Week 12: Elbow, Wrist and Hand Flashcards
Elbow Joint (3 Joints)
- Ulnohumeral joint
- Radiohumeral joint
- Proximal Radioulnar joint
*hinge joint
Elbow Ligaments (2)
- Ulnar (Medial) Collateral Ligament (UCL)
- Radial (Lateral) Collateral Ligament (RCL)
Ligaments of the Wrist and Hand (3)
- Collateral Ligaments of wrist & fingers
-Ulnar (Medial) Collateral Lig.
-Radial (Lateral) Collateral Lig. - Intercarpal Ligaments (dorsal, palmar)
- Triangular Fibrocartilage Complex (TFCC)
Triangular Fibrocartilage Complex (TFCC) aka Triangular Disc:
-Complex made up of load-bearing triangular fibrocartilage articular disc & ligaments on medial aspect of wrist
-Disperses axial load from carpals→ulna
-Thickened by the ulnar collateral ligament (UCL) medially
-TFCC is a major stabilizer of:
○ Ulnocarpal joint
○ Distal radioulnar joint
-Facilitates articulations at the wrist joint
Nerves at Elbow and Wrist (2 Main)
Note location of:
1. Ulnar nerve both at elbow & wrist
2. Median nerve under flexor retinaculum
Elbow Flexor Muscles (3)
- Biceps brachii (long head and short head)
- Brachialis
- Brachioradialis
Elbow Extensor Muscles (2)
- Triceps brachii (long head, medial and lateral head)
- Anconeus
Muscles of the Forearm, Wrist and Hand (Common Origins)
- Medial epicondyle= Common flexor tendon origin
- Lateral epicondyle= Common extensor tendon origin
Carpal Tunnel (4 Components)
- Flexor tendons
- Carpal bones
- Median nerve
- Transverse carpal ligament
Elbow ROM (2)
- Flexion/extension
- Pronation/supination
Wrist ROM (2)
- Flexion/extension
- Radial deviation/ulnar deviation
Digits ROM (3)
- Flexion/extension
- Abduction/adduction
- 1st-5th opposition/reposition
Lateral Epicondylitis a.k.a Tennis Elbow
-MOI: overuse of forearm extensors
-Common in tennis, squash, badminton
-Most common extensors affected:
○ Extensor Carpi Radialis Longus
○ Extensor Carpi Radialis Brevis
-S&S: TOP common extensor origin (lateral epicondyle), pain & weakness with wrist extension
-Acute management: stretch wrist extensors – in elbow extension & flexion; PIER (if “itis”), tennis elbow brace?
○Recall the “R” in PIER means rest – in some cases this means altered activity
-Eccentric strengthening program for forearm extensors
Medial Epicondylitis a.k.a Golfer’s Elbow
-MOI: overuse of wrist flexors
-Common in golfers & pitchers
-Most common flexors affected:
○ Flexor Carpi Radialis (FCR)
○ Pronator Teres (PT)
-S&S: TOP common flexor origin (medial epicondyle), pain & weakness with wrist flexion
-Acute care: stretch forearm flexors, PIER
Ruptured Biceps
-MOI: sudden lengthening of contracting muscle (eccentric) – e.g./ sudden load when lifting, or catching a heavy load
-Distal biceps tendon most common
-S&S: “Popeye muscle”/muscle balled up, bruising, pain near insertion of biceps into radial tuberosity, pain & weakness with elbow flexion & supination (complete ruptures might be painless)
-Acute management: PIER, pressure pad to approximate any remaining fibers, shorten biceps in sling to remove tension
-Surgical repair within first couple weeks for active people
DeQuervain’s Syndrome Tenosynovitis
-MOI: overuse of thumb due to gripping/wringing
-Inflammation of the tendons & sheath around the thumb tendons (Extensor Pollicis Brevis, Abductor Pollicis Longus)
-S&S: pain over tendons of thumb, weakness with thumb abduction or extension, pain with gripping
-Common in golf
-Special test: Finkelstein Test
-Acute management: PIER, thumb spica brace
-If left untreated, can progress to thickening/scarring & reduced ROM
Elbow Hyperextension Injuries
-MOI: FOOSH – landing on an extended elbow – sometimes with added external force
-S&S: anterior elbow pain & swelling from ligament/capsule sprain and/or muscle strain, posterior elbow pain from osteochondral lesion (olecranon in olecranon fossa of ulnohumeral joint)
-Need to rule out olecranon fracture – may see a deformity
-Acute Management: PIER, shorten injured tissues (elbow flexion) → sling
-Tape job for elbow hyperextension is very effective
-What do we need to consider when rehabbing that joint?
Ulnar Collateral Ligament Sprains of the Elbow
-MOI: FOOSH, overuse by repeat valgus force on the elbow
-S&S: pain & laxity (instability) in medial elbow joint
-Can include ulnar nerve symptoms
-Common in pitchers due to repeat high velocity force
-Tommy John surgery reconstructs UCL using a graft tendon -palmaris longus, semitendinosus, or gracilis
-Incidence of this injury/reconstruction is increasing
Collateral Ligament Sprains of the Wrist
-MOI: FOOSH, forced forearm rotation
○ Ulnar Collateral Ligament: valgus force
○ Radial Collateral Ligament: varus force
-S&S: pain, swelling & instability on medial (UCL) or lateral (RCL) aspect wrist
-Special Tests
○ UCL(MCL): Valgus Stress Test
○ RCL(LCL): Varus Stress Test
-Acute management: PIER → wrist wrap!
-Wrist tape job for RTP
Ulnar Collateral Ligament (UCL) Sprain of the Thumb a.k.a Skier’s Thumb or Gamekeeper’s Thumb
-MOI: traumatic or overuse hyperabduction of the thumb (1st metacarpophalangeal joint)
○ Traumatic = Skier’s thumb – thumb gets caught, FOOSH, catching ball
○ Overuse = Gamekeeper’s thumb – repeat gripping/twisting
-Can also result in avulsion fracture
-S&S: pain, swelling & instability at 1st MCP joint
-Surgery is recommended for instability to stabilize joint & prevents osteoarthritis longer term
-Acute management: PIER, possible x-ray to rule out avulsion
-Brace for healing
-Thumb tape job/brace for RTP
Thumb Tape Jobs Considerations
-Which ROM do you want to limit?
○ Hyperextension?
○ Abduction?
-Changes your pre/post special test
○ ROM you want to limit
○ 1st MCP instability glide into ext’n vs. valgus stress
-Starting position
○ What is required for sport?
-Ribbons & hoods – limit both ranges!
○ Be mindful of ribbon direction
Triangular Fibrocartilage Complex (TFCC) Tear
-MOI:
○ Acute: FOOSH, forced forearm rotation
○ Overuse: repetitive wrist motions (wrench, hammer, lifting)
-S&S: medial wrist pain, pain with ulnar deviation & loading through wrist, popping/clicking, wrist weakness
-Special Test: TFCC compression test (passive ulnar deviation with axial compression – loads through the disc)
-Acute management: PIER, brace as it heals
-Anti-inflammatory injections if needed, surgery for persistent instability
Elbow Dislocations
-Elbow joint bony structure provides a lot of stability – but enough force can cause dislocations
-MOI: FOOSH
-S&S: deformity, pain++, holding elbow, tingling/numbness?, shock
-Acute care: stabilize, splint, monitor/treat for shock, ER/EMS
-Reduction under sedation
Elbow Fractures and Surgical Approaches
-MOI: direct trauma/fall
-S&S: pain++, unable or unwilling to move elbow
-Acute care: splint, monitor for shock, ER for x-rays/surgical referral
-ORIF = Open Reduction Internal Fixation
Colles’ Fracture Distal Radius Fracture
-MOI: FOOSH
-Distal radius gets displaced posteriorly
-S&S: “dinner fork deformity”, pain++, numbness?
-Deformity is obvious, so no need for testing
-Acute management: splint, monitor for shock, emerge for x-rays, surgery if unable to align
Scaphoid Fractures
-MOI: FOOSH
-S&S: TOP of anatomical snuffbox
-Scaphoid has poor blood supply = decreased ability to heal
-Important to identify early & immobilize – cast or brace
Metacarpal (MC) and Finger Fractures
-MOI: axial compression (jammed) finger, direct trauma, being stepped on
-S&S: localized pain, swelling, unable to grip
-Acute care: Fingers: buddy tape to stabilize Hand (MC) – SAM Splint
-Can get avulsion fractures – tendon pulls off piece of bone
-Immobilization or surgical repair
Cyclist Palsy
*nerve condition
-MOI: compression from handlebars
-S&S: tingling/numbness/nerve pain, decreased muscle strength of 5th digit, hand cramping
-Common in new cyclists, distance cyclists
-Prevention: avoid hyperextension of wrist on handlebars, proper bike fit
-Acute care: PIER, splint
-May require NSAIDs
Carpal Tunnel Syndrome
*nerve condition
-MOI: overuse of wrist flexor tendons causing pressure on median nerve within carpal tunnel
-S&S: burning/tingling/numbness in anterior wrist & hand (along median nerve distribution – digits 1-3 and ½ of 4), decreased grip strength
-Acute care: bracing, PIER, anti-inflammatory treatment, proper ergonomic set up (prevention too!)
-Steroid injection?
-Surgery to open up tunnel if conservative treatment unsuccessful
