Neck and Upper Extremities - King Flashcards
What is Virchow’s Node?
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)
In what position should you palpate a patient’s thyroid gland?
Standing behind them
What is a thyroglossal cyst?
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)
Cervical Foraminal Compression Test (aka Spurling’s test)
Side bending to the affected side with compression down along the spinal axis- produces radicular symptoms
Maximum cervical compression test
Add extension and rotation to the same side as the head is side bent (this is used if/when Spurling’s is inconclusive)
***Distraction Test (Neck)
Superiorly placed traction on head (hands under mandible and occiput)… Used to alleviate radicular symptoms and support a diagnosis of radiculopathy
Thoracic Outlet Syndrome
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
Roo’s test (for TOS)
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
Adson’s test (for TOS)
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
Neck exam key points:
Cervical nodes Thyroid gland Symmetry of the neck Trachea midline SCM symmetrical Adson's and Roo's tests
Scapular winging (dyskinesia) cause?
Long thoracic nerve injury causing a weak serratus anterior muscle
Extremity strength testing:
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
***Empty Can Test (for SSP m.)
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
Lift-off Test (for SSC m.)
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
***Cross-over Test (for AC joint)
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
Drop-Arm Test (for RC… usually SSP m.)
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
Apley Scratch Test (for frozen shoulders)
Upper arm - Tests external rotation and abduction
Lower arm -Tests internal rotation and adduction
+ tests suggest adhesive capsulitis
Apprehension testing (for shoulder instability)
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
O’Brien’s test (for SLAP tears)
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
Speed’s test (for biceps tendon)
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
Hawkin’s Impingement Sign
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.)
Testing for subacromial bursa inflammation
Stabilize the shoulder and extend the humerus
Pain may indicate subacromial bursitis although the problem may the rotator cuff
What is cubital tunnel syndrome?
An ulnar nerve compression behind the medial epicondyle (type of peripheral neuropathies)
Typical hx for radial head subluxation (aka Nursemaid’s elbow)
Usually due to a sudden pulling on the child’s arm by an adult
Reduction for Nursemaid’s?
Fully supinate affected arm and then fully flex while placing medial pressure on the radial head…should pop back in
***Lateral epicondylitis and extensor tendinitis?
“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)
Medial epicondylitis and flexor tendinitis?
“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)
Enlargement of the ___________ node, especially on the left, suggests possible metastasis from a thoracic or an abdominal malignancy
Supraclavicular (Virchow’s)
Lateral epicondylitis test (tennis elbow)
Palpate the lateral epicondyle while resisting the patients wrist extension
Pain is a positive test
Associated with extensor tendonitis
Medial epicondylitis test (pitcher’s or golfer’s elbow)
Palpate the medial epicondyle while resisting the patient’s wrist flexion
Pain is a positive test
Associated with flexor tendonitis
Other tests for the elbow?
Varus and valgus testing (stabilize the humerus and move the forearm either laterally or medially)
Radiohumeral and ulnohumeral joint tests
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
Common issues with the hand & wrist (seen on inspection):
Hand: Rheumatoid arthritis (Ulnar deviation, Boutonniére deformity) Osteoarthritis (Heberden’s nodes - distal interphalangeal joints, Bouchard’s nodes - PIP's)
Wrist: Ganglion cyst(s)
What is a Boutonniere deformity (“button hole”)?
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”
Ulnar deviation
Commonly seen in RA, caused by weakening of the extensor tendons (flexors cause fingers to deviate in the ulnar direction)
Bouchard’s nodes
extensor surface over PIP’s
Heberden’s nodes
extensor surface over DIP’s (seen in OA of the hands)
Ganglion cyst location?
Usually seen over/in extensor retinaculum
Tinel’s sign (in the wrist for carpal tunnel syndrome)
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
Phalen’s maneuver (for carpal tunnel)
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
Colle’s fracture
Distal radius fracture with distal fracture fragment displaced dorsally
Often due to falling on an outstretched hand
Boxers fracture
Distal 5th metacarpal fracture with volar angulation
Often due to punching something like a wall
Scaphoid fracture
Snuffbox tenderness
Often missed on x-ray
Doesn’t heal well due to poor blood supply
Dupuytren’s contracture
Inflammation, thickening and contracture of the palmar fascia… most commonly in the 4th and 5th digits
Trigger finger
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
Grind test
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
***Finkelstein’s test
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)
Other tests for the hands:
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
