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254
J. L. Ferguson and D. C. Johnson
many cases, the second examination will be positive for a focal neurologic decit when the rst
was negative. Plain X-rays are often helpful in
visualizing spinal stenosis, particularly degenerative spinal stenosis. One can see intervertebral
disc degeneration, decreased interpedicular distance, a decreased sagittal canal diameter, and
facet degeneration. If a patient fails conservative
treatment and becomes a surgical candidate, the
location and degree of neurological compression
can be assessed with MRI or CT-myelogram.
The majority of patients with spinal stenosis,
especially the degenerative and combined variety, can be treated non-surgically with antiinammatory medication and physical therapy.
Finally, a lumbosacral corset is often helpful
in reminding the patient to avoid excessive
motion. This bracing serves as a reminder for
patients to engage their core muscles and relieve
pressure on the lumbar spine. However, when
used for a prolonged period this brace can become
compensatory and lead to weakening of the core
muscles (Fig.10.17).
Spondylolisthesis
Spondylolisthesis is a spinal condition where all
or part of a vertebra has slipped forward on
another. The word is derived from the Greek
spondylos, meaning “vertebra,” and olisthesis,
meaning “to slip.” There are several different
types of spondylolisthesis, but the most common
is that in which the lesion is in the isthmus or pars
interarticularis. If a defect can be identied, but
no slipping has occurred, the condition is termed
spondylolysis; if one vertebra has slipped forward on another (horizontal translation), it is
referred to as spondylolisthesis.
The etiology of the defect in spondylolysis is
not clear. Although there may be a hereditary
component, the lesion is seldom seen in patients
under the age of 5 and is found in 5% of people
over the age of 17. The most attractive explanation is that although these children inherit a
potential deciency in the pars, they are not born
with any identiable defect. Between the ages of
5 and 17, however, they become more active and
a stress fracture, caused by repetitive hyperextension stresses, can develop into a spondylolysis. It
is likely that most of these fractures occur during
the period of rapid growth known as the adolescent growth spurt and they are particularly prevalent in gymnasts and football players.
Spondylolisthesis has several characteristic
features, but the forward displacement is easily
recognized radiographically on the lateral projection (Figs.10.18 and 10.19). The degree of slip
Fig. 10.17 Axial and sagittal T2-Weighted MRI imaging demonstrating severe stenosis as the L3–L4 level due to facet
and ligamentum avum hypertrophy (white and blue lines, respectively)
0 III IVIII
10 The Spine
Fig. 10.18 Meyerding
classication system for
spondylolisthesis
255
Grade 1
Grade 2 25-50%
Grade 3 50-75%
Grade 4 75-100%
Spondyloptosis
Type
I
II
-IIA
-IIB
-IIC Acute fracture
III
IV Posttraumatic Acute fracture of posterior column, but not pars
VPathologic
VI latrogenic
Description Exampe
Dysplastic Congenital defect in neural arch
Isthmic Defect in the pars interarticularis
Spondylolysis (stress fracture of the pars)
Elongation of pars via repeated microtrauma (gymnasts, offensive linemen)
DegenerativeFacet joint degeneration
Infection, tumor, etc.
Post-surgical instability (over-resection of pars intra-operatively)
0-25%
>100%
Fig. 10.19 Wiltse classication system for spondylolisthesis
varies from patient to patient and can range from
minimal displacement to complete dislocation of
the vertebral body. Increased slipping rarely
occurs after the age of 20 unless there has been a
severe superimposed injury or surgical intervention. The period of most rapid progression coincides with the rapid growth spurt between the
ages of 9 and 15.
The most common clinical manifestation of
spondylolisthesis is low back pain. Although the
cause of this type of back pain in the adult has
been studied extensively, its origin is still not
clear. There is no clear understanding of how so
many patients develop this lesion between the
ages of 5 and 17, but still have no back complaints until perhaps age 35, when a sudden
twisting or lifting motion will precipitate an acute
episode of back and leg pain. Other patients with
signicant degrees of slipping, however, will go
through life with no discomfort.
256
J. L. Ferguson and D. C. Johnson
Although 50% of patients overall normally
cannot associate an injury with the onset of the
symptoms of those working in industry, almost
all report an associated incident. It is possible to
sustain an acute fracture of the pars, but it is a
very rare occurrence. If the acuity of a pars defect
is in question, it can be documented by a bone
scan within 3months of the injury; if the defect is
long-standing, the scan will be negative.
There is also frequently a buildup of a brocartilaginous mass at the defect, and this can
cause pain by irritating the nerve root as it exits.
It is thus not unusual in spondylolisthesis to have
the patient rst complain of back pain, but over
time have leg pain develop as the most troubling
symptom.
Once the symptoms begin, the patient usually
has constant low-grade back discomfort that is
aggravated by activity and relieved by rest. There
are some periods during which the pain is more
intense than others, but unless the picture is complicated by severe leg pain, total incapacitation is
rare. The patients are seldom aware of any sensory or motor decit. At this point, it should be
reemphasized that in some people even severe
displacement is asymptomatic and gives rise to
no disability. It is not uncommon to pick up a previously unrecognized spondylolisthesis on a routine gastrointestinal radiological study of a
50-year-old patient.
The physical ndings of this syndrome are
fairly characteristic. In the absence of any radicular pain, the patient exhibits no postural scoliosis;
but there is usually an exaggeration of the lumbar
lordosis and a palpable “stepoff” with a dimple at
the side of the abnormality. Occasionally, mild
muscle spasm is demonstrable, and in most
instances, some local tenderness can be elicited.
Although the range of motion is usually complete,
some pain can be expected on hyperextension.
Radiographs, particularly the lateral views,
conrm the diagnosis. Even the slightest amount
of forward slipping of the body of the involved
vertebra is readily discernible and the oblique
views will disclose the actual defect in the pars.
Flexion and extension (“dynamic”) views may
show instability, noted with translation or angulation of the upper vertebra on the lower.
The nonoperative treatment of the adult with
spondylolisthesis is much the same as that used
for backache from other causes. When the symptoms are acute, rest is indicated. If leg pain is a
signicant problem, then anti-inammatory medication can be quite benecial. Exercises, usually
a exion-extension program, should be started
once patients are in remission and they are usually advised to own a corset for use during occasional strenuous activity. Epidural steroid
injections may be useful in calming down an
acute radicular attack. If conservative treatment
is not successful, an operative approach can be
considered and would include a spinal fusion.
Lumbar Spine Algorithm
As with patients with neck pain, the task of the
physician when confronted with low back pain
patients is to integrate their complaints into an
accurate diagnosis and to prescribe appropriate
therapy. This problem (universe of low back pain
patients) has been formatted into an algorithm
(Fig.10.20), the aim of which is to select the correct diagnostic category and proper treatment avenues for each patient with low back pain. A specic
patient may fall outside the limits of the algorithm
and require a different approach and the physician
must constantly be on the alert for exceptions. The
algorithm can be followed in sequence and is also
presented in table form (Table10.4).
The information necessary to use the algorithm is initially obtained through the history and
physical examination. The key points in the history are differentiation of back pain that is
mechanical in nature from nonmechanical pain
that is present at rest, detecting changes in bowel
or bladder function and dening the precise location and quality of the pain. The physical examination must be oriented toward ruling out other
medical causes of low back pain, assessing neurologic function, and evaluating for the presence
of tension signs.
Following the low back pain algorithm, the
rst major decision is to make a ruling on the
presence or absence of CEC syndrome.
Mechanical compression of the cauda equina is a
10 The Spine
257
Low Back Pain
Neurologic or
progressive
deficit?
no
NSAIDs, Physical
Therapy (x6 weeks)
Back Pain
Predominant
Continue PT,
Consider
pain management
referral
Negative
X-rays
(if spondylolisthesis
present, obtain
flex/ext)
Instability
MRI/CT
Fusion +/-
Decompression
Fig. 10.20 Algorithm for the differential diagnosis of low back pain
yes
Leg Pain
Predominant
MRI
Positive
Epidural
Injections,
Surgery
MRI
Negative
Close
Observation/
Surgery
PT,
Pain Management
Table 10.4 Differential diagnosis and features of common causes of low back pain
Predominant
pain
Back strain Back
Disc herniation Leg
Spinal stenosis Back/leg
Spondylolisthesis Back
Spondyloarthropathy Back +
surgical emergency, much like myelopathy. Once
cauda equina is ruled out, further evaluation of
low back pain can be undertaken.
Cauda equina, with truly progressive motor
weakness, is the only surgical emergency in lumbar spine disease. This compression from a massive rupture of the L4–L5 disc in the midline is
usually due to pressure on the caudal sac, through
which pass the nerves to the lower extremities,
bowel, and bladder.
Constitutional
symptoms
Neurologic
exam
− − − − −
− +/− − −
− +/−
− −
−
The signs and symptoms of CEC are a complex mixture of low back pain, bilateral motor
weakness of the lower extremities, bilateral sciatica, saddle anesthesia, and even frank paraplegia with bowel and bladder incontinence or
urinary retention. Cauda equina compression can
be caused by either bone or soft tissue damage,
the latter generally a ruptured or herniated disc in
the midline. These patients should undergo an
immediate denitive diagnostic test and, if it is
Plain
X-rays
+
Dynamic
X-rays
−
+ + +
+
− −
CT/
MRI
+
+
258
J. L. Ferguson and D. C. Johnson
positive, emergency surgical decompression.
Historically, the myelogram was the study used
in this setting; however, the development of the
MRI has facilitated the noninvasive diagnosis of
CEC. The principal reason for prompt surgical
intervention is to arrest the progression of neurologic loss; the chance of actual return of lost neurologic function following surgery is small.
Although the incidence of CEC syndrome in the
entire back pain population is very low, it is the
only event that requires immediate operative
intervention; if its diagnosis is missed, the consequences can be devastating.
The remaining patients make up the overwhelming majority. They should be started on a
course of conservative (nonoperative) therapy
regardless of the diagnosis. At this stage, the specic diagnosis, whether a herniated disc or a
simple back strain, is not important to the therapy because the entire population is treated the
same way. A few of these patients will eventually
need an invasive procedure (surgery), but at this
point there is no way to predict which individuals will respond to conservative therapy and
which will not.
Conservative Treatment Modalities
As the algorithm indicates, all low back pain
patients, regardless of diagnosis (except those
with CEC syndrome), require an initial period
of conservative therapy. At present, there are
many modalities available, but few have been
scientically validated because of the difculty
in performing a prospective double-blind study
in this eld. Each treatment plan in popular use
today is surrounded by conicting claims for its
indications and efcacy. The purpose of this
section is to discuss the rationale behind the use
of some of the more common therapeutic
measures.
Controlled Physical Activity
Decreased activity has evolved over the years as
one of the most important elements in the treatment of low back pain. The degree of rest depends
on the severity of the symptoms and can vary
from complete bed rest to just a decrease in active
exercise.
The amount of rest prescribed varies for each
patient; these people should not be mobilized
until reasonably comfortable. The type of pathology will determine the duration of rest required.
Most patients with acute back strain will need
only 2–7days of bed rest before they can ambulate. However, a patient with an acute herniated
disc may require up to 1week of complete bed
rest with another 10days for gradual mobilization. Complete bed rest for long periods (more
than 2weeks) has a deleterious effect on the body
in general and should be closely monitored. As
their discomfort eases, the patient should be
strongly encouraged to take short walks, but to do
as little sitting as possible. Each patient should be
followed carefully and given a formal prescription for physical therapy. Close guidance with
physical therapists can allow for controlled return
to activity, activity modication and education,
core strengthening, and stretching to allow
patients to return to their previous levels of
function.
The purpose of controlled physical activity is
to allow any inammatory reaction that is present
to subside. Bed rest will not result in the disc’s
return to its original position. However, as the
disc herniates, it causes a secondary inammatory process responsible for the patient’s pain; if
this reaction can be brought under control, the
patient’s symptoms will disappear. This relief
may or may not be permanent.
Drug Therapy
The judicious use of drug therapy is an important
adjunct in the treatment of low back pain. As in
the cervical spine, there are three main categories
of drugs in common use: anti-inammatories,
analgesics, and muscle relaxants.
Anti-inammatory agents are employed
because of the belief that inammation within the
affected tissues is a major cause of pain in the low
back. This is especially true for those patients
with symptoms secondary to a herniated disc.
There are a variety of NSAIDs available.
Based on several scientic studies, none of these
appear to be superior to the others. Most patients
10 The Spine
259
will get signicant relief. Again, all antiinammatory medications are utilized in conjunction with controlled physical activity to
relieve pain; they do not replace adequate rest.
Occasionally, after an initial recovery, a patient
will experience intermittent recurrent attacks or
complain of a chronic low backache; in some
instances these patients will be helped by a maintenance dose of an anti-inammatory drug.
Analgesic medication is very important during the acute phase of low back pain. The goal is
to keep the patient comfortable while in bed.
Most of the anti-inammatory agents also have
analgesic properties. In more severe cases,
patients may require narcotic medications.
However this should be monitored closely (usually by a pain management specialist) and these
medications are only to be used sparingly.
The biggest mistake seen is treatment with
very strong narcotics such as oxycodone or
hydromorphone on an outpatient basis. Many of
these patients become addicted to the medication.
In other cases, patients try to shortcut the controlled physical activity and use analgesic medication instead. This, of course, will not work and
when the patient tries to stop the drug, the back
pain returns.
Muscle relaxants generally are not recommended for the treatment of low back pain. In
most cases, the muscle spasm is secondary to a
primary problem such as a herniated disc. If the
pain from the ruptured disc can be controlled, the
muscle spasm will usually subside.
Occasionally, muscle spasm will be so severe
that some type of treatment is required. Tizanidine
(zanaex), methocarbamol (Robaxin), or cyclobenzaprine (Flexeril) are the drugs recommended.
Diazepam (Valium) should be discouraged since
it is actually a physiological depressant and
depression is often an integral feature of back
pain syndromes. Administering diazepam to
depressed patients only increases their problems.
If anxiety is prominent and a sedative is needed,
phenobarbital will alleviate the symptoms.
In summary, drug therapy for low back pain
should be viewed as an adjunct to adequately
controlled physical activity. Anti-inammatory
medication should be the primary agent
employed. Analgesic medication should be used
selectively in a controlled environment and not
for extended periods. Muscle relaxants are generally not recommended and, if employed, should
be carefully monitored.
Trigger-Point Injection
Trigger-point therapy is indicated for nonradiating low back pain when a point of maximal tenderness can be identied. This procedure
involves the injection of steroids and Xylocaine
at an area of maximal tenderness in the low back.
The precise mechanism of action is not clear but
may be related to modulation of peripheral nerve
stimulation as it affects the afferent input perceived as pain.
Trigger-point therapy is easy to perform, has a
negligible risk, and may help certain patients.
Further controlled research is required to delineate the true value of this modality in the treatment of low back pain.
Epidural Steroid Injection
Epidural steroid injections are indicated for
severe lumbar radiculopathy, not, in most cases,
for nonradiating low back pain. They have generally been viewed as an intermediate form of
treatment between conservative and surgical
management. It is a more aggressive attempt at
pain relief after conservative therapy has failed,
yet avoids the disadvantages of surgery. The
rationale for this therapy is that lumbar radiculopathy (in the early phase) involves a signicant inammatory component, evoked by
chemical or mechanical irritation or an autoimmune response—all of which should be amenable to treatment with corticosteroid drugs in the
early stages.
Unfortunately, few studies have systematically and accurately studied the efcacy of this
treatment modality. Poorly controlled, nonrandomized studies have yielded controversial
results with a range of success rates from 25% to
75%. Another problem is that some studies have
attempted to determine the efcacy of epidural
steroids compared to epidural saline injection,
while others have compared their results to a true
placebo.
260
J. L. Ferguson and D. C. Johnson
Despite the lack of optimally designed investigations, upon review of the literature, certain
trends seem to be evident. Epidural steroids
appear to be more benecial in acute rather than
chronic radiculopathy, especially when no neurologic decit is present. Improvement may not be
noted until 3–6days after injection and may be
only temporary. No neurotoxicity has been
reported in humans or animal models; complications stem from the technique of epidural injection and are rare. Suppression of plasma
corticosteroid concentration may occur up to
3weeks following the injection.
The authors maintain that epidural steroids
may be helpful in relieving some component of
radicular pain in 40% of patients. Until controlled
investigations indicate otherwise, this is a treatment worth trying in patients who have failed
6weeks of conservative management in an effort
to avoid a major invasive procedure.
Traction
The application of traction to the lumbar spine is
a popular treatment for patients with herniated
discs. The theory is that stretching the lumbar
spine distracts the vertebrae so that the protruded
disc is allowed to return to a more normal anatomic position. In fact, the disc material probably
does not change position at all. Scientic evidence indicates that a traction force equal to 60%
of body weight is needed just to reduce the intradiscal pressure at the third lumbar vertebra by
25%. Such a force could not practically be
applied to a patient. Furthermore, there has never
been any proof that disc material returns to its
normal position following herniation.
Traction can be applied as gravity lumbar traction, autotraction, and through motorized techniques. None of these methods has been proven
to be more effective than the others. While a few
studies have shown traction to have a short-lived
benet on sciatica patients, most double-blind
studies have not demonstrated any positive effect.
In one study, two groups of patients with proven
herniated discs (by myelogram) were treated by
applying traction apparatuses to each group in
the hospital. However, for one group there were
weights in the traction bag; for the other, no
weights. There was no statistically signicant
difference between the two groups in terms of
relief of symptoms. Traction had no effect on spinal mobility, tension signs, deep tendon reexes,
paresis, or sensory decit and although it usually
was well tolerated, it made some patients worse.
Manipulation
Spinal manipulation is another popular conservative modality in treating low back pain. In the
USA, it is somewhat controversial because it is
performed mostly by chiropractors. The principle
involved is that any malalignment of the spinal
structures can be corrected by manipulation; the
assumption here is that the malalignment is the
etiology of the patient’s pain. Unfortunately,
there is no scientic proof for or against either
the efcacy of this therapy or its pathophysiological foundation.
The authors’ experience is that some patients
do have short periods of symptomatic relief after
manipulation, but must keep returning for repeated
sessions to maintain it, substantially increasing the
cost of treatment. Some patients, in fact, may be
harmed if pathologic bone disease such as a tumor
or osteopenia is present when manipulation is performed. At present, it is felt that manipulation is
not indicated for the routine treatment of chronic
low back pain. There is not adequate scientic evidence to justify its routine use.
Braces andCorsets
External support of the lumbar spine with a corset or brace is indicated for only a short period in
the average patient’s recovery process, and even
then only rarely. As the acute symptoms subside,
a properly tted corset or brace will aid the
patient in regaining mobility sooner. As the
recovery progresses, the patient usually should
abandon the brace in favor of an exercise program. With continued long-term use of a brace,
soft tissue contractures and muscle atrophy will
occur. The young patient should rely on a brace
only to hasten ambulation. In theory, strong, exible lumbar and abdominal muscles function as
an excellent internal brace because they are adjacent to the structures (vertebrae) that they are
supporting.
10 The Spine
261
Physical Therapy
Some form of exercise is probably the most commonly prescribed therapy for patients recovering
from low back pain. There are two regimens
commonly advocated: isometric exion exercises
and hyperextension exercises. These programs
are purported to reduce the frequency and intensity of low back pain episodes, although there is
no scientic evidence to support this contention.
The isometric exion exercises are the most
popular. They are based on the theory that by
reducing the lumbar lordosis, back pain is
decreased. This goal is achieved by strengthening
both the abdominal and lumbar muscles, thereby
creating a corset of muscles to support the lumbar
spine. Flexion exercises are commonly utilized in
patients with spondylolisthesis or spinal stenosis.
Hyperextension exercises are the other form
of therapy. They are purported to strengthen the
paravertebral muscles. These exercises generally
are used after a patient has satisfactorily performed a course of isometric exion exercises.
The goal is to have the paravertebral muscles act
as an internal support for the lumbar spine.
The authors believe that an exercise regimen
is very important for the rehabilitation of low
back patients. This regimen should not be instituted while the patient is experiencing acute pain,
but may be started after his symptoms have subsided to the point where no list or paravertebral
muscle spasm is present. The number of repetitions is increased gradually; if the patient has any
recurrence of acute symptoms, the exercises are
stopped. The patient is then closely monitored;
when his symptoms again decrease, the exercises
can be resumed.
There are many other treatment modalities
used for low back pain. These include hot packs,
cold packs, light massage, ultrasound, transcutaneous electrical nerve stimulation, and diathermy.
They are all well tolerated and pleasant. Most
patients experience some immediate relief of
symptoms, but unfortunately, there is not a longlasting impact on the disease process. There is no
evidence that any of these treatment modalities
offers any long-term benet or even adds to the
efcacy of decreased physical activity alone.
The utility of physical therapy cannot be overstated in its importance in the nonoperative management of lumbar pain. Guided exercises,
stretching, and alternative modalities are a critical tool in managing patients.
Operative Management
When patients fail extensive conservative management and advanced imaging supports the
diagnosis, operative intervention must be considered. In the lumbar spine, there are two basic
techniques used both separately and in conjunction to treat lumbar and radicular pain: decompression and fusion.
Decompression
In patients with minimal back pain whose symptoms are primarily radicular in nature, including
weakness and pain. Surgical decompression
without fusion can be considered. In the setting
of an acutely herniated disc, a microdiscectomy
can be considered and performed in a minimally
invasive fashion. This involves removing herniated disc material and decompressing the affected
nerve root under direct visualization.
Laminectomy is another procedure used for
decompression that involved surgically removing
the lamina causing stenosis at the affected levels.
This allows more room for the thecal sac and
nerve roots posteriorly. Other procedures such as
facetectomy and foraminotomy involve decompressing specic areas of the spine and allowing
more room for the exiting nerve roots.
Fusion
While decompression is a viable surgical option
for many patients, in patients who have severe
back pain, imbalance, or instability seen on imaging, fusion must also be performed to best alleviate their symptoms. Another situation where
fusion is indicated is when the decompression
procedure will require removing a signicant
portion (>50%) of the facet joints, thereby destabilizing the operative level. If fusion is not performed in this case, the patient may develop
iatrogenic instability, usually as a result of a pars
defect created by a wide decompression.
262
J. L. Ferguson and D. C. Johnson
There are a number of procedures available to
spine surgeons in order to perform fusion, but the
mainstay is the pedicle screw and rod construct
used in a posterolateral fusion. This involves
placing pedicle screws posteriorly to achieve
three column xation and then securing those
screws with bilateral rods that span all levels. The
transverse processes, facet joints, pars, and
remaining lamina are then decorticated and bone
graft products are placed with the goal of achieving a fusion mass in approximately 3–6months.
The previously unstable levels now act as one
single construct with the goal of improved alignment and reduced pain from prior instability.
Summary andConclusion
Neck and low back pain affects the majority of
adults at some time during the course of their
lives. Every physician should have a working
knowledge of the common pathologic conditions
and be able to differentiate a serious problem
from the more common benign types. In both the
cervical spine (myelopathy) and the lumbar spine
(cauda equina compression), disastrous sequelae
such as paralysis or loss of bowel and bladder
control can occur if these serious conditions are
not recognized in a timely fashion.
To help in the decision-making process, algorithms for both the cervical and lumbar spine
were described. This will allow the physician to
make the right diagnosis using the indicated diagnostic procedures at the correct time.
Further Reading
Kane PM, Daniels AH, Akelman E. Double crush syn-
drome. J Am Acad Orthop Surg. 2015;23(9):558–62.
https://doi.org/10.5435/JAAOS- D- 14- 00176.
Borenstein DG, Wiesel SW, Boden SD. Low back and
neck pain. 3rd ed. Philadelphia, PA: WB Saunders;
2004.
Frymoyer JW, Wiesel SW. The adult & pediatric spine.
3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2004.
Wiesel SW, Delahay JN.Principles of orthopaedic medi-
cine and surgery. Philadelphia, PA: WB Saunders;
2001.
The Elbow
KyleW.Zittel andMichaelW.Kessler
11
Introduction
When elbow and forearm function are compromised by pain, injury, or loss of motion, signicant disability can result. The goals of this chapter
are to present the elbow’s functional anatomy,
describe how to clinically evaluate this region,
and how to approach diagnosis and treatment of
common elbow problems.
We discuss presentations of elbow pathology
encountered in outpatient clinic, chronic atraumatic settings, while incorporating management
principles and sequelae of acute traumatic injury,
with a general focus on adult and adolescent
patient populations. An in-depth review of pediatric elbow anatomy, injuries, and treatment is
out of the scope of this text.
Anatomy
Skeletal
The elbow joint contains three osteochondral
(bone-cartilage) articulations between the proximal forearm and distal humerus: the ulnar-
K. W. Zittel · M. W. Kessler (*)
MedStar Georgetown Orthopedic Institute,
Georgetown University School of Medicine,
Washington, DC, USA
Department of Orthopedics, MedStar Georgetown
University Hospital, Washington, DC, USA
e-mail: Michael.W.Kessler@gunet.georgetown.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
W. F. Postma et al. (eds.), Essentials of Orthopedic Surgery,
https://doi.org/10.1007/978-3-031-66215-7_11
humeral, radiohumeral, and radioulnar joints.
The ulnar-humeral and radiohumeral joints are
uniquely oriented side by side at the distal
humerus. These articulations allow hinge-type
motion in the exion–extension plane, and rotatory motion in the pronation–supination plane,
and can be performed throughout their full arcs
of motion simultaneously. The elbow’s bony
anatomy starts several centimeters proximal to
the joint itself, as the humeral shaft ares into
medial and lateral columns which end in medial
and lateral condyles. These form two distinctly
shaped articular surfaces at the joint line called
the trochlea and capitellum, and two, medial and
lateral, epicondyles (Fig.11.1).
The lateral column consists of the lateral epicondyle and the capitellum, a hemispherical structure that articulates with the concave, disk shaped,
proximal surface of the radial head to create the
radial-humeral joint (radiocapitellar joint). In the
proximal forearm, the radial head articulates medially with the ulna in a shallow recess called the
lesser sigmoid notch, located on the radial (lateral)
and volar-distal aspect of the olecranon. The sides
of the radial head articulating with the proximal
ulna are covered in a 240° arc of cartilage allowing
smooth rotatory motion. Distally, the head narrows to become the radial neck and angulates itself
medially on average 10–20° to the radial shaft
(160–170° neck shaft angle). At the radial neck
shaft junction, a prominent tuberosity is present
medially for the attachment of the biceps tendon
(radial/bicipital tuberosity).
263