MORPHOLOGICAL STUDY OF

PROXIMAL ULNA WITH CT SCAN IN

SOUTH INDIAN POPULATION

Dr.G. VIGNESH KARTHICK

GUIDE:Prof.P.GOPINATH MENON
AIM OF THE STUDY

 To analyze the apexes and angulations along

the posterior border of proximal ulna ,such as
varus angulation, dorsal angulation, hook
angulation–using computer aided software.

 An osteometric evaluation of proximal ulna.

ANATOMY
 The ulna is a long bone in the forearm. It lies
medially and parallel to the radius, . The ulna acts as
the stabilising bone, with the radius pivoting to
produce movement.

 Proximally, the ulna articulates with the humerus at

the elbow joint. Distally, the ulna articulates with
the radius, forming the distal radio-ulnar joint.
 Ulna is the latin word for elbow. It comes from the older
Greek word olene meaning elbow.

 Proximal ulna fractures occur in three locations:

 olecranon,
 Coronoid,
 and the proximal 3rd of ulna.
BORDERS
 Interosseous or lateral border : Sharpest in its middle two-
fourths. Inferiorly- it can be traced to the lateral side of the
head. Superiorly- it is continuous with the supinator crest.

 Anterior border: Thick and rounded. It begins from medial

side of the ulnar tuberosity, passes backwards in its lower
one- third, and terminates at medial side of styloid process.

 Posterior border is subcutaneous. Posterior border of

olecranon, and terminates at the base of styloid process.
SURFACES
 Anterior surface: lies between the anterior and interosseous
borders. A nutrient foramen is seen on the upper part of this
surface. The nutrient artery is derived from the anterior
interosseous artery.

 Medial surface : lies between the anterior and posterior

borders.

 Posterior surface: lies between the posterior border and

interosseous borders.
ARTICULATIONS
 Trochlear notch forms an articular surface that articulates
with the trochlea of the humerus to form the elbow joint.
 Radial notch articulates with the head of the radius to form
the superior radioulnar joint.
 The mechanism of injury is usually hyperextension,
hyperflexion, a direct blow to a flexed elbow, or a shear
force.

 pediatric population (age range, 0-16 years) accounted for

17.8% of ulna all fractures.

 44% of all forearm fractures in adults.

 Olecranon fractures are rare in children, accounting for only

5–7%1 of all elbow fractures
Ossification:
• The shaft and most of the upper end ossify from a
primary centre which appears during the 8th week
of development.
• The superior part of the olecranon process ossifies
from a secondary centre which appears during the
10th year. It forms a scale-like epiphysis which joins
the rest of the bone by 16th year. The lower end
ossifies from a secondary centre which appears
during the 5th year, and joins with the shaft by 18th
year
Muscle Direction Attachment

posterior part of superior surface

Triceps brachii muscle Insertion of Olecranon process (via
common tendon)

Anconeus muscle Insertion olecranon process (lateral aspect)

anterior surface of the

Brachialis muscle Insertion
coronoid process of the ulna
medial surface on middle portion
of coronoid process (also shares
Pronator teres muscle Origin origin with
medial epicondyle of the
humerus)
olecranon process and posterior
Flexor carpi ulnaris Origin
surface of ulna (also shares origin
muscle with medial epicondyle of the
humerus)
coronoid process (also shares
Flexor digitorum Origin
origin with medial epicondyle of
superficialis muscle the humerus and shaft of the
radius)

Flexor digitorum coronoid process, anteromedial

Origin surface of ulna (also shares origin
profundus muscle with the interosseous membrane)
 distal portion of anterior ulnar
Pronator quadratus musc Origin
shaft
le
posterior border of ulna (also
Extensor carpi ulnaris Origin
shares origin with
muscle lateral epicondyle of the humerus
)
proximal ulna (also shares origin
Supinator muscle Origin with lateral epicondyle of the
humerus)
posterior surface of ulna (also
Abductor pollicis longus Origin shares origin with the posterior
muscle surface of the radius bone)

dorsal shaft of ulna (also shares

origin with the dorsal shaft of the
Extensor pollicis longus Origin
radius and the interosseous
muscle membrane)

posterior surface of distal ulna

Extensor indicis muscle Origin (also shares origin with the
interosseous membrane)
Blood supply:

 The forearm (and ulna) is supplied by the ulnar artery and its
continuation as the common interosseous artery with the
anterior and posterior interosseous branches.

Nerve supply:

 Periosteum is supplied anteriorly by the anterior

interosseous nerve (branch of median nerve).
 Posteriorly, the periosteum is supplied by the posterior
interosseous nerve (branch of radial nerve)
PROXIMAL ULNA

 Important landmarks of the proximal ulna

are:

 Olecranon
 Coronoid process
 Trochlear notch
 Radial notch
 Tuberosity of ulna.
Olecranon :

 A large projection of bone that extends proximally, forming

part of trochlear notch. It can be palpated as the ‘tip’ of the
elbow. The triceps brachii muscle attaches to its superior
surface.

Coronoid Process :

 This ridge of bone projects outwards anteriorly, forming part

of the trochlear notch.
Trochlear Notch
 Formed by the olecranon and coronoid process. It is wrench
shaped, and articulates with the trochlea of the humerus.

Radial Notch
 Located on the lateral surface of the trochlear notch, this
area articulates with the head of the radius.

Tuberosity of Ulna
 An roughening immediately distal of the coronoid process. It
is where the brachialis muscle attaches
Proximal Ulna - Medial
view

1.Trochlear notch
2.Coronoid tip
3.Anteromedial facet
4.Sublime tubercle
5.Base of coronoid
6.Tuberosity
7.Olecranon
Proximal Ulna - Lateral view

1.Tuberosity
2.Supinator crest
3.Radial notch
4.Coronoid tip
MATERIALS

 30 pairs of ulnae were obtained from

cadaveric subjects of which 15 were male and
15 female.

 Computed tomography
METHODS
 30 pairs of south indian ulnae was separated into 2
groups -group-A(male) and group B-(female).

 Both the groups were CT scanned in batches and

groups

 Ulna was harvested form the cadaveric specimens .

 All specimens were scanned using 64-slice CT scan

with 0.6-mm contiguous axial slices.
PARAMETERS MEASURED
 Three apexes:
1.dorsal apex
2. varus apex
3. edge point

All of them were recorded in ratios relative to the ulnar

length.

 The angulations of the dorsal apex curve were defined

1. varus (α)
2. dorsal (β)
3. hook (γ)
VARUS ANGULATION

VARUS APEX
DORSAL ANGULATION

DORSAL APEX
 HOOK ANGULATION

HOOK ANGULATION

EDGE POINT
SAMPLES- ULNA 1

Ulna length Hook angulation

Dorsal angulation

Varus angulation
 Ulna length- 260mm

 Dorsal angulation-9 degrees

 Varus angulation-11 degrees

 Hook angulation-92 degrees

ULNA-2
Ulna length Hook angle

Dorsal angulation

Varus angulation
 Ulna length-225mm

 Dorsal angulation-4 degrees

 Varus angulation-10degrees

 Hook angulation-91 degrees

UNNA-3
Ulna length Hook angulation

Dorsal angulation

Varus angulation
 Ulna length –249mm

 Dorsal angulation-3 degrees

 Varus angulation-12 degrees

 Hook angulation-92 drgrees

ULNA-4
Ulna length Hook angulation

Dorsal angulation

Varus angulation
 Ulna length-273mm

 Dorsal angulation-5 degrees

 Varus angulation-12 degrees

 Hook angulation-92 degrees

ULNA -5
Ulna length Hook angulation

Dorsal angulation

Varus angulation
 Ulna length-230mm

 Dorsal angulation-6 degrees

 Varus angulation-10 degrees

 Hook angulation-91 degrees

ULNA-6
Ulna length Hook angulation

Dorsal angulation

Varus angulation
 Ulna length-239.7mm

 Dorsal angulation-9.0

 Varus angulation-12.4

 Hook angulation-92.5
 GROUP-A(male)
specimen Limb Length Apex relative to the ulna length % Angulation (degree)
of ulna
(mm) Varus Dorsal Edge Varus Dorsal Hook
1. Right/left 250 33 27 9 171 176 90

251 36 23 11 168 176 90

2. Right /left 249 33 26 8 171 175 91
247 28 22 10 172 176 91
3. Right /left 289 33 19 13 163 177 90
290 33 25 11 165 178 91
4. Right /left 274 38 23 11 169 176 90
274 39 19 9 168 176 91
5. Right /left 268 42 17 7 158 177 92
266 40 26 8 157 177 92
6. Right /left 299 32 25 10 155 176 92
298 32 22 11 155 175 92
7. Right /left 289 28 20 10 168 179 90
286 29 22 10 168 178 90
8. Right /left 278 27 25 9 160 175 91
277 27 26 10 162 176 92
9. Right /left 267 31 24 12 164 178 93
267 32 24 11 162 179 93
10. Right /left 225 35 26 12 168 178 90

227 36 23 12 166 178 90

 GROUP-A(female)
specimen Limb Length Apex relative to the ulna length % Angulation (degree)
of ulna
(mm) Varus Dorsal Edge Varus Dorsal Hook

1. Right/left 235 28 27 8 168 176 90

233 27 23 9 169 176 90

2. Right /left 255 33 24 7 166 177 91

256 34 26 7 165 179 91

3. Right /left 220 29 31 11 163 167 90

221 27 32 13 162 169 91

4. Right /left 226 26 27 10 167 178 90

225 25 29 10 168 179 90

5. Right /left 231 29 30 12 158 173 91

230 29 32 12 159 172 91

6. Right /left 230 31 20 13 159 171 90

230 29 25 12 159 172 91

7. Right /left 248 31 22 10 160 158 91

249 33 23 12 164 159 92

8. Right /left 215 25 25 9 151 160 90

217 25 29 8 151 160 90

9. Right /left 241 28 30 13 167 171 91

238 29 31 10 167 170 90

10. Right /left 259 33 35 12 162 172 91

257 35 36 10 162 174 91

Parameters measured
MEAN P -VALUE
MALE RIGHT / LEFT

Ulnar length 273.80 272 0.993

RATIOS OF APEXES
Varus apex 34.40 34.53 0.930
Dorsal apex 22.8 23.00 0.889
Edge point 10.02 10.00 0.800
ANGULATIONS:
Varus angulations 161.73 162 0.655
Dorsal angulations 175.01 175.13 0.949
Hook angulation 90.8 91.7 0.466
Parameters measured MEAN P- VALUE

FEMALE RIGHT LEFT

ULNA LENGTH 237.73 237.80 0.980

RATIO OF APEXES
VARUS APEX 30.33 29.87 0.702
DORSAL APEX 27.67 28.93 0.371
EDGE POINT 10.53 10.42 0.841
ANGULATIONS
VARUS ANGULATION 165.73 165.40 0.858

DORSAL 169.80 17047 0.761

ANGULATION
HOOK ANGULATION 90.33 90.56 0.429
Parameters MEAN
measured
(ULNA-RIGHT) MALE FEMALE P-VALUE

Ulna length 273.73 237.37 0.0005

RATIO OF APEXES
Varus apex 34.42 30.33 0.005
Dorsal apex 22.87 27.67 0.001
Edge point 10.20 10.53 0.603
ANGULATION
Varus angulation 161.73 165.73 0.032
Dorsal angulation 175.07 169.80 0.003
Hook angulation 90.87 90.33 0.141
Parameters MEAN
measured
(ULNA LEFT) MALE FEMALE P- VALUE

Ulna length 273.73 237.87 0.0005

RATIO OF APEXES
Varus apex 34.53 29.87 0.002
Dorsal apex 23.00 28.93 0.0005
Edge point 10.07 10.40 0.552
ANGULATION
Varus angulation 162.47 161.73 0.097
Dorsal angulation 175.13 175.03 0.015
Hook angulation 91.07 90.80 0.100
 Length of ulna (mm)
Length of ulna (mm)
280.0 273.8 273.7 280.0 273.8 273.7
270.0 270.0
260.0 260.0
250.0 250.0
240.0 237.7 237.9
240.0 237.7 237.9
230.0
230.0
220.0
220.0
210.0
Male Female 210.0
Right Left

Male Female
Right Left
Varus - Apex relative to the ulna Varus - Apex relative to the ulna length
length % %
35.0 34.4 34.5
35.0 34.4 34.5
34.0
34.0
33.0
33.0
32.0
32.0
31.0 30.3 31.0
29.9 30.3
30.0 29.9
30.0
29.0 29.0
28.0 28.0
27.0 27.0
Male Female Right Left

Right Left Male Female

 Dorsal - Apex relative to the ulna length %
35.0 Dorsal - Apex relative to the ulna length
30.0 27.7 28.9 %
35.0
25.0 22.9 23.0 28.9
30.0 27.7
20.0 25.0 22.9 23.0
15.0 20.0
15.0
10.0
10.0
5.0
5.0
0.0 0.0
Male Female Right Left

Right Left Male Female

Edge - A9pex relative to the ulna Edge - A9pex relative to the ulna
length % length %
10.6 10.5
10.6 10.5
10.5 10.4
10.5 10.4
10.4 10.4
10.3 10.3 10.2
10.2 10.2
10.2 10.1
10.1 10.1 10.1
10.0 10.0
9.9 9.9
9.8 9.8
Male Female Right Left

Right Left Male Female

 Varus - Angulation (degree)
Varus - Angulation (degree)
167.0
167.0 166.0 165.7 165.4
166.0 165.7 165.4 165.0
165.0 164.0
164.0
163.0 162.5
163.0 162.5 161.7
162.0 161.7 162.0
161.0 161.0
160.0 160.0
159.0 159.0
Male Female Right Left

Right Left Male Female

Dorsal - Angulation (degree)

Dorsal - Angulation (degree) 176.0
175.1 175.1
176.0 175.0
175.1 175.1
175.0 174.0
174.0 173.0
173.0
172.0
172.0
171.0 170.5 171.0 170.5
169.8 170.0 169.8
170.0
169.0 169.0
168.0 168.0
167.0
Male Female 167.0
Right Left
Right Left
Male Female
 Hook - Angulation (degree) Hook - Angulation (degree)
91.2 91.1 91.2 91.1
91.0
91.0
90.8
90.8 90.8
90.8
90.6 90.5
90.6 90.5
90.4 90.3
90.4 90.3
90.2
90.2
90.0
90.0
89.8
Male Female 89.8
Right Left
Right Left
Male Female
CONCLUSION

In conclusion, the ulna length between male and

female had a significant difference.

The average ratios of dorsal apex , varus apex ,in

relation to ulna length had gender difference.

Angulations such as dorsal angulation showed a

higher significant difference between male and
female .
 We also found significant difference in the
varus angulation between male and female .

 No significant difference between edge point

and the hook angulation

 We found no significant difference between

right and left ulna.
REFERENCES
 Grechenig W, Clement H, Pichler W, Tesch NP, Windisch G.
The influence of lateral and anterior angulation of the
proximal ulna on the treatment of a Monteggia fracture:
an anatomical cadaver study. J Bone Joint Surg Br
2007;89:836–8. Cro

 Ring D, Jupiter JB, Simpson NS. Monteggia fractures in

adults. J Bone Joint Surg Am 1998;80:1733–44.

 3. Strauss EJ, Tejwani NC, Preston CF, Egol KA. The
posterior Monteggia lesion with associated ulnohumeral
instability. J Bone Joint Surg Br 2006;88:84–9. C
 Duggal N, Dunning CE, Johnson JA, King GJ.
The flat spot of the proximal ulna: a useful
anatomic landmark in total elbow arthroplasty.
J Shoulder Elbow Surg 2004;13:206–7.
 5. Dumont CE, Pfirrmann CW, Ziegler D, Nagy
L. Assessment of radial and ulnar torsion
profiles with cross-sectional magnetic
resonance imaging. A study of volunteers. J
Bone Joint Surg Am 2006;88:1582–8. C
 Puchwein P, Schildhauer TA, Schöffmann S, Heidari
N, Windisch G, Pichler W. Three-dimensional
morphometry of the proximal ulna: a comparison to
currently used anatomically preshaped ulna plates.
J Shoulder Elbow Surg 2012;21:1018–23. CrossRef

 7. Rouleau DM, Canet F, Chapleau J, Petit Y,

Sandman E, Faber KJ, et al. The influence of
proximal ulnar morphology on elbow range of
motion. J Shoulder Elbow Surg 2012;21:384–8
 Rouleau DM, Faber KJ, Athwal GS. The
proximal ulna dorsal angulation: a
radiographic study. J Shoulder Elbow Surg
2010;19:26–30. CrossRef.

 Windisch G, Clement H, Grechenig W, Tesch

NP, Pichler W. The anatomy of the proximal
ulna. J Shoulder Elbow Surg 2007;16:661–6