II. Exam: Telemedicine
- Patient should expose both elbows for exam (e.g. short sleeve shirt)
- Perform observation (see below) and compare opposite side
- Patient palpates elbow at specifically directed points (see below)
- Perform Elbow Range of Motion (forward flexion, extension, pronation and supination)
- Test specific elbow strength (see below)
- Use Household Item Weights for resistance
III. Exam: Observation and General
- Perform Hand Neurovascular Exam
-
General appearance (comparing with opposite side)
- Erythema
- Deformity
- Biceps deformity may suggest Biceps Tendon Rupture (triceps tendon rupture may also occur)
- Swelling or joint effusion
- Ecchymosis (recent Trauma)
- Overlying skin changes
- Scars suggesting old Trauma
- Olecranon Tip and the 2 Epicondyles form:
- Olecranon Tip, Lateral Epicondyle, and Radial head
- Forms a posterior-lateral triangle
- Occupied by anconeus Muscle
- Excellent site for Joint Aspiration
- Olecranon bursa often bulges in posterior triangle
- Joint effusion bulges into antecubital fossa
- Forms a posterior-lateral triangle
- Carrying Angle
- Neutral elbow position with Forearm supinated
- Males: elbow flexed 5-10 degrees
- Females: elbow flexed 10-15 degrees
- Injury or infection alters angle (young higher risk)
- Cubitus varus (gunstock deformity)
- Carrying angle reversed
- Cubitus valgus
- Cubitus varus (gunstock deformity)
- Neutral elbow position with Forearm supinated
IV. Exam: Range of motion
- Normal elbow range of motion
- Extension: 180 degrees
- Flexion: 150 degrees
- Pronation: 160-180 degrees
- Supination: 90 degrees
- Full range of motion nearly excludes elbow Fracture (especially in adults)
- Fracture is unlikely (Test Sensitivity 99%) if intact four-way active range of motion
- Extension to 180, flexion to 90, supination to 90 and pronation to 180
- Vinson (2016) Am J Emerg Med 34(2):235-9 +PMID:26597495 [PubMed]
V. Exam: Strength (resisted Isometric) Mnemonic
- MFP: medial (epicondyle) flexors and pronators
- Medial Epicondylitis is provoked by wrist flexion and pronation
- LES: lateral (epicondyle) extensors and supinators
- Lateral Epicondylitis is provoked by wrist extension and supination
VI. Exam: Stability Testing
- Varus or Valgus stress
- Flex elbow to 30 degrees to unlock olecranon
-
Ulnar Collateral Ligament Injury most common
- Very significant injury for pitchers
- Resources
- Elbow Valgus and Varus Stress Tests (MSK Medicine, YouTube)
VII. Exam: Palpation
- Anterior
- Biceps tendon
- Median Nerve
- Anterior capsule
- Posterior
- Triceps tendon
- Olecranon fossa
- Medial
- Medial epicondyle
- Forearm flexor and pronator tendons
- Medial collateral ligament
- Ulnar Nerve
- Lateral
- Lateral epicondyle
- Radiocapitellar joint
- Radial head
- Radial Nerve
- Ulnar collateral ligament