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The Physical Exam Of The Arms, Part 1 (Or, Dr. Rob Drinks And Blogs)

Yes, it’s time for another installment of my series on the physical exam.  The goals of this series are:

  1. To educate my readers on the intricacies of the physical exam.
  2. To teach the anatomy and physiology as it relates to different parts of the human body.
  3. To delight my readers with my wit and fine prose.
  4. World peace.

untitled-1112So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals.  In fact, I have made absolutely no progress toward world peace.  I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.

Maybe I just need some new goals.  How about these:

  1. To irritate my high school English teachers.
  2. To cause at least 200 people to waste time that they could have spent watching Oprah.
  3. To make sure Canada stays north of us and does not sneak to Florida.
  4. To put those pesky French people in their place.


Yes, I think those are much better goals.

Extremely Upper

Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends.  We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don’t want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating.  Consider yourself warned.

The exam of the arms is usually only referred to vaguely during routine exams.  Most docs don’t deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says “I’m having problem with my arms”.  We doctors are proud of our mad skills.


What I am driving at is that the arm exam is a problem-oriented exam.  If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better.  If a kiss doesn’t work, usually an anti-inflammatory will (but we’ll get to that later).  And boo-boo problems with the arm are usually specific to the longitude and latitude on the body.  So today we will discuss the shoulder.

The Shoulder

deodorant-testersThe shoulder is a joint – meaning, it is a place where your body bends.  Without joints, your arms would be unwieldy and you’d whack everyone who came near to you.  Not only that; it would also make it impossible to put on deodorant.  So between whacking people and offending them with your odor, a jointless existence would truly be a hard one.  We all should thank our joints more often.

There is not a more complex joint in your body than your shoulder.  Here are some amazing facts about the shoulder:

  • There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
  • There are at least 18 muscles that are involved in shoulder movement.  Two of them have the word “rhomboid” in them.  I like the word “rhomboid.”
  • When people say the word “shoulder,” they may be referring to the joint, and they could be referring to the top part of their torso – between their neck and shoulder joints.  This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
  • The word “shoulder” rhymes with a lot of of words and so is very useful in poetry.  For instance:

You shouldn’t have told her that she’s looking older
She wants you to hold her with arm on her shoulder
And go get the folder that llamas once sold her
But there on the boulder the weather is colder.
A fine Jell-O mould or perhaps something bolder
Has rocked her and rolled her but never controlled her
So anger may smolder at cellular slime mold or
Other thingies, sort of.

See?  Pretty amazing, isn’t it?  Try doing that with “elbow!”  Perhaps Dino could write a haiku about it.

So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body.  This makes things very confusing for medical students when they have to describe the motion, as the joint doesn’t follow any of the rules the other joints have agreed upon.  Most joints can be bent (flexed) and straightened (extended).  Some joints (like the wrist) can be hyperextended and rotated as well.  All the other joints are content with these motions.  Is this good enough for the shoulder?  Not even close.

Here are the basic movements of the shoulder:

1.  Flexion – moving the arm forward toward the chest.

2.  Extension – moving the arm toward your back.

3.  Abduction – Being picked up by aliens and brought to their mother ship.  (This also refers to lifting your arms up from your sides).


4.  Adduction – Bringing your arms down back to your sides

5.  Rotation – Turning the arm around the axis of the humerus bone.

I have suggested a few more motions that may be added to the roster:

6.  Subflaxion – What you have to do to your shoulder to get your elbow in your ear.

7.  Soufflétion – When your shoulder is mixed with eggs and baked at 400 degrees.

8.  Mallardduction – When your shoulder gets down.

So far the shoulder committee hasn’t answered my mail.  I’m not sure why.

But really, the shoulder is very confusing to many medical professionals.  The range of motion is so great that it blurs the lines between the typical movements.  For instance, adduction is supposed to be when the limb is moved toward the body’s midline.  The shoulder makes this difficult.  When you put your arm by your side and when you raise it over your head, you move it toward midline.  Both could be considered adduction.  The same is true with flexion and extension – when is the shoulder joint opened up and when is it closed?

Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.

Wow.  1000 words already and I haven’t gotten to the actual exam.  I’ll give it a rest now and let you ruminate on words that rhyme with “elbow.”

I probably should sober up as well.

*This blog post was originally published at Musings of a Distractible Mind*

Sometimes It’s Better To Amputate

There’s no technological substitute for the human hand. Manual dexterity is incredibly hard to replicate, and so surgeons will go to great lengths to save injured hands. Unfortunately, sometimes the injury is too severe to allow for any meaningful functional recovery.

In these two cases, well-meaning surgeons refused to amputate the unsalvageable hands, thus delaying recovery and adaptation of prostheses.

This is a photo of a trauma victim who underwent extensive reconstruction of the hand, including transplantation of a toe to the thumb’s position. Gangrene set in and tracked up one of the tendon sheaths.


Photo Credit: Dr. Heikki Uustal

In this case, a burn victim was hoping to have some fingers reconstructed from his fist. He declined amputation and fitting with a prosthesis, despite the potential for enhanced function.


Photo Credit: Dr. Heikki Uustal

In both cases, a wrist disarticulation (amputation at the wrist) and prosthetic fitting (such as this myo-electric device with a self-suspending socket) might have provided a better functional and cosmetic outcome:

Photo Credit: Dr. Heikki Uustal

Photo Credit: Dr. Heikki Uustal

Sometimes, it’s better to amputate.

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