elbow extension applies an axial and valgus load to the supinated elbow. This test is positive if the patient becomes apprehensive or if the radial head dislocates (Karbach & Elfar, 2017). ● Prone push-up test : This test is similar to the chair push-up test. The patient is in a push-up position on the exam table with the elbow flexed to 90 degrees and the forearm in supination. The patient extends the elbows, as if completing a push-up. This test is positive if the patient becomes apprehensive or if the radial head dislocates. The chair push-up and prone push-up tests demonstrate a sensitivity of 87.5% if used individually and 100% if used together (Karbach & Elfar, 2017). ● Table-top relocation test : The table-top relocation test is theoretically more specific than the chair push- up or prone push-up test. For this test, the client puts their hand on the edge of a table with the forearm in supination. The client applies an axial load through the elbow while flexing it. This should cause apprehension at 40 degrees of flexion. Then the patient repeats this process but with the examiner applying pressure on the radial head with their thumb to prevent subluxation. This should eliminate the patient’s apprehension. Next, the examiner removes their thumb from the radial head of the partially flexed elbow, and radial head subluxation reproduces pain (Karbach & Elfar, 2017). Healthcare Consideration: Many injuries to the forearm and wrist are the consequence of a fall on an outstretched hand (FOOSH). The severity of FOOSH injuries varies, depending on several factors, including (Cirino, 2019): ● The force of impact with the ground. ● The type of ground/surface that is fallen on. ● The presence of any preexisting health and/or upper extremity issues.
Several tests for posterolateral instability include: ● Lateral pivot-shift test: The lateral pivot-shift test for posterolateral rotatory instability is performed with the patient supine and with the arm elevated over their head with the shoulder in full external rotation and the forearm supinated. The elbow is slowly flexed while a valgus, supinating, and axial force is applied. At 40 degrees of flexion, rotatory displacement is maximized and a skin dimple proximal to the radial head appears due to radial head dislocation. The dimple disappears with increased flexion as the radial head is reduced. This test is 38% sensitive (100% sensitive in anesthetized patients; Karbach & Elfar, 2017). ● Posterolateral rotary drawer test: Like the lateral pivot-shift test, the posterolateral rotary drawer test is done with the patient supine. The arm is overhead and the forearm is in full supination. The examiner flexes the elbow to 40 degrees and an anteroposterior force is applied to the radius and ulna. The test is positive if the patient becomes apprehensive (due to possible radial head subluxation; Karbach & Elfar, 2017). ● Chair push-up test : The chair push-up test is performed with the patient seated in a chair, with arms and the elbow abducted away from the body and flexed to 90 degrees with the forearm supinated. The patient puts their hands on the arms of the chair and pushes up like trying to get out of the chair. In this position, Varus posteromedial rotary instability test Varus posteromedial rotary instability occurs when the elbow undergoes an axial and valgus load with the forearm in pronation, which causes a fracture of the anteromedial facet of the coronoid and a rupture of the lateral collateral ligament. Tests for varus instability can be performed in the subacute state. To do so, the patient’s arm is abducted to 90 degrees and is neutral with regard to rotation. The client then flexes and extends the elbow, which causes a varus stress. With the absence of the medial buttress of the lateral collateral ligament and coronoid, the varus stress causes mechanical symptoms by loading the medial ulnohumeral joint (Karbach & Elfar, 2017)
FOREARM, WRIST, AND HAND INJURIES
Fractures Radial forearm fracture
Clinical Presentation Presenting symptoms include wrist deformity, swelling, ecchymosis, tenderness, and pain with wrist motion. Physical examination should include inspection of skin and soft tissue; assessment of vascular perfusion and pulse quality; nerve function testing; sensory testing; motor function testing of the intrinsic, thenar, and hypothenar muscles of the hand; and assessment of median nerve function (Hsu et al., 2023). Ulnar forearm fracture Fractures of the shaft of the ulna are called nightstick fracture s because they are commonly due to a direct blow to the ulna when the injured person is in a defensive position (such as what might occur with a police baton). Presenting symptoms include pain, tenderness, and swelling. Typically, this injury is unstable and requires operative intervention. Diagnosis of this condition relies on reported mechanism of injury and presenting symptoms (Passias et al., 2021).
Distal radius fractures are the most common fracture across the life span (Hjelle et al., 2020). In women, the incidence of this type of fracture is related to postmenopausal bone fragility, while the frequency for men stays steady until advanced age (Hjelle et al., 2020). In younger patients, these injuries are the result of high-energy events (e.g., fall from height, motor vehicle crash, athletic participation), while in older adults, the mechanism of injury is generally a low-energy event (e.g., fall from standing; Hsu et al., 2023). In older adults, patients who experience a radius fracture have an increased chance of a more major osteoporotic fracture. This should encourage clinicians to appropriately assess through thorough subjective interviews and refer for additional bone density result testing (Hjelle et al., 2020). The mechanism of injury is an axial force across the wrist, with bone density, wrist position, and force magnitude and direction determining the specifics of the injury. Most distal radius fractures are the of falling on a wrist that is extended and pronated (Hsu et al., 2023).
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