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Physical Examination of the Upper Extremities Prof.Dr.Hidayet Sarı Physical Medicine and Rehabilitation Department.

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Presentation on theme: "Physical Examination of the Upper Extremities Prof.Dr.Hidayet Sarı Physical Medicine and Rehabilitation Department."— Presentation transcript:

1 Physical Examination of the Upper Extremities Prof.Dr.Hidayet Sarı Physical Medicine and Rehabilitation Department

2 Shoulder Examination ANATOMY ANATOMY BonesBones JointsJoints MusclesMuscles BursaeBursae NervesNerves Blood supplyBlood supply

3 Bony Anatomy Anterior

4 Bony Anatomy Posterior

5 SHOULDER JOINTS 1.Glenohumeral 2.Scapula thoracic 3.Acromio-clavicular 4.Sterno-clavicular

6

7 Bony Anatomy Joints and Articulations STATIC STABILIZERS

8 Clinical Anatomy –Deltoid –Rotator cuff –Teres major –Latissimus dorsi –Biceps –Pectoralis muscles

9 Clinical Anatomy Rotator CuffRotator Cuff –Supraspinatus –Infraspinatus –Teres minor –Supscapularis POSTERIORANTERIOR

10 Clinical Anatomy Rotator CuffRotator Cuff –Supraspinatus ABD –Infraspinatus ER –Teres minor ER –Supscapularis IR Depress humeral head against glenoid to allow full abduction

11 Clinical Anatomy BursaeBursae –subacromial –subdeltoid –subscapular

12 Physical Examination Inspection Inspection Palpation –pressionPalpation –pression Range of motion examinationRange of motion examination Neurological examinationNeurological examination Special tests for the shoulder problemsSpecial tests for the shoulder problems Examination of the related areasExamination of the related areas

13 Shoulder Inspection Anterior sideAnterior side Posterior sidePosterior side Lateral sideLateral side Medial sideMedial side

14 Physical Exam Inspection Front & backFront & back Height of shoulder and scapulaeHeight of shoulder and scapulae Muscle atrophy, asymmetryMuscle atrophy, asymmetry

15 SHOULDER PALPATION and PRESSION BonesBones JointsJoints MusclesMuscles BursaeBursae NervesNerves Lymph nodesLymph nodes

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17

18 SHOULDER Range Of Motion Flexion-180 degreeFlexion-180 degree Extension -45 degreeExtension -45 degree Abduction -180 degreeAbduction -180 degree Adduction -30 degreeAdduction -30 degree Internal rotation -90 degreeInternal rotation -90 degree External rotation -90 degreeExternal rotation -90 degree

19 Physical Exam Range of Motion Forward flexion:Forward flexion: –0 o – 180 o

20 Physical Exam Range of Motion ExtensionExtension –0 o – 40 to 60 o

21 Physical Exam Range of Motion Internal rotationInternal rotation –80-90 o External rotationExternal rotation –80-90 o

22 Speed shoulder tests External rotation Internal rotation

23 Neurological Examination of the Shoulder Muscle tests : Muscle tests : FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction Internal rotationInternal rotation External rotationExternal rotation

24 Muscle testing scoring 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

25 Shoulder Abduction muscle test

26 Shoulder flexion and extension muscle test

27 Shoulder external and internal rotation muscle test

28 Shoulder abduction and adduction muscle test

29 Neurological Examination of the Shoulder sensory tests : sensory tests : C4C4 C5C5 C6C6 C7C7 C8C8 T1T1 T2T2

30 Special Tests for the Shoulder Problems Yergason test –biceps tendinitisYergason test –biceps tendinitis Neer impingement test-acromioclavicular impingementNeer impingement test-acromioclavicular impingement Drop arm test –rotator cuff tearDrop arm test –rotator cuff tear Resisted flexion (Speed)test –biceps tendinitisResisted flexion (Speed)test –biceps tendinitis Resisted abduction(Supraspinatus) test- supraspinatus lesionResisted abduction(Supraspinatus) test- supraspinatus lesion Aprehension test –glenohumeral joint instabilityAprehension test –glenohumeral joint instability

31 Yergason test Yergason test for biceps tendon instability or tendonitis.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.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.

32 Drop Arm Test Passive abduction to 90°Passive abduction to 90° Instruct patient to slowly lower armInstruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressureAt 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test(+) drop = (+) test

33 SHOULDER PAIN SPECIAL TESTS NeerNeer –PASSIVE –Forced forward flexion of arm with internally rotated shoulder –Test is positive if pain occurs at same point as with active forward flexion

34 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.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.

35 Rotator Cuff Strength Testing Weakness on examWeakness on exam Grade strength on 0→5 scaleGrade strength on 0→5 scale Compare to other sideCompare to other side Supraspinatus testing

36 Apprehension Test/Relocation Test

37 Differantial Diagnosis for shoulder pain Subacromial impingement syndromeSubacromial impingement syndrome Adhesive capsulitis –frozen shoulderAdhesive capsulitis –frozen shoulder Biceps tendinopatiBiceps tendinopati BursitisBursitis Rotator cuff pathologyRotator cuff pathology Glenohumeral joint pathologyGlenohumeral joint pathology Acromioclavicular joint pathologyAcromioclavicular joint pathology Sternoclavicular joint pathologySternoclavicular joint pathology Myofascial pain syndromeMyofascial pain syndrome Radiating or referred pain from cervical spineRadiating or referred pain from cervical spine

38 Subacromial Impingement Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal arch.Neer proposed that 95% of rotator cuff tears are due to chronic impingement between the humeral head and the coracoacrominal arch.

39 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.Stage 1 disease consists of edema and hemorrhage of the tendon due to occupational or athletic overuse, and is reversible under conservative treatment.

40 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.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.

41 ELBOW EXAMINATION AnatomyAnatomy EvaluationEvaluation Inspection-ObservationInspection-Observation Palpation-PressionPalpation-Pression Range of motionRange of motion Neurological examinationNeurological examination Special testsSpecial tests Examination of related areasExamination of related areas

42 ELBOW ANATOMY BonesBones JointsJoints LigamentsLigaments MusclesMuscles

43 Elbow Anatomy Medial Elbow

44 Elbow Anatomy Lateral Elbow

45 ELBOW Anatomy ELBOW Anatomy

46 EVALUATION INSPECTION INSPECTION Anterior –posterior sideAnterior –posterior side Medial-lateral sideMedial-lateral side Carrying angleCarrying angle SwellingSwelling

47 PALPATION and PRESSION Bone palpation : Bone palpation : Lateral epicondyleLateral epicondyle Radial headRadial head Medial epicondyleMedial epicondyle OlecranonOlecranon

48 SOFT TISSUE PALPATION Medial aspect Medial aspect Ulnar nerveUlnar nerve Wrist flexor –pronator groupWrist flexor –pronator group Medial collateral ligamentMedial collateral ligament Lateral aspect Lateral aspect Wrist extensors (ECRL-ECRB)Wrist extensors (ECRL-ECRB) Lateral collateral ligamentLateral collateral ligament Annular ligamentAnnular ligament

49 SOFT TISSUE PALPATION Anterior aspect Anterior aspect Cubital fossaCubital fossa Brachial arteryBrachial artery Median nerveMedian nerve Musculo-cutaneus nerveMusculo-cutaneus nerve Posterior aspect Posterior aspect Olecranon bursaOlecranon bursa Triceps tendonTriceps tendon

50 ELBOW ROM Flexion -135 degreeFlexion -135 degree Extension -0 degreeExtension -0 degree Pronation -90 degreePronation -90 degree Supination -90 degreeSupination -90 degree

51 NEUROLOGICAL EXAMINATION Muscle tests: Muscle tests: Flexion - Extension Flexion - Extension Pronation - SupinationPronation - Supination Sensation tests Sensation tests C5-C6-C7-C8-T1C5-C6-C7-C8-T1 Reflex test: Reflex test: Biceps reflex –C6Biceps reflex –C6 Brachioradial reflex –C6Brachioradial reflex –C6 Triceps reflex-C7Triceps reflex-C7

52 Elbow Reflex testing Biceps reflex –C6Biceps reflex –C6 Brachioradial reflex –C6Brachioradial reflex –C6 Triceps reflex-C7Triceps reflex-C7

53 SPECIAL TESTS Ligament tests (varus-valgus stres test)Ligament tests (varus-valgus stres test) Tennis elbow testTennis elbow test Golfers elbow testGolfers elbow test Tinels sign for ulnar nerveTinels sign for ulnar nerve

54 Ligament tests (varus-valgus stres test)

55 Tennis elbow test

56 Golfers elbow test

57 Tinels sign for ulnar nerve

58 COMMON ELBOW PROBLEMS Lateral epicondylitisLateral epicondylitis Medial epicondylitisMedial epicondylitis Olecranon bursitisOlecranon bursitis FracturesFractures Triceps tendinitisTriceps tendinitis Post immbolization capsular tightnessPost immbolization capsular tightness (contracture) (contracture)

59 EXAMINATION of the WRIST and HAND Anatomy Anatomy Surface anatomySurface anatomy Skeletal anatomySkeletal anatomy Fibrous anatomyFibrous anatomy MusclesMuscles NervesNerves Blood supplyBlood supply

60 Bony Anatomy Phalanges: 14Phalanges: 14 Sesamoids: 2Sesamoids: 2 Metacarpals: 5Metacarpals: 5 CarpalsCarpals –Proximal row: 4 –Distal row: 4 Radius and UlnaRadius and Ulna Lister’s tubercle

61 ANATOMY Surface anatomySurface anatomy Palmar surfacePalmar surface Radial borderRadial border Thenar surfaceThenar surface Thumb –index-middle-ring-small fingersThumb –index-middle-ring-small fingers Hypothenar surfaceHypothenar surface Dorsal surfaceDorsal surface İnterosseus muscleİnterosseus muscle

62 JOINTS Radio-carpalRadio-carpal Ulna-carpalUlna-carpal İnter-carpalİnter-carpal Metacarpo-phalangial (MCP)Metacarpo-phalangial (MCP) Proximal inter-phalangial (PIP)Proximal inter-phalangial (PIP) Distal inter-phalangial (DIP)Distal inter-phalangial (DIP)

63 Muscles

64 EVALUATION HistoryHistory Inspection-Observation (dorsum of the hand-palm of the hand ) Inspection-Observation (dorsum of the hand-palm of the hand ) Palpation-PressionPalpation-Pression Range of motionRange of motion Functional assessmentFunctional assessment Neurological examinationNeurological examination Special testsSpecial tests Examination of related areasExamination of related areas

65 INSPECTION Palmar Surface CreasesCreases Thenar and Hypothenar EminenceThenar and Hypothenar Eminence Arched FrameworkArched Framework Hills and ValleysHills and Valleys Web SpacesWeb Spaces

66 Palpation-Pression

67 ROM EXAMINATION Forearm pronation-90 degreeForearm pronation-90 degree Forearm supination -90 degreeForearm supination -90 degree Wrist flexion (palmar flexion)-90 degreeWrist flexion (palmar flexion)-90 degree Wrist extension (dorsal flexion )-90 degreeWrist extension (dorsal flexion )-90 degree Wrist radial deviation -30 degreeWrist radial deviation -30 degree Wrist ulnar deviation -20 degreeWrist ulnar deviation -20 degree

68 RANGE OF MOTION Wrist FlexionFlexion ExtensionExtension Radial deviationRadial deviation Ulnar deviationUlnar deviation –Ulnar deviation is greater than radial

69 FINGERS ROM MCP joint : MCP joint : Flexion -90 degreeFlexion -90 degree Extension -20 degreeExtension -20 degree PIP joint : PIP joint : Flexion -90 degreeFlexion -90 degree Extension -0 degreeExtension -0 degree DIP joint : DIP joint : Flexion -80 degreeFlexion -80 degree Extension -0 degreeExtension -0 degree

70 THUMB ROM FlexionFlexion ExtensionExtension AbductionAbduction AdductionAdduction OppositionOpposition

71 NERVES and BLOOD SUPPLY Radial nerveRadial nerve Median nerveMedian nerve Ulnar nerveUlnar nerve Radial arteryRadial artery Ulnar arteryUlnar artery

72 COMMON PROBLEMS FracturesFractures Tenosynovitis :Tenosynovitis : 1.Thumb extensors –De Querveins disease 2.Finger flexors tenosynovitis 3.Finger extensors tenosynovitis ArthritisArthritis 1.Rheumatoid arthritis (RA) 2.Osteoarthritis (OA) –bouchards nodes -heberdans nodes -heberdans nodes - First MCP OA-Rhizarthrosis

73 DeQuervain’s Tenosynovitis Inflammation of EXT Pollicis Brevis and ABD Pollicis Longus tendonsInflammation of EXT Pollicis Brevis and ABD Pollicis Longus tendons Tenderness - 1st Dorsal CompartmentTenderness - 1st Dorsal Compartment Finkelstein’s TestFinkelstein’s Test

74 Rheumatoid Arthritis MCP swellingMCP swelling Swan neck deformitiesSwan neck deformities Ulnar deviation at MCP jointsUlnar deviation at MCP joints Nodules along tendon sheathsNodules along tendon sheaths

75 Osteoarthritis Heberden’s nodes: DIPHeberden’s nodes: DIP Bouchard’s nodes: PIP

76 COMPRESSION NEUROPATHIES Median nerve compression syndromeMedian nerve compression syndrome carpal tunel syndrome (tinel and phalen test ) carpal tunel syndrome (tinel and phalen test ) Pronator syndromePronator syndrome Ulnar nerve compression syndromesUlnar nerve compression syndromes compression at the elbow ulnar tunel syndrome compression at the elbow ulnar tunel syndrome Compresssion at the wrist Guyon canal syndrome Radial nerve compression syndromesRadial nerve compression syndromes Posterior interosseous nerve syndrome Superficial radial nerve entrapment

77 SPECIAL TESTS Finkelsteins test –De Quervein tenosynovitisFinkelsteins test –De Quervein tenosynovitis Tinel test –CTS, UTSTinel test –CTS, UTS Phalens test –CTSPhalens test –CTS

78 Carpal Tunnel Tests Neurologic examNeurologic exam –Median nerve sensation and motor Phalen’s Test: both wrists maximally flexed for 1 minutePhalen’s Test: both wrists maximally flexed for 1 minute Tinel’s TestTinel’s Test

79 EXAMINATION of the RELATED AREAS Cervical spineCervical spine ShoulderShoulder ElbowElbow Arteries,veins,lymphArteries,veins,lymph gallbladder stonegallbladder stone HeartHeart


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