Special Tests: Shoulder, Elbow, Wrist/Hand Name Structure How to Positive Image

Transcription

1 Special s: Shoulder, Elbow, Wrist/Hand Name Structure How to Positive Image Shoulder Special ROM ing Apley s Scratch assessing function ROM of the shoulder ask pt to scratch their back while reaching over head with one hand & behind back with the other hand any difference in inability to touch opposite shoulder, if painful could indicate tendinitis Shoulder Instability Load & Shift capsule pt in seated position, examiner places hand over shoulder- ant/ post joint line to stabilize scapother hand grasp humeral head, loading it into glenoid fossa- test ant/post normal: 25% grade1: 50% of humeral head grade 2: >50% translation with spontaneous reduction grade 3: movement over glenoid rim- no reduction Anterior Apprehension capsule- anterior instability examiner abducts arm to 90, then externally rotates shoulder, if necessary an anterior pressure is applied to posterior aspect of humeral head look of apprehension on pt s face or resistance to further motion, pt states feeling same as during dislocation Posterior Apprehension capsule- posterior instability (uncommon) examiner flexes shoulder forward to 90 and internally rotates pt shoulder, posterior force is applied to elbow look of apprehension on pt s face or resistance to further motion, pt states feeling same as during dislocation Sulcus Sign capsulemultidirectional instability pt stands w arm of abduction & mm relaxed, examiner grasp pt s forearm above elbow & pull arm distally, look for depression created btw acromial hood & humeral head sulcus appears in subacromial area, measuring from inferior margin of acromion to humeral head Acromioclavicular s Cross over (adduction) Stress assess for dysfunction at AC joint examiner forward flex involved arm 90 (w elbow at 90 ), flexed arm is passively adducted across body reproduction of pt s symptoms

2 AC Shear assess for dysfunction at AC joint pt sitting, examiner cups both hands with one over scapula and one over clavicle then squeezes (force moving posteriorly- hand on lateral clavicle, force moving anteriorly- hand on spine of scapula) reproduction of pt s symptoms Labral s Crank integrity of glenoid labrum of the shoulder/dx of labral tears pt is placed in a seated position w the affected arm elevated 160 in scapular plane, axial load is applied to GH joint as humerus is internally/externally rotated pain w/wout a mechanical click, reproduction of the pt s activity related symptoms O Brien integrity of superior glenoid labrum/dx labral tears standing pt forward flexes the arm to 90 w elbow in ext, arm is add medially, followed by internal rotation- examiner applies downward force, movement repeated supinated pain (clicking) on 1st movement, reduced pain on second s for Muscle & Tendon Pathology Bicep Tendon & SLAP Lesions Speed s LH biceps tendon, and glenoid labrum (SLAP) pt s humerus forward flex 60, forearm supinated, elbow ext, examiner resists forward flexion pt complains of pain during forward flexion of shoulder Yergason s assesses bicipital tenosynovitis & integrity of glenoid labrum (SLAP) pt s elbow flexed to 90 & forearm is pronated, examiner holding Px wrist, pt actively supinate against resistence pt complains of pain localized to bicipital groove area, disorder in LH bicep Supraspinatus Tendon Empty Can integrity of rotator cuff mm (supraspin) examiner instructs pt to abd 90, medially rotate (thumb to floor), resists against examiner pt gives way, looks for pain or weakness, suggestive of tear or neuropathy of suprascapular n Drop Arm (Codman s) dx of shoulder impingement syndrome px actively or passively abd arm, arm is then released arm drops suddenly or pt has severe pain, inability to abd shoulder

3 Subscapularis Lift Off rotator cuffsubscap pt standing w elbow flexed & dorsum of hand over low back, pt lift off their arm away from back inability to move affected arm off low back, decrease ability to move the affected arm off love back (comparative) s for Impingement Neer primarily used to dx SIS & labrum &rotators (supraspin/biceps) pt standing & examiner stands behind (or in front) of pt, examiner stabilizes scap w one hand & forward flexes the arm w other until pain pain in the anterior or lateral part of the shoulder typically in the range Hawkins- Kennedy primarily used to dx SIS & labrum & rotators (supraspin) pt stands while examiner forward flexes arm 90 w elbow bent & towards chest, examiner forcibly medially rotates shoulder pain in anterior or lateral part of the shoulder s for TOS Adson s/ Reverse Adson dx of neuropathic or vascular compromise at brachial plexus pt is sitting w examiner behind, instruct pt to rotate head toward symptomatic side, pt extends head while examiner externally rotates/extends the shoulder, radial pulse is palpated, pt instructed to take deep breath and hold disappearance of radial pulse Roos (EAST) Maneuver dx of neuropathic or vascular compromise at brachial plexus examiner instructs pt to abd arm to 90, laterally rotates shoulder, flexes elbow to 90, positioned behind frontal plane, opens/ closes hand slowly for 3 minutes pt unable to keep arms in position for more than 3 mins, suffers from ischemia pain, heaviness or profound weakness of arm, numbness/tingling

4 Elbow Neurological s Tinel s at the Elbow assess partial/ complete neuro compromise at ulnar nerve at medial epicondyle in cubital tunnel examiner applies taps to the pt s ulnar nerve just proximal to the cubital tunnel tingling/pain along distribution of ulnar nerve, tingling (nerve is healing), pain (early in damage state) Ligamentous Instability s Varus/Valgus Stress integrity of medial (valgus) or lateral (varus) CL humerus ext rotated, forearm supinated, elbow flexed & stabilized, medial CL: valgus, lateral CL: varus considerable gapping, pain along medial/lateral joint lines Milking Maneuver test posterior band of the anterior bundle of ulnar collateral lig supine, shoulder flexed 90, pt s elbow flexed 90, opposite hand under humerus to grasp the affected thumb (pulling on the thumb will then apply a valgus stress on MCL), examiner palpates MCL for pain/gapping considerable gapping, pain along medial joint lines Muscle Tendon Pathology Golfer s Elbow (stretch or contract) strain/stress/ medial epicondyle examiner palpate pt s medial elbow, pt s elbow supinate& flexed, pt s elbow & wrist fully flexed against examiners resistance- alternative: elbow & wrist fully extended pain over medial epicondyle Cozen s strain/stress/ lateral epicondyle pt s elbow stabilized at lat epicon, pt makes a fist, forearm pronated folloed by radial deviation & extension of wrist, resists above movement reproduction of acute pain at lateral epicondyle, lateral epicondylitis Mill s strain/sprain/ lateral epicondyle pt s elbow stabilized at lat epicon, pt makes a fist, pt s elbow extended & wrist flexed, examiner places over pressure on above movement reproduction of acute pain at lateral epicondyle

5 Method 3 strain/stress/ lateral epicondyle pt s elbow fully extended, arm flexed forward, examiner applies pressure downward on the DIP of first 2 fingers reproduction of acute pain at lateral epicondyle Hand & Wrist Ligamentous Instability s & Carpal s DRUJ Ballotement instability of the DRUJ due to injury of ligs stabilizing the joint radius is grasped by examiner, distal ulna is fixed btw the examiner s thumb & indexmoved in dorsal & palmar directions ulna/radius show increased displacement w soft end-point resistance, pain Piano Key instability of the DRUJ due to injury of ligs stabilizing the joint pt sits w arm pronated while examiner stabilizes pt s arm w one hand, support pt s hand, push down on distal ulnar (like a piano key) difference in mobility in reference to other side (ulna springs back into position), pain Thumb UCL Laxity integrity of ulnar collateral lig of the thumb examiner stabilizes pt s hand & places pt s thumb into extension, examiner places valgus stress test to UCL valgus movement greater than (complete tear) Murphy s Sign tests dislocation of lunate ask pt to make a fist, visually inspect the dorsal aspect of the hand knuckle of 3rd MC head is level w knuckles of 2nd & 4th MT heads Anat. Snuff Box Compression assess for potential fx of the scaphoid (following trauma) pt rests involved forearm on table, pt extend thumb, examiner palpates into the floor of the snuff box pain in anatomical snuff box is an indication of a scaphoid fx Muscle, Tendon, Joint Pathology Finkelstein s presence of stenosing tenosynovitis (de Quervain s) in the AbPL + EPB tendons pt forms fist around thumb (w same hand), examiner stabilizes forearm, pt moves wrist into ulnar deviation increased pain at radial styloid process, pain along the length of the ext. poll. brev & abd. poll. longus tendons Brunelli s presence of stenosing tenosynovitis (de Quervain s) in the AbPL + EPB tendons examiner instructs pt to extend affected thumb against resistance in a a. ulnar deviated position b. radially deviated position increased pain along the radial styloid process, pain along the length of the ext. poll. brev & abd. poll. longus tendon Bracelet assesses for presence of RA examiner gives mild lateral compression of lower ends of radius & ulna increased pain at the radial & ulnar styloid process

6 Neurological s Tinel s At the Wrist median N. as crosses through carpal tunnel examiner taps the carpal tunnel at the wrist tingling & paresthesia into the thumb, index finger, middle, & lateral half of ring finger Phalen s/ Reverse Phalen s median N. as crosses through carpal tunnel pt maximally flexes their wrists, hold this position for about 1 minute (by pushing pt wrists together) tingling & paresthesia into the thumb, index finger, middle, & lateral half of ring finger Carpal Compression median N. as crosses through carpal tunnel pt s wrists neutral, pressure maintained for 30sec or until occurrence of abnormal sensation along median N tingling & paresthesia into the thumb, index finger, middle, & lateral half of ring finger Wringing non-specific test used to localize wrist pain ask pt to wring a cloth in both directions paresthesia: CTS pain at elbow: epicondylitis wrist discomfort: arthropathy/ carpal derangement Froment s Sign test for ulnar N. palsy by specifically testing the action of adductor pollicis pt asked to hold a piece of paper btw the thumb & flat palm, paper is pulled away from pt normal: individual can hold paper positive: pt flexed IP the thumb to try to maintain a hold on the paper Pinch Grip assess injury to anterior interosseous N. which is a branch of the median N examiner instructs pt to pinch the tips of the thumb & index finger together inability to touch the tips of the thumb & index, touching the pads of the thumb & index finger together Vascular s Allen s tests blood flow through radial/ulnar arteries pt is asked to open&close hand repeatedly, then close hand tightly, examiner uses finger pressure to occlude BOTH radial & ulnar aa, examiner releases one artery at a time to note flushing if skin or palm remains blanched for more than 5 sec indicate arterial occlusion