Principles of Hand Surgery and Therapy PDF
Preview Principles of Hand Surgery and Therapy
Principles of Hand Surgery and Therapy THIRD EDITION THOMAS E. TRUMBLE, MD Chief of Bellevue Hand Institute Bellevue Bone and Joint Physicians Bellevue, Washington GHAZI M. RAYAN, MD Clinical Professor Orthopedic Surgery University of Oklahoma Adjunct Professor of Anatomy/Cell Biology University of Oklahoma Director of Oklahoma Hand Surgery Fellowship Program Department of Hand Surgery INTEGRIS Baptist Medical Center Oklahoma City, Oklahoma JEFFREY E. BUDOFF, MD Orthopaedic Surgeon SouthWest Orthopedic Group Houston, Texas MARK E. BARATZ, MD Vice Chairman Department of Orthopaedics University of Pittsburgh Medical Center Pittsburgh, Pennsylvania DAVID J. SLUTSKY, MD The Hand and Wrist Institute Torrance, California Chief of Reconstructive Hand Surgery Harbor-UCLA Torrance, California 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 PRINCIPLES OF HAND SURGERY AND THERAPY, THIRD EDITION ISBN: 978-0-323-39975-3 Copyright © 2017 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). David J. Slutsky owns copyright for his original images, videos and other non-manuscript items which is used in the Work. 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 evaluat- ing and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liabil- ity, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2010 and 2001. Library of Congress Cataloging-in-Publication Data Names: Trumble, Thomas, editor. | Rayan, Ghazi M., editor. | Budoff, Jeffrey E., editor. | Baratz, Mark, editor. | Slutsky, David J., editor. Title: Principles of hand surgery and therapy / [edited by] Thomas E. Trumble, Ghazi M. Rayan, Jeffrey E. Budoff, Mark E. Baratz, David J. Slutsky. Other titles: Hand surgery and therapy Description: Third edition. | Philadelphia, PA : Elsevier, Inc., [2017] | Includes bibliographical references and index. Identifiers: LCCN 2016041047 | ISBN 9780323399753 (hardcover : alk. paper) Subjects: | MESH: Hand--surgery | Hand Injuries--therapy | Hand Deformities--therapy Classification: LCC RD559 | NLM WE 830 | DDC 617.5/75044--dc23 LC record available at https://lccn.loc.gov/2016041047 Content Strategist: Maureen Iannuzzi Content Development Manager: Rebecca Gruliow Publishing Services Manager: Catherine Jackson Senior Project Manager: Daniel Fitzgerald Designer: Miles Hitchen Printed in China. Last digit is the print number: 9 8 7 6 5 4 3 2 1 Contributors Joshua M. Abzug, MD Jeffrey D. Boatright, MD, MS Adam H. Dalgleish, CRNA, MSN Assistant Professor Department of Orthopaedic Surgery Director of Anesthesia University of Maryland School of University of Virginia Health System Eastside Surgery Center Medicine Charlottesville, Virginia Issaquah, Washington Director United States United States Pediatric Orthopaedics 21: The Paralytic Hand and Tendon Regional Anesthesia for the Upper Timonium, Maryland Transfers Extremity United States Jeffrey E. Budoff, MD Seth D. Dodds, MD 3: Pediatric Fractures Orthopaedic Surgeon Associate Professor 23: Upper Limb Reconstruction in Persons SouthWest Orthopedic Group Hand and Upper Extremity Surgery With Tetraplegia Houston, Texas Department of Orthopaedics Brian D. Adams, MD United States University of Miami Baylor College of Medicine 24: Tendinopathies of the Hand, Wrist, Miller School of Medicine Department of Orthopedic Surgery and Elbow Miami, Florida Houston, Texas United States Gregory M. Buncke, MD United States 12: Hand Infections, Injection Injuries, The Buncke Clinic 6: The Distal Radioulnar Joint and Snake Bites, and Extravasation Injuries San Francisco, California Triangular Fibrocartilage Complex United States Zachary Elstad, BS Julie Adams, MD 31: Thumb Reconstruction Following Medical Student Associate Professor Partial or Complete Amputation Georgia Regents University–University Orthopedic Surgery 32: Soft-Tissue Coverage of the Hand of Georgia Medical Partnership Mayo Clinic Medical College of Georgia Katherine A. Butler, MD Rochester, Minnesota and Austin, Athens, Georgia Orthopedic Surgery Resident Minnesota United States MedStar Union Memorial Hospital United States 2: Phalangeal Fractures and Baltimore, Maryland 7: Diagnostic and Therapeutic Arthroscopy Interphalangeal Joint Injuries United States for Wrist Injuries 20: Compressive Neuropathies Brooke Eytchison, OTR/L Salah Aldekhayel, MD, MEd Bellevue Hand Institute A. Bobby Chhabra, MD Hand & Microsurgery Fellow Bellevue Bone and Joint Physicians Lillian T. Pratt Distinguished Professor Harvard Medical School Bellevue, Washington and Chair Beth Israel Deaconess Medical Center United States Department of Orthopaedic Surgery Boston, Massachusetts Appendix: Hand Therapy University of Virginia Health System United States Charlottesville, Virginia John R. Fowler, MD 34: Congenital Hand Anomalies United States Assistant Professor Mark E. Baratz, MD 21: The Paralytic Hand and Tendon Department of Orthopaedics Vice Chairman Transfers University of Pittsburgh Department of Orthopaedics Pittsburgh, Pennsylvania Jason A. Craft, MD University of Pittsburgh Medical Center United States Mississippi Sports Medicine & Pittsburgh, Pennsylvania 9: Compartment Syndrome and Volkmann Orthopaedic Center United States Ischemic Contracture Jackson, Mississippi 37: Elbow Arthritis United States William B. Geissler, MD Andrea S. Bauer, MD 36: Elbow Arthroscopy and Instability Alan E. Freeland Chair of Hand Surgery Assistant Professor Professor and Chief, Division of Hand & Alexander B. Dagum, MD, FRCS (C), Department of Orthopaedic Surgery Upper Extremity FACS Harvard Medical School Chief, Section of Arthroscopic Surgery & Professor of Surgery and Orthopaedic Hand and Upper Extremity Surgeon Sports Medicine Surgery Department of Orthopaedic Surgery Department of Orthopaedic Surgery and Executive Vice Chair of Surgery and Boston Children’s Hospital Rehabilitation Chief of Plastic Surgery Boston, Massachusetts University of Mississippi Medical Center Stony Brook Medicine United States Jackson, Mississippi Department of Surgery 17: Brachial Plexus Injuries United States Stony Brook, New York 36: Elbow Arthroscopy and Instability United States 30: Replantation v vi Contributors Isak A. Goodwin, MD Robin King, CRNA, MSN Keith Lemay, PA-C Fellow Staff CRNA Bellevue Hand Institute The Buncke Clinic Anesthesia Department Bellevue Bone and Joint Physicians San Francisco, California Eastside Surgery Center Bellevue, Washington United States Issaquah, Washington United States 31: Thumb Reconstruction Following United States 14: Flexor Tendon Injuries Partial or Complete Amputation Regional Anesthesia for the Upper 25: Osteoarthritis Extremity Steven C. Haase, MD, FACS Kenneth R. Means, Jr., MD Clinical Associate Professor of Surgery Jason Kinney, BS Attending Physician & Clinical Research and Orthopaedic Surgery Medical Student Director Surgery Georgia Regents University–University Curtis National Hand Center University of Michigan Health System of Georgia Medical Partnership MedStar Union Memorial Hospital Ann Arbor, Michigan Medical College of Georgia Baltimore, Maryland United States Athens, Georgia United States 13: Burns and Frostbite of the Hand United States 20: Compressive Neuropathies 2: Phalangeal Fractures and Jacques Henri Hacquebord, MD Siddhant K. Mehta, MD Interphalangeal Joint Injuries Hand/Micro Fellow Resident Department of Orthopaedic Surgery Scott H. Kozin, MD Department of Orthopaedic Surgery and University of California Irvine Clinical Professor Rehabilitation Orange, California Department of Orthopaedic Surgery University of Mississippi Medical Center United States Temple University Jackson, Mississippi 26: Rheumatoid Arthritis Chief of Staff United States Shriners Hospitals for Children 36: Elbow Arthroscopy and Instability Warren C. Hammert, MD Philadelphia, Pennsylvania Professor of Orthopaedic and Plastic Scott A. Mitchell, MD United States Surgery Baylor College of Medicine 3: Pediatric Fractures Chief Department of Orthopedic Surgery 23: Upper Limb Reconstruction in Persons Division of Hand Surgery Houston, Texas With Tetraplegia Department of Orthopaedics and United States Rehabilitation Opeyemi E. Lamikanra, MD 6: The Distal Radioulnar Joint and University of Rochester Medical Center Orthopaedic Hand Surgery Fellow Triangular Fibrocartilage Complex Rochester, New York Department of Orthopaedics Susan Morehouse, PT, MSPT United States University of Miami Department of Physical Therapy and 11: Amputations and Prosthetics Miller School of Medicine Occupational Therapy Service Miami, Florida Dennis J. Heaton, MSPA Level 3 Physical Therapist United States DO Candidate 2017 Boston Children’s Hospital 12: Hand Infections, Injection Injuries, Pacific Northwest University Boston, Massachusetts Snake Bites, and Extravasation Injuries Yakima, Washington United States United States Lisa Lattanza, MD 17: Brachial Plexus Injuries 35: Fractures of the Forearm and Elbow Professor Peter M. Murray, MD Chief of Hand and Upper Extremity Thomas B. Hughes, MD Professor and Chairman Surgery Clinical Associate Professor of Department of Orthopaedic Surgery Department of Orthopaedic Surgery Orthopaedic Surgery Consultant University of California, San Francisco University of Pittsburgh School of Department of Orthopaedic Surgery and San Francisco, California Medicine Neurosurgery United States Orthopaedic Specialists Mayo Clinic 15: Extensor Tendon Injuries UPMC Staff Physician 35: Fractures of the Forearm and Elbow Pittsburgh, Pennsylvania Department of Orthopaedic Surgery and United States Anthony James Lauder, MD Nemoursurgery 9: Compartment Syndrome and Volkmann Longview Orthopedic Associates Children’s Clinic Ischemic Contracture Longview, Washington Jacksonville, Florida United States United States Clyde Johnson, PT, CHT 27: Carpal Avascular Necrosis: Kienböck 33: Benign and Malignant Neoplasms of Bellevue Hand Institute Disease and Preiser Disease the Upper Extremity Bellevue Bone and Joint Physicians Bellevue, Washington Nels Leafblad, MD Andrei Odobescu, MD United States University of Minnesota Medical School The Buncke Clinic Appendix: Hand Therapy Minneapolis, Minnesota San Francisco, California United States United States Sanjeev Kakar, MD 22: Cerebral Palsy, Stroke, and Traumatic 32: Soft-Tissue Coverage of the Hand Associate Professor of Orthopedics Brain Injury College of Medicine Kyle Oh, MD Mayo Clinic Thomas P. Lehman, MD, PT Physician Orthopedic Surgery Department of Orthopedic Surgery Kirkland Spinecare Mayo Clinic University of Oklahoma Kirkland, Washington Rochester, Minnesota Oklahoma City, Oklahoma United States United States United States 18: Management of Chronic Upper 33: Benign and Malignant Neoplasms of 1: Fractures and Ligament Injuries of the Extremity Pain and Factitious the Upper Extremity Thumb and Metacarpals Syndromes Contributors vii Derek Omori, PA-C, MPAS Melvin P. Rosenwasser, MD Megan Swanson, OTR/L, CHT Bellevue Hand Institute Robert E. Carroll Professor of Hand Bellevue Hand Institute Bellevue Bone and Joint Physicians Surgery Bellevue Bone and Joint Physicians Bellevue, Washington Columbia University Medical Center Bellevue, Washington United States Attending Physician United States 5: Scaphoid Fractures New York-Presbyterian Hospital Appendix: Hand Therapy New York, New York Samantha Lee Piper, MD Thomas E. Trumble, MD United States Hand and Upper Extremity Surgery Chief of Bellevue Hand Institute 4: Carpal Instability Department of Orthopedic Surgery Bellevue Bone and Joint Physicians Southern California Permanente Medical Mellisa Roskosky, MSPH Bellevue, Washington Group Clinical Research Program Manager United States San Diego, California Research 5: Scaphoid Fractures United States Athens Orthopedic Clinic 14: Flexor Tendon Injuries 15: Extensor Tendon Injuries Athens, Georgia 18: Management of Chronic Upper United States Extremity Pain and Factitious Margaret A. Porembski, MD 2: Phalangeal Fractures and Syndromes Instructor Interphalangeal Joint Injuries 19: Management of Upper Extremity Oklahoma Hand Surgery Fellowship Vascular Disorders and Injuries Program Cameron Schick, MD 25: Osteoarthritis Department of Hand Surgery Bellevue Hand Institute 26: Rheumatoid Arthritis Integris Baptist Medical Center Bellevue Bone and Joint Physicians 29: Ganglion, Mucous Cyst, and Carpal Oklahoma City, Oklahoma Bellevue, Washington Boss United States United States 31: Thumb Reconstruction Following 28: Dupuytren Disease 7: Diagnostic and Therapeutic Arthroscopy Partial or Complete Amputation for Wrist Injuries Gregory Rafijah, MD 32: Soft-Tissue Coverage of the Hand 10: Nail Bed and Fingertip Injuries Associate Clinical Professor 35: Fractures of the Forearm and Elbow 18: Management of Chronic Upper Orthopaedic Surgery Extremity Pain and Factitious Joseph Upton, MD University of California Irvine Syndromes Associate Professor Orange, California 19: Management of Upper Extremity Harvard Medical School United States Vascular Disorders and Injuries Senior Associate in Surgery Anatomy and Examination of the Hand, Boston Children’s Hospital Wrist, Forearm, and Elbow Michael J. Schreck, MD Boston, Massachusetts 8: Fractures and Malunions of the Distal Resident United States Radius Department of Orthopaedics and 34: Congenital Hand Anomalies 26: Rheumatoid Arthritis Rehabilitation University of Rochester Medical Center Ann E. Van Heest, MD Ghazi M. Rayan, MD Rochester, New York Professor Clinical Professor United States Department of Orthopaedic Surgery Orthopedic Surgery 11: Amputations and Prosthetics University of Minnesota University of Oklahoma Minneapolis, Minnesota Adjunct Professor of Anatomy/Cell Keith A. Segalman, MD United States Biology Associate Professor 22: Cerebral Palsy, Stroke, and Traumatic University of Oklahoma Orthopedic Surgery Brain Injury Director of Oklahoma Hand Surgery Johns Hopkins University Fellowship Program Attending Physician Thanapong Waitayawinyu, MD Department of Hand Surgery Curtis National Hand Center Associate Professor INTEGRIS Baptist Medical Center MedStar Union Memorial Hospital Hand and Microsurgery Oklahoma City, Oklahoma Baltimore, Maryland Department of Orthopaedics United States United States Faculty of Medicine 1: Fractures and Ligament Injuries of the 20: Compressive Neuropathies Thammasat University Thumb and Metacarpals Klong-Luang, Pathumthani Michael S. Shuler, MD 28: Dupuytren Disease Thailand Hand & Upper Extremity Surgeon 34: Congenital Hand Anomalies 27: Carpal Avascular Necrosis: Kienböck Athens Orthopedic Clinic Disease and Preiser Disease Patrick L. Reavey, MD, MS Athens, Georgia 29: Ganglion, Mucous Cyst, and Carpal Assistant Professor of Surgery United States Boss Section of Plastic and Reconstructive 2: Phalangeal Fractures and Surgery Interphalangeal Joint Injuries Peter M. Waters, MD University of Chicago Medicine Professor David J. Slutsky, MD Chicago, Illinois Department of Orthopaedic Surgery The Hand and Wrist Institute United States Harvard Medical School Torrance, California Anatomy and Examination of the Hand, Orthopaedic Surgeon in Chief Chief of Reconstructive Hand Surgery Wrist, Forearm, and Elbow Department of Orthopaedic Surgery Harbor-UCLA Boston Children’s Hospital Carol Recor, OTR/L, CHT Torrance, California Boston, Massachusetts University of Washington Medical United States United States Center 16: Nerve Repair and Nerve Transfers 17: Brachial Plexus Injuries Seattle, Washington United States Appendix: Hand Therapy viii Contributors Andrew James Watt, MD Benjamin K. Wilke, MD David W. Zeltser, MD Attending Physician Department of Orthopedic Surgery Hand Surgery Fellow Associate Program Director Mayo Clinic Orthopaedic Surgery Plastic & Reconstructive Surgery Jacksonville, Florida Columbia University Medical Center The Buncke Clinic United States New York, New York San Francisco, California 33: Benign and Malignant Neoplasms of United States Adjunct Clinical Faculty the Upper Extremity 4: Carpal Instability Plastic & Reconstructive Surgery Stanford University Hospitals & Clinics Stanford, California United States 31: Thumb Reconstruction Following Partial or Complete Amputation Preface The practice of medicine is unpredictable, which is part of the 2. Whenever I am tired, I need to make sure to avoid short cuts. challenge but also the risk of caring for patients. As surgeons 3. Bradburn’s law: I always need to believe my worst x-ray and learn and develop their skills, they forge certain principles and act on it. guidelines that keep their patients safe. I call this collection of 4. Full disclosure: I must understand the real problem causing experience and wisdom “the surgeon’s intuition.” How does the the issue with the deformity, fracture displacement, and so experienced clinician avoid missing a critical diagnosis, such as a on before starting surgery, no matter how many tests or how subtle compartment syndrome? How does the seasoned surgeon much research it takes on my part. piece everything back together when things go badly between 5. Emergency room recycle rule: If a patient returns to the dangerous machinery and the delicate hand? Lastly, what do emergency room in the same time window, I have to advance you do with the exasperating patient with a real problem but no the workup and be ready for emergency surgery. obvious cause? The goal of Principles of Hand Surgery and Therapy 6. Compartment syndrome dictum: If I think it might be is to distill the intangible intuitions from the Advanced Graduate compartment syndrome, it is my problem to solve it Program of Hard Knocks into an algorithm, a manual, or the immediately. Holy Grail, much the same way Virginia Apgar taught her stu- 7. Reagan “Trust but verify”: If I ask for an emergency consult, dents what she looked for when she decided to hand a thriving I have to verify that the consult is done within 24 hours. baby to its mother or call for an intensive care team for a baby on 8. Lifeline rule: If I am over my head, I need to humbly call in a the verge of collapse, so that maybe the next generation would not “lifeline” by phoning a friend to ask for advice. have to learn critical lessons by hard knocks that can be stressful 9. Back-up plan: Even for the simplest case, such as hardware for the physician and the patient. I have given a lot of thought to removal, I have to have a back-up plan to make sure I can these lessons. My co-editors—Ghazi Rayan, MD, Jeffrey Budoff, find that elusive screwdriver (or other key equipment) or MD, Mark Baratz, MD, and David Slutsky, MD—are the type of have permission to perform that additional surgery if the un- “go-to” surgeons you call when things get tough, and they helped expected happens. to assemble an incredible group of authors who are always there 10. Hardest of all: When things are not going well in surgery, in a pinch, whether it is by contributing a complex chapter or I need to stay calm because the rest of the team takes their mapping out a solution to a heartbreaking complication being clues from you the surgeon. If you get rattled and lose con- experienced by a patient. The goal of Principles of Hand Surgery centration, so does the entire team. If you are calm but deter- and Therapy is to draw upon the collective insights of the com- mined, they will stay focused and work efficiently. munity of hand surgeons and hand therapists to provide the best I am grateful for the lessons that someone else taught me, to spare recommendations for surgery and rehabilitation to expertly and me the agony and embarrassment of making such a mistake. Other safely care for our patients. The following intuitions or guidelines lessons were painful. Much of what I am sharing is part of a collec- are not always easy or expedient to follow, especially when my ego tive experience. Feedback and more lessons from wiser surgeons are tries to get in the way, but they have served me when followed: always welcome. The practice of medicine is always evolving. 1. Whenever any member of the team is worried about some- Thank you for understanding. thing, such as a nerve at risk, I need to take time out to solve the problem and make sure it is safe to proceed. Thomas E. Trumble, MD ix Acknowledgments This textbook is a labor of love, and it comes at a great cost in wizard, Reid Malmquist, for computer solutions, video expertise, terms of time and finances. During the time the authors contrib- and overall IT troubleshooting. uted to write a chapter, they could have been working clinically To the publishing team at Elsevier, especially Maureen and paid for at least 1 year of college tuition for one of their chil- Iannuzzi and Daniel Fitzgerald—thank you for babysitting us, dren. Why do we write these textbooks? Because we learned a keeping us on track, and letting us add the “cool stuff” for this substantial portion of our craft the hard way, and we remember third edition. being up in the wee hours with that cold sweat trying figure out To all the editors and coauthors, as my friends and c olleagues— how to get that impossible fracture back together or to conjure up we owe you a debt of gratitude for your leadership in our societies a way to cover that ever-expanding soft-tissue defect. We wanted and your amazing contributions to this publication. You are the to write our lessons into a practical book with detailed figures and “band of brothers and sisters” that I turn to when I have tough videos to provide step-by-step instructions to help our colleagues questions, and I know that you are always available to our readers to solve tough problems for their patients to relieve pain and at meetings and on e-mail as that lifeline of support in this chal- improve function. We also feel your pain when it comes to study- lenging world of medicine. ing for “the boards.” This book contains all the core knowledge But most of all, I want to thank you as my friends and family. to pass a board examination in hand surgery. Life is humbling, and I have enough sense at this point in my To my wife Sara—thank you for your steadfast love, support, career to realize the mistakes that I have made and to give thanks and organizational skills to launch a book during a perfect storm for your support so that I can learn from them and overcome of life’s challenges. them. To our team at Bellevue Hand Institute—I greatly appreci- In remembrance of Dorothy Mae Trumble (April 28, 1928 to ate our family of Alan Boyd, Elle Busch, Keith Lemay, PA-C, April 13, 1996), a loving mother and wife who “always believed and Derek Omori, PA-C for tracking down figures, assisting with in her boys.” videos, and helping to edit. Of course, a shout-out goes to my IT x Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow Patrick L. Reavey, MD, MS, Gregory Rafijah, MD KEY SURGICAL VIDEOS Video E1-1 Elbow Anatomy Video E1-4 General Examination of Hand and Wrist Tendon See the video for a detailed anatomy of the elbow. Function Video E1-2 Radius Anatomy See the video for a detailed demonstration of an exam for tendon function in the wrist and digits. See the video for a detailed anatomy of the distal radius. Video E1-3 Wrist Anatomy See the video for a detailed anatomy of the wrist. INTRODUCTION with humerus both resist posterior subluxation and the coronoid additionally provides resistance to varus stress. The goal of this chapter is to provide a detailed discussion of The articulation between the radial head and radial notch of the anatomy of the hand, wrist, forearm, and elbow, with a focus the proximal ulna forms a synovial pivot joint, allowing rotation on critical information for the surgeon. Other chapters contain of the forearm into supination and pronation (Fig. E1.3). Distal detailed descriptions of specific anatomy (ie, carpal ligaments; see to the radial neck, the radial tuberosity is a medial-sided eminence Chapters 4 and 5) and key aspects of examining these pathologies. that serves as an attachment for the biceps tendon. Radiographi- Except for the neurovascular anatomy, this chapter will be cally the radial tuberosity projects medially and opposite to the divided into anatomic areas. This results in some repetition of radial styloid of the distal radius with the forearm in supination. information, especially with regard to the musculature of the arm. However, this format will closely tie together with the Ligaments examination section and will reinforce useful clinical knowledge. The anatomy of the upper extremity can be described by The stability of the elbow through the entire arc of motion is structural relationships (radial vs. ulnar, palmar or volar vs. dor- achieved by a complex group of ligaments anterior, posterior, sal) or relative to the position of the arm in a supine patient lateral, and medial. The medial ligament complex is more devel- (medial vs. lateral, anterior vs. posterior). These different terms oped and offers more stability than the lateral. This complex will be used interchangeably based on commonly used para- consists of anterior, posterior, and transverse bundles, of which digms. It is important to remember that in the supine position the anterior bundle is the major medial stabilizer (Fig. E1.4).1 the radius is in a lateral position while the ulna is medial, and Isometric fibers do not exist within the anterior medial collateral the dorsal aspect of the forearm and hand is posterior while the ligament (AMCL); however, “nearly” isometric areas are located volar surface is anterior. on the lateral aspect of the attachment site of the AMCL on the A list of common abbreviations used in this chapter appears medial epicondyle, near the anatomic axis of rotation. The lateral in Box E1.1. collateral ligaments consist of the radial collateral ligament, the lateral ulnar collateral ligament (LUCL), the annular ligament (which encircles the radial head), and the accessory lateral col- Elbow Anatomy lateral ligament (Fig. E1.5). The annular ligament and LUCL are considered the most important lateral stabilizers of the elbow.2 Bones The anterior and posterior ligaments are merely thickenings of the capsule and offer little anteroposterior stability over the bony The elbow joint is a complex structure comprising three articula- configuration. The insertion of the lateral (radial) collateral liga- tions: humerus and ulna, humerus and radius, and proximal ulna ment complex close to the axis of rotation is therefore uniformly and radius. The axis for elbow rotation is centered at trochlea and taut throughout flexion-extension movement. capitellum. The trochlea of the distal humerus articulates with The annular ligament originates and inserts on the anterior the trochlear notch (also called semilunar notch) of the ulna. The and posterior margins of the lesser sigmoid notch. The anterior coronoid process of the ulna is a triangle-shaped anterior projec- insertion becomes taut during supination, and the posterior ori- tion forming the distal portion of the trochlear notch and is more gin becomes taut in pronation. prominent on the radial aspect. The humeral capitellum articu- The LUCL functions as the primary lateral stabilizer of the lates with the radial head. The humeroulnar and humeroradial ulnohumeral joint (functions in stabilizing a varus) stress, and defi- joints together form a synovial hinge joint, allowing the elbow ciency of this ligament results in posterolateral rotatory instability. one axis of motion: flexion and extension. The medial ridge of The LUCL inserts on the distal humerus at the isometric point. the trochlea is slightly larger than the lateral ridge of the capi- tellum. This gives the articular surface approximately 6 degrees Musculature of outward motion along the epicondylar axis (carrying angle). Overall, the bony anatomy results in inherent elbow stability The triceps muscle is the extensor of the elbow. The three heads (Figs. E1.1 and E1.2): the coronoid and radial head articulations of the triceps originate in the glenoid and humerus, and they e1
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