LESSON: ELBOW REGION EXAMINATION AND RADIOHUMERAL JOINT

EVALUATION
• Hinge/Ginglymus joint
ELBOW COMPLEX
• between the capitulum of the humerus and the head
-compound synovial joint of the radius

-AKA "cubital articulations"

• Ulnohumeral or trochlear joint
• Radiohumeral joint
• Superior radioulnar joint

-2° of freedom

SUPERIOR RADIOULNAR JOINT

• Pivot joint

• head of the radius is held in proper relation to the

ulna and humerus by the annular ligament

ULNOHUMERAL JOINT

• Hinge/Ginglymus joint

• between the trochlea of the

humerus and the trochlear
notch of the ulna

• leads to the carrying angle

at the elbow (passes
downward and medial)

LIGAMENTOUS STRUCTURES

• Ulnar collateral ligament

-Osborne Fascia*
• Radial collateral ligament
• Annular ligament
• Interosseous membrane
• Oblique cord
Medial Collateral Lateral Collateral
Ligament (MCL/UCL) Ligament (LCL/RCL)

• Against valgus stress • Against varus stress

• Anterior fiber (Primary) • Lateral radial (Primary)
• Transverse fiber • Lateral Ulnar
• Posterior bundle
• Tardy ulnar palsy
(ulnar nerve)

MIDDLE
RADIOULNAR
ARTICULATIONS

• is not a joint
(functional joint)

• made up of the
radius and ulna and
the interosseous
membrane between
the two bones

• interosseous
membrane is tense
only midway between
supination and
pronation (neutral
position).

• prevents proximal
displacement of the
radius on the ulna.

• Oblique cord connects the radius and ulna,

running from the lateral side of the ulnar tuberosity
to the radius slightly below the radial tuberosity.

• assists in preventing (distal) displacement of the

radius on the ulna, especially during movements
involving pulling.
PATIENT HISTORY Osteochondritis dissecans

How old is the patient? • ages of 15 and 20

What is the patient's occupation? • repetitive trauma is the primary cause
• Correlated with little leaguer's elbow
Tennis elbow (lateral epicondylitis): 35 years of age or
older repetitive wrist extension in their occupations or
activities, requiring wrist stabilization in slight
extension

• How old is the patient? What is the patient's

occupation?
• What was the mechanism of injury?
-Were any repetitive activities involved?
-Does the patient’s job involve any repetitive activity?
-Did the patient perform any unusual activities in the
previous week?

Nursemaid or pulled elbow:

• .A child who complains of pain in the elbow and

lacks supination

• examiner could suspect a dislocation of the head of

the radius.

• "come-along" tug on the arm, or the child may trip

while the parent is holding the hand

• Centralized "pop" and weakness of elbow flexion
may be the result of a distal biceps rupture.
How long has the patient had the problem?
Does the condition come and go?
What activities aggravate the problem?
• seriousness of the condition and how much it others
the patient
• Muscle pathology: pain is present when activating
the muscle or lengthening (stretching the muscle)
What are the details of the present pain and other
symptoms?
•What are the sites and boundaries of the pain?
• Is the pain radiating, does it ache, and is it worse at
night
•Aching pain over the lateral epicondyle that radiates
ma) indicates a tennis elbow problem.
• Depending on the patient's age and past history, the
examiner may want to consider referral of pain from
the cervical spine or the possibility of a double crush
neurological injury.
• Also, multiple joint diseases (e.g., rheumatoid
arthritis, osteoarthritis) must be considered if the
patient complains of pain in several joints.
Are there any activities that increase or decrease
the pain? Does pulling (traction), twisting (torque),
or pushing (compression) alter the pain?
• Writing, twisting arm motions (e.g., turning the key,
opening the door), ironing, gripping, carrying, and
leaning on the forearm all stress the elbow.
• Such questions may indicate the tissues being
stressed or the tissues injured.
Are there any positions that relieve the pain?
• Patients often protectively hold the elbow to the side
(in the resting position) and hold the wrist for support,
especially in acute conditions
Is there any indication of deformity, bruising,
wasting, or muscle spasm?
Are any movements impaired?
• Flexion or extension is limited, two joints may be
involved, the ulnohumeral or the radiohumeral.
• Supination or pronation is problematic, any one of OBSERVATION
five joints could be involved: the radiohumeral,
superior radioulnar at the elbow, middle radioulnar,
inferior radioulnar, or ulnomeniscocarpal joints at the
wrist.

What is the patient unable to do functionally?

• Which hand is dominant?

• Is the patient able to position the hand properly?
• Are abnormal movements of the upper limb complex
necessary to position the hand?

What is the patient's usual activity or pastime?

• Goose egg Appearance
Have any of these activities been altered or
- Sharply demarcated over the olecranon
increased in the past month?
—-----------process
-Held in approximately 70° of flexion
Does the patient complain of any abnormal nerve
distribution pain?

• Triangular Space vs Triangle Sign

• Note the presence and location of any tingling or
numbness for reference when checking dermatomes
• Bony and soft tissue contours
and peripheral nerve distribution later in the
-larger forearm because of muscle and bone
examination.
—---------hypertrophy on the dominant side
• Snapping on the medial side may indicate recurrent
dislocation of the ulnar nerve or the medial head of
the triceps dislocating over the medial epicondyle

Does the patient have a history of previous

overuse injury or trauma?

• This question is especially important in regard to the

elbow because the ulnar nerve may be affected by
tardy ulnar palsy
 Reflexes and Cutaneous Distribution
Triangular Space Triangle Sign

swelling exists on all At 90 degrees Flexion, • Biceps (C5*-C6)

three joints of the elbow the olecranon process • .Brachioradialis (C5-C6*)
complex of the ulna and the • Triceps (C7*_C8)
medial and lateral
Landmarks: between epicondyles form an
the radial head, tip of isosceles triangle
olecranon, and lateral
epicondyle Fully extended, the
three points normally
form a straight line

fracture, dislocation, or
degeneration leading to
loss of bone or
cartilage*

Median Nerve (C6-T1) at the Elbow

Ligament of Struthers,

• an anomalous structure found in approximately

1% of the population

• runs from an abnormal spur on the shaft of the

humerus to the medial epicondyle of the humerus

EXAMINATION • Humerus supracondylar process syndrome*

• Functional Range of Motion

Two heads of pronator teres

• pronator teres remains normal, but the other

muscles supplied by the median nerve are affected,
as is its sensory distribution
Anterior Interosseous Nerve
Radial Nerve (C6-T1) at the Elbow
• branch of the median nerve

• FPL, the lateral half of the FDP, and pronator
quadratus muscles
• Anterior interosseous nerve syndrome or
Kiloh-Nevin syndrome
Spiral Groove
• fracture of the shaft of the humerus
• all of the extensor muscles of the arm, only the
triceps is spared

• no sensory loss, because the anterior

interosseous nerve is a motor nerve

Arcade or canal of Frohse

• fibrous arch in the supinator muscle occurring in

30% of the population

• Functional involvement of forearm extensor

Ulnar Nerve (C7-C8, T1) at the Elbow
muscles and functional wrist drop,

Cubital tunnel
• Through the tunnel or between the two heads of
the flexor carpi ulnaris muscle.
• Cubitus valgus
• Inc compression when flexed; dec when extended
• Tardy ulnar palsy
 Radial Tunnel .• Trauma, tight casting, swelling, FA pronation with
• anterior to the head of the radius wrist flexion and ulnar deviation may cause the
• mimic tennis elbow (Rule of nine test) compression and produce paresthesia

• Cheiralgia paresthetica orWartenberg disease

RULE-OF-NINE TEST OF THE ELBOW

• Tenderness over two proximal lateral circles (red

circles) indicates radial nerve irritation

• Tenderness over pressure points of 5 and 6 yellow

circles) indicates proximal median nerve

Radial Nerve (C6-T1) at the Elbow

At the junction of extensor carpi radialis longs

and brachioradialis

• primarily of nocturnal pain along the dorsum of

the wrist, thumb, and web space.