1.  HOMEWORK REVIEW & EXAM

2.  ANATOMY FOR ELBOW, FOREARM, WRIST, & HAND

3. ELBOW  Humeroulnar and humeroradial joints  Flexion and extension  Common Flexor Tendon  Tendon shared by flexor Ms: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris  Common Extensor Tendon  Tendon shared by extensor Ms: extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris  Proximal and distal radioulnar joints  Pronation and supination

4. ELBOW

5. ELBOW HYPOMOBILITY  Myositis ossificans  Internal derangement  Subluxation of radial head  Recovery from surgery / trauma

6. HYPERMOBILITY OF THE JOINTS  May also be called:  Joint laxity (or hyperlaxity within capsule / ligaments)  Double-jointedness  Loose joint  May be seen with:  Down syndrome (a developmental disability)  Ehlers-Danlos syndrome (an inherited syndrome affecting elasticity  Marfan syndrome (a connective tissue disorder)  Hypermobility syndrome  Bone structure: bone shape or the depth of the joint sockets  Muscle structure: muscle tone or strength  Poor sense of proprioception (the ability to sense how far you are stretching)  Family history: hypermobility is often inherited

7. WHEN TO SEEK TREATMENT  Pain in the loose or hypomobile joint during or after movement  Sudden changes in the appearance of the joint, muscles, or skin  Changes in mobility, specifically in the joints above and/or below affected joint  Changes in the functioning of your arms and legs, compensatory

8. ELBOW LIGAMENTS  Radial and Lateral Collateral Ligaments  Provide support for the sides of the joint  Medial and Ulnar Collateral Ligaments  Connect the humerus to the ulna and keep it tightly in place as it slides through olecranon  Can be torn with injury or dislocation  Annular Ligament  Holds the proximal radioulnar joint together  Wraps around the radial head and holds it tight against the ulna  Can be torn when entire elbow or radial head is dislocated

9. ELBOW LIGAMENTS

10. ELBOW  Superficial to olecranon process of the ulna  Protects process and reduces friction  Brachial artery  Crosses crease in elbow  Splits into radial and ulnar arteries  Only blood supply to hand

11. CUBITAL VALGUS VS. VARUS  Normal = “carrying angle”  The angle formed by the long axis of the humerus and the long axis of the ulna and is most evident when the elbow is straight and fully supinated  The normal carrying angle in women is 10-15 degrees; and is 5-10 degrees in males  Cubital Valgus = “carrying angle” greater than 15 degrees  Cubital Varus = “carrying angle” less than 5-10 degrees

12. WRIST  Radiocarpal joint – radius and proximal row of carpals  Flexion, extension, radial deviation (abduction), ulnar deviation (adduction)  Carpal Tunnel – anterior wrist  Carpal bones + flexor retinaculum (transverse carpal ligament)  Medial attachments – pisiform & hamate  Lateral attachments – trapezium & scaphoid  Holds 9 tendons and the medial nerve  Indicated in carpal tunnel syndrome

13. WRIST  Tunnel of Guyon (Guyon’s canal) – medial wrist  Created by division of flexor retinaculum (transverse carpal ligament)  Ulnar artery and nerve pass through  Indicated in ulnar neuropathy  Anatomical Snuff Box – lateral wrist  Synovial sheath shared by abductor pollicis longus, extensor pollicis brevis, and styloid process of radius  Indicated in DeQuervain’s Tenosynovitis

14. ANATOMICAL SNUFF BOX  In anatomical position:  posterior border is extensor pollicis longus  anterior border is extensor pollicis brevis and abductor pollicis longus  proximal border is composed of trapezium and scaphoid

15. ACRONYMS FOR WRIST BONES  Lateral to Medial  Row 1:  Some – Scaphoid  Lovers – Lunate  Try – Triquetrum  Positions – Pisiform  Row 2:  That - Trapezium  They - Trapezoid  Can’t - Capitate  Handle – Hamate

16. WRIST

17. WRIST & FINGERS

18. FINGERS  Metacarpophalageal joints  Flexion and extension (sagittal plane)  Abduction and adduction (frontal plane)  Proximal interphalangeal joints (PIP)  Flexion and extension (sagittal plane)  Distal interphalangeal joints (DIP)  Flexion and extension (sagittal plane)

19. THUMB  Carpometacarpal joint (CMC)  Flexion and extension – frontal plane  Abduction and adduction – sagittal plane  Metacarpophalangeal joints (MCP)  Flexion and extension – frontal plane  Abduction and adduction – sagittal plane  Interphalangeal joints (IP)  Flexion and extension – frontal plane

20. FLEXOR TENDONS, ARTERIES, & NERVES AT WRIST

22.  MUSCLES OF THE ELBOW, FOREARM, WRIST & HAND

23. BRACHIALIS  The distal ½ of the anterior shaft of the humerus (beginning just distal to the deltoid tuberosity) to the  tuberosity and coronoid process of the ulna.  The brachialis flexes the forearm at the elbow joint.

24. CORACOBRACHIALIS  Coracoid process of the scapula to the  middle 1/3 of the medial shaft of the humerus  The corabrachialis flexes, adducts, and horizontally flexes the arm at the shoulder joint

25. PRONATOR TERES  From the medial epicondyle of the humerus (via the common flexor tendon), the medial supracondylar ridge of the humerus, and the coronoid process of the ulna to the  middle ⅓ of the lateral radius.  The pronator teres pronates the forearm at the radioulnar joints; it also flexes the forearm at the elbow joint.

26. EXTENSOR CARPI RADIALIS LONGUS (ECRL)  From the distal ⅓ of the lateral supracondylar ridge of the humerus to the  radial side of the posterior hand at the base of the second metacarpal.

27. EXTENSOR CARPI RADIALIS BREVIS (ECRB)  From the lateral epicondyle of the humerus (via the common extensor tendon) to the  radial side of the posterior hand at the side of the base of the third metacarpal.

28. ECRL AND ECRB ACTIONS  Radially deviate (abduct) the hand at the wrist joint.  Extend the hand at the wrist joint.  Flex the forearm at the elbow joint.  Both extensors carpi radialis muscles have the same actions.

29. SUPINATOR  Lateral epicondyle of the humerus and the supinator crest of the ulna to the  proximal ⅓ of the radius (posterior, lateral, and anterior sides).  The supinator supinates the forearm at the radioulnar joints.

30. ABDUCTOR POLLICIS LONGUS  From the middle ⅓ of the posterior radius, interosseus membrane, and ulna to the  base of the metacarpal of the thumb.  Abducts the thumb at the carpometacarpal joint.  Extends the thumb at the carpometacarpal joint.  Radially deviates the hand at the wrist joint.

31.  Muscles to Review The following muscles were presented in first year – please review

32. DELTOID  Lateral ⅓ of the clavicle and the acromion process and spine of the scapula to the  deltoid tuberosity of the humerus  The entire deltoid abducts the arm at the shoulder joint and downwardly rotates the scapula at the shoulder and scapulocostal joints.  The anterior deltoid also flexes, medially rotates, and horizontally flexes the arm at the shoulder joint.  The posterior deltoid also extends, laterally rotates, and horizontally extends the arm at the shoulder joint.

33. BICEPS BRACHII  Supraglenoid tubercle (long head) and coracoid process (short head) of the scapula to the  radial tuberosity and the deep fascia overlying the common flexor tendon.  Flexes the forearm at the elbow joint  Supinates the forearm at the radioulnar joints  Flexes the arm at the shoulder joint

34. TRICEPS BRACHII  Infraglenoid tubercle of the scapula (long head) and the posterior shaft of the humerus (lateral and medial heads) to the  olecranon process of the ulna.  The triceps brachii extend the forearm at the elbow joint; the long head also adducts and extends the arm at the shoulder joint.

35. BRACHIORADIALIS  Proximal ⅔ of the lateral supracondylar ridge of the humerus to the  styloid process of the radius.  Flexes the forearm at the elbow joint.  Can also pronate the supinated forearm at the radioulnar joints to a position halfway between full pronation and supination;  Or supinate the pronated forearm at the radioulnar joints to a position halfway between full pronation and supination.

36.  CONDITIONS PART I

37. LATERAL EPICONDYLITIS (TENNIS ELBOW)  Definition:  Chronic collagen degeneration in extensor tendons and enthesopathy (attachment site) at the lateral epicondyle of the humerus  Common overuse injury affecting 1-3% of the population  Extensor carpi radialis brevis is most affected due to line of pull  Causes:  Repeated tensile stress on tendons – excessive concentric extension or eccentric flexion  Sports, occupations, and hobbies that require repetitive grasping of objects  Repetitive supination and pronation  Trigger points in extensor tendons may create excess tensile loads  History:  Pain in lateral elbow that radiates into forearm  Generalized aching; sharp pain if aggravated  Acute onset is rare  Generally unilateral symptoms

38. LATERAL EPICONDYLITIS (TENNIS ELBOW)  Observations:  No visible clues  Inflammation/enthesitis (inflammation of attachment site) can’t be seen  Palpation:  Tenderness and pain at the lateral epicondyle of humerus  Hypertonic extensors; fibrotic and ropy  Referral patters from extensor trigger points  Pain from entrapment of posterior interosseous nerve may present  Testing:  AROM:  Possible pain with extension - minor contraction required  Pain at end-range of flexion – extensor stretch  PROM:  Pain uncommon from extension, pain at end-range of flexion

39. LATERAL EPICONDYLITIS (TENNIS ELBOW)  MRT:  Pain with extension  RMI produces weakness  Nerve compression in radial tunnel also produces weakness  Special Tests:  Tennis Elbow Test  Contraindications:  None  Rule out posterior interosseous nerve compression with two differential tests - resisted tennis elbow/radial tunnel syndrome  Epicondylitis – pain on wrist extension; PIN compression – weak with resisted extension with little increase of pain  Treatment Goals: (stage dependent)  Stimulate collagen production – deep friction  Restore wrist function – stripping, myofascial work, active engagement

40. LATERAL EPICONDYLITIS (TENNIS ELBOW)  Reduce hypertonicity and pain  Deactivate trigger points  Treatment protocol: 1. Warm up tissue – myofascial, trigger points, lengthening 2. Identify adhesion in common extensor tendon – only treat 1 or 2 per session 3. Cross-fiber friction small section per session: engage tissue perpendicularly, 6 or more deep strokes; release gently 4. Flush with effleurage 5. Stretch 6. Ice – immediately in clinic, then at home (cross-fiber friction causes inflammation)  Treatment: 2 times a week for 2-3 weeks; after some healing, move on to once per week  Stress that homecare is very important  Hydrotherapy:  Ice to reduce pain

41. LATERAL EPICONDYLITIS (TENNIS ELBOW)  Self-care:  Self massage: cross-fiber friction, stripping  Stretch: extensors  Strengthen: flexors and upper arm and shoulder muscles  Rest from offending activities

42. MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)  Definition:  Chronic collagen degeneration of the wrist flexor tendons where they attach to the medial epicondyle of the humerus  Enthesopathy at the attachment site  Pronator teres often involved due to its coordinated effort with wrist flexors and proximity of its proximal attachment  Causes:  Excessive tensile stress from repetitive or prolonged contractions of the flexor group  Repetitive pronation and supination: stress placed on pronator teres  Sports injuries: swing or throw; valgus force on elbows and tendons  Correlates with carpal tunnel syndrome  History:  Pain on medial side of elbow that radiates into forearm  Generalized aching pain, rarely acute; sharp if aggravated  Usual gradual onset

43. MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)  Possible neurological sensations in ulnar nerve distribution of the hand  Ask about activities involving repetitive gripping  Pain when shaking hands  Recommended to differentiate between: carpal or cubital tunnel, pronator teres syndromes  Observations:  No visible clues  Possible excessive cubital valgus  Palpation:  Tender forearm flexors  Testing:  AROM:  Possible pain in wrist flexion if condition is severe  PROM:  Possible pain in flexion  Possible pain in full extension or supination at end range stretch

44. MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)  MRT:  Pain with resisted flexion  Pain with resisted pronation if pronator teres is involved  Weakness due to RMI  Special Tests:  Golfer’s Elbow Test  Contraindications:  Caution when frictioning near ulnar nerve at proximal flexor tendons  Caution with ice treatment – possible nerve damage to ulnar nerve  Treatment Goals: (stage dependent)  Stimulate collagen production – deep friction  Restore wrist function – stripping, myofascial work, active engagement  Reduce hypertonicity and pain in flexors and pronator teres  Deactivate trigger points

45. MEDIAL EPICONDYLITIS (GOLFER’S ELBOW)  Treatment protocol: 1. Warm up tissue – myofascial, trigger points, lengthening 2. Identify adhesion in common flexor tendon – only treat 1 or 2 per session 3. Cross-fiber friction small section per session: engage tissue perpendicularly, 6 or more deep strokes; release gently 4. Flush with effleurage 5. Stretch 6. Ice – immediately in clinic, then at home (cross-fiber friction causes inflammation)  Treatment: 2 times a week for 2-3 weeks; after some healing, move on to once per week  Stress that homecare is very important  Hydrotherapy:  Ice to reduce pain  Self-care:  Self massage: cross-fiber friction, stripping  Stretch: flexors