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

Hamiltons ruler sign +ve

Fullness of
deltopectoral groove

Dugas 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 (Apleys 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
- Hawkins test
- Jobes test

ROTATOR CUFF
INTEGRITY TEST

GERBERS 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

YERGASONS TEST
(BICEPS TENDINITIS/INSTABILIT Y)

OBRIEN TEST
(SLAP LESION)

ACROMIO-CLAVICULAR
JOINT ARTHRITIS

One-finger test

CROSS ARM TEST

(A-C JOINT ARTHRITIS)

PHYSICAL EXAMIMATION
OF
THE ELBOW

ANATOMY

ANATOMY

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

Heuters 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

Cozens test

Medial epicondylitis

Reverse Cozens 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

Listers 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
- Finkelsteins test
False +ve

MEDIAN CARPAL TUNNEL

latl >;; medl

: Radial a.
:Flexor carpi radialis
:MediaN n.
: Palmaris longus
: flexor digitorum Superficialis
: Ulnar A.
: ulnar N.
: 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

Boutonnire

Rupture of the central slip

INSPECTION
Deformity

Mallet finger

INSPECTION
Deformity

Swan neck

INSPECTION
Deformity

Boutonnire

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

Wartenburgs test

Egawas test

TRIGGER FINGER

Obstructive tenovaginitis obliterans

of the flexor tendon sheath

P.E. - Local tenderness

- Triggering of finger

THANK YOU FOR YOUR ATTENTION