Chapter 19: The Elbow, Forearm, Wrist and Hand
What causes the dislocation of the phalanges?
- A blow to the tip of the finger (directed upward from palmar side) : Forces 1st or 2nd joint dorsally - Results in tearing of supporting capsular tissue and hemorrhaging - Possible rupture of flexor or extensor tendon(s) and or chip fractures may also occur - may be closed or open
What causes Olecranon Bursitis?
- A direct blow or falling on a bent elbow - Superficial location makes it extremely susceptible to injury (acute or chronic) - Most commonly injured bursa in the elbow
What are the signs of lateral epicondylitis?
- Aching pain in region of lateral epicondyle during and after activity - Pain worsens and weakness in wrist and hand develop - elbow has decreased ROM; pain with resistive wrist extension and full extension of the elbow
How do you care for wrist tendonitis?
- Acute pain and inflammation treated with ice massage 4 times a day for the first 48-72 hours, NSAIDs and rest - Use of wrist splint may protect injured tendon - PRE can be instituted once swelling and pain subsided (high rep, low resistance)
What are the signs of a wrist ganglion?
- Appears on the back of the wrist generally - Occasional pain with lump at site - pain increases with use
What causes a wrist sprain?
- Arises from any abnormal, forced movement - Falling on hyperextended wrist, violent flexion or torsion
What are the signs of a forearm shaft fracture?
- Audible pop or crack followed by moderate to severe pain, swelling and disability - Edema, ecchymosis with possible crepitus - Older athlete may experience extensive damage to soft tissue structures
How do you care for a Hamate fracture?
- Casting wrist and thumb is treatment of choice - Hook of hamate can be protected with doughnut pad to take pressure off area
What is the cause of a Colles' fracture and which direction does the displacement occur? This is sometimes called a what?
- Caused by a fall on an extended wrist, forcing the radius and ulna into hyperextension (Occurs in lower end of radius and ulna) - Displacement occurs posteriorly - Sometimes called a dinner fork deformity
How do you care for a boutonniere deformity?
- Cold application, followed by splinting of PIP - Splinting must be continued for 5-8 weeks - Athlete is encouraged to flex distal phalanx
What is the cause of carpal tunnel syndrome?
- Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel - Result of repeated wrist flexion or direct trauma to anterior aspect of wrist
How do you care for a ulnar nerve injury?
- Conservative management- avoid aggravating condition - Surgery may be necessary if stress on nerve can not be avoided
How do you care for an elbow sprain?
- Conservative treatment- RICE elbow flexed at 90 degrees in a sling for at least 24 hours - Gradual work on elbow ROM - Athlete should modify activity: Gradual throwing progression If unstable, MCL can be reconstructed -- Tommy Johns procedure- Recreating the UCL. Usually takes two different tendons (palmaris longus of hamstring) to do so.
How do you care for carpal tunnel syndrome?
- Conservative treatment; rest immobilization, NSAIDs - If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament
What are signs of jersey finger?
- DIP can not be flexed, finger remains extended - Pain and point tenderness over distal phalanx
What is the cause of a fifth metacarpal fracture?
- Direct axial force or compressive force - Fractures of the 5th metacarpal are associated with boxing or martial arts
What are the signs of injury for forearm splints and other strains
- Dull ache between extensors - Weakness and pain with contraction - Point tenderness in interosseous membrane
What causes fractures to the elbow?
- Fall on flexed elbow or from a direct blow - Fracture can occur in any one or more of the bones - Fall on outstretched hand often fractures humerus above condyles or between condyles
What is the cause of a Smiths fracture and which direction does it displace?
- Falling on a flexed wrist - displacement occurs anteriorly -- Less common
How do you care for a collateral ligament sprain?
- Ice for the acute stage - X-ray to rule out fracture and splint for support
How do you care for a subungeal hematoma?
- Ice pack for pain and swelling reduction - Elevation - Drill nail within 12-24 hours to relieve pressure -- Perform under sterile conditions -- May be required to drill a second time due to additional blood accumulation
How do you care for osteocohondritis dissecans of the elbow?
- If repeated locking occurs, loose bodies may be removed surgically - Without removal, arthritis may develop
How do you care for a dislocated elbow?
- Immobilize and refer to physician for reduction -Following reduction, elbow should remain splinted in flexion for 3 weeks
How do you care for olecranon bursitis?
- In acute conditions, ice - Chronic cases require protective therapy - If swelling fails to resolve, aspiration may be necessary - Can be padded in order to return to competition
How do you care for a scaphoid fracture?
- Must be splinted and referred for X-ray prior to casting (May be missed initially because it does not show up on X-ray very well) - Immobilization last 6 weeks and is followed by strengthening and protective tape - Wrist requires protection against impact loading for 3 additional months - Often fails to heal due to poor blood supply
How do you care for jersey finger?
- Must be surgically repaired - Rehab requires 12 weeks and there is often poor gliding of tendon, with possibility of re-rupture
How do you care for a wrist ganglion?
- Old method was to first break down the swelling through digital pressure and then apply pressure pad to encourage healing - New approach includes aspiration, chemical cauterization with subsequent pressure from pad - Surgical removal is the most effective way- only true treatment
How do you care for mallet finger?
- PRICE and splinting (in extension) for 6-8 weeks
How to care for lateral epicondylitis
- PRICE, NSAIDs and analgesics - Deep friction massage - ROM exercises and PRE --> Hand grasping while in supination, avoidance of pronation motions - mobilization and stretching in pain free ranges - Use of a counter force or neoprene sleeve - Proper mechanics and equipment instruction is critically important
How do you care for a fifth metacarpal fracture?
- PRICE, refer to physician for reduction and immobilization - Deformity is reduced, followed by splinting for 3-4 weeks
How do you care for a forearm shaft fracture?
- PRICE, splint, immobilize and refer to physician - Athlete is usually incapacitated for 8 weeks
What are the signs of an elbow sprain?
- Pain along the medial aspect of the elbow - Inability to grasp object - Point tenderness over the MCL
What are signs of a fifth metacarpal fracture?
- Pain and swelling; possible angular or rotational deformity - palpable defect is possible - When patient makes a fist the knuckle will be depressed or shrunken
What are the signs of mallet finger?
- Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx - Unable to extend distal end of finger (carrying at 30 degree angle) - Point tenderness at the sight of injury
What are signs of wrist tendinitis?
- Pain on active use or passive stretching - Tenderness and swelling over involved tendon
What are signs of Gamekeepers thumb?
- Pain over UCL in addition to weak and painful pinch - Tenderness and swelling over medial aspect of thumb
What are signs of medial epicondylitis?
- Pain produced with forceful flexion: Pain may radiate down arm - Point tenderness and mild swelling - Passive movement of wrist seldom elicits pain but active movement does
What are the signs of a wrist sprain?
- Pain swelling and difficulty with movement
What are the signs of a contusion?
- Pain swelling, and hematoma - If repeated blows occur, heavy fibrosis and possibly bony callus could form within hematoma
What are signs of olecranon bursitis?
- Pain, swelling and point tenderness - Swelling will appear almost spontaneously and without unusual pain and heat
What is the cause of wrist tendinitis
- Primary cause is overuse of the wrist - Repetitive wrist accelerations and decelerations
What are the signs on a subungual hematoma?
- Produces extreme pain due to pressure- nail loss will ultimately occur - Discoloration- bluish-purple - Slight pressure on nail will exacerbate condition
What is the cause of an ulnar nerve injury?
- Pronounced cubital valgus may cause deep friction problem - Ulnar nerve dislocation - Traction injury from valgus force, irregularities with tunnel, subluxation of the ulnar due to lax impingement or progressive compression of ligament on the nerve
How do you care for a contusion?
- Proper care in acute stage involves PRICE for 20 minutes every 1.5 waking hours, followed up with additional cryotherapy and exercise the next day - Can protect with padding
How do you care for a wrist sprain?
- Refer to physician for X-ray if severe - PRICE, splint and analgesics - Have athlete begin strengthening soon after injury - Tape for support can benefit healing and prevent further injury
What is the cause of a boutonniere deformity?
- Rupture of extensor tendon dorsal to the middle phalanx - Forces DIP joint into extension and PIP into flexion
What is the cause of Jersey finger?
- Rupture of flexor digitorium profundus tendon from insertion on distal phalanx - Often occurs with ring finger when athlete tries to grab a jersey
What are signs of a boutonniere deformity?
- Severe pain, obvious deformity and inability to extend DIP joint - Swelling, point tenderness
What are the signs of a collateral ligament sprain?
- Severe point tenderness at the joint; collateral ligaments - Lateral or medial joint instability when flexed
How do you care for a phalanx fracture?
- Splint in slight flexion around gauze roll or curved splint- avoid full extension : Relaxes flexor tendons - Refer to physician - Fracture of distal phalanx is generally less complicated than fracture of middle or proximal phalanx
What is the cause of gamekeepers thumb?
- Sprain of UCL of MCP joint of the thumb - Mechanism is forceful abduction of proximal phalanx occasionally combined with hyperextension
What are signs of a scaphoid fracture?
- Swelling, severe pain in anatomical snuff box -- Borders of anatomical snuff box= extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus
What are signs of a dislocation of the elbow?
- Swelling, severe pain, disability - May be displaced backwards, forwards, or laterally (Backwards/Posterior is most common) - complications with median and radial nerves and blood vessels - Rupture and tearing of stabilizing ligaments will usually accompany the injury
What is the cause of a wrist ganglion
- Synovial cyst (herniation of joint capsule or synovial sheath of tendon) - Generally appears following wrist strain or repeated forced hyperextension
How do you care for forearm splints and other strains?
- Treat symptomatically - Strengthen forearm - Utilize cryotherapy, thermotherapy and wraps for support and protection
What is the cause of a contusion?
- Ulnar side receives majority of blows due to arm blocks - Can be acute or chronic - Result of direct contact or blow
what are signs of an ulnar nerve injury?
- generally respond with paresthesia in 4th and 5th fingers
How do you care for gamekeepers thumb?
- immediate followup must occur - if instability exists, athlete should be referred to an orthopedist - If stable, X-ray should be performed to rule out fracture - Thumb splint should be applied for protection for 3 weeks or until pain free
What are signs of a fractured elbow?
- may or may not result in visual deformity - hemorrhaging, swelling, muscle spasm
What are the signs of a phalanx fracture?
- pain and swelling - Tenderness at point of fracture
What are signs of osteocohondritis dissecans of the elbow?
- sudden pain, locking; range usually returns in a few days - swelling, pain and crepitus (bone grinding on bone) may also occur
How do you care for a dislocation of the phalanges?
-Reduction should be performed by physician - X-ray to rule out fractures - Splint for 3 weeks in 30 degrees of flexion (inadequate immobilization may lead to instability or excessive scar tissue accumulation) - Buddy tape for support upon return - Special consideration must be given for thumb dislocations and MCP dislocations - MCP joint of thumb dislocation occurs with thumb forces into hyperextension - Any MCP dislocation will require immediate care by a physician
How do you care for medial epicondylitis?
-Sling, rest, cryotherapy or heat through ultrasound - Analgesic and NSAIDs - Curvilinear brace below elbow to reduce elbow stressing - Severe cases may require splinting and complete rest for 7-10 days
What is another name for a boutonniere deformity?
A buttonhole deformity
What causes a collateral ligament sprain?
An axial force to the tip of the finger- Produced the "jammed" effect
What is another name for a fifth metacarpal fracture?
Boxers fracture
What is the cause of mallet finger?
Caused by a blow that contact tip of the finger avulsion extensor tendon from insertion
What is the cause of a scaphoid fracture?
Caused by force on outstretched hand, compressing schaphoid between radius and second row of carpal bones
What is the most common forearm fracture?
Colles' Fracture
What age group is a forearm shaft fracture common in?
Common in active children and youth- due to falls and direct blows
What sport are forearm splints and other strains common in?
Common in gymnastics, occurs just like shin splints, either early in the season or late in the season
What causes a subungual hematoma?
Contusion of distal finger causing blood accumulation in the nail bed
Mallet finger disrupts extension of which joint?
DIP
What is the cause of an elbow sprain?
Elbow hyperextension or a valgus force
Which muscles originate on your lateral epicondyle?
Extensors
What is the most likely cause of a posterior elbow dislocation?
Falling on an outstretched hand
Which muscles originate on your medial epicondyle?
Flexors
Which bone of the forearm is more likely to be fractured?
Fracturing the ulna or radius singularly is rarer than simultaneous fractures to both
What is another name for medial epicondylitis?
Has many other names but the most common one is golfers elbow.
what causes a dislocation of the elbow?
High incidence in sports caused by fall on outstretched hand with elbow extended or severe twist while flexed
How do you care for a fractured elbow?
Ice and sling for support- refer to physician
What causes elbow osteocohondritis disseans?
Impairment of blood supply to the anterior surface resulting in degeneration of articular cartilage, and bone creating loose bodies within the joint (basically not getting the nutrition it needs so it will start to disintegrate)
What nerve runs in the carpal tunnel?
Median Nerve
What is the cause of a forearm strain?
Most come from severe static contraction
What is the cause of a Hamate fracture?
Occurs as a result of a fall or more commonly from contact while athlete is holding an implement (tennis racket, golf club, hockey stick, lacrosse stick)
What is the cause of medial epicondylitis?
Repeated forceful flexion of the wrist and extreme valgus torque of elbow
What is the cause or forearm splints?
Repeated static contractions- Creates minute tears in connective tissues of forearm (interosseous membrane)
What causes lateral epicondylitis?
Repetitive microtrauma to insertion of extensor muscle of the lateral epicondyle
what is the most commonly fractured carpal bone?
Scaphoid
What are signs of carpal tunnel syndrome?
Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumb
What is another name for Gamekeepers thumb
Skiers thumb
What is another name for lateral Epicondylitis?
Tennis elbow
What finger is jersey finger seen in most commonly?
The ring finger
What is the cause of a phalanx fracture?
There are multiple mechanisms of injury; crushed, hit by ball, twisted
What do you have to tear to have a tommy johns surgery?
UCL (Ulnar collateral ligament of elbow)
What force stretches the UCL out of the elbow?
Valgus force
Wrist tendinitis is commonly seen in which sports?
Weight lifting and rowing
What are the signs of a Hamate fracture?
Wrist pain and weakness (4th/5th digit due to ulnar nerve compression), along with point tenderness
What is the most common wrist injury?
Wrist sprain
Fractures of the elbow are seen more in what age group?
children and young athletes