1. Elbow Joint
Bones
humerus
ulna
radius
Elbow & Wrist

2. 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

3. Elbow Structures Anterior View coronoid fossa radial fossa
lateral epicondyle
trochlea
capitulum
medial epicondyle
coronoid process
Anterior View

4. Elbow Ligaments Anterior view of right elbow joint annular ligament
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

5. Elbow ROM flexion/extension 145º active, 160º passive
need º 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

6. Elbow Flexors biceps brachii brachialis brachioradialis
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

7. Elbow Extensors triceps brachii anconeus 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

8. Radioulnar Joints Supination Pronation 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

9. 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)

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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
Phalanges
III D IV V

16. Radiocarpal jt is the articulation between the scaphoid & radius
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

17. Radial & Ulnar Deviation
proximal row of carpals
glides over distal row
ROM
radial dev º
ulnar dev º

18. Carpometacarpal (CMC) jt
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

19. 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

20. Wrist Extensors NOTE: Origin on lateral epicondyle extensor carpi
radialis longus
extensor
digitorum
extensor carpi
radialis brevis
Wrist Extensors
NOTE: Origin
on lateral
epicondyle
extensor carpi
ulnaris
Because the extensors act
on the elbow jt, elbow jt pos.
will influence extensor output

21. Wrist Flexors all fusiform muscles NOTE: Origin on medial epicondyle
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

22. 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

23. 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 retinaculum respectively
(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

24. Grip strength
related to wrist position
strongest when wrist is slightly ulnar deviated and hyperextended
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

25. 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

26. 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

27. 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

28. 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.