MUSCULOSKELETAL EXAMINATION OF THE ELBOW, FOREARM, WRIST AND HAND (P1)

PART 1: ELBOW (Anatomy review, S&O of elbow )

Primary role is to position an individual’s hand in the appropriate location to perform its function (fine motor activities, gripping, grasping, etc) 

THE ELBOW COMPLEX / ELBOW

How many degrees of freedom?

1 DoF (Flex & Ext)

Does your elbow respond well to trauma?

Nah, it gets cooked (Mostly stabilized by ligaments and dynamic stabilizers; Harder to keep the integrity of the structure)

Magee stuff: Joint also responds poorly to harsh treatment, or incorrect treatment.

Enumerate joints that make up the elbow complex

Ulnohumeral (trochlear joint), Radiohumeral, Superior Radioulnar Joints (rotation) 

these joints also make up the cubital articulations

Which joint of the elbow is the most stable?

Ulnohumeral (trochlear joint)

(Also responsible for the carrying angle)

On full extension of the ulnohumeral joint, which part of the olecranon process is not in contact with the trochlea?

On full extension, the medial part of the olecranon process is not in contact with the trochlea

On full flexion of the ulnohumeral joint, which part of the olecranon process is not in contact with the trochlea?

on full flexion, the lateral part of the olecranon process is not in contact with the trochlea.

A small amount of medial and lateral rotation occurs at the ulnohumeral joint, how many degrees of rotation happens in early flexion and which direction does it rotate?

5° of medial rotation occurs

how many degrees of rotation happens in late flexion and which direction does it rotate?

5° of lateral rotation occurs.

The radial side of the elbow has an empty space due to the incongruency of the radiohumeral joint, what direction of dislocation does this cause?

Posterolateral dislocation (Most Common)

Patients with posterolateral rotary instability have pain and discomfort in the elbow along with possible locking, clicking, snapping, or slipping,

most likely noted at ___________ as the arm goes into an extension arc of motion, especially with the forearm _______________.

most likely noted at 40° of flexion as the arm goes into an extension arc of motion, especially with the forearm supinated.

Ligaments found at the medial side of the elbow are/is called the?

Which motion/force does these/this ligament/s prevent?

Ulnar collateral ligament

Valgus force / motion (Force that pushes elbow inward)

Which portion of the UCL houses the Ulnar nerve?

Posterior Ulnar Collateral Ligament

(Common cause for medial elbow pain)

What is the band between the two heads of the flexor carpi ulnaris muscle called?

The ulnar nerve passes through here as well

Osborne’s band

Sign indicated by loss of the hypothenar muscles and flattening of the palmar metacarpal arch

Masse’s sign

If there is an inability to flex the distal interphalangeal joints of the little and ring fingers what sign is present?

Pollock’s sign

Clawing of the fourth and fifth digits is observable, what sign is present?

Benediction Sign/ Preacher’s Sign/ Duchenne sign

Fan-shaped; stronger than medial ligaments; needs to restrict more dt the absence of the olecranon process and fossa

Lateral collateral Ligaments

the LCL (Lateral Collateral ligament) complex tensioned by the radial head and extensor muscles are important to prevent what type of instability?

Posterolateral rotary instability

Innervation of the elbow:

Musculocutaneous, Radial, Median and Ulnar nerves

Ulnohumeral (Trochlear) Joint:

Resting position:

Close packed position:

Capsular pattern:

Resting position: 70° elbow flexion, 10° supination

Close packed position: Extension with supination

Capsular pattern: Flexion, extension

Radiohumeral Joint:

Resting position:

Close packed position:

Capsular pattern:

Resting position: Full extension and full supination

Close packed position: 90° flexion, 5° supination

Capsular pattern: Flexion, extension, supination, pronation

True or False:
In extension, the medial/ulnar collateral ligament, the anterior capsule, and the ulnohumeral articulation resist valgus translation.

True

True or False:
90° of flexion, the posterior bundle of the medial collateral ligament provides the main restraint against valgus translation

FALSE:
90° of flexion, the ANTERIOR bundle of the medial collateral ligament provides the main restraint against valgus translation

The ulnar collateral ligament has three parts, which along with the flexor carpi ulnaris muscle, forms what structure? and which nerve passes through this structure?

Cubital tunnel (most common area of ulnar nerve impingement)

Ulnar nerve

Injuries that increase the carrying angle put abnormal stress on the cubital tunnel, impingement of the ulnar nerve here can cause what type of palsy?

Tardy ulnar palsy (Chronic)

Cubital tunnel syndrome (Acute)

Superior Radioulnar Joint

Resting position:

Close packed position:

Capsular pattern:

Superior Radioulnar Joint

Resting position: 35° supination, 70° elbow flexion

Close packed position: 5° supination

Capsular pattern: Equal limitation of supination and pronation

What ligament holds the superior radioulnar joint in place?

Annular Ligament

This joint is not a true joint; made up of the radius, ulna and interosseous membrane between the two

Middle radioulnar articulation

True or False:

The interosseous membrane is tense during midprone or neutral position; it also helps prevent proximal displacement of the radius on the ulna during FOOSH.

True

Which ligament found on the LCL whose fibers run at a right angle to the interosseous membrane; assists in preventing displacement of the radius on the ulna during traction/pulling injuries

Oblique Cord

Roots of:

• Radial nerve :

• Median nerve:

• Ulnar nerve:

Roots of:

• Radial nerve : C5-C8, T1

• Median nerve: C6-C8, T1

• Ulnar nerve: C8, T1

pain on resisted extension of the middle finger which suggests compression of the radial nerve at the flexor digitorum superficialis arch manifests in what sign?

Maudsley’s sign

most common site of compression of the posterior interosseous nerve; a fibrous arch in the supinator muscle occurring in 30% of the population.

Canal / Arcade of Frosche

True or false:

Diagnosis of posterior interosseous nerve impingement is often delayed because there is no sensory deficit.

True

(Motor nerve so no sensory deficit)

The radial nerve may also be compressed at:

• the entrance to the radial tunnel anterior to the head of the radius,

• near where the nerve supplies brachioradialis and extensor carpi radialis longus (leash of Henry),

• between the ulnar half of the tendon of extensor carpi radialis brevis and its fascia

• distal border of supinator

  what syndrome is this called?

Radial tunnel syndrome

elicits pain with little muscle weakness and may mimic tennis elbow

Condition where there is compression of the superficial branch of the radial nerve as it passes under the tendon of the brachioradialis.

Cheiralgia paresthetica or Wartenberg disease/sign

• sensory only

• and the patient complains primarily of nocturnal pain along the dorsum of the wrist, thumb, and web space.

• Pressure between the junction of the ECRL and Brachioradialis reproduces symptoms

Most active and intricate parts of the UE

Does not respond well with serious trauma 

•  Because it highly depends on ligamentous structures (inert) for stability  

• Trauma = sprain or tearing = instability or deficiencies of the UE kinetic chain

FOREARM, WRIST, AND HAND

True or false:
The UE kinematic chain comprising of the shoulder, elbow, cervical region and hand play an important role in functional activities (IADLs & BADLs)

FALSE:
The UE kinematic chain comprising of the shoulder, elbow, WRIST and hand play an important role in functional activities (IADLs & BADLs)

The FOREARM, WRIST, AND HAND has a protective role both as motor and sensory organ 

• Sensory = __________ (detection of hazards) 

• Motor = for _______

• Sensory = withdrawal reflex (detection of hazards) 

• Motor = for ADLs

Objectives of ASSESMENT

• _________ of assessment 

  • Which specific structure causes pain, instability, difficulty 

• Evaluation of _____________ 

  • Consequent compensation; how much compensation is happening

Objectives: 

• Accuracy of assessment 

  • Which specific structure causes pain, instability, difficulty 

• Evaluation of remaining function 

  • Consequent compensation; how much compensation is happening

Common age for lateral epicondylalgia / tennis elbow

• Inflamed tendon d/t overuse & repetitive stresses or strains

• In severe cases such as tendinosis, It can happen without any movement

>35 y/o

Type of pain, duration & location of tennis elbow

Aching, Intermittent & Radiating pain until wrist extensors

Note that if caused by tendinosis pain can be CONSTANT

Traction injury affecting the annular ligament & head of the radius; commonly affects younger people

Undeveloped annular ligament = displacement = dislocation of radial head 

Nursemaids Elbow

What are the presentations of Nursemaid’s elbow?

Decreased supination and pain on lateral side of the elbow

True or False:
For people with “Blue collar” jobs we have to consider medial and lateral epicondylitis dt repeated flexion and extension.

True

Type of pain, duration and location of Medial epicondylitis

Aching, Intermittent & Radiating pain until wrist flexors

Note that if caused by tendinosis pain can be CONSTANT

What causes systemic presentation on the hands?

• Nodes or deformities on the hands = altered mechanics of gripping and functioning of the hand

• More common in older patients

Rheumatoid Arthritis

Common MOI for Wrist Fractures & Elbow dislocations

FOOSH

MOI for contusions and displacement of the radius and ulna unto the humerus

Fall on tip of the elbow

True or False
The shoulder complex should also be checked and palpated during a FOOSH / Fall on tip of elbow injury

True:
Force may be transferred to the clavicle causing fracture, Translational forces may affect the labrum.

When considering injuries dt Repetitive stress in sports which type of stress should we consider when it comes to pitching / throwing? (direction of stress)

Valgus stress

What phase of pitching has the most valgus stress?

Late Cocking Phase

What is the type of injury caused by severe valgus extension force to the elbow because of repetitive throwing causing a medial side traction injury (e.g., sprain of the medial collateral ligament) and a lateral side compression/contusion injury

• Common in younger population dt undeveloped inert structures

Little leaguer’s elbow

• osteochondral damage either on the olecranon process or olecranon fossa can also be present.

If the patient felt a pop followed by pain and swelling on the medial side of the elbow, it may indicate what type of sprain?

Ulnar collateral ligament sprain

If the pop was more centrally located in the elbow, followed by a weakness in elbow flexion, what structure is affected?

The distal biceps may be ruptured

Other Pertinent Pt Hx (Summary)

Referral of pain from cervical spine 

• paraesthesia, pins and needles, can be nerve root affectations with distal manifestations

Multiple joint diseases 

• RA, Scleroderma, systemic conditions

Specific activities that increase or decrease the pain 

• Sports, weightbearing activities, occupational demands 

Snapping on the medial side of the elbow 

• Ligamental or nerve 

Previous hx of overuse or trauma

• Occupation / Sports

Demographics in the Subjective examination include:

Initials, Age, Medical Hx (Htn/DM/Asthma), Handedness, Gender

Which conditions should be considered when the patient is a female?

Women = ↑ ligamentous laxity leading to an increased carrying angle (Note in PA)

Women are more predisposed to RA

Chief Complaint:
What are the most common areas of pain for the elbow wrist and hand?

medial, lateral, and above the elbow

anterior wrist which radiates to the hand, with medial distribution (carpal tunnel) 

Pain on specific finger (mallet) 

If patient complains of instability of the elbow what structures should you assess?

Inert Stabilizers / Ligament Stability

Significant Weakness + Pain during MMT indicates what type of tendon injury?

Low grade strain

Significant Weakness + No Pain during MMT indicates what type of tendon injury?

Tendon Rupture

If the patient complains of Heaviness (tires easily) with numbness, paresthesia/tingling sensation (usually radiating) what structure may be affected?

Nerve may be compressed

• Find out where the nerve is compressed

Term for the combination of proximal and distal Sx (compression at the nerve root paired with compression of the distal nerve structure)

Double crush syndrome

Pain Assessment

Refresh ur brain this shit the same

HPI (read to refresh)

When and how did it start? 

• How long has the problem been present

Mode of onset

• insidious, sudden, congenital

Mechanism of injury

• FOOSH, direct blow, repetitive trauma

Activities altered or increased

• Significant changes in training or use 

Pertinent events related to injury

Course of symptoms

• Acute = 48-72 hrs

• Subacute = >2 wks

Chronic = 2-6 months

MD consultation (Also HPI)

Ancillary Procedures 

• Radiographic findings, MRI, EMG-NCV 

Prescribed Medications 

• NSAIDS, Pain killers

Management provided 

• Orthosis, surgical repairs, casts 

Referral to Rehab

Adjust treatment based to function the patient currently has

PMHx

Previous injuries of the same area or other areas (UE kinematic chain)

Treatment or meds given, recovery

Steroids - leads to osteoporosis, joint laxity

• Corticosteroid - stops inflammation = ↓bone density = osteoporosis 

Analgesics - day of tx, no symptoms (pain) leads to a false negative

• Family History (RA)

• Previous PT session

Physical and Social Environment

Family support (especially geriatric and pediatric) 

Pertinent house furniture or appliances (UE related)

Lifestyle and Work

Occupation (type of work, usual position, ergonomics)

Hobbies, recreational activities, sports

Knowledge on stretching, warm-up and cooldown, protective equipment

Smoker, drinker, diet, sleep considerations

Pt’s Goal (alam mo na to)

for SUBJECTIVE what should we focus on?

Focus on MOI and HPI with correlation to C/C = good diff dx

OBJECTIVE EXAMINATION (skip VS)

OI (read)

Manner of arrival (protective guarding of arm)

Mental Status/Orientation

Body Type (ectomorph, mesomorph, endomorph)

Attachments

Adaptive devices (sling, splint, forearm band, orthoses, cast)

• External fixators 

Head to foot observations (OI): (Read)

• Change in color 

  • Cyanotic (Lack of bloodflow)

  • Redness/Erythema (Persistent inflammation or vascular compromise)

• Scars or wounds 

• Bruising or hematoma

                Ecchymosis (Muscle tears) 

                Hematoma (Blood clotting)

                Bruising (d/t trauma)

Change in texture (OI) (Read)

Dry & scaly skin (dec sympathetic activity)

Smooth, shinny, glossy (inc sympathetic) = predisposed to wounds and scarring dt increased calcium deposit

Swelling (OI) (Read)

• Localized (bursa or extraarticular) / Generalized (intraarticular)

• Landmark: Medial and lateral epicondyle

(+/-) Postural Deviations 

most common type of localized (extraarticular) swelling: ___________

most common type of localized swelling: olecranon bursitis

landmark for anthropometrics to measure generalized (intraarticular) swelling : __________

Lateral elbow / epicondylar area

Deformities of the elbow (OI AND PA)

Carrying angle 

• Cubitus varus/cubitus valgus

Normal carrying angle for
MALE:_______

FEMALE:________

Normal carrying angle for
MALE: 5–10 degrees (11° to 14° dalawa value ni magee ang gulo)

FEMALE: 10 -15 degrees (13° to 16°)

Note that cubitus valgus is normal, but excessive cubitus valgus is a deformity

This is characterized by an excessive carrying angle with sprain on medial elbow and compression of lateral elbow

Cubitus Valgus

This is characterized by a decreased/negative carrying angle with sprain on lateral elbow and compression of medial elbow

Cubitus Varus / Gunstock deformity (more severe varus dt trauma)

General Reminders for PALPATION

Usually done last because of pain but documented p OI

Take note of

• Muscle tone, spasm, guarding, Endfeel

• Skin temperature

• subluxation/dislocation 

• Edema (pitting or non-pitting) 

  • Lymphatic issue 

• Tenderness

• Crepitations

• Tightness

• Contracture

• Taut Bands, Nodules, Trigger Points

• Joint play

PALPATION OF THE ELBOW

Patient’s arm should be relaxed

Patient position: Supine or Sitting

Anterior aspect elbow → Medial lateral→ Lateral → Posterior

Anterior elbow palpation

Inspect the the biceps tendon, brachialis, brachial artery Coronoid Process, head of Radius, and radial tuberosity in the cubital fossa

The median and musculocutaneous nerves are also found in the fossa, but they are not palpable. Pressure on the median nerve may cause symptoms in its cutaneous distribution.

If the patient is complaining of pain and/or tenderness along the anteromedial humerus, radius, or ulna, especially after repeated stress, with possibility of periostitis results in what?

Humeral shin splints or Forearm splints

precursors to stress fractures.

Medial elbow palpation

Inspect wrist flexor–forearm pronator groups of muscles, MCL and ulnar nerve (the nerve is not directly palpable, but pressure on the nerve often causes abnormal sensations in its cutaneous distribution.)

Lateral elbow palpation

Inspect wrist extensor muscles, brachioradialis and supinator, LCL and annular ligament

If the examiner palpates the lateral epicondyle, the posterior radial head, and the olecranon tip, the anconeus “soft spot” will be found within this triangle. Pressure applied over the patient’s lateral forearm about 3 to 5 cm (1.2 to 2 inches) distal to the elbow crease (over the supinator muscle) with the wrist in full supination will cause pain if there is pathology in the radial nerve

Posterior elbow palpation

Inspect the Triceps, Olecranon Process and Olecranon Bursa

ANTHROPO- METRIC MEASUREMENTS:

Measurement to compare muscle bulk

Limb Girth Measurements

Measurement for swelling (Golden standard)

Volumetric Measurements 

• N = 10mL difference 

• Swelling =30-50 mL difference

Deep Tendon Reflex 

Biceps =________

Triceps = ________

Brachioradialis = ________

Biceps = C5-C6 

Triceps = C7-C8 

Brachioradialis = C5-C6

A normal functional position of elbow:

90° of flexion & Forearm between pronation and supination

The forearm may also be considered to be in a functional position when slightly pronated, as in writing. From this position, forward flexion of the shoulder along with slightly more elbow flexion (up to 120°)

most ADLs are performed at ranges between _______ of flexion and between ______ of pronation and _____ of supination

most ADLs are performed at between 30° and 130° of flexion and between 50° of pronation and 50° of supination

A triangle is formed by the olecranon process and the medial and lateral epicondyles of the humerus when the arm is flexed to 90° this triangle is sometimes called the what?

Triangle sign

Ligament that runs from an abnormal spur on the shaft of the humerus to the medial epicondyle of the humerus which is present in 1% of the population

ligament of Struthers

Median nerve passes here and can be compressed

If the median nerve is compressed at the Ligament of Struthers what syndrome is this called?

Humerus supracondylar process syndrome

• Inital = Sensory loss (aka nauuna sensory loss)

• Secondary = motor loss

  • Wrist and finger flexion + thumb movements are most affected

If the median nerve is compressed where it passes through the two heads of pronator teres what syndrome is this called?

Pronator syndrome / Proximal median nerve entrapment

Muscles below pronator teres affected; pronator teres normal

Impingement of the anterior interosseous nerve leads to what syndrome?

Anterior interosseous nerve syndrome / Kiloh-Nevin syndrome or sign

• Impaired flexor pollicis longus, lateral half of the flexor digitorum profundus, and pronator quadratus muscles

• Characterized by the “OK-sign”