Upper Extremity Exam

Question 1

Protectors

Answer 1

Rotator cuff

Question 2

Positioners

Answer 2

Deltoid

Question 3

Stabilizers

Answer 3

Trapezius, levator scapulae, rhomboid major / minor, pectoralis minor & serratus anterior

Question 4

Propellers

Answer 4

Pectoralis major & latissimus dorsi

Question 5

Rotator Cuff (Protectors)

Answer 5

-Synergistically stabilize the humeral head against glenoid -Supraspinatus Abduction / “scaption” -Infraspinatus External rotation -Teres minor External rotation -Subscapularis Internal rotation

Question 6

General Upper Extremity Inspection

Answer 6

“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

Question 7

Shoulder – Palpation

Answer 7

-Start on the uninvolved extremity -Modify palpation pattern so you palpate the painful area last -Ask the patient to report any tenderness during palpation

Question 8

Flexion

Answer 8

Principle muscles -Anterior deltoid -Pectoralis major (clavicular head) -Coracobrachialis -Biceps brachii

Question 9

Extension

Answer 9

Principle muscles -Latissimus dorsi -Teres major -Posterior deltoid -Triceps brachii (long head)

Question 10

Abduction

Answer 10

Principle muscles -Supraspinatus -Middle deltoid

Question 11

Horizontal adduction

Answer 11

Principle muscles -Pectoralis major -Coracobrachialis

Question 12

Internal rotation

Answer 12

Principle muscles -Subscapularis -Anterior deltoid -Pectoralis major -Teres major -Latissimus dorsi

Question 13

External rotation

Answer 13

Principle muscles -Infraspinatus -Teres minor -Posterior deltoid

Question 14

Acromioclavicular Joint Sprain

Answer 14

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

Question 15

Acromioclavicular Joint Sprain Exam

Answer 15

-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)

Question 16

Anterior Shoulder Instability

Answer 16

-Mechanism Forced combination of abduction and external rotation -20 – 40% sustain neurologic injury Axillary nerve Brachial plexus -Subluxation vs. dislocation

Question 17

Anterior Shoulder Instability EXAM

Answer 17

-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)

Question 18

Subacromial Impingement Syndrome (SAIS)

Answer 18

-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

Question 19

Acromion Morphology & Shape

Answer 19

-Hooked = increased subacromial pressure Decrease subacromial space More contact with RC tendons Increased risk of SAIS → increased risk of RC tear

Question 20

Subacromial Impingement Syndrome (SAIS) EXAM

Answer 20

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)

Question 21

Rotator Cuff Tear

Answer 21

-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

Question 22

Rotator Cuff Tear - Clinical Presentation

Answer 22

-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

Question 23

Rotator Cuff Tear – Physical Exam

Answer 23

-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)

Question 24

Medial Elbow - Palpation

Answer 24

Question 25

Lateral Elbow - Palpation

Answer 25

Question 26

Palpation of elbow

Answer 26

* 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

Question 27

Lateral Epicondylitis “Tennis Elbow”

Answer 27

* 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

Question 28

Medial Epicondylitis “Golfer’s Elbow”

Answer 28

* Pain with palpation of the common flexor tendon insertion * Golfer’s elbow stretch test * Pain / weakness with resisted wrist flexion & grip strength

Question 29

Wrist & Hand - Palpation

Answer 29

* Palpate the anatomical snuff box * Palpate the patient’s joints between your thumb & index finger. * “Capillary refill is \< 2 seconds.”

Question 30

Allen Test

Answer 30

* 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

Question 31

Median Nerve

Answer 31

Motor * Abductor pollicis brevis * Flexor pollicis brevis (superficial head) * Opponens pollicis * First and second lumbricals

Question 32

•Carpal tunnel

Answer 32

* 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

Question 33

Phalen’ Test

Answer 33

* 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

Question 34

Tinel's sign

Answer 34

* 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

Question 35

DeQuervain’s tenosynovitis

Answer 35

* 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):

Question 36

Flexor Tendon Injury “Jersey Finger”

Answer 36

•Spontaneous (RA) or Traumatic (forced extension of actively flexed finger) ## Footnote * MC flexor digitorum profundus * 4th (ring) finger affected most commonly 75%

Question 37

Finklestein Test

Answer 37

* 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.

Question 38

Mallet Finger

Answer 38

* 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

Question 39

Trigger Finger

Answer 39

* Nodular thickening of the flexor tendon * MC at the MP joint * MC idiopathic (but RA and DM at increase risk)

Question 40

Dupuytren’s Contracture

Answer 40

* 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

Question 41

Ganglia of Wrist and Hand

Answer 41

•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

Question 42

Osteoarthritis of the hand

Answer 42

* 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