Elbow, Wrist and Hand Injuries

Anatomical Structures

Radial Styloid Process

Ulnar Styloid Process

Olecranon and Coronoid Processes of the Elbow

Metacarpophalangeal Joint (Mp)

Proximal Interphalangeal Joint (Pip)

Distal Interphalangeal Joint (Dip)

Anatomical Snuffbox

Elbow:

Articulations of the humerus, radius, and ulna. [ olecranon process ]

Medial collateral ligament: 3 portions, anterior, posterior, oblique

The anterior fibers are tight in extension, while the posterior fibers are tight in flexion [ beyond 90 degrees ] The posterior fibers are fan shaped and thin when compared to the anterior fibers.

The lateral collateral ligament consists of a capsular thickening which runs from the lateral epicondyle to the annular ligament.

Muscles

Biceps, 2 origins, 1 on the superior region of the glenoid and the other on the coracoid process. Insertion is into the tuberosity of the radius and is thus the primary supinator of the forearm.

Brachial, originates on the humerus, extends anteriorly across the joint and inserts into the ulna.

Triceps, 3 heads, originates from the inferior posterior glenoid and humerus to insert into the olecranon process of the ulna.

Flexor - pronator group, originates on the medial

Epicondyle, extends down the arm to insert at the wrist and fingers.

Extensor - supinator group, originates at the lateral epicondyle and extends down the forearm dorsally into the wrist and hand.

Olecranon bursae, separates the skin over the tip of the elbow from the pointed end of the ulna.
[ Olecranon process ]

Radial - humeral bursae, lies anteriorly between the radial head and the lateral epicondyle between the muscle attachments.

Movements

Elbow: flexion - extension

Wrist: supination - pronation - ulnar and radial deviation flexion and extension

Flexion and extension originate at the humeroradial and humeroulnar joints while pronation and supination occur from the radio scaphoid (Navicular) articulations at the wrist and the radioulnar joint at the elbow.

Bones

Elbow injuries

1. Upper arm contusions

2. Elbow

a. Ulnar nerve contusions (funny bone)
b. Ulnar nerve neuritis from throwing

Tinel Sign

The patient is positioned with the elbow in a flexed position. The practitioner taps over the medial side of the elbow in the ulnar notch. Tingling and neurological symptoms in the forearm and or fingers is considered positive for ulnar nerve pathology. 

c. Radial nerve
d. Olecranon bursitis
e. Hyperextension

3. Ligament sprains

a. Medial
b. Lateral
c. Hyper extension
d. Little league elbow

Proper evaluation postioning calls for the shoulder to be completed externally rotated so the shoulder joint is stabilized and the elbow can then be placed into varus and valgus stress with minimal shoulder accessory movement. 

The medial epicondyle has been disrupted in this adolescent baseball player from throwing too much. The loose area at the base of the olecranon is the epiphysis or growth plate.

4. Muscular strains and tears.

Avulsion of the triceps muscle from the olecranon as the result of a strong eccentric force against an outstretched arm.

5. Epicondylitis

a. Medial - golfers elbow
b. Lateral - tennis elbow

Passive Tennis Elbow Test

Tests for tennis elbow include placing the elbow in full extension, the wrist is then flexed, pain over the lateral epicondyle is a positive indication for tennis elbow or lateral radial epicondylitis. 

Golfer elbow is evaluated by having the patient pronate and flex the wrist and forearm at the same time. A positive result is when pain is isolated over the medial epicondylar attachment of the flexor / pronator muscle mass. 

Cozen's Test -

The patient is seated, the practitioner stabilizes the elbow while palpating the lateral epicondyle. The patient pronates and extends the wrist against resistance. Pain with motion and or over the condyle is positive for tennis elbow. 

This test can be made even more selective by having the patient extend each finger while the wrist is flexed. 

6. Dislocations (fractures of the coronoid process occur in approx. 35-40% of elbow dislocations)

Dislocations of the elbow are infrequent occurrences in intercollegiate athletics. However, when they do occur, the are often serious injuries due to the potential for fractures and impaired distal circulation.

Notice the "dimples" of the olecranon and the outline of the radial head

X-ray of posterior lateral dislocated elbow.

Dislocation is reduced.

No fractures are present.

.

Notice the fractures of the coronoid process and the free fragment that is off of the radial head that is blocking the joint from reducing. Fractures are present in approximately 35-40% of all elbow dislocations.

Immediate treatment calls for immobilization for 7-10 days followed by bracing in a hinged elbow brace for a period of 3-4 weeks with gradual increasing in the range. The total time missed including rehabilitation will be somewhere in the 4-6 week range for an athlete participating in collision type activities. Throwing players will miss more time in order to regain full proprioceptive function.

The Don Joy, I.R.O.M. Brace is a single sided adjustable hinged elbow brace that allows the practitioner to control the range of motion during the recovery and rehabilitation process.

This Don Joy, Playmaker brace is actually a modified knee brace in a small size that allows for protection when playing. The extension stops are set to 20 or 30 degrees of extension. The Dry Tech material is lighter and breathes much better than neoprene type materials.

7. Fractures

Hand And Wrist Injuries

1.Mallet finger [ extensor tendon ]

Mallet fingers most commonly occur in the long, ring and little fingers of the dominant hand. 

A good result following treatment will result in an extension lag of < 15°, a poor result will result in an extension lag of > 30°. 

2. Game keepers thumb [ ulnar collateral ligament ]

Non involved side	Carrying angle	Gamekeepers sprain, notice the amount of joint laxity

3. Jersey finger [ rupture of the profundus tendon ]

4. Tendon injuries (Testing for tendon attachment)
a. Profundus
b. Superficialis

Profundus tendon testing	Superficialis tendon testing

5. Collateral ligament tears

6. Central Slip / Volar plate injuries. These structures act to control both the extensor tendons and hyper extension of the fingers. Whenever a patient has a jammed finger or has had a dislocation, a rupture of the central slip must be considered. 

Central Slip Diagnostic Tests

(Smith and Ross Test)

Place the wrist into full flexion and forcibly flex the MPj's. Evaluate PIP joint      extension , a 15-20° loss of extension is considered a positive diagnostic finding. (Szabo)

7. Boutonniere deformity - recognition is often hard to initially detect. This injury is very often associated with a palmar dislocation of the PIP joint. Flexion of the PIP with hyperextension of the DIP. Usually associated with a central slip tear or disruption. 

8. Swan neck deformity - hyper extension of the PIP with hyper flexion of the DIP.

9. Colles fracture [ radius ]

10. Bennett's fracture [ thumb ]

The extensor tendons tend to pull down on the first metacarpal shaft and displace the fragment.	Intra medullary screw fixation.

11. Scaphoid - Navicular fractures [ limited blood supply comes form the distal portion of the bone to the proximal]

The proximal pole of the Scaphoid (Navicular) bone is fractured. These fractures have to be immobilized for the best healing. Since the Scaphoid derives the blood supply from the distal end to the proximal end the incidence of non unions in the healing process is high.

At times, the fracture is not present on normal x-ray and it is necessary to get a bone scan to confirm the fracture. The dark area shows the increased bone activity at the scaphoid (Navicular) bone.

3M makes an excellent casting material for use as a playing cast. The Semi Rigid cast stays "rubbery" when applied as is fully legal for play.

12. Anatomical snuffbox consists of the extensor pollicis longus and brevis tendons plus the abductor pollicis longus.

13. Lunate dislocations (this injury is potentially very serious because of the potential for nerve damage)

Dislocated lunate	Reduction with "K" wire fixation

14. Boxers fractures [ metacarpals ] 4th or 5th. Distal head fracture.

15. Metacarpal Shaft Fractures

Examination of the metacarpals involves the practitioner loading the shaft via direct pressure in both a linear and axial loaded position. While x-ray examination is the best way to assess potential fractures, clinical / field examination is usually accurate for gross fractures until they are confirmed with radiographs. 

Fractured 4th metacarpal	Fixation using a mini plate
4th Metacarpal Butterfly Frx.	Repaired with intramedullary K wires
click on picture for larger view

16. Dislocated fingers "but it’s just a finger"
Always x-ray fingers following a dislocation to rule out any small avulsion type or chip fracture of the articular surfaces or digits.

17. "Smash" injuries to the finger.

	This finger was smashed between a squat bar and the weight rack resulting in an avulsion of the distal tip of the finger and nail.
Side view of finger showing the exposed distal phalange.
	Surgical repair of the finger. It was necessary to shorten the distal end of the phalanx. Primary closure of the finger was then completed. The patient will lose approximately 1/4" of the distal end of the finger but otherwise will have full recovery.
The healed finger approximately 3 months post trauma.

Special Clinical Tests for the Wrist and Hand

Finkelstein Test for de Quervain's Disease of the abductor pollicis longus and extensor pollicis brevis tendons. 

The patient makes a fist around the flexed thumb, the wrist is then placed into ulnar deviation, pain along the extensor and abductor tendons of the thumb is a positive finding and thus indicative of tenosynovitis. 

Phalen Test

This tests for Carpal Tunnel Syndrome. The patient flexes both wrists and places the dorsal side against each other and holds this position for approximately 30 seconds.  Neurological symptoms and or tingling in the median nerve dermatome is considered positive for Carpal Tunnel Syndrome involving the median nerve. 

Tinel Sign

The practitioner taps over the palmar side of the distal wrist over the carpal tunnel. Tingling and or reproduction of the neurological symptoms is considered to be a positive test. 

Special thanks to Bert Franks, M.D., Joe Milne, M.D., Steve Brotherton, M.D., and Will Lowe, M.D. for their assistance with x-rays and "guidance."

Questions or comments: T. Ross Bailey, M.Ed. ATC, LAT