THE UPPER EXTREMITY

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THE UPPER EXTREMITY SELECTED TOPICS R. MICHAEL
RODRIGUEZ, M.D. ASSOCIATE PROFESSOR OF
MEDICINE VANDERBILT UNIVERSITY SCHOOL OF MEDICINE
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EXAMINATION OF THE HANDS, FINGERS AND WRIST
COMPARE OPPOSITE SIDE
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RAYNAUDS PHENOMENA
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RAYNAUDS PHENOMENON

• DIGITAL ISCHEMIA ON EXPOSURE TO COLD
• THIS REACTION TO COLD REPRESENTS VASOCONSTRICTION
  OF THE DIGITAL ARTERIES, PRECAPILLARY ARTERIOLES
  AND CUTANEOUS AV SHUNTS
• DIFFERENTIATE FROM ACROCYANOSIS WHICH IS
  CONTINUED CYANOSIS OF THE HANDS OR FEET WHEN
  EXPOSED TO COLD TEMPERATURES

NEJM 20023471001-1008
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RAYNAUDS PHENOMENON
USUAL SEQUENCE OF DISCOLORATION IS WHITE
(PALOR) BLUE (CYANOSIS) RED (RUBOR). NOTE
THAT ALTHOUGH THE CLASSIC TEACHING IS AS
DESCRIBED ABOVE, THIS DOES NOT ALWAYS OCCUR.
NEJM 20023471001-1008
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(No Transcript)
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NEJM 20023471001-1008
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CARPAL TUNNEL SYNDROME
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CARPAL TUNNEL SYNDROME ETIOLOGY

• THIS SYNDROME IS DUE TO COMPRESSION OF THE
  MEDIAN NERVE AT THE WRIST (SEE FIGURE ON
  SUBSEQUENT SLIDE).

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CLASSIC PATTERN SYMPTOMS AFFECT AT LEAST TWO OF
DIGITS 1,2, OR 3. PERMITS SYMPTOMS IN 4TH AND 5TH
DIGITS, WRIST PAIN AND RADIATION OF PAIN PROXIMAL
TO THE WRIST. DOES NOT ALLOW SYMPTOMS ON THE PALM
OR DORSUM OF THE HAND.
PROBABLE PATTERN SAME AS ABOVE EXCEPT PALMAR
SYMPTOMS ARE ALLOWED UNLESS CONFINED SOLELY TO
THE ULNAR ASPECT. IN THE POSSIBLE PATTERN NOT
SHOWN INVOLVE ONLY 1 OF DIGITS 1,2, OR 3.
JAMA 20002833110-3117 MOSBYS GUIDE TO THE
PHYSICAL EXAMINATION 5TH ED.
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CARPAL TUNNEL SYNDROMESYMPTOMS

• NUMBNESS IN THE HAND
• TINGLING IN THE HAND
• PAIN IN THE HAND
• BURNING IN THE HAND
• PAIN MAY RADIATE TO THE ARM
• ALL OF THE ABOVE MAY OCCUR DURING THE NIGHT

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CARPAL TUNNEL SYNDROME SIGNS
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TINELS SIGN STRIKE THE PATIENTS WRIST AS SHOWN.
A TINGLING SENSATION RADIATING DOWN THE WRIST TO
THE HAND IN THE DISTIBUTION OF THE MEDIAN NERVE
IS A POSITIVE SIGN.
PHALEN TEST HAVE THE PATIENT HOLD THEIR WRISTS AS
SHOWN FOR ONE MINUTE. NUMBNESS AND PARAESTHESIA
IN THE DISTRIBUTION OF THE MEDIAN NERVE IS A
POSITIVE TEST.
JAMA 20002833110-3117 MOSBYS GUIDE TO THE
PHYSICAL EXAMINATION 5TH ED.
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THUMB ABDUCTION TEST
TESTS THE STRENGTH OF THE ABDUCTOR POLLICIS
BREVIS WHICH IS INERVATED BY THE MEDIAN NERVE.
HAVE THE PATIENT PLACE THEIR PALM UP WITH THEIR
THUMB PERPENDICULAR TO IT. APPLY DOWNWARD
PRESSURE ON THE THUMB. WEAKNESS IS ASSOCIATED
WITH CARPAL TUNNEL SYNDROME. JAMA
20002833110-3117 MOSBYS GUIDE TO THE PHYSICAL
EXAMINATION 5TH ED.
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CARPAL TUNNEL SYNDROME CLINICAL ASSOCIATIONS

• PREGNANCY
• RHEUMATOID ARTHRITIS
• DIABETES
• WRIST TRAUMA
• OCCUPATIONAL (KEYBOARD USE)

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THE GOUT
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GOUT - SYMPTOMS

• ACUTE ONSET
• EXTREMELY PAINFUL PATIENTS COMPLAIN OF SEVERE
  PAIN WHEN THE INVOLVED AREA TOUCHES CLOTHING
• MAY BEGIN AFTER USE OF DIURETICS, AFTER SURGERY,
  EXCESSIVE ETOH
• OCCASIONALLY FEVER

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GOUT - SIGNS

• CLASSIC SITE - THE BIG TOE
• OTHER JOINTS MAY BE INVOLVED
• TOPHI
• SWELLING
• REDNESS

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TOPHACEOUS GOUT
TOPHI
TOPHI REPRESENT URIC ACID DEPOSITS THEY MAY BE
LOCATED OVER THE HANDS, FEET, ELBOWS AND EARS
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PODAGRA
ACUTE GOUTY ATTACK INVOLVING THE FIRST
METARSOPHALANGEAL JOINT
NEJM 1995332646
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RHEUMATOID ARTHRITIS
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RHEUMATOID ARTHRITIS SYMPTOMS

• MORNING STIFFNESS gt 1 HR
• GRADUAL OR SUDDEN ONSET
• PAIN
• WEAKNESS
• FATIGUE USUALLY 4-5 HRS AFTER AWAKENING
• SYMMETRIC

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RHEUMATOID ARTHRITIS - SIGNS
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BOUTONNIERE DEFORMITY
SWAN NECK DEFORMITY
ULNAR DEVIATION
MOSBYS GUIDE TO THE PHYSICAL EXAMINATION 5TH ED.
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HAYGARTHS NODES (FUSIFORM SWELLING)
PIP
THESE NODES ARE INFLAMATORY NOT
DEGENERATIVE PAINFUL TYPICAL OF RA REMEMBER RA
DOES NOT INVOVE THE DIP
MOSBYS GUIDE TO THE PHYSICAL EXAMINATION 5TH ED.
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ULNAR DEVIATION
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OSTEOARTHRITIS
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CLINICAL DIFFERENCES BETWEEN RA AND OA
SWARTZ TEXTBOOK OF PHYSICAL DIAGNOSIS 4TH ED
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OSTEOARTHRITIS
HEBERDENS NODE
BOUCHARDS NODE
HEBERDENS NODE NONPAINFUL, DIP BOUCHARDS NODE
NONPAINFUL, PIP
MOSBYS GUIDE TO THE PHYSICAL EXAMINATION 5TH ED
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DUPUYTRENS CONTRACTURE
USUALLY INVOLVES 4TH AND 5TH DIGIT PAINLESS
FLEXION OF 4TH AND 5TH DIGITS TOGETHER OR
ALONE SECONDARY TO THICKENING AND CONTRACTION OF
PALMAR TENDON ASSOCIATIONS ALCOHOLICS, TB?
MOSBYS GUIDE TO THE PHYSICAL EXAMINATION 5TH ED
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THE ALLEN TEST
4
1
2
3
4
PURPOSE TO EVALUATE BLOOD SUPPLY TO THE
HAND METHOD ASK PATIENT TO OPEN AND CLOSE THEIR
WRIST (1) WITH THE PATIENTS WRIST CLOSED, APPLY
PRESSURE TO THE ULNAR AND RADIAL ARTERY (2) ASK
THE PATIENT TO OPEN THEIR HAND, RELEASE ONE OF
THE ARTERIES (3), THE HAND SHOULD FLUSH
IMMEDIATELY, IF NOT THEN THE ARTERY IS PARTIALLY
OR COMPLETELY OCCLUDED (4)
HOPPENFELD PHYSICAL EXAMINATION OF THE HANDS AND
EXTREMITIES APPELTON AND LANGE 1976
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PAIN IN THE HAND
PAIN IN THE HAND MAY ARISE FROM LOCAL FACTORS OR
FROM MORE PROXIMAL AREAS ARM OR NECK
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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C-5 NEUROLOGIC LEVEL
SHOULDER ABDUCTION
BICEPS
LATERAL ARM
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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C-6 NEUROLOGIC LEVEL
WRIST EXTENSION
BRACHIORADIALIS
LATERAL FOREARM
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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C-7 NEUROLOGIC LEVEL
WRIST FLEXION FINGER EXTENSION
TRICEPS
MIDDLE FINGER
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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C-8 NEUROLOGIC LEVEL
FINGER FLEXION
MEDIAL FOREARM
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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T-1 NEUROLOGIC LEVEL
FINGER ABUCTION
MEDIAL ARM
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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MAJOR PERIPHERAL NERVES
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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THE ELBOW
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THE ELBOW - HISTORY

• USEFUL QUESTIONS
• OCCUPATION
• RECREATIONAL
• WHERE IS THE PAIN LOCATED
• WHEN DID THE SYMPTOMS BEGIN
• WHEN DO THE SYMPTOMS OCCUR
• ARE THERE NEUROLOGIC SYMPTOMS

AM FAM PHYS 200061693-700
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THE ELBOW - EXAMINATION

• AS WITH ANY JOINT BEGIN WITH
• INSPECTION
• PALPATION
• RANGE OF MOTION
• COMPARE TO THE OPPOSITE SIDE

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DIFFERENTIAL DIAGNOSIS OF ELBOW PAIN

• EPICONDYLITIS (MEDIAL AND LATERAL)
• INFECTION
• CRYSTAL DISEASE
• RHEUMATIC DISEASE
• TRAUMA
• ENTRAPMENT SYNDROMES (ULNAR N. RADIAL N.)

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LATERAL EPICONDYLITIS ( TENNIS ELBOW)
A
B
SYMPTOM DIFFUSE ELBOW PAIN EXAMINATION PALPATE
LATERAL EPICONDYLE (A) HAVE THE PATIENT EXTEND
THEIR WRIST AGAINST YOUR HAND (B) POSITIVE
EXAM PATIENTS WITH TENNIS ELBOW MAY HAVE PAIN
ELICITED BY EACH OF THESE EXAMINATIONS
MOORE G ATLAS OF THE MUSCULOSKELETAL EXAMINATION
ACP-ASIM2003
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MEDIAL EPICONDYLITIS (GOLFERS ELBOW)
SYMPTOM ELBOW PAIN EXAMINATION PALPATION OF
MEDIAL EPICONDYLE AND HAVE THE PATIENT FLEX THEIR
WRIST AGAINST YOUR HAND POSITIVE EXAM PAIN WITH
PALPATION OF THE MEDIAL EPICONDYLE OR WRIST
FLEXION
MOORE G ATLAS OF THE MUSCULOSKELETAL EXAMINATION
ACP-ASIM2003
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YERGASON TEST
PATIENT
PURPOSE TO EVALUATE THE BICEPS TENDON PATIENTS
ELBOW IS FLEXED TO 90, THE EXAMINER RESISTS THE
PATIENTS ATTEMPT TO SUPINATE AND FLEX THE
ELBOW PAIN INDICATES BICEP TENDONITIS
AMERICAN FAMILY PHYSICIAN 2000613079-3088
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THE SHOULDER
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THE HISTORY

• IS THEIR ANY PAIN AND WHERE
• SPORTS ACTIVITIES
• LIMITATIONS FROM THE INJURY
• WHAT MAKES IT BETTER OF WORSE
• HOW DID IT HAPPEN
• HOW LONG AGO
• ANY NECK PAIN OR H/O INJURY

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ANATOMY OF THE SHOULDER GIRDLE
MUSCLES OF THE ROTATOR CUFF
AMERICAN FAMILY PHYSICIAN 2000613079-3088
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APLEY TEST TESTING RANGE OF MOTION
TESTING ABDUCTION AND EXTERNAL ROTATION
TESTING ADDUCTION AND INTERNAL ROTATION
AMERICAN FAMILY PHYSICIAN 2000613079-3088
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THE ROTATOR CUFF
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THE ROTATOR CUFF

• COMPARE THE AFFECTED EXTREMITY TO THE UNAFFECTED
  SIDE
• USUALLY PAIN ACCOMPANIED BY WEAKNESS

AMERICAN FAMILY PHYSICIAN 2000613079-3088
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TESTING THE SUPRASPINATUS THE EMPTY CAN TEST
PATIENT
HAVE THE PATIENT ABDUCT THE SHOULDERS TO 90 IN
FORWARD FLEXION WITH THE THUMBS POINTING
DOWNWARD THE PATIENT TRYS TO ELEVATE THE ARMS
AGAINST RESISTANCE
AMERICAN FAMILY PHYSICIAN 2000613079-3088
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TESTING THE INFRASPINATUS AND TERES MINOR
PATIENT
ELBOW IS FLEXED TO 90 THE PATIENT TRYS TO
EXTERNALLY ROTATE THE ARM AGAINST RESISATANCE
AMERICAN FAMILY PHYSICIAN 2000613079-3088
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THE DROP ARM TEST
PURPOSE TO DETECT TEARS IN THE ROTATOR
CUFF HAVE THE PATIENT FULLY ABDUCT THEIR ARM THEN
ASK THE PATIENT TO SLOWLY LOWER THE ARM TO THEIR
SIDE IF THERE IS A TEAR IN THE ROTATOR CUFF THE
ARM WILL DROP FROM APPROXIMATELY 90 ABDUCTION
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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WINGING OF THE SCAPULA
INDICATES WEAKNESS OF THE SERRATUS ANTERIOR
MUSCLE (LONG THORACIC N, C5-C6-C7) AND IS
APPARENT WHEN THE PATIENT ATTEMPTS A PUSH UP
AGAINST THE WALL
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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SENSORY DERMATOMES OF THE SHOULDER REGION
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976
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SHOULDER PAIN
REMEMBER PAIN IN THE SHOULDER MAY BE REFERRED
HOPPENFELD PHYSICAL EXAMINATION OF THE SPINE AND
EXTREMITIES APPELTON AND LANGE 1976