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:

• Deformities of joint/bones/alignment: carrying angle (men 5-10˚, women 10-15˚): increased angle (cubitus valgus); reversed angle (cubitus varus/‘gunstock’ deformity)
• Skin: scars, sinuses, swellings, 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 (80˚) of wrist while elbow flexed to 90˚
• Supination (90˚) of wrist while elbow flexed to 90˚

Special tests

Lateral collateral ligament

Flex elbow to 30˚and apply varus force while forearm supinated

Medial collateral ligament

Flex elbow to 30˚and apply valgus force while forearm pronated

Tennis elbow test

With the patient’s forearm fully pronated, and their wrist fully flexed, ask patient to extend wrist while applying resistance (pain at lateral epicondyle = positive test)

Golfer’s elbow test

With the patient’s forearm fully supinated, 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

How is valgus force applied to the elbow joint?

To apply a vaLgus force, press on the Lateral side of the joint

How is varus force applied to the elbow joint?

To apply a varus force, press on the medial side of the joint

Some questions for you

What is Golfers elbow?

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What are some differentials of elbow pain?

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Please can you name two ligaments in the elbow?

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What is the most common fracture to affect the elbow?

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1. Elbow exam
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