The Elbow, Examination

THE ELBOW

ORTHOPEDIC EXAMINATION

Sreeraj S R

ANATOMICAL FEATURES

� Compound synovial

joint.

� Made up of

1. Ulnohumeral joint

2. Radiohumeral joint

3. Superior radio ulnar

joint

Sreeraj S R

ULNOHUMRAL

JOINT/TROCHLEAR JOINT

� Found between trochlea of humerus and trochlear notch of ulna.

� Uniaxial hinge joint.

� Axis of movement is downwards and medially.

� This leads to carrying angle.

� Resting position is elbow flexed to 70° and forearm supinated 10°.

� Close pack position is extension with the forearm in supination

� Capsular pattern is flexion more limited than extension.

Sreeraj S R

RADIOHUMERAL JOINT

� Formed between capitulum of humerus and head of radius.

� Uniaxial hinge joint.

� Resting position is with the elbow fully extended and forearm fully supinated.

� Close packed position is elbow flexed to 90° and forearm supinated to 5°.

� Capsular pattern is flexion more limited than extension.

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SUPERIOR RADIOULNAR JOINT

� Head of the radius is held in a proper relation to the ulna and humerus by the annular ligament.

� Uniaxial pivot joint.

� Resting position is 35°supination and 70° elbow flexion.

� Closed packed position is supination of 5°.

� Capsular pattern is equal limitation of supination and pronation.

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LIGAMENTS

� Medial collateral ligament, with its three bundles. The anterior bundle is the most important functionally, since it provides valgus and anteroposterior stability.

� Lateral ligament complex. It would appear that the most important structure is the lateral collateral ligament, which blends with the annular ligament.

� Origin and insertion of anconeus, which covers the capsule and collateral ligaments on the lateral side.

� The anconeus muscle, appears to be chiefly a joint stabilizer, serving as an active collateral ligament. This would account for the fact that it is often torn when the lateral collateral ligament complex is ruptured as a result of elbow dislocation.

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MUSCLES

� Elbow flexion

� Biceps

� Brachialis

� Brachioradialis

� Pronator Teres

� Elbow extension

� Triceps

� Anconeus

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MUSCLES (cont.)

� Wrist extensors (lateral

epicondyle)

� Extensor carpi radialis

longus

� Extensor carpi radialis

brevis

� Extensor carpi ulnaris

� Wrist flexors (medial

epicondyle)

� Flexor carpi radilais longis

� Flexor carpi ulnaris

� Palmaris longus

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MUSCLES (cont.)

� Pronators

� Pronator teres

� Pronator quadratus

� Supinators

� Biceps brachii

� Supinator

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EXAMINATION- INSPECTION

� Look for swelling and muscle wasting, both suggestive of infective arthritis like TB, RA, olecranon bursitis etc. The swollen joint is always held in semi flexed position to reduce intra articular pressure and pain.

� Note for sign of effusion i.e. Filling of hollows seen in flexed elbow, above olecranon and on RU joint.

� Note and compare Carrying Angle on both sides.

� Formed by long axis of humerus and midline of forearm

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cubitus valgus

� Increase in carrying angle

� Male norms – 11-14°

� Female norms – 13-16°

� Larger angles are considered abnormal

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cubitus varus

� Decrease in carrying

angle

� Usually develops

secondary to condylar

humerus fracture

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EXAMINATION-MOVEMENTS

� Full extension is limited in OA, RA, Old Fractures of Radial head etc.

� Hyper extension up to 15° accepted normal. Beyond this look for hyper mobility in other joints like Ehlers Danlos syndrome.

� Ask the patient to touch both shoulders. A slight difference in Flexion between the sides is obvious. Normal is 145°.Restriction is common in fractures and arthritis.

� Ask the patient to hold the elbows closely, turn the palms upwards in supination(80°) and compare the sides. Now turn palm down in pronation(75°) and compare the sides. Pron. /Supn. affected in fracture, dislocation, arthritis etc.

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� Flexion & Extension

measured with a

goniometer at the lateral

aspect of elbow

� Normal ROM is 0-140°

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� Measuring pronation: The

vertical limb of the

goniometer is placed parallel

to the long axis of the

humerus, while the

horizontal limb is placed on

the back of the wrist (to

eliminate additional motion

at the radiocarpal joint). The

mean value is 70°

� Measuring supination: The

horizontal limb is placed on

the anterior aspect of the

wrist. The mean value is 85°.

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EXAMINATION-PALPATION

� Three bony landmarks -

the medial epicondyle,

the lateral epicondyle,

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

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� The elbow joint may be palpated inside a triangle formed by the bony prominences of the lateral epicondyle, the radial head, and the olecranon. This palpation will reveal even minor effusions or mild synovitis. Puncture for joint aspiration is performed inside this triangle. Similarly, an arthroscopy portal may be placed there (posterolateral portal).

� 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.

� Press the thumb firmly into the space on lateral side between radial head and humerus and do pronation and supination. Tenderness is a sign of radial head injury, OA and Osteochondritis.

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� Flexing the elbow allows

palpation of the

olecranon fossa on either

side of the triceps

tendon.

� Palpate olecranon for

tenderness post fracture

and olecranon bursitis.

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� For the palpation of brachioradialis, the patient is asked to clench his or her fist and flex the elbow with the forearm in neutral position (mid-way between pronation and supination) and with the fist blocked under a table.

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� The wrist extensors are

palpated at the elbow by

asking the patient to

extend the wrist against

resistance.

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� Palpation of the medial

aspect of the elbow : -

Above the medial

epicondyle is the ridge

on which the

intermuscular septum

inserts. Two centimeters

above the epicondyle is

the site used for lymph

node palpation.

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� The ulnar nerve is palpated

behind the intermuscular

septum. It may sometimes

sublux or roll on the

epicondyle.

� Ulnar nerve instability is

more easily tested with the

arm in slight abduction and

external rotation, with the

elbow flexed between 20 and

70°.

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� 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.

� The flexor - pronator muscles must be tested as a unit, by asking the patient to perform wrist adduction and flexion against resistance .

� Anteriorly, the bulk of the flexor-pronator group restricts the extent of joint palpation.

� Laterally, brachioradialis will be felt; and in the middle, the biceps tendon is readily accessible if the patient is made to flex the forearm against resistance.

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� Palpation of the medial

biceps expansion

(lacertus fibrosus), which

courses over the brachial

vessels and the median

nerve.

� the pulse of the brachial

artery will be felt deep to

this aponeurosis.

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COMMON ELBOW

CONDITIONS� Tennis Elbow.

� Cubitus Varus.

� Cubitus Valgus.

� Tardy Ulnar Nerve Palsy.

� Ulnar Neuritis and Ulnar Tunnel Syndrome.

� Olecranon Bursitis.

� Pulled Elbow

� Osteoarthritis and Osteochondritis.

� Rheumatoid Arthritis.

� T B of Elbow.

� Myositis Ossificance

� Fractures/Dislocations

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SPECIAL TESTS

� Commonly known as tennis elbow

� Occurs in mostly 30-50 years age group

� Due to degeneration of the tendon fibres over the lateral epicondyle which are involved in wrist extension

� severe burning pain on outside of elbow

� Pain worse on gripping or lfting objects and with direct pressure over lateral epicondyle

� Pain may radiate down forearm

� TENNIS ELBOW

Sreeraj S R

SPECIAL TESTS :

TENNIS ELBOW

� Cozen’s test : The patient’s elbow is stabilized by the examiner’s thumb, which rests on the patient’s lat. epicondyle.

� The patient is then asked to make a fist, pronate the forearm, and radially deviate and extent the wrist while the examiner apply resistance.

� A positive sign is sudden severe pain in the area

Sreeraj S R

SPECIAL TESTS :

TENNIS ELBOW

� Mill’s test : while

palpating lat. Epicondyle,

the examiner passively

pronate the patient’s

forearm, flexes the wrist

fully and extends the

elbow.

� A positive test is

indicated by pain over

the area.

Sreeraj S R

SPECIAL TESTS :

TENNIS ELBOW

� Tennis Elbow test : The

examiner resists

extension of the third

digit of the hand distal to

the proximal IP joint,

stressing the ED muscle

and tendon.

� A positive test indicated

by pain over the area

Sreeraj S R

SPECIAL TESTS :

TENNIS ELBOW

� The Chair Test : Ask the

patient to attempt to lift

a chair with elbow

straight and shoulders

flexed to 60°

� Difficulty to perform and

complain of pain over

lat. aspect is a positive

sign

Sreeraj S R

SPECIAL TESTS :

TENNIS ELBOW

� Thomson’s test : Ask the

patient to clench the fist,

dorsiflex the wrist and

extend the elbow. A

forceful palmar flexion

against patient’s

resistance

� Pain over the area is a

positive sign

Sreeraj S R

SPECIAL TESTS :

GOLFER’S ELBOW

� Also known as Medial

epicondylitis

� Similar to Tennis elbow

� Most common in men 20-50

years

� Pain over medial elbow, may

radiate down inner forearm

� Pain worse when make

fist/shake hands

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SPECIAL TESTS :

GOLFER’S ELBOW

� Golfer’s elbow test : Flex

the elbow, supinate the

hand, and then extend

the elbow.

� Pain over the med.

Epicondyle is a positive

sign.

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Olecranon Bursitis

� Infection/inflammation

of bursa

� Causes-

1. Trauma

2. Prolonged pressure

3. Infection

4. Medical conditions e.g.

rheumatoid

arthritis/gout

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SPECIAL TESTS :

Medial Ligamentous Injuries� MCL/ UCL/ ”Little Leaguer’s

Elbow”

� Caused by repetitive microtraumas that may result in numerous disorders of growth in the elbow

� Usually injured due to valgus trauma (acute) or repetitive overhead throwing activities (chronic)

� Evaluate with valgus stress test :–Elbow flexed 25-30 degrees. Abduction or valgus force is applied to the distal forearm while the ligament is palpated

� The examiner feels the ligament tense when stress is applied

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SPECIAL TESTS :

Lateral Ligamentous Injuries� Less common than medial

ligamentous injuries

� If LCL damaged, varus opening present with stress

� Varus laxity increases with annular ligament injury due to separation of head of radius from ulna

� Evaluate with varus stress test –Elbow flexed 25-30° and stabilized with the examiner’s hand.

� An adduction force is applied by the examiner to the distal forearm.

� The examiner feels the ligament tense when stress is applied

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SPECIAL TESTS:

POSTEROLATERAL

INSTABILITY1. Posterolateral Rotary Apprehension Test : PL elbow instability is

common in cases of ulna/radius displacement. Patient lies supine with arm to be tested overhead. Grasp patient’s wrist & extend elbow. A mild supination force applied to forearm at wrist. Patients elbow is then flexed while a valgus stress and compression applied to elbow. If there is PL instability a look of apprehension will become evident as the elbow moved to flexion.

Sreeraj S R

TEST FOR NEUROLOGICAL

DYSFUNCTION : Cubital Tunnel

Syndrome

� Tinel Sign: The area of ulnar nerve in the groove between olecranon process and med. epicondyle is tapped.

� A + ve sign is indicated by tingling sensation in ulnar distribution distal to the point of compression. This indicates point of regeneration of sensory fibers. The most distal point at which abnormal sensation felt represents the limit of nerve regeneration.

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DYSFUNCTION

� Wartenberg’s Sign: Sitting with hands on table. The examiner passively spreads fingers apart and asks patient to bring them together.

� Inability to bring little finger close indicates Ulnar neuropathy.

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DYSFUNCTION� Elbow Flexion Test: Patient

is asked to fully flex elbow with extension of the wrist and shoulder girdle abduction and depression and hold it for 3 to 5 minutes.

� A positive test is indicated by tingling or parasthesia in ulnar nerve distribution

� The test is confirmatory for cubital tunnel syndrome

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DYSFUNCTION: Ulnar nerve

injuries

� Loss of sensation as shown

� Motor supply to small muscles of hand except thenar muscle and 1st

two lumbricals

� Produces decreased grip strength

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DYSFUNCTION: Median Nerve

Injury

� Occasionally damaged in supracondylar fractures

� More commonly in wrist lacerations

� Produces loss of sensation as shown

� High injuries produce decreased strength in wrist flexion, loss of ulna deviation and thumb opposition

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DYSFUNCTION: median nerve� Test For Pronator Teres

Syndrome: Patient sits with elbow flexed to 90°.Examiner strongly resists pronation as the elbow is extended.

� A positive test is indicated by tingling or parasthesia in median nerve distribution.

� Also called humerus supracondylar process syndrome

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DYSFUNCTION

� Pinch Grip Test:

Patient is asked to pinch

the tips of index and

thumb together.

� If patient is unable to

pinch tip to tip and have

a pulp to pulp pinch it is

indicative of injury to

ant. interosseous nerve,

branch of median nerve.

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DYSFUNCTION: ant. intr. nerve

� Can be entrapped as it

passes between the two

heads of pronator teres

muscle

� known as ant. intr. nerve

syndrome or Kilho-

Nevin syndrome

� Pinch deformity

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DYSFUNCTION: radial nerve

� Injury can be due to trauma or compression in between the two heads of supinator in the arcade or canal of Frohse

� Can also be a radial tunnel syndrome

� Compression of superficial branch of radial nerve as it passes under the tendon of brachioradialis.

� Only sensory changes and patient complaints of nocturnal pain along the dorsum of wrist, thumb and web space

� Known as Cheiralgia parasthetica or Wartenberg’s disease

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Dermatomes

� C5 – lateral arm

� C6 – lateral forearm, thumb and index finger

� C7 – posterior forearm and middle finger

� C8 – medial forearm, ring and little fingers

� T1 – medial arm

� Except T2 all other dermatomes extend distally to forearm and hand

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Myotomes

� C5 – shoulder abduction

� C6 – elbow flexion, wrist

extension

� C7 – elbow extension, wrist

flexion

� C8 – finger flexion/grip

strength

� T1 – finger

abduction/adduction

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Cutaneous distribution

� Pain may be referred to

the elbow and

surrounding tissues from

neck, often mimicking

Tennis Elbow, shoulder

or wrist.

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REFLEXES

� Biceps (C5,C6)

� Brachioradialis (C5-C6)

� Triceps (C7- C8)

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Humerus Fractures

� Supracondylar fracture

� Supracondylar fracture

with posterior elbow

dislocation

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Humerus Fractures

� Most common in

children/adolescents from

fall on flexed elbow or

hyperextension mechanism

� Deformity present if

displaced, often missed on

initial evaluation if

nondisplaced

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Ulnar Fractures

� Olecranon process fractures� If stable/nondisplaced,

short immobilization period (45-90 degrees of flexion)

� If displaced, Internal Fixation with longer immobilization period and early ROM if tolerated

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Ulnar Fractures

� Coronoid process

fracture

� May be associated with

posterior elbow

dislocation

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Fracture over olecranon

� Mechanism

-fall on point of elbow

-sudden triceps

contraction

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Radial Fractures

� Radial head fracture classifications (Mason)� Type I: nondisplaced

� Type II: fracture with displacement, depression or angulation

� Type III: comminuted fracture of head

� Type IV: comminuted fracture associated with elbow dislocation

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Anterior Elbow Dislocation

� Rare occurrences

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Elbow dislocation

� Usually fall onto

outstretched hand

� Severe pain at elbow and

swelling

� Minimal movement

� Check sensation/pulses

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Volkmann’s Ischemic Contracture

� Condition most often associated with supracondylar humerus fracture and/or posterior elbow dislocation

� Spasm, swelling or direct pressure compress brachial artery inhibiting distal circulation

� The fingers can be extended if the wrist is flexed

� When the hands are put in prayer position, there is an uncloseable gap between them

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Elbow Exam

1. Deformity

2. Check wrist

pulse

3. Sensation

Dislocaton

1. Passive ext

2. Valgus test

3. Varus test

Hyperextension

Fell on Arm or Outstretched Hand

1. Medial

Epicondylitis

Test

Little League Elbow

Medial Elbow Pain in

Young Pitcher

1. Tennis Elbow Test

2. Cozen's Test

Lateral Epicondylitis

Gradual Onset of Pain

After Heavy Use

Symptoms

The Elbow, Examination

Education

Transcript of The Elbow, Examination