1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 13 Elbow, Wrist, and Hand Conditions

2. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elbow Anatomy 3 articulations (single capsule) –Humeroulnar (elbow joint) Trochlea of humerus with trochlear fossa of ulna Hinge joint; flexion and extension

3. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elbow Anatomy (cont’d) 3 articulations (single capsule) (cont’d) –Humeroradial Capitellum of humerus with proximal radius Gliding joint

4. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elbow Anatomy (cont’d) 3 articulations (single capsule) (cont’d) –Proximal radioulnar Head of radius with radial notch of ulna; joined by annular ligament

5. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elbow Anatomy (cont’d) Skeletal features of the upper arm, elbow, and forearm

6. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

7. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Elbow Anatomy (cont’d) Bursae –Several small –Olecranon bursa Superficial

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist and Hand Anatomy Skeletal feature of the wrist and hand. A. Anterior view. B. Posterior view

9. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Wrist Anatomy (cont’d) Intercarpal joints –Gliding joints –Minimal contribution to wrist movement

11. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hand Anatomy Carpometacarpal joints (CM) –Thumb Saddle joint; flexion, extension, abduction, adduction, and opposition –Fingers Gliding joints

12. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Hand Anatomy (cont’d) Metacarpophalangeal joints (MCP) –Thumb Hinge joint; flexion and extension –Fingers Condyloid joints; flexion, extension, abduction, adduction, and circumduction

13. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

14. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Nerves –Musculocutaneous –Median –Ulnar –Radial Nerves of the elbow region Nerves of the wrist and hand

15. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Blood vessels –Brachial Ulnar and radial Numerous divisions Blood supply to the wrist and hand Blood supply to the elbow region

16. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

17. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Muscles of the anterior arm and forearm

18. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

19. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

20. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d)

21. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d)

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Elbow Movements –Flexion & extension (humeroulnar joint & humeroradial joint –Supination & pronation (proximal radioulnar joint)

23. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Wrist movements –Flexion –Extension/ hyperextension –Radial deviation –Ulnar deviation –Circumduction Directional movement capabilities at the wrist. A. Sagittal plane movements. B. Frontal plane movements

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) CM –Thumb – flexion, extension, abduction, adduction MP – fingers –Flexion –Extension –Abduction –Adduction MP – thumb –Flexion –Extension IP –Flexion –Extension

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Directional movement capabilities at the fingers and thumb

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Elbow, Wrist, & Hand Conditions Physical conditioning –Flexibility –Strength Protective equipment –Shoulder pads Proper skill technique –Throwing motion –Proper falling technique

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Management –Standard acute –If symptoms persist > 2-3 days, physician referral

29. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis Acute and chronic MOI –Fall on a flexed elbow –Constantly leaning on elbow –Repetitive pressure and friction

30. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis (cont’d) S&S –Tender, swollen, relatively painless –Rupture – goose egg visible –Motion limited at extreme of flexion – tension increases over bursa

31. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis (cont’d) Management –Standard acute –Possible aspiration –NSAIDs

32. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Olecranon Bursitis (cont’d) Septic bursitis –Infection can occur in the absence of trauma due to Skin breakdown Poor blood supply

33. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

34. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains and Dislocations Elbow sprain –MOI Repetitive tensile forces Hyperextension injury (from fall on extended arm) Sudden violent valgus or varus force

35. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

36. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

37. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

38. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

39. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains and Dislocations (cont’d) Elbow – Ulnar dislocation Elbow dislocation

40. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains and Dislocations (cont’d) Elbow – Ulnar dislocation –S&S Snapping or cracking sensation Severe pain, rapid swelling Total loss of function Obvious deformity

41. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

42. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

43. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

44. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains and Dislocations (cont’d) Wrist (cont’d) –Management: Immobilize Standard acute Physician referral to rule out fracture or carpal dislocation

45. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

46. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

47. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains and Dislocations (cont’d) Finger sprains and dislocations –MOI: Collateral ligaments : varus/valgus stress; hyperextension Volar plate: hyperextension

48. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

49. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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”

50. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sprains and Dislocations (cont’d) Finger sprains and dislocations (cont’d) Dislocation variants of the PIP joint. A. Dorsal

51. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains Elbow –MOI: Excessive overload against resistance Overstretching –Often occurs simultaneously with sprain

52. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

53. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

54. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

55. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Jersey finger (cont’d) –Management: Standard acute Immediate physician referral

56. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

57. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Mallet finger (cont’d) –Management: Standard acute Immediate physician referral Mallet finger

58. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

59. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

60. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Strains (cont’d) Boutonniere deformity (cont’d) –Management: Immediate physician referral Boutonniere deformity

61. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

62. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

63. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

64. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Lateral epicondylitis –Most common overuse injury in adult elbow –Due to eccentric loading of the extensor muscles –Contributing factors

65. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

66. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

67. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

68. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

69. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

70. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes Carpal Tunnel Syndrome –Contains median nerve, finger flexors, & flexor pollicis longus –Due to direct trauma, repetitive overuse, or anatomic anomalies Carpal tunnel

71. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

72. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

73. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Entrapment Syndromes (cont’d) Ulnar nerve entrapment Impingement of the ulnar nerve

74. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

75. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

76. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

77. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

78. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

79. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Distal radius/ulna fracture (cont’d) –Smith’s Distal radius, with displacement of distal fragment toward palmar aspect

80. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

81. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

82. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Forearm fracture

83. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

84. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Scaphoid fracture (cont’d)

85. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

86. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

87. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

88. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Bennett’s fracture

89. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Boxer’s fracture –Distal metaphysis or neck of fourth or fifth metacarpals –Inherently unstable Boxer’s fracture

90. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

91. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Boxer’s fracture (cont’d) –Management: immobilize in position of function; ice without compression; immediate physician referral

92. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

93. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Fractures (cont’d) Phalangeal fracture (cont’d)

94. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

95. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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