Upper Extremity Joint Exam (Part 1)

Transcript

• 00:11we're going to demonstrate a joint
• 00:13examination in a couple of minutes.
• 00:14But before we do that,
• 00:16I want to emphasize a couple of
• 00:18points that are important as
• 00:19you examine a patient's joints.
• 00:21The patient should be undressed
• 00:23and in an examining gown.
• 00:25The upper extremity should be
• 00:27examined with the patient seated,
• 00:28the lower extremities examined
• 00:30with the patient supine.
• 00:32It's important to know the anatomy
• 00:34of the joint capsule itself,
• 00:36as well as surrounding Bursa.
• 00:38It's also important to know the
• 00:40range of motion of certain joints,
• 00:41particularly the wrists,
• 00:43the glenohumeral joint,
• 00:44and the hips.
• 00:46You can't diagnose tendonitis if
• 00:48you don't know the active range of
• 00:50motion via affected tendon because
• 00:53you make the diagnosis by resisting
• 00:55that active range of motion.
• 00:57So you're diagnosed rotator cuff,
• 00:59tendonitis, bicipital tendonitis,
• 01:00and the flexors and extensors of the wrists.
• 01:05Also recognize that the pattern
• 01:07of joint involvement can be very
• 01:10helpful in the diagnosis you make.
• 01:12So generalize,
• 01:13Osteoarthritis affects the DI P's,
• 01:15the Pi P's,
• 01:16the first carpal metacarpal joint, hip,
• 01:18knee, and tarsal metatarsal joints.
• 01:20Rheumatoid arthritis affects
• 01:22virtually every joint in the
• 01:25body except the DIP of the hand,
• 01:28the common joints to look at,
• 01:30of the metacarpal fluential joints,
• 01:31and the Pi P's and the wrists
• 01:33and every other joint.
• 01:35Psoriatic arthritis has a
• 01:37predilection for certain joints.
• 01:39It commonly affects the DIP
• 01:41joints of the hands and the
• 01:43interfluential joints of the toes,
• 01:45but can also affect any other joint.
• 01:48So we'd like to talk today about
• 01:51a screening joint examination.
• 01:53When you're evaluating a patient
• 01:55with a musculoskeletal problem,
• 01:57the gold standard for the diagnosis is
• 01:59not the MRI and not a laboratory test.
• 02:02It's the finding on physical exam.
• 02:04After you've done the physical exam,
• 02:06the exam may lead you to
• 02:08certain diagnostic tests,
• 02:09but the key is the physical exam.
• 02:12So as we examine joints,
• 02:13we're interested in several things.
• 02:15We want to know whether there's any
• 02:17joint swelling and whether that
• 02:19swelling is Bony or soft tissue.
• 02:21We want to know whether there's
• 02:23any malalignment of the joint.
• 02:24We want to know the range of
• 02:26motion of certain joints,
• 02:28particularly the wrists,
• 02:30the shoulder and the hip.
• 02:33And we also want to know
• 02:35which joints are involved,
• 02:36because the pattern of joint involvement
• 02:39gives us a very strong clue about
• 02:41what diagnosis the patient has.
• 02:43So we start with the patient
• 02:46sitting facing you to do the upper
• 02:49extremities and we start with
• 02:50a distal interphalingeal joint.
• 02:52Well,
• 02:53we'd look to see if there's any swelling,
• 02:55if the soft tissue swelling of
• 02:57the distal interferential joint.
• 02:59The leading diagnosis is psoriatic arthritis.
• 03:02For reasons unknown to anyone,
• 03:05that joint is frequently involved
• 03:07in psoriatic arthritis.
• 03:09The most common disease to affect
• 03:12the distal interferential joint,
• 03:13however is generalized osteoarthritis.
• 03:16Osteoarthritis is a disease
• 03:18of articular cartilage.
• 03:20So when you have cartilage loss,
• 03:22you have asymmetry and medial or
• 03:25lateral deviation of the joint.
• 03:28So if there's generalized osteoarthritis,
• 03:30you're going to get what's called
• 03:32Bony enlargement because of the
• 03:34osteophytes and you'll have medial
• 03:36or lateral deviation of the joints.
• 03:38So the distal interphalangeal
• 03:40joint thinks psoriatic arthritis
• 03:42and generalized osteoarthritis.
• 03:44Gout of course can affect any joint.
• 03:47Proximal interphalential joint is
• 03:49involved in both inflammatory arthritis,
• 03:52particularly rheumatoid arthritis
• 03:54and generalized osteoarthritis.
• 03:56So with generalized osteoarthritis,
• 03:58again you're going to see Bony
• 04:01enlargement and medial or
• 04:02lateral deviation of the joint.
• 04:04With inflammatory arthritis,
• 04:06particularly rheumatoid arthritis,
• 04:08you're going to see what we call fusiform
• 04:10swelling that is most of the swelling
• 04:12at the joint and in a tapering both
• 04:14proximately and distantly to the joint.
• 04:17Now the proximal interferential
• 04:18joint is the site of several common
• 04:21Mal alignments that we used to see
• 04:23very commonly in rheumatoid disease.
• 04:26Now that we have medications that
• 04:28can affect the Natural History,
• 04:30we don't see it as often,
• 04:31but the two most common ones are
• 04:34what's called a boutineer deformity.
• 04:36And with a boutineer deformity you
• 04:39have hyperflexion of the PIP joint
• 04:41and hyperextension of the DIP joint.
• 04:44And the the deformity occurs because of
• 04:47chronic constant swelling of the PIP joint.
• 04:51There is the tendon that goes
• 04:53over the dorsum of the finger,
• 04:55has a medial slip in it,
• 04:57there's a medial and lateral component to it.
• 05:00So with persistent swelling,
• 05:02the that tendon opens up and slips medial
• 05:05and laterally to the joint and you get
• 05:08a buttonhole or boutonniere deformity.
• 05:10The other common deformity that
• 05:12affects patients with longstanding
• 05:14rheumatoid arthritis is what's
• 05:16called the swan neck deformity.
• 05:18And the swan neck deformity gives
• 05:20you hyperextension of the PIP
• 05:22and hyperflexion of the DIP.
• 05:25That is not due to disease of
• 05:27the PIP or the DIP.
• 05:30It's due to swelling and inflammation
• 05:33of the metacarpal phalangeal
• 05:36joints with shortening of the the
• 05:39extensor tendon and the socalled
• 05:44shortening and telescoping of that tendon,
• 05:46which gives you the swan neck deformity.
• 05:50The joints that are most
• 05:52helpful in diagnosing rheumatic
• 05:54disease are the metacarpal,
• 05:57phalangeal joints or the knuckles.
• 05:59Normally there should be an
• 06:02indentation between each knuckle,
• 06:04a valley between the heels of the knuckles.
• 06:07If that valley is filled in and you
• 06:09see swelling between the knuckles,
• 06:11that's an indication of inflammation
• 06:14of the metacarpal phalangeal joints.
• 06:16And it's pretty diagnostic
• 06:18of inflammatory arthritis.
• 06:20Can be rheumatoid arthritis,
• 06:21can be lupus, can be psoriatic arthritis,
• 06:24but it's not osteoarthritis.
• 06:25So swelling of the metacarpal
• 06:27phalangeal joints is a very helpful
• 06:30sign for inflammatory arthritis.
• 06:32Sometimes you'll have patients that will
• 06:34have a lot of foot pain and you can't
• 06:37see some of the joints of the foot,
• 06:39particularly the metatarsal phalangeal joint.
• 06:41So a patient that comes in with severe
• 06:44metatarsal pain and you find thickening
• 06:46of the metacarpal phalangeal joints,
• 06:48that's a very helpful sign that you're
• 06:51probably dealing with an inflammatory
• 06:53arthritis causing the patient's pain.
• 06:56Now there are several other
• 06:57things to look for on the hand.
• 06:59Sometimes patients will have deformities
• 07:01of the finger joints with no arthritis.
• 07:05That occurs frequently in a condition
• 07:08known as Dupitron's contracture,
• 07:09and that's contracture and thickening
• 07:12of the palmar aponeurosis.
• 07:13And if it's severe,
• 07:15you'll sometimes get flexion
• 07:17of the PIP&DIP joint.
• 07:18And the way in which you diagnose
• 07:21Dupitron's contracture is just run
• 07:22your finger over the palm of the hand.
• 07:24And if you feel linear thickening here,
• 07:27you know you have Dupitron's contractures.
• 07:30Another common abnormality that
• 07:32occurs in the hand area is what's
• 07:35called Decreveins disease.
• 07:37There is a common sheath for the extensor
• 07:41and abductor tendons of the thumb that
• 07:44runs right over the radial styloid.
• 07:47And when that sheath is irritated,
• 07:50you'll sometimes get a
• 07:51good deal of pain over the
• 07:55area proximal to the thumb.
• 07:58And the way in which you diagnose
• 08:00theaker veins is you ask the
• 08:01patient to take their thumb,
• 08:03put it in the palm of their hand,
• 08:04make a fist, and then you take the hand
• 08:07and just move it in this fashion here.
• 08:10All right.
• 08:10And this will produce significant pain
• 08:13if a patient has dupitron's contractures.
• 08:16Another condition that can affect the
• 08:18finger is the what we call a trigger finger.
• 08:22And a trigger finger is caused by a
• 08:25flexure tendon nodule and thickening
• 08:28of fibrosis of the tendon sheath.
• 08:31So clinically,
• 08:32a trigger finger is when the patient
• 08:34tells you that they get up in the morning,
• 08:36bend their hand and can't open
• 08:38up their finger and have to take
• 08:40another finger to open that up.
• 08:41And that's due to the tendon nodule
• 08:45getting caught behind the narrowed
• 08:47area of the flexor tendon sheath.
• 08:51The wrist we want to check range
• 08:54of motion because generalized
• 08:56osteoarthritis does not affect the wrist.
• 09:00If you have wrist disease,
• 09:01you have inflammatory arthritis.
• 09:03Anything from gout to rheumatoid
• 09:05arthritis can affect the wrist.
• 09:07So normally you should have at any
• 09:10age roughly 90 degrees of flexion and
• 09:1390 degrees of extension of the wrist.
• 09:16If a patient has asymptomatic loss
• 09:18of range of motion of the wrist,
• 09:21think inflammatory arthritis.
• 09:22I may not have it,
• 09:23but that's one of the clues to make
• 09:26us look for inflammatory arthritis.
• 09:29So when examining the hands,
• 09:30you're looking for patterns of disease.
• 09:34Generalized osteoarthritis affects
• 09:36the distal interfalendial joint,
• 09:38the proximal interfalendial joint,
• 09:40the first carpal metacarpal joint,
• 09:43the acromioclavicular joint,
• 09:44the hips, the knees,
• 09:46and the tarsal metatarsal joints of the foot.
• 09:49Inflammatory arthritis usually
• 09:51doesn't affect the DIP joint
• 09:53unless it's psoriatic arthritis,
• 09:55but most importantly,
• 09:57very commonly affects the metacarpal
• 09:59phalangeal joints or knuckles and the wrists.
• 10:03You also want to make sure you look
• 10:05for trigger fingers for dupitrons,
• 10:06contractures, and for decreveins disease.
• 10:11So we look at the elbow.
• 10:13We're first interested in the
• 10:15range of motion of the elbow,
• 10:17so it's very easy to check.
• 10:19You see if you can take your thumb
• 10:20and touch your shoulder and then
• 10:22simply straighten the elbow out.
• 10:23If you can do that,
• 10:24you've got normal range of
• 10:26motion of the elbow.
• 10:27Now when we're looking at the elbow,
• 10:29we're particularly interested
• 10:30in the elbow joint,
• 10:32the what's called the electronon
• 10:34Bursa and then what's called
• 10:36tennis elbow or golfer's elbow.
• 10:38And that's actually a tendonitis.
• 10:40So this model of the elbow points
• 10:43out that this is the humerus and
• 10:46this is the humeral epicondyle.
• 10:48Here just distal to the humeral
• 10:51epicondyle is the radial head,
• 10:54and the
• 10:57radio ulnar articulation proximally is
• 11:00at the elbow, distally is at the wrist.
• 11:04So when I look at the elbow,
• 11:07I'm going to start bringing my thumb
• 11:10down the patient's forearm until I
• 11:13find a Bony prominence right here.
• 11:15And that Bony prominence
• 11:17is the lateral epicondyle.
• 11:18As I go more distally,
• 11:20I feel an indentation and then I
• 11:23feel a second Bony prominence.
• 11:25So that's probably the radial head.
• 11:27But to make sure, I rotate,
• 11:30pronate, and supinate the wrist,
• 11:32and if that bone rotates under my thumb,
• 11:35it is the radial head.
• 11:37The importance of that is I want to
• 11:39then take my finger and go between
• 11:41the radial head and the electronon
• 11:43and this space here between the
• 11:44radial head and the electronon.
• 11:46That's where you feel the
• 11:49synovial capsule of the elbow.
• 11:51So if the synovitis of the elbow,
• 11:54this is where you will see it.
• 11:55You can actually tap or aspirate the
• 11:58elbow joint fairly simply in that area.
• 12:00Now there's a second area very close to that,
• 12:03right at the tip of the electronon.
• 12:05And the tip of the electronon is
• 12:07what's called the electronon Bursa.
• 12:08People talk about water on the elbow,
• 12:11they're talking about the electronon Bursa.
• 12:13So swelling here is the electronon Bursa.
• 12:16Swelling here is a synovial capsule,
• 12:19the true elbow joint.
• 12:21Now, we sometimes use the term tennis elbow,
• 12:25and we use it.
• 12:27Another term for that is lateral
• 12:30epicondylitis,
• 12:30but that's actually that's incorrect
• 12:32because the epicondyle is completely normal.
• 12:35So tennis elbow is a tendonitis of
• 12:39the extensor muscles of the wrist.
• 12:41Those muscles have their origin on the
• 12:44lateral epicondyle of the humerus and
• 12:46their insertion on the carpal bones.
• 12:48So these patients will complain
• 12:50of severe pain here.
• 12:52But the way to diagnose tennis elbow
• 12:54is by resisting the active range
• 12:57of motion of the affected tendon.
• 12:59So I'll ask Andrea to pull her hand
• 13:01back like this to extend her wrist,
• 13:03and now will resist that.
• 13:05So I'm resisting her extension of
• 13:06the wrist if that produces pain.
• 13:09Here, that's tennis elbow.
• 13:10The 2nd tendon is the medial
• 13:13at the medial epicondyle,
• 13:16so-called golfer's elbow, much less common.
• 13:18But with golfer's elbow the tendon's
• 13:20origin is on the medial epicondyle
• 13:23insertion again is in the carpal bones.
• 13:26And here you ask the patient to flex their
• 13:28wrist and you do it against resistance.
• 13:30So Andrea will flex her wrist
• 13:32and I'll resist that.
• 13:34And if that produces pain here,
• 13:36that's so-called Golfer's elbow.
• 13:40So the shoulder is the joint that
• 13:44is most involved with pain and the
• 13:48examination is absolutely key.
• 13:50So there are actually three joints
• 13:52and a pseudo joint in the shoulder.
• 13:54The three joints are the Glenoumeral joint,
• 13:57here, the acromioclavicular joint,
• 14:00and the sternal clavicular joint.
• 14:03The pseudo joint is the movement
• 14:05of the scapular on the thorax.
• 14:08So when you and I pick up our arm,
• 14:12we move our scapular about 30 degrees
• 14:16and we call that scapular humeral rhythm.
• 14:20When the patient picks their arm up,
• 14:24they will move their arm to 1
• 14:28degree for every two degrees
• 14:30movement of the glenohumeral joint.
• 14:32Now another thing I want you to notice
• 14:35as I'm using this model here is that
• 14:38as we passively abduct the humerus,
• 14:40we pinch 4 structures between the chromium
• 14:45and the greater tuberosity of the humerus.
• 14:48Three of the rotator cuff tendons,
• 14:50the so-called sit tendons,
• 14:53the supraspinatus,
• 14:54the intraspinatus and a Terry's
• 14:56minor have their origin on the
• 14:58greater tuberosity of the humerus.
• 15:00Right on top of those tendons is a
• 15:03Bursa called the subacromial Bursa.
• 15:05So when you abduct your arm,
• 15:08if I passively abduct Andrea's arm
• 15:12between 45 and 120 degrees or so,
• 15:16if pain is produced with that movement,
• 15:18we call it a painful arc and it tells
• 15:21us that there is something going on
• 15:24either in those three rotator cuff
• 15:27tendons or in the subacromial Bursa.
• 15:30As as we examine the shoulder,
• 15:33we're first interested in the passive
• 15:36range of motion of the Glenouneral joint,
• 15:39so we find a Bony prominence here.
• 15:41This is a superior spine of the scapula
• 15:43that's going to be our marker okay.
• 15:44So my hand is on the superior
• 15:46spine of the scapula,
• 15:48and then I'm going to
• 15:50passively abduct Andrea's arm.
• 15:51I don't want her to move it
• 15:52because if she movements moves it,
• 15:54she's going to move her scapular
• 15:56and her humerus at the same time,
• 15:58as we've just demonstrated.
• 15:59So I take Andrea's arm and I gently
• 16:03abduct the arm and the point at which
• 16:05the scapular rises is about 90 degrees,
• 16:08and that's the normal Glenohumeral Abduction.
• 16:11So we find the extent of Glyniorinal
• 16:14Abduction by passively abducting the
• 16:16arm until the scapular starts to rise.
• 16:19We then check external rotation.
• 16:21Very simply,
• 16:22rotate the arm until it gets
• 16:24a little bit tight,
• 16:25and that's called external
• 16:27or lateral rotation,
• 16:28and then medial or internal
• 16:30rotation is to move it medially
• 16:32until it gets a little bit tight.
• 16:34Normally it's about 80
• 16:35degrees of internal rotation,
• 16:3790 degrees of external rotation,
• 16:39and 90 degrees of abduction.
• 16:42The next maneuver I'm going to do,
• 16:43we talked a little bit earlier
• 16:45about the painful arc.
• 16:46I'm going to take this arm and
• 16:48I'm going to passively abduct it
• 16:50up to around 120 degrees or so.
• 16:52If the patient complains of pain
• 16:55anywhere between 45 and 1:20,
• 16:57we call it a painful arc,
• 16:59and we're concerned about either
• 17:01the rotator cuff tendons or
• 17:03the subacromial Bursa.
• 17:04All right,
• 17:05now I next want to look and
• 17:07see if there's anything wrong
• 17:09with the rotator cuff muscles,
• 17:12so I'm going to ask the patient
• 17:14to contract that muscle.
• 17:16So abduction is caused.
• 17:18The abduction is the action of the
• 17:21supraspinatus tendon and the deltoid
• 17:24muscle of deltoid muscle rarely,
• 17:27if ever, causes shoulder pain.
• 17:29So if there's pain or difficulty
• 17:31with abduction,
• 17:31it's usually the supraspinatus.
• 17:33So I'll ask the patient to pick their
• 17:35arm up and I'll see if they can
• 17:37do that. OK, so she's able to abduct her arm.
• 17:39Fine. OK, now she had pain
• 17:41here and had a painful arc.
• 17:43I would, just as we did with tennis elbow,
• 17:45I would resist the superspinatus.
• 17:47So I would ask Andrea to pick up
• 17:49her arm and I would resist that.
• 17:51So if that maneuver caused pain here,
• 17:54I'd be concerned about
• 17:56superspinatus tendonitis.
• 17:58Now the intraspinatus and the Terry's
• 18:02minor cause external or lateral rotation.
• 18:05So I want Andrea to keep her
• 18:07elbow by her side and then to
• 18:10move her arm out like this okay.
• 18:12So that tells me that she has good
• 18:15infraspinatus and Terry's minor.
• 18:16And again, if she had shoulder pain,
• 18:18I would resist that movement to
• 18:20see if that reproduced her pain.
• 18:22So we we've looked at the supraspinatus,
• 18:25the infraspinatus,
• 18:26and the Terry's minor tendon.
• 18:29One of the key laws in musculoskeletal
• 18:32medicine is that if active range of motion
• 18:36is less than passive range of motion,
• 18:39you worry about a muscle tear.
• 18:41So we did demonstrate that Andrea
• 18:43has 90 degrees of passive abduction
• 18:46of her glenohumeral joint,
• 18:48and when she picks her arm up,
• 18:50she also has 90 degrees of active abduction.
• 18:53So they're the same.
• 18:54We're not too worried about the muscle
• 18:57because both of them are working
• 18:59fine Now a couple of other muscles
• 19:01we want to look at in the shoulder.
• 19:03One of them is the biceps.
• 19:05So the biceps muscle actually has
• 19:07three maneuvers we want to look at.
• 19:09The 1st is flexion of the elbow.
• 19:12So I'll ask Andrea to take her wrist,
• 19:14bring it up to her shoulder,
• 19:16and I'll resist that.
• 19:17So if that produces pain here,
• 19:19I'm concerned about bicipital tendonitis.
• 19:22The 2nd maneuver to look at the biceps
• 19:24tendon is have the patient put their
• 19:27elbow straight and pick up their arm.
• 19:29We call this flexion of the shoulder.
• 19:30So I'm going to ask Andrea to
• 19:32pick up her arm like that,
• 19:33and I'm going to resist that
• 19:34if that produces pain.
• 19:35Here again,
• 19:36that's a sign of bicipital tendonitis.
• 19:39The third maneuver,
• 19:41a little complicated,
• 19:42is keep your elbow by your side and then
• 19:45externally rotate or supinate the wrist.
• 19:47So I'm going to ask Andrea to do that.
• 19:48OK And I'm going to resist that.
• 19:51So if that maneuver causes pain here,
• 19:53that's another sign of bicipital tendonitis.
• 19:57So we're checking for rotator
• 20:00cuff tendonitis,
• 20:01we're checking for a rotator cuff tear,
• 20:03and we're checking for subacromial
• 20:06Bursitis and bicipital tendonitis.
• 20:08Now Andrea has a problem
• 20:09on her right shoulder,
• 20:10so we're going to look at the right shoulder.
• 20:12So here we'll look for the
• 20:14passive range of motion.
• 20:16So I relax Andrea's arm,
• 20:18I'm going to gently abduct it,
• 20:20and she's going to tell me if
• 20:22she has any discomfort at all.
• 20:23And actually she does have a
• 20:25little loss of range of motion.
• 20:26So I get up to about 60 degrees
• 20:29and the scapula starts to rise.
• 20:31So her Glenny Humeral Abduction
• 20:33on the right side is
• 20:36only 60 degrees.
• 20:37I will check the rotation.
• 20:39Her external rotation is also limited.
• 20:42So when I take her arm here
• 20:43and try to externally rotate,
• 20:45I can only rotate about 30 degrees.
• 20:47It should be 90, it's only about 30.
• 20:49And then Internal Rotation is about 45 or so.
• 20:53So she has some limitation of passive
• 20:55range of Motion of the Glenohumeral Joint.
• 20:59Now when I ask Andrew,
• 21:00let's try this side and her left arm,
• 21:02I ask her to pick her arm up. Does it?
• 21:04Fine. OK, now, on the right side,
• 21:07let's try to pick the arm up.
• 21:08She can't do it. OK.
• 21:10All right, so the passive range of
• 21:12motion of Andrea's right Glenny
• 21:14humeral joint was about 60 degrees.
• 21:17The active range of motion was 10 or 15.
• 21:20So we're worried about a rotator cuff tear,
• 21:23particularly a superspinatus tear.
• 21:25So there's a second maneuver. Will do.
• 21:28And again, take Andrea's left arm,
• 21:30take the left arm, hold it up,
• 21:32and she can hold it up.
• 21:33Fine. OK.
• 21:33I'll be gentle here,
• 21:35take the right arm, I pick it up,
• 21:37ask her to hold it up and she can't.
• 21:39And we call that a drop on sign.
• 21:41So the physical examination of Andrea's
• 21:44right shoulder demonstrates that she
• 21:46has signs of a super spinotist hair
• 21:48with a little bit of loss of range
• 21:51of motion of her glenohumeral joint.
• 21:53So the exam gives you an awful
• 21:55lot of information.
• 21:57It's been confirmed on MRI that
• 21:59she has a right supraspinatus tear,
• 22:01but we almost didn't need the MRI
• 22:03because the physical exam told us
• 22:05what was going on in the shoulder.
• 22:07So for the shoulder,
• 22:08we're interested in passive range of motion,
• 22:11abduction,
• 22:11external internal rotation of
• 22:13the Gleny humeral joint.
• 22:14We're concerned about a painful arc.
• 22:18We want to know the status
• 22:19of the rotator cuff tendons,
• 22:21supraspinatus,
• 22:22infraspinatus and Terry's minor.
• 22:24We want to know whether they can be
• 22:26moved and whether there's any pain on
• 22:28resisted movement of those tendons.
• 22:30And finally,
• 22:31we want to learn about the bicipital
• 22:33tendon by checking resisted elbow flexion,
• 22:36shoulder flexion and supination of the arm.
• 22:43So I'd like to review some of the
• 22:45specific things we talked about in our
• 22:47overview of upper extremity joints.
• 22:49Looking at the hands,
• 22:50the distal interphalangeal joints
• 22:52are commonly involved in generalized
• 22:54osteoarthritis and psoriatic arthritis.
• 22:56Proximal interphalangeal,
• 22:57both generalized osteoarthritis
• 22:59and inflammatory arthritis.
• 23:01The metacarpal phalangeal joints are
• 23:04specific for inflammatory arthritis.
• 23:06Dupitrons, contractures,
• 23:07a trigger finger,
• 23:08and decrevene tenosynovitis are all
• 23:11mechanical things that can affect the hands.
• 23:14Look at wrist range of motion
• 23:16because the wrist is not involved
• 23:17in generalized osteoarthritis.
• 23:19So if you have decreased
• 23:20wrist range of motion,
• 23:22that indicates you're probably dealing
• 23:24with an inflammatory arthritis.
• 23:25At the elbow you find the synovial
• 23:28capsule by running your finger between
• 23:30the radial head and the electronon.
• 23:33You look at the electron on Bursa,
• 23:34which sits right on top of the elbow,
• 23:36and you make a diagnosis of tennis
• 23:39elbow by resisting wrist extension,
• 23:41Golfer's elbow by resisting wrist flexion.
• 23:44Looking at the shoulder,
• 23:45we look at the glenohumeral joint,
• 23:47the chromial clavicular joint,
• 23:48the sternal clavicular joint,
• 23:50and the movement of the scapular on
• 23:52the thorax as you abduct the arm,
• 23:55so-called scapular humeral rhythm.
• 23:56The way in which you determine range
• 23:59of motion with the glynumeral joint is
• 24:01put your hand on the superior spine to
• 24:03the scapula and passively abduct the arm.
• 24:06When the scapula starts to move,
• 24:08you have Glynumeral Abduction,
• 24:10lateral or external.
• 24:12It should be roughly 90 degrees,
• 24:13medial or internal roughly 80 degrees.
• 24:17A painful arc occurs when you pinch
• 24:19one of four structures between
• 24:20the humerus and the chromium.
• 24:23Those structures are the supraspinatus,
• 24:25Intraspinatus, and Terry's minor tendons,
• 24:27and the subacromial Bursa.
• 24:29The supraspinatus and deltoid
• 24:31are involved in abduction,
• 24:33infraspinatus and Terry's minor
• 24:35and external rotation,
• 24:36Terry's major in subchatularis.
• 24:38In internal rotation to diagnose
• 24:41rotator cuff tendonitis,
• 24:43you would have pain on resisted abduction
• 24:46or external rotation of the shoulder.
• 24:49You diagnose a tear when there
• 24:51is less active range of motion
• 24:54than passive range of motion.
• 24:56You diagnose precipital tendonitis if
• 24:58there is pain on flexion of the elbow,
• 25:00forward flexion of the arm,
• 25:02or supination of the wrist
• 25:03while the arms at the side.