PHYSICAL EXAMINATION OF THE ELBOW By Abdullah Radwan

1. PHYSICAL EXAMINATION OF THE ELBOWByAbdullah Radwan

2. The elbow joint (hinge variety) is a relatively stable joint, with firm osseous support. It is composed of three articulations: • The humeroulnar joint • The humeroradial joint • The radioulnar joint These joints are covered by the same capsule.

4. Physical examination of the elbow INSPECTION • Carrying angle • Swelling • Scars BONY PALPATION • Medial epicondyle • Medial suprcondylar line of the humerus • Olecranon • Ulnar border • Olecranon fossa • Lateral epicondyle • Lateral supracondylar line of the humerus • Radial head

5. SOFT TISSUE PALPATION • Zone I→ medial aspect • Zone II → posterior aspect • Zone III→ lateral aspect • Zone IV→ anterior aspect

6. RANGE OF MOTION Active range of motion • Flexion → 135 • Extension → 0-5 • Supination → 90 • Pronation → 90 Passive range of motion • Flexion and Extension • Supination and Pronation

7. NEUROLOGICAL EXAMINATION • Muscle testing • Reflex testing • Biceps reflex → C5 • Brachioradialis reflex → C6 • Triceps reflex → C7 • Sensation testing

8. SPECIAL TESTS • Tests of ligamentous stability • Tinel sign • Tennis elbow test • Golfer elbow test EXAMINATION OF RELATED AREAS

9. INSPECTION • Carrying angle - CUBITUS VALGUS- CUBITUS VARUS

10. INSPECTION Swelling • Localized - swollen olecranon bursa • Diffuse→ the patient may have to hold elbow in flexed position (about 45) so that the joint can reach its maximum volume and accommodate the swelling with minimum pain. • supracondylar fracture • crush injury of the elbow

11. INSPECTION Scars • Burn • Needle puncture scarring

12. BONY PALPATION • Crepitation may be • Synovial or bursal thickening • Fractue • Osteoarthritis

13. BONY PALPATION Medial epicondyle • It is frequently fractured in children

14. BONY PALPATION Medial suprcondylar line of the humerus • Occasionally a small bony process may develop on it , trapping the median nerve → symptoms of median nerve compression.

15. BONY PALPATION Olecranon • Although it feels subcutaneous to touch, it is covered by the olecranon bursa and the triceps tendon and aponeurosis which are very thin at the apex of the olecranon and do not hinder palpation.

16. BONY PALPATION Ulnar border • It is the subcutaneous ulnar border from the olecranon down to the ulnar styloid process at the wrist.

17. BONY PALPATION Olecranon fossa • At the distal end of the posterior humerus. • Receive the olecranon during elbow extension. • Filled with fat and covered by triceps muscle and aponeurosis. • Precise palpation is difficult. Lateral epicondyle • Smaller and • less defined than • the medial epiconddyle.

18. BONY PALPATION Lateral supracondylar line of the humerus • Extend up to the deltoid tuberosity. • The medial epicondyle, the olecranon process and the lateral epicondyle form an isoceles triangle when elbow is flexed (90) and a relatively straight line when elbow is extended. • Tested by thumb on the lateral epicondyle, index on the olecranon, and middle finger on the medial epicondyle and flex and extend the elbow.

19. BONY PALPATION Radial head • Lies deep within a visible depression in the skin just medial and posterior to the wrist extensor muscle group. • During supination and pronation it will rotate under your thumb. • Pain may indicate synovitis or OA of the head itself.

20. SOFT TISSUE PALPATION elbow should be flexed 90 and shoulder in abduction and extension Zone I → medial aspect Ulnar nerve • In a groove between the medial epicondyle and olecranon process. • Thickening due to scar tissue → tingling sensation in the patient ring and little fingers. • Rough palpation → pinprick like shocks down the forearm and hand (funny bone). • May be injured secondary to: • supracondylar or epicondylar fracture or by • Direct trauma

22. Wrist flexor-pronator muscle group (medial epicondyle, common flexor origen) • Pronator terescovered by other muscles and is not palpable. • Flexor carpi radialisby making a tight fist and radially deviate and flex the wrist • Palmaris longusby flexing the wrist and touch the tips of thumb and little finger in opposition (in about 7% may be absent). • Flexor carpi ulnaris(on the ulnar side along its length down to the pisiform bone.

23. Common flexor origin

24. Common flexor origin

25. Medial collateral ligament • One of the basic stabilizers for the humeroulnar articulation. • Similar to knee’s medial collateral ligament. • From medial epicondyle to the medial margin of the ulna’s trochlear notch. • Tenderness from a sprain by sudden, forced vulgus stress to the elbow. Supracondylar lymph nodes • When swollen → slippery lumps epicondylar.

26. Medial collateral ligament

27. Zone II - posterior aspect Olecranon bursa • If it is inflamed → boggy and thick swelling. Triceps muscle • 3 heads (long, medial and lateral heads) • Have the patient lean on a table or desk as if he were supporting his weight on a cane or crutch.

28. Zone III – lateral aspect • Wrist extensors (common extensor origin) • Called (mobile wad of three) 1. brachioradialis → resisted elbow flexion in the neutral position. 2. extensor carpi radialis longus 3. extensor carpi radialis brevis (tennis elbow)

29. Lateral collateral ligament • Like knee’s lateral collateral ligament. • From lateral epicondyle down to the side of annular ligament that encircles the radius. • Not directly palpable. • Tederness → sprain by sudden varus stress Anular ligament • Cups the radial head and neck. • Not directly palpable • Pathology may affect the ligament or the radial head.

30. Zone IV – anterior aspect Cubital fossa • Triangular space bordered by brachioradialis laterally and pronator teres medially, the base is imaginary line between epicondyles. • Structures pass from lateral to medial: • Biceps tendon • Brachial artery • Median nerve • Radial nerve

31. Cubital fossa

32. Biceps tendon (closed fist in supination under the table and try to lift the table) • Ruptured when elbow forcibly flexed against strong resistance- tender anticubital fossa. Brachial artery (pulsation medial to biceps tendon). Median nerve (directly medial to the brachial artery) ?Radial nerve (lateral to biceps tendon- not palpable)

33. RANGE OF MOTION Active range of motion Flexion → 135 • At humerulnar and humeroradial joints. • Patient should touch his shoulder. • Flexion is limited by muscle mass of anterior arm. Extension → 0 - 5 • At humerulnar and humeroradial joints. • Muscular may by not able to extend the elbow to 0 degree because of biceps muscle tension.

34. Flexion and Extension

35. Supination – 90 • At radio-ulnar articulations at elbow and wrist. • Hold a pencil in each hand and supinate both forearm→ pencils parallel to floor. Pronation – 90 • The same test as in supination. • At radio-ulnar articulations at elbow and wrist. Passive range of motion • Flexion and extension • Supination and pronation

36. NEUROLOGICAL EXAMINATION MUSCLE TESTING Flexion by • Brachialis • Biceps when forearm supinated • Brachioradialis • Supinator Extension by • Triceps • Anconeus

37. Supination by • Biceps • Supinator • Brachioradialis Pronation • Pronator teres • Pronator quadratus • Flexor carpi radialis

38. REFLEX TESTING • Biceps reflex- C5 • Brachioradialis reflex – C6 • Triceps reflex – C7

39. SENSATION TESTING • Lateral arm → C5 • Lateral forearm → C6 • Medial forearm → C8 • Medial arm → T1

40. SPECIAL TESTS LIGAMENTOUS STABILITY • For medial and lateral collateral ligaments • Vulgus stress test • Varus stress test

41. SPECIAL TESTS TINEL SIGN • Tapping the area in the groove between medial epicondyle and olecranon → tingling along forearm and ulnar distribution at wrist.

42. SPECIAL TESTS TENNIS ELBOW TEST • Resisted dorsiflexion of the wrist after making a fist. Golfer’s elbow test • Resisted planter flexion of the wrist after making a fist.

43. EXAMINATION OF THE RELATED AREAS • Herniated cervical disc • Cervical spondylosis • Wrist pathology like RA • Shoulder pathology

44. Thank you