1. The Elbow, Wrist, and Hand
Chapter 20

2. Skeletal Anatomy – Wrist and Hand
The Wrist and Hand
Made up of 27 bones
8 carpal bones make up the wrist
5 metacarpals from the structure of the hand
14 phalanges
2 for the thumb
3 for each other 4 fingers

3. Skeletal Anatomy - Elbow
3 bones of the elbow joint
Humerus
Radius
Ulna
Many structures surround the elbow
Ligaments
Nerves
Muscles
Bursa sacs

4. Muscles of the Elbow Forearm Flexors Forearm Extensors Brachialis
Biceps Brachii
Brachioradialis
Forearm Extensors
Triceps Brachii
Anconeus

5. Common injuries of the Elbow
Several causes for a variety of athletic injuries
Direct trauma
Indirect trauma
Acute/Chronic stresses
These MOIs can result in several injuries
Contusions
Sprains
Strains
Dislocations
Fractures
Nerve involvement

6. Contusions
Common injury that may involve the muscles of the forearm and subcutaneous bony prominences of the elbow
Usually caused by a direct blow
Symptoms
Bruising
Subsequent bleeding
Stiffness during function or
active motion
Treatment
PRICE
Prevents myositis ossificans

7. Olecranon Bursitis Inflammation of the olecranon bursitis Treatment
Caused by direct blows to the olecranon process
Can be accompanied by infection due to the frequent abrasions that occur over the tip of the elbow
Treatment
Depends on whether infection is involved
Uninfected bursitis
Ice compresses
Rest
Anti-inflammatory meds
Pain meds
Aspiration of the bursa

8. Ulnar Nerve Contusion
Caused by a direct blow the medial epicondyle of the humerus
Athlete complaints of immediate pain and burning sensation down the ulnar side of the forearm to the ring and little fingers
Also known as hitting the “funny bone”
Treatment
None is usually necessary

9. Elbow Strains Normally occur with a sudden overload to the elbow joint
can acute or chronic
Acute Strains
Sudden excessive overload
Tenderness over the affected area
Pain on function or resisted motion
Chronic Strains
Result of continued overuse
Overuse syndrome
Chronic degenerative processes
Common areas of acute strains
Common flexor tendon
Medial epicondyle
Common extensor tendon
Lateral epicondyle

10. Elbow Sprains
Usually due to forced hyperextension or valgus/varus forces
Symptoms
Click or pop
Sharp pain at injury
Tenderness
Localized swelling
Pain when repeating MOI
Usually relieved by bending the elbow

11. Epicondylitis
Usually caused by repetitive overload of the attached musculotendinous units
Occurs in the region of the medial and lateral epicondyle of the humerus
Called “tennis elbow” if lateral
Called “golfer’s elbow” if medial
If it occurs in younger patients, called “little leaguer elbow”
Can also accompany an injury to the growth plate of the epiphysis

12. Epicondylitis cont’d Symptoms Without proper treatment condition
Pain when used
Possible swelling
Local tenderness
Pain with resisted wrist motion
Without proper treatment condition
may worsen
May develop into prolonged degenerative changes
Causes chronic epicondylitis
Contractures of the elbow
Reduced friction
Possible rupture of muscle tendon unit
Treatment
RICE
Modifying activities that aggravate conditions
Preventive measures
Using proper technique/equipment
Limiting stress
Adequately warming up
stretching

13. Dislocations of the Elbow
Most commonly involves the posterior displacement of the ulna and radius in relationship to the humerus
Often caused by a fall onto an outstretched hand with elbow in extension
Symptoms
Obvious deformity
Loss of elbow function
Considerable pain
Initial exam should include evaluation
of nerve function of hand and fingers
Treatment
Immobilzation
Immediate referral to physician of medical facility
Possible vascular and neurological damage

14. Forearem/Elbow Fractures
The result of either direct trauma or indirect stresses transmitted through the upper extremity by falling on an outstretched arm
Fractures in younger athletes commonly
involve epiphyseal plate fractures
Symptoms
Directly related to degree of severity
Point tenderness
Hemorrhaging
Swelling
Limited ROM
Disability at elbow or hand
Increased pain with movement
Treatment
Immobilization
Ice
Prompt referral to physician or medical clinic

15. Volkmann’s Contracture
Occurs in the absence of blood flow (ischemia) to the forearm
Can lead to contracture, where joint remains bent and cannot straighten
Causes
Increased pressure from swelling or trauma
Fracture
3 Levels of severity in Volkmann’s Contracture
Mild
Involves contracture of 2 or 3 fingers
No limited loss of sensation
Moderate
Involves all fingers being flexed
Thumb stuck in palm
Wrist may be stuck in flexion
Usually loss of sensation in the hand
Severe
Involves all muscles in forearm (flexors and extensors)
Fingers
Severely disabling condition

16. Volkmann’s Contracture cont’d
Symptoms
Severe pain when a muscle running through a compartment is passively moved
Forearm may be swollen
Shiny
Painful when squeezed
Pain does not improve with rest, but continues to worsen with time
If condition is not corrected
Decreased sensation
Weakness
Paleness of the skin

17. Ulnar Nerve Injury
Repetitive throwing and/or swinging can cause irritation, compression, or entrapment in the cubital tunnel
Called cubital tunnel syndrome
Symptoms
Pain along the inner aspect of the elbow
Tenderness of the medial epicondylar groove
Paresthesia (numbness or tingling) of ring and little finger

18. Radial Nerve Injury
Usually caused by entrapment of the nerve which passes through a tunnel formed by several muscles and tendons
Also called radial tunnel syndrome
Symptoms
Pain over lateral aspect of the elbow
Pain over radial head

19. Median Nerve Injury
Includes entrapment or compression due to hypertrophy of the pronator teres or repetitive pronation of the forearm
Called pronator teres syndrome
Symptoms
Pain radiating down the anterior forearm
Numbness and tingling in the thumb, index, and middle fingers
Resistive pronation may increase the pain

20. Muscles of the hand and wrist
Muscles that move the Wrist
2 Flexor Carpi muscles
2 Extensor Carpi muscles
2 Palmaris muscles
Muscles that move the Hand
1 Supinator muscles
2 Pronator muscles
Muscles that move the Thumb
2 Flexors
2 Extensors
1 adductor
2 abductors
1 opponens
Muscles that move the Fingers
3 flexors
2 extensors
3 abductors

21. Injuries to the hand and wrist
Common injuries
Fractures
Dislocations
Contusions
Sprains
Tendonitis
Nerve Impingements

22. Finger Fractures Can involve any of the 14 phalange bones.
Most can be treated with a finger splint
Boxer’s Fracture
A break of the 5th metacarpal leading to the little finger
Baseball (mallet) finger
Painful injury that occurs when a ball or other object strikes the tip of the finger, bending it beyond its normal ROM which tears the finger tendon and damages cartilage

23. Finger Fractures cont’d
Jersey Finger
Caused by tearing the flexor tendon to the fingertip
Usually occurs from grabbing a jersey during a tackle.
Ring finger is the most often affected
Scaphoid fracture
Affects the scaphoid bone
Paplpation of the anatomical snuffbox will cause pain, indicates a fracture may be present

24. Finger Fractures cont’d
Colles Fracture
A break of the radius just above the wrist
Treatment for all fractures
RICES (rest, ice, compression, elevation, support)
Evaluation by a physician

25. Dislocations and subluxations
Fairly common injuries
Causes
Ball striking fingertip
Finger getting hooked into equipment
Symptoms
Immediate pain
Swelling
Crooked finger
Usually can’t be bent or straightened
Treatment
Ice
Immobilization
Immediate treatment by physician

26. Contusions
Usually caused by direct blows or falling onto a hard surface
With nails become contused, pressure may cause a physician to drain blood from beneath the nail

27. Sprains of the wrist and hand
Gamekeeper’s thumb
Sprain of the ulnar collateral ligament of the metacarpalphalangeal joint (MPJ)
Common in alpine skiiing
Caused by force applied to the medial side of the thumb, forcing the MPJ to stretch, tear, or even rupture

28. Tendonitis
The inflammation of the tendons caused by overuse or repetitive stress
Symptoms
Ache or pain at the wrist
Worsens forceful gripping, rapid wrist movements or moving the wrist or fingers to an extreme position
Treatment
The same as other forms of tendonitis
Most common sites in the wrist
Base of the thumb near anatomical snuffbox
deQuervian’s tenosynovitis

29. Nerve Impingement Also called Carpal Tunnel syndrome
An inflammatory disorder caused by the following
Repetitive stress
Physical injury
Other conditions that cause swelling around the median nerve near the carpal tunnel
Symptoms
Pain
Numbness
Tingling in the wrist, hand, fingers (except little finger)
Tendency to drop things
Loss of sense of heat or cold
Feeling of swelling, even though it is visibly swollen
Symptoms may occur only when the hand is being used or only when at rest
Treatment
RICE
In severe cases, surgery to decompress the median nerve

30. Ganglion Cyst
A small, usually hard lump above a tendon or in a capsule that encloses a joint
Also called a synovial hernia or synovial cyst
It is common in handball, racquetball, squash and tennis
Cause of the cyst is unknown

31. Boutonniere Deformity
An injury to the extensor tendon affecting the proximal interphalangeal joint (PIP) at the middle of the finger or the distal interphalangeal joint at the end of the finger
Caused by a direct blow to a bent finger
Symptoms
Problems flexing and extending the finger
Physician should be contacted immediately
Joints will be painful and tender
Finger misshapen or deformed
The athlete will not be able to straighten it
Treatment
Must be done promptly
Athlete may not regain normal use of the finger