The Elbow, Wrist, and Hand

Chapter 20

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

Skeletal Anatomy – Wrist and Hand

3 bones of the elbow joint◦ Humerus◦ Radius ◦ Ulna

Many structures surround the elbow◦ Ligaments◦ Nerves◦ Muscles◦ Bursa sacs

Skeletal Anatomy - Elbow

Forearm Flexors◦ Brachialis◦ Biceps Brachii◦ Brachioradialis

Forearm Extensors◦ Triceps Brachii◦ Anconeus

Muscles 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

Common injuries of the Elbow

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 myositis ossificans

Contusions

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

Olecranon Bursitis

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

Ulnar Nerve Contusion

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

Elbow Strains

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

Elbow Sprains

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

Epicondylitis

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

Epicondylitis cont’d

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

Dislocations of the Elbow

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

Forearem/Elbow Fractures

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

Volkmann’s Contracture

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

Volkmann’s Contracture cont’d

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

Ulnar 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

Radial Nerve Injury

Includes entrapment or compression due to hypertrophy of the pronator teres or repetitive pronation of the forearm◦ Called pronator teres syndrome

Symptoms◦ Pain radiating down the

anterior forearm◦ Numbness and tingling in the

thumb, index, and middle fingers

◦ Resistive pronation may increase the pain

Median Nerve Injury

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

Muscles of the hand and wrist

Common injuries◦ Fractures◦ Dislocations◦ Contusions◦ Sprains◦ Tendonitis◦ Nerve Impingements

Injuries to the hand and wrist

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

Finger Fractures

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

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

Finger Fractures cont’d

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

Dislocations and subluxations

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

Contusions

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

Sprains of the wrist and hand

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’s tenosynovitis

Tendonitis

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

Nerve Impingement

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

Ganglion Cyst

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

Boutonniere Deformity