Thoracic Outlet Syndrome

Group of s/s that result from compression of the subclavian vessels and brachial plexus @ the superior aperture of the thorax. Maybe caused by trauma, repetitive motions, overuse, and some systemic diseases such as diabetes and thyroid disease. Patients may complain of neck and shoulder pain with numbness and tingling affected the entire upper extremity. The ulnar side of limb is predominantly involved. Using the affected extremity in an overhead or elevated position is difficult.

Clinical s/s-

Upper extremity pain Upper extremity paresthesias Grip weakness Upper extremity edema Upper extremity coldness Excessive dryness of arm or hand Excessive sweating of arm or hand

TEST RATIONALE

Allen’s Test	Opening and closing fist diminishes blood flow to the hand causing blanching. When pressure of one of the arteries is released the hand should fill with blood which turns it a pinkish color and veins distend. A delay of more than 10 secs. In returning a pinkish color to the hand indicates either ulnar or radial artery insufficiency. The artery being tested is the one not being manu- ally occluded.
Adson’s Test	Rotation and extension of the head compress the subclavian artery and brachial plexus. A decrease or absence of the amplitude of the radial pulse indicates a compression of the vascular component of the neurovascular bundle (subclavian artery) by a spastic or hypertrophied anterior scalene on a cervical rib or mass such as a pancoast tumor. Paresthesias in the upper extremity indicates compression of the neural component of the neurovascular bundle (brachial plexus)
Eden’s Test (Costaclavicular Test)	Forcing shoulders posteriorly decreases the space between the clavicle and 1st rib. The neurovascular bundle (brachial plexus, axillary artery) and the axillary vein run through a narrow cleft beneath the clavicle and top of the 1st rib. Decrease or absence of radial pulse indicates a compression to the vascular component of the neurovascular bundle. This compression causes a decrease in the space between the clavicle and 1st rib This decrease may be caused by a recent or healed fracture to the clavicle or 1st rib with or without callus formation, dislocation of the medial aspect of the clavicle or a spastic or hypertrophoied subclavius muscle. Compression of the brachial plexus is usually localized to a nerve root or peripheral nerve distribution. Compression of the axillary vein typically presents as diffuse radicular vascular discomfort not localized to a nerve root or peripheral nerve distribution.
Wright’s Test	Axillary atery, vein and three cords of the brachial plexus pass under the pectoralis minor muscle on the coracoid process. Abduction of the arm 180 deg. Stretches these structures around the tendon of the pectoralis minor muscle and the coracoid process. Decrease or absence of the radial pulse indicates compression of the axillary artery either by a spastic or hypertrophied pectoralis minor muscle or by a deformed hypertrophied coracoid process.

TEST PROCEDURE (+) sign DX

Allen’s Test	Patient seated Open and close fist 5x’s, on 5th time keep fist closed Using one thumb occlude ulnar artery, one thumb occlude radial artery Instruct patient open fist (palm should look pale) Release one thumb @ a time. Radial 1st b/c slowest filling, then release 2nd ~ 1sec apart (count how long palm fills w/blood) Hand should take less than 5 secs to return to normal color	Longer than 5secs. For hand to return to normal color	T.O.S. due to radial or ulnar occlusion
Adson’s Test Adsons-Ant. scalene	Patient seated Locate radial pulse unilaterally Patient rotates head to involved side (side pulse taken) + extend their head up ** checking anterior scalene, looking up, stretch arm out Ask patient to take a deep breath and hold it and you do the same for 30secs	Decrease intensity radial pulse (strength)	T.O.S. due to anterior scalene occlusion of subclavian artery
Modified Adson’s Test Mod. Ads- Middle Scalene	Patient seated Locate radial pulse unilaterally Patient rotates head to UN-involved side (side pulse not taken) + extend their head up ** checking anterior scalene, looking up, stretch arm out Ask patient to take a deep breath and hold it and you do the same for 30secs	Decrease intensity radial pulse (strength)	T.O.S. due to middle scalene occlusion of subclavian artery
Eden’s Test (eden=costal ribs)	1) patient seated place hands behind them stand behind patient and take bilateral radial pulse simultaneously bring chin to chest and shoulders down and back (brings clavicle and rib closer together) hold 30 secs.	Decrease intensity of radial pulse	T.O.S. due to costal-clavicular occlusion subclavian artery (Rib 1 + clavicle)
Wright’s Test (Hyper-Abduction test)	1) patient seated and you stand behind them locate one patients radial pulse whle arm is @ their side Hyper-abduct patient’s shoulder ~ 180 deg. (take patient’s arm + bring right up)	Decrease intensity of radial pulse	T.O.S. tight pectoralis minor occluding subclavian artery

WRIST ORTHO TEST

S/S:

• PAIN (P)


• NUMBNESS (N)


• TINGLING (T) (PINS & NEEDLES)


• WEAKNESS (W)

CAUSES:

• REPETITIVE STRESS


• FALLING ON OUTSTRETCHED HAND


• CERVICAL SUBLUXATION

MECHANISM OF INJURY:

• TENDONITIS


• COLLAPSE CARPAL TUNNEL


• DISLOCATED LUNATE
  *** LUNATE IS MOST COMMONONLY DISLOCATED BONE IN BODY
  ***SCAPHOID IS MOST COMMONONLY FRACTURED BONE IN BODY

1. PHALEN'S TEST: MEDIAN NERVE ENTRAPMENT, COLLAPSE CARPAL TUNNEL

• PT SEATED


• DEMONSTRATE FOR TO TO PLACE THE DORSUM OF BOTH HANDS TOGETHER


• WITH FINGERS POINTING DOWNWARD + FOREARMS PARALLEL TO THE FLOOR.


• HOLD FOR 60 SECONDS ( OR UNTIL THE SYMPTOMS ARE REPRODUCED.


• (+) PAIN, NUMBNESS, TINGLING


• Dx: CTS (CARPAL TUNNEL SYNDROME)

2. REVERSE PHALENS TEST: MEDIAN NERVE STRETCH, TENDINITIS PROBLEM

• SAME AS PHALEN'S TEST EXCEPT PALMS TOGETHER + POINTING UPWARD


• SAME AS PHALEN'S TEST AND Dx SAME AS PHALENS TEST

3.TINEL TEST

• PT SEATED


• HOLD PT'S HAND IN SUPINATION


• TAP THE WRIST OVER THE MEDIAN NERVE 3X


• ASK THE PT IF THEY HAVE ANY PAIN, NUMBNESS, TINGLING AFTER EACH TIME YOU STRIKE


• (+) P,N,T


• Dx: CTS

4.CARPAL TUNNEL COMPRESSION TEST

• PT SEATED


• PT HAND SUPINATED COMPRESS MEDIAN NERVE WITH BOTH THUMBS


• HOLD FOR 1 MINUTE, UNTIL THE SYMPTOMS HAVE BEEN REPRODUCED


• (+) PAIN, NUMBNESS, OR TINGLING


• Dx: CARPAL TUNNEL SYNDROME (CTS)

Diagnostic & Disease III

Week 4
Dian (Withdrawal)/Kuang(Mania)
Dian (-)

• Excessive stillness
• Doesn't speak much
• Non-expressive & appears depressed
• Blank countenance & withdrawn
• Possibley Inhibited thinking or blocked sense orifices (Coma extreme case)

Kuang (+)

ORTHO ELBOW TEST

LATERAL EPICONDYLITIS TESTS
A. COZEN'S TEST
-PT SEATED
-INSTRUCT PT. TO PLACE THEIR ELBOW IN FLEXION & WRIST IN EXTENSION.
-PLACE ONE HAND ON PT'S SHOULDER (STABILIZE) & GRAB PT;S FIST WITH OTHER HAND.
-INSRUCT PT TO RESIST AS YOU PULL ON FIST.
-(+) PAIN IN LATERAL EPICONDYLE
-Dx: LATERAL EPICONDYLITIS aka TENNIS ELBOW
-MNEMONIC: PULL UP COVERS AND GET COZY

B. MILLS TEST
-PT SEATED
-INSTRUT PT. TO PLACE ELVOW IN EXTNESION & WRIST IN EXTENSION.
-PLACE ONE HAND ON PT'S HOULDERS & OTHER HAND GRABS PT'S FIST.
-HAVE PT RESIST AS YOU PULL ON FIST.
-(+) PAIN IN LATERAL EPICONDYLE
-Dx: LATERAL EPICONDYLITIS aka TENNIS ELBOW.
-MNEMONIC: TAKE COVERS OFF TO GOT WORK AT THE MILLS
C.MEDIAL EPICONDYLITIS TEST
-PT SEATED
-INSTRUCT PT TO EXTEND ELBOW & FLEX WRIST.
-PLACE 1 HAND ON PT'S SHOULDER & GRAB PT'S FIST WITH OTHER HAND.
-HAVE PT RESIST AS YOU PULL ON FIST.
-(+) PAIN IN MEDIAL EPICONDYLITIS.
-Dx: MEDIAL EPICONDYLITIS aka GOLFER'S ELBOW.

D.LIGAMENT STABILITY TEST (aka LIGAMENT INSTABILITY,AB/ABDUCTIN STRESS, OF VALGUS/VARUS STRESS TEST)
-PT SEATED
-PLACE PT'S ELBOW IN EXTENSION
-GRAB PT'S WRIST WITH 1 HAND
-THEN CONTACT PT'S LATERAL ELBOW WITH OTHER HAND.
-PUSH MEDIALLY ON THE ELBOW.
-THEN SWITCH HANDS & REPEAT, THEN PUSH LATERALLY.
-(+) MEDIAL OR LATERAL DEVIATION OF THE ELBOW.
-Dx: TORN/WEAK LATERAL COLLATERAL LIGAMENT





E. WARTENBURG SIGN
-PT SEATED
-INSTRUCT PT TO PLACE PALM FLAT ON TABLE.
-YOU PASSIVELY SPREAD THEIR FINGERS.
-(+) INABILITY TO ADDUCT PINKY.
-Dx: ULNAR NERVE NEURITIS.