Download Chapter 13 Power Point - Garnet Valley School District

Chapter 13
Elbow, Wrist, and Hand
Conditions
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Elbow Anatomy
• 3 articulations (single capsule)
– Humeroulnar (elbow joint)
• Trochlea of humerus with
trochlear fossa of ulna
• Hinge joint; flexion and extension
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Elbow Anatomy (cont’d)
• 3 articulations (single capsule) (cont’d)
– Humeroradial
• Capitellum of humerus with
proximal radius
• Gliding joint
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Elbow Anatomy (cont’d)
• 3 articulations (single capsule) (cont’d)
– Proximal radioulnar
• Head of radius with radial notch of ulna;
joined by annular ligament
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Elbow Anatomy (cont’d)
Skeletal features of the upper
arm, elbow, and forearm
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Elbow Anatomy (cont’d)
• Ligaments
– Ulnar (medial) collateral
– Radial (lateral) collateral
– Annular
Major ligaments and the olecranon bursa of the
elbow. A. Medial view. B. Lateral view
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Elbow Anatomy (cont’d)
• Bursae
– Several small
– Olecranon bursa
• Superficial
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Wrist and Hand Anatomy
Skeletal feature of the wrist and hand.
A. Anterior view. B. Posterior view
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Wrist Anatomy (cont’d)
• Radiocarpal joint
– Radius with scaphoid, lunate, and triquetrum
– Condyloid joint
• Sagittal plane motions (i.e., flexion,
extension, and hyperextension)
• Frontal plane motions (i.e., radial deviation
and ulnar deviation)
• Circumduction
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Wrist Anatomy (cont’d)
• Intercarpal joints
– Gliding joints
– Minimal contribution to wrist movement
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Hand Anatomy
• Carpometacarpal joints (CM)
– Thumb
• Saddle joint; flexion, extension, abduction,
adduction, and opposition
– Fingers
• Gliding joints
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Hand Anatomy (cont’d)
• Metacarpophalangeal joints (MCP)
– Thumb
• Hinge joint; flexion and extension
– Fingers
• Condyloid joints; flexion, extension,
abduction, adduction, and circumduction
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Hand Anatomy (cont’d)
• Interphalangeal joints (IP)
– PIP and DIP hinge joints; flexion and extension
Skeletal features of the wrist and hand.
A. Anterior view. B. Posterior view
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• Nerves
Anatomy (cont’d)
– Musculocutaneous
– Median
Nerves of the elbow
region
– Ulnar
– Radial
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Nerves of the wrist
and hand
Anatomy (cont’d)
• Blood vessels
Blood supply to
the elbow region
– Brachial
• Ulnar and radial
• Numerous
divisions
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Blood supply to the
wrist and hand
Kinematics and Major Muscle Actions
• Elbow
– Flexors
• Brachialis; biceps; brachioradialis
• Effectiveness depends on supination/pronation
position
– Extensors
• Triceps; anconeus
– Pronation and supination
• Pronator quadratus; pronator teres supinator
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Kinematics and Major Muscle Actions
(cont’d)
Muscles of the anterior arm and forearm
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Kinematics and Major Muscle Actions
(cont’d)
• Wrist and Hand
– Flexors
• Flexor carpi radialis & flexor carpi ulnaris
• Palmaris longus
• Flexor digitorum superficialis & flexor
digitorum profundus
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Kinematics and Major Muscle Actions
(cont’d)
• Wrist and Hand (cont’d)
– Extensors
• Extensor carpi radialis longus, extensor carpi
radialis brevis, & extensor carpi ulnaris
– Radial deviation
• Flexor carpi radialis & extensor carpi radialis
– Ulnar deviation
• Flexor carpi ulnaris & extensor carpi ulnaris
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Kinematics and Major Muscle Actions
(cont’d)
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Kinematics and Major Muscle Actions
(cont’d)
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Kinematics and Major Muscle Actions
(cont’d)
• Elbow Movements
– Flexion & extension (humeroulnar joint &
humeroradial joint
– Supination & pronation (proximal radioulnar
joint)
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Kinematics and Major Muscle Actions
(cont’d)
• Wrist movements
– Flexion
Directional movement capabilities at the
wrist. A. Sagittal plane movements. B.
Frontal plane movements
– Extension/
hyperextension
– Radial deviation
– Ulnar deviation
– Circumduction
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Kinematics and Major Muscle Actions
(cont’d)
• CM
• MP – thumb
– Thumb – flexion,
extension, abduction,
adduction
– Flexion
– Extension
• IP
• MP – fingers
– Flexion
– Flexion
– Extension
– Extension
– Abduction
– Adduction
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Kinematics and Major Muscle Actions
(cont’d)
Directional movement capabilities at the fingers and thumb
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Prevention of Elbow, Wrist, & Hand
Conditions
• Physical conditioning
– Flexibility
– Strength
• Protective equipment
– Shoulder pads
• Proper skill technique
– Throwing motion
– Proper falling technique
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Contusions
• Arm and forearm vulnerable
• S&S
– Rapid swelling – can limit ROM
• Chronic blows
– Development of ectopic bone
• Myositis ossificans – brachialis belly; proximal
deltoid insertion
• Tackler’s exostosis
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Contusions (cont’d)
• Management
– Standard acute
– If symptoms persist > 2-3 days, physician
referral
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Olecranon Bursitis
• Acute and chronic
• MOI
– Fall on a flexed elbow
– Constantly leaning on elbow
– Repetitive pressure and friction
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Olecranon Bursitis (cont’d)
• S&S
– Tender, swollen, relatively painless
– Rupture – goose egg visible
– Motion limited at extreme of flexion – tension
increases over bursa
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Olecranon Bursitis (cont’d)
• Management
– Standard acute
– Possible aspiration
– NSAIDs
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Olecranon Bursitis (cont’d)
• Septic bursitis
– Infection can occur in the absence of trauma due
to
• Skin breakdown
• Poor blood supply
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Olecranon Bursitis (cont’d)
• Septic bursitis (cont’d)
– S&S
• Area hot and tender to touch; swelling
• Restricted ROM
• Individual shows traditional signs of infection
(e.g. malaise , fever)
– Management
• Physician referral
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Sprains and Dislocations
• Elbow sprain
– MOI
• Repetitive tensile forces
• Hyperextension injury (from fall on extended
arm)
• Sudden violent valgus or varus force
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Sprains and Dislocations (cont’d)
• Elbow sprain (cont’d)
– S&S
• UCL
• Pain on medial aspect of the elbow
• Point tenderness over the ligament
• Pain with valgus force
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Sprains and Dislocations (cont’d)
• Elbow sprain (cont’d)
– S&S (cont’d)
• RCL
• Pain lateral aspect of elbow
• Pain with varus force
– Management: standard acute; physician referral
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Sprains and Dislocations (cont’d)
• Elbow – Proximal radial head dislocation
– Adolescents: often associated with immature
annular ligament
– Due to: longitudinal traction of an extended and
pronated upper extremity
– Inability to pronate and supinate pain free
warrants immediate physician referral
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Sprains and Dislocations (cont’d)
• Elbow – Ulnar dislocation
– Younger than 20 years old
– MOI
• Hyperextension
• Sudden, violent unidirectional valgus force
drives ulna posterior or posterolateral
– Associated conditions
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Sprains and Dislocations (cont’d)
• Elbow – Ulnar dislocation
Elbow dislocation
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Sprains and Dislocations (cont’d)
• Elbow – Ulnar dislocation
– S&S
• Snapping or cracking sensation
• Severe pain, rapid swelling
• Total loss of function
• Obvious deformity
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Sprains and Dislocations (cont’d)
• Elbow – Ulnar dislocation (cont’d)
– S&S (cont’d)
• Arm held in flexion, with forearm appearing
shortened
• Olecranon and radial head palpable posteriorly
• Slight indentation in triceps visible just
proximal to olecranon
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Sprains and Dislocations (cont’d)
• Elbow – Ulnar dislocation (cont’d)
– Management
• Activate emergency plan, including
summoning of EMS
• Coach should avoid changing position of the
arm
• If tolerable, apply cold
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Sprains and Dislocations (cont’d)
• Wrist
– MOI: axial loading on proximal palm during fall
on outstretched hand
– S&S
• Point tenderness on dorsum of radiocarpal
joint
• ↑ Pain with active or passive extension
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Sprains and Dislocations (cont’d)
• Wrist (cont’d)
– Management:
• Immobilize
• Standard acute
• Physician referral to rule out fracture or carpal
dislocation
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Sprains and Dislocations (cont’d)
• Thumb sprain – Gamekeeper’s thumb
– Tear of the ulnar collateral ligament at MCP joint
– MOI: forceful abduction of the thumb when the
MCP of the thumb is near full extension
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Sprains and Dislocations (cont’d)
• Thumb sprain – Gamekeeper’s thumb (cont’d)
– S&S
• Palmar aspect of joint is painful and swollen;
possible ecchymosis
• Instability
– Management:
• Standard acute; physician referral
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Sprains and Dislocations (cont’d)
• Finger sprains and dislocations
– MOI:
• Collateral ligaments : varus/valgus stress;
hyperextension
• Volar plate: hyperextension
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Sprains and Dislocations (cont’d)
• Finger sprains and dislocations (cont’d)
– S&S
• Painful, swollen finger
• Dislocation
• Most common PIP
• Obvious deformity may or may not be
present
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Sprains and Dislocations (cont’d)
• Finger sprains and dislocations (cont’d)
– Management:
• Immobilization; cold; immediate physician
referral
• Coach should not attempt to reduce a
dislocation
• Should not assume injury is a “jammed finger”
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Sprains and Dislocations (cont’d)
• Finger sprains and dislocations (cont’d)
Dislocation variants of the PIP joint.
A. Dorsal
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Strains
• Elbow
– MOI:
• Excessive overload against resistance
• Overstretching
– Often occurs simultaneously with sprain
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Strains (cont’d)
• Elbow (cont’d)
– S&S:
• Flexors (brachialis, biceps brachii, and
brachioradialis)
• Pain with resisted elbow flexion
• Extensor (triceps) – pain with resisted elbow
extension
• Wrist flexors – pain with resisted wrist flexion
• Wrist extensors – pain with resisted wrist
extension
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Strains (cont’d)
• Elbow (cont’d)
– Management:
• Grade 1 – standard acute; if symptoms persist
> 2-3 days, physician referral
• Grade 2 or 3 – cold; sling; immediate
physician referral
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Strains (cont’d)
• Jersey finger
– Rupture of flexor digitorum profundus tendon
– MOI: rapid extension of finger (e.g., gripping
opponent’s jersey … opponent turns & twists to
get away … jerking action)
– S&S
• Tendon palpable at proximal finger.
• Unable to flex the DIP joint against resistance
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Strains (cont’d)
• Jersey finger (cont’d)
– Management:
• Standard acute
• Immediate physician referral
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Strains (cont’d)
• Mallet finger
– Avulsion of extensor mechanism
– MOI: forceful flexion (due to object hitting the
end of the finger)
– S&S
• Pain; swelling
• Mallet deformity
• Lack of active extension at DIP joint
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Strains (cont’d)
• Mallet finger (cont’d)
– Management:
• Standard acute
• Immediate physician referral
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Mallet finger
Strains (cont’d)
• Boutonniere deformity
– Rupture of central slip of extensor mechanism
and damage to volar plate
– MOI:
• Blunt trauma to dorsal aspect of PIP
• Rapid, forceful flexion of PIP against
resistance
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Strains (cont’d)
• Boutonniere deformity (cont’d)
– S&S
• Deformity not apparent immediately, develops
over 2–3 weeks
(hyperextension MCP jt, flexion PIP jt, &
hyperextension DIP jt )
• Swelling at PIP
Lack of extension at PIP
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Strains (cont’d)
• Boutonniere deformity (cont’d)
– Management:
• Immediate physician referral
Boutonniere deformity
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Strains (cont’d)
• Medial epicondylitis
– Due to repeated valgus forces
– Combined flexor muscle strain, ulnar collateral
ligament sprain, and ulnar neuritis
– Common in adolescent athletes
– “Little league elbow” – medial humeral growth
plate is involved
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Overuse Conditions (cont’d)
• Medial epicondylitis (cont’d)
– S&S
• Swelling, ecchymosis, & point tenderness at
humeroulnar joint or medial epicondyle
• Pain with resisted wrist flexion and pronation
• If nerve involved, tingling & numbness radiate
to forearm & hand
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Overuse Conditions (cont’d)
• Medial epicondylitis (cont’d)
– Management
• Do not permit to continue activity until seen
by a physician
• Suggest application of cold to decrease pain
and spasm
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Overuse Conditions (cont’d)
• Lateral epicondylitis
– Most common overuse injury in adult elbow
– Due to eccentric loading of the extensor muscles
– Contributing factors
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Overuse Conditions (cont’d)
• Lateral epicondylitis (cont’d)
– S&S
• Pain anterior or just distal to lateral
epicondyle; may radiate into forearm
extensors during and after activity
• Pain with resisted wrist extension; Pain with
action of picking up a full cup of coffee
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Overuse Conditions (cont’d)
• Lateral epicondylitis (cont’d)
– Management
• Do not permit to continue activity until seen
by a physician
• Suggest application of cold to decrease pain
and spasm
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Overuse Conditions (cont’d)
• Tendinitis and stenosing tenosynovitis
– Due to strenuous and repetitive training inflame
tendon and tendon sheaths
– Abductor pollicis longus and extensor pollicis
brevis are commonly affected
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Overuse Conditions (cont’d)
• Tendinitis and stenosing tenosynovitis (cont’d)
– S&S
• Stiffness and an aching pain that is
aggravated by activity -may appear several
hours after participation in physical activity
• Pain localized over the involved tendons
• Pain aggravated with passive stretching and
resisted motion of the affected tendons
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Overuse Conditions (cont’d)
• Tendinitis and stenosing tenosynovitis (cont’d)
– Management
• Do not permit to continue activity until seen
by a physician
• Suggest application of cold to decrease pain
and spasm
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Nerve Entrapment Syndromes
• Carpal Tunnel Syndrome
Carpal tunnel
– Contains median
nerve, finger flexors,
& flexor pollicis longus
– Due to direct trauma,
repetitive overuse,
or anatomic anomalies
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Nerve Entrapment Syndromes (cont’d)
• Carpal Tunnel Syndrome (cont’d)
– S&S
• 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
• Grip and pinch strength may be limited
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Nerve Entrapment Syndromes (cont’d)
• Carpal Tunnel Syndrome (cont’d)
– Management
• Suggest application of cold to decrease pain
and spasm
• Do not permit to continue activity until seen
by a physician
• Do not use compression wrap
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Nerve Entrapment Syndromes (cont’d)
• Ulnar nerve entrapment
Impingement of the ulnar nerve
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Nerve Entrapment Syndromes (cont’d)
• 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)
• Unable to grasp a piece of paper between the
thumb and index finger
• Slight weakness in grip strength
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Nerve Entrapment Syndromes (cont’d)
• Ulnar tunnel syndrome (cont’d)
– Management
• Suggest application of cold to decrease pain
and spasm
• Do not permit to continue activity until seen
by a physician
• Do not use compression wrap
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Nerve Entrapment Syndromes (cont’d)
• Cyclist's palsy
– Due to leaning on handlebar for extended
period; leads to swelling in hypothenar area
– Symptoms mimic ulnar nerve entrapment
syndrome, but disappear rapidly after end of
ride
– Key: proper padding; varying hand position
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Fractures
• Distal radius/ulna fracture
– Mechanism: axial loading; fall on outstretched hand
– Monteggia’s
• Distal ulna with associated dislocation of radial
head
– Galeazzi's
• Distal radius with associated dislocation or
subluxation of distal radioulnar joint
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Fractures (cont’d)
• Distal radius/ulna fracture (cont’d)
– Colles’
• Distal metaphysis of radius, with
displacement of distal fragment
dorsally
Clinical view of a Colles’ fracture
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Fractures (cont’d)
• Distal radius/ulna fracture (cont’d)
– Smith’s
• Distal radius, with displacement of distal
fragment toward palmar aspect
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Fractures (cont’d)
• Distal radius/ulna fracture (cont’d)
– S&S
• Intense pain, swelling, deformity, and a false
joint
• Possible
• Circulatory impairment
• Median nerve may be damaged as it passes
through the forearm.
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Fractures (cont’d)
• Distal radius/ulna fracture (cont’d)
– Complication: Volkmann’s contracture
• S&S: hand is cold, white, & numb; severe pain
with passive extension of fingers
– Management: immobilization; immediate
physician referral
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Fractures (cont’d)
Forearm fracture
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Fractures (cont’d)
• Scaphoid fracture
– 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
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Fractures (cont’d)
• Scaphoid fracture (cont’d)
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Fractures (cont’d)
• Metacarpal fracture (typical)
– Mechanism: axial compression
– S&S:
• ↑ pain and palpable – palm, directly over
involved metacarpal
• ↑ pain with percussion and compression
– Management: immobilize in position of function;
ice without compression; immediate physician
referral
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Fractures (cont’d)
• Bennett’s fracture
– Articular fracture – proximal end of first
metacarpal
– Mechanism: axial compression
– Pull of APL tendon displaces shaft proximally;
deep volar ligament holds small medial fragment
in place → fracture-dislocation
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Fractures (cont’d)
• Bennett’s fracture (cont’d)
– S&S
• Localized pain and swelling; ↑ pain with inward
pressure long axis
– Management: immobilize in position
of function; ice without compression;
immediate physician referral
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Fractures (cont’d)
Bennett’s fracture
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Fractures (cont’d)
• Boxer’s fracture
– Distal metaphysis or neck of fourth or fifth
metacarpals
– Inherently unstable
Boxer’s fracture
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Fractures (cont’d)
• Boxer’s fracture (cont’d)
– S&S
• Sudden pain, inability to grip, rapid swelling,
and deformity
• Point tenderness; crepitus
• Delayed ecchymosis
• ↑ pain with axial compression and percussion
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Fractures (cont’d)
• Boxer’s fracture (cont’d)
– Management: immobilize in position of function;
ice without compression;
immediate physician referral
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Fractures (cont’d)
• Phalangeal fracture
– Mechanism: compression; hyperextension
– S&S:
• ↑ pain with circulative compression of phalanx
• ↑ pain with percussion and compression (long axis)
– Management: immobilize in position of function;
ice without compression; immediate physician
referral
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Fractures (cont’d)
• Phalangeal fracture (cont’d)
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Coach and Onsite Assessment
• S &S that require immediate physician referral:
– Possible epiphyseal or apophyseal injuries
– Tingling or numbness in the forearm or hand
– Obvious deformity suggesting a dislocation or
fracture
– Excessive joint swelling
– Significantly limited range of motion
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Coach and Onsite Assessment
• S &S that require immediate physician referral:
(cont’d)
– Weakness in a myotome
– Gross joint instability
– Absent or weak pulse
– All adolescent wrist sprains because of possible
epiphyseal or apophyseal injuries
– Any unexplained pain
• Refer to Application Strategy 13.1
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