NMS I - Final Exam Part 2: Elbow, Wrist, & Hand Orthopedic Test

How do you perform the Elbow Flexion Test?

1) Seated

2) Patient completely flexes elbows & hold in position for up to 5 minutes

3) Pain?

What is a positive for Elbow Flexion Test?

Paresthesia or tingling that develops in the ulnar distribution of the forearm in less than 5 minutes

What does paresthesia or tingling that develops in the ulnar distribution of the forearm in less than 5 minutes indicate in the elbow flexion test?

Cubital Tunnel Syndrome

(stress to ulnar nerve at cubital tunnel)

How do you perform the Tinel's Sign at the Elbow?

1) Patient seated

2) Tap groove between olecranon process and lateral epicondyle with reflex hammer (1 inch above & 1 inch below each groove on medial & lateral side)

3) Pain? Repeat w/ symptomatic side

What is a positive sign for Tinel's Sign at the Elbow?

Hypersensitivity

When there is hypersensitivity over the medial epicondylar groove in Tinel's Sign at the elbow, what does this indicate? How about over the lateral epicondylar groove?

Medial = Neuritis or neuroma of Ulnar nerve (Ulnar neuropathy)

Lateral = Neuritis or neuroma of Radial nerve (Radial neuropathy)

How do you perform Cozen's Test?

1) Patient seated

2) Patient clenches fist tightly, extends wrist & maintains pronated position

3) Stabilize forearm and apply resistance to patients extended wrist

4) Pain? Repeat w/ other side

What is a positive Cozen's Test?

Pain over lateral epicondyle

What does a pain over the lateral epicondyle in Cozens Test indicate? (2)

Lateral epicondylitis or Radio-humeral bursitis

How do you perform Golfer's Elbow Test (Reverse Cozens)?

1) Patient seated

2) Patient clenches fist tightly, flexes wrist and maintains supination position

3) Patient flexes wrist and elbow against resistance

4) Pain? Repeat on symptomatic side

What is a positive for Golfer's Elbow Test (Reverse Cozens)?

Pain over medial epicondyle

What does pain over the medial epicondyle in Reverse Cozens indicate?

Medial epicondylitis

How do you perform Lift Test?

1) Patient seated w/ forearm on lap

2) Patient clenches sandbag or barbell tightly & extends wrist, maintaining pronated position

3) Pain?

4) Patient flexes wrist & maintain supination position

5) Pain?

6) Repeat w/ symptomatic side

What is a positive during the Lift Test during extension? Flexion?

Extension: Pain over lateral epicondyle

Flexion: Pain over medial epicondyle

What would pain over the medial epicondyle in Lift Test indicate? Pain over the lateral epicondyle?

Medial epicondylitis

Lateral epicondylitis

How do you perform the Ligamentous Instability Test?

1) Patient seated

2) Stabilize patients arm w/ one hand on medial elbow and other at wrist

3) Patient elbow slightly flexed and an adduction (varus) force applied

4) Pain/laxity?

5) Examiner stabilizes on lateral elbow and an abduction force is applied.

6) Pain /laxity?

7) Repeat w/ symptomatic side

When performing a Varus force during the ligamentous instability test, what ligament is being tested? Valgus force?

Varus (adduction) = Lateral collateral ligament

Valgus (abduction) = Medial collateral ligament

What is a positive Ligamentous Instability Test?

Laxity or Pain compared to the uninvolved elbow

How do you perform Mill's Test?

1) Patient seated

2) Examiner passively flex elbow, wrist, & fingers and supinates forearm

3) Examiner maintains patient position while extending their elbow to maximum extension

4) Pain?

5) Repeat on symptomatic side

NOTE: All moves described above should be done in a smooth, continuous manner!

What is a positive in Mill's Test?

Elbow pain increases

What does an increase in elbow pain during Mill's test indicate?

Lateral epicondylitis (Tennis elbow)

How do you perform Kaplan's Test?

1) Patient seated w/ elbow flexed to 90

2) Patients grip strength assessed w/ dynamometer

3) Tennis elbow brace placed on patient about 3 cm below elbow joint line

4) Grip strength reassessed w/ brace on

5) Pain?

6) Repeat w/ symptomatic side

What is a positive Kaplan Test?

increased grip strength or decreased pain in the presence of a tennis elbow brace

What does an increased grip strength or decreased pain in the presence of a tennis elbow brace during Kaplan test indicate?

Lateral epicondylitis

T/F: The results of Kaplan test is very suggestive of the treatment parameters you should use to assist the patient.

TRUE

(application of elbow brace)

How do you perform Tinel's sign at the wrist?

1) Patient seated w/ elbow flexed and forearm supinated

2) Examiner slightly dorsiflexes patients wrist and hand

3) Percuss volar surface of wrist over carpal tunnel w/ reflex hammer

4) Pain?

5) Repeat w/ symptomatic side

What is a positive for Tinels Sign at the Wrist?

Tingling/pain along the median nerve distribution (thumb, index finger, middle finger, and lateral half of the ring finger)

What does tingling/pain along the thumb, index finger, middle finger, and lateral half of the ring finger, distal to the point of percussion indicate?

Carpal Tunnel Syndrome due to Regeneration of the Median nerve

What does tingling/pain along the thumb, index finger, middle finger, and lateral half of the ring finger, distal & proximal to the point of percussion indicate?

Carpal Tunnel Syndrome due to neural inflammation an degeneration of the Median Nerve

What is the nerve conduction rate of the Median nerve? What would you see if there is compression?

65

If compression the value would be less than 65

How do you perform Part 1 of the Phalen's Test?

1) Patient seated w/ both elbows flexed and arms pronated

2) Wrist flex and dorsal surfaces of hands approximated together

3) Position maintained for at least 60 seconds

4) Pain?

How do you perform Part 2 of the Phalen's Test (Reverse Phalen's)?

1) Patient seated w/ both elbows flexed and arms pronated

2) Wrist extended and the palms of the hands approximated to each other

3) Patient maintains this position for the 60 seconds

4) Pain?

What is a positive test for Part 1 or Part 2 of Phalen's Test?

Radiating pain through thumb, index finger, & lateral half ot he middle finger

What does radiating pain through thumb, index finger, & lateral half of the middle finger in Phalens Test indicate? Reverse Phalens test?

Phalens = Carpal tunnel syndrome by neural ischemia to Median nerve

Reverse Phalens = Carpal tunnel syndrome by neural stretch and compression by surrounding tissues to the Median n.

How do you perform Froment's Test?

1) Patient seated

2) Patient adducts thumb to the tip of the index finger

3) Examiner places piece of paper between the patients thumb & index finger

4) Instruct patient to resist allowing the paper to be pulled from the grip of the index finger and thumb

5) Examiner attempts to pull the paper from the grip of the patients index finger and thumb

6) Pain? Repeat w/ symptomatic side

What is a positive Froment's Test?

When pull paper from grip of patient, you see their terminal phalanx of the thumb go into flexion to add support

During Froment's test when you see their terminal phalanx of the thumb go into flexion to add support, what does this indicate?

Paralysis of the adductor pollicus muscle due to ulnar nerve injury/palsy

How do you perform Pinch Grip Test?

1) Patient seated

2) Patient pinches tip of index finger to tip of thumb

3) Paper placed between and the patient resists allowing the paper to be pulled form the grip of the index/thumb

4) Pain? Repeat w/ symptomatic side

What is a positive Pinch Grip Test?

Terminal phalanx of thumb goes into pulp of the finger to a pulp of the thumb grip

What does terminal phalanx of thumb goes into pulp of the finger to a pulp of the thumb grip during Pinch Grip Test indicate?

weakness of anterior interosseous nerve

How do you perform the Bunnell-Littler Test?

1) Patient seated w/ elbow flexed, forearm pronated & wrist extended

2) Examiner slightly extends the MCP of the digit under examination

3) Examiner flexes PIP & DIP joints

4) Pain?

During Bunnell-Littler test, if the joint under examination cannot be passively flex, what does this suggest? How about if there is pain and/or joint contracture of the PIP and DIP joints?

Tight intrinsic musculature or contracture of joint capsule

Osteoarthritis

How do you perform the Finkelstein's Test?

1) Patient seated

2) Patient makes fist w/ thumb inside fingers

3) Examiner passively deviates wrist in ulnar direction

4) Pain? Repeat symptomatic side

What is a positive Finkelstein's test?

Pain over abductor pollicis longus & extensor pollicis brevis tendons at wrist

What does pain over abductor pollicis longus & extensor pollicis brevis tendons at wrist indicate in Finkelstein's test?

Stenosing tenosynovitis in the abductor pollicis longus & extensor pollicis brevis

How do you perform Mannkoptf's Sign?

1) Examiner establishes patient resting heart rate

2) Apply mechanical pressure or electrical stimulation over painful area while monitoring pulse

What is a positive Mannkoptf's Sign?

Increase in pulse rate of 10 or more BPM

What does an increase in pulse of 10 or more BPM in Mannkoptf's Sign?

Pain is ORGANIC

(sign would be absent in simulated pain)