- Hello. This next video here is just a little bit of a demystification of the
orthopedic elbow exam. We're going to go over some basic tests and what we look for
as orthopedic surgeons in regards to evaluating an elbow exam. So first off
when you evaluate a patient for an elbow injury, you're going to inspect the
patient, just watch the patient, see what they're doing when they're sitting in your
office. Sometimes they're sitting there holding their elbow, sometimes they're in
a sling, sometimes they're in a splint. So it's very important number one, just to
look at the patient and see how they're sitting, see if there's any swelling, any
bruising, any deformity. Also, make sure you get a very good history, what's their
mechanism of injury? Did they land directly on their wrist and hand? Did they
land on their elbow? This all plays a big role in regards to what we're looking for
and kind of helps narrow down our diagnosis. So the next thing we do is we
basically, we'll look at the elbow, and I'll have the patients compare, show me
both they're elbows out in full extension. So I'll have them go ahead and extend
their elbows both ways, and then we'll see exactly what the difference is. If one
elbows like this, and one elbows coming to full extension, then you obviously have a
contracture, you have something here that's impeding them from getting the full
extension. So, you evaluate both elbows in full extension, then you have them bend
their elbows, and then you evaluate their supination, which is the palms up, and
then their pronation, which is the palms down. This actually tells us a lot about
what's going on in the radiocapitellar joint up here. Because if they cannot
fully pronate, or if they're stuck, that means that something physically is in the
joint and keeping them from rotating the wrist, or rotating their elbow, or they
may have a radial head fracture, or broken bone, or some swelling, or inflammation
that's keeping them from rotating. So that's first and foremost, is looking at
the range of motion. The next thing you want to do is
palpation, you want to see exactly where they hurt. So, you'll go ahead and just
break down the elbow in different sections. So you'll start by palpating on
the outside area of the elbow, this is the lateral epicondyle, which is this little
bone over here. Then you have the radial head over here right below it. And
sometimes you can feel the radiocapitellar joint kind of rolling back and forth here.
Next, we palpate the olecranon tip over here. Sometimes patients will have what we
call an olecranon bursitis, which is almost like this little fluid filled
balloon in the back of the elbow here, which is a very common thing that we see
in the office, usually due to trauma. And then, you palpate the medial epicondyle
over here and see if there's any abnormality in any of those bones, if you
see any kind of crepitus, which means crunchiness, or a deformity, or swelling.
Then we go to specific tests in regards to the elbow. The first test that I like to
do, just depending on where the patient's complaining of the pain, if they're
complaining of pain laterally, on the outside of the elbow, we usually go ahead
and look at their strength and have them lift the wrist up, hold their wrist up
real strong. If they have pain with that motion then that usually isolates it to
the lateral epicondyle, then that may mean that they have a tennis elbow or lateral
epicondylitis. And then we have them flex the elbow and resist with a flexion. If
they have pain with flexion, then sometimes they'll have a tendonitis on the
inside of the elbow which is known as medial epicondylitis. This is called
tennis elbow, this is called golfer's elbow. And that just means you have a
tendonitis or an overuse injury of the tendon on either the outside or the inside
of the elbow. The next test we'll do, if we're leaning towards a lateral
epicondylitis or a tendonitis on the outside of the elbow, have them spread
their fingers out, and have them resist us as we push this middle finger down. This
is called a piano key sign, and the reason it hurts out here in the elbow is because
the tendon that inserts here, the ECRB, also inserts down here at the base of the
metacarpal of this finger here. So when you hold that finger up and it
hurts up here, then that means that you may have a tendonitis or a lateral
epicondylitis. The last test for tennis elbow that we usually do, is we'll have
the patient grip as they're doing a handshake, they'll flex their elbow and
then they squeeze, and you bring their arm into full extension, and then they have
pain at the lateral side, that's also consistent with a tennis elbow or
lateral epicondylitis. The next test we'll do is, we'll look at the elbow stability.
And the best way to do that is basically stressing the elbow back and forth in full
extension and then a little bit at 30 degrees flexion, and then we can test the
ligaments stability on the outside and on the inside of the elbow. Some patients are
naturally laxed and have a little bit of looseness, so it's important to do a
comparative evaluation on the other elbow. Other patients, if they have significant
pain or if you feel a large pop or snap when you stress the elbow, then obviously
that means that they have a recurrent instability at the elbow. The next test
that we'll do is, we'll look at the inside aspect of the elbow. We talked about the
lateral epicondylitis, now we'll look at the medial epicondylitis. If we press this
bone here and it hurts, then it may be a tendonitis on that side as well. But we
already showed you before, if it's painful when they resist you at volar flexion here
that maybe indicate medial epicondylitis. Now some people may
describe numbness and tingling going down the inside aspect of their forearm with
medial pain and that may be indicative of a ulnar nerve compression. There's a nerve
that runs behind this bone here, that's basically that funny bone, and innervates
this whole inner aspect of the forearm and these two fingers. So they feel these
tingling burning sensations going down the inside of the elbow, you can recreate that
symptom by just tapping this little nerve over here, and if you start to feel that
again usually that's indicative of a cubital tunnel syndrome which is an
irritation of the ulnar nerve. If we have somebody like a pitcher that comes in and
they're throwing, and repetitively throwing and you feel a pop or snap in the
inside of the elbow, sometimes they'll come in and they'll show us their elbow.
They have some swelling on the inside of the elbow, some bruising of the elbow.
That makes us worried for or looking for more of an ulnar collateral ligament
injury or a ligament injury on the inside aspect of the elbow. So usually they start
by palpating along the ulnar collateral ligament. If they have pain then we'll
stress it with the varus valgus stress. The next thing we'll do is something
called the valgus extension stress test, where you have them lift their thumb up,
we'll have them fully abduct the shoulder, flex their elbow, and create a valgus
stress where we pull on this thumb as they come into extension. That puts stress
across the ulnar collateral ligament. If that's creating pain to the patient, then
that indicates possibly an ulnar collateral ligament injury and usually
we'll have to get something like an MRI arthrogram or an MRI to further evaluate
the ligament to make sure that it's okay. There are other symptoms such as a a
synovitis or a plica band syndrome that you can have in patients where they have a
recurrent snapping or clicking in the elbow, or even osteochondritis dissecans
where you have a cartilage flap within the elbow. Often times you can palpate
sometimes these snapping or popping usually in this lateral, posterior lateral
area of the elbow with recreating range of motion. If your feel any kind of snapping
or clicking in that area, usually an MRI is warranted to further evaluate that
region. Last but not least, we like to look at the anterior and the posterior
aspects of the elbow. There are two major tendons on either side. The first one that
we look at is the anterior aspect and this is the distal bicep. So you have the
biceps muscle here, and you have the small biceps tendon here that inserts at the
radial tuberosity deep into this forearm region. So if a patient comes in after
they maybe caught something after it fell down or lifting something heavy, and they
felt a snap or a pop in the front of their elbow, they see a little bit of swelling
or bruising, they see a little bit of ecchymosis, and a deformity in their
biceps and they come in complaining of weakness and pain.
What we'll do is, we'll first off, we'll palpate the biceps, which will feel like
this strong cord-like tendon here, we'll rotate the wrist a little bit, and then
we'll have them what we call a supination stress test, where they rotate their hand
against resistance. And we have them do that, and if they have severe pain here or
weakness, then that usually will indicate a distal biceps injury. Especially if you
can't palpate that cord-like tendon in the front, okay. And we usually get an MRI to
evaluate that further. Next, we'll look at the posterior aspect of the elbow. And if
you see any swelling or bruising, or sometimes you can palpate a defect in this
triceps region, you have the patients push out against you and feel this triceps, and
see if there's any defect or pain there. That would usually indicate maybe a
triceps injury or calcification at the distal triceps. So we start with a plain
x-ray of course, but usually an MRI would be helpful to see what the tendon looks
like, or even an ultrasound. So this is basically a what we do for a elbow exam,
just the nuts and bolts. If you have any questions or would like to get an
evaluation, please call us at 281-633-8600. Thank you.