CHAPTER 23: ELBOW, WRIST, AND HAND INJURIES
CHAPTER 23: ELBOW, WRIST, AND HAND INJURIES


This is Chapter 23 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Chiropractic Management of Sports and Recreational Injuries”

Second Edition ~ Wiliams & Wilkins


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Injuries of the Distal Arm and Elbow
  Physical Approach
  Roentgenologic Considerations 
  Contusions and Strains
  Elbow Sprains 
  Tennis Elbow 
  Olecranon Bursitis
  Subluxations 
  Fractures and Dislocations 
  Nerve Compression Injuries
  Miscellaneous Pathologic Signs
Injuries of the Forearm and Wrist
  Biomechanical Considerations of the Wrist
  Contusions, Strains, and Related Conditions 
  Wrist Sprain
  Tenosynovitis 
  Arterial Obstruction 
  Edema 
  Subluxations  
  Fractures and Dislocations  
  General Nerve Injuries and Disorders 
  Radial Nerve Injury and Wrist Drop 
  Median Nerve Injury and Entrapment 
  Ulnar Nerve Injury and Claw Hand
Injuries of the Hand and Fingers
  Etiology and Physical Approach 
  Contusions and Lacerations  
  Strains, Sprains, and Related Disorders 
  Fractures and Dislocations
  Miscellaneous Pathologic Signs
  Injuries of the Nails and Fingertips

Chapter 23: Elbow, Wrist, and Hand Injuries

This chapter discusses traumatic-related disorders of the elbow, forearm, wrist, hand, and fingers. As in all traumatic injuries, the sooner the patient is examined after injury, the more accurate the diagnosis. Swelling, spasm, tenderness, and motion limitations rapidly cloud the picture.


     Injuries of the Distal Arm and Elbow

The highest incidence of elbow injury is in tennis, golf, Little League baseball, and occasionally in javelin throwing. Most forearm injuries are the result of direct blows or falls. Commonly seen are avulsion-type injuries of the elbow as a result of acute or chronic strain at a site of tendon or ligament attachment.

Physical Approach

Parkes divides common sports injuries involving the elbow into three categories according to their prevalence:

(1) musculotendinous,

(2) articular, and

(3) neurovascular. Most injuries are the result of either a sudden unguarded or a repetitive overload on the joint mechanism. This is especially true if the joint is weak or inflexible.

An outline of common sports injuries about the elbow is shown in Table 23.1


Table 23.1. Common Sports-Related Elbow Injuries

Syndrome                            Typical Clinical Picture                                    
 
MUSCULOTENDINOUS INJURIES  
Lateral Aspect                  Pain on gripping, point tenderness at the
  Extensor carpi radialis        attachment of the common extensor tendon.
    brevis strain, tendinitis   Pain is aggravated by resisted hyperextension
  Lateral epicondylitis          of the wrist or passive wrist flexion
  Lateral epicondyle spur or     with the elbow extended. Some swelling is
    adjacent calcium             usually present.
    deposition                      
  Posteromedial radial head            
   subluxation                       
  Lateral olecranon subluxation       
                                         
Anterior Aspect                 Anterior elbow pain aggravated by use, point
  Biceps-brachialis strain,      tenderness over the insertion of the biceps
   tendinitis, rupture           tendon. Pain is increased by resisted elbow
  Anterior olecranon             flexion, forearm supination, and passive
   subluxation                   elbow extension. Antecubital swelling is
  Superior ulna subluxation      usually present.
  Avulsion at radial tuberosity 
                                      
Medial Aspect                   Pain on throwing, forearm tennis shot, or
  Strain, tendinitis, or         gripping. Point tenderness at attachment of
   rupture of wrist flexors      common tendon to medial epicondyle. Pain is
   and forearm pronators         aggravated by resisted wrist flexion or
  Medial epicondylitis, with     passive wrist extension when the elbow is
   or without avulsion           extended
  Medial olecranon subluxation       
                                         
Posterior Aspect                Pain on repetitive extension (eg, throwing,
  Triceps strain, tendinitis     tennis, weight lifting, gymnastics). Point
  Olecranon avulsion             tenderness at or just above the insertion of
   (uncommon)                    the triceps on the olecranon process. Pain
  Bursitis                       is aggravated by resisted extension or
  Posterior olecranon            passive flexion of the elbow.
   subluxation                      
        
ARTICULAR INJURIES  
Lateral Compartment             Lateral elbow pain on throwing, gymnastics,
  Traumatic damage to radial     racquet sports, sometimes associated with
   head, capitellum, or both     joint clicking, catching, grinding. 
  Osteochondral fractures       Tenderness and swelling over radiocapitellar
  Compression osteochondritis    joint. Grating on forced forearm supination
   of capitellum (youth)         and pronation (often), and reduced range of
  Osteochondritis of             elbow extension.
   radial head                     
  Superior ulnar subluxation        
  Loose body formation             
                                         
Medial Compartment              Medial elbow pain and swelling aggravated by
  Capsular tear                  valgus stress (eg, throwing, weight lifting),
  Calcium deposition             point tenderness below medial epicondyle
  Coronoid process spur          near humeral-ulnar joint, and possible
  Ulnar nerve entrapment         sensitive ulnar nerve. Pain is aggravated by
                                 passive wrist extension or active flexion.
                                       
Posterior Compartment           Posterior pain on elbow extension, often
  Olecranon tip spur             with a catching or locking sensation; point
  Olecranon hypertrophy          tenderness in the olecranon fossa; reduced
  Loose body formation           range of extension.
  Olecranon fatigue fracture         
  Posterior olecranon                 
   subluxation                        
 
NEUROVASCULAR INJURIES 
Ulnar Nerve Entrapment         Paresthesiae and weakened motor power in 4th
  Cubital tunnel syndrome       and 5th fingers, point tenderness in cubital
                                tunnel.
                                        
Pronator Teres Syndrome        Anterior elbow pain, usually radiating into
  Median nerve entrapment       thumb, index finger, and middle finger.
                               Forearm cramps (sometimes), and tenderness
                                over pronator teres. Pain is aggravated by
                                resisted forearm pronation and passive
                                supination. Possible thumb abduction weakness
                                and sensory loss in the 1st, 2nd, and 3rd
                                digits.
                                   
Musculocutaneous Nerve         Weak elbow flexion, absent biceps reflex,
 Entrapment                     biceps and brachialis atrophy, and numbness/
                                tingling and numbness along the radial-volar
                                aspect of the forearm.
                                        
Radial Nerve Entrapment        Elbow pain along the lateral extensor muscle
  (Uncommon)                    group. Tenderness along the radial nerve
                                anteriorly about the radial head, but not
                                over the lateral epicondyle as in tennis
                                elbow. Pain is aggravated by passive forearm
                                supination and pronation and forced extension
                                of the wrist and 3rd finger. Weakness
                                and stiffness of the extensor-supinator
                                muscles are usually exhibited.
                                     
Brachial Artery Impingement    Signs of vascular insufficiency; eg,
  Supracondylar fracture        progressively increasing pain, pain on passive
  Posterior or posterolateral   extension of the fingers, median nerve
   dislocation                  paresthesia.


A review of pertinent neurologic, orthopedic, and peripheral vascular manuevers, reflexes, and tests relative to the elbow and forearm is shown in Table 23.2.


Table 23.2. Review of Neurologic, Orthopedic, and Peripheral Vascular Manuevers, Reflexes, Signs, or Tests Relative to the Elbow and Forearm

   Biernacki's sign                Medial epicondyle test
   Bikele's test                   Mill's test
   Brachioradialis reflex          Muscle strength grading
   Cogwheel sign                   Periosteoulnar reflex
   Cozen's test                    Periosteoradial reflex
   Elbow abduction stress test     Kaplan's test
   Elbow adduction stress          Radial reflex
   Elbow extension stress test     Range of motion tests
   Elbow flexion stress test       Strumpell's pronation sign
   Elbow pronation stress test     Tinel's elbow test
   Elbow supination stress test    Tinel's sign
   Erb's sign                      Triceps reflex
   Light touch/pain tests          Ulnar reflex

      Roentgenologic Considerations

As a consequence of avulsion injury, bone fragments may be seen in the area of the epicondyles or olecranon process, and epicondyle spurs may point to chronic stress. Standard projections are A-P, lateral, and oblique views. An intra-articular bone fragment may sometimes be only elicited by tomography, and comparative views of the sound limb are frequently necessary.

Soft Tissues.   Displacement of fat pads is often found at the elbow after injury. It can occur in any injury that distends the joint capsule. A pad appears as a thin strip of radiolucent fat density. The anterior fat pad is normally seen on lateral views, but the posterior humeral pad is hidden by the epicondyles' posterior extensions. However, the posterior pad will become visible at the posterior edge of the humerus on lateral views if effusion causes displacement of the pad. The most important complication is ischemia of the forearm, which may cause an irreversible contracture deformity.

Growth Centers.   Normal ossification of distal humeral epiphyses is not an even process, especially during the periods of rapid growth and development; thus knowledge of secondary ossification centers of the elbow is necessary in dealing with children or teenagers. One or more bony centers may remain uneven in density and irregular on the margins, especially the trochlea and olecranon epiphyses. Because of this irregularity, careful differentiation must be made from osteochondrosis and epiphysitis. The trochlear center is irregularly mineralized and always develops from several small foci. The lateral epicondyle does not fuse directly with the humerus as the medial epicondyle does; rather, it fuses first with the neighboring epiphyseal ossification center, the capitellum, then the fused mass joins the end of the shaft of the humerus. After injury, the position of various centers must be evaluated for possible displacement, laceration, and incarceration into the joint.

Pitching Injuries.   Avulsion and displacement of the medial epicondyle may complicate supracondylar fracture, or they may occur in association with softtissue trauma alone. Biceps spasm after 5 min of pitching strongly suggests an avulsion. Finger numbness following pitching suggests a scalenus anticus syndrome from a cervical or 1st rib condition. Avulsion and displacment of the epicondyle are common between 7 and 17 years of age and vary from slight epicondylar separation to complete avulsion and displacement into the elbow joint. Displacement and fragmentation of the medial condyle in youthful baseball pitchers (Little Leaguer's elbow) is increasing in incidence.

It has been estimated that two of every three professional baseball pitchers have an elbow abnormality. Arm and forearm hypertrophy is typical. Hypertrophy of the humerus is invariably demonstrated in roentgenography, and traction spurs and loose bodies of bone within the elbow joint are frequent. Most loose bodies are found in the olecranon fossa, near the epicondyle, and near the tip of the coronoid process --where ulnar nerve irritation is likely. In 50% of professional pitchers, flexion contracture of the elbow is present. In addition to pitching, outfield throwing and batting mishaps account for similar injuries.


Contusions and Strains

Traumatic Inflammation of the Elbow.   There may be an injury to the upper radioulnar articulation by sudden overpronation or oversupination followed by pain over the articulation with limitation of rotation. Normally, the olecranon bursa will not be palpable; in bursitis, it will feel boggy and thick. Trigger points are commonly found just below the horizontal midline of the antecubital fossa over the proximal radius and ulna. When the joint proper is involved, motion is limited chiefly in extension and may persist indefinitely. An associated injury to the brachialis anticus muscle with contracture is common. In children, a strip of periosteum may be torn from the anterior humerus, followed by bone formation and blocked joint motion. Local myositis ossificans may also develop in the tendon of the brachialis anticus. Some cases will be complicated by ulnar neuropraxia.

Management.   During the early stage, rest in a sling for 3-4 days is required for the acute symptoms to subside. Thereafter, physical therapy with passive and progressive active exercises are recommended. Diathermy is especially helpful in absorption of joint effusion. Rarely is joint aspiration necessary.

Distal Bicipital Strain.   Strains of the bicipital attachment to the ulna are not common. They occur in elbow hyperextension injuries and in overenthusiastic weight-lifting efforts. The course of the tendon will be tender on palpation. Management consists of rest in a sling for a few days along with standard sprain therapy.


Elbow Sprains

Intra-articular or extra-articular injuries to the elbow without fracture are not uncommon and are peculiarly resistant to treatment. There may be a primary or secondary injury to the upper radioulnar articulation by sudden overpronation or oversupination, followed by pain over the articulation and limited rotation. Overlooking radial-head dislocation is a common orthopedic pitfall.

      DIFFERENTIATION

Forced joint movement beyond full extension, abduction, or adduction causes ruptures within the capsular apparatus and its contained reinforcing ligaments from their attachment to the humerus, radius, and ulna. The capsule is tender and frequently distended with blood. Movement in the direction of injury aggravates the pain, and there is some restriction at extreme ranges.

  1. Hyperextension Sprain.   Hyperextension sprains strongly mimic posterior dislocation of the elbow. Swelling and tenderness will be found at the joint capsule posteriorly, bicipital tendon, olecranon fossa, lateral and medial collateral ligaments, and attachments of the flexors and extensors at the medial condyle. Pain is relieved by flexion and increased on attempted extension. If the joint proper is involved, extension is chiefly limited, and it may persist for weeks or years.

  2. Hyperabduction Sprain.   Tenderness is found below the lateral epicondyle, indicating sprain of the ulnar collateral ligament. Pain is increased by forcing the elbow into valgus stress.

  3. Hyperadduction Sprain.   Tenderness is exhibited below the medial epicondyle, indicating sprain of the radial collateral ligament. Pain is increased by forcing the elbow into varus stress.


Ligamentous Stability Test.   To judge stability of medial and lateral collateral ligaments of the elbow, hold the patient's wrist with one hand and cup your stabilizing hand under the patient's distal humerus. As the patient is directed to slightly flex his elbow, (1) push medially with your active hand and laterally with your stabilizing hand, then (2) push laterally with your active hand and medially with your stabilizing hand. With your stabilizing hand, note any joint gapping during either the valgus or varus stress maneuver.

Other Elbow Stress Tests.   Besides elbow abduction and adduction, stability and range of motion should also be tested in extension, flexion, pronation, and supination. These motions should be carefully attempted when the elbow joint is as relaxed as possible. Pain or motion restriction will be found if contrac- tures, acute tendinitis, and/or acute joint pathology are present. If negative, the tests should be repeated against patient resistance. Pain or instability will then be found if sprain, acute or chronic tendinitis, and/or chronic joint pathology are present.


      MANAGEMENT

During the acute hyperemic stage, structural alignment, cold, firm compression, rest in a sling, positive galvanism, ultrasound, vitamin C, manganese glycerophosphate, rest and possibly elevation are indicated. Swelling and joint limitation usually subside in 2-4 days. After 48 hr, passive congestion may be managed by contrast baths, light massage, gentle passive manipulation, sinusoidal stimulation, ultrasound, and a mild range of motion exercise can be initiated. Great care must be taken throughout management that treatment (eg, vigorous manipulation) does not induce further reaction. Injuries of the proximal radial articulation and annular ligament, key components in pronation and supination, are often frustrating to manage.

During the stage of consolidation, local moderate heat, moderate active exercise, moderate range of motion manipulation, and ultrasound are beneficial. In the stage of fibroblastic activity, deep heat, deep massage, vigorous active exercise with and without weights, negative galvanism, ultrasound, and active joint manipulation speed recovery and inhibit postinjury effects. An elbow "cinch-strap" is a helpful but annoying support during competitive activity to prevent overextension. When myositis ossificans becomes a complication, surgical removal of the bony mass may be required.


Tennis Elbow

"Tennis elbow" is a painful condition of traumatic origins which occurs about the external epicondyle of the humerus. The term incorporates a group of conditions, especially epicondylitis or radiohumeral bursitis. It is caused by repeated violent elbow extension combined with sharp twisting supination or pronation of the wrist against resistance. The result is severe contraction of the extensor-supinator muscles of the forearm. The clinical picture is one of synovitis, subperiosteal hematoma, fibrositis, or partial rupture of the fibrous origin of muscles and ligaments at the affected epicondyle, with some associated periostitis. Radial nerve entrapment may be involved. If the medial epicondyle is sore, the flexor-pronator muscles and medial ligaments are affected. The lateral epicondyle area is affected seven times more often than the medial epicondyle.

Bowerman reports that strain of the lateral epicondylar area is actually more common in golf than in tennis. In fact, the disorder commonly referred to as "tennis elbow" is a misnomer in that it has a higher incidence in golf, badminton, squash, rowing, manual labor, and even violin playing than tennis. It is not uncommon in bowlers and professional chess players.

Roentgenologic Considerations.   X-ray features in the elbow may include softtissue calcification at the margin of the lateral joint, lateral epicondyle and capitellum erosion and fragmentation, and spur development at the coronoid process of the ulna. A medial slope deformity of the lateral condyle of the humerus is frequently related. Strenuous unilateral use of the active upper extremity (eg, tennis) often leads to hypertrophy of muscle and bone in the forearm and hands as compared to the nondominant side in young players. Increased radial length and width is frequently found.

Typical Signs.   Hasemeir describes the typical symptomatic picture as pain over the outer or inner side of the elbow, distal to the affected epicondyle. Pain may be severe and radiate when the patient extends his arm. The pain is usually sharp and lancinating on exertion, but it may be dull, aching, and constant. Squeezing an object with the fingertips is usually painful (writer's cramp). Tenderness, heat, and swelling are found over the affected epicondyle, and limited passive movement on extension may be found. This is the result of microscopic and macroscopic tears at the common origin of the extensor and flexor muscle groups -- occurring as a consequence to overstress of tendon fibers. The supinator has its tendinous orgin just behind the common extensor tendon. Grip strength as well as supination and pronation strength are affected.

Cozen's Test.   With the patient's forearm stabilized, instruct him to make a fist and extend his wrist. Grip the elbow with your stabilizing hand and grip the top of the patient's fist with your active hand and attempt to force the wrist into flexion against resistance. A sign of tennis elbow is a severe sudden pain at the lateral epicondyle area.

Mills' Test.   The patient is instructed to make a fist, flex forearm, fully flex fingers and wrist, pronate forearm, and then attempt to extend forearm against resistance. This stretches the extensor and supinator muscles attaching to the lateral epicondyle. Pain at the elbow during this maneuver is an indication of radiohumeral epicondylitis.

Kaplan's Test.   This is a two-phase test.

(1) The seated patient is given a hand dynamometer and instructed to extend the involved upper limb straight forward and squeeze the instrument as hard as possible. Induced pain and grip strength are noted.

(2) The test is then repeated as before except that this time the examiner firmly encircles the patient's forearm with both hands (placed about 1-2 inches below the antecubital crease). Induced pain and grip strength are noted. If the second phase of the test shows increased reduced pain and increased grip strength when the muscles of the proximal forearm are compressed, lateral epicondylitis is indicated.

Management.   For adjustment procedure, see posteromedial subluxation of the radial head. Seek signs of possibly associated cervical, upper dorsal, and 1st rib subluxations. Rest with sling, cold packs, immobilization of wrist and elbow, diathermy, and ultrasound are the common adjunctives utilized. Treatment is similar to that of sprain. Underwater ultrasound is recommended by many. Return to activity immediately upon fading of symptoms invites recurrence. Squeezing a rubber ball helps in recuperation. Graduated restoration to painless function under competitive conditions is vital before full activity is resumed. Strengthening of the wrist extensors is important.

Vapocoolant Technique in Grade I and II Strains and Sprains.   Place the patient in the sitting position with the elbow slightly flexed and abducted. Isolate trigger areas and site of major pain in the arm, elbow, and forearm, and spray sites. At the same time, ask the patient to extend his elbow and then slowly return it to the relaxed position. Repeat the spraying and active movement three or four times. Have the patient indicate with his finger the major source of pain. As the pain shifts position, spray the affected area. Once relief has been obtained in flexion-extension, add forearm pronation and supination in extension, spraying painful sites as necessary between movements. Have the patient attempt movements against resistance, and spray the painful area if necessary. Once relief is obtained, correct any subluxations isolated, apply an ace bandage or "tennis elbow" support, and instruct the patient in home exercises for 1-2 min each half hour during waking hours. Begin resistance and stretching exercises as soon as logical.


      VARIATIONS

Golfer's Elbow.   A severe opposite strain at the origin of the flexor pronator muscles at the medial epicondyle and strain of the medial ligament is sometimes called "golfer's elbow". Subperiosteal hematoma and periostitis are often involved. Poor warmup is usually the underlying cause in golf (or bowling), but taking a divot too deep during chipping is the initiating factor. Treatment is the same as that for tennis elbow, but the adjustment is reversed. That is, the wrist and fingers are extended and the forearm supinated while the elbow is fully extended.

Medial Epicondyle Test.   On the side of involvement, the patient is instructed to flex the elbow about 90° and supinate the hand. If severe pain arises over the medial epicondyle when the patient in this position attempts to extend the elbow against resistance, medial epicondylitis (golfer's elbow) is suggested.

Baseball Elbow.   This is the same condition in chronic form seen with baseball pitchers caused by elbow extension and snapping pronation or supination as the pitcher throws a "slider" or "breaking curve". Degenerative changes are more common on the medial epicondyle, thus indicating pronator strain. It can be considered an elbow "whiplash" injury where the olecranon impinges the fossa at the distal humerus. Stress fracture or traumatic epiphysitis is often associated in adolescents. Loose bodies from cartilage flaking, trochlea osteophytes, medial ligament ossicles, and olecranon chips are frequently related.

Javelin Elbow.   When the javelin is thrown, the olecranon pivots medially in the trochlea and its tip is forced against the edge of the fossa during the extreme forearm pronation and elbow extension. This may result in repeated sprain from amateur "round house" throws, complicated by fracture fragments, calcification, and spur development along the course of the medial collateral ligament of the elbow. Transient ulnar nerve paralysis and "Little League" symptoms are early indications. In some cases, a "golfer's elbow" syndrome is seen from flexor-origin strain.


Olecranon Bursitis

Mobility of the upper extremity is provided by this a fluid-filled bursa which is exposed when the elbow is fixed on a firm surface. It is subject to direct impact hemorrhage, abrasion, contusion, laceration, and puncture, as well as from common indirect mechanisms, all of which may cause chronic inflammation, thickening of synovium, and formation of excessive fluid. The mechanism of injury is usually one of repetitive direct injury, constant friction of extensor tendons as in tennis elbow, and/or repetitious local injuries with synovial irritation. Local pain, tenderness, swelling, and movement restrictions are exhibited. Incidence is high in basketball and indoor racket sports from falls on a hard floor. Secondary infection readily converts the inflammation into an abscess.

Management.   Treat with cold, compression, and elevation for 1-2 days. Refer for aspiration if necessary, but crisscross taping in elbow extension usually brings quick relief. In mild-moderate cases, an elastic ankle support can be worn with the heel opening placed on the antecubital fossa. Recurrent swelling is common, and protective elbow padding is necessary long after symptoms subside.


Subluxations

Most subluxations in the elbow area will offer dramatic relief upon correction. Generally, correction is made with a quick, short thrust to minimize the pain (and time) of relocation. It is essential that the patient's muscles be relaxed or correction will be inhibited and extremely painful. Naturally, quick thrusts are contraindicated in arthritic and sclerotic conditions or if adhesions are advanced.

      POSTERIOR-MEDIAL RADIAL HEAD SUBLUXATION

This "pulled elbow" injury results from the radial head being jerked from the annular ligament, presenting symptoms of pain and tenderness in the area of the radial head. It was once called "Nursemaid's elbow", frequently found after young children were quickly lifted up by their extended forearm. Motion is severely limited in pronation and supination, but flexion and extension are normal. The arm is held in a pronated position, and pain is fairly localized at the elbow. X-ray films are negative. Incidence is high in judo, especially with the young. This type subluxation is commonly associated with tennis elbow or wrist trauma, lateral elbow pain, and restricted anterolateral radial-head motion.

Adjustment.   When manipulation is indicated, the physician holds the affected elbow with one hand in such a manner that his thumb rests on the back of the head of the radius. With the other hand, the doctor holds the patient's hand and moves the arm into a position of slight flexion of the elbow, full forearm pronation, and full flexion of the wrist. This manipulation (Mills' movement) consists in fully extending the elbow while maintaining pronation and flexion of the wrist. The movement is made gently, but quite sharply; thus, it is essential that the patient's muscles be relaxed. The manipulation causes no pain to a normal elbow, but there is sharp pain when a tennis elbow is "freed" that is quickly followed by relief. Evaluate the integrity of the pronator quadratus, biceps brachii, brachioradialis, wrist extensors, and supinator. Treat as a severe sprain, and offer rest in a flexion sling for several days.

Alternative Adjustment Procedure.   To re-establish the slipped radial head, grasp the hand of the seated patient and extend the wrist. Support the elbow firmly with your contact hand. Flex the elbow to a right angle. Maintain axial compression along the radius, and firmly alternate forearm supination and pronation in a "screwing" manner until the head of the radius slips back into position. A click can usually be felt and heard on replacement.


      MEDIAL OLECRANON SUBLUXATION

Subluxation of the olecranon medially is often seen in association with ulna nerve paresthesias, wrist or elbow trauma, medial elbow pain, triceps dyskinesia, decreased distance between olecranon and medial epicondyle, and restricted lateral olecranon joint motion.

Adjustment.   Face cephally on the affected side of the supine patient. The patient's arm is moderately abducted, and the elbow is extended. Your medial semi-extended contact hand is cupped on the medial aspect of the olecranon, while your stabilizing hand grasps the back of the patient's forearm. The elbow is brought into full extension, and a short thrust is made from the medial to the lateral with the contact hand while the stabilizing hand applies lateral to medial pressure. Evaluate the intregrity of the lateral and medial triceps.

Alternative Adjustment Procedure.   Doctor and patient positions are as above. Abduct the arm and extend the patient's elbow. Firmly grasp the medial olecranon with the 1st and 2nd fingers of your contact hand, and stabilize the patient's distal forearm with your other hand. A short, brisk, pronating, medial to lateral pull and elbow extension is made with your contact hand as your stabilizing hand supinates the lower forearm.


      LATERAL OLECRANON SUBLUXATION

This type of subluxation is related to elbow or wrist trauma, lateral elbow pain, triceps dyskinesia, decreased distance between olecranon and lateral epicondyle, and restricted medial olecranon motion.

Adjustment.   Face caudally on the affected side of the prone patient. Abduct the arm, extend the elbow, and internally rotate the extremity. Make a soft pisiform contact with your medial hand on the lateral aspect of the olecranon, and stabilize the patient's lower forearm with your other hand. A short, brisk, thrust is made caudally to shift the olecranon medially as your stabilizing hand pronates the lower forearm. Evaluate the integrity of the lateral and medial triceps.


      ANTERIOR OLECRANON SUBLUXATION

Subluxation of the olecranon anteriorly is seen in relation to hyperextension sprains and restricted posterior olecranon motion.

Adjustment.   Stand on the affected side and obliquely face the sitting patient. Moderately abduct the arm, and flex the elbow. Place your contact hand on the dorsal aspect of the patient's distal forearm. Cup your stabilizing hand deep within the antecubital fossa, and wrap your thumb around the forearm. Make a short, brisk thrust with your contact hand towards the patient's shoulder, using your stabilizing hand as a fulcrum to bring the olecranon out of its depressed position. Evaluate the integrity of the biceps brachii, brachialis, brachioradialis, and triceps.


      POSTERIOR OLECRANON SUBLUXATION

This type of subluxation is associated with elbow or wrist trauma, epicondyle and bursa tenderness, triceps dyskinesia, and restricted anterior olecranon movement.

Adjustment.   Stand on the affected side of the sitting patient so that you are facing caudally. Abduct the patient's arm, extend the elbow, and slightly externally rotate the forearm. Cup the patient's elbow with your medial stabilizing hand, and place your thumb and index finger against the epicondyles for leverage. With your contact hand, grasp the volar aspect of the patient's lower forearm. A short, brisk, thrust is made towards the floor on the distal forearm as your stablizing fingers apply counterpressure upward. Evaluate the integrity of the triceps and biceps.


      SUPERIOR ULNA SUBLUXATION

Subluxation of the ulna superiorly is related to elbow or wrist trauma. It is often a consequence of a falling person catching himself with an outstretched hand, resulting in the ulna being jammed upward against the humerus.

Adjustment.   The patient sits next to a narrow table, leans forward to slightly forward-abduct his arm, and extends his forearm horizontal to the table's surface. The elbow should never be fully extended as this will subject the tip of the olecranon process to injury. Stand on the opposite side of the table and face the patient. With your contact hand, grasp the ulnar aspect of the patient's lower forearm and slightly rotate it externally. Cup your other hand against the patient's lower anterior humerus and extend your elbow to stabilize the patient's arm. Apply traction with your contact hand, and then make a short, quick pull to bring the ulna towards your body. Evaluate the integrity of the triceps and wrist flexors and extensors.

Alternative Adjustment Procedure.   Stand on the affected side of the supine patient. Abduct his arm, and flex his elbow. Grasp the patient's lower forearm with both hands, with emphasis on the ulnar aspect, and place your knee in the patient's antecubital fossa for stabilizing. Traction is applied, followed by a strong upward pull.


Fractures and Dislocations

The radial head at the elbow transmits the force of a fall on the hand to the shoulder; thus explaining why the radial head is a common site of fracture in the elbow area. Subtle impaction fractures of the distal humerus and radial head are not uncommon and often can only be witnessed on x-ray film after a week or two. Acute signs are local swelling, tenderness about the radial head, and severe pain increased on pronation or supination. Severe displacement is not typical.

Olecranon fractures result from a fall on the elbow or excessive triceps action. Displacement may be severe because of the strong pull of the triceps. Olecranon stress fractures are seen in overuse throwing injuries (eg, baseball, javelin).

      ASSESSMENT

If obvious deformity and crepitus are not present, check range of motion, and determine radial pulse. Assess sensation by light touch and distal motion function by having the patient appose thumb and forefinger. Elbow fractures and dislocations should be reduced by an orthopedist; splint in "as is" position, sling, and refer. Delay in referral can easily result in massive heterotopic bone formation. Myositis ossificans, nerve damage, brachial arterial compression, contractures, abnormal carrying angle, and joint stiffness may complicate recovery from any severe elbow injury. Poorly reduced supracondylar fractures, resulting in cubitis valgus, readily lead to ulnar neuritis.

      ROENTGENOLOGIC CONSIDERATIONS

Elbow dislocations are usually the result of excessive hyperextension where the olecranon and radial head are displaced posteriorly. Severe soft-tissue damage is associated, usually resulting in subperiosteal hematoma. Comminuted or marginal fracture fragments from the radial head are frequently related with elbow dislocations. In uncomplicated cases, gentle forward traction on the forearm with the humerus stabilized can be conducted to ease pain prior to referral. Roentgenography is required to analyze possible complications prior to considering even simple dislocation reduction.

Especially within the adolescent player, trochlea, capitellum, and epicondyle growth centers may be enlarged, fragmented, displaced, or prematurely fused. Epiphyseal lines cause the most errors in interpretation of this area. Epiphyseal cartilage may be lacerated and the ossification centers displaced, sometimes into the articular cavity.

The most common fracture is a line running from the anterior to the posterior surface of the humeral shaft (supracondylar) with the proximal fragment shifted anteriorly. Fractures in the area of the elbow usually involve the joint. In the order of frequency, the most common fractures are supracondylar, fractures of the humerus, olecranon, head of the radius, and coronoid process. A fracture line between the condyles (intercondylar) or through one or both of the condyles (diacondylar) may be seen. Fracture of the ulnar shaft with dislocation of the radial head (Monteggia injury) and fracture of the radial head may also be presented.


Nerve Compression Injuries

      RADIAL NERVE COMPRESSION AT THE ELBOW

This nerve compression syndrome features pain and disturbed sensation in the area of distribution of the superficial branch, thus frequently confused with De Quervain's disease. If the deep branch is involved, pain is at or below the lateral epicondyle.

Examination.   On palpation, the nerve trunk is tender near the origin of the extensor muscles, and active extension of the fingers initiates or aggravates pain. If the elbow is extended and the 3rd finger is actively extended against resistance, pain is especially increased because the extensor carpi radialis inserts at the base of the 3rd metacarpal.

Management.   If conservative therapy fails to afford relief, exploratory surgery is indicated.


      MUSCULOSPIRAL CONTUSION

The course of the radial nerve in the musculospiral groove along the lateral aspect of the distal-third humerus is relatively superficial and not infrequently receives a contusion. The clinical picture ("dead arm") is one of sudden radiating pain throughout the distal radial distribution and extensor paralysis. Damage is rarely permanent, and symptoms usually ease within a few minutes.

Management.   Local ice massage and nerve-contusion management will usually be adequate. If symptoms persist, neurologic consultation is necessary.


      ULNAR NERVE COMPRESSION AT THE ELBOW

This nerve compression disorder is often called cubital tunnel syndrome or tardy ulnar nerve palsy. It is the result of trauma or compression of the ulnar nerve at the elbow when the medial ligament ruptures during elbow dislocation. It may also be involved if the medial epicondyle becomes fractured. This consequence is disability and pain along the ulnar aspect of the forearm and hand. Early signs are inability to separate the fingers and disturbed sensation of the 4th and 5th digits. Interosseous atrophy is usually evident, and light pressure on the cubital tunnel initiates or aggravates pain. Nerve conduction studies help to confirm the diagnosis.

Management.   The cause is often repetitive trauma, and response to conservative therapy is poor unless the source of irritation can be removed. Surgery may stop progressive neuropathy, but it does not guarantee return of normal neurologic function.



Miscellaneous Pathologic Signs

Tinel's Elbow Test.   The groove between the olecranon process and the medial epicondyle is tapped with the pointed end of a reflex hammer. A hypersensitive response is seen in ulnar neuritis or neuroma.

Strumpell's Pronation Sign.   The patient is asked to extend the elbows, project the arms forward, and supinate the hands. If the patient is unable to keep an affected limb from drifting into pronation during active flexion or elevation of the arms from this position, it is said to be a sign (pathologic reflex) of an upper motor lesion (eg, hemiplegia).

Biernacki's Sign.   Deep pressure over the ulnar nerve behind the elbow normally causes pain, even in a patient with a high pain threshold. A lack of response suggests a lesion of the fibers carrying deep pressure impulses or a lesion in the posterior columns of the spinal cord. Some authorities feel this sign is pathognomonic of tabes dorsalis.

Cogwheel Sign.   If during passive elbow flexion and extension, the muscles feel taut (lead pipe rigidity) and the motion is felt like a series of irregular and jerky catches and releases (cogwheel motion), a lesion in the extrapyramidal system of the basal ganglia is indicated (eg, paralysis agitans).

Erb's Sign.   If during the application of a galvanic current to a nerve or muscle motor point produces a tonic muscle contraction (tetanic reaction) rather than the normal single "make and break" response, hyperexcitability of the peripheral nerve is indicated (eg, as in tetany).



     Injuries of the Forearm and Wrist

Restriction in pronation suggests pathology at the elbow, radioulnar articulation at the wrist, or within the forearm. Restriction in supination is associated with a disorder of the elbow or radioulnar articulation at the wrist. Thickened tissues may cause compression symptoms, and nerve injury is often secondary to epicondylar fracture or severe trauma. The wrist extensors on the lateral aspect are often associated with tennis elbow. A palpable nontender ganglion may be found on either the dorsal or volar aspect of the wrist, felt as a pea-sized or slightly larger jelly-like cyst. Note any atrophy of the thenar (eg, median nerve compression) or hypothenar eminence (eg, ulnar nerve compression).

Tenderness.   Tenderness over the medial collateral ligament, rising from the medial epicondyle, is a sign of valgus sprain. Muscle tenderness in the wrist flexor-extensor group is characteristic of flexor-pronator strain (eg, tennis, screwdriving motions). Tenderness in the first tunnel on the radial side is a common site for stenosing tenosynovitis associated with a positive Finkelstein's sign. Check for rupture of the tendon in the third tunnel, often resulting from a healed Colle's fracture defect at the dorsal radial tubercle or arthritis causing tendon wearing. Tenderness in the 5th or 6th tunnel is characteristic of synovitis, dorsal carpal subluxation, dislocation of the ulnar head, or rheumatoid arthritis. Check the easily fractured scaphoid by sliding it out from under the radial styloid with ulnar deviation of the wrist. Radial deviate the wrist and check the triquetrum, a common site of fracture. Pain, tenderness, and swelling about the ulnar styloid process suggest a Colle's fracture or a local pathology such as arthritic erosion.


Biomechanical Considerations of the Wrist

Trauma of the wrist should never be taken lightly. An improperly diagnosed and treated case can readily lead to severe arthritis. Good management rests on a thorough knowledge of the underlying anatomy of the carpal bones and fibrocartilage complex.

The wrist complex is far more than eight bones arranged in two horizontal rows between the forearm and hand. Three vertical columns must also be considered. The wrist is essentially a biaxial joint that is capable of motion in two planes:

(1) radial and ulnar deviation and

(2) palmar flexion and extension. The patterns of movement between the two horizontal carpal rows are reciprocal to each other. In radial deviation (about 15°), the distal row moves toward the radius, while the proximal row moves toward the ulnar. In ulnar deviation (about 35°), these movements are reversed; ie, the distal row moves ulnarly, while the proximal row moves radially.

The most important ligaments of the wrist are the volar and intercapsular groups. The weaker dorsal ligaments are arranged in laminar bands. As the proximal carpal row lack tendon support, the integrity of the volar ligament intracapsular supporting system is vital.


Etiology

The most common wrist injuries seen in treating the athlete are shown in Table 23.3.


Table 23.3. Common Sports-Related Injuries and Related Disorders of the Wrist and Distal Forearm
   Anterior carpal subluxation             Perilunar dislocation
   Approximated distal radius and ulnar    Pisiform fracture
   Arterial obstruction                    Posterior carpal subluxation 
   Avascular necrosis of the lunate        Scaphoid fracture
    (Kienbock's disease)                   Scaphoid nonunion
   Carpal tunnel syndrome                  Scaphoid rotary subluxation
   Entrapment syndromes                      (scaphoid-lunate dissociation)
   Hamate hook fracture                    Tenosynovitis
   Inferior radius subluxation             Trans-scaphoid perilunar dislocation
   Lunate dislocation                      Wrist sprain 
   Metacarpal base posterior
     subluxation


Physical Approach

A review of pertinent neurologic, orthopedic, and peripheral vascular manuevers, reflexes, and tests relative to the wrist is shown in Table 23.4


Table 23.4. Review of Neurologic, Orthopedic, and Peripheral Vascular Manuevers, Reflexes, Signs, or Tests Relative to the Wrist
   Allen's test                  Phalen's test
   Bracelet test                 Radial stress test
   Extension stress test         Range of motion tests
   Finkelstein's test            RUM tests
   Finsterer's test              Tinel's sign
   Flexion stress test           Tinel's wrist test
   Froment's adduction test      Ulnar stress test
   Froment's cone sign           Ulnar tunnel triad
   Light touch/pain tests        Wrist drop test
   Maisonneuve's sign            Wrist tourniquet test
   Muscle strength grading


Contusions, Strains, and Related Conditions

Forearm Contusions.   In many contact sports, the lateral forearm is a favorite weapon. Contusions, abrasions, lacerations, and bone bruises are common, but fractures are not. Forearm bruises are quite painful and exhibit functional weakness, but they respond quickly to standard care. Precautions against myositis ossificans should always be made. Treat with cold, compression, and elevation regardless of initial appearance. Swelling in the athlete is often hidden within well-developed forearm muscles. Rest in a sling for 1-2 days, diathermy, ultrasound, and massage are helpful. Protective padding should be applied during competitive activity for 2-3 weeks. Subperiosteal hematoma responds well to diathermy and ultrasound.

Traumatic Inflammation of the Wrist.   Traumatic arthritis of the wrist is often associated with severe sprain, fracture, and dislocation of the carpals, especially scaphoid fracture and lunate dislocation. The symptoms are typical of tenosynovitis in other joints. Cold should be applied initially, followed by strapping or a leather wrist corset worn for several weeks until pain and swelling subside.

Forearm Strains.   These usually affect the flexors. Simple strains such as from overenthusiastic weight lifting respond quickly to rest and routine strain management, but chronic strain (eg, crew) can develop into a frustrating problem if the athlete insists on continuing the sport. Avulsion at the bicipital tubercle and stress fracture of the olecranon are sometimes associated.

Brachialis Calcification.   Following brachialis strain, a local myositis ossificans may develop in the brachialis anticus tendon. This is usually the result of recurrent bruising and bleeding, preventable by proper padding. Management is similar to that of supraspinatus calcification. This should be followed by passive and active exercises to return joint mobility to normal.

Contractures.   After cerebral lesions involving the arm center and in almost any spinal or peripheral nerve lesion which involves one set of muscles and spares another, healthy muscles contract (or overact) and permanent deformities result. In trauma-related hysteria, similar contractures occur. Contractures have in themselves little or no diagnostic value but indicate a late and stubborn stage of whatever lesion is present.

Unilateral Wasting.   Rapid atrophy occurs in all types of neuritis, as well as in poliomyelitis and progressive muscular atrophy. In the latter, it occurs without complete paralysis, though the wasted muscles are, of course, weak. Progressive muscular atrophy usually begins in the muscles at the base of the thumb and between it and the index finger. Less often, the process begins in the deltoid. In either case, the rest of the arm muscles are involved later. In the atrophies just mentioned, a lack of the trophic or nourishing functions are assumed to explain the trophic wasting. From this, we can distinguish atrophy due simply to disuse of the muscles without nerve lesions. Slow atrophy of disuse occurs in the arm in hemiplegia, infantile or adult, and in other cerebral lesions involving the arm center or the fibers leading down from it. Cervical rib syndrome disorders occasionally leads to wasting as well as pain in the corresponding arm. The atrophy often seen in hysterical cases is probably due to disuse and is similar to that occurring in an arm that has been splinted after fracture or dislocation.


Wrist Sprain

Wrist sprain (eg, jammed wrist) is very common in many sports and may be associated with fractures and dislocations of the carpals, elbow, or shoulder girdle. Consequently, all severe wrist-joint injuries should include roentgenography of the elbow and shoulder.

Examination.   The symptoms are the same as in any other extremity joint sprain and may be associated with tenosynovitis. Severe wrist sprains are invariably accompanied by carpal and/or radial subluxations. On the dorsal aspect of the wrist, the scaphoid is the common carpal problem; on the ventral aspect, it is the lunate, hamate, and pisiform. Extension sprain with radial deviation is characterized by tenderness along the ulnar-metacarpal collateral ligament. Dorsiflexion sprain features tenderness along the volar aspect of the wrist and distal radius. In either case, pain is short of fracture and crepitus is absent. Palpation of the anterior wrist is greatly hampered by the tendon bulk of the area and useless on either aspect after swelling has taken place. Scaphoid fracture, a dangerous situation, is often mistaken as a sprain.

Flexion/Extension Stress Tests.   The examiner moves the wrist firmly into flexion and extension. If pain is induced, wrist fracture, subluxation, sprain, acute tendinitis, or pathology are suggested. If negative, the movements are repeated against patient resistance. Induced pain then indicates wrist strain, rupture, acute or chronic tendinitis, or pathology.

Radial/Ulnar Stress Tests.   The examiner moves the wrist firmly into radial and ulnar deviation (abduction and adduction). If pain is induced, sprain, acute tendinitis, joint pathology, fracture, or subluxation are suggested. If negative, the movements are repeated against patient resistance. Induced pain then indicates acute or chronic tendinitis, strain, rupture, or joint pathology.

Management.   Quick on-field examination can usually eliminate fracture in a few minutes before swelling takes place, and proper support can allow the player to continue competition. Never apply tape completely around the anterior wrist. During the acute stage, structural alignment, cold, compression, strapping, positive galvanism, rest and possibly elevation are indicated. After 48 hr, passive congestion may be managed by contrast baths, light massage, gentle passive manipulation, sinusoidal stimulation, ultrasound, and a mild range of exercise initiated. Vitamin C and manganese glycerophosphate are advisable throughout treatment of most any sprain. During consolidation, local moderate heat, active exercise, mobilization, and ultrasound are beneficial. In the stage of fibroblastic activity, deep heat and massage, vigorous active exercise, ultrasound, and active joint manipulation speed recovery and inhibit postinjury effects.

Kienboeck's Disease.   This disorder is a slowly progressive osteitis of the lunate, sometimes following wrist injuries. The condition is caused by interference with the blood supply from partial dislocation with spontaneous replacement of the bone. This is a rarefaction-type osteitis similar to that of Kummell's disease, with symptoms of pain on use. Prolonged immobilization and treatment for severe sprain are indicated. In rare cases, excision of the bone may be necessary.

Finsterer's Test.   This is a two-phase test for Kienbock's disease. (1) If when clenching the fist firmly the normal prominence of the 3rd knuckle is not produced, the test is initially positive. (2) If percussion of the 3rd metacarpal just distal to the dorsal aspect of the midpoint of the wrist elicits abnormal tenderness, the test is confirmed.


Tenosynovitis

The forearm's extensor muscles are often affected in racket-sport players, oarsmen, and canoeists. The clinical picture is one of pain along the dorsal forearm, crepitus along the extensor tendons, swelling (palable and visible), and possible hypertrophy of the thumb's extensors and abductors.

Management.   Treat as a severe strain with rest, anterior crisscross strapping with the elbow almost flexed to a right angle, and anti-inflammatory measures. A proximal radial or ulnar subluxation is sometimes involved. Fasciectomy and paratendon excision may be necessary in stubborn cases.


Arterial Obstruction

Allen's Test.   The sitting patient elevates his arm and is instructed to make a tight fist to express blood from his palm. The examiner occludes radial and ulnar arteries proximal to the wrist by finger pressure. The patient then lowers the hand and relaxes the fist, and the examiner releases the arteries one at a time. Some examiners prefer to test the radial and ulnar arteries individually in two tests. The sign is negative if the pale skin of the palm flushes immediately when the artery is released. The sign is positive if the skin of the palm remains blanched for more than 3 sec. The patient should not hyperextend the palm as this will constrict skin capillaries and render a false positive sign. This test, which should be performed before Wright's test, is significant in vascular occlusion at or distal to the wrist of the artery tested.


Edema

The four most common causes of arm edema are

(1) thrombosis of the axillary or brachial vein, usually from heart disease;

(2) pressure of masses;

(3) inflammation, usually with evidence of lymphangitis spreading up the arm from a septic wound on the hand; and

(4) deep axillary abscess: an insidious painful septic focus may burrow so deeply in the axilla that edema of the arm, as well as pain, is produced. Leukocytosis and slight fever accompany it. The diagnosis is easily made provided we are aware of the existence of this uncommon but distinct clinical entity which is increasing in prevalence with the sale of powerfully astringent underarm deodorants. The cause of edema is usually brought out by the general physical examination of the heart, local lesions, urinalysis, etc. The arm should be investigated for vessel changes and for the evidence given by their pulsations as to the efficiency of the heart.


Subluxations

As in any adjustive procedure, fracture, dislocations, and arthritis must be ruled out. Heat is frequently necessary prior to correction to afford maximum patient relaxation and rapid physiologic response to correction. Bilateral x-ray films for comparison are helpful in diagnosis.

      SEPARATED DISTAL RADIUS AND ULNA

This type of subluxation is commonly seen in association with carpal tunnel syndrome, chronic wrist pain, and after wrist trauma.

Adjustment.   Stand on the side of involvement, and face the standing or sitting patient. Grasp the patient's wrist with both hands so that your overlapping thumbs are crossed against the lateral aspect of the distal radius and your interlaced fingers cup the medial aspect of the ulna. Apply a strong squeeze with your hands to approximate the distal radius and ulnar while simultaneously making a quick downward thrust with your thumbs by extending your elbows. Evaluate the integrity of the pronator quadratus.


      APPROXIMATED DISTAL RADIUS AND ULNA

Approximated distal radius and ulna are often seen in chronic wrist pain or following wrist and hand trauma.

Adjustment.   Stand on the side of involvement, and face the standing or sitting patient. Grasp the patient's wrist with both hands so that your overlapping thumbs cross between the dorsal aspects of the distal radius and ulna and your interlaced fingers cup the volar aspect of the lower forearm. Apply a strong thumb thrust inward by extending your elbows while simultaneously using your fingers to separate the distal radius and ulna.


      INFERIOR RADIUS SUBLUXATION

An inferiorly subluxated radius is often a consequence of wrist sprain from a fall on the outstretched hand.

Adjustment.   Stand on the side of involvement, and face the supine patient. Moderately flex the patient's elbow, and be sure that it is firm against a padded table. Grasp the wrist so that your thumbs overlap at the styloid process of the lateral distal radius and your fingers cup the medial aspect of the distal ulna. Apply thumb pressure against the radius, towards the patient's elbow, and then make a short, quick, forward thrust with moderate body weight. Evaluate the brachioradialis, biceps brachii, and pronator teres.


      ANTERIOR CARPAL SUBLUXATION

Subluxation of a carpal anteriorly is related to carpal tunnel syndrome, chronic wrist pain, extension sprain, and restricted posterior wrist flexion. The lunate is the most common carpal involved.

Adjustment.   Stand on the side of involvement, and face the standing or sitting patient. Grasp the patient's wrist with both hands so that a double indexfinger contact is made under the volar aspect of the carpal involved and the rest of your fingers supporting the other carpals. Lift the patient's forearm slightly, flex the wrist a few degrees, and place traction on the wrist. Relax the joints with mild sideward movements. The correction is made by holding firm contact pressure with your index fingers and snapping the wrist quickly into extension. Never forcibly flex the wrist as this will cause sprain. With athletes having highly developed forearms (eg, tennis pros), it may be necessary to place your knee in the patient's antecubital fossa for counterpressure. Evaluate the radius, pronator quadratus, and the extensor carpi radialis longus and brevis.

Alternative Adjustment Procedure.   Turn the involved wrist palm up. Make overlapping thumb contact on the involved carpal, and support the patient's dorsal hand with your fingers. Apply traction, slightly flex the wrist, and make firm posteriorly-directed thumb pressure while rolling the wrist through alternated rotation, extension, flexion, and lateral flexion by describing a wide figure 8.


      POSTERIOR CARPAL SUBLUXATION

This type of subluxation is frequently associated with wrist trauma, chronic pain upon motion, carpal tunnel syndrome, and restricted wrist extension.

Adjustment.   Stand on the side of involvement, and face the standing or sitting patient. Grasp the patient's pronated wrist with both hands so that an overlapping thumb contact is made on the involved carpal, with the rest of your fingers supporting the volar aspect of the wrist. Apply traction to the wrist, make a quick downward thumb thrust by extending your elbows, while simultaneously extending the patient's wrist a few degrees. Again, it may be necessary to apply counterpressure with your knee within the patient's antecubital fossa. Evaluate the pronator quadratus and the flexor carpi radialis and ulnaris.

Alternative Adjustment Procedure.   This is the reverse of the alternative adjustment procedure for an anterior carpal, varied by turning the involved wrist palm down and taking thumb contact on the dorsal aspect of the carpal.


      METACARPAL BASE POSTERIOR SUBLUXATION

A metacarpal base subluxated posteriorly is associated with pain especially increased by wrist flexion, excessive wrist flexion sprain, wrist ganglion, and restricted wrist extension.

Adjustment.   Stand on the side of involvement of the sitting patient. The patient's wrist should be resting on a firm pillow. Grasp the patient's involved digit with your contact hand so that your thumb rests on the proximal head of the metacarpal and your fingers wrap aound the involved finger for stability. With your other hand, take a pisiform contact on top of the distal phalanx of your contact thumb. Apply moderate distal traction with your contact fingers and make a short, quick thrust downward by fully extending your elbows. As the thrust is made, the patient's wrist will dorsiflex. Evaluate the muscles of the wrist and hand.


Fractures and Dislocations

Uncomplicated low-forearm fractures and dislocations should be aided somewhat on-field by steady axial traction. Assess motor and sensory function of the hand, and note circulation by capillary filling of the fingernails with finger pressure. Pad, splint in the position of function, and refer. Roentgenography is required to analyze possible complications prior to considered reduction.

      INJURIES AT THE PROXIMAL FOREARM AND SHAFTS

P-A and lateral x-rays views are standard, but several degrees of obliquity may be necessary. Comparison should be made with views of the contralateral (uninjured) arm.

Fractures of the bones in the forearm usually involve both bones. Sometimes, however, these bones do not fracture at the same level. The bulk of forearm bone injuries are from falls or direct blows. When a midarm blow fractures the radius or ulna, both ends of each bone must be evaluated for possibly associated subluxation, dislocation, and rotational abnormality. Dislocation of the proximal radius accompanies midulna fracture in Monteggia injury, while midradius fracture is accompanied by distal ulnar subluxation in the Galeazzi fracture. The ulna is usually displaced posteriorly when the distal ulna is subluxated. In radial or ulnar fractures, ulnar rotational abnormalities may be a complication. Malposition of the bicipital tubercle proximally and the ulnar styloid distally are helpful clues to rotational abnormalities.

      INJURIES AT THE DISTAL FOREARM

In cases where a fracture of the distal radius is difficult to view on film, careful inspection of the pronator muscle fat pad should be made just proximal to the wrist. It may be the only radiologic sign present. This fat pad, which separates the pronator quadratus muscle and tendons of the flexor digitorum profundus, is normally viewed on lateral films of the wrist. Blurring, bowing, or obliteration of the fat pad may be seen as a consequence of injury or disease of the radius or volar soft tissues.

Fracture of the distal radius (Colles') is the first consideration in wrist injuries, but the close relationship of both forearm and wrist bones and all articulations must be carefully evaluated. The joint spaces between the carpal bones are normally uniform. Epiphyseal fractures and fractures through the growth plate with or without shifting are not uncommon in youth. The typical deformity in this injury is a compression of the posterior margin of the radius, resulting in a backward tilting of the anterior surface as viewed in the lateral view. The articular margin of the radius will be disturbed, and the distal radius may be fragmented and impacted. Old fractures are differentiated from recent ones by the presence of rarefaction and the absence of a distinct fracture line.

On the lateral view, the radiocarpal articulation should be carefully evaluated. The radial longitudinal axis normally extends through the lunate's midpoint. On the P-A view, disruption of the distal radio-ulnar articulation is seen as joint widening or narrowing. During an impacted fracture of the radius, bone fragments are frequently telescoped and both styloid processes are seen at the same but more distal level; ie, the radial styloid is normally seen 1-cm distal to the ulnar styloid process.

Maisonneuve's Sign.   Normal extension of the wrist rarely exceeds 75°. Marked hyperextension (near 90°) is a sign of Colle's fracture.


      CARPAL FRACTURE-DISLOCATIONS

Any carpal may be a potential fracture or dislocation site. In order of frequency, the bones usually involved are the scaphoid, lunate, and capitate --all of which may be associated with injuries of the radius or ulna. Of the carpals, the lunate is the most frequently dislocated; the scaphoid is the most frequently fractured. The scaphoid is the most lateral of the four bones in the proximal row of carpals; the lunate, second from thumb side.

Even slight tenderness in the anatomic snuffbox about the scaphoid and swelling obliterating the space between the thumb's extensor tendons suggest the danger of scaphoid fracture which may not appear on film for 10-14 days. Axially directed percussion on the knuckle of the patient's index finger when his fist is closed will usually elicit scaphoid pain if fractured. Bone necrosis and nonunion are always a danger as the bone is poorly nourished in a third of the population. Scaphoid fracture has a high incidence in ice hockey.

      BOXER'S WRIST (LUNATE INJURY)

This dislocation-fracture may be seen in any athlete from a fall on the outstretched hand, but it is most common in boxers whose hands are carelessly wrapped. Damage to the median nerve is a complication. The clinical picture is one of anterior wrist swelling, with stiff and semiflexed fingers. Carpal dislocations, especially lunate or paralunate, are frequently missed during evaluation. These are often associated with a trans-scaphoid fracture and necrosis.

The lunate usually dislocates posteriorly or anteriorly, disrupting its relationship with the neighboring carpals and the distal radius. Anterior displacement is the common mechanism, where the bone rests deep in the annular ligament and may affect the median nerve. The lunate is loosely stabilized by an anterior and posterior ligament which contains small nutritive blood vessels. A torn ligament thus interferes with the lunate's nutrition, resulting in necrosis. On a P-A view, the lunate's normal quadrilateral shape becomes triangular, and the third metacarpal and capitate usually move proximally. With paralunate dislocation, the lunate keeps normal alignment with the radius but the distal carpals become displaced from their normal position with associated changes in intercarpal joint spaces.

      GOLFER'S WRIST

If a full golf swing hits the ground or a hard object other than the ball, an isolated fracture of the wrist may result. The mechanism appears to be one of violent contraction of the flexor carpi ulnaris insertion through the pisiformhamate ligament. Roentgenography may show a fracture of the hamate.


General Nerve Injuries and Disorders

RUM Tests.   Quick RUM (radial, ulnar, medial nerve) neurologic tests are as follows:

  • Radial nerve:   Have patient extend wrist. Nerve pathology causes wrist drop. The radial nerve supplies sensory fibers to the dorsum of the hand on the radial aspect, especially at the web between the thumb and index finger.

  • Ulnar nerve:   Have patient hold a piece of paper by opposing thumb and index finger (Froman's cone sign). The examiner tries to pull the piece of paper away while the patient resists. If the patient cannot hold on to the slip, the weakness suggests ulnar nerve pathology. The ulnar nerve supplies sensory fibers to the ulnar aspect of the hand, both dorsal and palmar surfaces, and the ring and little fingers.

  • Median nerve:   The median nerve is tested by asking the patient to touch each finger with the thumb. Remember that the median nerve is under the transverse carpal ligament. The median nerve supplies sensory fibers to the radial aspect of the palm and the palmar surfaces of the thumb and first two fingers, but it is purest on the palmar surface of the tip of the index finger.

Referred Pain.   Cervical osteoarthritis or rheumatoid arthritis of the wrist may refer pain to the elbow, as can shoulder pathology. Symptoms may be referred to the wrist or hand from the cervical spine, shoulder, or elbow such as from cervical disc disorders, osteoarthritis, brachial plexus syndromes, shoulder and elbow entrapments.

Hysterical and Traumatic Neuroses.   The history and mode of onset, the frequent association of sensory symptoms which do not fit the distribution of any peripheral nerve, spinal segment, or cortical area, the normal reflexes, and the electrical reactions distinguish most cases of this type, but sometimes diagnosis is most difficult.

Tinel's Test.   As a differential diagnostic aid between complete and incomplete peripheral nerve interruption one might apply Tinel's test. Normally, percussion of a nerve above or below a point of complete severence elicits no subjective sensations. In cases of partial severance or in cases of compression of this given peripheral nerve where some conduction is preserved, percussion distal to the involvement will elicit a tingling paresthesia below the point of tapping. This represents a positive Tinel's sign. This sign, if positive, is also indicative of nerve regeneration if it is elicited over a nerve which had previously been negative on percussion. In this respect, it may have prognostic as well as diagnostic value.


Radial Nerve Injury and Wrist Drop

In addition to causes such as wounds and lacerations, the radial nerve may be damaged by fracture of the middle third of the humerus or externally by pressure from a crutch in the axilla, or from the arm hanging over a bench, table, or the like during unconsciousness. The oustanding symptom is "wrist drop". The thumb cannot be abducted (pollicis longus and brevis paralysis), finger flexion is impaired, and the wrist cannot be extended. When the nerve is actually severed or "caught", surgery is required.

Wrist Drop Test.   The two opposing palms are placed together with the hands in dorsiflexion. On separation, failure to maintain dorsiflexion indicates a positive test and is significant of radial nerve impairment.


Median Nerve Injury and Entrapment

The median nerve is commonly injured in laceration of the anterior wrist. Consequently, sensation and motion of the fingers should be carefully studied. It is difficult to lacerate any of the flexors of the medial anterior wrist without damaging the median nerve. When injured, the characteristic "flat hand" deformity results.

Median nerve paresthesias may have their cause in the spine but just as common from interference in the thoracic outlet, the shoulder, the elbow, or at the wrist. Correction must be directed to where the interference is located and not where it "should" be.

Carpal Tunnel Syndrome.   This is a nerve compression syndrome featuring median nerve entrapment at the carpal tunnel resulting in symptoms in the hand and fingers, often extending up the arm to the elbow. The cause may be either an increase of structural volume within the tunnel or any condition that tends to narrow the tunnel. The history will often indicate an old scaphoid fracture, peralunar dislocation, or tendinitis at the wrist. Frequently, the history tells of a fall stopped abruptly by the palm of the hand when the wrist was sharply dorsiflexed or of overstress in people who strongly manipulate their wrists (eg, javelin, tennis, hockey, batting, or with chiropractors, bakers, hairdressers, waiters). A syndrome may also be produced by radial or ulnar arterial impairment since these arteries also pass beneath the transverse carpal ligament. Such symptoms may be aggravated by pressure of a sphygmomanometer cuff during blood pressure evaluation.

Signs and Symptoms.   There is a history of pain, numbness, and tingling, which worsen at night and with wrist compression, in the first two or three digits and/or the area proximal to the wrist. Weakness is exhibited by a history of dropping light objects and difficulty in holding a pen or pencil while writing. Venous engorgement and a bulge may be seen of the flexor mass in the distal wrist which is characteristic of tenosynovitis or hypertrophied muscles. The first sign is swelling at the volar wrist. Later, thenar atrophy and sensation impairment of the thumb, forefinger, middle finger, and medial half of the ring finger exhibit. In many cases, there is distinct difficulty in pronating or supinating the forearm. Compression or percussion of the carpal ligament usually initiates or increases pain. Electromyogram and nerve conduction studies offer confirmative data for a diagnosis. Misdiagnosis is sometimes seen by attributing a unilateral or bilateral syndrome to slight arthritic changes of the midcervical vertebrae.

Phalen's Test.   Have the patient place both flexed wrists into opposition and apply slight pressure for 30-45 sec. A positive sign of carpal tunnel syndrome is the production of symptoms (eg, pain, tingling).

Tinel's Wrist Test.   With the patient's elbow flexed and the hand supinated, the volar surface of the wrist is tapped with the broad end of a triangular reflex hammer. If this induces pain in all fingers of the involved hand except the little finger, carpal tunnel syndrome is indicated.

Wrist Tourniquet Test.   A sphygmomanometer cuff is wrapped around the involved wrist of a seated patient. The cuff is inflated to a point just above the patient's systolic blood pressure level and maintained for 1--2 minutes. If an exacerbation of pain is exhibited, carpal tunnel syndrome is indicated.

Ochsner's Clasping Test.   The patient is instructed to clasp the hands to- gether and interlock the fingers. If the index finger on the involved side fails to flex, median nerve paralysis is indicated --with the lesion at or above the level where the nerve to the flexor digitorum superficialis branches.

Wartenburg's Oriental Prayer Sign.   The patient is instructed to fully extend the adducted fingers and the thumb of each hand so that the palms are flat and then to move both hands so that the thumbs and index fingers touch. In median nerve palsy, the thumbs will not touch because of paralysis of the abductor pollicis brevis.

Management.   The cause for the syndrome must be determined. During this investigation, anti-inflammatory therapy and a cock-up wrist splint for immobilization may be applied. Invariably, the subluxation is one of joint spread at the distal radial-ulnar articulation. If pain originates or extends to the elbow, a subluxation of the proximal radius may also be involved. Following corrective adjustment, it is well to apply a leather wrist strap over a felt pad for about 2 weeks; an elastic wrist band is contraindicated. Underwater ultrasound, pulsating diathermy, acupuncture, and B complex have been found helpful. Referral for surgery is indicated if neurologic symptoms fail to respond or increase after a trial of conservative therapy.


Ulnar Nerve Injury and Claw Hand

This nerve is more commonly injured than any other nerve of the upper extremity with the exception of the radial nerve. The injuries are usually at the inner side of the elbow where it is quite vulnerable in its superficial position along the elbow's posteromedial aspect. Most injuries can be prevented with proper elbow padding. When damaged, a characteristic "claw hand" results, with sensory loss of the medial side of the hand.

Ulnar Compression at the Wrist.   This compression syndrome features ulnar nerve entrapment, usually in the canal of Guyon. Entrapment may be of the superficial or the deep branch of the ulnar nerve, but the superficial branch is rarely affected by itself. The pisiform-hamate tunnel syndrome is similar to but less frequently seen than that of carpal tunnel syndrome.

Signs and Symptoms.   Entrapment of the deep branch produces a motor loss exhibited by a weak pinch, weak little finger and thumb abduction, inability to actively flex the metacarpophalangeal joints, and interosseous atrophy. Compression of the superficial branch features burning sensations in the 4th and 5th digits. Palpation of the pisiform-hamate tunnel initiates or aggravates pain. In roentgenography, a hamate fracture or pisiform dislocation may be found in tangential views.

Froment's Test.   In paralysis of the ulnar nerve, there is an inability to approximate the tips of fingers to the thumb to form a cone (cone sign) or to make an "O" with the thumb and index finger.

The Ulnar Tunnel Triad.   If inspection and palpation over the ulnar tunnel in the wrist determines the three signs of

(1) tenderness,

(2) clawing of the ring finger, and

(3) hypothenar wasting, ulnar compression in the tunnel of Guyon is indicated.

Management.   The cause for the syndrome must be determined. During this investigation, anti-inflammatory therapy and immobilization may be applied. Goodheart states that subluxation of the hamate or pisiform towards the wrist and in the direction of the hand's dorsal aspect is a common finding. This is usually the result of a sharp blow to the pisiform area when the wrist is dorsiflexed. A double-thumb contact on the subluxated carpal with a thrust directed distally is usually sufficient for correction. In most cases, the mechanical correction should be supported by placing a piece of felt over the affected carpal and strapped for about 2 weeks. Adjunctive therapy is similar to that for carpal tunnel syndrome. Referral for exploratory surgery is indicated if neurologic symptoms fail to respond or increase after a trial of conservative therapy.


Rheumatoid Arthritis

Bracelet Test.   The examiner surrounds the patient's wrist with the thumb and forefinger and applies mild--moderate compression to the distal ends of the radius and ulna. If acute pain arises in the wrist and/or radiates to the fore- arm or hand, rheumatoid arthritis should be suspected.



     Injuries of the Hand and Fingers

The hand, being the least protected and most active part of the upper extremity, is easily hurt. From a structural standpoint, the hand is made for grasping, not for hitting. Bilateral grip strength is best tested with a dynamometer and pinch strength by a pinch meter if objective records are necessary.

Etiology and Physical Approach

The most common hand/finger injuries seen in treating the athlete are shown in Table 23.5. A review of pertinent neurologic, orthopedic, and peripheral vascular manuevers, reflexes, and tests relative to the hand and fingers is shown in Table 23.6


Table 23.5. Common Sports-Related Injuries and Related Disorders of the Hand and Fingers
   Abrasions                           Lacerations 
   Carpometacarpal joint sprain        Metacarpal fracture/dislocation
   Carpometacarpal subluxation         Metacarpophalangeal joint sprain
   Contusions                          Metacarpophalangeal subluxation
   Extensor pollicis longus rupture    Phalanx fracture/dislocation
   Extensor tendon central slip        Subluxation of extensor tendon over  
   Flexor tendon rupture                metacarpophalangeal joint
   Interphalangeal joint sprain        Terminal extensor tendon strain  
   Interphalangeal subluxation          or avulsion
   Joint fixations                     Thumb fracture/dislocation


Table 23.6. Review of Neurologic, Orthopedic, and Peripheral Vascular Manuevers, Reflexes, Signs, or Tests Relative to the Hand and Fingers
   Bunnel-Littler's test                   Light touch/pain tests
   Extensor digitorum communis test        Muscle strength grading
   Flexor digitorum superficialis test     Ochsner's clasping test
   Finkelstein's test                      Palmomental reflex
   Flexor digitorum profundus test         Pollicus longus tests
   Froment's cone sign                     Range of motion tests
   Kleist's hooking sign                   Wartenburg's prayer sign
   Klippel-Weil's test


Contusions and Lacerations

Palm damage tends to injure skin, vessels, tendons, and nerves. Injuries of the dorsal hand tend to damage only skin, tendons, and infrequently bones. Highly painful compression injuries can severely damage all structures.

      ABRASIONS AND BRUISES OF THE HAND

All cuts should be quickly cleaned and examined for deep injury. Use cold, compression, and elevation as necessary to reduce edema. Take care to avoid serious hand infection from careless management of small lacerations. The hand is particularly vulnerable to infection with venous and lymphatic extension. Contusions of the dorsal aspect of the hand usually come from being stepped on when down. Cleats, sticks, and skate blades, obviously, increase the severity of the injury. Palmar bruises are often seen over the metacarpal heads in the glove hand of the hockey goalie, baseball player, or handball enthusiast.

Hamate Bruise.   Sometimes a bone bruise is seen situated deep in the proximal hypothenar eminence in the hamate-pisiform area. This affliction is common to sports requiring a hand-held object such as a hockey stick, ski pole, bat, or racket due to impact on the hamate prominence. It may also be seen from a fall when the outstretched hand strikes an irregular surface. Chronic aggravation results in deep swelling, carpal-tunnel-like vascular symptoms, and distal neuralgia. Initial treatment must be quick to minimize bleeding and swelling through cold, compression, elevation, and rest. Padding, often specially designed, must be worn as long as tenderness persists. During recovery, corrective manipulation, local heat, ultrasound, and massage may be applied to relieve related soreness; however, rest and careful padding is the priority therapy.

Karate Lump.   It is not uncommon for karate enthusiasts to scarify their hands and feet by striking a straw-covered pliable post (makiwara) in several years of practice. The result can be scar-tissue development over the injured part, most commonly witnessed at the dorsal aspect of the 3rd and 4th metacarpophalangeal joints. Severe pain on flexion of the 3rd finger is typical. An entrapment syndrome may be produced as infiltrative scar tissue clamps the extensor tendon. In minor injuries, transient swelling and painful metacarpophalangeal joints will be seen. Occasionally, hand and wrist fractures will be presented. Remarkably, a large number of hands severly abused by such a severe form of hand conditioning show no visible soft-tissue calcification or damage to the metacarpal heads.

Handlebar Palsy.   An overuse injury experienced by bicylists is occasionally seen which is a neuropathy secondary to injury of the deep palmar branches of the ulnar nerve (handlebar palsy). The trauma results from prolonged severe pressure on the handlebars during long races. The clinical picture is one of muscle weakness and wasting in the intrinsic muscles of the hands without sensory impairment. This disorder is sometimes seen in factory workers from the constant pressure of industrial tools and thus may not be sports related.

Boxer's Knuckle.   Two conditions are involved here which may be separate or superimposed:

(1) After trauma, a bursa may form over a metacarpal head and become chronically inflammed.

(2) Distraction of the metacarpal ligament may result in boxer's who have their hands taped in full extension, when the intermetacarpal ligaments are relatively slack. As the hand is flexed, the ligaments tighten and the fingers are forced into apposition which tend to cause ligamentous distraction if any material becomes inserted between the fingers.

Aneurysms of the Hand.   In sports where the hand is used as a bat (eg, handball, karate) or struck or crushed, aneurysms and thrombosis of the palm may occur. The two common sites are at the hook of the hamate and at the base of the thenar eminence where branches of the radial and ulnar arteries are relatively unprotected from injury.

      CUT TENDONS

Flexor Digitorum Profundus Test.   This sign is based on the fact that flexor digitorum profundus tendons work only in unison. Stabilize the metacarpophalangeal and interphalangeal joints in extension. Have the patient flex the finger being tested at the distal interphalangeal joint. If the patient cannot do this, the sign is positive and indicates a cut tendon or denervated muscle.

Flexor Digitorum Superficialis Test.   To test the integrity of the flexor digitorum superficialis tendon, hold all of the patient's fingers in extension except for the finger being tested. Have the patient flex the tested finger at the proximal interphalangeal joint. If the patient cannot do this, the sign is positive for a cut or absent tendon.


Strains, Sprains, and Related Disorders

Severe finger sprains with or without avulsed fragments are frequently treated in sports care. In acute sprain, the ligament tears and allows the bone ends to subluxate and disrupt the integrity of the joint structure. Local pain, tenderness, swelling, and motion restriction are exhibited. A previously torn ligament may predispose a joint to recurring luxation because of laxity of the stabilizers.

      THE SPRAINED THUMB

A severe injury can occur to the inner thumb ligaments from a fall on a thumb directed outward or when caught in an opponent's uniform. This often results in a complete tear which requires surgery. The thumb is also often jammed, and the medial or lateral ligaments sprained, when hitting with the closed fist.

Pollicus Longus Tests.   The examiner stabilizes the proximal phalanx of the patient's thumb, and the patient is instructed to flex and extend the distal phalanx. Inability to flex the phalanx indicates an injury to the tendon of the flexor pollicus longus. Inability to extend the phalanx indicates an injury to the tendon of the extensor pollicus longus.

Management.   Treat as a severe sprain, and strap with a figure-8 bandage using half-inch tape. As soon as the acute stage passes, advise several hot soaks a day to "flood" the thenar muscles and help prevent joint stiffness or a "glass thumb". Squeezing a rubber ball helps to strengthen grip during recuperation.

Bowler's Thumb.   Ulnovolar neuroma (bowler's thumb) is the result of trauma to the digital nerve from the edge of the thumb hole in the ball. After repeated bowling, fibrous proliferation and enlargement of the 3rd and 2nd fingers are frequently seen. Callus formation may be evident on roentgenography.

Skier's Thumb.   In skiing, a rupture to the ulnar collateral ligament of the thumb may occur during a fall on a slope when the leather loop at the handle of the ski pole is wrapped around the thumb (skier's thumb). This injury can be avoided if a pole is used without a loop at the handle.


      METACARPOPHALANGEAL AND INTERPHALANGEAL SPRAINS

The mechanism of metacarpophalangeal injury is one of sudden hyperextension or a severe lateral force. Subluxation, pain, and disability are often severe, and recovery is slow until ligaments tighten to prevent recurring subluxation.

The interphalangeal joints are easily sprained, torn, and dislocated. This is due to their thin capsule, delicate collateral ligaments, and slender articulations. Associated subluxations are often left untreated by the unaware, resulting in long-term disability and possible permanent deformity.

A twisted finger causes painful tears of the collateral ligaments. Capsulitis is a common complication. Immobilize in moderate flexion, and treat as a severe sprain. Graduated exercises may begin in about 10 days.

Extensor Digitorum Communis Test.   The patient is instructed to first make a fist, and then to extend all fingers. Inability to extend any finger indicates an injury to that particular tendon of the extensor digitorum communis.


      MALLET (BASEBALL) FINGER

In sports, a hard object may strike a finger resulting in an extensor digitorum tendon injury where the tendon avulses from its insertion at the posterior base of the terminal phalanx. The jammed distal phalanx assumes a position of about 70°. It appears "dropped" and is rigidly flexed, with active distal interphalangeal extension severely limited. In such an injury, small bone fragments may be seen at the distal interphalangeal joint's posterior aspect on roentgenography. Both phalangeal fractures and extensor tendon abnormalities may produce mallet finger.

Unexpectedly, few such injuries are caused by a baseball. Most are the result of a finger striking the ground or a hard object. In fact, the incidence of such injuries in baseball is far below those seen in basketball, volleyball, football, and soccer.

Management.   If there is no crepitus and the range of joint motion is normal, a simple strapping of the splinted injured finger with its neighbor may be sufficient for stability. Treat as a severe sprain, and apply a molded splint. There is no need for manipulation, but a slight "milking" action helps prior to strapping to disperse stagnant fluids. Inspect weekly, and re-tape as is necessary for the degree of healing taken place. Operative repair seldom gives better results.


      GANGLION

A ganglion is a cystic swelling occurring in association with a joint or tendon sheath, apparently formed by a defense mechanism when the wrist is repeatedly twisted and strained. It has a fibrous outer coat and an inner synovial layer containing a thick gelatinous fluid. A common site is in the wrist or hand; they are rarely found in the ankle or foot. A firm localized swelling and possible weaken grip strength are found. Aching or sometimes pain from pressure on adjacent structures is typically exhibited.

      SUPPURATIVE TENOSYNOVITIS

If pus collects within the sheath of a palm tendon, four characteristic features (Karavel's cardinal points) are witnessed:

(1) The finger is carried in slight flexion for comfort;

(2) The finger is swollen in its entire circumference in contrast to swelling from a localized infection;

(3) Pain is increased during involved finger extension; and

(4) Marked pain is felt along the course of the inflammed tendon sheath.


      DE QUERVAIN'S DISEASE

This is a painful stenosing tenosynovitis due to the relative narrowness of the common tendon sheaths of the abductor pollicis brevis and longis. Tendon thickening occurs on the dorsum of the hand at the base of the thumb. Repetitive wrist and thumb overstress may produce pain along the distal radius which is increased by thumb motion. Chronic irritation causes the thumb's extension tendons to become inflammed as they pass through the narrow tunnel on the lateral wrist. Incidence is highest in racket sports, table tennis, golf, and bowling, and sometimes results from clipping hedges or piano playing.

Finkelstein's Test.   The patient is asked to make a fist with his thumb tucked inside his palm. The examiner stabilizes the patient's wrist with one hand and ulnar deviates the wrist with his other hand. Sharp pain in the area of the first wrist tunnel (radial side) strongly points toward stenosing tenosynovitis (De Quervain's disease) where inflammation of the synovial lining narrows the tunnel opening causing pain on tendon movement.

Management.   Treat as a severe sprain, and provide rest with splinting. If conservative management fails, refer for pain relief, steroids, and possible surgical release. Surgery is required to free the binding if conservative measures fail.


      TRIGGER FINGER

This is an entrapment syndrome produced by scar tissue compressing an extensor tendon, often a consequence of De Quervain's disease. It's incidence is high in fencing. Squeezing action by the constricted sheath tends to develop a pealike mass distal to the thickening. It is most often seen in the thumb, but several fingers may rarely be affected. Simple surgery remedies the situation.

      CONTRACTURES

Bunnel-Littler or Retinacular Test.   Hold the metacarpophalangeal joint in slight extension and try to flex the proximal interphalangeal joint of any finger being tested. If the joint cannot be flexed in this position, it is a positive sign that the intrinsic muscles are tight or capsule contractures exist. To distinguish between intrinsic muscle tightness and capsule contractures, let the involved metacarpophalangeal joint flex slightly, relaxing the intrinsics, and move the proximal interphalangeal joint into flexion. Full flexion of the joint shows tight intrinsics; limited flexion indicates probable contracture of the interphalangeal joint capsule.


      FUSIFORM EFFUSION

A palpable fusiform effusion at the proximal interphalangeal finger joints may be centered on the joint and be symmetrical on both sides. Even if signs of osseous change are not evident in x-ray films, a rheumatic diathesis exists.


Fractures and Dislocations

All contact sports have a high incidence of metacarpal fractures, but severe displacement is not common.

      FINGER FRACTURES

The incidence of metacarpophalangeal thumb joint fracture-dislocation is highest in wrestling and skiing. A fracture of a proximal phalanx tends to displace anteriorly in an angular fashion because of lumbrical pull. A rotated phalanx, often noted by a nail's relationship with its neighbors, is an indication of fracture. Fracture symptoms mimic severe sprain plus abnormal bone or joint contour. Crepitus is not always exhibited in finger fractures.

      FINGER DISLOCATIONS

Many finger dislocations often spontaneously reduce themselves. Dislocation of the proximal interphalangeal joint usually entails severe injury of the collateral ligaments and is likely to heal with an instable, swollen, stiff joint.

Examination.   During on-field evaluation, judge bone length of a suspected fracture or dislocation by comparing with the uninjured hand. Check by applying axial and leverage pressure to patient tolerance. Keep in mind that incomplete and impacted fractures may be present, yet associated tendon, nerve, and vascular damage are quite rare in sports. Comparative x-ray views of the sound limb are frequently helpful. Depending upon one's expertise, roentgenography may or may not be required to analyze possible complications prior to considered reduction.

Management.   These conditions are extremely painful; thus, care must be taken to assure that one attempt at correction is sufficient. Do not use prior traction as in many other adjustments; the pain is too great. For good control and to avoid slippage, place the patient's phalanx, distal to the injured joint, high between your index and middle finger, then gently close your hand into a fist with your thumb over your index finger. Stabilize the patient's hand with your free hand.

Simple dislocations may be reduced by increasing the deformity and using leverage to slip the distal articulation into normal position. In metacarpophalangeal dislocations, hyperextend the phalanx and apply pressure and traction at its base to quickly slip it over the metacarpal head. This is much better than straight axial traction. If the displacement is superior-medial or superiorlateral, your pull and pressure must be varied accordingly.

Follow correction immediately with a finger splint that is strapped to an adjoining finger. Treat as a severe sprain, and apply a molded splint for 4-6 weeks. Note that the index finger's metacarpophalangeal joint is extremely resistant to closed reduction and often requires surgery.

      THUMB DISLOCATIONS

Dislocation often occurs between the 1st metacarpal and carpal joint, often difficult to detect, or between the 1st metacarpal and phalangeal joint. Reduction and general management is the same as for finger dislocations.

Fistfighter's Dislocation-Fracture.   A fracture of the 4th and/or 5th metacarpal, especially at the neck, is often referred to as a "fighter's" dislocation-fracture. The bone's head and neck are often pushed into the palm. This is most often seen in the bare-knuckled fighter or during riots rather than with the gloved boxer who more commonly presents a fracture at the proximal third of the 1st metacarpal.


Miscellaneous Pathologic Signs

Kleist's Hooking Sign.   The patient is instructed to place both supinated hands forward, with the elbows moderately flexed. The examiner grasps the fingers and gently moves them into extension. If the patient's fingers react into flexion rather than passively going into extension, this pathologic reflex is thought by several authorities to indicate a frontal or thalamic lesion.

Klippel-Weil's Test.   The examiner quickly pries open the flexed fingers of the spastic limb. A reflex response of automatic thumb flexion and adduction indicates a pyramidal tract lesion.

Palmomental Reflex.   The examiner strokes the palm of the patient with a moderately blunt instrument. In pyramidal tract disease, the ipsilateral mentalis muscle will often contract so that the lower lip will protrude and raise and the skin of the chin wrinkles so that a facial expression of contempt or scorn is produced.


Injuries of the Nails and Fingertips

Finger nailbed injuries are quite common. The degree of injury may vary from nail splits to painful complete nail avulsion at the base with tears in the nailbed. The nailbed is contiguous with the periosteum of the underlying bone. Bleeding may be associated with phalanx fracture or a crush injury.

Management.   In uncomplicated avulsions, apply cold to reduce bleeding and swelling. An avulsed nail should be repositioned and a light pressure bandage applied to keep it from snagging clothing or other objects until it painlessly separates by itself. Care must be taken not to bandage the distal end so tightly as to restrict drainage.

Subungeal Hematoma.   If a painful blood pool develops from lack of drainage, referral may be necessary for relief. Several sports physicians describe a common method utilized by trainers: A paper clip is heated in flame to incandescence and then thrust through the intervening nail whereupon it strikes the entrapped blood pool which immediately cools the clip. Hirata states that the method is crude but effective, causes little if any discomfort, and affords immediate relief. The channel created offers a track for drainage, but it also affords a door for secondary infection which may later require excision of the overlying nail. A secondary osteomyelitis is always a threat.

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