Elbow joint

anatomy, examination and some associated medical conditions of elbow joint

1. Elbow Joint Dr. Fathima Bharkath

2. Joint between the lower end of humerus and upper ends of radius & ulna Two articulations: Humero -ulnar: b/w the trochlea of the humerus and trochlear notch of the ulna Humero-radial: b/w the capitulum of humerus and head of radius Complexity of joint further increased by superior radio-ulnar joint Together known as cubital articulations Type : hinge type of synovial joint

3. Anteroposterior & Lateral Radiograph

4. Ligaments

5. Capsular Ligament (Joint capsule) Fibrous sac enclosing the joint cavity Attachment: Above: medial epicondyle, upper margins of radial, coronoid, and olecranon fossa and lateral epicondyle of humerus Below: anterior and medial margins of coronoid process of ulna, upper margin of the annular ligament and upper and medial margins of olecranon process

6. Medial Ligament (Ulnar Collateral Ligament) Triangular in shape with apex attached to medial epicondyle of humerus and base to the coronoid and olecranon processes of ulna Divided into 3 parts: anterior, posterior and inferior-united by a thin region Medial collateral ligament is related to ulnar nerve

7. Lateral Ligament (Radial Collateral Ligament) Extends from lateral epicondyle of the humerus to the annular ligament in which it blends

8. Relations Anteriorly: Brachialis muscle Median nerve Brachial artery Tendon of biceps brachii The last three structures are separated from joint capsule by brachialis Posteriorly: Tendon of triceps Anconeus

9. Laterally: Common extensor origin of muscles of forearm Extensor carpi radialis brevis Radial nerve Medially: Flexor carpi ulnaris Ulnar nerve ( posteromedially ) Common flexor origin of muscles of forearm ( antromedially )

10. Bursae related to elbow joint Subtendinous olecranon bursa : small bursa b/w triceps tendon & upper surface of olecranon process Subcutaneous olecranon bursa : large bursa b/w skin & subcutaneous triangular area on the posterior surface of olecranon Bicipitoradial bursa : small bursa seperating biceps tendon from smooth anterior part of radial tuberosity A small bursa seperating the biceps tendon from the oblique cord

11. Stability of the elbow joint Elbow joint is stable due to: Pulley-shaped trochlea of humerus fits properly into jaw like trochlear notch of ulna Strong ulnar and radial collateral ligaments

12. Blood Supply Arterial anastomosis around the elbow formed by branches of brachial, radial and ulnar arteries Nerve Supply Articular branches from: Radial nerve(through its branch to anconeus ) Musculocutaneous nerve (through its branch to brachialis) Ulnar nerve Median nerve

13. Movements Flexion and extension at humer -ulnar and humero -radial joints Range of flexion: 140° Muscles producing movement : Flexion: Brachialis Biceps brachii Brachioradialis Extension: Triceps Anconeus

14. Supination and pronation are rotatory movements of forearm which occur at superior radio-ulnar joint Muscles producing movement: Supination Supinator Biceps brachii supinates the forearm while the elbow is flexed Brachioradialis supinates the pronated forearm to midprone position Pronation Pronator teres Pronator quadratus Brachioradialis pronates the supinated forearm to mid prone position

15. Carrying Angle The transverse axis of elbow joint is oblique being directed downwards and medially This is because medial flange of trochlea lies about 6mm below its lateral flange The angle of deviation of long axis of forearm from long axis of arm is termed as carrying angle Carrying angle disappears during pronation and full flexion of forearm

16. Varies from 5-15° & is more pronounced in females (wider carrying angle in females avoids rubbing of forearms with wider female pelvis while carrying loads)

17. Examination of elbow joint

18. History Taking Age and gender: Rheumatoid arthritis- young adult women Osteoarthritis- old age Acute arthritis- young children Tuberculous arthritis- children & adolescents Occupation: manual workers more often victims of osteoarthritis Mode of onset & progress: Acute onset with constitutional disturbances-acute arthritis Insidious onset- chronic arthritis (tuberculous, rheumatoid arthritis & osteoarthritis)

19. Pain Site: Localized to the affected joint Referred to some other joint (pain in the elbow may be referred from the neck or shoulder disorders) Character: Dull aching- chronic arthritis Throbbing- acute arthritis Night cry- tuberculous joint (when patient is awake joint is kept immobilized by muscle spasm, but during sleep muscles relax and allow friction b/w the eroded articular surfaces giving rise to night cry)

20. Relation to movements: Movement aggravates pain Osteoarthritis- pain more in early mornings when patients gets up from the bed and with gradual movement of joint, pain is eased off due to increase in synovial secretion

21. Locking: due to presence of loose bodies within the joint Deformity: seen in late stages of rheumatoid arthritis, osteoarthritis & tuberculous arthritis Past history of trauma, tuberculosis, gonorrhoea, syphilis, typhoid fever or pneumonia Family history of haemophilia, tuberculosis, gout, rheumatism

22. Physical Examination Generalized wasting & cachectic features- tuberculosis of joints Fever High temperature: acute suppurative arthritis Evening rise in temperature: tuberculous arthritis

23. Local Examination Inspection: The affected joint and the corresponding healthy joint should be fully exposed and placed in same position

24. Position Patient is asked to stand straight with his arm at the side of the body with the palms looking forward (anatomical position) Carrying angle: 10° in males & 20° in females Varus and valgus deformity of elbow is only obvious when the joint remains straight and disappears when joint is flexed Optimum position (position in which capacity within the joint is maximum) of elbow joint: semiflexed position

25. Swelling Any swelling near elbow joint is noted Normal hollows on either side of olecranon are obliterated in effusion of the joint Great effusion of the elbow joint shows fullness in the antecubital fossa Olecranon bursitis (miner’s or students elbow): swelling over olecranon process Bicipitoradial bursitis: inflammation of the biceps near its insertion giving rise to slight swelling in front of the elbow joint

26. Skin over the joint: Red, glossy skin- acute inflammation Scar, sinus, ulcer & deformity- late features of tuberculous arthritis Muscular wasting: When joint is diseased muscles concerned in movement of the joint will show wasting

27. Palpation Local temperature: Acute inflamed joint will be warm- acute arthritis, olecranon bursitis, bicipitoradial bursitis Temperature of the diseased joint must be compared with that of the healthy joint

28. Tenderness: The bones in the vicinity of the joint(tender in fracture) and the bony attachments of various ligaments(tender in sprain) are palpated for tenderness Tennis elbow: tenderness over common extensor origin from lateral epicondyle Golfer’s elbow: tenderness over common flexor origin from medial epicondyle

29. Bony components: Lower part of humerus, upper part of radius and ulna are palpated for any thickening or irregularity(evidence of previous osteomyelitis) The three bony points(tip of olecranon, medial and lateral epicondyle)- form a triangle when elbow is flexed and come to a straight horizontal line when the elbow is extended

30. Swelling: Swellings around the elbow are palpated Fluctuant swelling will be seen in effusion of the elbow and in all bursitis In effusion of the elbow joint, first there will be filling up of concavity on each side of olecranon (the synovial cavity is nearest to the surface at this region and the posterior ligament is thin & lax)

31. With accumulation of more fluid , a swelling is noticed on the posterolateral aspect of the joint over the radiohumeral joint Crossed fluctuation can be elicited b/w this area and swelling over the medial aspect of olecranon(distinguishes an effusion from enlargement of bursa beneath the triceps tendon)

32. Muscular wasting: corroborated with inspection findings Examination of supratrochlear lymph node : Flex the elbow to right angle to relax the surrounding structures and node will be palpated on the anterior surface of the medial intermuscular septum 1 cm above the base of medial epicondyle Unilateral enlargement- infective lesions of hand, wrist forearm Bilateral enlargement- suggests generalized disease( eg . Syphilis)

33. Movements Both active and passive movements should be examined Active: movements made by patients effort Passive: movements made by physician & patient remains passive Following are noted: Does movement cause pain? If so, when does it stat and disappear Is there any restriction of movement? If so at what angle (osteoarthritis-limitation of movement in all directions)

34. Is there any protective muscular spasm? (demonstrated by short sharp movement- muscle will be seen to go into spasm) Is there any crepitus felt during movement of joint? (suggests osteoarthritis) Elbow joint has two components: humero-ulnar and superior radio-ulnar joints

35. Humero -ulnar joint permits flexion and extension superior radio-ulnar joint permits supination and pronation- best examined when elbow joint is kept flexed at 90° & arm kept by the side of the chest (when elbow is extended these movements will be mixed with rotation of the humerus

36. Measurements Measurements of the length of the limbs and circumference of the limbs above the joint at the same level on both sides to detect muscular wasting Auscultation Fine crepitation heard in osteoarthritis

37. General Examination Examination of lungs and cervical lymph nodes in case of suspected tuberculous arthritis Rheumatic fever- cardiac examination Search for septic foci in teeth, tonsils, air sinuses in case of acute arthritis, rheumatic fever Examination of neighbouring joints: referred pain in elbow may be from neck or shoulder disorders

38. Differential Diagnosis

39. Acute arthritis Effusion of elbow joint Painful joint held in semi-flexed position (optimum position) Normal concavity on either side of olecranon will disappear Effusion will elicit transmitted fluid impulse b/w two sides of olecranon posteriorly and at the bent of elbow anteriorly

40. Chronic arthritis Uncommon Tuberculosis occurs in adults more often than in children Charcot’s joint Occasionally affects elbow joint

41. Osteochondritis dissecans Capitulum & head of radius is generally involved Complaints of aching pain and recurrent effusion X-ray: dense spot affecting articular surface which may later on detach forming a loose body in the joint

42. Tennis elbow [Lateral epicondylitis] More often seen among tennis players Common extensor origin is damaged & subsequent adhesion binds torn to un-torn fibres and to the joint capsule Patient complains of pain on the lateral aspect of the elbow, accentuated by dorsiflexion of the wrist when the extensor muscles are put to action Palpation: tenderness over lateral epicondyle of humerus

43. Cozen’s test: when patient is asked to extend his clenched fist against resistance, pain is experienced at the lateral epicondyle Mill’s manoeuvre: patient’s wrist is passively flexed when his forearm is pronated- causes pain in the attachment of common extensor tendons

44. Golfer’s/Base baller's elbow [Medial epicondylitis] Pain & tenderness over the medial epicondyle of humerus Due to strain or tear of common flexor origin with subsequent inflammation of medial epicondyle, following repetitive use of flexors of forearm as during playing golf

45. Student’s/Miner’s elbow Bursa over the olecranon process sometimes gets infected and leads to effusion in it (olecranon bursitis) Due to repeated movement of the skin over the olecranon bursa Mainly affects students and the friction is caused while writing, b/w the skin over the olecranon and the table

46. Bicipitoradial bursitis Very rare Bursa beneath the tendon of biceps becomes inflamed and effused Due to repeated throwing of a ball Patient complaints of pain over the insertion of biceps tendon which is accentuated by flexion and supination (movements caused by biceps at the elbow)

47. Elbow Tunnel Syndrome Affects ulnar nerve Involvement of ulnar nerve occurs when it passes b/w the two heads of flexor carpi ulnaris This condition may be due to osteoarthritis of elbow joint and ulnar nerve is injured by the osteophytes