Examination of the Shoulder Bruce S. Wolock, MD Towson Orthopaedic Associates 3 Joints, 1 Articulation 1. Sternoclavicular 2. Acromioclavicular 3. Glenohumeral 4. Scapulothoracic AC Separation Bony Landmarks 1. Suprasternal notch 2. Sternoclavicular joint 3. Coracoid 4. Acromioclavicular joint 5. Acromion 6. Greater tuberosity of the humerus 7. Bicipital groove 8. Scapular spine 9. Scapular borders-vertebral and lateral Sternoclavicular Dislocation Soft Tissues 1. Rotator Cuff 2. Subacromial bursa 3. Axilla 4. Muscles: a. Sternocleidomastoid b. Pectoralis major c. Biceps d. Deltoid Congenital Absence of Pectoralis Major Pectoralis Major Rupture Soft Tissues (con’t) e. Trapezius f. Rhomboid major and minor g. Latissimus dorsi h. Serratus anterior Range of Motion: Active and Passive 1. Abduction - 90 degrees 2. Adduction - 45 degrees 3. Extension - 45 degrees 4. Flexion - 180 degrees 5. Internal rotation – 90 degrees 6. External rotation – 45 degrees Muscle Testing 1. Flexion a. Primary - Anterior deltoid (axillary nerve, C5) - Coracobrachialis (musculocutaneous nerve, C5/6 b. Secondary - Pectoralis major - Biceps Biceps Rupture- Longhead Muscle Testing 2. Extension a. Primary - Latissimus dorsi (thoracodorsal nerve, C6/8) - Teres major (lower subscapular nerve, C5/6) - Posterior deltoid (axillary nerve, C5/6) b. Secondary - Teres minor - Triceps Abduction Primary a. Middle deltoid (axillary nerve, C5/6) b. Supraspinatus (suprascapular nerve, C5/6) Secondary a. Anterior and posterior deltoid b. Serratus anterior Deltoid Ruputure Axillary Nerve Palsy Adduction Primary a. Pectoralis major (medial and lateral pectoral nerves, C5-T1 b. Latissimus dorsi (thoracodorsal nerve, C6/8) Secondary a. Teres major b. Anterior deltoid External Rotation Primary a. Infraspinatus (suprascapular nerve, C5/6) b. Teres minor (axillary nerve, C5) Secondary a. Posterior deltoid Internal Rotation Primary a. Subscapularis (upper and lower subscapular nerves, C5/6) b. Pectoralis major (medial and lateral pectoral nerves, C5-T1) c. Latissimus dorsi (thorasodorsal nerve, C6/8) d. Teres major (lower subscapular nerve, C5/6) Secondary a. Anterior deltoid Scapular Elevation (Shrug) Primary a. Trapezius (spinal accessory nerve, CN X1) b. Levator scapulae (C3, C4, dorsal scapular nerve) Secondary a. Rhomboid major b. Rhomboid minor Spinal Accessory Nerve Palsy Scapular Retration (Attention) Primary a. Rhomboid major (dorsal scapular nerve, C5) b. Rhomboid minor (dorsal scapular nerve, C5) Secondary a. Trapezius Winged Scapula Scapular Protraction (Reaching) Primary a. Serratus anterior (long thoracic neer, C5/7) Reflex Testing Cervical Spine Sensation Testing C4-Neck C5-Shoulder C6-Lateral forearm , thumb and index fingers C7-Middle finger C8-Medial forearm, small and ring fingers T1-Medial arm T2-Axilla Related Areas 1. Cervical spine 2. Cardiac 3. Thoracic outlet Thoracic Outlet Syndrome Special Tests 1. Impingement sign 2. Drop-arm test 3. Apprehension test 4. Sulcus sign Sulcus Sign Elbow Anatomy Bruce S. Wolock, MD HUMERUS lateral epicondyle capitellum coronoid fossa trochlea olecranon fossa anterior view medial epicondyle posterior view RADIUS head tuberosity neck head ULNA coronoid olecranon process process shaft radial notch Ligaments Medial Annular Lateral Ulnar Collateral Collateral medial collateral (medial epicondyle to ulna) lateral ulnar collateral (lat. epicondyle to ulna) annular (lateral epicondyle, around radius, to ulna) 5 MUSCLES ORIGINATE FROM MEDIAL EPICONDYLE pronator teres fcr pl fds fcu 5 MUSCLES ARISE FROM LATERAL EPICONDYLE 5 Muscles Have More Proximal Humeral Origins 1 5 2 3 4 NAME THE 15 MUSCLES CROSSING THE ELBOW 5 originate on lateral epicondyle 5 originate on medial epicondyle 2 originate on lateral supracondylar ridge 1 originates on scapula & posterior humeral shaft 5 1 originates on scapula & anterior humeral shaft 1 originates on anterior humeral shaft ANOMALOUS MUSCLE CROSSING ELBOW medial epicondyle to ulna: anconeus epitrochlearis (rare) Elbow Cross-Sectional Anatomy Viewing from new perspectives aids understanding Goal: conceptualize the anatomy three-dimensionally For orientation: 27 You are looking at a right upper limb as if standing on tip thumb of right middle finger and looking toward shoulder Yellow line shows level of the section small middle ring finger index finger anterior finger lateral medial finger posterior For orientation: Section through midpalm thumb thenar mc muscles 47 first web muscles small anterior mc lateral medial posterior For orientation: Section through median distal radius and ulna nerve 67 ulnar radial styloid styloid anterior lateral medial posterior extensor tendons For orientation: Section through mid forearm 107 fcr ecrl fcu fdp radius anterior edc ulna lateral medial posterior ecu Section through proximal forearm and radial tuberosity 1. two forearm supinators: supinator, biceps 127 br fds 2. two branches ecrl of same radial 3. two nerve: tuberosity arteries radial nerve supplying anterior lateral medial forearm: posterior radial, ulnar Section through elbow joint 1. Useful for biceps doing pull- ups tendon 2. “small 137 head” in brachialis Latin trochlea annular capi- ligament tellum 3. Joint responsible for ulna forearm anterior lateral medial rotation: posterior radio-ulnar joint Section through condyles of humerus 1. supinates forearm biceps 2. major 147 artery and brachialis nerve: brachial artery humerus median nerve medial epicondyle olecranon anterior 3. the “funny bone” lateral medial triceps posterior tendon ulnar nerve Section through distal humerus 1. injury causes wrist drop biceps after humeral brachialis shaft fx: 157 median radial 3. inserts nerve nerve on radius: brachio- humerus ulnar radialis nerve anterior 2. inserts lateral medial posterior on ulna: triceps The Elbow Physical Examination Bruce S. Wolock, MD History • Age, dominance, occupation, avocations • Severity, when and where • Injury (mechanism of action) • Numbness and tingling • Previous problems DO NOT FORGET NECK, SHOULDER, WRIST Physical Exam • Inspection • Palpation (bony, soft tissue) • Range of motion • Neurologic examination • Special tests Inspection: anterior Carrying angle: normally 10 degrees in men 15 degrees in women varus valgus deformity deformity Inspection: lateral Inspection • Posterior • Medial – subluxation of ulnar nerve Inspection: symmetry Bony Palpation Bony Palpation Bony Palpation Bony Palpation Soft Tissue Palpation Pronator teres FCR PL FDS Flexor carpi ulnaris Soft Tissue Palpation Anconeus ECU EDQ ECRB EDC Soft Tissue Palpation Soft Tissue Palpation TAN = tendon-artery-nerve Soft Tissue Palpation Nerves: Radial Median Ulnar check for subluxation with e/f Range of Motion • Flexion-extension at humeroulnar and humeroradial joints • Supination-pronation at radioulnar at wrist and elbow • Active and passive Range of Motion Flexion >135 Extension 0 or more compare to opposite side Pronation/supination ~80/~80 Compare to opposite side Keep elbows against flanks to block shoulder compensation MUSCLE GRADING as usual 5 Normal Gravity +Full Resistance 4 Good Gravity +Some Resistance 3 Fair Gravity 2 Poor Gravity eliminated 1 Trace Flicker, no joint movement 0 Zero No contractility Neurologic Exam: Motor • Flexion: Brachialis, biceps (musc. n., C5,C6) • Extension: Triceps (radial n., C7) • Supination: Biceps, supinator (radial n., C6) • Pronation: Pronator teres (med. n., C6), pronator quadratus (ain, C8, T1) Neuro Exam: Reflexes • Biceps - C5 • Brachioradialis – C6 • Triceps – C7 Neuro C5 Exam: Sensation C6 T1 C8 C7 Functional Motion • Functional range e/f = 30/130 – loss of flexion more disabling than loss of extension • Functional range p/s = 50/50 Ligament Stability Special Tests • Tinel sign • Tennis elbow stress • Posterolateral rotatory instability .