L5: UE Assessment Flashcards
What are the three types of joints in the UE?
Examples?
-
Synovial
- Hinge joint: elbow joint, interphalangeal joints
- Condylar joint: metacarpoplangeal (knuckle) joints, wrist joints
- Ball-and-socket joint: shoulder joints
- Cartilaginous
- Fibrous
Anatomy
What are the superficial veins of the UE?
What are the lymph nodes of the UE?
- Superficial veins
- Cephalic
- Bascilic
- Lymph nodes
- Axillar
- Epitrochlear (~inner elbow)
ROS: What would you be looking for in each of the following systems?
Skin
Musculoskeletal
Cardiovascular
Neurovascular
-
Skin
- Changes in color
- Temperature
- Hair distribution
- Ecchymosis
- Atrophy
- Swelling
- Asymmetry
-
Musculoskeletal
- Joint stiffness
- Pain
- Restriction of motion
- Joint swelling/edema
- Deformity
- Myalgia
-
Cardiovascular
- Claudication
-
Neurovascular
- Numbness
- Tingling
- Burning sensation
Principles of examination:
Proximal to distal or distal to proximal?
What are the components of the exam?
What are ou assessing for in each
What do you always examine last?
- Evaluate: Proximal to Distal
- Evaluate painful area last
- Components of examination:
- Inspection
- Palpation
- Range of Motion
- Neurologic
- Vascular
- Special Tests
Tenderness to Palpation (TTP)
How to assess?
- Localize as specifically as possible
- “ONE finger”
- Anatomical location usually provides diagnosis
- Bone, muscle, bursa, tendon, ligament, or combination
- Correlate with positive findings on inspection
Muscle Strength
What are the 6 grades of muscle function?
Grade 0: No muscle contraction
Grade 1: Visible contraction, no joint movement
Grade 2: Joint motion, but not against gravity
Grade 3: Movement against gravity only
Grade 4: Movement with some resistance
Grade 5: Full strength with full resistance
Winged Scapula
What is it?
what is injured?
- Paralysis of the serratus anterior from injury to the long thoracic nerve
Glenohumeral Dislocation
What type of dislocation is the most common?
Clinical presentation?
-
Dislocation
- 95% Anterior
- 5% posterior
-
Inspection
- Arm held in position of protection
- Sulcus Sign
- Arm held in position of protection
Shoulder: Palpation
What are you palpating for?
- Palpate and verbalize muscles and bony landmarks of the shoulder:
- Clavicle
- Acromioclavicular (AC) joint
- Acromion process
- Coracoid process
- Humerus
- Bicipital groove
- Tenderness
- Unilateral or bilateral
- Localized or radiating
Shoulder: ROM testing
What actions are you testing?
ROM testing should be done both passive and active:
- Flexion/Extension
- Abduction/Adduction
- Internal/External rotation
ROM: Rotator Cuff Function
What are the actions of the rotator cuff?
Which muscle does which action?
- Abduction
- Supraspinatus
- External Rotation
- 80% Infraspinatus
- 20% Teres Minor
- Internal Rotation
- Subscapularis
Impingement syndrome
What is it?
What causes it?
- Mechanical phenomenon
- Not enough space
Arc Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
Pain Provocation Test: Painful Arc Test
-
How to test
- Passively adduct arm 0– 180
- Determine degrees of pain
-
Positive test:
- Pain between 60° and 120°
-
DDx:
- Subacromial impingement
- Rotator cuff tendinitis
Neer’s Sign
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Stabilize scapula with one hand
- Rotate hand away
- Raise patient’s arm into full forward flexion
-
Positive test:
- Pain with internal rotation
-
DDx:
- Subacromial impingement
- Rotator cuff tendinitis
Hawkins
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Stabilize shoulder with one hand
- Flex elbow to 90
- Internally rotate shoulder (“rock” the arm)
-
Positive test:
- Pain
-
DDx:
- Supraspinatus impingement
- Rotator cuff tendonitis
External Lag Sign
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Flex elbow to 90 degrees
- Passively externally rotate shoulder
-
Positive test:
- Inability to maintain external rotation
-
DDx:
- Supraspinatus pathology
External Rotation Resistance Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Ask patient to flex elbows to 90° in supination
- Stabilize one arm
- Apply internal pressure at wrist
- Ask patient to externally rotate against resistance
-
Positive test:
- Pain or weakness
-
DDx:
- Infraspinatus pathology
Gerber Lift Off
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Patient seated or seated
- Ask patient to rest dorsum of hand on low back/sacrum
- Ask patient to lift off to increase amount of internal rotation
- Apply gentle resistance to hand
-
Positive test:
- Inability to lift off or maintain resistance
-
DDx:
- Subscapularis pathology
Empty Can (Jobe’s Test)
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Elevate arms 90slightly away from midline
- Internally rotate arm, thumbs down (pour out can of soda)
- Resist downward pressure
-
Positive test:
- Weakness or pain (inability to maintain resistance and may indicate supraspinatus injury/tear)
-
DDx:
- Rotator cuff tear
- Tendinopathy
Drop Arm
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Passively abduct shoulder to 120
- Patient to slowly lower arm back to side
-
Positive test:
- Weakness, difficulty with smooth ROM
-
DDx:
- Rotator cuff tear
- Tendinopathy
Adhesive Capsulitis
Symptoms
What is it?
- Adhesive Capsulitis (Frozen Shoulder)
- Diffuse, dull, aching pain
- Usually no localized tenderness
- Progressive restriction of ROM in multiple planes: Mechanical restriction
- Usually unilateral
Apley Scratch Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Ask patient to reach for opposite scapula
- Abduction/External Rotation
- Adduction/Internal Rotation
- Compare ROM to both sides
- Ask patient to reach for opposite scapula
-
Positive test:
- Asymmetry in comparison ROM
-
DDx:
- Rotator cuff pathology
- Labral pathology
- Arthritis
- Adhesive capsulitis
Sulcus Sign
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Arm in neutral position by side
- One hand to stabilize shoulder
- Apply downward pressure at elbow
-
Positive test:
- ≥ 2cm depression of humeral head
-
DDx:
- Inferior shoulder instability
- Subluxation
Apprehension, Relocation, and Release Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Patient supine
- Elbow flexed 90
- Externally rotate shoulder (towards head)
- Apply posterior pressure to humerus (relocation)
- Abruptly remove pressure from humerus (release)
-
Positive test:
- Pain with external rotation & relieved with internal rotation
-
DDx:
- Shoulder laxity/ instability (i.e. previous shoulder dislocation or chronic laxity)
Speeds
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Extend elbow with full supination
- 60-90° shoulder flexion
- Ask patient to resist downward pressure
-
Positive test:
- Pain
-
DDx:
- Biceps tendonitis
Yergason Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Arm positioned like shaking hands, but with elbow at torso
- One hand to stabilize upper arm, hold patient’s hand with other
- Patient to supinate & externally rotate against resistance
-
Positive test:
- Pain or popping/clicking along biceps tendon
-
DDx:
- Biceps subluxation
- Biceps tendonitis
Cross-Body Adduction
How to perform the test?
What is a positive test?
What is the differential diagnosis?
Acromioclavicular (AC) Joint: Cross-body Adduction Test
-
How to test:
- Examiners adducts pts arm across body toward other arm
-
Positive test:
- Pain (pain elicited and localized to the AC joint)
-
DDx:
- AC pathology
O’Brien’s Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Place one hand on shoulder
- Arm flexed to 90
- Adduct arm 10-15
- Patient to resist downward pressure on wrist
-
Positive test:
- Pain or weakness in: labral, AC, biceps
-
DDx:
- Biceps tendonitis
Deformity of Upper Arm
Causes?
- Acute trauma: fracture
- Previous trauma: malunion, nonunion
- Biceps rupture
- Tumor
Elbow: ROM
What do you test for ROM?
For strenght testing?
-
ROM:
- Flexion and extension
- Pronation and supination
-
Strength Testing:
- Flexion/extension
- Supination/pronation
Epicondylitis
What is it?
What is it called when you injure the medial side? Test?
What is it called when you injure the lateral side? Test?
- Overuse syndromes
- Inspection/Palpation: localized pain and swelling
- Reproducible pain with wrist flexion (medial) or extension (lateral) against resistance
- Medial: Golfers Elbow
- Flexor pronator muscle group
- Pain with resisted wrist flexion
- Lateral: Tennis Elbow
- Extensor supinator muscle group
- Pain with with resisted wrist extension
Olecranon Bursitis
What is it?
Cause?
- Inflammation of the bursa with fluid accumulation
- May be due to local irritation, trauma, or infection
- Pain suggests trauma or infectiona
Tinels Sign at Elbow
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Tap median nerve at wrist or ulnar nerve at elbow.
-
Positive test:
- Shooting electric sensation or paresthesia over ulnar nerve distribution
-
DDx:
- Cubital Tunnel Syndrome
Subcutaneous Nodules
Colles’ Fracture (distal radius)
- Colles’ Fracture (distal radius)
- Often happens when falling on outstretched arms
- Displaced dorsally
Hand Inspection
Swan neck
Boutonnière
Palmar thickening
Ulnar deviation
Nodes
- Swan neck: hyperextension of PIP joints with fixed flexion of DIP
- Boutonnière: flexion of PIP joint with hyperextension of DIP joint
- Palmar thickening (cords): Dupuytren’s contracture
- Ulnar deviation: RA
- Nodes: Heberden & Bouchard
Ulnar deviation
MCP and PIP
Rheumatoid Arthritis
Hand Nodes
Heberden nodes
Bouchard nodes
Rheumatoid nodules
-
Heberden nodes: osteoarthritis (OA)
- NOT characteristic of rheumatoid arthritis u dorsolateral aspects of DIP joints
- usually hard and painless
-
Bouchard nodes: OA>> RA
- less common than Heberden nodes in OA u nodes at PIP joints
- Swelling at PIPs (and MCPs) more common in RA
- Rheumatoid nodules: common on dorsum of hand
Boutonniere & Swan Neck Deformity
Action at PIP joints?
Action at DIP joints?
Carpal Tunnel Syndrome
Cause?
Nerve involved?
Result?
- Median nerve and flexor tendons pass through tunnel
- Median nerve becomes compressed by inflammation of the synovium
- Results in compression neuropathy with pain, paresthesias, and thenar atrophy
Tinels Sign at the Wrist
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Slightly extend at the wrist
- Percuss over the median nerve
-
Positive test:
- Shoot electric sensation or paresthesia in the distribution of the median nerve
-
DDx:
- Carpal tunnel
Phalens Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Patient to maintain flexion OR extension of the wrists for 60+ s.
-
Positive test:
- paresthesia in the distribution of the median nerve
-
DDx:
- Carpal tunnel syndrome
de Quervain’s Tenosynovitis
What is it?
Cause?
- Inflammation of the 1st dorsal compartment involving the sheath of the abductor pollicis longus and extensor pollicis brevis
- Causes: overuse/repetitive gripping
Finkelstein Test
How to perform the test?
What is a positive test?
What is the differential diagnosis?
-
How to test:
- Arms out in front of body, make a fist with thumb inside
- Ulnar deviate wrist (downward)
- Provider may then attempt to ↑ degree of ulnar deviation
-
Positive test:
- Pain along radial dorsal wrist (1st dorsal compartment)
-
DDx:
- de Quervain’s tenosynovitis
Ganglion Cysts
What are they?
Inspection?
Palpation?
ROM?
- Collection of synovial fluid within a joint or tendon sheath
- Herniation of synovial tissue from capsule or tendon sheath
- Inspection: dorsal radial & volar aspects of wrist
- Palpation: Soft mobile mass
- ROM: May restrict motion or become painful with repetitive activity
Anatomic Snuffbox Palpation
How to perform the test?
What is a positive test?
What is the differential diagnosis?
What are the borders of the anatomical snuffbox?
-
How to test:
- Palpate anatomical snuff box
-
Positive test:
- Tenderness
-
DDx:
- Scaphoid/navicular fx.
- Borders
- Lateral border:
- Extensor pollicis brevis and abductor pollicis longus
- Medial border:
- Extensor pollicis longus
- Lateral border:
Dupuytren’s Contracture
What is it?
A condition in which one or more fingers bend in towards the palm due to the development of fibrous connective tissue between the tendons of the finger.
Capillary Refill
How to test?
What is normal?
- Place pressure over nail beds to cause blanching then quickly remove
- Observe the time elapsed for full return of color
- Normal: < 2 seconds
Wrist and Hand ROM
What are you evaluating?
- Wrist flexion and extension
- Radial and ulnar deviation
- MCP, PIP, DIP flexion
- Make a fist
- Digit extension with abduction/adduction
ROM of the Digits
How to test?
Wrist & Hand Strength Testing
What are you testing?
- Wrist flexion/extension
- Test grip strength:
- Ask patient to grip your two fingers and squeeze
Neurologic Check: Sensory
What nerves?
How to test?
Sensory check:
Axillary
Radial
Median
Ulnar
Neurologic check: Motor
How to test?
- Motor examination of the hand:
- Rock: Median nerve
- Paper: Radial nerve
- Scissors: Ulnar nerve
- OK: Anterior Interosseus n. (AIN)
- Branch of the Median n.
- Mnemonic: “OK, Stop, Spread “em”
- OK = Rock
- Stop = Paper
- Spread ‘em = Scissors
Neurovascular
-
Median
- Sensory
- Palmar tip of index finger
- Motor
- Pronated full fist
- Recurrent branch: palmar thumb abduction
- AIN: “OK” sign
- Sensory
-
Radial
- Sensory
- Dorsum 1st webspace
- Motor
- Wrist, finger, thumb extension
- Sensory
-
Ulnar
- Sensory
- Palmar tip of small finger
- Motor
- Cross fingers or spread against resistance
- Adduction of thumb
- Sensory
