Elbow Examination John M. Lavelle, D.O.

Anatomy

Bones Bones: 3 articulations: Humerus, ulnar, radius Trochlear, coronoid, capitellum, radial head 3 articulations: Radiocapitellar joint Ulnarhumeral joint Proximal radioulnar

Ligaments

Muscles

Muscles

Epicondyles

Nerves: Ulnar Nerve: Median Nerve: Passes behind the medial epicondyles and lies over ulnar collateral ligament and under bicipital aponeurosis and pronator teres. Median Nerve: Passes medial to the brachial artery, in front of the point of insertion of the brachialis muscle and deep to the biceps.

Nerves Radial Nerve: Passes posterior to the distal humerus.

Observe Effusions Cubital vein Muscles Scars Deformity Bursitis Fistula Thrombus Muscles Tear Scars Track marks Deformity Dislocations

Palpate Active ROM & Passive ROM Lateral Epicondyle Medial Epicondyle Flexion: 0° to 160° Pronation: 80° Supination: 85° Include ab/adduction Appreciate crepitus, tenderness Lateral Epicondyle Brachioradialis, ECRL, ECRB, EDC Medial Epicondyle Pronator teres, FCR, PL, FDS, FCU

Palpate Olecranon Radial head Ulnar nerve Bursa Radial head Superior/Inferior dysfunction Ulnar nerve Dislocation Biceps tendon and Triceps tendon Cubital fossa syndrome, Clicking triceps syndrome Forearm tension Muscles Fascia

Neuro Exam MMT Sensation Biceps, Triceps, Wrist Extensors, Flexion of 3rd DIP joint, Abduction of digiti minimi Sensation Radial, median, ulnar, medial/lateral/posterior antebrachial cutaneous nerves

Muscle Tests Lateral Epicondylitis Medial Epicondylitis Distal Bicep Resisted third digit extension – worsens pain as it tightens fascia over ECRB Resisted wrist extension- ECRB (Cozen’s test) Medial Epicondylitis Resisted wrist flexion- FCR (Cozen’s Test) Distal Bicep Yergason’s test Triceps Resisted elbow extension Pronator Syndrome - Median Neuropathy Resisted forearm pronation

Ulnar Collateral ligament Palpate optimally at 30-60° flexion

Ulnar Collateral ligament Milking Maneuver: Arm at 70° and elbow at 90°, a valgus pressure is applied by supporting the elbow and placing traction on the thumb…like milking a cow. Moving valgus stress test: Shoulder abducted to 90° and elbow flexed fully, apply a valgus force to the elbow, until shoulder fully externally rotated. While maintaining valgus pressure elbow is quickly extended.

Ulnar Collateral Ligament Valgus Stress: Patient sitting with the elbow flexed to 20 to 30°. Examiner stands with distal hand around the athlete's wrist (medially) and the proximal hand over the athlete's elbow joint (laterally) Examiner stabilizes the wrist and applies a valgus stress to the elbow with the proximal hand

Lateral Collateral Ligaments Radial Collateral Ligament Lateral Ulnar Collateral Ligament Acc. Lateral Collateral Ligament Annular Ligament

Lateral Collateral Ligaments                                                             Lateral Collateral Ligaments Pivot Shift Test: Nursemaid Elbow Performed with the patient in the supine position, with the affected arm positioned overhead. The wrist and the elbow are lightly forced into supination while a valgus strain is applied to the elbow as it is moved from extension to flexion and back again. A positive test result is an apprehension response by the patient and/or frank subluxation or dislocation with a "clunk" as the radial head reduces during manipulation.

Ulnar Nerve Flexion Test Tinel sign Pinch Grip Test Athlete maximally flexes the elbow and holds the position for 3 to 5 minutes. Radiating pain into the median nerve distribution in the athlete's arm and/or hand – Cubital Fossa Syndrome Passive Flexion Test/Ulnar nerve subluxation test As above but move elbow into flexion/extension Can palpate snapping triceps and/or ulnar nerve over medial epicondyle Tinel sign Patient sitting with the elbow in slight flexion. Examiner grasps athlete's wrist (laterally) with distal hand. Examiner stabilizes the wrist and taps on the ulnar nerve in the ulnar notch with the index finger Pinch Grip Test Patient sitting or standing. Examiner instructs patient to pinch the tips of the thumb and index finger together – Positive test shows anterior interosseous nerve impinged between the two heads of the pronator muscle.

Thank You!