A 6 year old boy has a history of recurrent dislocation of the right shoulder. On examination, the ohopedician puts the patient in the supine position and abducts his arm to 90 degrees with the bed as the fulcrum and then externally rotates it but the boy does not allow the test to be performed. The test done by the ohopedician is:
A i.e. Aprrehension test Apprehension test, fulcrum test, crank test, lobes relocation test, and surprise testsQ are provocative tests to evaluate anterior shoulder instability. In contrast jerk test is a provocative maneuver for posterior gleno humeral instability.Although it is generally used to test for inferior instability (laxity), the sulcus test is also positive in many patients with multidirectional instability. Test for Evaluation of Glenohumeral Joint Instability in Recurrent Dislocation Anterior Instability * Anterior Apprehension Tests- In general these maneuver mimics the positioning of subluxation or dislocation and cause apprehension & reflex guarding.- So application of anterior directed force to the humeral head from the back and/ or abduction & external rotation of arm results in patients apprehension that the joint will dislocate. And the patient does not allow the test to be performed.Q - Variations include . 1. Apprehenson test: The patient is placed in supine position with the shoulder slightly off the table, abducted 90-100deg and in neutral rotation. Form this point, the shoulder isexternally rotated until the feeling of apprehension (getting ready to dislocate) is repoed by patient. 2.Fulcrum Test is apprehension test with a hand of examiner on posterior aspect of humerus to form a fulcrum and exaggerate instability 3.Crank Test is an apprehension test (in sitting position) with application of anteriorily directed force on posterior humeral head to exaggerate instability. 4.Surprise Test (most accurate) is another variant of apprehension test where examination stas with a posteriorly directed force on anterior shoulder. So the patient does not experienceapprehension even when the shoulder is in abduction & maximal external rotation. By abruptly removing, this (posterior) force, the patient will suddenly experience apprehension 5.Andrew's Test (e.s.p valuable in patients with possible secondary gain). This test is done by placing the patient prone with the arm abducted and externally rotated and applying anterior direction force to posterior pa of shoulder. Placing a patient in prone may eliminate the learned response to anterior apprehension testing. * lobes Relocation Test- It is similar to apprehension test, but a posteriorly directed force is placed on anterior aspect of shoulder to eliminate feeling of apprehension, at the end.- If relief is obtained by applying a posterior directed force to the humeral head the test is +ve Posterior Instability * Jerk (provocative) Test- This test can be carried out in sitting or supine position. If done in supine the shoulder is slightly off the table, in 90deg forward flexion and internal rotation. An axial load is placed on humerus (by pushing axially against the flexed elbow) such that the humeral head translocates posteriorly. By gradually adducting the shoulder, the humeral head may sublux or even dislocate posteriorly and produce in sudden jerk.When the shoulder is taken out of adduction the humeral head will abruptly reduce back onto the glenoid and produce another jerk. * Posterior Apprehension TestApplying a posterior directed force to forward flexed & internally rotated shoulder, produce apprehension. * Posterior Clunk TestApplying a posterior stress to forward flexed & internally rotated shoulder produce clunk as the humeral head subluxes posteriorly * Jahnke TestA posterior directed force is applied to forward flexed shoulder. The shoulder is then moved into coronal plane by applying an anterior directed force to humerus head. A clunk occurs as humral head reduces from the subluxed position. * Circumduction TestThe patient is instructed to actively move the shoulder in a large circle staing from a flexed, internally rotated, and cross body position then to forward flexion -+ then to an abducted & externally rotated position --> and lastly to the arm at the side. - The examiner stands behind and palpates the posterior shoulder. If positive the joint subluxes in the flexed, internally rotated and cross body position and reduces as the shoulder is moved. * Push - Pull Testis simultaneously pushing humeral head posteriorly (of 90deg abducted shoulder in supine position) and pulling the lower end of humerus upward (by pulling flexed elbow through long axis of forearm). This produces apprehension. Inferior Instability Sulcus Test and Sign- It is done with the arm in both 0 degrees & 45 degrees of abduction by pulling the extermity distally and observing for a sulcus or dimple between humeral head & acromian. - Subluxation at 0 degree of abduction is more indicative of laxity at the rotator interval & subluxation at 45 degree is indicative of laxity of inferior gleno- humeral ligament complex. * Shift & Load Test observes amount of anterior & posterior translation of humeral head, in 0deg abduction.* Shoulder Lachman and Drawer Test also measures amount of anterior & posterior translation* Dugas, Callaway & Hamilton ruler (Mn "DCH") tests are positive in (already) dislocated shoulder.
Apprehension test
Sulcus test
Dugas test
MC Murray's test