Clinical 6: Upper Limb Exam

Question 1

What sort of things are you looking for in the should examination observation stage?

Answer 1

Scars
Deltoid wasting
Winging of the scapular
Buldge in proximal portion of the upper arm.
Rotator cuff wasting

Question 2

What are you feeling for in the shoulder examination?

Answer 2

The temperature of the shoulder joint
Light touch sensation distally (e.g hands)
Feel the deltoid muscle for tenderness
Feel the trapezius muscle for tenderness
Bony structures: sternocalvicular joint, clavicle, acromion, coracoid process, head of humerus, greater trochanter of humerus, spine of scapular, borders of scapula

Question 3

What active movements should be assessed in the shoulder exam?

Answer 3

External rotation and abduction - hands behind their head and elbows out to the side.
Internal rotation and adduction - hands behind back and reach as far as able.
Shoulder flexion - point at ceiling
Shoulder extension - behind them
Abduction - side to touch above head
Adduction - across front of body
External rotation - arc motion on flexed elbow
Internal rotation - hand behdin back and as far up spine as able
Scapular movement - stand behdin the patient and ask to raise both arms anterolaterally

Question 4

What passive movements of the shoulder should be assessed?

Answer 4

Flexion - to ceiling
Extension - arms out behind
Abduction
Adduction
External rotation
Internal rotation

Question 5

What does painful abduction of the shoulder indicate?

Answer 5

Impingement of the supraspinatus muscle

Question 6

What does crepitus in the shoulder suggest?

Answer 6

Arthiritis in the glenohumeral joint

Question 7

What does pain and complete stiffness in the shoulder suggest?

Answer 7

Adhesive capsulitis
‘frozen shoulder’

Question 8

What special tests should be preformed in the shoulder exam?

Answer 8

External rotation against resistance
Internation rotation against resistance
Jobe’s test (Empty can test)
Scarf test (Cross arm test)

Question 9

How do you test external rotation of the shoulder against ressitance?
Why?

Answer 9

Position in arm in slight abduction and elbow flexed at 90 degrees
Ask to push against your hand
Poor ability of pain indiciates infraspinatous or teres minor teat and tendinopathy.

Question 10

How do you test insternal rotation against resistance?
Why?

Answer 10

Ask patient to place dorsum of their hand against their lower back
Apply light resistance to the hand towards the patient back
Ask patient to move hand off the back
Tenderness indicates subscapularis tendinopathy.

Question 11

What is the epmty can test of the shoulder?
What is its purpose?

Answer 11

Ask patient to flex shoulder to 90 degrees in the plan of the scapular
Ask to imagine emptying coke cans out on the floor
Ask to resisit pushing hands down.
Tenderness indicates subacromial pathology

Question 12

What is the scarf test of the shoulder?
Why do we do it?

Answer 12

Shoulder and elbow in 90 degrees
Hold scapula to reduce movement
Passively adduct the arm across the body
Pain at extremes of motion indicat Acromclavicular injury.

Question 13

What are the looking for in an elbow examination?

Answer 13

Erythmya
bruising/scarring/swelling
Rheumatoid nodules
Psoriatic plaques
Wating around the elbow
Assess the carrying angle
Ask patient to hold arms out horizontally in front of them with palms facing upwards - look for fixed flexion deformity.

Question 14

What are you feeling for in the elbow examination?

Answer 14

Assess the difference in joint temperature
Light touch sensation distally
The lateral epicondyle
The medial epicondyle
The olecranon
Biceps tendons - when flexed to 90 degrees
Radial head - best felt by passively pronation/supination forearm whilst palpating.

Question 15

What active movements should be assessed int he elbow examination?

Answer 15

Flexion
Extension
Supination
Pronation

Question 16

What special tests should be performed in the elbow examination?

Answer 16

Wrist Flexion against resistance (support elbow, ask to clench first and start from 90 degrees elbow flexion)
Extension against resistance (support elbow, ask to clench fist and start from 90 degrees elbow flexion).

Question 17

What passive movements should be assessed in the elbow exam?

Answer 17

Flexion
Extension
Supination
Pronation
Hold joint at the elbow and fee for crepitus

Question 18

What are you looking for on the wrist examination?

Answer 18

Put hands of pillow to suport and observe both sides, ask to lif hand slightly to look at dorsal surface breifly.
Swelling
Skin changes
Nail changes
Wasting
Swan neck deformity.
Boutonniere deformity
Dropped fingers
wrist joint abnormalities
Subluxation of MCP joint and ulnvar deviation

Ask to lift arms up and show elbows for rheumatoid nodules and psoriatic plaques.

Question 19

What are you feeling for in the wrist examination?

Answer 19

Compare the temperature of the two joints
Squeeze the metacarpal bones
Feel of all joint bones (knuckles in fingers and thumbs)
Feel thenar and hypthenar muscle bulk (palmar hand)
Feel for palmar thickening
Palpate the radial and ulnar pulses
Check capillary refill time
Assess light touch sensation
Palpate extensor tendons of the thumb
Palpate medial border of the forearms to elbow
Palpate scaphoid in the anatomical snuff box

Question 20

What passive movements should be completed int eh wrist examination?

Answer 20

Extension - prayer
Flexion - upside down prayer

Question 21

What hand function movements should be assessed in the wrist examination?

Answer 21

Finger extension against resistance
Finger abduction aginst resistance
Thumb adbuction - against resistanct
Power grip - ask to grip index fingers
Pincer grip - ask to touch top of thumb to tip of each of their fingers
Pincer power - ask to pinch your index finger between their tip of thumb and index finger
Picking up a small object - pick up a coin using one hand.

Question 22

What special tests should be completed in the wrist examination?

Answer 22

Tinels test
Phalens test

Question 23

What is tinels test?
What is its purpose?

Answer 23

Lay the patient hand on a table with the palm facing upwards
Tap with index finger over the median nerve at the wrist crease
Tingling or discomfort can indicate median nerve pathology.

Question 24

What is phalens test?
What is its purpose?

Answer 24

Ask the patient to flex both wrists, placing the dorsum of their hands back to back
Ask to maintain for 60 seconds
Tingling or discomfort radiating into fingers suggests median nerve compression (e.g carpal tunnel syndrome)