Physical Examination of the Elbow

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CHAPTER 4 Physical Examination of the Elbow

HISTORY

Without question the value of a precise history cannot be overstated. Pain is the most common complaint. The severity of the pain and whether it is intermittent or constant, the quantity and type of analgesia used, and the association of night pain are all important characteristics. The functional compromise experienced, whether it be recreational activity or activities of daily living, should be discussed. Frequently, the patient who has lived with chronic pain, such as that accompanying rheumatoid arthritis, has learned certain accommodative activities that have assisted in lessening or eliminating pain from a conscious level. When considering intervention, it is extremely helpful to determine if the pain is getting better, getting worse, or remaining constant.

Functionally, the elbow is the most important joint of the upper extremity, because it places the hand in space away from or toward the body. It provides the linkage, allowing the hand to be brought to the torso, head, or mouth. Because of this, the examiner must be aware of the interplay of shoulder and wrist function as they complement the usefulness of the elbow. However, a considerable limitation of elevation and abduction function can exist at the shoulder complex without producing an appreciable compromise in most activities of daily living. This is true because only a relatively small amount of shoulder flexion and rotation is necessary to place the hand about the head or posteriorly about the waist or hip, and scapulothoracic motion can compensate for glenohumeral motion loss. Full pronation and supination can be achieved only when both the proximal and distal radioulnar joints are normal.6,25

Conditions involving the lateral joint, that is, the radiocapitellar articulation, generally evoke pain that extends over the lateral aspect of the elbow with radiation proximally to the midhumerus or distally over the forearm. The pain may be superficial, directly over the lateral epicondyle or radial head, for example, or deep, localized poorly in the area of the proximal common extensor muscle mass supplied by the posterior interosseous nerve. For reasons that remain unclear, the posterior lateral ulnohumeral joint appears to be a “watershed” referral point for a spectrum of remote conditions. Less commonly, nonspecific symptoms poorly localized to the medial aspect of the elbow can represent ulnar nerve pathology, medial epicondylitis or arthrosis.

As is well known, symptoms from cervical radiculopathy can usually be distinguished by a specific radicular distribution of pain and associated neurologic abnormality of the upper extremity. Today, a suspicion of cervical etiology is readily resolved with the magnetic resonance imaging (MRI) scan.

PHYSICAL EXAMINATION

AXIAL ALIGNMENT

Axial malalignment of the elbow, when compared with the opposite side, suggests prior trauma or a skeletal growth disturbance. To determine the carrying angle, the forearm and hand should be supinated and the elbow extended; the angle formed by the humerus and forearm is then determined (Fig. 4-1A). Although there is considerable variation with race, age, sex, and body weight, an average of 10 degrees for men and 13 degrees for women has been calculated as the mean carrying angle from several reports.3,4,13,14

Angular deformities, such as cubitus varus or valgus, are also easily identifiable (see Fig. 4-1B and C). The elbow moves from a valgus to varus alignment as with flexion. In a post-traumatic condition, however, abnormalities in the carrying angle cannot be accurately assessed in the presence of a significant flexion contracture (see Chapter 3). Rotational deformities following supracondylar or other fractures of the humeral shaft may be difficult to perceive.

POSTERIOR ASPECT

A prominent olecranon suggests a posterior subluxation or migration of the forearm on the ulnohumeral articulation. Occasionally, marked distortion is associated with surprisingly satisfactory function (Fig. 4-4). Rupture of the triceps tendon at its insertion should be suspected if this finding is accompanied by loss of active extension. Loss of terminal passive extension of the elbow is a sensitive but nonspecific indicator of intra-articular pathology. Loss of active motion with full passive extension suggests either mechanical (triceps avulsion) or neurologic conditions.

The prominent subcutaneous olecranon bursa is readily observed posteriorly when it is inflamed or distended (Fig. 4-5). Rheumatoid nodules frequently are found on the subcutaneous border of the ulna (see Chapter 74).

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FIGURE 4-5 An inflamed or enlarged olecranon bursa is one of the more dramatic diagnoses made by observation in the region of the elbow.

(From Polley, H. G., and Hunder, G. G.: Rheumatologic Interviewing and Physical Examination of the Joints, 2nd ed. Philadelphia, W.B. Saunders Co., 1978.)

MEDIAL ASPECT

On occasion the ulnar nerve may be observed to displace anteriorly during flexion with recurrent subluxation of the ulnar nerve.8 Otherwise, few landmarks are observable from the medial aspect of the joint. The prominent medial epicondyle is evident unless the patient is obese.

ASSOCIATED JOINTS AND NEURAL FUNCTION

No examination of the elbow is complete without a review of the cervical spine and all other components of the upper extremity. If the elbow pain has a radicular pattern, it is important to review the patient’s cervical spine alignment and range of motion and perform neurologic testing of the entire upper extremity. The main nerve roots involved with elbow function are C5-7 (Fig. 4-6). There is considerable overlap in the sensory dermatomes of the upper extremity. The general distribution of sensory levels includes C5, the lateral arm; C6, the lateral forearm; C7, the middle finger; and C8 and T1, the medial forearm and arm dermatomes, respectively.

Biceps function from innervation of C5-C6 is a flexor of the elbow and forearm supinator. The reflex primarily tests C5 and some C6 competency. The C6 muscle group of most interest is the mobile wad of three, consisting of the extensor carpi radialis longus and brevis and the brachioradialis muscles. These also are known as the radial wrist extensors and should be assessed for strength and reflex integrity. The reflex is primarily a C6 function, with some C5 component. The primary elbow muscle innervated by C7 is the triceps, which should always be assessed for strength and reflex. Wrist flexion and finger extension also are primarily supplied by C7, with some C8 innervation (see Fig. 4-6).

Elbow pain may be referred from the shoulder; therefore, a visual inspection of the shoulder for muscle wasting and appearance should be made, followed by an appropriate functional assessment. Specific attention should be directed toward motion and the spectrum of impingement tendinitis or rotator cuff pathology which often is manifested by pain in the brachium.

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