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 front
Scars – suggestive of previous injury / surgery
Swelling / erythema of the joint – may suggest acute injury / inflammatory arthritis / infection
Carrying angle – 5-15 degrees – females tend to have more significant carrying angles than males
Inspect from side
Fixed flexion deformity – often post traumatic
Olecranon bursitis – the swelling overlying the olecranon is often most noticeable from this angle
Scars / swelling / erythema
Inspect from the back
Rheumatoid nodules – firm lumps on the elbow / olecranon – indicate systemic rheumatoid disease
Psoriatic plaques – well defined pink / red elevated lesions with silvery scale
Feel
Temperature – a hot joint may indicate inflammatory arthritis or infection
Palpate the joint lines – including the epicondyles and olecranon for any localised tenderness
Move
Assess each of the movements of the elbow joint actively and passively:
- Elbow flexion – 145º
- Elbow extension – 0º
- Pronation – 70º
- Supination – 85º
When moving the joint passively assess for crepitus.
Special tests
Medial epicondylitis – a.k.a. “Golfer’s elbow”
Wrist flexion against resistance
1. The patient should be seated for this assessment, with their elbow flexed at 90º
2. Palpate the medial epicondyle with one hand and hold the patient’s wrist with your other hand
3. Ask the patient to actively flex the wrist against resistance whilst their elbow is also flexed
A positive test would be a complaint of discomfort along the medial aspect of the elbow in the region of the medial epicondyle.
Golfer’s elbow test
1. The patient should be seated or standing
2. Stabilise the elbow whilst palpating the medial epicondyle
3. Passively supinate the forearm
4. Extend the patient’s wrist
5. Extend the patient’s elbow fully
A positive test would be a complaint of discomfort along the medial aspect of the elbow in the region of the medial epicondyle.
Lateral epicondylitis – a.k.a. “Tennis elbow”
Cozen’s test
1. Stabilise the patient’s elbow, placing your fingers over the patient’s lateral epicondyle
2. Ask the patient to make a fist and pronate the forearm
3. Ask the patient to radially deviate the wrist
4. Ask the patient to extend their wrist against your resistance
A positive test would involve pain felt over the area of the lateral epicondyle
Mill’s test
1. Position the patient standing
2. Stabilise the elbow whilst also palpating the lateral epicondyle
3. Passively pronate the patient’s forearm
4. Flex the patient’s wrist
5. Extend the forearm fully
A positive test would involve pain felt over the area of the lateral epicondyle
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
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