Clinical Examination of the Elbow in Orthopedics

1. CLINICAL EXAMINATION OF THE
ELBOW
Dr. Gautamsinha
Resident Orthopedics
Dr. Hardas Singh Orthopedic Hospital
& Superspecialty Research Center

2. ANATOMY :
• Compound j oint
• Hinge j oint
• Common Synovial Cavit y
• Cubit al Art iculat ion :
o Humero-Ulnar J t . (b/ w Trochlear Not ch of Ulna &
Trochlea of Humerus)
o Humero-Radial J t . (b/ w Radial Head & Capit ulum of
Humerus)
o Superior Radio-Ulnar J t . (b/ w Radial Head & Radial
Not ch of Ulna)

3. Bony Structure of Elbow :

4. Ligaments of the Elbow :
oUlnar Collat eral Ligament
oRadial Collat eral
Ligament
oAnular Ligament

5. Ulnar Collateral Ligament :
o Tr iangular in shape
o Ext ends f r om medial epicondyle t o
medial mar gin of t r ochlear not ch.
o UCL is over lapped by Triceps , FCU ,
FDS & Ulnar ner ve.

6. Radial Collateral Ligament :
o Tr iangular in shape
o Ext ends f r om lat er al
epicondyle t o annular ligament .
o I t is relat ed t o Supinat or and
ECRB

7. Annular Ligament :
• Binds t he Radial Head t o t he Radial
not ch of t he Ulna
• Does Pronat ion & Supinat ion

8. Bursae :
o Subcut aneous Olecranon
Bur sa :
Deep t o t he skin, but
superf icial t o t he Tr iceps
br achii t endon & t he
Olecr anon
o Subt endinous Olecr anon
Bur sa :
Reduces f rict ion b/ w t he
Olecr anon & Triceps
br achii muscle.

9. MOVEMENTS AT THE ELBOW:
• Flexion
• Ext ension
• Pronat ion
• Supinat ion

10. Vascular Supply :
Anast omot ic Net work derived f rom :
•Brachial A.
•Prof unda Brachii A.
•Radial A.
•Ulnar A.

11. INNERVATION :
• Radial N.
• Musculocut aneous N.
• Ulnar N.
• Median N.

12. SURFACE LANDMARKS :

13. IMAGING :
Antero-Posterior View Lateral View

14. MUSCLES :
 Elbow Flexion :
 Biceps
 Br achialis (Chief Flexor)
 Br achior adialis
 Pr onat or Teres
 Elbow Ext ension :
 Tr iceps
 Anconeus

15. MUSCLES :
 Pronat ors :
 Pronat or t er es
 Pronat or quadrat us
 Supinat ors :
 Biceps br achii
 Supinat or

16. CLINICAL HISTORY :
I nst abilit y
St if f ness
Disabilit y
Which hand?
How old?
Occupat ion
Any hist ory of
I nj ury
Can lif t heavy
weight s?
Can r each f or t hings in
t he cupboar d?
Can comb his hair ?
Can r each his mout h?
Can t ake care of bowel
hygiene?
Can do hammering?

17. CLINICAL HISTORY :
• Sleep : Af f ect ed or not
• Pain in part icular range : Terminal
ext ension or f lexion
• Pin and t ingly sensat ion; any
weakness
• Any previous t reat ment ?
• Co-morbid Medical problem?

18. INSPECTION :
1. Attitude of the limb:
How limb is placed?

19. INSPECTION :
2. Alignment of the Elbow & Forearm :
•Carrying Angle -
Angle b/w Axis of arm to the Axis of the
forearm
Patient standing w/ arm close to the chest &
forearm supinated
Normal: Males 11º (Range 2-26º)
Females 13º (Range 2-22º)
In the presence of a fixed flexion deformity of
the elbow, this angle cannot be commented

20. INSPECTION :
• 3. Any deformity of the elbow :
Flexion deformity Elbow injury
Arthritis
Cubitus Valgus Lateral condylar
fracture
Supracondylar
fractures
Cubitus Varus or
gunstock
deformity
Is a classical
manifestation of
malunion of
supracondylar
fracture

21. INSPECTION :
4. Swellings around the elbow-
o Over olecranon process - Students elbow
Olecranon bursitis
o In front/Antecubital fossa - Myositis
o On lateral side - Dislocated Radial head
5.Muscle wasting
6.Any surgical scar, Sinus

22. PALPATION :
 Temperature
Tenderness - Humero-radial joint line
Biceps tendon & Ulnar nerve
Palpation of bones - Lateral Epicondyle
Olecranon
Radial head
Medial epicondyle

23. • The wrist ext ensors are palpat ed at
t he elbow by asking t he pat ient t o
ext end t he wrist against resist ance.

24. HOW TO FEEL RADIAL
HEAD ?
• Elbow in flexion
Feel the lateral condyle
Below the lateral condyle there is a fossa
In the fossa feel the radial head
Confirm it by rotating the forearm

25. 3 POINT BONY RELATIONSHIP :
• Components - Medial Epicondyle
Tip of Olecranon
Lateral epicondyle
With elbow extended: They are at same level
With elbow flexed: Isosceles triangle with
elbow at 90º

26. PALPATION :
• Lymph Node Palpation : 2cm above the medial
epicondyle

27. PALPATION :
• The ulnar nerve is palpated behind the
intermuscular septum.
• It may sometimes sublux or roll on the
epicondyle.

28. PALPATION :
Tenderness over Lat eral
Epicondyle
Tennis Elbow
Tenderness over Medial
Epicondyle
Golf er’s Elbow
Tears of t he UCL
Medial Epicondyle inj ury
Tenderness over Olecranon Olecranon Bursit is
Fract ure
Tenderness int o t he space
on t he Lat eral side of t he
elbow b/ w Radial head &
Humerus
Radial Head inj ury
OA
Ost eochondrit is Dessicans
AbN mass over Biceps
Tendon
Myosit is Ossif icans
Loose Bodies et c.

29. RANGE OF MOVEMENTS :

30. EXTENSION :
• Measure w/ a Goniometer
• Normal range - 0 º
• Functional range - 30 º - 130 º;
• up to 15º hyperextension is normal
(Women)
• >15º - Look for Hypermobility in other
Joints (Ehler Danlos Syndrome)

31. LOSS OF FULL EXTENSION :
• OA
• RA
• Old Fract ures (especially of t he
Elbow involving t he Elbow)

32. RANGE OF MOVEMENTS :
Flexion :
•Ask t he pat ient t o at t empt t o t ouch
bot h shoulders.
•N - 145º
•Rest rict ion of Flexion :
All Fract ures around elbow
All f orms of Art hrit is

33. PRONATION-SUPINATION :J oint s involved - Radiocapit ullar j oint ,
Superior & I nf erior
Radioulnar j oint
Ask t he pat ient t o hold t he elbows closely t o t he
sides.
Turn t he palms upwards int o supinat ion and
compare t he sides & downwards int o pronat ion
and compare t he sides
Normal -
Supinat ion 80 º
Pronat ion 75 º
Funct ional range 50 º each direct ion

34. PRONATION-SUPINATION :
↓
Pr onat ion/ Supinat ion
MC in Colle’s #
Loss of
Pr onat ion/ Supinat ion
Elbow Dislocat ion
RA
OA
Pur e Supinat ion Loss Pulled Elbow in
Childr en

35. ULNAR NERVE TEST :
1. Thickening : Hansen’s disease
2. Subluxation :
• Gently palpate the nerve b/w medial epicondyle and
Olecranon.
• Now flex and extend.
On flexion, there is subluxation of the nerve
anteriorly with a palpable snap.
15% of population ulnar nerve subluxates.

36. ULNAR STRETCH TEST:
• Provocative test for ulnar entrapment at
the
elbow joint
• Elbow flexion; forearm supination and
wrist in dorsiflexion

37. INSTABILITY SIGNS :
Valgus and Varus w/ elbow in 30º &
0º
w/ shoulder in Internal Rotation for
varus test and External Rotation for
valgus test, varus or valgus force is
given with in 30º joint

38. PLRI (POSTEROLATERAL ROTARY
INSTABILITY TO TEST UCL)
Only per f or med if t her e is any inst abilit y,
mainly f or post ero-lat eral subluxat ion
Technique:
Pat ient supine and ar m overhead
Supinat ion & valgus w/ axial compression
elbow is now f lexed
at 40-70 º, t he radial head is maximally
subluxat ed
Addit ional f lexion cause a visible clunk of
reduct ion

39. CHAIR TEST FOR POSTEROLATERAL
INSTABILITY:
Reluct ant t o f ull ext end t he
elbow when r ising f rom a
chair

40. TESTS FOR TENNIS ELBOW/MEDIAL
EPICONDYLITIS :
Cozens sign (Active) -
Elbow 90* ; Forearm pronated
Dorsiflex wrist against resistance
Positive when pain at lateral epicondyle

41. TESTS FOR TENNIS ELBOW :
Mills sign (Passive) –
While palpat ing t he lat er al epicondyle, t he
examiner pronat es t he pat ient s f or ear m
Passive f lexion of t he wrist f ully and t hen
ext ends t he elbow
Positive when pain at lateral epicondyle

42. TESTS FOR TENNIS ELBOW :
Resisted extension of the middle
finger -
Resist ance j ust dist al t o PI P j oint of
t he middle f inger w/ f orearm in
pronat ion.
Positive when pain at lateral epicondyle

43. TESTS FOR TENNIS ELBOW :
The Chair Test -
Ask t he pat ient t o at t empt t o lif t a
chair wit h elbow st raight and
shoulders f lexed t o 60°
Dif f icult y t o perf orm and complain of
pain over lat . aspect is a posit ive sign

44. TESTS FOR TENNIS ELBOW :
Thomson’s t est -
Ask t he pat ient t o clench t he f ist ,
dorsif lex t he wrist and ext end t he
elbow.
A f orcef ul palmar f lexion against
pat ient ’s resist ance
Pain over t he area is a posit ive sign

45. GOLFER’S ELBOW/MEDIAL EPICONDYLITIS :
Golf er’s elbow t est -
 Flex t he elbow, supinat e t he hand,
and t hen ext end t he elbow.
 Pain over t he med. Epicondyle is a
posit ive sign.

46. OLECRANON BURSITIS :
 I nf ect ion/ inf lammat ion of bursa
 Causes-
1. Trauma
2. Prolonged pressure
3. I nf ect ion
4. Medical condit ions e.g. rheumat oid
art hrit is/ gout

47. TEST FOR NEUROLOGICAL
DYSFUNCTION : CUBITAL TUNNEL SYNDROME Tinel Sign : Area of ulnar nerve in t he
groove
b/ w olecranon process and
med.
epicondyle is t apped.
 A +ve sign is indicat ed by t ingling sensat ion
in ulnar dist ribut ion dist al t o t he point of
compression.
 I ndicat es point of regenerat ion of sensory
f ibers.
 The most dist al point at which abnormal
sensat ion f elt represent s t he limit of
nerve regenerat ion.

48. ELBOW FLEXION TEST :
 Pat ient is asked t o f ully f lex elbow
w/ ext ension of t he wrist & shoulder
girdle abduct ion & depression and
hold it f or 3-5 mins.
 A +ve t est is indicat ed by t ingling or
parast hesia in ulnar nerve
dist ribut ion
 Conf irmat ory f or cubit al t unnel
syndrome

49. TEST FOR NEUROLOGICAL
DYSFUNCTION: ULNAR NERVE INJURIES
 Loss of sensat ion as shown
 Mot or supply t o small muscles of
hand except t henar muscle and 1st
t wo lumbricals
 Produces decreased Grip St rengt h

50. TEST FOR NEUROLOGICAL
DYSFUNCTION: MEDIAN NERVE INJURY
 Occasionally damaged in
supracondylar f ract ures
 More commonly in Wrist lacerat ions
 Produces loss of sensat ion as shown
 High inj uries produce decreased
st rengt h in wrist f lexion, loss of
ulnar deviat ion & t humb opposit ion

51. TEST FOR NEUROLOGICAL
DYSFUNCTION: ANT. INTR. NERVE
 Can be ent rapped as it passes b/ w
t he t wo heads of pronat or t eres -
Ant . int r. nerve syndrome/ Kilho-
Nevin syndrome
 Pinch def ormit y

52. TEST FOR NEUROLOGICAL
DYSFUNCTION: RADIAL NERVE I nj ury can be due t o t rauma or
compression in b/ w t he t wo heads of
supinat or
 I n Radial t unnel syndrome
 Compression of superf icial branch of radial
nerve as it passes under t he t endon of
brachioradialis
 Cheiralgia parast het ica - Only sensory
changes and pat ient complaint s of
noct urnal pain along t he dorsum of wrist ,
t humb & web space

53. THANK YOU..!!