ELBOW: ANATOMY AND ELBOW: ANATOMY AND EXAMINATIONEXAMINATION

Dr. Jose Rico-PeceroDr. Jose Rico-Pecero

Orthopaedics DepartmetOrthopaedics Departmet

Newham University Newham University HospitalHospital

ANATOMYANATOMY

• Effective use of our hands requires stable, Effective use of our hands requires stable, painless elbow joints. painless elbow joints.

• Structures:Structures: - bones and joints.- bones and joints. - ligaments and tendons. - ligaments and tendons. - muscles. - muscles. - nerves. - nerves. - blood vessels. - blood vessels.

Bones and jointsBones and joints

The elbow proper consists of three articulations that share one synovial cavity:

• Humeroulnar articulation.

• Humeroradial articulation.

• Proximal radioulnar articulation.

Bones and jointsBones and joints

MusclesMuscles• FlexionFlexion

- brachialis- brachialis- biceps brachii- biceps brachii- brachioradialis- brachioradialis- pronator teres (when flexion is - pronator teres (when flexion is resisted)resisted)

• ExtensionExtension- triceps brachii- triceps brachii- anconeus (a minor contributor)- anconeus (a minor contributor)

• PronationPronation- pronator teres- pronator teres- pronator quadratus- pronator quadratus

• Supination Supination - biceps brachii- biceps brachii- supinator- supinator

• Ant Comparment arm:

- Brachialis

- Bicep Brachialis

• Post Compartment arm:

- Tricep Brachii

• Ant Compartment forearm:

- Pronator teres

- Pronator cuadratus

• Post Comparment forearm:

- Brachioradialis

- Supinator

- Anconeus

Ligaments and TendonsLigaments and Tendons

The fibrous capsule The fibrous capsule is supported by is supported by three ligaments:three ligaments:

- Anular ligament. - Anular ligament.

- Radial collateral - Radial collateral ligaments.ligaments.

- Ulnar collateral - Ulnar collateral ligaments. ligaments.

BursaesBursaes

1.1. Subcutaneous Subcutaneous olecranonolecranon bursa bursa

Deep to the skin, but Deep to the skin, but superficial to the triceps superficial to the triceps brachii tendon and the brachii tendon and the olecranon, lies the olecranon, lies the subcutaneous olecranon subcutaneous olecranon bursa.bursa.

2.2. SubtendinousSubtendinous olecranonolecranon

bursa bursa.. The subtendinous The subtendinous

olecranon bursa reduces olecranon bursa reduces friction between the friction between the olecranon and the triceps olecranon and the triceps brachii muscle.brachii muscle.

Surface landmarks of the Surface landmarks of the elbowelbow

Imaging the elbowImaging the elbow

Anteroposterior (AP)Anteroposterior (AP) Lateral (L)

EXAMINATIONEXAMINATION

• Inspection: Observe the whole Inspection: Observe the whole patient, front and back, looking patient, front and back, looking especially for deformity. especially for deformity.

The physiological valgus (“carrying angle”) of the elbow is increased when a load is being carried. Normally, the angle is between 9 and 14° when the

elbow is extended and the forearm is supinated.

EXAMINATIONEXAMINATION• 2. Palpation: Feel for tenderness.2. Palpation: Feel for tenderness.

Palpation starts at the posterior aspect, with the patient standing with his or her shoulder braced backwards. The three palpation landmarks - the two epicondyles and the apex of the olecranon - form an equilateral triangle when the elbow is flexed 90°, and a straight line when the elbow is in extension

Flexing the elbow allows palpation of the olecranon fossa on either side of the triceps tendon.

Anatomical landmarks on the lateral aspect of the elbow: The radial head is palpated with the thumb, while the examiner’s other hand is used to pronate and supinate the forearm.

Palpation and testing of brachioradialis, a forearm flexor.

Palpation and testing of the wrist extensors

Palpation of the medial aspect of the elbow. Above the medial epicondyle is the ridge on which the intermuscular septum inserts. Two centimetres above the epicondyle is the site used for lymph node palpation.

The ulnar nerve is palpated behind the intermuscular septum. It may sometimes sublux or roll on the epicondyle. Ulnar nerve instability is more readily demonstrated if the elbow is flexed 60° and the upper limb is abducted and

externally rotated

Diagrammatic view of the pattern of the flexor-pronator group: The thumb represents pronator teres; the index, flexor carpi radialis; the middle finger, palmaris longus; and the ring finger, flexor carpi ulnaris

Palpation of the medial biceps expansion (lacertus fibrosus), which courses over the brachial vessels and

the median nerve

EXAMINATIONEXAMINATIONAccentuate the pain of Accentuate the pain of

tennis elbow. tennis elbow.

• 4. Tennis elbow: point 4. Tennis elbow: point tenderness. tenderness.

• 5. Tennis elbow: pain 5. Tennis elbow: pain on resisted extension.on resisted extension.

• 6. Tennis elbow: pain 6. Tennis elbow: pain on passive stretch.on passive stretch.

EXAMINATIONEXAMINATION

7. Examine extension. 7. Examine extension.

EXAMINATIONEXAMINATION

8. Examine flexion. 8. Examine flexion.

EXAMINATIONEXAMINATION

• 9. Examine 9. Examine supination.supination.

• 10. Examine 10. Examine pronation.pronation.

EXAMINATIONEXAMINATION

11. Pivot shift of 11. Pivot shift of elbow (instability). elbow (instability).

EXAMINATIONEXAMINATION

12. Provocative test for 12. Provocative test for Cubital Tunnel Syndrome Cubital Tunnel Syndrome (puts tension on ulnar (puts tension on ulnar nerve at elbow). nerve at elbow).

EXAMINATIONEXAMINATION

13. Palpate the ulnar nerve. 13. Palpate the ulnar nerve.