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Elbow examination

Introduction

  • Wash hands
  • Introduce self
  • Ask Patient’s name, DOB and what they like to be called
  • Explain examination and obtain consent
  • Expose arms
  • General inspection: patient, e.g. age, pain/discomfort, signs of trauma; around bed, e.g. mobility aids, sling

Look

You should inspect from the front, sides and behind.

  • Carrying angle (men 5-10˚, women 10-15˚)
    • Cubitus valgus = increased angle
    • Cubitus varus (‘gunstock’ deformity) = reversed angle
  • Fixed flexion deformity 
  • Skin: scars, bruising, sinuses, swelling, erythema
  • Rashes: psoriatic plaques, rheumatoid nodules (feel up extensor surface)
  • Muscles: wasting, look for biceps ‘Popeye’ sign/lump (biceps tendon rupture)

Feel

Ask about any pain and then start by examining the normal side.

  • Skin: palpate general area for temperature, effusions and soft tissue swelling/tenderness (e.g. olecranon bursitis)
  • Bony landmarks
    • Palpate olecranon tip, medial epicondyle, lateral epicondyle (palpate in extension and in flexion)
    • Palpate radial head with thumb on rotation of forearm
  • Palpate tendons
    • Common extensor origin – just distal to lateral epicondyle (pain = Tennis elbow)
    • Common flexor origin – just distal to medial epicondyle (pain = Golfer’s elbow)
  • Palpate ulnar groove between the olecranon process and the medial epicondyle (paraesthesia in ulnar nerve distribution = cubital tunnel syndrome)

Move

Test active then passive movements.

  • Flexion (145˚)
  • Extension (0˚) 
  • Pronation (85˚) of wrist while elbow flexed to 90˚
  • Supination (90˚) of wrist while elbow flexed to 90˚
  • SPECIAL TESTS:
Lateral collateral ligamentFlex elbow to 30˚and apply varus force while forearm supinated
Medial collateral ligamentFlex elbow to 30˚and apply valgus force while forearm pronated
Tennis elbow testWith elbow at 90˚, forearm pronated, and wrist fully flexed, ask patient to extend wrist while applying resistance (pain at lateral epicondyle = positive test)
Golfer’s elbow testWith elbow at 90˚, forearm pronated, and wrist fully extended, ask patient to flex wrist while applying resistance (pain at medial epicondyle = positive test)

Function

  • Move hand to mouth
  • Place hands behind head

To complete

  • Thank patient and restore clothing
  • ‘To complete my examination, I would examine the shoulders and wrists, and perform a distal neurovascular examination.’
  • Summarise and suggest further investigations you would consider after a full history 

Valgus and varus forces

Some questions for you

Try a station

  1. Elbow exam
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