Elbow, Forearm, Wrist, & Hand. Bony Anatomy. Objectives. Bones. Bones. Bones
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1 Objectives Elbow, Forearm, Wrist, & Hand Chapter 19 Identify and discuss the functional anatomy of the elbow and forearm Discuss the common injuries associated with these anatomical structures Bones Humerus Bony Anatomy Anterior View full extension Medial Medial epicondyle Lateral Lateral epicondyle Radial Radial head Radius Ulna Bones Humerus Bones Posterior View full extension OlecranonOlecranon Groove Groove for ulnar nerve Radial Radial head Medial Medial epicondyle Lateral Lateral epicondyle Ulna Radius Lateral View full extension Lateral Lateral epicondyle OlecranonOlecranon Radial Radial head Humerus Radius Ulna 1
2 Bones Bones of the Wrist Lateral View 90 deg. flexion Humerus Radius Radius Ulna Carpals (8) Ulna Dorsal View Bones of the Wrist Bones of the Hand Radius Ulna Carpals (8) Metacarpals (5) Phalanges (14) Proximal (5) Middle (4) Distal (5) Palmar View Joints of the Hand & Fingers Metacarpophalangeal (MCP) Interphalangeal Proximal (PIP) Distal Distal (DIP) Ligaments 2
3 Ligaments of the Elbow Lateral View Capsule Anular Ligament Ligaments of the Elbow Anterior View Radial (Lateral) Collateral Anular Ligament Anterior Capsule Ulnar (Medial) Collateral Radial (Lateral) Collateral Ligaments of the Elbow Ligaments of the Wrist Medial View Anular Ligament Ulnar (Medial) Collateral Palmar View Dorsal View Ligaments of the Fingers Ligaments of the Fingers Joint capsule Collateral ligaments Palmar ligaments Transverse ligaments of MCP Palmar View Joint capsule Collateral ligaments Volar (Palmar) ligaments 3
4 Muscles Muscles of the Forearm Elbow flexors/extensors Forearm pronators/supinators Wrist flexors/extensors Finger flexors/extensors Muscles Tricep Muscles Bicep Elbow extensors Anconeus Elbow flexors Brachioradialis Muscles Wrist Extensors Finger Extensors Ext. carpi radialis longus Ext. carpi radialis brevis Ext. digitorum Ext. digiti minimi Ext. carpi ulnaris Muscles Thumb Extensors Abductor pollicis longus Ext. pollicis brevis Ext. pollicis longus 4
5 Muscles Muscles Wrist Flexors Flexor carpi ulnaris Palmaris longus Pronators Pronator teres Flexor carpi radialis Pronator quadratus Muscles Supinators Supinator Elbow Injuries Contusions Acute Soft Tissue Injuries Contusion to olecranon bursa Significant swelling Mild to moderate pain Limited elbow flexion Sprains Acute Soft Tissue Injuries Excessive joint loading Ulnar collateral sprains caused by valgus force 5
6 Sprains Acute Soft Tissue Injuries Radial collateral sprains caused by hyperextension w/forearm supinate Sprains Acute Soft Tissue Injuries Anterior capsular sprain caused by forced hyperextension of the elbow Sprains Acute Soft Tissue Injuries Signs & Symptoms Sensation of pop Point tenderness Swelling Decreased ROM Pain and/or laxity with stress test(s) Strains Acute Soft Tissue Injuries One-time episode of excessive overload or stretch Excessive eccentric loads Strains Acute Soft Tissue Injuries Wrist flexor/pronator group Wrist extensor/supinator supinator group Distal biceps tendon (rare) Distal triceps tendon (rare) Chronic Soft Tissue Injuries Bursitis Tendinitis Epicondylitis (lateral: tennis elbow; medial: golfer s s elbow) Periostitis Valgus overload instabilities 6
7 Bursitis Chronic Soft Tissue Injuries Fluid accumulation in olecranon bursa Caused by repetitive friction or direct trauma Bursitis Signs & Symptoms Chronic Soft Tissue Injuries Large localized accumulation of fluid in the bursa Limited ROM Warm to the touch Tendinitis Chronic Soft Tissue Injuries Overuse injury Inflammatory response at tendon insertion site Chronic Soft Tissue Injuries Epicondylitis Degenerative changes Lateral (tennis elbow) Medial (golfer s s elbow) Less common Chronic Soft Tissue Injuries Lateral Epicondylitis Tennis Elbow Causes Repeated tension and stress on the wrist extensor & supinator groups Backhand in tennis Faulty mechanics Inadequate muscle strength & endurance Poor racket fit (improper string tension, grip size, racket weight or size) Chronic Soft Tissue Injuries Lateral Epicondylitis Tennis Elbow Signs & Symptoms Gradual onset of pain along lateral epicondyle Pain with gripping and wrist extensor activities Pain with passive stretching 7
8 Chronic Soft Tissue Injuries Medial Epicondylitis Golfer s Elbow Causes Repeated tension or stress on the wrist flexor & pronator groups baseball pitching golf swing overhead tennis serve forehand racket motion Faulty mechanics Chronic Soft Tissue Injuries Medial Epicondylitis Golfer s Elbow Signs & Symptoms Gradual onset of pain along medial epicondyle Point tenderness just distal and lateral to the medial epicondyle (common flexor tendon) Pain with resisted wrist flexion & forearm pronation Pain with passive stretching Ulnar nerve symptoms Traumatic Distal Humerus Potential for neurovascular injury (peripheral nerves) Dislocations & Subluxations Humeroulnar Joint Posterior most common Hyperextension during forced axial loading Ulna & radius usually displace together Potential for neurovascular injury Brachial artery Entrapment of medial and/or ulnar nerve Dislocations & Subluxations Humeroulnar Joint Dislocations & Subluxations Radioulnar Joint Signs & Symptoms Pain Limited ROM Elbow effusion Inability to supinate Tenderness over antecubital area 8
9 Bony Lesions 2 to Repetitive Stress Traction Apophyseal and Epiphyseal Injuries Little league elbow Repetitive valgus forces Starts out as apophysitis Bony Lesions 2 2 to Repetitive Stress Osteochondral Defects Osteochondritis dissecans Most often seen in young throwers Compressive forces damage blood supply to the capitellum & radial head Aseptic necrosis Loose body Bony Lesions 2 2 to Repetitive Stress Osteochondral Defects Osteochondritis dissecans General Evaluation Principles History Observation General Assessment How athlete holds elbow Location and degree of swelling and discoloration Carrying angle Relationship between olecranon and epicondyles 0 to 90 Observation Carrying angle normal males: 5 5 General Assessment females: 10 to 15 9
10 Observation Carrying angle Cubital varus gunstock deformity General Assessment Observation Carrying angle Cubital valgus General Assessment Observation General Assessment Relationship between olecranon and epicondyles 0 to 90 General Evaluation Principles Observation Swelling, deformity, discoloration Alignment of fingers/joint General Evaluation Principles Observation Hand/finger creases Size & shape of fingernails Spoon shaped - fungal infections Club shaped - respiratory & heart conditions Motion of fingers General Evaluation Principles Palpation Bony & soft tissue structures Deformity Crepitus Warmth Compare bilaterally 10
11 Wrist & Hand Injuries Sprains Strains, tendon avulsions Chronic inflammatory conditions Wrist Sprains Distal radial ulnar joint Radiocarpal joints Intercarpal joints Wrist Sprains Mechanism of Injury Falling on outstretched hand Hyperflexion Hyperextension Jamming,, compressive forces Wrist Sprains Signs & Symptoms Pain Swelling Point tenderness over involved joint Pain w/active and passive ROM Finger Sprains jammed finger MCP, PIP, DIP Finger Sprains Collateral ligaments Mechanism of Injury Axial force that produces valgus/varus stress Volar ligaments Mechanism of Injury Hyperextension force 11
12 Finger Sprains Signs & Symptoms Pain Swelling Point tenderness over involved joint/ligament Collateral sprains: pain/laxity w/valgus & varus stress tests Volar sprains: laxity with PIP hyperextension Finger Sprains Evaluation Valgus stress test Varus stress test Ulnar (medial) collateral Radial (lateral) collateral Finger Sprains Finger Sprains Management Refer for x-raysx Collateral sprains Splint until pain subsides PIP: flexion DIP: full extension Buddy tape for activity Volar sprains Splint flexion x 3 wks Buddy taping Complications Collateral sprains Deformity Loss of function Volar sprains Swan-neck neck deformity DIP hyperflexion,, PIP hyperextension Pseudoboutonniere deformity DIP hyperextension, PIP hyperflexion Thumb Sprains Gamekeeper s s (Skier s) Thumb Sprain of UCL of MCP Mechanism of Injury Forced ABD/hyperextension of thumb Thumb Sprains Signs & Symptoms Pain Swelling Point tenderness over UCL Pain and/or weakness with pinching (2nd or 3rd degree) 12
13 Thumb Sprains Management Refer for x-raysx Partial tears Splint or cast for wks w/mcp in slight flexion Complete tears Surgical repair required Muscle/Tendon Injuries Mallet finger Rupture/avulsion of extensor tendon at DIP insertion Muscle/Tendon Injuries Mallet finger Mechanism of injury Forced flexion of DIP Muscle/Tendon Injuries Mallet finger Signs & Symptoms Pain Point tenderness over the distal attachment Flexion deformity of distal phalanx Inability to actively extend DIP Muscle/Tendon Injuries Mallet finger Evaluation Mallet finger test (extensor tendon avulsion test) Muscle Tendon Injuries Mallet finger Management Refer for x-raysx Splint DIP in extension or hyperextension x wks Splint for activity another 4 wks 13
14 Muscle Tendon Injuries Mallet finger Complications Permanent flexion deformity Muscle Tendon Injuries Boutonniere deformity Rupture/avulsion of central slip of extensor tendon Musculotendinous Injuries Boutonniere deformity Mechanism of Injury Forced flexion of PIP Signs & Symptoms Pain at PIP joint Point tenderness near tendon s insertion Weakness or inability to extend PIP Musculotendinous Injuries Boutonniere deformity Evaluation Extensor superficialis tendon test Management Refer for x-raysx Splint PIP in extension w/dip left unrestricted x wks Splint for activity an additional 4 wks Musculotendinous Injuries Boutonniere deformity Complications Flexion deformity Loss of motion/ function Muscle/Tendon Injuries Jersey Finger Rupture/avulsion of the flexor digitorum profundus 14
15 Muscle/Tendon Injuries Jersey Finger Mechanism of Injury Forced extension of flexed DIP Muscle/Tendon Injuries Jersey Finger Signs & Symptoms Pain Swelling Point tenderness at insertion site of flexor digitorum profundus Inability to actively extend DIP Muscle/Tendon Injuries Jersey Finger Evaluation Flexor digitorum profundus test Muscle/Tendon Injuries Jersey Finger Management Surgical repair Splint/buddy tape prior to referral PIP in flexion Muscle/Tendon Injuries Jersey Finger Complications Loss of motion/function Scarring Navicular (scaphoid) Fx Typical mechanism: falling on an outstretched hand 15
16 Navicular (scaphoid) Fx Signs & symptoms Evaluation Navicular (scaphoid) Fx Management Distal radius fx (Colles s fx) silver fork deformity Distal radius fx (Colles s fx) Mechanism Falling on outstretched hand Distal radius fx (Colles s fx) Signs & Symptoms Immediate pain swelling Tenderness Deformity Sensation changes if the median nerve is injured Distal radius fx (Colles s fx) Management Splint Refer to physician 16
17 Distal radius fx (Smith fx) Opposite of Colles s fx Volar displacement of distal fragments Distal radius fx (Smith fx) Mechanism Falling on back of hand hyperflexion Distal radius fx (Smith fx) Signs & Symptoms Same as Colles s fx Management Same as Colles s fx Bennett s fx Phalangeal fx Chronic Inflammatory Injuries Tendinitis/Tenosynovitis De Quervain s Disease Trigger Finger Dupuytren s Contracture Wrist Ganglion 17
18 Soft Tissue Subungeal hematoma Ganglion cyst Trigger finger Questions? 18
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