Elbow

Conditions

  • Tennis Elbow
  • Golfer’s Elbow
  • Stiff Elbow
  • Cubitus Valgus
  • Cubitus Varus
  • Elbow Instability
  • Elbow Arthritis
  • Congenital Dislocation of the Radial Head
  • Radioulnar Synostosis
  • Rheumatoid Elbow with Nodules

General Examination

Look

  • With elbows extended and then with shoulders flexed
  • Comment on:
    • Scars, asymmetry, carrying angle, swellings, obvious loss of motion

Move

  • Abduct and flex shoulders to 90 degrees:
    • Assess elbow extension and flexion
    • Assess passively if incomplete
  • Arms at side, elbows flexed, thumbs up:
    • Assess supination & pronation
    • Quantify range as compared to opposite side

Feel

  • Systematically feel for pain:
    • Lateral epicondyle, RC joint, olecranon fossa, medial epicondyle, ulnar nerve for subluxation or sensitivity, flexor and extensor masses

Special Tests

Instability

  • MCL:
    • ER shoulder, supinate forearm, and flex elbow slightly
  • LCL:
    • IR shoulder, pronate forearm, and flex elbow slightly
  • Pivot Shift for Posterolateral Rotatory Instability:
    • Reliant on elbow hinging around an intact MCL (like Knee)
    • Ideally patient under GA
    • Flex shoulder 90 degrees, supinate and extend elbow
    • Apply axial and valgus force
    • Bring elbow into flexion
    • Radial head subluxates at 45° then reduces with greater flexion

Cubitus Valgus (or Varus)

  • ROM
  • Palpation:
    • Over ulnar nerve and medial epicondyle in particular
    • Pain
    • Subluxation
    • Tinel’s
  • Assess Ulnar Nerve in Hand:
    • Look:
      • Interosseus wasting
      • Comment on Wartenberg’s Sign
    • Sensory:
      • 5th finger
      • Dorsum of hand (ulnar aspect)
    • Motor:
      • 1st dorsal interosseus
      • FDP to ring finger
      • FCU if unsure

Tennis or Golfer’s Elbow

  • If patient has any medial or lateral pain or history indicative:
    • Provocative Tests:
      • Resisted wrist and 3rd finger extension
      • Resisted finger flexion

Arthritis

  • If pain on ROM or palpation or restricted motion:
    • Describe where in range pain is:
      • Throughout
      • End range - impingement
    • Crepitus
    • Pain on varus or valgus
    • Make a fist – is there pain? Indicates RC impaction and arthritis

Stiff Elbow

  • Assess passive and active ROM
  • Assess if pain present during motion arc
  • Assess function:
    • Can they get hand to mouth and hand to perineum

Congenital Dislocation of the Radial Head

  • Look, Feel, Move:
    • Fullness over radial aspect
    • Cubitus valgus or varus
    • Restricted supination and extension
    • Describe where radial head is dislocated (anterior, posterior, lateral):
      • Posterior tends to be congenital
      • Anterior tends to be associated with other conditions
    • Look for features of associated conditions
    • Examine other side
  • Associated Conditions:
    • Idiopathic
    • Hyperlaxity or paralytic:
      • CP, Down’s Syndrome, Arthrogryposis, Marfan’s, Ehlers-Danlos
    • Congenital:
      • Nail Patella Syndrome
      • Achondroplasia
      • Multiple Hereditary Osteochondromatosis
  • Management:
    • Leave alone if asymptomatic
    • Surgical results poor – only if significant pain:
      • Open reduction with radial shortening
      • Excision
      • Ulnar lengthening (if ulna significantly short e.g., MHE)

Radioulnar Synostosis

  • Look, Feel, Move:
    • Scars from past trauma
    • Deformity or shortening of limb
    • ROM decreased especially pronation & supination
    • Is there an associated congenital radial head dislocation?
    • Flexion & extension relatively retained depending on pathology
  • Causes & Classification:
    • Congenital or Traumatic
    • Partial or Complete
    • Fibrous or Bony
  • Risk Factors for Traumatic:
    • High energy trauma
    • Head injury
    • Restricted post-op ROM
    • Single incision approach
    • Crush injury
    • Fractures at same level
    • Delayed surgery
    • Open fracture
  • Management:
    • Often unrewarding
    • Encourage non-operative
    • Excision with interposition:
      • Complex with high risk and unpredictable outcome
    • Rotational Osteotomy:
      • Radius easier – shorten to decrease tension

Rheumatoid Elbow

  • Look:
    • Describe all features of rheumatoid in the elbow and hand:
      • Scars may be very faint
  • Move:
    • Assess ROM of elbow and shoulder concurrently
  • Feel:
    • Pain, crepitus, and warmth
  • Special Tests:
    • Must examine neurologic function:
      • Especially PIN and ulnar nerve
    • Functional Assessment
    • Screen shoulders, neck, and hands
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