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Elbow Joint. Bones. humerus. ulna. radius. Elbow Joint. A very stable joint that assists shoulder in application of force and controlling placement of hand in space. humeroulnar joint. humeroradial joint. Asymmetrical structure of trochlea creates angulation of ulna

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slide1

Elbow Joint

Bones

humerus

ulna

radius

slide2

Elbow Joint

A very stable joint that assists shoulder

in application of force and controlling

placement of hand in space

humeroulnar joint

humeroradial

joint

Asymmetrical structure

of trochlea creates

angulation of ulna

when extended known

as the carrying angle

proximal

radioulnar

joint

slide3

Elbow Structures

coronoid fossa

radial fossa

lateral epicondyle

trochlea

capitulum

medial epicondyle

coronoid process

Anterior View

slide4

Anterior view of right elbow joint

Elbow Ligaments

Varus

Valgus

annular ligament

holds radius up

into the elbow jt.

medial/ulnar collateral resists valgus stresses

ulnar collateral is taut in all joint positions

valgus support very important since most forces are directed medially (creating a valgus force)

lateral/radial collateral resists varus stresses

because varus stresses are rare support from

these ligaments is less significant

slide5

Elbow ROM

flexion/extension

145º active, 160º passive

need 100-140º to perform ADL’s

(e.g., reach back of head to comb hair need 140º

only 15º needed to tie a shoe)

supination/pronation

85º supination; 70º pronation

need 50º supination & 50º pronation to perform ADL’s

slide6

Elbow Flexors

biceps brachii

multi-articular muscle

whose effectiveness

is dependent on

position of shoulder

& radioulnar jts

Flexors are almost

twice as strong as

the extensors making

us better pullers than

pushers

brachialis

brachioradialis

(Used more in rapid mvmts or against resistance)

Note: brachialis is the

MOST EFFECTIVE

elbow flexor!

biceps brachii not

effective when pronated

slide7

Elbow Extensors

triceps brachii

long head is bi-articular

so its force production

dependent on shoulder

position

lateral head is strongest

yet is relatively inactive

unless acting against

resistance

anconeus

medial head is the

‘workhorse’ of this group

active in all positions

slide8

Radioulnar Joints

biceps brachii

supinator

active in rapid

mvmts or

against

large loads

always active

Supination

Pronation

pronator teres

active in rapid mvmts

or against large loads

pronator quadratus

always active

slide9

Forearm muscle contribution in throwing

Biceps brachii & brachialis active to

flex elbow (& abduct shoulder)

Biceps most susceptible

to strain during this phase

triceps activity drops off sharply - biceps brachii and brachialis quickly become active to decelerate elbow

triceps brachii becomes active

to extend elbow (some dispute this)

slide10

Injury potential in forearm

Mainly a consequence of repetitive activities

dislocations are possible

often accompanied by fracture

of medial epicondyle

myositis ossificans of brachioradialis

deposits of ectopic bone in muscle

2nd most common site behind quads

high velocity overhead movements

(e.g., throwing, tennis serve)

large tensile forces developed medially

large compressive forces developed laterally

large shear forces developed posteriorly

this is created by the development of a large

VALGUS force on elbow during late cocking and

early acceleration

slide11

Medial Epicondylitis

linked to movements containing

high velocity valgus extension

mechanism

large valgus torque near maximal

external rotation resisted by

a large varus torque generated

by the soft tissue in the elbow

little leaguer s elbow
Little Leaguer’s Elbow
  • medial epicondylitis
    • medial strain imparted during the initial forward phase of throw as hand and elbow lag behind trunk and shoulder
    • curveball pitching will magnify this medial strain throughout pitch and therefore is not recommended for young pitchers
medial elbow injuries little leaguer s elbow
Medial Elbow Injuries (“Little Leaguer’s Elbow”)

Sprain or rupture of

ulnar collateral ligaments

medial epicondylitis

tendinitis of wrist flexors

avulsion fractures of medial epicondyle

osteochondritis dissecans to the capitulum

(a lesion in the bone and articular cartilage)

where the radial head is pushed up into

the capitulum due to the compressive

load developed from the valgus force

tennis elbow
Tennis elbow
  • lateral epicondylitis -inflammation/microdamage to tissues on the lateral side of the humerus, 30%-40% of tennis players will develop some amount of this injury
  • causes include poor technique and equipment
    • e.g. off-center shots and rackets strung too tightly
  • The pain is exacerbated by activities involving extension of the wrist. These include lifting a suitcase, shaking hands, turning doorknobs, etc
slide15

The Wrist

and Hand

Radiocarpal Joint

Distal Radioulnar Joint

I

Carpals

WRIST - radiocarpal joint

condyloid joint

ulna makes no contact with carpals but floats on disc so it does not influence wrist mvmt during supination/pronation

II

Metacarpals

P

M

III

Phalanges

D

IV

V

slide16

The scaphoid may be

one of the most

important carpals

because it supports

the weight of the arm

and transmits the

forces between the

hand and the forearm

Radiocarpal jt is the articulation

between the scaphoid & radius

scaphoid

Midcarpal joint

Wrist ROM

flexion: 70-90º need 10-15º for ADL’s

extension: 70-80º need 35º for ADL’s

ROM reduced when fingers are flexed

slide17

Radial & Ulnar Deviation

proximal row of carpals

glides over distal row

ROM

radial dev. 15-20º

ulnar dev. 30-40º

slide18

CMC of thumb is a saddle

jt that allows flex/ext,

ab-/adduction & rotation

these movements permit

thumb to touch each finger

(known as opposition)

opposition is very

important in all gripping &

prehension tasks

Carpometacarpal (CMC) jt

Concave transverse arch metacarpals

to facilitate gripping

slide19

Metacarpophalangeal (MCP) jts

MCP of thumb is a hinge

jt allowing only flex/ext

MCP of fingers is a condyloid jt

permitting flex/ext and ab-/adduction

slide20

extensor carpi

radialis longus

extensor

digitorum

extensor carpi

radialis brevis

extensor carpi

ulnaris

Wrist Extensors

NOTE: Origin

on lateral

epicondyle

Because the extensors act

on the elbow jt, elbow jt pos.

will influence extensor output

slide21

flexor carpi

radialis

flexor carpi

ulnaris

Wrist Flexors

all fusiform muscles

NOTE: Origin

on medial

epicondyle

palmaris

longus

strongest flexor

strength increased by

encasing the pisiform in

its tendon such that it

becomes a sesamoid bone

that improves the mechanical

advantage of the muscle

Absent in 13%

of population

slide22

Radial Deviation - created by the radial muscles

Extensor carpi radialis longus

& brevis

Flexor carpi radialis

Ulnar Deviation - created by the ulnar muscles

Extensor carpi ulnaris

Flexor carpi ulnaris

slide23

Most of the muscles acting on wrist

& fingers originate outside of the hand

in the region of the elbow so they are

known as extrinsic muscles

Tendons are held in place

on the dorsal and palmar

sides by the extensor &

flexor retinaculumrespectively

(a thick band of fibrous tissue

running transversely across

the wrist)

intrinsic muscles of the hand include

4 muscles on thumb forming the

thenar eminence and 3 muscles on the pinky

forming the hypothenar eminence

slide24

Grip strength

related to wrist position

strongest when wrist is slightly ulnar deviated and hyperextended

grip @ 40º extension is 3X stronger than in 40º flexion

neutral grip is safest position that minimizes strain on wrist structures

power grip utilizes extrinsic muscles

precision grip utilizes intrinsic muscles

Thumb position greatly influences grip

thumb in plane of the hand in an

adducted position such that fingers

flex around object a power grip is

created

thumb is positioned perpendicular to

hand and moved into opposition a

precision grip is created

slide25

Wrist actions in activities

dynamic actions

golf/baseball swing: active radial and ulnar

deviation in the preparatory and power phases respectively

static actions

piano playing/typing: must maintain a stable, static

position in order to maximize finger action

slide26

Wrist/Hand Injuries

falls - broken with outstretched hand

forces wrist into position of extreme

extension or flexion

sprain wrist ligaments

strain wrist flexors

fracture schaphoid

fracture distal radius

one of the most frequently fractured

areas of the body because of its

lower density and the size of the

forces it usually accommodates

Overuse injuries - repetitive strain injuries

tenosynovitis of radial flexors and thumb muscles

from canoeing, rowing, tennis, and fencing

medial epicondylitis due to overuse of wrist flexors

slide27

Carpal Tunnel Syndrome

repeated wrist flexion/extension may inflame

wrist flexor tendons to the point that

they apply pressure and constrict

the median nerve which innervates

the radial side of the hand (thenar muscles)

wrist stabilization in a neutral position is

recommended as treatment or prevention

often using an external device

Ulnar Nerve Injuries

occurs due to trauma to the elbow

note that this nerve is not encased in the

carpal tunnel

Carpal Tunnel

tunnel formed by the carpals (floor and walls) and the roof is formed by a transverse ligament and retinaculum

slide28

Basic Steps in Open Carpal Tunnel Release

Step 1

  A small incision, usually less than 2 inches, is made in the palm of the hand. In some severe cases, the incision needs to be extended into the forearm another 1/2 inch or so.

Step 2  After the incision is made through the skin, a structure called the palmar fascia is visible. An incision is made through this material as well, so that the constricting element, the transverse carpal ligament, can be seen.

Step 3  Once the transverse carpal ligament is visible, it is cut with either a scalpel or scissors, while making sure that the median nerve is out of the way and protected.

Step 4  Once the transverse carpal ligament is cut, the pressure is relieved on the median nerve.

Step 5  Finally, the skin incision is sutured. At the end of the procedure, only the skin incision is repaired. The transverse carpal ligament remains open and the gap is slowly filled by scar tissue.