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By: Dr. Mujahid Khan

2 Lymphatic Drainage of Breast

Its importance is the relation to the spread of cancer from breastThe lymph vessels from the medial
quadrants of breast pierce 2nd, 3rd and 4th intercostal spacesEnter the thorax to drain into the internal
thoracic lymph nodes

3 Lymphatic Drainage of Breast

The lymph vessels from the lateral quadrants of the breasts drain into pectoral group of axillary
nodesCancer occurring in the lateral quadrant of breast tends to spread to the axillary nodesLymph
nodes of axilla can be removed surgically but thoracic metastases are difficult or impossible to treat

4 Lymphatic Drainage of Breast

60% of breast cancers occur in the upper lateral quadrantThe lymphatic spread of the cancer to the
opposite breast, abdominal cavity or to the root of the neck is caused by obstruction of the normal
lymphatic pathways by malignant cells or destruction of lymph vessels by surgery or radiotherapy

5 Lymphatic Drainage of Breast

In localized breast cancers, simple mastectomy or lumpectomy, followed by radiotherapy of axillary
lymph nodesThe excised mass includes following:The large area of skin overlying the tumor including the
nippleAll the breast tissueThe pectoralis major muscle and fascia

6 Lymphatic Drainage of Breast

The excised mass includes following:Pectoralis minor and fasciaAll the fat, fascia and lymph nodes in the
axillaFascia covering the upper part of the rectus sheathSerratus anterior, subscapularis and latissimus
dorsi musclesAxillary blood vessels, brachial plexus and nerves to serratus anterior and latissimus dorsi
are preserved

7 Fractures of the Clavicle

Clavicle is exposed to trauma because of its positionIt is the most commonly fractured bone in the
bodyIts fracture usually occur as a result of a fall on the shoulder or outstretched handThe force is
transmitted along the clavicle and breaks it at the weakest point, that is the junction of the middle and
outer thirdAfter the fracture, the lateral fragment is depressed by the weight of the arm and is pulled
medially and forward

8 Fractures of the Clavicle

The medial end is tilted upward by the sternocleidomastoid muscleThe close relationship of the
supraclavicular nerves to the clavicle may result in their involvement is callus formation after the
fractureThis may be the cause of persistent pain over the side of the neck

9 Compression of Brachial Plexus

The interval between the clavicle and the first rib in some patients may become narrowed and thus is
responsible for compression of nerves and blood vessels

10 Fractures of ScapulaThey are usually occur in a runover accident victims or occupants of automobiles
involved in crashesInjuries are usually associated with fractured ribsMost fractures of scapula require
little treatment because the muscles on the anterior and posterior surfaces adequately splint the

11 Humeral Head FractureHumeral head fracture can occur during the process of anterior and posterior
dislocations of the shoulder jointThe fibrocartilaginous glenoid labrum of the scapula produces the
fractureLabrum can become jammed in the defect making the reduction of the shoulder joint difficult

12 Greater Tuberosity Fracture

It can be fractured by direct trauma, displaced by the glenoid labrum during dislocation of shoulder
jointWhen associated with a shoulder dislocation, severe tearing of the rotator cuff with the fracture
can result in the greater tuberosity remaining displaced posteriorly after the shoulder joint is
reducedOpen reduction of the fracture is necessary to attach the rotator cuff back into place

13 Lesser Tuberosity Fracture

Lesser tuberosity fracture accompanies posterior dislocation of the shoulder jointThe bone fragment
receives the insertion of the subscapularis tendon, a part of the rotator cuff

14 Surgical Neck Fracture

Surgical neck of the humerus lies immediately distal to the lesser tuberosityIt can be fractured by a
direct blow on the lateral aspect of the shoulderIn indirect manner by falling on the stretched hand

15 Fracture of Shaft of Humerus

Fractures of humeral shaft is commonThe radial nerve can be damaged where it lies in the spiral groove
on the posterior surface of the humerus under cover of the triceps muscle

16 Fracture of the Distal End of Humerus

Supracondylar fractures are common in childrenOccur when the child falls on the outstretched hand
with the elbow partially flexedInjuries to the median, radial and ulnar nerves are commonDamage to or
pressure on the brachial artery can occur at the time of fracture or from swelling of the surrounding

17 Fracture of the Distal End of Humerus

The circulation to the forearm may be interferedLeading to Volkmann’s ischemic contractureUlnar nerve
can undergo irritation on the irregular bony surface after the bone fragments are reunited

18 Rotator Cuff Tendinitis

Rotator cuff consists of the tendons of the subscapularis, supraspinatus, infraspinatus and teres minor
musclesThese muscles are fused to the underlying capsule of the shoulder jointPlays an important role
in stabilizing the shoulder jointLesions of the cuff are a common cause of pain in the shoulder region

19 Rotator Cuff Tendinitis

Excessive overhead activity of the upper limb may be the cause of tendinitisDuring abduction of the
shoulder joint, the supraspinatus tendon is exposed to friction against the acromionUnder normal
conditions, the amount of friction is reduced to a minimum by the large subacromial bursa

20 Rotator Cuff Tendinitis

Degenerative changes in the bursa are followed by degenerative changes in the underlying
supraspinatus tendonThese may extend into the other tendons of the rotator cuffClinically the condition
is known as subacromial bursitis, supraspinatus tendinitis or pericapsulitisIt is characterized by the
presence of a spasm of pain in the middle range of abduction

21 Rotator Cuff Tendinitis

In advanced cases, the necrotic supraspinatus tendon can become calcified or ruptureCauses serious
interference in the normal abduction of the shoulder jointPatient will be unable to initiate the abduction
of the armIf the arm is passively assisted for the first 15° of abductionDeltoid can then take over and
complete the movement to a right angle

22 Sternoclavicular Joint Injuries

The strong costoclavicular ligament firmly holds the medial end of the clavicle to the first costal
cartilageViolent forces directed along the long axis of the clavicle usually result in fracture of the
boneDislocation of sternoclavicular joint takes place occasionally

23 Sternoclavicular Joint Injuries Anterior Dislocation

It results in the medial end of the clavicle projecting forward beneath the skinIt may also pulled upward
by the sternocleidomastoid muscle

24 Sternoclavicular Joint Injuries Posterior Dislocation

It usually follows direct trauma applied to the front of the joint that drives the clavicle
backwardDisplaced clavicle may press on the trachea, esophagus and major vesselsIf the costoclavicular
ligament ruptures completely, it is difficult to maintain the normal position of the clavicle once
reduction has been accomplished

25 Acromioclavicular Joint Injuries

A severe blow on the point of the shoulder, during blocking or tackling in football can result in the
acromion being thrust beneath the lateral end of the clavicle, tearing the coracoclavicular ligamentThe
condition is known as shoulder separationThe displaced outer end of clavicle is easily palpableThe
dislocation is easily reduced but withdrawal of support results in redislocation

26 Stability of Shoulder Joint

The shallowness of the glenoid fossa and lack of support provided by weak ligaments make this joint
unstableIts strength almost entirely depends on the tone of the short muscles that bind the upper end
of humerus to scapulaThe tendons of these short muscles form the rotator cuffThe least supported part
of the joint lies in the inferior location

27 Anterior Dislocation of Shoulder Joint

Sudden violence applied to the humerus with joint fully abducted tilts the humeral head downward onto
the inferior week part of the capsuleThe humeral head comes to lie inferior to the glenoid fossaThe
strong flexors and adductors of the shoulder pull the humeral head forward and upward

28 Posterior Dislocation of Shoulder Joint

Posterior dislocations are rareUsually caused by direct violence to the front of the jointThe rounded
appearance of the shoulder is lostA subglenoid displacement of the humeral head can cause axillary
nerve damageDownward displacement of humerus can also stretch and damage the radial nerve

29 Dermatomes and Cutaneous Nerves

Dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper
limbC7 dermatome is situated on the middle fingerC8, T1 and T2 dermatomes are along the medial
margin of the limb

30 Dermatomes and Cutaneous Nerves

Skin over the shoulder point and halfway down the lateral surface of deltoid is supplied by
supraclavicular nerves C3 & 4Pain may be referred to this region as a result of inflammatory lesions
involving diaphragmatic pleura or peritoneumPleurisy, peritonitis, subphrenic abscess or gall bladder
disease may be responsible for shoulder pain

31 Venipuncture and Blood Transfusion

The superficial veins are used for venipuncture, transfusion and cardiac catheterizationWhen the patient
is in shock, the superficial veins may not be visibleThe cephalic vein lies in the superficial fascia posterior
to the styloid process of radius

32 Venipuncture and Blood Transfusion

The median cubital vein in the cubital fossa is separated from the underlying brachial artery by the
bicipital aponeurosisThis protects the artery from a mistaken injection of irritating drugs into itIn
extreme hypovolemic shock, excessive venous tone may inhibit venous blood flow and thus delay the
introduction of intravenous blood into the vascular system

33 Lymphangitis and Lymphadenitis

Once the infection reaches the lymph nodes, they become enlarged and tender, known as
lymphadenitisMost of the lymph vessels from the fingers and palm pass to the dorsum of the hand
before passing up into the forearmThe frequency of inflammatory edema, or abscess formation may
occur on the dorsum of the hand after infection of the fingers and palm

34 Biceps Brachii and Osteoarthritis of the Shoulder Joint

The tendon of the long head of biceps is attached to the supraglenoid tubercle within the shoulder
jointAdvanced osteoarthritic changes in the joint can lead to erosion and fraying of the tendon by
osteophytic outgrowthsRupture of the tendon may also occur

35 Fractures of Radius and Ulna

Fracture of the head of radius can occur from fall on the outstretched handFractures of neck of the
radius occur in young children from falls on the outstretched handFractures of the shafts of the radius
and ulna may or may not occur togetherDisplacement of the fragment is usually considered

36 Fractures of Radius and Ulna

Fracture of one forearm bone may be associated with a dislocation of the other boneIn Monteggia’s
fracture the shaft of the ulna is fracturedAnterior dislocation of the radial head with rupture of the
anular ligamentIn Galezzi’s fracture the proximal third of the radius is fractured and distal end of ulna is
dislocated at the distal radioulnar joint

37 Fractures of Radius and Ulna

Colles’ fracture is a fracture of the distal end of radius resulting from a fall on the outstretched
handCommonly occurs in older than 50 yearsPosterior displacement of the fragment referred as dinner-
fork deformity
38 Fractures of Radius and Ulna
Smith’s fracture of the distal end of the radius occurs from a fall on the back of the handIt is reversed
Colles’ fractureThe distal fragment is displaced anteriorly

39 Injuries to the Bones of the Hand

It is common in young adultsUnless treated properly, the fragments will not unitePermanent weakness
and pain of wrist will resultDislocation of the lunate bone occasionally occurs in young adults falling on
an outstretched hand that causes hyperextension of the wrist jointInvolvement of median nerve is

40 Injuries to the Bones of the Hand

Fractures of metacarpal bones may occur as a result of direct violenceClenched fist striking a hard
objectThe boxer’s fracture commonly produces an oblique fracture of the neck of the fifth or fourth
metacarpal bonesThe distal fragment is commonly displaced proximallyShortening the finger posteriorly

41 Injuries to the Bones of the Hand

Bennett's fracture is a fracture of the base of the metacarpal of the thumbCaused by a violence applied
along the long axis of the thumb or the thumb is forcefully abductedThe fracture is oblique and causes
instability to the carpometacarpal joint of the thumb

42 Compartment Syndrome of Forearm

The forearm is enclosed in a sheath of deep fasciaThis sheath with interosseous membrane and fibrous
muscular septa divides the forearm into several compartmentsAny edema can cause secondary vascular
compression of blood vesselsThe deep fascia must be incised surgicallyA delay of even 4 hours may
cause an irreversible damage to the muscles

43 Anatomic Snuff BoxThe term commonly used for a triangular skin depression on the lateral side of
the wristBounded medially by the tendon of extensor pollicis longus and laterally by abductor pollicis
longus and extensor pollicis brevisScaphoid bone can easily be palpated herePulsations of the radial
artery can be felt here

44 Tennis ElbowIt is caused by a partial tearing or degeneration of the origin of the superficial extensor
muscles from lateral epicondyle of humerusIt is characterized by pain and tenderness over the lateral
epicondylePain radiating down the lateral side of forearmIt is common in tennis players

45 Dupuytren’s Contracture
It is a localized thickening and contracture of palmar aponeurosisIt commonly starts near the root of the
ring finger and draws that finger into the palmLater the condition involves the little finger in the same
mannerIn long standing cases, the pull on the fibrous sheaths of these fingers results in flexion of the
proximal interphalangeal jointsThe distal interphalangeal joints are not involved

46 Trigger FingerThere is a palpable or even audible snapping when a patient is asked to flex and extend
the fingersCaused by the presence of a localized swelling of one of the long flexor tendons that catches
on a narrowing of the fibrous flexor sheath anterior to the metacarpophalangeal jointCan be treated
surgically by incising the fibrous flexor sheath

47 Fascial Spaces of Palm and Infections

The fascial spaces of the palm are clinically important because they can become infectedDistended with
pus as a result of the spread of infection in acute suppurative tenosynovitisThey can be infected after a
penetrating wounds such as falling on a dirty nail

48 Pulp Space InfectionThe pulp space of the fingers is a closed fascial compartment situated in front of
the terminal phalanx of each fingerInfection of such a space is common and seriousCommonly occurring
in the thumb and index fingerBacteria are usually introduced into the space by pinpricks or sewing

49 Pulp Space InfectionEach space is subdivided into numerous smaller compartments by fibrous
septaAccumulation of inflammatory exudate within the compartment causes quick rise in pressureIf the
infection is left without decompression, infection of terminal phalanx can occur

50 Pulp Space InfectionIn children, pressure on the blood vessels could result in necrosis of diaphysisThe
close relationship of the proximal end of the pulp space to the digital synovial sheath accounts for the
involvement of the sheath in the infectious process when the pulp-space infection has been neglected

51 Elbow Joint InjuriesThe elbow joint is stable because of the wrench-shaped articular surface of the
olecranon and pulley-shaped trochlea of the humerusIt also has strong medial and lateral ligaments

52 Dislocations of Elbow Joint

Elbow dislocations are commonMost are posterior and usually follows falling on the outstretched
handCommon in children because the part that stabilizes the joint is incompletely developed

53 Damage to the Ulnar nerve

Close relationship of the ulnar nerve to the medial side of the joint makes it vulnerable in dislocation or
in fracture dislocations in this regionThe nerve damage can occur at the time of injury or weeks, months
or years laterContinued friction between the medial epicondyle and the stretched ulnar nerve
eventually results in ulnar palsy

54 Wrist Joint InjuriesThe joint is stabilized by the strong medial and lateral ligamentsA fall on the
outstretched hand can strain the anterior ligament of the wrist jointSynovial effusion, joint pain and
limitation of movement may occurSign and symptoms must not be confused with those produced by a
fractured scaphoid or dislocation of the lunate bone
1- long thoracic nerve: medial winging of the scapula is most commonly caused by deficit in the
serratus anterior muscle due to impingement of the long thoracic nerve.
2- 2- Median nerve injury: carpal tunnel syndrome: inflammation of the carpal tunnel
compresses the median nerve and causes tingling, numbness, weakness, or pain in the
thumb, index finger, middle finger, and half of the ring finger. Surgical release of the carpal
tunnel is needed.
3- 3- Ulnar nerve injury: cubital tunnel syndrome: pressure on the nerve at the elbow can cause
numbness or pain in the elbow, hand, wrist, or fingers. Compression of the ulnar nerve below
the elbow may lead to claw hand.
4- 4- Posterior interosseous nerve injury: at about the level of the lateral epicondyle, the radial
nerve begins to divided into the deep branch and the superficial branch of the radial nerve.
The posterior interosseous nerve (deep) enters the extensor compartment of the forearm
through the supinator muscle. The posterior interosseous nerve supplies these muscles on
the radial side and dorsal surface of the forearm. The posterior interosseous nerve does not
supply cutaneous sensation and is purely a motor nerve. Entrapment at the Arcade of
Frohse: with injury to the posterior interosseous nerve, the patient will experience difficulty
with extension of the fingers only.
5- 5- Anterior interosseous nerve injury: about half the way down the forearm, the anterior
interosseous nerve exits from the dorsal lateral aspect of the median nerve. The anterior
interosseous nerve is purely motor. All the muscles in front of the forearm are supplied by the
median nerve except the medial half of the flexor digitorum profundus. The anterior
interosseous nerve gives branches to three muscles: Pronator quadratus, lateral half of the
flexor digitorum profundus, flexor pollicis longus. The patient will be unable to give the OK
sign due to paralysis of the flexor pollicis longus and the flexor digitorum profundus.
6- 6- Radial nerve injury: radial nerve compression or injury may occur at any point along the
course of the nerve.
7- 7- Axillary nerve injury: the axillary nerve supplies the deltoid muscles, giving sensation over
the shoulder area. The axillary nerve originates from the posterior cord of the brachial
plexus. When the nerve is injured: weakness of shoulder abduction, atrophy of the deltoid,
numbness in the deltoid region. The axillary nerve is commonly injured due to fractures or
dislocations of the shoulder joint.
8- 8- Femoral nerve injury: the muscles of the anterior compartment of the thigh are innervated
by the femoral nerve. The usual cause of femoral nerve dysfunction are due to trauma or
compression of the nerve. The quadriceps tendon is a strong tendon which groups the four
muscles that extend the knee: rectus femoris, vastus intermedius (under rectus femoris),
vastus medialis, vastus laterlaris. Differential diagnosis: tears of the quadriceps tendon,
patellar tendon injury or patellar fractures cause an inability to extend the knee. A quadriceps
tendon rupture is rupture of the tendon that inserts into the top of the patella.
9- 9- Posterior tibial nerve injury: the tarsal tunnel is located just below the medial malleolus of
the ankle and is covered with a thick band of ligaments called the flexor retinaculum. The
flexor retinaculum protect the structures contained within the tunnel such as the posterior
tibial nerve. The structures which also pass through the tunnel include the posterior tibial
artery, the tendons of the tibialis posterior, flexor digitorum longus, and the flexor hallucis
longus. Tarsal tun el syndrome is a compression neuropathy caused by compression of the
posterior tibial nerve within the tarsal tunnel. With tarsal tunnel syndrome there will be pain
and numbness on the plantar aspect of the foot and heel. Tibial nerve compression with
tarsal tunnel syndrome is similar to carpal tunnel syndrome which occurs at the wrist. 10-
Common peroneal nerve injury: the ankle and foot dorsiflexors are supplied by the peroneal
nerve which is part of the sciatic nerve. The sciatic nerve starts in the lower back and runs
through the buttock and lower limb. In the lower thigh, just above the back of the knee, the
sciatic nerve divides into two nerves, the tibial and the peroneal nerves, which innervate
different parts of the lower leg. The common peroneal nerve then travels anterior, around the
fibular neck, dividing into superficial and deep peroneal nerves. The deep peroneal nerve
gives innervation to the tibialis anterior muscle of the lower leg which is responsible for
dorsiflexion of the ankle. Conditions causing foot drop: injury to the knee: knee dislocation: in
the event of knee dislocation, it is important to check for common peroneal nerve and
popliteal artery injury.

These four rotator cuff muscles all originate from the scapula and insert into the proximal humerus .
Supraspinatus The supraspinatus muscle arises from the supraspinous fossa and is inserted into the
superior facet of the greater tubercle of the humerus . The supraspinatus abducts the arm and
stabilizes the humerus. A tear in the supraspinatus muscle will result in the inability to abduct the
shoulder. The supraspinatus and the infraspinatus muscles are both supplied by the suprascapular
nerve (C5, C6), which arises from the superior trunk of the brachial plexus. When testing the
supraspinatus muscle, a physician can perform the Neer Impingement Test, Hawkin’s Test or the
Jobe’s Test. In the Jobe’s test, the supraspinatus muscle is tested with the shoulder abducted to 90°,
flexed to 30°, and maximally internally rotated. Downward pressure is resisted primarily by the
supraspinatus muscle. Jobe’s test is probably the best test for this muscle function. Infraspinatus
The infraspinatus muscle is a thick triangular muscle located on the posterior aspect of the scapula.
It originates from the infraspinatus fossa and inserts into the middle facet of the greater tubercle of
the humerus. The infraspinatus is the primary external rotator with the arm to the side and it also
helps to stabilize the humerus. External rotation of the shoulder occurs in conjunction with the teres
minor. The infraspinatus muscle and the supraspinatus muscles are supplied by the suprascapular
nerve (C5,C6), which arises from the superior trunk of the brachial plexus . When there is a tear of
the infraspinatus muscle, the patient will have dysfunction with external rotation of the arm. The
infraspinatus muscle is usually evaluated by testing the external rotation of the shoulder with the arm
to the side, it is testing the external rotation of the arm against resistance. During the external
rotation lag test, the examiner passively rotates the arm into full external rotation. The test is positive
when the examiner lets go of the arm and the patient is unable to maintain the position of full
external rotation. Teres Minor The teres minor originates at the lateral border and adjacent posterior
surface of the scapula and it inserts at the greater tubercle of the humerus. The teres minor muscle
is involved in external rotation of the arm along with the infraspinatus muscle (infraspinatus is the
primary external rotator of the arm). The teres minor muscle is innervates by the posterior branch of
the axillary nerve (posterior cord C5, C6) . When testing the teres minor, the physician will conduct
the Horn Blower’s Test. This tests the external rotation with the arm held in 90° of abduction . The
test is positive if the arm falls into internal rotation. Subscapularis The subscapularis is a large
triangular muscle, which fills the subscapular fossa and inserts into the lesser tubercle of the
humerus and the front of the capsule of the shoulder joint (Figure 12).The subscapularis rotates the
head of the humerus medially (internal rotation) and adducts the arm. It is the internal rotator of the
arm. The subscapularis muscle is innervated by the upper and lower subscapular nerves (posterior
cord C5, C6, C7). The physician can test the subscapularis muscle by performing the Lift-off test. If
the patient is unable to lift the hand off of the lower back, then a tear of the subscapularis tendon is
suspected. The lift-off lag test is another test that may be utilized. The examiner will hold the
patient’s hand away from the back at the lumbar region and let go. The patient will be unable to keep
the hand away from the back if the tendon is torn. A third test that may be used is the belly-press
test. The physician has the patient press the palm of the hand against the abdomen with the wrist in
a neutral position, this is an example of an intact subscapularis tendon. A positive sign for the belly-
press test occurs if the patient is unable to press his belly without wrist volar flexion or the elbow
falling posteriorly.

Tinel’s test for carpal tunnel syndrome

Dr. Ebraheim’s educational animated video describes examination test of the hand. Adequate
evaluation of the hand is necessary for the management of hand and wrist conditions or injury.
Knowledge of certain specific tests will help the clinician to reach the correct diagnosis and provide
adequate treatment. These are some of the most useful tests that are used frequently for evaluation
of wrist and hand conditions. De Quervain's syndrome: inflammation of the sheath or tunnel that
surrounds the two tendons that control movement of the thumb. Finklestein’s test: the patient makes
a fist with the fingers closed over the thumb and the wrist is bent towards the little finger. The hand is
pulled so that the involved tendon is stretched, causing a sharp, local pain if injury and inflammation
are present. What is carpal tunnel syndrome? Pressure placed on the median nerve due to
thickening of the transverse carpal ligament. Can lead to numbness, tingling or weakness of the
hand and fingers. Tinel’s test: the tinel’s test is used to determine symptoms of carpal tunnel
syndrome. The test is considered positive if symptoms of tingling worsen while tapping on the
median nerve at the wrist. •Pahlen’s test: the Phalen’s maneuver is a diagnostic test performed to
determine if the patient has CTS. The back of the hands are pressed together, compressing the
nerve, which may cause symptoms of CTS. •Froment’s test: the Froment's test is used to test for
palsy of the ulnar nerve which may occur with entrapment of the ulnar nerve within the cutibal tunnel.
What is cubital tunnel syndrome? Occurs due to compression of the ulnar nerve at the elbow.
Froment’s test: when pinching a piece of paper between the thumb and index finger, the thumb IP
joint will flex if the adductor pollicis muscle is weak due to ulnar nerve palsy. •The OK sign is used to
check for paralysis of the anterior interosseous nerve due to entrapment or compression injury. This
nerve is a branch of the median nerve that innervates the muscles of the deep group of the anterior
compartment of the forearm. Patients with paralysis of the anterior interosseous nerve will unable to
make the OK sign. •Wrist drop: condition of the hand and wrist that determines the presence of
radial nerve injury. •The Allen's test: The examiner applies pressure with the thumbs occluding the
ulnar and radial arteries. Patient is asked to make a fist. Patient is then asked to open the hand.
When the examiner releases the ulnar artery, the patient;s ulnar artery will cause blood flow to the
hand. What is basal thumb arthritis? Arthritis affecting the thumb joint . Grind test: by axial loading,
pushing and rotating the thumb metacarpal bone, grinding may be felt within the joint. •Watson’s
test: also called the scaphoid shift test, it is diagnostic test used to evaluate scaphoid stability. The
examiner places a thumb over the patient’s scaphoid tuberosity which is the distal pole of the
scaphoid on the volar surface. The other fingers of the examiner’s same hand are placed dorsally
above the radius. The patient’s wrist is placed initially into an ulnar deviation and the examiner's
other hand deviates the wrist radially and flexes it slightly. With pressure on the tuberosity of the
scaphoid, the scaphoid is pushed dorsally out of the radial fossa. If there is instability of the
scaphoid, the test will be positive and produce pain and a “clunk”. •Lumbrical plus finger: caused by
laceration of the flexor digitorum profundus distal to the origin of the lumbricals. Lumbrical is tighter
than FDP. Most common in the middle finger. With injury of the flexor digitorum profundus tendon,
the patient is unable to maintain the grip when the examiner releases the finger. •Testing the
integrity of the flexor tendon: keep the PIP of the finger extended and see if the patient can flex the
DIP. Keep the other fingers extended and then see if the patient can flex the PIP joint of the involved
finger. When multiple slips of the superficialis tendon are cut, identify the tendon properly. The
superficial tendon of the long and ring fingers are volar at the wrist. •Bunnell test •Elson’s test: used
to determine if the patient has a central slip tear before the deformity is present. •When holding a
relaxed cascade, the fingers should normally point towards the region of the scaphoid. Malrotation of
the finger will causes the affected finger to deviate from its normal rotational direction. Malrotation is
especially important with finger metacarpal fractures.