Radioulnar Synostosis

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5.6. Inspection (6): The carrying angle may be measured with a goniometer. Average values of carrying angle: Males: 11° (range 2°-26°) Females: 13° (range 2°-22°).

Carrying AngleRheumatoid Arthritis And Hyperextension

5.7. Movements (1): Extension: (A) Full extension, 0°, is present if the arm and forearm can be made to lie in a straight line. (B) Loss of full extension is especially common in osteoarthritis, rheumatoid arthritis, and old fractures (particularly of the radial head) involving the elbow joint.

5.8. Movements (2): Hyperextension: If the elbow can he extended beyond the neutral position, record this as *X° hyperextension". Up to 15° is accepted as normal, especially in women. Beyond this, look for hypermobility in other joints (for example as may occur in the Ehlers-Danlos syndrome).

5.9. Movements (3): Flexion (1): (Screening test) Ask the patient to attempt to touch both shoulders. A slight difference in flexion between the sides is then usually obvious.

Ehlers Danlos Syndrome And FracturesRheumatic Joint HypermobilityRadial Ulnar Synostosis Images

5.10. Movements (4): Flexion (2): The range of flexion may be measured. Normal range = 145°.

Restriction of flexion is common after all fractures round the elbow, and in all forms of arthritis.

5.11. Movements (5): Pronation/ supination screening (1): Ask the patient to hold the elbows closely to the sides. Turn the palms upwards into supination and compare the sides.

5.12. Movements (6): Pronation/ supination screening (2): Now turn the palms downwards in pronation, again comparing the sides.

Elbow Pronation PencilRadioulnar Supination

5.13. Movements (7): Supination: Supination may be recorded. Give the patient a pencil to hold, and note the angle from the vertical that can be achieved. Normal range = 80°.

5.14. Movement (8): Pronation: This may he measured in the same way. Normal range = 75°. Pronation/supination movements may be reduced after fractures at the elbow, in the forearm and at the wrist (e.g. most commonly after Colles' fracture). Loss may also occur after dislocation of the elbow, and rheumatoid and osteoarthritis. Pure supination loss may occur in children with pulled elbow.

5.15. Palpation (1): Begin by locating the epicondyles and the olecranon. If in doubt, flex the elbow and note the equilateral triangle normally formed by these structures. This relationship is disturbed in elbow subluxations.

Elbow SynostosisOlecranon BursitisPalpation Brachialis

5.16. Palpation (2): Palpate the lateral epicondyle with the thumb. Sharply localized tenderness here or just distal is almost diagnostic of tennis elbow. Carry our confirmatory tests (22 et seq.). Note that after the injection of hydrocortisone locally (e.g. for tennis elbow) tenderness becomes more diffuse.

5.17. Palpation (3): Palpate the medial epicondyle. Tenderness occurs here in golfer's elbow, tears of the ulnar collateral ligament, and injuries of the medial epicondyle.

5.1 8. Palpation (4): Tenderness over the olecranon is uncommon, apart from after fracture and infected olecranon bursitis, both of which are usually obvious.

Olecranon Ankylosis TherapyUncomon BursitisInfected Olecranon Bursitis

5.19. Palpation (5): Press the thumb firmly into the space on the lateral side of the elbow between the radial head and humerus. Now pronate and supinate the arm. Tenderness here is common after injuries of the radial head, osteoarthritis and osteochondritis dissecans.

5.20. Palpation (6): Palpate the front of the elbow on both sides of the biceps tendon while flexing and extending the elbow through 20°. Note the presence of any abnormal masses (e.g. myositis ossificans, loose bodies).

5.21. Palpation (7): Roll the ulnar nerve under the fingers behind the medial epicondyle. Note whether there is any difference between the sides. If indicated, carry out a fuller examination of the nerve.

Chair Lifting Test Tennis ElbowChair Lift Test ElbowChair Lifting Test Tennis Elbow

5.22. Additional tests: Tennis elbow (1): Flex the elbow and fully pronate the hand. Now extend the elbow. Pain over the lateral epicondyle is almost diagnostic of tennis elbow.

5.23. Tennis elbow (2): As an alternative, pain may be sought by pronating the arm with the elbow fully extended.

5.24. Tennis elbow (3): The chair test. Ask the patient to attempt to lift a chair (of about 3.5 kg in weight) with the elbows extended and the shoulders flexed to 60°. Difficulty in performing this manoeuvre, with complaint of pain on the lateral aspect of the affected elbow, is suggestive of tennis elbow.

Middle Finger Test Tennis ElbowPronate Supinate ArmChair Test Tennis Elbow

5.25. Tennis elbow (4): I'homsen 's test: Ask the patient to clench the fist, dorsiflex the wrist and extend the elbow. Try to force the hand into palmar flexion while the patient resists. Severe pain over the external epicondyle is again most suggestive of tennis elbow.

(5): Repeat, this time attempting to flex the extended middle finger rather than the wrist.

5.26. Additional tests: golfer's elbow:

Flex the elbow, supinate the hand, and then extend the elbow. Pain over the medial epicondyle is very suggestive of golfer's elbow.

5.27. Additional tests: ulnar nerve (1):

Inspect the medial side of the elbow carefully while the patient flexes and extends the joint. The nerve is visible in the thin patient, and displacement on movement may be obvious.

Ulnar Nerve Palsy
5.28. Ulnar nerve (2): Palpate again and note the extent of any tenderness, and whether the nerve is thickened. Look again for cubitus valgus. Look for evidence of ulnar nerve palsy.

5.29. Additional tests: elbow instability: Both valgus and varus instability may be tested by stressing the joint in extension and 30° flexion (as performed for the collateral ligaments in the knee). Alternatively, for valgus instability (which is the commonest), anchor the patient's arm in 30° elbow flexion against your side (1 ). apply a valgus stress (2), and feel for any gap opening up on the medial side (3).

5.30. Radiographs (1): Normal anteroposterior radiograph of the elbow.

Coronoid Process Radial Head

5.33. Radiographs (4): In examining the standard lateral projection, note (R) the radial head; (Co) the coronoid process of the ulna; (Ol) the olecranon.

5.32. Radiographs (3): Normal lateral radiograph of the elbow.

5.33. Radiographs (4): In examining the standard lateral projection, note (R) the radial head; (Co) the coronoid process of the ulna; (Ol) the olecranon.

5.31. Radiographs (2): In examining the standard AP view trace out the outline of (M), the medial epicondyle; (OF) the olecranon and coronoid fossae; (L) the lateral epicondyle; (Ca) the capitulum; (R) the radial head; (Tu) the tuberosity of the radius; (Co) the coronoid process of ulna; (Tr) the trochlea.

Example TrochleaLoose Boddies Radial Head

5.34. Radiographs (5): Look for (J) any defects in the capitulum suggesting osteochondritis dissecans; (K) loose bodies (usually secondary to osteoarthritis or osteochondritis); (L) incompletely remodelled supracondylar fracture (usually associated with loss of flexion); (M) old Monteggia fracture (fracture of ulna and dislocation head of radius), usually associated with reduction of pronation and supination.

5.35. Radiographs (6): Note the presence of (N) a congenital synostosis (with inevitable loss of pronation and supination); (O) myositis ossificans (with clinically restriction of flexion). Note any osteoarthritic changes with, for example, (P) joint space narrowing. (Q) bony sclerosis of the joint margins. (R) osteophytes, (S) loose body formation, or (T) evidence of previous fracture.

5.36. Radiographs (7): Where the radial head is suspect, radiographs should he taken in the anteroposterior plane (A) in midposition, (B) in supination, (C) in pronation. These may bring an area of osteochondritis of the radial head or an old fracture into profile.

Loose Boddies Radial Head

5.37. Radiographs (8): Normal anteroposterior radiograph of the elbow of a child of 8.

5.39. Radiographs (10): If there is any doubt, radiographs of both sides should be taken. Note that if a child over the age of 6 has injured the elbow there is every likelihood that the medial epicondyle has become displaced into the joint if it cannot be seen in the anteroposterior view, or if it can be seen in the lateral. (A) Normal, (B) displaced.

5.38. Radiographs (9): Interpretation of radiographs of the elbow in children is made difficult by the changes produced by the successive appearance of ossification in the epiphyses (and there are both gender and race variations). The old mnemonic 'cite' (capitulum. internal epicondyle. trochlea, external epicondyle) for the appearance of the epiphyseal centres at 3. 6. 9 and 12 years, is sufficiently accurate for normal purposes.

Radioulnar Synostosis

5.40. Pathology (1): The proximal radioulnar joint is not present, and no pronation/supination movements are possible. The epiphysis of the olecranon has not yet united. Diagnosis: congenital radioulnar synostosis.

Elbow Pathology

5.41. Pathology (2): After an elbow injury a large mass of bone has formed in the front of the joint, and has virtually obliterated all movements.

Diagnosis: myositis ossificans.

Infective MyositisElbow Infective Arthritis

5.42. Pathology (3): All the joint surfaces are irregular, and the bone texture has a motheaten appearance. Diagnosis: septic (infective) arthritis of the elbow.

5.43. Pathology (4): There is gross disturbance of the architecture of the elbow joint, and bony ankylosis has occurred. Diagnosis: in this case the cause was a gunshot wound to the elbow, with extensive bone damage.

Olecranon Elbow PathologyOlecranon Angle

5.44. Pathology (5): There is an obvious defect in the olecranon, with separation of the fragments. The complaints was of weakness of elbow movements.

Diagnosis: ununited fracture of the olecranon. Injuries of this type may have surprisingly few symptoms, but there is often weakness (as was the case here) and restriction of extension.

5.45. Pathology (6): The radiograph is of an acute case where, following a dislocation of the elbow, there was marked restriction of movements.

Diagnosis: the medial epicondyle has displaced and become trapped in the joint.

Monteggia Fracture Extension Type

5.46. Pathology (7): Both projections show narrowing of the joint space between the ulna and the humerus, with a degree of marginal bone sclerosis. In the lateral view there is lipping of the olecranon, and multiple loose bodies are present.

Diagnosis: osteoarthritis of the elbow with loose body formation. Synovial chondromatosis may have a similar appearance.

5.47. Pathology (8): The radial head has lost its normal site of articulation with the capitulum. and there is a cubitus valgus deformity. The appearances are of a long-standing lesion. Diagnosis: this is an old Monteggia fracture dislocation of the elbow. The ulnar fracture has healed and is no longer visible, but the dislocation of the radial head persists. In this case there was an associated tardy ulnar nerve palsy.

Radial Ulnar SynostosisHumerus Ankylosis With OlecranonDistal Radioulnar Synostosis

5.48. Pathology (9): The articular surfaces between the humerus and ulna have been virtually obliterated following a long period of pain, swelling and loss of function in the elbow.

Diagnosis: in this case this was due to tuberculous infection of the joint, and ankylosis has resulted.

5.49. Pathology (10): There is a gap between the distal articular complex of the humerus and the distal humeral shaft. There was little movement left in the elbow joint itself, but there was a limited range of rather unstable movements proximal to it. Diagnosis: this is an example of longstanding non-union following a supracondylar fracture of the humerus.

5.50. Pathology (11): The arrow points to an abnormality in the region of the coronoid fossa. This was associated with severe restriction of elbow flexion. Diagnosis: this is a large loose body. In the single view the source is not obvious, but the most likely causes are osteochondritis dissecans or osteoarthritis. The loss of flexion is due to a purely mechanical block to movement.

Radioulnar Synostosis

5.51. Pathology (12): This lateral radiograph shows a large loose bony mass lying in the front of the elbow joint. Diagnosis: loose body, probably secondary to osteochondritis dissecans or osteoarthritis. In some cases loose bodies of this type may be extruded and come to lie in the brachialis muscle, where their mechanical effects on elbow flexion are less obtrusive.

5.52. Elbow radiographs: Examples of pathology (13): This radiograph shows an irregularity of the capitulum involving its articular surface. This was associated with aching pain in the joint of several months' duration.

Diagnosis: osteochondritis of the capitulum.

5.53. Aspiration of the elbow joint: The most direct and safest approach is from the lateral side. Flex the elbow to 90°; to locate the radial head, pronate and supinate the arm. and feel with the thumb for its rotation. After infiltration of the area with local anaesthetic, introduce the aspirating needle in the area of the palpable depression between the proximal part of the radial head and the capitulum.

Complications occurring after Colles' fracture 90

Ganglions 90

de Quervains disease 91

Extensor tenosynovitis 91

Osteoarthritis of the wrist 91

Rheumatoid arthritis 91

Carpal tunnel syndrome 92

Ulnar tunnel syndrome 92

Ehlers-Danlos syndrome 93

Tuberculosis of the wrist 93

Carpal instabilities 93

Irspection 94-95

Palpation 95-96

Movements 96-98

Joint hypermobility 97

Crepitus 99

de Quervains tenosynovitis 99 Carpal tunnel syndrome 99-101 Radioulnar laxity 101 Carpal instability 102 Radiographs 102-107 Pathology 1 02-107 Aspiration of the wrist 107

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