Chapter 20

The Wrist and Hand
◦ Made up of 27 bones
 8 carpal bones make up the wrist
 5 metacarpals from the structure of the hand
 14 phalanges
 2 for the thumb
 3 for each other 4 fingers

3 bones of the elbow
joint
◦ Humerus
◦ Radius
◦ Ulna

Many structures
surround the elbow
◦
◦
◦
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Ligaments
Nerves
Muscles
Bursa sacs

Forearm Flexors
◦ Brachialis
◦ Biceps Brachii
◦ Brachioradialis

Forearm Extensors
◦ Triceps Brachii
◦ Anconeus

Several causes for a variety of athletic injuries
◦ Direct trauma
◦ Indirect trauma
◦ Acute/Chronic stresses

These MOIs can result in several injuries
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Contusions
Sprains
Strains
Dislocations
Fractures
Nerve involvement

Common injury that may involve the muscles
of the forearm and subcutaneous bony
prominences of the elbow
◦ Usually caused by a direct blow

Symptoms

Treatment
◦ Bruising
◦ Subsequent bleeding
◦ Stiffness during function or
active motion
◦ PRICE
 Prevents myositis ossificans

Inflammation of the olecranon bursitis
◦ Caused by direct blows to the olecranon process
◦ Can be accompanied by infection due to the
frequent abrasions that occur over the tip of the
elbow

Treatment
◦ Depends on whether infection is involved
◦ Uninfected bursitis
 Ice compresses
 Rest
◦ Anti-inflammatory meds
◦ Pain meds
◦ Aspiration of the bursa

Caused by a direct blow the
medial epicondyle of the
humerus
◦ Athlete complaints of
immediate pain and burning
sensation down the ulnar side
of the forearm to the ring and
little fingers
 Also known as hitting the “funny
bone”

Treatment
◦ None is usually necessary

Normally occur with a sudden overload to the elbow
joint
◦ can acute or chronic

Acute Strains

Chronic Strains

Common areas of acute strains
◦ Sudden excessive overload
◦ Tenderness over the affected area
◦ Pain on function or resisted motion
◦ Result of continued overuse
◦ Overuse syndrome
◦ Chronic degenerative processes
◦ Common flexor tendon
 Medial epicondyle
◦ Common extensor tendon
 Lateral epicondyle


Usually due to forced
hyperextension or
valgus/varus forces
Symptoms
◦
◦
◦
◦
◦
Click or pop
Sharp pain at injury
Tenderness
Localized swelling
Pain when repeating MOI
 Usually relieved by bending
the elbow

Usually caused by repetitive
overload of the attached
musculotendinous units
◦ Occurs in the region of the
medial and lateral epicondyle
of the humerus
◦ Called “tennis elbow” if lateral
◦ Called “golfer’s elbow” if
medial
◦ If it occurs in younger patients,
called “little leaguer elbow”
◦ Can also accompany an injury
to the growth plate of the
epiphysis


Symptoms
◦
◦
◦
◦
Pain when used
Possible swelling
Local tenderness
Pain with resisted wrist motion
◦
◦
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◦
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May develop into prolonged degenerative changes
Causes chronic epicondylitis
Contractures of the elbow
Reduced friction
Possible rupture of muscle tendon unit
Without proper treatment condition
may worsen

Treatment

Preventive measures
◦ RICE
◦ Modifying activities that aggravate conditions
◦
◦
◦
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Using proper technique/equipment
Limiting stress
Adequately warming up
stretching

Most commonly involves the posterior
displacement of the ulna and radius in
relationship to the humerus
◦ Often caused by a fall onto an outstretched hand with
elbow in extension

Symptoms
◦
◦
◦
◦

Obvious deformity
Loss of elbow function
Considerable pain
Initial exam should include evaluation
of nerve function of hand and fingers
Treatment
◦ Immobilzation
◦ Immediate referral to physician of medical facility
◦ Possible vascular and neurological damage

The result of either direct trauma or indirect stresses
transmitted through the upper extremity by falling on an
outstretched arm
◦ Fractures in younger athletes commonly
involve epiphyseal plate fractures

Symptoms
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
Directly related to degree of severity
Point tenderness
Hemorrhaging
Swelling
Limited ROM
Disability at elbow or hand
Increased pain with movement
Treatment
◦ Immobilization
◦ Ice
◦ Prompt referral to physician or medical clinic

Occurs in the absence of blood flow (ischemia) to the
forearm
◦ Can lead to contracture, where joint remains bent and cannot
straighten

Causes

3 Levels of severity in Volkmann’s Contracture
◦ Increased pressure from swelling or trauma
◦ Fracture
◦ Mild
 Involves contracture of 2 or 3 fingers
 No limited loss of sensation
◦ Moderate



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Involves all fingers being flexed
Thumb stuck in palm
Wrist may be stuck in flexion
Usually loss of sensation in the hand
◦ Severe
 Involves all muscles in forearm (flexors and extensors)
 Fingers
 Severely disabling condition

Symptoms
◦ Severe pain when a muscle running through a
compartment is passively moved
◦ Forearm may be swollen
◦ Shiny
◦ Painful when squeezed
◦ Pain does not improve with rest, but continues to
worsen with time
◦ If condition is not corrected
 Decreased sensation
 Weakness
 Paleness of the skin

Repetitive throwing and/or
swinging can cause irritation,
compression, or entrapment in
the cubital tunnel
◦ Called cubital tunnel syndrome

Symptoms
◦ Pain along the inner aspect of the
elbow
◦ Tenderness of the medial
epicondylar groove
◦ Paresthesia (numbness or tingling)
of ring and little finger

Usually caused by
entrapment of the nerve
which passes through a
tunnel formed by several
muscles and tendons
◦ Also called radial tunnel
syndrome

Symptoms
◦ Pain over lateral aspect of
the elbow
◦ Pain over radial head

Includes entrapment or
compression due to
hypertrophy of the
pronator teres or
repetitive pronation of the
forearm
◦ Called pronator teres
syndrome

Symptoms
◦ Pain radiating down the
anterior forearm
◦ Numbness and tingling in the
thumb, index, and middle
fingers
◦ Resistive pronation may
increase the pain

Muscles that move the Wrist
◦ 2 Flexor Carpi muscles
◦ 2 Extensor Carpi muscles
◦ 2 Palmaris muscles

Muscles that move the Hand
◦ 1 Supinator muscles
◦ 2 Pronator muscles


Muscles that move the Thumb
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2
2
1
2
1
Flexors
Extensors
adductor
abductors
opponens
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◦
3
2
3
1
flexors
extensors
abductors
adductor
Muscles that move the Fingers

Common injuries
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Fractures
Dislocations
Contusions
Sprains
Tendonitis
Nerve Impingements

Can involve any of the 14
phalange bones.
◦ Most can be treated with a finger
splint

Boxer’s Fracture
◦ A break of the 5th metacarpal
leading to the little finger

Baseball (mallet) finger
◦ Painful injury that occurs when a
ball or other object strikes the tip
of the finger, bending it beyond its
normal ROM which tears the finger
tendon and damages cartilage

Jersey Finger
◦ Caused by tearing the flexor
tendon to the fingertip
 Usually occurs from grabbing a
jersey during a tackle.
 Ring finger is the most often
affected

Scaphoid fracture
◦ Affects the scaphoid bone
◦ Paplpation of the anatomical
snuffbox will cause pain,
indicates a fracture may be
present

Colles Fracture
◦ A break of the radius just above the wrist

Treatment for all fractures
◦ RICES (rest, ice, compression, elevation, support)
◦ Evaluation by a physician


Fairly common injuries
Causes
◦ Ball striking fingertip
◦ Finger getting hooked into
equipment

Symptoms
◦ Immediate pain
◦ Swelling
◦ Crooked finger
 Usually can’t be bent or straightened

Treatment
◦ Ice
◦ Immobilization
◦ Immediate treatment by physician

Usually caused by
direct blows or falling
onto a hard surface
◦ With nails become
contused, pressure
may cause a physician
to drain blood from
beneath the nail

Gamekeeper’s thumb
◦ Sprain of the ulnar
collateral ligament of the
metacarpalphalangeal
joint (MPJ)
 Common in alpine skiiing
◦ Caused by force applied
to the medial side of the
thumb, forcing the MPJ to
stretch, tear, or even
rupture


The inflammation of the tendons
caused by overuse or repetitive
stress
Symptoms
◦ Ache or pain at the wrist
 Worsens forceful gripping, rapid wrist
movements or moving the wrist or
fingers to an extreme position

Treatment
◦ The same as other forms of
tendonitis
◦ Most common sites in the wrist
 Base of the thumb near anatomical
snuffbox
 deQuervian’s tenosynovitis


Also called Carpal Tunnel syndrome
An inflammatory disorder caused by the
following
◦ Repetitive stress
◦ Physical injury
◦ Other conditions that cause swelling around the
median nerve near the carpal tunnel

Symptoms

Treatment
◦ Pain
◦ Numbness
◦ Tingling in the wrist, hand, fingers (except
little finger)
◦ Tendency to drop things
◦ Loss of sense of heat or cold
◦ Feeling of swelling, even though it is visibly
swollen
◦ Symptoms may occur only when the hand is
being used or only when at rest
◦ RICE
◦ In severe cases, surgery to decompress the
median nerve

A small, usually hard
lump above a tendon
or in a capsule that
encloses a joint
◦ Also called a synovial
hernia or synovial cyst

It is common in
handball, racquetball,
squash and tennis
◦ Cause of the cyst is
unknown

An injury to the extensor tendon
affecting the proximal
interphalangeal joint (PIP) at the
middle of the finger or the distal
interphalangeal joint at the end of the
finger
◦ Caused by a direct blow to a bent finger

Symptoms

Treatment
◦ Problems flexing and extending the
finger
◦ Physician should be contacted
immediately
◦ Joints will be painful and tender
◦ Finger misshapen or deformed
◦ The athlete will not be able to straighten
it
◦ Must be done promptly
◦ Athlete may not regain normal use of the
finger