The arthroscope has proven to be the ideal tool for evaluation of intra-articular pathology about the elbow.¹ However, this has not always been the case. In 1931, Burman² described early arthroscopy of the elbow joint with a 3-mm endoscope. He concluded that the elbow is “unsuitable for examination since the joint is so narrow,” only to offer a rebuttal the next year. However, it was not until 1985, when Andrews and Carson³ described their technique, that widespread use of the arthroscope to treat elbow pathology was adopted. Early techniques centered on evaluation of the intra-articular space, synovectomy, excision of osteophytes, débridement of osteochondral lesions, and removal of loose bodies. Recently, this has expanded to include everything from ulnohumeral arthroplasty and the treatment of lateral epicondylitis to the treatment of fractures and autograft replacement for osteochondritis dissecans. It seems as though new applications are being developed constantly.

The potential advantages of treating elbow pathology arthroscopically include reducing iatrogenic insult by decreasing incision size, a more thorough evaluation of the intra-articular compartments of the elbow, and possibly reducing scarring and potential stiffness by limiting disruption of the capsule. The disadvantages center squarely on the technical requirements needed to safely and effectively perform the procedure because of the close proximity of neurovascular structures. A thorough knowledge of the anatomy of the elbow from the arthroscopist’s perspective is critical in reducing the chances of neurovascular injury.⁴ The purpose of this chapter is to describe the anatomy, portal placement, setup, and technique to perform a safe and thorough arthroscopic evaluation of the elbow.

Prior to performing arthroscopic surgery of the elbow, a thorough understanding of the relevant anatomy must be obtained. Superficial landmarks can be palpated and marked for reference during surgery.⁵ Starting posteriorly, the triceps tendon and olecranon can be palpated. Moving medially, the ulnar nerve should be palpated in the groove along the posterior aspect of the medial epicondyle. A subluxable ulnar nerve is present in 16% of the population.⁶ The medial epicondyle should be marked. The antecubital fossa is palpated anteriorly. Laterally, the lateral epicondyle, radial head, and tip of the olecranon form a triangle marking the boundaries of the “soft spot” of the elbow.

Superficial nervous structures include the medial and lateral antebrachial cutaneous nerves. The lateral antebrachial cutaneous nerve, the termination of the musculocutaneous nerve, emerges from the distal portion of the biceps and travels laterally across the brachioradialis muscle proximal to the antecubital fossa. As it turns laterally, it branches and provides sensation for the lateral aspect of the forearm. The medial antebrachial cutaneous nerve travels along the medial arm with the basilic vein. It branches well proximal to the elbow joint and provides sensation to the medial aspect of the forearm. Damage to superficial nerves can be avoided by incising the skin only and using blunt trocars.⁷

The deeper neurovascular structures include the median, radial, and ulnar nerves and the brachial artery. The brachial artery emerges between the brachialis and biceps muscles lateral to the median nerve (Figure 1). It travels just medial to the biceps tendon and deep to the biceps aponeurosis. It bifurcates just distal to the joint at the level of the radial head. The median nerve travels along with the brachial artery along the anterior surface of the brachialis muscle. As it crosses the elbow joint, it is just medial to the
brachial artery. As it enters the forearm, it courses just deep to the pronator teres but superficial to the deep head of the pronator. The ulnar nerve travels posterior to the medial intermuscular septum. At the level of the elbow, it courses posterior to the medial epicondyle and can often be palpated in this area. As it enters the forearm, the ulnar nerve travels between the flexor digitorum superficialis and the flexor digitorum profundus. The radial nerve curves posteriorly around the humerus and penetrates the lateral intermuscular septum well proximal to the elbow joint (Figure 2). It then travels between the brachialis and brachioradialis muscles. It branches into the superficial radial nerve and posterior interosseous nerve just proximal to the elbow joint. The superficial radial nerve passes into the forearm just deep to the brachioradialis. The posterior interosseous nerve continues distally and courses into the supinator muscle while curving around the lateral aspect of the radial head.