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LIVING ANATOMY – FINAL EXAM REVIEW

Suprasternal notch – Move your hands medially from the position on the deltoid and acromion (you are
standing behind patient) until you feel the suprasternal notch. (Lies around T2/T3)

Sternoclavicular joint – The sternoclavicular joint is the articulation between the sternal end of the
clavicle and the sternum. It is wedge-shaped and contains a small, impalpable fibrous disk. At rest, only
the inferior portion of the sternal end makes contact with the sternum. When the clavicle is elevated, the
sternal end pivots on the sternum.
o Seated or supine. Slide your fingers medially along the shaft of the clavicle.
o Just lateral to the body’s centerline, the shaft will broaden to become the bulbous sternal end.
o Locate the joint by sliding your finger medially off the sternal end. Passively elevate,
depress and abduct the scapula. Then explore the changes occurring at the sternoclavicular
joint.

Clavicle – The superficial clavicle lies horizontally across the upper chest and has a gentle “S” shape. It
is an attachment site for a number of muscles. Both ends of the clavicle are superficial and accessible.
The lateral end is relatively flat and often rises slightly higher than the acromion. The medial end is
found and articulates with the sternum.
o Seated. Locate the acromion and walk your fingers medially onto the shaft of the clavicle.
o Grasp the clavicle’s cylindrical body between your find and thumb and explore its length
from the acromion to the sternum. Observe how its acromial end rises superiorly while its
sternal end curves inferiorly.

Coracoid process of the scapula – The coracoid process of the scapula is the beak-like projection found
inferior to the shaft of the clavicle. Depending on the position of the scapula, it is often found in the
deltopectoral groove between deltoid and pectoralis major fibers.
o Seated or supine. Lay your thumb along the lateral shaft of the clavicle.
o Slide inferiorly off the clavicle no more than an inch and a half. Locate the tip of the
coracoid process by compressing your fingerpads into the tissue.
o As the coracoid becomes more apparent, get a better understanding of its shape and size by
sculpting a circle around its edges.

Acromioclavicular joint – The acromioclavicular joint is the small articulation between the acromion of
the scapula and the acromial end of the clavicle. The anterior and superior surfaces of this thin crevice
can be palpated directly.
o Seated or supine. Located the acromion.
o Glide medially toward the clavicle. Your finger will feel a small “step” as you rise up onto
the surface of the clavicle.
o Backtrack slightly. Just lateral to the step will be the joint’s slender ditch.

Acromion – The acromion is the lateral aspect of the spine of the scapula and is located at the top of the
shoulder. It has a flat surface and articulates with the clavicle’s lateral end. The acromion serves as an
attachment site for the trapezius and deltoid muscles. The acromial angle is the small corner that can be
felt along the acromion’s lateral/posterior aspect.
o Seated or supine. Locate the spine of the scapula.
o Follow the spine as it rises superiorly and laterally to the top of the shoulder. Use your
fingerpads to explore the acromion’s flat surface.
o Explore and sculpt around all sides of the acromion and its attachment to the clavicle.

Greater tuberosity of the humerus – The greater tubercle is located inferior and lateral to the
acromion. It is shaped more like a low mound than a pointy hill. It is an attachment site for three of the
four rotator cuff muscles – supraspinatus, infraspinatus, and teres minor.
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LIVING ANATOMY – FINAL EXAM REVIEW
Seated or supine. Shaking hands with your partner, locate the acromion.
Slide off the acromion inferiorly and laterally approximately one inch.
The solid surface located deep to the deltoid fibers will be the greater tubercle. You may
feel a small dip between the acromion and the tubercle.

Bicipital groove (aka Intertubercular Groove) – It is situated between the greater and lesser tubercles,
and is roughly a pencil’s width in diameter. Within the groove lies the tendon of the long head of the
biceps brachii.
o Place your thumb on the greater tubercle.
o Begin to rotate the arm laterally. As the humerus rotates, the greater tubercle will move out
from under your thumb and be replaced by the slender ditch of the intertubercular groove.

Lesser tuberosity of the humerus – The lesser tubercle is smaller than the greater tubercle and is an
attachment site for the fourth rotator cuff muscle – subscapularis.
o Continuation from directions above of bicipital groove.
o From the bicipital groove, continue to laterally rotate the arm, your thumb will rise out of the
groove onto the lesser tubercle.

Deltoid tuberosity – The deltoid tuberosity is located on the lateral side of the mid-humeral shaft. It is a
small, low bump that serves as an attachment site for the converging fibers of the deltoid muscle.
o Seated or supine. Locate the acromion.
o Slide off the acromion and down the lateral aspect of the arm.
o When you reach the halfway point between the shoulder and elbow, there will be a small
mound on the lateral side of the arm.

Shaft of the humerus – The humerus is the bone of the arm. The proximal humerus articulates with the
glenoid fossa of the scapula to form the glenohumeral joint. The glenohumeral joint is a synovial, balland-socket joint with a wide range of movement. The deltoid muscle and numerous tendons surround
the proximal humerus and the glenohumeral joint.

Spine of the scapula – The spine of the scapula is a superficial ridge located just off the top of the
shoulder. It runs at an oblique angle to the body, spanning from the acromion to the medial border. It is
an attachment site for the posterior deltoid. It is an attachment site for the posterior deltoid and middle
and lower fibers of the trapezius.
o Partner prone. Lay your hand across the upper back and slide your fingertips inferiorly until
they roll over the superficial spine.
o Strum your fingers vertically, palpating its width and edges. Also explore its entire length
by palpating laterally toward the acromion and medially toward the vertebral column.
o Located at Vertebral level T3

Superior angle of the scapula – The superior angle is located at the superior end of the medial border.
It serves as the inferior attachment site for the levator scapula muscle. Because the angle is located deep
to the trapezius muscle, it may not be as easy to isolate as the inferior angle.
o Patient prone. Scoop the shoulder with you hand to raise it off the table. This will soften the
overlying muscles.
o Locate the medial border. Slide your fingertips superiorly along the border to find the
superior angle.
o You may need to move an inch superior to the spine of the scapula to reach the superior
angle.
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LIVING ANATOMY – FINAL EXAM REVIEW

Inferior angle of the scapula – There are two angles of the scapula, one on either end of the medial
border. The inferior angle is superficial and located at the medial border’s lower end.
o Patient prone. Place your partner’s hand in the small of his/her back. Glide your fingers
inferiorly along the medial border.
o At the end of the medial border, the edge of the scapula will turn a corner and start to rise
superiorly and laterally. This corner is the inferior angle.
o Located at vertebral level T7

Lateral border of the scapula – The lateral border extends superiorly and laterally from the inferior
angle toward the axilla or “armpit”. It is an attachment site for the teres major and teres minor muscles
and due to the thickness of these tissues, may not be as clearly defined as the medial border.
o Patient prone. Drape the arm off the side of the table. Slide your thumb from the inferior
angle superiorly along the lateral border.
o Follow the border in the direction of the axilla. If the musculature is too thick to palpate
through, try curling your thumb underneath the tissue. This is most effective when locating
the infraglenoid tubercle.

Medial border of the scapula – The medial border is the long edge of the scapula that runs parallel to
the vertebral column. It can measure five to seven inches in length, depending on body type. The medial
border is an attachment site for the rhomboids and serratus anterior and is deep to the trapezius.
o Patient prone. Place your partner’s hand in the small of his back to raise the medial border
off the ribs. For more exposure, scoop and raise the shoulder with one hand.
o Locate the spine of the scapula and glide your fingertips medially until they slide off the
spine onto the medial border.
o Follow the medial border inferiorly and superiorly; note that it extends further inferiorly
from the spine of the scapula than superiorly.
Be able to identify they vertebral levels for:
Suprasternal notch: T2/T3
Spine of the Scapula: T3
Inferior angle of the scapula: T7

Sternocleidomastoid – The Sternocleidomastoid is located on the lateral and anterior aspects of the
neck. It has a large belly with two heads that both merge to attach behind the ear at the mastoid process.
The SCM is superficial, completely accessible and often visible when the head is turned to the side.
o Lay supine with the practitioner at the head of the table. Locate the mastoid process of the
temporal bone, the medial clavicle and the top of the sternum.
o Draw a line between these landmarks to delineate the location of the SCM. Both SCMs
form a “V” on the front of the neck.
o Have your partner raise his/her head very slightly off the table as you palpate the SCM. It
will usually protrude visibly. To make it more distinct, rotate the head slightly to the
opposite side and then ask him/her to flex the neck.
o Palpate along the borders of the SCM, follow it behind the earlobe and then down to the
clavicle and sternum. Sculpt around the skinny sternal tendon and the wider clavicular
tendon.

Pectoralis Major – The pectoralis major is a broad, powerful muscle located on the chest. It is divided
into three segments – the clavicular, sternal, and costal fibers.
o Have your partner lie supine. With his/her shoulder slightly abducted, sit or stand facing
him/her.
o Locate the medial shaft of the clavicle and move inferiorly onto the clavicular fibers.
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LIVING ANATOMY – FINAL EXAM REVIEW
o Explore the surface of the pectoralis major. Follow the fibers laterally as they blend with the
deltoid and attach at the greater tubercle.
o Grasp the belly of the pectoralis major by sinking your thumb into the axilla. Ask your
partner to medially rotate his/her shoulder against your resistance.
ROTATOR CUFF (SITS):
 Supraspinatus – Located in the supraspinous fossa, deep to the trapezius’ upper fibers. Its belly runs
underneath the acromion and attaches to the humerus’ greater tubercle.
o Prone. Locate the spine of the scapula. Slide your fingers up into the supraspinous fossa.
o Palpate through the trapezius and onto the supraspinatus fibers. As you palpate, note how
the fibers run parallel to the spine.
o Follow the belly laterally until it tucks under the acromion.

Infraspinatus – Located in the infraspinous fossa. Most of its belly is superficial with a medial portion
deep to the trapezius and a lateral portion beneath the deltoid.
o Prone, with the forearm off the side of the table. Locate the spine, medial border and lateral
border of the scapula.
o Form a triangle around the infraspinatus by laying a finger along each of these landmarks
o Palpate in the triangle and strum across the infraspinatus fibers. Follow them laterally as
they converge underneath the deltoid to attach to the humerus.

Teres minor – A small muscle that is squeezed between the infraspinatus and teres major. It is located
high in the axilla and can be challenging to grasp.
o Prone, with the arm off the side of the table. Locate the lateral border of the scapula;
specifically, its superior half. Slide laterally off the lateral border onto the surface of the
teres minor.
o Compress into and across its tube-shaped belly. Move inferiorly and compare it in size to
the teres major. Also, reach your thumb up into the axilla and grasp the belly of the teres
minor as your would a sandwich.
o Ask your partner to laterally rotate his shoulder.

Subscapularis – Located on the scapula’s anterior surface and is sandwiched between the subscapular
fossa and serratus anterior muscle.
o Cannot be palpated

3 parts of Deltoid Muscle- Located on the cap of the shoulder. Fibers can be divided into three
segments: anterior, middle, and posterior.
o Seated. Locate the spine of the scapula, the acromion and the lateral one-third of the
clavicle. Note the “V” shape these landmarks form.
o Locate the deltoid tuberosity.
o Palpate between these landmarks to isolate the superficial, convergent fibers of the deltoid.
Explore the deltoid’s most anterior and posterior aspects.

Biceps brachii – Lies superficially on the anterior arm. Has a long head and a short head that merge to
form a long, oval belly. The tendon of the long head passes through the intertubercular groove of the
humerus helping to stabilize the tendon as it rises over the top of the shoulder.
o Supine or seated. Bend the elbow and shake hands with your partner.
o Ask your partner to flex his/her elbow against your resistance. Palpate the anterior surface
of the arm and locate the hard, round belly of the biceps.
o Follow the belly distally to the inner elbow. Note how the muscle belly thins, becoming a
solid, distinct tendon. Then follow the biceps proximally to where it tucks beneath the
anterior fibers of the deltoid.
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
Tendon of the long head of Biceps Brachii
o Locate the intertubercular groove. Laterally rotating the arm may make it easier to pinpoint
the tendon.
o Ask your partner to gently flex his elbow against your resistance in order to feel the biceps
tendon become taut in the intertubercular groove. Be aware that the deltoid’s anterior fibers
will also contract upon flexion of the shoulder.

Coracobrachialis - A small, tubular muscle located in the axilla that is deep to the pectoralis major and
anterior deltoid.
o Supine. Laterally rotate and abduct the shoulder to 45 degrees. Locate the fibers of the
pectoralis major. This tissue forms the axilla’s anterior wall and will be a reference point for
locating coracobrachialis.
o Lay one hand along the medial side of the arm and move your fingerpads into the armpit.
o Have your partner horizontally adduct gently against your resistance. Isolate the solid edge
of the pectoralis major then slide off the pectoralis major fibers posteriorly (into the axilla)
and explore for the slender, contracting belly of the coracobrachialis. Its belly may be
visible upon adduction.

Triceps Brachii – Only muscle located on the posterior arm. The triceps has three heads: long, lateral,
and medial that all converge into a thick, distal tendon proximal to the elbow.
o Prone. Bring the arm off the side of the table and palpate the posterior aspect of the arm.
Outline the edge of the posterior deltoid and then explore the size and shape of the triceps.
o Locate the olecranon process to outline the distal tendon of the triceps. Then ask your
partner to extend his elbow as you apply resistance at his/her forearm. Slide your other hand
off the olecranon process proximally and onto the broad triceps tendon.
o With your partner still contracting, widen your fingers and palpate the medial and lateral
heads on either side of the tendon.

Trapezius – Lies superficially along the upper back and neck.
o Upper Fibers:
o Prone. These fibers form the easily accessible flap of muscle lying across the top of the
shoulder. Along the posterior neck they are surprisingly skinny, each being only an inch
wide.
o Grasp the superficial tissue on the top of the shoulder and feel the upper trapezius fibers.
Take note of their slender quality.
o Follow the fibers superiorly toward the base of the head at the occiput. To feel the fibers
along the posterior neck contract, stand at the head of the table and ask our partner to extend
his/her head off the table. Then follow the fibers inferiorly to the lateral clavicle.
o
o
o
Middle Fibers:
Locate the spine of the scapula.
Slide medially from the spine of the scapula onto the trapezius and move your fingers across
its fibers. The trapezius fibers are superficial and thin, so explore at a superficial level and
not deeper into the rhomboids or erector spinae muscles.
o
o
Lower Fibers:
Locate the edge of the lower fibers by drawing a line from the spine of the scapula to the
spinous process of T-12.
Palpate along this line and push your fingers into the edge of the lower fibers. Ask your
partner to hold his arms out in front of him (like Superman) and feel for the superficial fibers
of the trapezius.
o
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LIVING ANATOMY – FINAL EXAM REVIEW
Attempt to lift the lower fibers between your fingers, raising them off the underlying
musculature.

Rhomboid Major and Minor – The rhomboid muscles are located between the scapula and
vertebral column. They are difficult to distinguish individually. They have thin fibers that lie deep
to the trapezius and superficial to the erector spinae muscles.
o Prone. Locate the scapula’s medial border and the spinous processes of C-7 through T-5.
o Palpating through the thin trapezius, explore the area you have identified and strum
vertically across the fibers of the rhomboids. Palpate all sides of the rhomboids. On some
individuals you can press your fingers into the lower border of the rhomboid major and
locate its edge.

Latissimus Dorsi – The broadest muscle of the back. Its thin, superficial fibers originate at the low
back, ascend the side of the trunk and merge into a thick bundle at the axilla. Both ends of the
latissimus dorsi are difficult to isolate; however, its middle portion next to the lateral border of the
scapula is easy to grasp.
o Prone with the arm off the side of the table. Locate the scapula’s lateral border.
o Using your fingers and thumb, grasp the thick wad of muscle tissue lateral to the lateral
border. This is the latissimus dorsi.
o Feel the latissimus fibers contract by asking your partner to medially rotate his shoulder
against your resistance. As this occurs, follow the latissimus fibers superiorly into the axilla
and inferiorly on the ribs.

Demonstrate the following movements at the shoulder joint:
o Abduction of the arm
o Adduction of the arm
o Extension of the arm
o Flexion of the arm
o Internal (medial) rotation of the arm
o External (lateral) rotation of the arm
o Circumduction of the arm

Biceps brachii reflex and spinal nerve involved: Although innervated by C5 and C6 of the
musculocutaneous nerve, its reflex action is primarily C5. To test, place the patient’s arm over your
opposite arm, so that it rests upon your forearm. With your hand supporting the patient’s arm under
the elbow’s medial side, place your thumb on the tendon of the biceps in the cubital fossa. When his
arm is totally relaxed, tap your thumbnail with the narrow end of the reflex hammer. The biceps
should jerk slightly. (p55 Hoppenfeld)

Triceps brachii reflex and spinal nerve involved: The triceps is innervated by the radial nerve and
the reflex is a function of C7. Keep the pateint’s arm the same as the biceps brachii reflex. Have the
arm completely relaxed. Tap the triceps tendon where it crosses the olecranon fossa with the
narrower end of the refex hammer. You should be able to see the reflex or to feel it as a slight jerk
on your supporting forearm. (p55 Hoppenfeld)

Apley “scratch” test: This is the quickest active way to evaluate a patient’s range of motion. First,
to test abduction and external rotation, ask the patient to reach behind his head and touch the
superior medial angle of the opposite scapula. Next, to determine the range of internal rotation and
adduction, instruct the patient to reach in front of his head and touch the opposite acromion. Third,
to further test internal rotation and adduction, have the patient reach behind his back to touch the
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LIVING ANATOMY – FINAL EXAM REVIEW
inferior angle of the opposite scapula. Observe the patient’s movement during all phases of testing
for any limitation of motion or for any break of normal rhythm or symmetry. (p21 Hoppenfeld)
Palpate the following bony structures of the elbow and forearm:
medial epicondyle of the humerus – directly medial to the olecranon process. Is is prominent.
lateral epicondyle of the humerus – is lateral to the olecranon process and is smaller and less prominent
than the medial
medial supracondylar line of the humerus – locate the medial epicondyle and move proximally (it appears
to be the ridge just superior to the epicondyle on the humerus)
lateral supracondylar line of the humerus – same as above except on the lateral side
olecranon process – located on the proximal end of the ulna and articulate with the distal part of the
humerus. It forms the point of the elbow. Passively flex and extend the elbow to notice how the olecranon
process feel in different positions.
shaft of the ulna
olecranon fossa – is a cavity on the posterior, distal end of the humerus designed to accommodate the
olecranon. Find the olecranon process and roll your fingers proximally around the top pressing through the
triceps tendon and into the fossa
Lateral epicondyle Lateral supracondylar line of the humerus radial head – locate the lateral epicondyle of the humerus and slide distally off the lateral epicondyle, across
the small ditch between the humerus and radius and onto the head of the radius.
radial tuberosity – Find the radial head and move slightly distal. It is difficult to feel, but if you keep your
fingers just below the head of the radius and have the person supinate and pronate the arm you should be able
to distinguish it.
shaft of the radius – flex the elbow at 90 degrees and pit the forearm in a neutral handshake position. Locate
the head of the radius and slide distally off the head. Continue down the forearm and feel the radius become
superficial near the wrist.
FLEXOR muscle group of forearm - wrist flexors
pronator teres – shake hands and flex elbow at 90 and locate the distal tendon of the biceps brachi and ask
partner to flex elbow against resistance. Slide distally off the tendon into the valley between the
brachioradialis and forearm flexors. Sink your thumb into this space and explore the finger-wide pronator
belly running obliquely from the medial elbow across the radius. Follow it to the medial epicondyle of the
humerus where it originate and notice how it blends with the other muscles. This muscle inserts at the
middle of the lateral surface of the radius where the tendon tucks under the brachioradialis.
flexor carpi radialis and Palmaris longus –Flex partners elbow at 90 and supinate the forearm and ask your
partner to flex her wrist against your resistance. At the center of the wrist will be two superficial tendons
carpi radialis and palmaris longus. Palmaris may be absent. If both are present the palmaris will be the most
medial. Your partner can also abduct and relax her wrist to create a distinct contraction of the flexor carpi
radialis. Radialis originates at the common flexor tendon of the medial condyle and inserts at the bases of the
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LIVING ANATOMY – FINAL EXAM REVIEW
2 and 3 metacarpals. Pamaris Longus originates at the same place and inserts at the flexor retinaculum
and the palmar aponeurosis
flexor carpi ulnaris – flex the elbow to 90 and supinate the forearm and begin at the distal tendon by
locating the pisiform and slide proximally until you feel the tendon and follow the tendon up to the muscle
belly. The muscle lies a finger’s width away from the ular shaft.
nd
rd
flexor digitorum superficialis - beginning at the wrist, locate the tendons of the superficial flexors. Passive
flexion of the wrist will soften the tendons and allow for easier access. It originates at the common flexor
tendon from the medial epicondyle of the humerus, ulnar collateral ligament, coronoid process of the ulna
and the shaft of the radius. I then inserts by four tendons into the sides of the middle phalanges of 2nd through
5th fingers. Have the person flex elbow to 90 and squeeze the tips thumb and pinky together. You should be
able to feel the digitorum muscles bulging.
triceps brachii tendon (distal or tendon of insertion) – It inserts on the olecranon process of the ulna. Have
the person lie prone on a table and have her extend the elbow and resist pressure. Then palpate the tendon
proximal to the olecranon process.
Wrist EXTENSOR muscle group (also known as "the mobile was of three")
Brachioradialis – flex the elbow at 90 with the forearm in a neutral position ask your partener to flex their
elbow against your resistance. The brachioradialis should bulge out on the lateral side of the elbow. If it is
not visible then locate the orgin at the lateral supracondylar ridge and slide distally with your partner still
contracting until you reach the insertion at the styloid process of the humerus.
extensor carpi radialis longus and brevis – shake hand and flex the elbow at 90. Locate the brachioradialis
and slide laterally off its belly on to the extensor carpi radialis fibers. Then have your partner abduct and
relax her wrist with resistance. Follow the fibers as far as you can.
Longus and brevis- orginate at the lateral supracondylar ridge of humerus. Longus inserts at the base of the
2nd metacarpal and brevis into the base of the 3rd metacarpal.
brachii tendon (of insertion, the distal tendon) – The biceps brachii inserts at the tuberosity of the radius and
aponeurosis of the biceps brachii. Bend the elbow and shake hands with the person and have your partner
offer resistance. Follow the belly of the muscle distally to the inner elbow where the muscle becomes thin
and solid forming a distinct tendon.
bicipital aponeurosis- a broad aponeurosis of the biceps brachii which is located in the cubital fossa of the
elbow and separates superficial from deep structures in much of the fossa.
The bicipital aponeurosis originates from the distal insertion of the biceps brachii. While the tendon of the
biceps inserts on the radius, the aponeurosis stretches from the medial side of the biceps tendon and passes
obliquely downward and medially across the brachial artery. It is continuous with the antebrachial fascia
covering the origins of the flexor muscles of the forearm.
The aponeurosis reinforces the cubital fossa, and helps to protect the brachial artery and the median nerve
running underneath. This protection is important during venipuncture (taking blood) from the median cubital
vein.
Demonstrate the following movements at the elbow joint:
-flexion of the forearm- ask the patient to bend his elbow
-extension of the forearm- ask the patient to straightern his elbow
Demonstrate the following movements at the proximal and distal radioulnar joints:
-supination of the forearm – the patient flexes the forearm to where a 90 degree angle is created at
the elbow joint. The palm is facing upward.
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LIVING ANATOMY – FINAL EXAM REVIEW
-pronation of the forearm – the patient flexes the forearme to where a 90 degree angle is created at
the elbow joint. The plam is facing downward.
Test the brachioradialis reflex (C5-C6, primarily C6) using the flat edge of the reflex hammer.
This reflex will be tested proximal to the wrist, just before the tendon insets into the radius.
Locate the tendon of the brachioradialis muscle.
To support the patient’s arm: with the patient’s arm next to his side, you hold the inside of his arm and have
the patient’s forearm rest on top of your forearm.
Using the flat edge of the reflex hammer with your other hand, tap the brachioradialis tendon. A radial jerk
should be noted.
Active Range of motion tests:
Measuring flexion and extension of the elbow joint using the goniometer:
 Place center of goniometer on the center of the lateral epicondyle
Patient: May be sitting or standing during the active range of motion tests
Physician: At the patient’s side or directly in front of patient
Flexion: 135°+
 Have patient bend their elbow and try to touch the front of their shoulder with their hand
 Flexion is limited by muscle mass of the anterior arm
Extension: 0°/-5°
 Have the patient straiten their elbow as far as they can.
 Most males can achieve 0°
 Those who are muscular may not be able to extend the elbow to 0°
 Females are normally able to extend arm to a minimum of 0°
 Many are able to hyperextend elbow as much as 5° beyond straight position
Measuring supination and pronation of the elbow joint using the goniometer:
 Place the center of the goniometer on the middle 1/3rd of the proximal phalanges between the 3rd and
4th digits
 The goniometer should be parallel to the ground
Supination: 90° - Two Methods
- Place the goniometer
 Method 1:
 Tell patient to flex elbow to 90° and then hold the flexed elbow into their waist
 This prevents any substituting shoulder adduction and flexion
 Then have the patient put their closed fist in front of them, palm down
 Have the patient rotate their fist until the palm faces upward
 Method 2:
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LIVING ANATOMY – FINAL EXAM REVIEW
 Have the patient hold a pencil in the fist of each hand with palm side down
 Then have the patient move both forearms simultaneously into supination
 Normal supination – pencils will be parallel to the ground
 Asymmetry indicates restricted supination in the arm
Pronation: 90°\
 Have the patient hold a pencil in the fist of each hand with palm side down
 Then have the patient move both forearms simultaneously into pronation
 Normal pronation – pencils will be parallel to the ground
 Asymmetry indicates restricted pronation in the arm
* Supination and pronation should be performed as one test, since the two motions essentially describe a
single arc of motion
Passive range of motion tests:
These tests should be performed if the patient is unable to demonstrate the active tests.
Flexion and Extension:
 Have the patient tuck his elbow into their waist
 Stabilize their arm in this position by cupping their olecranon process in your hand and holding their
elbow against the patients body
 Now flex and extend their forearm
 Look for blockage of motion within the elbow joint
 Splinting of the joint
 Record potential cause of blockage and degree of limitation
Supination and Pronation:
 Have the patient tuck his elbow into their waist
 Stabilize their arm in this position by cupping their olecranon process in your hand and holding their
elbow against the patients body
 With other hand, grip the patients hand as if shaking their hand
 Supinate and pronate the forearm slowly
 Look for blockage of motion within the elbow joint
 Record potential cause of blockage and degree of limitation
Muscle strength testing:
Flexion:
 Stand in front of the patient
 Support and stabilize the patients arm by cupping your hand around the posterior portion of the
elbow just proximal to the joint
 Place your free hand on the forearm’s palmar surface and wrap your fingers around the distal end
 Ask the patient to flex slowly
 At 45°, begin to apply resistance
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 After determining maximum resistance the patient can overcome, test the opposite elbow in the same
manner
Extension:
 Stand in front of the patient
 Support and stabilize the patients arm by cupping your hand around the posterior portion of the
elbow just proximal to the joint
 The hand will be positioned as a fist at a vertical position
 Place your free hand on the forearm’s palmar surface and wrap your fingers around the distal end
 Ask the patient to extend their arm slowly from the flexed position
 Before they reach 90°, begin to apply resistance
 Resisting pressure should be constant and firm
 After determining maximum resistance the patient can overcome, test the opposite elbow in the same
manner
Supination:
 Stand in front of the patient
 Support and stabilize the patients arm by cupping your hand around the posterior portion of the




elbow just proximal to the joint
 The hand will be positioned as a fist at a vertical position
Place your free hand on the forearm’s dorsal surface and wrap your fingers around the distal end
Place the thenar eminence of your resisting hand upon the dorsal surface of the patients radius at the
distal end
 Then wrap your fingers medially around the ulna
Instruct the patient to begin supination from the prone position
 As the patient moves their forearm into supinationm gradually increase your resistance
After determining maximum resistance the patient can overcome, test the opposite elbow in the same
manner
Pronation:
 Stand in front of the patient
 Support and stabilize the patients arm by cupping your hand around the posterior portion of the
elbow just proximal to the joint
 The hand will be positioned as a fist at a vertical position
 Place your free hand on the forearm’s palmar surface and wrap your fingers around the posterior
border of the ulna
 Ask the patient to begin forearm pronation from a position of supination
 As the patient moves their forearm into pronation gradually increase your resistance
 After determining maximum resistance the patient can overcome, test the opposite elbow in the same
manner
Palpate the following bony structures of the wrist and hand:
styloid process of the ulna
The styloid process of the ulna is palpated at the posterior/medial side of the wrist. Gently grasp the patient’s
hand in a hand-shaking style; with your other hand palpate the posterior aspect of the styloid process of the
ulna on the medial side of the wrist just proximal to the carpal bones of the hand; specifically the pisiform.
styloid process of the radius
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The styloid process of the radius is palpated at the posterior/lateral side of the wrist. Gently hold the
patient’s hand in your own in a pronated position. With your other hand, palpate the styloid process of the
radius just proximal on the lateral side of the carpal bones of the wrist; specifically proximal to the scaphoid.
tubercle of the radius (Lister's Tubercle)
Lister’s Tubercle is located on the dorsal surface of the radial styloid process. Using your thumb, locate the
dorsal surface of the styloid process of the radius. Lister’s tubercle will be palpated on the styloid process of
the radius immediately medial in the direction of the styloid process of the ulna.
scaphoid aka navicular (in the floor of the anatomic snuffbox):
Locate the radius styloid process, slide your thumb distally off the process, falling between the superficial
tendons and into the natural ditch where the scaphoid will be found. Passively adduct the wrist and feel for
the scaphoid to buldge into your thumb. Now abduct the wrist and feel the scaphoid disappear back into the
wrist.
lunate:
Most frquently dislocated carpel. Locate Lister's tubercle and the base of the third metacarpel. With the wrist
slightly extended, lay your thumb between these points and notice how it falls into a small cavity. This is the
location of the lunate and capitate. Set your thumb at the proximal end of this cavity. Then flex the wrist and
feel the lunate press into your finger. Next extend the wrist and feel the lunate disappear back into the wrist.
triquetral aka triquetrum:
From dorsal side of hand, locate the styloid process of the ulna. Slide distally, noting the slender ditch, before
rising to the surface of the triquetrum. Then, abduct the wrist and note how the triquetrum protrudes to the
side. Adduct and feel the bone disappear back into the wrist.
Pisiform: Run your index finger along the anteromedial aspect of the wrist crease. The pisiform is felt as the
largest and most distal bony protuberance before the surface of the palm is reached.
Trapezium: Extend your right thumb and use the tip of your left thumb to palpate along the floor of the
anatomical snuff box until the base of the 1st metacarpal is felt. Then perform opposition of the thumb to
touch the pad at the base of the little finger. The bony eminence under your thumb is the Trapezium.
Trapezoid: Hold the left hand of someone else dorsal side up and pinch the knuckle of their index finger
with your thumb on the dorsal side and your index finger on the palmar side. Hold the 2nd metacarpal with
your right hand also with your thumb on the dorsal side. Move the knuckle up and down with your left hand
and find the base of the 2nd metacarpal with your right hand. The trapezoid is just proximal to the base of the
2nd metacarpal.
capitate
The capitate lies in the distal carpal row between the third metacarpal bone (which has the largest and most
prominent base of the metacarpals) and the tubercle of the radius. It is the largest of all the carpal bones and
is palpable immediately proximal to the base of the third metacarpal (Figure 24, Hoppenfield, p. 68). When
the wrist is in a neutral position, you will find a small depression in the area of the capitate, a depression
which is actually a curve in the capitate itself. When the wrist is flexed this depressions rolls distally, and the
capitate slides out from under the lunate to create a fullness where the depression has been.
hook of the hamate
The hook of hamate is situated slightly distal and radial to the pisiform. To locate it, place the
interphalangeal joint of your thumb upon the pisiform, pointing the tip of your thumb toward the web space
between the patient’s thumb and index fingers (Figure 32, Hoppenfield, p. 71) and rest the tip of your thumb
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upon the patient’s palm. The hook of hamate lies directly under your thumb tip. But since it is buried deep
under layers of soft tissue, you must press firmly to find its rather shallow contour. The hook is of clinical
importance because it forms the lateral (radial) border of the tunnel of Guyon, which transports the ulnar
nerve and artery to the hand.
metacarpals I-V (NOTE: Fracture of the metacarpals occurs most often at the neck where the shaft
meets the head.)
The metacarpals may be palpated in order, moving from the index to the little finger. Keep your thumb on
the patient’s palm and locate the base of the second metacarpal with your index and middle fingers, and
palpate its full length. The dorsal and radial aspects are almost subcutaneous and are easily palpable (Figure
34, Hoppenfield, p. 72). Interruptions or excrescences (outgrowths) of bone along the dorsal aspect or
unusual tenderness suggest a possible fracture. The third, forth and fifth metacarpals should be palpated in
the same manner. The second and third metacarpals are anchored firmly to the carpus and are consequently
immobile, providing for the index and middle fingers the stability necessary to perform pinch movement and
fine motion. In contrast, the fourth and fifth metacarpals are mobile.
The first metacarpal should be palpated for continuity in bone structure from the anatomic snuffbox to the
metacarpophalangeal joint. It is shorter and broader than the other metacarpals. Tenderness elicited in the
joints at either end should be noted.
metacarpophalangeal joints
phalanges (14 on each hand)
proximal interphalangeal joints (PIP)
distal interphalangeal joints (DIP) (Hoppenfeld, p.73)
- Patient's hand: prone, neutral
- Use your index finger and thumb to palpate at the patient's fingertip and proceed proximally to the DIP
joint
the carpal bones (Hoppenfeld, p.65-71)
- Patient's hand: usually prone
- Your hand: thumb on the radial styloid process, index and middle fingers on ulnar styloid process
- Proceed distally in a linear fasion, keeping in mind the proximal and distal rows of the carpal bones
scaphoid (aka: navicular)
- Patient's hand: prone position and ulnar deviation.
- Your hand: supine, so that you can place your thumb on the radial styloid process
and palpate distally. The scaphoid is the first bone after the radial styloid process.
trapezium
- similar to scaphoid, but continue distally to next carpal bone
- have patient flex and extend his/her thumb
lunate
- Patient's hand: prone position, neutral
- Your hand: thumb on top of patient's wrist, fingers below
- With your thumb, find the tubercle of the radius (Lister's tubercle), which lies about 1/3 of he way
across the dorsum of the wrist from the radial styloid process.
- Use your thumb to palpate distally, in the direction of the 3rd metacarpal. It's the 1st bone
following the tubercle of the radius.
- As you palpate, ask the patient to flex and extend his/her wrist.
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capitate
- similar to lunate, but continue distally to next bone
- lies between the lunate and the 3rd metacarpal
triquetrum
- Patient's hand: radial deviation, prone
- Your hand: using your thumb and index finger, find the ulnar styloid process
- Palpate distally. Immediately you should find it on the dorsal side of the wrist
pisiform
- same as triquetrum, but lies on the palmar surface of the triquetrum
- it's a sesamoid bone that is formed within the flexor carpi ulnaris tendon
hamate (hook of the hamate)
- Patient's hand: supine, neutral
- Your hand: place the interphalangeal joint of your thumb on the piziform, pointing the tip of your
thumb toward the web space between the patient's thumb and index finger. The hook of hamate lies directy
under your thumb tip.
trapezium
- Patient's hand: prone, neutral
- Your hand: thumb on dorsal side, fingers below
- Find scaphoid and palpate distally in the direction of the index finger. It lies betwee the scaphoid
and the metacarpal of the index finger.
Palpate the following muscles and tendons of the wrist and hand:
-tendons bordering the anatomic snuffbox
1. abductor pollicis longus (Hoppenfeld, p.77, 97)
- Patient's hand: prone with thumb abducted (thumb pointed at the floor
- Your hand: with your fingers on the dorsum of the patient's hand, place your thumb on the radial
styloid process and proceed toward the base of the thumb
- ask the patient to point his/her thumb at the floor, relax, then repeat while palpating
2. extensor pollicis brevis: can be palpated on the radial border of the anatomical snuff box.
Located on the dorsal, radial side of hand, palpate the inner boarder of the anatomical snuff box. Tendon
is more easily palpated when the thumb is in extended position.
3. extensor pollicis longus: located on the dorsum of the hand, can be palpated on the ulnar
side of the anatomical snuff box. There is about a 45 degree angle between it and extensor pollicis brevis.
-tendons lying next to the radial side of the radial tubercle
1. extensor carpi radialis longus - Extensor carpi radialis longus/brevis, located on the
dorsum of the hand- ask client to clench fist. The tendons then stand out slightly on radial side of the radial
dorsal tubercle.
2. extensor carpi radialis brevis
-tendons which function in extension of the fingers
1. extensor indicis
2. extensor digitorum communis
-tendons which function in extension of the fingers
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3. extensor digiti minimi—have patient be seated or comfortable. To palpate, have patient
rest his palm on the table or desk and ask him to raise his little finger. The movement of the extensor digiti
minimi can be felt in the depression radial and slightly distal to the ulnar styloid process on the dorsum of
hand. Perform bilateral examination with the other hand. Hoppenfield p.79
-tendon in the groove between the apex of the styloid process of the ulna and the ulnar head
1. extensor carpi ulnaris—patient seated or comfortable. Palpating the ulnar aspect of the
dorsum of hand. Ask patient to extend wrist and deviated ulnarly. It is aso palpable if the patient makes an
extended fist then deviate ulnarly. Palpate for the extensor carpi ulnaris from its insertion on the base of the
5th metacarpal, to its origin proximally passing over the ulnar styloid process and up the forearm. Be sure to
examine bilaterally (with other hand. Hoppenfield p.80
-tendons involved in flexion of the hand at the wrist
1. flexor carpi ulnaris—patient seated or comfortable. Palpating the ulnar aspect of the palm of hand. Ask
patient to flex his wrist against your resistance. Palpate the tendon from the wrist, moving proximally up the
forearm. Be sure to examine bilaterally (with other hand). Hoppenfield p.80
Moving across the anterior aspect, the examiner may be able to palpate the long flexor tendons in a lateral
to medial direction:
Flexor carpi radialis, flexor pollicis longus, flexor digitorum siperficialis, flexor digitorum profundus,
palmaris longus, and flexor carpi ulnaris (inserts into pisiform bone)
Palmaris Longus lies over the tendons of the flexor digitorum superficialis, which lie over the tendons of the
flexor digitorum profundus. It lies between the flexor carpi ulnaris and flexor carpi radialis
It can be palpated by touching the pads of the fifth and first fingers and flexing the wrist. The tendon, if
present, will be very visible.
Origin- medial epicondyle of humerus and inserts into distal half of flexor retinaculum and palmar
aponeurosis.
Action- flexion of hand at wrist
Flexor Carpi Radialis- It runs just laterally to flexor digitorum superficialis.
On a person's distal forearm, right before the wrist, they will see either two or three tendons. Flexor carpi
radialis is the most lateral (closest to the thumb) of these. (The most medial one is flexor carpi ulnaris, and
the middle one, if it exists is palmaris longus.)
Origin- Medial epicondyle of humerus and inserts into base of second metacarpal
Action- flexes and abducts hand at wrist
-tendons involved in flexion of the fingers
1. Flexor Digitorum superficialis- To test flexor digitorum superficialis, one finger is flexed at the proximal
interphalangeal joint against resistance, while the remaining three fingers are held fully extended (to inactive
flexor digitorum profundus).
Origin-Humoulnar head: medial epicondyle of humerus, ulnar collateral ligament, and coronoid process of
ulna and the Radial head: superior half of anterior border of radius and inserts into bodies of middle
phalanges of digits 2-5.
Action- Flexes middle phalanges at proximal interphalangeal joints of medial four digits; acting more
strongly, it also flexes proximal phalanges at metacarpophalangeal joints and hand
2. flexor digitorum profundus - Shake hands with your partner and flex the elbow 90 degrees. Palpate
through the area between the carpi ulnaris, radialis and palmaris longus bellis. Passive flexion of the wrist
softens the tissue and may allow for easier access. Along the anterior surface of the wrist, explore on either
side of the superficial tendons of the flexor carpi radialis and palmaris longucs and locate a few of the deeper
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digitorum tendons. Along the ulnar shaft, the medial aspect of the digitorums is superficial. Locate this
tissue by palpating alongside the ulnar shaft as you ask your partner to alternately press together her pinkie
and thumb tips.
-muscles of the thenar eminence
1. abductor pollicis brevis (superficial layer) - Locate the base of the thumb. Palpate
around the surface of the first metatarsal bone as well as the webbing between your thumb and finger. Ask
your partner to squeeze her thumb and pinkie finger together. With contraction note how the eminence
becomes dense and compact. Brevis will be the superficial muscle.
2. opponens pollicis (middle layer) - See above. This will be in the middle layer.
3. flexor pollicis brevis (deep layer)
The flexor pollicis brevis cannot be individually palpated because it lies deep to the other muscles of
the thenar eminance. Its action (flexion of the thumb) can be tested by having the patient move the thumb
toward the hypothenal eminence. The practitioner should then use his or her thumb to attempt to pull the
patient's thumb out of flexion.
Passive range of motion in which the practitioner holds the proximal and distal phalanges and slowly
moves the digit into flexion should result in 90 degrees of flexion at the interphalangeal joint and 50 degrees
of flexion at the metacarpophalangeal joint.
-muscles of the hypothenar eminence
The hypothenar eminence runs from the base of the little finger to the pisiform. The three muscles in this
zone are indistinguishable from each other. The compartment is supplied by the ulnar nerve, so compression
of the nerve may cause atrophy or altered sensation.
1. abductor digiti minimi
To test finger abduction, have the patient spread his or her fingers away from the midline of the hand. The
practitioner then tries to force the ring finger and little finger together.
2. opponens digiti minimi
To test opposition, instruct the patient to touch the tops of the thumb and little finger together. The
practitioner holds the patient's thenar eminence with one hand and the hypothenar eminence with the other
hand and tries to pull the patients fingers apart by forcing the metacarpals underlying the eminences away
from the midline of the hand. The opponens digiti minimi acts at the carpometacarpal joint and not on the
phalanges.
3. flexor digiti minimi: Have the patient rest his arm upon a table and ask him to raise
his little finger. The movement of the extensor digit minimi (lies over the radialulnar articulation)
can be felt in the depression radial to the styloid process. Like the extensor indicis, the extensor
digit minimi can move independently. This independent movement is demonstrable by having the
patient extend both his index and little fingers while keeping the other fingers in flexion.
Palpate the four bony prominences which define the space known as the Carpal Tunnel and identify
their positions, i.e. medial and lateral.
-pisiform: with the hand in the anatomical position probe the anterolateral region of the
triquetrium, you will feel a small sesmoid bone. The pisiform is formed within the flexor carpi
ulnaris tendon. Remember that the triquetrium lies just distal to the ulnar styloid process, and the
triquetrium lies under the pisiform.
-tubercle of the scaphoid: scaphoid is also know as the navicular. It is situated on the radial
side of the carpus. It represents the floor of the snuff box. The navicular is the largest bone in the
proximal carpal row. Have the patient ulnar deviate the wrist which causes the navicular to slide out
from under the radial styloid process that it become palpable.
Palpation of the hook of the Hamate
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The Hamate is one of the carpal bones of the wrist. It has a hook that is on the palmar side of the bone. It is
located distal and radial to the pisiform.
To locate, place the interphalangeal joint your thumb upon the pisiform, pointing the tip of your thumb
toward the web space between the patient’s thumb and index finger, rest the tip of your thumb upon the
patient’s palm. The hook of the hamate lies directly under your thumb tip, it hard to feel because it is buried
beneath layers of soft tissue. Press firmly to feel its shallow contour. (Hoppenfeld pp 71)
Palpation of the tubercle of the trapezium
Often the tubercle of the trapezium is difficult to distinguish from the tubercle of the scaphoid. The tubercle
of the trapezium is located proximal to the 1st metacarpal of the thumb and distal to the hand crease.
Demonstrate two simple tests used to confirm a diagnosis of Carpal Tunnel syndrome:
-Tinel Sign - elicits or reproduces pain in the distribution of the median nerve: With your finger,
percuss (tap) lightly over the course of the median nerve in the carpal tunnel which is on the lower edge of
the palm a little distal to the flexor (hand) crease. The course of the medial nerve is straight down from the
middle finger. (Bates 555)
-Phalen's Test - reproduces tingling of the fingers- Hold the patient's wrists in acute flexion for 60
seconds. Or alternatively , ask the patient to press the backs of both hands together to form right
angles. These maneuvers compress the median nerve.
If numbness and tingling develop over the distribution of the median nerve (e.g. plamar surface of
thumb/index and middle and part of ring fingers) the sign is positive, suggestion carpal tunnel syndrome.
Demonstrate the following movements at the wrist joint:
-Flexion of the hand- With the patient's forearm stabilized, place the wrist in extension and place your
fingertips in the patients palm. Ask the patient to flex the wrist against gravity, then against resistance.
-extension of the hand- With the patient's forearm stabilized, place the wrist in flexion and put your
hand on the patient's dorsal metacarpals. As the patient to extend the wrist against gravity, then against
graded resistance.
Radial Deviation: with the patient’s palm up, grab his/her forearm just above the wrist joint with one hand
and grab his/her hand with your other hand. Move the patient’s wrist so the angle between the radius and
thumb decreases.
Ulnar Deviation: with the patient’s palm up, grab his/her forearm just above the wrist joint with one hand
and grab his/her hand with your other hand. Move the patient’s wrist so that the angle between the ulna and
the little finger decreases.
-In rheumatoid arthritis, ulnar deviation is common (hand deviates toward the ulna)
-Ulnar deviation allows you to palpate the navicular
-Ulnar deviation (30 degrees) is greater than radial deviation (20 degrees), because the ulna doesn’t
articulate directly with the carpus.
What is the clinical significance of a restricted ulnar deviation?
-Restricted ulnar deviation of the wrist may be due to a comminuted Colle’s fracture (recall
that a Colle’s fracture is a fracture at the distal end of the radius).
Midline of the Palm: line through the middle of the middle finger that divides the hand into right and left
halves
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Demonstrate the following movements at the 1st metacarpophalangeal joint:
-flexion of the thumb
Have the patient move his thumb across him, palm and touch the pad at the base of the little finger. This
motion (transpalmer abduction) tests active flexion of the metacarpophalangeal and interphalangeal joints of
the thumb.
-extension of the thumb
Ask the patient to move his thumb laterally away from his fingers. There should be an angle of about 50°
between the index finger and thumb (Also known as radial abduction).
-abduction of the thumb
Instruct the patient to spread his thumb anteriorly away from his palm and then to return it to the palm.
Normally, the thumb and index finger form an angle of 70° when the thumb is in full abduction. Bringing the
thumb back to the palm demonstrates full adduction.
opponens: patient should be able to bring the tip of the thumb to the tips of all other fingers.
Demonstrate the following movements at the metacarpophalangeal joints II-V.
flexion of the digits (all joints): have patient make a fist, movement should be uniform.
-extension of the finger: extend the fingers at the knuckle joint (metacarpophalangeal)
-abduction of the finger: move fingers at knuckle joint away from each other
-adduction of the finger: move fingers at knuckle joint back toward each other
-rotation of the finger- Have patient extend finger. Place your hand on the metacarpophalangeal joint to
stabilize the joint. Grab the finger and rotate it medially and laterally. Note any pain or discomfort. Compare
with other fingers/hand.
Demonstrate the following movements at the interphalangeal joints:
-flexion of the interphalangeal jointsProximal IP joint- Stabilize finger by holding it between the metacarpophalangeal joint and the proximal IP
joint. Flex the finger at the proximal IP joint. Note any resistance to mmt/pain.
Distal IP joint- Stabilize the finger by holding it between the proximal and distal IP joints. Flex the finger at
the distal IP joint. Note any resistance to mmt/pain.
-extension of the interphalangeal jointsProximal IP joint- Stabilize finger by holding it between the metacarpophalangeal joint and the proximal IP
joint. Extend the finger at the proximal IP joint. Note any resistance to mmt/pain.
Distal IP joint- Stabilize the finger by holding it between the proximal and distal IP joints. Extend the finger
at the distal IP joint. Note any resistance to mmt/pain.
Briefly describe the following pathologies of the finger joints:
Deformities can result from generalized disorders (eg, arthritis) or dislocations, fractures, and other localized
disorders. Most nontraumatic localized disorders can be diagnosed by physical examination. Once a hand
deformity becomes firmly established, it cannot be significantly altered by splinting, exercise, or other
nonsurgical treatment.
Mallet Finger
Mallet finger is a flexion deformity of the distal interphalangeal joint preventing extension (see Fig. 1: Hand
Disorders: Mallet finger. ).
Fig. 1
Mallet finger.
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Impaired flexion at the distal interphalangeal joint can result from a tendon injury or bony avulsion.
This deformity results from an extensor tendon rupture or an avulsion fracture of the distal phalanx. Closed
injuries may be treated with splinting that holds the distal interphalangeal (DIP) joint in extension and leaves
the proximal interphalangeal (PIP) joint free. Avulsion fractures are usually united after 6 wk, but pure
tendon injuries require an additional 2 to 4 wk of night-time splinting. Surgery may be required if there is a
fracture that involves a large proportion of the articular surface or if the joint is subluxated.
Swan-Neck Deformity
A swan-neck deformity consists of hyperextension of the PIP joint, flexion of the DIP joint, and, sometimes
flexion of the metacarpophalangeal joint (see Fig. 2: Hand Disorders: Boutonnière and swan-neck
deformities. ).
Fig. 2 Boutonnière and swan-neck deformities.
Although characteristic in RA, swan-neck deformity has several causes, including untreated mallet finger,
laxity of the ligaments of the volar aspect of the PIP joint, spasticity of intrinsic hand muscles, rupture of the
flexor tendon of the PIP joint, and malunion of a fracture of the middle or proximal phalanx. The inability to
correct or compensate for hyperextension of the PIP joint makes finger closure impossible and can cause
severe disability. Treatment is aimed at correcting the underlying cause when possible (eg, correcting the
mallet finger or any bony malalignment, releasing spastic intrinsic muscles). Mild deformities in patients
with RA may be treated with a functional ring splint.
True swan-neck deformity does not affect the thumb, which has only one interphalangeal joint. However,
severe hyperextension of the interphalangeal joint of the thumb with flexion of the metacarpophalangeal
(MCP) joint can occur; this is called a duck bill, Z (zigzag) type, or 90-angle deformity. With simultaneous
thumb instability, pinch is greatly impaired. This deformity can usually be corrected by interphalangeal
arthrodesis along with tendon reconstruction at the MCP joint.
Boutonnière Deformity
(Buttonhole Deformity)
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A boutonnière deformity consists of flexion of the PIP joint accompanied by hyperextension of the DIP joint
(see Fig. 2: Hand Disorders: Boutonnière and swan-neck deformities. ).
This deformity can result from tendon laceration, dislocation, fracture, osteoarthritis, or RA. Classically, the
deformity is caused by disruption of the central slip attachment of the extensor tendon to the base of the
middle phalanx, allowing the proximal phalanx to protrude (“buttonhole”) between the lateral bands of the
extensor tendon. Initial treatment consists of splinting, but it must occur before scarring and fixed deformities
develop. Surgical reconstruction often cannot restore normal motion but may decrease the deformity and
improve hand function.
Be able to find and palpate the following pulses:
BRACHIAL ARTERY - The brachial a. is a continuation of the axillary a. and runs between the biceps and
triceps brachii. Its pulse can be felt between these muscles on the medial side of the arm. Before the
brachial artery branches off to the radial and ulnar aa, its pulse can be felt at the elbow, just medial to the
biceps brachii tendon.
1)
Seated or supine. Abduct the arm and place your finerpads on the medial side of the arm. A helpful
guide is the shallow dip which forms between the biceps and triceps.
2)
Gently press your fingers toward the shaft of the humerus to feel the brachial pulse.
3) The brachial pulse can also be detected just medial to the distal tendon of the biceps brachii.
RADIAL ARTERY (in the anatomical snuffbox and on the anterior wrist between the tendons of
brachioradialis and FCR) – The radial a. is often used for taking a pulse. It is detectable on the anterior wrist
between the tendon of the flexor carpi radialis and the shaft of the radius. Locate the radial pulse by placing
two fingerpads on the flexor side of the wrist. Move laterally and gently press to feel the pulse.
* The ANATOMICAL SNUFFBOX lies just dorsal and distal to the radial styloid process. The tendons
bordering it become more prominent when the thumb is extended. The RADIAL BORDER of the snuffbox
is composed of the abductor pollicis longus and the extensor pollicis brevis tendons which pass over the
radial styloid process and etch a small groove on its lateral aspect. The ULNAR BORDER of the snuffbox is
the extensor pollicis longus tendon and the floor the navicular bone. Any tenderness elicited on the floor of
the snuffbox suggests a fracture. Occasionally, the deep branch of the radial a. is palpable where it crosses
the navicular bone. The terminal branches of the superficial radial nerve are also palpable where they cross
the extensor pollicis longus tendon.
ULNAR ARTERY - The ulnar a. is found proximal to the pisiform and medial to the plamaris longus
tendon. Its pulse may not be as easily accessible as the radial pulse. Locate the ulnar pulse by moing your
fingerpads to the medial side of the flexor surface.
Discuss the Allen test to determine radial and ulnar artery competency.
Ask the patient to open and close his fist quickly several times, and then to squeeze his fist tightly so that the
venous blood is forced out of the palm. Place your thumb over the radial artery and your index and middle
finger over the ulnar artery, and press them against the underlying bones to occlude them. With the vessels
still occluded, instruct the patient to open his hand. The palm of the hand should be pale. Then release one of
the arteries at the wrist, while maintaining the pressure upon the other one. Normally, the hand flushes
immediately. It does not react, or if it flushes very slowly the released is partially or completely occluded.
The other artery should be tested similarly, and the opposite hand checked for comparison. A modified
version of the Allen test permits the evaluation of the patency of the digital arteries.
Discuss a modified version of the Allen test to determine digital artery competency.
A modified version of the Allen test permits the evaluation of the patency of the digital arteries. Instruct the
patient to open and close his fist quickly, several times, and then to hold it tightly closed to force the venous
blood from the palmar aspect of the fingers. With the hand still in a fist, place your thumb and index finger
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on the sides of the base of the involved finger, pressing them to the bone to occlude the digital arteries. When
the patient opens his hand, the test finger should be paler than the others. The finger normally flushes when
pressure is released from one of the arteries. If it does not, the patency of that digital vessel is in question.
The other digital artery should be tested in the same way and the corresponding finger on the opposite hand
checked for comparison.
Identify the following veins of the upper extremity:
-cephalic vein: The cephalic vein is located in the subcutaneous tissue along the anterolateral surface
of the proximal forearm and arm and is often visible through the skin. The cephalic vein passes superiorly
between the deltoid and pectoralis major in the deltopectoral groove and then in the deltopectoral triangle,
where it empties into the termination of the axillary vein.
-basilic vein: The basilic vein is a large superficial vein of the upper limb that helps drain parts of
hand and forearm. It originates on the medial (ulnar) side of the dorsal venous network of the hand, and it
travels up the base of the forearm and arm. The cephalic and basilic veins are joined across the cubital fossa
by the median cubital vein. Most of its course is superficial; it generally travels in the fat and other fasciae
that lie superficial to the muscles of the upper extremity. Before reaching the axilla, it pierces the deep fascia
to join the brachial vein.
-median cubital vein: is formed by branches of the basilic and cephalic veins across the cubital fossa
superficial to the bicipital aponeurosis. It is a superficial vein sometimes used for venipuncture.
-dorsal venous arch: On the dorsum of the hand, the dorsal venous arch collects venous drainage from
the posterior surface of the hand and digits. Both the basilic and cephalic veins arise from the dorsal venous
arch.
Review the innervation of the muscles of the upper extremity.
Elbow nerve supply reflex tests:
** Excessive response may be due to an upper motor neuron lesion (ex: central nerve injury from a stroke),
and diminished response may be due to a lower motor neuron problem (ex: peripheral nerve injury).
-Biceps Brachii (Musculocutaneous n.: C5-C6, primarily C5)
Purpose: Check functioning of C5 nerve root
Technique: Patient sitting. Place the patient’s forearm over your opposite arm so that it rests on your
forearm, have them bend their elbow slightly and fully relax their arm. With your hand supporting the
patient’s arm under the elbow’s medial side, place your thumb on the tendon of the biceps in the cubital
fossa (you should be able to feel the tendon of the biceps stand out under your thumb when their elbow is
slightly flexed). Apply a brisk tap (on your own thumb nail) with the narrow end of the reflex hammer.
Test reflex on both sides; they should be equal. Record as normal, increased, decreased.
Response: Normal – Biceps should jerk slightly, small flexion response of the elbow.
-Brachioradialis (Radial n.: C5-C6, primarily C6)
Purpose: Check functioning of C6 nerve root
Technique: Patient position and arm supported in same way as for Biceps Brachii. Using the broad side of
the hammer, strike the brachioradialis tondon, which is accessible at the distal end of the radial side of the
forearm just proximal to the styloid process.
Test reflex on both sides; they should be equal. Record as normal, increased, decreased.
Response: Slight elbow flexion response
-Triceps Brachii (Radial n.:C7-C8, primarily C7)
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Purpose: Check functioning of C7 nerve root
Technique: Patient position and arm supported in same way as for Biceps Brachii. Make sure the arm is
fully relaxed. Using the narrow side of the hammer, tap the triceps tendon where it crosses the olecranon
fossa just proximal to the olecranon process.
Response: Slight elbow extension response
Discuss the following common areas of nerve entrapment:
Suprascapular Notch: entrapment compresses Suprascapular N. (C5-C6)
The suprascapular notch is located in the lateral part of the upper border of the scapula, just next to the base
of the coracoid process. The superior transverse scapular ligament converts the notch into a foramen. The
foramen serves as a passage way for the suprascapular nerve(C5-C6), which runs laterally across the
posterior cervical triangle. This nerve supplies the supraspinatus muscle and the shoulder joint, then descends
through the notch of the scapular neck to innervate the infraspinatus muscle. Entrapment of this nerve causes
postero-lateral shoulder pain with weakness.
Carpal Tunnel: entrapment compresses Median N. (C5-T1)
The carpal tunnel is formed by the flexor retinaculum (anteriorly) and carpal bones (posteriorly). The tunnel
is a passageway for the medial nerve and the tendons of flexor pollicis longus, flexor digitorum profundus,
and flexor digitorum superficialis muscles. Entrapment of the median nerve(C5-T1) leads to carpal tunnel
syndrome causing pain and numbness of the structures innervated by the median nerve. The entrapment can
be caused by reduced size of the osseofibrous carpal tunnel resulting from inflammation of flexor
retinaculum, arthritic changes in carpal bones, or inflammation and thickening of the synovial sheaths of the
flexor tendons.
Cubital (Ulnar) Tunnel: entrapment compresses Ulnar N. (C7-T1)
The cubital tunnel is formed by the medial epicondyle of the humerus and the muscles and ligaments
surrounding the bone (tendinous arch that joins the humeral and ulnar heads formed by the flexor carpi
ulnaris muscle attachments.) The ulnar nerve(C7-T1) passes through this tunnel posterior to the medial
epicondyle (funny bone). Entrapment of the ulnar nerve leads to cubital tunnel syndrome that usually
produces numbness and tingling in the medial part of the palm and the ring and little fingers.
-Tunnel of Guyon (also known as handlebar’s palsy in bikers)
On the palm (anterior surface of the hand), the ulnar nerve passes under the pisohamate ligament between
two small wrist bones, the pisiform and hamate. The roof is formed by the volar carpal ligament and
pisohamate ligament and the ulnar nerve bifurcates within the canal into superficial and deep branches. The
Ulnar Nerve supplies sensation to the little finger and half of the ring finger. Guyon's Canal syndrome is
numbness and tingling in the ring and small fingers caused by irritation or compression injury of the ulnar
nerve in the Guyon's canal. This is a common injury for bikers (where it is known as 'handlebars palsy') since
they often lean their weight forward on their handlebars and put the force right on this tunnel.
p. 844 Moore & Dalley – Ulnar Canal Syndrome (Guyon Tunnel Syndrome) Compression of the ulnar nerve
may occur at the wrist where it passes between the pisiform and the hook of hamate. The depression between
these bones is converted by the pisohamate ligament into an osseofibrous tunnel, the ulnar canal. Ulnar
canal syndrome is manifest by hypoesthesia in the medial one and a half fingers and weakness of the
intrinsic muscles of the hand. “Clawing” of the 4th and 5th fingers (hyperextension at the
metacarpophalangeal joint with flexion at the proximal interphalangeal joint) may occur, but—in
contradistinction to proximal ulnar nerve injury—their ability to flex is unaffected and there is no radial
deviation of the hand.
Identify the dermatomes in the upper extremity and how to test the integrity of sensation in the upper
extremity.
See pictures on pp. 746, 747 Moore & Dalley – As a consequence of plexus formation, two patterns of
cutaneous innervation occur in the upper limb: (1) segmental innervation (dermatomes) by spinal nerves and
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(2) innervation by multisegmental peripheral (named) nerves. Dermatomes are easiest to visualize if the
limb is placed in its initial embryonic position (abducted with the thumb directed superiorly).
To test the integrity of sensation in each dermatome/spinal nerve, palpate the skin covering the region of that
specific dermatome.
Locate the cubital and axillary group of lymph nodes and describe the direction of drainage of lymph
from the upper extremity.
Cubital lymph nodes P 749, Moore & Dalley – Superficial lymphatic vessels arise from lymphatic plexuses
in the skin of the fingers, palm, and dorsum of the hand and ascend mostly with the superficial veins, such as
the cephalic and basilic veins. Some vessels accompanying the basilic vein enter the cubital (lymph) nodes,
located proximal to the medial epicondyle and medial to the basilic vein. Efferent vessels from these lymph
nodes ascend in the arm and terminate in the humeral (lateral) axillary lymph nodes.
Palpation directions: Have patient sitting. Flex patient’s forearm, while cupping elbow with left arm. Find
epicondyles of the humerus by putting hand around the humerus posteriorly and sliding hand down (putting
pressure on the arm) until your fingers hit the lateral and medial epicondyles. Beginning at the medial
epicondyle, slide fingers across about 1 cm. Cubital lymph nodes lie just medial to the area where the median
cubital vein branches off from the basilic vein.
Axillary lymph nodes P 773, Moore & Dalley – Efferent lymphatic vessels from the pectoral (anterior)
nodes, subscapular (posterior) nodes, humeral (lateral) nodes pass to the central nodes – the only
palpable axillary group of lymph nodes. The central nodes are three or four large nodes situated deep to the
pectoralis minor near the base of the axilla, in association with the second part of the axillary artery. Efferent
vessels from the central nodes pass to the apical nodes.
The apical nodes are located at the apex of the axilla along the medial side of the axillary vein and the first
part of the axillary artery. The apical nodes receive lymph from all other groups of axillary lymph nodes as
well as from lymphatics accompanying the proximal cephalic vein. Efferent vessels from the apical group of
nodes traverse the cervicoaxillary canal. These efferent vessels ultimately unite to form the subclavian
lymphatic trunk, although some vessels may drain en route through the clavicular (infraclavicular and
supraclavicular) nodes.
Once formed, the subclavian trunk may be joined by the jugular and bronchomediastinal trunks on the right
side to form the right lymphatic duct, or it may enter the right venous angle independently. On the left side,
the subclavian trunk most commonly joins the thoracic duct.
Palpation directions: Have patient sitting, ask patient to relax the shoulder and hold patient’s arm with your
left arm. Elevate patient’s arm slightly below the level of the clavicle. Reach high into the apex of the axilla
(armpit) and place fingers (pointing up) in toward the chest wall.
What is the clinical significance of referred pain to the shoulder and back of the neck?
p. 512, Moore & Dalley – Sudden, forceful extension of the neck can also injure the vertebral column and
spinal cord. Head butting or illegal face blocking in football may lead to a hyperextension injury of the
neck. Such severe hyperextension is most likely to injure posterior parts of the vertebrae, fracturing by crush
or compression of the vertebral arches and their processes. Fractures of cervical vertebrae may radiate pain to
the back of the neck and scapular region because the same spinal sensory ganglia and spinal cord segments
receiving pain impulses from the vertebrae are also involved in supplying neck muscles. Hyperextension
(“whiplash” injury) of the neck also occurs during rear-end motor vehicle collisions. In these types of
hyperextension injuries, the anterior longitudinal ligament is severely stretched and may be torn.
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