Clinical examination of elbow joint
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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