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THE COMBINED ORTHOPEDIC, NEUROLOGICAL,
SPECIAL MANUAL TESTING, DISCOVERY AND RECORDING OF THE ELBOW
BASIC EXAMINATION OF THE
ELBOW
OBSERVATION-SITTING:
The Elbow Carrying
Angle. There would be a slight valgus deviation between the humerus and
the ulna when the forearm is supinated and the elbow
is extended.
MALES =5-10
degrees
FEMALES =10-15
degrees
If the carrying
angle is more than 15 degrees=cubitus
valgus.
If the
carrying angle is less than 5 degrees=cubitus
varus.
Swelling
resulting from olecranon bursitis (students elbow) sharply demarcated as
a "goose egg" over olecranon process.
If
suspect fracture
or ipiphyseal injury the distal humerus and cubitus varus results, a
gun stock deformity .
EXAMINATION-SITTING:
ACTIVE MOVEMENT::
Pain Discovered
over esimate normals.
Flexion
of the elbow 140-150 degrees-end
feel is tissue approximation. In a thin
individual
the end feel may be bone to bone as a result of the coronoid process
hitting against the coronid fossa.
Extension
of the elbow 0-10
Extension is 0 hyperextension to 10
May be
noted
especially in woman. This is normal if on both sides and no hx
of trauma. The end feel is bone to bone.
This is the first motion lost in injury and first to recover.
Supination
of the forearm 90
and feel is tissue
stretch.
Pronation
of the
forearm 80-90
end feel is
tissue stretch.
Note: Both
supination/pronation ROM only 75
with the remaining 15
result of wrist action.
PASSIVE
MOVEMENTS-SITTING
Flexion-end
feel is tissue approximation.
Extension-end feel is bone to
bone.
Supination end feel tissue
stretch
Pronation end feel tissue
stretch.
A capsular pattern
for the elbow complex as a whole is more limitation of flexion than
extension.
RESISTED ISOMETRIC
MOVEMENTS-SITTING:
Elbow
Flexion Pain Restriction
Elbow
Extension Pain Restriction
Supination Pain Restriction
Pronation Pain Restriction
Wrist
Flexion Pain Restriction
Wrist
Extension Pain Restriction
SPECIAL TESTING:-SITIING:
Only tests that will confirm the diagnosis should be performed.
Ligamentous Instability test.
Patient's arm is stabilized with the
examiners hand on the elbow and the wrist. The elbow is slightly flexed
30-30.
An adduction or varus forces is applied to
test the lateral collateral ligament. Then
the examiner places a abduction or vlagus force
to test the medial collateral ligament. Some advocate varus done
with arm in full medial rotation and valgus done in full
lateral rotation.
Positive Negative
Tennis Elbow or Cozens'
Test for Lateral epicondylitis. Extend and pronate arm and extend the
wrist. Stabilize the elbow and attempt to flex the wrist
the patient resists.
Positive Negative
Golfer's Elbow
Medial epicondylitis.
Patient's forearm is supinated and the elbow and wrist are
extended by the examiner. + -
Tinel's Sign
The ulnar nerve in the groove (between the olecranon process and medical
epicondyle is tapped. Tingling sensation in the ulnar distribution of
the forearm and hand=postive test for nerve regeneration at the most
distal end of tingling=limit of regeneration.
Present Absent
Pronator Teres Syndrome
Elbow flexed to 90 degrees. Examiner resists pronation as the elbow is
extended. Tingling or paresthesia in median nerve distribution.
Positive Negative
Pinch Grip Test
Thumb and first finger should touch tip to tip. If pads of finger and
thumb touch then pathology to anterior interosseous nerve,
branch of median nerve. Thus entrapment os anterior
interosseous nerve as it
passes between the two heads of the pronator teres muscle. Positive
Negative
REFLEXES AND
CUTANEOUS DISTRIBUTION-SITTING:
Bicep
C5/C6 Right Left
Brachioradialis
C5/C6 Right Left
Triceps C7C8 Right Left
Median Nerve
A. pinched at elbow under ligament of Struthers
(found in 1% of
population)
medial elbow) known as Humerus
supracondylar process syndrome (e.g. Will you
be the physician who missed this? Indeed.).
Pronator Syndrome
B. entrapment of the median nerve by the
pronator teres=weakness of the flexor carpi radialis, palmaris with
sensory disturbance to the
median nerve.
Ant. Interosseous Syndrome
C. Pinching of anterior interosseous (branch median n.) by two
heads of pronator teres muscle leads to funcitonal impairment of
flexor pollicis longus, flexor ditorum profundus, and pronator
quadratus. Known as
Anterior interosseous nerve syndrome characterized
by pinch test. If pinched just before anterior
interosseous nerve then median nerve pinch known as pronator
syndrome.
Ulnar Nerve compressed in the
cubital tunnel yields tardy ulnar palsy. The greater the elbow is
flexed the more the nerve is stretched. (medial side). Symptoms.
RADIAL NERVE.
The posterior
interosseous nerve, in front of the lateral epicondyle of the humerus
can be compressed as it passes between the two supinator heads in the
arcade or canal of Frohse, a fibrous arch in the supinator muscle.
Compression is due to repetitive supination. Symptoms are functional
involvement of the forearm extensor muscles with no sensory deficit.
This condition, Radial tunnel
syndrome
may mimic tennis elbow.
JOINT PLAY MOVMENTS-SITTING
Pain
Restriction Radial deviation of ulna and radius on humerus (similar to
stress test)
Pain Restriction
Ulnar deviation of ulna and radius on humerus (similar to stress test)
Pain Restriction
Distraction of olecranon process on humerus in 90
degrees
of flexion
Pain Restriction
Anteroposterior glide of radius on humerus
PALPATION-SITTING:
(Positive findings noted to the left of area of investigation)
Bony
Olecranon
Olecranon fossa
Medial epicondyle
Lateral epicondyle
Radial Head
Radial tubercle
Soft:
Medial Ulnar nerve
Medial collateral ligament
Supracondylar lymph nodes
Flexor muscles Lateral to Medial
Pronator Teres
Flexor Carpi
Radialis
Palmaris
Longus
Flexor Carpi
Ulnaris
Posterior
Olecranon bursa Triceps muscle
Lateral Wrist extensors Mobile wad of three
Brachioradialis
Extensor Carpi
Radialis longus
Extensor Carpi
Radialis Brevis
Anterior Cubital Fossa Borders
line between
epicondyles
Brachioradialis
Pronator Teres
Contents
(lateral to medial)
Musculocutaneous nerve
Biceps tendon
Brachial
artery
Median nerve.
BIOMECHANICAL CORRELATION NORMS FOLLOW:
ACTION MUSCLE NERVE
ROOT
Flexion Brachialis
Musculocutaneous C5-C6 (7)
Biceps brachii
Musculocutaneous C5-C6
Brachioradialis Radial
C5-C6 (7)
Pronator teres Median
C6-C7
Flexor carpi ulnaris
Ulnar C7-C8
Extension Triceps
Radial C6-C8
Anconeus
Radial C7-C8 (T1)
Supination Supinator Post.
interosseous radial C5-C6
Biceps Brachii
Musculocutaneous C5-C6
Pronation Pronator quadratus Ant. interosseous
median C8, T1
Pronator teres
Median C6-C7
Flexor carpi radialis Median
C6-C7
Flexion of wrist Flexor carpi radialis
Median C6-C7
Flexor carpi ulnaris
Ulnar C7-C8
Extension of wrist Ext. carpi radialis longus
Radial
C6-C7
Ext carpi radialis brevis Post.
interosseous (radial) C7-C8
Ext carpi ulnaris Post
interosseious (radial) C7-C8
by
Scott D. Neff, DC DABCO
MPS-BT CFE
DABFE FFABS FFAAJTS as a dedication to the medical students of our
world.
©
"Why does this magnificent applied
science which saves work and makes life
easier, bring us little happiness? The simple answer runs, because we
have not yet learned to make sensible use of it." Albert Einstein 1931
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