Assessment How to undertake Conditions being assessed for.

1 Both shoulders are exposed Exposure should include the neck and elbows (joint
appropriately maintaining dignity of above/below) to allow for a full assessment
patient.

2 LOOK: General inspection of the Examine from the front, back and axillae Swelling, deformity/asymmetry, bruising, erythema,
shoulders and surrounding structures wounds, comparing to opposite side

3 FEEL: Bony structures palpated Palpate from sternoclavicular joint along clavicle to Palpated for pain, bony tenderness, swelling,
acromioclavicular joint. Around the acromion and crepitus, instability
coracoid process, scapula and humeral head

4 FEEL: Soft Tissue Structures . Palpate over the deltoid, trapezius, proximal bicep Palpated for joint pain/tenderness, warmth, swelling,
(upper humerus), muscles overlying scapula muscle spasm. Pain/tenderness may be the result of
(rotator cuff), supraspinatus tendon, sub-acromial acute injury e.g. tear of rotator cuff or overuse
bursa condition e.g. tendonitis, impingement

5 Sensation distal to the injury Assess sensation over the regimental badge Reduced/altered sensation over regimental badge
assessed area/deltoid muscles of both arms (axillary nerve), area suggests axillary nerve damage (primarily in
and the median/radial/ulnar nerve areas, compare anterior shoulder dislocation), may also find shoulder
to opposite side weakness. Nerve supply to the upper limbs pass
close to shoulder joint (brachial plexus), prone to
injury.

6 Vascular status assessment Distal circulation - radial pulse, capillary refill time Major blood vessels that supply the upper limb pass
in the nail beds, skin colour/temperature of hands close to the shoulder joint - at risk of injury
7 MOVE: Active range of movements Ask patient to move affected area in all ranges of Looking for reduced/painful range of motion, when
assessed motion. Flexion, extension, internal and external pain occurs. Normal ROM - flexion 180 deg /
rotation, abduction, adduction, circumduction. extension 60 deg / abduction 180 deg / internal
Compare to opposite side. rotation 90 deg / external rotation 70-90 deg.

Abduction/adduction: supraspinatus - pain =

tendonitis, loss of power = tear. External rotation:
infraspinatus/teres minor - pain = tendonitis, loss of
power = tear. No shoulder movement or fixed internal
rotation suggests frozen shoulder

Passive movements/tests - Required for the OSCE however in practice, if a bony injury/fracture/dislocation is suspected then passive movements are contraindica
8 MOVE: Passive ranges of movement Clinician moves the shoulder. Flexion, extension, Assessing range of movement, looking for when pain
assessed internal and external rotation, abduction, adduction, occurs, for instability, crepitus. Problems can be
circumduction. Compare to opposite side. suggestive of tear/impingement, overuse / joint
degeneration. Also useful to differentiate between
physical impedance of range of motion vs
psychological impedance of range of motion.

9 Drop Arm Test Abduct the arm/shoulder passively to 90 degrees, If the patient is unable to control the downward
patient may sit or stand. Ask the patient to hold the movement of their arm it is positive for a full
arm in this position and remove your hands. thickness rotator cuff tears especially of the
supraspinatus or infraspinatus. Beware that the arm
may drop suddenly and be prepared to offer support
as the patient lowers

10 Horizontal Flexion Test The patients abducts the shoulder to 90 degrees Pain in the acromioclavicular joint suggests an
and passes the arm across the chest, putting a injury/sprain
hand on the opposite shoulder (as if doing a
stretch)

11 Joint above and below assessed Utilisation of a basic look feel move assessment of Associated injury to the neck/cervical spine or elbow
the joints above and below to ensure no injury from
transferred forces has occurred

12 Thanks patient and allows to dress

Tips

Shoulder examination can be done with the patient sitting,

but may be easier standing for range of movement tests
later

Failure to follow the look/feel/move approach in

sequence may result in unsafe practice.

To palpate the supraspinatus tendon, extend the shoulder

to bring the supraspinatus anterior to the acromion
process

Failure to assess sensation distally = unsafe practice

Failure to assess circulation distally = unsafe practice

 Active movements must always be performed before
passive movements are attempted

passive movements are contraindicated.

If a bony injury/fracture/dislocation is suspected then
performing passive movements are contraindicated.

https://www.youtube.com/watch?v=JXgRBeqToik&t=66s
 Assessment How to undertake
1 Both elbows are exposed appropriately Exposure should include the shoulders and wrists
maintaining dignity of patient. (joint above/below) to allow for a full assessment

2 LOOK: General inspection of the elbows Inspecting for bruising, swelling, deformity, wounds,
and surrounding structures erythema, resting arm position e.g. avoiding extension

3 FEEL: Bony structures palpated Palpate along the shaft of humerus, medial & lateral
epicondyles of the elbow, olecranon, radial head,
proximal ulnar, along the ulna and radius to the wrist

4 FEEL: Soft Tissue Structures . Palpate over the distal bicep & triceps, lateral and
medial collateral ligaments, proximal muscles of
forearm and insertion points at the lateral and medial
epicondyles

5 Sensation distal to the injury Testing sensation distal to elbow. Radial/Median/Ulna

assessed nerve innervation areas of the forearm/hand. Compare
to the opposite side.

6 Vascular status assessment Assessing colour, temperature of the limb distally, CRT
and character of radial pulse. Comparison to the
opposite side.

7 MOVE: Patients active range of Ask patient to flex and extend the elbow joint, supinate
movements assessed and pronate. Compare to opposite side

Passive movements/tests - Required for the OSCE however in practice, if a bony injury/fracture/dislocation is s
8 MOVE: Passive ranges of movement Clinician moves the patient's elbow - flexion,
assessed extension, supination, pronation. Compare to opposite
side.

9 Resisted extension/flexion of the wrist Ask the patient to flex/extend at the wrist - does this
cause pain in the elbow/forearm?

10 Joint above and below assessed Utilisation of a basic look feel move assessment of the
joints above and below to ensure no injury from
transferred forces has occurred

11 Thank the patient and allow to dress

 Conditions being assessed for.

Palpated for pain, bony tenderness , swelling, crepitus

indicative of fracture

Palpated for pain, tenderness, swelling, muscle

spasm. Pain on palpation at insertion of extensor
muscles at lateral epicondyles indicative of lateral
epicondylitis (Tennis elbow), if found on medial side -
medial epicondylitis (Golfer's elbow).

Reduced/altered sensation suggests damage to the

median/radial/ulnar nerve - especially vulnerable in
elbow dislocation, supracondylar fracture in children.

Signs of reduced/absent circulation distally indicates

damage to the brachial/radial/ulnar arteries. Normal
CRT = <2 seconds

Looking for reduced range of motion, pain on a

particular range of motion, patient reporting locking
and/or grinding

y injury/fracture/dislocation is suspected then passive movements are contraindicated.

Assessing range of movement, looking for when pain
occurs, for instability, crepitus. If found can suggest
overuse injury or degeneration. Also useful to
differentiate between physical impedance of range of
motion vs psychological impedance of range of
motion.

Pain on the lateral epicondyle/elbow - tennis elbow.

Medial epicondyle - golfer's elbow. +/- pain in the
forearm

Associated injury to the shoulder and wrist

 Tips

Failure to follow the look/feel/move approach in

sequence may result in unsafe practice.

Failure to assess sensation = unsafe practice

Failure to assess circulation = unsafe practice

Active movements must always be performed before

passive movements are attempted

ve movements are contraindicated.

If a bony injury/fracture/dislocation is suspected then
performing passive movements are contraindicated.
 Assessment
1 Both wrists and hands are exposed
appropriately maintaining dignity of
patient.

2 LOOK: General inspection of the wrists

and hands and surrounding structures

3 FEEL: Bony structures palpated

4 Anatomical Snuff Box Tenderness

5 Scaphoid Tubercle Tenderness

6 Dorsal Scaphoid Tenderness

7 FEEL: Soft Tissue Structures .

8 Sensation distal to the injury

assessed

9 Vascular status assessment

10 MOVE: Patients active range of

movements assessed - WRIST

11 MOVE: Patients active range of

movements assessed -
HAND/FINGERS

12 Axial Loading of Thumb

13 Assess for rotational deformity

14 Assess for extensor lag

Passive movements/tests - Required for the OSCE however in practice, if a bony injury/fracture/dislocation is
15 MOVE: Passive ranges of movement
assessed

16 Joint above and below assessed

17 Thanks patient and allows to dress

How to undertake
Exposure should include the elbows and hands/fingers (joint
above/below) to allow for a full assessment

Inspecting for bruising, swelling, deformity (wrist/hand/fingers),

wounds, erythema. Remove rings if able to - risk of swelling

Palpates distal radius and ulnar, carpal bones, meta-carpals,

proximal/intermediate/distal phalanges, MCPJ, PIPJ, DIPJ all
digits, scaphoid landmarks (see below)

Locate over radial aspect of wrist between tendons (extensor

policis brevis and extensor policis longus) palpate here for pain.

Palpate over palmar surface of wrist just outside of the ASB

Palpate over dorsal surface of wrist just outside of the ASB

Distal muscles of forearm palpated, lumbrical muscles in the

palm, collateral ligaments/volar plate of the fingers, thenar and
hypothenar eminences

Testing sensation distal to wrist. Radial/Median/Ulna nerve

innervations of hand/fingers - compare to opposite side

Assessing colour, temperature, CRT and character of radial

pulse - compare to opposite side

Ask patient to perform flexion, extension of the wrist, radial &

ulna deviation, supination & pronation, circumduction.

Hand- Flexion and extension of fingers (make a fist then extend

fingers), abduction, adduction of all digits including thumb,
opposition of thumb to fingers, thumb flexion and extension

Grasp the thumb distally and place pressure on the thumb along
its axis toward the wrist

Ask patient to slowly flex their fingers and look for any crossing
over.
 Ask patient to close their fist, then slowly open it and look to see
if all fingers extend at the same time.

Required for the OSCE however in practice, if a bony injury/fracture/dislocation is suspected then passive movements are co
Clinician will perform Wrist- flexion, extension, radial & ulna
deviation, supination & pronation, circumduction. Hand- Flexion
and extension of fingers (make a fist then extend), abduction,
adduction of all digits including thumb, opposition of thumb to
fingers, thumb flexion and extension

Utilisation of a basic look feel move assessment of the joints

above and below to ensure no injury from transferred forces has
occurred
Conditions being assessed for. Tips
Asking the patient to place both hands on a flat surface
will make examination easier for patient and clinician

Failure to follow the look/feel/move approach in

sequence may result in unsafe practice.

Palpated for pain, bony tenderness, swelling,

crepitus indicative for fracture

Pain on palpation would suggest potential scaphoid

fracture

Pain on palpation would suggest potential scaphoid

fracture

Pain on palpation would suggest potential scaphoid

fracture

Skin and joint temperature. Pain/tenderness,

swelling, crepitus.

Reduced/altered sensation suggests damage to the Failure to assess sensation = unsafe practice
median/radial/ulnar nerve

Reduced/absent circulation distally indicates Failure to assess circulation = unsafe practice

damage to the brachial/radial/ulnar arteries. Normal
CRT = <2 seconds

Looking for reduced range of motion, pain on a Active movements must always be performed before
particular range of motion passive movements are attempted

Looking for reduced range of motion, pain on a

particular range of motion, overlapping of the
fingers, rotation deformity (metacarpal fracture),
extensor lag, droop of distal phalanx (mallet finger -
extensor tendon injury), boutonniere deformity,

Pain in the wrist would suggest potential scaphoid

fracture

Suggestive of spiral MC fracture (Red flag and

needs hand surgeon input)
 Suggestive of extensor tendon issue.

racture/dislocation is suspected then passive movements are contraindicated.

Assessing range of movement, areas of
painful/reduced movement. Can be suggestive of
overuse / joint degeneration. Also useful to
differentiate between physical impedance of range
of motion vs psychological impedance of range of
motion.

Injury to the elbow and fingers (or furthest joint

distally)