Sarmiento22
has argued that the evolution of a carrying angle in apes is related to
the need to bring the center of mass of the body beneath the support-
ing hand during suspensory locomotion in a manner similar to that
in which the valgus knee of humans brings the foot nearer the center
6 PART I Fundamentals and General Considerations
cg
FIG 1.7 Frontal view of an arm-swinging gibbon showing the skeletal
structure of the forelimb. The carrying angle of the elbow brings the
center of mass (i.e., center of gravity [cg]) more nearly directly under
the supporting hand. (Adapted from Sarmiento EE: Functional Differ-
ences in the Skeleton of Wild and Captive Orang-Utans and Their
Adaptive Significance. Ph.D. Thesis, New York University, 1985.)
of mass of the body during the single limb support phase of walking
(Fig. 1.7).
All of these features have been retained in humans because of
their continued advantages for tool use and other behaviors. Powerful
flexion is clearly important. The continued importance of the carrying
angle is perhaps less obvious, but one advantage that it does offer is
that flexion of the elbow is accompanied by adduction of the forearm,
thus bringing the hands more in front of the body, where most
manipulatory activities are undertaken.
The morphology of the modern human elbow is not identical
to that of the ape elbow, however. In some cases, the differences are
simply a matter of degree. For example, although both apes and
humans are distinguished from other primates in the medial orienta-
tion of the radial tuberosity, it is more extreme in position in the
ape; in the human it is typically slightly anterior to true medial. In
addition, although the olecranon is short in both humans and apes
compared with most monkeys, it is slightly longer in humans than in
apes and also shaped to maintain this length throughout the range of
flexion—both of which are advantageous for powerful manipulatory
activities.6
Other differences between the elbow morphology of humans and
that of apes can be related to the fact that the human forelimb has no
role in locomotion. These differences include a less robust coronoid
process and a relatively narrower, proximally oriented trochlear notch
in humans, indicating relative stability in flexion rather than the need
to support the weight of the body during quadrupedal locomotion in
extension.1,13 Humans possess a smaller and more distally placed lateral
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
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-
teristic of extant hominoids. It has a globular capitellum, well-developed
medial and lateral trochlear ridges, and a deep zona conoidea forming
the medial wall of a recessed gutter between the capitellum and
trochlea.20 In general, the elbow region of Proconsul resembles that of
extant hominoids in features related to general stability and range of
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
members of the genera Dryopithecus (from Europe), Sivapithecus
(from Europe and Asia), and Oreopithecus (from Europe), displayed
the features characteristic of the modern hominoid elbow. Although it
is possible that these features arose in parallel in different genera, the
more parsimonious explanation is that they inherited this morphology
from an early to middle Miocene common ancestor, possibly similar
to P. heseloni.16,29,31 Assuming that the characteristic features of the
hominoid elbow are shared derived traits—that is, traits inherited from
a single common ancestor—we can say that the elbow morphology of
modern apes and humans can be dated to roughly 15 to 20 mya.
The majority of paleoanthropologists agree that humans are most
closely related to the African apes (chimpanzees and gorillas) and that
the two lineages arose in the late Miocene or earliest Pliocene period
(between 10 and 4 mya).8 The earliest known fossils of the human
lineage (hominids) date from the early Pliocene era, approximately 4
to 5 mya. There are three genera of these earliest hominids currently
recognized, Ardipithecus, Paranthropus, and Australopithecus. The latter
is the best known and most widespread genus, and includes the famous
“Lucy” skeleton from Hadar, Ethiopia (Australopithecus afarensis).7,12
The genus Homo, to which our own species belongs, first appeared
about 2.5 to 2 mya in East Africa with its earliest member species,
Homo habilis.
All of the hominids from the Pliocene period were bipedal, although
some probably spent significant time climbing trees.23–26,28 The devel-
opment of bipedalism freed the upper extremity from the requirements
of locomotion, placing greater emphasis on increasing mobility. The
ability to supinate and pronate was an immense advantage to hominids
 CHAPTER 1 Phylogeny 7

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
was also critical in efficient tool handling, which developed approxi-
mately 2 mya, at about the same time as H. habilis, although there is
debate about which species of early hominid was responsible for
making them.27
Several distal humeri are known from these early hominid species.
All of the early hominid distal humeri lack the steep lateral margin of
the olecranon fossa that is characteristic of chimpanzees and gorillas.
However, they do show a considerable amount of morphologic varia-
tion in other characteristics (Fig. 1.8). On the basis of the contour of
the distal end of the humeral shaft, the placement of the epicondyles,
and the configuration of the articular surface, the fossil distal humeri
have been divided into two groups. The first group is characterized
by a weakly projecting lateral epicondyle that is placed low, at about
the level of the capitellum, and by a moderately developed lateral
trochlear ridge.23,24 These are features shared with modern humans,
and consequently, this group generally is referred to as early Homo.
The second group includes the Australopithecus and Paranthropus
species and is characterized by a well-developed lateral epicondyle that
is high relative to the capitellum. These features are similar to those
of modern apes.
A number of fragments of early hominid proximal radii have been
recovered representing each of the currently recognized species. The
proximal radial fragments that have been attributed to early Homo
display a much narrower bevel around the capitellar fovea than that of
the modern apes and the earlier hominin group. This provides for
articulation with a more shallow zona conoidea and a more vertical
and uniformly wide surface on the side of the head for articulation
with the ulna, favoring pronosupination over stability. Other primitive
hominoid features include thick cortices, a relatively long and angu-
lated radial neck (lower neck shaft angle), and a more anteromedially
(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
pattern of evolution.18,19
Some early hominid ulnae that have been recovered appear
to retain many primitive features, including a longer, more curved
shaft, greater mediolateral width proximally, and a nonprominent
interosseous border.1,2,10 However, early human ulnae attributed to the
genus Homo are similar to those of modern humans in having a
prominent interosseous border, a supinator crest, and a well-marked
hollow for the play of the tuberosity of the radius.4,5,15 It appears,
therefore, that many of the characteristics that distinguish the human
elbow from that of the ape can be found in the earliest members of
our genus.
In overview, the combination of comparative anatomy and the
fossil record indicates that the modern human elbow owes its begin-
nings to our hominoid ancestry. Current evidence suggests that many
of the characteristic features of the human distal humerus and proxi-
mal radius and ulna can be projected back approximately 15 to 20 mya
to a common ancestor of extant apes and humans. Functional analysis
suggests that this morphologic structure arose in hominoid primates
in response to the need for stabilization throughout the flexion-
extension and pronosupination ranges of motion to permit a more
versatile form of forelimb use. This morphology was still largely intact
following the evolution of upright posture and bipedal locomotion in
the earliest known hominids. However, as the forelimb became less and
less involved in locomotion, the hominid elbow underwent additional
modifications, relaxing some of the emphasis on stabilization and
increasing performance throughout the range of movement. The fossil
record indicates that the distinct form of the modern human elbow
probably first appeared about 2 mya in our ancestor H. habilis. This
morphology has changed only subtly during all subsequent stages of
human evolution.
ACKNOWLEDGMENTS
SGL would like to thank Jack Stern and John Fleagle for helpful com-
ments on earlier versions of this chapter and Luci Betti-Nash for the
preparation of figures.
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8 PART I Fundamentals and General Considerations
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16. Martin L, Andrews P: Cladistic relationships of extant and fossil
hominoids. J Hum Evol 16:101, 1987.
17. O’Connor BL, Rarey KE: Normal amplitudes of radioulnar pronation and
supination in several genera of anthropoid primates. Am J Phys Anthropol
51:39, 1979.
18. Patel BA: The hominoid proximal radius: re-interpreting locomotor
behaviors in early hominins. J Hum Evol 48:415, 2005.
19. Pearson OM, Grine FE: Re-analysis of the hominid radii from Cave of
Hearths and Klasies River Mouth, South Africa. J Hum Evol 32:577,
1997.
20. Rose MD: Another look at the anthropoid elbow. J Hum Evol 17:193,
1988.
21. Rose MD: Functional anatomy of the elbow and forearm in primates. In
Gebo D, editor: Postcranial adaptation in nonhuman primates, DeKalb, IL,
1993, Northern Illinois Press, p 70.
22. Sarmiento EE: Functional differences in the skeleton of wild and captive
orang-utans and their adaptive significance, Ph.D. Thesis, 1985, New York
University.
23. Senut B: Humeral outlines in some hominoid primates and in
Plio-Pleistocene hominids. Am J Phys Anthropol 56:275, 1981.
24. Senut B: Outlines of the distal humerus in hominoid primates:
application to some Plio-Pleistocene hominids. In Chiarelli AB,
Corruccini R, editors: Primate evolutionary biology, Berlin, 1981, Springer
Verlag, p 81.
25. Senut B, Tardieu C: Functional aspects of Plio-Pleistocene hominid limb
bones: implications for taxonomy and phylogeny. In Delson E, editor:
Ancestors: the hard evidence, New York, 1985, A. Liss, p 193.
26. Stern JT, Jr, Susman RL: The locomotor anatomy of Australopithecus
afarensis. Am J Phys Anthropol 60:279, 1983.
27. Susman RL: Fossil evidence for early hominid tool use. Science 265:1570,
1994.
28. Susman RL, Stern JT, Jr, Jungers WL: Arboreality and bipedality in Hadar
hominids. Folia Primatol 43:113, 1984.
29. Szalay FS, Delson E: Evolutionary history of the primates, New York, 1979,
Academic Press.
30. Trinkaus E, Churchill SE: Neandertal radial tuberosity orientation. Am J
Phys Anthropol 75:15, 1988.
31. Ward CV, Walker A, Teaford MF: Proconsul did not have a tail. J Hum Evol
21:215, 1991.

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.
Abnormal and surgical anatomy is addressed in subsequent chapters
of this book dealing with the pertinent condition.
TOPICAL ANATOMY AND GENERAL SURVEY
The contours of the biceps muscle and antecubital fossa are easily
observed anteriorly. Laterally, the avascular interval between the
brachioradialis and the triceps, the so-called column, is an important
palpable landmark for surgical exposures (Fig. 2.1). Laterally, the
tip of the olecranon, the lateral epicondyle, and the radial head
also form an equilateral triangle and provide an important landmark
for joint aspiration and elbow arthroscopy (see Chapters 39 and
80). The flexion crease of the elbow is in line with the medial and
lateral epicondyles and thus actually reflects the joint axis and is 1 to
2 cm proximal to the joint line when the elbow is extended (Fig. 2.2).
The inverted triangular depression on the anterior aspect of the
extremity distal to the epicondyles is called the cubital (or antecubital)
fossa.
The superficial cephalic and basilic veins are the most prominent
superficial major contributions of the anterior venous system and
communicate by way of the median cephalic and median basilic veins
to form an “M” pattern over the cubital fossa (Fig. 2.3).2
The extensor forearm musculature originates from the lateral epi-
condyle and was termed the mobile wad by Henry.37 This forms the
lateral margin of the antecubital fossa and the lateral contour of the
forearm and comprises the brachioradialis and the extensor carpi
radialis longus and brevis muscles. The muscles comprising the
contour of the medial anterior forearm include the pronator teres,
flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. Henry
has demonstrated that their relationship and location can be approxi-
mated by placing the opposing thumb and the index, long, and ring
fingers over the anterior medial forearm. The dorsum of the forearm
is contoured by the lateral extensor musculature, consisting of the
anconeus, extensor carpi ulnaris, extensor digitorum quinti, and exten-
sor digitorum communis.
Dermal innervation about the proximal elbow is quite variable,
being provided by the lower lateral cutaneous (C5, C6) and medial
cutaneous (radial nerve, C8, T1, and T2) nerves of the arm. The
forearm skin is innervated by the medial (C8, T1), lateral (musculo-
cutaneous, C5, C6), and posterior (radial nerve, C6–C8) cutaneous
nerves of the forearm (Fig. 2.4).19
OSTEOLOGY
Humerus
The distal humerus consists of an arch formed by two condyles that
support the articular elements of the trochlea and capitellum (Fig. 2.5).
2
Medial to the trochlea, the prominent medial epicondyle serves as
a source of attachment of the medial ulnar collateral ligament and the
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
the supinator-extensor muscle group originate from the flat, irregular
surface of the lateral epicondyle.
Anteriorly, the radial and coronoid fossae accommodate the radial
head and coronoid process during flexion. Posteriorly, the olecranon
fossa receives the tip of the olecranon.
In approximately 90% of individuals,85 a thin membrane of
bone separates the olecranon and coronoid fossae. The medial supra-
condylar column is smaller than the lateral and explains the vulner-
ability of the medial column to fracture caused by trauma and some
surgical procedures.56 The posterior aspect of the lateral supracondy-
lar column is flat, allowing ease of application of contoured plates for
fractures involving this structure. The prominent lateral supracondy-
lar ridge serves as a site of attachment for the brachioradialis and
extensor carpi radialis longus muscles anteriorly and for the triceps
posteriorly (Fig. 2.6). It is also an important landmark for many
lateral surgical approaches, especially for the “column procedure” (see
Chapters 11 and 54).
Proximal to the medial epicondyle, approximately 5 to 7 cm along
the medial intramuscular septum, a supracondylar process may be
observed in 1% to 3% of individuals.44,48,80 A fibrous band termed the
ligament of Struthers sometimes originates from this process and
attaches to the medial epicondyle.38 When present, this spur serves as
an anomalous insertion of the coracobrachialis muscle and an origin
of the pronator teres muscle.34 Various pathologic processes have been
associated with the supracondylar process, including fracture44 and
median4 and ulnar nerve38 entrapment (see Chapter 72).
Radius
The radial head articulates with the capitellum. It exhibits a cylindrical
symmetrical shape with a depression in the midportion to accom-
modate the capitellum. The osseous contour of the radial head, on the
other hand, actually is more elliptical in shape, with a major and minor
axis. The disk-shaped head is secured to the ulna by the annular liga-
ment (Fig. 2.7). Distal to the radial head, the bone tapers to form the
radial neck, which, along with the head, is vulnerable to fracture.82 The
radial tuberosity marks the distal aspect of the neck and has two dis-
tinct parts (Fig. 2.8). The anterior surface is covered by a bicipitoradial
bursa protecting the biceps tendon during full pronation. However, it
is the rough posterior aspect that provides the site of attachment of
the biceps tendon. During full pronation the tuberosity is in a dorsal
position; this allows repair of a ruptured biceps tendon through a
posterior approach11 (see Chapter 63) and is helpful to determine axial
alignment of proximal radial fractures.26 In addition to the bicipital
9
10 PART I Fundamentals and General Considerations

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.)
12 PART I Fundamentals and General Considerations

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

FIG 2.6 Typical supracondylar process located approximately 5 cm
proximal to the medial epicondyle with its characteristic configuration.
radial bursa, several other potential bursae have also been described
about the elbow (Fig. 2.9).
Ulna
The proximal ulna provides the greater sigmoid notch (incisura
semilunaris), which serves as the major articulation of the elbow that
is responsible for its inherent stability (Fig. 2.10). The cortical surface
of the coronoid process serves as the site of insertion of the brachialis
muscle and of the oblique cord. Medially, the sublime tubercle serves
triceps tendon attaches to the posterior aspect of the olecranon
process.
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
crest serves as the site of attachment to the supinator muscle. On this
crest, a tuberosity occurs that is the site of insertion of the lateral ulnar
collateral ligament.51,56,65
ELBOW JOINT STRUCTURE
Articulation
The elbow joint articulation is classified as a trochoginglymoid joint.76
The ulnohumeral joint resembles a hinge (ginglymus), allowing flexion
 CHAPTER 2 Anatomy of the Elbow Joint 13

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).

FIG 2.8 Proximal aspect of the radius demonstrating the articular
margin for articulation with the lesser sigmoid notch, the radial neck,
and tuberosity. The neck angulates about 15 degrees away from the
tuberosity.
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
degrees of articular cartilage that articulates with the ulna, hence
approximately 120 degrees of the radial circumference is not articular
and amenable to open reduction internal fixation (ORIF) for fracture15

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.
14 PART I Fundamentals and General Considerations
Guiding ridge Greater sigmoid notch
Transverse groove
of greater
sigmoid notch
Tubercle Olecranon
Ulnar tuberosity
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.
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.
(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
of the radial head is void of cartilage. This part of the radial head lacks
subchondral bone and thus is not as strong as the part that supports
the articular cartilage; this part has been demonstrated to be the
portion most often fractured.82 The head and neck are not colinear
with the rest of the bone and form an angle of approximately 15
degrees with the shaft of the radius, directed away from the radial
tuberosity28 (see Fig. 2.8).
Proximal Ulna
In most individuals, a transverse portion of nonarticular cartilage
divides the greater sigmoid notch into an anterior portion comprising
the coronoid and the posterior olecranon (Fig. 2.14).
Coronoid
Radial notch
Supinator crest
and tuberosity
B
30°
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.
In the lateral plane, the sigmoid notch forms an arc of about 190
degrees.73 The contour is not a true hemicircle but rather is ellipsoid.
This explains the articular void in the midportion.84
The orientation of the articulation is approximately 30 degrees
posterior to the long axis of the bone (Fig. 2.15). This matches the
30-degree anterior angulation of the distal humerus, providing stabil-
ity in full extension. In the frontal plane, the shaft is angulated from
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
is discussed in Chapter 3.
The lesser sigmoid notch consists of a depression with an arc of
about 70 degrees and is situated just distal to the lateral aspect of the
coronoid and articulates with the radial head.
 CHAPTER 2 Anatomy of the Elbow Joint 15

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
of the coronoid medially as well as to the annular ligament laterally.
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
greatest capacity of the elbow, 25 to 30 mL,69 occurs at about 80 degrees
of flexion.40,69
The anterior capsule is normally a thin transparent structure, but
significant strength is provided by transverse and obliquely directed
fibrous bands.22,56
Plica synovalis. A fold of the anterior capsule, the plica synovalis,
is invariably present but is of variable prominence. Duparc credits
Testut with the original description in 1928,24 but the clinical relevance
as the cause of a snapping elbow is credited to Miyazaki et al. in 1958.54
It courses from proximal to distal and obliquely from lateral to medial.
FIG 2.16 There is a slight (approximately 4 degrees) valgus angulation
of the shaft of the ulna with respect to the greater sigmoid notch.
In so doing, it crosses the joint obliquely over the radial head and neck
and inserts into the anterior distal capsule near the lesser sigmoid
notch (Fig. 2.19). While a normal structure, it can become thickened
and in so doing produces the well-recognized symptom complex rec-
ognized as a snapping elbow. It has also been implicated in tennis
elbow–like symptoms in those without the classic snapping sensation
(see Chapter 59).
The anterior capsule is, of course, taut in extension but becomes
lax in flexion. The joint capsule is innervated by highly variable
branches from all major nerves crossing the joint, including the
contribution from the musculoskeletal nerve (Fig. 2.20).29
16 PART I Fundamentals and General Considerations

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).
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