Elbow, Wrist, and Hand Exam + Intervention Flashcards
List common functional limitations found in Elbow, Wrist, and Hand disorders
- Gripping/lifting
- eating
- pushing/pulling
- typing
- catching/throwing
- w/b through the UE
List special tests for the elbow, wrist and hand
- ULTT
- Wright Test
- Thoracic Slump
- Pressure provocation test
- elbow extension, flexion, supination, pronation tests
- biceps squeeze test
- moving valgus stress test
- varus stress test (LCL)
- Valgus stress test (MCL)
- Ulnar collateral ligament test
- Finkelstein’s test
- Anatomic Snuffbox tenderness
of all of the elbow fracture tests which has the best -LR?
Elbow Extension Test
the rest have great +LR but poor -LR
Elbow flexion, pronation, supination tests
what is the pressure provocationt test for?
Cubital tunnel syndrome
describe the procedure for the pressure provocation test
support UE at distal wrist, place the patient’s elbow in 20º of elbow flexion and full supination
apply pressure just proximal to the cubital tunnel and hold 1 min
+test = provocation of concordant symptoms along the ulnar nerve distribution
Which special tests can help rule out elbow instability?
Moving Valgus stress test
Varus stress test (LCL)
Valgus stress test (MCL)
describe the procedure for the moving valgus stress test?
apply valgus torque as shoulder reaches full external rotation
quickly extend elbow to 30º while maintaining valgus at elbow
+test = medial elbow pain provocation from 120-70º flexion
describe the procedure for the varus stress test
- stabilize pt’s wrist between your trunk and proximal upper arm while grasping their distal upper arm with both hands
- apply varus force to elbow
- repeat in 20-30º of flexion
+test = elbow pain provocation
describe the procedure for the valgus stress test
- stabilize pt’s wrist between your trunk and upper arm while grasping their distal upper arm with both hands
- apply valgus force to elbow
- repeat 20-30º of flexion
+test = elbow pain provocation
what is the ulnar collateral ligament test indicated for?
gamekeeper’s thumb (thumb instability)
describe the procedure for the ulnar collateral ligament test
- stabilize 1st metacarpal w/pincer grip and grasp proximal phalanx of 1st digit with other hand
- extend pt’s thumb
- apply valgus stress to MCPJ
+test = valgus motion >30º
what is Finkelstein’s Test indicated for?
de Quervain’s Tenosynovitis
describe the procedure for Finkelstein’s Test
- sitting, grasping ipsilateral thumb
- stabilize wrist and passively take pt through procedure
- pt adducts the wrist
+test = pain over APL/EPB tendons
T/F: the Finkelstein’s Test is a good test
FALSE
research properties are weak
useful with other findings
Anatomic Snuffbox Tenderness is a test indicated for what?
Scpahoid fracture
List the different neurodynamic tests performed at the UE and what is a positive finding/test
- Median nerve bias
- Ulnar nerve bias
- Radial nerve bias
+test = concordant symptoms reproduction, response altered by movement of distal body part, test difference with laterality
List the components/procedure for the Median Nerve bias neurodynamic test
- Scapular depression
- Shoulder abduction to 110º
- Forearm supination
- Wrist/hand extension
- Shoulder ER
- Elbow extension
List the components/procedure for the Radial nerve bias neurodynamic test
- Scapular depression
- Forearm pronation
- Elbow extension
- Wrist/and finger flexion
- Shoulder IR
- Shoulder slight extension
- Shoulder abduction
List the components/procedure for the Ulnar Nerve bias neurodynamic test
- Scapular depression
- Shoulder abduction to 110º
- Shoulder ER
- Elbow flexed
- Forearm pronated
- Wrist/hand extension
Structural stress testing of the distal UE includes AROM, PROM for which joints?
- Humero-ulnar (flx/ext
- Radio-ulnar (pronation/supination)
- Radio-carpal (flx/ext and ABD/ADD)
- MCP (flx/ext)
- IP (flx/ext)
- CMC
List bone and joint palpation sites that should be checked for the distal UE
- M/L epicondyle
- Olecranon process
- Humero-ulnar and Humero-radial joint lines
- Radial head
- Carpals
- Trapezium, Hamate, Pisiform, Scaphoid, Lunate, Capitate
- Metacarpals
- Phalanges
- CMC Joint
- IPJs
- MCPs
- Radial styloid process
- Lister’s tubercle
List soft tissue palpation sites that should be checked during the distal UE exam
- Muscle bellies/tendons:
- Biceps, brachilias, brachioradialis, triceps
- Guyon’s Canal
- Common extensor tendon
- Common flexor tendon
- Carpal tunnel
- TFCC
what joints are tested during the Joint Mobility testing portion of the distal UE exam? match them with their glides
- Humero-ulnar (P)
- Humero-radial (A/P)
- Proximal radio-ulnar (A/P)
- distal radio-ulnar (A/P)
- Radiocarpal (V/D and Radial/Ulnar)
- CMC (Palmar/Dorsal and Radial/Ulnar)
- MCP, PIP, DIP (Palmar/Dorsal)
List confirmation tests for the distal UE exam
- Elbow flexion test
- Tinel’s sign
- Cozen’s test
- Resisted Tennis Elbow Test
- Passive Tennis Elbow Test
- Phalen’s Test
- Tinel’s test
- Median Nerve Compression test
which confirmation tests are for Cubital Tunnel Syndome?
- Elbow flexion test
- Tinel’s sign
describe the procedure for the Elbow Flexion Test
- Pt fully flexes elbow and extends wrist
- Pt monitored for symtpoms over 3 minutes
+test = pain/paresthesia, anesthesia along ulnar nerve distribution
great +LR
describe the procedure for Tinel’s sign
- facing pt, support their wrist
- percuss cubital tunnel 4-6x with finger
+test = reproduction of symptoms along ulnar nerve distribution
great +LR
which confirmation tests are for lateral epicondylopathy?
- Cozen’s Test
- Resisted Tennis Elbow Test
- Passive Tennis Elbow Test
describe the procedure for Cozen’s Test
- pt is positioned sitting w/elbow flexed to 90, making a fist, wrist in pronation and radial deviation
- facing pt’s sympomatic side, support elbow w/thumb on lateral epicondyle
- pt extends fist against your resistance
+test = pain reproduction at lateral epicondyle
describe the procedure for the resisted tennis elbow test
- pt is sitting and you are facing their sympomatic side
- pt extends the 3rd digit against resistance
+test = pain reproduction at lateral epicondyle
describe the procedure for the passive tennis elbow test
- pt is sitting and you are on their symptomatic side
- pt elbow is passively extended
- pronate their forearm and flex their wrist
+test = pain reproduction at lateral epicondyle
What confirmation tests are for Carpal Tunnel Syndrome?
- Phalen’s Test
- Tinel’s Test
- Median Nerve Compression Test
describe the procedure for Phalen’s Test
- pt is sitting and you are observing
- pt hold forearm vertically and drips wrist into full flexion x 60 secs
+test = symptom reproduction along median nerve distribution
conflicting data (well studied)
describe the procedure for Tinel’s Test
- pt sitting, supinated wrist and flexed elbow, position yourself facing pt
- carpal tunnel percussed 4-6x
+test = symptom reproduction along median nerve
conflicting data
describe the procedure for the Median Nerve Compression test
- pt sitting w/forearm supinated
- face the pt and grasp wrist w/thumbs over their carpal tunnel
- between flexor carpi radialis and palmaris longus)
- pressure applied to carpal tunnel x15 sec - 2 min
+test = symptom reproduction along median nerve
great +LR and -LR
list some work related factors that should be included in pt edu related to distal UE disorders
- tracker ball vs. mouse
- workstation set-up
- dictation application for entering electronic data
- non-work related factors → minimize texting
list some potential complications to corticosteroid injections
- local infection
- post-injection steroid flare (temporary worsening of pain in the first 24 to 36 hrs after injection)
- atrophy of subcutaneous fat
- local depigmentation of the skin
- tendon rupture
what are the types of nerve mobilizations?
- active vs passive
- gliders vs tensioners
give a brief description explaining some of the potential mechanisms for nerve mobilizations
- thought to decrease adhesions and allow improved movement of peripheral nerves
- may increase neural vascularity allowing increased oxygenation of the nerve and a resultant decrease in ischemic pain
- dispersion of noxious fluids
- improvement of axoplasmic flow
T/F: nerve mobilizations are strongly supported for treatment of CTS and cubital tunnel syndrome
FALSE
there are case studies/expert opinions supporting nerve mobs with CTS
conflicting research in regard to efficacy for cubital tunnel syndrome
list interventions used in the management of OA
- Inflammatory management
- thermal/cryotherapy
- Exercises
- gripping/resistive exercises
- ROM exercises
- Manual Therapy
- Joint mobs
- Joint Protection
- Splinting
- activity modification
describe the general management of elbow, wrist, and hand sprains
- post-op vs conservative
- inflammatory/pain management (acute)
- protection of injury site (splinting/casting) → injury and time dependent
- Pt edu
- progression of PROM/AAROM/AROM/Resistive exercise as appropriate
- consider healing timeframes
- communication w/MD (especially post-op restriction)
- Progress to stabilization exercises/return to functional activity
describe the general management for tendinopathies
- NSAIDs, local steroid injection, Sx
- Education
- resting position
- activity mods
- Protection
- splinting
- activity mods
- Exercise
- stretching
- AROM/tendon gliding
- eccentrics
- Post-op management
what would tendon glides be indicated for?
- prevent adhesion postop
- address adhesion with tenosynovitis
- maintain/improve ROM
- pain relief
describe general management of lateral epicondylitis and interventions that may be used
- pt edu/act mods
- inflammatory/pain management interventions
- eccentrics
- Joint manipulation
- C/S
- T/S
- Elbow/forearm/wrist
- Joint mobs (including MWM)
- soft tissue mobilization
- ROM/stretching exercises
what broad categories of joint mobilization interventions are available for the elbow/forearm?
- Manipulation
- Mobilization w/movement
- end-range stretch and oscillation mobs
list the manipulations that can be performed at the elbow/forearm
- Mill’s manipulation
- Watson manipulation (scaphoid whip)
describe the Mills manipulation
- target of force → post aspect of olecranon and post aspect of radial head
- relative structural movement → forced extension elbow
- pt position → standing w/arm at side, shoulder IR, pronation, wrist flexion
- force directed ventrally
- indicated for lateral epicondylopathy
describe Watson’s manipulation
- target of force → pt scaphoid between thumb (dorsal) and index finger (ventral), bilaterally
- relative structural movement → scaphoid on radius (PT provides ventral force on scaphoid during quick extension of wrist)
- pt position → sitting, pronated
- indication → lateral epicondylopathy
list MWM that can be performed at the elbow/forearm
- lateral glide of humero-ulnar joint
- anterior humero-radial w/active supination
- posterior humero-radial w/active pronation
list end-range stretch and oscillation mobs that can be peformed at the elbow/forearm
- humero-ulnar → distraction
- humero-radial → anterior, posterior
- proximal radio-ulnar → anterior
list end-range stretch and oscillation mobs that can be performed at the wrist and hand
- radio-carpal
- anterior/posterior
- radial/ulnar
- IP, MCP
- anterior/posterior
- traction
