Joints of the upper limb

Question 1

What causes movement in a joint?

Answer 1

Usually a particular muscle group(more important to know this then it is to learn the individual muscles)

Question 2

What are the compartments of the upper arm and forearm?

Answer 2

anterior and posterior compartments for both

Question 3

What do muscles of the anterior compartment of the upper arm do?

Answer 3

produce flexion of the elbow

Question 4

What do the muscles of the posterior compartment of the upper arm do?

Answer 4

produce extension of the elbow

Question 5

What do the muscles of the anterior and posterior compartments of the forearm do?

Answer 5

anterior- produce flexion at the wrist and fingers

posterior-produce extension of the wrist and fingers

Question 6

How can you test muscles generally in the upper limb?

Answer 6

Ask the patient to actively contract the muscle to produce a certain movement and at the same time you actively resist the muscle

If the muscle group is accessible on the surface of the limb you may also palpate the surface of the muscle and feel the strength of the contraction

Question 7

What are the joints of the upper limb?

Answer 7

Scapulthoracic- between the scapula and thoracic wall

Glenohumeral joint(shoulder joint)- humerus articulates with the scapula

Elbow joint- the distal end of the humerus articulates with the proximal ends of the 2 forearm bones the radius and the ulna

Proximal Radio-ulnar joints- when the palm of the hand is facing forward the hand is SUPINATED and the ulna and radius joint at the proximal end of the forearm

Distal Radio-ulnar joints- When the palm of the hand is facing backwards the hand is in the PRONATION position where the radius rotates around in front of the ulna to lie diagonolly across it causing the distal ends of the radius and ulna to be joined

Radiocarpal (wrist joint)- The distal end of the raidu and the articular disc of the distal radioulnar joint articulates with the proximal row of carpal bones(except pisiform) The distal end of the ulna does not take part in the wrist joint

Intercarpal-joints between the adjacent carpal bones and the midcarpal joint between the proximal and distal rows of the carpal bones

Carpometacarpal (CMC)- the proximal ends of the metacarpal bones articulate with the distal row of the carpal bones. almost no movement occurs at the 2nd and 3rd CMC and only slight in the 4th and 5th

Intermetacarpal joint-the metacarpal of the thumb articulates with the trapezium to form a saddle joint which allows the thumb to move in various planes

Metacarpophalangeal(MP) -the heads of the metacarpals (distal ends) articulate with the bases of the proximal phalanges to form the MP joints

Interphalangeal (IP) the heads of the proximal phalanges (distal ends) articulate with the bases of the distally located phalanges and form the IP joints

Question 8

what movement is associated with each joint of the upper limb?

Answer 8

Scapulothoracic- elevation, depression, protraction(moving forward), retraction(moving backwards) of the shoulders and rotation of the scapula

Shoulder Joint- flexion of the arm at the shoulder (both forwards and backwards, extension, abduction(move arm sideways away form the body), internal rotation move hand inwards across the body with elbow bent), external rotation(extend arm outward and rotate like the exercise to get rid of bingo wings), circumduction

Elbow joint- flexion (so wrist is up in front of shoulder), extension,

Radioulnar joints-pronation(palm facing down), supination(palm facing up)

Wrist- flexion (up and down), extension, adduction(wrist moves sideways towards the body when palm is facing upwards), abduction(wrist moves back straight after adduction

Intercapal and midcarpal- flexion-extension and abduction-adduction of the wrist

Intermetacarpal-very restricted sliding movements

Metacarpophalangeal (MP)-Flexion, extension, abduction, adduction, and circumduction (although the MP joint of the thumb is limited to flexion and extension).

Interphalangeal- Flexion and extension only

Question 9

What are the 7 basic types of movements to describe joint movements?

Answer 9

1-elevation and depression
2-Protraction and retraction
3-Flexion and extension
4-abduction and adduction
5-circumduction
6-internal and external rotation
7-Pronation and supination

Question 10

What are the five general rules when examining the joints?

Answer 10

1-look -visual inspection
2-Feel-palpation
3-Move-range of passive movements
4-Measure-measure the degree of movements
5-Compare with the opposite limb

For this it is important to expose the whole of the upper limb and shoulder regions much as possible

Question 11

name the 3 steps to take in the examination?

Answer 11

1- ALWAYS ask the patient if they have any PAIN prior to the palpation and the passive movement

2- Visual inspection and palpation

3- Ask the patient to relax the muscle of the lib and trunk

4- hold the part of the limb and move the joint GENTLY

5- look for stability of the joint crepitus, tone(esp for rigidity and spasticity), pain and range of movements

6- notice and record any abnormalities during the PASSIVE movement of the joint and always compar one limb with the opposite side

Question 12

describe the assessment of passive joint movements and tone of the upper arm?

Answer 12

1-ask patient to completely relax so arm goes floppy
2-Passively circumduct at the shoulder joint to detect stiffness or reduced tone and repeat at the other shoulder joint
3-Passively flex and extend at the elbow joint to detect stiffness or reduced tone and repeat at the other elbow
4-passively pronate and supinate at the radioulnar joints to detect stiffness and reduce tone (for both)
5- Passively flex and extend at the wrist joints to detect stiffness or reduced tone

Question 13

describe how you test the muscle power at the shoulder, elbow and radioulnar joints?

Answer 13

1- ask patient if they are okay to remove their shirt
2-ask them to push up against the wall with their hands flat and feel for contraction on the lateral thoracic wall and check for winging of the scapula (testing extrinsic shoulder muscles and serratus anterior)
3-ask them to take a couple of steps back and raise there arm out to the side and you try to bring it back to their side(do with both arms)
4-Ask them to raise their shoulders up to there ears and say that you are going to try and stop them and then do this(tests extrinsic shoulder muscle trapezius). Feel for contraction when resisting elevation of the shoulder
5- ask them to lay back down on the bed
6- ask them to try and move their arm up and out ot he side and then try and stop them (test for intrinsic shoulder muscle s-Deltoid). Feel for the contraction of the clavicular head of the deltoid (repeat on both arms)
7-ask them to try and move their arm out again but before they do keep them at the patients side(test intrinsic shoulder muscle-supraspintus) Feel for contraction above the scapula spine
8-Ask them to bend arm at the elbow and try and move arm out to the side as you push against it(testing intrinsic shoulder muscles -infraspinatus/teres minor) Feel for contraction below the scapular spine
9-Do same as 8 but with patient moving arm in towards the body(testing intrinsic shoulder muscle-Sunscapularis) Cannot feel for contraction as muscle is located on the anterior surface of the scapula
10-Ask patient to bring their arm out and up towards the side and then try and move it back down as you push against it (testing Pectoral group-Pectoralis Major). Feel for contraction at the anterior axillary fold
11- ask patient to bend there arm at the elbow and then try to move it up towards their shoulder (testing elbow flexors- Brachialis/Biceps Brachaii) Feel for contraction on the anterior arm as you push against it
12- Ask patient to do the same thing as 11 but to try and extend the arm(testing elbow extensor-triceps brachaii)Feel for contraction on the posterior arm as you push up against it
13-ask patient to have palm facing upwards towards the ceiling and try and rotate it to face downwards as you try to stop them (testing Pronators-pronator quadrants and the pronator teres). Feel for contraction of the pronator teres on the anterior forearm
14-Ask patient to have palm towards the floor and try and turn it up as you try to prevent it(testing the Supinator) Feel for contraction posteriorly around the superior third of the radius bone

Question 14

What bones are included in the pectoral girdle?

Answer 14

Clavicle and scapula

Question 15

What is the skeleton divided into?

Answer 15

Appendicular skeleton-limbs

Axial skeleton -skull, hyoid bone, neck, spine, ribs, sternum

Question 16

How is the upper limb connected tot he axial skeleton?

Answer 16

Via the pectoral girdle

Question 17

What is the acromioclavicular joint and sternoclavicular joint?

Answer 17

Acromioclavicular-when the clavicle articulates with the acromian process of the scapula laterally

Sternoclavicular- when the clavicle articulates with the manubrium of the sternum medially

both are PLANE SYNOVIAL joints

Question 18

Where does the spine of the scapula end?

Answer 18

ends laterally in the ACROMION PROCESS

Question 19

What is the coracoid process?

Answer 19

It projects anteriorly from the scapula

Question 20

What helps increase the range of movement of the upper limb?

Answer 20

The clavicle as it holds the upper limb clear of the trunk which increase the range of movement

Question 21

What type of joint is the glenohumeral joint?

Answer 21

ball and socket synovial joint

Question 22

What type of joint is the elbow joint?

Answer 22

synovial hinge joint which only permits flexion and extension

Question 23

What kind of joint is formed when the metacarpal of the thumb articulates with the trapezium?

Answer 23

Saddle joint which allows the thumb to move in various planes

Question 24

At which Carpometacarpal joints is movement restricted?

Answer 24

2nd and 3rd- almost no movement

4th and 5th- only slight movement

Question 25

What does the range of movement of a joint depend on?

Answer 25

joint structure, ligaments, tendons, muscles, skin, tissue injury, fat tissue, body temperature, activity level, age and sex

these can also effect the hypermobility or hypomobility of a joint

Question 26

What is responsible for skeletal muscle tone?

Answer 26

Neuromuscular activity in the muscles responsible for voluntary movement at a joint usually causes a few fibres within a muscle to be in a state of contraction all the time.

This contraction is responsible for muscle tone

Question 27

How can you test the loss or increase in muscle tone?

Answer 27

Tested passively by moving the joints and comparing the resistance to the movements by the muscles on the two sides of the body

you will feel some residual resistance even thought the patient is not consciously contracting the muscle, this residual resistance is muscle tone

Question 28

What is responsible for muscle tone?

Answer 28

REFLEX CONTROL from the afferent nerve endings situated in the muscle itself .

The integrity of the spinal segmental reflex arc is the basic mechanism underlying the muscle tone

Question 29

What is hypotonia and what causes it?

Answer 29

Reduced tone

Caused by a breach/disruption in the spinal segmental reflex arc and if the simple spinal reflexes are not functioning as the muscle will be fully relaxed

you experience this if you have a LOWER MOTOR NEURONE problem/lesion

Question 30

What is hypertonia and what is it caused by?

Answer 30

Increased muscle tone

The upper motor neurons can have and INHIBITORY EFFECT on the lower motor neurons. So if the cerebral contorl is disrupted e.g. an Upper Motor Neuron lesion/problem, the inhibition is lost and the muscle tone is exaggerated

Question 31

What are the upper motor neurones?

Answer 31

Nerves from the cerebral cortex, midbrain, pons and medulla

Question 32

What is a prime mover?

Answer 32

Main muscle responsible for producing a specific movement of the body part

Question 33

How do you test the Scapulothoracic joint and what are the prime movers for each movement type?

Answer 33

Elevation - Superior trapezius, levator scapulae, rhomboids

Depression -Inferior trapezius, pectoralis minor, serratus anterior

Protraction -Pectoralis minor, serratus anterior

Retraction -Rhomboids, middle trapezius, latissimus dorsi

Rotation -Glenoid fossa faces upwards or downwards as scapula rotates

Rotation-up: - Superior trapezius, inferior trapezius, serratus anterior

Rotation down:-Pectoralis minor, latissimus dorsi, rhomboids
levator scapulae

As the patient carries out each of these movements you need to push against and resist the movement of each muscle so they can be palpated or seen and the strength and power tested

Question 34

How do you test the Glenohumeral joint and what are the prime movers for each movement type?

Answer 34

Flexion-Pectoralis major, deltoid (anterior fibres)

Extension -Deltoid (posterior fibres)

Abduction-Supraspinatus initially and then central deltoid

Adduction- Pectoralis major, latissimus dorsi

Internal rotation-Subscapularis

External rotation - Infraspinatus

As the patient carries out each of these movements you need to push against and resist the movement of each muscle so they can be palpated or seen and the strength and power tested

Question 35

How do you test the Elbow joint and what are the prime movers for each movement type?

Answer 35

Flexion-Biceps, brachialis, brachioradialis (pronator teres)

Extension -Triceps (anconaeus)

As the patient carries out each of these movements you need to push against and resist the movement of each muscle so they can be palpated or seen and the strength and power tested

Question 36

How do you test the Radio ulnar joints and what are the prime movers for each movement type?

Answer 36

Supination- Supinator, Biceps

Pronation-Pronator quadratus, Pronator teres

As the patient carries out each of these movements you need to push against and resist the movement of each muscle so they can be palpated or seen and the strength and power tested

Question 37

What are the key features of a normal muscle inspection?

Answer 37

Muscle groups and muscle bulk should appear and feel symmetrical

No muscle movement should be present at rest

Question 38

How do we grade muscle strength

Answer 38

For noting the strength/power a numerical scale used - Medical Research Council (MRC) Muscle Power scale.

There is a 0 to 5 rating scale for muscle strength:

0/5 -No movement
1/5 -Barest flicker of movement of the muscle, though not enough to move the structure to which it’s attached
2/5 -Voluntary movement which is not sufficient to overcome the force of gravity. For example, the patient would be able to slide their hand across a table but not lift it from the surface.
3/5 -Voluntary movement capable of overcoming gravity, but not any applied resistance. For example, the patient could raise their hand off a table, but not if any additional resistance were applied.
4/5 -Voluntary movement capable of overcoming “some” resistance
5/5 -Normal strength

’+’ and ‘-‘ can be used indicate more subtle descriptions of power (e.g., 4+ or 4- , 3+ or 3-, etc.) For instance if a patient can overcome “moderate but not full resistance”

Question 39

What are the movements of the scapula against the thoraci wall and what are the prime mover muscles and agonists

Answer 39

Elevation- Trapezius(descending part)(prime mover), Levator scapulae, Phomboids

Depression-Gravity(prime mover), pectoralis major, inferior sternocostal head, Latissimus dorsi, Trapezius(ascending part), Serratus anterior(inferior part), Pectoralis minor

Protraction- Serratus anterior(prime mover), Pectoralis major, Pectoralis minor

Retraction-Trapezius(middle part)(prime mover), Rhomboids, Latissmus dorsi

Upwards rotation- Trapezius(descending part)(prime mover), trapezius(Ascending part), Serratus anterior(inferior part)

Downwards rotation-Gravity, Levator scapulae, Rhomboids, Latissimus Dorsi(prime mover), Pectoralis minor, Pectoralis major

Question 40

Which nerve goes to each muscle involved in movement ?

Answer 40

Trapezius (descending and ascending part)- Spinal Accessory nerve

Levator scapulae and rhomboids- Dorsal scalpular
Pectoralis Major-Pectoral nerves

Latissimus dorsi-Thoracodorsal

serratus anterior- Long thoracic nerve

Pectoralis minor- medial pectoral nerve

Sub clavius - Nerve to subclavius

Deltoi-Axillary nerve

Supraspinatus- Supraspinatus nerve

Infraspinatus- suprascapular nerve

Teres minor- Axillary nerve

Teres Major- Lower subscapular nerve

Subcapularis- upper and lower subscapular nerve

Biceps Brachii-Musculocutaneous

Coracobrachialis- Musculocutaneous

Brachialis-Musculocutaneous nerve and radial nerve

Triceps Brachii-Radial nerve

Anconeus-Radial nerve

Supinator Muscel-deep branch of the redial nerve

Pronator quadrants- median nerve

Pronator teres- Median nerve

Question 41

What are the 4 rotator cuff muscles and what is their function?

Answer 41

Intrinsic shoulder muscles that are part of the glenohumeral joint and give it more stability

Supraspinatus, Infraspiantus, teres minor, subscapularis

Question 42

Where are the flexor and pronator muscle?

Answer 42

anterior compartment of the forearm

Question 43

Where are the extensor and supinator muscles?

Answer 43

In the posterior compartment of the forearm

Question 44

What muscles groups are in the wrist, hand and digits

Answer 44

1) Flexors and extensors of the wrist
2) Abductors and adductors of the wrist
3) Superficial, and deep digital flexors
4) Extensors of the digits
5) Thenar, and hypothenar muscles
6) Palmar and dorsal interossei

Question 45

What movement happens at the wrist?

Answer 45

lexion, extension, ulnar deviation (adduction) and radial deviation (abduction), circumduction (rotatory)

Question 46

How do you test the movements of the wrist joint

Answer 46

1-Before starting, the patient holds their hand in a neutral position
2-You will apply opposing force with your hand either on the dorsum or on the palm of your colleagues hand while they perform extension or flexion movements respectively at the wrist joint.
3- For testing adduction and abduction, you will hold the distal end of the forearm (above wrist) with one hand and apply an opposing force with your other hand to the ulnar or radial side of the patient’s hand.