Clinical examination of elbow joint

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Clinical examination of elbow joint

  1. 1. CLINICAL EXAMINATIONOF ELBOW JOINT Dr K. Anjaneyulu Prof & HOD of OrthopaedicsGandhi Medical College / gandhi hospital Secunderabad 1
  2. 2. The approach for clinical examination oftrauma cases differs from non traumaticconditionsIt also differs - acute injuries examination fromold neglected cases 2
  3. 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. 4. COMMON COMPLAINTS• Pain• Swelling• Stiffness• Deformity• Instability• Paraesthaesias / neuro. manife 4
  5. 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. 6. PHYSICAL EXAMINATION• Inspection• Palpation• Movements• Measurements• Distal Neurovascular Status• Regional Lymphnodes• Thickening of Ulnar nerve• Special Tests 6
  7. 7. ELBOW FRACTURES IN CHILDREN• 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. 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. 9. CARRYING ANGLEMALE 7 - 10 deg.FEMALE 10 - 15 deg.Disappears onpronation &flexion of elbowCompare withopposite side 9
  10. 10. ATTITUDE & DEFORMITY Cubitus varusGunstock deformity Cubitus valgus 10
  11. 11. INSPECTION 11
  12. 12. OLECRANON BURSITIS 12
  13. 13. TUBERCULOSIS 0F ELBOWDiffuse SwellingFlexion DeformityMuscle Wasting 13
  14. 14. PALPATION• Local rise of temperature• Tenderness• Bony components• Soft Tissue components• Ulnar nerve thickening• Supratrochlear lymph node 14
  15. 15. LOCAL RISE OF TEMPERATURE Infective - Pyogenic Tubercular Inflammatory - Polyarthritis Acute Myositis Traumatic - Fresh injury - haematoma oedema 15
  16. 16. TENDERNESSMaximum point of tenderness 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. 17. PALPATIONBONY COMPONENTS irregularity, bowing, thickeningand 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. 18. THREE BONY POINT RELATIONSHIP COMPARE WITH OPPOSITE NORMAL ELBOW • Medial epicondyle Extension • Lateral epicondyle • OlecranonFLEXION 18
  19. 19. PALPATION OF SUPRATROCHLEAR NODE• 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. 20. TENNIS ELBOWPalpate on thelateral epicondylenear the commonextensor origin 20
  21. 21. PALPATION OF ULNAR NERVEPalpate in the groovebehind theMedial epicondyle 21
  22. 22. MOVEMENTSROMFlexion - 135Extension - 0Supination - 90Pronation - 90 22
  23. 23. FLEXION & EXTENSION 23
  24. 24. FIXED FLEXION FLEXIONDEFORMITY 24
  25. 25. CRITICAL ANGLE OF FLEXIONThe arc of flexion 30 – 110 degInspite of some degree of morbidity withpartial limitation of motion a person will beable to perform the day to day activities without much difficulty 25
  26. 26. HYPEREXTENSION 26
  27. 27. Neutral rotation Supination PronationExamined with arm by the side of trunk andelbow in 90 deg. flexion 27
  28. 28. SUPINATION PRONATION 28
  29. 29. MEASUREMENTS• 3 bony point relationship• Arm length & girth• Forearm length & girth• carrying angle – cannot be assessed in FFD 29
  30. 30. SPECIAL TESTSTests for Tennis Elbow • Mill’s Manouvre • Cozen’s TestBicipital Tendinitis Yergason’s signTests for Ligamentous Laxity • Varus stress • Valgus stress 30
  31. 31. MILL’S MANOUVREElbow flexed, Forearm slightly pronated & Wrist slightlydorsiflexedPatient tries to supinate the forearm against resistanceProduces pain at the elbow 31
  32. 32. COZEN’S TESTDorsiflexion of thewrist againstresistance withelbow in flexioncauses pain at theelbowIn TENNIS ELBOW 32
  33. 33. YERGASON’S TESTFOR BICIPITAL TENDINITISSupination of the forearm against resistance with elbow at 90 deg. produces pain at the elbow 33
  34. 34. VARUS STRESS TEST 34
  35. 35. VALGUS STRESS TEST 35
  36. 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. 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. 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. 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. 40. CUBITUS VARUS 40
  41. 41. POSTERIOR DISLOCATION OF ELBOW• 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. 42. # LATERAL CONDYLE HUMERUS• 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. 43. Cubitus valgus Non Union Lat. Condyle # 43
  44. 44. Fracture Lateral CondyleWidening of interepicond. lineRIGHT LEFT RIGHT 44
  45. 45. MYOSITIS OSSIFICANS• H/o injury (can form with or without fracture)• H/o massage• Irregular bony mass infront & behind of elbow• Limitation of movts of elbow / ankylosis 45
  46. 46. Thank You for your kind attention 46

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