Examination of the upper extremity

2 Examination of the upper extremity





Synopsis




image Physical examination of the upper extremity starts with a detailed and accurate patient history.


image Physical examination of the upper extremity consists of inspection, palpation, measurement of length, girth and ranges of motion, assessment of stability, and detailed assessment of the associated nerve and vascular systems.


image Thorough understanding of the anatomy, physiology and biomechanics of the upper extremity is essential to perform a physical examination correctly and to make a correct diagnosis of pathologic conditions of the upper extremity.


image Examiners must master correct physical examination techniques based on the anatomic, physiologic and biomechanical rationale.


image Even if a patient’s complaint focuses on only the hand, the entire upper extremity should be examined.


image It is essential to master correct techniques of physical examination to identify the pathologic conditions of patients.


image Each technique of physical examination is based on the anatomic, physiologic and biomechanical rationale of the musculoskeletal, nerve or vascular systems.


image Examiners should have their own routine protocol of examination of the upper extremity so not to leave a part unexamined.


image Comparison of the affected upper extremity with the contralateral unaffected one helps examiners identify pathologic conditions of the affected one.


image Imaging tools such as X-rays, CT or MRI should be used to confirm the diagnosis drawn from the physical examinations or to choose the most possible diagnosis among the several differential diagnoses.



Obtaining a patient history


The patient history can be the most important tool in developing an accurate diagnosis. The history should not only detail the patient’s current complaint, but should also document other elements of the patient’s history which may be of great significance for interpreting the patient’s current problem and choosing between treatment options. A patient history should include information on the patient’s demographics, current complaint, medical history, allergies, medications, and socioeconomic status. The time course of the patient history interview should be documented.




Current complaint


All information on the patient’s current problem, including symptoms of pain, numbness, tingling (paresthesia), weakness, dislocation, coldness, clumsiness or poor coordination and clicking or snapping, should be documented. Each symptom should be characterized according to its location, intensity, duration, frequency, radiation and associated symptoms. The patient history should include information on activities or treatments that aggravate or ameliorate the symptoms. It is also important to record the time and place at which the initial injury occurred and the mechanism by which it was incurred.


In trauma cases, the following data are especially significant:



In nontrauma cases, the following data are especially significant:







Physical examination of the hand


Accurate diagnosis of hand problems depends on a systematic, careful physical examination. Physical examination should be performed routinely following a specific protocol. Even if the patient complains of a problem limited to the hand, the physical examination should start at the neck and shoulder region because the hand is suspended by the bones of the forearm, which connect proximally to the elbow joint, which in turn is stabilized by the humerus and the shoulder joint. In addition, numbness of the hand may be associated with cervical problems. The following eight elements (inspection, palpation, measurement of range of motion, stability assessment, musculotendinous assessment, nerve assessment, vascular assessment, and specific tests) should be included in the examination procedure for patients with problems of the upper extremities. An understanding of the interrelationships among these elements is helpful for drawing accurate diagnostic conclusions. Repeated physical examinations reveal how symptoms change over time, which is important for assessing the effectiveness of the treatment.



Inspection


When inspecting the upper extremities, it is essential to compare the affected extremity with the contralateral extremity because the latter can be used as a normal reference if the injury is unilateral.











Stability assessment


The tightness of the ligaments around a joint, morphology of the surface of a joint and musculotendinous balance around a joint are useful indices of joint stability. When assessing joint stability, the biomechanical and physiological properties of the ligaments should be taken into consideration and the stress forces applied should be appropriate for the ligament in question. For example, the straight portions of the bilateral collateral ligaments of the finger metacarpal (MP) joints tighten when the joint is in the flexed position (Fig. 2.1), whereas those of the PIP joints tighten when the joints are in an extended position. The stability of ligaments is tested by holding the portions distal and proximal to the joint and gently moving the joint passively to stress the ligaments that stabilize the joint. It is useful to measure the opening angle of the affected joint under stress using X-rays and to compare the opening angle of the affected joint with that of the corresponding healthy joint of the opposite hand (Fig. 2.2). The tear of the ulnar collateral ligament of the thumb MP joint is known to be Stener lesion. The radial collateral ligament instability of the thumb MP joint demonstrates palmar dislocation and ulnar deviation of the thumb MP joint. The radial collateral ligament courses from the distal-palmar to proximal-dorsal direction, the line of which is almost perpendicular to the sagittal axial line of the thumb, the MP joint has tendency to be dislocated palmarly, when the ligament is not functioning. Because the force vector of the adductor pollicis muscle is more transverse to the axial line than that of the thumb abductor muscles, which is more parallel to the axis of the thumb, the thumb MP joint with the radial collateral ligament insufficiency demonstrates ulnar deviation. On the other hand, the long-lasting ulnar collateral ligament insufficiency of the thumb MP joint may also show palmar dislocation.




Assessment of the stability of wrist joints is complex and difficult. The stability of the wrist joint is determined by the stability of the radiocarpal, ulnocarpal, distal radioulnar and midcarpal joints. Special tests for assessing the stability of specific ligaments or imaging tools such as X-rays, CT or MRI may be helpful in making a diagnosis.



Musculotendinous assessment


The integrity of the tendon and the strength of the muscle should be considered when conducting a musculotendinous assessment.






Tests for specific muscles



Extrinsic muscles













Intrinsic muscles







Nerve assessment


Evaluation of peripheral nerves should include both motor and sensory function. To evaluate the motor function of the hand, it is necessary to understand not only the anatomy and biomechanics of the muscles of the upper extremity but also the peripheral innervation of the muscles. An understanding of the order in which branches of the nerve trunk innervate muscles is important for assessing nerve recovery after a nerve injury or a compression neuropathy.


Sensibility testing also relies on knowledge of peripheral nerve anatomy. It is essential to understand which parts of the hand are innervated by which peripheral nerves. Peripheral nerve palsy should be diagnosed using motor and sensory evaluation. When the outcome of a motor assessment does not coincide with that of a sensory assessment, abnormal innervation of muscles or an unusual anastomosis between peripheral nerves should be considered. The Martin–Gruber connection is an abnormal innervation of the median nerve to the motor branch of the ulnar nerve. Patients with cubital tunnel syndrome and this nerve connection may have a sensory palsy of the ulnar nerve without motor palsy.


Comprehensive sensibility evaluation includes static and dynamic two-point discrimination (2 PD) testing, Semmes–Weinstein monofilament testing, vibrotactile threshold testing, and cold-heat testing. The 2 PD test evaluates the tactile sensation of the skin and assesses density of the perception receptors in the skin. Stimuli generated by the static 2 PD test are mainly sensed by Merkel cells (slow-adapting mechanoreceptors), while the main receptors of stimuli generated by the moving 2 PD test are Meissner corpuscles (quick-adapting receptors). In the static 2PD test, a caliper is applied longitudinally to the digit and the smallest distance between the tips of the caliper that the patient can distinguish is measured.4 The moving 2PD test is the smallest perceived distance between the tips of a caliper that is moved longitudinally along the ulnar or radial aspect of the finger.5

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Feb 21, 2016 | Posted by in General Surgery | Comments Off on Examination of the upper extremity
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