Transcript Physical Examination of the Upper Extremities

Physical Examination of the
Upper Extremities
Prof.Dr.Hidayet Sarı
Physical Medicine and Rehabilitation
Department
Shoulder Examination
ANATOMY
• Bones
• Joints
• Muscles
• Bursae
• Nerves
• Blood supply
Bony Anatomy
Anterior
Bony Anatomy
Posterior
SHOULDER JOINTS
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Glenohumeral
Scapula thoracic
Acromio-clavicular
Sterno-clavicular
Bony Anatomy
Joints and Articulations
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STATIC STABILIZERS
Clinical Anatomy
– Deltoid
– Rotator cuff
– Teres major
– Latissimus dorsi
– Biceps
– Pectoralis muscles
Clinical Anatomy
• Rotator Cuff
– Supraspinatus ABD
– Infraspinatus ER
– Teres minor ER
– Supscapularis IR
Depress humeral head against glenoid to allow full abduction
Clinical Anatomy
• Bursae
– subacromial
– subdeltoid
– subscapular
Physical Examination
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Inspection
Palpation –pression
Range of motion examination
Neurological examination
Special tests for the shoulder problems
Examination of the related areas
Shoulder Inspection
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Anterior side
Posterior side
Lateral side
Medial side
Physical Exam
Inspection
• Front & back
• Height of shoulder
and scapulae
• Muscle atrophy,
asymmetry
SHOULDER PALPATION and
PRESSION
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Bones
Joints
Muscles
Bursae
Nerves
Lymph nodes
SHOULDER Range Of Motion
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Flexion-180 degree
Extension -45 degree
Abduction -180 degree
Adduction -30 degree
Internal rotation -90 degree
External rotation -90 degree
Physical Exam
Range of Motion
• Forward flexion:
– 0o – 180o
Physical Exam
Range of Motion
• Extension
– 0o – 40 to 60o
Physical Exam
Range of Motion
• Internal rotation
– 80-90o
• External rotation
– 80-90o
Speed shoulder tests
External rotation
Internal rotation
Neurological Examination of the
Shoulder
Muscle tests :
• Flexion
• Extension
• Abduction
• Adduction
• Internal rotation
• External rotation
Muscle testing scoring
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0 No contraction
1 Flicker or trace contraction
2 Active movement, with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and
resistance
• 5 Normal power
Shoulder Abduction muscle test
Shoulder flexion and extension
muscle test
Shoulder external and internal
rotation muscle test
Shoulder abduction and adduction
muscle test
Neurological Examination of the
Shoulder
sensory tests :
• C4
• C5
• C6
• C7
• C8
• T1
• T2
Special Tests for the Shoulder
Problems
• Yergason test –biceps tendinitis
• Neer impingement test-acromioclavicular
impingement
• Drop arm test –rotator cuff tear
• Resisted flexion (Speed)test –biceps tendinitis
• Resisted abduction(Supraspinatus) testsupraspinatus lesion
• Aprehension test –glenohumeral joint instability
Yergason test
• Yergason test for biceps
tendon instability or
tendonitis.
• The patient's elbow is
flexed to 90 degrees, and
the examiner resists the
patient's active attempts
to supinate the arm and
flex the elbow.
Drop Arm Test
• Passive abduction to 90°
• Instruct patient to slowly
lower arm
• At 90° abducted arm will
suddenly drop, may need
to add slight pressure
• (+) drop = (+) test
SHOULDER PAIN
SPECIAL TESTS
• Neer
– PASSIVE
– Forced forward flexion of
arm with internally
rotated shoulder
– Test is positive if pain
occurs at same point as
with active forward
flexion
Speed’s Maneuver
• Forward flex the shoulder
against resistance while
maintaining the elbow in
extension and the forearm in
supination. Pain or
tenderness in the bicipital
groove in dicates bicipital
tendinitis.
Rotator Cuff Strength Testing
• Weakness on exam
• Grade strength on 0→5 scale
• Compare to other side
Supraspinatus testing
Apprehension Test/Relocation Test
Differantial Diagnosis for shoulder
pain
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Subacromial impingement syndrome
Adhesive capsulitis –frozen shoulder
Biceps tendinopati
Bursitis
Rotator cuff pathology
Glenohumeral joint pathology
Acromioclavicular joint pathology
Sternoclavicular joint pathology
Myofascial pain syndrome
Radiating or referred pain from cervical spine
Subacromial Impingement
• Neer proposed that 95% of rotator cuff tears are due to chronic impingement
between the humeral head and the coracoacrominal arch.
Subacromial Impingement
• Stage 1 disease consists of edema and hemorrhage of
the tendon due to occupational or athletic overuse, and
is reversible under conservative treatment.
Subacromial Impingement
• Stage 2 disease shows progressive inflammatory changes of the
rotator cuff tendons and the subacromial-subdeltoid bursa, and
can be treated by removing the bursa and dividing the
coracoacromial ligament after failed conservative management.
ELBOW EXAMINATION
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Anatomy
Evaluation
Inspection-Observation
Palpation-Pression
Range of motion
Neurological examination
Special tests
Examination of related areas
ELBOW ANATOMY
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Bones
Joints
Ligaments
Muscles
Elbow Anatomy
Medial Elbow
Elbow Anatomy
Lateral Elbow
ELBOW Anatomy
EVALUATION
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INSPECTION
Anterior –posterior side
Medial-lateral side
Carrying angle
Swelling
PALPATION and PRESSION
Bone palpation :
• Lateral epicondyle
• Radial head
• Medial epicondyle
• Olecranon
SOFT TISSUE PALPATION
Medial aspect
• Ulnar nerve
• Wrist flexor –pronator group
• Medial collateral ligament
Lateral aspect
• Wrist extensors (ECRL-ECRB)
• Lateral collateral ligament
• Annular ligament
SOFT TISSUE PALPATION
Anterior aspect
• Cubital fossa
• Brachial artery
• Median nerve
• Musculo-cutaneus nerve
Posterior aspect
• Olecranon bursa
• Triceps tendon
ELBOW ROM
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Flexion -135 degree
Extension -0 degree
Pronation -90 degree
Supination -90 degree
NEUROLOGICAL
EXAMINATION
Muscle tests:
• Flexion - Extension
• Pronation - Supination
Sensation tests
• C5-C6-C7-C8-T1
Reflex test:
• Biceps reflex –C6
• Brachioradial reflex –C6
• Triceps reflex-C7
Elbow Reflex testing
• Biceps reflex –C6
• Brachioradial reflex –C6
• Triceps reflex-C7
SPECIAL TESTS
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Ligament tests (varus-valgus stres test)
Tennis elbow test
Golfers elbow test
Tinels sign for ulnar nerve
Ligament tests (varus-valgus stres
test)
Tennis elbow test
Golfers elbow test
Tinels sign for ulnar nerve
COMMON ELBOW PROBLEMS
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Lateral epicondylitis
Medial epicondylitis
Olecranon bursitis
Fractures
Triceps tendinitis
Post immbolization capsular tightness
(contracture)
EXAMINATION of the WRIST
and HAND
Anatomy
• Surface anatomy
• Skeletal anatomy
• Fibrous anatomy
• Muscles
• Nerves
• Blood supply
Bony
Anatomy
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Phalanges: 14
Sesamoids: 2
Metacarpals: 5
Carpals
– Proximal row: 4
– Distal row: 4
• Radius and Ulna
Lister’s tubercle
ANATOMY
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Surface anatomy
Palmar surface
Radial border
Thenar surface
Thumb –index-middle-ring-small fingers
Hypothenar surface
Dorsal surface
İnterosseus muscle
JOINTS
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Radio-carpal
Ulna-carpal
İnter-carpal
Metacarpo-phalangial (MCP)
Proximal inter-phalangial (PIP)
Distal inter-phalangial (DIP)
Muscles
EVALUATION
• History
• Inspection-Observation (dorsum of the hand-palm of
the hand )
• Palpation-Pression
• Range of motion
• Functional assessment
• Neurological examination
• Special tests
• Examination of related areas
INSPECTION
Palmar Surface
• Creases
• Thenar and Hypothenar
Eminence
• Arched Framework
• Hills and Valleys
• Web Spaces
Palpation-Pression
ROM EXAMINATION
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Forearm pronation-90 degree
Forearm supination -90 degree
Wrist flexion (palmar flexion)-90 degree
Wrist extension (dorsal flexion )-90 degree
Wrist radial deviation -30 degree
Wrist ulnar deviation -20 degree
RANGE OF MOTION
Wrist
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Flexion
Extension
Radial deviation
Ulnar deviation
– Ulnar deviation is
greater than radial
FINGERS ROM
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MCP joint :
Flexion -90 degree
Extension -20 degree
PIP joint :
Flexion -90 degree
Extension -0 degree
DIP joint :
Flexion -80 degree
Extension -0 degree
THUMB ROM
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Flexion
Extension
Abduction
Adduction
Opposition
NERVES and BLOOD SUPPLY
• Radial nerve
• Median nerve
• Ulnar nerve
• Radial artery
• Ulnar artery
COMMON PROBLEMS
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Fractures
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Tenosynovitis :
1. Thumb extensors –De Querveins disease
2. Finger flexors tenosynovitis
3. Finger extensors tenosynovitis
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Arthritis
1. Rheumatoid arthritis (RA)
2. Osteoarthritis (OA)
–bouchards nodes
-heberdans nodes
- First MCP OA-Rhizarthrosis
DeQuervain’s Tenosynovitis
• Inflammation of EXT
Pollicis Brevis and ABD
Pollicis Longus tendons
• Tenderness 1st
Dorsal Compartment
• Finkelstein’s Test
Rheumatoid Arthritis
• MCP swelling
• Swan neck
deformities
• Ulnar deviation at
MCP joints
• Nodules along
tendon sheaths
Osteoarthritis
• Heberden’s nodes:
DIP
• Bouchard’s nodes:
PIP
COMPRESSION
NEUROPATHIES
• Median nerve compression syndrome
carpal tunel syndrome (tinel and phalen test )
• Pronator syndrome
• Ulnar nerve compression syndromes
compression at the elbow ulnar tunel syndrome
Compresssion at the wrist Guyon canal syndrome
• Radial nerve compression syndromes
Posterior interosseous nerve syndrome
Superficial radial nerve entrapment
SPECIAL TESTS
• Finkelsteins test –De Quervein tenosynovitis
• Tinel test –CTS, UTS
• Phalens test –CTS
Carpal Tunnel Tests
• Neurologic exam
– Median nerve sensation
and motor
• Phalen’s Test:
both wrists maximally
flexed for 1 minute
• Tinel’s Test
EXAMINATION of the RELATED
AREAS
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Cervical spine
Shoulder
Elbow
Arteries ,veins ,lymph
gallbladder stone
Heart