Download Elbow Examination

Elbow Examination
Haroon Majeed
Key Points
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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
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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 EhlersDanlos 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
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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