Neck and Upper Extremities - King

Question 1

What is Virchow’s Node?

Answer 1

Supraclavicular node of the deep chain that is sometimes palpable in thoracic or abdominal malignancies

It is the only normally palpable node of the deep nodes (most cervical lymphatic drainage is into the deep system)

Question 2

In what position should you palpate a patient’s thyroid gland?

Answer 2

Standing behind them

Question 3

What is a thyroglossal cyst?

Answer 3

During embryonic development, thyroid tissue migrates from the base of the tongue through the thyroglossal duct into the neck…If the duct does not close before birth a thyroglossal duct cyst may form (this is rare)

Question 4

Cervical Foraminal Compression Test (aka Spurling’s test)

Answer 4

Side bending to the affected side with compression down along the spinal axis- produces radicular symptoms

Question 5

Maximum cervical compression test

Answer 5

Add extension and rotation to the same side as the head is side bent (this is used if/when Spurling’s is inconclusive)

Question 6

***Distraction Test (Neck)

Answer 6

Superiorly placed traction on head (hands under mandible and occiput)… Used to alleviate radicular symptoms and support a diagnosis of radiculopathy

Question 7

Thoracic Outlet Syndrome

Answer 7

Occurs when there is compression of vessels and nerves in the area of the clavicle

Happens when there is an extra cervical rib or because of a tight fibrous band that connects the spinal vertebra to the rib

Question 8

Roo’s test (for TOS)

Answer 8

Arms abducted to 90°, externally rotated

Elbows flexed at 90°

Patient slowly opens and closes his hands for 3 minutes

If there is weakness, numbness or tingling of the hand or arm the test is positive

Question 9

Adson’s test (for TOS)

Answer 9

Palpate the radial pulse with the elbow and shoulder in extension

Continue to palpate pulse and move the arm the arm into abduction and external rotation and flex elbow

Have the patient turn their head away from the side being tested

If the pulse diminishes then the test is positive for thoracic outlet syndrome

Question 10

Neck exam key points:

Answer 10

Cervical nodes
Thyroid gland
Symmetry of the neck
Trachea midline
SCM symmetrical 
Adson's and Roo's tests

Question 11

Scapular winging (dyskinesia) cause?

Answer 11

Long thoracic nerve injury causing a weak serratus anterior muscle

Question 12

Extremity strength testing:

Answer 12

Use the following scale when recording and reporting strength so that the measured strength is the numerator, i.e. measured strength/5 (always use denominator)

0 - No active movement

1 - Muscle contraction, no movement

2 - Full active ROM with gravity eliminated e.g, horizontal to floor

3 - Full active ROM against gravity, e.g, perpendicular to
floor

4 - Full active ROM against partial resistance

5 - Full active ROM overcome full resistance

Question 13

***Empty Can Test (for SSP m.)

Answer 13

Abduct arms to 90° and forward flex to 45°

Internally rotate to point thumb downward (like emptying a can of soda)

Then put gentle pressure downward on both arms

Pain or weakness indicates injury to the supraspinatus muscle

Question 14

Lift-off Test (for SSC m.)

Answer 14

With arm internally rotated so dorsum of hand rests on low back, have patient lift the hand off their low back posteriorly against your resistance

Question 15

***Cross-over Test (for AC joint)

Answer 15

Adduct the arm across the chest which compresses the acromioclavicular joint and causes pain if there has been disruption of the AC joint or arthritis

Question 16

Drop-Arm Test (for RC… usually SSP m.)

Answer 16

Examiner abducts patient’s arm to 90° and asks patient to slowly lower arm to their side

If the patient’s arm drops to their side, the test is positive indicating a rotator cuff problem, most often the supraspinatus

Question 17

Apley Scratch Test (for frozen shoulders)

Answer 17

Upper arm - Tests external rotation and abduction
Lower arm -Tests internal rotation and adduction
+ tests suggest adhesive capsulitis

Question 18

Apprehension testing (for shoulder instability)

Answer 18

Arm is abducted to 90° and externally rotated

Put the other hand on the back of the shoulder and push gently forward while gently extending the arm

Any look of alarm on the patients face or pain is a positive test for a loose joint capsule and potential subluxation or dislocation

Question 19

O’Brien’s test (for SLAP tears)

Answer 19

Flex arm to 90°and adduct across the chest

Internally rotate with the thumb pointing down and push down on the arm

Pain is a positive test for a labral tear (SLAP- Superior labrum anterior to posterior)

Confirmed by repeating with thumb pointing up and no pain

Question 20

Speed’s test (for biceps tendon)

Answer 20

Flex straight arm to 90° with the palm facing upward

The patient resists the student pushing down

If pain occurs in the area of the bicipital groove the test test is positive indicating biceps tendonitis

Question 21

Hawkin’s Impingement Sign

Answer 21

Examiner grasps patients elbow with one hand and their distal forearm with the other

Examiner passively externally rotates the shoulder
(impinges subscapularis muscle)

Examiner passively internally rotates the shoulder
(impinges supraspinatus, teres minor, and infraspinatus mm.)

Question 22

Testing for subacromial bursa inflammation

Answer 22

Stabilize the shoulder and extend the humerus

Pain may indicate subacromial bursitis although the problem may the rotator cuff

Question 23

What is cubital tunnel syndrome?

Answer 23

An ulnar nerve compression behind the medial epicondyle (type of peripheral neuropathies)

Question 24

Typical hx for radial head subluxation (aka Nursemaid’s elbow)

Answer 24

Usually due to a sudden pulling on the child’s arm by an adult

Question 25

Reduction for Nursemaid’s?

Answer 25

Fully supinate affected arm and then fully flex while placing medial pressure on the radial head…should pop back in

Question 26

***Lateral epicondylitis and extensor tendinitis?

Answer 26

“Tennis elbow” (usually chronic)

Sx: Pain in the lateral elbow and dorsal region of the forearm…worse with wrist extension, gripping or lifting

Cause: Repetitive use of forearm extensors (causes micro tears of the common tendinous attachments at the lateral epicondyle)

Question 27

Medial epicondylitis and flexor tendinitis?

Answer 27

“Golfer’s elbow” (usually chronic)

Sx: Pain in the medial elbow and velar region of the forearm…worse with wrist flexion, gripping or lifting

Cause: Repetitive use of the forearm flexors (causes micro tears of the common tendinous attachments at the medial epicondyle)

Question 28

Enlargement of the ___________ node, especially on the left, suggests possible metastasis from a thoracic or an abdominal malignancy

Answer 28

Supraclavicular (Virchow’s)

Question 29

Lateral epicondylitis test (tennis elbow)

Answer 29

Palpate the lateral epicondyle while resisting the patients wrist extension

Pain is a positive test

Associated with extensor tendonitis

Question 30

Medial epicondylitis test (pitcher’s or golfer’s elbow)

Answer 30

Palpate the medial epicondyle while resisting the patient’s wrist flexion

Pain is a positive test

Associated with flexor tendonitis

Question 31

Other tests for the elbow?

Answer 31

Varus and valgus testing (stabilize the humerus and move the forearm either laterally or medially)

Question 32

Radiohumeral and ulnohumeral joint tests

Answer 32

Position the elbow where discomfort occurs, then radially or ulnarly deviate the wrist to compress the radial head or ulna into the humerus

Pain indicates a problem with that joint

Question 33

Common issues with the hand & wrist (seen on inspection):

Answer 33

Hand: 
Rheumatoid arthritis (Ulnar deviation, Boutonniére deformity)
Osteoarthritis (Heberden’s nodes - distal interphalangeal joints, Bouchard’s nodes - PIP's) 

Wrist:
Ganglion cyst(s)

Question 34

What is a Boutonniere deformity (“button hole”)?

Answer 34

Seen in chronic arthritis, especially in RA, you get deposition of crystals and cyst formation on the extensor joints of the fingers, decreases ROM, “easy to spot”

Question 35

Ulnar deviation

Answer 35

Commonly seen in RA, caused by weakening of the extensor tendons (flexors cause fingers to deviate in the ulnar direction)

Question 36

Bouchard’s nodes

Answer 36

extensor surface over PIP’s

Question 37

Heberden’s nodes

Answer 37

extensor surface over DIP’s (seen in OA of the hands)

Question 38

Ganglion cyst location?

Answer 38

Usually seen over/in extensor retinaculum

Question 39

Tinel’s sign (in the wrist for carpal tunnel syndrome)

Answer 39

Sharply tap over the location of the median nerve in the carpal tunnel, on the palmar surface of the wrist, using your index and middle finger, or a reflex hammer

A positive test is noted by reproduction of the patient’s pain typically a shooting pain or parasthesias in the distribution of the median nerve

Tinel’s sign is not specific for carpal tunnel syndrome…it can be used in the diagnosis of any compression neuropathy

Question 40

Phalen’s maneuver (for carpal tunnel)

Answer 40

Ask the patient to flex both wrists to 90 degrees and place the dorsal aspect of the hands together, and hold them in that position for one minute

A positive test results in reproduction of the patient’s pain

Question 41

Colle’s fracture

Answer 41

Distal radius fracture with distal fracture fragment displaced dorsally

Often due to falling on an outstretched hand

Question 42

Boxers fracture

Answer 42

Distal 5th metacarpal fracture with volar angulation

Often due to punching something like a wall

Question 43

Scaphoid fracture

Answer 43

Snuffbox tenderness

Often missed on x-ray

Doesn’t heal well due to poor blood supply

Question 44

Dupuytren’s contracture

Answer 44

Inflammation, thickening and contracture of the palmar fascia… most commonly in the 4th and 5th digits

Question 45

Trigger finger

Answer 45

Inflammation of the flexor digitorum tendon sheath which becomes trapped under the A-1 pulley (retinaculum) just proximal to the MCP joints during flexion, and extension of the finger requires assistance and often snaps/triggers as it slips past the pulley

Question 46

Grind test

Answer 46

Tests for carpo-metacarpal osteoarthritis

Most commonly found at 1st carpo-metacarpal joint

Abduct thumb and grasp base of metacarpal and rotate it back and forth looking for discomfort

Question 47

***Finkelstein’s test

Answer 47

Put the patient’s thumb inside their fist, and then gently ulnar deviate the wrist

If pain occurs along the thumb or wrist, the test is positive for tenosynovitis of the extensor pollicis brevis and abductor pollicis longus (De Quervain’s Disease)

Question 48

Other tests for the hands:

Answer 48

Varus/Valgus ligament stress:
Stabilize the proximal bone with one hand while using the other hand to deviate the distal bone to the ulnar and radial sides checking for ligamentous instability

Thumb/Ulnar collateral ligament stress:
Put stress on the upper thumb joint, by pushing the thumb away from the hand