II. Exam: Telemedicine

  1. Patient should expose both elbows for exam (e.g. short sleeve shirt)
  2. Perform observation (see below) and compare opposite side
  3. Patient palpates elbow at specifically directed points (see below)
  4. Perform Elbow Range of Motion (forward flexion, extension, pronation and supination)
  5. Test specific elbow strength (see below)
    1. Use Household Item Weights for resistance

III. Exam: Observation and General

  1. Perform Hand Neurovascular Exam
  2. General appearance (comparing with opposite side)
    1. Erythema
    2. Deformity
      1. Biceps deformity may suggest Biceps Tendon Rupture (triceps tendon rupture may also occur)
    3. Swelling or joint effusion
    4. Ecchymosis (recent Trauma)
    5. Overlying skin changes
    6. Scars suggesting old Trauma
  3. Olecranon Tip and the 2 Epicondyles form:
    1. Elbow extended: transverse line
    2. Elbow flexed: isosceles triangle
  4. Olecranon Tip, Lateral Epicondyle, and Radial head
    1. Forms a posterior-lateral triangle
      1. Occupied by anconeus Muscle
    2. Excellent site for Joint Aspiration
    3. Olecranon bursa often bulges in posterior triangle
      1. Joint effusion bulges into antecubital fossa
  5. Carrying Angle
    1. Neutral elbow position with Forearm supinated
      1. Males: elbow flexed 5-10 degrees
      2. Females: elbow flexed 10-15 degrees
    2. Injury or infection alters angle (young higher risk)
      1. Cubitus varus (gunstock deformity)
        1. Carrying angle reversed
      2. Cubitus valgus

IV. Exam: Range of motion

  1. Normal elbow range of motion
    1. Extension: 180 degrees
    2. Flexion: 150 degrees
    3. Pronation: 160-180 degrees
    4. Supination: 90 degrees
  2. Full range of motion nearly excludes elbow Fracture (especially in adults)
    1. Fracture is unlikely (Test Sensitivity 99%) if intact four-way active range of motion
    2. Extension to 180, flexion to 90, supination to 90 and pronation to 180
    3. Vinson (2016) Am J Emerg Med 34(2):235-9 +PMID:26597495 [PubMed]

V. Exam: Strength (resisted Isometric) Mnemonic

  1. MFP: medial (epicondyle) flexors and pronators
    1. Medial Epicondylitis is provoked by wrist flexion and pronation
  2. LES: lateral (epicondyle) extensors and supinators
    1. Lateral Epicondylitis is provoked by wrist extension and supination

VI. Exam: Stability Testing

  1. Varus or Valgus stress
    1. Flex elbow to 30 degrees to unlock olecranon
  2. Ulnar Collateral Ligament Injury most common
    1. Very significant injury for pitchers
  3. Resources
    1. Elbow Valgus and Varus Stress Tests (MSK Medicine, YouTube)
      1. https://www.youtube.com/watch?v=bCqPTSgW3-c

VII. Exam: Palpation

  1. Anterior
    1. Biceps tendon
    2. Median Nerve
    3. Anterior capsule
  2. Posterior
    1. Triceps tendon
    2. Olecranon fossa
  3. Medial
    1. Medial epicondyle
    2. Forearm flexor and pronator tendons
    3. Medial collateral ligament
    4. Ulnar Nerve
  4. Lateral
    1. Lateral epicondyle
    2. Radiocapitellar joint
    3. Radial head
    4. Radial Nerve
    5. Ulnar collateral ligament

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