Comprehensive Elbow Examination

Courtesy: Vinay Kumar Signh, NIMS and EVA Hospital, Jaipur, India

General Examination

• General build and nutritional status.

• Presence of pallor, icterus, cyanosis, clubbing, lymphadenopathy, or edema.

• Vital signs.

• Height, weight, body mass index, and arm span.

• Neurocutaneous markers.

• Secondary sexual characteristics.

• Evidence of generalized ligamentous laxity.

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Local Examination

Local examination of the elbow includes:

1. Inspection

2. Palpation

3. Movements

4. Measurements

5. Special tests

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Inspection

• The elbow should be inspected from the anterior, lateral, medial, and posterior aspects.

• The patient is asked to place both upper limbs in the anatomical position for comparison.

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Attitude of the Limb

• Observe how the limb is held at rest.

• Protective flexion posture may suggest pain or injury.

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Alignment of the Elbow and Forearm

• Assess the carrying angle.

Carrying Angle

• Patient stands with the arm close to the chest and forearm supinated.

• The angle between the long axis of the arm and the long axis of the forearm represents the carrying angle.

• Normal values:

  • Males: 5 to 10 degrees

  • Females: 10 to 15 degrees

• Carrying angle cannot be accurately assessed in the presence of a fixed flexion deformity.

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Deformities of the Elbow

• Flexion deformity:

  • Common after elbow trauma or arthritis.

• Cubitus valgus:

  • Seen after lateral condyle fractures and occasionally supracondylar fractures.

• Cubitus varus (gunstock deformity):

  • Classical malunion following supracondylar fracture of the humerus.

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Anterior Aspect Inspection

• Inspect the cubital fossae on both sides.

• Look for:

  • Fullness or swelling, such as myositis ossificans

  • Visible pulsations or prominent veins

  • Sinuses or surgical scars

  • Muscle wasting

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Lateral Aspect Inspection

• Observe for swelling and deformity.

• Assess muscle contour.

• Identify the mobile wad of three muscles.

• Inspect biceps and triceps:

  • Popeye sign suggests biceps tendon rupture.

• Tenting of triceps:

  • Seen in posterior dislocation of the elbow.

• Look for swelling over the olecranon.

• Inspect the anconeus triangle for fullness.

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Posterior Aspect Inspection

• Observe:

  • Triceps tendon

  • Olecranon prominence

  • Para-olecranon region

  • Medial and lateral epicondyles

• Look for:

  • Abnormal lumps or swelling, such as in neglected elbow dislocation

  • Muscle wasting

  • Sinuses or scars

  • Prominent veins

• Assess the three-point bony relationship.

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Palpation

1. Local rise of temperature.

2. Tenderness.

3. Palpation of bony landmarks:

   • Lateral epicondyle

   • Olecranon

   • Radial head

   • Medial epicondyle

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Soft Tissue Palpation

• Anteriorly:

  • Palpate the cubital fossa for swelling or tenderness.

  • Palpate the biceps tendon and lacertus fibrosus during resisted elbow flexion.

• Medially:

  • Palpate the ulnar nerve just posterior to the medial epicondyle.

  • Palpate the epitrochlear lymph node.

• Posteriorly:

  • Palpate for swelling in the para-olecranon region.

  • Palpate the tip of the olecranon.

• Laterally:

  • Palpate the anconeus triangle for effusion or tenderness.

  • Palpate one finger breadth distal to the lateral epicondyle to assess the origin of extensor carpi radialis brevis in lateral epicondylitis.

• Joint lines:

  • Anterior joint line

  • Posterior joint line

  • Radiocapitellar joint

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Movements of the Elbow

• Flexion: 0 to 140 degrees

• Extension: up to 10 degrees of hyperextension

• Pronation: 0 to 70 degrees

• Supination: 0 to 85 degrees

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Measurements

Upper Limb Length

• Arm length:

  • Anterolateral border of the acromion to the lateral epicondyle.

• Forearm length:

  • Lateral epicondyle to radial styloid.

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Hueter Triangle

• Distance from olecranon to medial epicondyle.

• Distance from olecranon to lateral epicondyle.

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Muscle Wasting

• Identify the area of maximum wasting.

• Measure circumferential girth and compare with the opposite side.

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Bone Length Measurements

• Radial length:

  • Lateral epicondyle to radial styloid.

• Ulnar length:

  • Olecranon tip to ulnar styloid.

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Carrying Angle

• Measured between the long axis of the arm and the long axis of the forearm.

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Special Tests

Elbow Instability

• Varus stress test

• Valgus stress test

• Posterolateral rotatory instability test

• Chair push-up test

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Lateral Epicondylitis (Tennis Elbow)

• Cozen test

• Mills test

• Maudsley test

• Chair test

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Medial Epicondylitis (Golfer’s Elbow)

• Resisted wrist flexion test

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Radial Tunnel Syndrome

• Long finger extension test

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Pronator Syndrome

• Prolonged resisted pronation test

• Prolonged resisted elbow flexion test

• Long finger proximal interphalangeal joint flexion test

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Cubital Tunnel Syndrome

• Tinel sign at the elbow

• Prolonged elbow flexion test

• Ulnar nerve compression test

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Other Examinations

• Examination of joints above and below:

  • Shoulder

  • Wrist

• Regional lymph node examination:

  • Cubital fossa

  • Axilla

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Neurovascular Examination

• Deep tendon reflexes:

  • Biceps reflex

  • Triceps reflex

  • Supinator reflex

• Motor and sensory examination of:

  • Ulnar nerve

  • Median nerve

  • Radial nerve

• Peripheral pulses:

  • Radial pulse

  • Ulnar pulse