EDUCATIONAL OBJECTIVES

The learner should, at the completion of the chapter, be able to perform the following:

• Understand the anatomy of the elbow, forearm, wrist, and hand.
• Identify the components of an evaluation format.
• Recognize the common injuries associated with the elbow, forearm, wrist, and hand.
• Understand the principles of rehabilitation exercises for the elbow, forearm, wrist and hand.
• Understand the preventive/supportive techniques and protective devices for the elbow, forearm, wrist, and hand.
• Review musculoskeletal conditions/disorders for the elbow, forearm, wrist and hand.

The elbow joint is an intricate collection of bones, muscles, ligaments and nerves. It permits the movements of flexion, extension, pronation and supination. Many sports place specific demands on the elbow and each movement can lead to a specific injury. The elbow joint often delivers, and sometimes receives, accidental blows that can cause bruising, fracture, dislocation or nerve damage. Excessive stresses are placed on the elbow in throwing and racquet sports.

The humerus, the largest bone of the upper extremity, has two articulating condyles at its distal end. Of the two bones of the lower arm, the ulna acts as a stationary axle and the radius turns around it as the forearm and hand rotate. The proximal end of the ulna has a bony protuberance called the olecranon process. It is the olecranon process that articulates with the proximal radius. Hanging your arm at your side with the palm facing forward, the small bony prominence closest to the body is the medial epicondyle of the humerus. The lateral epicondyle is on the opposite side. When the elbow is bent, the olecranon process is observed and easily palpable, as it is the pointed bony prominence at the bent elbow. Ligaments and tendons use the distal knobs of the humerus as a base of attachment. The elbow is made up of two joints, called the humeroulnar and humeroradial. Within these joints, the ligaments that support this joint are the ulnar collateral, radial collateral, annular, and isisceles triangle (anterior oblique, posterior oblique, and transverse oblique) ligaments.

The medial condyle articulates with the ulna of the lower arm to allow flexion and extension of the elbow. The lateral condyle of the humerus articulates with the radius, allowing pronation and supination of the lower arm and hand. The elbow joint is considered to have very strong ligamentous and muscular support. Medial and lateral collateral ligaments support this joint. The medial collateral ligament is attached to the humerus and the ulna. The lateral collateral ligament is attached to the humerus and the radius. Adding further to the elbow's stability is the annular ligament. This ligament attaches to the ulna and completely encircles the head of the radius. The annular ligament helps keep the radius and ulna from separating.

The muscles that control the elbow's movement originate above the elbow, on the humerus and the scapula (shoulder blade). These muscles include: biceps, triceps, and brachialis. The numerous muscles that control the movements of the forearm, wrist, and fingers originate on the two epicondyles of the humerus. Muscles that allow the forearm to flex and pronate are the flexor capri radialis, flexor capri ulnaris, flexor digitorum sublimis, and flexor pollicis longus. Forearm muscles that permit extension and supination are the extensor digitorum communis, extensor capri radialis brevis, extensor capri ulnaris, and extensor pollicis longus.

The wrist and hand is the site of some of the most minor, yet irritating, conditions suffered by athletes. Examples of these conditions include blisters, calluses, and chronic sprains and strains. These conditions can be disabling if excessive stress is applied. The wrist and hand contain 27 bones (eight carpel bones, five metatarsal, and 14 phalanges) and 38 joints. The carpel bones are the navicular, lunate, triquetrum, pisiform

trapezium, trapezoid, capitate, and hamate. A common way to remember these bones is using the first letter of this statement: Never Leave The Player, The Trainer Can Help.

The navicular is commonly fractured and the lunate is often dislocated. The mid hand region is made up of the five metacarpel bones, and the fingers have 14 bones known as the phalanges. Within the wrist and hand, there are numerous joints that allow movement. These are the radiocarpal, midcarpal, carpometacarpal, intercarpal, metacarpophalangeal (MCP), and interphalangeal, which include distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints in the fingers. The muscles surrounding the wrist and hand include abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, adductor pollicis, abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi, palmar interossei, and dorsal interossei.

This area of the body is innervated by a number of different nerves. The sensory distribution of a nerve root is called a dermatome, which produces feeling in a certain anatomical area. The motor distribution of a group of muscles innervated by a single nerve root is called a mytome and it produces movement of anatomical structures.

ELBOW, FOREARM, WRIST, AND HAND ANATOMY

Bones

1. Humerus
2. Radius
3. Ulna
4. Navicular (scaphoid)
5. Lunate
6. Triquetrum
7. Pisiform
8. Trapezium
9. Trapezoid
10. Capitate
11. Hamate
12. Metacarpals (5)
13. Phalanges (14)

Elbow

1. Medial Collateral (Ulna) Ligament
2. Lateral Collateral (Radial) Ligamanet
3. Annular Ligament
4. Isosceles triangle (Anterior Oblique, Posterior Oblique, Transverse Oblique)
5. Interosseous Membrane

1. Ulnar collateral ligament
2. Radial collateral ligament
3. Palmar (volar) radiocarpal ligament

1. Transverse carpal ligament
2. Collateral ligaments of the phalanges

Elbow

1. Humeroulnar
2. Humeroradial
3. Radioulnar

1. Radiocarpal
2. Midcarpal
3. Carpometacarpal
4. Intercarpal
5. Radioulnar
6. Carpometacarpal

1. Metacarpophalangeal (MCP)
2. Interphalangeal: Proximal (PIP) and Distal (DIP)

Elbow

Flexion and Extension: metacarpophalangeal and interphalangeal (proximal and distal) joints
Abduction and Adduction: metacarpophalangeal joints
Thumb Flexion, Extension, Abduction and Adduction: carpometacarpal and metacarpophalangeal joints
Opposition: movement of the thumb to touch all other fingers

1. Biceps - Flexion and supination of arm
2. Triceps - Extends forearm and upper arm
3. Coracobrachialis - adduction; assists in flexion and pronation of the arm
4. Brachialis - Flexion at elbow
5. Anconeus - Extension at elbow
6. Brachioradialis - Flexion at elbow
7. Supinator - Supination
8. Pronator Teres - Pronation
9. Pronator Quadratus - Pronation
10. Forearm Flexors and Pronators
Flexor Carpi Radialis
Flexor Carpi UlnarisFlexor
Digitorium Sublimis
Flexor Pollicis Longus
Flexor Digitorum Profundus
Flexor Digitrom Superficialis
Palmaris Longus
11. Forearm Extensors and Supinators
Extensor Digitoriun Communis
Extensor Capri Radialis Brevis
Extensor Carpi Radialis Longus
Extensor Capri Ulnaris
Extensor Pollicis Longis
12. Wrist/Hand/Fingers Extrinsics
Flexor Digitorum Profundus - flexion of DIP joint
Flexor Digitorum Superficialis - flexion of PIP joint
Abductor Pollicis Longus - adduction of MC and flexion of MCP of thumb
Extensor Pollicis Brevis - abduction of the thumb
Extensor Pollicis Longus - extension of thumb
Extensor Digitorum Communi - extension of MCP joint
Extensor Indicis Propius - extension of MCP joint
Extensor Digitorum Quinti Propius (Digitus Minimi) - extension of MCP joint
Flexor Pollicis Longus - flexion of MCP joint of thumb
13. Wrist/Hand/Fingers Intrinsics
Lumbricals I, II, III & IV - flexion of MCP joints; extension of IP joints.
Palmar Interossei - adduction of digit 1, 2, 3, & 4; flexion of MCP and extension of IP joints of digits
Dorsal Interossei - abduction, flexion, and extension of the above
Adductor Pollicis - adducts the thumb
Opponens Pollicis - opposition of thumb
Abductor Digiti Minimi - abduction of the little fingerFlexor
Digiti Minimi Brevis - flexion of MCP joint of little finger
Opponens Digiti Minimi - opposition of little finger

Myotomes
C4 - Shoulder Shrugs
C5 - Abduction Test of the Arms
C6 - Wrist Extension
C7 - Triceps (Extension)
C8 - Finger Flexion
T1 - Finger Abduction
When determining strength of myotomes, provide resistive force.

Nerve Sensory: Upper Extremities
Radial Nerve - In between thumb
Median Nerve - Index finger tip
Ulnar Nerve: 5th finger tip

EVALUATION FORMAT

The first purpose of an evaluation is to determine if a serious injury has occurred. The evaluation format of History, Observation, Palpation and Special Tests are thoroughly covered in Chapter 2 and Chapter 6. Listed below is an abbreviated version of this format.

History: Questions should include mechanism of injury, location of pain, sensations experienced, and previous injury.

Observation: Compare the uninvolved to the involved upper extremity and look for bleeding, deformity, swelling, discoloration, scars, and other signs of trauma.

Palpation: Using bilateral comparison, palpate neurological, circulatory, and anatomical structures, and assess for potential fractures.

Special Tests: Special tests assess disability to ligament, muscle, tendon, accessory anatomical structures, inflammatory conditions, range of motion, and pain or weakness in affected area. These tests are well beyond the expertise of a student athletic trainer.

ASSESSMENT TESTS

All injured joints should be properly evaluated. The purpose of a thorough evaluation is to enable the allied health professional to properly assess the severity of the injury and to make recommendations regarding treatment and possible return to participation. Listed below is a review of evaluation techniques utilized by certified athletic trainers. For further information, the learner should consult this chapter's references for a comprehensive description of assessment tests.

ELBOW

Tests for Ligament Stability

Valgus or Abduction Stress: evaluates the medial (ulna) ligament stability of the elbow
Varus or Adduction Stress: evaluates the lateral (radial) ligament stability of the elbow

Epicondylitis Tests--Lateral

Resisted Wrist Extension: determines the presence of lateral epicondylitis
Resisted Long Finger Extension: determines the presence of lateral epicondylitis
Palmar Flexion-Pronation Stretch: determines the presence of lateral epicondylitis

Epicondylitis Tests--Medial

Resisted Wrist Flexion: determines the presence of medial epicondylitis
Wrist Extension-Supination Stretch: determines the presence of medial epicondylitis

Neurological Dysfunction Tests

Tinel Sign - Elbow: detects inflammation of the ulnar nerve
Pronator Teres Syndrome: detects inflammation or entrapment of the median nerve
Pinch Grip: detects anterior interosseus nerve dysfunction

WRIST and HAND

Bony Integrity Tests

Anatomical Snuffbox Compression: indicates possibility of a navicular (scaphoid) fracture
Murphy's Sign: test for dislocation of the lunate

Ligamentous Tests (fingers/thumb)

PIP and DIP Collateral Ligament: assesses the stability of the radial and ulna ligaments of the phalanges
MCP Collateral Ligament: assesses the stability of the radial and ulna ligaments of the metacarpophalangeal joints
Gamekeeper's Thumb: assesses the ulnar collateral ligament stability at the metacarpophalangeal joint

Musculoskeletal Tests

Finkelstein's: determines presence of tenosynovitis in the abductor pollicis longus and extensor pollicis brevis tendons of the thumb
Flexor Digitorum Superficialis: assesses flexor digitorum superficialis tendon function
Flexor Digitorum Profundus: assesses flexor digitorum profundus tendon function
Mallet Finger: assesses extensor tendon integrity at the DIP joint
Boutonniere Deformity: assesses central slip integrity of extensor tendon at PIP joint

Carpal Tunnel Tests

Phalen's or Wrist Press: detects presence of carpal tunnel syndrome
Tinel's Sign - Wrist: detects presence of carpal tunnel syndrome

CONDITIONS THAT INDICATE AN ATHLETE SHOULD BE REFERRED FOR PHYSICIAN EVALUATION

• Gross deformity
• Suspected fracture or dislocation
• Significant pain, especially on joint movement
• Circulation or neurological impairment
• Joint instability
• Loss of sensation (motor or sensory)
• Abnormal sensations such as clicking, popping, grating or weakness
• Any doubt about severity or nature of the injury

Sprain: Injuries to the elbow, forearm, wrist and hand joint are common. With a mechanism of excessive stress to the joint, injuries to ligaments are classified as sprains. Sprains are placed into one of three categories: first degree (mild), second degree (moderate), or third degree (severe).

Olecranon Bursitis: Inflammation by either direct blow (contusion) or overuse will cause inflammation of the olecranon bursa. Inflammation to the bursa results in the affected area having a thick and warm feeling. When this occurs, referral to a physician is essential. Once this condition has been evaluated, basic treatment could include ice or heat, and external compression (elastic wrap).

Carpal Tunnel Syndrome: This medical condition is caused by pressure on the median nerve. Symptoms occur as a result from constriction in the carpal tunnel and pressure on the median nerve. Treatment of carpal tunnel syndrome usually begins with a wrist splint, rest and medications. Non-surgical treatments help temporarily in many cases, especially if symptoms are mild. If unsuccessful, medical re-evaluation is recommended.

Navicular Fracture: One of the most disabling conditions in sports, a fracture to the navicular (scaphoid) is common. Since these injuries usually result from a fall on an extended wrist, fractured navicular bone often leads to non-union of the bone fragments due to its poor blood supply. Usually severe pain is located in the anatomical snuffbox. Medical treatment requires P.R.I.C.E.S., x-ray, and re-evaluation on a weekly basis.

Dislocation/Subluxation: Injuries to the head of the radius, lunate and phalanges (fingers) are common sites of dislocations and subluxation.Most of these injuries occur from force placed on a outstretched hand with the elbow in extension. As with all dislocation, always suspect a fracture. Medical referral for a comprehensive evaluation is needed.

Epicondylitis: A medical term with a suffix of "itis" means inflammation. Epicondylitis is classified as a inflammation of the epicondyle and the tissues adjoining the humerus. Common sites for epicondylitis is in the elbow joint. Medial (inside) epicondylitis is referred to as pitchers elbow, whereas tennis elbow affects the lateral (outside) epicondyle.

Contusion: These injuries are caused by a direct blow or by falling on the extremity. Contusion is a bruising of tissue, which commonly occurs to the hand and ulna side of the forearm. Basic first aid treatment would be protection, rest, ice, compression, elevation and support.

Subungual Hematoma: When the fingernail receives a contusion (bruise), a subungal hematoma can occur. This excessive force will develop an accumulation of blood under the fingernail. Immediate treatment includes ice and medical referral to remove the fluid (blood).

REHABILITATION

Sending an athlete back to competition before healing is complete leaves the player susceptible to further injury. The best way to determine when healing is complete is by the absence of pain during stressful activity and by the return of full range of motion and strength, power and endurance to the affected muscle group. Prior to the beginning of any rehabilitation exercise program, the athletic trainer should consult with the sports medicine team to establish an individual program tailored for that individual athlete and the specific injury to be rehabilitated. The following list of exercises can be used as rehabilitative or preventive exercises.

Range of Motion Exercises

Elbow
Flexion
Extension
Supination
Pronation

Wrist
Flexion
Extension
Radial Deviation
Ulnar Deviation
Supination
Pronation

Fingers
Flexion and Extension
Abduction and Adduction
Thumb Flexion, Extension, Abduction and Adduction
Opposition

Elbow
Arm Flexion (bicep curls)
Arm Extension (triceps extension)

Wrist, Hand and Fingers
Hand Squeeze
Finger Abduction
Pinch Grip
Lateral/Key Pinch Grip

Before returning to competition, the following rehabilitation guidelines must be met

Full range of motion

Strength, power and endurance are proportional to the athlete's size and sport

No pain during running, jumping or cutting

Whether to apply adhesive and/or elastic bandages to an uninjured anatomical structure is a decision the athletic trainer will have to make. All injured joints should be supported initially. The basic taping and wrapping techniques are listed.

Wrapping Techniques for Compression

Elbow
Wrist/Hand

The use of protective devices is beneficial, if they are properly selected, used in the appropriate setting, correctly fitted, properly applied, and used within the rules and guidelines of the specific sport. Consultation with an equipment specialist and certified athletic trainer is highly encouraged. Listed next are various protective devices that are commercially available to use as an adjunct or replacement to a taping or wrapping procedures.

Listed next are musculoskeletal conditions/disorders that affect the elbow, wrist and /or hand. Define and review these conditions using a medical dictionary.

• Forearm Splints
• Ganglion
• Nerve injury (Median, Radial, Ulnar)
• Osteochondritis Dissecans
• Supracondylar Fracture
• Volkman's Fracture
• Volkmann's Ischemic Contracture

• Baseball Finger
• Barton Fracture
• Bennett Fracture
• Boutonniere Deformity
• Boxers Fracture
• Colles' Fracture
• Felon
• GameKeeper's Thumb
• Mallet Finger
• Murphy's Sign
• Profundus Tendon Rupture (Jersey Finger)
• Smith's fracture

REFERENCES

American Academy of Orthopedic Surgeons (1991) Athletic Training and Sports Medicine (2^nd ed.). Park Ridge, IL; American Academy of Orthopedic Surgeons.

Anderson M. and Hall S. (1995) Sports Injury Management Baltimore: Williams and Wilkins.

Gallaspy, J. & May D. (1996) Signs and Symptoms of Athletic Injuries St. Louis, Mosby

Garrick J & Webb D. (1990) Sports Injuries: Diagnosis and Management Philadelphia: W.B. Saunders

Harrelson G. & Andrews J. (1993) Physical Rehabilitation of the Injured Athlete Philadeplhia: W.B. Saunders

Hoppenfield, S. (1976) Physical Examination of the Spine and Extremities New York: Appleton, Century, and Crofts.

Norkin & White (1985) Measurement of Joint Motion: A Guide to Goniometry Philadelphia: F.A. Davis Co..

Stone R. & Stone J. (1997) Atlas of Skeletal Muscles (2^nd ed.) Dubuque: McGraw Hill.

Wright K. & Whitehill W. (1996) The Comprehensive Manual of Taping and Wrapping Techniques Gardner: Cramer Products.

Suggested Multimedia Resources

Wright, K, Harrelson, G. Fincher L & Floyd, R. (1996) Sports Medicine Evaluation Series: Elbow Dubuque: McGraw Hill.

Wright, K, Harrelson, G. Fincher L & Floyd, R. (1996) Sports Medicine Evaluation Series: Wrist and Hand Dubuque: McGraw Hill.

Wright K. & Whitehill W. (1997) Sports Medicine Taping Series: Wrist and Hand Dubuque: McGraw Hill.

Wright K. & Whitehill W. (1997) Sports Medicine Taping Series: Shoulder and Elbow Dubuque: McGraw Hill.

Chapter 12 - Review Questions

Completion:

1. The _____ and _____ tests assess the elbow collateral ligaments.
2. The anatomical snuffbox test can help identify a possible _____ of the navicular (scaphoid) bone.
3. _____ _____ is the accumulation of blood under the fingernail.
4. Pronation and supination are suggested exercises for _____ rehabilitation.
5. The bones that form the elbow are the _____, _____, and _____.
6. The_____ is similar to the femur of the leg, as both have two_____ at their _____ or lower ends.
7. Of the two bones of the forearm, the _____ acts as a stationary axle.
8. The elbow joint has very strong _____ and _____ support.
9. Helping to stabilize the elbow joint, by attaching to the ulna and encircling the head of the radius, is the _____ ligament.
10. The three muscle groups that control the movement of the elbow are the _____, _____, and the _____.
11. The wrist joint is formed by the distal ends of the _____ and _____, and by the _____ _____ bones.

Short Answer:

1. Name the 3 ligaments of the elbow joint.
2. List two suggested exercises for rehabilitation of the wrist and hand.
3. Name the eight bones that make up the wrist.
4. Name the 3 groups of bones of the hand.

Textbook Source: Wright K. & Whitehill W. (1996) The Comprehensive Manual of Taping and Wrapping Techniques Gardner: Cramer Products

Wrist

Purpose: To provide support and stability for the wrist.
General Conditions Procedure Used For: Sprains and strains.
Anatomical Structure: dorsal and palmar radiocarpal ligaments and the radial and ulnar collateral ligaments
Anatomical Position:    Hyperextension: Wrist positioned in slight flexion and finger spread apart.
                                   Hyperflexion: Wrist positioned in slight extension and fingers spread apart.
                                   Supplies Needed: 1" and 1-1/2" adhesive tape, and 1" and 2" elastic tape
Pre-Taping Procedure: With the wrist in a supinated position, in slight extension and fingers spread apart.
Taping Procedures:
1. Apply two anchor strips of 1" and 2" elastic tape. The 2" anchor should be applied around the mid-forearm; the 1" anchor around the 2nd through 5th metacarpal heads.
2. Using adhesive tape, construct a five to seven strip butterfly pattern that will extend from the proximal anchor to the distal anchor. To prevent hyperflexion, place this butterfly pattern on the hand’s dorsal aspect. To prevent hyperextension, place butterfly pattern on the hand’s palmar aspect.
3. Next, apply a second series of anchor strips.
4. Then, apply a 1" strip of elastic tape in a figure of eight pattern. Begin on the dorsal aspect of the forearm, cross diagonally to the 2nd metacarpal, encircle the distal aspect of the 2nd through 5th metacarpals, continue across the palmar aspect to the 5th metacarpal and cross diagonally from there to the radial aspect of the wrist and encircle the wrist. Two to three figures of eight can be applied.
5. A final continuous closure strip is applied with 2" elastic tape. Begin on the proximal anchor and spiral the tape, overlapping one-half its width, and ending on the distal anchor. Secure the elastic tape ends with anchors of adhesive tape.

Thumb Spica

Purpose: To provide support and stability for the 1st Metacarpophalangeal (MP) joint of the hand.
General Condition Procedure Used for: Sprain.
Anatomical Structure: Thumb and wrist.
Anatomical Position:    Hand in palm-down position, with thumb slightly flexed and phalanges adducted.
Supplies Needed: 1" adhesive tape
Pre-Taping Procedure: With the wrist in a supinated position, in slight extension and fingers spread apart.
Taping Procedures:
1.  Apply an anchor strip of adhesive tape around the wrist.  Start at the ulnar condyle, cross the dorsal aspect of the distal forearm, and encircle the wrist.
2.  Apply the first of three support strips for the 1st MP joint. Starting at the ulnar condyle, cross the dorsum of the hand, cover the lateral joint line, encircle the thumb, proceed across the palmar aspect of the hand, and finish at the ulnar condyle.  This is commonly referred to as a thumb spica.  Repeat this procedure.
3.  To help hold this procedure in place, apply a final anchor strip around the wrist.

Finger Splint

Purpose: To aid in support of the injured interphalangeal (IP) joint.
General conditions procedure used for: sprains to the phalanges of the hand.
Anatomical structure: lnterphalangeal joint.
Anatomical position:    phalanges placed in extension.
Supplies needed: 1/2" adhesive tape and gauze, felt or foam rubber.
Pre-Taping Procedure: You should cut your gauze to the appropriate size before you begin. Place the phalanges in extension.
Taping Procedures:
1. Place gauze between affected and adjacent phalanges.
2. Apply 1/2" adhesive tape around the proximal and distal aspects of the affected and adjacent phalanges. This technique is known as buddy taping. In high-risk sports, you should pair and tape the 2nd and 3rd phalanges, and the 4th and 5th phalanges together.

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