Elbow, Wrist and Hand Anatomy + Presentation Flashcards
what is cubitus valgus?
carrying angle of the elbow
typically 10-15º
greater in females (average = 13, male average = 10)
less in children, increases w/age
what is the functional importance of the carrying angle?
compensates for the change of orientation of the radius
allows the axis of the hand to stay in the longitudinal plane
what ligaments stablize both the humero-ulnar and humero-radial joint?
anterior capsule
radial and ulnar collateral ligaments
where are the radial collateral ligaments and when are they taut?
attaches to the lateral epicondyle and annular ligament
blends with the ulna posteriorly
blends with supinator and ECRB
taut throughout most of flexion range
where is the ulnar collateral ligmanet and when is it taut?
triangular band (ant, post, inferior parts)
attaches medial epicondyle, medial coronoid margin, medial margin of olecranon
anterior band taut throughout most of flexion
posterior band taut between 1/2 and full extension
what is the resting position (open pack position) of the humero-ulnar joint? Closed pack?
70 degree flexion
10 degrees supination
closed pack = full extension and supination
what is the resting position (open pack) for the humero-raidal joint? Closed pack?
full extension and supination
closed pack = 90 degree flexion and 5 degrees supination
describe the vascular supply to the scaphoid, why is this clinically important?
no vascular supply to proximal scaphoid,
the scaphoid is commonly fractured, and the lack of vascular supply can result in necrosis to the proximal pole
describe the ulno-carpal joint
both the distal ulna and prox triquetrium are convex
TFCC is placed there
what is the roof of the carpal tunnel?
Flexor retinactulum of the wrist
what passes through the carpal tunnel?
- FDS tendons (4) w/synovial sheath
- FDP tendons (4) w/synovial sheath
- FPL tendon
- median nerve
list the columns of the hand and what bones are in each
- Lateral
- scaphoid, trapezoid and first 2 metacarpals
- Intermediate
- middle phalanx
- Medial
- triquetrum, pisiform, hamate, 4th and 5th metacarpal
List the joints that make up the finger joints
- Intermetacarpal
- Metacarpophalangeal (MCP)
- Interphalangeal (IP)
what are the palmar plates?
fibrocartilage attachments off the base of the anterior aspect of the proximal phalanx to the neck of the metacarpal
covers MCPs and IPs
what is the function of the palmar plates?
- increase the area of the articular surface
- resist hyperextension with ligamentous attachment to proximal bony structures
- reinforce the joint capsule
- prevent impingement of flexor tendons during MCP flexion
- protect articular cartilage in extension on impact (high fives!)
- has healing capacity
what are finger pulleys?
series of arcuate and cruciate pulleys that hold the tendons of the fingers close to the axis of rotation
improves mechanical advantage
prevents bowstringing
what innervates the supinator?
deep branch of radial nerve
this muscle is wound around the radial neck (unwind’s the unla)
what innervates the pronator quadratus?
anterior interosseous nerve
what makes up the borders of the anatomic snuffbox?
- extensor pollicis brevis
- abductor pollicis longus
- extensor pollicis longus
contents → scaphoid and trapezium
what makes up the borders of Guyon’s Canal?
lateral border of the pisiform
transverse carpal ligament
pisohamate ligament
list the contents of Guyon’s Canal
- ulnar nerve
- bifurcates late in the canal (superfical palmar cutaneous nerve
- ulnar artery
list the roots, motor and sensory innervations for the Axillary Nerve
- Roots → C5, C6
- Motor → Deltoid, Teres minor
- Sensation → lateral proximal upper arm
list the roots, motor and sensory innervations of the Radial Nerve
- Roots → C5-T1
- Motor → Triceps
- Sensation → posterior aspect of digits 1-3 and lateral half of digit 4
list the roots, motor and sensory innervations of the Posterior Interosseous Nerve
- Roots → C7, C8
- Motor → ECRB, ECU, EI, EDM, EPB, EPL, APL, ED
list the roots, motor and sensory innervations for the Musculocutaneous Nerve
- Roots → C5-C7
- Motor → Coracobrachialis, biceps, brachialis
- Sensation → lateral cutaneous nerve of forearm
list the roots, motor and sensory innervations of the Median Nerve
- Roots → C6-T1
- Motor → PT, FCR, PL, FDS, APB, FPB, OP, Thenar muscles ( recurrent branch), radial lumbricals
- Sensation → palmar lateral hand and digits 1-3 and radial 4th digit
list the roots, motor and sensory innervations of the Anterior Interosseous nerve
- Roots → C7, C8
- Motor → Pronator quadratus, FDP (lateral), FPL
list the roots, motor and sensory innervations of the Ulnar nerve
- Roots → C7-T1
- Motor → FCU, FDP (medial half)
- Sensation → dorsal cutaneous branch (palmar digit 5 and medial half of digit 4)
List the most common clincial presentations of the elbow, wrist, and hand
- Fractures and other bony abnormalities
- inflammatory arthropathies
- Finger deformities
- Osteoarthropathies
- Dupuytren Contracture
- Ligament sprain
- Wrist
- UCL (1st MCP)
- Gamekeeper’s Thumb
- TFCC Injury
- Intercarpal Instability
- Tendinopathies
- DeQuervain Disease
- Ganglia
List the types of fractures that can occur at the wrist and hand
- Distal radius fracture
- Carpal fractures
- metacarpal fractures
- finger fractures
List various types of distal radius fractures
- Colles frx
- Smith frx
- Barton frx
- Buckle Frx
what is the difference between Smith and Colle fractures?
- Colle frx → occur secondary to a FOOSH w/extended wrist
- Smith frx → FOOSH w/flexed wrist and volar displacement
what is a Barton frx?
the fracture line extends through the radius and the articular surface at the distal radius
what is a buckle fracture?
compressive fracture that occurs at the distal radius and commonly seen in younger folks
which carpal is the most common to be fractured?
Scaphoid
most common among 15-30 y/o
common at waist and proximal pole
what is the most common MOI of scaphoid fractures?
FOOSH in a position of radial deviation
describe the symptomology of scaphoid fractures
deep, dull radial wrist pain
pain w/gripping/squeezing
what physical examination findings would found with a scaphoid fracture?
tenderness anatomic snuffbox/scaphoid
local swelling/bruising
often not visible on x-rays directly following injury
what can a lunate fracture progress into?
Kienbock’s Disease
what is Kienbock’s disease?
osteonecrosis of the lunate
concern for carpal collapse
important to screen for this disease
how is Kienbock’s disesae managed?
surgically
conservatively → immobilization 6-10 weeks f/b progression of ROM/resistive exercises
List types of inflammatory arthropathies
- RA
- ulnar drift
- Boutonniere deformity
- Swan neck deformity
- Septic arthritis
- Gouty arthritis
what is Boutonneire Deformity?
flexion of the PIPJ, hyperextension of the DIPJ
MOI → a rupture of the central band, lateral bands slip to the palmar side of the axis of rotation of the PIPJ
what is a Swan neck deofrmity?
hyperextension of the PIPJ and flexion of the DIPJ
MOI → disruption of the volar plate at the PIPJ, lateral bands bowstring dorsally, increasing the moment arm of the intrinsics and causing PIPJ extension
what is a mallet deformity?
flexion of the DIPJ: extensor tendon rupture
more related to trauma
describe the clinical presentation of the osteoarthropathy of the CMC
- Pain at the base of the thumb
- Hx prior trauma possibly
- Crepitus
- Pain ROM at end range (multi-directional)
- Pain w/resistance
- Women > Men
- Age > 45 yrs more commonly
list physical examination findings for arthropathies
- Deformities (more common inflammatory arthropathies)
- also including nodules
- Tenderness to palpation of joint line
- Diminished ROM
- painful/weak resistance testing
- painful/weak grip testing
- painful/hypomobile joint mobility testing
how is RA managed?
- Inflammatory management
- consider period of remission vs/ exacerbation
- thermal/cryotherapy
- Exercises
- gripping/resistive exercises
- ROM exercises
- Joint protection
- splinting
- activity modification
what is a Dupuytren Contraction?
nodule formation palmar/digital fascia
pitting of skin observed
Natural course:
- cord structures cause contractures and impaired motion of tendons
- MCP and PIP commonly affected
- less commonly affected DIP
- thickening/shortening of fascia
List the risk factors for Dupuytren Contractures
- Caucasian
- Increasing age
- Male gender (7-15x > women)
- Alcoholism
- DM
- Smoking
- Hand trauma/surgery
- 5th digit most commonly affected (70%)
what is Gamekeeper’s thumb?
sprain to the 1st MCP
ulnar collateral ligament sprain
MOI → valus movement to 1st MCP
local tenderness/swelling
+Ulnar collateral ligmanet test
what is a common MOI for TFCC injuries and what most likely shows up during the patient interview?
MOI → FOOSH, repetitive pronation/supination w/loading
Pt interview → medial wrist pain, clicking/popping with wrist motions
list physical exam findings for TFCC lesions
- tenderness in area of TFCC
- swelling w/more acute trauma
- A/PROM painful/limited ulnar deviation
- supination w/ulnar deviation position to start
- pain/tenderness w/mobility testing of radiocarpal joint with ulnar deviation bias
what is intercarpal instability?
disruption of interosseous and/or mid-carpal ligaments
independent movement of carpals
list the various types of tendinopathies of the wrist
- wrist flexors
- finger flexors
- extensors of the wrist and fingers
- intersection syndrome
- trigger finger
what is intersection syndrome?
ECRL and ECRB where crossing deep to APL and EPB
tenderness 6-8 cm proximal to Lister’s tubercle
what things in a pt interview make you think tendinopathy of the wrist?
typically insidious onset/microtrauma MOI
List physical exam findings for tendinopathies of the wrist
- local tenderness
- painful w/tensile loading (stretching)
- P/AROM and resistive testing
- possibly palpable thickening of tenosynovium
- crepitus w/tendon moving through tendon sheath
what is trigger finger?
enlargement of tendon/pulley affecting tendon as it pistons through A1 pulley
typcially at MC head
most common 3rd digit
*As they try and extend the nodule get caught going through the A1 pulley and then bursts through causing it to rapidly extend (hence trigger finger)
list risk factors for trigger finger
- DM
- young children
- menopausal women
- RA
describe clinical presenation/symtpoms of trigger finger
- c/o painful snapping at MCP area during flexion/extension motions of fingers
- limited/painful finger motions
- crepitus w/motion (palpable vs auditory)
what is De Quervain’s Tenosynovitis (DQT)?
disorder involving the tendons of the abductor pollicus longus (APL) and extensor pollicis brevis (EPB) tendons
thickening of soft tissue structures surrounding the invovled tendons = impaired tendon gliding
no active inflammatory process
more prevalent in women than men
list the associated demographics for DQT
- women
- work-related injury
- computer users who use a mouse or trackball
- text messaging
- repetitive fine-motor task (typing)
list physical exam findings for de Quervain’s tenosynovitis (DQT)
- local tenderness
- painful ROM that places tensile load (stretch) on APL and EPB
- +Finkelstein’s test
- painful resistance testing APL and EPB
what is a ganglia?
AKA bible cyst
thin-walled cyst over joint capsule/tendon sheath
filled w/mucoid hyaluronic acid (spontaneous)
common A/P wrist and fingers
list physical exam findings/clinical presentation for ganglia
you will see it/notice it
possible compression on ulnar/median nerves
pt interview: may/may not be painful; aches w/flexion/extension of joint
