PHYSICAL EXAMINATION
OF THE UPPER EXTREMITY
Pa t L a u p a tta ra ka s em
M D . F R C O S T.
Department of
Orthopaedics
Khon Kaen University
Thailand
OBJECTIVES
 To understand
- Basic upper extremities anatomy
- Basic upper extremities examinations
PHYSICAL EXAMINATION
OF
THE SHOULDER
SCOPE FOR SHOULDER EXAMINATION
1.
2.
3.
4.
5.
6.
7.
General considerations
Shoulder anatomy
Inspection
Palpation
Range of motion
Strength testing
Special test




Rotator cuff
Laxity VS Instability
A-C joint
Biceps & SLAP
WHY IS SHOULDER EXAMINATION
NOT SO SIMPLE?
 Pain and other symptom patterns NOT specific
 Structures NOT always accurately palpable
 Several pathology can co -exist
Patient history
1.
2.
3.
4.
5.
Age
Occupation
Hand dominance
Activity level
Pain/other symptoms in details
• Neurovascular symptoms
• Impaired movements
• Instabilities
SHOULDER ANATOMY
GENERAL CONCEPT
1.
2.
3.
4.
5.
6.
7.
Approach
Undress patient
Compare both sides
Examination of joints above & below
Neurovascular examination
Referred pain
General ligamentous laxity
GENERAL INSPECTION
1.
2.
3.
4.
Body-neck posture
Shoulder symmetry
Musculature
Bony prominence
& joint
Medial border prominent = Rhomboids atrophy
Lateral border prominent = Latissimus dorsi atrophy
Superior border prominent = Trapezius or Supraspinatus atrophy
MUSCLE ATROPHY
INSPECTION
 Lateral
 Shoulder inferior subluxation




Acromion & AC joint
Middle deltoid muscle
Biceps brachii muscle
Triceps muscle
LATERAL INSPECTION
SHOULDER DISLOCATION
Hamilton’s ruler sign +ve
Fullness of
deltopectoral groove
Duga’s test
Test for anterior
shoulder dislocation
Tenderness
PALPATION
Deformity
PALPATION
 Long head biceps tendon palpation
 Shoulder IR 10°
 Below anterolateral margin of acromion 1-4 cm
RANGE OF MOTION




-
Anatomical position
Active  Passive motion
Scapulohumeral rhythm
Isolated & combine
Glenohumeral
F/E, Ab/Ad, Elevation IR/ER
Scapulothoracic
RANGE OF MOTION
ROM (PASSIVE & ACTIVE)
 Flexion
ROM (PASSIVE & ACTIVE)
 Extension
ROM (PASSIVE & ACTIVE)
 Abduction
ROM (PASSIVE & ACTIVE)
 Adduction
 Cross chest or shoulder adduction
ROM (PASSIVE & ACTIVE)
 External & internal rotation shoulder 90° abduction
Zero position
ER
IR
ROM (PASSIVE & ACTIVE)
 External rotation arm at the side
 Shoulder 0° abduction)
Zero
position
ER
ROM (PASSIVE & ACTIVE)
 Internal rotation arm at the side
(0° abduction)
F = T7
M = T9
To abdomen
Behind the back (Apley’s scratch test)
Arm length
C7 spinous process
Radial styloid
MUSCLE POWER
 Motor grading system ( 0-5)
1. Prime mover: e.g.,




Deltoid
Trapezius
Pectoralis
Latissimus dorsi
2. Primary stabilizer (rotator cuf f)
1.
2.
3.
4.
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
3. Others: e.g.,


Biceps
Triceps
SPECIAL TESTS
1.
2.
3.
4.
Rotator cuff
Instability
Biceps & SLAP
A-C joint
ROTATOR CUFF
 Rotator cuf f integrity test
1. Assessment of rotator cuf f function
-
Lift-off test
Belly press/off test
Bear hug test
Internal/external resistance stress test
2. Lag test
- External/internal rotation lag sign
- Drop sign
 Impingement test
- Neer impingement sign/test
- Hawkin’s test
- Jobe’s test
ROTATOR CUFF
INTEGRITY TEST
GERBER’S LIFT-OFF TEST
(SUBSCAPULARIS)
Positive: subscapularis tendon rupture
BELLY PRESS TEST
(SUBSCAPULARIS)
Positive: subscapularis tendon tear
BELLY-OFF SIGN
(SUBSCAPULARIS)
EXTERNAL ROTATION LAG SIGN
(INFRASPINATUS)
 Specific test for infraspinatus
 Weakness not specific to cuf f tear
Positive: inflammation or tear of infraspinatus and/or teres minor
DROP SIGN
 Shoulder abduction 90° and
maximum external rotate
 Elbow flexion 90°
 Asked patient to maintained
position
 Positive : drop
Positive: tear of infraspinatus
DROP ARM TEST
(SUPRASPINATUS)
 Massive tear
 Severe denervation
 R/O stif f shoulder
ROTATOR CUFF
IMPINGEMENT
SIGNS/TEST
JOBE SUPRASPINATUS TEST
(SUPRASPINATUS)




Arm elevated 90 degrees at scapular plane
Thumb up/thumb down
Resist abduction
+ve for weak & pain
NEER IMPINGEMENT SIGN
(SUPRASPINATUS)
 Arm elevation
 Tender at anterolateral
aspect of acromion
NEER IMPINGEMENT SIGN
(SUPRASPINATUS)
Raises affected arm in
forced forward flexion
while stabilized scapula
 Greater tuberosity impinge
against acromion
Impingement test
 10ml of 1% xylocaine
injection in subacromion
bursa
HAWKINS’ TEST
(SUPRASPINATUS)
 Forward flexion & IR
 Greater tuberosity impinge against coracoacromial ligament
PAINFUL ARC
(SUPRASPINATUS)
 Neer (1972)
 Pain with arm elevation
70-120 degrees abduction
 Clinical ef fectiveness
- Sensitivity = 74%
- Specificity = 81%
LAXITY & INSTABILITY TEST
Sulcus sign
Anterior drawer
Posterior drawer
Load and shif t
Translation
grading
ANTERIOR DRAWER TEST
POSTERIOR DRAWER TEST
INFERIOR LAXIT Y SIGN (SULCUS TEST)
VOLUNTARY VS INVOLUNTARY
INSTABILITY
APPREHENSION TEST
RELOCATION & SURPRISING TEST
BICEPS TENDINITIS/INSTABILITY
& SLAP LESION
SPEED TEST
YERGASON’S TEST
(BICEPS TENDINITIS/INSTABILIT Y)
O’BRIEN TEST
(SLAP LESION)
ACROMIO-CLAVICULAR
JOINT ARTHRITIS
One-finger test
CROSS ARM TEST
(A-C JOINT ARTHRITIS)
PHYSICAL EXAMIMATION
OF
THE ELBOW
ANATOMY
ANATOMY
มักเป็ นตัวแรกที่ขาด
เวลาศอกหลุด
มักเป็ นตัวสุดท้ ายที่ขาด
เวลาศอกหลุด
INSPECTION
 Deformity
Lateral epicondyle
Abnormal triceps sulcus
Prominent olecranon process
INSPECTION
 Carrying angle
PALPATION
 Triangular land marks of the elbow
 Tip of olecranon process
 Lateral epicondyle
 Medial epicondyle
Heuter’s line
TRIANGULAR LANDMARKS
Medial epicondyle
Lateral epicondyle
Tip of olecranon process
PALPATION
 Lateral soft spot of the elbow
 Between lateral epicondyle, radial head and olecranon
PALPATION
 Cubital tunnel
MOTION: FLEXION/EXTENSION
Fulcrum = Lateral epicondyle
Fixed arm = Imaginary line
parallel to the ground
Moving arm = ulnar shaft
MOTION: PRONATION/SUPINATION
SPECIAL TESTS
Lateral epicondylitis
Cozen’s test
Medial epicondylitis
Reverse Cozen’s test
PHYSICAL EXAMINATION
OF
THE WRIST
ANATOMY
ANATOMY
INSPECTION
 Deformity
 Swelling
 Signs of inflammation
Dinner fork deformity
PALPATION : VOLAR
Hook of Hamate
Scaphoid tubercle
Pisiform
PALPATION : DORSUM
Lister’s tubercle
Anatomical snuff box
ROM (ACTIVE & PASSIVE)
ROM (ACTIVE)
Extension
Flexion
DE QUERVAIN DISEASE
• Obstructive tenovaginitis obliterans
st
of the 1 dorsal retinacular compartment
P.E. - Local tenderness
- Finkelstein’s test
False +ve ได้ ต้ องระวัง
MEDIAN CARPAL TUNNEL
โครงสร้ างที่ข้อมือ latl –>;; medl
“รถ ไฟ มา พา สาว เอา หน้ า ฟาด”
รถ : Radial a.
ไฟ :Flexor carpi radialis
มา :MediaN n.
พา : Palmaris longus
สาว : flexor digitorum Superficialis
เอา : Ulnar A.
หน้ า : ulnar N.
ฟาด : Flexor carpi ulnaris
MEDIAN CARPAL TUNNEL
30-60 years old
Female:Male = 2-3:1
Signs and symptoms
 Numbness median N.
distribution
 Burning and numbness
 Awaken sleep
P.E.
 Tinel sign
 Phalen test
MEDIAN CARPAL TUNNEL
Tinel sign
Phalen test
INTERSECTION SYNDROME
Inflammation at the
crossing point of 1 st
and 2 nd dorsal
compartment
P.E.
 Pain on dorsum of
wrist
 Crepitus when resist
wrist extension and
thumb extension
 Occasional
PHYSICAL EXAMINATION
OF THE HAND
ANATOMY
ANATOMY
INTRINSIC MUSCLES
INTRINSIC MUSCLES
Important
Trigger finger
FLEXOR TENDON PULLEY SYSTEM
FLEXOR AND EXTENSOR MECHANISM
SENSATION
INSPECTION
 Deformity
Ulnar claw hand
INSPECTION
 Deformity
Ulnar Drift Hand
INSPECTION
 Deformity
Boutonnière
Rupture of the central slip
INSPECTION
 Deformity
Mallet finger
INSPECTION
 Deformity
Swan neck
INSPECTION
 Deformity
Boutonnière
Swan neck
INSPECTION
 Deformity : OA PIP
Inspection
INSPECTION
 Deformity : OA DIP
INSPECTION
 Deformity
4 cardinal signs of Kanavel
Purulent tenosynovitis
VOLKMANN ISCHEMIC CONTRACTURE
FINGER ROTATION EXAMINATION
Scaphoid tubercle or FCR
FINGER FLEXOR EXAMINATION
FDS
FDP
Wartenburg’s test
Egawa’s test
TRIGGER FINGER
Obstructive tenovaginitis obliterans
of the flexor tendon sheath
P.E. - Local tenderness
- Triggering of finger
THANK YOU FOR YOUR ATTENTION