Neck UE exam (Pitcher) Flashcards
Common causes of hoarseness
Acute infection Smoking Tumors Thyroid Enlargement Damage to the Recurrent Laryngeal Nerve
Common causes of enlarged lymph nodes
metastatic cancer
lymphoma
infection
common causes of enlarged thyroid
goiter
thyroid cancer
common causes of neck/ arm pain
central or peripheral nerve impingement
torticollis
lymphadenopathy
thyroiditis
Common Neck Conditions
Somatic dysfunction
Muscle sprain or spasm
Torticollis- Sternocleidomastoid spasm causes ipsilateral sidebending and contralateral rotation
Thoracic outlet syndrome
Disc herniation- often causes nerve root impingement
Spondylolisthesis- forward displacement of one of the vertebra may compress the spinal cord
Osteoarthritis- chronic degenerative arthritis
Ankylosing spondylitis- spinal inflammatory degenerative arthritis that causes vertebral fusion
Vertebral fracture- caused by trauma, osteoporosis, malignancy,
TMJ
Temporomandibular Joint (TMJ): May radiate pain to neck region
Palpate at rest then during slow opening and closing of mouth
Crepitus, clicks, clunk, locking or fear of locking
Anterior neck triangle borders
Superior-Mandible
Medial-Midline of the Neck
Lateral-Sternocleidomastoid muscle
Posterior neck triangle borders
Inferior-Clavicle
Posterior-Trapezius Muscle
Anterior-Sternocleidomastoid Muscle
Cervical Triangles: Mass Differential
Preauricular and angle of jaw: salivary gland or parotid
Posterior triangle: high index of suspicion for malignancy
Supraclavicular (esp left): suggest malignancy.
Anterior triangle: enlarged LN, branchial cleft cyst
Central: thyroid or malignant origin, dermoid cyst, thyroglossal duct cyst
Cervical lymphatic drainage
Most lymphatic drainage is into the deep system
Deep nodes are deep to sternocleidomastoid muscle and normally not palpable except the supraclavicular node when enlarged
Virchow’s Node-palpable left sided supraclavicular node suggests thoracic or abdominal malignancies
Right sided enlarged supraclavicular lymph node suggests malignancy of mediastinum, lungs or esophagus
Goiter
Often grow slowly, may be due to Hashimoto’s thyroiditis or iodine deficiency, be asymptomatic , can cause some obstructive symptoms (most usual is exertional dyspnea, then cough)if large enough. Evaluation includes the search for nodules and cellular exam if found. Other causes are Graves, benign multinodular goiter, cancer
Thyroglossal duct cyst
Congenital epithelial remnant of the thyroglossal tract that forms a cyst due to an unknown stimulus. May contain thyroid cancerous cells.
Branchial Cleft Cyst
Typically near mandibular angle and anterior to SCM
Benign but get infected, typically removed
Structural Neck Exam. Inspection: Posture
Position of the head and trunk in 2 positions
Nose Midline
Laterally- Ear in line with the shoulder, greater trochanter, fibular head, and lateral malleolus
Spinal curves –
front to back
side to side
Structural Neck Exam: Palpation
Lymph nodes Range of motion Thyroid Clavicle, upper ribs TART - Spinous processes - Paraspinal musculature - Transverse Processes
Structural neck exam: range of motion- active and passive
Flexion- 45°
Extension- 60°
Rotation- 80°
Side bending- 45°
Range of neck motion and muscles involved
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
Radiculopathy
Radiculopathy: Central is true dermatomal
Screen with sensory exam and deep tendon reflexes bilaterally
Cervical Foraminal Compression Test
(Spurling’s maneuver)
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
Distraction Test
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.
Anomalous cervical rib
Tight fibrous band that connects the spinal vertebra to the rib
Muscle anomalies: variable insertion points
Injury: whiplash, repetitive motion (working overhead)
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 restore the gap
Roo’s Test
(for thoracic outlet syndrome)
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
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.
Common causes of upper extremity trouble
Injury
- Contusions
- Fractures
- Tendon or ligament tears
- Repetitive use
tendonitis
bursitis
Muscular Disorders
- Muscular dystrophy
- Rabdomyolysis
Bone and Joint Disorders
- Arthritis- osteo or rheumatoidShoulder joint types
Acromioclavicular: Synovial condylar Glenohumeral Synovial spheroidal type Labral ring Rotator cuff
Rotator Cuff Muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Shoulder Exam Inspection and Palpation
Acromioclavicular Joint
Glenohumeral joint
- Arm extension exposes sub acromial structures
Scapula
- Winging of the scapula- Long thoracic nerve injury causing a weak serratus anterior muscle
Humerus
Shoulder exam range of motion
Abduction- 180° Adduction- 75° Flexion- 180° Extension- 60° External Rotation- 90° Internal Rotation- 100°
Shoulder Strength movements and muscle actions
Trapezius Superior- elevation Middle- retraction Inferior- depression Levator Scapula- elevation Rhomboids- retraction Pectoralis- depression (in and down) Biceps- flexes humerus Coracobrachialis- flexes and adducts the humerus Latissimus Dorsi- extends and medially rotates humerus
Strength Testing: Neurologic screening
Isolate the joint about which you are testing strength. For example, if you are testing strength of elbow flexion, hold the arm on both sides of the elbow.
Compare one side to other.
Use the following scale when recording and reporting strength so that the measured strength is the numerator, i.e. measured strength/5
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
Rotator Cuff Injuries
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.
SITS: Supraspinatus, Infraspinatus, Teres Minor, Subscapularis
To test supraspinatus
Hold resistance at elbow
Patient abducts against resistance
(arm bent 90 degrees)
To test subscapularis
Patient rotates forearm medially against resistance
arm bent 90 degrees
To test infraspinatus, teres minor
Patient rotates forearm laterally against resistance
arm bent 90 degrees
To test thoracohumeral group
patient adducts forearm against resistance
arm bent 90 degrees
Shoulder special test: 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.
Shoulder special test: subscapularis 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.- Bear Hug
The patient crosses a hand to the opposite shoulder and attempts to oppose an examiner effort to lift the hand off the shoulder. Inability to resist the examiners effort is subscapularis weakness.
- Bear Hug
Infraspinatus
Use strength testing
maneuver comparing
bilaterally
(arms bent 90 degrees, looks like abducting)
Shoulder special tests: 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.
Shoulder special tests: Drop Arm Test
supraspinatus tendon rupture
Shoulder special tests: Apley Scratch Test
Upper arm- Tests external rotation and abduction
Lower arm-Tests internal rotation and adduction
Tests ROM
If deficient, suggests adhesive capsulitis
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.
Anterior dislocation 95-97% compared to posterior dislocation
Shoulder Special Tests: O’Brien’s Test
Glenoid labrum stability
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 tear (SLAP- Superior labrum anterior to posterior).
Shoulder Special Tests: Speed’s Test
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.
Shoulder Special Tests: Hawkin’s Impingement Sign
Examiner grasps patients elbow with one hand and their distal forearm with the other
Examiner passively internally rotates the shoulder
Impinges primarily supraspinatus
Confirm supraspinatus pathology (empty can, drop arm)
Shoulder Special Tests: Neer’s Impingement sign
Stabilize scapula
Internally rotate and flex arm
Subacromial impingement Supraspinatus pathology
Shoulder special tests: Subacromial Bursa
Stabilize the shoulder and extend the humerus. Pain may indicate subacromial bursitis although the problem may the rotator cuff.
Normal ranges of Elbow Motions
Extension: 0 degrees
Flexion: 150 degrees
Pronation: 70 degrees
Supination: 90 degrees
Common Elbow Conditions
Sprains
Olecranon Bursitis
Epicondylitis- lateral and medial
Associated tendinitis- Flexor or extensor
Nursemaid’s elbow (radial head dislocation)
Posterior elbow (ulnar dislocation)
Somatic dysfunctions- radial head anterior/posterior
Osteoarthritis or rheumatoid arthritis
Fractures
Peripheral neuropathies
Cubital Tunnel Syndrome- ulnar nerve compression behind the medial epicondyle
Radial Head somatic dysfunction
Normal Motion
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
Radial head subluxation
Also known as 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
Reduce by applying mild posterior pressure on the radial head while fully pronating. Feel for a click
OR
Apply mild posterior pressure on radial head, fully supinate, apply some traction and flex the elbow.
Lateral epicondylitis and Extensor Tendinitis
Tennis Elbow
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
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.
Elbow Special Tests: Lateral Epicondylitis Test (tennis elbow)
Palpate the lateral epicondyle while resisting the patients wrist extension. Pain is a positive test.
Associated with extensor tendonitis
Elbow Special Tests: 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
Elbow Special Tests: Collateral ligament disruption
Valgus and Varus Stress Tests-
For the valgus stress test, push on the lateral side
of the elbow while abducting the distal forearm
away from the body. Feel for looseness.
For the Varus stress test, do the opposite.
Elbow Special Tests: 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.
Hand anatomy- joints
a - Carpometacarpal joint b - Metacarpophalangeal joints c - Proximal interphalangeal joints d - Distal interphalangeal joints e - Interphalangeal joint of thumb
Hand and Wrist Inspection
Hand
Rheumatoid arthritis:
Ulnar deviation
Boutonniére deformity
Osteoarthritis:
Heberden’s nodes-distal interphalangeal
Bouchard’s nodes-proximal interphalangeal
Hand and Wrist Palpation
Radius, ulnar styloid, and the radiocarpal and radioulnar joints. Anatomic snuffbox: scaphoid/navicular Carpometacarpal joints Lateral and medial aspects - Metacarpal-phalangeal (MCP) - Proximal interphalangeal (PIP) - Distal interphalangeal (DIP)
Hand and Wrist ranges of motion
Most often checked with active range of motion
Wrist
Extension - 70 degrees
Flexion- 90 degrees
Radial deviation (abduction) - 20 degrees
Ulnar deviation (adduction) - 55 degrees
Hand MCP hyperextension - 30 degrees MCP flexion - 90 degrees PIP and DIP extension - 0 degrees PIP and DIP flexion - 90 degrees Opposition - thumb should touch the 5th MCP
Wrist special tests: Tinel’s sign
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.
Wrist special test: 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.
Common Wrist and Hand problems
Tenosynovitis- DeQuervain’s disease and others
Ganglion cysts
Synovial lining extensions that fill with fluid that often becomes gelatinous
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)
Boxer’s 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.
Hand special tests: 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.
Hand special tests: 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).
Hand Special tests: Varus/ Valgus ligament stress, Thumb/ Ulnar collateral ligament stress
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. Compare bilaterally!
