Shoulder, Elbow, Wrist, and Hand Chapters 16, 17, 18 Shoulder, Elbow, Wrist, and Hand

Bones of the Shoulder Joint Shoulder Bones Parts of the Bones Made up of three bones: Humerus, Clavicle, and Scapula. Bony parts to know: Humerus: Head of humerus, Greater Tubercle, Lesser Tubercle, Intertubercular groove Scapula: Acromion Process, Coracoid Process, Glenoid Fossa, Spine of scapula, Medial border, Lateral border, Superior border Clavicle: Acromial end, sternal end

Bones of the Elbow Joint Parts of the bones 3 bones – Humerus (Yellow Arrow), Ulna (Aqua Arrow), and Radius (Dk. Green Arrow) Parts of the bones: Humerus – Medial Epicondyle (Orange Arrow), Lateral Epicondyle (Blue Arrow), Coronoid Fossa (Black Arrow), Trochlea (Red Arrow), Capitulum (Dk. Blue Arrow), Olecranon Fossa (not pictured) Ulna – Olecranon Process (not pictured), Trochlear Notch (Lgt. Green Arrow), Coronoid Process (Lgt. Purple Arrow), Radial Notch (Dk. Purple Arrow) Radius – Head of Radius (Purple Arrow), Radial Tuberosity (Brown Arrow)

Bones of the Wrist and Hand Carpals 8 carpal bones Metacarpals 5 metacarpals Phalanges 14 phalanges

Ranges of Motion Elbow Shoulder Wrist Flexion Extension Supination Pronation Wrist Radial Deviation Ulnar Deviation Shoulder Abduction Adduction Flexion Extension Internal Rotation External Rotation Horizontal Abduction Horizontal Adduction Circumduction Elevation Depression Protraction Retraction

Muscles of the Shoulder Rotator Cuff Muscles: AKA “SITS” muscles Subscapularis Origin Insertion Function Infraspinatus Teres Minor Supraspinatus Subscapularis: Origin: subscapular fossa of the scapula. Insertion: Lesser tubercle of the humerus. Function: Medially rotates the arm; draws the humerus toward the glenoid fossa, strengthening the shoulder joint. Infraspinatus: Origin: Infraspinous fossa of scapula Insertion: Greater tubercle of the humerus Function: Laterally rotates the arm; draws humerus towards the glenoid fossa, strengthening the shoulder joint. Teres Minor: Origin: upper 2/3 of dorsal surface of the lateral border of the scapula Function: Laterally rotate the arm and weakly adducts it; draws the humerus towards the glenoid fossa, strengthening the shoulder joint. Supraspinatus: Origin: supraspinous fossa of scapula Insertion: greater tubercle of the humerus Function: Abducts the arm; draws the humerus towards the glenoid fossa, strengthening the shoulder joint.

Pectoralis Muscles Pectoralis Major Pectoralis Minor Origin Insertion Function Pectoralis Minor Pectoralis Major: Origin: Medial half of the clavicle, sternum, upper six or seven ribs. Insertion: Lateral lip of the intertubercular groove of humerus. Function: Flexes, adducts, and rotates the arm medially. Pectoralis Minor: Origin: 3rd, 4th, and 5th ribs. Insertion: Coracoid process of the scapula. Function: Stabilizes the scapula by drawing it forward and downward.

Subclavius Muscle Origin Insertion Function Subclavius: Origin: 1st rib and its costal cartilage Insertion: inferior surface of the clavicle Function: draws the shoulder forward and downward.

Serratus Anterior Origin Insertion Function Both red and purple areas in the illustration Serratus Anterior: Origin: Outer surfaces of the upper 8-9 ribs. Insertion: Anterior surface of the medial border of the scapula Function: rotates scapula, raising the point of the shoulder in full flexion and abduction of the arm; draws the scapula forward as in the act of pushing.

Trapezius and Latissimus Dorsi Origin Insertion Function Latissimus Dorsi Trapezius: Origin: Superior nuchal line and external occipital protuberance of occipital bone, ligamentum nuchae, spinous processes of C7 – T12 vertebrae Insertion: Lateral 1/3 of clavicle, acromion and spine of the scapula Function: Steadies, raises, retracts, and rotates the scapula; acting together, all parts raise the point of the shoulder in full abduction and flexion of the arm; acting together, the upper parts extend the head. Latissimus Dorsi: Origin: spinous processes of the lower 6 thoracic vertebrae and thoracolumbar fascia, lumbar and sacral spinous processes, and the lower 3 - 4 ribs. Insertion: Floor of the intertubercular groove of the humerus. Function: Extends, adducts, and medially rotates the humerus at shoulder joint.

Scapular Rotators Levator Scapulae Origin Insertion Function Rhomboid Major Rhomboid Minor Teres Major Levator Scapulae: Origin: Transverse processes of the first 3 – 4 cervical vertebrae. Insertion: Medial border of the scapula between the spine and the superior angle. Function: Elevates and slightly retracts the scapula. Rhomboid Major: Origin: Ligamentum nuchae and the spinous processes of T2 – T5 vertebrae. Insertion: Medial border of the scapula between the spine and the inferior angle. Function: Retracts and elevates the scapula; the lower part depresses the lateral angle, assisting in adduction of the arm. Rhomboid Minor: Origin: Ligamentum nuchae and spinous processes of C7 – T1 vertebrae. Insertion: Medial border of the scapula at the root of the spine. Function: Retracts and elevates the scapula. Teres Major: Origin: Dorsal surface of the lateral border of the scapula, near the inferior angle. Insertion: Medial lip of the intertubercular groove of the humerus. Function: Adducts, extends, and medially rotates the arm.

Deltoid Muscles Origin Insertion Function Deltoid: Origin: lateral 1/3 of the clavicle, lateral border of the acromion process, and spins of the scapula. Insertion: Deltoid tuberosity of the humerus. Function: Abducts the arm; some flexion and extension, some medial and lateral rotation.

Biceps Brachii Origin Insertion Function Short Head Long Head Biceps Brachii: Origin: Short Head: Apex of coracoid process of the scapula (medial origin) Origin: Long Head: Supraglenoid tubercle of scapula (lateral origin). Insertion: tuberosity of the radius. Function: flexes arm, flexes forearm, supinates hand.

Triceps Brachii Origin Insertion Function Long Head Lateral Head Medial Head Insertion Function Triceps Brachii: Origin: Long Head: Infraglenoid tubercle of scapula Origin: Lateral Head: posterior surface of the humerus above the radial groove Origin: Medial Head: posterior surface of humerus below the radial groove. Insertion: olecranon of the ulna. Function: Extends forearm; the long head extends and adducts the arm.

Brachialis Origin Insertion Function Brachialis: Origin: distal half of anterior surface of the humerus. Insertion: Tuberosity and coronoid process of the ulna. Function: Flexes the forearm.

Coracobrachialis Origin Insertion Function Coracobrachialis: Origin: Apex of the coracoid process of the scapula. Insertion: Middle 1/3 of the medial surface of the humerus. Function: flexes and adducts the arm.

Muscles of the Elbow, Wrist, and Hand Anconeus Origin Insertion Function Anconeus: Origin: Lateral epicondyle of the humerus. Insertion: Olecranon of the ulna and synovial membrane of the elbow joint. Function: Extends the forearm.

Superficial Wrist Flexor Muscles Flexor Carpi Radialis Origin Insertion Function Palmaris Longis Flexor Carpi Ulnaris Flexor Digitorum Superficialis Flexor Carpi Radialis: Origin: the medial epicondyle of the humerus. Insertion: base of the 2nd metacarpal bone. Function: flexes the hand and helps with radial deviation. Palmaris Longis: Origin: the medial epicondyle of the humerus. Insertion: palmar aponeurosis Function: Flexes the hand. Flexor Carpi Ulnaris: Origin: the medial epicondyle of the humerus. Insertion: Pisiform bone and base of the 5th metacarpal bone. Function: flexes hand and helps with ulnar deviation. Flexor Digitorum Superficialis: Origin: the medial epicondyle of the humerus. Insertion: shafts of the middle phalanges of medial four fingers. Function: flexes the middle phalanx of each finger; by continued action, flexes the proximal phalanx and hand.

Deep Wrist Flexor Muscles Flexor Digitorum Profundus Origin Insertion Function Flexor Pollicis Longus Flexor Digitorum Profundus: Origin: Medial epicondyle of the humerus and the coronoid process of the ulna, the interosseous membrane, and the ventral surface of the ulna. Insertion: bases of the distal phalanges of the medial four fingers Function: flexes the distal phalanx of each finger; by continued action flexes the other phalanges and to some extent the hand. Flexor Pollicis Longus: Origin: Ventral surface of the radius and the interosseous membrane. Insertion: base of the distal phalanx of the thumb Function: flexes the distal phalanx of the thumb; by continued action, flexes the proximal phalanx.

Superficial Wrist Extensor Muscles Extensor Carpi Radialis Longus Origin Insertion Function Extensor Carpi Radialis Brevis Extensor Digitorum Extensor Digiti Minimi Extensor Carpi Ulnaris Extensor Carpi Radialis Longus: Origin: lateral epicondyle and supracondylar ridge of the humerus Insertion: dorsal surfacce of the base of the 2nd metacarpal bone Function: Extends and helps with radial deviation. Extensor Carpi Radialis Brevis: Origin: lateral epicondyle and supracondylar ridge of the humerus Insertion: Dorsal surface of base of 3rd metacarpal bone. Extensor Digitorum: Origin: lateral epicondyle and supracondylar ridge of the humerus Insertion: extensor expansions of the fingers Function: extends the phalanges; by continued action, extends the hand. Extensor Digiti Minimi: Origin: lateral epicondyle and supracondylar ridge of the humerus Insertion: extensor expansion of the little finger Function: extends the little finger Extensor Carpi Ulnaris: Origin: lateral epicondyle and supracondylar ridge of the humerus Insertion: Base of the 5th metacarpal bone Function: extends and helps with ulnar deviation.

Deep Wrist Extensor Muscles Abductor Pollicis Longus Origin Insertion Function Extensor Pollicis Brevis Extensor Pollicis Longus Extensor Indicis Abductor Pollicis Longus: Origin: Posterior surface of the middle of the radius and ulna, and the interosseous membrane. Insertion: base of the 1st metacarpal bone Function: abducts the thumb; and by continued action, helps with radial deviation. Extensor Pollicis Brevis: Origin: Posterior surface of the middle of the radius, and the interosseous membrane. Insertion: base of the proximal phalanx of the thumb Function: extends the proximal phalanx of the thumb; by continued action, helps with radial deviation. Extensor Pollicis Longus: Origin: Posterior surface of the middle of the ulna, and the interosseous membrane. Insertion: base of the distal phalanx of the thumb Function: Extends the distal phalanx of the thumb; by continued action, abducts the hand. Extensor Indicis: Origin: Posterior surface of the distal end of the ulna, and the interosseous membrane Insertion: extensor expansion of the index finger Function: extends the index finger

Brachioradialis Origin Insertion Function Brachioradialis: Origin: lateral epicondyle and supracondylar ridge of the humerus Insertion: lateral side of the base of the styloid process of the radius. Function: flexes the forearm.

Supinator Origin Insertion Function Supinator: Origin: lateral epicondyle of humerus, ulna and annular ligament. Insertion: lateral surface of the proximal part of the radius. Function: Supinates the hand.

Pronator Muscles Pronator Quadratus Pronator Teres Origin Insertion Function Pronator Teres Pronator Quadratus: Origin: Distal ventral surface of the ulna Insertion: anterior surface of the distal part of the radius. Function: Pronates the hand Pronator Teres: Origin: two heads: 1/ medial epicondyle of humerus, 2/ coronoid process of ulna. Insertion: Lateral surface of the radius Function: Pronate the hand.

Common Injuries Shoulder Elbow Acromioclavicular Ligament Sprain (Shoulder Separation) Glenohumeral Ligament Sprain Rotator Cuff Strain Impingement Syndrome Bicipital Tendinitis Biceps Tendon Rupture Clavicular Fracture Humeral Fracture Epiphysis Injury (epiphyseal fracture) Avulsion Fracture Glenohumeral Dislocation and Subluxation Elbow Ulnar Collateral Ligament Sprain Elbow Flexor Strain Elbow Extensor Strain Wrist Flexor Strains Wrist Extensor Strains Tennis Elbow (Lateral Epicondylitis) Little League Elbow (Medial Epicondylitis) Ulna Dislocation Elbow Hyperextension Olecranon Bursitis

Common Injuries (Continued) Wrist Sprains Dislocation of the Lunate Interphalangeal Collateral Ligament Sprain Dislocation of the Interphalangeal Joint or the Metacarpal Phalangeal Joint Gamekeeper’s Thumb de Quervain’s Tendinitis Mallet Finger Jersey Finger Boutonniere Deformity Scaphoid Fracture Radial Collateral Ligament Sprain (Thumb Sprain)

Ulna Dislocation Etiology Signs and Symptoms Treatment Etiology: high incidence in sports activities. Most often caused by a fall on an outstretched hand with the elbow in hyperextension, or by a severe twist while the elbow is in a flexed position. Most common is a posterior dislocation. Can be distinguished from the supracondylar fracture by observing that the lateral and medial epicondyles are normally aligned with the shaft of the humerus. Signs and symptoms: profuse hemorrhage and swelling, severe pain and disability, may include injury to median and radial nerves as well as the blood vessels in the area. A radial head fracture often occurs with this dislocation. Treatment: apply cold and pressure immediately, sling for support and refer to physician immediately (can activate EMS, or if stable can be transported with family). Check neurovascular status in extremity. Athlete will be x-rayed and reduced at the hospital.

Dislocated Finger Etiology Signs & Symptoms Treatment Etiology – The phalanges are prone to dislocation, sprain, and fractures. Usually caused by a blow to the finger or violent twisting of the finger. Signs & Symptoms – Obvious deformity, loss of function, pain, swelling. Treatment – Splint in position found, DO NOT ATTEMPT TO REDUCE, ice, elevate and send to physician for x-ray and reduction.

Gamekeeper’s Thumb Etiology Signs & Symptoms Treatment Etiology – sprain to the ulnar collateral ligament of the MCP joint of the thumb. Common in skiers and tackle football players. Mechanism is usually a forceful abduction of the proximal phalanx, which is occasionally combined with hyperextension. Signs & Symptoms – The athlete c/o pain over the ulnar collateral ligament in addition to weak and painful pinch. Tenderness and swelling present over medial aspect of the thumb. Treatment – Any laxity present in the joint = automatic referral to physician. If joint is stable, x-ray to rule out fracture, thumb splint should be applied for at least 3 weeks or until pain free. Thumb spica taping should be used during participation in sports.

de Quervain’s Tendinitis Etiology Signs & Symptoms Treatment Etiology: condition brought on by irritation or swelling of the tendons found along the thumb side of the wrist. The irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment; this makes it difficult for the tendons to move as they should. The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping or gripping things, or turning the wrist. Signs and Symptoms: Pain over the thumb side of the wrist is the main symptom. The pain may appear either gradually or suddenly. It is felt in the wrist and can travel up the forearm. The pain is usually worse with use of the hand and thumb, especially when forcefully grasping things or twisting the wrist. Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region. There may be an occasional "catching" or "snapping" when moving the thumb. Because of the pain and swelling, it may be difficult to move the thumb and wrist, such as in pinching. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger. (Finkelstein Test) Treatment: The goal is to relieve the pain caused by the irritation and swelling. In some cases, your doctor may recommend resting the thumb and wrist by wearing a splint. Anti-inflammatory medication taken by mouth or injected into that tendon compartment may help reduce the swelling and relieve the pain. In some cases, simply not doing the activities that cause pain and swelling may allow the symptoms to go away on their own. When symptoms are severe or do not improve, surgery may be recommended.

Mallet Finger Etiology Signs & Symptoms Treatment: Etiology: common in sports, sometimes called baseball or basketball finger. Caused by a blow from a thrown ball that strikes the tip of the finger, jamming and avulsing the extensor tendon from its insertion along with a piece of bone. Signs and symptoms: pain at the DIP joint. X-ray may reveal avulsion fracture. Unable to extend finger, carrying it at approximately a 30-degree angle. Point tenderness at the site of injury and the avulsed bone can often be palpated. Treatment: PRICE for pain and swelling. If no fracture present, the finger should be splinted immediately in a position of extension for 6-8 weeks. If fracture is present, surgery may be required to repair.

Jersey Finger Etiology Signs & Symptoms Treatment Etiology: rupture of the flexor digitorum profundus tendon from its insertion on the distal phalanx. Most often occurs with the ring finger when trying to grad an opponent’s jersey. Can also result in an avulsion fracture. Signs & Symptoms: DIP joint can not be flexed, finger remains in the extended position; pain and point tenderness over distal phalanx. Treatment: Surgery is required to repair tendon, otherwise athlete will not be able to flex DIP joint. This can cause weakness in the grip.

Boutonniere Deformity Etiology Sign & Symptoms Treatment Etiology: caused by a rupture of the extensor tendon dorsal to the middle phalanx. Trauma occurs at the tip of the finger, which forces the DIP joint into extension and the PIP joint into flexion. Signs & Symptoms: pain and inability to extend the DIP joint. Swelling, point tenderness, and obvious deformity present. Treatment: cold application to control pain and swelling. Splinting of the PIP joint for 5-8 weeks is necessary. While splinted the athlete is encouraged to flex the distal phalanx.

Scaphoid Fracture Etiology Signs & Symptoms Treatment Etiology: Most frequently fractured of the carpal bones. Caused by a force on an outstretched hand, which compresses the scaphoid bone between the radius and the second row of carpal bones. Often fails to heal properly because there is not an adequate supply of blood to this area. Signs & Symptoms: Swelling in the area of the carpal bones severe point tenderness of the scaphoid bone in the anatomical snuffbox, and scaphoid pain that is elicited by upward pressure exerted on the long axis of the thumb by radial flexion. Treatment: Cold should be applied, and referred to physician for x-ray and splinting. If fracture is present will be splinted for at least 6 weeks.