Neck and upper limb exam Flashcards
Identify clinically important anatomical structures of the cervical vertebrae
- Vertebral structure : Body, Cartilaginous discs, Synovial facets, Spinous processes (C7 Vertebra prominence) Transverse processes
- Sternocleidomastoid
- Thyroid gland (causes the most pathology)
Anterior Triangle Borders
- superior
- medial
- lateral
– Superior-Mandible
– Medial-Midline of the Neck
– Lateral-Sternocleidomastoid muscle
Describe important surface anatomical landmarks of the neck
• Hyloid, thyroid cartilage, and cricoid cartilage (this ligament in between there is very little cartilage and it is very thin so if a patient is chocking, you can make an incision, you can save their life (cricothyoidotomy)
Explain proper technique for examining cervical lymph nodes
- preauricular
- occipital
- deep cervical
- submandibular
- submental
- supraclavicular
- Preauricular
- Occipital (stretch around the neck→ drainage over the ear and over to the back of the head)
- Deep cervical -get your hand under the SCM
- Submandibular (midway bw the mandible and submental area
- Sumbental- right in front of the chin
- Supraclavicular- right on top of the clavicle
Describe cervical lymph node and lymphatic drainage of the neck
- Most lymphatic drainage is into the deep system
- Deep nodes are deep to sternocleidomastoid muscle and normally not palpable except the supraclavicular node
- Virchow’s Node-supraclavicular node of the deep chain that is sometimes palpable in thoracic or abdominal malignancies
what muscles allow for different range of motion
- flexion
- ext
- rotation
- SB
– Flexion- anterior neck muscles
– Extension- posterior neck muscles
– Rotation- trapezius, scalene, sternocleidomastoid (SCM), splenius, longissimus, semispinalis, and obliqus capitis
– Side bending- trapezius, scalene, SCM, splenius, longissimus, semispinalis, obliqus, longus and rectus capitis
Cervical Foraminal or Compression Test or Spurling’s maneuver
– Side bending to the affected side with compression down along the spinal axis- produces radicular symptoms and should exaggerate them. If this doesn’t work, try max cervical compression test
Maximum cervical compression test
– Add extension and rotation to the same side as the head is side bent
Distraction Test
– You provide traction (pull up the head) to alleviate radicular symptoms and support a diagnosis of radiculopathy. So if this makes it better then you could support that there was compression
Etiology of 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.
Symptoms and treatment of thoracic outlet syndrome
Symptoms include:
– pain in the neck and shoulders
– numbness in the last 3 fingers and forearm.
• Thoracic outlet syndrome is usually treated with physical therapy which helps strengthen and straighten the shoulders.
Roo’s test
Diagnose thoracic outlet:
– 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
Diagnose thoracic outlet
– 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→ it means subclavian a is being impingement
Supraspinatus Injury–> empty can test
• 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.
Subscap injury–> Lift-off test
• 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.
Crossover Test
• 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.
Rotator Cuff test
Common injury, can be acute or chronic. Cause: Lifting heavy objects or repetitive abduction or overhead use of the arm. Symptoms: pain inferior to the anterior border of the acromion or referred pain to the anterior deltoid insertion on the humerus. Pathology: Acromial spurring, subacromial impingement and bursitis, microtears of the supraspinatus, or complete tear.
Drop arm test (supraspinatous)
– 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 tes
Upper arm- Tests external rotation and abduction. Lower arm-Tests internal rotation and adduction. Suggest adhesive capsulitis→ repetitive damage to shoulder joint, the capsul around the joint itself gets stiff and decreases motion.
Apprehension test
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. If the shoulder is too lax and the rotator cuff muscle isn’t holding their shoulder enough so when you do if feels like you might be dislocating their shoulder so they become apprehensive.
O’Brian’s Test
Done for biceps tendonitis
– 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.
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 muscle, teres minor muscle, and Infraspinatus muscle
Subacromial Bursa
– Stabilize the shoulder and extend the humerus. Pain may indicate subacromial bursitis although the problem may the rotator cuff.
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
Varus/valgus testing
similar to knee tests if angle of elbow is varus (elbows point out) or valgus (elbows point in)
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
Tinel’s sign
special wrist test
– 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
– 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.
Grind test
Tests for carpo-metacarpal osteoarthritis. Most commonly found at 1st carpo-metacarpa 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).
Varus/Valgus ligament stress test
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.
Winged scapula
damage to long thoracic n causing weak serratus anterior
Lateral epicondylitis and Extensor Tendinitis (Tennis Elbow) clinical presentation/symptoms
- Generally chronic not acute
- Symptoms: Pain in the lateral elbow and dorsal region of the forearm. Worse with wrist extension, gripping or lifting.
- Cause: Repetitive use of forearm extensors
- Pathology: microtears of the tendinous attachment at the lateral epicondyle of the extensor carpi radialis brevis (ECRB), the supinator, extensor carpi radialis longus (ECRL), and the extensor digitorum communis (EDC)
Medial epicondylitis and Flexor Tendinitis (Golfers Elbow) symptoms
- Generally chronic not acute
- Symptoms: Pain in the medial elbow and volar region of the forearm. Worse with wrist flexion, gripping or lifting.
- Cause: Repetitive use of forearm flexors
- Pathology: microtears of the common tendinous attachment at the medial epicondyle of the flexor carpi radialis (FCR), pronator teres, palmaris longus, flexor carpi ulnaris (FCU), flexor digitorum superficialis.
SD of radial head
- Posterior with Pronation and Anterior with Supination
- Radial Head Posterior Somatic Dysfunction→ Does not move anteriorly with supination
- Radial Head Anterior Somatic Dysfunction→ Does not move posteriorly with pronation
- Compare both sides
Cubital tunnel symdrome
ulnar nerve compression behind the medial epicondyle
Radial head subluxation or nursemaid’s elbow
usually due to sudden pulling on the arm by an adult. Grip the radial head and feel its movement during pronation and supination. Then try to glide it anteriorly and posteriorly. Similar to looking for radial head somatic dysfunction
Ganglion cysts
Synovial lining extensions that fill with fluid that often becomes gelatinous
Tenosynovitis-
DeQuervain’s disease and others
Osteoarthritis
OA of the hands shows Heberden’s nodes at the DIP joints.. May not be symmetric
Rheumatoid arthritis
RA of the hands shows deformity of the wrist, MCP and PIP joints, but not the DIP joints. Ulnar deviation. Symmetric.
Psoriatic arthritis
Involves the DIP joints, and inflammation of the skin
Gout
Inflammation of the joint due to deposition of uric acid crystals
Carpal tunnel syndrome
median n. compression (more in neuro)
Colles’ Fracture
Distal radius fracture with distal fracture fragment displace 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** important one
Snuffbox tenderness, Often missed on x-ray, Doesn’t heal well due to poor blood supply. Blood supply is on the distal side so if it fractures, the proximal side can necrosis
Dupuytren’s contracture
Inflammation, thickening and contracture of the palmar fascia most commonly in the 4th and 5th digits. (Dr. Lee has this)
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.
Muscle strength scale
From 0-5
begin with normal side, isolate joint you want to test strength, compare both sides, and rate using the scale
• 0 - No active movement (wont see this unless patient is dead)
• 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
Speeds test
(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
