Elbow, Wrist & Hand Elbow, Wrist & Hand EvaluationEvaluation

Common Injuries to the Elbow, Common Injuries to the Elbow, Wrist, Hand & FingersWrist, Hand & Fingers

► Lateral epicondylitis Lateral epicondylitis – “tennis elbow”– “tennis elbow”

►Medial epicondylitis Medial epicondylitis – “golfer’s elbow”, – “golfer’s elbow”, “little league elbow”“little league elbow”

►HyperextensionHyperextension► SprainsSprains►DeQuervain’s DeQuervain’s

diseasedisease►DislocationsDislocations► BursitisBursitis

► Carpal tunnel Carpal tunnel syndromesyndrome

►Mallet fingerMallet finger► Boutonniere deformityBoutonniere deformity► Subungual hematomaSubungual hematoma► ContusionsContusions► Pathological Pathological

hand/finger positions hand/finger positions (S & R, p.295-300)(S & R, p.295-300)

► FracturesFractures Colles’ fxColles’ fx

The Elbow – Joints & The Elbow – Joints & MovementMovement

► Ginglymus or hinge-jointGinglymus or hinge-joint► Humeroulnar joint & Radioulnar joint – 2 interrelated Humeroulnar joint & Radioulnar joint – 2 interrelated

jointsjoints

► Movements:Movements: Flexion & Extension – primarily between ulna & humerusFlexion & Extension – primarily between ulna & humerus

► 00 to 145 to 145 -150 -150

Anatomy Anatomy ElbowElbow

Humerus:Humerus: TrochleaTrochlea

CapitulumCapitulum Coronoid Fossa Coronoid Fossa

Medial & Lateral Medial & Lateral EpicondyleEpicondyle

Radius:Radius:Radial headRadial headRadial neckRadial neck

Radial tuberosityRadial tuberosityRadial FossaRadial Fossa

Ulna:Ulna:Coronoid ProcessCoronoid Process

Olecranon ProcessOlecranon ProcessUlna TuberosityUlna Tuberosity

Elbow Elbow LigamentsLigamentsAnterior ViewAnterior View

AnnularAnnular

Medial (Ulnar)Medial (Ulnar)CollateralCollateral

Lateral (Radial) Lateral (Radial) CollateralCollateral

Muscles - ElbowMuscles - Elbow

► FlexionFlexion Biceps BrachiiBiceps Brachii BrachialisBrachialis BrachioradialisBrachioradialis **Pronator Teres - weak**Pronator Teres - weak

Muscles - ElbowMuscles - Elbow

► ExtensionExtension Triceps BrachiiTriceps Brachii AnconeusAnconeus

Muscles - ElbowMuscles - Elbow

► PronationPronation Pronator TeresPronator Teres Pronator QuadratusPronator Quadratus BrachioradialisBrachioradialis

Muscles - ElbowMuscles - Elbow

► SupinationSupination Biceps BrachiiBiceps Brachii SupinatorSupinator BrachioradialiBrachioradiali

ss

NeuroanatomyNeuroanatomy

►Brachial Plexus – C5, C6, C7, C8, & T1Brachial Plexus – C5, C6, C7, C8, & T1►Branches:Branches:

Radial Nerve (C5, C6, C7 & C8)Radial Nerve (C5, C6, C7 & C8) Median Nerve (C6 & C7)Median Nerve (C6 & C7) Ulnar Nerve (C8 & T1)Ulnar Nerve (C8 & T1) Musculocutaneous Nerve (C5 & C6)Musculocutaneous Nerve (C5 & C6)

Neuroanatomy – Radial & Neuroanatomy – Radial & Median NervesMedian Nerves

Neuroanatomy – Neuroanatomy – Musculocutaneous & Ulnar Musculocutaneous & Ulnar

NervesNerves

DermatomeDermatomess

Anterior ViewAnterior View

DermatomeDermatomess

Posterior ViewPosterior View

Neurovascular Neurovascular AnatomyAnatomy► Forearm ArteriesForearm Arteries

Palmar Palmar AspectAspect

Dorsal Dorsal AspectAspect

Wrist & Wrist & HandHand

Palmar AspectPalmar Aspect

PhalangesPhalangesMetacarpalsMetacarpals

CarpalsCarpals

CarpalsCarpals

Scaphoid Scaphoid (boat (boat shaped)shaped)

Lunate Lunate (moon shaped)(moon shaped)Triquetrum Triquetrum (3 (3

cornered)cornered)Pisiform Pisiform (pea shaped)(pea shaped)

TrapeziumTrapeziumTrapezoidTrapezoid

Capitate Capitate (head (head shaped)shaped)

Hamate Hamate (hooked)(hooked)

Carpal BonesCarpal Bones► Concave on palmar sideConcave on palmar side► Bony arch is spanned by transverse carpal & volar Bony arch is spanned by transverse carpal & volar

ligamentsligaments► Creates carpal tunnelCreates carpal tunnel► Median nerve & all flexor tendons except flexor carpi Median nerve & all flexor tendons except flexor carpi

ulnaris & palmaris longus pass through carpal tunnelulnaris & palmaris longus pass through carpal tunnel

Anatomical SnuffboxAnatomical Snuffbox

► Extensor pollicis Extensor pollicis longus (medial side)longus (medial side)

► Extensor pollicis Extensor pollicis brevis (lateral side)brevis (lateral side)

► Abductor pollicis Abductor pollicis longus (lateral side)longus (lateral side)

MedialLateral

Ligaments & Ligaments & Volar PlatesVolar Plates

Palmar AspectPalmar Aspect

Volar = palmar sideVolar = palmar side

LigamentsLigamentsDorsal AspectDorsal Aspect

Triangular Triangular FibrocartilageFibrocartilage

LigamentLigament(TFCC)(TFCC)

*extends from ulnar side *extends from ulnar side of distal radius & of distal radius &

attaches to ulna @ base attaches to ulna @ base of ulnar styloid processof ulnar styloid process

*disc provides stability to *disc provides stability to wristwrist

*major stabilizer of distal *major stabilizer of distal radioulnar jointradioulnar joint

Joints & MovementsJoints & Movements

►Wrist joint Wrist joint Condyloid-typeCondyloid-type Flexion, extension, abduction (radial Flexion, extension, abduction (radial

deviation), adduction (ulnar deviation)deviation), adduction (ulnar deviation)►Motion occurs mostly in proximal carpal row & Motion occurs mostly in proximal carpal row &

distal radiusdistal radius►7070°°-90-90° ° of flexionof flexion►6565°°-85-85°° of extension of extension►1515°°-25-25°° of abduction of abduction►2525°°-40-40°° of adduction of adduction

Joints & MovementsJoints & Movements► FingersFingers

Metacarpophalangeal Joint Metacarpophalangeal Joint (MCP)(MCP)►CondyloidCondyloid►00°°-40-40°° of extension of extension►8585°°-100-100°° of flexion of flexion

Proximal interphalangeal Proximal interphalangeal Joint (PIP)Joint (PIP)►GinglymusGinglymus►Full extension to 90Full extension to 90°°--

120120°° of flexion of flexion Distal interphalangeal Joint Distal interphalangeal Joint

(DIP)(DIP)►GinglymusGinglymus►Flex 80Flex 80°°-90-90°° from full from full

extensionextension

Thumb JointsThumb Joints► 2 joints2 joints

Metacarpophalangeal (MCP)Metacarpophalangeal (MCP)►GinglymusGinglymus►Full extension into 40Full extension into 40°-°-9090° ° of flexionof flexion

Interphalangeal (IP)Interphalangeal (IP)►GinglymusGinglymus►Flex 80Flex 80°°-90-90°°

► Carpometacarpal (CMC) jointCarpometacarpal (CMC) joint► Saddle jointSaddle joint► 5050°-°-7070°° of abduction of abduction► Flex 15Flex 15°°-45-45°° & extend 0 & extend 0°°-20-20°°

Finger MovementFinger Movement► Middle phalange is reference Middle phalange is reference

point to differentiate point to differentiate abduction & adductionabduction & adduction Thumb, index & middle fingers Thumb, index & middle fingers

abduct when they move abduct when they move laterally toward radial side of laterally toward radial side of handhand

Ring & little fingers abduction Ring & little fingers abduction when they move medially when they move medially toward ulnar side of handtoward ulnar side of hand

Medial movement of thumb, Medial movement of thumb, index & middle fingers toward index & middle fingers toward ulnar side of hand is adductionulnar side of hand is adduction

Lateral movement of ring & Lateral movement of ring & little finger toward radial side of little finger toward radial side of hand is adductionhand is adduction

Extrinsic Muscles of HandExtrinsic Muscles of HandExtrinsic muscles of wrist & hand grouped Extrinsic muscles of wrist & hand grouped

according to function & locationaccording to function & location► 6 muscles move wrist 6 muscles move wrist but notbut not fingers & fingers &

thumbthumb 3 wrist flexors3 wrist flexors

►flexor carpi radialisflexor carpi radialis►flexor carpi ulnarisflexor carpi ulnaris►palmaris longuspalmaris longus

3 wrist extensors3 wrist extensors►extensor carpi radialis longusextensor carpi radialis longus►extensor carpi radialis brevisextensor carpi radialis brevis►extensor carpi ulnarisextensor carpi ulnaris

Extrinsic Muscles of HandExtrinsic Muscles of Hand► 9 muscles primary movers of phalanges9 muscles primary movers of phalanges

Also involved in wrist joint actionsAlso involved in wrist joint actions Generally weaker in their wrist actionsGenerally weaker in their wrist actions FlexorsFlexors

►Flexor digitorum superficialisFlexor digitorum superficialis►Flexor digitorum profundusFlexor digitorum profundus►Flexor pollicis longus (thumb flexor)Flexor pollicis longus (thumb flexor)

ExtensorsExtensors►Extensor digitorumExtensor digitorum►Extensor indicisExtensor indicis►Extensor digiti minimiExtensor digiti minimi►Extensor pollicis longus (thumb extensor)Extensor pollicis longus (thumb extensor)►Extensor pollicis brevis (thumb extensor)Extensor pollicis brevis (thumb extensor)

Abductor of thumb & wristAbductor of thumb & wrist Abductor pollicis longusAbductor pollicis longus

Wrist Abductors & AdductorsWrist Abductors & Adductors►Wrist abductorsWrist abductors

Generally cross wrist joint anterolaterally & Generally cross wrist joint anterolaterally & posterolaterally to insert on radial side of handposterolaterally to insert on radial side of hand►Flexor carpi radialisFlexor carpi radialis►Extensor carpi radialis longusExtensor carpi radialis longus►Extensor carpi radialis brevisExtensor carpi radialis brevis►Abductor pollicis longusAbductor pollicis longus►Extensor pollicis longusExtensor pollicis longus►Extensor pollicis brevisExtensor pollicis brevis

►Wrist adductorsWrist adductors Cross wrist joint anteromedially & Cross wrist joint anteromedially &

posteromedially to insert on ulnar side of handposteromedially to insert on ulnar side of hand ►Flexor carpi ulnarisFlexor carpi ulnaris►Extensor carpi ulnarisExtensor carpi ulnaris

Anterior Aspect of Elbow Anterior Aspect of Elbow

Posterior Aspect of ElbowPosterior Aspect of Elbow

Intrinsic Hand MusclesIntrinsic Hand Muscles► Intrinsic hand muscles Intrinsic hand muscles have origins & insertions on have origins & insertions on

bones of handbones of hand Radial side - four muscles of thumb Radial side - four muscles of thumb

►opponens pollicisopponens pollicis►abductor pollicis brevisabductor pollicis brevis►flexor pollicis brevisflexor pollicis brevis►adductor pollicisadductor pollicis

Ulnar side - three muscles of little fingerUlnar side - three muscles of little finger►opponens digiti minimiopponens digiti minimi►abductor digiti minimiabductor digiti minimi►flexor digiti minimi brevisflexor digiti minimi brevis

Remainder of hand - 11 different musclesRemainder of hand - 11 different muscles►4 lumbricals4 lumbricals►3 palmar interossei3 palmar interossei►4 dorsal interossei 4 dorsal interossei

►Thenar eminenceThenar eminence - muscular pad on - muscular pad on palmar surface of 1palmar surface of 1stst metacarpal metacarpal abductor pollicis brevisabductor pollicis brevis opponens pollicisopponens pollicis flexor pollicis brevisflexor pollicis brevis adductor pollicisadductor pollicis

►Hypothenar eminenceHypothenar eminence - muscular pad - muscular pad that forms ulnar border on palmar that forms ulnar border on palmar surfacesurface abductor digiti minimiabductor digiti minimi flexor digiti minimi brevisflexor digiti minimi brevis opponens digiti minimiopponens digiti minimi

Intrinsic Muscles of HandIntrinsic Muscles of Hand

TendonsTendonsDorsal AspectDorsal Aspect

Ext. Pollicis BrevisExt. Pollicis BrevisExt. Pollicis LongusExt. Pollicis Longus

Ext. DigitorumExt. DigitorumExt. IndicisExt. Indicis

Ext. Digiti MinimiExt. Digiti Minimi

Elbow & Forearm EvaluationElbow & Forearm Evaluation►HistoryHistory

Ask Generic history questions - MOI, ?Ask Generic history questions - MOI, ?noises/sensations, Burning/Stinging? noises/sensations, Burning/Stinging?

Ask Specific history questions - was your Ask Specific history questions - was your hand planted? Did you fall on an hand planted? Did you fall on an outstretched hand?outstretched hand?

►ObservationObservation Carrying Angle (Carrying Angle (> > )) ► 1010-15-15 5 5-10-10

Cubital RecurvatumCubital Recurvatum Cubital ValgusCubital Valgus Bony alignment, Soft tissue Bony alignment, Soft tissue Discoloration, swelling, etc.Discoloration, swelling, etc.

Elbow & Forearm EvaluationElbow & Forearm Evaluation► PalpationPalpation

Bony landmarks, Soft tissueBony landmarks, Soft tissue Swelling, crepitus, temperature, etc.Swelling, crepitus, temperature, etc. Cubital fossa – brachial artery, median n., Cubital fossa – brachial artery, median n.,

musculocutaneous n.musculocutaneous n.►Brachioradialis – lateral borderBrachioradialis – lateral border►Pronator teres – medial border Pronator teres – medial border

► Stress/Special TestsStress/Special Tests ROM (AROM, PROM, RROM): ROM (AROM, PROM, RROM): - 0-145°; / - - 0-145°; / -

normally 0° normally 0° butbut can have hyperextension; can have hyperextension; pronation/supination 170-180°pronation/supination 170-180°

Valgus/Varus Stress testsValgus/Varus Stress tests Tinel’s SignTinel’s Sign Compression/Squeeze TestCompression/Squeeze Test NeurologicNeurologic

Wrist & Hand EvaluationWrist & Hand Evaluation►HistoryHistory

Ask Generic history questions - MOI, Ask Generic history questions - MOI, ?noises/sensations, Burning/Stinging? ?noises/sensations, Burning/Stinging?

Ask Specific history questions - was your hand Ask Specific history questions - was your hand planted? Did you fall on an outstretched hand? planted? Did you fall on an outstretched hand?

►ObservationObservation Discoloration, swellingDiscoloration, swelling Posture of handPosture of hand Deformity, palmar creases, color of skin & Deformity, palmar creases, color of skin &

fingernails, thenar & hypothenar eminences, fingernails, thenar & hypothenar eminences, thenar webspacethenar webspace

Murphy’s sign, Silverfork deformity, Boutonniere Murphy’s sign, Silverfork deformity, Boutonniere deformity, mallet finger deformity, rotational deformity, mallet finger deformity, rotational malalignment, missing knucklemalalignment, missing knuckle

Wrist & Hand EvaluationWrist & Hand Evaluation► PalpationPalpation

Ulna (styloid process), Radius (Lister’s tubercle, Ulna (styloid process), Radius (Lister’s tubercle, styloid process), Carpals, Metacarpals, styloid process), Carpals, Metacarpals, Phalanges, joints, muscles, ligaments, Carpal Phalanges, joints, muscles, ligaments, Carpal Tunnel, Anatomical snuffboxTunnel, Anatomical snuffbox

Temperature, deformity, swellingTemperature, deformity, swelling

► Stress/Special TestsStress/Special Tests ROM, Grip strength, Pinch test, test ea. joint on a ROM, Grip strength, Pinch test, test ea. joint on a

fingerfinger Valgus/Varus Stress tests of all joints, Glide Valgus/Varus Stress tests of all joints, Glide

testing of ligamentstesting of ligaments Phalen’s TestPhalen’s Test

Stress/Special Tests continuedStress/Special Tests continued Tinel’s SignTinel’s Sign Glide tests – ulnar glide, superior glide, Glide tests – ulnar glide, superior glide,

inferior glideinferior glide Finkelstein TestFinkelstein Test Transverse Compression, Compression Test, Transverse Compression, Compression Test,

Tap or Percussion (Long bone Compression) Tap or Percussion (Long bone Compression) TestTest

Watson Test – (Scaphoid shift)Watson Test – (Scaphoid shift) ReflexesReflexes Capillary refillCapillary refill PulsePulse

ReferencesReferences

► Thompson, C. & Floyd, R. T. (2004). Thompson, C. & Floyd, R. T. (2004). Manual Manual of Structural Kinesiologyof Structural Kinesiology, 15, 15thth ed. ed.

► Primal 3D Interactive SeriesPrimal 3D Interactive Series► Starkey, C. & Ryan, J. (2003). Starkey, C. & Ryan, J. (2003). Orthopedic & Orthopedic &

Athletic Injury Evaluation HandbookAthletic Injury Evaluation Handbook..► Agur, A. & Dalley, A. (2005). Agur, A. & Dalley, A. (2005). Grant’s Atlas of Grant’s Atlas of

AnatomyAnatomy..►McDevitt, E. & Roberts, W. (1999). Dorsal McDevitt, E. & Roberts, W. (1999). Dorsal

Dislocations of the MCP Joint Assessment Dislocations of the MCP Joint Assessment and Closed Reduction. and Closed Reduction. The Physician & The Physician & Sportsmedicine,Sportsmedicine, 27(7), p. 75. 27(7), p. 75.