ELBOW & HAND CLINICAL DISCUSSION

Carrying Angle – formed by Biceps: Strongest elbow flexor, but not the chief bc of its
longitudinal axis of humeral shaft and many functions
ulna; where the two angles meet
Lateral Angulation – caused by the
medial portion of the trochlea
projected more distally

 APPEARS – elbow extension; FA supination

 DISAPPEARS – elbow flexion beyond 30; FA pronation
 Normal Value:
o Male: 5 – 10 Female: 10 – 15  
 Problems:
o < 5 - Cubitus Varus
o > 15 - Cubitus Valgus
o -15 - Gunstock Deformity

HUMEROULNAR/HUMERORADIAL JOINT
Humeroulnar Humeroradial
Type Modified Hinge Jt (Ginglymus)
Trochlea of Humerus + Capitulum + radial
Articulation Trochlear Notch of fovea
Ulna
MCL (Against Valgus) LCL (Against Varus)
- Ant. (1st restraint) - Lat. Radial (1st
Ligaments
- Tranverse restraint)
- Posterior - Lateral Ulnar
Flexion: Coronoid Flexion: Radial Head &
Process & Fossa Fossa
Kinematics
Extension: Olecranon Extension: no contact Radial Dev: Ulnar Dev:
Process & Fossa Ulnar Glide of Prox. Radial Glide of Prox.
Carpals Carpals
Extension of Distal Extension of Prox.
SPURT & SHUNT MUSCLES Carpals Carpals
 Shunt/Stability Muscle: Prox. Attachment (origin) is Flexion of Prox. Flexion of Distal
Carpals Carpals
near to the jt.; Distal Attachment (insertion) is far from
the jt. axis; e.g. Brachioradialis
 Spurt/Mobility Muscle: Prox. Attachment (origin) is far
to the jt.; Distal Attachment (insertion) is near to the jt.;
e.g. biceps, brachialis, Hamstrings

1st CMC Jt.

 Type: Saddle Jt.
 Articulation: Trapezium + 1st MCP
 Kinematics:
o Flex/Ext – “Farehas” (Concave)
o AB/AD – “Apposite” (Convex) – Post./Ant. Glide
  characterize heterotopic bone formation in the
muscle tendon unit, capsule, or ligamentous structures
 CAUSE: TRAUMA, NEUROLOGICAL IMPAIRMENTS,
AGGRESSIVE STRETCHING
 Dur. repair, bone tissue forms within a muscle causing
muscle to harden
ANATOMICAL PULLEYS (5) & CRUCIFORM PULLEYS (3)
 Note: Muscle (contractile); Bone (noncontractile)
 Cover flexor tendons
 CONTRAINDICATIONS: Massage, passive stretching,
(e.g., FDS, FDP)
and resistive exercise
 Prevents bowstringing
 Stretching can break the formed bone causing fx,
of flexor tendon
muscle tear, muscle rupture
 Digital Tendon Sheath
 formed bone/mass is not a true bone which can
 A1 – Trigger Finger
break easily
 A3 & A4 – Rheumatoid
 MC area in UE: BRACHIALIS (chief)
Arthritis
 LE: QUADS (mc contused)
TRIAD “PAPAFLEX”
Pa Pain
Pa Palpable Mass
Flex Flexion Contracture

LATERAL EPICONDYLITIS MEDIAL EPICONDYLITIS

Tennis Elbow Golfer’s Elbow
MOI: Repetitive Wrist MOI: Repetitive Wrist
Extension (Backhand Swing) Flexion and Pronation
MOST AFFECTED MUSCLE IS
ECRB MUSCLES AFFECTED:
All mm passing thru lat. PRONATOR TERES, FCR
epicondyle are affected
Manifestations: Manifestations:
Weakness of Extensors Weakness of Flexors
Lesion: Pain in Flex/Ext Pain in Flex/Ext
A1: MCP Lateral Epicondyle: Origin of Finger Extensors
A3: PIP
A5: DIP

CLINICAL CONDITIONS:
ELBOW:

MYOSITIS OSSIFICANS – “inflammation d/t ossification (bone

formation in muscle)”
 Formation of bone in atypical locations of the body.
FOR CASE PRES: LATERAL (TENNIS ELBOW) & MEDIAL  Subluxation of Radial Head
EPICONDYLITIS ( GOLFER’S ELBOW )  Annular Ligament Laxity
LATERAL EPICONDYLITIS:
 pain in the common wrist extensor tendons along lat.
epicondyle and radiohumeral jt w gripping activities
 painful condition of the elbow caused by overuse.
 inflammation of the tendons that join the FA mm on the
outside of the elbow
MEDIAL EPICONDYLITIS
 same degenerative pathologic changes as those termed
in lateral epicondylitis
 more correctly termed medial epicondylosis OLECRANON BURSITIS
 involves common flexor/pronator tendon at the  Olecranon – pointy bone at the tip of the elbow
tenoperiostea junction near the medial epicondyle  Bursa – thin sac of fluid that lies bet. this boney tip and
EPIDEMIOLOGY: the skin; helps the skin slide over the bone smoothly
 Lateral & medial epicondylitis were described as injury o ACUTE: STUDENT’S ELBOW
resulting from lawn tennis & any form of golf-like o CHRONIC: MINER’S ELBOW, DRAFTSMAN ELBOW
activities respectively. o HALLMARK: GOOSE EGG APPEARANCE OF ELBOW
 It is reported to occur in up to 50% of tennis players &
o COMFORTABLE POS: ELBOW 70 FLEXION
same thing but in a lesser extent for golf players and any
o MEDS: CORTICOSTEROIDS
activity that places excessive repetitive stress on the
lateral or medial forearm musculature can cause these
conditions.
CLINICAL MANIFESTATIONS:
 Common Impairments:
 Gradually increasing pain in the elbow region after
excessive activity of the wrist and hand.
 Pain when the involved muscle is stretched or when
it contracts against resistance.
 Decreased muscle strength and endurance for the PANNER’S DISEASE/ OSTEOCHONDROSES
demand.  Avascular Necrosis (Avn) of Entire Capitulum (humerus)
 Decreased grip strength, limited by pain.  7- 10 yrs old: d/t repetitive trauma/use – blood supply at
 Tenderness with palpation at the site of this age not fully functioning “nadevelop pala”
inflammation, such as over the lateral or medial  Lat. Elbow Pain
epicondyle, head of the radius, or in the muscle
belly.
 Common Functional Limitations/Disabilities
 Inability to participate in provoking activities, such as
racket sports, throwing, or golf.
 Difficulty with repetitive forearm/wrist tasks, such as
sorting or assembling small parts, typing on a
keyboard or using a mouse, gripping activities, using a
hammer, turning a screwdriver, shuffling papers, or
playing a percussion instrument
OSTEOCHONDRITIS
PUSHED ELBOW  when a fragment of bone in a joint separate from the
 MOI: FOOSH rest of the bone because its blood supply is faulty
 Axial Compression Fracture of Radial Head  Lesion to the Focal Point of Capitulum
 Posterolateral D/L of the Radial Head  9-15 yrs old: d/t repetitive trauma/use
PULLED ELBOW/NURSEMAID’S ELBOW**  Lat. Elbow Pain
 MOI: ELBOW EXT, FA PRON
 Kids < 7: annular not fully developed BOXER’S ELBOW/ OLECRANON IMPINGEMENT SYNDROME
  Posterior impingement is due to over use and repetitive o forearm pronation
forced extensions of the elbow.  o wrist flexion
 Sx: o thumb adduction
o Pain and tenderness o MCP joints in extension
at the back of the o IP joints in flexion
elbow  Si/sx:
o swelling of the o Paresthesia
elbow o Pulselessness
o elbow stiffness and o Pain
towards the late o Paralysis
stages an inability to o Pallor
fully straighten the elbow o Increased Pressure
LITTLE LEAGUER’S ELBOW FLEXOR ZONES
 OVERUSE INJURY ZONE I (FDP) – CAN’T FLEX DIP
 aching, sharp pain, and swelling on the inside of the ZONE II (FDS)– CAN’T FELX DIP + PIP
elbow  No Mans Land
 i.e., baseball pitching for young athletes ZONE III (Neck of MCP) – CAN’T MAKE INTRINSIC PLUS
o repetitive motion  overuse  tendon/lig tear  POSITION
avulsion  Intrinsic Plus Pos. (FLEX MCP; EX IP)
o Avulsion Fx: area of attachment of tendon is pulled ZONE IV (Carpal Tunnel) – INABILITY TO MAKE FIST,
o Usually happens in acceleration phase DAMAGES MEDIAN AND ULNAR NN
 FDP = 4
 FDS = 4
 FPL = 1
 Median N. = 1
ZONE V (Prox. to Wrist) – CAN’T FLEX FINGER + WRIST

Claw Hand Deformity

FRACTURE/ D/L
COLLE’S (DINNER FORK) & SMITH’S (GARDEN SPADE)
ANT. FOREARM COMPARTMENT SYNDROME
and VOLKMANN ISCHEMIC CONTRACTURE
 Haversian Canal: nutrition, blood supply of bone
 Volkmann’s Canal: communicate haversian canal
o Broken during fracture bc horizontal FOBOTH: Fall On Back Of The Hand
o Causing deficient blood supply (ischemia) to the
bone
 If Ischemia is not reversed, it leads to
necrosis
 MC cause: Fracture (supracondylar fracture)
 Damage: brachial artery
o Supplies FA, wrist hand
o Tear: no blood supply to tissues, muscle, bones
 Causing contracture
 contracture positioning
o elbow flexion
 CARPAL TUNNEL SYNDROME
 Affected: 4 FDP & FDS, 1 FPL, 1 Median N.
 (-) sensation/tingling, paresthesia, atrophy (mm
supplid by median n. weakens/↓size
 One of the most common cumulative trauma
CARPALS disorders in which the median nerve is compressed
FX: (MC  least) under the flexor retinaculum 2ᴼ to many factors within
1. SCAPHOID (MC) the carpal tunnel characterized by sensory loss and
 Pain @ Snuffbox motor weakness.
 AVN – Preisser’s  Repetitive hand and wrist movement, such as with
2. LUNATE keyboarding or use of vibratory tools, has been
3. TRIQUETRUM associated with CTS.
D/L: (MC least)  Anything that decreases the space in the carpal tunnel
1. LUNATE (MC) or causes the contents of the tunnel to enlarge could
 Anterior D/L compress or constrict the mobility of the median nerve,
 AVN: causing a compression or traction injury and
 BODY: KIENBOCK’S neurological symptoms distal to the wrist.
 DISTAL: BURN’S  Etiology
2. SCAPHOID  Majority cases of CTS are idiopathic
3. TRIQUETRUM  Repetitive, awkward or sustained wrist
TRIGGER FINGER postures/movements like flexion, extension, or
 AKA Snapping Finger, Digital Tenosynovitis Stenosans, gripping activities or sustained pressure can all lead to
Stenosing Tenosynovitis median nerve compression and trauma.
 Tenosynovitis: inflammation of the covering of tendon  Resting pad for typewriters, gamers
 Stenosans: ↓ space/tunnel  Pregnant: ↑ fluid vol.  impinge structures causing
 MC: 3RD AND 4TH DIGIT carpal tunnel syndrome
 A1 pulley becomes inflamed or thickened  medical conditions associated with CTS include
o d/t repetitive, overuse, wear & tear diabetes, RA & OA as well as obesity and pregnancy
 develop a small nodule (NOTTA’S NODULE) decreasing carpal tunnel space.
o Dur. Flexion, nodule becomes trapped (sheath)  Infrequently CTS can be caused by a mass lesion at the
o Snaps when flexed returns to flex wrist, such as ganglion cyst or neurofibroma, or
o Passive to extend associated with acute trauma to the wrist.
Clinical manifestations
The typical presentation of CTS includes:
 Increasing pain in the hand with repetitive use,
paresthesias and numbness of the second and third
digits and variably the thumb and lateral fourth digits,
 although often the patient will have more diffuse  Warmth and tenderness with palpation in the region of
complaints of the entire hand being numb. inflammation.
 Progressive weakness or atrophy in the thenar  Frequently, an imbalance in muscle length and
muscles and first two lumbricales (ape hand strength or poor endurance in the stabilizing muscles.
deformity), and perceived as difficulty opening jars, The fault may be more proximal in the elbow or
buttoning or dropping objects. shoulder girdle, then causing excessive load and
 Tightness in then adductor pollicis and extrinsic substitute motions at the distal end of the chain.
extensors of the thumb and digits 2 and 3.  Pain that worsens with the provoking activity of the
 Irritability or sensory loss in the median nerve fingers, thumb, or wrist, which may affect grip or
distribution. repetitive hand motions.
 Possible decreased joint mobility in the wrist and
GAMEKEEPER’S or
metacarpophalangeal joints of the thumb and digits 2
SKIER’S THUMB
and 3.
 Tear of UCL
Epidemiology
 d/t trauma, high-speed
 Women (3 times) > Men
object  thumb moving
 Bilateral affectation but more severe in the dominant
laterally
hand.
JERSEY FINGER
 There are numerous causes for carpal tunnel
 FDP rupture
syndrome, including high-force, high-repetition jobs,
 Hyperextension Injury of DIP
prolonged posturing and vibration.
 MC: 4TH DIGIT
 As many as 20% pregnant women may experience
DUPUYTREN’S CONTRACTURE
median nerve symptoms because compression of the
 Contracture of palmar fascia
nerve as a result of fluid retention causes swelling in
 Bilateral affectation (ULNAR  RADIAL)
the carpal tunnel
 PAINLESS
 MC: 4TH AND 5TH DIGIT ASSOCIATED WITH “PEYRONIES
 M>F DISEASE” – contracture of penis
 ORTHO: HAND SPLINT
Extensor Tunnel DUPUYTREN’S CONTRACTURE
STAGES:
I. APoL EPoB (De Quervain’s Tenosynovitis) IV. EI, EDCommunis
I- PROLIFERATIVE: nodular thickening of fascia
II. ECRL ECRB V. EDM
II- INVOLUTIONAL: longitudinal thickening of fascia
III. EPoL VI. ECU
III- RESIDUAL: flexion contracture of digits
IV. EI, EDC

DE QUERVAIN’S TENOSYNOVITIS/ HOFFMAN’S DISEASE/ DEFORMITIES

WASHERWOMAN’S THUMB/ BLACKBERRY THUMB 1. ULNAR DRIFT
 D/t repetitive wear & tear, overuse  in Rheumatoid Arthritis patient
 Tenosynovitis of First Dorsal Wrist Compartment: APL  in R.A – jt. abnormal contact
EPB  WRIST IN Radial Dev.
 ORTHOSIS: THUMB SPICA  FINGERS IN Ulnar
 MC d/o of wrist wrist pertaining to inflammation of the Drift
1st dorsal compartment of the wrist w/c involves APL  ORTHO: ULNAR DRIFT
& EPB tendon 2 to repetitive forceful gripping w ulnar SPLINT
dev. Of wrist/repetitive use of
thumb
2.
 Froment’s Sign THUMB SPICA
Clinical manifestations
 Pain when related muscle
contracts or movement of
another jt. that causes gliding of ZIGZAG
the tendon through the sheath. OSTEOARTHRITIS
 NODES:
“HEBERDIP”
 o Heberden* – osteophyte at DIP
o Bouchard – osteophyte at PIP
o Heberden (OA); Bouchard (RA)

6. MALLET/ DROPPED/ BASEBALL FINGER

 AFFECTED: TERMINAL EXTENSION TENDON
3. ZIGZAG DEFORMITY OF THUMB  POSITION:
ZIGZAG ha Arthritis  MCP AND PIP – NORMAL
– displaced joints  DIP- FLEXED

Extensor Hood Mechanism

1. Extensor Digitorum Communis
(EDC) – Contraction alone 
MCP Hyperextension
2. Lumbricals  actively assists EDC
3. Interossei  actively assists EDC
4. Lateral Band  connects PIP to
DIP
5. Central Slip

4. SWAN NECK
 AFFECTED: LATERAL BAND SWAN BOUTONNIERE
NECK
 FDS RUPTURE
FLEX DIP EXT
 ORTHO: SILVER RING
5. BOUTONNIERE EXT PIP FLEX
 AFFECTED: CENTRAL SLIP FLEX MCP EXT
 Ring Splint