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Introduction
The elbow is a complex joint that connects the hand to
the shoulder and allows the hand to work in space. It
has a complex arrangement of osseous and ligamentous
interactions that contribute to its stability. The proximal
radius is cylindrical with a concave surface that articulates
with the capitellum. The greater sigmoid notch of the
olecranon articulates with the trochlea, which is shaped
like a spool. This is a hinge joint (ginglymus) that allows
flexion and extension. There is also an articulation between the ulna and radius, and this, along with the radiocapitellar joint, is a trochoid joint that allows axial rotation
and pivoting [1].
The elbow capsule and ligaments add to the inherent osseous stability of the joint. The capsule surrounds all three
of the elbows articulations. Medially there is a complex of
ligaments that comprise the medial collateral ligament
complex. There are anterior, posterior, and transverse
(oblique/ligament of Cooper) bundles. Previous work
has established that the anterior bundle is the most important stabilizer for valgus torques [29]. This anterior
bundle can be divided into anterior and posterior bands.
The anterior is taught in extension and the posterior in
flexion due to the cam effect of the condyles [4]. The lateral collateral ligament complex is comprised of the radial
and ulnar collateral, annular, and accessory ligaments. This
complex is responsible for stabilizing the elbow against
varus stress and posterolateral instability.
These basic osseous and ligamentous stabilizers lead to an
inherently stable joint, and chronic joint instability after
simple dislocation is rare [1012]. Serious trauma and
chronic injury due to athletic activities can lead to instability. Further delineation of the biomechanics and kinematics of the elbow will help us prevent and treat elbow
injuries in the future.
Elbow stability
With advances in techniques and hardware for open reduction and internal fixation of elbow fracture dislocations, interest in elbow stability has increased. The terrible triad
of the elbow medial and lateral collateral injury, radial
head fracture, and coronoid fracture lead to elbow instability. Several experiments were performed recently to further elucidate how these structures affect elbow stability.
Schneeberger et al. [13] designed an interesting study to
simulate how the radial head and coronoid process contribute to posterolateral instability. Their study compared
cadaveric elbows that had combinations of radial head
276
ulnaris is the most important, followed by the flexor digitorum superficialis and then the pronator teres.
Pediatric supracondylar humerus fractures are commonly
treated by the orthopedist and can lead to a cubitus varus
deformity. It has been thought that cubitus varus was only
a cosmetic deformity and had no long-term consequences
[1820]. Recently, posterolateral instability in patients
with longstanding cubitus varus has been reported in
the literature [2126]. Beuerlein et al. [27] performed
an experiment to test the effect of cubitus varus on lateral
collateral ligament strain and ulnohumeral joint widening.
Interestingly, they found that at 20! degrees of varus there
was significant joint space widening and a significant increase in ligament strain at 25!. This new information
may change the way orthopedists treat pediatric patients
with residual cubitus varus after supracondylar humerus
fractures.
278 Elbow
Miscellaneous topics
Much research has been done on gait analysis of the lower
extremity, but little attention has been focused on these
same characteristics for activities of daily living for the upper extremity. This information will help us design better
implants and design better computer models of the forces
and motions around the shoulder and elbow. Murray and
Johnson [33] performed an experiment that catalogued
the kinematics of some basic activities of the upper extremity and then used these data to calculate the forces
and motions around the shoulder and elbow. Interestingly,
the greatest amount of elbow flexion was required to reach
the back of the head and the greatest moment arm occurred during lifting a block to head height. They omitted
hygienic tasks from their study and this will need to be
elucidated in the future.
A long-term complication with elbow arthroplasty has
been stress at the bonecement interface. In the past,
constrained prostheses were used and failed at this interface. Now less constrained devices are used, but exactly
how much freedom is necessary is unknown. Kasten
et al. [34] studied ulnar motion through pronation and supination and found that the ulna rotates 3.2!. This may
have significance for the design of future implants.
Finally, computer models of the elbow and other joints will
play a significant role in the future development of total
joint prostheses and possibly one day replace cadaveric or
in-vitro studies if they become accurate enough. Recently
Giesl et al. [35] developed a human elbow computer model
that demonstrates elbow stability from osseous and muscle forces at 90! of flexion. Although this has little clinical
relevance now, it is exciting to ponder what we may be
able to do with these simulations in the future.
Conclusion
The elbow is a complex joint with interactions between
osseous, ligamentous, and muscular units. It is an integral
joint in the upper extremity that connects the hand to the
shoulder and torso, allowing us to perform many of our activities of daily living and our athletic endeavors. Trauma
to this important joint can be a devastating injury, especially when it causes instability. Recent literature has
helped to elucidate the roles of the radial head and coronoid and collateral ligaments in elbow stability. These
experiments on cadaveric specimens also suggest what
types of repairs will be required to achieve stability, and
which ones we can forego. Interestingly, new literature
has challenged our belief that cubitus varus deformities
of the elbow were merely cosmetic deformities and that
these injuries may lead to instability. New kinematic data
on pediatric throwers suggest that, in order to prevent elbow injury, we might want to alter the mechanics of throwing in child athletes to limit the amount of external
rotation that they achieve. A database containing the kinematics of the upper extremity during daily activities will
help us to better design total joints and understand the
motions and forces required to perform these tasks. Finally,
new computer models may one day help us to perform experiments without the use of cadavers or in-vitro studies.
of special interest
of outstanding interest
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