Ch 4 Physical Exam Upper Extremity Flashcards
Palpation of the upper extremity includes:
Acromioclavicular joint
Subacromial bursa
Long head of the biceps
Normal shoulder motion is a composite movement that couples:
Glenohumeral motion with movement of the scapula on the thorax
Scapular movement is derived from motion of the:
Acromioclavicular and sternoclavicular joints
While evaluating flexion and abduction note the:
Glenohumeral rhythm
___% of abduction should occur at the humerus
60%
__% of abduction should occur at the scapula
40%
Normal flexion is up to:
180 degrees
Normal range of extension is up to:
50 degrees
Normal range of abduction is up to:
180 degrees
Normal range of adduction is up to:
50 degrees
1) Place arm behind the head with elbows out
2) Have patient lower his thumb along the spine to their lowest point
3) Note what spinous process the patient can reach
External Rotation
1) Ask the patient to place the arm behind the back and reach as high as possible
2) Note the highest spinous process that can be reached with hiking the thumb
Internal Rotation
1) Anterior Deltoid
2) Have patient raise the arm forward in the sagittal plane and provide resistance
3) Pain may be suggestive of biceps tendinitis
Flexion
1) Posterior Deltoid
2) Have patient raise the arm backward in the sagittal plane and provide resistance
Extension
1) Middle Deltoid
2) Have patient raise arm to 90 degrees of abduction with the elbow flexed at 90
degrees
Abduction
What muscle?
1) Place arm in 90 degrees of abduction with slight horizontal adduction and internal rotation
2) Push down on the distal arm as the patient resists this pressure
3) Pain may be suggestive of rotator cuff tendinitis
Supraspinatus
What muscle?
1) Have patient place their hand behind the back with the palm facing away from the body
2) Have patient lift away from the back while providing resistance
3) AKA Gerber lift off
Subscapularis
1) Have patient tightly hold their humerus next to the chest
2) Attempt to abduct patients arm while they provide resistance
Adduction
1) Place the patients arm at the side in neutral rotation with elbow flexed to 90 degrees
2) Attempt to externally rotate the arm, maintain this position while applying moderate to firm pressure at the distal forearm
External rotation
1) Place the patients arms at the side in neutral rotation with elbow flexed to 90 degrees
2) Attempt to internally rotate the arm, maintain this position while applying moderate to firm pressure at the distal forearm
3) Test the strength of the Infraspinatus and Teres Minor
Internal rotation
What muscle?
1) Have patient forward flex their arms as you depress the arm with one hand and palpate the scapula with the other
2) When weak, the scapula will “wing” at the vertebral border
Serratus Anterior
1) Have the patient place both hands on the iliac crest
2) Push patients arm forward with your hand at the elbow and palpate the vertebral border of the scapula with the other hand
If functional then these muscles will lay flat against the chest wall
Rhomboid
1) Used to diagnose shoulder impingement or rotator cuff tears
2) Place one hand on the posterior aspect of the scapula to maintain in the anatomical position and use your hand to take the patients internally rotated arm by the wrist into full flexion
3) This maneuver compresses the greater tuberosity against the anterior acromion
Neer’s Impingement Sign
1) This test reinforces a positive Neer sign for impingement
2) Flex the patients shoulder to 90 degrees, flex the elbow to 90 degrees and place the forearm in neutral rotation
3) Support the elbow and then passively internally rotate the humerus
4) Pain to the subacromial space is indicative of rotator cuff tear or tendinitis
Hawkin’s Impingement Sign
1) Place patients arms in 90 degrees of abduction, 30 degrees of horizontal abduction and internal rotation with the elbow extend.
2) Push down on the distal arm as the patient resists this pressure
3) A positive sign is pain focal to the middle aspect subacromial space
Empty Can Test
1) Detects tears in the rotator cuff tear (supraspinatus)
2) Instruct patient to fully abduct their arm then ask them to slowly lower it to the side
3) If there are tears in the rotator cuff the arm will drop to the side from a position of about 90 degrees
4) If the patient is able to hold his arm in abduction, a gentle tap on the forearm will cause the arm to fall to his side.
Drop Arm Test
1) Evaluates the teres minor
2) Support patient’s arm in 90 degrees, slightly adducted, elbow flexed to 90 degrees
3) Apply resistance as patient externally rotates arm
4) Weakness indicates a positive sign
Hornblower’s Test
1) This test is helpful in diagnosing biceps tendonitis and bicep strength
3) Have patient forward flex the shoulder to 45 degrees while flexing the elbow to 90 degrees
4) Have the patient resist you as you attempt to pull their arm into shoulder and elbow extension
5) Patient will be positive for biceps tendinitis if they experience pain in the bicipital groove
Speed’s Test
1) Test subscapularis strength and possible tendon rupture
2) Instruct the patient to place the hand behind the back, palm facing away from the body
3) Apply resistance as the patient lifts away from the back
Gerber Lift-off Test
1) With patient standing or supine (for acute or chronic dislocations), place patients arm in 90 degrees abduction, with elbow flexed to 90 degrees
2) Gently externally rotate humerus to 90 degrees
3) Patients with anterior instability may be apprehensive in this position because of the sense of impending dislocation
4) Pain with apprehension is less specific
Apprehension Sign for Anterior instability
1) With patient supine, place patients arm in 90 degrees abduction, with elbow flexed to 90 degrees, and 90 degrees of external rotation
2) Apply posterior force to the anterior proximal humerus at point of external rotation when patient feels apprehensive
3) This should precent anterior subluxation
4) Test is positive if relief of pain and apprehension occurs
5) Suggests anterior glenohumeral instability
Relocation Test of Jobe
1) With patient’s arm relaxed to side place one hand on the posterior scapula and use the other hand to apply traction to the patient’s arm in an inferior direction
2) This maneuver will cause inferior subluxation of the humeral head and a widening of the sulcus between the humerus and acromion
3) A visible dimple is a positive sulcus sign
4) A positive sulcus suggest that the patient has inferior shoulder instability
Sulcus Sign
1) Place the patient’s arm in 90 degrees of flexion with maximal internal rotation with the elbow flexed at 90 degrees
2) Adduct the arm cross body in the horizontal plane while applying an axial load at the elbow to push the humerus in a posterior direction
3) If the maneuver causes a posterior subluxation or dislocation, the humeral head can be felt to clunk or jerk back into the joint as the arm is then horizontally abducted
Jerk Test
1) Flex patients shoulder to 90 degrees and then horizontally adduct the arm across the body
2) Pain over the acromioclavicular joint pathology
Cross Body or Horizontal Adduction Test
1) Place the patient’s arm in flexion 90 degrees of flexion, horizontally adduct to 20-30 degrees.
2) Have patient point thumb down, apply downward force against resistance.
3) Apply force again, but with forearm supinated.
4) Positive: Pain is worse with thumbs down, relieved with forearm supinated. Suggest labral pathology.
Obrien’s Test
Elbow angle is made by the intersection of the axes of the ____ and the ______ with the elbow extended and the forearm supinated
Humerus
Forearm
Normal elbow angle
5-8 degrees
Focal edema over the olecranon is suggestive of:
Olecranon bursitis
Generalized edema and skin abrasions to the posterior aspect of the elbow is suggestive of:
Olecranon fracture
Tenderness and warmth suggestive of:
Bursitis
Tenderness and crepitus suggestive of:
Fracture
Tenderness just above the olecranon suggest:
Triceps tendinitis
Tenderness just distal to the lateral epicondyle is suggestive of
Lateral epicondylitis
Palpate immediately distal to the medial epicondyle
Tenderness is suggestive of:
Medial Epicondylitis
Palpate the ulnar groove that lies between the posterior to the medial epicondyle and medial tip of the olecranon
Light tapping may produce local pain and paresthesia’s in the medial forearm and ulnar two fingers that suggest ulnar nerve entrapment
Tinel Sign
Palpate over the olecranon
Tenderness and possible warmth is suggestive of:
Olecranon bursitis
Palpate over the olecranon
Tenderness with crepitus is suggestive of:
Olecranon fracture
Normal elbow flexion is:
140-150 degrees
Normal elbow extension is:
0 degree
Normal forearm pronation is:
80 degrees
Normal forearm supination is:
80 degrees
Pain in the bicipital groove is suggestive of
Bicep Tendinitis
Flexion weakness may be due to ___ nerve root pathology
C5-C6
Pain on the triceps tendon is suggestive of:
Triceps tendinitis
Extension weakness may be due to ____ nerve root pathology
C7-C8
Supination is from ____ nerve roots
C5-C6
Pronation is from _____ nerve roots
C6-C7
Wrist flexion weakness may suggest:
a) Medial epicondylitis
b) Rupture of the wrist flexor
c) Lesion involving the median nerve (C6 or C7) or ulnar nerve (C8-T1)
Pronation weakness may suggest:
a) Rupture of the pronator or fracture of the medial elbow
b) Lesion of the median nerve or C6 or C7 nerve roots
c) Pain to the medial elbow during this maneuver may suggest medial epicondylitis
Wrist extension weakness may suggest:
a) Lateral Epicondylitis
b) Rupture of the wrist extensor
c) Fracture of the lateral elbow
d) Lesion involving the radial nerve (C6 to C8)
Lateral aspect of the forearm to the first digit involves:
C6
Palmer aspect of the second and third digits:
C7
4th and 5th digits involves:
C8
Medial aspect of the forearm
T1
1) Assess the stability of the medial ligamentous structures, primarily the ulnar collateral ligament
2) With the patient seated or supine, stabilize the lateral side of the elbow with one hand and place the other hand distally on the medial aspect of the elbow
3) Place elbow in slight flexion, approximately 20 degrees
4) Well maintaining stability with your proximal hand, use distal hand to abduct the forearm.
Valgus stress
1) Assess the stability of the lateral collateral ligament in the lateral capsule
2) With the patient seated or supine stabilize the medial side of the elbow with one
hand and place your other hand distally on the lateral aspect of the distal forearm
3) Place elbow and slight flexion approximately 20 degrees
4) With maintaining stability with your proximal hand use your distal hand to adduct the forearm
Varus Stress
1) Instruct the patient to fully flex the elbow with wrist extension for 3-5 minutes
2) Tingling, numbness and paresthesia in the ulnar nerve distribution is positive
for cubital tunnel (ulnar nerve) syndrome.
Elbow Flexion Test
1) Position the patient with the forearm in pronation
2) Resist extension of the third digit distal to the proximal interphalangeal joint, stressing the extensor digitorum tendon
3) Pain to the lateral epicondyle is positive for lateral epicondyle
Long Finger test
1) To perform tinel testing for the Ulnar nerve, lightly percuss the ulnar nerve at the cubital tunnel or ulnar groove
2) Reproduction of paresthesia into the ulnar nerve distribution is positive
3) Suggest ulnar nerve entrapment
Tinel sign
Palpate in the anatomical snuff box for possible:
Scaphoid fracture
Pain or crepitus of the palm is suggestive of:
Arthritis or instability of this joint
1) Place the patients forearm in pronation and the carpus aligned with the plane of the forearm
2) Have patient flex wrist
3) Normal range is 75-80 degrees
Flexion
1) Place the patients forearm in pronation and the carpus aligned with the plane of the forearm
2) Have patient extend the wrist
3) Normal range is 70 to 80 degrees
Extension
1) Place the patients forearm in pronation and the carpus aligned with the plane of the forearm
2) Have patient deviate the hand and the carpometacarpal joints to the radial aspect of the wrist
3) Normal range is 20-25 degrees
Radial Deviation
1) Place the patients forearm in pronation and the carpus aligned with the plane of the forearm
2) Have patient deviate the hand and the carpometacarpal joints to the ulnar aspect of the wrist
3) Normal range is 35-40 degrees
Ulnar Deviation
1) To make a gross estimate of finger flexion have the patient maximally flex the fingers by making a fist with the wrist in a neutral position
2) The fingertips should touch the distal palmer crease
3) If there is a deficiency noted then you must measure the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints for possible flexor tendon injury
Finger Flexion
1) With the wrist in neutral position instruct the patient to fully extend the fingers
2) If there is a deficiency noted then you must measure the metacarpophalangeal proximal interphalangeal and distal interphalangeal joints for possible extensor tendon injury
Finger Extension
1) This movement is collective of the carpometacarpal, metacarpophalangeal and interphalangeal joints
2) Ask the patient to touch the tip of the thumb to the base of the 5th digit
3) Impairment is measured by the distance from the tip of the thumb to the base of the 5th digit
Thumb Opposition
1) Flexion occurs at the metacarpophalangeal (MCP) joint and the interphalangeal (IP) joint
2) Isolate the first MCP joint and have the patient flex the thumb then isolate the IP joint and have the patient flex
3) MCP flexion is typically 50-60 degrees
4) IP flexion is typically 55-75 degrees
Thumb Flexion
1) Have patient place palm up on the exam table with fingers extended
2) Hold the proximal interphalangeal joint (PIP) in extension
3) Ask the patient to flex the distal interphalangeal joint (DIP)
4) Inability to flex the DIP may indicate injury to the profundus or median ulnar nerve injury
Flexor Digitorum Profundus (FDP)
1) Have patient place palm up on the exam table with the fingers extended
2) Hold the fingers into extension except the finger being tested
3) Ask the patient to flex the finger
Flexor Digitorum Superficialis (FDS)
1) With the patient’s hand placed palm up have the patient abduct the thumb by placing it straight up
2) Resist against this motion by pushing the thumb down to the table
3) Weakness indicates damage to the median nerve that is consistent with carpal tunnel syndrome
Thumb Abduction
1) Have the patient squeeze three of your fingers
2) Decreased grip strength may indicate weakness of the finger flexors or intrinsic muscles of the hand
Grip strength
Ulnar Nerve Stimulates the tip of the
5th digit
Median Nerve stimulates the tip of the:
Thumb
Radial nerve stimulates the dorsal surface of the:
Thumb metacarpal
1) To perform to Tinel testing for the median nerve lightly percuss the median nerve at the wrist flexion crease in line with the metacarpal of the long finger
2) Pain and /or paresthesia into the median nerve distribution is a positive sign
3) Suggests Carpal Tunnel Syndrome
Tinel Sign
1) To perform this test have the patient make a fist with a thumb inside the fingers
2) Push the fist into ulnar deviation
3) Pain at the dorsoradial aspect of the wrist indicates a stenosing tenosynovitis of
the abductor pollicis longus and extensor brevis
Finkelstein
1) Ask the patient to position the elbow in a relaxed extension and then allow gravity flexion at the wrist
2) Numbness or tingling in the distribution of the median nerve within 60 seconds is a positive sign
3) Suggest carpal tunnel syndrome
Phalen Maneuver
1) Ask for patient to pinch a piece of paper between the thumb and index fingertip while you apply tension to the other end of the paper
2) If the adductor pollicis muscle is weak to thumb interphalangeal joints will flex
3) Suggest ulnar nerve paralysis
Froments Sign
1) Isolate the involved finger at the middle phalanx
2) Instruct the patient to actively extend the distal interphalangeal joint
3) Inability to actively extend the distal interphalangeal joint is suggestive for extensor tendon avulsion
Mallet Finger Test
