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