Elbow, Wrist & Hand Elbow, Wrist & Hand EvaluationEvaluation

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Common Injuries to the Elbow, Common Injuries to the Elbow, Wrist, Hand & FingersWrist, Hand & Fingers

►► Lateral epicondylitis Lateral epicondylitis ––““tennis elbowtennis elbow””

►► Medial epicondylitis Medial epicondylitis ––““golfergolfer’’s elbows elbow””, , ““little little league elbowleague elbow””

►► HyperextensionHyperextension►► SprainsSprains►► DeQuervainDeQuervain’’ss diseasedisease►► DislocationsDislocations►► BursitisBursitis

►► Carpal tunnel Carpal tunnel syndromesyndrome

►► Mallet fingerMallet finger►► Boutonniere deformityBoutonniere deformity►► SubungualSubungual hematomahematoma►► ContusionsContusions►► Pathological Pathological

hand/finger positions hand/finger positions (S & R, p.295(S & R, p.295--300)300)

►► FracturesFracturesCollesColles’’ fxfx

The Elbow The Elbow –– Joints & MovementJoints & Movement

►► GinglymusGinglymus or hingeor hinge--jointjoint►► HumeroulnarHumeroulnar joint & joint & RadioulnarRadioulnar joint joint –– 2 interrelated joints2 interrelated joints

►► Movements:Movements:Flexion & Extension Flexion & Extension –– primarily between ulna & humerusprimarily between ulna & humerus►► 00°° to 145to 145°° --150150°°

The Elbow The Elbow –– Joints & MovementJoints & Movement►► RadioulnarRadioulnar jointjoint►► TrochoidTrochoid or pivotor pivot--type jointtype joint►► SyndesmosisSyndesmosis –– interosseusinterosseus membranemembrane►► Movements: Movements:

Supination Supination -- 8080°°--9090°° from neutralfrom neutralPronation Pronation -- 7070°°--9090°° from neutralfrom neutral

Anatomy ElbowAnatomy ElbowHumerus:Humerus:

TrochleaTrochleaCapitulumCapitulum

CoronoidCoronoid FossaFossaMedial & Lateral EpicondyleMedial & Lateral Epicondyle

Radius:Radius:Radial headRadial headRadial neckRadial neck

Radial tuberosityRadial tuberosityRadial FossaRadial Fossa

Ulna:Ulna:CoronoidCoronoid ProcessProcess

Olecranon ProcessOlecranon ProcessUlna TuberosityUlna Tuberosity

Elbow Elbow LigamentsLigamentsAnterior ViewAnterior View

AnnularAnnular

Medial (Ulnar)Medial (Ulnar)CollateralCollateral

Lateral (Radial) Lateral (Radial) CollateralCollateral

Muscles Muscles -- ElbowElbow

►► FlexionFlexionBiceps Biceps BrachiiBrachiiBrachialisBrachialisBrachioradialisBrachioradialis****PronatorPronator Teres Teres -- weakweak

Muscles Muscles -- ElbowElbow

►► ExtensionExtensionTriceps Triceps BrachiiBrachiiAnconeusAnconeus

Muscles Muscles -- ElbowElbow

►► PronationPronationPronatorPronator TeresTeresPronatorPronator QuadratusQuadratusBrachioradialisBrachioradialis

Muscles Muscles -- ElbowElbow

►► SupinationSupinationBiceps Biceps BrachiiBrachiiSupinatorSupinatorBrachioradialisBrachioradialis

NeuroanatomyNeuroanatomy

►►Brachial Plexus Brachial Plexus –– C5, C6, C7, C8, & T1C5, C6, C7, C8, & T1►►Branches:Branches:

Radial Nerve (C5, C6, C7 & C8)Radial Nerve (C5, C6, C7 & C8)Median Nerve (C6 & C7)Median Nerve (C6 & C7)Ulnar Nerve (C8 & T1)Ulnar Nerve (C8 & T1)MusculocutaneousMusculocutaneous Nerve (C5 & C6)Nerve (C5 & C6)

NeuroanatomyNeuroanatomy –– Radial & Median Radial & Median NervesNerves

NeuroanatomyNeuroanatomy –– MusculocutaneousMusculocutaneous& Ulnar Nerves& Ulnar Nerves

DermatomesDermatomesAnterior ViewAnterior View

DermatomesDermatomesPosterior ViewPosterior View

Neurovascular Neurovascular AnatomyAnatomy►► Forearm ArteriesForearm Arteries

PalmarPalmar AspectAspect

Dorsal AspectDorsal Aspect

Wrist & HandWrist & HandPalmarPalmar AspectAspect

PhalangesPhalangesMetacarpalsMetacarpals

CarpalsCarpals

CarpalsCarpals

ScaphoidScaphoid (boat shaped)(boat shaped)LunateLunate (moon shaped)(moon shaped)

TriquetrumTriquetrum (3 cornered)(3 cornered)PisiformPisiform (pea shaped)(pea shaped)

TrapeziumTrapeziumTrapezoidTrapezoid

CapitateCapitate (head shaped)(head shaped)HamateHamate (hooked)(hooked)

Carpal BonesCarpal Bones►► Concave on Concave on palmarpalmar sideside►► Bony arch is spanned by transverse carpal & volar Bony arch is spanned by transverse carpal & volar

ligamentsligaments►► Creates carpal tunnelCreates carpal tunnel►► Median nerve & all flexor tendons except flexor Median nerve & all flexor tendons except flexor

carpi ulnaris & carpi ulnaris & palmarispalmaris longus pass through carpal longus pass through carpal tunneltunnel

Anatomical SnuffboxAnatomical Snuffbox

►► Extensor pollicis longus Extensor pollicis longus (medial side)(medial side)

►► Extensor pollicis brevis Extensor pollicis brevis (lateral side)(lateral side)

►► Abductor pollicis Abductor pollicis longus (lateral side)longus (lateral side)

MedialLateral

Ligaments & Ligaments & Volar PlatesVolar Plates

PalmarPalmar AspectAspect

Volar = Volar = palmarpalmar sideside

LigamentsLigamentsDorsal AspectDorsal Aspect

Triangular Triangular FibrocartilageFibrocartilage

LigamentLigament(TFCC)(TFCC)

*extends from ulnar side of *extends from ulnar side of distal radius & attaches to distal radius & attaches to

ulna @ base of ulnar ulna @ base of ulnar styloidstyloidprocessprocess

*disc provides stability to *disc provides stability to wristwrist

*major stabilizer of distal *major stabilizer of distal radioulnarradioulnar jointjoint

Joints & MovementsJoints & Movements

►►Wrist joint Wrist joint CondyloidCondyloid--typetypeFlexion, extension, abduction (radial deviation), Flexion, extension, abduction (radial deviation), adduction (ulnar deviation)adduction (ulnar deviation)►►Motion occurs mostly in proximal carpal row & distal Motion occurs mostly in proximal carpal row & distal

radiusradius►►7070°°--9090°° of flexionof flexion

►►6565°°--8585°° of extensionof extension

►►1515°°--2525°° of abductionof abduction

►►2525°°--4040°° of adductionof adduction

Joints & MovementsJoints & Movements►► FingersFingers

MetacarpophalangealMetacarpophalangeal Joint Joint (MCP)(MCP)►►CondyloidCondyloid

►►00°°--4040°° of extensionof extension

►►8585°°--100100°° of flexionof flexion

Proximal Proximal interphalangealinterphalangeal Joint Joint (PIP)(PIP)►►GinglymusGinglymus

►►Full extension to 90Full extension to 90°°--120120°° of flexionof flexion

Distal Distal interphalangealinterphalangeal Joint Joint (DIP)(DIP)►►GinglymusGinglymus

►►Flex 80Flex 80°°--9090°° from full from full extensionextension

Thumb JointsThumb Joints►► 2 joints2 joints

MetacarpophalangealMetacarpophalangeal (MCP)(MCP)►►GinglymusGinglymus

►►Full extension into 40Full extension into 40°°--9090°° of flexionof flexion

InterphalangealInterphalangeal (IP)(IP)►►GinglymusGinglymus►►Flex 80Flex 80°°--9090°°

►► CarpometacarpalCarpometacarpal (CMC) joint(CMC) joint►► Saddle jointSaddle joint►► 5050°°--7070°° of abductionof abduction

►► Flex 15Flex 15°°--4545°° & extend 0& extend 0°°--2020°°

Finger MovementFinger Movement►► Middle phalange is reference Middle phalange is reference

point to differentiate abduction & point to differentiate abduction & adductionadduction

Thumb, index & middle fingers Thumb, index & middle fingers abduct when they move laterally abduct when they move laterally toward radial side of handtoward radial side of handRing & little fingers abduction when Ring & little fingers abduction when they move medially toward ulnar they move medially toward ulnar side of handside of handMedial movement of thumb, index & Medial movement of thumb, index & middle fingers toward ulnar side of middle fingers toward ulnar side of hand is adductionhand is adductionLateral movement of ring & little Lateral movement of ring & little finger toward radial side of hand is finger toward radial side of hand is adductionadduction

Extrinsic Muscles of HandExtrinsic Muscles of HandExtrinsic muscles of wrist & hand grouped Extrinsic muscles of wrist & hand grouped according to function & locationaccording to function & location

►► 6 muscles move wrist 6 muscles move wrist but notbut not fingers & thumbfingers & thumb

3 wrist flexors3 wrist flexors

►►flexor carpi radialisflexor carpi radialis

►►flexor carpi ulnarisflexor carpi ulnaris

►►palmarispalmaris longuslongus

3 wrist extensors3 wrist extensors

►►extensor carpi radialis longusextensor carpi radialis longus

►►extensor carpi radialis brevisextensor carpi radialis brevis

►►extensor carpi ulnarisextensor carpi ulnaris

Extrinsic Muscles of HandExtrinsic Muscles of Hand►► 9 muscles primary movers of phalanges9 muscles primary movers of phalanges

Also involved in wrist joint actionsAlso involved in wrist joint actionsGenerally weaker in their wrist actionsGenerally weaker in their wrist actionsFlexorsFlexors►►Flexor digitorum superficialisFlexor digitorum superficialis►►Flexor digitorum profundusFlexor digitorum profundus►►Flexor pollicis longus (thumb flexor)Flexor pollicis longus (thumb flexor)

ExtensorsExtensors►►Extensor digitorumExtensor digitorum►►Extensor indicisExtensor indicis►►Extensor digiti minimiExtensor digiti minimi►►Extensor pollicis longus (thumb extensor)Extensor pollicis longus (thumb extensor)►►Extensor pollicis brevis (thumb extensor)Extensor pollicis brevis (thumb extensor)

Abductor of thumb & wristAbductor of thumb & wristAbductor pollicis longusAbductor pollicis longus

Wrist Abductors & AdductorsWrist Abductors & Adductors►► Wrist abductorsWrist abductors

Generally cross wrist joint Generally cross wrist joint anterolaterallyanterolaterally & & posterolaterallyposterolaterally to insert on radial side of handto insert on radial side of hand►►Flexor carpi radialisFlexor carpi radialis►►Extensor carpi radialis longusExtensor carpi radialis longus►►Extensor carpi radialis brevisExtensor carpi radialis brevis►►Abductor pollicis longusAbductor pollicis longus►►Extensor pollicis longusExtensor pollicis longus►►Extensor pollicis brevisExtensor pollicis brevis

►► Wrist adductorsWrist adductorsCross wrist joint Cross wrist joint anteromediallyanteromedially & & posteromediallyposteromedially to insert on ulnar side of handto insert on ulnar side of hand

►►Flexor carpi ulnarisFlexor carpi ulnaris

►►Extensor carpi ulnarisExtensor carpi ulnaris

Anterior Aspect of Elbow Anterior Aspect of Elbow

Posterior Aspect of ElbowPosterior Aspect of Elbow

Intrinsic Hand MusclesIntrinsic Hand Muscles►► Intrinsic hand muscles Intrinsic hand muscles have origins & insertions on have origins & insertions on

bones of handbones of hand

Radial side Radial side -- four muscles of thumb four muscles of thumb ►►opponensopponens pollicispollicis

►►abductor pollicis brevisabductor pollicis brevis

►►flexor pollicis brevisflexor pollicis brevis

►►adductor pollicisadductor pollicis

Ulnar side Ulnar side -- three muscles of little fingerthree muscles of little finger►►opponensopponens digiti minimidigiti minimi

►►abductor digiti minimiabductor digiti minimi

►►flexor digiti minimi brevisflexor digiti minimi brevis

Remainder of hand Remainder of hand -- 11 different muscles11 different muscles►►4 4 lumbricalslumbricals

►►3 3 palmarpalmar interosseiinterossei

►►4 dorsal 4 dorsal interosseiinterossei

►►ThenarThenar eminenceeminence -- muscular pad on muscular pad on palmarpalmarsurface of 1surface of 1stst metacarpalmetacarpal

abductor pollicis brevisabductor pollicis brevisopponensopponens pollicispollicisflexor pollicis brevisflexor pollicis brevisadductor adductor pollicispollicis

►►HypothenarHypothenar eminenceeminence -- muscular pad that muscular pad that forms ulnar border on forms ulnar border on palmarpalmar surfacesurface

abductor digiti minimiabductor digiti minimiflexor digiti minimi brevisflexor digiti minimi brevisopponensopponens digiti digiti minimiminimi

Intrinsic Muscles of HandIntrinsic Muscles of Hand

TendonsTendonsDorsal AspectDorsal Aspect

Ext. Pollicis BrevisExt. Pollicis BrevisExt. Pollicis LongusExt. Pollicis Longus

Ext. DigitorumExt. DigitorumExt. IndicisExt. Indicis

Ext. Digiti MinimiExt. Digiti Minimi

Elbow & Forearm EvaluationElbow & Forearm Evaluation►►HistoryHistory

Ask Generic history questions Ask Generic history questions -- MOI, MOI, ?noises/sensations, Burning/Stinging? ?noises/sensations, Burning/Stinging? Ask Specific history questions Ask Specific history questions -- was your hand was your hand planted? Did you fall on an outstretched hand?planted? Did you fall on an outstretched hand?

►►ObservationObservationCarrying Angle (Carrying Angle ( > > ))►► 1010°°--1515°° 55°°--1010°°

CubitalCubital RecurvatumRecurvatumCubitalCubital ValgusValgusBony alignment, Soft tissue Bony alignment, Soft tissue Discoloration, swelling, etc.Discoloration, swelling, etc.

Elbow & Forearm EvaluationElbow & Forearm Evaluation►► PalpationPalpation

Bony landmarks, Soft tissueBony landmarks, Soft tissueSwelling, Swelling, crepituscrepitus, temperature, etc., temperature, etc.CubitalCubital fossa fossa –– brachial artery, median n., brachial artery, median n., musculocutaneousmusculocutaneous n.n.►►BrachioradialisBrachioradialis –– lateral borderlateral border►►PronatorPronator teres teres –– medial border medial border

►► Stress/Special TestsStress/Special TestsROM (AROM, PROM, RROM): ROM (AROM, PROM, RROM): -- 00--145145°°; / ; / -- normally normally 00°° butbut can have hyperextension; pronation/supination can have hyperextension; pronation/supination 170170--180180°°Valgus/Varus Stress testsValgus/Varus Stress testsTinelTinel’’s Signs SignCompression/Squeeze TestCompression/Squeeze TestNeurologicNeurologic

Wrist & Hand EvaluationWrist & Hand Evaluation►► HistoryHistory

Ask Generic history questions Ask Generic history questions -- MOI, ?noises/sensations, MOI, ?noises/sensations, Burning/Stinging? Burning/Stinging? Ask Specific history questions Ask Specific history questions -- was your hand planted? was your hand planted? Did you fall on an outstretched hand? Did you fall on an outstretched hand?

►► ObservationObservationDiscoloration, swellingDiscoloration, swellingPosture of handPosture of handDeformity, Deformity, palmarpalmar creases, color of skin & fingernails, creases, color of skin & fingernails, thenarthenar & & hypothenarhypothenar eminences, eminences, thenarthenar webspacewebspaceMurphyMurphy’’s sign, s sign, SilverforkSilverfork deformity, Boutonniere deformity, Boutonniere deformity, mallet finger deformity, rotational deformity, mallet finger deformity, rotational malalignmentmalalignment, missing knuckle, missing knuckle

Wrist & Hand EvaluationWrist & Hand Evaluation►► PalpationPalpation

Ulna (Ulna (styloidstyloid process), Radius (Listerprocess), Radius (Lister’’s tubercle, s tubercle, styloidstyloidprocess), Carpals, Metacarpals, Phalanges, joints, process), Carpals, Metacarpals, Phalanges, joints, muscles, ligaments, Carpal Tunnel, Anatomical snuffboxmuscles, ligaments, Carpal Tunnel, Anatomical snuffboxTemperature, deformity, swellingTemperature, deformity, swelling

►► Stress/Special TestsStress/Special TestsROM, Grip strength, Pinch test, test ea. joint on a fingerROM, Grip strength, Pinch test, test ea. joint on a fingerValgus/Varus Stress tests of all joints, Glide testing of Valgus/Varus Stress tests of all joints, Glide testing of ligamentsligamentsPhalenPhalen’’s Tests Test

Stress/Special Tests continuedStress/Special Tests continuedTinelTinel’’s Signs SignGlide tests Glide tests –– ulnar glide, superior glide, inferior ulnar glide, superior glide, inferior glideglideFinkelstein TestFinkelstein TestTransverse Compression, Compression Test, Tap Transverse Compression, Compression Test, Tap or Percussion (Long bone Compression) Testor Percussion (Long bone Compression) TestWatson Test Watson Test –– ((ScaphoidScaphoid shift)shift)ReflexesReflexesCapillary refillCapillary refillPulsePulse

ReferencesReferences

►► Thompson, C. & Floyd, R. T. (2004). Thompson, C. & Floyd, R. T. (2004). Manual of Manual of Structural KinesiologyStructural Kinesiology, 15, 15thth ed.ed.

►► Primal 3D Interactive SeriesPrimal 3D Interactive Series►► Starkey, C. & Ryan, J. (2003). Starkey, C. & Ryan, J. (2003). Orthopedic & Orthopedic &

Athletic Injury Evaluation HandbookAthletic Injury Evaluation Handbook..►► AgurAgur, A. & , A. & DalleyDalley, A. (2005). , A. (2005). GrantGrant’’s Atlas of s Atlas of

AnatomyAnatomy..►► McDevittMcDevitt, E. & Roberts, W. (1999). Dorsal , E. & Roberts, W. (1999). Dorsal

Dislocations of the MCP Joint Assessment and Dislocations of the MCP Joint Assessment and Closed Reduction. Closed Reduction. The Physician & The Physician & SportsmedicineSportsmedicine,, 27(7), p. 75.27(7), p. 75.