Physical Examination Findings to Look for in Elbow Swelling with Severe Osteoarthritis
On physical examination of a patient with elbow swelling and severe osteoarthritis, you should systematically assess for joint effusion, range of motion limitations, crepitus, osteophytes, and loose bodies, as these findings will directly impact treatment decisions and patient outcomes.
Positioning for Examination
For a thorough elbow examination in osteoarthritis, position the patient as follows 1:
- Sitting position
- For ventral (anterior) assessment: Full extension of the elbow joint with forearm supination
- For dorsal (posterior) assessment: Flexion of the elbow joint at 90° angle
- For dorsal scans: Hand placed on hip or thigh with moderate internal rotation of the humerus
Key Examination Components
1. Joint Effusion Assessment
- Examine the olecranon fossa for swelling, which is a common location for synovitis 1
- Check for fluctuance and ballottement of fluid
- Look for fullness in the "soft spots" (triangular depressions) lateral and medial to the olecranon
2. Range of Motion
- Assess active and passive:
- Flexion (normal: 140-150°)
- Extension (normal: 0-10°)
- Pronation and supination (normal: 80-90° each)
- Document any mechanical blocks to motion
- Note pain with movement and at which point in the range it occurs
3. Bony Changes
- Palpate for osteophytes around joint margins
- Check for bony enlargement of the radial head
- Assess for joint crepitus during movement
- Evaluate for loose bodies by feeling for catching or locking during movement
4. Soft Tissue Assessment
- Examine for synovial thickening
- Check for olecranon bursitis (posterior swelling)
- Assess for tenosynovitis of surrounding tendons
- Evaluate for periarticular rheumatoid nodules or crystal deposition 1
5. Neurovascular Examination
- Test for ulnar nerve symptoms (tingling in 4th and 5th digits)
- Assess for cubital tunnel syndrome with Tinel's test at the elbow
- Check for median and radial nerve function
Imaging Correlation
After your physical examination, radiographs are the most appropriate initial imaging study 1. Look for:
- Intra-articular bodies
- Heterotopic ossification
- Osteochondral lesions
- Joint space narrowing
- Osteophytes
- Soft tissue calcification
Common Pitfalls to Avoid
- Failing to assess for mechanical symptoms that might indicate loose bodies or osteophytes
- Overlooking ulnar nerve symptoms which frequently accompany severe elbow osteoarthritis
- Not comparing with the contralateral elbow, which can provide valuable information 1
- Focusing only on the elbow joint itself without examining surrounding structures
By following this systematic approach to examining a patient with elbow swelling and severe osteoarthritis, you can accurately assess the extent of disease, identify complications, and guide appropriate treatment decisions to improve patient outcomes.