UPPER EXTREMITY I ○​ Orientation:

■​ Middle 2/3
●​ Convex side: anterior
TOPIC OUTLINE ●​ Concave side: posterior
■​ Lateral 1/3
I.​ Shoulder Complex ●​ Convex side: posterior
A.​ Joints ●​ Concave side: anterior
B.​ True Joints ○​ Trivia: MC fractured bone
C.​ False Joints ○​ MOI
II.​ Osseous Parts ■​ FOOSH
A.​ Clavicle ■​ FOS
B.​ Scapula ■​ Medial blow to shoulder
C.​ Humerus ○​ Displacement
III.​ True Joints ■​ Medial fragment displacement
A.​ SC Joint ●​ Def: medial fragment of the scapula is tilted
B.​ AC Joint superiorly by SCM
C.​ GH Joint ■​ Lateral fragment displacement
IV.​ False Joints ●​ Def: lateral fragment is pulled downward by
A.​ Bicipital Groove gravity & medially by pectoralis major
B.​ SA Joint ○​ Structures that pass through costoclavicular space
C.​ ST Joint (going downward & forward):
V.​ Shoulder Complex Stability ■​ Subclavian Artery
VI.​ Walls Of The Axilla ■​ Brachial plexus
VII.​ Quadrangular & Triangular Spaces ●​ Mx in complete Fracture: surgery
VIII.​ Shoulder Complex Angles ●​ Mx in incomplete Fracture: figure of 8
IX.​ Brachial Plexus bandaging
→​Scapula positioning: retraction
→​Usual muscle damaged: Pectoralis
major
SHOULDER COMPLEX
●​ Joints
○​ A total of 6 joints provide mobility to the shoulder
complex
○​ Trivia: the shoulder complex is the most mobile
complex
●​ True joints
○​ Def: joints that have bone to bone connection
○​ Glenohumeral joint ​
■​ Articulation: humeral head + glenoid fossa
■​ Type: synovial ball & socket
■​ Trivia: most important true joint
○​ Acromioclavicular joint
■​ Articulation: acromion process + lateral end of
clavicle
○​ Sternoclavicular joint
■​ Articulation: manubrium & 1st costal cartilage +
medial end of clavicle
■​ Type: saddle
■​ Trivia: only connection of shoulder complex to
the axial skeleton
●​ False joints
○​ Aka functional joints
○​ Subacromial joint
■​ Def: space below acromion process & above the
humerus
○​ Scapulothoracic joint
■​ Trivia: most important false joint with no true
arthrokinematics ●​ Scapula
■​ Scapulohumeral rhythm ratio: 2 (GH) : 1 (ST) ○​ Def: flat triangular bone of the shoulder complex
●​ Stability of the shoulder complex ○​ Loc: thoracic wall between 2nd & 7th ribs
○​ Static stability ○​ Number of borders: 3
■​ Aka structural stability ○​ Number of angles: 3
■​ Degree of stability: less stable ○​ Vertebral levels
■​ Provider of stability: SC joint ■​ T2 = Superior angle
○​ Dynamic stability ■​ T3 = Spine of scapula
■​ Degree of stability: more stable ■​ T7 = Inferior angle
■​ Provider of stability: RC muscles ○​ Parts
■​ Acromion process
OSSEOUS PARTS ●​ Aka summit of the shoulder
●​ Orientation: PLS
●​ Clavicle ●​ Types
○​ Def: Long slender bone that lies horizontally at root →​Type I: Flat
of neck →​Type II: Curved
○​ Type of articulation with acromion: Plane joint →​Type III: Hooked
○​ Type of articulation with sternum: saddle joint
 ■​Associated with impingement
syndrome
■​Painful arc: 60-120°
→​Type IV: upturned; least common

■​ Coracoid process
●​ Orientation: anterosuperior
●​ Coracoacromial ligament
→​Articulation: coracoid to acromion
→​Fxn: prevents posterior humeral
translation
■​ Spine of scapula
●​ Def: extension of acromion process medially TRUE JOINTS OF THE SHOULDER GIRDLE
●​ Fxn: used to located supraspinous &
infraspinous fossa ●​ Sternoclavicular joint
●​ Structures ○​ Type: saddle or sellar
→​Above: Supraspinous fossa ○​ Shape: ovoid
→​Below: Infraspinous fossa ○​ Articulation: medial clavicle + manubriosternal area
→​Anterior: Subscapular fossa ○​ Ligamentso
■​ Glenoid fossa ■​ Interclavicular Ligament
●​ Def: shallow cavity of the scapula ●​ Prevents depression of clavicle
●​ Glenoid labrum ●​ Protects subclavian artery & brachial plexus
→​Fxn: enhances depth of fossa by 50% ■​ Costoclavicular Ligament
●​ Prevents excessive elevation of clavicle
●​ Counterpart to Interclavicular Ligament
HUMERUS ■​ Sternoclavicular Ligament
●​ Anterior SCL: prevents retraction
●​ Proximal humerus
●​ Posterior SCL: prevents protraction
○​ Humeral head
○​ Accessory structures
■​ Def: forms 1/2 of a sphere
■​ SC disc
■​ Loc: intracapsular
●​ Fxns: shock absorption & hinge & pivot
○​ Anatomical neck
mechanism of arm
■​ Def: end attachment of shoulder joint capsule
●​ Mechanisms:
○​ Surgical neck
→​Elevation & depression: disc becomes
■​ Def: site of fracture or damage of the axillary
part of the sternum (mnemonic: EDS)
nerve
→​Protraction & retraction: disc becomes
●​ Leading to: deltoid & teres minor weakness
part of the clavicle (mnemonic: PRC)
○​ Kinematics
QUESTION ■​ DOF: 3
●​ Elevation-depression
What is the swallow tail sign? ●​ Protraction-retraction
●​ Posterior longitudinal rotation
Inability to extend both UEs symmetrically 2°
posterior deltoid weakness ■​ Axes: 3
■​ Contributions​
●​ To elevation: contributes ≤90°
○​ Tuberosities ●​ To posterior rotation: contributes ≥90°
■​ Greater tuberosity ●​ Limit of arm elevation in (-) posterior
●​ Loc: lateral rotation of SC: up to 110° only
●​ Palpation technique: IR
●​ Attached muscles: SIT
■​ Lesser tuberosity
●​ Loc: medial
●​ Palpation technique: ER
●​ Attached muscles: subscapularis
○​ Spiral groove
■​ Aka radial groove, musculospiral nerve passway,
radial nerve passway
■​ Def: site of humeral fracture where radial nerve ●​ Acromioclavicular joint
can be damaged ○​ Type: synovial plane
●​ Leading to wrist & finger extensor ○​ Articulation: Lateral end of clavicle + acromion
affectation process
●​ Spared muscle: long head of triceps ○​ Step Deformity
■​ Def: torn AC ligament
 ●​ Glenohumeral joint
○​ Type; Synovial ball & socket joint/Universal joint
○​ Articulation: humeral head & glenoid fossa
■​ Orientation of the humeral head: MPS
■​ Orientation of the glenoid fossa: SAL
○​ Angle of Inclination​
■​ Def: formed by axis of humeral head & neck +
axis of humeral shaft
■​ N: 130-150°
○​ Angle of Torsion
■​ Def: formed by axis of humeral head & neck +
axis of humeral condyles
■​ N: approximately 30° of retrotorsion
○​ Coracohumeral Ligament
■​ Articulation: coracoid process to greater & lesser
tubercle
■​ Fxn:
●​ Limits excessive ER
●​ Prevents downward translation of humerus
■​ Greatly involved with AdCap & DM
■​ Capsular pattern of SH: ERABIR
○​ Glenohumeral Ligament
■​ Fxn Limits excessive ER
■​ Common Direction of Shoulder Dislocation:
○​ Acromioclavicular Ligaments
anteroinferior
■​ Superior: primary force that prevents inferior
●​ Contraindicated movement after A-I
translation of clavicle
dislocation: ABER/D2 flexion
■​ Inferior: secondary force that prevents superior
■​ Divisions
translation of clavicle
●​ Superior: limits ER at 0-45°
○​ Coracoclavicular Ligament
●​ Middle: limits ER at 45-90°
■​ Conoid & trapezoid ligament
●​ Inferior: limits ER at >90°
●​ Articulation: coracoid + clavicle
●​ Conoid
→​Shape: triangular
→​Fibers: post, med, vertical fibers
→​Fxn: primarily prevents superior
translation of clavicle
●​ Trapezoid
→​Shape: Quadrangular
→​Fibers: ant, lat, horizontal fibers
→​Fxn: prevents medial displacement of
scapula

■​ Foramina
●​ Foramen of Weitbrecht
→​Loc: between superior & middle
●​ Foramen of Rouvier
→​Loc: between middle & inferior
●​ MC site of dislocation: Weitbrecht
○​ Kinematics
■​ DOF: 3
■​ Axes: 3
○​ Accessory Structures
■​ Acromioclavicular Disc
●​ Trivia as to mobility: not as mobile as SC
disc
●​ Changes
→​<2 years old: (+) Fibrocartilaginous
union
→​>2 years old: meniscoid
fibrocartilaginous remnant
■​ Kinematics
●​ DOF: 3
●​ Axes: 3
■​ Curvatures for movement:
●​ ER/IR: horizontal curvature
●​ Anterior/Posterior: vertical curvature
■​ Contributions
●​ Upward Rotation
●​ Posterior tilting of scapula
 FALSE JOINTS
●​ Bicipital groove
○​ Aka intertubercular groove
■​ Boundaries
●​ Medial: teres major
●​ Lateral: pectoralis major
●​ Roof: latissimus dorsi
●​ Floor: transverse humeral ligament
●​ Subacromial joint
○​ Aka supraspinatus outlet, suprahumeral joint
○​ Places the supraspinatus at risk in malfunction
○​ Acromiohumeral interval
■​ During arms at side: 10 mm
■​ During arm elevation: 5 mm
○​ Subacromial bursa
■​ Fxn: prevents excessive friction at SA joint
■​ May lead to SA bursitis QUADRANGULAR & TRIANGULAR SPACES
■​ Differential diagnoses ●​ Quadrangular space
●​ Impingement syndrome ○​ Superior border: teres minor
●​ AC joint sprain ○​ Inferior border: teres major
■​ 1° manifestation: anterior shoulder pain ○​ Medial border: long head of triceps
●​ Scapulothoracic joint ○​ Lateral border: humerus
○​ Def: after 30° of arm abduction, a 2:1 rotation ○​ Contents
between the GH & ST joint occurs ■​ Posterior circumflex artery
○​ Phases ■​ Humeral artery
■​ Phase 1 ■​ Axillary nerve
●​ Humerus: 30° abduction ●​ Triangular space
●​ Scapula: setting phase ○​ Superior border: teres minor
●​ Clavicle: 0-5° elevation ○​ Inferior border: teres major
■​ Phase 2 ○​ Medial border: none
●​ Humerus: 40° abduction ○​ Lateral border: long head of triceps
●​ Scapula: 20° upward rotation ○​ Contents
●​ Clavicle: 15° elevation ■​ Circumflex scapular artery
■​ Phase 3
●​ Humerus: 60° abduction
●​ Scapula: 30° upward rotation
●​ Clavicle: posterior rotation

STABILITY
●​ Static Stability
○​ Negative intraarticular p°
■​ In the event of positive pressure → unstable GH
joint
●​ Treatment: surgery
○​ Upward tilt of fossa provides bony block against
inferior translation
○​ Passive tension from ligaments
●​ Dynamic Stability
○​ Force Couple
■​ Def: two opposing forces create rotation
○​ Positive Translatory Force ANGLES
■​ Direction: upward
■​ Large positive translatory & small rotary forces:: ●​ Angle of inclination
Deltoids & GH stabilization ○​ Def: Formed by axis of humeral head & neck + axis of
■​ Small Positive Translatory forces: supraspinatus humeral shaft
& GH joint ○​ Normal angle: 130 - 150°
○​ Negative Translatory Force​
■​ Direction: downward
■​ Rotator Cuff & GH stability: SIT muscle

WALLS OF THE AXILLA

●​ Anterior: Pectoralis Major & Minor, Subclavious mm
(PecPecSub)
●​ Posterior: Subscapularis, Latissimus dorsi, Teres major
(SuLaTeMa)
●​ Lateral: Biceps long head in bicipital groove,
Coracobrachialis (BiBico)
●​ Medial: Ribs 2-6 + Serratus Anterior
●​ Angle of Torsion ○​ Axillary: C5 C6 (ASSASINATION)
○​ Def: Formed by axis of humeral head & neck +
humeral condyles
○​ Best viewed in Superior view
○​ Normal: approximately 30° of retrotorsion

○​ Median: C5-T1 (5 MICE)

BRACHIAL PLEXUS

●​ Origin: ant rami of C5 - T1

●​ Code: RoTonDaCuBao
●​ # of Branches: 16

○​ Radial: C5 - T1 (5 RATS)

●​ Trivias
○​ Radical Mastectomy leads to long thoracic nerve
injury
○​ Radial Neck Dissection leads to CN 11 injury
○​ Largest branch is the Radial Nerve because it
supplies majority post arm & forearm
●​ Branches:
○​ Musculocutaneous: C5 C6 C7 (3 MUSKETEERS)

○​ Ulnar: C8 T1 (2 UNICORN)
 UPPER EXTREMITY II CUBITAL FOSSA
●​ Contents from lateral to medial (mnemonic: Be Right There
TOPIC OUTLINE Always My PT)
○​ Brachialis
I.​ Elbow Complex ○​ Radial nerve
A.​ Bones ○​ Tendon of biceps
B.​ Joints ○​ Brachial artery
C.​ Cubital Fossa ○​ Median nerve
D.​ Carrying Angle ○​ Pronator teres
E.​ Muscles
II.​ Forearm Complex
A.​ Joints
B.​ Muscles
III.​ Wrist complex
A.​ Carpal bones
B.​ Joints
IV.​ Hand
A.​ Joints
B.​ Arches
V.​ Important Landmarks
A.​ Carpal Tunnel
B.​ Flexor Zones
C.​ Extensor Hood Mechanism
D.​ Extensor Tunnels
E.​ Anatomical Pulleys
F.​ Anatomic Snuffbox

ELBOW COMPLEX
CARRYING ANGLE
●​ Trochlea
○​ Def: hourglass projection ●​ Carrying angle
○​ Articulates with ulna via the trochlear notch ○​ Def: lateral angulation of the elbow
●​ Capitulum ○​ Formed by longitudinal axis of humerus shaft & ulna
○​ Def: spherical projection ○​ Present components
○​ Articulates with radius via radial fovea ■​ Elbow: extension
■​ FA: supination
○​ Absent components
■​ Elbow: flexion beyond 30
■​ FA: pronation
○​ Normal values
■​ Males: 5-10°
■​ Females: 10-15°
■​ If ≤5°: cubitus varus
■​ If ≥5°: cubitus valgus
■​ If -15°: gunstock deformity

●​ Medial collateral ligament

○​ Fxn: prevents excessive valgus stress
○​ Fibers
■​ Anterior fibers limit extension
■​ Posterior fibers limit flexion
○​ Deformity prevented: subluxation at HU articulation
●​ Lateral collateral ligament
○​ Fxn prevents excessive varus stress
○​ Deformity prevented: subluxation at HU articulation
○​ Structure stabilized: radial head at HR articulation FLEXOR MUSCLES OF THE ELBOW
●​ Humeroulnar joint
●​ Brachialis
○​ Type: modified hinge
○​ Aka chief elbow flexor
○​ Articulation: trochlea & trochlear notch
○​ OINA
○​ 1° ligament: anterior MCL
■​ O: anterior midshaft of humerus
●​ Humeroradial joint
■​ I: coronoid process or ulnar tuberosity
○​ Type: modified hinge
■​ N: musculocutaneous
○​ Articulation: capitulum & radial fóvea
■​ A: elbow flexion & pronation
○​ 1° ligament: radial LCL
○​ Spurt muscle
●​ Biceps brachii ●​ Taut: FA in neutral
○​ Aka strongest flexor & supinator ●​ Slack: supination or pronation
○​ OINA ●​ Fxns
■​ O: →​Muscle attachment
●​ Long head: supraglenoid tubercle →​Protects FA bones from injury via shock
●​ Short head: coracoid process absorption
■​ I: bicipital tuberosity ●​ Distal radioulnar joint
■​ N: musculocutaneous ○​ Type: pivot/trochoid
■​ A: ○​ Articulation: ulnar head & ulnar notch
●​ Shoulder: weak flexion ○​ Kinematics: pronation & supination
●​ Elbow: flexion ○​ Ligaments
●​ FA: supination ■​ Radioulnar ligament
○​ Spurt muscle ●​ Fxn: prevents volar & distal diastasis
●​ Brachioradialis
○​ Aka longest elbow flexor
○​ OINA FOREARM ROTATORS
■​ O: lateral supracondylar ridge ●​ Supinator
■​ I: proximal to radial styloid process ○​ Effectiveness in elbow flexed to 90°: 4x as effective
■​ N: radial nerve ○​ Effectiveness in elbow extended to 90°: 2x as
■​ A: positioning FA to midposition effective
○​ To isolate: perform terminal elbow flexion
EXTENSOR MUSCLES OF THE ELBOW ●​ Pronator
○​ Pronator teres
●​ Triceps brachii ○​ Pronator quadratus
○​ OINA ■​ Aka chief FA pronator
■​ O ○​ Stronger pronator: PT
●​ Long head: infraglenoid tubercle
●​ Short & lateral head: posterior humeral
shaft WRIST COMPLEX
■​ I: olecranon process ●​ Carpal bones (Mnemonic: Scared Lovers Try Positions That
■​ N: radial nerve They Cannot Handle)
■​ A: ○​ Proximal bones
●​ Shoulder: flexion ■​ Scaphoid
●​ Elbow: extension ■​ Lunate
○​ Heads ■​ Triquetrum
■​ Long head is prone to insufficiency ■​ Pisiform
■​ Lateral head is the strongest head ○​ Distal bones
■​ Short head is active regardless of resistance ■​ Trapezium
●​ Anconeus ■​ Trapezoid
○​ 1° fxn: assist elbow extension & stabilizes FA in ■​ Capitate
rotation ■​ Hamate
○​ OINA ●​ Ossification of carpal bones (Mnemonic: Come Home Try
■​ O: lateral epicondyle Luneta Taradun Sa Pilipinas)
■​ I: lateral olecranon ○​ Capitate
■​ N: radial nerve ○​ Hamate
■​ A: assist elbow extension ○​ Triquetrum
○​ Lunate
FOREARM COMPLEX ○​ Trapezoid
○​ Scaphoid
●​ Proximal radioulnar joint ○​ Pisiform
○​ Type: pivot/trochoid ●​ Scaphoid
○​ Articulation: radial head & notch ○​ Aka navicular
○​ Kinematics: pronation & supination ○​ In the anatomic snuffbox: floor
○​ Ligaments ○​ In terms of fracture: MC fractured carpal
■​ Annular ligament ○​ In terms of mobility: most mobile carpal
●​ Def: a 4/5 of a ring ligamentous support for ○​ Manifests at: 1-2 weeks
the radial head & PRU articulation ○​ Associated with:
●​ Nursemaid’s elbow ■​ Swelling of anatomic snuffbox
→​Aka pulled elbow ■​ Preiser’s disease (AVN of scaphoid)
→​Def: subluxation of radial head from ○​ Boundaries
annular ligament ■​ Lateral: APL & EPB
→​Position ■​ Medial EPL
■​Elbow: extended ○​ Nerve content: radial artery
■​FA: pronated ●​ Lunate
■​ Quadrate ligament ○​ In terms of dislocation: MC dislocated carpal
●​ Fxns ■​ Complications
→​Limits radial spin ●​ Anterior dislocation
→​Maintains radial head up radial notch ●​ CTS & (+) Murphy’s sign 2° compression of
→​Reinforces capsule median nerve at carpal tunnel
■​ Oblique cord ○​ Causes of CTS
●​ Fxn: limit to supination & offer major ■​ Lunate dislocation
stabilization to PRU joint ■​ Pregnancy
■​ Interosseus membrane ■​ Faulty biomechanics
●​ Def: provides stability for superior & inferior
radioulnar joints
 ○​ Palpation site: distal to lister’s tubercle with the wrist
flexed CARPAL TUNNEL
○​ Kienbock’s disease: AVN of lunate ●​ Carpal tunnel contents
○​ Burn’s disease: AVN of distal lunate ○​ 10 in total
●​ Triquetrum ■​ 4 FDP tendons for light hand closure
○​ Aka bed of pisiform ■​ 4 FDS tendons for forceful hand closure
○​ Ossification order: 3rd ■​ 1 FPL tendon
●​ Pisiform ■​ 1 median nerve
○​ Aka smallest carpal
○​ Bone classification: sesamoid bone
○​ Trivia: does not participate in wrist articulation
●​ Trapezium
○​ Aka greater multangular
○​ Articulated with 1st CMC joint
○​ In terms of position: most lateral
●​ Trapezoid
○​ Aka lesser multangular
○​ In terms of size: 2nd smallest carpal
●​ Capitate
○​ Aka os magnum
○​ Ossification order: first
●​ Hamate
○​ Aka unciform
○​ Pisohamate ligament
■​ Forms the Guyon’s canal
■​ Passageway of ulnar nerve

WRIST JOINTS

●​ Radiocarpal joint
FLEXOR ZONES OF THE HAND
○​ Type: condyloid/ellipsoid
○​ Articulation: distal radius + scaphoid, lunate, & ●​ Flexor zones
triquetrum ○​ Zone I
○​ DOF: 2 ■​ Hallmark: FDP
○​ 1° ligament: radiocarpal ligament ■​ If damaged
●​ Midcarpal joint ●​ Lost fxns: DIP flexion
○​ Type: plane ●​ Clinical sign: Sweater finger & jersey finger
○​ Articulation: proximal & distal carpals sign
○​ DOF: 2 ○​ Zone II
○​ 1° ligament: transverse carpal ligament ■​ Hallmark: FDS
●​ Components of radial deviation ■​ Aka no man’s land
○​ Proximal carpal: ulnar glide & flexion ■​ If damaged
○​ Distal carpal: extension ●​ Lost fxns: DIP & PIP flexion
●​ Clinical sign: Fibrous lacertus damage
○​ Zone III
HAND JOINTS
■​ Hallmark: neck of metacarpals
●​ 2nd to 5th CMC ■​ If damaged
○​ Type: plane joint ●​ Lost fxns: finger flexion & extrinsic plus
●​ 1st CMC position
○​ Type: saddle/sellar ○​ Zone IV
○​ Articulation: trapezium + 1st MCP ■​ Hallmark: carpal tunnel
○​ Kinematics ○​ Zone V
■​ Flexion-extension: same glide ■​ Hallmark: area proximal to wrist
■​ Abduction-adduction: opposite glide ■​ If damaged
●​ Lost fxns: wrist flexion

ARCHES OF THE HAND

●​ Proximal transverse
○​ Keystone: capitate
●​ Distal transverse
○​ Keystone: middle finger
●​ Longitudinal arch
○​ Loc: between 2nd & 3rd finger
 EXTENSOR HOOD MECHANISM
●​ Extensor digitorum communis
○​ Aka 1° muscle for finger extension
○​ Action if alone: MCP hyperextension
○​ Typically assists lumbricals & interossei

ANATOMIC SNUFFBOX

●​ Anatomic snuffbox
○​ Aka foveola radialis
○​ Anterior or radial border: APL & EPB
○​ Posterior or ulnar border: EPL
○​ Floor: scaphoid & trapezium
○​ Content: radial artery

EXTENSOR TUNNELS

●​ Tunnel I: APL & EPB

●​ Tunnel II: ECRL & ECRB
●​ Tunnel III: EPL
●​ Tunnel IV: EI & EDC
●​ Tunnel V: EDM
●​ Tunnel VI: ECU
●​ Last muscle to recover in injury: extensor indicis
●​ In ulnar nerve injury, last muscle to recover: adductor
pollicis

ANATOMICAL & CRUCIFORM PULLEYS

●​ Anatomical Pulleys & Cruciform Pulleys
○​ Fxn: prevention of bowstringing of flexor tendons
●​ Digital tendon sheath
○​ Fxn: mechanical lock of finger flexor tendon
●​ A1
○​ Associated with trigger finger
○​ Fxn: mechanical locking
○​ MC fingers affected: 3rd & 4th
●​ A3 & A4
○​ Associated with RA
●​ A1 & A2
○​ Associated with MCP
●​ A3
○​ Associated with PIP
●​ A4 & A5
○​ Associated with DIP
 UPPER EXTREMITY ●​ AC jt sprain
○​ Affected ligaments: AC + CC
CONDITIONS ○​ MOI: direct trauma to shoulder or AC
○​ Manifestation
■​ Shoulder separation 2°:
TOPIC OUTLINE ●​ Step deformity
●​ Point tenderness
I.​ Clavicular Conditions ○​ ST
II.​ Scapular Conditions ■​ O’Brien test
III.​ Shoulder Conditions ●​ Sig: AC pathology of SLAP II Lesion
A.​ Dislocation ■​ Horizontal Adduction Test
B.​ SLAP Lesion ●​ Aka adduction test, crossbody test, AC
C.​ Impingement crossover test, apley’s scarf test
D.​ Tendinitis ●​ Sig: AC/SC pathology
E.​ Adhesive Capsulitis ○​ Painful arc
F.​ TOS ■​ at 0-60°: typically painless; LOM may be d/t
G.​ CRPS muscle tear or shoulder dislocation
IV.​ Nerve Entrapments ■​ at 60-120°: GH pathology (e.g., impingement or
A.​ Radial Nerve tendinitis)
B.​ Ulnar Nerve ■​ at 90-130°: shoulder impingement (bursal,
C.​ Median Nerve superior aspect of RCT, or biceps tendon
D.​ Axillary Nerve impingement)
E.​ Suprascapular Nerve ■​ at 120-170°: typically painless
V.​ Elbow ■​ at 170-180°: AC pathology (typically last 30° or
A.​ Epicondylitis towards ROMEs)
B.​ Pulled vs Pushed Elbow ○​ Rockwood Classification of Ligamentous Sprain
C.​ Little Leaguer’s Elbow ■​ RC I
D.​ Olecranon Bursitis ●​ Hallmark: ligament stretched
E.​ Myositis Ossificans ●​ Ligament status
F.​ Boxer’s Elbow →​AC: sprained
G.​ Volkmann’s Ischemic Contracture →​CC: intact
H.​ Panner’s Disease ■​ RC II
I.​ AVN ●​ Hallmark: partial rupture of AC ligaments
VI.​ Wrist & Hand ●​ Ligament status
A.​ CTS →​AC: torn
B.​ Fracture →​CC: sprained
C.​ Deformities ●​ CC space: ↑'d by 25%
VII.​ Congenital Anomalies ■​ RC III
●​ Hallmark: complete rupture of AC & CC
●​ Ligament status
CLAVICULAR CONDITIONS →​AC: torn
→​CC: torn
●​ SC joint dislocation ●​ CC space: CC space ↑'d by 20-100%
○​ Frequency: accounts for less than 1% of all ●​ Step deformity: (+)
dislocations ■​ RC IV
○​ Anterior dislocation ●​ Hallmark: posterior translation of clavicle
■​ Commonality: MC; 2/3 of all cases ●​ Step deformity: (+)
■​ MOI: direct trauma ■​ RC V
■​ Hallmark: protrusion of medial clavicle ●​ Hallmark: clavicle displaced under skin
○​ Posterior dislocation ●​ CC space: CC space ↑'d >100%
■​ Def: more severe & painful ●​ Imaging: (+) deltotrapezial fascia tear
■​ Manifestations ●​ Step deformity: (+)
●​ Vascular problems ■​ RC VI
●​ Breathing & swallowing issues ●​ Hallmark: inferior translation of clavicle
●​ Clavicular fracture under coracoid process
○​ MOI: FOOSH ●​ Step deformity: (+)
○​ Age: ≤25
○​ Commonality of fracture based on part:
■​ Middle 1/3 of clavicle: 80%
■​ Lateral 1/3 of clavicle: 15%
■​ Medial 1/3 of clavicle: 5%
○​ Fracture of the middle 1/3 of clavicle
■​ Specific site of fracture: between junction of
middle & lateral clavicle
■​ Displaced clavicular fracture
●​ Has (+) 15-20 mm muscle shortening 2°
displacement
●​ Skin tenting
→​Def: Elevated clavicle where the
fractured segment moves forward
●​ MC complication: infection
■​ Management
●​ If non-displaced: immobilization with sling
supported by F8 bandaging
●​ If displaced: surgery
 SCAPULAR CONDITIONS SHOULDER CONDITIONS

●​ Sprengel's deformity ●​ MC dislocation directions (mnemonic: SAPAPALP)

○​ Aka Eulenberg syndrome ○​ AC: superior
○​ Def: failure of scapula to develop & descend ○​ SC & GH: anteroinferior
○​ PE: high & undescended scapula ○​ Elbow: posterolateral
○​ Trivia: MC congenital deformity of shoulder ○​ Lunate: anterior
○​ Manifestations ○​ Hip: posterior
■​ Shoulders: asymmetric ○​ Knee: anterior
■​ Neck: short appearing ○​ Patella: lateral
■​ Scapular: smaller than normal & in IR ○​ Ankle: posterior
■​ LOM: abduction ●​ Anterior shoulder dislocation
○​ MOI: ABER
○​ Contraindicated movement: ABER/D2 Flexion
○​ Complications
■​ Axillary nerve traction
●​ Aka circumflex nerve
●​ Def: MC nerve injury associated with
shoulder dislocation
■​ Bankart Lesion
●​ trivia: MC lesion associated with anterior
shoulder dislocation
●​ Def: lesion at the anteroinferior labrum
(mnemonic: BankAI)
■​ Hill-Sachs Lesion
●​ Def: compression of the posterolateral
aspect of humeral head
●​ Other causes
→​Avulsion of greater tuberosity
→​Proximal humeral fracture
●​ Posterior shoulder dislocation
○​ MOI: FOOSH/FADIR
○​ Associated injuries
■​ Lesser tubercle fracture
●​ Snapping scapula ■​ Bennett’s lesion (ossification of posteroinferior
○​ Aka scapulothoracic scapula glenoid rim)
○​ Def: scapula rubs over underlying ribs ■​ Reverse bankart lesion (posteroinferior labral
○​ Types of sound lesion)
■​ Gentle friction: normal crepitus ■​ Reverse hill-sachs lesion: compression fracture
■​ Louder grating: bursitis, atrophy, fibrosis, or of anteromedial aspect of humeral head
anomalous muscular insertion ●​ SLAP Lesion
■​ Loud snapping: tumor, osteophyte formation, or ○​ Def: lesion at the site where bicep tendon anchors to
malunion of rib fracture the labrum
●​ Scapular winging ○​ MOI:
○​ Medial winging ■​ FOOSH
■​ Aka open book ■​ Sudden biceps traction
■​ Affected muscle: serratus anterior ○​ Type II SLAP lesion
■​ Affected nerve: LTN ■​ Phase of throwing: late cocking phase since
■​ Cause: radical mastectomy or rucksack palsy there is max ER
■​ To elicit: pushup, punchout, or protraction ■​ Common population: pitchers
○​ Lateral winging ○​ Types
■​ Aka sliding door ■​ I: labrum fraying
■​ Affected muscle: trapezius ■​ II: partial labral tear (MC)
■​ Affected nerve: CN 11 ■​ III: bucket handle tear
■​ Cause: radical neck dissection ■​ IV: extension of lesion of biceps tendon
■​ To elicit: slight abduction ≥90° ■​ V: bankart & biceps tendon lesion
■​ VI: unstable separation of biceps tendon
■​ VII: extension of lesion to middle GH ligament
○​ Snyder classification
■​ Snyder I
●​ Labrum: fraying
●​ Biceps tendon: intact
■​ Snyder II
●​ Labrum: fraying
●​ Biceps tendon: detached
■​ Snyder III
●​ Labrum: bucket handle tear
●​ SICK scapula ●​ Biceps tendon: intact
○​ Scapular IR & forward malposition ■​ Snyder IV
○​ Inferomedial border prominence ●​ Labrum: bucket handle tear
○​ Coracoid pain ●​ Biceps tendon: detached
○​ Dyskinesia ■​ Snyder V
●​ Hallmark: bankart lesion
■​ Snyder VI
●​ Hallmark: unstable flap
 ■​ Snyder VII ○​ Special tests
●​ Hallmark: middle GH ligament injury ■​ To test for supraspinatus tendinosis:
○​ Surgical procedures hawkins-kennedy/neer’s/yocum
■​ Bankart surgery ■​ To test for supraspinatus rupture: empty can test
●​ Def: reparation of labrum via reattachment ■​ To test for rotator cuff rupture: drop arm test
●​ Trivia: MC surgical procedure ■​ Neer’s stage of supraspinatus tendinitis
●​ Clinical pearl: pt should wear a sling for 4 ●​ Neer Stage I: edema/hemorrhage/
weeks inflammation
■​ Magnuson-Stack ●​ Neer Stage II: fibrosis or tendinitis
●​ Def: subscapularis tendon is removed from ●​ Neer Stage III: osteophyte formation +
its insertion & transferred to the greater partial tear
tuberosity ●​ Neer Stage IV: multiple tendon tears
●​ Cons ●​ Bicipital tendinitis
→​Tightens subscapularis in to IR ○​ Def: inflammation of biceps tendon in the bicipital
→​Lessens ROM but ↑'s stability groove
●​ Clinical pearl: avoid ER ○​ Trivia: 2nd MC cause of anterior shoulder pain
■​ Putti-platt ○​ Causes
●​ Def: tendons are transferred from lesser ■​ Overuse such as those in weight lifters
tuberosity to glenoid rim ■​ Ligamentous laxity
●​ Cons ○​ Associated sign: popeye’s sign → biceps tendon
→​Tightens subscapularis in to IR rupture
→​Lessens ROM but ↑'s stability ○​ Special tests
→​Motion loss: ER > Ab > IR ■​ Test for bicipital tendonitis: speed’s test
●​ Shoulder impingement ■​ Test for biceps tendon tear: ludington’s test
○​ Tendinitis vs tendonitis vs tenosynovitis vs ■​ Test for integrity of transverse humeral ligament:
tenovaginitis yergasons
■​ Tendinitis: Tendon inflammation. ●​ Calcific tendinitis
■​ Tendinosis: Tendon degeneration ○​ Def: deposition of hydroxyapatite (crystalline Ca++
■​ Tenosynovitis: Inflammation of synovial phosphate) in the tendons of the RC
membrane covering tendon ○​ Cause: unknown
■​ Tenovaginitis: Thickening of tendon sheath ○​ Manifestation: pain & inflammation
○​ MC site of impingement: subacromial tendonitis ○​ Sites
○​ Primary impingement ■​ 80%: supraspinatus tendon
■​ Def: impingement where the actual ■​ 15: infraspinatus tendon
impingement is the cause of pain (has an ■​ 5%: subscapularis tendon
anatomical source of pain) ●​ Frozen shoulder
●​ Typically due to ○​ Aka adhesive capsulitis or diabetic periarthritis
→​Type III acromion ○​ Sex affectation: F > M
→​Thickened coracoacromial ligament ○​ Age: 40-60 yo
○​ Secondary impingement ○​ Causes (mnemonic: DIRATI)
■​ Def: impingement where the cause is typically 2° ■​ Diabetes
underlying disease ■​ Immobilization
■​ Trivia: more common than 1° impingement ■​ Recent strain
■​ Common causes ■​ Arthritis
●​ GH instability ■​ Trauma
●​ Scapular dyskinesis ■​ Idiopathic
●​ Weak scapular stabilizers ○​ Capsular patterns: ER > Ab > IR
○​ Special test: Apley’s scratch test
○​ Management
QUESTION
■​ Pendulum
What is the MC cause of anterior shoulder pain? ■​ Codman’s exercise
■​ Sperry’s exercise
Thickened coracoacromial ligament ○​ X-ray: normal
○​ Stages
■​ FS Stage I
●​ RC tendonitis
○​ Causes ●​ Aka pre-adhesive stage
■​ Anatomical ●​ Degree of pain: discomfort
●​ LOM: (-)
●​ Such as os acromiale which is the failure of
the acromion to ossify ●​ Duration: 1-3 months
■​ Trauma or overuse ■​ FS Stage II
●​ Aka freezing
●​ MC in throwers & swimmers in the FIR
position ●​ Degree of pain: most painful stage
●​ Also common in repetitive overhead ●​ LOM: progressive
●​ Duration: 3-9 months
activities
■​ Degeneration ■​ FS Stage III
●​ Such as in aging ●​ Aka frozen
●​ Degree of pain: ↓'d pain
○​ Supraspinatus tendinitis
■​ Aka swimmer’s shoulder ●​ LOM: most restricted
■​ Def: degeneration of the hypovascular ●​ Duration: 9-15 months
supraspinatus tendon under the acromion ■​ FS Stage IV
■​ MC causative swimming style: freestyle + ●​ Aka thawing
●​ Degree of pain: (-)
butterfly
○​ Acromiohumeral interval ●​ LOM: ↓'d LOM
■​ N interval: 7-14 mm ●​ Duration: 15-24 months
■​ Possible complications if <N: rotator cuff tear
●​ Thoracic outlet syndrome →​Hypertrichosis (accelerated hair
○​ Def: compression of the subclavian artery & the growth)
brachial plexus (C8 to T1) ■​ Stage II
○​ Sites of compression ●​ Aka dystrophic
■​ Compression between scalenes leads to scalenus ●​ Duration: 1-2 years
anticus syndrome ●​ Edema: brawny
■​ Compression between coracoid process & ●​ Degree of osteoporosis: diffused
pectoralis minor leads to hyperabduction ●​ Temperature: cool
syndrome ●​ Color of extremity, skin, & nails: mottled
■​ Compression between clavicle & first rib leads to cyanotic
costoclavicular syndrome ●​ Atrophy: intrinsic muscles
○​ Ssx ●​ Other findings
■​ Weakness →​Hyperhidrosis
■​ Pulselessness →​Nail bed changes
■​ Paresthesia →​Bone demineralization
○​ Special tests ■​ Stage III
■​ Costoclavicular brace test or military brace test ●​ Aka atrophic
■​ Halstead’s maneuver ●​ Duration: years
■​ Adson’s test ●​ Edema: periarticular swelling
■​ Roos test ●​ Degree of osteoporosis: generalized &
■​ Allen’s test pathologic
■​ Wright test ●​ Temperature: cool
●​ Complex regional pain syndrome ●​ Color of extremity, skin, & nails: brittle nails
○​ Other names (mnemonic: CRAP3S4) ●​ Atrophy: marked atrophy
■​ Causalgia ●​ Other findings
■​ Reflex Sympathetic Dystrophy →​Skin is shiny & thin
■​ Algoneuropathy →​Contracture formation
■​ Post-traumatic Vasospasm ■​ Stage IV
■​ Post-traumatic osteoporosis ●​ Def: stage III + burning pain, allodynia,
■​ Post-infectious Sclerodactylia analgesia, & osteoporosis
■​ Sudeck’s Atrophy
■​ Shoulder hand Syndrome
■​ Stein Bröckers Syndrome NERVE ENTRAPMENTS
■​ Sympathalgia ●​ Radial nerve
○​ Def: neuropathic pain syndrome with pain & ○​ Crutch palsy
autonomic dysfunction leading crippling contractions ■​ Site of impingement: axilla
of limb ■​ Muscle involved: triceps
○​ MC affects the distal predominant area ■​ Manifestation: wrist drop
○​ Types ○​ Spiral groove fracture
■​ Type I ■​ Muscle spared: triceps
●​ Aka RSD ○​ Radial tunnel syndrome
●​ Def: injury without specific nerve ■​ Def: impingement of PIN
involvement ■​ Spared muscles: ECRL, ECRB, & supinator
■​ Type II ■​ Sprared movement: wrist extension
●​ Aka causalgia ■​ Wrist drop: (-)
●​ Def: injury with specific nerve involvement ■​ Manifestation: lateral elbow pain
○​ Ssx (mnemonic: STAMP) ○​ Supinator syndrome
■​ Sensory ■​ Def: impingement at the arcade of frohse
●​ Allodynia ■​ Spared muscle: ECRL, ECRB, & brachioradialis
●​ Hyperalgesia ■​ Wrist drop: (-)
■​ Temperature & trophic skin changes ○​ Wartenberg syndrome
●​ Asymmetrical coolness ■​ Aka cheiralgia paresthetica or handcuff palsy
●​ Abnormal hair growth ■​ Def: impingement of the superficial branch of
●​ Brittle nails the radial nerve
■​ Autonomic ■​ Manifestation: sensory loss at the wrist
●​ Hyperhidrosis ●​ Ulnar nerve
●​ Swelling ○​ Cubital Tunnel Syndrome which manifests as
●​ Edema weakness of hypothenar muscle
■​ Motor ○​ Biker’s Palsy as a direct result of impingement at
●​ Weakness tunnel of guyon
●​ Atrophy ●​ Median nerve
■​ Pain ○​ Supracondylar process syndrome
●​ Burning pain ■​ Site of impingement: ligament of struthers
○​ Stages ■​ Affected muscle: pronator teres
■​ Stage I ○​ Pronator teres syndrome
●​ Aka acute ■​ Def: impingement of median nerve by heads of
●​ Duration: 6-12 months pronator teres
●​ Degree of edema: minimal ■​ Spared muscle: pronator teres
●​ Degree of osteoporosis: spotty ○​ Kiloh-nevin syndrome
●​ Temperature: normal to warm ■​ Def: impingement of AIN
●​ Color of extremity, skin, & nails: red to blue ■​ Clinical findings
●​ Atrophy: (-) ●​ (+) pinch grip test
●​ Other findings: ●​ (-) okay sign
→​Muscle spasm ○​ Carpal tunnel syndrome
→​Stiffness ■​ Trivia: MC neuropathy
 ■​ Causes (mnemonic: POTOL) ○​ Significance of late cocking phase: phase of ↑'d
●​ Pregnancy valgus force at the elbow
●​ Obesity ○​ Significance of acceleration phase: phase where
●​ Trauma force is transmitted to the elbow
●​ Overuse ●​ Olecranon bursitis
●​ Lupus ○​ Aka if acute: students elbow
■​ Ssx (mnemonic: SWAN) ○​ Aka if chronic: miners or draftsman’s elbow
●​ Sensory loss at lateral 3 & 1/2 of fingers ○​ Hallmark: goose-egg appearance
●​ Weakness of thenar eminence ○​ Ssx
●​ Ape or simian hand (flattening of thenar ■​ Pain
eminence) ■​ Swelling
●​ Nocturnal pain ■​ Slight LOM
●​ Axillary nerve ○​ Position of comfort: 70° elbow flexion
○​ Commonly affected muscles: deltoids & teres minor
●​ Suprascapular nerve
QUESTION
○​ Commonly affected muscle: supraspinatus
○​ Common causes What is a septic olecranon?
■​ Impingement at suprascapular notch
■​ Rucksack wearing Bursitis 2° staphylococcus infection
●​ Dead arm syndrome
○​ MC affects young athletic adults ●​ Myositis ossificans
○​ Age range: 21-30 yo
○​ Def: abnormal bone growth at muscle
○​ MC cause: repetitive throwing ○​ Cause: trauma or contusion
○​ Ssx ○​ Side effect of supracondylar fracture
■​ Psychological disorder
○​ MC sites
■​ Labral tear ■​ UE: brachialis
■​ Anterior shoulder dislocation ■​ LE: quadriceps
■​ RC tear
○​ Ssx (mnemonic: PaPaFlex)
■​ Apprehension ■​ Pain
■​ Palpable mass
ELBOW ■​ Flexion contracture
○​ Contraindicated activity: passive stretching
●​ Boxer’s elbow
EPICONDYLITIS: LATERAL VS MEDIAL ○​ Def: posterior elbow impingement
○​ MOI: excessive extension & valgus force
LATERAL MEDIAL ○​ Ssx: pain & LOM towards elbow flexion
●​ Volkmann’s Ischemic Contracture
MOI Repetitive wrist extension Repetitive wrist flexion + ○​ Aka anterior FA compartment syndrome
pronation ○​ Def: brachial plexus injury as a complication of
supracondylar fracture
Affected ECRB (can also include Pronator teres ○​ PE findings
muscles ECRL & Brachioradialis) ■​ Claw-like deformity
■​ Atrophy
ST Cozens, Mills, & Maudsley Medial epicondyle test ■​ Pain
■​ Pallor
Advice Larger or two handed Looser or large grip ■​ Pulselessness
grip Strike ground less ■​ Paresthesia
Use of counterforce or FA forcefully ■​ Paralysis
brace ○​ Management
■​ Fasciotomy
●​ Ratio: to ↓ p°
PUSHED VS PULLED ELBOW ●​ Value to use in (+) necrosis: 30 mm Hg
●​ Value to use in (+) surgery: 40 mm Hg
PUSHED PULLED ●​ Panner’s disease
○​ Def: AVN of capitulum
MOI Posterolateral FOOSH Pulling on pronated FA & ○​ Age: 7-10 yo
extended elbow
○​ Sex affectation: M > F
●​ Osteochondritis dissecans
Associated Elbow dislocation Radial head dislocation
○​ Def: focal lesion at the capitulum
injury Radial head fracture Lax annular ligament
○​ Age 9-15 yo

●​ Little leaguer’s elbow ADDENDUM

○​ Def: MCL injury at the elbow
○​ Age range: 9-12 yo Other avascular necrosis in the body:
○​ MOI: excessive valgus ●​ AVN of scaphoid: preiser’s
●​ AVN of lunate: keinbocks
●​ AVN of distal lunate: burns
●​ AVN of spine of vertebral endplate: scheuermanns
●​ AVN of VBs: calves
●​ AVN of femoral head in children: LCPD
●​ AVN of femoral head in adults: chandler’s
●​ AVN of navicular: kohlers
●​ AVN of 2nd MTT: freibergs
●​ AVN of talus: diaz
●​ AVN of calcaneus: severs
 ●​ Trigger finger
FA, WRIST & HAND
○​ Other names (mnemonic: SSD)
●​ Functional contributions of the hand regions ■​ Snapping Finger
○​ W&H: 90% ■​ Stenosing Tenosynovitis
○​ Thumb: 40-50% ■​ Digital Tenovaginitis Stenosans
○​ Index: 20% ○​ Def: Mechanical locking of A1 pulley
○​ Middle: 20% ○​ Cause: Inflammation of flexor tendon sheath (Notta’s
○​ Ring: 10% Nodule)
●​ Fractures & dislocations ○​ PE finding: Snaps upon extension
○​ MC fractured carpal: scaphoid ○​ MC affects: 3rd + 4th digits
○​ MC dislocated carpal: lunate ●​ Dupuytren's contracture
○​ Def: palmar fascia contracture
○​ MC affects: 4th & 5th digits
COLLES VS SMITH FRACTURES ○​ Management: hand splint
○​ Stages
COLLES SMITH ■​ Stage I: loose nodule formation
■​ Stage II: tight nodule formation
Manifestation Dinner fork Garden spade ■​ Stage III: contracture of 1-2 fingers
■​ Stage IV: fixed finger contracture
MOI FOOSH FOBOTH ●​ Jersey finger
○​ Def: rupture of the FDP of the 4th digit
Fracture area Distal radius Distal radius ○​ PE finding: inability to flex DIP
○​ MOI: hyperextension
Wrist angulation Posterior Anterior ○​ Special test: sweater finger
●​ Gamekeeper’s thumb
○​ Monteggia fracture ○​ Aka skier’s thumb
■​ Fractured: ulna ○​ Def: lesion of the UCL of the thumb
■​ Dislocated: radius ○​ MOI: hyperextension or hyperabduction injury 2°
○​ Galeazzi fracture FOOSH
■​ Fractured: radius ●​ Stener’s lesion
■​ Dislocated: ulna ○​ Def: grade 3 tear of the UCL + Interposition of
adductor pollicis aponeurosis between torn end of
ligament & base of 1st phalanx
○​ Special test: application of varus stress to the thumb,
should have a normal angulation of 15°
○​ Grading
■​ Grade I: painful upon movement but not laxity
■​ Grade II: 15 to 30° laxity
■​ Grade III: >30° rupture
●​ Intersection syndrome
○​ Def: inflammation at the crossing of APL + EPB &
ECRL + ECRB
○​ Manifestation: dorsoradial distal FA pain
○​ Aggravating factor: wrist extension

○​ Boxer’s fracture DEFORMITIES

■​ Def: fracture of neck of 5th MC ●​ Nodes
■​ Stages ○​ Associated condition: OA
●​ Sclerosis ○​ Bouchard’s Nodes: PIP
●​ Fragmentation ○​ Heberden’s Nodes: DIP
●​ Collapse ●​ ZigZag Deformity
●​ Arthritis ○​ MC affects: thumb
■​ Associated signs ○​ Associated condition: RA
●​ Murphy’s Sign ○​ CMC: flexed
→​Significance: scapholunate dislocation ○​ IP: flexed
→​Procedure: make a fist & check height ○​ MCP extend
of MCP ●​ Ulnar Drift
→​Positive sign: unequal equal height ○​ Seen in RA
●​ Terry-Thomas Sign ○​ Ulnar deviation of wrist & hand
→​Significance: scapholunate dislocation ●​ Mannerfelt Syndrome
→​Procedure: check scaphoid & lunate ○​ Aka Boutonniere of Thumb
gap ○​ IP joint goes extension
→​Positive sign: >3-5mm gap ○​ Ruptured tendon: FPL
○​ Bennette’s fracture ●​ Other deformities
■​ Def: fracture of base of 1st MC ○​ Swan neck deformity: rupture of FDS or dorsal
■​ Direction: anterior migration of lateral bands
■​ MOI: FOOSH ○​ Boutonniere deformity: rupture of central slip of EDC
●​ De Quervain’s disease or volar migration of lateral bands
○​ Aka washerwoman’s thumb, hoffman’s disease, or ○​ Mallet finger deformity: aka baseball finger, rupture
stenosing tenosynovitis of terminal extensor tendon of EDC
○​ Def: inflammation of the tendon sheaths of the first
dorsal compartment (APL & EPB)
○​ Trivia: MC tendinopathy at the wrist
○​ ST: finkelstein’s test
 SWAN NECK BOUTONNIERE MALLET

MCP F E N
PIP E F N
DIP F E F

CONGENITAL ANOMALIES OF UE

●​ Amelia: Absence of upper limbs

●​ Aphalangia: absence of metacarpal
●​ Acheira: Absence of wrist & hand
●​ Meromelia: partial absence of limb
●​ Phocomelia: aka intercalary, seal-limb or flipper-like limb
●​ Hemimelia: absence of entire half of UE
●​ Adactylia: absence of finger
●​ Polydactyly: too many fingers
●​ Macrodactyly: enlarged thumb
●​ Syndactyly: webbed fingers MC at 2nd & 4th fingers
●​ Clinodactyly: curved little finger
●​ Camptodactyly: bent little finger
●​ Lobster claw hand: hereditary absence of 2nd to 4th digits
●​ Arachnodactyly: aka Marfan’s syndrome; hereditary
abnormally long fingers with spider like appearance
●​ Madelung’s deformity: volar displacement of wrist, hand, &
radius
○​ LOM: wrist extension > supination > pronation
UPPER EXTREMITY SPECIAL TESTS ■​ Apprehension
■​ Posterior pain

TOPIC OUTLINE

I.​ Shoulder
A.​ Anterior Instability
B.​ Posterior Instability
C.​ Inferior Instability
D.​ Labral Pathology
E.​ Muscle Pathology
F.​ Impingement
II.​ Elbow
A.​ Ligamentous Instability
B.​ Epicondylitis
C.​ Neural Dysfunction
III.​ Forearm, Wrist, & Hand
A.​ Ligament, Capsule, Joint Pathology ●​ Jobe relocation test
B.​ Neural Dysfunction ○​ Sig:
■​ GH instability
■​ Posterior impingement
ANTERIOR INSTABILITY AT THE SHOULDER ○​ Patient position: supine
○​ Procedure: PT applies posterior translation
●​ Dugas test ○​ (+) sign:
○​ Sig: dislocation without reduction ■​ Apprehension relieved
○​ Patient position: seated with hand resting on ■​ Posterior pain relieved
opposite shoulder
○​ Procedure: lower the elbow
○​ (+) sign: LOM & pain

●​ Apprehension test ●​ Anterior release test

○​ Aka crank test ○​ Aka surprise test
○​ Sig: traumatic GH instability ○​ Sig:
○​ Patient position: supine ■​ GH instability
○​ Procedure: slowly ER with the shoulder in 90° abd ■​ Posterior impingement
○​ (+) sign: apprehension ○​ Patient position: supine
○​ Procedure: release posterior translation at Jobe
relocation test
○​ (+) sign
■​ Pain & forward translation
■​ Posterior pain

●​ Rockwood test
○​ Sig: anterior shoulder instability in all angles
○​ Patient position: sitting
●​ Fulcrum ○​ Procedure: laterally rotate the shoulder
○​ Sig: ○​ (+) sign:
■​ Traumatic GH instability ■​ Apprehension at 0°
■​ Posterior impingement ■​ Uneasiness at 45°
○​ Patient position: supine ■​ Apprehension at 90°
○​ Procedure: slowly ER with the shoulder in 90° abd ■​ Uneasiness at 120 °
with the fist behind the GH
○​ (+) sign:
 ●​ Jerk test
○​ Sig:
■​ posterior GH instability
■​ Posterior inferior labral instability
○​ Patient position: sitting with shoulder in forward
flexion & IR
○​ Procedure:
■​ Horizontally adduct & push the arm posteriorly
■​ Return to original position
○​ (+) sign:
■​ Clunk at procedure I
■​ Clunk at procedure II

●​ Load & shift test I

○​ Sig: GH instability
○​ Patient position: seated
○​ Procedure: load & shift the GH head anteriorly
○​ (+) sign: ≥26° translation
●​ Push-pull test
●​ Load & shift test II ○​ Sig: posterior instability
○​ Sig: atraumatic GH instability ○​ Patient position: supine with arm in scaption
○​ Patient position: supine ○​ Procedure: push at the humeral head & pull the wrist
○​ Procedure: load & shift the GH head anteriorly + ER ○​ (+) sign: ≥51° translation
○​ (+) sign: ≥26° translation

●​ Norwood stress test

○​ Sig: posterior GH instability
○​ Patient position: supine with shoulder abduction
60-100°, shoulder ER at 90°, & elbow flexion at 90°
POSTERIOR INSTABILITY AT THE SHOULDER ○​ Procedure: horizontally adduct + IR the arm while
pushing the humerus posteriorly
●​ Load & shift test I ○​ (+) sign: humeral head slips posteriorly
○​ Sig: GH instability
○​ Patient position: seated
○​ Procedure: load & shift the GH head anteriorly
○​ (+) sign: ≥26° translation

●​ Load & shift test II

○​ Sig: atraumatic GH instability
○​ Patient position: supine
○​ Procedure: load & shift the GH head anteriorly + ER
○​ (+) sign: ≥26° translation
○​ Sig:
○​ Patient position: ●​ Circumduction
○​ Procedure: ○​ Sig: posterior GH instability
○​ (+) sign: ○​ Patient position: standing
○​ Procedure: circumduction from EXAB to FLEXAD
○​ (+) sign: posterior subluxation of GH head
 ○​ Procedure: push the elbow anterosuperiorly
INFERIOR INSTABILITY AT THE SHOULDER
○​ (+) sign: pop & crack with anterior shoulder pain
●​ Sulcus sign
○​ Sig: inferior instability
○​ Patient position: standing
○​ Procedure: pull arm down
○​ (+) sign: sulcus between humeral head & acromion
process
■​ Grading
●​ +1: <1 cm sulcus
●​ +2: 1-2 cm sulcus
●​ +3: >2 cm sulcus

MUSCLE PATHOLOGY AT THE SHOULDER

●​ Supraspinatus test
○​ Aka empty can test
○​ Sig: Supraspinatus tear
○​ Patient position:
■​ abducted to 90° with IR
■​ abducted to 90° with IR & scaption
○​ Procedure: resist the arm movement in both positions
●​ Feagin test
○​ (+) sign: weakness or pain
○​ Sig: anteroinferior instability
○​ Patient position: standing with arms at 90° abduction
○​ Procedure: push anteriorly & inferiorly
○​ (+) sign: sulcus above coracoid process

●​ Speeds test
○​ Aka biceps test or straight arm test
○​ Sig:
■​ Bicipital paratenonitis
■​ Superior labral tear
○​ Patient position: elbow extension
LABRAL PATHOLOGY ○​ Procedure: resist elbow flexion + FA supination
○​ (+) sign:
●​ Clunk test ■​ Pain in bicipital groove
○​ Sig: labral tear ■​ Pain in joint line
○​ Patient position: supine
○​ Procedure: place arm into full ABER then push
humeral head anteriorly
○​ (+) sign: clunk or grinding

●​ Anterior slide test

○​ Sig: humeral head slides over the labrum 2° labral
lesion
○​ Patient position: standing, but ideally sitting with
hand resting on waist
●​ Yergason test ●​ Lift off sign
○​ Sig: rupture or tear of transverse humeral ligament ○​ Aka gerber test
○​ Patient position: elbow flexed & FA pronated ○​ Sig: subscapularis tear
○​ Procedure: supinate FA & ER shoulder while palpating ○​ Patient position: hand on the small back
for long head of biceps tendon ○​ Procedure: pt lifts arms away
○​ (+) sign: biceps tendon pops out ○​ (+) sign: inability
○​ Alternatives
■​ Belly press test
■​ Napoleon test

●​ Ludington test
○​ Sig: rupture of long head of biceps
○​ Patient position: hand clasp behind head
○​ Procedure: pt contracts & relaxes biceps with PT
palpating IMPINGEMENT AT THE SHOULDER
○​ (+) sign: (-) palpable tension
●​ Neer’s test
○​ Sig: overuse injury of supraspinatus tendon
○​ Patient position: sitting or standing
○​ Procedure: full passive abduction with arm in IR
○​ (+) sign: pain

●​ Heuter sign
○​ Sig: rupture of distal biceps tendon
○​ Patient position: elbow flexed & FA pronated
○​ Procedure: resist elbow flexion & FA supination
○​ (+) sign: (-) supination ●​ Hawkins-Kennedy
○​ Sig: supraspinatus paratenonitis/tendonitis
●​ Drop arm test ○​ Patient position: standing
○​ Aka codman’s test ○​ Procedure: full passive forward flexion with arm in IR
○​ Sig: RC tear ○​ (+) sign: pain
○​ Patient position: passive 90° abduction of shoulder
○​ Procedure: pt slowly lowers the arm
○​ (+) sign: inability
●​ Yocum test
○​ Sig: supraspinatus paratenonitis/tendonitis ●​ Mills test
○​ Patient position: sitting or standing with hand on ○​ Sig: lateral epicondylitis
opposite shoulder ○​ Patient position: sitting
○​ Procedure: elevate the elbow ○​ Procedure: PT stretches towards elbow extension &
○​ (+) sign: pain FA pronation
○​ (+) sign: pain

●​ Maudsley test
●​ Causes of secondary impingement ○​ Sig: lateral epicondylitis
○​ Inflammation of subacromial space ○​ Patient position: sitting
○​ RC tendon degeneration ○​ Procedure: PT resists extension of middle finger
○​ Osteophytes under AC joint ○​ (+) sign: pain
○​ Hooked acromion
○​ GH hypomobility

LIGAMENTOUS INSTABILITY AT THE ELBOW

●​ Varus/valgus instability test
○​ Sig:
■​ MCL injury
■​ LCL injury
○​ Patient position: sitting or standing
○​ Procedure:
■​ Varus: push FA to abd
●​ Golfer’s elbow test
■​ Valgus: push FA to add
○​ Sig: medial epicondylitis
○​ (+) sign:
○​ Patient position: FA supination with wrist & elbow in
■​ Pain at medial elbow
extension
■​ Pain at lateral elbow
○​ Procedure: provide overpressure
○​ (+) sign: pain

EPICONDYLITIS
●​ Cozen’s test
○​ Sig: lateral epicondylitis
○​ Patient position: sitting
○​ Procedure: PT resists wrist extension & radial
deviation
○​ (+) sign: pain
QUESTION

What would you call a pt with both lateral & medial

epicondylitis?

Country club elbow

NEURAL DYSFUNCTION AT THE ELBOW

●​ Tinel sign
○​ Sig: regeneration of nerve fiber if post-op
○​ Patient position: sitting
○​ Procedure: tap at the cubital tunnel
 ○​ (+) sign: tingling on ulnar distribution

●​ Pinch grip test

○​ Aka OK sign
○​ Sig: AIN pathology
○​ Patient position: sitting
○​ Procedure: have pt perform OK sign
○​ (+) sign: inability

●​ Elbow flexion test

○​ Sig: cubital tunnel syndrome
○​ Patient position: sitting/standing
○​ Procedure: have pt perform elbow flexion, wrist
extension, shoulder abduction, & shoulder depression
○​ (+) sign: tingling on ulnar distribution

●​ Wartenberg sign LIGAMENTOUS, CAPSULE, OR JOINT PATHO AT WRIST

○​ Sig: ulnar neuropathy
○​ Patient position: sitting ●​ Shock test
○​ Procedure: pt places fingers in adduction ○​ Aka finger extension test
○​ (+) sign: little finger remains in abduction ○​ Sig:
■​ Radiocarpal ligament injury
■​ Inflammation
■​ Scaphoid instability
■​ Kienbock’s disease
○​ Patient position: wrist flexion
○​ Procedure: resist finger extension
○​ (+) sign: pain

●​ Test for Pronator teres syndrome

○​ Sig: pronator teres syndrome
○​ Patient position: elbow flexed with FA supinated
○​ Procedure: oppose the position
○​ (+) sign: paresthesia at median nerve distribution
●​ Murphy’s sign ●​ Bunnel-littler test
○​ Sig: lunate dislocation ○​ Sig:
○​ Patient position: have pt place hand to a fist ■​ Intrinsic muscle/capsule tightness
○​ Procedure: check level of MCP heads ■​ Intrinsic muscle tightness
○​ (+) sign: unlevel heads ■​ Capsule tightness
○​ Patient position: fingers extended
○​ Procedure:
■​ Flex PIP with MCP in neutral
■​ Flex PIP with MCP flexed
○​ (+) sign: ​
■​ (-) PIP flexion at P1
■​ (+) PIP flexion at P2
■​ (-) PIP flexion at P2

●​ Piano key test

○​ Sig: DRU instability
○​ Patient position: FA pronation
○​ Procedure: push ulnar palmarly
○​ (+) sign: excessive motion

●​ Finkelstein test
○​ Sig: De Quervains or Hoffman’s disease
○​ Patient position: thumb in fist
○​ Procedure: ulnar deviation
○​ (+) sign: pain

●​ Haines-Zancolli test
○​ Aka retinacular test
○​ Sig:
■​ Retinacular/capsule tightness ●​ Sweater finger
■​ Retinacular tightness ○​ Aka jersey finger
○​ Patient position: fingers extended ○​ Sig: FDP rupture
○​ Procedure: ○​ Patient position: open palm
■​ Flex DIP with PIP in neutral ○​ Procedure: have pt close the fist
■​ Flex DIP with PIP flexed ○​ (+) sign: inability to flex DIP
○​ (+) sign: ​
■​ (-) DIP flexion at P1
■​ (+) DIP flexion at P2
 NEURAL DYSFUNCTION AT THE WRIST
●​ Froment's paper syndrome
○​ Sig: ulnar nerve paralysis
○​ Patient position: hold paper between index & thumb
○​ Procedure: PT pulls paper
○​ (+) sign: flexion of IP joint (tip-to-tip)

●​ Phalen’s & reverse phalen’s test

○​ Sig: CTS
○​ Patient position: standing
○​ Procedure:
■​ Have pt hold the hands in maximum wrist flexion
■​ Have pt hold the hands in maximum wrist
extension
○​ (+) sign: paresthesia in median nerve distribution

●​ Tinel sign
○​ Sig: CTS
○​ Patient position: sitting
○​ Procedure: tap at carpal tunnel
○​ (+) sign: paresthesia in median nerve distribution

●​ Allen’s test
○​ Sig: vascular compromise
○​ Patient position: sitting
○​ Procedure: have pt close hands with PT compressing
radial & ulnar arteries; then PT releases arteries one
at a time with hand open
○​ (+) sign: slow return of redness