Examination of the elbow
For the initial medical examination no specific equipment is required. The patient’s part of the body of interest should be uncovered and all other parts of the body should be gowned prior to medical examination. Some critical elements of the investigation such as testing for limb movement may not be applicable if a bone fracture is suspected.
For any musculoskeletal pathology it is essential to have a thorough understanding of the anatomy, as the examination will assess differences to normal anatomical structures and functions. It is necessary to acquire information on preexisting conditions or trauma, including the mechanisms of injury, changes in motility and function, swelling and treatments received. The patient will also provide a clear description of current symptoms.
Important landmarks of the elbow
The landmarks represent a guide to the doctor in the examination of the specific region of the body that may be compromised by injury or degenerative conditions. The main points of reference are the edges of bones that are easily identifiable with palpation. At the elbow they are:
The olecranon is the bony extremity of the elbow protruding in both a relaxed or flexed position. It is most vulnerable to injury due to falls.
Medial and lateral epicondyle
The two epicondyles of the humerus are located at either side of the elbow. They are important landmarks to assess the existence of any conditions that affect the muscles and tendons of the elbow and forearm (e.g. tennis elbow for the lateral, and golfer’s elbow for the medial epicondyle) including alterations in the range of movement of the elbow joint.
The hallmarks of any musculoskeletal pathology are pain, redness (erythema), swelling, increased warmth, deformity, neurological symptoms and loss of function. The doctor will commence with a visual observation of the affected area, which will be compared to the contralateral, unaffected side. This will identify the presence of scars, rashes, lesions, asymmetry, deformity and atrophy that will assist in the formation of a diagnosis.
Palpation of specific areas of the upper extremities aims to reproduce symptoms if a peripheral nerve entrapment is suspected. A positive diagnosis leads to increased pain and specific neurological symptoms as compared to the healthy arm.
With the patient in a sitting position the shoulder is moved in a 90 degrees abduction with extension or flexion of the elbow. Palpation is conducted medially to the bicep (mid humeral) at inner elbow and distally at the wrist.
For assessing the radial nerve, the palpation is performed proximal to the lateral epicondyle (on the posterior side of the elbow), or on the distal radius (wrist) and snuffbox (the natural cavity formed at the radial aspect of the wrist when the thumb is extended).
The elbow is flexed and rotated outwards. The ulnar nerve is gently pressed above the lateral epicondyle along the cubital tunnel of the elbow.
Range of movement
The patient is asked to actively move each joint to determine any changes in function, presence of instability and level of pain. It is also critical to monitor the same movements of the non injured region of the body to obtain an overall functional status of the patient. If abnormalities are present, the patient is subjected to a range of passive activities to assess increased or impaired range of movements. Subsequently, specific instability tests may be performed.
Flexion - Extension
The movements of the elbow joint are constrained to extension and flexion only. Active flexion is limited to 140°. Passive flexion (forearm is bent against the upper arm with flexors relaxed) can reach 160°. Passive flexion is limited by tension in the posterior capsular ligament and triceps brachii.
Pronation - supination
Supination/Pronation is a forearm function, consisting in the rotation of the hand either palm up or down. With supination the ulna and radius are parallel, with pronation they cross one another.
The patient abducts the arm to 90º at shoulder level and then flexes in the elbow with the hand reaching towards the back of the head. This movement is impaired with subacromial bursitis, rotator cuff pathology and frozen shoulder.
The modified Phalen's test, or wrist flexion test is mostly used to diagnose the symptoms of a carpal tunnel syndrome caused by increased pressure on the median nerve. The examiner flexes the patient’s wrists maximally and holds this position for one minute by pushing firmly the hand. Tingling into the thumb, index finger, the middle and lateral half of the ring finger indicates a positive test. The original test was described as pushing both flexed wrists together.
Tinel’s sign (Ulnar nerve - elbow)
This test is used to examine the ulnar nerve (at the elbow). The examiner taps the area of the ulnar nerve in the groove between the olecranon process and medial epicondyle. A positive sign is indicated by a tingling sensation in the ulnar distribution of the forearm and hand distal to the point of compression. The most distant point, at which the abnormal sensation is felt, represents the limit of nerve regeneration.
Tinel’s sign (Median nerve - wrist)
The examiner taps the area of the medial nerve over the wrist and a positive sign is indicated by a tingling sensation in the medial nerve distribution of the palm of the hand. The most distant point at which the abnormal sensation is felt, represents the limit of nerve regeneration.
Assessing paraplegia and tetraplegia
The level of paralysis is based on the ASIA Impairment Scale of The American Spinal Cord Injury Association. In order to help classify differing degrees of spinal cord injury, the ASIA impairment scale is used to compare and understand residual function.
A - Complete: No motor or sensory function in the lowest sacral segment (S4-S5)
B - Incomplete Sensory function below neurologic level and in S4-S5, no motor function below neurologic level
C - Incomplete Motor function is preserved below neurologic level and more than half of the key muscle groups have a muscle grade less than 3
D - Incomplete Motor function is preserved below neurologic level and at least half of the key muscle groups below neurologic level have a muscle grade 3
E - Normal Sensory and motor function.
Levels of paralysis
Methods to define the level of the paralysis:
Biceps jerk C5 /C6
Supinator jerk C6
Extensor digitorum reflex C7
Triceps jerk C7/ C8
Abdominal reflex T8-T12
Knee jerk L2 / L4
Ankle jerk L5 / S1 / S2
Bulbo-spongiosus reflex S2-S4
Anal reflex S5
Plantar reflex L5-S
There are four types of vascular examination:
Pulses of the upper extremity
An absent or weak pulse may affect the entire or one part of the body. It is measured in areas were an artery passes close to the skin such as the wrist.
To measure the pulse of the radial artery the examiner places the index and middle finger over the underside of the wrist, proximal to the base of the thumb. Once the pulse is felt, the number of beats is counted for one full minute.
Two areas of the wrist are chosen for this examination:
1. Pulse of the radial artery over the distal end of the radius on the palmar side (see picture)
2. Pulse of ulnar artery over the palmar side of the distal ulna.
Capillary refill is a test performed to assess the rate at which blood refills empty capillaries. Normally it should take less than three seconds. The examiner applies pressure to the finger until it turns white, indicating that blood has been forced out from the tip of the finger. Iftimerequired to return to colour following the pressure release exceeds three seconds it indicates poor peripheral perfusion and dehydration.
Oedema - cyanosis - clubbing
Oedema is caused by fluid building up in the body's tissue and usually occurs in the feet, ankles and legs but can also be observed in the upper extremities. Cyanosis refers to a low oxygen level in blood. It is a condition in which fingers, toes and lips appear blue. Clubbing results from chronic low levels of blood oxygen. The ends of the finger appear enlarged and the nails adopt a shape curved downwards.
The lymphatic system is a network of tissues and organs, which play a very important role in the immune system by clearing away infection and keeping your body fluids in balance. If the lymphatic system is impaired, fluid will build in the tissues, causing swelling or lymphoedema.
The Allen’s test is used to determine changes in arterial blood flow to the hand. The examiner applies pressure on the wrist to occlude both the radial and ulnar arteries. When the patient opens the hand, it will appear pale due to the lack of blood flow. Then the examiner releases only one artery (ulnar artery) ad if the colour at the finger tips returns within 7 seconds, it indicates that the opposite, radial artery is intact and supplies sufficient blood. This test is often carried out prior to radial artery canulisation for medical treatment.