Elbow Examination Haroon Majeed
Key Points Inspection Palpation Movements Neurological Examination Special tests Joints above and below
Before Starting Introduce yourself Explain to the patient what the examination entails and obtain verbal consent Expose the patient appropriately expose both upper arms to the shoulder Tell the patient to alert you if they experience any discomfort always watch the patient s face while examining
Inspection From the Front, Back and Sides: Skin changes - nodules, bruising, scars, sinuses Swelling - generalised swelling (infective, trauma or rheumatoid arthritis) or localised swelling (olecranon bursitis, rheumatoid nodules or tophi). Earliest sign of an effusion is the filling out of the hollow seen in the flexed elbow above the olecranon on either side of the triceps tendon Muscle wasting (infective arthritis and rheumatoid arthritis) Abnormal posture
Carrying angle: Ask the patient to extend both elbows in front of them and compare both sides Measure with a goniometer Males - 11 (range 2-26 ) Females - 13 (range 2-22 ) Increase or loss of angle suggestive of malunited fracture or major elbow instability
Deformity varus (decrease in carrying angle) valgus (increase in carrying angle) deformity
Palpation Does it hurt? ALWAYS ask the patient before touching them! Note any nodules or gouty tophi Skin temperature (use the dorsal surface of your hand to compare temperatures) Palpate the following, noting any tenderness: Lateral epicondyle (tennis elbow) Medial epicondyle (golfer s elbow, tear of ulnar collateral ligament) Olecranon (infected olecranon bursitis, secondary to a fracture) Radio-humeral joint (osteoarthritis, injuries to the radial head and osteochondritis dissecans) Palpate the radio-humeral joint - thumb placed into space on lateral aspect of the elbow between radial head and humerus. Forearm is then supinated and pronated Examine the antecubital fossa (both medial and lateral to the biceps tendon, in flexed and extended positions) and note whether any masses are present (myositis ossificans / loose bodies) Palpate the ulnar nerve behind the medial epicondyle. Is it thickened or hypersensitive to palpation
Movements These should be performed first actively and then passively Flexion (0-145 ) - "Can you bend your arm?" Reduced in osteoarthritis, rheumatoid arthritis and after fractures around the elbow Extension (0 ) - "Can you straighten your arm?" Arm and forearm should lie in a straight line in a fully extended position. Inability to fully extend the elbow may be present in osteoarthritis, rheumatoid arthritis and after fractures around the elbow. Upto 15 of hyperextension accepted is normal especially in women but if more than this, consider Ehlers- Danlos and other connective tissue disorders
Supination (0-80 ) - "Keeping your elbows tucked in at the side (thumbs facing forwards and elbows flexed to approximately 90 ), can you turn your palm so that it faces the ceiling?" Range from neutral position (neutral being mid prone) Pronation (0-75 ) - "Keeping your elbows tucked in at the side (thumbs facing forwards and elbows flexed to approximately 90 ), can you turn your palm so that it faces the floor?" Range from neutral position
Special Tests Instability Both valgus and varus testing are performed with the elbow in full extension and several degrees of flexion to about 30 to unlock the olecranon from the olecranon fossa Valgus testing is performed with the elbow fully pronated so that posterolateral rotatory instability is not mistaken for valgus instability, which occurs because the ulna and radius as a unit rotate away from the humerus in response to valgus stress when the LCL is disrupted Forced pronation prevents this from happening by using the intact medial soft tissues as a hinge or fulcrum, just as the periosteum is used for this purpose during the reduction of a supracondylar fracture in a child Varus testing is easiest to perform with the shoulder fully internally rotated
Posterolateral Instability Lateral Pivot Shift Test is used in the diagnosis of posterolateral rotatory instability With the patient in the supine position and the affected extremity overhead, the wrist and elbow are grasped (as the ankle and knee are held while examining the leg) The elbow is supinated with a mild force at the wrist and a valgus moment is applied to the elbow during flexion This action results in a typical apprehension response with reproduction of the patient's symptoms and a sense that the elbow is about to dislocate Reproducing the actual subluxation and the clunk that occurs with reduction can usually only be accomplished with the patient under GA, or after injecting local anaesthetic into the elbow joint The lateral pivot-shift test performed in this manner results in subluxation of the radius and ulna from the humerus, which causes a prominence posterolaterally over the radial head and a dimple between the radial head and the capitellum. As the elbow is flexed to approximately 40 or more, reduction of the ulna and radius together on the humerus occurs suddenly with a palpable, visible clunk. It is the reduction that is apparent
Tennis elbow - pain on resisted dorsiflexion of the wrist Golfer's elbow - pain on resisted palmar flexion of the wrist Neurological problems Ulnar tunnel neuropathy - fully flex the elbow for 5 minutes and check for ulnar nerve symptoms Radial tunnel syndrome - pain on palpation around the supinator muscle (arcade of Frohse). Pain eliminated by LA injection indicative of radial tunnel syndrome