shoulder examination salient points · shoulder examination and salient points ... translation of...

Shoulder Examinationand

Salient PointsTeton Hand Conference

Rhett Griggs, M.D.2.3.10

Anatomy First

• Anatomy– Soft tissue– Bony– Static stability– Dynamic stability

• Surface anatomy• DDx

General format

• Initial impressions• Inspect…LOOK• Palpate…FEEL• Move• Neuro assessment• Vascular assessment• Stability assessment• Special tests

Art Class• Successful tx requires the

correct dx.• Get to know your pt.

– Occup/dom/marital status– Sports/leisure activity– PMH/gen disorders– Lifestyles– Expectations– Shoulder exam– Imaging

• LISTEN TO THEM

History

• CC– What is the dom sym

• AGE– 18 yo vs 70 yo

• MOI– Chronicity– Biomechanical clues

• Prev tx/response• Current status• How it effects the pt.

Pain Symptoms• MC initial symptom• Note:

– onset – site – periodicity – character – radiation – agg/relieving factors– assoc sym– intensity

• LISTEN

• Question:– Night pain

• Rtc• OA• Infection• tumor

– Pain with activities• Throwing athletes

– Functional weakness• Tough adl’s=tough pitch

Instability Symptoms

• 2nd mc complaint• My shoulder comes out vs pain complaints• TUBS vs AMBRII

– Traumatic Unidirectional w/ a Bankart-Surgery• Specific event/trauma• MC pattern of instability: Anterior and unidirectional

– Atraumatic MDI w/ bilateral shld findings Responsive to Rehab. If sx-inferior cap shift

• Rarely traumatic• Avoid positions or sports that is ‘uncomfortable’

Complaints

• Pain • Instability• Stiffness • Weakness

Many approaches

• Location– Anterior, lateral, superior, posterior

• Structural– Bone, tendon, joint

• Comprehensive• History

Basic Physical exam

• Initial impressions• Inspection• Palpation

– Bony– Soft tissue

• ROM• Neuro• Special tests

Initial impressions

• General diseases– Rheumatoid, congenital,

• Physiologic – Athlete vs Accountant

• Habitus• Distress

– Shortness of breath, clutching shoulder• Performance

– Ambulation, disrobing and ROM assessment

Inspection

• Attitude– Splint, Erb’s

• Winging• Deformities• Swelling• Skin

– Trauma– Blemishes

• Naked

Atrophy, Asymmetry

Scapular winging

Palpation

• Surface anatomy– SC, clavicle, ACJ– Codman’s point– Coracoid– Scapula– Bicipital groove

• Soft tissues– ED, amyloid

• Muscle contraction.

• Region• Depth• tissue

ROM

• ROM– Position in back– Standing and supine– Compare with opposite and age norms– Active and passive– Total elevation, ER in ADD and ABD, IR

• Society of American Shoulder and Elbow Surgeons

• Quality of movement– ST motion, catching, clicking

Neurologic testing• Must be reproducible• Guidelines

– Test in maximal mechanical advantage

– Isolate – See and feel the muscle

contract– 0-5 grading system– compare

• 0 Zero– No muscle contraction

palpable• 1 Trace

– No movement without gravity• 2 Poor

– Muscle moves part but w/o gravity

• 3 Fair– Muscle moves part against

gravity• 4 Good

– Against gravity with resistance. May add +/-

• 5 Excellent– Normal strength against full

resistance.

Neuro levels

• C5 Deltoid, Lateral deltoid, Biceps• C6 Biceps/ecrb, thumb sensory, BR• C7 Triceps/wrist flex, MF, Triceps• C8 Finger flexors, SF, no reflex• T1 Intrinsics, Medial forearm

Review

Salient Points

Salient points

• Normal exam – Understand the Look,

Feel, Move norms.• Cuff• Biceps• Impingement• Instability• Joint

• Not included– Fractures– Differential dislocation– Separation– Radiology

RTC Evaluation

• SS, IS, TM, SC.• Role of the RTC

• Look:– Asymmetry, atrophy,

compensation.• Feel:

– Facets, Codman’s point, Quality, compare

• Move:– Painful arc,

compensatory mech

RTC Testing• Supraspinatus

– Jobe, empty can test• Infraspinatus/TM

– Gunslinger– Hornblower– ER lag sign

• Subscap– Lift off– Belly press– Sacral lag sign

Jobe’s “Empty Can” test

Gunslinger

ER Rotation LAG

Subscapularis testing

Biceps

• Anatomy• Look

– Cuff pathology and head depression.• Feel

– Bicipital groove• Move

– Special tests.

Biceps• Special tests

– Speed’s• Elbow /, FA sup, 60 ff with risistance

– Yergason’s• Elbow 90, FA pronated, resist active supination

• SLAP– O’Brien’s

• Stabilize scap, 10 add, thumbs up/down– SLAP-rehension

• O’brien’s at 45 degrees adduction– Biceps load

• 120 abd, sup and ER, flex elbow

Speed’s test

Yergason’s Test

Obrien’s test

Obrien’s

• Obrien’s 268 person study.– 100% sensative– 98.5% specific

• Stetson (2002)– 54% sensative– 31% specific

• Guanche (2003) – 63% sensative– 73% specific

Impingement

• Bursitis• Tests:

– Hawkin’s Test– Neer’s- sign (test=injection)

Hawkins test

Neer’s sign

Instability

• Look– Symmetry,

• Feel– MDI, joint palpation

• Move

• Instability is a symptom

• Laxity is a sign

Instability

• Special tests– Apprehension– Load and shift– Relocation– Symptomatic translation

• Symptom reproduction as dominant symptom

Apprehension test

Load and Shift• Assess at add, 45 and 90• Anterior• Posterior• inferior

• Grade• 0 No translation• I Mild

– 0-lcm translation

• II Moderate– 1-2 cm or translates to

glenoid rim

• III Severe– >2cm translation or over

the rim of the glenoid

Arthritis

• Look– Geyser sign, cogwheeling, motion.

• Feel– crepitus

• Move– GH ratio

Arthritis

• Special tests– AC

• Cross arm adduction• palpation

– GH• GH grind• XR

Cross arm adduction

GH DJD

Questions

Question

• Initial postoperative management after repair of an acute RTC tear includes– A AROM– B Active abduction to prevent scarring– C PROM w/in a safe zone determined at sx– D eccentric strengthening exercises

Answer

• C PROM– PROM in a safe zone determined at surgery

with passive elevation and ER is the std of care. Early AROM, IR and resistive ex’s increase the risk of repair rupture.

– Iannotti

More thought

• Which ligamentous structures are the primary static restraints to inferior translation of the arm with the shoulder is in 0 degrees of abd and neutral rotation?– A Inf and middle GH ligament– B Middle and superior GH ligament– C Superior GH lig and Coracohum lig– Coracohumeral and coracoclavicular lig.

answer

• SGH and Coracohumeral ligament.– SGH and CH ligaments-restraint to inf

translation when the shoulder is in 0 abd and neutral rotation.

– MGH lig-more important in midranges of abduction

– IGHL-more important at 90 degrees of abd.

Key Points

• Listen to the patient• Observe, palpate, move• No one diagnostic test• Always compare

Questions

Basic shoulder exam

Warm Up

Elbow Examination

Teton Hand ConferenceRhett Griggs, M.D.

2.4.2010

Format

• Basic anatomy• Inspection• Palpation• ROM• Neuro• Special tests/key points

Basic Anatomy

• Ginglymus joint• 3 articulations

– Humeroulnar– Humeroradial– PRUJ

• Surface anatomy– superficial

• Ligament restraints

Capsule

• Provide stabilization in full flexion and full extension.

• Blends with annular ligament and covers tip of olec, and coronoid process.

• Most lax at 60-70 degrees– Prolonged immob risks contracture.

Ligaments• Medial

– MCL• Anterior• Posterior

– Transverse

• Lateral– LCL (Radial)– Annular– Lateral ulnar collateral– Acc. Lat collateral– Anconeus

Nervous Anatomy

Biomechanics

• 60% HR• 40% UH• Force of loads

– 2-3x body wt– 10x lifted weight

• Stability 50/50– Bony– Ligamentous

• MCL 78% valgus• Bony valgus stability

– <20, >120 flexion.• Varus stability

controversial

Physical exam

• Framework of a starting point.

• Inspection• Palpation• ROM• Neurovascular• Special tests

Activities/overuse associations• Bowling

– Biceps tendinosis– radial tunnel syndrome

• Boxing– Triceps tendinosis

• Football, wrestling or basketball – Olecranon bursitis– GolfGolfer's elbow (trailing arm)– radial tunnel syndrome

• Gymnastics– Biceps tendinosis, – triceps tendinosis– Posterior dislocation– Posterolateral rotatory instability

• Weight lifting– Biceps tendinosis, – triceps tendinosis, – anterior capsule strain, – radial tunnel syndrome, – ulnar nerve entrapment

• Racquet sports– Pronator syndrome, – triceps tendinosis, – olecranon stress fracture, – lateral tennis elbow, – radial tunnel syndrome, – golfer's elbow, – ulnar nerve entrapment

• Rowing– Radial tunnel syndrome

• Skiing– Ulnar nerve entrapment

• Swimming– Radial tunnel syndrome

• Throwing– Pronator syndrome, – triceps tendinosis, – olecranon impingement/stress fx– radiocapitellar chondromalacia, – ulnar collateral ligament sprain, – golfer's elbow, – ulnar nerve entrapment

Common Dx—anatomic location

• Anterior elbowBiceps tendinosisPronator syndromeAnterior capsule strainPronator syndrome

• Posterior elbowTriceps tendinosisOlecranon impingementOlecranon stress fractureOlecranon bursitis

• Lateral elbowLateral tennis elbowRadial tunnel syndromeRadiocapitellar chondromalaciaPosterolateral rotatory instability

• Medial elbowMedial tennis elbow (golfer's elbow)Ulnar collateral ligament sprainUlnar nerve entrapment

Inspection• Carrying angle

– Cubitus valgus– 5-15 degrees

• Gunstock deformity– Cutius varus

• Olecranon bursitis• Scars/burns/erythema

Palpation of surface-bony anatomy• Medial epicondyle• Medial supracon rdge• Olecranon• Olecranon fossa• Lateral epicondyle• Lat supracond rdge• Radial head• Radiocapitellar joint

Soft tissue palpation

• Medial– Ulnar nerve, flexor mass, PT/FCR/PL/FCU– MCL, Lymph nodes

• Posterior– Olecranon bursa, Triceps

• Lateral– Wrist extensors, BR, ECRL/B, LCL, annular lig

• Anterior– Cubital fossa, biceps tendon, brachial art– Median nerve, Musculocutaneous nerve

ROM and Neuro testing

• Extension/flexion: 0/140+

• Supination/Pronation: 90/90

• Muscle testing• Reflex testing• Sensation testing

Neuro exam-muscle testing• Flexion, C5/6

– Brachialis– Biceps

• Extension, C7– Triceps

• Supination, C5/6, C6– Biceps, – Supinator

• Pronation, C6, C8/T1– PT– PQ

Neuro Exam-reflex testing• Biceps

– C5• Brachioradialis

– C6• Triceps

– C7

• Sensation C5-T1

Review

Special test& Particular conditions• Valgus stress test• Varus stress test• Medial epicondylitis• Lateral epicondylitis• Radial tunnel syndrome• Cubital tunnel syndrome• Posterolateral instabiltiy

Valgus stress test

Valgus instability

• Rarely chronic in general population• Seen after dislocation, radius fracture• 30% of professional baseball players• 40% with ulnar nerve damage• Milking test

Varus stress test

Tennis ElbowLateral epicondylitis• 1873, Runge first described: “its aetiology

is varied, its pathogenesis unknown, and its treatment uncertain.”

• Equal gender ratio, 30’s-50’s.• Hx of overuse• Find actual site of pain.

– Insertion, radial head artic, MTJx, rad tunnel• Night pain suggest nerve entrapment

Cozen’s Test-Tennis elbow

Medial epicondylitis-Golfers Elbow• 5-7x less frequent• Men>Women• 50% ulnar nv damage

• Differentiate the pain.– Medial epi– Flexor pronator mass– Chronic lesion of MCL

• Stress it

Golfers elbow-Medial epicondyle

Treatment

• OT/PT– Ionto/phono/counterforce

• Steroid injection– How many times

• PRP– ??

• Surgical

Radial tunnel syndrome

• Anatomy• Associations• Entrapment sites

– RC fascia, L of Henry, Arcade of Frohse, Sup.– ECRB fascia.

• Tests– Direct palpation– Third Finger Extension test– Repetitive wrist extension test

Cubital tunnel syndrome

• Ulnar nerve• Entrapment sites

– Bn 2 heads of FCU– Arcade of Struthers

• Hiatus in medial intermuscular septum– Osborne’s ligament

• Medial epicondyl to olecranon– FCU muscular fibers– Anconeus

Pronator syndrome• Median nerve• Sites of compression

– Supracondylar process– lig of Struthers- tip of process to med epi– bicipital apo– PT dp hd– FDS origin

• Tests– Resisted E flexion with FA sup-bic apo– Resisted FA pronation with E /- PT heads– Isolated LF flexion- FDS

Treatment

• PT/OT• Observation

– NSAIDS, act mod, night time splint• Surgical

Posterolateral Instability

• Most frequent form of elbow instability.

PLRI• Valgus instability with lateral lesions.• Rotational displacement of the ulna on the humerus,

– leading to supination of the ulna in relation to the humerus. • Dislocation occurs around intact MCL with dislocating

force acting on a forearm in ER exerts an axial stress in flexion and valgus.

• PLI is associated with ER of the ulna during testing in valgus with forearm supination.

• This instability disappears during valgus testing with the forearm pronated the structure being tested is the MCL

Posterolateral instability

• Pain and sensation of snapping or catching. • Symptoms are marked in near-extension with

the forearm supinated. • An extension deficit in 1/3 of the patients. • The main structure that has been damaged is

the lateral collateral ligament. • The lateral pivot shift is enhanced if the lateral

collateral ligament is transected, or if all the collateral ligaments are cut.

PL instability Stages

• O’Driscoll describe three stages of instability. • Stage 1 is posterolateral rotatory instability.

– the lateral ulnar collateral ligament is torn at this stage– Positive lateral pivot shift test. – Seen after dislocation, and varus stress.

• Stage 2: incomplete dislocation-– ulna perched on the trochlea.

• Stage 3: complete dislocation; coronoid behind humerus– Stage 3a, anterior bundle of the medial collateral ligament is

intact; the elbow will be stable in valgus following reduction– Stage 3b, MCL is torn resulting in gross instability after

reduction.

Is it Clear?

O’driscall’s Test -Lateral pivot shift test

• The examiner holds the wrist and the elbow. The forearm is supinated, and a valgus stress is applied as the elbow is taken from extension into flexion. The “snap” noted by the patients can only be reproduced under general anaesthesia; it occurs around 40° of elbow flexion.

• Inset: Diagrammatic representation of rotatory subluxation of ulna on humerus around the pivot of the medial collateral ligament

Lateral pivot shift• The arm is placed

alongside the body, in full internal rotation. The forearm is supinated, and axial compression and valgus stress are applied as the elbow is moved from the fully extended to a flexed position.

QUESTIONS

Q1

• What nerve does the arcade of struthers potentially compress?

• Ulnar

• Arcade of struthers, Osborne’s ligamentts, FCU, osteophytes at medial epicondyle.

Q2

• What Nerve does the LIGAMENT of struthers compress?

• Median nerve.• Sites of compression for pronator

syndrome: supracondylar process, lig of struthers, biciptal aponeurosis, PT, FDS.

Wrist Examination

Rhett Griggs, M.DTeton Hand Conference

2.5.2010

How are you feeling?

Wrist Examination

• General PMH• Pain, weakness or

instabilty.• Focused Components

– Cervical– Skin– Soft tissue– Bone– ligamentous

All regions• Observation

– Posture– Atrophy

• A/PROM• Wrist

– Ext/Flex: 80/80– R/UD: 20/30

• Digits– FFE/FFF– Opposition

• MMT– E flex/wrist ext C6– E ex/wrist flex: C7– Finger Flex: C8– Finger ABD: T1

• Dynomometer• MMR

– Biceps C5– BR C6– Triceps C7

Methodical examination• Position

– Sitting elbow on table– Free of clothing

• Starting– Away from pain– Dorsal then volar– Regional

My approach to Examination

• 4 regions– Radial– Dorsal– Ulnar– Palmar

• Inspection• Palpation• Motion• NV• Special tests

Inspection

Radial Wrist Exam• FCR

– Tendonitis at trapezius • Scaphoid tuberosity

– Radial to FCR– Radial deviation– Hold in UD

• ST joint– Distal and radial to tub– Move thumb– ST OA- RD+dorsal

force on scaphoid.

• Radial artery• 1st dorsal compart.• Dequervain’s• Intersection

Scapho-Trapezial joint

• Snuffbox• Radial and ulnar

deviation

Radial wrist exam

• SBRN• 1st CMCJ• Snuffbox• Radial styloid

Dorsal wrist exam

• Dorsal Lunate pole• SL interval

– SLIL, Occult ganglion• 4th and 5th compart.

– Tenosynovitis palp• CMC joints

– Localized ttp,– Boss at 2nd/3rd mc

• Mid row

Capitate and midrow entry

• 1cm distal to listers• Feel SLIL• Distal and slight ulnar

with wrist flexed feel capitate-lunate artic.

Ulnar wrist exam

• Ulnolunate– Lunate chondro– TFC tear– Grind test differentiates

• LT joint• DRUJ• ECU• Ulnar head/styloid

Ulnar wrist

• Pisiform• Triquetrum• Hamate

Palmar wrist examulnar side

• Pisiform• Hook of hamate• FCU• Ulnar nerve

Palmar exam

• PL• Cut branch of Med nerve

– At wrist crease bn PL and FCR• Synovitis and effusion

– Circumferential pressue causes pain.

Surface Anatomyrecap

• Dorsal– Radial styloid– Snuffbox and tendons– Listers– Lunate– DRUJ– Ulnar head (pro)– Ulnar styloid (sup)– Ulnar snuffbox and

tendons

• Volar– Scaphoid tubercle– Pillars of CT– Basal joint– Radial artery– Ulnar artery– Metacarpals

Why we do hand

Instabiltiy

Instability

• SL instability• LT instability• Midcarpal instability• DRUJ instability• Radiocarpal instability• Capitolunate instability• Differentiated with lidocaine

CID/CIND

• CID- carpal instability dissociative– Disruption a row– VISI, DISI

• CIND- Carpal instability non dissociative– Disruption bn rows, radiocarpal/midcarpal– Ligamentously lax patients, malunion radius

• CIC- carpal instability Combined– Disruption both w/in and bn rows– Perilunate dislocations

Exam Basics

• Know anatomy• 4 basic steps

– Know MOI– Symptoms/localization– Exam of articulations– Define clunks or clicks

• Laxity• Special tests

Laxity

• Pisiform push• Differentiates laxity

from dorsal r/u dislocation.

Watson’s Test

SLIL Instability

• Watson’s wrist flexion-finger extension test

• Watson’s Scaphoid shift test. Scaphoid shear

LT instability• Reagan’s/shuck test

• Triquetral shift

• Kleinman’s test shear

Midrow Instability

DRUJ instability

• R/U Ballottement test

Others• Phalens• Tinels• Froment’s• Shrivel/sweat test• Allen’s• Finkelstein’s• Bunnel-Littler• Varus/valgus thumb• Pisotriquetral grind.

Don’t be overconfident

Thank you.

• Hand Clinics, February 2010

• [email protected]

Q2

• What is the difference bn intersection syndrome and Dequervain’s.

shoulder examination salient points · shoulder examination and salient points ... translation of...

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