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CLINICAL EXAMINATION OF ELBOW JOINT

Dr K. AnjaneyuluProf & HOD of Orthopaedics

Gandhi Medical College / gandhi hospitalSecunderabad

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The approach for clinical examination of trauma cases differs from non traumatic conditions

It also differs - acute injuries examination from old neglected cases

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• Hinge joint (Humero ulnar, Radiohumeral Sup.Radioulnar)

• Common - childhood injuries

• Easily prone for stiffness

• Often neglected & inappropiately Rx

• Functional position - different - R – L

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COMMON COMPLAINTS

• Pain• Swelling• Stiffness• Deformity• Instability• Paraesthaesias / neuro. manife

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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

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PHYSICAL EXAMINATION

• Inspection• Palpation• Movements• Measurements• Distal Neurovascular Status• Regional Lymphnodes• Thickening of Ulnar nerve• Special Tests

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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)

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INSPECTION

• Attitude & deformity • Carrying angle• Swelling

para olecranon areaanconeus soft spot radiocapitellar joint general diffuse swelling - effusion (semiflexed elbow)

• Skin Sinuses, scars, oedema, engorged veins

• Muscle wasting

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CARRYING ANGLE

MALE 7 - 10 deg.FEMALE 10 - 15 deg.

Disappears on pronation & flexion of elbow

Compare with opposite side

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ATTITUDE & DEFORMITYCubitus varus

Gunstock deformity Cubitus valgus

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INSPECTION

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OLECRANON BURSITIS

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TUBERCULOSIS 0F ELBOW

Diffuse Swelling

Flexion Deformity

Muscle Wasting

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PALPATION

• Local rise of temperature • Tenderness• Bony components • Soft Tissue components• Ulnar nerve thickening• Supratrochlear lymph node

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LOCAL RISE OF TEMPERATURE

Infective - Pyogenic

Tubercular

Inflammatory - Polyarthritis

Acute Myositis

Traumatic - Fresh injury - haematoma

oedema

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TENDERNESSMaximum point of tenderness Lat. Epicondyle - Tennis elbow

Med. Epicondyle - Golfer’s elbowLower end of Humerus - S/C #

HumerusRadial head - # Radial head Upper end of Ulna - Olecranon #

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PALPATIONBONY COMPONENTS

irregularity, bowing, thickening and steps

Medial epicondyleLateral epicondyleOlecranonSupracondylar ridgesRadial head and capitellum (springing of forearm)

Soft TissueMedial aspectLateral aspectPosterior aspectAnterior aspect

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THREE BONY POINT RELATIONSHIP

COMPARE WITH OPPOSITE NORMAL ELBOW • Medial epicondyle• Lateral epicondyle• Olecranon

Extension

FLEXION

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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)

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TENNIS ELBOW

Palpate on the lateral epicondyle near the common extensor origin

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PALPATION OF ULNAR NERVE

Palpate in the groove behind the Medial epicondyle

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MOVEMENTS

ROM

Flexion - 135

Extension - 0 Supination -

90 Pronation - 90

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FLEXION & EXTENSION

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FIXED FLEXION DEFORMITY

FLEXION

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CRITICAL ANGLE OF FLEXION

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

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HYPEREXTENSION

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Neutral rotation Supination Pronation

Examined with arm by the side of trunk and elbow in 90 deg. flexion

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SUPINATION PRONATION

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MEASUREMENTS

• 3 bony point relationship• Arm length & girth• Forearm length & girth• carrying angle – cannot be assessed in FFD

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SPECIAL TESTS

Tests for Tennis Elbow

• Mill’s Manouvre• Cozen’s Test

Bicipital Tendinitis Yergason’s signTests for Ligamentous Laxity

• Varus stress• Valgus stress

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MILL’S MANOUVRE

Elbow flexed, Forearm slightly pronated & Wrist slightly dorsiflexedPatient tries to supinate the forearm against resistanceProduces pain at the elbow

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COZEN’S TEST

Dorsiflexion of the wrist against resistance with elbow in flexion causes pain at the elbow

In TENNIS ELBOW

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YERGASON’S TEST

FOR BICIPITAL TENDINITIS

Supination of the forearm against resistance with elbow at 90 deg. produces pain at the elbow

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VARUS STRESS TEST

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VALGUS STRESS TEST

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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

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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

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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

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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

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CUBITUS VARUS

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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

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# 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

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Cubitus valgus Non Union Lat. Condyle #

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Fracture Lateral CondyleWidening of interepicond. line

LEFT RIGHT

RIGHT

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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

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Thank You for your kind attention