Geriatric Physical Diagnosis: The Upper Extremities

Mark E. Williams, MD

Disclosures

November 17, 2009

In This Article

Elbow Examination

The elbow is a complex hinge whose basic range of motion occurs in a single plane. Pronation and supination of the forearm result from motion of the radius on the capitellum and at the radioulnar articulation.

The Sequence of the Examination

  1. Inspect the elbow for deformities and nodules

  2. Check the passive and active range of motion

  3. Feel for epitrochlear lymphadenopathy and areas of tenderness

  4. Search for nerve entrapment syndromes

Inspection

The elbow joint is fairly visible and many abnormalities can be uncovered by careful observation. Most of the joint action is best observed from the side of the patient and from the back. The angle of full extension is called the carrying angle. It is about 10° in men and is slightly greater in women. Any significant increase or decrease in this angle indicates pathology.

Bony Deformities. Elbow deformities usually result from previous trauma and may not be conspicuous when the elbow is flexed. Check for cubitus varus and cubitus valgus deformities with the forearm extended as straight as possible (but not hyperextended). Varus deformity (sometimes called gunstock deformity) represents a decrease in the carrying angle and is usually caused by a previous supracondylar fracture.

A cubitus valgus deformity is an increase in the carrying angle. It can be associated with chronic stretching of the ulnar nerve. Sometimes former throwing athletes, such as football quarterbacks or baseball players, will have an increase in the carrying angle on their dominant arm.

The epicondyles and the olecranon should form an equilateral triangle. Consider subluxation if the triangle is not present or if there is extreme prominence of the olecranon. This finding is seen in rheumatoid arthritis.

Nodules and Swelling. Rheumatoid nodules are located on the medial aspect of the extensor surface of the elbow. An old clinical teaching stated that the first rheumatoid nodule would be located 2 inches distal to the elbow joint (possibly caused by minor trauma when one sits at a table because the forearm usually contacts the table edge approximately 2 inches from the joint).

Tophi are also found around the elbow joint. The presence of other tophaceous deposits helps distinguish these nodules from other possibilities.

Swelling from an effusion can sometimes be appreciated on the side of the elbow as a bulging in the olecranon groove.

Atrophy and Muscle Wasting. Careful inspection can also reveal scars from previous surgery or trauma as well as muscle wasting or atrophy from ulnar or median nerve entrapment.

Check for atrophy of the flexor carpi ulnaris in the forearm. (If you have forgotten the location of this useful muscle, flex and extend your ring and little fingers and observe the muscles that contract in the medial forearm.) Atrophy of this muscle suggests radiculopathy of the eighth cervical nerve root (C8) or nerve entrapment at the elbow (cubital tunnel syndrome). Polyneuritis and trauma can produce ulnar neuropathy in addition to the entrapment syndromes.

Atrophy of the flexor carpi radialis of the lateral forearm suggests entrapment of the median nerve at the elbow (also called pronator syndrome due to entrapment by the ligament of the pronator teres).

Active Range of Motion

Elbow range of motion is critical to feeding, using a telephone, and opening a door, so it is important to carefully assess passive and active mobility. Pain can produce a difference in the passive and active range of motion.

Endpoint Resistance. Joint abnormalities can change the feeling of the movement and the nature of the feeling at the extremes of the range. For example, a rubbery endpoint suggests that something is inside the joint. A rock-hard endpoint at the extremes implies bone-on-bone limitation. Muscle contraction due to spasm or pain produces a fluid increase in resistance.

Elbow Flexion and Extension. Flexion and extension are key components of the elbow range of motion needed to perform daily activities. Limited range of motion suggests degenerative joint disease or previous fracture. Limited extension is an important sign of abnormality in the elbow joint because it is the first aspect of the range of motion to be influenced. Painful extension suggests radial tunnel syndrome or lateral epicondylitis. Painful flexion suggests medial epicondylitis.

Supination and Pronation. Supination and pronation are not as critical for activities of daily living as are flexion and extension. Impairment suggests degenerative joint disease or previous radial fracture. Pain on supination and pronation suggests fracture of the radial head. Lead-pipe rigidity to passive supination and pronation of the forearm suggests early parkinsonism.

Palpation

Epitrochlear Lymph Nodes. The presence of epitrochlear lymph nodes is always abnormal and suggests syphilis. An easy way to feel for them is to shake hands with the patient while you support the elbow in the palm of your other hand. Your supporting fingers will lie along the medial aspect of the upper arm in position to appreciate any nodules or swelling. This technique was called the potential "father-in-law's" handshake for obvious reasons.

Tenderness and Swelling Over the Olecranon. Tenderness and swelling over the olecranon suggests olecranon bursitis. Transilluminate the swelling to differentiate olecranon bursitis from gouty tophi, rheumatoid nodules, or abscess. The olecranon bursa does not communicate with the joint; therefore, elbow range of motion may not be painful with this condition. A gelatinous mass with internal nodules suggests chronic olecranon bursitis; consider diabetes mellitus, renal failure, and systemic lupus erythematosus as predisposing causes.

Tenderness Over the Medial Aspect of the Elbow. Tenderness over the medial aspect of the elbow is an important observation. Discomfort over the medial epicondyle suggests medial epicondylitis or golfer's elbow. Characteristically, there will be pain on resisted palmar flexion at the wrist. Check for a dimple next to the radial head, which suggests a severe medial collateral ligament tear. If present, test for stability by having the patient lie supine with the arm held perpendicular (straight up in the air) and the elbow flexed about 30° to move the olecranon from its fossa. Stability can be assessed by gently moving the joint medially and laterally in both supination and pronation.

Also check for median nerve entrapment syndromes.[1] Carpal tunnel syndrome is entrapment of the nerve at the wrist. Check Tinel's sign[2] (reproducing tingling paresthesias by tapping on the nerve in the middle of the wrist) and touching thumb to the fingertips to evaluate median nerve function. In addition, perform Phalen's maneuver by having the dorsal aspects of the hands touch to produce tingling on acute passive wrist flexion. The anterior interosseous syndrome is nerve entrapment between wrist and elbow.

The combination of thumb weakness and thenar atrophy without Tinel's sign suggests the pronator syndrome with nerve entrapment at the elbow. The patient may have a claw hand with weakness of finger flexion and weak "OK" sign and thenar atrophy.

Jules Tinel (1879-1952)[3] was a French neurologist born into a family of 5 generations of physicians. His teachers were some of the greatest names in French medicine at the beginning of the 20th century. Tinel obtained his doctorate in 1910 and during World War I served as the head of the neurologic center in Le Mans, France.

After the war, Tinel worked on the psychosomatic aspects of medicine. He was also actively involved in the French resistance and was imprisoned. His son Jacques was killed by the Nazis. In 1945,, he worked at Boucicaut Hospital in Paris, France. He died of heart failure in 1952.

Tinel is remembered for discovering 2 clinical signs, both of which involve tapping on a peripheral nerve trunk. One sign is evidenced by tapping over the median nerve in the wrist to produce the tingling sensation of carpal tunnel syndrome. The other sign is seen by tapping over any peripheral nerve trunk that has been damaged and noting the tingling sensation as a sign of regeneration.


Tenderness Over the Lateral Aspect of the Elbow. Tenderness to palpation over lateral epicondyle suggests lateral epicondylitis (tennis elbow). Pain can be demonstrated on resisted dorsiflexion of the wrist. Pain at the lateral epicondyle on passive pronation of forearm is called Mill's maneuver.[4] Check also Cozen's sign (flexing elbow against resistance with fist held in pronation).

Check for radial nerve entrapment by looking for decreased sensation over the dorsal hand and lateral forearm. Also look for painful finger extension with the wrist flexed and pronated. Another clue of radial nerve entrapment is tingling in the radial distribution with tapping over arcade of Frohse,[5,6,7] which is present in over 60% of individuals and is located in the superior hiatus of the supinator muscle.

Tenderness of the medial aspect of the hand with palpation between the olecranon and medial epicondyle suggests cubital tunnel syndrome (ulnar nerve entrapment). The ulnar nerve can be trapped in several anatomic sites:

  • The arcade of Osborne[8] (under the 2 heads of the flexor carpi ulnaris) -- the most common location;

  • The arcade of Struthers[9,10] (a thin band extending from the medial head of the triceps muscle to the medial intermuscular septum; located approximately 8 cm proximal to the medial epicondyle); and

  • The ulnar groove.

Prolonged elbow flexion can stretch the nerve over the epicondyle (analogous to Phalen's test at the wrist) and sometimes reproduce the paresthesias associated with this syndrome.

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