Elbow/Wrist/Hand

TFCC (white book)

-is made up of ligaments and cartilage structures within the distal radio ulnar joint between the distal ulna and carpal bones -Fibrocartilage disc in this complex is sometimes referred to as the "meniscus of the wrist" -Stabilizer for the wrist -Shock absorber TFCC is injured either by repetitive rotational loading of the wrist or by a sudden FOOSH (wrist extended and forearm rotated) Signs and Symptoms -pain in the ulnar wrist during gripping and forearm supination -pronation activities -Click may be heard -palpatation pressure applied directly over the disc produces pain

Ulnar Nerve Injury

-repetitive throwing sports such as baseball pitching -repetitive overhead activities (Lateral/ER) -Ulnar nerve becomes stretched -mechanically irritated -even subluxed out of its sulcus -adjcent soft tissues structures can also compress the nerve Signs and Symptoms -fourth or fifth digit numbness or tingling -postermedial elbow pain

Two most overuse injuries of the wrist are

1) Carpal tunnel syndrome 2)De Quervain's syndrome

Pain Assessments

1) eliminate OR confirm trigger points 2) neurological pathology 3) localized injury as the source of the pain *If the pain is NOT neurologically based, trigger points may often be the source especially when the site of injury differs from the location of the pain and the pain complaints do not align with typical neurological symptoms

Wrist Sprain

A wrist sprain occurs when the strong ligaments that support the wrist stretch beyond their limits or tear. This occurs when the wrist is bent or twisted forcefully, such as caused by a fall onto an outstretched hand Wrist Mechanism: axial loading on proximal palm during fall on outstretched hand S&S Standard - sprain Specific Point tenderness on dorsum of radiocarpal joint↑ Pain with active or passive extension Need to rule out fracture, especially scaphoid fx Management: standard acute; NSAIDs

Which tendons are affected with DeQuervain's Syndrome?

APL & EPB Abductor pollicis longus (APL) Extensor Pollicis Brevis (EPB)

Axis of the wrist

All muscles of the wrist cross the axis of rotation Capitate bone produces movement at the wrist

Radioulnar joint

Articulation between the radius and ulna and their proximal ends. Produces supination and pronation Convex Radial head Concave Ulna radial notch Opposite direction example to improve -supination the force is applied posterior to anterior -to improve pronation the FORCE is applied anterior to posterior

dynamic stabilizer in sprain/hyperextension

The elbow will rely on the dynamic stability from the muscles to substitute for damaged ligamentous and capsular tissues Main dynamic stabilizer for the elbow after sprains are the -medial flexors -Flexor Carpi Ulnaris is the greatest contribution to elbow stability -pronator muscle come off the medial epicondyle

Pulley System

There are five flexor tendon pulleys in the fingers that are named A1-A5, and consists of annular ligament pulleys, and cruciate pulleys. The flexor tendon pulley system. The thumb only has two pulleys that are described as A1 and A2.

Trigger finger

Trigger finger is a condition that causes pain, stiffness, and a sensation of locking or catching when you bend and straighten your finger. The condition is also known as "stenosing tenosynovitis." The ring finger and thumb are most often affected by trigger finger, but it can occur in the other fingers, as well. Trigger finger is a condition in which one of your fingers gets stuck in a bent position. Your finger may bend or straighten with a snap — like a trigger being pulled and released. Trigger finger is also known as stenosing tenosynovitis (stuh-NO-sing ten-o-sin-o-VIE-tis). It occurs when inflammation narrows the space within the sheath that surrounds the tendon in the affected finger. If trigger finger is severe, your finger may become locked in a bent position. People whose work or hobbies require repetitive gripping actions are at higher risk of developing trigger finger. The condition is also more common in women and in anyone with diabetes. Treatment of trigger finger varies depending on the severity.

Elbow instability

UCL elbow joint primary stabilizer

Ulnar nerve entrapment

Ulnar nerve entrapment Ulnar tunnel syndrome Due to repetitive compressive trauma to the palmar aspect of the hand S&S Numbness in the ulnar nerve distribution (especially little finger) + Froment's sign Slight weakness in grip strength + Tinel's sign Management: splinting, NSAIDs; activity modification

Flexor retinaculum (transverse carpal ligament)

structure that crosses the palmar aspect of the wrist forming the most anterior aspect of the carpal tunnell prevents the tendons from the flexor musculature from "bowstringing" as the is FLEXED

transverse carpal ligament (flexor retinaculum)

-Roof of the carpal tunnel -Retains the finger and thumb flexor tendons and the median nerve at the wrist -The site of carpal tunnel syndrome

Thick palmar fascia has two layers

1)superficial - an extension of the flexor retinaculum (transverse carpal ligament) and the palmaris longus tendon expands over the volvar hand and runs into each of the fingers 2) deep - covers the floor of the palm and runs between the thenar and hyopthenar eminences

Velocity in elbow and forearm in throwing sports

Baseball = 2300/s Javelin = 1900/s Tennis = 982/s Fast Pitch soft ball = 680/s

Distal radius/ulna fracture (cont.)

Distal radius/ulna fracture (cont.) Smith's Distal radius, with displacement of distal fragment toward palmar aspect S&S: normal fracture Concerns:Circulatory impairmentNerve damage Management: immobilization in a vacuum splint; immediate physician referral

UCL ligament

Elbow joint primary stabilizer

Finger Tip Injuries

Finger Tip Injuries Subungual hematoma Blood under fingernail Due to direct trauma Need to rule out fracture Management Soak in ice water for 10-15 minutes If pain does not diminish, may need to be drained under supervision of a physician Refer to Application Strategy 16.1

Ganglion cysts

Ganglion cysts Benign tumor mass on dorsal aspect of wrist Associated with tissue sheath degeneration Treatment: symptomatic

Rehab for Hyperextension/sprain

Initial passive phase rehab relieve pain and swelling Active and Active assistive ROM ***DO NOT APPLY RESISTANCE TO THE FLEXOR CARPI ULNARIS MAY LEAD TO OVER STRESS OF THE MEDIAL JOINT***

Medial elbow is stretched during flexion activities the stresses placed on this part of the elbow are going to be tension Tension Injuries repeated tension stress tendinopathy medial joint sprains and strains

Medial elbow is stretched during flexion activities the stresses placed on this part of the elbow are going to be tension Tension Injuries repeated tension stress tendinopathy medial joint sprains and strains

Bowstringing

browstringing of a tendon is similar in appearance to an archers bowstring. the tendon bowstrings away from the wrist when the pulley system holding the tendon in place ruptures and the tendon is no longer in proximity to the bone

Triangular Fibrocartilage

complex called TFCC stabilizers Cartilaginous disc that sits between the ulna, lunate and triquetrum -disc provides stability to the wrist joint -connecting the radius and ulna together -allowing better forces through the wrist

Ulnar and Wrist deviation

convex on concave rotations at both radiocarpal and midcarpal joints roll and slide occurs in the opposite direction at both joints Radial deviation (20 degrees) is less than Ulnar deviation (30 degrees)

Extensor Retinaculum Ligament

crosses dorsal aspect of the wrist covering the tendons of the extensor musculature prevents the tendon from "bowstringing" as the wrist EXTENDED

Strain de Quervain's tenosynovitis

de Quervain's tenosynovitis Stenosing tenosynovitis of APL and EPB A forceful grasp, combined with repetitive use of thumb and ulnar deviation -microscopic damage occur -structure cannot rebuild before additional stress is applied -scar tissue develops and chronic pain occur making it a difficult injury to manage S&S Pain over radial styloid process ↑ with thumb and wrist motion Point tenderness over the tendons Pain with RROM thumb abduction+ Finkelstein's test Management: standard acute; NSAIDS

Radial collateral ligament (RCL) Elbow

encircles the head of radius and holds it against the radial notch of ulna.

Carpal Tunnel

located at the deep surface of the flexor retinaculum Median nerve enters the palm through the carpal tunnel Tenosynovitis Inflammation of the flexor retinaculum may result in compression of the median nerve

Dorsal Radiocarpal ligament (DRL)

major ligament on the dorsal surface of the wrist ligament originates on the posterior surface of the distal radius and styloid process of the radius and attaches to the lunate and triquetrum Limits wrist Flexion

Midcarpal Joint

motion of the wrist results in complex motion between the proximal and distal of carpals with the exception of the pisiform

Grips

power Precision Lateral pinch max grip strength

Strain Boutonnière deformity

Boutonnière deformity Rupture of central slip of extensor tendon at the middle phalanx Mechanism: rapid forceful flexion of PIP Result: hyperextension at MCP, flexion of PIP, hyperextension of DIP S&S No active extension Deformity usually not present immediately, but develops over 2-3 weeks Management: standard acute; injury that limits PIP extension to <30º: immediate physician referral

Finger Dislocation

Can involve collateral ligaments and volar plate MCP Rare, but easily recognizable Hyperextension or shear PIP Hyperextension and axial loading (e.g., ball striking extended finger) DIP Usually occur dorsally Individual often reduces injury on their own S&S: swollen, painful finger Management: immobilization; ice; immediate physician referral

De Quervain's Disease

Carpal Tunnel Ulnar nerve entrapement Cycists palsy Games Keepers Thumb Radial Nerve entrapment Colles fracture Foosh = fall on outside of hand

Humeroulnar Joint and Humeroradial Joint Concave Ulna and Concave Radius Convex Humerus Same Direction Distraction stretch the anterior and posterior capsule Elbow is placed in flexion and distraction is applied Posterior capsule is stretched to increase elbow flexion

Concave Ulna and Concave Radius Convex Humerus Same Direction Distraction stretch the anterior and posterior capsule Elbow is placed in flexion and distraction is applied Posterior capsule is stretched to increase elbow flexion

DRUJ

DRUJ - Dorsal Radial Ulnar Joint Typically injured when a person as a fall -Hyper extension of the wrist

Dislocation

Distal radioulnar joint (DRUJ) Isolated or with radial fracture Mechanism: hyperextension With hyperpronation: ulna dorsal dislocation; with hypersupination: ulna volar dislocation S&S Pain; deformity; extensive swelling Dorsal dislocation - ulnar head prominent dorsally; volar dislocation - wrist appears narrow (result of overlap of the distal radius and ulna)elbow flexion and extension - normal unless fracture present; pronation and supination of forearm - limited Management: immobilization of limb in vacuum splint; immediate transportation to physician

Strain Dupuytren's contracture

Dupuytren's contracture Nodules develop in palmar aponeurosis that limit finger extension and cause a flexion deformity S&S Fixed flexion deformity is visible Finger cannot be extended Management: surgical repair

Complications after hand injuries

Edema - excessive edema= there is a loss of VISCOELASTICITY in the had soft tissues which increases resistance to motion edema has a direct effect on the joints = lack ROM Stiffiness = lacks mobility Collagen = constant remodeling of tissues -Proliferation -Remolding Phases creating new bonding patterns to increase its strength a permanent structure in its healing progression = soft tissue structure around the injured segment are placed in a shortened position they develop joint stiffness

Trigger Points MOST commonly found in Elbow complex muscles

Elbow Flexor Biceps Brachii Brachoradialis Elbow Extensor Triceps Brachii

Anatomic Snuff box

Extensor pollicis longus Extensor pollicis brevis Abductor pollicis longus

Primary Wrist Flexors

FCR, FCU, palmaris longus

Secondary wrist flexors

FDP, FDS, FPL

FOOSH injury

FOOSH - Fall On Out Stretched Hand

Wrist Sprain - Gamekeeper's thumb

Gamekeeper's thumb or Skiers thumb Tear of the UCL of the MP joint Mechanism: MP in extension and forceful abduction S&S Palmar aspect of joint - pain; swelling+ abduction stress Management: standard acute; instability: spica cast for 3-6 weeks; severe: surgical repair

Strain Intersection syndrome

Intersection syndrome Tendinitis or friction tendinitis in 1st and 2nd dorsal compartments of wrist Overuse of radial extensors by excessive curling S&S Point tenderness on the dorsum of the forearm, 2-3 finger breadths proximal to the wrist joint Crepitus with AROM or PROM Management: ice massage; rest; NSAIDs; splinting; avoiding exacerbating activities

Strain Jersey Finger

Jersey finger Rupture of flexor digitorum profundus from distal phalanx Mechanism: rapid extension (from active flexion) S&S Unable to flex the DIP Palpate tendon in proximal aspect of finger Hematoma formation along the entire flexor tendon sheath Management: standard acute; physician referral

Lateral Elbow is compressed during lateral activities

Lateral Elbow is compressed during lateral activities Compression injuries to the bone osteochondritis dissecans in young athletes bony osteophytes loose body formations articular damage degeneratoin in older athletes

Tendon sheaths

Level of the metacarpal heads - point where flexor tendons enter a flexor tendon sheath Annular pulleys Keep flexor tendons and sheath closely applied to phalanges Cruciate pulleys Collapse to allow full digital flexion

Radial collateral ligament (RCL) WRIST

Limits limits ulnar deviation and becomes taut when the wrist is in extremes of extension and flexion Location ligament originates styloid process of the radius inserts on the scaphoid and trapezium

Ulnar collateral ligament

Location Connects the medial epicondyle of the humerus to the ulna Limits Radial deviation

Anular Ligament

Location encircles the head of the radius and holds it in the radial notch of the ulna

Oblique Cord

Location flat fascial band that extends from the lateral side of the ulnar tuberosity to distal to the radial tuberosity, fibers run at right angles to the interosseous membrane, not present in all people

Tunnel of Guyon

Location is a space that is located between the hook of the hamate, pisiform, palmar carpal ligament and the flexor retinaculum passage for the ulnar nerve and artery as they enter the hand compression on the nerve in this location may result in ulnar tunnel syndrome

Radiocarpal Joint

Location proximal joint surface of the radiocarpal joint is formed by the distal radius and the radioulnar articular disc, which connects the medial aspect of the distal radius to the distal ulna. the distal joint surface is formed by the scaphoid, lunate, and triquetrum. two degress of freedom encased in a strong capsule reinforced by numerous ligaments shared with the midcarpal joint

Wrist Dislocation Lunate

Lunate Axial loading displaces in volar direction S&S Point tenderness - dorsum of hand just distal to radius Thickened area on the palm palpable just distal to end of radius (proximal to the third metacarpal)Passive and active motion may not be painful Caution: bone into carpal tunnel - compression of median nerve Management: immobilization of limb in vacuum splint; immediate transportation to physician

palmar radiocarpal ligament

Maintains the alignment of the associated joint structures and limits hyperextension of the wrist and Wrist Extension Attaches capitate triquetrum scaphoid

Strain Mallet finger

Mallet finger Rupture of extensor tendon from DIP distal phalanx Mechanism: forceful flexion of PIP S&S Pain, swelling **Lack of extension at DIP** Management: standard acute; physician referral *forceful flexion that teas the extensor sheath on top Mallet finger is the term usually applied to extensor avulsion fractures. However, this entity may also be caused by distal extensor tendon ruptures. Either one results in an inability to extend the DIP joint. Mallet finger injuries are named for the resulting flexion deformity of the fingertip, which resembles a mallet or hammer. Mallet finger injuries are caused by the disruption of the extensor mechanism of the phalanx at the level of the distal interphalangeal joint, usually due to a forced flexion at the distal interphalangeal joint. This injury results in the inability to extend the distal phalanx. A mallet fracture occurs when the extensor tendon also causes avulsion of the distal phalanx.

Median nerve Entrapment

Median nerve Anterior interosseous nerve syndrome Following set of strenuous or repetitive elbow motion exercises Affects motor but not sensation S&S Acute - sudden loss of use of flexor pollicis longus index finger profundus tendons Gradual - weakness becomes apparent during heavy activity + pinch grip test Management: splint extremity; avoid heavy activity

Carpal tunnel syndrome

Median nerve, finger flexors, and flexor pollicis longus Due to direct trauma, repetitive overuse, or anatomic anomalies Signs and Symptoms Awakening pain in middle of night; often relieved by "shaking out their hands"Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger + Phalen's maneuver + Tinel's sign Weak thumb abduction

TFCC Ligaments

Palmar Radio Ulnar Ulnar carpal Dorsal radio ulnar ligament Articular disc

Phalangeal fracture

Phalangeal fracture Mechanism: compression; hyperextension S&S: ↑ pain with circulative compression of phalanx ↑ pain with percussion and compression (long axis) Management: standard acute; splint; immediate physician referral

Primary Extrinsic ligaments of the wrist

RCL Palmar Radiocarpal Ligament (3) Ulnar Collateral Ligament

Radial nerve entrapment

Radial nerve entrapment Distal posterior interosseous nerve syndrome Due to compression associated with repetitive and forceful wrist dorsiflexion S&S Deep, dull ache in wrist, reproduced with: Forceful wrist extension Deep palpation of forearm with wrist in flexion Management: standard acute; activity modification

Major joints of the wrist

Radiocarpal Joint Midcarpal Joint

Scaphoid fracture (snuffbox)

Scaphoid fracture (snuffbox) S&S History of falling on an outstretched hand Point tenderness in anatomic snuff box Pain with inward pressure along long axis↑ pain with wrist extension and radial deviation Management: standard acute; splint; physician referral Concern: aseptic necrosis Scaphiod has a bad blood supply!!!!

Sprains commonly occur in hyperextension

Sprains commonly occur in hyperextension injuries or medical collateral ligament sprain Hyperextension causes -causes pain in the anterior and medial joint -Ulnar collateral ligament sprains cause medial joint pain -bone contusion -pain of the olecranon -when VALGUS overstresses occurs the medial collateral ligament which is the PRIMARY STABILIZING UNIT FOR THE ELBOW is injured The elbow will rely on the dynamic stability from the muscles to substitute for damaged ligamentous and capsular tissues Main dynamic stabilizer for the elbow after sprains are the -medial flexors -Flexor Carpi Ulnaris is the greatest contribution to elbow stability -pronator muscle

Strain Gymnast's wrist

Stress fracture to distal radial epiphyseal plate Mechanism: compression (maximum dorsiflexion) S&S: Diffuse tenderness - dorsum of midcarpal area ↑ pain with extreme motion Management: splinting; NSAIDs; activity modification

Superficial radial nerve entrapment

Superficial radial nerve entrapment Compressed at the wrist Aggravated by repeated pronation and supination Tight wrist straps S&S Burning pain and sensory changes in dorsoradial aspect of wrist, hand, dorsal thumb, and index finger + Tinel's sign Management: standard acute; activity modification

Swan neck deformity

Swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it (DIP flexion with PIP hyperextension).

Tendinopathies - Trigger Finger

Tendinopathies Trigger finger Finger flexors contract but are unable to re-extend Due to a nodule within tendon sheath or sheath too constricted to allow free motion S&S Locking usually occurs when wakening from sleep Painful popping sensation when PIP joint is passively returned to extension Management: NSAIDs, resting finger; splinting when necessary; possible cortisone injections into the sheath

Common extensor tendon from the lateral epicondyle of humerus

The common extensor tendon is a tendon that attaches to the lateral epicondyle of the humerus. It serves as the upper attachment (in part) for the superficial muscles that are located on the posterior aspect of the forearm: The common extensor tendon that originates from the lateral epicondyle of the elbow is directly involved. The extensor carpi radialis brevis (ECRB) extensor carpi radialis longus (ECRL) extensor digitorum extensor digiti minimi extensor carpi ulnaris come together to form the common extensor tendon