HOMEWORK REVIEW
& EXAM
S
ANATOMY FOR
ELBOW, FOREARM,
WRIST, & HAND
S
ELBOW
S
Humeroulnar and humeroradial joints
S
S
Common Flexor Tendon
S
S
Tendon shared by flexor Ms: pronator teres, flexor carpi radialis, palmaris
longus, flexor digitorum superficialis, flexor carpi ulnaris
Common Extensor Tendon
S
S
Flexion and extension
Tendon shared by extensor Ms: extensor carpi radialis brevis, extensor
digitorum, extensor digiti minimi, extensor carpi ulnaris
Proximal and distal radioulnar joints
S
Pronation and supination
ELBOW
ELBOW HYPOMOBILITY
S
Myositis ossificans
S
Internal derangement
S
Subluxation of radial head
S
Recovery from surgery / trauma
HYPERMOBILITY OF THE JOINTS
S
S
May also be called:
S
Joint laxity (or hyperlaxity within capsule / ligaments)
S
Double-jointedness
S
Loose joint
May be seen with:
S
Down syndrome (a developmental disability)
S
Ehlers-Danlos syndrome (an inherited syndrome affecting elasticity
S
Marfan syndrome (a connective tissue disorder)
S
Hypermobility syndrome
S
Bone structure: bone shape or the depth of the joint sockets
S
Muscle structure: muscle tone or strength
S
Poor sense of proprioception (the ability to sense how far you are stretching)
S
Family history: hypermobility is often inherited
WHEN TO SEEK
TREATMENT
S
Pain in the loose or hypomobile joint during or after movement
S
Sudden changes in the appearance of the joint, muscles, or skin
S
Changes in mobility, specifically in the joints above and/or below affected joint
S
Changes in the functioning of your arms and legs, compensatory
ELBOW LIGAMENTS
S
Radial and Lateral Collateral Ligaments
S Provide support for the sides of the joint
S
Medial and Ulnar Collateral Ligaments
S Connect the humerus to the ulna and keep it tightly in place as it slides through
olecranon
S Can be torn with injury or dislocation
S
Annular Ligament
S Holds the proximal radioulnar joint together
S Wraps around the radial head and holds it tight against the ulna
S Can be torn when entire elbow or radial head is dislocated
ELBOW LIGAMENTS
ELBOW
S
Superficial to olecranon process of the ulna
S
S
Protects process and reduces friction
Brachial artery
S
Crosses crease in elbow
S
Splits into radial and ulnar arteries
S
Only blood supply to hand
CUBITAL VALGUS VS. VARUS
S
Normal = “carrying angle”
S
The angle formed by the long axis of
the humerus and the long axis of the
ulna and is most evident when the
elbow is straight and fully supinated
S
The normal carrying angle in women
is 10-15 degrees; and is 5-10
degrees in males
S
Cubital Valgus = “carrying angle” greater
than 15 degrees
S
Cubital Varus = “carrying angle” less than
5-10 degrees
WRIST
S
Radiocarpal joint – radius and proximal row of carpals
S
S
Flexion, extension, radial deviation (abduction), ulnar deviation (adduction)
Carpal Tunnel – anterior wrist
S
Carpal bones + flexor retinaculum (transverse carpal ligament)
S
Medial attachments – pisiform & hamate
S
Lateral attachments – trapezium & scaphoid
S
Holds 9 tendons and the medial nerve
S
Indicated in carpal tunnel syndrome
WRIST
S
S
Tunnel of Guyon (Guyon’s canal) – medial wrist
S
Created by division of flexor retinaculum (transverse carpal ligament)
S
Ulnar artery and nerve pass through
S
Indicated in ulnar neuropathy
Anatomical Snuff Box – lateral wrist
S
Synovial sheath shared by abductor pollicis longus, extensor pollicis brevis,
and styloid process of radius
S
Indicated in DeQuervain’s Tenosynovitis
ANATOMICAL SNUFF BOX
S
In anatomical position:
S
posterior border is extensor pollicis
longus
S
anterior border is extensor pollicis
brevis and abductor pollicis longus
S
proximal border is composed of
trapezium and scaphoid
ACRONYMS FOR WRIST
BONES
S
Lateral to Medial
S
Row 1:
S
S
Some – Scaphoid
S
Lovers – Lunate
S
Try – Triquetrum
S
Positions – Pisiform
Row 2:
S
That - Trapezium
S
They - Trapezoid
S
Can’t - Capitate
S
Handle – Hamate
WRIST
WRIST & FINGERS
FINGERS
S
S
Metacarpophalageal joints
S
Flexion and extension (sagittal plane)
S
Abduction and adduction (frontal plane)
Proximal interphalangeal joints (PIP)
S
S
Flexion and extension (sagittal plane)
Distal interphalangeal joints (DIP)
S
Flexion and extension (sagittal plane)
THUMB
S
S
S
Carpometacarpal joint (CMC)
S
Flexion and extension – frontal plane
S
Abduction and adduction – sagittal plane
Metacarpophalangeal joints (MCP)
S
Flexion and extension – frontal plane
S
Abduction and adduction – sagittal plane
Interphalangeal joints (IP)
S
Flexion and extension – frontal plane
FLEXOR TENDONS, ARTERIES, & NERVES AT
WRIST
FLEXOR TENDONS, ARTERIES, & NERVES AT
WRIST
MUSCLES OF THE
ELBOW, FOREARM,
WRIST & HAND
S
BRACHIALIS
S
The distal ½ of the anterior shaft of the
humerus (beginning just distal to the deltoid
tuberosity)
to the
S
tuberosity and coronoid process of the ulna.
S
The brachialis flexes the forearm at the elbow
joint.
CORACOBRACHIALIS
S
Coracoid process of the scapula
to the
S
middle 1/3 of the medial shaft of the
humerus
S
The corabrachialis flexes, adducts, and
horizontally flexes the arm at the shoulder
joint
PRONATOR TERES
S
From the medial epicondyle of the humerus
(via the common flexor tendon), the medial
supracondylar ridge of the humerus, and the
coronoid process of the ulna
to the
S
middle ⅓ of the lateral radius.
S
The pronator teres pronates the forearm at
the radioulnar joints; it also flexes the
forearm at the elbow joint.
EXTENSOR CARPI RADIALIS
LONGUS (ECRL)
S
From the distal ⅓ of the lateral supracondylar
ridge of the humerus
to the
S
radial side of the posterior hand at the base of
the second metacarpal.
EXTENSOR CARPI RADIALIS
BREVIS (ECRB)
S
From the lateral epicondyle of the
humerus (via the common extensor
tendon)
to the
S
radial side of the posterior hand at the
side of the base of the third metacarpal.
ECRL AND ECRB ACTIONS
S
Radially deviate (abduct) the hand at the wrist joint.
S
Extend the hand at the wrist joint.
S
Flex the forearm at the elbow joint.
S
Both extensors carpi radialis muscles have the same actions.
SUPINATOR
S
Lateral epicondyle of the humerus and the
supinator crest of the ulna
to the
S
proximal ⅓ of the radius (posterior, lateral,
and anterior sides).
S
The supinator supinates the forearm at the
radioulnar joints.
ABDUCTOR POLLICIS
LONGUS
S
From the middle ⅓ of the posterior radius,
interosseus membrane, and ulna
to the
S
base of the metacarpal of the thumb.
S
Abducts the thumb at the carpometacarpal
joint.
S
Extends the thumb at the carpometacarpal
joint.
S
Radially deviates the hand at the wrist
joint.
Muscles to Review
The following muscles were presented in first
year – please review
S
DELTOID
S
Lateral ⅓ of the clavicle and the acromion process
and spine of the scapula
to the
S
deltoid tuberosity of the humerus
S
The entire deltoid abducts the arm at the shoulder
joint and downwardly rotates the scapula at the
shoulder and scapulocostal joints.
S
The anterior deltoid also flexes, medially rotates,
and horizontally flexes the arm at the shoulder
joint.
S
The posterior deltoid also extends, laterally
rotates, and horizontally extends the arm at the
shoulder joint.
BICEPS BRACHII
S
Supraglenoid tubercle (long head) and
coracoid process (short head) of the scapula
to the
S
radial tuberosity and the deep fascia overlying
the common flexor tendon.
S
Flexes the forearm at the elbow joint
S
Supinates the forearm at the radioulnar joints
S
Flexes the arm at the shoulder joint
TRICEPS BRACHII
S
Infraglenoid tubercle of the scapula (long
head) and the posterior shaft of the
humerus (lateral and medial heads)
to the
S
olecranon process of the ulna.
S
The triceps brachii extend the forearm at
the elbow joint; the long head also adducts
and extends the arm at the shoulder joint.
BRACHIORADIALIS
S
Proximal ⅔ of the lateral supracondylar
ridge of the humerus
to the
S
styloid process of the radius.
S
Flexes the forearm at the elbow joint.
S
Can also pronate the supinated forearm at
the radioulnar joints to a position halfway
between full pronation and supination;
S
Or supinate the pronated forearm at the
radioulnar joints to a position halfway
between full pronation and supination.
CONDITIONS
PART I
S
LATERAL EPICONDYLITIS (TENNIS
ELBOW)
S
S
S
Definition:
S
Chronic collagen degeneration in extensor tendons and enthesopathy (attachment site)
at the lateral epicondyle of the humerus
S
Common overuse injury affecting 1-3% of the population
S
Extensor carpi radialis brevis is most affected due to line of pull
Causes:
S
Repeated tensile stress on tendons – excessive concentric extension or eccentric
flexion
S
Sports, occupations, and hobbies that require repetitive grasping of objects
S
Repetitive supination and pronation
S
Trigger points in extensor tendons may create excess tensile loads
History:
S
Pain in lateral elbow that radiates into forearm
S
Generalized aching; sharp pain if aggravated
S
Acute onset is rare
S
Generally unilateral symptoms
LATERAL EPICONDYLITIS (TENNIS
ELBOW)
S
S
S
Observations:
S
No visible clues
S
Inflammation/enthesitis (inflammation of attachment site) can’t be seen
Palpation:
S
Tenderness and pain at the lateral epicondyle of humerus
S
Hypertonic extensors; fibrotic and ropy
S
Referral patters from extensor trigger points
S
Pain from entrapment of posterior interosseous nerve may present
Testing:
S
S
AROM:
S
Possible pain with extension - minor contraction required
S
Pain at end-range of flexion – extensor stretch
PROM:
S
Pain uncommon from extension, pain at end-range of flexion
LATERAL EPICONDYLITIS (TENNIS
ELBOW)
S
S
S
S
Pain with extension
S
RMI produces weakness
S
Nerve compression in radial tunnel also produces weakness
Special Tests:
S
S
MRT:
Tennis Elbow Test
Contraindications:
S
None
S
Rule out posterior interosseous nerve compression with two differential tests - resisted
tennis elbow/radial tunnel syndrome
S
Epicondylitis – pain on wrist extension; PIN compression – weak with resisted
extension with little increase of pain
Treatment Goals: (stage dependent)
S
Stimulate collagen production – deep friction
S
Restore wrist function – stripping, myofascial work, active engagement
LATERAL EPICONDYLITIS (TENNIS
ELBOW)
S
S
Reduce hypertonicity and pain
S
Deactivate trigger points
S
Treatment protocol:
1.
Warm up tissue – myofascial, trigger points, lengthening
2.
Identify adhesion in common extensor tendon – only treat 1 or 2 per session
3.
Cross-fiber friction small section per session: engage tissue perpendicularly, 6 or
more deep strokes; release gently
4.
Flush with effleurage
5.
Stretch
6.
Ice – immediately in clinic, then at home (cross-fiber friction causes inflammation)
S
Treatment: 2 times a week for 2-3 weeks; after some healing, move on to once per
week
S
Stress that homecare is very important
Hydrotherapy:
S
Ice to reduce pain
LATERAL EPICONDYLITIS (TENNIS
ELBOW)
S
Self-care:
S
Self massage: cross-fiber friction, stripping
S
Stretch: extensors
S
Strengthen: flexors and upper arm and shoulder muscles
S
Rest from offending activities
MEDIAL EPICONDYLITIS (GOLFER’S
ELBOW)
S
S
S
Definition:
S
Chronic collagen degeneration of the wrist flexor tendons where they attach to the
medial epicondyle of the humerus
S
Enthesopathy at the attachment site
S
Pronator teres often involved due to its coordinated effort with wrist flexors and
proximity of its proximal attachment
Causes:
S
Excessive tensile stress from repetitive or prolonged contractions of the flexor group
S
Repetitive pronation and supination: stress placed on pronator teres
S
Sports injuries: swing or throw; valgus force on elbows and tendons
S
Correlates with carpal tunnel syndrome
History:
S
Pain on medial side of elbow that radiates into forearm
S
Generalized aching pain, rarely acute; sharp if aggravated
S
Usual gradual onset
MEDIAL EPICONDYLITIS (GOLFER’S
ELBOW)
S
S
S
S
Possible neurological sensations in ulnar nerve distribution of the hand
Ask about activities involving repetitive gripping
Pain when shaking hands
Recommended to differentiate between: carpal or cubital tunnel, pronator teres
syndromes
S
Observations:
S No visible clues
S Possible excessive cubital valgus
S
Palpation:
S Tender forearm flexors
S
Testing:
S AROM:
S Possible pain in wrist flexion if condition is severe
S PROM:
S Possible pain in flexion
S Possible pain in full extension or supination at end range stretch
MEDIAL EPICONDYLITIS (GOLFER’S
ELBOW)
S
S
S
S
Pain with resisted flexion
S
Pain with resisted pronation if pronator teres is involved
S
Weakness due to RMI
Special Tests:
S
S
MRT:
Golfer’s Elbow Test
Contraindications:
S
Caution when frictioning near ulnar nerve at proximal flexor tendons
S
Caution with ice treatment – possible nerve damage to ulnar nerve
Treatment Goals: (stage dependent)
S
Stimulate collagen production – deep friction
S
Restore wrist function – stripping, myofascial work, active engagement
S
Reduce hypertonicity and pain in flexors and pronator teres
S
Deactivate trigger points
MEDIAL EPICONDYLITIS (GOLFER’S
ELBOW)
S
S
S
Treatment protocol:
1. Warm up tissue – myofascial, trigger points, lengthening
2. Identify adhesion in common flexor tendon – only treat 1 or 2 per session
3. Cross-fiber friction small section per session: engage tissue perpendicularly, 6 or
more deep strokes; release gently
4. Flush with effleurage
5. Stretch
6. Ice – immediately in clinic, then at home (cross-fiber friction causes inflammation)
Treatment: 2 times a week for 2-3 weeks; after some healing, move on to once per
week
Stress that homecare is very important
S
Hydrotherapy:
S Ice to reduce pain
S
Self-care:
S Self massage: cross-fiber friction, stripping
S Stretch: flexors