CLIN SKILLS: Upper Limb Exam

Question 1

general process for MSK upper limb exam

Answer 1

• introduction
• look
• feel
• move
• special tests

Question 2

inspection for shoulder exam

Answer 2

• muscle bulk
• asymmetry/abnormal posture
• skin
• swelling
• deformity e.g. winging of scapula - ask them to place their hands on their hips when you look from behind

Question 3

palpation for shoulder exam

Answer 3

• bony landmarks: sternal notch, sternoclavicular joints, clavicles, AC joints, deltoid, infraspinatus, supraspinatus muscle bulk, greater and lesser tubercules, bicipital groove, coracoid process, spine of scapula, medial border of scapula, inferior angle of scapula, subacromial space
• effusion
• swelling
• temperature

Question 4

movements for shoulder exam

Answer 4

• ACTIVE > PASSIVE, UNAFFECTED SIDE 1st, CHECK FOR CREPITUS
• flexion - 180˚
• Extension – 65˚
• Abduction – 180˚ active and 90˚ passive (STABILISE SCAPULA)
• Adduction – 50˚
• External rotation – 65˚
• Internal rotation – 90˚

Question 5

special tests for shoulder exam (just list them)

Answer 5

• supraspinatus impingement: hawkins, neer, painful arc
• resisted movements (muscle tears): empty can (supraspinatus), external rotation (infraspinatus + teres minor), lift off (subscapularis), biceps
• other: apprehension, apley scratch

Question 6

when is neer’s test/painful arc positive?

Answer 6

• pain within 70-120 degrees flexion or abduction

Question 7

if there is a rotator cuff tear, will active or passive movements be affected?

Answer 7

• active
• passive may still be normal as long as joint is still intact/stable

Question 8

inspection for elbow exam

Answer 8

• muscle bulk
• asymmetry: carrying angle (should be 5-10˚ valgus)
• skin
• swelling: rheumatoid nodules, gouty tophi, olecranon bursitis
• deformity

Question 9

palpation for elbow exam

Answer 9

• bony landmarks: medial epicondyle, lateral epicondyle, olecranon, ulnar nerve
• effusion
• swelling: rheumatoid nodules, gouty tophi, olecranon bursitis
• temperature

Question 10

special tests for elbow exam

Answer 10

• medial epicondylitis: check if pain, palm facing Pt in supination, get them to bring palm towards them against resistance
• lateral epicondylitis: check if pain, dorsum facing Pt in pronation, get them to bring dorsum towards them against resistance

Question 11

movements for elbow exam

Answer 11

• flexion - 150˚
• extension - 0˚
• pronation and supination - 90˚

Question 12

special tests for hand + wrist

Answer 12

• hand function tests (GP OK): grip strength, practical, opposition strength, key grip
• carpal tunnel tests: Phalen’s (flex wrists against each other and hold for 30 seconds) and Tinel (percuss carpal tunnel)
• Finkelstein test: flex thumb and make a fist, perform ulnar deviation

Question 13

special tests for elbow

Answer 13

• medial epicondylitis: resisted wrist flexion in supination
• lateral epicondylitis: resisted wrist extension in pronation

Question 14

inspection for hand/wrists

Answer 14

• muscle bulk
• asymmetry - fixed ulnar deviation
• skin (inc. scars due to carpal tunnel surgery)
• swelling
• deformity

Question 15

palpation of elbow

Answer 15

• bony landmarks: anatomical snuffbox, wrist joint (radial styloid, ulnar head, ulnar styloid, lister’s tubercle, carpals)
• effusion
• swelling
• temperature

Question 16

wrist movements ROM

Answer 16

• flexion - 75˚
• extension - 75˚
• radial deviation - 20˚
• ulnar deviation - 20˚

Question 17

inspection of hand

Answer 17

• muscle bulk (thenar + hypothenar eminence)
• asymmetry/abnormal contour
• skin
• swelling
• deformity

Question 18

hand deformities

Answer 18

• pitting nails (psoriatic arthritis)
• sausage shaped fingers (psoriatic arthritis)
• mallet finger: DIP is naturally flexed and returns to flexed position if you try to straighten it
• trigger finger: DIP is naturally flexed but can be straightened if you passively do it
• boutonniere: fixed extension of DIP and flexion of PIP (RA)
• swan neck: flexion of DIP and extension of PIP (RA)
• Z deformity of the thumb (RA)
• Bouchard’s nodes: PIP joint (OA)
• Heberden’s nodes: DIP joint (OA)
• Dupuytren’s contraction: fixed flexion deformity on 3-5th digits (thickening of palmar fascia)

Question 19

palpation of hands

Answer 19

• bony landmarks: MCP, PIP, DIP joints
• effusions
• swelling: rheumatoid nodules + gouty tophi
• temperature

Question 20

movement for hands

Answer 20

• PIPs and DIPs - don’t forget thumb
• MCP joints: flexion (90), extension (30) abduction and adduction - can do all fingers together
• thumb: flexion, extension, abduction, adduction, opposition

Question 21

special tests for hands

Answer 21

• hand function tests (GP OK): grip strength, practical test, opposition strength, key grip
• carpal tunnel: Whalen’s, tinel
• Finkelstein

Question 22

carpal tunnel tests

Answer 22

• phalen’s test: flex both wrists against each other for 30 seconds - tingling/numbness
• tinel sign (T=tap): percuss carpal tunnel on palmar surface - do they feel any tingling or numbness

Question 23

Finkelstein test

Answer 23

• for De Quervain’s tenosynovitis/tendinitis
• ask the Pt to flex thumb and make a fist around it and then perform ulnar deviation (towards 5th finger)

Question 24

OA vs RA

Answer 24

• RA (autoimmune - chronic inflammation of synovium): morning stiffness for 1 hr or more, pain improves w/ activity but returns @ rest, usually bilateral
• OA (repeated movements degrade articular cartilage): morning stiffness for 30 mins or less, pain after activity but better @ rest, crepitus, can be unilateral