Chapter 27 The Elbow Forearm Wrist and Hand

Anatomy – Elbow and Forearm Osteology Humerus v Trochlea/groove v Medial/lateral condyles v Capitellum v Coronoid fossa v Radial fossa Ulna v Coronoid process v Ulnar tuberosity Radius v Radial head v Radial neck v Radial tuberosity Copyright 2005 Lippincott Williams & Wilkins

Elbow Osteology/Ulnar Ligaments Copyright 2005 Lippincott Williams & Wilkins

Elbow Arthrology Proximal Articulations v Humeroulnar v Humeroradial v Radioulnar Distal Articulation v Distal

Myology v Pronator teres v Supinator v Biceps brachii v Brachialis v Brachioradialis v

Anatomy – Wrist Osteology v Scaphoid v Lunate v Triquetrum v Pisiform v Trapezium

Arthrology of Wrist Joints v Radiocarpal v Midcarpal v Intercarpal Copyright 2005 Lippincott Williams

Wrist Complex Radiocarpal Joint v Radius/articular disk v Scaphoid v Lunate v Triquetrum Midcarpal Joint v Scaphoid v Lunate v Triquetrum with trapezium v Trapezoid v Capitate v Hamate Copyright 2005 Lippincott Williams & Wilkins

Wrist Complex Copyright 2005 Lippincott Williams & Wilkins

Radiocarpal Joint Copyright 2005 Lippincott Williams & Wilkins

Ligaments of Wrist and MCP Copyright 2005 Lippincott Williams & Wilkins

Myology Extensors of Wrist Flexors of Wrist v Extensor carpi radialis v Flexor carpi ulnaris longus/brevis v Flexor carpi radialis v Extensor carpi ulnaris v Pronator quadratus Copyright 2005 Lippincott Williams & Wilkins

Hand Osteology and Ligaments of Finger 5 Metacarpals (MCP) and 14 phalanges (PH) Copyright

Myology of Hand v Extensor digitorum v Extensor indicis v Extensor digiti minimi v Opponens digiti minimi v Dorsal interossei v Palmaris longus v Flexor digitorum superficialis v Flexor digitorum profundus v Flexor digiti minimi v Palmar interossei Copyright 2005 Lippincott Williams & Wilkins

Intrinsic Anatomy of the Hand Copyright 2005 Lippincott Williams & Wilkins

Functioning Myology at the Thumb v Adductor pollicis v Abductor pollicis longus v Abductor pollicis brevis v Opponens pollicis v Flexor pollicis longus v Flexor pollicis brevis v Extensor pollicis longus v Extensor pollicis brevis Copyright 2005 Lippincott Williams & Wilkins

Regional Neurology v Median nerve v Ulnar nerve v Radial nerve Copyright 2005 Lippincott

Kinesiology – Elbow and Forearm ROM of Elbow v 0– 135 actively v 0– 150 passively v Motion is primarily gliding of ulna on trochlea Pronation v 0– 80 v Radius X’s over ulna Copyright 2005 Lippincott Williams & Wilkins

Kinesiology – Wrist Ideal ROM v 80° flexion – 70° extension v Resting position between 20– 35 extensor + 10– 15 ulnar deviation v Most ADLs require functioning within 10° flexion – 35° extension v Frontal plane 15° radial dev. – 30° ulnar dev. v Radiocarpal joint – primarily gliding movement Copyright 2005 Lippincott Williams & Wilkins

Hand Kinesiology CMC v 2 nd– 4 th permits 1° of freedom in flexion and extension. v 4 th is slightly more mobile than 2 nd and 3 rd. v 5 th CMC increases significantly and also allows abduction and adduction. v Thumb – 20° flexion – 45° extension 0 – 40° abduction. v Primary role of CMC – Cupping of the hand forming palmar arches. Copyright 2005 Lippincott Williams & Wilkins

MCP Joint v 4 th MCP – 2° of freedom (flexion and extension) v Mobility increases from radial-ulnar sides v AROM – 90° flexion – 10° extension v Functional flexion 60° v Abduction/adduction – 20° Copyright 2005 Lippincott Williams & Wilkins

IP Joints PIP v 0– 100° flexion (radial side) v 0– 135° flexion (ulnar

Extensor Mechanism Composed of: v Extensor hood v Extensor digitorum v Palmar interossei v

Grip Activity – Four Stages: 1. 2. 3. 4. 5. Hand opens. Fingers close about the object. Increase force to a level appropriate for task. Hand reopens to release object. Two types – Power grip, prehension grip Copyright 2005 Lippincott Williams & Wilkins

Power Grip/Prehension Grip Copyright 2005 Lippincott Williams & Wilkins

Examination and Evaluation 1. Should include comprehensive exam of upper quarter. 2. Presence of comorbidities (diabetes, etc. ) requires different techniques than in those patients without these issues. 3. Medical history along with objective information forms basis for chosen interventions. Copyright 2005 Lippincott Williams & Wilkins

Observations and Clearing Tests Posture and position of limb are crucial!! v v v v General Observations Posture – head and neck Muscle tone Quality, color, temperature of skin Quality of nails Carrying angle – elbow Swelling Resting position of elbow Ability to use limb v v v v Resting Position of Hand Swan-neck deformity Boutonniere deformity Ulnar drift Clubbing of DIPs Heberden’s or Bouchard’s nodes Claw fingers Dupuytren’s contracture Mallet or trigger finger Copyright 2005 Lippincott Williams & Wilkins

Mobility Examination Elbow and Forearm v AROM/PROM v Overpressure – Flexion/extension, pronation/supination v Distraction and anterior, medial, lateral glides Wrist v AROM/PROM v Overpressure for flexion/extension, radial/ulnar deviation v Distraction and anterior/posterior, radial/ulnar glides v Radiocarpal/midcarpal, intercarpal, CMC assessment. Copyright 2005 Lippincott Williams & Wilkins

Mobility Examination (cont. ) Hand v AROM/PROM, overpressure – Flexion/extension, abduction/adduction v Distraction and anterior/posterior, radial/ulnar glides v Muscle extensibility. v All muscles crossing the elbow, wrist, and hand v Intrinsic muscles of the hand Copyright 2005 Lippincott Williams & Wilkins

Muscle Performance Examination v Grip and pinch force measurements. v Pain and inflammation v VAS, palpation for warmth, swelling Other Tests v Ligament stability v Soft tissue mobility v Neurologic status v Functional status Copyright 2005 Lippincott Williams & Wilkins

Therapeutic Exercise for Common Physiologic Impairments Hypomobility v Surgery, neurologic injuries, burns, and falls. Treatment v Heat and joint mobs for capsular mobility v Passive prolonged stretch + heat v Postural correction and strengthening of antagonist v Neural gliding techniques if immobility of neural tissue is present Copyright 2005 Lippincott Williams & Wilkins

Active Motion of Forearm Copyright 2005 Lippincott Williams & Wilkins

Impaired Muscle Performance v Fractures, dislocations, contusions, sprains, tendon lacerations, burns, nerve entrapments, etc. all impair torque ability. 1. Neurologic causes 2. Muscular causes 3. Disuse and deconditioning Copyright 2005 Lippincott Williams & Wilkins

Neurologic Causes v Neurologic pathology – DJD, cervical spine injuries v Radial/ulnar nerve compression v Injury, compression, traction, Ischemia Treatment v Nerve entrapment – Release techniques v Traction + stabilization techniques v Strengthening exercises in positions that minimize compressive or traction forces Copyright 2005 Lippincott Williams & Wilkins

Muscular Causes v Tendinopathies (elbow and wrist) v Tendon lacerations (hand) Treatment v Dynamic exercises for elbow and wrist v Closed chain (against wall/counter) v PROM, AAROM, and AROM v Mobilization early to prevent adhesions v Resistance after healing at surgical sites (~8 weeks) Copyright 2005 Lippincott Williams & Wilkins

Disuse and Deconditioning v Proximal deconditioning leads to distal overuse. v Repetitive work encourages this! Treatment v Postural training in neutral range. v Muscle endurance training proximal – distal. Copyright 2005 Lippincott Williams & Wilkins

Endurance Impairment 1. Often seen at hand wrist 2. Imbalance of flexor and extensors and other factors Treatment 1. High repetition/low resistance for involved muscles with appropriate rest. 2. POSTURE should be emphasized during exercises. 3. Subsequent exercises should focus on strengthening at length muscles will be at during functional activities. Copyright 2005 Lippincott Williams & Wilkins

Pain and Inflammation Impairment v Result of injury, surgery, central/local nerve compression v OA, RA also produce pain and inflammation Treatment v Grade I oscillations + ice Copyright 2005 Lippincott Williams & Wilkins

Posture and Movement Impairment v Most common – Work/hobby-related. v Lateral/medial epicondylitis, CTS, etc. Treatment v Allow adequate rest time v Ensure proper tool size (when applicable) v Reinforce good posture v Control cycle time, recovery time, exertion frequency Copyright 2005 Lippincott Williams & Wilkins

Computer Workstation Posture Copyright 2005 Lippincott Williams & Wilkins

Therapeutic Exercise Interventions for Common Diagnoses Cumulative Trauma Disorders (CTD) Factors v v v v Work pace Same task, little variability Concentrated forces on smaller physiologic elements Decreased time for rest Increase in service and high-tech jobs Aging workforce Reduction in staff turnover Increased awareness of problem Copyright 2005 Lippincott Williams & Wilkins

CTD – Treatment v Evaluate and adjust workplace environment. v Incorporate preventative maintenance mechanisms as appropriate. v Postural training. v Education regarding relaxation during “nonactive” activities. Copyright 2005 Lippincott Williams & Wilkins

Nerve Injuries v Carpal tunnel syndrome v Cubital tunnel syndrome v Radial tunnel syndrome Treatment v Medications, splinting, electrotherapy v Neural release/gliding techniques v Soft tissue massage v Stretching and strengthening exercises Copyright 2005 Lippincott Williams & Wilkins

Musculotendinous Injuries v Lateral epicondylitis v Medial epicondylitis v De Quervain’s syndrome v Trigger

Treatment of Musculotendinous Injuries v Relative rest v Occasional bracing/splinting v Inflammation control (theurapeutic modalities and ice) v Friction massage v Therapeutic exercise (stretching, strengthening) Copyright 2005 Lippincott Williams & Wilkins

Bone and Joint Injuries v Medial elbow instability v Elbow dislocations v Carpal instability v Gamekeeper’s thumb v Olecranon fractures v Radial head fracture v Colles fracture v Scaphoid fracture v Metacarpal fracture v Phalangeal fracture Copyright 2005 Lippincott Williams & Wilkins

$Treatment of Bone and Joint Injuries 1. Splinting for partial tears and fractures 2.$

Treatment of Bone and Joint Injuries 1. Splinting for partial tears and fractures 2. Isometric contractions as soon as possible 3. Adjunctive interventions (ice, therapeutic modalities, etc. ) 4. PROM/AAROM/AROM – Mobilization (consider stage of healing) 5. Strengthening exercises to restore dynamic function Copyright 2005 Lippincott Williams & Wilkins

Splinting/Stretching Copyright 2005 Lippincott Williams & Wilkins

Strengthening – Grip/Pinch Copyright 2005 Lippincott Williams & Wilkins

Complex Regional Pain Syndrome v Formerly RSD v 2 types – with and without nerve involvement Treatment v Pain must be controlled first! (e. g. , elevation + moist heat prior to massage) v TENS v AROM, joint mobs, CPM, static progressive splinting v Dynamic splinting when edema is stabilized Copyright 2005 Lippincott Williams & Wilkins

Stiff Hand Restricted Motion “Stiff hand” describes joint limitation from variety of causes (burns, fractures, trauma, etc. ) Treatment v Heating before mobilization (articular limitations) v Strengthening, stretching, static splinting v Dynamic splinting Copyright 2005 Lippincott Williams & Wilkins

Summary ü Ulnar, median, or radial nerve may become entrapped. ü UCL is primary static stabilizer and flexor carpi ulnaris is dynamic stabilizer of medial elbow. ü Grip is divided – Power grip when force is primary objective, prehension grip is used when precision is main goal. ü Mobility activities – Traditional stretching, joint mobilization, tendon nerve gliding exercises. Copyright 2005 Lippincott Williams & Wilkins

Summary (cont. ) ü CTDs are a result of a combination of factors. ü Conservative management of CTS is successful when hand wrist postures and activities are considered and monitored. ü Individuals with CRPs have varying degrees of pain, trophic changes, loss of mobility, and functional limitations. ü Interventions for stiff hand include mobility activities, splinting, and strengthening exercises. Copyright 2005 Lippincott Williams & Wilkins