UE DSA Caldwell Flashcards
Visual inspection
for asymmetry
Survey the entire upper extremity for color change, skin alteration, or unusual bony contours.
- Boney
- Soft tissue
- Atrophy or swelling?
- Including superior clavicle head @ sternoclavicular joint
- Skin for rashes, pustules
Ancient formula of rubor, tumor, dolor, calor
Basic Neurologic and Circulatory Tests
Pulses - Brachial - Radial DTRs Motor Strength Dermatomes
Pulse Check
1. Temporal artery at the temple above and lateral to the eye 2. External maxillary (facial) artery at the point of crossing the mandible 3. Carotid artery on the side of the neck 4. Brachial artery on the inner side of the biceps 5. Radial artery on the radial bone side of the wrist 6. Femoral artery in the groin 7. Popliteal artery in the popliteal fossa 8. Posterior tibial pulse Posterior to the inner ankle 9. Dorsalis pedis artery on the anteriosuperior aspect of the foot
Lymphatic DRAINAGE
Right Lymphatic Duct (RLD) formed by a merger in the Right jugular trunk, the Right subclavian trunk, and the Right transverse cervical trunks. 1 cm in length.
- just head and right arm/ chest
Everything else- left lymphatic duct
Shoulder Pain
some sources of Viscerosomatic
lungs heart diaphragm gallbladder spleen
elbow, cervical spine
Tests to Evaluate for Radiculopathy
C5: biceps DTR, deltoid motor, lateral upper arm for light touch
C6: brachioradialis DTR, biceps (and wrist extensors) motor, lateral forearm, thumb, index finger for light touch
C7: triceps DTR, triceps motor (and wrist flexors, finger extensors), light touch to long finger
C8: motor: interossei (and finger flexors, thenar muscles)
light touch: ring and little finger, medial forearm
T1: motor- interossei, light touch- above and below elbow
The STERNOCLEIDOMASTOID(SCM) MUSCLE
Is the principal muscular landmark of the neck
Passes from the manubrium of the sternum and medial 1/3 of the clavicle to the mastoid process of the temporal bone and superior nuchal line
Acts unilaterally to draw the mastoid process anteriorly and inferiorly, rotating the face toward the contralateral side
Contracts bilaterally to draw the head forward and the chin upward
Is an accessory muscle of respiration
*** Is innervated by the accessory nerve (CN XI) and the anterior ramus of C2
SCM trouble
May be congenitally shortened or spasmodically contracted, positioning the head as it would be positioned by strong unilateral contractions; this is congenital and spasmodic torticollis, respectively
Autonomic Nervous System
Sympathetic innervation to the upper extremity
T2-T8
Actual origins from T5 to T7
Sympathetic trunk courses anterior to the rib heads.
Spinal cord levels usually represented in branches of the BRACHIAL PLEXUS include in principal terminal branches the
Musculocutaneous nerve (C5-7) LC Axillary nerve (C5-6) PC Radial nerve (C5-T1) PC Median nerve (C5-T1) LC, MC Ulnar nerve (C8-T1) MC
Lateral Cord, Posterior Cord, Medial Cord
Standard Method Of Recording Amplitude Of A Reflex
0 Absent 1/4 = Decreased but present 2/4 = Normal 3/4 = Brisk with unsustained clonus 4/4 = Brisk with sustained clonus
Standard Method Of Recording Motor Strength
0 (Zero)
No evidence of contractility
1/5 (trace)
Evidence of slight contractility; no joint motion
2/5 (poor)
Complete range of motion with gravity eliminated
3/5 (fair)
Complete range of motion against gravity
4/5 (good)
Complete range of motion against gravity with some resistance
5/5 (normal)
Complete range of motion against gravity with full resistance
Motor strength chart
Shoulder elevation: trapezius, C2,3 Accessory nerve
Posterior elbow approxiation: Rhomboids, C4,5, Dorsal scapular nerve
Shoulder abduction at 90 degrees: Deltoid, C5 (C6), Circumflex nerve
Elbow flexion at 90 degrees: Biceps (C5) C6, MSC nerve
Elbe extension at 90 degrees: Triceps (C6) C7 (C8, T1), Radial nerve
Finger and wrist flexion : C8, Median and ulnar nerves
Finger abduction and adduction: Intrinsic muscles, T1 Ulnar nerve
Sensory Testing
Upper Extremity Sensation testing with light touch, pinprick, or two-point discrimination C5-lateral arm C6-lateral forearm C7-index finger C8-medial forearm T1-medial arm Sensory testing to the hand
Upper Extremity Neurologic Exam
Tested with light touch, pinprick, or two-point discrimination
- Sensation is intact, diminished, or absent
Dermatomes
- C5-lateral arm
- C6-lateral forearm
- C7-index finger
- C8-medial forearm
- T1-medial arm
Peripheral nerves
Radial, median, ulnar
PROM vs. AROM
Same as AROM with doctor moving the part of the upper extremity
ACTIVE = Patient Performing Motion PASSIVE = Physician Performing Motion Unassisted by the Patient
Physiologic Barrier – is the farthest a patient can actively move a joint/structure
Anatomic Barrier – is the farthest an examiner can passively move the joint/structure beyond the physiologic barrier before causing injury/pain
Shoulder Articulations
Structural: Thoracic cage Scapula Clavicle Humerus
Functional: Scapulothoracic Acromioclavicular Sternoclavicular Glenohumeral
Rotator Cuff Muscles***
Supraspinatus- attaches to superior facet of greater tubercle. Suprascapular N. (C4,5,6). Initiates and assists in ABDuction
Infraspinatus- attaches to middle facet of greater tubercle. Suprascapular N. (C5, 6). External rotation
Teres Minor- attaches to inferior facet of greater tubercle. Axillary N. (C5, 6). External rotation.
Subscapularis: attaches to lesser tubercle. Upper and lower subscapular n. (C5,6,7). INternal rotation
Glenohumeral Joint Motions
INTernal Rotation EXTernal Rotation Flexion Extension ABDuction ADDuction
glenohueral joint: Spheroidal (ball and socket)
Convex surface in concave cavity
Wide-ranging flexion, extension, abduction, adduction, rotation, circumduction
Scapulohumeral Rhythm
Scapular Movements include
- Elevation
- Depression
- Protraction
- Retraction
- Upward Rotation
- Downward Rotation
Scapulohumeral Rhythm - 2:1 ratio of humeral abduction compared with scapular rotation - For every 3° 2° humeral abduction 1° scapular rotation
Acromioclavicular Joint
Synovial joint
Motion
- Abduction
- Internal and External Rotation
Testing Positions
In scaption, (90° shoulder ABDuction, 30° forward of coronal plane, and 90° elbow flexion)
- Internal Rotation
- External Rotation
Evaluation for Superior Clavicle
Patient can be supine or seated for evaluation.
Place your index fingers over the medial end of the clavicle.
Patient shrugs his shoulder.
Superior clavicle is the side that is more superior.
Elbow Joint
Humero-ulnar
- primarily flexion and extension)
Humero-radial
- (pronation and supination)
Proximal radio-ulnar
- (pronation and supination)
Elbow movements:
Flexion, extension, pronation, supination, and a small amount of abduction and adduction.
Carrying Angle (elbow)
The trochlear notch of the ulna has a slight spiral allowing for slight ABduction of forearm
The angle of deviation from the long axis of the humerus = the Carrying Angle
Angle between blue & red lines
Measured grossly by visual inspection
Normal:
Males 5-15°
Females 10-15°
Abnormal:
>15°, cubitus valgus
<5° -10°, cubitus varus
Elbow abduction means abduction of the forearm at the elbow.
Elbow adduction means adduction of the forearm at the elbow.
Interosseous Membrane
The interosseous membrane has fibers extending from the true elbow to the wrist joints
This membrane allows for the sharing of compressive forces & movements
The interosseous membrane has anterior (1) and posterior fibers (2). Note the different directions of these fibers.
This membrane transmits forces from wrist to elbow, elbow to wrist, ulna to radius, and radius to ulna.
These reciprocal forces contribute to the intimate connection between the elbow and wrist in regards to the perception of pain. Dysfunction at the wrist can generate pain in the elbow just as dysfunction in the elbow can cause pain appreciated in the wrist.
Pronation and Supination
During pronation
The distal radius crosses over ulna and moves anterior and medial while the more proximal radial head glides (moves) posterior.
During supination
The distal radius moves posterior & lateral while the more proximal radial head glides (moves) anterior.
Therefore, the movement of supination and pronation have reciprocal actions on the radius.
ABducted or ADDucted Elbow
Hold the patient’s wrist or forearm between your arm and lateral rib cage.
Grasp the elbow: the lateral MP or PIP joints of the index fingers provide the fulcrum on each side against the posterolateral aspects of the proximal radius and ulna.
Place the elbow in partial extension.
Localize to take the tissue slack out before thrusting.
The difference between the two techniques is the direction of the localization and thrust.
ABducted elbow: thrust is from medial to lateral (varus force)
ADDucted elbow: thrust is from lateral to medial (valgus force)
Elbow Flexion Restriction
Stand in front on the same side as the dysfunction.
Support the flexed elbow with the forearm position remaining in neutral.
The right hand, in this example, is held at the ulnar side.
The elbow is flexed to the point of initial resistance.
Elbow Extension Restriction
Stand in front on the same side as the dysfunction.
Support the extended elbow with the forearm position remaining in neutral.
The right hand, in this example, is held at the ulnar side.
The elbow is extended to the point of initial resistance.
Bones of the Wrist
Right hand, dorsal view:
Left to right proximal
Scaphoid, Lunate, Triquetrum, Pisiform
Left to right distal
Trapezium, Trapezoid, Capitate, Hamate
True Wrist – Radiocarpal
Distal radius Scaphoid Lunate Triquetral Articular disc
Injuries such as a puncture of a finger by a rusty nail can cause
infection of the digital synovial sheaths. When inflammation of the tendon and synovial sheath occurs (tenosynovitis), the digit swells and movement becomes painful. Because the tendons of the 2nd, 3rd, and 4th fingers nearly always have separate synovial sheaths, the infection is usually confined to the infected finger. If the infection is untreated, however, the proximal ends of these sheaths may rupture, allowing the infection to spread to the midpalmar space
Handlebar Neuropathy
People who ride long distances on bicycles with their hands in an extended position against the hand grips put pressure on the hooks of their hamates, which compresses their ulnar nerves. This type of nerve compression, which has been called handlebar neuropathy, results in sensory loss on the medial side of the hand and weakness of the intrinsic hand muscles.
Palmar Grasp Reflex
Place your fingers into the baby’s hands and press against the palmar surfaces.
The baby will flex all fingers to grasp your fingers.
Birth to 3–4 mos.
Apley Scratch Test
The position at the upper left arm tests for external rotation and abduction of the shoulder.
The patient reaches behind his or her head to attempt to touch the superior medial angle of the opposite scapula.
The positions at the lower left test for internal rotation and adduction of the shoulder.
The patient reaches behind his back to touch the inferior angle of the opposite scapula.
Drop Arm
To screen for possible rotator cuff tear
Have the patient to fully abduct the arm.
Then tell the patient to slowly lower the arm to the side.
Tears in the rotator cuff muscles (especially the supraspinatus) cause the arm to drop to the side once the arm has been lowered to about 90º of abduction.
The patient will not be able to lower the arm slowly and smoothly no matter how many times he tries.
Empty Can Tests
To do the empty can test, have the patient assume a shoulder abduction angle of approximately 45º and internal rotation, point the thumb down (like to empty a can)
Apply slight pressure downward on the arm to test for any subtle weakness in portions of the rotator cuff.
Apprehension Test
In shoulder dislocation the humerus seems to “slip out of the joint” when the arm is abducted and externally rotated.
The patient anticipates this happening and resists abduction and external rotation.
A positive apprehension sign for anterior instability when the examiner places the arm in this position. Any shoulder movement may cause pain, and patients hold the arm in a neutral position.
Impingement Sign
This test is performed to screen for possible impingement at the glenohumeral joint.
The patient’s arm is internally rotated at the glenohumeral joint.
The shoulder is then passively flexed with thumb down in front of the body.
A positive sign is anterior shoulder pain which suggests impingement syndrome.
Yergason’s Test
Tests the stability of the long head of biceps tendon in the bicipital groove.
Grasp the flexed elbow in one hand, holding the wrist with your other hand.
Have the patient flex the elbow while you maintain resistance.
Externally rotate the patient’s arm as he or she resists, while at the same time pulling downward on the elbow.
Positive test: the biceps tendon pops out of the bicipital groove and the patient experiences pain.
If it is stable in the groove, it remains secure and the patient should experience no discomfort.
Phalen Test
Both wrists are flexed by opposing the dorsal surface of each hand.
Wrist flexion is maintained for sixty seconds.
This test is positive if there is numbness, tingling, or pain that follows the distribution of the median nerve into the thumb and next three digits.
This test can be positive in carpal tunnel syndrome.
Tinel Test
Tapping over the median nerve over the transverse carpal ligament region.
This test is positive if there is numbness, tingling, or pain that follows the distribution of the median nerve into the thumb and next three digits.
This test can be positive in carpal tunnel syndrome.
Finkelstein
This is a test for de Quervain’s tenosynovitis.
This involves the tendons of the extensor pollicis brevis and the abductor pollicis longus muscle groups.
To test for this, flex the MCP and IP joint of the thumb while ulnarly deviating the wrist and palpating over the tendon sheath on the anterior aspect of the anatomic snuff box (abductor pollicis longus and extensor pollicis brevis tendons).
This test is positive if there is pain over this area.
