OSCE 7 Elbow, wrist, hand competency

Question 1

neurologic and sensory exam for elbow

Answer 1

Muscle Reflex
o Biceps
o Brachioradialis
o Triceps
 Tested Nerve Root
o C5
o C6
o C7
 Dermatomes: C5-T1

Question 2

elbow normal and cubitus varus/ valgus angles

Answer 2

 Normal: 5° - 15°

o Cubitus Varus: 15°

Question 3

UCL/ MCL test

Answer 3

 Valgus stress test: arm slightly abducted and externally
rotated. Forearm supinated and flexed to 30 deg. Slight
medial directed valgus stress is applied to elbow joint.
o (+) Test pain/tenderness with palpation and valgus
stress; increased laxity (degree of laxity correlates
to degree of injury to UCL)

Question 4

LCL/ RCL test

Answer 4

Varus stress test: arm slightly abducted and internally
rotated. Elbow flexed to 15 deg. A slight varus stress is
applied to the elbow joint
o (+) Test = pain or increased laxity in LCL

Question 5

Tinel test

Answer 5

• for ulnar nerve entrapment
  Tap between olecranon and medial epicondyle in ulnar
  groove
  o (+) Test = eliciting tingling sensation down
  forearm within ulnar nerve distribution
  o Indicates ulnar nerve entrapment, cubital tunnel
  syndrome

Question 6

golfer’s elbow test

Answer 6

Golfer’s Elbow Test for medial epicondylitis
 Anterior forearm/flexor compartment
 Patient’s elbow is flexed to 90° and forearm is placed in
supination with the wrist neutral and palm facing up. The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s wrist to resist
movement. Instruct the patient to flex the wrist.
o (+) Test = pain/tenderness around the medial
epicondyle

Question 7

Tennis Elbow test (Cozen’s test)

Answer 7

Tennis Elbow Test (Cozen’s test)
 Posterior forearm/extensor compartment
 Patient’s elbow is flexed to 90° and forearm is placed in
pronation with wrist neutral and palm facing down. Examiner
places one hand under proximal forearm for stabilization and the
other hand over the patient’s hand to resist movement. Instruct
the patient to extend the wrist.
o (+) Test = pain/tenderness around lateral epicondyle,
may radiate down lateral forearm

Question 8

Olecranon bursitis

Answer 8

Olecranon bursa lies superficial to posterior elbow joint.
Posterior elbow distention and discomfort due to overuse
(“students elbow”) or occupational (“miners elbow”) or
athletic injury. Region is often painless and range of
motion is normal.

Question 9

“Little League Elbow”

Answer 9

Pain over the medial epicondyle, initially after throwing (repetitive valgus distraction forces), progresses to
persistent pain.
 Most common elbow injury during childhood (growth plates not fused/secondary ossification centers absent)
 As bone development matures most common injury seen
evolves (apophysitis  avulsion  ligamentous injury)

Question 10

“Nursemaid’s elbow” / radial head instability

Answer 10

Annular ligament tear and/or radial head subluxation from
annular ligament
 Pain with palpation of radial head with anterior
displacement of radial head and restriction to posterior
glide

Question 11

Coupled Motions at Elbow

Answer 11

Ulnar adduction with supination
 Ulnar abduction with pronation
 Radial head anterior glide with supination
 Radial head posterior glide with pronation
[P for Posterior, P for Pronation]

Question 12

flexion at wrist

Answer 12

Flexion
o Ex: Flexor carpi radialis, Palmaris longus
o Coupled movement: dorsal/posterior carpal glide
 80° - 90°

Question 13

extension at wrist

Answer 13

 Extension
o Ex: Extensor carpi radialis longus and brevis
o Coupled movement: ventral/anterior carpal glide
 70°

Question 14

adduction (wrist)

Answer 14

Adduction (ulnar deviation)
o Ex: flexor and extensor carpi ulnaris
o Coupled movement: ulnar abduction
30 - 40 degrees

Question 15

abduction (wrist)

Answer 15

: flexor carpi radialis, extensor carpi radialis longus
and brevis
o Coupled movement: Ulnar adduction
20° - 30°

Question 16

ok sign

Answer 16

tests anterior interosseous n.
 Motor branch of median nerve innervating:
o Flexor pollicis longus
o Deep flexors of digits 2 and 3
o Pronator quadratus
 On examination, if neuropathy present, patient cannot
make an “O” with thumb and forefinger pinched
together

[ O for a. interOsseOus n]

Question 17

Tinel’s sign

Answer 17

Indicates entrapment of Median Nerve or Carpal Tunnel
Syndrome.
o Can be elicited by tapping over the transverse carpal ligament (between thenar/hypothenar eminences) with either the tip of the examiner’s finger or reflex hammer with the patient’s wrist held in extension.
o (+) Test = parasthesias/numbness/ tingling/pain radiating to
thumb, index and middle finger (median n. distribution); CTS

Question 18

Phalen’s sign

Answer 18

Place dorsal aspects of patient’s hands together and force into wrist flexion. Hold for 60 seconds
o (+) Test = any reproduction of symptoms/parasthesias in the
distribution of the median nerve; CT
[HELPP!! my HANDS ARE PHALLEN!!!]

Question 19

Allen Test

Answer 19

Evaluates functioning of radial and ulnar arteries.
o Occlude both arteries while patient makes a fist. Have patient
open and close fist; palm should be pale.
o Release pressure on ulnar artery and observe for color return
to hand within 5-10 seconds. Repeat with radial artery.
[ ALLEN IS SO PALE]

Question 20

 DeQuervain’s Tenosynovitis

Answer 20

Pain and inflammation from repetitive overuse of
tendons in first dorsal compartment. Patients
complain of dorsal-lateral wrist and thumb pain,
occasionally with radiation into lateral hand and
thumb. Get a careful hx about repetitive activities.
 Will have positive Finkelstein test.
 Possible inflammation sites:
o Abductor pollicis longus
o Extensor pollicis brevis

Question 21

Finkelstein Test

Answer 21

Utilized to assess for tenosynovitis of the 1st dorsal compartment, aka. DeQuervain’s syndrome.
 Examiner asks patient to make a fist encompassing
their thumb and ulnar deviate the wrist.
 (+) Test = increased pain in first dorsal compartment/
lateral wrist; DeQuervain’s tenosynovitis

Question 22

Scaphoid fracture

Answer 22

Most common carpal bone fracture, due to falling
forwards/backwards on outstretched hand. Patient
complains of dull achiness deep in radial aspect of
wrist after a fall. Decreased ROM, decreased grip
strength, tenderness in anatomical snuff box.
Important to diagnose and treat due to risk of
avascular necrosis.
 Pain in anatomical snuffbox following “foosh”
treated as fracture with spica cast – immediate
radiographic evidence not always visible; may
require repeat imaging
 Can confirm with CT or MRI if necessary

Question 23

Colle’s Fracture

Answer 23

Fracture of the distal radius in the forearm with
dorsal (posterior) and radial displacement of the wrist
and hand.

Question 24

 Trigger Finger

Answer 24

flexor tendon restriction

Question 25

jersey finger

Answer 25

forced ext of DIP, flexor tendon rupture FDP

Question 26

Mallet finger

Answer 26

Jammed finger, Distal extensor disruption at DIP

Question 27

messed in Gamekeepers/Skiers thumb

Answer 27

UCL

Question 28

Ulnar nerve entrapment at wrist

Answer 28

guyons canal - between hook of hamate and pisiform