April 11, 2024

Elbow examination are performed to evaluate the different pathologies of the elbow from traumatic and non-traumatic.

Clinical approaches from

  • Trauma
  • Non-Trauma cases

Elbow Joint is a Hinge Joint (Humero-ulnar articulation)

But look for

  • Radioulnar
  • Superior Radioulnar joint

Common childhood injury: Prone to stiffness due to neglected and inappropriately treatment

To know the functional position (Right / Left)

Clinical Presentation

  • Pain
  • Swelling
  • Stiffness
  • Deformity
  • Instability
  • Paresthesia/ Neurological manifestation

History Taking

  • Duration of pain
  • Dominant limb and profession
  • History of Injury/ constitutional symptoms
  • H/O polyarthralgia
  • Management history
  • History of massage
  • Limitation of ADL
  • Referred pain neck/ shoulder

Inspection

Swelling

Localized

  • Paraolecranon area
  • anconeus
  • Soft spot
  • Radiocapitullar joint

Generalized

Look for effusion

Look in the semiflexed elbow

Skin conditions (SEADS)

Attitude and deformity

Look from the Front, Side, and Behind [ Usually in flexed position]

Front

Ask the patient to stand straight, arm by side of the body, elbow flexed, forearm supinated, palm looking forward, fingers extended

Carrying Angle

ALWAYS COMPARE WITH THE OPPOSITE SIDE

Normal outward deviation of extended and supination forearm from the axis of the arm

Elbow examination (Carrying angle)
Carrying angle in elbow examination

Look for bicep bulge/ bicep tendons

Cubital fossa

Flexion deformity

Male : 7 – 10 degree

Female: 10-15 degree

Carrying angle cannot be demonstrated in flexion attitude as it disappears in pronation of forearm and flexion of the elbow

Front Side

Look for anterior and posterior broadening of the elbow

The prominence of medial and lateral condyle of humerus

From Behind

Olecranon

  • See whether it is prominent?
  • Whether it is displaced or not?

Paraolecranon fullness/ depression

Tricep muscle bulge/ tricep tendon

The upper end of ulna/ Back of medial and lateral epicondylar tips

Anconeous triangle

Anconeous triangle of elbow
Anconeous triangle

In the case of the fluid collection, this portion usually bulges

Lies anconeus muscle

  • Radial Head
  • Tip of olecranon
  • Lateral Epicondyle

Swelling

  • Localized: Rheumatoid nodules, Olecranon bursitis
  • Diffused: Effusion-> semi-flexed position

Earliest sign filling out of the hollow in flexed elbow above the olecranon

Next is swelling of the radiohumeral joint

See for muscle wasting in the arm and forearm

Palpation

Local rise of temperature

Palpate normal side-> then affected side-> then again normal side

Causes

  • Infective (Pyogenic/ tubercular)
  • Inflammatory (Polyarthritis/ Acute myositis)
  • Traumatic
  • Fresh Injury
  • Hematoma

Tenderness:

Over bony prominence and Joint line

  • Maximum Point of tenderness
    • Lateral epicondyle=Tennis elbow
    • Medial epicondyle= Golfer elbow
    • The lower end of humerus=Supracondylar fracture of Humerus (Palpate with elbow semiflexed and forearm supinated)
    • Radial head= Radial head fracture
      • Fix arm side of the chest, flex to 30-degree elbow and by supinating/ pronating palpate radial head)
    • Upper end of ulna= Olecranon fracture
  • In bony components:
    • Look for
    1. Tenderness
    2. Irregularity
    3. Bowing
    4. Thickening
    5. Steps

Palpate soft tissue components

  • Medial aspects
  • Lateral Aspects
  • Anterior aspects
  • Posterior aspects

Ulnar nerve palpation

Supratrochlear Lymph nodes

Describe 3 Bony point relationship

  • Should make a mark on both the sides
  • Compare with the opposite side
  • In Flexion= Near isosceles triangle
  • In Extension= Straight
Three bony point anatomy and relations in elbow examination
Three bony point anatomy and relations in elbow examination

Palpation of the supratrochlear group of Lymph Nodes

Flex elbow 90° to relax structures

Palpate the anterior surface of the medial intermuscular septum, 1 cm above the medial epicondyle

Enlarged Lymph nodes will slip between the finger and thumb

Palpable in

  • Unilateral: Infective lesions in hand, wrist, forearm
  • Bilateral: Syphilis

Swelling

Fluctuant ( Effusion, Bursitis)

Filling up concavity on each side of the olecranon

Swelling over anconeus

The cross fluctuation between medial para olecranon swelling and posterolateral swelling => Fluid in joint

Elbow effusion
Elbow effusion

Palpation of Mobile wad of three

Consist:

  1. Brachioradialis
  2. ECRL
  3. ECRB

Originates from lateral epicondyle and its supracondylar ridge

Palpate with the forearm in neutral position and wrist in rest

( Normally muscles are tractable under the skin and can be moved between fingers)

Palpation of cubital fossa

Biceps tendon- Brachial Artery- Median Nerve

Palpation of ulnar nerve

In the groove behind the medial epicondyle

Flex the elbow

Palpate with 3-4 fingers and check

  • Thickened or not
  • Pliable or fixed
  • Tender or not
  • Normal position or not

Always compare with another side

Movements

Elbow Flexion

Ask patient to attempt to touch both shoulders (135°-145°)

Elbow Extension

Ask the patient to straighten their elbow (Normal 0°)

Hyperextension up to 15° can be possible in

  • Adolescence female
  • Ligament laxity
  • Ehler Danlos syndromeme

Fixed Flexion Deformity (FFD)

In all fixed flexion deformity extension is 0°

Free flexion can be present

In fixed flexion deformity of 20°, extension is 0° and free flexion can be present between 20° to 90°

Forearm Supination/ Pronation

Ask the patient to flex the elbow to 90°

Fix the elbow to the side of the chest

Rotate closed fist with palm Upward (Supination), Downward (Pronation) -> Generally Pen is used

Supination = 80°

Pronation=75°

Muscle action of Elbow

Measurement

3 Bony Point

Arm length and girth (maximum girth from the bony point)

Forearm Length: From lateral epicondyle to radial styloid

Arm Length: Angle of the acromion to Lateral epicondyle

To identify, trace the spinous process medially at the point where it bends forward to become the angle of acromion

Special Tests for Elbow Examination

Test for Tennis Elbow

Flex the elbow

Pronate the hand

Extend the elbow

Pain over the lateral epicondyle

(Also increase by flexion of the wrist)

Maudsley’s Test

Resisted 3rd Digital extension

Cozen test

Resisted wrist extension with radial deviation and full pronation

Chair test

Ask the patient to attempt to lift the chair of about 3.5 kg in weight with the elbow extended and shoulder flexed to 60°

Difficult in performing this maneuver is suggestive of a positive test

Mill’s maneuver

Ask the patient to keep his elbow straight and wrist flexed

Pronate the forearm

A patient will have pain in the lateral epicondyle

Tests for Golfer’s elbow

Reverse Mill’s maneuver

Flex the elbow

Supinate hand and extend the elbow and wrist

Pain over medial epicondyle (+)

Reverse Cozen test

Seated patient and elbow flexed 120°

Forearm supinated with the wrist slightly flexed towards the ulna

Examiner put pressure on the palm using one hand

Stabilized elbow and palpate medial epicondyle

Pain (+)

Other Test:

Ask the patient to keep elbow extended and forearm supinated

Ask to make a fist

Flex the wrist against the resistance of the examiner

Pain (+)

Elbow Instability

Test for ligamentous laxity

Flex elbow to 30 degrees

  • Varus Stress test
  • Valgus Stress test

Posterolateral rotational Instability

Flex the elbow to 30° to unlock the olecranon from the olecranon fossa, maximally externally rotating the humerus to stabilize the shoulder joint

Apply Valgus force ( to access the medial ligaments)

Then fully internally rotating the humerus and applying a varus force to access the lateral ligaments

Neurological Examinations

Distal pulses

Examination of the cervical spine

Examination of shoulder

Examination of hand and wrist

Examination of the elbow of the opposite side