◀ 견관절과 주관절의 기초 I

Biomechanics of the elbow

충남의대

신현대

Elbow function,
1) link in the lever arm system
2) fulcrum of the forearm lever
3) load-carrying joint

Kinematics

- Trochoginglymoid joint
: 2 degrees of motion (flexion-extension, supination-pronation)
- Articular component
1) trochlea, capitulum
2) upper end of the ulna
3) head of the radius
- Three articulations : radiohumeral, ulnohumeral, radioulnar

1. Flexion-Extension

- Elbow joint motion: hinge type

- Flexion axis
: helical motion of the flexion axis
: attributed to the obliquity of the trochlear
groove along which the ulna moves
- Amount of potential varus-valgus and axial
laxity that occurs during elbow flexion
: 3~4 degrees

2. Center of rotation

- Locus of the instanat center of rotation

: area 2 to 3 mm in diameter at the center of
the trochla Fig. 1. configuration and dimensions of the locus of
- Axis of motion in flexion and extension the instant center of rotation of the elbow.

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: Does not change during flexion-extention (Youm and associate)

: Variations of up to 8 degrees in the position of the screw axis
(Morrey and associate)
1) axis of rotation: internally rotates 3- 8 degrees relative to the plane of the epicondyles.
2) In the coronal plane: a line perpendicular to the axis of rotation forms a proximally and
laterally opening angle of 4 to 8 degrees with the long axis of the humerus.
→ inspired the development of semiconstrained elbow replacement design

- Center of rotation?identified from external landmarks.

: In the sagittal plane,
1) axis lies anterior to the midline of the humerus
2) axis lies on a line that is collinear with anterior cortex of the? distal humerus
: In the coronal orientation, idefined by the plane of the posterior cortex of the distal humerus.
: Axis emerges from the center of the projected center of the capitellum and from the
anterioinferior aspect of the medial epicondyle.

3. Forearm rotation

- Radiohumeral joint
: Common transverse axis with the elbow joint
: Coincides with the ulnohumeral axis during flexion-extension motion.
- Radius rotates around the ulna
: Allowing for forearm rotation or supination-pronation.
- Longitudinal axis of the forearm
: Convex head of radius at proximal radioulnar joint - convex articular surface of ulna at the dist
radioulnar joint.
- Axis is oblique, rotation is independent of elbow position.
- Axis of forearm rotation (Mori)
: Passing through the attachment of the interosseous membrane at the ulna in the distal fourth of
the forearm
- Less than 10% angulation of either the radius or the ulna
: Causes no functionally significant loss of forearm rotation.
- Radius has been shown to migrate proximally whit pronation.

4. Carrying angle

- Defined as that formed by the long axis of the humerus and the long axis of the ulna.
- Men: averages 10 to 15 degrees (Women, 15 to 20 degrees)
- Definition 1: the carrying angle is the acute angle formed by the long axis of the humerus as the
long axis of the ulna projects on the plane contailning the humerus.

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- Definition 2: the carrying angleis described as the acute angle formed by the long axis of theulna
and the projection of the long axis of the humerus onto the plane of ulna.
- Definition 3: the carrying angle is defined analytically as the abduction-adduction angle of the ulna
whit respect to the humerus when eulerian angles are being used to describe arm motion.

5. Restriction of motion

- Elbow flexion range

: from 0 degree or slightly hyperextended to about 150 degrees in flexion.
- Forearm rotation
: from 75 degrees (pronation) to 85 degrees (supination).
- Cartilage of the trochlea
: arc of about 320 degrees
- Sigmoid notch
: arc of about 180 degrees
- Arc of the radial head depression
: 40 degrees, which articulates with the capitullum, presenting an angle of 180 degree.
- The factors limiting joint extension (Kapandji)
: impact of the olecranon process on the olecranon fossa
: tension of the anterior ligament and the flexor muscles
: tautness of the anterior bundle of the medial collateral ligament as serving as a check to
extension
- The factors limiting passive flexion
: impaction of the radial head against the radial fossa
: impact of the coronoid process against coronoid fossa
: tension from the capsules and triceps
: Anterior muscle bulk of the arm and forearm, along with contraction of the triceps prevent active
flexion beyond 145 degrees.
- For pronation and supination (Braune and Flugel)
: passive resistance of the stretched antagonist muscle restricts the excursion range?more than that
of the ligamentous structures.
- Quadrate ligament (Spinner and Kaplan)
: provide some static constraint to forearm rotation.
- Impingement of tissue restrains pronation,
: especially by the flexor pollicis longus, which is forced against the deep finger flexor.
- Entire range of active excursion in an intact arm is about 150 degrees.

6. Capacity and Contact Area of the Elbow Joint

- Capacity: average about 25 ml (maximum capacity at about 80 degrees of flexion)

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- The upper rim of the radial head made no contact at all

- At the humeroulnar joint, the articular surfaces were always in contact during some phases of
movement.
- Radiocapitellar joint, contact during flexion under no externally applied load
- Contact areas of the elbow occur at four“facets”
: two at the coronoid, two at the olecranon?

Elbow Stability

- The Static soft tissue stabilizers

: include the collateral ligament complexes and the anterior capsule.
- The lateral collateral ligament originates from the lateral condyle at a point through which the axis
of rotation passes.
- The medial collateral ligament has two discrete components, neither of which originates at a site
that lies on the axis of rotation
: Anterior portion of anterior bundle is taut in extension the converse is true for posterior fibers of
anterior bundle.
: Different parts of the medial collateral ligament complex will be taut at different positions of
elbow flexion.
- The lateral collateral ligament lying on the axis of rotation will assume a rather uniform? tension,
regardless of elbow position.
- Lateral ulnar collateral ligament
: inserts on the ulna and, as such, helps to stabilize the lateral ulnohumeral joint
: essential to control the pivot shift maneuver (O’Driscoll and associates)
- Lateral ligament complex
: the major component in the varus and rotatory stability is the structure termed the lateral ulnar
collateral ligament
: lateral complex is a major stabilizer of elbow joint and functions with or without the radial head
: lateral complex is also an important stabilizer in forced varus and external rotation.

Articular and Ligamentous Interaction

Table 1. Percent contribution of restraining varus-valgus displacement

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- In extension,
: the anterior capsule provides about 70 % of soft tissue restraint to distraction, whereas the medial
collaeral ligament assumes this function at 90 degrees of flexion.
- Varus stress
: In extension, checked by the joint articulation (55 percent) and soft tissue, lat collateral ligament,
capsule
: In flexion, the articulation provides 75 percent of varus stability.
- Valgus stress
: In extension, equally divided between the medial collateral ligament, the capsule, and the joint
surface
: In flexion, the capsular constribution is assumed by the medial collateral ligament, which is the
primary stabilizer (54%) to valgus stress at this portion. Anterior portion of medial collateral
ligament provides virtually all of the structure’s functional contribution.
: The radial head is a secondary stabilizer for resisting valgus stress, whereas the medial collateral
ligament is the primary stabilizer against valgus force.
- Contribution of the articular geometry
: Valgus stress, both in extension and at 90 degrees of flexion, was primarily? (75~85%) resisted by
the proximal half of the sigmoid notch, whereas varus stress was resisted primarily by the distal
half, or the coronoid portion of the articulation, both in extension (67%) and in flexion(60%).
: Serial portions of the coronoid are removed the elbow becomes progressively more unstable.
This is especially true if the radical head has been resected. As little as 25% resection causes
elbow subluxation at about 70 dgrees of flexion.

Fig. 2. Contribution of articular geometry

Force Across Elbow Joint

Distributive forces on the articular surfaces

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- With the elbow extended and axaially loaded, distribution of stress across the joint
: 40% across the ulnohumeral joint and 60% across th radiohumeral joint
- With the elbow in valgus realignment,
: 12%t of the axial load is transmitted through the proximal end of the ulna,
- With the elbow in varus alignment,
: 94% of the axial force is transmitted to proximal ulna
- The greatest force was transmitted across the radiohumeral joint in full extension
- When elbow flexion
: inward rotation of the forearm against resistance imposes large torque to the joint
: twice body weight tension into the medial collateral ligament and three times body weight at the
radiohumeral joint
- The greatest force on the radial head occurs with the forearm in pronation
- Significant force with daily activities that not only occur at the radiohumeral & ulnohumeral joints
but also are generated in the collateral ligaments (Nicol).

REFERENCES

01. An KN and Morrey BF: Biomechanics of the elbow. In: Morrey BF 3rd ed. The elbow and its disorders.
Philadelphia, W.B Saunders: 43-60, 2000.
02. An KN, Morrey BF and Chao EYS: The effect of partial removal of proximal ulna on elbow constraint.
Clin Orthop, 209:270-279, 1986
03. Ball CM, Galatz and Yamaguchi k: Elbow instability: Treatment strategies and emerging concepts. In:
Beaty JH ed. Insttuctional course lectures. Rosemont, IL,?American academy of orthopaedic surgeons:
53-61, 2002
04. Cohen MS and Hastings H: Rotatory instability of the elbow: The anatomy and role of the lateral
stabilizers. J Bone Joint Surg, 79-A: 225-233, 1997
05. Davidson PA, Pink M, Perry J and Jobe FW: Functional anatomy of the flexor pronator muscle group in
ralation to the medial collateral ligament of the elbow. Am J soprts med, 23: 245-250
06. King GJW and An KN: Biomechanics and functional anatomy of the elbow. In: Norris TR ed.
Orthopaedic knowledge update: Shoulder and elbow, Rosemont, IL:301-310, 1997.
07. London JT: Kinematics of the elbow. J Bone Joint Surg, 61-A: 529-535, 1981.
08. Markolf KL, Lamey D, Yang S, Meals R and Hotchkiss R: Radioulnar?load-sharing in the forearm: A
study in cadavera. J Bone Joint Surg, 80-A:?879-885, 1998.
09. Morrey BF: Anatomy and kinematics of the elbow. In: Tullos HS ed. Instructional course lectures.
Illinois, American academy of orthopaedic surgeons: 11-16, 1991.
10. Morrey BF: Anatomy of the elbow joint. In: Morrey BF ed. The elbow and its disorders Philadelphia,
W.B. Saunders: 13-25. 2000.
11. Morrey BF: Applied anatomy and biomechanics of the elbow joint. In: Anderson LD ed. Instructional
course lectures. St. Louis, C.V Mosby, American academy of orthopaedic surgeons: 59-68, 1986.
12. Morrey BF and An KN: Functional anatomy of the ligaments of the elbow. Clin Orthop 201: 84-90,
1985.
13. Morrey BF, An KN and Stormont TJ: Force transmission through the radial head. J Bone Joint Surg, 70-

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A: 250-256, 1988.
14. Morrey BF and Chao EY: Passive motion of the elbow joint. J Bone Joint Surg. 58-A: 501-508, 1976.
15. Morrey BF, Tanaka S and An KN: Valgus stability of the elbow. Clin Orthop, 265: 187-195, 1991.
16. O’Driscoll SW, Bell DF and Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint
Surg, 73-a: 440-446, 1991.
17. O’Driscoll SW, Morrey BF and An KN: Intraarticular pressure and capacity of the elbow. Arthroscopy,
6: 100-103, 1990.
18. Regan WD, Korinek SL, Morrey BF and An KN: Biomechanical study of ligaments around the elbow
joint. Clin Orthip, 271:170-179, 1991.
19. Schwab GH, Bennett JB, Woods GW and Tullos HS: Biomechanics of elbow instability The role of the
medial collateral ligament. Clin Orthop, 146: 42-52, 1980.
20. Yamaguchi K: Evaluation and arthroscopic treatment of common injuries. Twent-first annual meeting,
Arthroscopy association of north America, Washington: 464-469, 2002.

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