UE - Elbow, wrist & hand Flashcards
THE ELBOW & FOREARM
Three Articulations:
Three Articulations:
1. HU (humeroulnar) jt
2. HR (humeroradial) jt
3.PRU (proximal radioulnar) jt
Trochlea (Metro)
Laterality?
Trochlea + Ulna =
Medial aspect
- Trochlea + Ulna =
Ulnohumeral jt
Capitulum
Capitulum + Radial fovea =
Lateral aspect
- Capitulum + Radial fovea =
Radiohumeral jt
A child you are working with caught a fall during a sport event which resulted her to have a valgus injury on the elbow. Assuming a bony lesion, you know that immobilization will be necessary for her to prevent the avascular necrosis of which bone?
A. Olecranon process
B. Capitulum
C. Trochlea
D. Ulnar head
B. Capitulum
Capitulum avascular necrosis = Panners
Capitulum Avascular Necrosis
Panner’s Dse
CARRYING ANGLE
Normal Value?
Landmarks?
Male value?
Female value?
Cubitus Valgus:
Cubitus Varus:
Gunstock Deformity:
- Long axis of humerus
- Long axis of ulna c elbow
straight and supinated
Normal Value? 5-15
M: 5-10 degrees
F: 10-15 degrees
Cubitus Valgus: >15 degrees
Cubitus Varus: <5 degrees
Gunstock Deformity: -15 degrees
HUMERO-ULNAR JOINT
Aka: Trochlear jt
Type of joint:
Articulation:
Type of joint: Hinged
Articulation: Trochlea + Ulna
Humeroulnar Joint
OPEN-PACKED POSITION:
CLOSE-PACKED POSITION:
CAPSULAR PATTERN:
OPEN-PACKED POSITION: 70 flexion, 10 supination
CLOSE-PACKED POSITION: Full ext c Full supination
CAPSULAR PATTERN: Flex, Ext
Humeroulnar Joint
PJM?
❑ Stabilize humerus c gait belt @ 45
degrees
❑ Provide distal glide in a scoop
motion (J scoop)
❑ To ↑ flexion
HUMERO-RADIAL JOINT
Articulation:
Permits:
Articulation: Capitulum + Radial fovea
Permits: radius to rotate to any
degrees to allow FA S/P
HUMERO-RADIAL JOINT
OPEN-PACKED POSITION:
CLOSE-PACKED POSITION:
CAPSULAR PATTERN:
OPEN-PACKED POSITION: Full ext c Full supination
CLOSE-PACKED POSITION: 90 flexion, 5 supination
CAPSULAR PATTERN: Flex, Ext, Supination, Pronation
HUMERO-RADIAL JOINT PJM purpose
❑ To ↑ HR jt mobility
❑ To manipulate a pushed elbow
Proximal Radioulnar Joint
OPEN-PACKED POSITION:
CLOSE-PACKED POSITION:
CAPSULAR PATTERN:
OPEN-PACKED POSITION: 70 flexion, 35 supination
CLOSE-PACKED POSITION: 5 supination
CAPSULAR PATTERN: Supination=Pronation
LIGAMENTS OF THE ELBOW
1.
2.
3.
4
5.
Interosseous Membrane
Oblique Cord
Annular Ligament
Medial Collateral Ligament
Lateral Collateral Ligament
Interosseous Membrane
Aka:
Function:
Tensed when FA is in?
Prevents displacement of radius during?
Aka: Middle Radioulnar jt
Function: Helps distribute forces throughout the FA
Tensed when FA is in midposition
*Prevents displacement of radius during PUSHING
Oblique Cord
Prevents displacement of radius during?
From ulna to radial tuberosity
Prevents displacement of radius during PULLING
Annular Ligament
Affected in:
Nursemaid’s elbow is what?
Encircles the radius but it is freely
attached
Affected in: Pulled elbow/
Nursemaid’s elbow
- Head of radius is subluxed
inferiorly to the annular ligament
Medial Collateral Ligament
Aka:
MCL + FCU =
Has three (3) Bands:
Aka: Ulnar Collateral Ligament
Major restraint to Valgus stress from 20-120
deg of flex
Primary stabilizer of the elbow jt
MCL + FCU = cubital tunnel
Has three (3) Bands:
Anterior Band – limits ext
Posterior Band – limits flex
Transverse Part
Lateral Collateral Ligament
Aka:
Primary restraint to ____________
Resist:
MC unstable =
Aka: Radial Collateral Ligament
Primary restraint to Posterolateral instability
Resist: Varus stress
MC unstable = Posterolateral elbow dislocation
VALGUS and VARUS
STRESS TEST
❑ Passive
❑ Elbow @ 20-30 deg flex
❑ Palpate medial/lateral elbow
❑ Provide Valgus/Varus force at the FA
❑ Check for Abn movement
Moving Valgus
Stress Test
❑ 1st = Sh abd 90 c full elbow flex
❑ 2nd = ext elbow while maintaining
valgus stress
❑ (+) pain @ 120-70 degrees
❑ Indic: partial tear of MCL
BURSA AT THEELBOW
- lubrication, nourishment, ↓ friction during jt motions
- Olecranon bursa
Main bursa of the elbow complex.
Lies posteriorly between the skin and the olecranon process. - Deep intratendinous bursa and deep subtendinous bursa
Between the triceps tendon and olecranon
Olecranon bursitis
Aka: Dart thrower’s, Miner’s, Draftman’s,
Student’s Elbow
MC
Tx:
MC injured bursa in the elbow
Goose egg appearance
Tx: RICE, US, ES
If conservative mgt fails: Aspiration (drain fluid)
Triangle sign of the elbow
3 Landmarks:
N:
(+):
3 Landmarks:
1. Lateral epicondyle
2. Medial epicondyle
3. Olecranon process
N: Ext = 3 landmarks are aligned
90 Flex = Isosceles/Scalene
triangle
(+): one side is longer
Indic: swelling, Fx, dislocation
Major elbow flexor Nerve?
Brachialis
Biceps Brachii
Brachioradialis
Major elbow extensors?
Triceps Brachii
Anconeus
Major elbow flexor Nerve - Musculocutaneous nerve
Brachioradialis - Msc + Radial nn
Major elbow extensors - Radial nn
Biceps brachii
MMT?
Strongest:
Substitutes:
MMT:Elbow flex while FA supinated
Strongest: FA supinator (**trivia)
Substitutes: for Abd when the Sh is in ER to
compensate for supra and delts weakness
Heuter’s Sign: Ask px to flex elbow c FA
pronated & PT resistance (brachialis)
N: FA supinated (strong biceps help
brachialis) = (+) Heuter sign
If no FA supination = distal biceps rupture
Heuter’s Sign:
Heuter’s Sign: Ask px to flex elbow c FA
pronated & PT resistance (brachialis)
N: FA supinated (strong biceps help
brachialis) = (+) Heuter sign
If no FA supination = distal biceps rupture
Ludington’s Test
Procedure
(+):
Indic
❑ Alternate contxn of biceps
❑ (+): no palpable contxn
❑ Indic: Long head biceps
tendon rupture
Brachialis
Nn:
MMT:
Workhorse: Active in all elbow motions
Nn: Musculocutaneous nn
MMT:FA pronated
Largest cross section in UE
MC affected in: Myositis Ossificans
(Calcium deposits in ms belly)
Brachioradialis
MMT?
Cheiralgia Paresthetica (Aka: Wartenburg Dse)
MMT: FA in neutral
Cheiralgia Paresthetica (Aka: Wartenburg Dse)
* Affectation of Superficial Radial nn under the
Brachiorads
* Pure sensory affectation @ dorsal wrist,
dorsal thumb, dorsal 1st webspace
If Musculocutaneous nn is severed, which ms
substitute for elbow flex?
If Biceps, Brachialis, & Brachiorads are all
affected?
substitute for elbow flex? -
If Biceps, Brachialis, & Brachiorads are all
affected?
HIS/LOP
heuter
ludington
Heuter - insertion problem
ludington - origin problem
Crutch Walking ms
- Lats Dorsi – most impt
- Triceps
- Lower Trapz
Initiates elbow extension
Anconeus
Works as an: elbow flexor when
the FA is pronated
Pronator Teres
Terrible Triad of the Elbow (Dislocation)
- Radial head Fx
- Coronoid process Fx
- Rupture of collateral
ligaments
Mobile wad: ms active during
gripping, hammering & sawing
“Wadialis” Triad
“Wadialis” Triad
1. ECRL
2. ECRB
3. Brachiowadialis
Cubital Fossa
Contents:
BOUNDARIES:
Lateral: Medial:
Floor:
Superior:
Roof:
be right there always my PT
<lateral>
Brachiorads, Radial nn, Tendon of biceps,
Artery (Brachial), Median nn, Pronator Teres
BOUNDARIES:
Lateral: BR Medial: PT
Floor: L: M:
Superior: imaginary line bet the epicondyles
Roof: skin, fascia, bicipital aponeurosis
</lateral>
Your patient, who is a carpenter, is having difficulty loosening a screw using his left hand. Upon evaluation,
you determine that the patient requires joint mobilization on the DRU joint. Which glide would you
use?
A. Dorsal glide
B. Volar glide
C. Medial glide
D. Lateral glide
A. Dorsal glide
Wrist and Hand Complex
Functional position of the wrist
Functional position of the wrist
- greatest power of grip
- 20-35 deg of ext and 10-15 deg of UD
DISTAL RADIOULNAR JOINT
Type of joint:
OPEN-PACKED POSITION:
CLOSE-PACKED POSITION:
CAPSULAR PATTERN:
mobilization:
Type of joint: Pivot
OPEN-PACKED POSITION: 10 supination
CLOSE-PACKED POSITION: 5 supination
CAPSULAR PATTERN: Full ROM, pain on extreme rotation
mobilization:
DRU pron: ant glide
PRU pron: post glide
Main stabilizer of the DRU jt
TRIANGULAR FIBROCARTILAGE
COMPLEX
TRIANGULAR FIBROCARTILAGE
COMPLEX Function
Functions:
1. Assist in binding the distal radius to
the ulnar styloid process
2. ↑ joint congruency
3. Cushions against compressive
forces
MC Fx carpal bone (MOI: FOOSH)
Scaphoid
Scaphoid Neck = avascular (poor healing –>
necrosis)
Preiser’s Dse
MC dislocated carpal bone – “Dislonate”
Lunate (aka: semilunar bone)
Lunate AVN:
Body =
Distal lunate =
Body = Kienbock’s Dse
Distal lunate = Burns Dse
(+) Murphy’s sign
Lunate (aka: semilunar bone)
- Sesamoid bone
- Formed under the FCU tendon
- ↑ the leverage during flex/ext
- Only attached to the triquetrum
- Only visible at the palmar – Xray
Pisiform
- Largest carpal bone
- Articulate c all the carpals except pisiform
Capitate (Os Magnum)
(-) Murphy Sign
Lunate Dislocation
- Connected to pisiform thru Pisohamate
ligament - Forming the Tunnel of Guyon
- Passageway for ulnar nn & artery
Hamate
RADIOCARPAL JOINT
Articulation between the radius and the proximal row of carpals
(scaphoid, lunate, triquetrum)
Aka:
Type of joint:
OPP:
CPP:
CP:
MOBILIZATION
Aka: Wrist joint
Type of joint: Ellipsoidal
OPP: Neutral c slight UD
CPP: Ext
CP: F=E
MOBILIZATION
inc flexion =dorsal glide
inc extension= volar glide
inc ulnar deviation= lateral/radial glide
inc radial deviation= ulnar/medial glide
MIDCARPAL JOINT
OPP:
CPP:
CP:
OPP: Neutral/slight flex c UD
CPP: Full ext
CP: equal in all direction
INTERCARPAL JOINTS
Type of joint:
Watson Test?
Type of joint: Plane
❑ 1st = Full UD + slight ext
❑ 2nd = apply pressure on
scaphoid (palmar aspect) +
counterforce at dorsal FA
❑ 3rd = RD + Flex
❑ (+) pain = scaphoid Fx
❑ (+) pain, post sublux of scaphoid
& thunk upon removal of
pressure = scaphoid instability
CARPOMETACARPAL
CM of thumb:
CM of four fingers:
MOBILIZATION of 1st CMC:
CM of thumb: Saddle
CM of four fingers: Plane
1st CMC:Very mobile
: MC site of OA of the hand
2nd and 3rd: stable
4th and5th: mobile
: adjusts to shape of what we grasp
MOBILIZATIONof 1st CMC:
abd/add - opposite-dorsal glide
flex/extend - ulnar glide
CMC THUMB
OPP:
CPP:
CP:
OPP: midway bet flex/ext & abd/add
CPP: full opposition
Cap: Abd, Ext
CMC FINGERS
OPP:
CPP:
CP:
OPP: midway bet flex/ext
CPP: full flex
Cap: Equal limitations in all direction
MCP Joint (Thumb)
OPP:
CPP:
CP:
Type of joint: Condyloid
OPP: slight flex
CPP: full opposition
Capsular Pattern: Flex, Ext
Aka: Gamekeeper’s Thumb
MOI: Fall in abducted thumb
Rupture of: UCL/MCL
Skier’s Thumb
Skier’s Thumb
N Valgus:
<30-35:
>30-35:
N Valgus: 15 deg
<30-35: partial tear of MCL
>30-35: complete tear
Skier’s Thumb
MOI:
Rupture of:
MOI: Fall in abducted thumb
Rupture of: UCL/MCL
Cascade Sign
❑ Flex MCP and PIP jt
❑ N: converge to scaphoid
❑ If not: trauma/Fx to digits c
altered alignments
Thickening of the palmar
fascia
Dupuytren’s
Contracture
Dupuytren’s
Contracture
❑ MC:
❑ DM px:
❑ MC: 4th & 5th digits
❑ DM px: 3rd & 4th digits
Serves to prevent the tendons from
“bow-stringing” when the tendons
turn a corner at the wrist.
Secures the tendons in place
Extensor Retinaculum
Spans the area between the scaphoid tubercle & pisiform proximally, and the hook of hamate & tubercle of trapezium distally
Transforms the carpal arch into a
tunnel, through which pass the median nerve and some of the tendons of the hand.
Flexor Retinaculum
Structures that pass superficial to
the flexor retinaculum
Flexor carpi ulnaris tendon
Ulnar nerve
Ulnar artery
Palmar cutaneous branch of the ulnar nerve
Palmaris longus tendon (if present)
Palmar cutaneous branch of the median nerve
Structures that pass beneath
the flexor retinaculum
Flexor digitorum superficialis (4)
Flexor digitorum profundus tendons (4)
Flexor pollicis longus
Median nerve
Carpal Tunnel
CTS Dx
Special tests (4)
- Serves as a conduit for the
median nn & 9 flexor tendons - CTS Dx = EMG NCV
- Special tests
- Phalen’s
- Tinel’s
- Flick
- Carpal Compression
Tunnel of Guyon
Location?
Artery and nerve that passes?
If compressed:
Innervated Muscles:
A depression superficial to the flexor retinaculum.
Located between the hook of the hamate and the pisiform bones.
Ulnar artery and ulnar nerve pass through
the canal.
If compressed: altered sensation at the little finger & medial half of the ring finger
Innervated Muscles: AFO AIM
afo digiti minimi
adductor pollicis
interossei (pad dab)
medial half of lumbricals
Froment’s Paper Sign
❑ N: Thumb add – intact Add Pollicis
❑ (+): flexion of thumb IP = (+) Froment’s
❑ (+): Hyperext of MCP = (+) Jeanne’s
weak adductor pollicis
Pinch Grip Test
Aka: Okay sign/Kiloh Nevin Syndrome
Negative test =
Positive test =
Indicates:
Negative test = Tip to Tip
Positive test = Pulp to pulp
Indicates: entrapment of AIN between the
heads of pronator muscle
ANATOMIC SNUFFBOX
Lateral:
Medial:
Floor:
- (+)
= ___________ Fx
Lateral:AbPoLo, ExPoBre
Medial: ExPoLo
Floor: Scaphoid
- (+) tenderness on floor
= Scaphoid Fx
TENODESIS EFFECT
❑ Active wrist ext → passive finger flex
❑ d/t passive insufficiency of ____________
causing shortening of ______tendons
❑ Px c SCI _____ to facilitate grasping
❑ C/I stretching of ___________
❑ Active wrist ext → passive finger flex
❑ d/t passive insufficiency of finger flexors
causing shortening of FDP tendons
❑ Px c SCI C6 to facilitate grasping
❑ C/I stretching of long finger flexors
Intrinsic muscles:
Thenar vs
Hypothenar muscles:
Lumbricals vs
Interossei
Thenar
- Abd pollicis
-FPB
- OP
- ADD POLLICIS
Hypothenar: AFO
ABD DM
FDMB
ODM
Lumbricals
-Quick closure of hands
Interossei
- guttering/wasting
EXTENSOR HOOD
EDC
Lumbricals & Interossei
1 Central & 2 Lateral Bands
EDC - inserts on proximal phalanx
EDC
Lumbricals & Interossei
1 Central & 2 Lateral Bands
Interplay of Intrinsics + EDC
if only EDC?
if only Intrinsic?
If all active?
how to stretch intrinsic?
if only EDC - MCP ext IP’s flex = Intrinsic minus (claw hand)
if only Intrinsic - MCP flex, IP’s ext = Intrinsic plus
If all active - MCP PIP DIP ext
how to stretch intrinsic? - Intrinsic minus
Extensor Hood Rupture Test
❑ Aka:
❑ Procedure
❑ (+):
❑ Indic
❑ Aka: Elson Test
❑ Flex PIP 90 at edge of table
❑ Actively ext PIP while palpating middle phalanx
❑ (+): weak PIP ext c hypertext at DIP jt
❑ Indic: Torn central slip
Flexor Pulleys
A1 –
A2 –
A3 –
A4 –
A5 –
A1 – MCP jt
**Trigger finger = 3rd & 4th
fingers
A2 – shaft of proximal
phalanx
A3 – PIP jt
A4 – Shaft of mid phalanx
A5 – DIP jt
Flexor tendon zones
I.
II.
III.
IV.
V.
I. DIP joint
II. NO MANSLAND – No blood supply =
poor healing
III. Metacarpals
IV. CARPALTUNNEL
V. Distal Forearm
Extensor tendon zones
I.
II.
III.
IV.
V.
VI.
VII.
I. DIP Joint
II.Middle Phalanx
III- PIP Joint
IV- Proximal Phalanx
V- MCPJoint
VI.Dorsum of the
Hand
VII. Dorsal Wrist
Terminal Slip?
Central Slip?
Swan neck deformity?
Terminal Slip - Mallet Finger (DIP flex)
Central Slip - Boutonniere deformity
EFE - MCP ext, PIP flex and DIP ext.
Swan neck deformity- FEF
- MCP flex, PIP hyperext and DIP flex.
- contracture of the instrinsic or volar plate rupture
-RA; Trauma
Precision Grip: ______ nn
Power Grip: ______ nn
Precision Grip: Median nn
Power Grip: Ulnar nn
