Chapter 27
The Elbow, Forearm, Wrist,
and Hand
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Anatomy – Elbow and Forearm
Osteology
Humerus
 Trochlea/groove
 Medial/lateral condyles
 Capitellum
 Coronoid fossa
 Radial fossa
Ulna
 Coronoid process
 Ulnar tuberosity
Radius
 Radial head
 Radial neck
 Radial tuberosity
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Elbow Osteology/Ulnar Ligaments
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Elbow Arthrology
Proximal Articulations
 Humeroulnar
 Humeroradial
 Radioulnar
Distal Articulation
 Distal radioulnar
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Myology
Pronator teres
Supinator
Biceps brachii
Brachialis
Brachioradialis
Triceps
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Anatomy – Wrist
Osteology
Scaphoid
Lunate
Triquetrum
Pisiform
Trapezium
Trapezoid
Capitate
Hamate
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Arthrology of Wrist
Joints
Radiocarpal
Midcarpal
Intercarpal
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Wrist Complex
Radiocarpal Joint
 Radius/articular disk
 Scaphoid
 Lunate
 Triquetrum
Midcarpal Joint
 Scaphoid
 Lunate
 Triquetrum
 Triquetrum with
trapezium
 Trapezoid
 Capitate
 Hamate
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Wrist Complex
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Radiocarpal Joint
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Ligaments of Wrist and MCP
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Myology
Extensors of Wrist
Flexors of Wrist
Extensor carpi radialis Flexor carpi ulnaris
longus/brevis
Flexor carpi radialis
Extensor carpi ulnaris Pronator quadratus
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Hand Osteology and Ligaments
of Finger
5 Metacarpals (MCP)
and 14 phalanges
(PH)
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Myology of Hand
Extensor digitorum
Extensor indicis
Extensor digiti minimi
Opponens digiti
minimi
Dorsal interossei
Palmaris longus
Flexor digitorum
superficialis
Flexor digitorum
profundus
Flexor digiti minimi
Palmar interossei
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Intrinsic Anatomy of the Hand
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Functioning Myology at the Thumb
Adductor pollicis
Abductor pollicis
longus
Abductor pollicis
brevis
Opponens pollicis
Flexor pollicis longus
Flexor pollicis brevis
Extensor pollicis
longus
Extensor pollicis
brevis
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Regional Neurology
Median nerve
Ulnar nerve
Radial nerve
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Kinesiology – Elbow and Forearm
ROM of Elbow
 0–135 actively
 0–150 passively
 Motion is primarily gliding of ulna on trochlea
Pronation
 0–80
 Radius X’s over ulna
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Kinesiology – Wrist
Ideal ROM
 80° flexion – 70° extension
 Resting position between 20–35 extensor + 10–15 ulnar
deviation
 Most ADLs require functioning within 10° flexion – 35°
extension
 Frontal plane 15° radial dev. – 30° ulnar dev.
 Radiocarpal joint – primarily gliding movement
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Hand Kinesiology
CMC
 2nd–4th permits 1° of freedom in flexion and extension.
 4th is slightly more mobile than 2nd and 3rd.
 5th CMC increases significantly and also allows
abduction and adduction.
 Thumb – 20° flexion – 45° extension 0 – 40° abduction.
 Primary role of CMC – Cupping of the hand and forming
palmar arches.
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MCP Joint
4th MCP – 2° of freedom (flexion and
extension)
Mobility increases from radial-ulnar sides
AROM – 90° flexion – 10° extension
Functional flexion 60°
Abduction/adduction – 20°
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IP Joints
PIP
0–100° flexion (radial side)
 0–135° flexion (ulnar side)
Functional ROM 60°
DIP
10° extension – 80° flexion
Functional ROM 40°
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Extensor Mechanism
Composed of:
Extensor hood
Extensor digitorum
Palmar interossei
Dorsal interossei
Lumbricals
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Grip
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
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Power Grip/Prehension Grip
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Examination and Evaluation
Should include comprehensive exam of upper
quarter.
Presence of comorbidities (diabetes, etc.)
requires different techniques than in those
patients without these issues.
Medical history along with objective information
forms basis for chosen interventions.
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Observations and Clearing Tests
Posture and position of limb are crucial!!
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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
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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
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Mobility Examination
Elbow and Forearm
 AROM/PROM
 Overpressure – Flexion/extension, pronation/supination
 Distraction and anterior, medial, lateral glides
Wrist
 AROM/PROM
 Overpressure for flexion/extension, radial/ulnar deviation
 Distraction and anterior/posterior, radial/ulnar glides
 Radiocarpal/midcarpal, intercarpal, CMC assessment.
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Mobility Examination (cont.)
Hand
 AROM/PROM, overpressure – Flexion/extension,
abduction/adduction
 Distraction and anterior/posterior, radial/ulnar glides
 Muscle extensibility.
 All muscles crossing the elbow, wrist, and hand
 Intrinsic muscles of the hand
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Muscle Performance Examination
 Grip and pinch force measurements.
 Pain and inflammation
 VAS, palpation for warmth, swelling
Other Tests
 Ligament stability
 Soft tissue mobility
 Neurologic status
 Functional status
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Therapeutic Exercise for Common
Physiologic Impairments
Hypomobility
 Surgery, neurologic injuries, burns, and falls.
Treatment
 Heat and joint mobs for capsular mobility
 Passive prolonged stretch + heat
 Postural correction and strengthening of antagonist
 Neural gliding techniques if immobility of neural
tissue is present
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Active Motion of Forearm
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Impaired Muscle Performance
 Fractures, dislocations, contusions,
sprains, tendon lacerations, burns, nerve
entrapments, etc. all impair torque ability.
1. Neurologic causes
2. Muscular causes
3. Disuse and deconditioning
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Neurologic Causes
 Neurologic pathology – DJD, cervical spine
injuries
 Radial/ulnar nerve compression
 Injury, compression, traction, Ischemia
Treatment
 Nerve entrapment – Release techniques
 Traction + stabilization techniques
 Strengthening exercises in positions that minimize
compressive or traction forces
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Muscular Causes
 Tendinopathies (elbow and wrist)
 Tendon lacerations (hand)
Treatment
 Dynamic exercises for elbow and wrist
 Closed chain (against wall/counter)
 PROM, AAROM, and AROM
 Mobilization early to prevent adhesions
 Resistance after healing at surgical sites (~8weeks)
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Disuse and Deconditioning
 Proximal deconditioning leads to distal overuse.
 Repetitive work encourages this!
Treatment
 Postural training in neutral range.
 Muscle endurance training proximal – distal.
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Endurance Impairment
 Often seen at hand and wrist
 Imbalance of flexor and extensors and other factors
Treatment
 High repetition/low resistance for involved muscles with
appropriate rest.
 POSTURE should be emphasized during exercises.
 Subsequent exercises should focus on strengthening at
length muscles will be at during functional activities.
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Pain and Inflammation Impairment
 Result of injury, surgery, central/local nerve
compression
 OA, RA also produce pain and inflammation
Treatment
 Grade I oscillations
 Grade I oscillations + ice
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Posture and Movement Impairment
 Most common – Work/hobby-related.
 Lateral/medial epicondylitis, CTS, etc.
Treatment
 Allow adequate rest time
 Ensure proper tool size (when applicable)
 Reinforce good posture
 Control cycle time, recovery time, exertion
frequency
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Computer
Workstation Posture
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Therapeutic Exercise Interventions for
Common Diagnoses
Cumulative Trauma Disorders (CTD)
Factors
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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
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CTD – Treatment
Evaluate and adjust workplace environment.
Incorporate preventative maintenance
mechanisms as appropriate.
Postural training.
Education regarding relaxation during “nonactive” activities.
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Nerve Injuries
 Carpal tunnel syndrome
 Cubital tunnel syndrome
 Radial tunnel syndrome
Treatment
 Medications, splinting, electrotherapy
 Neural release/gliding techniques
 Soft tissue massage
 Stretching and strengthening
exercises
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Musculotendinous Injuries
Lateral epicondylitis
Medial epicondylitis
De Quervain’s syndrome
Trigger finger
Tendon laceration
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Treatment of Musculotendinous Injuries
Relative rest
Occasional bracing/splinting
Inflammation control (theurapeutic
modalities and ice)
Friction massage
Therapeutic exercise (stretching,
strengthening)
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Bone and Joint Injuries
Medial elbow
instability
Elbow dislocations
Carpal instability
Gamekeeper’s thumb
Olecranon fractures
Radial head fracture
Colles fracture
Scaphoid fracture
Metacarpal fracture
Phalangeal fracture
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Treatment of Bone and Joint Injuries
Splinting for partial tears and fractures
Isometric contractions as soon as possible
Adjunctive interventions (ice, therapeutic
modalities, etc.)
PROM/AAROM/AROM – Mobilization
(consider stage of healing)
Strengthening exercises to restore
dynamic function
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Splinting/Stretching
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Strengthening – Grip/Pinch
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Complex Regional Pain Syndrome
 Formerly RSD
 2 types – with and without nerve involvement
Treatment
 Pain must be controlled first! (e.g., elevation +
moist heat prior to massage)
 TENS
 AROM, joint mobs, CPM, static progressive
splinting
 Dynamic splinting when edema is stabilized
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Stiff Hand and Restricted Motion
“Stiff hand” describes joint limitation from
variety of causes (burns, fractures,
trauma, etc.)
Treatment
 Heating before mobilization (articular
limitations)
 Strengthening, stretching, static splinting
 Dynamic splinting
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Summary
 Ulnar, median, or radial nerve may become
entrapped.
 UCL is primary static stabilizer and flexor carpi
ulnaris is dynamic stabilizer of medial elbow.
 Grip is divided – Power grip when force is
primary objective, prehension grip is used when
precision is main goal.
 Mobility activities – Traditional stretching, joint
mobilization, tendon nerve gliding exercises.
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Summary (cont.)
 CTDs are a result of a combination of factors.
 Conservative management of CTS is successful when
hand and wrist postures and activities are considered
and monitored.
 Individuals with CRPs have varying degrees of pain,
trophic changes, loss of mobility, and functional
limitations.
 Interventions for stiff hand include mobility activities,
splinting, and strengthening exercises.
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