By Dr. Marcus Judge

OSCE

During any examination in an OSCE it is important to understand the pathology and reasoning behind each of the signs and symptoms elicited. This applies even when the patient being examined is 'normal'. This article explains how to perform an elbow examination and the key findings you should look for, showing you what each sign means and what conditions it may indicate.

The elbow is examined using the classic musculoskeletal framework of look, feel and move, followed by a small number of special tests and an assessment of the surrounding neurovascular structures (the nerves and blood vessels). Throughout, remember that the elbow is a hinge joint formed by the humerus, ulna and radius. Pronation (turning the palm down) and supination (turning the palm up) of the forearm occur at the proximal and distal radio-ulnar joints, not at the elbow hinge itself. The proximal radio-ulnar joint, near the elbow, shares the elbow's joint capsule.

Contents

  1. Introduction
  2. General Inspection
  3. Look (Closer Inspection)
  4. Feel
  5. Move
  6. Special Tests
  7. Neurovascular Assessment
  8. Olecranon Bursitis
  9. Completing the Examination
  10. Quiz

Introduction

Wash your hands and put on personal protective equipment (PPE), such as gloves, if there is a risk of contact with body fluids or broken skin.

Introduce yourself to the patient and mention your grade, for example third-year medical student, junior doctor or consultant.

Confirm the patient's details, taking 3 points of identification usually: full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail.

Expose both upper limbs fully from the shoulders down. Examining both sides is essential, as many findings (such as swelling, deformity or a difference in carrying angle) are only obvious when the elbows are compared with one another.

Position the patient standing or sitting so that you can walk around them and view the limbs from the front, side and back.

Ask whether the patient is currently in any pain, and where it is, before you touch them. This both shows courtesy and helps you avoid causing distress during palpation and movement.

No specific equipment is required for an elbow examination, but offer a chaperone (a trained third person who is present as support) if the patient wants one, and have a goniometer (a hinged ruler that measures joint angles) available if you wish to measure the range of movement precisely.

General Inspection

Begin by standing back and observing the patient as a whole. Look for signs of systemic disease (disease affecting the whole body), since the elbow is a common site for the skin and joint features of inflammatory conditions.

Note whether the patient appears comfortable or is holding the arm guarded and protected, which suggests pain or instability. Observe their general demeanour and whether they are well or unwell.

Scan the surrounding bedside for clues, such as mobility aids, an arm sling, splints or analgesia, all of which point towards recent injury, surgery or chronic joint pathology.

Look on the extensor surfaces (the back of the elbow) for psoriatic plaques: well-demarcated (with a clear edge), salmon-pink scaly plaques. The elbow is a classic site for psoriasis (a long-term inflammatory skin condition that causes scaly patches). Recognising it matters because psoriatic arthritis (a long-term inflammatory arthritis) affects up to 30% of people with psoriasis. Also note any obvious lumps over the elbow. These may be rheumatoid nodules, which are a sign of rheumatoid arthritis (an autoimmune inflammatory arthritis), or tophi (firm, white nodules of urate crystals under the skin), which are a sign of gout (arthritis caused by urate crystals).

Look (Closer Inspection)

Inspect each elbow closely from the front, the side and behind, comparing left with right. Where one elbow is known to be symptomatic, inspect the asymptomatic side first so you have a baseline for normal before examining the affected joint.

Look for scars, which may indicate previous trauma or surgery such as fracture fixation, nerve transposition (moving the ulnar nerve to a new position) or joint replacement. The position of a scar can hint at the underlying procedure.

Look for swelling. Diffuse swelling of the joint may represent an effusion (excess fluid in the joint) or inflammatory arthropathy (inflammatory joint disease). A discrete, fluctuant swelling over the point of the elbow (fluctuant means soft, with fluid that moves under pressure) suggests olecranon bursitis. This is inflammation of the bursa (a small fluid-filled sac that cushions the bone) overlying the olecranon (the bony point of the elbow), and it is sometimes called 'student's elbow'.

Look for muscle wasting of the upper arm or forearm. Wasting suggests disuse atrophy secondary to chronic joint pathology, or denervation (loss of nerve supply) from a lower motor neurone lesion (damage to the nerve running to the muscle) such as nerve entrapment.

Look for rheumatoid nodules (firm, non-tender subcutaneous lumps over the extensor surface and olecranon) and psoriatic plaques, as described above.

Assess the carrying angle. With the arm extended and the palm facing forwards, the forearm normally deviates laterally away from the body by approximately 5–15°. This is the carrying angle, and it is typically slightly greater in women. An angle greater than 15° is termed cubitus valgus. It is associated with previous trauma or congenital conditions such as Turner's syndrome (a chromosomal condition in females in which all or part of one X chromosome is missing). Over time it can stretch the ulnar nerve, causing a 'tardy ulnar nerve palsy' (late-onset weakness and numbness from ulnar nerve damage). An angle that is reduced or reversed is termed cubitus varus ('gunstock deformity'). It classically follows a malunited (badly healed) supracondylar fracture of the humerus in childhood, which is a break just above the elbow.

Finally, look for any fixed flexion deformity, in which the elbow cannot be fully straightened. This may follow previous joint trauma, longstanding arthritis or muscular spasticity (abnormally tight, stiff muscles).

Cubitus Varus and Cubitus Valgus SimpleMed

Image - The carrying angle of the elbow. An increased angle is cubitus valgus, while a reduced or reversed angle is cubitus varus, often following a supracondylar fracture

Creative commons source by Mikael Häggström [Public domain / CC0 1.0]

Feel

Before palpating, check once more that the patient is not in pain, and watch their face for discomfort throughout.

First assess temperature. Using the back of your hand, compare each elbow against the patient's own forearm and against the other side. A joint that feels noticeably warm points towards an active inflammatory process. When warmth is accompanied by swelling and tenderness, the differential includes septic arthritis (infection inside the joint), a flare of inflammatory arthritis, and olecranon bursitis. Septic arthritis is a medical emergency and must not be missed.

Systematically palpate the bony landmarks and soft tissues, asking the patient to tell you of any tenderness:

  • The olecranon (the point of the elbow) and the overlying bursa: tenderness or a soft, spongy swelling here suggests olecranon bursitis or a fracture.
  • The medial epicondyle (the bony bump on the inner side of the elbow): tenderness here is found in medial epicondylitis ('golfer's elbow'), an overuse injury of the common flexor tendon origin (the shared attachment of the forearm flexor muscles).
  • The lateral epicondyle (the bony bump on the outer side of the elbow): tenderness here is found in lateral epicondylitis ('tennis elbow'), an overuse injury of the common extensor tendon origin (the shared attachment of the forearm extensor muscles). It is the most common cause of persistent elbow pain seen in general practice.
  • The head of the radius, found just distal to the lateral epicondyle (it can be felt to rotate as you pronate and supinate the forearm). Tenderness here may indicate a radial head fracture or arthritis.
  • The biceps tendon, palpated in the anterior cubital fossa (the hollow at the front of the elbow) as the patient flexes the elbow against resistance. It should feel taut and continuous. Tenderness suggests biceps tendonitis (inflammation of the tendon). A palpable gap or a soft-tissue mass that has retracted up the arm ('reverse Popeye' sign) suggests a distal biceps tendon rupture (a tear where the tendon attaches to the radius). In rupture, resisted supination of the forearm is weak.

Feel for any nodules over the extensor surface (rheumatoid nodules) and assess any swelling for whether it is fluctuant (suggesting fluid, as in a bursa or effusion) or firm (suggesting a nodule or bony abnormality).

Move

Movement is assessed first actively (the patient moves the joint themselves) and then passively (you move the joint for them while they relax). Comparing the two helps localise a problem. A reduction in active movement with preserved passive movement suggests a tendon, muscle or nerve problem. An equal reduction in both suggests a problem within the joint itself, such as an effusion, arthritis or a mechanical block.

Assess the following movements at the elbow, comparing both sides:

  • Flexion: ask the patient to bend the elbow and touch their shoulder. Normal range is approximately 0–145°.
  • Extension: ask the patient to fully straighten the arm. The elbow should return to the neutral 0° position; some individuals, particularly those with joint hypermobility (unusually flexible joints), can hyperextend slightly. An inability to fully straighten indicates a fixed flexion deformity.

Then assess forearm rotation, which occurs at the radio-ulnar joints. With the elbows tucked into the sides and flexed to 90° (to eliminate any contribution from shoulder rotation), ask the patient to turn the palms:

  • Pronation: palms turned to face the floor, approximately 0–80°.
  • Supination: palms turned to face the ceiling, approximately 0–85°.

During passive movement, place a hand over the joint to feel for crepitus (a grinding or crackling sensation as the joint moves). Crepitus reflects roughened joint surfaces and is commonly associated with osteoarthritis (wear-and-tear arthritis). Note any pain or restriction in the range of movement and the point in the arc at which it occurs.

Special Tests

A small number of provocation tests help confirm the common tendinopathies (painful tendon problems) and assess ligamentous stability. They work by stressing the affected structure to reproduce the patient's pain.

Lateral epicondylitis ('tennis elbow') affects the common extensor origin, so it is provoked by loading the wrist extensors:

  • Cozen's test: with the elbow extended, ask the patient to make a fist and extend the wrist against your resistance. Pain felt over the lateral epicondyle is a positive result.
  • Mill's test: keep a finger on the lateral epicondyle while you hold the forearm pronated with the wrist and fingers flexed, then passively extend the elbow. This stretches the common extensor origin, and reproduction of pain over the lateral epicondyle supports the diagnosis.

Medial epicondylitis ('golfer's elbow') affects the common flexor origin, so it is provoked by loading the wrist flexors. With the elbow extended and forearm supinated, ask the patient to flex the wrist against resistance. Pain over the medial epicondyle is a positive result (this is sometimes called the reverse Cozen's test).

To assess the collateral ligaments, which provide side-to-side stability, apply gentle stress with the elbow flexed to around 30°:

  • Valgus stress (a force that pushes the forearm away from the body) tests the medial (ulnar) collateral ligament. Pain or excessive looseness (laxity) suggests injury to this ligament, which is a common throwing injury.
  • Varus stress (a force that pushes the forearm towards the body) tests the lateral (radial) collateral ligament.

Neurovascular Assessment

The elbow lies close to several important nerves, so a brief neurovascular screen completes the examination. This is particularly important after trauma or where deformity (such as cubitus valgus) may stretch a nerve.

The ulnar nerve passes behind the medial epicondyle in the cubital tunnel (the groove behind the inner elbow), where it is superficial and vulnerable. Compression or irritation here (cubital tunnel syndrome) causes tingling and numbness in the little finger and the ulnar half of the ring finger. It also causes weakness of the small muscles of the hand. Gently tapping over the nerve behind the medial epicondyle (Tinel's test) may reproduce these tingling symptoms.

Briefly assess the median and radial nerves as well, checking sensation across the hand and power of the relevant muscle groups, as all three nerves cross the elbow.

Check the distal circulation by palpating the radial pulse and assessing capillary refill time (how quickly colour returns to a fingertip after you press it). It should be less than two seconds. A delayed refill or absent pulse raises concern for reduced blood supply (vascular compromise), which can complicate elbow fractures and dislocations.

Olecranon Bursitis

Olecranon bursitis deserves special mention as a frequent cause of elbow swelling and one of the most visually striking elbow findings. The olecranon bursa is a fluid-filled sac that cushions the point of the elbow and allows the skin to glide smoothly over the bone. When it becomes inflamed, fluid accumulates, producing a soft, fluctuant swelling directly over the olecranon, often described as resembling a small egg or balloon at the tip of the elbow.

Causes include repetitive pressure or trauma, inflammatory disease such as rheumatoid arthritis or gout, and infection. Aseptic bursitis is still an inflammatory disorder and may be painful or tender. Warmth, redness, marked tenderness, a skin break or systemic illness should prompt assessment for infection, but appearance alone does not reliably distinguish septic from aseptic bursitis. Suspected infection needs prompt clinical assessment and appropriate investigation, including bursal fluid analysis when indicated.

Olecranon Bursitis SimpleMed

Image - Olecranon bursitis, seen as a fluctuant swelling directly over the point of the elbow due to fluid accumulating within the inflamed bursa

Public Domain Source NJC123 [Public domain]

Completing the Examination

Thank the patient and wash your hands.

Summarise your findings.

To complete the examination, state that you would do three things. First, perform a thorough neurovascular assessment of the entire limb. Second, examine the joint above and below (the shoulder and the wrist and hand) to look for referred pain (pain felt in one place but coming from another) and associated pathology. Third, assess the patient's function, for example by asking them to perform everyday tasks such as eating or combing their hair.

Further investigations to suggest include plain radiographs (X-rays) of the elbow, to assess for fracture, dislocation, arthritis or an effusion. Ultrasound or MRI is used where soft-tissue pathology such as a tendon tear or ligament injury is suspected. Relevant blood tests include inflammatory markers (C-reactive protein and erythrocyte sedimentation rate, which rise with inflammation or infection), rheumatoid factor if rheumatoid arthritis is suspected (anti-CCP, anti-cyclic citrullinated peptide, antibodies can be added if it is negative), and serum urate if gout is suspected. Serum urate can be lower than expected during a gout flare, so a result in the normal range does not rule gout out. Aspiration of any effusion or bursa (drawing fluid off with a needle) allows microscopy, culture and crystal analysis if infection or crystal arthropathy (joint disease caused by crystals) is suspected.

Quiz

Preview the Elbow OSCE Examination quiz

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