Elbow Examination – OSCE Guide


Elbow joint examination frequently appears in OSCEs and you’ll be expected to identify the relevant clinical signs using your examination skills. This elbow joint examination OSCE guide provides a clear step-by-step approach to examining the elbow joint, with an included video demonstration. Musculoskeletal examinations can be broken down into four key components: look, feel, move and special tests. This can be helpful as an aide-memoire if you begin to feel like you’ve lost your way during an OSCE.


Introduction

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Briefly explain what the examination will involve using patient-friendly language: “Today I need to examine your elbows, which will involve looking, feeling and moving them.” 

Gain consent to proceed with the examination.

Wash your hands.

Adequately expose the patient’s upper limbs.

Position the patient standing facing you with their arms by their side in the anatomical position.

Ask the patient if they have any pain before proceeding with the clinical examination.


Look

General inspection

Clinical signs

Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology:

  • Scars: may provide clues regarding previous upper limb surgery.
  • Muscle wasting: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

Objects or equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

  • Aids and adaptations: support slings are often used to manage elbow joint pathology.
  • Prescriptions: prescribing charts or personal prescriptions can provide useful information about the patient’s recent medications (e.g. analgesia).

Closer inspection of the elbow joints

Ask the patient to stand and turn in 90° increments as you inspect the upper limbs from each angle for evidence of pathology.

Anterior inspection

Inspect the anterior aspect of the elbow joints and upper limbs, noting any abnormalities:

  • Carrying angle: a small degree of cubitus valgus, formed between the axis of a radially deviated forearm and the axis of the humerus. The presence of a carrying angle of between 5-15° is normal (females typically have a more significant carrying angle than males).
  • Cubitus valgus: a carrying angle of greater than 15°. Cubitus valgus is typically associated with previous elbow joint trauma or congenital deformity (e.g. Turner’s syndrome).
  • Cubitus varus: a carrying angle of less than 5° which is also known as “gunstock deformity”. Cubitus varus typically develops after supracondylar fracture of the humerus.
  • Scars: note the location of the scar as this may provide clues as to the patient’s previous surgical history or indicate previous joint trauma.
  • Bruising: suggestive of recent trauma or surgery.
  • Swelling: note any evidence of asymmetry in the size of the elbow joints that may suggest unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation).
  • Abnormal bony prominence: may indicate fracture or dislocation of the elbow joint.

Lateral inspection

Inspect the lateral aspect of the elbow joints, noting any abnormalities:

  • Scars: again look for scars indicative of previous trauma or surgery.
  • Fixed flexion deformity of the arm: may be caused by previous joint trauma or muscular spasticity.
  • Muscle wasting: suggestive of disuse atrophy secondary to joint pathology or a lower motor neuron lesion.

Posterior inspection

Inspect the posterior aspect of the elbow joints, noting any abnormalities:

  • Scars: again look for scars indicative of previous trauma or surgery.
  • Rheumatoid nodules: subcutaneous firm lumps typically located over the elbow joint associated with rheumatoid arthritis.
  • Psoriatic plaques: well-demarcated scaly plaques typically arising over the extensor surfaces such as the elbow joint. It is important to be able to recognise psoriasis in a musculoskeletal examination given the strong association between psoriasis and psoriatic arthritis.
  • Elbow inspection
    Inspect the elbow joints

Feel

Temperature

Assess and compare elbow joint temperature using the back of your hands.

Increased temperature of a joint, particularly if also associated with swelling and tenderness may indicate septic arthritis, inflammatory arthritis or olecranon bursitis.

Elbow joint palpation

Palpate each elbow joint, noting any swelling, bony irregularity or tenderness:

  • Radial head
  • Radiocapitellar joint
  • Lateral epicondyle of the humerus
  • Olecranon
  • Medial epicondyle of the humerus

Biceps tendon palpation

Palpate the biceps tendon on each arm to assess for evidence of tendonitis or rupture:

1. Ask the patient to actively flex their elbow to 90º.

2. Palpate over the anterior elbow flexion crease and identify the biceps tendon which should feel taut. Note any tenderness and feel for evidence of discontinuity suggestive of rupture.

Resisted supination of the forearm is weak in patients with a biceps tendon rupture and painful in biceps tendonitis.

  • Elbow joint palpation
    Assess elbow joint temperature

Move

The elbow joint of each arm should be assessed and compared.

If the patient is known to have an issue with a particular elbow, you should assess the ‘normal’ elbow first for comparison.

Active movement

Active movement refers to a movement performed independently by the patient. Ask the patient to carry out a sequence of active movements to assess joint function. As the patient performs each movement, note any restrictions in the range of the joint’s movement and also look for signs of discomfort.

It’s important to clearly explain and demonstrate each movement you expect the patient to perform to aid understanding.

Active elbow flexion

Normal range of movement: 0-145°

Instructions: Ask the patient to bend their elbows.

Active elbow extension

Normal range of movement:

Instructions: Ask the patient to straighten out their arms as far as they are able to.

Active pronation

Normal range of movement: 0-85°

Instructions: Ask the patient to turn their forearm so that their palm is facing the ground.

Active supination

Normal range of movement: 0-90°

Instructions: Ask the patient to turn their forearm so that their palm is facing the ceiling.

Passive movement

Passive movement refers to a movement of the patient, controlled by the examiner. This involves the patient relaxing and allowing you to move the joint freely to assess the full range of joint movement. It’s important to feel for crepitus as you move the joint (which can be associated with osteoarthritis) and observe any discomfort or restriction in the joint’s range of movement.

If abnormalities are noted on active movements (e.g. restricted range of movement), assess joint movements passively.

Ask the patient to fully relax and allow you to move their arm for them.

Warn them that should they experience any pain they should let you know immediately.

Repeat the above movements passively, feeling for any crepitus during the movement of the joint.

  • Elbow flexion
    Assess active elbow flexion

Special tests

Medial epicondylitis (golfer’s elbow)

Medial epicondylitis involves the inflammation of the flexor tendons at their insertion point secondary to overload injury (e.g. minor unrecognised trauma occurring during the swinging of a golf club). To quickly screen for medial epicondylitis you can ask the patient to perform active wrist flexion against resistance.

Active wrist flexion against resistance

1. Ask the patient to take a seat and flex their elbow to 90º.

2. Stabilise the patient’s elbow by supporting the forearm whilst firmly palpating the medial epicondyle with your fingers.

3. Hold the patient’s wrist with your other hand.

4. Ask the patient to make a fist and flex their wrist whilst you apply resistance.

Positive test: The combination of firm palpation over the medial epicondyle and resisted flexion will likely elicit a familiar pain experienced by the patient over the medial epicondyle.

  • Golfer's elbow
    Assess active wrist flexion against resistance

Lateral epicondylitis (a.k.a. tennis elbow)

Lateral epicondylitis involves the inflammation of the extensor tendons at their insertion point secondary to overload injury (e.g. minor unrecognised trauma occurring during the swinging of a tennis racket). To quickly screen for lateral epicondylitis you can ask the patient to perform active wrist extension against resistance.

Active wrist extension against resistance

1. Ask the patient to take a seat and flex their elbow to 90º.

2. Stabilise the patient’s elbow by supporting the forearm whilst firmly palpating the lateral epicondyle with your fingers.

3. Hold the patient’s wrist with your other hand.

4. Ask the patient to make a fist and extend their wrist whilst you apply resistance.

Positive test: The combination of firm palpation over the lateral epicondyle and resisted extension will likely elicit a familiar pain experienced by the patient over the lateral epicondyle.

  • Tennis elbow
    Assess active wrist extension against resistance

To complete the examination…

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Wash your hands.

Summarise your findings.

Example summary

“Today I examined Mrs Smith, a 32-year-old female. On general inspection, the patient appeared comfortable at rest, with no stigmata of musculoskeletal disease. There were no objects or medical equipment around the bed of relevance.

“Assessment of the upper limbs revealed a normal elbow joint appearance, with no tenderness on palpation. The range of movement of both elbow joints was normal. “

“In summary, these findings are consistent with a normal elbow joint examination.”

“For completeness, I would like to perform the following further assessments and investigations.”

Further assessments and investigations

  • Examination of the joint above (shoulder) and below (wrist).
  • Full neurovascular examination of the upper limbs.
  • Further imaging if indicated (e.g. X-ray and MRI).

Reviewer

Mr Tejas Yarashi

Trauma & Orthopaedic Surgeon (ST7)


References

  1. Mikael Häggström. Adapted by Geeky Medics. Cubitus valgus and varus. Licence: CC0. Available from: [LINK].
  2. James Heilman, MD. Adapted by Geeky Medics. Psoriasis plaque. Licence: CC BY-SA. Available from: [LINK].

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