The Upper Extremity
Basic overview of UE anatomy (do not memorize, just get an idea of the structures)
Joints of the hand
&
Nerve distribution of hand (know both of these)
The arthritic hand. Two main forms Osteoarthritis (OA) break down in the joint itself, eventually when
severe enough the cartilage between the bones will be completely gone and bone on bone occurs with
bone breakdown. Noted nodules, subluxed thumb, swan neck deformities, ulnar drift.
Rheumatoid Arthritis (RA) autoimmune disorder where the immune system attacks the joint itself.
Noted flare ups with edema at joints (also signs of OE are common).
CMC joint of thumb (most common site of arthritis in the hands)
Thumb Spica splints provide CMC joint of thumb with support and prevent overuse. Ensure pt can
oppose thumb to digits.
Boutonniere Deformity: characterized by PIP flexion and DIP hyperextension. Can use an oval 8 to
correct (prevent PIP flexion bottom image).
Swan Neck deformity (seen with arthritis) flexion of the DIP and hyperextension of the PIP. Can use an
oval 8 to correct (prevent PIP extension top image).
Trigger Finger – nodule that adheres to flexor tendon when digit is brought into full flexion (make a fist,
tight grasping) nodule moves through sheath to flex, but catches when attempting to extend even to
neutral. (mild: clicking or popping noted, moderate: catches, digit remains in flexion, but triggers and
releases to extension, severe: digit catches in flexion and requires external force to extend).
Splints (inhibit full digit flexion/making a tight fist) usually focuses on preventing the MP to flex.
Medial and Lateral Epicondylitis – unlike their name they do not necessary mean inflammation. They
are tears to the muscle or the tendon at or near the epicondyle. They are usually marked with pain and
tenderness.
Lateral Epicondylitis (Tennis Elbow): injury to the extensor muscle or tendon on the lateral aspect of the
elbow. Recommend pts avoid active/aggressive extension of the wrist and digits.
Medial epicondylitis (Golfer’s Elbow): injury to the flexor muscle or tendon on the medial aspect of the
elbow. Recommended pts avoid active/aggressive flexion of the wrist and digits.
Brace recommended to provide support to the muscle/tendon while they heal.
Peripheral nerve disorders
Carpal Tunnel Syndrome – impingement/compression of the median nerve (innervates the volar aspect
of the palm, thumb, index, middle, and lateral aspect of ring fingers). Median nerve compressed under
the carpal tunnel ligament (usually swelling occurs) where there is a narrow passage for the nerves and
tendons, any increase in fluids in this area can cause pressure onto the nerve resulting in pain,
paresthesia (tingling, “zinging” sensation or numbness). Avoid wirst/digit flexion (flexor tendons run in
the carpal tunnel along with the median nerve).
Lots of pre-fabricated braces or can fabric a wrist cock up splint (can have thumb spica also) for wrist
support (to inhibit wrist flexion, usually in 10-15 degress of wrist extension).
Guyon’s canal: compression of the ulnar nerve at the wrist level. Causes numbness and tingling to ulnar
nerve distribution of hand (see below). Treat with wrist support as in CTS.
Cubital Tunnel Syndrome: compression of the ulnar nerve at the medial elbow.
Elbow padding support to decrease pressure to ulnar nerve. Avoid aggressive elbow flexion or
extension, avoid pressing pressure on elbows (hands on desk to type, supported elbow on table, etc.)
Raidal
Radial tunnel syndrome – compression of the medial nerve at the lateral aspect of the elbow (often
confused with lateral epicondylitis). Tenderness and pain, weakness and lack of innervation to the
extensor muscles of the wrist and digits (wrist drop). Sometimes rest and time can help, sometimes this
condition is permanent. Help the pt be functional during this time of wait.
Dynamic Extension splint – allows for active digit flexion but returns the digits to neutral when relaxed
to prevent stretching of the extension tendons. Also there are pre-fabricated splints.