Special Test for Elbow and Wrist Flashcards
What does the Cozens test (tennis elbow) and Reverse Cozens/Golfers elbow indicate and how to perform it?
Lateral Epicondylitis (Tennis Elbow) and Medial Epicondylitis (Golfers Elbow) respectively
How to perform:
1. Cozens
* Stabilize patients forearm
* Have patient make a fist and pronate, radially deviate, and extend his wrist
* Examiner forces wrist into flexion against patient’s resistance
* Positive = Sudden severe pain at the lateral epicondyle (common extensor origin)
- Reverse Cozens
3.* Stabilize patients forearm
* Have patient make a fist and supinates and flexes his wrist
* Examiner forces wrist into extension against patient’s resistance
* Positive = Sudden severe pain at the medial epicondyle (common flexor origin)
What does the Supination lift test indicate and how to perform it?
Indication= dorsal tear of the triangular fibrocartilage complex - TFCC
How to perform:
* patient seated with elbow flexed to 90 degrees
* forearms supinated, place the hands on the underside of a table
* patient is asked to lift the table
* positive = pain on the ulnar side of the wrist and difficulty applying force
What does the Triangular Fibrocartilage Complex (TFCC) Load test indicate and how to perform it?
Indicates = TFCC Tear/Injury
How to perform:
* The examiner holds the patient’s forearm with one hand and the patient’s hand with the other hand.
* The examiner then ulnar deviates the wrist and applies a stretch like pressure in the same direction, while moving the hand dorsally and palmarly
* Positive = is indicated by pain, clicking or crepitus in the area of TFCC
What does the Allen’s Test indicate and how to perform it?
Indicates = Vascular compromise to radial artery or ulnar artery
How to perform:
* Patient opens and closes their hand multiple times, then makes a fist
* Examiner holds down the radial and ulnar arteries with the thumb and index finger
* Let go of the artery you are testing and the patients hand should go pink on the side of the artery just released
* Repeat same evaluation for the other artery
* Positive = Skin stays white, no apparent return of blood flow after decompression of the artery
More in depth Steps How to Perform the Modified Allen’s Test
Position the Patient’s Hand:
The patient is seated or supine with their hand resting comfortably.
Opening and Closing the Hand:
Ask the patient to open and close their hand rapidly 5–10 times. This action “wrings out” venous blood from the hand.
After the last cycle, instruct the patient to make a fist tightly to keep the blood out of the palm.
Occlusion of the Arteries:
The examiner uses their thumb and index finger to compress both the radial artery and the ulnar artery simultaneously at the wrist.
This blocks arterial blood flow into the hand, causing it to appear pale.
Releasing One Artery:
Instruct the patient to relax their hand, opening it gently (but not fully extended, to avoid artificially altering blood flow).
Release either the radial artery or the ulnar artery and observe the color return to the hand.
Assess Blood Flow:
A normal result (negative test): The hand quickly becomes pink as blood flow is restored via the released artery.
A positive test: The hand remains pale and white, indicating inadequate blood flow through the released artery.
Repeat for the Other Artery:
Repeat the process, this time releasing the opposite artery, and evaluate for normal or abnormal blood flow.
Key Points
Relax the hand properly: The patient should relax their hand (not fully extend the fingers) when you release the artery. Overextension can tighten the skin and vessels, potentially impeding blood flow and affecting test results.
Observe carefully: Pay attention to how quickly the hand “pinks up.” Slower capillary refill can indicate partial obstruction.
Clinical Use
The Modified Allen’s Test helps:
Assess collateral circulation: This is especially important when considering arterial access (e.g., for blood gas sampling or arterial cannulation).
Identify arterial insufficiency: A positive result can indicate blockage or inadequate arterial supply from either the radial or ulnar artery.
What does the Finkelstein’s Test aka DeQuervain’s Test indicate and how to perform it?
Indicates = first dorsal compartment stenosing tenosynovitis (Abductor pollicis longus and Extensor pollicis brevis), AKA DeQuervain’s tenosynovitis
How to perform:
* Patient makes a fist with their thumb tucked in
* Examiner deviates the wrist in the ulnar direction
* Positive = pain in the area of the first dorsal compartment
What does the Phalen’s Test (Flexion) & Reverse Phalen’s (Extension) indicate and how to perform it?
Indicates = Carpal tunnel syndrome (CTS)
How to Perform: Patient places the dorsal aspect of one hand against the dorsal aspect of the other, causing flexion of the wrists
* This is held for at least one minute while the patient reports changes in sensation or pain
* Positive = Reproduction of neurologic symptoms
More info.
Phalen’s Test (Flexion)
Mechanism:
Phalen’s test involves wrist flexion, which narrows the carpal tunnel by compressing its contents, including the median nerve.
In wrist flexion, the transverse carpal ligament tightens, reducing the space within the carpal tunnel.
This compression can irritate or aggravate the median nerve, especially if the tunnel is already compromised (e.g., due to inflammation, swelling, or structural abnormalities as in carpal tunnel syndrome).
Why it causes stress:
The flexed position compresses the nerve against other structures in the tunnel (tendons, synovial lining), and any pre-existing swelling or thickening amplifies this compression.
Reverse Phalen’s Test (Extension)
Mechanism:
Reverse Phalen’s involves wrist extension, which stretches the median nerve as it runs through the carpal tunnel.
In this position, the flexor tendons are lengthened, and the nerve is placed under tensile stress.
Extension also narrows the proximal part of the carpal tunnel because the structures are shifted posteriorly, potentially causing irritation.
Why it causes stress:
The nerve is stretched, and a taut nerve is more sensitive to irritation, especially if there is underlying damage, inflammation, or fibrosis.
What does the Tinel’s Test indicate and how to perform it?
Indicates = A neuroma in the ulnar nerve or whatever nerve you tap
How to perform:
* Patient sitting with both wrists facing up on their lap
* Examiner uses a reflex hammer or their re-enforced finger to tap the the transverse carpal ligament on the volar aspect of the wrist
* Positive = Paresthesia in the median n. distribution with percussion
What does the Mill’s Test & Reverse Mill’s Test indicate and how to perform it?
Mill’s Test Indicates = Lateral epicondylitis (Tennis Elbow)
Reverse Mill’s Test indicates= * Indicates = Medial epicondylitis (Golfer’s Elbow)
How to perform Mill’s Test:
* Place patient in the position where their elbow is extended, wrist pronated and flexed
* Examiner then push on the wrist while supporting the elbow into flexion
* Positive = Pain at lateral epicondyle
Reverse Mill’s Test:
* Place patient in the position where their elbow is extended, wrist pronated and extended
* Examiner then push on the wrist while supporting the elbow into extension
* Positive = Pain at medial epicondyle
What does the Valgus Stress and Varus Stress Test indicate and how to perform it?
Valgus Stress Test Indicate: Indicates = Sprain of the
medial collateral ligament. As you are stabilizing the ulnar and radius and moving the humerus laterally.
Varus Stress Test Indicates= Lateral collateral ligament pathology. As you are stabilizing the ulnar and radius and moving the humerus medially.
How to Perform:
Valgus: Cup the posterior aspect of the patients elbow in one hand
* Hold the wrist in the other hand
* Your hand on the elbow will act like a fulcrum around which your other hand will force the forearm
* Force his forearm laterally (valgus stress)
* Assess at 0, 30, and 90 degrees; meaning move the arm to these ranges and then apply a force in whichever direction to perform the test i.e. at 30 degrees move the forearm laterlly to test for Valgus stress
* Positive = Pain, increased medial joint gapping
Valrus: * Same as Valgus stress test except that you now you force his arm medially (varus stress)
* Positive = Pain or laxity in the lateral joint of the elbow
A 25-year-old athlete presents with wrist pain after falling on an outstretched hand during a volleyball game. She reports swelling and difficulty moving her wrist. On examination:
Palpation of the dorsal wrist is difficult due to significant tenderness.
Bracelet Test and TFCC Load Test are positive.
Range of motion is limited in flexion and extension.
What is the most likely diagnosis?
A) Scaphoid fracture
B) Wrist sprain
C) Carpal tunnel syndrome
D) Distal radial fracture
Correct Answer:
B) Wrist sprain
Rationale for Correct Answer:
A wrist sprain is the most likely diagnosis, given the mechanism of injury (fall on an outstretched hand), tenderness, swelling, and positive results from the Bracelet and TFCC Load Tests. These findings strongly suggest ligamentous injury or soft tissue involvement rather than a fracture or nerve-related condition.
Rationale for Wrong Answers:
A) Scaphoid fracture: While a fall on an outstretched hand can cause a scaphoid fracture, the hallmark is tenderness in the anatomical snuffbox, which is not explicitly noted here. Additionally, no specific tests or imaging results indicate a fracture.
C) Carpal tunnel syndrome: This condition typically presents with numbness, tingling, or weakness in the median nerve distribution. The mechanism of injury and clinical findings here are not consistent with carpal tunnel syndrome.
D) Distal radial fracture: A distal radial fracture is possible after a fall, but it would likely present with obvious deformity, intense localized pain, and bony tenderness. The absence of these findings makes it less likely in this case.
How do you perform the Bracelet Test and what does a positive finding mean?
Approximating the distal ends of ulna and radius to give stability back to the wrist that is no longer there. That is why braces feel so good to those with wrist sprain/carpal tunnel/ carpal instability.
○ (+) Forearm, wrist or hand pain -> RA, OA/DJD at the wrist
(+) Abnormal ROM -> ligament laxity, instability
(+) Forearm, wrist, or hand pain: Positive findings in this test, such as pain, may suggest conditions like rheumatoid arthritis (RA), osteoarthritis (OA), or degenerative joint disease (DJD) in the wrist, where joint inflammation or degeneration can cause discomfort with compression.
(+) Abnormal ROM: When performing this test, a positive finding of abnormal range of motion may indicate ligament laxity or joint instability. If the ligaments around the wrist are compromised, the joint may not maintain normal alignment under stress, resulting in excessive or irregular movement, even during the test’s compression. This abnormal ROM is a sign that the ligaments are not providing adequate support to the joint, contributing to instability.
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In cases of a wrist sprain, carpal instability, or ligament laxity, the wrist may feel painful or unstable because the ligaments are not adequately supporting the joint. Compression provided by the Bracelet Test can help in two key ways:
Stabilizing the Joint: By approximating the distal radius and ulna, compression temporarily reduces the load on the overstretched or injured ligaments. This can create a sense of stability that may feel relieving to the patient, especially if the ligaments themselves are the primary source of instability or discomfort.
Redistributing Pressure: The compression helps align and stabilize the carpal bones, which can reduce abnormal joint movement that often contributes to pain.
However, whether the Bracelet Test feels good or hurts depends on the underlying pathology:
In wrist sprains or carpal instability, the compression might provide relief by stabilizing the joint.
In conditions like RA (rheumatoid arthritis), OA (osteoarthritis), or degenerative joint disease (DJD), squeezing the wrist could exacerbate pain due to inflamed or degenerated joint surfaces.
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Carifying Question: but wouldn’t holding the wrist stop the abnormal ROM
ChatGPT said:
ChatGPT
Good question! It seems logical that compressing or stabilizing the wrist during the Bracelet Test might limit abnormal ROM, but here’s why abnormal ROM can still be observed:
When performing the Bracelet Test, the compression provides stability to the distal radius and ulna, but it doesn’t fully immobilize the wrist or eliminate movement within the joint. The test can reveal underlying instability by highlighting the response of the joint to this additional stability.
In cases where there is ligament laxity or instability, even with compression, the carpal bones may still shift or move abnormally due to weakened or stretched ligaments. Essentially, the stability provided by the test isn’t enough to completely prevent abnormal movement if the ligaments are not functioning properly.
Therefore:
Abnormal ROM observed during the test suggests that the ligaments are not effectively restraining the joint, even with added compression. This is a sign that the joint may be unstable and prone to excessive movement without support.
