Examination of the Upper Extremities PDF

Examination of the Upper Extremities Lauren Clemmons, DO, FACOFP Learning Objectives Describe the basic Anatomy of the upper extremities. Describe what can be found on Inspection of the upper extremities and how to verbalize findings. Explain the technique for Inspection of the upper extremities. De...

Examination of the Upper Extremities Lauren Clemmons, DO, FACOFP Learning Objectives Describe the basic Anatomy of the upper extremities. Describe what can be found on Inspection of the upper extremities and how to verbalize findings. Explain the technique for Inspection of the upper extremities. Describe what can be found on Palpation of the upper extremities and how to verbalize findings. Explain how to adequately Palpate the upper extremities. Describe how to test Range of Motion of the upper extremities. Describe how to test Strength in the upper extremities. Describe the Clinical Significance of normal and abnormal upper extremity physical exam findings. Document the upper extremity physical exam findings. 2 Upper Extremity Skills Inspection These are the 4 we will practice Palpation in skills lab Range of Motion Thursday. Strength Testing These Deep Tendon Reflexes you Pulses know already. Soft Touch Vibration Position Sense Superficial Pain We’ll practice Capillary Refill this in Cardio. 3 Upper Extremity 4 Anatomy Review Surface Anatomy 5 Anatomy Review Shoulder 6 Anatomy Review Elbow 7 Anatomy Review Wrist/Hand 8 Anatomy Review- Wrist/Hand 9 Inspection Overall Size Gross Deformity Alignment Contour Symmetry Skinfolds Muscle Wasting Fasciculations Skin changes Swelling Always look at BOTH sides, all aspects. Verbalize your findings: “No concerning asymmetry noted, no skin changes or muscle wasting.” If this is what you see! “I don’t see any joint swelling or redness.” “There is redness and swelling overlying the dorsal wrist.” 10 Inspection- Shoulders Look at both shoulders!!! 11 Inspection- Shoulders 12 Inspection- Shoulders Inspection- Elbows Observe flexed and extended. Note carrying angle. 14 Inspection- Elbows 15 Inspection- Wrist 16 Inspection- Hands Look at both surfaces! Contour Inflammation Masses Position and deviation of fingers Palmar and phalangeal creases Thenar and hypothenar eminences All Joints Note: Tenderness? Growths? Swelling? Between fingers Nails 17 Inspection- Hands Ulnar Deviation at the MCPs from Rheumatoid Arthritis Osteoarthritis affecting PIPs and DIPs 18 Inspection- Hands Raynaud’s phenomenon Dupuytren's contracture 19 Palpation Bones/Joints/Muscles/Fascia/Skin/Arteries/Nodes Note: Heat Tenderness Swelling Crepitus Tone Masses OPP!!- “tissue texture changes” 20 Palpation Hands Palpate each DIP and PIP Squeeze the MCPs Arms 21 Palpation- Lateral Epicondylitis “Tennis Elbow” 22 Palpation- Medial Epicondylitis “Golfer’s Elbow” 23 Palpation- Pulses Not for this Skills Lab or Exam Block! Palpate with the pads of your fingers The pulses are best palpated over arteries that are close to the surface of the body and lie over bones. Radial artery: lateral flexor surface Ulnar artery: medial flexor surface **overlying tissues may obscure pulsations in the ulnar artery** Brachial Artery: at the bend of the elbow just medial to the biceps tendon 24 Capillary Refill Not for this Skills Lab or Exam Block! 25 Palpation Verbalize: “I don’t feel any masses or swelling”. “No warmth, no crepitus.” “Please let me know if any of this causes pain.” “Warm, fluctuant, 1 cm mass dorsomedial aspect of right wrist.” 26 Range of Motion Key Principles: Demonstrate for patient or give clear instructions. Stand/Sit so that you can truly view the motion. Make sure to have patient attempt the full range. You can test active OR passive range of motion. 27 Range of Motion- Shoulder What are the 6 motions of the shoulder? Flexion Restricted range of motion occurs in: Extension Bursitis Abduction Capsulitis Rotator cuff Adduction tears or sprains Internal rotation Tendinitis External rotation 28 Range of Motion- Shoulder Flexion: “Raise your arms in front of you and overhead.” Extension: “Raise your arms behind you.” 29 Range of Motion- Shoulder Abduction: “Raise your arms out to the side and overhead.” Make sure to demonstrate 180⁰!! 30 Range of Motion- Shoulder Adduction: “Cross your arm in front of your body.” This motion combines some flexion with adduction. True adduction is 50⁰ max. 31 Range of Motion- Shoulder Internal Rotation “Raise your arm to shoulder level; bend your elbow and rotate your forearm toward the floor.” OR “Place one hand behind your back and touch your shoulder blade.” External Rotation “Raise your arm to shoulder level; bend your elbow and rotate your forearm toward the ceiling.” OR “Place one hand behind your neck or head as if you are brushing your hair.” 32 Range of Motion- Elbow What are the motions of the elbow? Flexion “Bend your elbow.” Extension “Straighten your elbow.” Supination “Turn your palms up, as if carrying a bowl of soup.” Pronation “Turn your palms down.” 33 Range of Motion-Hand/Wrist/Fingers What are the motions of the wrists, hands, and fingers? Metacarpophalangeal flexion and hyperextension Finger flexion: thumb to each fingertip and to the base of the little finger Finger flexion: fist formation Finger abduction Wrist flexion and hyperextension Wrist radial and ulnar movement 34 Strength Testing Shoulder- Shrug, Abduction and Adduction You can also check internal and external rotation. Elbow- Flexion and Extension Wrist- Flexion and Extension Fingers- Grip, abduction, thumb opposition 35 Strength Testing 36 Strength Testing- Shoulders Trapezius (CN XI, “Spinal Accessory Nerve”): Ask the patient to shrug both shoulders upward against your hands. “Don’t let me pull you down.” Also, have patient abduct (C5/Deltoid/Axillary Nerve) and adduct against resistance. 37 Strength TestingBrachial Plexus Review 38 Strength Testing- Elbow Test flexion (C5, C6—biceps and brachioradialis) and extension (C6, C7, C8—triceps) at the elbow by having the patient pull and push against your hand. 39 Strength Testing- Wrist Test extension at the wrist (C6, C7, C8) by asking the patient to make a fist and resist as you press down. extensor carpi radialis longus and brevis (radial nerve) extensor carpi ulnaris (radial nerve) Hold here with other hand. Also, check flexion. flexor carpi radialis (median nerve) flexor carpi ulnaris (ulnar nerve) 40 Strength Testing- Hands/Fingers Test the grip (C7, C8, T1). Ask the patient to squeeze two of your fingers as hard as possible and not let them go. To avoid getting hurt by strong grips, place your own middle finger on top of your index finger. Consider even checking grip one side at a time. 41 Strength Testing- Hands/Fingers Test finger abduction (C8, T1, ulnar nerve). Position the patient's hand with palm down and fingers spread. Instruct the patient to prevent you from moving any fingers as you try to force them together 42 Strength Testing- Hands/Fingers Test opposition of the thumb (C8, T1, median nerve). Ask the patient to touch the tip of the little finger with the thumb, against your resistance. OK to have patient touch thumb to pinky. Make sure that the force you apply is against the thumb. 43 Sample Documentation Upper Extremities: No asymmetry, redness, swelling or deformity noted. No masses. No tenderness to palpation. No tissue texture changes. Full ROM in all joints. Strength 5/5. Right elbow: Soft tissue swelling and mild erythema noted laterally. Tender to palpation along lateral epicondyle. Unable to fully flex or extend due to pain. Strength 4/5. 44 Thursday’s Skills Lab § Check schedule § Skills Lab attire § Skills: § Inspection § Palpation § Range of Motion § Strength Testing § 3 Question Quiz- Bring iPad!! § Watch the Upper Extremity Video PRIOR to lab. 45 References Bickley, Lynn S., et al. Bates Guide to Physical Examination and History-Taking. 12th ed., Wolters Kluwer Health/Lippincott Williams & Wilkins, 2017. Suneja, M. (2020). DeGowin's Diagnostic Examination, 11th Edition (11th ed.). Chicago, IL: McGraw-Hill Education. 46 Questions? General course or grading questions? ACOM PCS Course Director email: [email protected] Office hours available by appointment: Lauren Clemmons, DO, FACOFP [email protected] 47