Lecture 9 - Conditions Of The Elbow & Wrist Flashcards
What is the functional ROM at the elbow?
- Extension to flexion - 0° - 135°
- Pronation to Supination - 70°- 90°
- Hyperextension - 5°
What is the postural observation of the elbow?
- Elbow Flexed: visual formation, isosceles triangle; formed by the olecranon process & the humeral epicondyles
- Elbow Extended: A straight line is formed by the olecranon process & humeral epicondyles
- Carrying Angle: the natural anatomical angle where the forearm points slightly outwards (away from the body) when the elbow is fully extended, typically ranging in Males: 5° & Female: 10°- 15°
What are 2 fractures of the elbow?
- distal humerus
- proximal radius/ulna
What is the MOI of elbow fractures?
- FOOSH or direct impact
- All fractures will result in a great deal of swelling in the area that may often occlude (hide) the actual injury
- There will be extensive pain in the elbow joints
- There will be associated muscle spasm of the surrounding musculature
What is the treatment of elbow fractures?
- Always assess distal MSC
- Splint & support the joints above & below the injury in the most comfortable position available
- Arrange for transport to medical attention
What is volkmann’s ischemic contracture?
- Where a fracture may involve blood vessel & nerve damage, loss of blood flow (4-6 hrs) to the forearm muscles can result in necrosis of the tissue & contracture (hardening) of the muscles
- Deformity is seen with the wrist & the proximal finger joints in extension & the distal finger joints in flexion
What is the MOI of elbow dislocations?
- FOOSH with the elbow forced into hyper-extension (i.e., reaching with arm to brace a fall)
- Severe torsion or varus/valgus force at the elbow when in a flexed position
What is the treatment of elbow dislocations?
- Never try to reduce an elbow dislocation
- Have the individual place the arm in the most comfortable position & apply a splint
- Transport to hospital
What are the complications of elbow dislocations?
- Myositis ossificans (bone tissue forms around muscle) & calcification (calcium build up) of tissue around the joint
- Decreased functional range of motion from scar tissue
- Ulnar nerve entrapment by scar tissue
- Damage to arteries & nerves is always a potential complication
What is the MOI of elbow contusions?
- Direct blow - Very common in athletic activities
- Most often involves the olecranon bursa
What are the signs & symptoms of elbow contusions?
- Very painful
- Rapid swelling if bursa is involved
- Ulnar Neuropraxia with paraesthesia into the ring & baby finger
What is the treatment of elbow contusions?
- PIER, sling support
- Modalities as necessary
- Pad support for return to play
What is the MOI of elbow sprains?
- Valgus or Varus force damaging either ulnar collateral or radial collateral ligament complex
What is the treatment of elbow sprains?
- PIER, rest, sling support, NSAIDS, modalities as necessary
What is epicondylitis?
- Describes an inflammation at the elbow involving the attachment of the common flexor or extensor tendons of the forearm muscles
- causes Tennis Elbow: lateral Epicondylitis & Golfers Elbow: medial Epicondylitis
What is the MOI of epicondylitis?
- Direct trauma
- Overuse & improper mechanics involving wrist movement where there is repeated eccentric loads
What is the treatment of epicondylitis?
- Rest, PIER, Massage (transverse friction), ultrasound, EMS, NSAIDS, support/splint
What are 3 injuries that occur in the elbow from throwing?
- medial tension
- lateral compression
- posterior compression
How do elbow injuries occur when throwing?
- During the acceleration phase of pitching as the humerus is whipped forward there is a great valgus force placed on the trailing bent elbow
- The result is a large tensile load on the medial structures & an equally stressful compression load on the lateral side
What is little league elbow?
- an overuse injury in young athletes, caused by repetitive throwing motions that stress the growth plate on the inside of the elbow
What are the conditions of little league elbow?
- Medial epicondyle epiphysis last to close around the elbow ( susceptible to avulsion injuries)
- Osteochondritis dessecans of the capitulum
- Osteochondrosis of the radial head
What is Colle’s fracture?
- a fracture involving the distal end of the radius, ulna, or both
What is the MOI of Colle’s fracture?
- impact force through an extended or flexed wrist forcing the distal radius & ulna up & back
- Classical sign is a drop down of the hand from the forearm when the arm is held level (Silver Fork or Spoon Deformity)
What is the treatment of Colle’s fracture?
- splint & transport to medical care
What are forearm splints?
- aching through the extensors of the forearm
- most often seen in gymnasts & weight lifters
What’s is the MOI of forearm splints?
- Excessive landing on the hands (i.e., tumbling in gymnastics)
- Excessive & repetitive strain (i.e., weight lifting)
- Prevalent Twice in an Athletic Season:
- At the beginning where there is inadequate strength & endurance
- At the end where fatigue & excessive activity with inadequate rest has prevailed
What is the treatment of forearm splints?
- rest, ice, electrical modalities, NSAIDS
What is de quervain’s tenosynovitis/tendinosis?
- initial inflammation of the extensor pollicis brevis & abductor pollicis longus tendons
- Highly prevelant in women of 30-50 years of age
What is the etiology of De Quervain’s Tenosynovitis/Tendinosis?
- the tendons are enclosed in a fibrous sheath or synovium
- thickening of the synovium results from repetitive movement of the thumb in combination with radial deviation of the wrist
- this action causes irritation & swelling of the tendons
What causes De Quervain’s Tenosynovitis/Tendinosis?
- manual activities in sport, work with computers, gaming, lifting heavy items
- May occur after acute trauma such as a blow to the dorsal side of thumb/wrist
What are the signs & symtoms of De Quervain’s Tenosynovitis/Tendinosis?
- Swelling & redness in the area affected
- pain & tenderness at the radial side of the wrist proximal to the radial styloid
- Pain can radiate to the forearm or to the tip of the thumb
- Pain is exacerbated during pinching & grasping activities.
- Crepitus & a catching or snapping sensation especially during thumb/& or wrist movements
What is the treatment of De Quervain’s Tenosynovitis/Tendinosis?
- Identify the casual factors & rest
- adaptations to daily tasks to alleviate thumb pain.
- thumb/wrist splint may help with rest & protection
- NSAIDS (short term use only)
- ultrasound, warm whirlpool & LASER therapy may help
- Massage & other soft tissue techniques to loosen tissues & improve pain-free movement
- Appropriate conditioning exercises to address flexibility, strength & proprioception
- Cortisone if other treatments don’t work
Why are the wrist & hands easy to injure?
- there is very little muscle or fat padding to protect the underlying bony
structures. - Easy to assess generally- most injuries present with local point tenderness, swelling & reduced function
- Tested by pulling or pushing & twisting of carpals, metacarpals and phalanges; if painful or crepitus is noted there may be a fracture
What is the MOI of wrist & hand injuries?
- direct impact, FOOSH
- Injured structures include the carpals, metacarpals, phalanges, ligaments, tendons
What is the MOI of a scaphoid fracture?
- Generally a fall on the out stretched hand forcing the wrist into hyper-extension
What are the signs & symptoms of a scaphoid fracture?
- Acute pain & swelling in the area of the anatomical snuff box
- approx. 20% of the population the scaphoid has blood supply into only one side
- If it is not allowed to heal properly avascular necrosis may result
What is the treatment of a scaphoid fracture?
- Refer to physician for X-RAY and follow up care
- cast is applied to immobilize the wrist & the thumb up to the distal phalange
- At 10 days re-x-ray-look for signs of # healing (ie callus formation)
- If there are no signs of healing & clinically there is still pain a bone scan is usually ordered, This is a two part process
What is the 2 step process of a bone scan?
- a) radioactive tracer usually Technetium-99 is introduced intravenously
- b) scanning X-Ray is taken approx. 3 hours later looking for tracer uptake
What is the MOI of a lunate dislocation?
- a fall on the hand hyper-extending the wrist
- The lunate bone dislocates towards palm
What are the signs & symptoms of a lunate dislocation?
- Pain & swelling in the mid carpal region
- Difficulty in flexion & extension of the wrist
- Paralysis or-numbness of hand flexors may occur due to pressure on median nerve
What is the treatment of a lunate dislocation?
- splint, Ice, refer to medical attention
What is wrist ganglion?
- Defined as a rupture (herniation) of the tendon sheath or joint capsule
What is the MOI of wrist ganglion?
- Cause is not known
- Some cases, this wrist has been previously injured
- Repetitive injuries, such as those that can occur from playing tennis or golf frequently seem to play a role in ganglion development
What is the treatment of wrist ganglion?
- dorsal wrist ganglions were treated by breaking them without rupturing the skin, done with a mallet (or bible)
- 50 percent of wrist ganglions may eventually go away by themselves
- Surgery to remove the cyst if there is increasing pain or pressure on nerve tissue is noted
What is a closed rupture procedure of wrist ganglion?
- multiple needle punctures is another nonsurgical treatment option for dorsal wrist ganglions
- In this procedure, the cyst wall is punctured with a needle, & anti-inflammatory & numbing drugs are injected into the cyst
What is the MOI of phalange fractures?
- direct blow, FOOSH
What is the treatment of a phalange fracture?
- Ice, splint, refer to medical attention
- Wire Reduction - using small, thin wires (K-wires) to hold the bone fragments in place during healing, often after closed reduction
What is the MOI of a phalange dislocation?
- most often a direct blow to the tip of the finger
- Joints Involved: DIP, PIP, MP
What are the possible tissues damaged in a phalange dislocation?
Capsule, Ligaments, Nerve, Blood Vessels, Bone
What is the treatment of a phalange dislocation?
- Splint, ICE, Medical attention for reduction
- Splint for 3 weeks max. any more will lead to severe tissue contracture
What is the MOi of phalange sprains?
- direct blow to the tip of the finger may injure the DIP, PIP, or MP joints capsule &/or ligaments
What are the signs & symptoms of a phalange sprain?
- Swelling, Pain, Loss of ROM
- Incapacitating to hand function in many cases
What is the treatment of a phalange sprain?
- ice, splint, refer to medical care if a fracture is suspected
What is mallet finger?
- injury causing the fingertip to droop & become bent, often due to a torn or stretched tendon at the end of the finger, preventing the fingertip from straightening
What is the MOI of mallet finger?
- Direct blow to the tip of a finger
- There is a forced hyperflexion of the DIP joint
- The extensor tendon is torn away from its insertion on the base of the distal phalanx
What are the signs & symptoms of mallet finger?
- Pain & swelling at the DIP joint
- The DIP joint remains bent because the extensor tendon has torn away from its insertion on the base of the distal phalanx
What is Boutonnière Deformity?
- Results from a rupture of the extensor tendon at the middle phalanx which forces the PIP joint into excessive flexion, with the DIP joint going into extension
What is the treatment of Boutonnière Deformity?
- Splint, ICE, refer to medical attention
- Doctor will have PIP splinted in extension 3-4 weeks
What is the MOI of a thumb dislocation?
- Direct impact to the end of the distal phalanx resulting in a hyperextension of the MP joint
- Quite often the proximal phalange moves into the thenar muscle
What is the treatment of a dislocated thumb?
- Do not attempt reduction due to chance of fracture
- Splint. ICE, Refer to medical attention
What is game keepers thumb? What are the signs & symptoms? What is the treatment?
- a Sprain of the UCL of the MCP joint of the thumb
- Signs & Symptoms:
- Pain, Swelling, Loss of ROM, Unable to Pinch Grip
- Treatment:
- as per any other sprain - Rest, PIER, Rule out Fracture, Splint Support
What is the general reconditioning of the wrist, hand, & fingers?
- Should start as soon as possible after the acute inflammatory reaction has ended or as with fractures once the immobilization is removed
What are the steps in reconditioning the wrist, hand & fingers?
- Active ROM
- Passive ROM (Joint Play)
- Strength Look at both the Intrinsic group (especially the Thenar & Hypothenar muscles)
- Extrinsic muscles of the forearm that control wrist & finger movements
What are typical exercises to include in the reconditioning of the wrist, hand, & fingers?
- Intrinsic & Extrinsic- squeezing ball, power web
- Radial & Ulnar deviation using dumbbell with weight on one side only
- Fore arm Pronation & Supination using dumbbell
