PS SESSION : ELBOW WRIST AND HAND EXAMINATION PART 1
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This includes the PS session about Elbow and forearm examination in block 4.2
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PS SESSION : ELBOW WRIST AND HAND EXAMINATION PART 1
- 1. EVALUATION OF ELBOW & FOREARM DR. UTKARSH SHAHI ASSISTANT PROFESSOR DEPARTMENT OF ORTHOPAEDICS
- 4. ELBOW CONDITIONS Injury and mechanical derangement. Congenital and developmental abnormalities. Infection and inflammation. Arthritis and rheumatic disorders. Metabolic and endocrine disorders. Tumours and lesions that mimic them. Neurological disorders and muscle weakness.
- 5. HISTORY TAKING PATIENT DETAILS CHIEF COMPLAINTS HISTORY OF PRESENT ILLNESS PAST HISTORY FAMILY HISTORY PERSONAL HISTORY TREATMENT HISTORY NEGATIVE HISTORY
- 6. COMPLAINTS PAIN STIFFNESS SWELLING DEFORMITY WEAKNESS INSTABILITY PARASTHESIA LOSS OF FUNCTION
- 7. THE ATHLETE’S ELBOW It is important to remember when examining the elbow of any athlete or manual laborer that adaptations to repetitive stresses induced by sport/work activities may result in “abnormal” findings which may not represent true pathology
- 8. SPECIFIC POINTS IN HISTORY Any Traumatic events Falls, dislocations, lacerations, fractures Recent athletic activity Throwing history When, where, how much, how well, how fast Changes in routine or training regimen Pain or instability with throwing 85% of throwers with medial elbow instability complain of pain in the acceleration phase of throwing Neurologic symptoms with throwing
- 9. PAIN Site Time and mode of onset Severity or Intensity Character or Nature Progression Referred pain Aggravating factors Relieving factors Any diurnal variation Any seasonal variation
- 10. PAIN The extent of reference is governed by a number of factors. The depth of the structure beneath the skin. The position of the structure within the dermatome. The severity of the lesion
- 11. REFERRED PAIN
- 12. REFERRED PAIN
- 14. SWELLING Site Shape Size First notice Associated Symptoms •Pain •Pressure •Neurological •Vascular •Articular Progression Any other swelling Reducibility Any discharge •If present •Duration •Regular or intermittent •Character of discharge
- 15. DEFORMITY Site Associated Symptoms • Neurological • Vascular • Articular Amount of disability Time of Onset • Congenital • Developmental • Acquired Correctability • Completely correctable • Partially correctable • Incorrectable
- 17. INSTABILITY Time of Onset •Congenital •Developmental •Acquired Frequency •Single episode •Recurrent Aggravating factors Associated symptoms •Pain •Disability •Neurovascular Reducibility •Reducible •Irreducible Associated Illness
- 18. PARASTHESIA Aetiology Mode of onset Duration Site and Pattern Progression Aggravating and Relieving Factors
- 19. LOSS OF FUNCTION Mode of onset • Sudden • Gradual Duration • Congenital • Chronic • Acute Involved region and function(s) Progression Associated features
- 20. DIFFERENTIAL DIAGNOSIS 1. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 2. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 4. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
- 21. DIFFERENTIALS IN ELBOW Trauma Tumour Infections Instability Elbow Anatomy & Biomechanics Medial UCL Injury & Valgus Instability Posterolateral Elbow Rotatory Instability (PLRI) Valgus Extension Overload (Pitcher's Elbow) Tendon conditions Distal Biceps Avulsion Lateral Epicondylitis (Tennis Elbow) Medial Epicondylitis (Golfer's Elbow) Articular conditions Elbow Arthritis Osteochondritis Dissecans of Elbow Little League Elbow Olecranon Stress Fracture Elbow Stiffness and Contractures
- 23. PHYSICAL EXAM - GENERAL Develop a standard routine Alleviate the patient's fears Adequate exposure - bilateral Compare both sides
- 24. GENERAL EXAMINATION Vitals •Pulse •Blood Pressure •Respiratory Rate •Temperature Consciousness Orientation Comfort level Position of Patient Height and Weight General Appearance Pallor Icterus Clubbing Cyanosis Pupillary Reaction Lymphadenopathy Dexterity Anything specific
- 26. REGIONAL EXAMINATION • InspectionLOOK • PalpationFEEL • Active/Passive movement • Strength TestingMOVE • Shortening or Lengthening • Range of Motion • Regional measurements MEASURE • Depends upon specific region in considerationSPECIAL TESTS
- 27. INSPECTION Normal carrying angle in adult Male = 10-11 degrees valgus Female = 13 degrees valgus Common for throwers to have > 15 degrees valgus at elbow Person with large elbow effusion will tend to hold elbow flexed 70-80 degrees as this corresponds to greatest volume of elbow joint capsule
- 29. INSPECTION Medial epicondyle, antecubital fossa, lateral recess, olecranon tip Ecchymosis anteriorly may indicate biceps tendon rupture Ecchymosis medially may indicate a fracture of the medial epicondyle or avulsion injury
- 30. INSPECTION Prominence of the olecranon tip may indicate posterior/posterolateral dislocation or triceps avulsion Olecranon bursa should be inspected If enlarged may represent bursitis Aseptic vs. septic Ulnar nerve subluxation may be visible
- 31. Inspection
- 32. Bony Palpation Olecranon Posteromedial tip (impingement) Proximal shaft (stress fractures) Epicondyles Fractures Epicondylitis Radial Head Fractures Dislocations
- 33. Palpation of medial side Palpate in flexion to move flexor-pronator mass anteriorly
- 34. Lateral epicondyle Radial Head Lateral olecranon Soft spot Palpation Posteriorly
- 35. EPICONDYLITIS Medial Epicondylitis (Golfer’s Elbow) Palpate medial muslce mass/epicondyle while resisting active pronation Pain either within muscle belly or directly over epicondyle Lateral Epicondylitis (Tennis Elbow) Palpate mobile wad while resisting active supination (ECRB most common offender) Pain within muscle belly or over epicondyle
- 36. BONY IMPINGEMENT Impingement of the posteromedial tip of the olecranon in the olecranon fossa Pain occurs as the elbow is snapped into extension More common in throwing athletes
- 37. PALPATION Soft Tissues Antecubital Fossa Mobile wad, biceps tendon, brachial pulse Median nerve not generally palpable Medial Flexor-pronator mass Ulnar nerve UCL
- 38. BICEPS TENDON RUPTURE Palpation in the antecubital fossa Absence of typically prominent tendon Resisted supination will increase prominence +/- Pain in antecubital fossa Ecchymosis may be present
- 39. ULNAR NERVE INSTABILITY Ulnar nerve held in cubital tunnel by overlying and investing fascia Rupture or stretch of this tissue may lead to subluxation of nerve Paresthesias Pain with subluxation May have pain with palpation
- 40. ULNAR NERVE INSTABILITY Ulnar nerve subluxes anteriorly with increasing flexion of elbow Nerve “snaps” back with rapid active extension Typically the “snap” back into the cubital tunnel creates the pain or paresthetic symptoms Compression wrap or brace may be enough to keep nerve from subluxing Patients with paresthesias may require elective ulnar nerve transfer
- 41. ULNAR NERVE IMPINGEMENT Anomalous bands of triceps insertion may impinge ulnar nerve as they snap over medial epicondyle Sensation of “snapping” as the arm is actively extended with ulnar nerve symptoms “Snapping Triceps Syndrome” Spinner and Goldner, JBJS 1998 Nerve is stable in cubital tunnel
- 42. RANGE OF MOTION Active followed by passive ROM Normal ROM in adult 0 – 140 degrees +/- 10 degrees in sagittal plane 80-90 degrees of forearm rotation in each direction With progressive extention, elbow moves into increasing valgus
- 44. ELBOW ROM Flexion -135 degree Extension -0 degree Pronation -90 degree Supination -90 degree
- 45. RANGE OF MOTION Loss of motion in athlete attributable to: Capsular contracture Capsular strain Musculotendinous contracture or strain Loose body Osteophyte formation Scar tissue
- 46. Strength Examination Any routine examination of the elbow should include a strength examination Rotator cuff Deltoid Biceps Triceps Pronation and Supination Wrist dorsal- and volar-flexion Grip, Intrinsics, and APL
- 47. Testing Flexion Strength Brachioradialis Biceps
- 49. SPECIAL TESTS Ligament tests (varus-valgus stres test) Tennis elbow test Golfers elbow test Tinels sign for ulnar nerve
- 50. VALGUS STRESS VARUS STRESS
- 53. TİNELS SİGN FOR ULNAR NERVE
- 54. NEUROLOGICAL EXAMINATION Muscle tests: Flexion - Extension Pronation - Supination Sensation tests C5-C6-C7-C8-T1 Reflex test: Biceps reflex –C6 Brachioradial reflex –C6 Triceps reflex-C7
- 55. Elbow Reflex testing BICEPS REFLEX BRACHIORADIALIS REFLEX TRICEPS REFLEX
- 57. Arthroscopic Stress View for UCL Laxity
- 58. Stress Radiography • GRADED STRESS X- RAYS IN EVALUATION OF INJURY TO THE UCL OF THE ELBOW
- 60. MRI of Torn UCL