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Chapter 12
INJURIES TO THE ARM, WRIST, AND HAND
Anatomy Review. The bones of the arm are the humerus, radius, and ulna. The proximal end of
the humerus articulates with the glenoid fossa of the scapula forming the glenohumeral joint. The
distal end of the humerus articulates with both forearm bones forming the elbow joint, which
comprises three specific articulations: the humeroulnar, humeroradial, and proximal radioulnar
joints. The distal end of the forearm articulates with the carpal bones, forming the radiocarpal and
distal radioulnar joints.
A. Joints of the arm allow flexion/extension and pronation/supination at the elbow (Figures
12.1 and 12.2 on page 168) and flexion/extension and radial and ulnar deviation at the wrist.
B. The annular ligament of the elbow stabilizes the head of the radius within the proximal
radioulnar joint, thus allowing that articulation to pronate and supinate while simultaneously
allowing the radial head to articulate within the capitulum of the humerus.
C. The musculature of the arm is extensive (refer to Figure 12.3 on page 169). It is
dominated by the elbow extensor and flexors that include the biceps brachii, brachialis, triceps
brachii, and anconeus. The muscles and their specific actions and innervations are listed in Time
Out 12.1 on page 170.
D. The forearm includes a large number of muscles for movements of the forearm, wrist,
hand, and fingers. The majority of these muscles originate from the regions of the humeral
epicondyles. The forehand muscles can be divided into the extensor/supinator and flexor/pronator
groups. The muscles are listed with their specific actions and innervations in Time Out 12.2 on page
172.
I. Soft-Tissue Injuries to the Upper Arm. The majority of injuries to the upper arm are either
contusions or fractures. Strains occur, but they are uncommon. In contact sports, blows to the arm
occur frequently. In such cases, the underlying muscle tissue is compressed between the skin and
the humerus. Depending on the magnitude of the force, damage may be significant. If this injury is
repeated, myositis ossificans traumatica can result.
A. Myositis Ossificans Traumatica. This condition involves chronic inflammation of muscle
that leads to the development of bone-like tissue within the muscle. It is quite common in football
and is known as tackler’s exostosis. An exostosis is a “benign growth projecting from a bone
surface characteristically capped by cartilage.”
1. Myositis ossificans traumatica develops over a period of weeks or months, often
being ignored in the early stages, when it is typically dismissed as a simple bruise. This injury,
however, can develop into a more serious one.
2. Signs and symptoms of upper-arm contusions include a recent history of contusion
to the region; pain, discoloration, and swelling in the region of the injury; spasm and subsequent
loss of strength in the affected muscle; and possible neurologic symptoms including loss of
sensation or muscle function distal to the site of the injury.
3. First aid care includes immediate application of ice and compression, which is best
accomplished by using a bag of crushed ice that is secured with a wide elastic wrap tied around the
arm.
4. Place the arm in a sling for 24 hours.
5. In cases of severe pain or symptoms that persist beyond 72 hours, refer the athlete
for a complete medical evaluation.
B. Triceps Injuries. Injuries to the triceps muscles are not common. The mechanism of
injury is a direct blow to the posterior elbow or fall on an outstretched hand. Either mechanism can
result in a partial or complete rupture of the muscle or its tendon.
1. This injury is rare, but may be associated with either a fracture of the radial head
or the olecranon process. This injury can occur among a wide range of athletes, including
competitive weight lifter, power lifter, body builder, alpine skier, and volleyball player.
a. These injuries are classified as muscle strains, and depending on their
severity and location, they may require immediate medical attention.
b. Partial or complete ruptures may require surgery. In less severe cases,
treatment involves extensive immobilization (1 month) in a splint with the elbow in 30° of flexion.
2. Signs and symptoms include the athlete reporting a sudden popping in the region
of the posterior humerus or elbow, significant pain in the elbow region or just proximal in the area
of the triceps tendon, visible defect within the muscle or tendon near the olecranon process, and
discoloration and swelling that may not occur until hours after the injury.
3. First aid care includes immediate application of ice and compression, which is best
accomplished by using a bag of crushed ice that is secured with a wide elastic wrap tied around the
arm.
4. Place the arm in a sling with elbow flexed to 90° if pain can be tolerated.
5. If pain is severe or there is a visible defect in the triceps muscle or its tendon, refer
the athlete immediately to a medical facility.
II. Fractures of the Upper Arm. Such injuries are quite rare and may be associated with activities
that involve collisions between participants or high-speed falls.
A. Signs and symptoms include severe pain in upper arm, deformity, loss of function and
unwillingness to use the arm, and muscle spasm. Additionally the athlete reports having
heard a snap or pop at the time of injury. If the radial nerve is involved, there may be sensory loss in
the dorsal forearm and wrist as well as loss of strength in the wrist extensors.
1. In cases of stress fractures, pain may not be associated with a specific traumatic
event, but the athlete may report a change in training program.
B. First aid includes immediate application of ice and compression in conjunction with a
properly constructed splint that is best accomplished by using a bag of crushed ice that is secured
with a wide elastic wrap tied around the arm.
1. Discontinue ice application if symptoms indicate radial nerve involvement is
developing or circulatory deficit is observed.
C. Apply a standard sling-and-swathe bandage and evaluate distal circulation periodically to
make sure blood flow has not been impaired.
1. Squeeze the nail bed of a finger and observe the return of blood to the fingertip.
D. Treat for shock and transport immediately to a medical facility.
III. Elbow Injuries. These injuries are common in sports and range from simple abrasions or
contusions to complete dislocations or fractures. Epicondylitis and sprains can also occur, but
dislocations and fractures are probably the most severe elbow injuries.
A. Sprains and Dislocations. The three joints of the elbow are bound together by several
ligaments. The ulnar and radial collateral ligaments reinforce the elbow joint capsule both medially
and laterally. These two ligaments protect the elbow from valgus and varus forces. Additionally the
radial head is held in position by the annular ligament.
1. The elbow may be sprained by a variety of mechanisms that include falls,
particularly when the athlete falls backwards with the elbow locked in extension.
2. Sprains also result from both valgus and varus forces that occur suddenly as the
arm is trapped in a vulnerable position.
3. Dislocations of the elbow constitute extreme sprains. The mechanism for injury is
typically a fall in which the elbow is either flexed or fully extended. The force of impact causes the
forearm bones to be driven posteriorly out of their normal position (refer to Figure 12.7 on page
174).
a. The deformity is obvious, and the injury may be associated with a fracture
of either the radius or ulna, or both.
4. Signs and symptoms of elbow sprains and dislocations include mild swelling and
localized pain (minor sprains) and difficulty gripping objects or making a fist.
a. In dislocations, gross elbow deformity will be present. Additionally, the
athlete experiences severe pain in the joint and loss of function.
b. Possible neurological symptoms distal to the elbow are characterized by
numbness along the distribution of major nerves, particularly the ulnar nerve.
5. First aid care for minor injuries involves the immediate application of ice and
compression, using a bag of crushed ice held in place with an elastic wrap.
a. After the ice and compression are applied properly, the arm should be
placed in a sling-and-swathe bandage.
6. In cases of obvious dislocations, prevent complications by immediately applying
ice and compression in combination with a properly applied splint.
a. Splinting requires special attention to avoid moving the displaced forearm
bones. The splint should be applied on either or both sides of the elbow. Refer to Figure 12.8 on
page 175.
7. Dislocations are serious injuries. The athlete should be treated for shock and
arrangements made to transport to a medical facility.
B. Fractures. Elbow fractures generally involve the distal humerus, just above the
epicondyles, or the proximal ulna or radius. Any fracture or dislocation of the joint may
result in damage to the neurovascular structures.
1. Such damage can occur when the athlete or someone else moves the broken bone
while administering first aid.
2. If the radial artery is compressed, circulation to the forearm is reduced or stopped,
resulting in a Volkmann’s contracture (refer to Figure 12.9 on page 175). If uncorrected, it
becomes a permanent deformity.
a. Elbow fractures need to be handled carefully and the blood supply to the
forearm monitored until the athlete is transported to a medical facility.
3. The mechanisms of injury are similar to those for sprains and dislocations.
Fractures of the olecranon are associated with falls in which the elbow is in a flexed position and
the impact occurs on the tip of the joint.
4. Signs and symptoms include a recent history of significant elbow trauma
associated with significant pain and dysfunction; immediate swelling in the region; and in the case
of displaced fractures, deformity.
a. If the blood supply is compromised, the forearm and hand will feel cold
and clammy, and the athlete will report numbness in the hand.
5. First aid care includes immediate application of ice; however, avoid compressing
the area around the joint because of the risk for vascular problems with this type of injury.
a. Place a bag of crushed ice over the area and hold it in place with a non-
elastic cloth bandage such as a triangular cloth sling.
b. Apply some type of splint, taking great care to avoid moving the elbow
bones as shown in Figure 12.8.
c. Treat the athlete for shock and arrange for transport to a medical facility.
C. Epicondylitis of the Elbow. The epicondyles of the humerus are located just proximal to
the distal articular surfaces of the bone, the capitulum and trochlea (refer to Figure 12.10 on page
176). The medial epicondyle is larger and is the site of attachment for flexor muscles of the forearm
and the ulnar collateral ligament. The lateral epicondyle is smaller and is the site of attachment for
the extensor muscles of the forearm and the radial collateral ligaments.
1. Sports that require continuous gripping of an object combined with simultaneous
wrist actions can place considerable stress on tissues of the epicondylar region.
a. During the 1970s, debate existed regarding the effects of excessive
throwing in the development of an injury in child baseball players (pitchers) commonly called
Little League elbow. The throwing mechanism is associated with inflammation of the medial
epicondyle (medial epicondylitis). Rules now limit the maximum number of innings young pitchers
can throw during a season.
b. Golf has been associated with medial epicondylitis and is called golfer’s
elbow; tennis elbow involves the lateral humeral epicondyle and the tendon of the extensor carpi
radialis brevis muscle.
1) This problem may be caused by overload (excessive numbers of
shots), incorrect technique, a racket handle that’s too small, a recent change in racket that involves
different materials, a grip that’s too right between shots, or a muscle imbalance and/or loss of
flexibility.
c. The first step in treating the problem is identifying the cause(s). Treatment
with ice application before and after practice as well as a strengthening program may be helpful.
d. Signs and symptoms include pain in region of one, or both of the
epicondyles that becomes worse during or immediately after activity; pain radiating distally into the
flexor/pronator or extensor/supinator muscles; pain elicited near the epicondyles when wrist
movements are resisted; swelling in the region of the painful epicondyle.
1) In severe or chronic cases, crepitus may be noted over the region of
the affected epicondyle.
e. Since these are typically overuse injuries, first aid is not practical. When
symptoms worsen, application of ice and compression by using a bag of crushed ice that is secured
with an elastic wrap may be helpful.
f. If symptoms persist, medical referral is necessary. Long-term treatment
includes rest, reduced participation, and possibly anti-inflammatory drugs.
D. Osteochondritis Dissecans of the Elbow. The throwing mechanism can result in an
impingement syndrome between the radial head and the capitellum of the humerus. The action of
high-velocity extension can cause the elbow to develop a valgus overload that results in an
abnormal compression of the elbow on the lateral side of the joint.
1. Over time and with continued throwing, the cartilage on the proximal end of the
radius can become inflamed and even fracture, resulting in a condition known as osteochondritis
dissecans.
a. Another possible mechanism for this injury is axial loading of the forearm,
such as is common in falls or in sports that place the forearm in a weight-bearing position. The
impact force is transmitted up the forearm and causes the head of the radius to be jammed against
the humerus.
2. During the initial phases of development, the athlete will experience pain while
participating in the sport.
a. Joint inflammation and stiffness may occur, particularly 12 to 24 hours
after participation.
3. In well-established cases, cartilage fragments (loose bodies or “joint mice”) may
form within the joint.
a. The elbow may lock, which occurs when a loose body is caught between
moving bone ends within the joint.
4. In advanced cases, the elbow may develop osteoarthritis.
5. First aid care includes referring an athlete with a history of trauma to the elbow
joint and the above symptoms to a physician for diagnostic evaluation.
a. Immediate symptoms respond to a bag of crushed ice held in place with an
elastic wrap.
b. If fragments are identified in the joint, arthroscopic surgery may be
needed.
c. The nonsurgical approach to treatment involves rest followed by extensive
rehabilitation exercise to strengthen the muscles surrounding and ligaments of the joint.
E. Contusions of the Elbow. External blows to the elbow are common in sports. Little
protective equipment is available.
1. The majority of contusions result in temporary discomfort that normally improves
within a few days. An exception is the olecranon bursa, a large sac located between the skin and the
olecranon process of the ulna.
a. Falling on a flexed elbow or sustaining repeated blows to the olecranon
area can irritate this bursa and cause acute bursitis.
2. The most obvious sign of olecranon bursitis is swelling around the olecranon
process of the ulna.
a. Symptoms include pain and stiffness, especially when the elbow is flexed.
b. The skin temperature over the olecranon may be elevated; the skin over the
area may be taut; and the joint may show signs of internal hemorrhage.
3. Immediate first aid care includes application of a bag of crushed ice held in place
with an elastic bandage.
4. If signs and symptoms of olecranon bursitis appear, refer the athlete to a
physician.
V. Wrist and Forearm Injuries. The wrist is complex due to its small size and the large number of
tendons that serve it as well as the thumb and fingers (see Figure 12.11 on page 178). These tendons
are tightly bound together underneath bands of connective tissue known as the retinaculum. Also
passing through the wrist region are the major nerves and blood vessels that supply the hand and
fingers.
A. Aside from simple contusions, distal forearm fractures in sports are relatively uncommon.
Contusions are treated with ice, compression, and elevation, followed up with the
application of protective padding.
1. The most serious of forearm injuries involve the fractures distal in the forearm,
just proximal to the wrist joint. The most well known of such injuries is Colles’ fracture, which
involves a transverse fracture of the distal radius. Its related fractures are serious and must be cared
for properly to avoid complications.
a. Signs and symptoms of distal forearm fractures include a recent history of
significant trauma to the wrist region associated with hearing a popping sound and/or feeling a
snapping of the bones.
1) A deformity between the arm and forearm is typical (silver fork
deformity). In the case of Colles’ fracture, the hand is driven backwards and outwards (see Figure
12.13 on page 179).
2) Swelling, often severe, develops quickly and may affect the hand
and fingers.
3) Pain is usually severe, and motion of the wrist, hand, or fingers will
be curtailed significantly.
4) Broken bones may place pressure on nerves causing a loss of
sensation in either the hand or fingers or both.
b. First aid care involves immediate application of ice, compression, and
elevation. This is best accomplished by a bag of crushed ice that is held in place with an elastic
wrap. Do not apply ice if you suspect vascular or nerve supply is affected. Some type of splint
should be applied to protect the area (see Figure 12.23 on page 186).
1) Fingertips need to be exposed to monitor the blood supply to the
hand. This is done by squeezing a nail bed and observing the return (or lack of) of the normal
reddish color of the tissue.
2) Once the ice, compression, and splint are in place, the affected
region should be elevated carefully using a standard sling-in-swathe bandage.
3) It is imperative to treat the athlete for shock and transport him or
her to a medical facility immediately.
B. Wrist Fractures. Fractures of the carpal bones occur in sports. The most common
fractures involve the scaphoid bone (see Figure 12.14 on page 180). This bone can receive
considerable forces when the wrist is in extension. Scaphoid fractures generally occur at the site
known as the waist, the narrowest portion of the bone.
1. Other wrist bones that can be fractured include the lunate, pisiform, and hamate.
a. Because the carpals are small, deformity is typically not present when
fractures occur and evaluation is difficult. When in doubt about the injury, it’s best to refer the
athlete to a physician for evaluation.
2. Signs and symptoms include a recent history of wrist trauma associated with
snapping or popping sensation; wrist pain that is aggravated with movement. Perform the snuffbox
test; if painful, the test is positive (see Figure 12.15 on page 180).
a. The athlete may be unwilling or unable to move the wrist; doing so may
result in considerable pain.
b. The athlete may state that the wrist feels locked in a certain position, a sign
that can indicate a dislocation or fracture.
3. First aid care includes the immediate application of ice, compression, and
elevation in conjunction with some type of splint that immobilizes the wrist (see Figure 12.23).
a. Once in place, support the extremity with a standard sling-and-swathe
bandage while leaving the fingertips exposed to facilitate monitoring blood flow beyond the level of
the splint.
C. Wrist Sprains and Dislocations. When it is not as severe, the mechanism that results in a
wrist fracture may also cause a sprain or dislocation in that region. The radiocarpal joint is bound
together by a network of ligaments known as the palmar and dorsal radiocarpal ligaments. Refer to
Figures 12.16 and 12.17 on page 181. Several smaller ligaments bind the remaining wrist bones to
form a series of joints collectively called the intercarpal joints.
The most common sprain of the wrist is cause by a forceful hyperextension that stretches
and possibly tears the palmar radiocarpal ligament. In severe cases of this injury, dislocation of one
or more carpal bones results. The most common dislocation of the wrist involves the lunate bone,
which is located between the distal end of the radius and the capitate bone. The mechanism of
injury for a dislocated lunate is forceful hyperextension. In severe cases, the lunate will put pressure
on the tendons and nerves of the carpal tunnel region of the wrist, resulting in significant symptoms
in the hands and fingers.
1. Signs and symptoms of wrist sprains and dislocations include a history of
sustaining a forced hyperextension of the wrist combined with a snapping or popping sensation
within the bones of the wrist joint.
a. Moving the wrist or, in some, even attempted movement will be painful
and not successful.
b. In cases of dislocation, the wrist may be locked so the athlete is unable to
move it.
c. Numbness and/or pain may radiate from the wrist into the hand and
fingers. In the case of lunate dislocations, the median nerve may be affected, producing symptoms
known as carpal tunnel syndrome.
d. Swelling of the wrist may be limited.
2. First aid care includes the immediate application of ice, compression, and
elevation, and some type of splint. A bag of crushed ice held in place by an elastic wrap is effective.
Do not apply ice if you suspect that either the vascular or nerve supply is compromised.
3. Elevation is best achieved using a standard sling-and-swathe bandage.
4. In cases of severe pain or possible dislocation, it is important to refer the athlete to
a health care facility.
D. Nerve Injuries to the Wrist. Three major nerves (median, radial, and ulnar) cross the wrist
from the forearm into the hand. The most commonly injured nerve is the median, which
passes through the carpal tunnel of the wrist (see Figure 12.18 on page 182). Dense, strong
ligaments as well as bone surround this tunnel.
1. The exact cause of carpal tunnel syndrome is unknown, but probably involves
swelling within the tunnel caused by tendonitis or sprains of the region. The pressure of the swelling
negatively affects the median nerve.
a. The majority of cases involving athletes tend to be the result of overuse
injuries. Sports that typically involve gripping a racket or other object for extended periods of time
have a high incidence of carpal tunnel syndrome.
2. Another nerve-related injury involves the ulnar nerve as it passes through the
region on the ulnar side of the forearm. This nerve is in the vicinity of the pisiform bone and the
hook of the hamate bone within the tunnel of Guyon.
a. Signs and symptoms of ulnar nerve injury include sensory loss to a portion
of the hand and fingers as well as loss of strength in the fingers affected by the ulnar nerve.
3. Signs and symptoms of nerve injuries to the wrist include loss of sensation to a
portion of the hand and/or fingers that follows the distribution of the major nerve in the region.
a. Pain and tenderness in the wrist on the palmar side. The pain may radiate
into the hand.
b. An associated tendonitis of the wrist or a recent history of trauma to the
area.
c. Symptoms may worsen when the wrist is fully flexed or extended or an
object is tightly gripped.
4. This injury tends to develop over time, unless cases in which a nerve of the wrist
is aggravated by an acute injury such as a severe contusion or sprain.
a. When the injury is associated with acute trauma, the best approach is
immediate application of ice, compression, and elevation. Do not apply ice if you suspect either the
vascular or nerve supply is compromised. Splinting may be necessary.
5. An athlete with a history of recurrent pain and stiffness in the wrist with the above
neurologic symptoms should be referred to a physician for a complete evaluation.
a. If a nerve-related problem is present, treatment generally involves rest,
anti-inflammatory drugs, and in some cases, a splint. In severe cases, surgical decompression of the
nerve may be required.
E. Unique Tendon Problems of the Wrist
1. Perhaps the most common form of tenosynovitis of the wrist involves the tendons
of the thumb (refer to Figure 12.19 on page 183). Commonly known as de Quervain’s disease, this
condition is actually an overuse injury that typically involves the tendons of the extensor pollicis
brevis and the abductor pollicis longus muscles as they pass across the radial styloid process.
2. The mechanism of injury is vague but probably involves overuse of the wrist
and/or thumb.
a. Initially, the tendons and synovial sheath around the tendons become
inflamed, resulting in pain, swelling, and stiffness.
b. As the injury progresses, the tendons become caught within the anatomic
tunnel. Thumb movements, especially flexion and extension, will be extremely painful, and wrist
movements will be impeded.
3. Signs and symptoms include pain and tenderness within the region of radial
styloid process, specifically involving the tendons of the abductor pollicis longus and the extensor
pollicis brevis. Swelling in the area of the styloid process occurs and, in advanced cases, nodules
form on one of more of the tendons.
a. The athlete may report that the tendons are catching within the wrist during
activity.
b. Thumb flexion with ulnar deviation of the wrist will increase pain and
related symptoms.
4. If diagnosed early, treatment includes rest, immobilization with some form of
splint, and drug therapy to treat the inflammation.
a. In advanced or recurring cases, surgery is highly effective.
5. A ganglion results from a herniation of the synovium surrounding the tendons at
the wrist. The herniated area fills with synovial fluid and produces a bump that is commonly on the
dorsal side of the wrist (refer to Figure 12.20 on page 184). The specific cause of ganglions is
unknown.
a. Ganglions vary in appearance, some appear as a soft, fluid filled mass just
under the skin; others are a hard painful mass over a tendon.
b. Signs and symptoms include a visible swelling in the region of the
extensor or flexor tendons of the wrist. In advanced cases, a painful, hardened nodule may be
present over a tendon.
c. In some cases, ganglions spontaneously regress. If the ganglion does not
hinder function, most physicians recommend leaving it alone. If the ganglion interferes with
performance or is unattractive, it can be surgically removed. Even after surgery, a ganglion may
recur.
VI. Hand Injuries. The fingers and hands are injured in many sports, especially baseball, softball,
basketball, and football. The hand is comprised of 19 bones: 5 metacarpals and 14 separate
phalanges of the fingers (refer to Figure 12.21 on page 185). Muscles that originate in the forearm
and have tendons that pass into the hand and fingers affect movements of the joints of the hand.
Within the hand are small intrinsic muscles that precisely move the thumb and fingers. The nerves
and blood vessels of the hand are the major structures that cross the wrist.
A. Hand Fractures. Fractures can occur to any of the 19 bones in the hand.
1. A unique injury to the thumb is the Bennett’s fracture. This injury often occurs
from a blow to the hand while it is in a clenched-fist position. The force causes the proximal end of
the first metacarpal bone to be driven into the wrist. The result is a fracture-dislocation of the first
metacarpal bone away from the greater multiangular bone (trapezium) of the wrist. (Refer to Figure
12.22 on page 185).
a. The affected thumb will appear shorter when compared to the other thumb.
Significant swelling near the base of the thumb over the carpometacarpal joint is also present.
2. Fractures of the metacarpal bones of the fingers can also occur as a result of a
blow to a clenched fist. The most common injury involves the fourth and/or fifth metacarpal bone(s)
near the proximal end(s) and is known as boxer’s fracture.
a. Due to the ligamentous structure of this area, displaced fractures are rare,
therefore deformity is not a common sign.
3. Metacarpals may be fractured simply by a crushing mechanism, as in having the
hand stepped on.
4. Fractures of the phalanges also occur frequently in sports, particularly fractures of
the proximal phalanges. Most of these injuries remain undisplaced and are easily treated with
splinting, unless the fracture resists fixation and requires surgery to repair.
a. A serious complication is rotational deformity, which results when the
bone ends unite incorrectly.
5. Signs and symptoms of hand fractures include a recent history of significant
trauma to the hand, followed by pain and dysfunction of the hand and fingers. In cases of displaced
fractures, observable deformity may be present, either as a bump, protrusion, or oddly shaped
finger. In cases of compound fractures, the skin will be broken over the region of the fracture.
a. There will be significant inflammation with any fracture of the hand or
finger.
6. First aid care includes immediate application of ice, compression, and elevation,
and some type of splint. This is best accomplished by a bag of crushed ice held in place by a narrow
elastic wrap that leaves the fingernails exposed.
a. Elevation is achieved by placing the arm in a standard sling-and-swath
bandage.
b. Depending on the site of the fracture, various splints may be used.
Splinting an isolated phalangeal fracture involves buddy taping the fractured finger to an adjacent
one. Fractures of the metacarpal bones are best treated by immobilization of the entire hand.
c. The athlete should be transported to a medical facility. Fractures of the
hand must be treated as serious injuries.
B. Sprains and Dislocations of the Hand. Any joint in the hand can be subjected to
sufficient trauma to result in a sprain, and if the trauma is severe enough, a dislocation. Most
common forms of these injuries are gamekeeper’s thumb, mallet (baseball finger), and boutonnière
deformity.
1. Gamekeeper’s Thumb. This injury involves a sprain of the ulnar collateral
ligament of the thumb (metacarpophalangeal or MP joint). Mechanism of injury is a valgus force
applied to the MP joint of the thumb, which commonly occurs in alpine skiing.
a. This injury makes the thumb very unstable and interferes with the normal
function of the hand. In many instances, this injury is accompanied by an avulsion fracture of a
bone fragment from the base of the proximal phalanx.
b. Signs and symptoms include significant point tenderness over the region of
the ulnar collateral ligament. The athlete may report having felt a snap during the injury.
Additionally there will be swelling over the MP joint of the thumb and the athlete will be unable or
unwilling to move the thumb.
c. First aid care involves the immediate application of ice, compression, and
elevation. This is best accomplished by placing a small bag of crushed ice around the injured joint
and securing it with an elastic wrap. Elevate the arm by placing it in a simple sling.
d. Refer the athlete to a health care facility for further evaluation and
treatment.
2. Mallet (baseball) Finger. This injury involves the distal phalanx of a finger and
takes its name from the shape of the deformity and also because it commonly occurs in baseball.
This injury results from a blow to the tip of the finger when actively extending the finger from a
flexed position. This can result in an avulsion of the extensor digitorum tendon, with or without a
small bone fragment from the base of the distal phalanx.
a. The fingertip can no longer be extended, thus producing the deformity at
the DIP joint (refer to Figure 12.26 on page 188).
b. The most important sign of the mallet finger deformity is associated with
recent trauma to the fingertip, and the finger may be point tender on the dorsal surface of the base of
the distal phalanx, directly over the site of insertion of the extensor digitorum tendon.
c. First aid care involves the immediate application of ice, compression, and
elevation. This is best accomplished by placing a small bag of crushed ice around the involved
finger and securing it with a small elastic wrap.
1) Immediately splint the finger with the DIP joint extended. Do not
let the distal phalanx fall back into the flexed position.
2) Elevate the arm by placing it in a simple sling.
3) Refer the athlete to a health care facility for further evaluation and
treatment.
3. Jersey Finger. Much like the mallet finger, this injury involves tearing a finger
tendon away from its attachment (refer to Figure 12.27 on page 188). In this case, the flexor
digitorum profundus (FDP) is torn away from the distal phalanx when the finger gets caught in an
opponent’s clothing.
a. Signs and symptoms include the inability to flex the DIP joint of the
affected finger. The athlete reports having felt something snap or tear away at the area of the
fingertip. Point tenderness on the volar surface of the distal phalanx of finger will be evident.
b. First aid includes the immediate application of ice, compression, and
elevation. This is best accomplished by placing a small bag of crushed ice around the involved
finger and securing it with a small elastic wrap.
c. Splint the finger in a position of extension at the DIP and proximal
interphalangeal joints.
d. Elevate the arm by placing it in a simple sling and refer the athlete to a
medical care facility.
4. Boutonnière Deformity. This injury involves the proximal interphalangeal
(PIP) joint of the fingers. The extensor digitorum tendon crosses the dorsal surface of the PIP joint.
The mechanism of injury involves striking the playing surface with the fingers in a flexed position
while simultaneously attempting to extend the fingers.
The force causes a tearing of the central portion of the tendon, which then allows the PIP
joint to pop through the opening like a button through a buttonhole.
a. The athlete will report a violent flexion injury to the finger, possibly
associated with the sensation of tearing or popping over the PIP joint.
b. The injury will be followed by significant weakness in finger extension at
the pip joint, and the joint becomes painful, swollen, and then stiff.
1) If left uncorrected, a deformity may develop that is characterized
by hypertension of MP and DIP joints with flexion of the PIP joint (refer to Figure 12.28 on page
189).
c. Initially this injury should be treated by application of ice, compression,
and elevation. This is best accomplished by placing a small bag of crushed ice around the involved
finger and securing it with a small elastic wrap.
1) Elevate the arm by placing it in a simple sling.
d. If any of the above signs are present, immediately refer the athlete to a
medical care facility.
1) In cases in which the initial injury has not been treated and
deformity results, medical referral is mandatory.
VII. Wrist and Thumb Taping. This procedure can help prevent injuries to the wrist and thumb
because it reduces excessive movement from contact, which reduces the number of sprains in the
area. Review Figures 12.30 through 12.39 and the figure legends.
REVIEW QUESTIONS
1. List the three articulations of the elbow.
Answer:
1.) Humeroulnar
2.) Humeroradial
3.) Radioulnar
Page: 168
2. Explain the term myositis ossificans traumatica as it relates to a condition of the upper arm
known as tackler’s exostosis.
Answer: Myositis ossificans traumatica involves chronic inflammation of muscle, leading to the
development of bone-like tissue within the muscle. It is quite common in football—so much so that
the condition has become known as tackler’s exostosis.
Page: 168
3. List the signs and symptoms of a humeral fracture.
Answer:
1.) Severe pain in the region of the upper arm with a recent history of trauma to the area.
2.) Deformity may be present and visible, especially when compared with the opposite extremity.
3.) Loss of function of and unwillingness to use the extremity.
4.) Muscle spasm in the musculature surrounding the extremity.
5.) The athlete may report having felt a snap or heard a pop at the time of injury.
6.) If the radial nerve is involved there may be loss of sensation into the dorsum of the forearm and
wrist. This may also result in loss of strength in the wrist extensors.
7.) In cases of stress fracture, pain may not be associated with a specific traumatic incident. Instead,
that athlete may report a change in a training program—for example, a sudden increase in the
intensity or volume of a strength-training program.
Page: 171
4. Explain and/or demonstrate the first aid procedures for an athlete with a suspected fracture of the
humerus.
Answer:
1.) Immediately apply ice and compression in conjunction with a properly constructed splint.
2.) Apply a standard sling-and-swathe bandage as described by the National Safety Council.
3.) As with any injury requiring the application of a splint, periodic evaluation of circulation distal
to the site of the splint is essential to guarantee that blood flow has not been impaired.
Pages: 172–173
5. Describe briefly the mechanism of injury for a posterior dislocation of the elbow.
Answer: The mechanism of injury is typically a fall in which the elbow is in either an extended or
flexed position.
Page: 174
6. List the signs and symptoms of a dislocation of the elbow.
Answer:
1.) In cases of dislocations, gross deformity of the elbow with abnormal positioning of the forearm
bones behind the distal end of the humerus.
2.) Severe pain and total dysfunction of the elbow joint.
3.) Possible neurologic symptoms distal to the elbow characterized by numbness along the
distribution of major nerves. The ulnar nerve appears to be the most vulnerable to this specific
injury.
Page: 174
7. True or False: The ulnar nerve is the most commonly damaged nerve in a dislocation of the
elbow.
Answer: True. The ulnar nerve appears to be the most vulnerable to this specific injury.
Page: 174
8. Explain and/or demonstrate the appropriate first aid care for an athlete with a suspected
dislocation of the elbow.
Answer:
1.) In cases of obvious dislocations, the primary concern is to prevent complications, which can be
extremely serious and include compression on the neurovascular structures in the elbow region.
Immediately apply ice and compression in combination with a properly applied splint.
2.) Splinting of this injury requires special attention to avoid moving the displaced forearm bones. It
is recommended by the National Safety Council that the splint be applied on either or both sides of
the elbow.
3.) The athlete should be treated for shock, and arrangements must be made for transportation to a
medical facility.
Page: 174
9. Define the term Volkmann’s contracture.
Answer: This condition involves the reaction of the forearm musculature to a lack of blood supply.
If left uncorrected it becomes a permanent deformity.
Page: 174
10. Review the signs and symptoms of either medial or lateral epicondylitis of the elbow.
Answer:
1.) Pain in the region of either the medial or lateral epicondyle. Symptoms have become worse
during or immediately after participation.
2.) Pain radiating distally into either the flexor/pronator or extensor/supinator muscles, depending
on which epicondyle is involved.
3.) Pain may be elicited in the region of the epicondyles during resisted wrist flexion or extension,
depending on which epicondyle is involved.
4.) Swelling in the region of the painful epicondyle.
5.) In severe and chronic cases, crepitus may be noted over the region of the affected epicondyle.
Page: 176–177
11. Define osteochondritis dissecans.
Answer: The cartilage on the proximal end of the radius can become inflamed and even begin to
fracture, resulting in a condition known as osteochondritis dissecans.
Page: 177
12. What are the signs and symptoms of osteochondritis dissecans of the elbow?
Answer:
1.) During the initial phases of development the athlete will experience pain during participation.
2.) Joint inflammation and stiffness may be noted, particularly 12 to 24 hours after participation.
3.) In well-established cases, cartilage fragments may form with the joint; these are commonly
known as joint mice.
4.) The athlete may experience a locking of the elbow, which occurs when a loose body is caught
between the moving bone ends within the joint.
5.) In advanced cases the elbow may develop osteoarthritis.
Page: 177
13. What is the location of the olecranon bursa of the elbow?
Answer: The olecranon bursa is located between the skin and the olecranon process of the ulna.
Page: 177
14. True or False: A Colles’ fracture involves the carpal bones of the wrist.
Answer: False. It involves a transverse fracture of the radius.
Page: 178
15. Describe the signs and symptoms of a Colles’ fracture.
Answer:
1.) The athlete will have a recent history of significant trauma to the wrist region associated with
having heard a popping sound and/or felt a snapping of the bones.
2.) A deformity, known as the silver fork deformity, between the arm and wrist is typical; in the
case of a Colles’ fracture the hand is driven backwards and outward.
3.) Swelling, often severe, develops quickly and may affect the hand and fingers.
4.) Pain is generally severe, and motion of the wrist, hand, or fingers will be significantly curtailed.
5.) In cases in which broken bone(s) put pressure on nerves, loss of sensation may be noted in either
the hand or fingers or both.
Page: 178–179
16. Explain and/or demonstrate the appropriate first aid procedures for an athlete with a suspected
Colles’ fracture.
Answer:
1.) Immediately apply ice, compression, and elevation. In addition, some type of splint must be
applied.
2.) Make sure that the fingertips are exposed in order to monitor the blood supply to the hand.
3.) Once in place, the ice, compression, and splint should be elevated carefully using a standard
sling-and-swathe bandage.
4.) Because of the pain and damage associated with this type of injury, it is imperative that the
athlete be treated for shock and transported to a medical facility immediately.
Page: 179
17. Which one of the following carpal bones can be located within a region at the base of the thumb
known as the anatomical snuff box?
a.) Lunate
b.) Hamate
c.) Capitate
d.) Pisiform
e.) Scaphoid
Answer: E
Page: 180
18. True or False: The most common form of wrist sprain is the result of forced hyperextension.
Answer: True.
Page: 181
19. What anatomic structures within the wrist form the tunnel of Guyon?
Answer: The pisiform bone and the hook of the hamate bone
Page: 182
20. Which major nerve passes through this tunnel?
Answer: The ulnar nerve
Page: 182
21. What musculotendinous unit is most often involved in the condition known as de Quervain’s
disease?
Answer: Extensor pollicis brevis and abductor pollicis longus
Page: 183
22. Define the condition known as ganglion.
Answer: Technically, a ganglion is a herniation of the synovium surrounding the tendons at the
wrist.
Page: 183
23. Explain and demonstrate the appropriate first aid care for a suspected phalangeal fracture of the
hand.
Answer:
1.) Immediately apply ice, compression, elevation and some type of splint.
2.) Elevation can be easily achieved by placing the arm in a standard swing-and-swathe bandage.
3.) Depending on the specific site of the fracture, a variety of splinting techniques can be used.
4.) The athlete should be transported to the appropriate health care facility for further evaluation and
treatment.
Page: 185
24. Which of the specific ligamentous structure is damaged in the condition known as gamekeeper’s
thumb?
Answer: The ulnar collateral ligament
Page: 186
25. Describe the signs and symptoms of gamekeeper’s thumb; explain and demonstrate the
appropriate first aid for an athlete suspected of having sustained such an injury.
Answer: See Signs and Symptoms and First Aid Care sections on page 184.
Page: 187
26. Explain the mechanism of injury and the structures involved in the condition known as mallet
finger.
Answer: Mallet finger involves the distal phalanx of a finger. The injury is so named because of the
resulting deformation gives the distal segment of the finger the appearance of a mallet. The
mechanism is quite precise: The tip of the finger must receive a blow at the time the finger is
extending from a flexed position.
Page: 187
27. Explain the mechanism of injury and the structures involved in the condition known as
boutonniere deformity.
Answer: Boutonniere deformity involves the proximal interphalangeal joint of the fingers. The
mechanism for this injury is characterized by severe forced finger flexion.
Page: 188
28. Explain the mechanism of injury and the structures involved in the condition known as jersey
finger.
Answer: Jersey finger involves tearing away a finger tendon from its attachment. In this case the
mechanism of injury involves catching a finger in an opponent’s clothing. In the attempt to grip the
clothing, as the opponent pulls away, the tendon of the flexor digitorum profundus is torn away
from its attachment on the distal phalanx.
Page: 188