Lecture 6 2
Terms
undefined, object
copy deck
- Bones of the elbow
-
-humerus
-radius
-ulna - humerus anterior
-
-Lateral epicondyle
-Capitulum
-Trochlea
-Coronoid fossa
-Medial epicondyle - humerus posterior
-
Lateral epicondyle
Capitulum
Trochlea
Olecranon fossa
Medial epicondyle - radius
-
head
neck
shaft - ulna
-
Olecranon process
Coronoid process
Shaft - joints of the elbow
-
humeroulnar
humeroradial
proximal radioulnar - humeroulnar joint
-
true hinge joint
flexion and extention only - humeroradial joint
-
capitulum of humerus and proximal radius
motion restricted to 2 degrees adjacent to humeroulnar joint - muscles acting on the elbow
-
Biceps brachii
Brachialis
Brachioradialis
Triceps brachii
Pronator teres
Supinator - Brachioradialis
-
Origin – distal humerus
Insertion – distal radius
Action – flex elbow in neutral position
Innervation – radial n. (C6) - Pronator teres
-
Origin – medial epicondyle
Insertion – radius
Action – pronate wrist
Innervation – median n. (C7) - Supinator
-
Origin – lateral epicondyle
Insertion – proximal radius
Action – supinate wrist
Innervation – radial n. (C6) - Bicep Brachii
-
Origin – short head = coracoid process; long head = glenoid
Insertion – proximal radius
Action – supinate wrist and flex elbow
Innervation – musculocutaneous n. (C6) - Brachialis
-
Origin – distal humerus
Insertion – proximal radius
Action – flex elbow
Innervation – musculocutaneous n. (C6) - Elbow Flexion
- Brachialis >> biceps brachii>brachioradialis
- elbow extension
- triceps brachii
- elbow pronation
-
-rotation of radius around ulna
-pronator=quadratus>pronator teres - elbow supination
- supinator > biceps brachii
- nerves of the elbow
-
musculocutaneous
median
radial
ulnar - triceps brachii
-
Origin – long head = glenoid; lateral & medial heads = posterior humerus
Insertion – proximal ulna
Action – extend elbow
Innervation – radial n. (C7-T1) - musulocutaneous nerve
-
motor - flexors of arm
sensory - lateral forearm - median nerve
-
Motor = flexor muscles of wrist and hand, intrinsic flexor muscles on radial side of palm
Sensory = lateral 2/3rds of palm and dorsum of 2nd and 3rd fingers - radial nerve
-
Motor (deep branch) = most of extensor-supinator muscle group
Sensory (superficial branch) = dorsum of hand - ulnar nerve
-
Motor = portions of flexor muscles of wrist, most of intrinsic hand muscles
Sensory = 5th and half of 4th finger on both dorsum and palm - throwing mechanics at elbow
-
-Significant phases for elbow motion = late cocking, acceleration, deceleration
-Most valgus stress in early acceleration - late cocking phase
-
Elbow flexion increases
Triceps higher activity than flexors
Wrist extensors active - acceleration phase
-
Elbow rapidly extends with strong triceps action
Strong wrist/finger flexor activity - deceleration phase
-
Elbow flexors reach peak intensity (eccentric)
Triceps activity diminishes rapidly - ulnohumeral dislocation
-
Deformity
Pain and swelling, particularly medially
loss of function
Considered medical emergency
R/O circulatory, nerve impairment
Immediate immobilization
Closed reduction under anaesthesia ASAP - radioulnar dislocation
-
Subluxed/dislocated radial head
Nursemaid’s or housemaid’s elbow
Pulled-elbow syndrome
Longitudinal traction on extended and pronated upper extremity - little league elbow
-
skeletally immature athlete
avulsion of medial epicondyle w/ 2 degree tension stress - LL elbow etiology
-
Cocking and acceleration phases cause considerable forces at elbow
-Medial = UCL injury, avulsion of medial growth plate, strain of flexor muscles, ulnar neuropathy
-Lateral = lateral epicondylitis, cartilage injury, loose bodies
-Follow through causes hyperextension
-Bone spurs, avulsion fracture - LL elbow signs and symptoms
-
Non-limiting ache during performance - limiting ache and post-activity ache
Localized tenderness, swelling, ecchymosis - LL elbow management
-
-“Crow-hop methodâ€
-Curveball, slider, knuckleball, forkball developed after age 14 – 15
-2 appearances/week, 3 days rest in between
-Age 8-10 = 50 pitches/game
-Age 11-14 = 70 - 75 pitches/game
-Age 15-18 = 90 – 105 pitches/game - management 2
-
Activity modification (limit at home throwing)
Rest/immobilization X 2-3 weeks
No throwing for 12 weeks
Surgery if persistent medial instability/ulnar neuropathy - elbow tendonitis
-
Intrinsic factors
-Genetic predisposition
-Uncorrected sport-imposed deficiencies
-Muscular imbalance
-Joint laxity
Extrinsic factors
-Training errors
-Equipment
-Sport technique
-Environmental conditions - Medial/Ulnal collateral ligament sprain
-
-late cocking, acceleration phase of throwing
-ulnar nerve often involved
-tommy john surgery - Valgus extension overload syndrome
- poor mechanics, infelxibility, fatigue
- Ulnar neuritis
-
Associated with MCL sprain/rupture
Tensile stress along ulnar nerve
Positive Tinel’s sign
Tingling, numbness along medial forearm and into ring and little finger
Weak grip - Overuse elbow injury management
-
Inflammatory/pain control
-PRICEMM
Activity modification
Control/eliminate injury producing activity
Stretching/flexibility
Strengthening
Modify equipment, mechanics/technique
Bracing/taping - bones of the wrist and hand
-
Radius
Ulna
Carpals
Metacarpals
Phalanges - Carpals proximal row
-
scaphoid
lunate
triquetrum
pisiform - carpals distal row
-
trapezium
trapezoid
capitate
hamate - metacarpals
-
1-5, lateral to medial
Proximal end = base
Distal end = head (knuckle)
Shafts (bodies) - phalanges
-
Bones of the digits (miniature long bones)
Proximal end = base
Distal end = head
Thumb has 2, all others have 3 - joints of the wrist and hand
-
Distal radioulnar
Radiocarpal
-TFCC
Carpometacarpal
Metacarpophalangeal
Interphalangeal - muscles acting of the wrist and hand
-
Extrinsic
Intrinsic
Flexor-pronator
Extensor-supinator
Retinacula
Tendon sheaths - movements of the wrist
-
sagittal plane - flexion and extension
frontal plane - radial and ulnar deviation
-circumduction - movements of the hand
-
Flexion/extension
-Fingers & thumb
Abduction/adduction
-Fingers & palmar
Opposition (thumb only) - nerves of the wrist and hand
-
median
ulnar
radial - injuries to the wrist and hand
-
bone
ligament
tendon
nerve - fractures of the wrist and hand
-
radius
scaphoid
metacarpals - radius fractures
-
Colles’ fracture
-“dinner fork deformityâ€
-Within 1-1½ inches of wrist joint
-Distal segment displaces dorsally
Smith’s fracture
-Opposite of colles’
-Distal segment displaces volarly
-Median nerve injury associated
Surgery (ORIF) is often indicated - Scaphoid fracture management
-
Nonunion or aseptic necrosis
Long-arm thumb cast - short-arm thumb cast - silicone spica splint - Bennett's fracture
-
1st metacarpal
Thumb hyperabduction
Pinning (< 3 mm) or ORIF - Boxer's fracture
-
5th metacarpal
Closed fist punch
Palpable deformity - Acute fracture management
-
Assess circulatory and nerve status
Ice, compression, immobilization
Splint/immobilize hand/fingers in position of function
Slight wrist extension
Slight finger flexion - sprain / dislocation
-
Wrist sprain/dislocation
Gamekeeper’s thumb
Finger sprain/ dislocation - wrist sprain / dislocation
-
Axial loading on proximal palm during fall with outstretched hand producing wrist hyperextension
Palpable tenderness, swelling
Pain with active or passive wrist extension
Marked deformity with dislocation
Ice, compression, immobilization
Pain/inflammation control
Brace/tape/splint as appropriate - gamekeepers thumb
-
aka “skier’s thumbâ€
Sprain of ulnar (medial) collateral ligament of MP joint of thumb
Forceful abduction of thumb away from hand
Palpable tenderness, swelling at MP joint
Pain with valgus stress
Manage by controlling pain/inflammation, taping, splinting - finger sprain/dislocation
-
-Excessive varus/valgus stress and hyperextension
-Injury often at proximal attachment of ligament
-Palpable tenderness, swelling, limited ROM
-Deformity with dislocation
-Assess neurovascular status
-Ice, compression, immobilization
-R/O fracture
-“Buddy taping†- strains of the wrist and hand
-
Tendon rupture
Jersey finger
Mallet finger
Boutonniere deformity
Tendonopathy
De Quervain’s
Trigger finger
Nerve entrapment
Carpal Tunnel - jersey finger
-
-Rapid, forceful extension of distal phalanx, avulsing/rupturing finger flexor tendon
-Inability to flex distal phalanx
-Surgery within 7-10 days to reattach tendon - Mallet finger
-
-Rapid, forceful flexion of distal phalanx, avulsing/rupturing finger extensor tendon
-Inability to extend distal phalanx
-Splint for 6-8 weeks in full extension - Boutonniere deformity
-
-Rapid, forceful flexion of PIP joint against resistance
-Rupture of extensor tendon at middle phalanx, leaving no active extensor mechanism over PIP joint
-Deformity develops over 2-3 weeks as flexors dominate, without extensor presence
-Splint in full extension for 6 weeks - Dequervain's tenosynovitis
-
-Common in racquet sports
-Repetitive use of thumb and ulnar deviation
-Excessive friction between 2 tendons sharing common sheath
-Palpable tenderness with painful thumb movements
-Pain reproduced with resisted thumb abduction and stretching wrist/thumb in ulnar deviation
-Pain/inflammation control, rest, activity modification
-Thumb spica splint immobilization - Trigger finger
-
Most common in ring and middle finger
Results in crepitus finger “locking†in flexion
Inflammation control, splinting
Steroid (cortisone) injection - Carpal tunnel syndrom
-
Compression of median nerve within carpal tunnel
Pain, numbness, tingling, burning on palmar aspect of thumb, index, middle finger
Diminished grip/pinch strength
Symptom reproduction with compression over carpal tunnel - carpal tunnel syndrome management
-
Splint wrist in slight extension, particularly at night
Inflammation control, activity modification
Steroid injection
Surgery