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Clinical examination of elbow joint
- 1. CLINICAL EXAMINATION OF ELBOWJOINT Dr K. Anjaneyulu Prof & HOD of Orthopaedics Gandhi Medical College / gandhi hospital Secunderabad 1
- 2. The approach forclinical examination of trauma cases differs from non traumatic conditions It also differs - acute injuries examination from old neglected cases 2
- 3. • Hinge joint(Humero ulnar, Radiohumeral Sup.Radioulnar) • Common - childhood injuries • Easily prone for stiffness • Often neglected & inappropiately Rx • Functional position - different - R – L 3
- 4. COMMON COMPLAINTS • Pain •Swelling • Stiffness • Deformity • Instability • Paraesthaesias / neuro. manife 4
- 5. HISTORY • Duration • Dominant Limb - Profession • H/O injury / consti. sympt. • H/o polyarthralgia / UTI • Rx History • H/o massage • Limitation of ADL • Referred pain from neck / shoulder 5
- 6. PHYSICAL EXAMINATION • Inspection • Palpation • Movements • Measurements • Distal Neurovascular Status • Regional Lymphnodes • Thickening of Ulnar nerve • Special Tests 6
- 7. ELBOW FRACTURES INCHILDREN • Neuro-motor exam may be limited by the child’s ability to cooperate because of age, pain, or fear. • Thumb extension - EPL (radial – PIN branch) • Thumb flexion - FPL (median – AIN branch) • Cross fingers - Interossei (ulnar) 7
- 8. INSPECTION • Attitude &deformity • Carrying angle • Swelling para olecranon area anconeus soft spot radiocapitellar joint general diffuse swelling - effusion (semiflexed elbow) • Skin Sinuses, scars, oedema, engorged veins • Muscle wasting 8
- 9. CARRYING ANGLE MALE 7 - 10 deg. FEMALE 10 - 15 deg. Disappears on pronation & flexion of elbow Compare with opposite side 9
- 10. ATTITUDE & DEFORMITY Cubitus varus Gunstock deformity Cubitus valgus 10
- 11. INSPECTION 11
- 12.
- 13. TUBERCULOSIS 0F ELBOW DiffuseSwelling Flexion Deformity Muscle Wasting 13
- 14. PALPATION • Local rise of temperature • Tenderness • Bony components • Soft Tissue components • Ulnar nerve thickening • Supratrochlear lymph node 14
- 15. LOCAL RISE OFTEMPERATURE Infective - Pyogenic Tubercular Inflammatory - Polyarthritis Acute Myositis Traumatic - Fresh injury - haematoma oedema 15
- 16. TENDERNESS Maximum point oftenderness Lat. Epicondyle - Tennis elbow Med. Epicondyle - Golfer’s elbow Lower end of Humerus - S/C # Humerus Radial head - # Radial head Upper end of Ulna - Olecranon # 16
- 17. PALPATION BONY COMPONENTS irregularity, bowing, thickening and steps Medial epicondyle Lateral epicondyle Olecranon Supracondylar ridges Radial head and capitellum (springing of forearm) Soft Tissue Medial aspect Lateral aspect Posterior aspect Anterior aspect 17
- 18. THREE BONY POINTRELATIONSHIP COMPARE WITH OPPOSITE NORMAL ELBOW • Medial epicondyle Extension • Lateral epicondyle • Olecranon F L E X I O N 18
- 19. PALPATION OF SUPRATROCHLEARNODE • Flex the Elbow to right angle to relax surrounding structures • Palpated on anterior surface of medial intermuscular septum 1 cm above the medial epicondyle • Not Palpable: Normal elbow, Traumatic causes • Palpable : Unilateral or Bil (systemic) 19
- 20. TENNIS ELBOW Palpate onthe lateral epicondyle near the common extensor origin 20
- 21. PALPATION OF ULNARNERVE Palpate in the groove behind the Medial epicondyle 21
- 22. MOVEMENTS ROM Flexion - 135 Extension - 0 Supination - 90 Pronation - 90 22
- 23.
- 24. FIXED FLEXION FLEXION DEFORMITY 24
- 25. CRITICAL ANGLE OFFLEXION The arc of flexion 30 – 110 deg Inspite of some degree of morbidity with partial limitation of motion a person will be able to perform the day to day activities with out much difficulty 25
- 26.
- 27. Neutral rotation Supination Pronation Examined with arm by the side of trunk and elbow in 90 deg. flexion 27
- 28. SUPINATION PRONATION 28
- 29. MEASUREMENTS • 3 bony point relationship • Arm length & girth • Forearm length & girth • carrying angle – cannot be assessed in FFD 29
- 30. SPECIAL TESTS Tests forTennis Elbow • Mill’s Manouvre • Cozen’s Test Bicipital Tendinitis Yergason’s sign Tests for Ligamentous Laxity • Varus stress • Valgus stress 30
- 31. MILL’S MANOUVRE Elbow flexed,Forearm slightly pronated & Wrist slightly dorsiflexed Patient tries to supinate the forearm against resistance Produces pain at the elbow 31
- 32. COZEN’S TEST Dorsiflexion ofthe wrist against resistance with elbow in flexion causes pain at the elbow In TENNIS ELBOW 32
- 33. YERGASON’S TEST FOR BICIPITALTENDINITIS Supination of the forearm against resistance with elbow at 90 deg. produces pain at the elbow 33
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- 36. CONCLUDE BY FOLLOWING •NEUROLOGICAL EXAMINATION Motor Sensory Thickening of ulnar nerve • EXAMINATION of DISTAL PULSES Brachial Radial • EXAMINATION OF CERVICAL SPINE • EXAMINATION OF SHOULDER , WRIST, OPPOSITE ELBOW 36
- 37. PULLED ELBOW • Children- 2 to 5 Yrs • H/o lifting the child with extended elbows • Continuous screaming – does not allow the elbow to be examined • Due to subluxation of radial head from the annular ligament • No obvious swelling or deformity • X- ray – normal • Reduction – instantaneous relief 37
- 38. COMMON EXAM CASES •Cubitus varus - malunited Supracondylar # • Cubitus Valgus - Non Union of Lateral condyle +/- Tardy Ulnar nerve Palsy • Neglected Posterior Dislocation Elbow • Ankylosed / Stiff Elbow Trauma/Infection Myositis Ossificans 38
- 39. CUBITUS VARUS • Gunstock deformity • Medial deviation of forearm • Thickening / irregularity of L/E of humerus • Sometimes difficult to identify lat.epicondyle • Relation of three bony points maintained • Downward Tilting of the triangle medially • Shortening of arm – forearm length equal • Hyperextension / limitation of flexion 39
- 40.
- 41. POSTERIOR DISLOCATION OFELBOW • Olecranon displaced posteriorly • Lower end of humerus normal • Three bony points relation altered • Bowstring sign positive • Arm length equal / forearm length decreased • Radial head in abnormal position • Limitation of movements / abnormal mobility 41
- 42. # LATERAL CONDYLEHUMERUS • Cubitus valgus deformity – increased carrying • Lateral supracondylar ridge irregular/ stepping • Medial supracondylar ridge normal • Widening of interepicondylar distance • Distance bet.lat.epicondyle and tip of olecranon increased • Abnormal mobility of lat.cond - nonunion 42
- 43. Cubitus valgus Non Union Lat. Condyle # 43
- 44. Fracture Lateral Condyle Wideningof interepicond. line RIGHT LEFT RIGHT 44
- 45. MYOSITIS OSSIFICANS • H/oinjury (can form with or without fracture) • H/o massage • Irregular bony mass infront & behind of elbow • Limitation of movts of elbow / ankylosis 45
- 46. Thank You foryour kind attention 46