Examination

Elbow & Forearm Examination

  • If a mechanism or pattern:
    • When did it happen?
    • What happened exactly?  Try to understand the mechanism and forces involved (if present)
    • What symptoms initially?
      • Where were the symptoms initially?
      • Describe pain – sharp / superficial / deep / ache / burning etc
      • What aggravates and what eases?
      • For LL problems, include ability to WB
    • What symptoms now?
      • Have the symptoms changed? Better / Worse? Location?
  • If no mechanism
    • How long has it been there?
    • Is there anything that they believe may have contributed to the development of the problem? Recent activity / inactivity
    • What symptoms are present?
    • Are they there all the time?
  • What treatment has been sought so far?
    • Assessment
    • Investigations
      • If imaging, do they have it with them?
      • If not, can we view it?
        • Private providers use online applications
        • If in another public hospital in Victoria, then can use the “Synapse Mix” service to get the images temporarily put on local network diagnostic imaging servers.
  • What management has been undertaken? Has it been effective
    • Splinting
    • Ice
    • Medications
  • History of problems in that area before
    • When?
    • How was it managed?
      • Assessment undertaken?
      • Investigations
      • Medications
    • Any ongoing problems?
  • Any associated symptoms (if a non mechanical cause or if at all suspicious)
    • Recent illness / fevers / sweats
    • Recent overseas / long haul travel / immobilisation (eg for suspected DVT)
    • Loss of appetite / loss of weight, etc
  • If has a wound
    • Tetanus status
  • If potentially needing procedural sedation or surgery (and consider this for anyone you are contemplating an x-ray for)
    • Fasting status (and tell them not to eat and drink until you tell them it is ok to do so)
Goals in ED
  • Identify changes to distal neurovascular function
  • Identify fractures / dislocations / subluxations
  • Identify pulled elbow
  • Identify tendon injury that may require URGENT repair
Distal NV function
  • Colour, Movement, Warmth, Sensation
  • Radial pulse
  • Median, Radial, Ulnar nerve function
    • Rock, Paper, Scissors, OK
Active Range of Motion
  • Flexion / Extension
  • Supination / Pronation
Palpation
  • Bones / Joints
    • Palpate entire length of Humerus, from shoulder to elbow
    • Palpate radius and ulnar from elbow down to wrist
  • Muscles
    • Biceps (in particular, identify the tendon)
    • Triceps (in particular, identify the tendon)
Special tests
  • Resisted
    • Elbow flexion
    • Elbow extension
  • Stability
    • Valgus / Varus
Imaging
  • X-ray
    • No clinical decision making rules for elbow / forearm imaging
    • Be suspicious of bony injury with the presence of:
      • Reduced ROM
      • Swelling / Deformity
      • Bony tenderness
  • Ultrasound
    • Generally not indicated in ED for most elbow problems
    • For ambiguous biceps / triceps tear, US may be useful
    • If obvious rupture – talk to Orthopaedics