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Elbow examination can occasionally appear in OSCEs, so it’s important you’re familiar with it. You should feel confident diagnosing local joint issues such as bursitis, but also be able to identify stigmata of systemic diseases such as psoriasis (plaques) and rheumatoid arthritis (nodules). Check out the elbow examination mark scheme here.



Introduction

Wash hands

Introduce yourself – state your name and role

Confirm patient details – name and DOB

 

Explain examination:

“I’d like to examine your elbow. This will involve having a look and feel of the joint, in addition to assessing the joint’s movement”

 

Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with the exam?”

Gain adequate exposure- ideally, you should be able to see the entire limb

Position patient – palms facing forwards with arms by their side (anatomical position)


Look

Inspect from the front

Scarssuggestive of previous injury / surgery

Swelling / erythema of the joint – may suggest acute injury / inflammatory arthritis / septic arthritis / cellulitis 

Carrying angle5-15 degrees – females tend to have more significant carrying angles than males

  • Cubitus valgus deformity (forearm deviated AWAY from the body – more so than normal) 
    • Common cause – trauma (i.e. non-union of a lateral condyle fracture of the distal humerus)
  • Cubitus varus deformity (a.k.a. Gunstock deformity) – forearm deviated TOWARDS midline of the body 
    • Common cause – malunion of a supracondylar humerus fracture that occurred during childhood

Inspect from the side

Fixed flexion deformityoften post traumatic 

Olecranon bursitis – the swelling overlying the olecranon is often most noticeable from this angle

Scars / swelling / erythema 

 

Inspect from behind

Rheumatoid nodules – firm lumps on the elbow/olecranon – indicate systemic rheumatoid disease

Psoriatic plaques – well-defined pink/red elevated lesions with silvery scale

  • Elbow inspection
    Inspect from the front

Feel

Temperature – a hot elbow may indicate inflammatory arthritis, septic arthritis or cellulitis (possibility secondary to olecranon bursitis) 

Palpate key landmarks around the elbow to elicit any localised tenderness:

  • Radial head / Capitellum / Radiocapitellar joint / Lateral epicondyle
  • Olecranon
  • Medial epicondyle

 

Biceps tendon

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

2. Palpate over the anterior elbow flexion crease to feel a taut structure which should be the biceps tendon

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

  • Elbow joint palpation
    Assess and compare temperature between elbow joints

Move

Assess each of the movements of the elbow joint actively and passively:

  • Elbow flexion – normal ROM: 0 – 145º
  • Elbow extension – normal ROM: 0º
  • Pronation – ensure the patient has their elbows by their sides, flexed at 90 degrees – normal ROM: 0 – 85º
  • Supination – normal ROM: 0 – 90º

When moving the joint passively assess for crepitus.

  • Elbow flexion
    Active elbow flexion (0 - 145º)

Special tests

Medial epicondylitis – a.k.a. “Golfer’s elbow”

Active wrist flexion against resistance

1. The patient should be seated for this assessment, with their elbow flexed at 90º

2. Stabilise the patient’s elbow by supporting the forearm with one hand and firmly palpating the patient’s medial epicondyle

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

4. Ask the patient to make a fist and actively flex the wrist

5. Ask the patient to hold the wrist in flexion while you try to passively extend it

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

  • Golfer's elbow
    Active wrist flexion against resistance (Medial Epicondylitis)

 

Lateral epicondylitis – a.k.a. “Tennis elbow”

Active wrist extension against resistance

1. Stabilise the patient’s elbow by supporting the forearm with one hand and firmly palpating the patient’s lateral epicondyle 

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

3. Ask the patient to make a fist and extend their wrist 

4. Ask the patient to hold the wrist in extension while you try to passively flex it by pushing down on the dorsum of the hand

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

  • Tennis elbow
    Active wrist extension against resistance (Lateral Epicondylitis)

To complete the examination…

Thank patient

Wash hands

Summarise findings

 

Suggest further assessments and investigations

  • Examine the joint above and below (shoulder /wrist)
  • Full neurovascular examination of the upper limbs
  • Further imaging of the joint if indicated – X-Ray / CT / MRI

Further reading

Arthritis research UK provides some excellent free guides to musculoskeletal examination and history taking [LINK]


REVIEWED BY 

Mr Tejas Yarashi

Trauma & Orthopaedic Surgeon (ST7)


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