Upper Extremity Flashcards
Type of joints
Cartilaginous, Synovial, Fibrous
How do you evaluate UE?
Proximal to Distal.
Painful area last.
Always _______!
Compare
Volar refers to:
anterior forearm
Inspection of UE
symmetry, size: edema or atrophy, alignment, deformity, color: skin, nails, masses, guarding
When do you palpate tender areas?
last
What type of deformities can exist?
angulation, shortening
Nodules description
tender/non-tender; mobile/fixed; soft/hard
Pulses
Compare bilaterally
Tenderness to Palpation (TTP) process
- localize as specifically as possible “ONE finger”
- anatomical location usually provides diagnosis - bone, muscle, bursa, tendon, ligament, or combo
- correlate with positive findings on inspection
Range of motion test
test each major joints for active range of motion followed by passive range of motion
Know ROM and watch for:
limitations of movement, instability, spasticity or pain
Compare ROM to:
opposite side of previous measurements if available suggestive of underlying problem
Muscle function chart gradings:
No muscle contraction
0
ROM quantified based on:
degrees of motion
Muscle function chart gradings:
Visible contraction, no joint movement
1
Muscle function chart gradings:
Joint motion, but not against gravity
2
Muscle function chart gradings:
Movement against gravity only
3
Muscle function chart gradings:
Movement with some resistance
4
Muscle function chart gradings:
Full strength with full resistance
5
Shoulder inspection
for color, size, symmetry, contour, deformity, and swelling
Shoulder asymmetry:
Could be indicative of:
loss of rounded contour
dislocation of shoulder or atrophy
Winged Scapula
paralysis of serratus anterior from injury to long thoracic nerve
Glenohumeral dislocation
dislocation: 95% anterior, 5% posterior
Inspection of glenohumeral dislocation and what is the sign called?
arm held in position of protection; sulcus sign
Shoulder palpation
Palpate and verbalize muscles and bony landmarks of the shoulder: clavicle, AC joint - acromion and coracoid process, Humerus, and Bicipital groove.
Shoulder ROM testing
Should be done both passive and active:
flexion/extension
abduction/adduction
internal/external rotation
Rotator Cuff Function:
Abduction
supraspinatus
Rotator cuff function:
External rotation
80% infraspinatus
20% teres minor
Rotator cuff function:
internal rotation
subscapularis
Strength testing of shoulder: testing against ROM example: “Don’t let me push them down” as you try to push down on distal upper arm
What are you testing?
Abduction strength (arm to side of body) Forward flexion - strength (arm in front of body)
Strength testing of shoulder: testing against ROM example: “Don’t let me push them up” as you try to push arms up
Adduction strength (arm to side of body Extension strength (arms in front body)
Rotator Cuff Assessment: Empty can test
resistance against forward flexion in hyperpronation (thumbs down), elbow extension, and abduction
What does rotator cuff assessment: empty can test: test for?
supraspinatus injury/tear
Rotator cuff assessment: Gerber’s Lift Off Test
place hand on back with shoulder internally rotated: push against-resistance
What are you testing for with Gerber’s Lift Off Test
subscapularis injury/tear
Rotator Cuff testing: Drop arm
provider passively abducts arm to 120 degrees - ask patient to slowly lower it
Positive drop arm test indicates
inability to complete this secondary to weakness and/or pain
Impingement syndrome is what kind of phenomenon? What does this syndrome result in?
How do you test for it?
mechanical phenomenon
results in painful arc of ROM (70-120 degrees)
Arc from 0 degrees to 180 degrees
Impingement Syndrome: Hawkin’s test
Passive flexion to 90 degrees and forceful internal rotate the shoulder
Hawkins Test tests for
impingement
if Hawkin’s test is painful –> impingement –> rotator cuff concerns
Impingement syndrome results in
PAIN
Hawkins and Arc looking for
PAIN
Empty can, drop arm, and gerber’s lift off tests test for
weakness
Neer’s impingement sign:
looking for?
how do you do it?
looking for pain –> subacromial impingement –> rotator cuff concerns
passive flexion with arm pronated and scapula is stabilized
Biceps Tendon Assessment : Yergason test
Elbow flex at 90 degrees with forearm pronated. Supinate forearm and externally rotate humerus against resistance.
Biceps Tendon Assessment : Yergason test
Elbow flex at 90 degrees with forearm pronated. Supinate forearm and externally rotate humerus against resistance.
Pt tries to supinate while PA resists them.
Biceps tendon assessment: Speed’s test
Arm extended in full supination with shoulder flexed. Elevate arm against resistance.
Deformities of upper arm (4)
acute trauma: fracture,
previous trauma - malunion, nonunion
biceps rupture
tumor
Glenohumeral instability: sulcus sign
Tests for:
arm in neutral relaxed position, provider will pull the arm downward.
depression or “sulcus” in shoulder near acromion
evaluates for inferior instability
patient may voluntarily show this sign
Glenohumeral instability: apprehension and relocation test
elbow flexed at 90 degrees, arm abducted at 90 degrees - apply external rotation at the shoulder and note apprehension
Pain and apprehension with ROM testing - Pain is relieved with relaxation/relocation.
AC Joint
cross-body adduction test
Cross Body Adduction test
examiners adducts patient’s arm across body toward other arm. Positive sign: pain elicited and localized to the AC joint
Adhesive Capsulities
frozen shoulder
Frozen shoulder symptoms
diffuse, dull, aching pain - usually no localized tenderness; progressive restriction of ROM; usually unilateral
Apley scratch test tests for:
frozen shoulder (adhesive capsulitis)
Comparison is key
What is Apley scratch test?
Put arm behind back and itch from inferior and superior angles
Anatomy of Elbow: veins and lymphatics
Superficial: cephalic, basilic
Lymph nodes: axillary, epitrochlear
When do you check epitrochlear nodes?
infection concern
Bony prominences of elbow
olecranon process
medial epicondyle
lateral epicondyle
radial head
What pulse do you check when inspecting and palpating elbows?
brachial pulse
How to differentiate between radial head and lateral epicondyle?
Radial head moves when supinating
Inspecting elbow for:
guarding - acute trauma, repetitive activity
deformity - acute trauma
redness - infection
swelling - acute trauma, infection, rheumatologic condition, repetitive activity
Masses - hard/soft, mobile/nonmobile
Elbow palpation and ROM - important to identify these bony prominences
LOCATION: distal humerus, medial epicondyle, lateral epicondyle, radial head, olecranon, proximal forearm
Elbow decreased ROM
flexion/extension
pronation/supination
How to test elbow movement?
Flexion and extension - flex 150 degrees back to head, extend to 0 degrees
Supination/pronation WITH HUMERUS stabilized
Epicondylitis
overuse syndrome
Inspecting/palpation of epicondylitis
localized pain and swelling
Epicondylitis: reproducible pain with:
wrist flexion (medial) or extension (lateral) against resistance
Medial epicondylitis: Golfer’s elbow
flexor pronator muscle group
Lateral epicondylitis: Tennis elbow
extensory supinator muscle group
Olecranon bursitis
inflammation of bursa with fluid accumulation
What causes olecranon bursitis?
local irritation, trauma, infection
Pain in olecranon bursitis suggests what?
trauma or infection
Nursemaid's elbow Affects what ages? What is it? What causes it? How does child present? How to test for it?
1-4 ages
subluxation/dislocation of radial head
common cause is sudden pull of pronated arm
Child guards extremity and limits ROM - holds elbow slightly flexed, forearm pronated
Feel radial head - will pop out
Forearm/wrist inspection
guarding, asymmetry, redness, swelling, masses, deformities: angular or rotational, contour, number of digits
Subcutaneous nodules
gouty tophi, rheumatoid arthritis
Colles’ Fracture
Dinner fork deformity
Common cause of Colles’ Fracture
fall backwards and distal radius pops out and overrides the rest of the bone
Hand and wrist palpation
distal radius and ulna (styloids)
carpals
metacarpals
MCP joints, PIP and DIP joints
Wrist palpation questions to ask
Maximal point of tenderness, radiating pain, distinguish between radius, ulna, or carpal bones, check for scaphoid tenderness - “snuff box”, distal neurovascular check - numbness, tingling
Carpal Tunnel Syndrome affects which nerve
median
____ tendons pass through carpal tunnel
flexor tendons
Median nerve in carpal tunnel becomes:
compressed by inflammation of the synovium
Carpal tunnel results in:
compression neuropathy with pain, paraesthesias, and thenar atrophy
Chronic carpal tunnel most likely results in:
thenar atrophy
Tinel’s Sign - how to perform
percuss over median nerve
What does a positive tinel’s sign look like?
Tingling sensation in the distribution of the median nerve
Phalen’s Test - how to perform
Flex wrists x 30-60 seconds
What is a positive phalen’s test result?
paresthesia in the distribution of the median nerve
de Quervain’s Tenosynovitis
inflammation of the 1st dorsal compartment involving the sheath of the abductor pollicis longus and extensor pollicis brevis
Causes of de Quervain’s Tenosynovitis
overuse/repetitive gripping
What test tests for de Quervain’s tenosynovitis?
finkelstein test - fist over thumb and ulnar deviation
What is a positive de Quervain’s Tenosynovitis?
pain
Ganglion cysts
collection of synovial fluid within a joint or tendon sheath - herniation of synovial tissue from capsule or tendon sheath
Inspecting for ganglion cysts:
dorsal radial and volar aspects of wrist
Palpation for ganglion cysts
soft mobile mass
ROM for ganglion cysts:
may restrict motion or become painful with repetitive activity
Scaphoid fracture
tender to palpation in the anatomical snuffbox
Lateral and medial borders of anatomical snuffbox
Lateral: extensor pollicis brevis and abductor pollicis longus
Medial: extensor pollicis longus
Radial deviation of hand is indicative of:
osteoarthritis
Ulnar deviation of hand is indicative of:
rheumatoid arthritis
Swan neck
hyperextension of PIP joints with fixed flexion of DIP
Boutonniere
flexion of PIP joint with hyperextension of DIP joints
Where are Heberden and Bouchard nodes located?
Heberden: DIP joints
Boucahrd: PIP joints
What type of nodes are found with osteoarthritis?
heberden’s nodes
What type of nodes are found with rheumatoid arthritis?
bouchard’s nodes
Heberden’s nodes are:
hard and painless
Bouchard’s nodes are:
boney enlargement
Rheumatoid nodeules
common on dorsum of hand
RA symptoms:
bouchard’s nodes
ulnar deviation
PIP joints - including swelling at proximal phalanx
OA symptoms
heberden's nodes DIP joints PIP joints (SOMETIMES) - EXCEPT AT PROXIMAL PHALANX
Capillary Refill
place pressure over nail beds to cause blanching then quickly remove
Normal capillary refill
observe time elapsed for full return of color - should be equal to or less than 2 seconds
Wrist and Hand ROM
wrist flexion and extension
radial and ulnar deviation
MCP, PIP, DIP flexion - “make a fist”
Digit extension with abduction/adduction
How to test MCP, PIP, and DIP flexion?
make a fist
Can miss a rotational deformity if:
you do not ask them to perform ROM
How to test wrist flexion and extension?
test grip strength: ask patient to grip your two fingers and squeeze
Neurologic check - sensory
axillary, radial, median, ulnar
Saddle joint example
movements
trapezium and carpal bone and 1st metacarpal bone
adduction/abduction
flexion/extension
circumduction
Hinge joint example
movements
Elbow
Flexion/extension
Pivot joint example
movements
Between C1 and C2 vertebrae
Rotational
Ball and socket joint example
movements
Hip joint
Flexion/extension
adduction/abduction
rotation
Condyloid joint example
movements
Between radius and carpal bones of wrist
Flexion/extension
Abduction/adduction
Plane joint example
movements
between tarsal bones
gliding movements
Which joint(s) produce nonaxial movement?
plane joint
Which joint(s) produce unilateral movement?
hinge joints, pivot joints
Which joint(S) produce bilateral movement
condylar joint, saddle joint
What joint(s) produce multiaxial movement?
ball and socket joint
