The Elbow, Examination
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  • 1. THE ELBOW ORTHOPEDIC EXAMINATION
  • 2. Sreeraj S R ANATOMICAL FEATURES Compound synovial joint. Made up of 1. Ulnohumeral joint 2. Radiohumeral joint 3. Superior radio ulnar joint
  • 3. 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.
  • 4. 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.
  • 5. Sreeraj S R 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.
  • 6. Sreeraj S R 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.
  • 7. Sreeraj S R MUSCLES Elbow flexion Biceps Brachialis Brachioradialis Pronator Teres Elbow extension Triceps Anconeus
  • 8. Sreeraj S R 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
  • 9. Sreeraj S R MUSCLES (cont.) Pronators Pronator teres Pronator quadratus Supinators Biceps brachii Supinator
  • 10. Sreeraj S R 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
  • 11. Sreeraj S R EXAMINATION- INSPECTION cubitus valgus Increase in carrying angle Male norms – 11-14° Female norms – 13-16° Larger angles are considered abnormal
  • 12. Sreeraj S R EXAMINATION- INSPECTION cubitus varus Decrease in carrying angle Usually develops secondary to condylar humerus fracture
  • 13. Sreeraj S R 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.
  • 14. Sreeraj S R EXAMINATION-MOVEMENTS Flexion & Extension measured with a goniometer at the lateral aspect of elbow Normal ROM is 0-140°
  • 15. Sreeraj S R EXAMINATION-MOVEMENTS 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°.
  • 16. Sreeraj S R 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
  • 17. Sreeraj S R EXAMINATION-PALPATION 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.
  • 18. Sreeraj S R EXAMINATION-PALPATION 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.
  • 19. Sreeraj S R EXAMINATION-PALPATION 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.
  • 20. Sreeraj S R EXAMINATION-PALPATION The wrist extensors are palpated at the elbow by asking the patient to extend the wrist against resistance.
  • 21. Sreeraj S R EXAMINATION-PALPATION 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.
  • 22. Sreeraj S R EXAMINATION-PALPATION 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°.
  • 23. Sreeraj S R EXAMINATION-PALPATION 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.
  • 24. Sreeraj S R EXAMINATION-PALPATION 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.
  • 25. Sreeraj S R 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
  • 26. Sreeraj S R 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
  • 27. 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
  • 28. 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.
  • 29. 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
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. Sreeraj S R 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.
  • 34. Sreeraj S R Olecranon Bursitis Infection/inflammation of bursa Causes- 1. Trauma 2. Prolonged pressure 3. Infection 4. Medical conditions e.g. rheumatoid arthritis/gout
  • 35. Sreeraj S R 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
  • 36. Sreeraj S R 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
  • 37. Sreeraj S R SPECIAL TESTS: POSTEROLATERAL INSTABILITY 1. 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.
  • 38. 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.
  • 39. Sreeraj S R TEST FOR NEUROLOGICAL 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.
  • 40. Sreeraj S R TEST FOR NEUROLOGICAL 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
  • 41. Sreeraj S R TEST FOR NEUROLOGICAL 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
  • 42. Sreeraj S R TEST FOR NEUROLOGICAL 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
  • 43. Sreeraj S R TEST FOR NEUROLOGICAL 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
  • 44. Sreeraj S R TEST FOR NEUROLOGICAL 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.
  • 45. Sreeraj S R TEST FOR NEUROLOGICAL 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
  • 46. Sreeraj S R TEST FOR NEUROLOGICAL 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
  • 47. Sreeraj S R 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
  • 48. Sreeraj S R Myotomes C5 – shoulder abduction C6 – elbow flexion, wrist extension C7 – elbow extension, wrist flexion C8 – finger flexion/grip strength T1 – finger abduction/adduction
  • 49. Sreeraj S R Cutaneous distribution Pain may be referred to the elbow and surrounding tissues from neck, often mimicking Tennis Elbow, shoulder or wrist.
  • 50. Sreeraj S R REFLEXES Biceps (C5,C6) Brachioradialis (C5-C6) Triceps (C7- C8)
  • 51. Sreeraj S R Humerus Fractures Supracondylar fracture Supracondylar fracture with posterior elbow dislocation
  • 52. Sreeraj S R 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
  • 53. Sreeraj S R 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
  • 54. Sreeraj S R Ulnar Fractures Coronoid process fracture May be associated with posterior elbow dislocation
  • 55. Sreeraj S R Fracture over olecranon Mechanism -fall on point of elbow -sudden triceps contraction
  • 56. Sreeraj S R 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
  • 57. Sreeraj S R Anterior Elbow Dislocation Rare occurrences
  • 58. Sreeraj S R Elbow dislocation Usually fall onto outstretched hand Severe pain at elbow and swelling Minimal movement Check sensation/pulses
  • 59. Sreeraj S R 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
  • 60. Sreeraj S R 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