The Elbow, Forearm, Wrist, and Hand

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1 Elbow - Bones The Elbow, Forearm, Wrist, and Hand Chapters 23 & 24 Humerus Distal end forms the medial & lateral condyles Lateral: capitulum Medial: trochlea Radius Ulna Sports Medicine II Elbow - Bones Convex capitulum of humerus articulates with concave head of radius Trochlea of humerus fits into an articulating groove semilunar notch Part of the ulna between the olecranon and coronoid processes Elbow - Joints Humeroulnar Olecranon process of ulna and trochlea & olecranon fossa of humerus Flexion & extension Humeroradial Radial head of radius with capitulum of humerus Flexion & extension Radioulnar Radial head w/ radial notch of ulna Pronation & supination 1

2 Elbow - Ligaments Ulnar (medial) collateral Most important for stability of the elbow; especially with activities that produce flexion-supination Medial epicondyle to proximal ulna Provides stability to a valgus force Radial (lateral) collateral Provides stability to a varus force Lateral epicondyle to the annular ligament on radius Does not attach to the radius Annular Extends from the ulna, forming a sling around the radial head Nerves Come from the brachial plexus (C4-T2) Musculocutaneous Radial Ulnar Median 2

3 Functional Anatomy Flexion: ~ 145 degrees Supination/Pronation: ~ 90 degrees Bony limitations, ligamentous support, and muscular stability help to protect the elbow from overuse and traumatic injury Elbow - HOPS History: same general questions Observation: Carrying angle: angle from humerus to ulna Usually degrees Triangle formed by epicondyles and olecranon process Elbow HOPS (cont.) Special/Stress Tests: ROM: Flexion, extension, supination, pronation Circulation Tinel s sign: Designed to determine ulnar nerve compromise Valgus/Varus ligament tests Same as knee collateral tests Elbow HOPS (cont.) Special/Stress Tests: Medial/Lateral Epicondylitis Tests Elbow flexed to 45 degrees and wrist extension is resisted (increases pain on lateral epicondyle) or resist wrist flexion (increases pain on?) 3

4 Elbow injuries Two most common mechanisms of elbow injury: Throwing Falling on the outstretched hand Ulnar Collateral Ligament Sprain UCL provides primary resistance to valgus stresses that occur during the late cocking and early acceleration phases of throwing, forehand stroke in tennis, or in the trailing arm during an improper golf swing. Most often injured due to a valgus force from repetitive trauma Ulnar Collateral Ligament Sprain One of the most common injuries seen in baseball to pitchers If the injury is bad enough, the athlete will have to have Tommy John Surgery Replacement of the UCL with: Palmaris longus (85% have this) Plantaris (ankle/knee) Hamstring Elbow - Injury Lateral Epicondylitis Tennis elbow Cause: Repetitive extension of wrist Signs/Symptoms: Aching pain during and after activity Tenderness over lateral epicondyle Pain with resisted extension of wrist & full extension of elbow PRICE, NSAIDs ROM exercises, strengthening, massage Counterforce or neoprene tennis sleeve Elbow - Injury Medial Epicondylitis Pitcher s elbow, Golfer s elbow Cause: repetitive forceful flexion of elbow Signs/Symptoms: Pain over medial epicondyle with forceful wrist flexion Swelling, point tenderness PRICE, NSAIDs, strengthening Counterforce brace 4

5 Elbow - Injury Ulnar Nerve Injuries Ulnar nerve hit often Funny Bone Signs/Symptoms: Paresthesia to fourth and fifth fingers Burning and tingling to fourth and fifth fingers Conservative - TIME Elbow - Injury Dislocation of the Elbow High incidence from a fall on the outstretched arm with elbow in hyperextension or severe twist while elbow in flexed position Displaced backward, forward, or laterally Signs/Symptoms: Deformity: olecranon process not where it should be Tearing of ligaments; profuse bleeding and subsequent swelling Splint & refer to physician Elbow - Injury Volkmann s Contracture A major complication of a serious elbow injury Swelling, muscle spasm or bone displacement can put pressure on brachial artery and inhibit blood flow pain in the forearm that gets worse when fingers are extended physician ASAP Forearm - Bones Ulna Considered an extension of the humerus Long, straight, & larger proximally Radius Considered an extension of the hand Thicker distally 5

6 Forearm Articulations Superior radioulnar Pivot joint; moves in a ring formed by the ulna and annular ligament Middle radioulnar Held together by the interosseous membrane Distal radioulnar Pivot joint; formed by head of ulna and small notch on radius Forearm - Muscles Wrist/Hand/Finger flexor muscles originate mainly at the medial epicondyle of the humerus Wrist/Hand/Finger extensor muscles originate mainly at the lateral epicondyle of the humerus Forearm - Injury Forearm Splints Related to shin splints Caused by repeated static contractions Often in gymnastics & cheerleading Happens early or late in season Forearm - Injury Fracture Blow or fall on the outstretched hand Fractures to ulna or radius singularly are rarer than simultaneous fractures 6

7 Forearm - Injury Colles Fracture One of the most common forearm fractures, involves distal end of radius Cause: fall on the outstretched hand Forcing wrist backwards and upwards into hyperextension Visible deformity, swelling, pain Sometimes no deformity and will be passed off as a bad sprain Ice, splint & sling, physician Wrist, Hand, Fingers - Anatomy Wrist is formed by 8 carpal bones Radius to Ulna 2 rows Distal Proximal Scaphoid (navicular) - Trapezium Lunate - Trapezoid Triquetral - Capitate Pisiform - Hamate Lower row of carpals articulate with the radius and ulna, except pisiform Articulates with the triangular fibrocartilage complex (TFCC) between the ulna and triquetral Wrist, Hand, Fingers - Anatomy 5 Metacarpal bones 14 phalanges 27 total bones Joints Carpometacarpal (CMC) Metacarpophalangeal (MCP) DIP, PIP, IP 7

8 Wrist, Hand, Fingers - Ligaments Ligaments bind carpal bones together Ulnar & Radial collateral ligaments of the wrist Transverse carpal ligament = roof of the carpal tunnel PIP joints have medial & lateral collateral ligaments Thickened joint capsule on palmer surface of PIP joints = Volar plate 8

9 Wrist, Hand, Fingers - Movements Wrist: flexion, extension, ulnar deviation, radial deviation Thumb: abduction, adduction, opposition PIP & DIP: flexion & extension Fingers: abduction & adduction MCP, IP of Thumb: flexion & extension Fifth Finger opposition Special Tests Finklestein s Test Test for de Quervain s syndrome Make a fist with thumb tucked in; ulnar flexion Sharp pain = stenosing tenosynovitis Pain over carpal tunnel may mean median nerve involvement Tinel s Sign Tap over transverse carpal ligament of the carpal tunnel; tingling, paresthesia Sign of carpal tunnel Special Tests Phalen s Test Used for carpal tunnel Flex wrist as far as possible and press them together; position held for about a minute Positive if pain in carpal tunnel area Special Tests Valgus/Varus and Glide Tests Check ligamentous integrity Wrist Sprain Most common wrist injury & often the worst managed Cause: Falling on hyperextended wrist is most common Repeated flexion, extension, lateral or rotary movements PRICE, wrist strengthening exercises, taping Splint for moderate sprains Wrist Tendinitis Cause: Occurs in weight lifters, rowers, and participates in other sports requiring repetitive wrist accelerations and decelerations PRICE (ice massage), splint?, strengthening when swelling has subsided 9

10 Carpal Tunnel Syndrome Tunnel formed by carpal bones & transverse carpal ligament Small space with a lot of tendons and the median nerve passing through the tunnel Results from inflammation of tendons within the space which leads to compression of median nerve People who do activities that require repetitive wrist flexion & extension Carpal Tunnel Carpal Tunnel Carpal Tunnel Syndrome Sensory & motor deficits Tingling, numbness, paresthesia in thumb, index & middle fingers Weak thumb movements Rest, immobilization, NSAIDs Injection with corticosteroid or surgery may be required Dislocation of Lunate Most common dislocated carpal bone Occurs from a forceful hyperextension of wrist pain, swelling, difficulty executing wrist & finger flexion Numbness or paralysis may be present splint & refer 10

11 Scaphoid Fracture Most frequently fractured carpal bone Caused by a force on outstretched hand, which compresses the scaphoid bone between radius & second row of carpals Swelling, severe point tenderness in anatomical snuffbox Ice, splint, refer Scaphoid Fracture Hamate Fracture Occurs from a fall or more commonly from contact when holding an implement (racket, bat, stick, golf club) Wrist pain, weakness, point tenderness Tingling, numbness, weakness in little & ring fingers are possible Ice, splint & refer Metacarpal Fractures Fracture of 5 th is called Boxer s fracture Mostly caused by direct axial force caused by punching a wall or person Ice, splint & refer 11

12 Mallet finger Mallet Finger Caused by blow from a thrown ball that strikes the tip of the finger, jamming and avulsing the extensor tendon along with a piece of bone Pain at DIP joint, unable to extend finger & has angle of ~30 degrees PRICE, refer Boutonnière Deformity Also called Buttonhole deformity Caused by rupture of extensor tendon over middle phalanx Trauma to tip of finger that forces DIP joint into extension and PIP into flexion Severe pain, swelling, point tenderness, inability to extend DIP joint Ice, splint PIP joint in extension & refer Jersey Finger Rupture of flexor digitorum profundus tendon from its insertion on distal phalanx Often to ring finger when trying to grab a jersey Can flex the DIP joint & finger in extended position Pain & point tenderness over distal phalanx Ice, splint & refer 12

13 Gamekeeper s thumb Gamekeeper s Thumb Sprain of ulnar collateral ligament of MCP joint of the thumb Common in skiers, goalies, when tackling during football Forceful abduction of proximal phalanx, usually combined with hyperextension Pain over UCL, weak & painful pinch Tenderness, swelling over medial thumb PRICE, refer Collateral Ligament Sprain Common in basketball, volleyball, football Jammed finger = axial force to tip of the finger PRICE, maybe splint Dislocations of Phalanges Caused by a blow to the tip of the finger by a ball Force of injury is usually directed upward from the palmar side Splint & refer Thumb dislocations should be considered serious due to function of the thumb Phalanx Fracture Stepped on, hit by a ball, twisted Pain & swelling Tenderness at the point of the fracture Ice & splint in a flexed position Reduces the deformity by relaxing the flexor tendons 13

14 Subungual Hematoma Contusion to the fingernail causing, bleeding underneath the fingernail Placed in ice water Two methods to release blood: Use special nail drill or scalpel Hot paper clip 14

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