Summary

Patient Standing
Introduce
Aids
Expose
Stigmata generalised disease

Look

Look with arms forward flexed approx 45°, elbows extended (i.e. out in front)
Alignment & Carrying angle
- Men 10° Women 13°
- Cubitus Valgus
  - check for tardy ulnar nerve palsy
    - nonunion fractured lateral condyle
    - premature closure of lateral distal humeral physis
- Cubitus Varus
  - gunstock deformity
    - Supracondylar fractures
Scars/Swellings/Sinus
- Wasting: Deltoid/Arm/Forearm
Popeye lesion

Hold arms abducted out to sides with palms facing up

Extension – active/passive both sides
Flexion – active/passive both sides
- Look at medial side
  - Scars – ulnar nerve transposition
Bring elbows to the front
- Look at posterior aspect
  - Bursitis
  - Rheumatoid nodules
  - Scars
- Look at axilla
Look at lateral side
- Effusion
- Scars – Kochers

Feel

Swelling/warmth/lump/Tenderness

Medial
- Medial epicondyle
- Flexor pronator mass
- Ulnar nerve
  - tenderness, size, location
  - tinel
  - stability
    - Palpate nerve while flexing / extending elbow feeling for subluxation
    - If positive
      - Check carrying angle & valgus / varus stability
Posterior
- Olecranon
  - Osteophytes
  - Olecranon apophysitis
    - localized bony tenderness but no oedema
    - Adolescent weightlifters or throwers
  - Olecranon bursitis
- Triceps insertion
Lateral
- Lateral epicondyle
- Capitellum/radiocapitellar joint (crepitus)
- Radial head
- Extensor origin
- Radial tunnel
Anterior
- Biceps tendon
- Lateral cutaneous nerve just lateral to this

Move

Active then Passive

Please follow me with these exercises

Bring your arms up with your hands facing upwards

Extension/flexion 0 -140°
- 30-130° necessary for ADL’s
active elbow extension
- 0 to 10° hyperextension
passive elbow extension
- note endpoint
  - hard – bony block, osteophytes, loose bodies in posterior compartment of elbow
  - soft – anterior soft tissue contracture, weakness or paralysis of triceps
- note pain
  - bony or soft tissue impingement
  - valgus extension overload in throwing athletes
    - osteophyte impingement
active elbow flexion
- 130-140°
- look for asymmetry
passive elbow flexion
- note endpoint
  - hard – anterior impingement due to osteophytes on coronoid process of ulna, ectopic ossification, large loose bodies
  - soft – posterior soft tissue contracture (rare)

Arms by the side & elbow flexed to 90°

Pronation/supination
NB
- Centre of rotation: midpoint of Capitellum at anterior inferior aspect of medial epicondyle
elbows tucked snugly against the sides
elbows flexed 90°
forearm rotation
- curved radius rotates around straight ulna
- pronation 70 – 80°
- supination 85°
- ADL’s require 50°
Supination/pronation power

Special Tests

Specific Muscles / movements

Biceps Brachii
- Resisted elbow flexion
Brachioradialis (radial nerve)
- Flex elbow to 90°
- Forearm in neutral rotation
- Push down on patient’s wrist against resistance
Triceps brachii (radial nerve)
- Resisted elbow extension
Supination strength
- Biceps (primarily) – musculocutaneous nerve
- Supinator – radial nerve

Supination strength is 15% greater than pronation
Dominant arm is 5-10% stronger

To test
- Elbow by the side & flexed to 90°
- Rupture of long head of biceps
  - Little change in strength
- Rupture of distal biceps tendon
  - Dramatic loss
- If ¯
  - ? Loss of musculocutaneous nerve
  - radial nerve
  - cervical Radiculopathy
Pronation strength
- Pronator teres – median nerve
- Pronator quadratus – median nerve
- Same position as supination

Sensation Testing

Median nerve
- 3.5 palmar fingers
- if nerve is cut distally, base of thumb is spared
Anterior Interosseous nerve
- no sensory deficit
Ulnar nerve
- 1.5 fingers
Radial nerve
- snuffbox

Nerve Compression Syndromes

Cubital Tunnel Syndrome

Most common nerve compression at elbow
Causes
- Idiopathic
- Activities requiring repetitive elbow movements
- Osteoarthritis
- Rheumatoid arthritis
- Fractures / Dislocations
- Cubitus valgus
- Instability of ulnar nerve
- Anconeus epitrochlearus muscle
Symptoms
- Pain to medial forearm
- Paraesthesias to ulnar nerve distribution of hand
Signs
- Benediction Hand
  - Little finger & ring finger are clawed
    - Flexed at the IPJ & hyperextended at MTPJ
- Muscle Wasting
  - Compression at wrist
    - Intrinsic muscles of hand
    - Weakness finger abduction adduction
  - Compression below elbow
    - Flexor carpi ulnaris
      - Weakness of wrist flexion in ulnar deviation
  - Compression at elbow
    - Flexor digitorum profundus to 4- 5th digits
Tests
- 1. Tinel’s Sign
- 2. Elbow Flexion test
  - Passively flex elbow to maximum & hold for 1 minute
  - Patient develops paraesthesia in small & ring finger
- 3. Ulnar nerve compression test
  - Same as elbow flexion test but also press on the nerve

Radial Nerve

Posterior Interosseous Nerve
Superficial Sensory Branch
Causes
- Adhesions
- Muscular anomalies
- Vascular aberrations
- Fibrotic bands
- Inflammatory conditions
- Tumours
- Fractures

Radial Tunnel Syndrome

Radial tunnel at the Arcade of Frohse
Tests
- Tenderness at the Arcade of Frohse
- Long Finger Extension Test
  - Patient fully extends all fingers & also wrist 30°
  - Now push down on middle finger over distal proximal phalanx while patient resists
    - Positive if reproduces pain
    - Also can be positive in lateral Epicondylitis
    - To distinguish between the two, they have different areas of tenderness 1 vs 4 fingerbreaths
- Muscle weakness
  - Unusual
  - Innervated before radial tunnel
    - Brachioradialis
    - ECRB
    - ECRL
  - Innervated distal to radial tunnel i.e. by PIN
    - ECU
    - EDC
    - EPL
    - EPB
  - Therefore in severe radial tunnel syndrome
    - wrist deviates to the radial side when the patient is instructed to actively extend it because the radial wrist extensors are functioning but the extensor carpi ulnaris is not

Pronator Syndrome

Median nerve compression between 2 heads of pronator teres
Tests
- Palpation
  - Resist patients pronation whist at the same time palpating firmly 3 fingerbreadths distal & medial to elbow crease
- Prolonged Resisted Pronation
  - Same as above but for 60 seconds

Other Median Nerve compression sites

Elbow by the lacertus fibrosus (biceps tendon)
- Symptoms reproduced by prolonged resisted elbow flexion & resisted forearm supination
At origin of flexor digitorum superficialis
- Symptoms may be reproduced by long finger PIP flexion test
  - Forearm supinated
  - Patient’s fingers flexed
  - Try to extend middle finger against resistance

Median Nerve Lesion Levels

Above elbow
- All muscles affected
  - Wrist flexion, finger flexion, thumb flexion, thumb opposition
Proximal forearm
- Wrist flexion may be unaffected
Wrist
- Only thenar muscles affected
  - Test opposition

Anterior Interosseous Nerve Syndrome

Causes
- Trauma, forearm masses, anomalous muscles
Symptoms
- Aching pain in forearm
- Weakness of FPL, FDP to index finger
- Weakness of Pronator quadratus
  - Test pronation strength with elbow fully flexed
Test
- Make ‘O’ with thumb & index finger, & try to separate
- Compare with other side

PROVOCATIVE TESTS FOR TENDINITIS

Lateral Epicondylitis

Resisted wrist extension
- Patient makes fist & extends the wrist
- Push down on wrist against resistance
- At same time you may apply pressure to extensor tendon origin

Medial Epicondylitis

Resisted wrist flexion
- Patient makes fist & flexes wrist in supination
- Examiner tries to extend wrist
- At same time you may apply pressure to flexor tendon origin
Resisted forearm pronation
- More reliable than resisted wrist flexion
- Due to pronator teres eccentric contraction

STABILITY TESTING

Varus – 20° flexion, wrist supinated
Valgus – 20° flexion, wrist pronated to take out PLRI

Valgus Stress Test

MCL most important stabilizer
Common in throwing athletes because throwing causes valgus stress at elbow

Fully ER limb at shoulder
Flex elbow to 15° to relax anterior capsule & unlock olcreanon process from Olecranon fossa
Grab arm above & below the elbow
Apply valgus force being careful not to rotate shoulder
Pronate forearm & repeat
- If there is laxity in pronation only
  - anterior portion of MCL is laxed
  - or the ulnar part of the LCL is laxed
Milking sign
- Elbows crossed
- Patient grasps thumb of affected side & applies valgus

Varus Stress Test

Limb is IR
Apply varus stress

Posterolateral Rotatory Instability

Pivot Shift Test, Posterolateral Rotatory Instability Test
- Position if deficient lateral ulnar collateral ligament
- Symptoms: episodes of subluxation or dislocation

Patient supine, arm above patient’s head
Elbow fully extended, shoulder max ER & forearm supinated
Apply valgus & axial compression force at elbow & supination force to forearm
- Results in rotatory subluxation of ulnohumeral joint with a posterolateral dislocation of radial head
Flex elbow
- At 40°, the subluxation is at maximum
- Radial head is most prominent & produces posterolateral prominence with an obvious skin dimple
Keep in flexing
- Sudden reduction of radiohumeral & ulnohumeral joints
This test is best done under GA
When done awake, it causes apprehension

Other

Wrist ROM
DRUJ ROM
Shoulder ROM

Neurovascular exam

Ulnar nerve in particular
PIN (Kochers) Median (anterior scar)
Pulse

Other tests

Neurological Examination
ulna
median
radial

Peripheral pulses
Joint above & below
Cervical Spine examination

PHYSICAL FINDINGS IN COMMON CONDITIONS OF ELBOW & FOREARM

Cubital Tunnel Syndrome

Tenderness over the course of ulnar nerve
Tinel’s sign in cubital tunnel
Ulnar nerve compression test
Elbow flexion test (variable)
Sensation
- Ulnar 1.5 fingers
Weakness & atrophy
Look for ulnar nerve instability
Elbow deformity, elbow instability

Lateral Epicondylitis

Tenderness
Resisted wrist extension
Pain with passive flexion of fingers & wrist with elbow fully extended

Radial Tunnel Syndrome

Tenderness at Arcade of Frohse
Longer finger extension causes pain
Weakness of finger & thumb extensors

Pronator syndrome

Tenderness in proximal forearm over pronator teres
Sensation
- 3.5 fingers
prolonged resisted pronation causes symptoms
weakness of median nerve muscles

Anterior interosseus nerve syndrome

O sign
- Weakness of FPL & FDP to index finger
- Weak pronator quadratus

Medial Epicondylitis

Tenderness over common flexor origin
Resisted wrist flexion test reproduces pain
Resisted forearm pronation reproduces pain

Distal Biceps tendon rupture

Swelling
Ecchymosis
Palpable gap in biceps tendon
Weak supination & elbow flexion

Valgus extension overload syndrome

Tenderness around tip of Olecranon
Pain with forced passive elbow extension
Increase valgus laxity (variable)

Osteoarthritis

Restricted flexion or extension
Effusion (variable)

Triceps tendinitis

Exacerbated by resisted elbow extension

Valgus extension overload

Valgus force imparted by throwing causes the medial border of Olecranon to impinge on the adjacent surface of olecranon fossa in extension

Posterior Interosseous nerve impingement (radial tunnel syndrome)

Between 2 heads of supinator in arcade of Frohse
Palpate 4 fingerbreaths distal to lateral epicondyle with patient’s arm pronated

Lateral Epicondylitis / Tennis elbow

Pain is greatest 1 fingerbreaths distal to lateral epicondyle with elbow flexed
Resisted wrist extension may exacerbate the pain of palpation
Usually effects ECRB

Intersection Syndrome

Inflammation of crossing of APL/EPB & ECRL/ECRB
Palpate dorsum of patient’s distal forearm with forearm fully pronated
4 fingerbreaths proximal to wrist
active dorsiflexion during palpation ↑ pain

Panner’s disease

Osteochondritis Dissecans of Capitellum
Adolescent gymnast or throwers

Medial epicondyle apophysitis / little leaguer’s elbow

Preadolescent / adolescent throwers

Medial Epicondylitis / golfer’s elbow / reverse tennis elbow / medial tennis elbow

Palpate 1 finger breath distal to medial epicondyle with elbow flexed
Active pronation exacerbates pain

Ulnar Nerve

Tinel’s sign