The Elbow, Wrist, and Hand

1. The Elbow, Wrist, and Hand Chapter 20

2. Skeletal Anatomy – Wrist and Hand • The Wrist and Hand • Made up of 27 bones • 8 carpal bones make up the wrist • 5 metacarpals from the structure of the hand • 14 phalanges • 2 for the thumb • 3 for each other 4 fingers

3. Skeletal Anatomy - Elbow • 3 bones of the elbow joint • Humerus • Radius • Ulna • Many structures surround the elbow • Ligaments • Nerves • Muscles • Bursa sacs

4. Muscles of the Elbow • Forearm Flexors • Brachialis • Biceps Brachii • Brachioradialis • Forearm Extensors • Triceps Brachii • Anconeus

5. Common injuries of the Elbow • Several causes for a variety of athletic injuries • Direct trauma • Indirect trauma • Acute/Chronic stresses • These MOIs can result in several injuries • Contusions • Sprains • Strains • Dislocations • Fractures • Nerve involvement

6. Contusions • Common injury that may involve the muscles of the forearm and subcutaneous bony prominences of the elbow • Usually caused by a direct blow • Symptoms • Bruising • Subsequent bleeding • Stiffness during function or active motion • Treatment • PRICE • Prevents myositisossificans

7. Olecranon Bursitis • Inflammation of the olecranon bursitis • Caused by direct blows to the olecranon process • Can be accompanied by infection due to the frequent abrasions that occur over the tip of the elbow • Treatment • Depends on whether infection is involved • Uninfected bursitis • Ice compresses • Rest • Anti-inflammatory meds • Pain meds • Aspiration of the bursa

8. Ulnar Nerve Contusion • Caused by a direct blow the medial epicondyle of the humerus • Athlete complaints of immediate pain and burning sensation down the ulnar side of the forearm to the ring and little fingers • Also known as hitting the “funny bone” • Treatment • None is usually necessary

9. Elbow Strains • Normally occur with a sudden overload to the elbow joint • can acute or chronic • Acute Strains • Sudden excessive overload • Tenderness over the affected area • Pain on function or resisted motion • Chronic Strains • Result of continued overuse • Overuse syndrome • Chronic degenerative processes • Common areas of acute strains • Common flexor tendon • Medial epicondyle • Common extensor tendon • Lateral epicondyle

10. Elbow Sprains • Usually due to forced hyperextension or valgus/varus forces • Symptoms • Click or pop • Sharp pain at injury • Tenderness • Localized swelling • Pain when repeating MOI • Usually relieved by bending the elbow

11. Epicondylitis • Usually caused by repetitive overload of the attached musculotendinous units • Occurs in the region of the medial and lateral epicondyle of the humerus • Called “tennis elbow” if lateral • Called “golfer’s elbow” if medial • If it occurs in younger patients, called “little leaguer elbow” • Can also accompany an injury to the growth plate of the epiphysis

12. Epicondylitis cont’d • Symptoms • Pain when used • Possible swelling • Local tenderness • Pain with resisted wrist motion • Without proper treatment condition may worsen • May develop into prolonged degenerative changes • Causes chronic epicondylitis • Contractures of the elbow • Reduced friction • Possible rupture of muscle tendon unit • Treatment • RICE • Modifying activities that aggravate conditions • Preventive measures • Using proper technique/equipment • Limiting stress • Adequately warming up • stretching

13. Dislocations of the Elbow • Most commonly involves the posterior displacement of the ulna and radius in relationship to the humerus • Often caused by a fall onto an outstretched hand with elbow in extension • Symptoms • Obvious deformity • Loss of elbow function • Considerable pain • Initial exam should include evaluation of nerve function of hand and fingers • Treatment • Immobilzation • Immediate referral to physician of medical facility • Possible vascular and neurological damage

14. Forearem/Elbow Fractures • The result of either direct trauma or indirect stresses transmitted through the upper extremity by falling on an outstretched arm • Fractures in younger athletes commonly involve epiphyseal plate fractures • Symptoms • Directly related to degree of severity • Point tenderness • Hemorrhaging • Swelling • Limited ROM • Disability at elbow or hand • Increased pain with movement • Treatment • Immobilization • Ice • Prompt referral to physician or medical clinic

15. Volkmann’s Contracture • Occurs in the absence of blood flow (ischemia) to the forearm • Can lead to contracture, where joint remains bent and cannot straighten • Causes • Increased pressure from swelling or trauma • Fracture • 3 Levels of severity in Volkmann’s Contracture • Mild • Involves contracture of 2 or 3 fingers • No limited loss of sensation • Moderate • Involves all fingers being flexed • Thumb stuck in palm • Wrist may be stuck in flexion • Usually loss of sensation in the hand • Severe • Involves all muscles in forearm (flexors and extensors) • Fingers • Severely disabling condition

16. Volkmann’s Contracture cont’d • Symptoms • Severe pain when a muscle running through a compartment is passively moved • Forearm may be swollen • Shiny • Painful when squeezed • Pain does not improve with rest, but continues to worsen with time • If condition is not corrected • Decreased sensation • Weakness • Paleness of the skin

17. Ulnar Nerve Injury • Repetitive throwing and/or swinging can cause irritation, compression, or entrapment in the cubital tunnel • Called cubital tunnel syndrome • Symptoms • Pain along the inner aspect of the elbow • Tenderness of the medial epicondylar groove • Paresthesia (numbness or tingling) of ring and little finger

18. Radial Nerve Injury • Usually caused by entrapment of the nerve which passes through a tunnel formed by several muscles and tendons • Also called radial tunnel syndrome • Symptoms • Pain over lateral aspect of the elbow • Pain over radial head

19. Median Nerve Injury • Includes entrapment or compression due to hypertrophy of the pronatorteres or repetitive pronation of the forearm • Called pronatorteres syndrome • Symptoms • Pain radiating down the anterior forearm • Numbness and tingling in the thumb, index, and middle fingers • Resistive pronation may increase the pain

20. Muscles of the hand and wrist • Muscles that move the Wrist • 2 Flexor Carpi muscles • 2 Extensor Carpi muscles • 2 Palmaris muscles • Muscles that move the Hand • 1 Supinator muscles • 2 Pronator muscles • Muscles that move the Thumb • 2 Flexors • 2 Extensors • 1 adductor • 2 abductors • 1 opponens • Muscles that move the Fingers • 3 flexors • 2 extensors • 3 abductors • 1 adductor

21. Injuries to the hand and wrist • Common injuries • Fractures • Dislocations • Contusions • Sprains • Tendonitis • Nerve Impingements

22. Finger Fractures • Can involve any of the 14 phalange bones. • Most can be treated with a finger splint • Boxer’s Fracture • A break of the 5th metacarpal leading to the little finger • Baseball (mallet) finger • Painful injury that occurs when a ball or other object strikes the tip of the finger, bending it beyond its normal ROM which tears the finger tendon and damages cartilage

23. Finger Fractures cont’d • Jersey Finger • Caused by tearing the flexor tendon to the fingertip • Usually occurs from grabbing a jersey during a tackle. • Ring finger is the most often affected • Scaphoid fracture • Affects the scaphoid bone • Paplpation of the anatomical snuffbox will cause pain, indicates a fracture may be present

24. Finger Fractures cont’d • Colles Fracture • A break of the radius just above the wrist • Treatment for all fractures • RICES (rest, ice, compression, elevation, support) • Evaluation by a physician

25. Dislocations and subluxations • Fairly common injuries • Causes • Ball striking fingertip • Finger getting hooked into equipment • Symptoms • Immediate pain • Swelling • Crooked finger • Usually can’t be bent or straightened • Treatment • Ice • Immobilization • Immediate treatment by physician

26. Contusions • Usually caused by direct blows or falling onto a hard surface • With nails become contused, pressure may cause a physician to drain blood from beneath the nail

27. Sprains of the wrist and hand • Gamekeeper’s thumb • Sprain of the ulnar collateral ligament of the metacarpalphalangeal joint (MPJ) • Common in alpine skiiing • Caused by force applied to the medial side of the thumb, forcing the MPJ to stretch, tear, or even rupture

28. Tendonitis • The inflammation of the tendons caused by overuse or repetitive stress • Symptoms • Ache or pain at the wrist • Worsens forceful gripping, rapid wrist movements or moving the wrist or fingers to an extreme position • Treatment • The same as other forms of tendonitis • Most common sites in the wrist • Base of the thumb near anatomical snuffbox • deQuervian’stenosynovitis

29. Nerve Impingement • Also called Carpal Tunnel syndrome • An inflammatory disorder caused by the following • Repetitive stress • Physical injury • Other conditions that cause swelling around the median nerve near the carpal tunnel • Symptoms • Pain • Numbness • Tingling in the wrist, hand, fingers (except little finger) • Tendency to drop things • Loss of sense of heat or cold • Feeling of swelling, even though it is visibly swollen • Symptoms may occur only when the hand is being used or only when at rest • Treatment • RICE • In severe cases, surgery to decompress the median nerve

30. Ganglion Cyst • A small, usually hard lump above a tendon or in a capsule that encloses a joint • Also called a synovial hernia or synovial cyst • It is common in handball, racquetball, squash and tennis • Cause of the cyst is unknown

31. Boutonniere Deformity • An injury to the extensor tendon affecting the proximal interphalangeal joint (PIP) at the middle of the finger or the distal interphalangeal joint at the end of the finger • Caused by a direct blow to a bent finger • Symptoms • Problems flexing and extending the finger • Physician should be contacted immediately • Joints will be painful and tender • Finger misshapen or deformed • The athlete will not be able to straighten it • Treatment • Must be done promptly • Athlete may not regain normal use of the finger