Upper Extremity Exam Flashcards
Protectors
Rotator cuff
Positioners
Deltoid
Stabilizers
Trapezius, levator scapulae, rhomboid major / minor, pectoralis minor & serratus anterior
Propellers
Pectoralis major & latissimus dorsi
Rotator Cuff (Protectors)
-Synergistically stabilize the humeral head against glenoid -Supraspinatus Abduction / “scaption” -Infraspinatus External rotation -Teres minor External rotation -Subscapularis Internal rotation
General Upper Extremity Inspection
“The shoulders, elbows, wrists, & fingers are symmetric without any discoloration, swelling, deformities, atrophy, or tremors.” -Dominant shoulder girdle may be slightly elevated -Guarding of movement patterns (e.g. removing shirt, transitioning from seated to standing) -Posture
Shoulder – Palpation
-Start on the uninvolved extremity -Modify palpation pattern so you palpate the painful area last -Ask the patient to report any tenderness during palpation
Flexion
Principle muscles -Anterior deltoid -Pectoralis major (clavicular head) -Coracobrachialis -Biceps brachii
Extension
Principle muscles -Latissimus dorsi -Teres major -Posterior deltoid -Triceps brachii (long head)
Abduction
Principle muscles -Supraspinatus -Middle deltoid
Horizontal adduction
Principle muscles -Pectoralis major -Coracobrachialis
Internal rotation
Principle muscles -Subscapularis -Anterior deltoid -Pectoralis major -Teres major -Latissimus dorsi
External rotation
Principle muscles -Infraspinatus -Teres minor -Posterior deltoid
Acromioclavicular Joint Sprain
Mechanism of injury -Fall on AC joint with arm at side; collision sports -Force applied to superior aspect of acromion → forces acromion inferior and medial
Acromioclavicular Joint Sprain Exam
-Inspection Elevated distal clavicle, “step” deformity (Grades II & III) Swelling -Palpation Tenderness with palpation of the AC joint, swelling, “step” deformity (Grades II & III) Trapezius muscle spasm -Special exams (+ for all 3 suggests AC joint sprain) Cross adduction body test (72/85) AC resisted extension test (AC shear test) (77/79) Active compression test (79/50)
Anterior Shoulder Instability
-Mechanism Forced combination of abduction and external rotation -20 – 40% sustain neurologic injury Axillary nerve Brachial plexus -Subluxation vs. dislocation
Anterior Shoulder Instability EXAM
-Inspection Flattened deltoid Fullness of anterior chest Prominence of acromion Guarding / protecting -Palpation -Provocative testing – not performed at the time of acute injury Apprehension test (98/72) Relocation test (97/78) Release test (92/84)
Subacromial Impingement Syndrome (SAIS)
-Prevalence of shoulder pain is 7-27% in US adult population -Most frequent cause of shoulder pain is SAIS -Mechanism: Repetitive microtrauma leads to inflammation and degeneration with the potential for tearing of the rotator cuff tendon(s) over time Supraspinatus Infraspinatus
Acromion Morphology & Shape
-Hooked = increased subacromial pressure Decrease subacromial space More contact with RC tendons Increased risk of SAIS → increased risk of RC tear
Subacromial Impingement Syndrome (SAIS) EXAM
Objective findings: Tenderness with palpation of the long head of the biceps tendon and rotator cuff insertion Potential pain and/or strength deficit with strength testing of the rotator cuff Special tests Painful Arc test (63/76) Hawkins-Kennedy test (80/56) Modified Hawkins-Kennedy test Neer test (72/60)
Rotator Cuff Tear
-Etiology Overuse MC Age-related degeneration Chronic mechanical impingement Traumatic -Generally originate in the supraspinatus tendon (90%) and may progress -Full-thickness tears uncommon < 40 y/o incidence increases > 40 y/o, especially >60 y/o
Rotator Cuff Tear - Clinical Presentation
-Recurrent shoulder pain for several months (overuse) -Specific injury that triggered the onset of the pain (traumatic) -Subacromial pain and pain localized to deltoid tuberosity -Night pain and difficulty sleeping on affected side -Weakness, catching, and grating especially when lifting the arm overhead
Rotator Cuff Tear – Physical Exam
-Tenderness with palpation of the rotator cuff insertion -AROM decreased Shoulder “shrug” with abduction -PROM normal -Pain / weakness with isolation of involved RC Supraspinatus Infraspinatus / teres minor Subscapularis -Special tests External rotation lag sign Drop arm (73/77) Empty can test (74/30)
Medial Elbow - Palpation
Lateral Elbow - Palpation
Palpation of elbow
- Attempt to palpate the epitrochlear nodes
- About 3cm above medial epicondyle, in groove between biceps & triceps
- Not usually palpable
- If palpable, may indicate local or distant infection
- If nodes palpable, note size, shape, consistency
Lateral Epicondylitis “Tennis Elbow”
- Overuse inflammatory injury involving common extensor tendon.
- Repetitive wrist or combined wrist and finger extension.
- Pain with palpation of the common extensor tendon insertion
- Mill’s test
- Pain and weakness with resisted wrist and finger extension, especially 3rd digit extension
Medial Epicondylitis “Golfer’s Elbow”
- Pain with palpation of the common flexor tendon insertion
- Golfer’s elbow stretch test
- Pain / weakness with resisted wrist flexion & grip strength
Wrist & Hand - Palpation
- Palpate the anatomical snuff box
- Palpate the patient’s joints between your thumb & index finger.
- “Capillary refill is < 2 seconds.”
Allen Test
- Test done before puncture of the radial artery to assure patency of the ulnar artery
- Instruct pt to make a fist
- Occlude the radial & ulnar arteries
- Release pressure over the ulnar artery
- Palm should flush within 3-5 seconds
Median Nerve
Motor
- Abductor pollicis brevis
- Flexor pollicis brevis (superficial head)
- Opponens pollicis
- First and second lumbricals
•Carpal tunnel
- Vague aching that radiates into the thenar area
- Pain accompanied by numbness in the median distribution
- Frequently drop objects, cannot open jars or twist off lids
- Pain worsened by repetitive motion/activities or remaining stationary for prolonged periods
- Symptoms worse at night
- Patient awakens at night with pain or numbness and needs to “shake out” the involved hand / wrist
- Flick sign → 93% sensitivity and 95% specificity for CTS
- Inspect the hand for thenar atrophy
- Testing thumb opposition against resistance may reveal weakness of thenar muscles
- Evaluate sensation over the median nerve distribution
Phalen’ Test
- Efficacy
- Test Sensitivity: 70 to 80%
- Test Specificity: 80%
- Inverse praying position
- Place each hand dorsum against each other
- Positive test suggests median neuropathy
- Wrist flexion reproduces carpal tunnel symptoms
- Most specific if symptoms occur within first 30 seconds
Tinel’s sign
- Efficacy
- Test Sensitivity: 44-70%
- Test Specificity: 94%
- Technique
- Percuss median nerve at carpal tunnel in wrist
- Positive test suggests median neuropathy
- Reproduces pain and tingling along median nerve course
DeQuervain’s tenosynovitis
- Inflammation of the sheath that surrounds the abductor pollicus longus and extensor pollicus brevis tendons
- Tendon sheath thickens and constricts the tendons
- Pain and tenderness in the first dorsal extensor compartment (anatomic snuffbox) aggravated by attempts to move thumb or make a fist
- Swelling may be noted
- Crepitation as patient flexes and extends thumb may be noted
- Pain with passive stretching of the tendons (a.k.a. Finklestein Test):
Flexor Tendon Injury “Jersey Finger”
•Spontaneous (RA) or Traumatic (forced extension of actively flexed finger)
- MC flexor digitorum profundus
- 4th (ring) finger affected most commonly 75%
Finklestein Test
- Direct the patient to place the thumb in their palm.
- Have them cover the thumb with the fingers of the same hand, forming a fist.
- Gently deviate the wrist towards the ulna. This stretches the inflamed tendons over the radial styloid, reproducing the patient’s pain.
Mallet Finger
- MC due to traumatic injury to the tip of a fully extended finger
- Rupture, avulsion or laceration of extensor tendon at base of distal phalanx
- Pain and inability to extend at the DIP
Trigger Finger
- Nodular thickening of the flexor tendon
- MC at the MP joint
- MC idiopathic (but RA and DM at increase risk)
Dupuytren’s Contracture
- Palmar fibromatosis
- “Viking disease”
- Men >50, northern European descent
- Nodular thickening and contraction of palmar fascia
- Minimal discomfort
- MC ring finger
- Flexion of finger at MCP then PIP
Ganglia of Wrist and Hand
•Synonyms
Synovial Cyst
Mucous cyst
- Cystic swelling overlying a joint or tendon sheath
- Herniation of synovial tissue from a joint capsule or tendon sheath
- Generally affect persons 15-40 years of age
- Common locations
Dorsum of the wrist
Volar radial aspect of wrist
•Less common locations
Base of finger
DIP joint
Osteoarthritis of the hand
- DIP and PIP joints are most often involved
- Stiffness and loss of motion in the fingers
- Heberden nodes = nodules at the DIPs
- Bouchard nodes = bony nodules at the PIPs
