Elbow, Wrist and Hand Flashcards
Elbow Carrying Angle
Males: 5°
Females: 10-15°
Cubitus Varus
<5° (adduction of ulna)
Cubitus Valgus
> 15° (abduction of ulna)
Elbow Anatomy
Olecranon process
Medial epicondyle
Lateral epicondyle
Radial head
Musculature involving wrist flexors and pronators
Musculature involving wrist extensors and supinators
Wrist/Hand Anatomy
Palmar and dorsal wrist Thenar and hypothenar eminences Flexor tendons Anatomic Snuffbox Distal Radius and Ulna Carpal Bones MCP, PIP, DIP
Anatomic Snuffbox Borders
Medial: Extensor Pollicus Longus
Lateral: Extensor Pollicus Brevis, Abductor Pollicus Longus
Proximal: Radial Styloid Process
Carpal Bones
Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, Hamate
Elbow Flexion
Biceps brachii, brachialis, brachioradialis, coracobrachialis ms.
140-150°
Elbow Extension
Triceps brachii, anconeus ms.
0-(-5)°
Elbow Supination
Supinator, biceps brachii ms.
90°
Elbow Pronation
Pronator teres, pronator quadratus ms.
90°
Wrist Flexion
Flexor carpi radialis, Flexor carpi ulnaris, Palmaris longus ms.
80-90°
Coupled Movement: Dorsal/posterior carpal glide
Wrist Extension
Extensor carpi radialis longus and brevis, extensor carpi ulnaris ms.
70°
Coupled Movement: Ventral/anterior carpal glide
Wrist Adduction
Ulnar Deviation
Flexor carpi ulnaris, extensor carpi ulnaris ms.
30-40°
Coupled Movement: Ulnar abduction
Wrist Abduction
Radial Deviation
Flexor carpi radialis, extensor carpi radialis longus and brevis ms.
20-30°
Coupled Movement: Ulnar adduction
Elbow Motions to test muscle strength
Flexion, extension, supination, pronation
Wrist Motions to test muscle strength
Flexion, extension, adduction, abduction
Hand Motions to test muscle strength
hand grip strength (patient squeezes physician’s 2nd and 3rd fingers)
Thumb: flexion, extension, abduction, adduction, opposition
Finger: flexion, extension, abduction, adduction
Sensory/Dermatomes of Elbow/Wrist/Hand
C5-T1 C5 - Lateral arm C6 - Lateral forearm ad thumb C7 -Middle Finger C8 - Medial forearm and little finger T1 - Medial arm
Valgus Stress Test
Arm slightly abducted and externally rotated. Forearm supinated and flexed to approximately 30°. Slight medial directed valgus stress applied to the elbow joint.
(+) Test: Pain/tenderness with palpation and valgus stress; increased laxity (degree of laxity correlates to degre of injury to UCL)
Indication: Sprained Medial (Ulnar) Collateral Ligament.
Varus Stress Test
Arm slightly abducted and internally rotated. Forearm supinated and flexed to approximately 15°. Slight lateral directed varus stress applied to the elbow joint.
(+) Test: Pain/tenderness with palpation; increased laxity in LCL.
Indication: Sprained Lateral (Radial) Collateral Ligament.
Tinel Test for Ulnar Nerve Entrapment
Tap between the olencranon and medial epicondyle in the ulnar groove.
(+) Test: Elicits tingling sensation down the forearm within ulnar nerve distribution.
Indication: Ulnar nerve entrapment/cubital tunnel syndrome.
Golfer’s Elbow Test
Patient’s elbow is flexed to 90° and forearm is placed in supination with the wrist neutral and the palm facing up. The examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s wrist to resist movement. Instruct the patient to flex the wrist.
(+) Test: pain/tenderness around the medial epicondyle.
Indication: Medial Epicondylitis (Golfer’s Elbow)
Tennis Elbow Test (Cozen’s test)
Patient’s elbow is flexed to 90° and forearm is placed in pronation with wrist neutral and palm facing down. Examiner places one hand under the proximal forearm for stabilization and the other hand over the patient’s hand to resist movement. Instruct the patient to extend the wrist.
(+) Test: pain/tenderness around lateral epicondyle, may radiate down lateral forearm.
Indication: Lateral Epicondylitis/Tennis Elbow.
Olecranon Bursitis
Olecranon bursa lies superficial to posterior elbow joint. Posterior elbow distention and discomfort due to overuse (“student’s elbow”) or occupational (“minor’s elbow”) or athletic injury. Region is often painless and range of motion is normal.
“Little League Elbow”
Group of problems related to stress of throwing in young athletes. Medial apophysitis (childhood), medial epicondyle avulsion fracture (adolescence), or medial collateral ligament tear (young adulthood).
Pain over the medial epicondyle, initially after throwing (repetitive valgus distraction forces), progresses to persistent pain. Most common elbow injury during childhood (since growth plates not fused/ secondary ossification centers absent). As the bone matures , most common injury seen evolves (as noted above).
Radial Head Instability
“Nursemaid’s Elbow”
Annular Ligament tear and/or radial head subluxation from annular ligament. Often result from trauma with traction of child’s extended arm. Pain with palpation of radial head with anterior displacement of radial head and restriction to posterior glide.
Coupled Motions at Elbow
Ulnar adduction with supination
Ulnar abduction with pronation
Radial head anterior glide with supination
Radial head posterior glide with pronation.
“OK” Sign
On examination, if neuropathy present, patient cannot make the “O” with thumb and forefinger pinched together.
Indicates: Issue with anterior intersseous n.
Carpal Tunnel Syndrome (CTS)
Entrapment of the median n. at the wrist in the carpal tunnel produces pain and paresthesia. Chronic cases may develop atrophy of instrinsic muscles of the hand (thenar eminence). Obtain history about repetitive movements. pregnancy, connetive tissue disorder, etc. Patients will also have grip weakness and weakness with thumb abduction.
Tinel’s sign
Tap over the transverse carpal ligament/flexor retinaculum (between the thenar/hypothenar eminences) with either the tip of the examiner’s finger or reflex hammer with the patient’s wrist held at extension.
(+) Test: parasthesia/numbness/tingling/pain radiating to the thumb index finger, and middle finger (median n. distribution).
Indicates: entrapment of median n. or carpal tunnel syndrome.
Phalen’s Sign
Place dorsal aspects of patient’s hands together and force into wrist flexion. Hold for 60 seconds.
(+) Test: any reproduction of symptoms, parasthesia distribution of the median n.
Indication: Carpal Tunnel Syndrome
DeQuervain’s Tenosynovitis
Pain and inflammation from repetitive overuse of tendons in first dorsal compartment. Patients complain of dorsolateral wrist and thumb pain, occasionally with radiation into lateral hand and thumb. Patients will also have grip weakness. Pain may be worsened with thumb movements.
Possible inflammation sites include tendon sheath, abductor pollicis longus, extensor pollicis brevis.
Finkelstein Test
Examiner asks patient to make a fist encompassing their thumb and ulnar deviate the wrist.
(+) Test: increased pain in first dorsal compartment (lateral wrist)
Indication: DeQuervain’s tenosynovitis
Ulnar Nerve Entrapment
“Handlebar Palsy”
Ulnar nerve gets entrapped in Guyon’s Canal (space between the hook of the hamate and pisiform, covered by flexor retinaculum at the base and the superficial palmar carpal ligament at the roof). Irritation leads to numbness, tingling, weakness and/or pain in the ulnar n. distribution.
Gamekeeper’s Thumb/Skier’s Thumb
Tear of the ulnar collateral ligament of the MCP. Due to hand positioning when killing game (rabbits) or falling on a ski pole. Pain in the medial aspect of MCP.
Mallot FInger
Extensor tendon injury at DIP
Trigger Finger
inflammation and narrowing of flexor tendon sheath
Jersey Finger
avulsion of flexor digitorum profundus from fingertip
Dupuytren’s Contracture
abnormal connective tissue thickening in the palmar fascia
Ganglion Cyst
Unknown cause or irritation. Fluid filled sac along with tendon sheath or joint capsule, mobile, transilluminates, nontender. Most commonly found in the dorsum of the wrist. Most will spontaneously resolve.
Also known as the Bible Cyst
Rheumatoid Arthritis
Autoimmune inflammatory condition. Causes inflammation of the joints, especially in the hands, wrists and knees. Causes inflammation in the lining of the joint and tissue damage leading to chronic pain and deformity.
Symptoms include ulnar deviation of the fingers, Bouchard nodes (PIP), Heberden nodes (DIP), subcutatneous nodules along the extensor surface of the proximal ulna or around the olecranon bursa.
Clubbed Fingers
Focal bulbous enlargement of terminal fingers. Angle between the nail and proximal nail fold >180. Proliferation of connective tissue between nail matrix and distal phalanx along with vasodilation with increased blood flow to the digits.
Causes: Unknown, but often associated with lung cancer, liver cirrhosis, cyanotic heart disease, bronchiectasis, etc.
Scaphoid Fracture
Most common carpal bone fracture due to falling on outstretched hand (FOOSH). Patient complains of dull achiness deep in radial aspect of wrist after a fall. Patient will also present with decreased ROM, grip strength and tenderness inside the anatomical snuffbox (good sensitivity).
Tenderness of the scaphoid tubercle (good specificity) can be found when physician extends the wrist and apply pressure to tubercle.
This area is prone to avascular necrosis secondary to blood supply. Immediate radiographic evidence will not show this, found with repeat imaging after about a week.
Colle’s Fracture
Fracture of the distal radius in the forearm with dorsal (posterior) and radial displacement of the wrist and hand. Has appearance of classic “dinner fork” deformity with bony step off.
Smith Fracture
Fracture of the distal radius in the forearm with ventral displacement of the wrist and hand.
Boxer’s Fracture
Fracture of the distal shaft of the 5th metacarpal. Usually due to punching a solid surface. Often, this is obtained in bar fights.
Monteggia Fracture
Fracture of the proximal ulna. Dislocation of the radial head.
Galeazzi Fracture
Fracture of the distal radius and dislocation of the ulna.
Nightstick Fracture
Isolated fracture of the mid shaft/distal ulna from a direct blow.
