SCIENTIFIC ARTICLE

Gross Anatomy of the Elbow Capsule:

ACadaveric Study
Lee M. Reichel, MD, Omar A. Morales, MD
Purpose The elbow is an inherently stable joint because of its bony articulation and sur-
rounding capsuloligamentous structures. Anatomic and biomechanical studies have focused
on the medial and lateral collateral ligamentous contributions to stability. In 1918, Gray
provided a qualitative description of the elbow capsule and its bers. Our study was
performed to detail the gross anatomy of the elbow capsule.
Methods We evaluated the elbow capsule of 6 paired, fresh-frozen cadaveric specimens to
detail gross capsular anatomy.
Results We identied 3 distinct bands within the anterior capsule and 3 distinct bands within
the posterior capsule.
Conclusions Further study is needed to delineate the functional meaning of these anatomic
ndings.
Clinical relevance Greater understanding of elbow capsule gross anatomy may lead to im-
proved understanding of acute and chronic elbow pathoanatomy and treatment modalities. (J
Hand Surg 2013;38A:110116. Copyright 2013 by the American Society for Surgery of
the Hand. All rights reserved.)
Key words Anterior elbow capsule, elbow anatomy, elbow capsule, elbow stability, posterior
elbow capsule.
T
HE ELBOW IS an inherently stable joint because
of its bony articulation and surrounding capsu-
loligamentous structures. Anatomic and biome-
chanical studies have focused on the medial and lateral
collateral ligamentous contributions to elbow stability,
but a paucity of literature exists regarding the anatomy
and function of the elbow capsule excluding the collat-
eral ligaments. It has been noted that oblique and trans-
verse brous bands exist in the anterior capsule of the
elbow.
1
Clinically, the elbow capsule is an important
contributor in the development of posttraumatic elbow
contractures and acutely has been used to augment
stability in complex elbow fracture dislocations with
coronoid fractures. To better understand this structure,
which encompasses the entire elbowjoint, we evaluated
the capsular gross anatomy of 6 paired, fresh-frozen
cadaveric elbows.
MATERIALS AND METHODS
We dissected 12 fresh-frozen cadaveric elbows (average
age, 73 y; 4 female and 2 male) of all structures except the
capsuloligamentous covering. None of the specimens had
evidence of prior surgery or injury to the elbow. We noted
distinct grossly identiable anatomic capsular bands ex-
cluding the medial and lateral collateral ligamentous com-
plexes on each specimen. We measured the lengths of
each structure. The authors performed all measurements
and agreed on them. Using a digital caliper with a resolu-
tion of 0.01 mm and accuracy of 0.1 mm, measurements
were repeated and averaged for each dened structure. We
Fromthe Department of Orthopedic Surgery, Baylor College of Medicine, Ben Taub General Hospital,
Houston, TX.
Receivedfor publicationJuly 12, 2012; acceptedinrevisedformSeptember 25, 2012.
The authors thank Scotty Bolleter, Chief, Ofce of Clinical Direction, Centre for Emergency Health
Sciences, Bulverde SpringBranchEmergency Medical Service.
No benets in any formhave been received or will be received related directly or indirectly to the
subject of this article.
Correspondingauthor: LeeM. Reichel, MD, Departmentof OrthopedicSurgery, Baylor Collegeof
Medicine, Ben Taub General Hospital, 1504 Taub Loop, Houston, TX 77030; e-mail:
leereichel@gmail.com.
0363-5023/13/38A01-0019$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2012.09.031
110 ASSH Published by Elsevier, Inc. All rights reserved.
took anterior capsular band measurements in full extension
and took posterior capsular band measurements in full
exion to maximize respective lengths. In 3 specimens, the
entire elbowwas painted with black paint, and we resected
the elbow capsuloligamentous structures, creating a nega-
tive template of the capsular dimensions for visualization
purposes only.
2
Before any painting, we then measured
midline distances from proximal to distal of the entire
anterior and posterior capsule in both full exion and full
extension.
We detailed gross anatomical descriptions of the elbow
capsule. We measured average lengths of distinct identi-
able bands of the anterior and posterior capsule and cal-
culated gross percent excursion (percent difference in cap-
sular length in full exion vs extension) of the anterior and
posterior capsule in full extension and exion.
RESULTS
Anterior capsule
We identied 3 bands on all specimens. One band
originated on the anterior lateral surface of the distal
humerus near the lateral supracondylar ridge and con-
tinued distal to insert on the anterior superior annular
ligament. We dened this band as the anterior lateral
band. A second band originated at the anterior medial
side of the elbow near the lateral part of the superior
medial trochlear ridge and continued laterally and dis-
tally to insert on the anterior central and medial annular
FIGURE 1: Anterior lateral, anterior medial oblique, and anterior transverse bands of the anterior capsule.
TABLE 1. Raw Length Measurement (Average)
of Anterior Capsular Bands, Lateral, Medial
Oblique, and Transverse
Specimen
Anterior
Lateral
Band (mm)
Anterior Medial
Oblique
Band (mm)
Anterior
Transverse
Band (mm)
1a 19.3 16.0 34.5
1b 24.4 23.3 35.3
2a 20.7 18.9 36.4
2b 18.4 15.1 38.3
3a 16.0 23.0 28.0
3b 15.5 15.3 26.7
4a 16.1 17.4 30.1
4b 18.2 22.0 24.8
5a 17.5 18.0 28.0
5b 19.9 28.9 25.9
6a 17.6 19.2 25.2
6b 15.6 17.9 19.7
Average 18 20 29
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ligament. We dened this band as the anterior medial
oblique band. The third band was a transverse band
crossing the elbow medially to laterally from the central
and inferior anterior medial trochlear ridge to the ante-
rior medial annular ligament. It also gave a contribution
insertion distal to the coronoid tip. We dened this band
as the anterior transverse band. In 2 of 12 specimens (1
matched pair), the anterior transverse band was nar-
rower and thicker and had an appearance of an acces-
sory annular ligament, except that it originated from the
anterior capsule rather than the ulna, but there was a
distinct separation from the annular ligament. These
ndings were consistent in the 12 specimens (Fig. 1).
Although all specimens contained each of the bands,
there was variability in their degree of development. In
general, the anterior lateral band was the least substan-
tial and well developed compared with the anterior
medial oblique and anterior transverse bands.
Table 1 presents individual lengths. The anterior lateral
band averaged 18 mm in length, the anterior medial
oblique band averaged 20 mm, and anterior transverse
band measured 29 mm.
In full extension, the mean midline distance from the
most proximal capsular attachment on the humerus to
the most distal capsular attachment on the anterior ulna
in full extension measured 50.2 mm, and 14.2 mm in
full exion. This corresponded to a 28% excursion of
the anterior capsule in the midline.
Posterior capsule
The posterior capsule also had 3 distinct bands (Fig. 2).
A transverse band crossed inferior to the olecranon
fossa frommedial to lateral, originating and inserting on
the medial and lateral posterior trochlear ridges. The
other 2 bands were opposing bands, 1 originating at the
medial posterior trochlear ridge and the other originat-
ing at the lateral posterior trochlear ridge, both inserting
on the posterior superior ridge of the olecranon tip.
These 3 bands formed an inverted triangular shape. We
dened these bands as the posterior transverse, poste-
rior medial oblique, and posterior lateral oblique.
Table 2 presents individual lengths of the posterior
bands. The posterior transverse band length averaged
21 mm. The posterior medial oblique band, measured
from the posterior medial origin to its ulnar insertion,
averaged 18 mm in length. The posterior lateral band,
FIGURE 2: Posterior transverse, posterior medial oblique, and posterior lateral oblique bands, which lie at the distal portion of the
olecranon fossa.
TABLE 2. Raw Length Measurements of
Posterior Capsular Bands, Transverse, Medial
Oblique, and Lateral Oblique
Specimen
Transverse
Band (mm)
Medial Oblique
Band (mm)
Lateral Oblique
Band (mm)
1a 24.0 20.0 18.0
1b 24.0 21.0 18.2
2a 21.0 17.8 15.1
2b 24.0 19.2 15.3
3a 18.0 16.0 18.0
3b 17.5 15.9 12.4
4a 20.8 13.3 15.9
4b 19.8 17.0 20.5
5a 24.7 19.6 20.8
5b 20.6 17.3 20.7
6a 19.4 18.2 20.1
6b 21.0 15.5 13.9
Average 21 18 17
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measured from the lateral humeral origin to the ulnar
insertion, averaged 17 mm in length.
The midline posterior capsular distance averaged 9.7
mm in full extension and 42.5 mm in full exion (Fig.
3). This corresponded to a 23% excursion of the pos-
terior capsule in the midline.
DISCUSSION
Anatomic studies of the elbow osseous, capsuloligamen-
tous, and muscular structures have been well documented,
but there is a paucity of literature detailing the anatomy of
the elbow capsule and its function. In 1918, Gray
3
pro-
vided a detailed qualitative description of the elbow cap-
sule, which he referred to as the anterior ligament and
posterior ligament, and provided a description of bands
similar to this report but without quantifying the structures
and with different nomenclature. Regarding the anterior
capsule, Gray stated, Its supercial bers pass obliquely
from the medial epicondyle of the humerus to the annular
ligament. The middle bers, vertical in direction, pass
from the upper part of the coronoid depression and be-
come partly blended with the preceding, but are inserted
mainly into the anterior surface of the coronoid process.
The deep or transverse set intersects these at right angles.
Gray described the posterior capsule: This posterior lig-
ament is thin and membranous, and consists of transverse
and oblique bers. . . . It is attached to the humerus imme-
diately behind the capitulum and close to the medial mar-
gin of the trochlea, to the margins of the olecranon fossa,
and to the back of the lateral epicondyle some distance
fromthe trochlea. Below, it is xed to the upper and lateral
margins of the olecranon. . . . Transverse bers form a
strong band which bridges across the olecranon fossa;
under cover of this band a pouch of synovial membrane
and a pad of fat project into the upper part of the fossa
when the joint is extended. Morrey noted the anterior
capsule inserts proximally above the coronoid and radial
fossae. Distally, the capsule attaches to the anterior margin
of the coronoid medially as well as the annular ligament
laterally.
1
He also described the anterior capsule as a thin
transparent structure with strength provided by transverse
and obliquely directed brous bands. King et al
4
reported
that the anterior capsule has transverse and obliquely
directed bands that have signicant strength and provide
an important stabilizing effect when the capsule becomes
taut in extension. The posterior capsule similarly becomes
taut in exion and may also have an important role as a
static stabilizer in this position. Morrey and An
5
dem-
onstrated the importance of the anterior capsule as a
stabilizer to varus stress and demonstrated that the
anterior capsule contributed 32% resistance to varus
stress and 85% of resistance to distraction in full
extension.
The focus of this anatomic cadaveric study was to
describe the gross anatomy of the anterior and posterior
capsular bands, excluding the medial and lateral collat-
eral ligaments. Three distinct bands have been identi-
ed on the anterior capsule of each specimen: the an-
FIGURE 3: Anterior and posterior view of a painted specimen with the capsule excised, demonstrating the area covered by the capsule.
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terior lateral band, anterior medial oblique band, and
anterior transverse band. Each of these bands had a
primary insertion point on annular ligament. In most
specimens, the anterior transverse band also inserted on
the coronoid tip as it crossed. Although we did not
evaluate them in this study, anterior capsular insertion
points on the annular ligament and coronoid process
and the behavior of the anterior capsule in various
amounts of exion may explain why capsular repair to
the footprint of a coronoid fracture in complex elbow
fracture dislocations may help provide stability to the
elbow.
6
Studies are needed to evaluate what portion of
the anterior capsule and in what degree of elbowexion
the capsule should be xed to the footprint of a coro-
noid fracture. In addition, in 2 specimens (1 matched
pair), the anterior transverse band was narrower and
thicker and had the appearance of an accessory annular
ligament, except that it originated from the anterior
capsule rather than the ulna, but there was a distinct
separation from the annular ligament.
We also identied 3 bands in the posterior capsule: the
posterior transverse, posterior medial, and posterior lateral
bands. These bands formed an inverted triangle inferior to
the olecranon fossa attaching from the humerus to the
posterior superior ridge of the olecranon tip. The posterior
capsule extended proximal to the olecranon fossa, but the
3 identiable bands resided inferior to the fossa. They
became tight in exion and bunched up into the superior
portion of the olecranon fossa superior to the olecranon tip
when the elbow was extended.
Based on their anatomical course, the anterior bands
may function as secondary ligamentous stabilizers of
the lateral collateral ligament, keeping the radial head
(and proximal radius and ulna) held anterior in a check-
rein fashion when the annular ligament is competent.
This is evident during elbow extension, because they
are visualized becoming taut, but this is only an obser-
vation. Biomechanical and sectioning studies are
needed to demonstrate the contribution of the anterior
capsular bands to elbowstability. In addition, tightening
FIGURE 4: Anterior capsular redundancy from extension to exion.
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of the anterior capsule and ligamentous bands in exten-
sion may function to counteract hyperextension of the
elbow, preventing the ulna from levering out of the
trochlea when the olecranon tip contacts with the olec-
ranon fossa. Conversely, the posterior bands were taut
in exion and may prevent the ulna from levering off
the trochlea during hyperexion. Safran and Baillar-
geon
7
postulated that the posterior capsule may serve as
a restraint to exion and posterior directed forces.
From extension to exion, there was a considerable
redundancy in anterior capsule, which folded on itself
to accommodate the shortened distance in exion (Fig.
4). The excursion of the anterior capsule was approxi-
mately 28% from exion to extension. This observation
may be relevant to capsular repair in terrible triad inju-
ries. The location of suture placement in the capsule and
the amount of elbowexion at time of suture placement
may greatly affect how tight the repair is. Conversely,
from exion to extension, the posterior capsule folded
on itself in the olecranon fossa superior to the tip of the
olecranon in full extension (Fig. 5). We calculated pos-
terior capsular excursion of 23%.
We saw discrete bands in all specimens but reported
only band lengths because they could reliably and re-
producibly be measured with visual inspection. We did
not report band widths because band width was variable
along the course of the band and there was no reliable
way to reproducibly obtain measurements. We mea-
sured capsular bands in specimens with intact capsules;
therefore, we did not measure capsular thickness. Dis-
rupting the capsule to measure thickness would result in
folding and redundancy, making thickness measurements
unreliable in this study. Small length differences were
attributed to differences in the specimen sizes (ie, large
specimens had longer lengths), but calculating averages
minimized these differences across all specimens.
Clearly, this is a small sample size, and examination
of more specimens might reveal other anatomical vari-
ations. In addition, because we performed the dissec-
tions and measurements together, we calculated no in-
traobserver or interobserver error.
This cadaveric study demonstrated the presence of 3
distinct bands present in both the anterior capsule and
posterior capsule, excluding the medial and lateral collat-
eral ligaments. Their functional contribution has not been
evaluated. Based on their anatomic course (origin on the
humerus and insertion on the annular ligament, which is an
attachment point for the lateral collateral ligament), we
presume that the anterior capsular bands are important
secondary ligamentous stabilizers to the annular ligament
and lateral collateral ligament, as well as a checkrein to
hyperextension of the elbow joint. Posterior ligaments
FIGURE 5: Posterior capsular redundancy from exion to extension.
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structures are presumed to function as a checkrein coun-
tering hyperexion. More study is needed to dene the
contribution of these bands to elbow stability.
REFERENCES
1. Morrey B. Anatomy of the elbow joint. In: Morrey B, Sanchez-Sotelo
J, eds. The Elbow and Its Disorders. Philadelphia, PA: Saunders
Elsevier; 2009:1823.
2. Fuss FK. The ulnar collateral ligament of the human elbow joint:
anatomy, function, and biomechanics. J Anat. 1991;(175):203212.
3. Gray H. Grays Anatomy. 20th ed. New York, NY: Lea & Febiger;
1918:321322.
4. King G, Morrey BF, An K. Stabilizers of the elbow. J Shoulder Elbow
Surg. 1993;2(3):165174.
5. Morrey BF, An K. Articular and ligamentous contributions
to the stability of the elbow joint. Am J Sports Med. 1983;11(5):
315319.
6. Cage DJ, Abrams RA, Callahan JJ, Botte MJ. Soft tissue attachements
of the ulnar coronoid process: an anatomic study with radiographic
correlations. Clin Orthop Relat Res. 1995;(320):154158.
7. Safran MR, Baillargeon D. Soft-tissue stabilizers of the elbow. J
Shoulder Elbow Surg. 2005;14(1 suppl S):S179S185.
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