Upper Limb

Brachial Plexus

Diagnostic Issues

 

Supraclavicular

- nerve root patterns of sensation and motor disturbance

 

Infraclavicular

- peripheral nerve root pattern / cord

 

Supraclavicular preganglionic

- dorsal scapular, long thoracic, suprascapular

- Horner's

- lack of sensation supraclavicular

- no tinel's

 

Supraclavicular postganglionic

- + Tinels

- tender posterior triangle

 

Look

 

Aids

 

Front

 

Horner's 

- suggests C8/T1 root avulsion

 

Posterior triangle swelling / bruising

 

Wasting deltoid / biceps / pectoralis

 

Biceps Wasting

 

Wrist drop

 

Side

 

Hand on head

- axillary scars

 

Back

 

Trapezius

Deltoid

Supraspinatus/ Infraspinatus

Static winging

 

Supraspinatous Infraspinatous Wasting

 

Feel

 

Palpate post triangle

- tenderness

- supraclavicular post ganglionic

 

Tinel's in post triangle

- supraclavicular post ganglionic

 

Sensation

 

Ask sensation

 

Supraclavicular C4 

- suggests preganglionic injury

 

Axillary nerve C5 

 

LCNF C6 musculocut n

 

SRN C6 (1st dorsal webspace) 

 

C6 median n (thumb)

 

C7 median n (MF)

 

C8 ulnar n (LF)

 

C8 MCNF m cord (med forearm)

 

T1 MCNA m cord

 

T2 ICBN

 

Motor

 

Trapezius 

- function of accessory nerve important

 

Roots / From Behind

 

Rhomboids

- shoulders back

- DSN C5

 

Rhomboid Testing

 

Serratus anterior

- push shoulder forward

- LTN C5-7

 

Suggest preganglionic

 

Trunk

 

Suprascapular Nerve (C5)

- supraspinatous

- infraspinatous

 

Front / Nerve Root innervation

 

Deltoid 

- C5

- axillary / posterior cord

 

Bicep

- C5

- musculocutaneous / lateral cord

 

Tricep

- C7

- radial / posterior cord

 

Wrist extension

- C6

- radial / posterior cord

 

Finger flexion

- C8

- median / medial and lateral cord

 

Finger abduction

- T1

- ulna nerve / medial cord

 

Decide if fits root pattern

- otherwise consider cord injury

 

Cords

 

Posterior Cord

- axillary nerve (deltoid + T minor)

- radial nerve

- subscapularis

- lat dorsi TDN C7 (hand on hip / cough)

 

Medial Cord

- medial median (FDP, FPL, AbPB)

- medial pectoral (sternal head)

- ulna nerve (interossei, LOAF)

- MCNA / MCNFA (decreased sensation medially)

 

Pectoralis Testing

 

Lateral Cord

- lateral median (FCR, PT)

- musculocutaneous (biceps, sensation lateral forearm)

- lateral pectoral (clavicular head)

 

Reflexes

 

Biceps C5

Triceps C7

BR C6

 

4Cs

 

Cephalad joint - Neck

Concealed - axilla

Circulation

Collagen

 

 

 

 

Dupuytren's Exam

Look

 

Palms up

 

Scars / Dimples / pits 

 

Nodules - palm, proximal to distal palmar crease

 

Cords - extend into fingers & cause contracture

 

Thumb

 

Fingers - contracture of MCPJ, PIPJ

 

Palms down

 

Garrod knuckle pads

 

Hueston Table Top Test

- contracture MCPJ

- contracure PIPJ

 

Feel

 

Nodules / Cords / Webspaces (Natatory cords)

 

Sensation

 

Move

 

Deformities 

- stiff or flexible

 

PIPJ

- true v apparent FFD

- spiral cord crossing MCPJ and PIPJ may contract both

- flex MCPJ

- assess PIPJ

 

Concepts

 

MCPJ Contracture

- Always correctable by removal of pretendinous bands

- Collateral ligaments are tightest in flexion

- Flexion deformity does not lead to collateral shortening 

- Resection central cord restores extension

 

PIPJ 

 

Contracture due to 4 cords

1.Central 

2.Spiral

- pushes NV bundle volar and midline 

- from spiral band and Grayson's ligaments

3.Lateral 

- lateral digital sheath

4.Retrovascular

 

Not always correctable unless release volar plate & accessory collateral ligaments 

- Collateral ligaments tightest in extension 

- Flexion deformity leads to collateral shortening 

 

 

Elbow

Intially

 

Introduce

Aids - slings

Expose - shirt off

Stigmata generalised disease

 

Look/ Move

 

Neck

 

ROM / exclude cervical radiculopathy

 

Shoulder

 

ROM

- touch hands on head 

- behind head

- to mouth 

- back pocket  

 

Elbows

 

1. Extend elbows to front

 

A.  Elbow

- carrying angle (N 7° - 12°)

- deformity

- bony prominences

- biceps bulk

 

B.  Forearm contour

- ulnar border - FDP

- radial border - mobile wad

 

C.  Hand

- thenar eminence

- hypothenar eminence

- look for clawing

 

2.  Flex elbows to front

- olecranon wounds / bursa

- medial or lateral surgical scars

 

3.  Flex elbows to side

- angle of flexion

- comment medial scars

- axilla

 

4 Extend  elbows to side

- angle of extension / FFD

 

5.  Pronation and supination 

- 80o each

- thumb up / thumb down with elbows in

 

Hands

 

Look at dorsum for interossei wasting

Wrist Flexion / Extension

Fist with thumb in and out 

Spread fingers

 

Feel

 

Medially

- medial epicondyle

- ulnar nerve tinel's / subluxation

 

Posterior

- oleranon/ triceps tendon

 

Laterally

- lateral epicondyle / tennis elbow

- radial head - stability / pain with rotation

 

Medially

- cubital fossa masses / biceps tendon

 

Special Tests

 

Medial Epicondylitis

- resisted wrist flexion & pronation

 

Lateral epicondylitis

- resisted wrist extension

- resisted MC Ill extension (ECRB)

 

Stability

 

Note stability in extension is predominantly bony

 

Valgus Instability

 

Jobe's Test

- MCL

- flex elbow to 25° (unlocks olecranon)

- pronate forearm (prevents false +ves due to lateral laxity)

- gentle valgus stress

- compare opposite side

 

Varus Instability

 

Varus strain 

- with elbow at 25°

 

O'Driscoll's Test / elbow Pivot Shift

- patients describe clunk on full extension & feel posterolateral pain

- ulnar portion of LCL (LUCL) is the key

- dislocation occurs with a valgus ER force pivoting the elbow on the intact MCL

 

Technique

- patient  supine with examiner at head of bed

- GHJ full flexed with hand over head

- Forearm supinated and Elbow extended

- Valgus stress applied

- Axial load

 

Positive if

- prominent radial head (dislocates) / pivot / pain

- max subluxation is at 40° flexion 

- with increased flexion reduces with snap

 

4Cs

 

Circulation

- brachial / radial pulse / ulnar

- Allen's test

 

Cephalad joint

- shoulder ROM

 

Collagen

- ligamentous laxity

 

Concealed

- cubital fossa

 

 

 

 

 

 

Median Nerve Exam

Look

 

Palm up

- Pointing index finger (Bennett's / AIN)

- Wasting thenar eminence

- wasted forearm muscles

- volar scarring

 

Thumb up

- wasting thenar eminence

- radial border wrist

 

Palm down

 

Palms together

- LF

- Axilla scars

 

Feel

 

Sensation

 

Lateral forearm - LCNF / lateral cord / C6

 

Thenar eminence - Palmar Branch Median Nerve / C6

 

IF - C6 Median nerve

 

MF - C7 Median nerve

 

LF - C8 Ulna nerve

 

Median Forearm - MFCN / medial cord / T1

 

Is sensation loss peripheral / dermatomal?

 

Move

 

Median nerve

 

PT (C6)

- first branch 

- test with elbow flexed

 

FCR (C6)

- flex wrist & palpate

 

FDS(C8) 

 

PL (C8)

 

AIN 

 

FDP IF/MF (C8) 

- make fist & resists IF extension

 

FPL (C8) 

- resists extension of IPJ

 

PQ (C8) 

- test with elbow extended (eliminate PT)

 

Motor Recurrent Branch (T1)

 

AbPB 

- patient abduct thumb away from palm against resistance

- palpate muscle belly

 

1st Lumbrical

- Lateral Digital Branch

- thumb to IF pad to pad

 

2nd Lumbrical 

- Medial Digital Branch

- thumb to MF pad to pad

 

Lumbricals

- extend DIPJ

- if not functioning --> unable to pulp to pulp

- will only be able to bring tip to tip

- because unable to extend DIPJ

 

Special Tests

 

Tinel's 

- start distal & move proximally

 

Phalen's 

- 60 second patient holds wrist flexed

 

Allen's test

- if considering CTD

 

C-spine examination

 

DDx

 

CTS

- normal sensation thenar eminence and forearm

 

AIN palsy

- no sensory deficit

- weak FPL / FDP / PQ

 

Pronator syndrome

- Pain only

 

C6

- weak wrist extensors

- decreased sensation medial forearm

 

TOS

- C8 / T1

- weak thenar eminence

- abnormal sensation medial forearm and LF

 

Brachial Plexus

 

Compression syndromes

 

Pronator Syndrome 

- ligament of struthers

- lacertus fibrosis

- pronator teres

- FDS

 

AIN Syndrome

- pronator teres

- FDS

- aberrant muscles or blood vessels

- trauma

 

CTS 

- palmar branch is not involved

RA Hand Exam

Screening of Joints

 

Neck

-  ROM

 

Shoulder

- behind head / to mouth

- to back pocket 

 

Elbows

- flex / extend elbows 

- pronation / supination with thumb up & elbows by side

 

Wrist

- flexion / extension

 

Hand

- make fist with thumb in and out 

- spread fingers

 

Functional Assessment of Hand

 

Power Grip 

Precision Grip 

Hook Grip 

Lateral Pinch Grip 

Tip Pinch

 

1.  Tip to Tip Pinch Grip

- pick up coin 

 

Tip to Tip Pinch Grip

 

2. Lateral pinch grip

- turn key

 

Lateral Pinch Grip

 

3. Precision grip

- write with pen

 

Precision Grip

 

4.  Power Grip

- turn knob 

 

Power Grip

 

5.  Hook Grip

- hold suitcase / fingers

 

Hook Grip

 

Look at Hands / Place on Pillow

 

Palms up

 

Scars

- CTD / flexor tendon synovectomy

Swelling

- flexor sheath synovium

Thenar & Hypothenar eminences

 

Thumb up

 

Thenar wasting

Swan neck / Boutonniere deformity

 

Palms down

 

RA Palm down

 

Wrist 

- synovitis / synovectomy

- wrist fusion

- caput ulna

- radial drift 

 

MCPJ 

- ulna drift / replacement / synovitis

- tendon subluxation

 

Fingers

- Swan neck, Boutonniere

 

Feel

 

Sensation

- median nerve / CTS

- ulnar nerve

 

Move

 

Extensor tendons

- drop fingers

- DDx - locked trigger, tendon subluxation, joint subluxation, PIN palsy

 

EPL

- ruptures over Listers

- IPJ is extended by intrinsics also

 

Flexor tendons

- rupture IF & thumb (synovitis)

- rupture FPL alone over trapezial ridge (Mannerfelt)

- triggering

 

MCPJs

- ? subluxed

 

Boutonniere deformity

- degree of lag

- passively correctable

- ? arthritic changes

 

Swan neck deformity

- passively correctable

- intrinsic tightness / Bunnell test

- arthritic changes

 

Bunnell Test

- test with MCP extended and flexed

- correct ulna deviation

- invalidated by MCPJ dislocation

- with tight interossei will have reduced PIPJ flexion with MCPJ extension

 

 

 

Radial Nerve Exam

Look

 

Splints

 

Wasting 

- triceps / extensor forearm

 

Arm up

- axilla / posterior / lateral elbow scars

 

Feel

 

Sensation

 

Axillary nerve - C5 / posterior cord

 

PCNFA

 

LCNF - C6 / Lateral Cord

 

SRN - C6 / Dorsal 1st Web

 

Median C6

- IF

 

State dermatomal or peripheral nerve

 

Move

 

Triceps C7

 

BR / ECRL - Radial Nerve

 

ECRB / EDC / EPL / EI - PIN

 

Supinator 

- elbow extension to eliminate biceps, resist pronation

 

Special Tests

 

Tinels

 

DDx

 

C7 lesion

- triceps power / reflex lost

- good wrist extension (C6)

 

C6 lesion

- triceps intact

- wrist extension lost

 

Posterior cord

- radial nerve + axillary nerve + subscapularis + lat dorsi

 

Site of injury

 

High lesion / no triceps

- Saturday night palsy

 

Intermediate lesion / triceps intact / no BR or ECRL

- humeral fracture

 

Low lesion / PIN Compression (FREAS)

- fascial bands

- recurrent radial

- ECRB

- arcade of Frohse

- exit supinator

 

 

 

Shoulder

Look

 

Exposure

Splint

Sling

 

From Front

 

Skin

- scars

 

Swelling

- SCJ

- clavicle

- ACJ

- biceps (rupture long head)

 

Popeye Biceps

 

Wasting

- deltoid

- trapezius

- arm

 

Deltoid Wasting

 

From Side

 

Turn affected side towards you

Wasting

- pectoral contour

 

From Back

 

Scapular symmetry

- height

- winging 

 

Wasting

- supraspinatus

- infraspinatus

 

SS IS Clinical Photo 1SS IS Clinical Photo 2

 

Feel

"Where is it painful ?"

 

Bony prominences

- SCJ

- clavicle

- ACJ (compare with other side)

- acromium

- biceps tendon

 

Scapular spine

 

Supraspinous fossa

- ganglion

- osteochondroma

 

Infraspinous fossa

- tenderness

- cuff defect

 

Move

 

Forward flexion

 

Active

- both arms raised forward, supinated

- range

- check axilla

 

Abduction

 

Active

- elevate both arms in coronal plane, supinated

- initiation

- range (160°-180°)

- rhythm

- arc of pain

- shoulder hiking

 

Passive

- if not full, passive to 180?

- active v passive

 

Observe arm lowering 

- arc of pain

- drop arm

 

Extension

 

Active

- both arms raised backward

 

External rotation

 

Active

 

Elbows flexed to 90o and arms by side

- start with arms forward

- rotate arms outwards (90°)

 

Passive

If not full, passive

 

Reduced ER

 

Internal rotation

 

Active

- ask to run thumb up spine

- mark good and compare bad

- thigh / buttocks / waist / LS / T12 / angle of scapula (T7) / tip of scapula (T2)

 

Rotator Cuff Power / Integrity

 

Power of supraspinatous

- 30° abduction

- in plane of scapula (30° forward from coronal plane)

- forearm pronated (thumb to the ground)

- resisted abduction

 

Supraspinatous testing

 

Power of Infraspinatous

 

1. Grade power external rotation

 

Infraspinatous Power

 

2.  Extensor lag

- take out to full passive ER

- release and see if lags

 

3.  Hornblower's

- positive if drop and IR

- suggests massive PS tear

- teres minor

 

Power of Subscapularis

 

1.  Gerber's Lift off test

- Gerber's test is normal if patient can hold hand off buttock

- patient must have full IR & not be limited by pain to use this test

- "Pathological lift off test - patient is unable to lift the dorsum of his hand off his back"

- put dorsum of patient's hand on buttock then lift it off buttock & let go

 

Subscapularis Lift Off Test 1Subscapularis Lift Off Test 2

 

2. Belly Press Test / Nelaton Test

- resisted internal rotation with hand on belly

- must keep elbow forward

- otherwise patient uses shoulder retractors

- positive if drop elbow

 

Subscapularis Belly Press Test

 

Impingement tests

 

Neer's impingement test

- passive forward flexion 

- forearm pronated

- scapula stabilised

- positive test - pain at arc 70-120°

 

Shoulder Neers Test

 

Hawkin's impingement test

- forward flex elbow to 90°

- internally rotate and adduct arm

- positive test - pain

 

Shoulders Impingement Test

 

ACJ

 

Cross body adduction

 

ACj Cross Body Adduction Test

 

Biceps

 

Speed's test

- resisted forward flexion at 90° with forearm supinated

- assess pain or popping at bicipital groove (long head of biceps)

 

Speeds Test

 

Yergason's Test

- externally rotate arm with elbow 90°

- resisted supination

- assess pain or popping at bicipital groove (long head of biceps)

 

Yergason's Test

 

Compression-Rotation test / McMurray's Shoulder test

- test for SLAP lesion

- patient supine 

- shoulder abducted 90°, elbow flexed 90°

- compression force to humerus

- humerus rotated

- attempt to trap torn labrum, positive if pain & click

 

O'Brien's

- SLAP lesion

- arm across body, in plane of scapula

- pain with stress abduction, thumb down

- nil pain with thumb up

 

Obriens Test

 

Instability

 

Sulcus sign

- needs to be compared to the opposite side

- patient

- in front of patient

- hands in lap

- pull down on both elbows

- look for sulcus

 

Shoulder Sulcus Sign

 

Anterior / Posterior Drawer

- sit next to patient

- stabilise shoulder girdle with 1 hand

- thumb on spine of scapula

- forefinger on coracoid

- centralize humerus

- must compare to normal side

- translate humeral head forward with other hand

- anterior & posterior translation noted

 

Anterior Apprehension Test

- patient lying

- shoulder abducted and elbow flexed 90°

- externally rotate shoulder

- positive test - look for apprehension 

 

Jobe Relocation Test

- patient supine

- arm abducted to 90°

- forced external rotation

- relocate by pushing humeral head posteriorly & superiorly

- usually described by putting hand on humeral shaft

 

Posterior Stress Test 

- stabilise scapula

- place shoulder in 90° forward flexion & 90° IR & adducted

- apply posterior force

- patient experiences pain +/- apprehension

- unlike anterior test patient has positive test if pain only

- note should reproduce the patients symptoms

 

Load and Shift

- patient lying down

- their hand under examiners armpit

- grasp neck of humerus with both hands

- load humerus into glenoid axially

- examinate stability annterior and posterior

 

Ligamentous Laxity

 

Wynne-Davies Criteria

1. Thumb touching forearm on flexing wrist

2. Fingers parallel to forearm with wrist extension

3. Elbows extend past 180°

4. Knees extend past 180°

5. Foot dorsiflex past 45°

 

Ligamentous Laxity Elbow HyperextensionLigamentous Laxity Thumb to Forearm

 

"If 3 of the 5 pairs of joints examined in any one individual showed this degree of laxity it is taken as positive."

 

Thoracic Outlet Tests

 

Adson Manoeuvre

- head toward side tested, neck extended

- palpate radial pulse of extended arm

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

Wright's Manoeuvre

- head turned away from tested arm, neck extended

- arm in 90° abduction & 90° extension

- palpate radial pulse 

- patient inhales deeply

- positive test if decrease or obliteration in pulse with concomitant reproduction of symptoms

 

4C's

 

Cephalad Joint Neck

 

ROM

 

Compression Test

- slight extension

- compression

 

Spurling's test

- neck in lateral flexion, rotation

- stressed with compression

- positive if pain in ipsilateral extremity

 

Circulation

 

Radial pulse

 

Concealed

 

Axilla

 

Collagen

 

 

Ulnar Nerve Exam

Look

 

Splints

 

Extend elbow to side

- medial wounds

- extension

 

Flex elbow to side

- flexion range

 

Flex elbow to front

- olecranon wound

 

Extend elbow to front

- anterior wounds

- carrying angle

- forearm wasting

 

Palm up

- clawing

- hypothenar eminence

- scars

 

Ulna Nerve Laceration

 

Thumb up

- thenar eminence

 

Ulna nerve wasting

 

Palm down

- interossei / adductor pollicis wasting

 

Adductor Pollicis WastingUlna nerve wasting

 

Palms together

- claw

- hypothenar eminence

 

Feel

 

Sensation

 

1.  LF & RF

 

2.  Dorsal branch ulna nerve

- branches above wrist

- runs under FCU

- dorsum of hand, ulna side

- dorsum LF and half RF to P2

 

3.  Palmar cutaneous branch

- above wrist

- hypothenar eminence

 

3.  Medial forearm (MCNF / T1)

- above ulna

 

Move

 

Above elbow

 

1.  FCU (C7)

- patient flexes wrist, palpate

 

2.  FDP (C8) 

- patient makes fist & resists extension of LF

 

Below wrist

 

1.  AbDM

- LF together

- first branch deep nerve

 

2.   1st Dorsal Interossei

- push both IF together

- last branch deep nerve

 

3.  Adductor Pollicis

- Froment's sign

- hold paper between thumb and IF
- positive if patient uses FPL to grip

 

Ulna Nerve Positive Froment's Sign

 

4.  Card sign

- between index and middle finger

- PAD

- palmar interossei adducting

 

5.  Lateral 2 lumbricals

- unable to pad to pad  LF / RF

- lumbricals extend DIPJ

- patient can only tip to tip

 

Special Tests

 

Tinel's - Cubital tunnel, Guyon's

 

Ulna nerve subluxation / tenderness

 

DDx

 

T1

- thumb APB weak / wasted

 

C8

- EDC / Wrist extension weak

 

TOS

- sensory loss above wrist

- Addson sign

 

Compression Syndromes

 

1.  Medial Intermuscular septum 

- arcade of Struthers (fascial band)

- septum

- hypertrophied medial head triceps

 

2.  Medial epicondyle

- tardy ulna nerve palsy, previous fracture

 

3.  Epicondylar groove

- intrinsic (SOL, synovitis, rheumatoid nodule

 

4.  Cubital Tunnel 

- tendinous arch of FCU

 

5.  Exit FCU

 

6.  Guyon's canal

- FDP OK

- palmar & dorsal br spared

- all small hand m's affected

 

7.  Deep motor branch only

- can be compressed against pisiform & hamate 

- with using mallet, vibrating tools

- sensation normal

Wrist Exam

Take watch off

 

Look

 

Palm up

- thenar wasting

- STT gangion

- thumb OA

- flexor synovitis

 

Thenar Wasting

 

Thumb up

- thenar wasting

 

Palm down

- dorsal SL ganglion

- extensor synovitis

 

Palms together

- claw ulna

- elbow scars

 

Move

 

Wrist 

- extension

- flexion

- radial / ulna deviation

- pronation / supination (thumb up)

 

Finger flex and extend

- thumb in and out

- spread fingers

 

 

Feel

 

Sensation

- ulna nerve / radial / median nerve / CTS

 

Radial side

 

Distal Radius

 

1st extensor compartment

- swelling EPB / APL

- Finklestein's

- flex and extend thumb

- feel crepitus

 

Intersection

- tenderness crossover EPB APL

 

Scaphoid

- snuffbox

- tuberosity

- Watson's test

 

Base of thumb

- tenderness

- deformity

- Grind Test

 

MCPJ thumb

- tenderness

- weakness ulna collateral

 

SL joint

Wartenberg's radial neuritis

 

Ulna side

 

ECU tendon

 

Lunotriquetral joint 

- instability test 

- one under each thumb & toggle 

- look for movement or pain

 

Ulna head

- deformity

- instability

 

Hamate Hook

- tenderness with #

 

DRUJ 

- synovitis

- tenderness

- piano key

- pro/sup subluxation, pain, clicking

 

TFCC 

- palpate for tenderness distal to ulna

- Grind test circ & press

- look for pain & crepitus

 

PisoTriquetral Joint 

- occupational injury

- press & rock against Triquetrum 

- look for pain & crepitus

- similar concept to patella

 

Guyon's canal

- Tinel's

 

Other

 

Allen's test

CTS

Ulna Nerve