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HOMEWORK REVIEW & EXAM

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ANATOMY FOR ELBOW, FOREARM,

WRIST, & HAND

ELBOW

Humeroulnar and humeroradial joints Flexion and extension

Common Flexor Tendon Tendon shared by flexor Ms: pronator teres, flexor carpi radialis,

palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris Common Extensor Tendon

Tendon shared by extensor Ms: extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris

Proximal and distal radioulnar joints Pronation and supination

ELBOW

ELBOW HYPOMOBILITY

Myositis ossificans

Internal derangement

Subluxation of radial head

Recovery from surgery / trauma

HYPERMOBILITY OF THE JOINTS

May also be called: Joint laxity (or hyperlaxity within capsule / ligaments) Double-jointedness Loose joint

May be seen with: Down syndrome (a developmental disability) Ehlers-Danlos syndrome (an inherited syndrome affecting elasticity Marfan syndrome (a connective tissue disorder) Hypermobility syndrome

Bone structure: bone shape or the depth of the joint sockets Muscle structure: muscle tone or strength Poor sense of proprioception (the ability to sense how far you are

stretching) Family history: hypermobility is often inherited

WHEN TO SEEK TREATMENT

Pain in the loose or hypomobile joint during or after movement

Sudden changes in the appearance of the joint, muscles, or skin

Changes in mobility, specifically in the joints above and/or below affected joint

Changes in the functioning of your arms and legs, compensatory

ELBOW LIGAMENTS

Radial and Lateral Collateral Ligaments Provide support for the sides of the joint

Medial and Ulnar Collateral Ligaments Connect the humerus to the ulna and keep it tightly in place as it slides

through olecranon Can be torn with injury or dislocation

Annular Ligament Holds the proximal radioulnar joint together Wraps around the radial head and holds it tight against the ulna Can be torn when entire elbow or radial head is dislocated

ELBOW LIGAMENTS

ELBOW

Superficial to olecranon process of the ulna Protects process and reduces friction

Brachial artery Crosses crease in elbow Splits into radial and ulnar arteries Only blood supply to hand

CUBITAL VALGUS VS. VARUS

Normal = “carrying angle” The angle formed by the long

axis of the humerus and the long axis of the ulna and is most evident when the elbow is straight and fully supinated

The normal carrying angle in women is 10-15 degrees; and is 5-10 degrees in males

Cubital Valgus = “carrying angle” greater than 15 degrees

Cubital Varus = “carrying angle” less than 5-10 degrees

WRIST

Radiocarpal joint – radius and proximal row of carpals Flexion, extension, radial deviation (abduction), ulnar deviation

(adduction)

Carpal Tunnel – anterior wrist Carpal bones + flexor retinaculum (transverse carpal ligament) Medial attachments – pisiform & hamate Lateral attachments – trapezium & scaphoid Holds 9 tendons and the medial nerve Indicated in carpal tunnel syndrome

WRIST

Tunnel of Guyon (Guyon’s canal) – medial wrist Created by division of flexor retinaculum (transverse carpal

ligament) Ulnar artery and nerve pass through Indicated in ulnar neuropathy

Anatomical Snuff Box – lateral wrist Synovial sheath shared by abductor pollicis longus, extensor

pollicis brevis, and styloid process of radius Indicated in DeQuervain’s Tenosynovitis

ANATOMICAL SNUFF BOX

In anatomical position: posterior border is extensor

pollicis longus anterior border is extensor

pollicis brevis and abductor pollicis longus

proximal border is composed of trapezium and scaphoid

ACRONYMS FOR WRIST BONES

Lateral to Medial

Row 1: Some – Scaphoid Lovers – Lunate Try – Triquetrum Positions – Pisiform

Row 2: That - Trapezium They - Trapezoid Can’t - Capitate Handle – Hamate

WRIST

WRIST & FINGERS

FINGERS

Metacarpophalageal joints Flexion and extension (sagittal plane) Abduction and adduction (frontal plane)

Proximal interphalangeal joints (PIP) Flexion and extension (sagittal plane)

Distal interphalangeal joints (DIP) Flexion and extension (sagittal plane)

THUMB

Carpometacarpal joint (CMC) Flexion and extension – frontal plane Abduction and adduction – sagittal plane

Metacarpophalangeal joints (MCP) Flexion and extension – frontal plane Abduction and adduction – sagittal plane

Interphalangeal joints (IP) Flexion and extension – frontal plane

FLEXOR TENDONS, ARTERIES, & NERVES AT WRIST

FLEXOR TENDONS, ARTERIES, & NERVES AT WRIST

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MUSCLES OF THE ELBOW, FOREARM,

WRIST & HAND

BRACHIALIS

The distal ½ of the anterior shaft of the humerus (beginning just distal to the deltoid tuberosity)

to the

tuberosity and coronoid process of the ulna.

The brachialis flexes the forearm at the elbow joint.

CORACOBRACHIALIS

Coracoid process of the scapula to the

middle 1/3 of the medial shaft of the humerus

The corabrachialis flexes, adducts, and horizontally flexes the arm at the shoulder joint

PRONATOR TERES

From the medial epicondyle of the humerus (via the common flexor tendon), the medial supracondylar ridge of the humerus, and the coronoid process of the ulna

to the

middle ⅓ of the lateral radius.

The pronator teres pronates the forearm at the radioulnar joints; it also flexes the forearm at the elbow joint.

EXTENSOR CARPI RADIALIS LONGUS (ECRL)

From the distal ⅓ of the lateral supracondylar ridge of the humerus

to the

radial side of the posterior hand at the base of the second metacarpal.

EXTENSOR CARPI RADIALIS BREVIS (ECRB)

From the lateral epicondyle of the humerus (via the common extensor tendon)

to the

radial side of the posterior hand at the side of the base of the third metacarpal.

ECRL AND ECRB ACTIONS

Radially deviate (abduct) the hand at the wrist joint. Extend the hand at the wrist joint. Flex the forearm at the elbow joint. Both extensors carpi radialis muscles have the same actions.

SUPINATOR

Lateral epicondyle of the humerus and the supinator crest of the ulna

to the

proximal ⅓ of the radius (posterior, lateral, and anterior sides).

The supinator supinates the forearm at the radioulnar joints.

ABDUCTOR POLLICIS LONGUS

From the middle ⅓ of the posterior radius, interosseus membrane, and ulna

to the

base of the metacarpal of the thumb.

Abducts the thumb at the carpometacarpal joint.

Extends the thumb at the carpometacarpal joint.

Radially deviates the hand at the wrist joint.

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Muscles to ReviewThe following muscles were presented in

first year – please review

DELTOID Lateral ⅓ of the clavicle and the acromion

process and spine of the scapula

to the

deltoid tuberosity of the humerus

The entire deltoid abducts the arm at the shoulder joint and downwardly rotates the scapula at the shoulder and scapulocostal joints.

The anterior deltoid also flexes, medially rotates, and horizontally flexes the arm at the shoulder joint.

The posterior deltoid also extends, laterally rotates, and horizontally extends the arm at the shoulder joint.

BICEPS BRACHII

Supraglenoid tubercle (long head) and coracoid process (short head) of the scapula

to the

radial tuberosity and the deep fascia overlying the common flexor tendon.

Flexes the forearm at the elbow joint

Supinates the forearm at the radioulnar joints

Flexes the arm at the shoulder joint

TRICEPS BRACHII

Infraglenoid tubercle of the scapula (long head) and the posterior shaft of the humerus (lateral and medial heads)

to the

olecranon process of the ulna.

The triceps brachii extend the forearm at the elbow joint; the long head also adducts and extends the arm at the shoulder joint.

BRACHIORADIALIS

Proximal ⅔ of the lateral supracondylar ridge of the humerusto the

styloid process of the radius. Flexes the forearm at the elbow joint. Can also pronate the supinated

forearm at the radioulnar joints to a position halfway between full pronation and supination;

Or supinate the pronated forearm at the radioulnar joints to a position halfway between full pronation and supination.

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CONDITIONSPART I

LATERAL EPICONDYLITIS (TENNIS ELBOW)

Definition: Chronic collagen degeneration in extensor tendons and enthesopathy

(attachment site) at the lateral epicondyle of the humerus Common overuse injury affecting 1-3% of the population Extensor carpi radialis brevis is most affected due to line of pull

Causes: Repeated tensile stress on tendons – excessive concentric extension or

eccentric flexion Sports, occupations, and hobbies that require repetitive grasping of objects Repetitive supination and pronation Trigger points in extensor tendons may create excess tensile loads

History: Pain in lateral elbow that radiates into forearm Generalized aching; sharp pain if aggravated Acute onset is rare Generally unilateral symptoms

LATERAL EPICONDYLITIS (TENNIS ELBOW)

Observations: No visible clues Inflammation/enthesitis (inflammation of attachment site) can’t be seen

Palpation: Tenderness and pain at the lateral epicondyle of humerus Hypertonic extensors; fibrotic and ropy Referral patters from extensor trigger points Pain from entrapment of posterior interosseous nerve may present

Testing: AROM:

Possible pain with extension - minor contraction required Pain at end-range of flexion – extensor stretch

PROM: Pain uncommon from extension, pain at end-range of flexion

LATERAL EPICONDYLITIS (TENNIS ELBOW)

MRT: Pain with extension RMI produces weakness Nerve compression in radial tunnel also produces weakness

Special Tests: Tennis Elbow Test

Contraindications: None Rule out posterior interosseous nerve compression with two differential tests

- resisted tennis elbow/radial tunnel syndrome Epicondylitis – pain on wrist extension; PIN compression – weak with resisted

extension with little increase of pain

Treatment Goals: (stage dependent) Stimulate collagen production – deep friction Restore wrist function – stripping, myofascial work, active engagement

LATERAL EPICONDYLITIS (TENNIS ELBOW)

Reduce hypertonicity and pain Deactivate trigger points Treatment protocol:

1. Warm up tissue – myofascial, trigger points, lengthening2. Identify adhesion in common extensor tendon – only treat 1 or 2 per

session3. Cross-fiber friction small section per session: engage tissue

perpendicularly, 6 or more deep strokes; release gently4. Flush with effleurage5. Stretch6. Ice – immediately in clinic, then at home (cross-fiber friction causes

inflammation) Treatment: 2 times a week for 2-3 weeks; after some healing, move on to

once per week Stress that homecare is very important

Hydrotherapy: Ice to reduce pain

LATERAL EPICONDYLITIS (TENNIS ELBOW)

Self-care: Self massage: cross-fiber friction, stripping Stretch: extensors Strengthen: flexors and upper arm and shoulder muscles Rest from offending activities

MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)

Definition: Chronic collagen degeneration of the wrist flexor tendons where they attach

to the medial epicondyle of the humerus Enthesopathy at the attachment site Pronator teres often involved due to its coordinated effort with wrist flexors

and proximity of its proximal attachment

Causes: Excessive tensile stress from repetitive or prolonged contractions of the

flexor group Repetitive pronation and supination: stress placed on pronator teres Sports injuries: swing or throw; valgus force on elbows and tendons Correlates with carpal tunnel syndrome

History: Pain on medial side of elbow that radiates into forearm Generalized aching pain, rarely acute; sharp if aggravated Usual gradual onset

MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)

Possible neurological sensations in ulnar nerve distribution of the hand Ask about activities involving repetitive gripping Pain when shaking hands Recommended to differentiate between: carpal or cubital tunnel, pronator teres

syndromes

Observations: No visible clues Possible excessive cubital valgus

Palpation: Tender forearm flexors

Testing: AROM:

Possible pain in wrist flexion if condition is severe PROM:

Possible pain in flexion Possible pain in full extension or supination at end range stretch

MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)

MRT: Pain with resisted flexion Pain with resisted pronation if pronator teres is involved Weakness due to RMI

Special Tests: Golfer’s Elbow Test

Contraindications: Caution when frictioning near ulnar nerve at proximal flexor tendons Caution with ice treatment – possible nerve damage to ulnar nerve

Treatment Goals: (stage dependent) Stimulate collagen production – deep friction Restore wrist function – stripping, myofascial work, active engagement Reduce hypertonicity and pain in flexors and pronator teres Deactivate trigger points

MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)

Treatment protocol:1. Warm up tissue – myofascial, trigger points, lengthening2. Identify adhesion in common flexor tendon – only treat 1 or 2 per session3. Cross-fiber friction small section per session: engage tissue

perpendicularly, 6 or more deep strokes; release gently4. Flush with effleurage5. Stretch6. Ice – immediately in clinic, then at home (cross-fiber friction causes

inflammation) Treatment: 2 times a week for 2-3 weeks; after some healing, move on to once

per week Stress that homecare is very important

Hydrotherapy: Ice to reduce pain

Self-care: Self massage: cross-fiber friction, stripping Stretch: flexors