Elbow, Wrist, Hand Flashcards
Golfer presents w/ dorsal wrist pain?
Dequervain’s syndrome
APL & EPB tendinitis
cubital tunnel- throwing phase most stressful to elbow
late cocking is greatest stress to the ulnar nerve
common dorsal wrist injury in golfers
APL/EPB tendinitis, or DeQuervain’s syndrome is the most common sports overuse injury along the dorsoradial wrist region.
indicators of MCL injury with throwing
loss of power but with little to no pain
medial elbow pain- structures most likely involved
PT
FCR
these are main tendons along the medial aspect of the elbow. When they are activated, they assist in minimizing valgus stress to the medial elbow region.
lateral epicondylitis- structures involved most to least
ECRB, EDC, ECRL, ECU
biceps brachii
short head: coracoid process of scap
long head: supraglenoid tubercle of scap
insertion: radial tuberosity, fascia of forearm
musculocutaneous C5-6
brachialis
distal half of anterior humerus -> coronoid process & ulnar tuberosity
musculocutaneous & radial nerve C5-7
pronator teres
ulnar head: coronoid process
humeral head: medial epicondyle
median nerve C6-7
Flexor carpi radialis
medial epicondyle -> base of 2nd MC
median nerve C6-7
palmaris longus
medial epicondyle->distal half of flexor retinac & apex of palmar aponeurosis
median nerve C7-8
flexor digitorum superficialis
humeroulnar head: medial epicondyle
radial head: superior half of anterior border of radius
-> shafts of middle phalanges
median nerve C7-T1
flexor digitorum profundus
meidal/lateral parts: proximal 3/4 of medial & anterior surfaces of ulnar & interosseous membrane
–> medial part: base of distal phalanges of 4/5th digits
lateral part: bases of distal phalanages of 2nd & 3rd digits
lateral half n: median nerve
medial half n: ulnar nerve
C7-8
flexor pollicis longus
anterior radius /interosseous membrane –> base of distal phalanx of thumb
median nerve C7-8
pronator quadratus
distal 1/4 ulnar –> distal 1/4 of radius
median nerve C7-8
flexor carpi ulnaris
humeral head: medial epicondyle
ulnar head: olecranon & posterior border
–> pisiform, hook of hamate, 5th MC
ulnar nerve C7-8
triceps brachii
long head: infraglenoid tubercle of scap
lateral head: posterior humerus superior to radial groove
medial head: posterior surface of humerus inferior to radial groove
–> proximal olecranon of ulnar and fascia of forearm
radial nerve C6-8
anconeous
lateral epicondyle –> lateral olecranon & superior posterior ulnar
radial nerve C6-8
brachioradialis
proximal 2/3 supracondylar ridge humerus –> lateral surface of distal radius proximal to styloid process
radial nerve C5-6
extensor carpi radialis longus
lateral supracondyle ridge humerus –> dorsal aspect of base of 2nd MC
radial nerve
C5-6
extensor carpi radialis brevis
latearl epicondyle–> dorsal aspect of 3rd MC base
radial nerve C7-8
supinator
lateral epicondyle, radial collateral & annular ligaments, supinator fossa, crest of ulna –> lateraal/post/anterior sufraces of proximal 1/3 of radius
radial nerve C6-7
extensor digitorum
lateral epicondyle –> extensor expansion of medial 4 digits
radial C7-8
extensor digiti minimi
lateral epicondyle
radial nerve C7-8
extensor carpi ulnaris
lateral epicondyle, posterior border of ulnar –> dorsal aspect of 5th MC
radial C7-8
abductor pollicus longus
radial nerve C7-8
ext pollicis longus
dorsal aspect of base of thumb insertion
radial nerve C7-8
xtensor pollicis brevis, ext pollicis brevis
radial nerve C7-8
abductor pollicus longus
median nerve C8-T1
opponens pollicis
flexor retinaculum of scaphoid, trapezium –> lateral side of 1st MC
median nerve C8-T1
flexor pollicis brevis
superficial head: median nerve
deep head: ulnar nerve
C8-T1
adductor pollicis
oblique & transverse heads
ulnar nerve C8-T1
abd digiti minimi
pisiform –> medial base of 5th phalanx
ulnar nerve C8-T1
flexor digiti minimi
hook of hamate/flexor retinaculum –> medial base of prox phalanx
ulnar nerve C8-T1
opponens digiti minimi
ulnar nerve C8-T1
lumbricals
1/2: lateral 2 tendons of FDS
3/4: medial 3 tendons of FDS
–> lateral sides of extensor expansions of digits 2-5
1/2: median nerve
2/3: ulnar nerve
C8-T1
dorsal interossei
adjacent sides of 2 MC –> base of prox phalanges, extensor expansions of digits 2-5
ABDuction
ulnar nerve C8-T1
palmar interossei
palmar surfaces of 2/4/5th MC –> bases of proximal phalanges, extensor expansions of digits 2/4/5
ADDuction
ulnar C8-T1
elbow fracture testing
elbow extension test SP/SN 1.0
supination test SP 0.97
lateral epicondyalgia findings, test
more common >40 yrs, 4x more in Men
pain with”
-palpation wrist extensor origin
-gripping
-passive wrist flexion
-resisted wrist extension
Cozens test
CPR for lateral epicondylitis
-Age >49
-affected side pain free grip >112 N (25.2lb)
-unaffected side pain free grip <335 N (75.3 lb)
-change in pain >25% following MWM
*1.0 sP if 3 variables present
medial epicondylagia test/findings
pain at wrist flexor, gripping
passive wrist extension, resisted wrist flexion
moving valgus test SN 1.0
press test (wrist) SN 1.0
Carpal tunnel special testing
wrist flexion-compression (SN .86, SP .95)
median nerve compression (SN 1, SP 0.97)
carpal compression test (.83 SN, .97 SP)
phalens .92 SP
ultrasound .94 SP
carpal tunnel CPR
-shaking hands for symptoms relief
-wrist ratio index >0.67
-symptom severity scale >1.9
-reduced median sensory field of digit 1
-age >45
- 3+ variables = SN .98
C8 radiculopathy muscles effected
pronator quadratus
FDS
FDP
*all innervated by median nerve
weakness of T1 nerve root- muscles affected
adductor pollicis
adductor pollicis brevis
opponens pollicis
flexor pollicis brevis
interossei
lumbricals 1 & 2
posterior interosseous nerve- muscles
motor nerve only
part of deep branch of radial nerve
wrist extensors
posterior interosseous entrapment vs C7 radiculopathy
C7 radiculopathy - would have weakness in: triceps, pronator teres, FCR
sensory deficits
posterior interosseous involvement: motor only, wrist extensors
C8 radiculopathy- muscles affected
paresthesia at medial elbow, into 4-5th digit
weakness of: pronator quadratus, FDS, first 2 FDP
^all associated with median nerve
Panners disease
disruption of growth plate of capitellum secondary to repetitive valgus force
<10 years old
*OCD- common in 10+ yrs
UCL ligament branches
anterior, transverse oblique, posterior
ulnar nerve entrapment site at elbow
cubital tunnel
ulnar nerve entrapment site at wrist
guyons canal
entrapment site for posterior interosseous nerve
arcade of Frohse
lateral pivot shift test
test for posterolateral rotary instability
kilo nevins syndrome
compression of anterior interosseous nerve - motor only nerve that leads patient unable to make OK sign
pronator teres syndrome
compression of median nerve which leads to motor AND sensory deficits
wartenbergs syndrome
superficial branch of radial nerve
-dorsal radial sensory nerve issue
-traction occurs with FA pronation, wrist flexion & UD
-compression occurs with FA pronation between ECRL & brachioradialis
-Finkelstein test
posterior interossoeous nerve syndrome
deep branch of radial nerve
trigger finger- annular pulley
A1 most commonly affected (second digit with compromised flexor tendon)
UQS strength
C5 elbow flex
C6 wrist ext
C7 elbow ext
C8 finger flex
T1 hand instrinsics
UCL - 3 bands
anterior
transverse/oblique
posterior
carpal tunnel s/s
-pain/N/T in at least 2 digits of 1/2/3 and in palm or dorsum of hand
-thenar muscle atrophy
-Numbness but not tingling/weakness: SN 92
-Noctural pain: SN 94
Colles fracture
distal radius & ulna with dorsal angulation, displacement & shortening
“dinner fork”
carpal instability
VISI
DISI
-VISI- disruption between trapezoid & lunate, allowing volar drift of lunate
-problems with flexion
-DISI- disruption between scaphoid & lunate, allowing scaphoid to float into volar flexion
-dorsiflexion problems
scapulounate angle
normal
VISI
DISI
normal = 30-60 deg
VISI < 30
DISI >70
SL gap <3 mm
-tendinopathy vs tenosynovitis
-tendinopathy- resisted test most painful
-tenosynovitis – stretch test most painful
Flexor carpi radialis injury findings
-full/swollen thenar eminence
-MOST pain with resisted test: wrist flexion and radial deviation
-wrist flexion activities- guitar, tennis
ulnar nerve compression at wrist- special test
froments sign - add pollicis brevis weakness, excess thumb flexion with pinching
first dorsal interossei strength
lateral UCL
-NOT a strong stabilizer but helps prevent PLRI posterior lateral rotary instability
-lateral epico –> proximal ulnar
taut in both flexion & extension
limit valgus from 0-140
*pain most with extension + supination
medial UCL
-bundles: anterior, posterior, intermediate (aka transverse)
-if you have instability, can cause pain laterally
-anterior – restrains pronation of ulna on humerus-test at 30-40 deg as this is most unstable is anterior is injured
test in pron,supination and moving valgus stress test
pathway, entrapment of radial nerve
across lateral elbow, ECRL innervated before it splits. Deep portion becomes posterior interosseous nerve to innervate rest of extensors. Superficial portion becomes dorsal radial sensory nerve
most common entrapment: -arcade of frohse tendinous portion of supinator
supinator, ECRB, fascia superficial to HRJ
Posterior lateral rotatory instability (PLRI)
MOI: dislocation- combo of valgus and supination with axial compression (hand planted) during flexion
radial tunnel syndrome
-localized tenderness over radial nerve, approx. 5cm distal to lateral epicondyle
-typically pain at night that may interfere with sleeping; arm fatigue common
-symptoms increase with use of tennis elbow strap
-ECRB & supinator will compress nerve with elbow in extension+pronation+wrist flexion
cubital tunnel syndrome
-Tinel test
-Elbow flexion test- pressure on ulnar nerve with elbow in terminal flexion
-scratch collapse test- resist ER, medial elbow is stroked, then retest ER
+ test Is sudden loss in strength
-neurodynamic test- fingers over eye (nerve glide position- owl or waiter
-ulnar nerve T8/C1 passes through at medial elbow
elbow capsular pattern
greater loss of flexion:extension at 4:1 ratio
Most commonly dislocated carpal
-lunate
prone to pathology- keinbocks, CAN, lunatomalacia
Carpal Bone anatomy
SLTPTTCH
Some Lovers Try Positions
That They Cannot Handle
Radial-> Ulnar
Proximal-> Distal
Scaphoid
Lunate
Triquetrum (important TFCC attachment)
Pisiform (sesamoid for FCU)
Hamate (ulnar nerve/a/v under hook)
Capitate (largest)
Trapezoid
Trapezium
Mallet finger
injury to DIP extensor tendon
avulsion at base of DIP
DIP “drooping”
Game keepers/ skiiers thumb
UCL injury
acute or chronic hyperextension
causing weakened grasp/pinch of thumb
Galeazzi Fracture
distal radius fracture & dislocate ulnar head from wrist
Swan neck deformity
what is it
treatment
finger stuck in DIP flexion & PIP hyper extension
FDS tendon glide
monteggia
proximal ulnar & dislocate radial head
night stick fracture
mid ulna
greenstick fracture
incomplete fracture due to young flexible bones (other bones too but common in forearm)
scapulounate angle
normal
VISI
DISI
normal = 30-60 deg
VISI < 30
DISI >70
SL gap <3 mm
nursemaids elbow
dislocated radial head. most common elbow trauma in peds 2-4 years
elbow ossification sequence
CRITOE
capitulum 6 mo-2 yr
radial head 4-7 yr
Internal (medial) epicon
trochlea 7-10 yr
olecranon 6-12yr
ext (lateral) epicon 10-14 yr
complete by mid teens
smith fracture
opposite of colles
distal fragment angled palmar or volarly
distal radius fracture
tolar fracture
buckle/compression fracture usually in peds
scaphoid fracture CPR
all 4 = 91% risk
Male
sport
anatomic snuffbox w/ ulnar deviation in 72 hr
scaphoid tubercle tenderness at 2 weeks
*NO fracture if NO pain with ulnar dev
scaphoid fracture “cluster”
if all 3 = 100% SN
snuffbox tenderness
scaphoid tubercle tenderness
longitudinal compression
boxers fracture
5th MC
bennet fracture
1st MC (thumb)
rolando fracture
MC base with 3 fragments
boutonneire deformity
what is it
treatment
finger is in PIP flexion & DIP extension due to torn central slip
tx: DIP flexion with goal to maintain length of lateral bands
TFCC components
articular disc
volar radioulnar ligament
extensor carpi ulnaris tendon
ulnar collateral ligament
meniscus homologue
dorsal radioulnar ligament
after flexor tendon repair of digit, what type of splint should be applied
dorsal splint with wrist in 20 deg flexion
MCP in 50 flexion
IP in extension
flexor tendon in which zone has poor px
zone II of hand is “no mans land”
what is most common fractured carpal bone
scaphoid
de quervains tenosynovitis
pain at base of thumb
turn your wrist, grasp anything or make a fist.
Dupuytren contracture
one or more fingers to bend toward the palm of the hand.
muscles innervated by median n
C6-7
pronator teres
FCR
C7-8
palmaris longus
FDS (C7-T1)
FDS lateral half
Flexor pollicis longus
pronator quadratus
C8-T1
abd pollicis brevis
opponens pollicis
lumbricals 1-2
muscles innervated by ulnar nerve
C7-8
FDS medial half
FCU
C8-T1
flexor poll brevis deep head
add pollicis
abd digiti minimi
flexor digiti minimi brevis
opponens digit minimi
lumbricals 3/4
dorsal interossei
palmar interossei
hand intrinsic muscles only innervated by median nerve
FOAL:
F: flexor pollicis brevis
O: opponens pollicis
A: abductor pollicis brevis
L: lateral two lumbricals
rest of hand by ulnar nerve
