Elbow/Wrist/Hand Labeling Sports med 2 Head Body Base Distal Phalanges Middle Distal Proximal Proximal Head Metacarpals Body 1st Metacarpal Base Trapezoid HamateHamateHamate Trapezium Carpals PisiformPisiform Capitate Triquetral Scaphoid Lunate Olecranon Lateral Fossa Epicondyle Medial Epicondyle Capitulum Trochlea Trochlea Olecranon Olecranon Head of Radius Neck of Radius Ulna Radius Interosseous Membrane Anterior Posterior Transverse Ulnar Carpal Ligament Collateral Ligament Radial Collateral Ligament Humerus Annular Ligament Biceps Brachii Tendon Radius Triceps Brachii Tendon Medial Collateral Ligament Olecranon Bursa Ulna Humerus Annular Ligament Lateral Biceps Brachii Tendon Epicondyle Lateral Radius Collateral Ligament Olecranon Ulna Biceps Brachii Brachialis Brachioradialis Supinator Pronator Teres Flexor Carpi Radialis Palmaris Longus Flexor Carpi Ulnaris Pronator Quadratus Triceps Flexor Brachii Digitorum Superificalis Anconeus Quick Question? What was more difficult during the knee and shoulder unit: Injuries or Special tests Elbow Sports med 2 Movements • Carrying angle – Females 10-15 degrees, Males 5 degrees • Flexion – 145 degrees • Extension: ?? • Pronation – 80 degrees • Supination – 85 degrees Articulations • Consists of 3 separate joints – Humeroulnar – Humeroradial – Proximal radioulnar Ligaments and Bursae • Medial collateral ligament – Prevents valgus forces • Lateral collateral ligament – Prevents varus forces (uncommon) • Annular ligament – Stabilizes head and neck of radius (strong) • Olecranon bursa – Between olecranon process and skin Musculature • Biceps Brachii, Brachialis, brachioradialis – Elbow flexion • Triceps brachii, anconeus – Elbow extension • Pronator teres and quadratus, supinator – Pronation and supination Nerve/Blood Supply • Median Nerve • Radial Nerve • Ulnar Nerve – Funny bone • Radial Artery • Ulnar Artery Assessment • History – Land on tip of bent elbow? (most common MOI) – Overuse from throwing? – Over extension? – Location and duration of pain? – Positions that increase or decrease pain? – Previous elbow injuries? – Locking or crepitation w/movement? YOUR TURN TO PRACTICE: HISTORY • Turn to someone near you and give different history questions back and forth until someone repeats, cannot think of one or lists something that does not belong. • Start first with: – Elbow questions – General questions – Any other specific joint questions NO NOTES, PHONES, FRIENDS; JUST YOU Assessment • Observations – Deformities, swelling – Carrying angle • Normal 5-15 degrees • Too little or too great could = fx – Decreased flexion or hyperextension – 45 degree angle, posterior observation of epicondyles and olecranon process to make isosceles triangle YOUR TURN TO PRACTICE: OBSERVATION • Turn to someone DIFFERENT and give different observations back and forth until someone repeats, cannot think of one or lists something that does not belong. • Start first with: – Elbow observations – General observations – Any other specific joint observations NO NOTES, PHONES, FRIENDS; JUST YOU Assessment • Bony Palpations – Medial epicondyle – Lateral epicondyle – Olecranon process – Radial head – Radius – ulna Assessment • Soft tissue palpations – Anterior • Biceps brachii • Brachialis • Brachioradialis • Pronater teres – Posterior • Triceps Brachii • supinator – Medial • Medial collateral ligament – Lateral • Lateral collateral ligament • Annular ligament YOUR TURN TO PRACTICE: PALPATION • Turn to someone DIFFERENT AGAIN and give different palpations back and forth until someone repeats, cannot think of one or lists something that does not belong. • Start first with: – Elbow observations – General observations – Any other specific joint observations NO NOTES, PHONES, FRIENDS; JUST YOU Strains • MOI: FOOSHA = hyperextension • S/S – AROM or RROM= pain – Point tender • TX – RICE possibly a sling – Cryotherapy, US, rehab – X-ray if severe Special Test: MMTs Elbow MMTs • Flexion • Extension • Pronation • Supination • Write in the muscle for each action YOUR TURN Elbow Dislocation • MOI – FOOSHA, or severe twist with flexion – Ulna and radius are pushed posterior (most common) • S/S – Severe pain, swelling and disability – Deformity – Probable radial head fx • TX – Ice, sling, check circulation – Refer for x-ray and reduction Elbow Fractures • MOI – FOOSHA, or direct blow • S/S – Possible visible deformity – Hemorrhage, muscle spasm, and swelling • TX – Stabilize, monitor distal pulse – Refer for x-ray, splint 6-8 weeks https://www.youtube.com/watch?v=MzJP4oiPz3k Medial Collateral Lig. (MCL) sprain • MOI – Valgus force from repetitive trauma – Tennis, golfing, throwing • S/S – Pn. On medial aspect of elbow – Parasthesia, and laxity • TX – Rest, NSAIDs, strengthening, correct form Special Test: Valgus Test Valgus Stress Test Picture Procedure/Positive Diagnosis Apply a medial force MCL sprain (valgus) to the elbow at 0 and 30 degrees to see laxity bilaterally or pain Varus Stress Test Picture Procedure/Positive Diagnosis Apply a lateral force (varus) LCL sprain to the elbow at 0 and 30 degrees to see laxity bilaterally or pain Volkmann’s Contracture • MOI – Complication of serious elbow injury – Muscle spasm, swelling, or bone pressure on the brachial artery • S/S – Pn. In the forearm that is worse when fingers are passively extended – Decreased or absent brachial and radial pulses • TX – Removal of constricting casts, wraps or braces, elevation – Can become permanent Ulnar Nerve Injuries • MOI – Pronounced valgus at the elbow – friction problem – Dislocation or pinched by a ligament during flexion activities • S/S – Paresthesia to fourth and fifth fingers • TX – Conservative, avoid activities that aggravate nerve – Possible surgery to move nerve anteriorly Special Test: Tinels Sign Tinel’s Sign Picture Procedure/Positive Diagnosis Stabilize wrist and tap the Ulnar nerve compromise ulnar groove (nerve) to see athlete complains of tinging down arm Epicondylitis • MOI – Lateral (tennis elbow) • Tennis, baseball, swimming, golfing • Repeated forearm flexion and extension – Medial (pitchers or golfers elbow) • Repetitive wrist flexion, valgus stress on elbow • S/S – Aching pn. During and after activity – decreased ROM – hand weakness • TX – RICE, NSAIDS, US – ROM, PRE, Deep friction massage – Elbow sleeve or band just below the bend of the elbow Special Test: Epicondylitis tests Cozen’s Test Picture Procedure/Positive Diagnosis Stabilize elbow and put Lateral epicondylitis or pressure over lateral tennis elbow epicondyle as you resist wrist extension; athlete complains of pain at lateral epicondyle Medial epicondylitis Test Picture Procedure/Positive Diagnosis Stabilize elbow and put Medial epicondylitis or pressure over medial Little League elbow epicondyle as you resist wrist flexion; athlete complains of pain at medial epicondyle Olecranon Bursitis • MOI – Direct blow • S/S – Pain, severe swelling, point tenderness • TX – Acute= ice, compression – Chronic = compression, modalities, aspiration – Padding for play Wrist/Hand Sports med 2 Articulations • Radiocarpal – Flexion, extension, abduction, and circumduction • Carpal – Gliding joints – Stabilized by anterior, posterior, and connecting ligaments • Metacarpal – Flexion, extension, abduction, adduction, circumduction • Phalangeal – Hinge joints – Proximal interphalangeal (PIP), Distal interphalangeal (DIP) Ligaments • Wrist – Ulnar Collateral ligament • Ulna to pisiform – Radial collateral ligament • Radius to scaphoid – Transverse carpal ligament • Roof of the “carpal tunnel” • Phalanges – Collateral ligaments Muscles • Flexors – Palmar surface – Flexor digitorum superficialis, flexor digitorum profundus • Extensors – Dorsal surface – Extensor digitorum longus, • Intrinsics – Abduction and adduction MMTs • Flexion • Extension • Ulnar deviation • Radial Deviation • Finger Abduction • Finger Adduction Blood/Nerve Supply • Nerves – Ulnar, radial – Median • Enters palm through carpal tunnel • Arteries – Radial – ulnar Allen’s Test Picture Procedure/Positive Diagnosis Athletes open & closes fist Radial or ulnar artery x3-4 and then closes, ATC compromise covers both arteries then releases one to see blood return to that side of the hand; repeat with other artery Assessment • History – MOI – Location and type of pain? – Increases or decreases pain? – History of trauma or overuse? – Any therapy given in the past? Assessment • Observations – Hand usage like writing, unbuttoning shirt – Open and close hand • Fully? Rythmically? – Touch thumb to each fingertip – Flat knuckle – Color of fingernails • Pale= poor circulation Assessment • Bony Palpations • Scaphoid (anatomical snuffbox) • Lunate • Hamate (hook) • Metacarpals • Phalanges (proximal, middle, and distal) Assessment Soft Palpations • Triangular fibrocartilage (TFCC) • Collateral ligaments of phalanges • Flexor and extensor muscles Tenosynovitis • MOI – Repetitive use and overuse of tendons and their sheaths • S/S – Pn with use, pn w/passive stretching – Tenderness, swelling over tendon • TX – Ice massage, NSAIDS, rest – ROM, contrast baths, US, PRE Special Test: Finkelsteins Finkelstein’s Test Picture Procedure/Positive Diagnosis Athlete closes thumb Tenosynovitis around same fist as ATC applies gentle ulnar deviation to see pain on radial side Carpal Tunnel Syndrome • MOI – Inflammation in the carpal tunnel, compresses median nerve – Repeated flexion, or direct blow • S/S – Tingling, numbness, weakness • TX – Rest, immobilization, NSAIDS – Possible surgery Special Test: Phalens Phalen’s Test Picture Procedure/Positive