The Elbow, Examination, Assessment

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

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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.

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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

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EXAMINATION- INSPECTION
cubitus valgus
Increase in carrying angle
Male norms – 11-14°
Female norms – 13-16°
Larger angles are
considered abnormal

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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