3336 Week 9: Elbow, Hand, and Finger

elbow joints

1. humeroulnar joint

2. humeroradial joint

3. radioulnar

elbow ROM

• flexion 0-140 degs

• extension 0-5 degs

• pronation 0-90 degs

• supination 0-90 degs

scenario: elbow

fractured humerus

• Common in children age + 12

• Fall off bike (FOOSH)

• May resemble a dislocated elbow, but much more serious

• Remember the proximity of nerves and arteries

• Median N in front, ulnar N on medial side

• Brachial artery front

• Orthopedic Emergency!

supracondylar fracture symptoms

• HX of MOI - bike, FOOSH

• pain ++

• light headed/dizzy

supracondylar fracture signs

• may or may not have visible deformity

• spasm

• swelling

• hemorrhage

• ± neurovascular signs

supracondylar assessment:

• palpatiob - start at tip of olecranon and palpate supracondylar ridge of humerus

• should be no pain or incontinuity on humerus - if so, could be fracture

• if deformity apparent: check radial pulse, median and ulnar n function

• beware of shock

in all patients with supracondylar fractures, the extremity should be assessed for:

• pulse

• skin colour

• temperature

• capillary refill

elbow dislocations

• One of the most serious acute injuries to the elbow

• Second most dislocated large joint, after the shoulder

• Major complication is neurovascular compromise

• Median/ulnar nerve and brachial artery

elbow dislocation MOI

• Shoulder abducted with forearm in supination, then forced flexion from extended position, causing it to dislocate posterior laterally

dislocation elbow symptoms and signs

• Report of extension to flexion + supination MOI

• Severe pain and disability

• Bulge behind elbow

• May have neurovascular symptoms

checking for median nerve

• innervates gun fingers

• if median n intact, the thumb can be rotated and flexed towards the pulp of the index finger (Opp. Pol. mm)

checking for ulnar nerve

• innervates tea fingers

• If ulnar N. intact it can activate Add. Pol. mm and hold paper between thumb and finger. If injured, thumb flexor mm do the work D.

• Intact ulnar N. allows normal finger abd/adduction

management for dislocated elbow

• rapid reduction is ecellent pain therapy, but first rule out fracture

• if in doubt, LEAVE IT AND ACTIVATE EAP

• to reduce: hold elbow at 45, apply gentle longitudinal traction to forearm - do not force!

• evaluate pulses/cap refill, median and ulnar n, and strength after reduction

• POLICE/PEACE and LOVE

• refer to hospital, may need imaging, usually coronoid or radial head fracture with it

• most elbow dislocations are stable once reduced and may be treated conservatively

olecranon bursitis

• Bursae are closed fluid filled sacs with a synovial lining that facilitates gliding of musculoskeletal structures over one another during motion.

• The floor of the olecranon bursa lies on the triceps tendon and olecranon, and the roof is loosely connected to the overlying skin of the elbow

• MOI usually fall or repeated rub/blows to elbow

• Single trauma

• Repeated rub from boards

• Student’s elbow

olecranon bursitis symptoms and signs

variable:

• point tenderness

• swelling

• red

• warm

• fever

management for olecranon bursitis

• POLICE/PEACE&LOVE

• Use cold compress to decrease swelling

• Monitor for infection

• Minor trauma and sometimes repetitive microtrauma are enough to allow bacterial invasion of the bursa

• Red, hot, increased temperature

• Must pad prior to return to sport

elbow: lateral aspect responsible for

• supination of forearm

• strong wrist extension

• mid elbow flexion

lateral elbow: static restraints

• Stability in response to varus stress is provided by the lateral collateral ligament complex.

• LCL complex runs from lateral epicondyle to annular ligament of the radius

primary static restraints against VARUS loading:

• Annular

• Radial collateral

• Lateral ulnohumeral/ulnar collateral

medial aspect of elbow responsible for

• pronation of forearm

• strong wrist flexion

• mild elbow flexion

medial elbow static restraints

• valgus stress is offset by ulnar collateral ligament complex

• runs from medial epicondyle to coronoid process and olecranon of the ulna

primary restraint against VALGUS loading

• anterior oblique 0-85 flexion

• posterior oblique 55 to end of flexion

• transverse 90 to end of flexion

MCL sprain

• Medial (ulnar) collateral ligaments are primary STATIC restraints to valgus stress • The failure capacity of the UCL is approached with pitching.

• Typical valgus torque of 64 N · m and a tensile force of 290 N

• On average the UCL withstands a valgus torque of 34 N

• m and a tensile force of 261 N

• Similar to the lateral knee, the muscles provide a large part of support.

MCL MOI

• Valgus stress from throwing or falls

• Can be result of acute or chronic injury

MCL sprain: acute and chronic

• Acute- Hx of fall or hyperextension with valgus Chronic- overload

• Throwers with poor mechanics - open up too soon

MCL sprain, signs/symptoms

• Pain localized to medial elbow

• Chronic: During the late cocking and early acceleration phases of pitching, decreased velocity accuracy or endurance, may not have inflammatory signs

• Acute: The player typically recalls a popping sensation along with a specific throw that prompted the on-set of symptoms, early inflammatory signs

• Varying instability/laxity on valgus stress at 20-30

• Ulnar nerve may be involved- +ve Tinel’s test

management for ACUTE MCL sprain

• POLICE and refer to physician

• Partial tears- brace and rehab

• Gain ROM

• Nonoperative management focuses on flexibility and strengthening of the forearm musculature, rotator cuff, and scapular stabilizers

• Medial muscle bulk strengthening to aid in support

management for CHRONIC MCL sprain

• Rest

• Decrease pain and increase ROM (address inflammation if present)

• Strengthen medial muscle bulk

• Correct throwing errors

• Address upper and lower chain issues

lateral epicondylosis: tennis elbow

• Associated with activities involving wrist extension against resistance

• Racquet sports, carpentry, bricklaying, sewing, knitting, computer work

• Usually slow but can be fast onset (itis)

• Micro vs. macroscopic injury

medial epicondylosis: golfers elbow

• Not as common

• (7-10x less)

• Seen in golfers (chunk) and tennis players who use top spin on forehand shot

• Occurs in medial flexor group

• Primarily pronator teres

tendinosis review

• Stage 1 : NO inflammation associated with pathologic tissue alterations

• Stage 2: Alterations characterized by disrupted collagen architecture Fibroblastic and hypervascular response, No inflammatory cells

• Stage 3: Tendinosis with tissue structural failure (e.g., microtearing)

• Stage 4: Continued failure with fibrosis/calcification

lateral epicondylosis signs and symptoms

• pain lateral aspects of elbow, usually ECRB m

• Maximal area of tenderness is within 1-2 cm of the epicondyle

• Pain before, during and after activity

• Pain with squeeze and grasp

• Pain reproduced with resisted wrist extension in a pronated and radially deviated wrist (Cozen’s test)

• Resisted extension of the middle finger - Ext digitorum or Extensor Carpi ulnaris

medial epicondylosis signs and symptoms

• Localized tenderness just below medial epicondyle

• Activity makes it worse

• Pain with resisted wrist flexion and/or pronation

• Pain with passive stretch into wrist extension

• Test ulnar nerve as it may become trapped in scar tissue

epicondylosis management

• POLICE/PEACE&LOVE if acute

• Modification of activity

• Limit FITT

• Correct technique/ergonomics

• Repair Stage

• Cryogenics vs. heat

• Ice (pain) and cross friction- breaks down disrupted collagen and aligns

• Heat will increase blood flow to region

• Stretching • Strengthening • Bracing/equipment modification

stretching lateral epicondylosis

Pronate forearm, extend the elbow and flex the wrist (flex the fingers)

stretching medial epicondylosis

• Extend the fingers, extend the wrist and extend the elbow

strengthening for tendinosis/epicondylosis

• Eccentric training has demonstrated promising results in the management of elbow tendinopathy when added to standard physical therapy treatment

• Improvements were greater for the Eccentric Group versus the Standard Treatment Group (percent improvement reported):

• Little consensus regarding parameters including: •Painful vs. non-painful • Sets/reps

practical eccentric strengthening for epicondylosis

bracing for lateral epicondylosis

• Brace treatment might be useful as initial therapy. Combination therapy has no additional advantage compared to physical therapy, but is superior to brace only for the short term

• A counterforce brace provided significant relief (frequency and level of pain) at 2-12 weeks, as well as a significant improvement in overall elbow function at 26 weeks, compared with the placebo brace

complexity of the wrist and hand

skin of hand: volar surface

• Thick

• Underlying fascial attachments

• Inelastic

• Hairless

• Ridges for grasping

skin of hand: dorsal surface

• Elastic

• Mobile

• Thinner

• Loose

• Pliable

• Must stretch 1 in. for fingers to close

edema in hand

• Frequently accumulates in dorsum.

• Can lead to contractures.

• Excessive swelling on dorsum can cause hand arches to collapse anteriorly and adduct the thumb.

• Finger ROM can be impaired.

• Edema causes reduced mobility and function of the hand in short term and in long term if fibrous formations occur

treatment for hand edema

• Must reduce early edema, or risk loss of function

• Measured by circumferential gauge or string wrapped around finger and track progress

• Use of POLICE, compression dressings and other modalities

wrist ROM

• Flexion 80

• Extension- 70

• Ulnar deviation 30

• Radial deviation 20

fractured radius: MOI

• Most common is the Colles Fracture, which runs through the distal metaphysis of the radius

• May fracture the ulna (styloid) MOI- Usually FOOSH, with distal fragment displacing dorsally

• Fall on flexed wrist is termed a Smith Fracture (distal fragment displaced palmarly)

fractured radius: signs and symptoms

• Pain on radial (thumb) side of forearm

• Local tenderness

• Dinner fork deformity (reverse in Smiths)

• If non-displaced

• Pain on percussion

• + swelling

• Passive pronation - Bends radius around ulna - If pain- send for imaging

• Stabilize with splint and sling transport

fractured scaphoid: MOI and symptoms

• Most common carpal fracture

• MOI is a fall on an extended wrist

• Symptoms- Post traumatic pain on the radial side of the wrist in anatomical snuffbox

signs of fractured scaphoid

• Sensitive examination findings include tenderness to palpation in the anatomical snuffbox (direct test), and pain on longitudinal compression of the thumb (indirect test)

• Wrist extension with radial deviation is reduced and painful (indirect test)

• Confused with wrist sprain/lunate subluxation as often does not show on initial X ray.

fractured scaphoid: management

• Surgical management of scaphoid fractures can provide significantly improved return to sport compared to conservative management • (mean 7.9 vs 13.9wks)

• Immediate return to sport in a cast should be avoided due to the significant risk of non-union.

scenario

fractured metacarpals: MOI

• Hand fractures comprise one-third of all fractures during athletic competition, with metacarpal fractures comprising two-thirds of hand-related injuries.

• MOI: Direct blow to the hand or as a result of punching something

metacarpal fractures: symptoms and signs (boxers and bennets fracture)

• The athlete generally presents with dorsal hand pain, swelling and deformity

• Pain on direct palpation and axial load through fingers/MCP joint (indirect test) or squeeze from side for 2nd and 3rd metacarpals

• Bennet’s fracture is an injury to the 1st metacarpal- usually surgical

• Boxer’s fracture is most common in 5th, then 4th metacarpal as a result of a punch

• Often see flexion deformity of the distal fragment that results in a “dropped knuckle”.

• The more proximal the fracture, the greater the knuckle will drop

fractured phalanges MOI

• MOI- Shaft fractures of the proximal and middle phalanges can occur in a variety of patterns

• Most mid-phalangeal fractures are transverse fractures related to direct blows

• Distal phalangeal fractures usually result from crushing injuries

fractured phalanges: symptoms and signs

• Pain on axial compression and or circulative compression around the phalanx

• 4 fingers tend to move as a unit and should maintain longitudinal and rotational alignment

• Fractures to middle or proximal phalanx may have deformation due to pull of tendons

• Look for overlapping fingers

1st aid for fractured phalanges

• Immobilize in wrist splint with gauze pad or roll to produce approximately 30 of flexion and refer for X rays

• Buddy taping and/ or protective splint wear in acceptable alignment can allow fast return to play of nondisplaced, non-articular fractures

finger dislocations MOI

• May occur at the DIP, PIP or MCP joints

• MCP joint dislocations are rare

• PIP joint is most common dislocation in the body

• MOI: Hyperextension and axial compression

• ball hits the end of a finger

finger dislocations: signs and symptoms

• DIP and PIP - swollen and painful finger.

• DIP dislocations usually occur dorsally and may have an open wound- These individuals often reduce the injury on their own

• PIP usually dislocates dorsally with visual deformity

• MP joint dislocations often present with the proximal phalanx at 90 to the metacarpal

finger dislocation first aid

• Due to probability of entrapping the volar plate, an untrained individual should not attempt reduction

• Immobilize in a wrist or finger splint and refer to physician

wrist sprains/instability

• Because of the proximity of structures in the wrist, diagnosis of these injuries can be challenging and is often a diagnosis of exclusion

• X-rays negative for fracture or dislocation

• Pain caused by capsular injury is subjective and varies from patient to patient

• Most commonly between the scaphoid and the lunate (Scapholunate ligament- SLL) but may be a number of structures

wrist sprain/instability MOI

• FOOSH or direct blow to or twisting of the wrist in combination with an extension moment

• Athletes of almost any sport involving violent contact with other players or the ground are prone to this injury on a hyperextended wrist. Cumulative microtraumatic injuries may also result in SLL damage.

wrist sprains/instability symptoms

• Pain, tenderness, on dorsum of joint

• Increase pain between scaphoid and lunate increases with active or passive extension.

• Remember that scaphoid fractures may not show immediately on X-ray

lunate subluxation/dislocations

Lunate Subluxation (wrist sprain)

• Axial load with radius compressing lunate in a volar direction

• Equally limited flexion and extension

• Loss of articulation between radius and lunate is a dislocation

• Lunate may move into the carpal tunnel

• Tinel’s test over carpal tunnel may be positive

• Dorsum of hand is point tender

• X ray shows “spilled teacup” sign with dislocation

wrist sprain/instability treatment

ulnar collateral ligament sprain of the first MCP joint

skiers or game keepers thumb (common in skiing, basketball, and football)

• MOI: Forced valgus of proximal phalanx of thumb

• Symptoms and signs:

• Tender and swollen over medial MCP joint

• Pain, ecchymosis, and swelling on the ulnar aspect of the thumb MCPJ.

• Pain with Valgus stress test and laxity greater than the contralateral side or 20-30 is considered positive.

treatment for game keepers thumb

• POLICE/PEACE&LOVE

• Tape/brace injuries with firm endpoints.

• Those with no endpoint refer to surgeon

mallet finger

• Mallet Finger - AKA Extensor Tendon Avulsion MOI is a blow from an object that hits the tip of the finger and is is commonly seen in softball, basketball, baseball, volleyball, or in receivers in football

• Causes an avulsion of the distal extensor tendon

signs and symptoms of mallet finger

• +/- Pain at dorsal DIP joint - When the bone is not involved, this lesion can be remarkably painless.

• Inability to actively extend DIP with PIP stabilized in full extension

mallet finger treatment

• POLICE

• Extension splinting of the DIP joint is appropriate for almost all mallet fingers, including those with bony fragments if there is no significant joint subluxation. Must be very diligent with splint wearing

Boutonniere deformity

• Boutonniere Deformity- AKA Extensor Digitorum Cummunis Tendon

• Result from a disruption of the central slip of the extensor digitorum at its insertion on the base of the middle phalanx

• Similar MOI as mallet finger, but at the PIP joint

• Blunt trauma over dorsal aspect of PIP or PIP forced into flexion against residence

boutonniere finger symptoms/signs

• Patients present with pain on dorsal side of PIP and the inability to extend at joint

• The deformity is often absent at initial presentation as the band slowly migrate volarly

• This results in PIP joint flexion and hyperextension at the distal interphalangeal (DIP) joint

boutonniere finger treatment

• Splint in full extension 6-8 weeks

• Rehabilitation goals are to regain full strength and range of motion and avoid a deformity.

jersey finger

• Jersey Finger - Flexor Digitorum Profundus (FDP) Rupture

• MOI- usually occurs on the ring finger when an athlete grabs an opponent’s jersey

• A disruption of the FDP tendon occurs because the DIP joint is actively flexed and then forced into extension.

• Either ruptures or avulses tendon

• The ring finger is involved in up to 75% of reported cases, but any digit may be injured.

jersey finger signs and symptoms

• Pain and point tenderness volar DIP

• Can’t flex DIP with MCP and PIP joints stabilized

jersey finger treatment

• POLICE- Splint in 30 flexion at PIP and DIP

• Significant grip and strength repercussions

• Requires surgery within 7-10 days

collateral ligament sprain PIP/DIP

• Partial or complete collateral ligament tears are often referred to as "jammed fingers,” MOI

• may occur at any interphalangeal joint with an ulnar or radial-directed force.

• They occur more often at the PIP joints than at the DIP joints

symptoms and signs for collateral ligament sprain DIP/PIP

• Pain at joint, tenderness and swelling.

• Rule out fracture via direct (palpation) and indirect (axial load) testing

• Test structure by flexing involved joint to 20-30 and apply valgus and/or varus stress.

• Compare to finger on contralateral hand

treatment for collateral ligament sprain DIP/PIP

• Nonsurgical management of collateral ligament injuries is almost always successful.

• Apply a splint or use buddy taping

• Athletes may continue to participate in their sport as pain and function allow.