Lecture No. 5 The Wrist, Hand, Forearm & Elbow by DR Chaman Lal PT

MS PT 2S Lecture# 5
The Wrist, Hand,

Forearm & Elbow
By: Dr.Chaman Lal PT
B .S.PT, PPDPT (M.Phil Physiotherapy), MPH (M.Phil Public Health),
Master in Physical Education & Sports Injuries (UOS),
Dip. in sports Injuries, PG in Clinical Electroneurophysiology (AKUH),
Registered.EEGT (USA), Member of ABRET, AANEM & ASET (USA),
MPPS(PAK), MPPTA(PAK),
PhD Physiotherapy Scholar (Malaysia).
Anatomy of the Elbow
Bones:
Humerus
Radius
Ulna
Ligaments:
◦ Ulnar Collateral Ligament
Connects the ulnar & humerus.
Protects the elbow against
valgus stress
◦ Annular Ligament
Surrounds the radial head.
Allows rotation of the radius .
◦ Radial Collateral
Ligament Connects the
humerus and radius. Protects
the elbow against varus stress
By: Dr Chaman Lal PT 2

Elbow Flexors
Elbow
Flexors:
Biceps Brachii
Brachialis
Brachioradialis

Elbow Extensors
Elbow
Extensors:
Triceps Brachii

Elbow Pronators
Elbow
Pronation
(forearm) :
Pronator Teres
Pronator
Quadratus

Elbow Supinators
Elbow
Supinators
(forearm):
Biceps brachii
Supinator muscles

Injury Evaluation
History
◦ Ask questions: How, where, when, who
Observation
◦ What do you see? Swelling, bruising, deformity
Palpation
◦ What do you feel? Instability, deformity, defects
Special Tests
◦ What structures are damaged?
◦ How stable is the joint?
◦ Are they point tender?

Injury Prevention
Acute injuries usually occur from trauma or falling
Wear protective padding to reduce the force of a
blow
Learning how to fall correctly
Chronic injuries are very common in the elbow,
forearm and wrist
Limit # of repetitions throwing or hitting a tennis
ball
Make sure of proper mechanics
Maintain appropriate strength and endurance levels
Stretch to warm up & stretch to cool down
Don’t overlook chronic injuries. REST if needed!

Olecranon
Bursitis
Cause: Can be caused by a
direct blow, falling on the tip
of the elbow or excessive
flexion/extension. This injury
can be acute or chronic
Signs & Symptoms:
Excessive swelling that
appears to be superficial,
redness, warmth
Care: Ice, rest, compression
sleeve. On rare occasions, the
elbow is drained. Pad when
return to play. Athlete may
take NSAIDs to reduce
swelling. Ultrasound may be
used if this is a chronic
condition

Olecranon Bursitis

Ulnar Collateral Ligament
Sprain
Cause: Hyperextension or During rehabilitation throwing
excessive Valgus Force. This is restricted for the first 12
injury usually occurs during weeks. After 12 weeks,
the cocking phase of the throwing is controlled by
throwing motion limiting & gradually
Signs & Symptoms: progressing the number of
Pain, Instability, numbness & throws per day
tingling, Point tenderness
over the UCL
Care: Ice, compression
sleeve, sling, rest. Follow up
with a physician for
evaluation, x-ray & MRI if
necessary. Surgery is
required to repair the injury.
Recovery after surgery is
approximately 9 months

UCL
Sprain Ulnar
Collateral Ligament

Stress on the
UCL

Repair

Repair
Using Palmaris Longus

Tendon

Ulnar Nerve Injury
Cause: Typically happens as a
result of a weak or torn UCL. It
can become strained,
chronically dislocated, or
impinged
Signs & Symptoms:

Paresthesia or burning in
fourth & fifth fingers,
weakness in forearm
Care: treat conservatively by

rest & restricting aggravation
motions. Surgery may be
required. Do not compress the
nerve with outside pressure

Ulnar Nerve Injury

Lateral Epicondylitis
Cause: repetitive wrist
extension. Wrist extensor
tendon become inflammed at
the attachment. AKA Tennis
Elbow
Signs & Symptoms :
Swelling, Pain with wrist
extension, aching, weakness,
point tenderness over lateral
epicondyle
Care: P.R.I.C.E, NSAIDs, Ice,
Range of Motion exs, stretching,
strengthening, Counterforce
brace

Lateral Epicondylitis

Medial Epicondylitis
Cause: repetitive wrist flexion Care: Rest, NSAIDs, Ice,
& elbow flexion. AKA as Little Range of Motion exs’s,
Leaguer’s elbow (medial stretching, strengthening,
apophysitis) Pitcher’s Elbow, Counterforce brace. Return
baseball’s elbow, Suitcase to play through throwing
elbow, forehand Tennis Elbow program if athlete is an
& Golfer’s Elbow overhead thrower, Severe
cases may require splinting.
Signs & Symptoms: Point
tenderness, Swelling over
medial epicondyle, Pain with
wrist Flexion, Pain radiating
down the arm, aching,
weakness, point tenderness
over medial epicondyle
Heeling takes 6-9 months

Medial
Epicondylitis

Elbow Dislocation
Cause: Fall on Care: Check pulses,
outstretched hand with immobilize injury,
elbow in hyperextension refer for
or a severe twist with emergency
elbow flexion
reduction, X-ray &
splinting
Signs & Symptoms: bones
can be displace anterior,
posterior, or laterally,
most noticeable
deformity is displaced
olecranon, widening of
joint, loss or ROM, nerve
injury, severe pain,
swelling
Elbow
Dislocation

Elbow
Fracture
Cause: Fall on outstretched
hand, fall on flexed elbow,
direct blow or trauma to elbow
Signs & Symptoms: May not

see a visible deformity.
Hemorrhage, swelling, muscle
spasms
Care: Ice, sling or splint,

immediate referral to ER for x-
ray & cast. Casting
(immobilization) is typically
limited to 3 weeks. After 3 wks.,
patient is moved to splint/
brace that stabilizes but allows
motion
Elbow
Fracture

Elbow Fracture

Volkmann’s
Contracture
A fractured elbow is associated
with rapid swelling that may
cause a Volkmann’s
contracture.
Volkmann's contracture results
from acute ischemia/necrosis of
the muscle fibers of the flexor
muscles in the forearm caused by
obstruction of the brachial artery
near the elbow.
The obstruction may be caused
by improper tourniquet use,
improper casting, compartment
syndrome, or profuse bleeding
of fractured bones. The two most
affected muscles are the flexor
digitorum profundus & flexor By: Dr Chaman Lal PT 30
Bracing

Anatomy of the Forearm
Bones: Radius &
Ulna
Joints: Superior,
Middle & Distal
Radioulnar Joint
Soft Tissue:
Interosseous
Membrane

Muscles of the Forearm
Muscles (anterior): Muscles (posterior):
◦ Biceps Brachii ◦ Triceps Brachii
◦ Brachialis ◦ Anconeous
◦ Pronator Teres ◦ Flexor Carpi Ulnaris
◦ Brachioradialis ◦ Extensor Carpi Ulnaris
◦ Flexor Carpi Radialis ◦ Extensor Digiti Minimi
◦ Palmaris Longus ◦ Extensor Carpi Radialis Longus
◦ Flexor Carpi Ulnaris ◦ Extensor Carpi Radialis Brevis
◦ Flexor Pollicis Longus ◦ Extensor Digitiorum
◦ Pronator Quadratus ◦ Abductor Pollicis Longus
◦ Extensor Pollicis Brevis
◦ Extensor Pollicis Longus

Muscle
s
Flexors
Extensors
Forearm Injury Evaluation
History: how did it happen, where does it hurt,
prior injury, loss of function, symptoms
Observation : swelling, deformity, discoloration,

skin defects, motion
Palpation : tenderness, edema, deformity, skin

temperature, bone fragments, continuity of bone

Contusion
Cause: Repeated blows to
the forearm or a blow with
significant force. Typically
occur on the ulnar side
Signs & Symptoms:
bruising, pain, swelling,
hematoma, myositis
ossificans may develop if the
injury is severe
Care: P.R.I.C.E., stretching,
Range of motion exercises,
Pad/Protect to return to play

Forearm
Fracture
Cause: typically caused by a blow
or falling on an outstretched hand
Signs & Symptoms: Pain,
swelling, deformity, ‘false joint’.
There is a danger of soft tissue
damage if the fractured bones
move significantly
Care: Splint & immediately refer
for x-ray & physician consult. Ice.
Typically casted for 6-8 weeks,
surgery may be required if the
deformity is significant.
Take Tylenol for pain, NOT
Ibuprofen. Ibuprofen can delay
fracture healing by hindering the
inflammatory response phase
Forearm
Fracture

Monteggia Fracture
The Monteggia fracture is a fracture of the proximal
third of the ulna with dislocation of the proximal
head of the radius. It is named after Giovanni
Battista Monteggia.
The recovery time is 6–12 weeks. A mild

hyperextension deformity is seen in 39–45% of
children after Monteggia fracture-dislocation.
Posterior interosseous nerve palsy is the most

common nerve injury in Monteggia fracture-
dislocations,. Most of these injuries are neuropraxia
and recover slowly after the anatomical reduction of
the radial head.
Continue….
All Monteggia fractures

are considered
unstable and require
intervention
For Monteggia fracture-

dislocations, best
treatment
includes ORIF of the
ulna diaphyseal
fracture.
Galeazzi Fracture
A Galeazzi fracture is a
fracture of the middle to
distal third of the radius.
It is associated with
dislocation or subluxation
of the distal radioulnar
joint (DRUJ).
It is sometimes associated
with wrist drop due to
injury to radial nerve,
extensor tendons or
muscles.

Difference between Galeazzi and
Monteggia fracture
Monteggia fractures and Monteggia
variants are fractures of the proximal
1/3 Ulna with concomitant proximal
radioulnar joint (PRUJ) disruption
(evident by radio-capitellar subluxation
or dislocation).
Galeazzi fractures are fractures of the
radial shaft with concomitant dislocation
of the distal radioulnar joint (DRUJ).
How to Remember Galeazzi /
Monteggia Fracture
Remember: GRE-MUR
G: Galeazzi
R: Radius fracture
U: Ulna posterior dislocation.
(anterior rare) (DRUJ)
M: Monteggia
U: Ulna fracture
R: Radial head anterior dislocation.
(PRUJ)
Colles’
Fracture
Cause: Fall on outstretched hand
forces the wrist into
hyperextension. The most
common forearm fracture. Distal
Radius displaced posteriorly with
Fracture.
Women>men
Also called Dinner Fork Deformity
Signs & Symptoms: visible

deformity, pain, swelling, quick
accumulation of blood. Median
nerve damage is possible if the
radius shifts forward enough
Care: Splint & immediately refer

for x-ray & physician consult. Ice.
Typically casted for 4-8 weeks.
Fracture deformity is usually
reduced under anesthesia. By: Dr Chaman Lal PT 46
Smith
Fracture
A Smith fracture is
an extraarticular
fracture of the distal
radius featuring a
volar displacement
or angulation of the
distal fragment.
It is also known as
a reverse Colle’s
fracture.

Barton’s Fracture
Barton's fracture is a
fracture dislocation
of the distal radius in
which either the volar
or dorsal aspect of
the distal radial
articular surface is
sheared off with
disruption of the
radiocarpal joint. It is
usually caused by
violent direct injury to
the wrist.
Anatomy of the Wrist and
Hand Ligaments:
Bones of the Wrist ◦ Complex series of
◦ 8 Carpal Bones ligaments that bind the
carpal bones to one another,
Bones of the Hand to the ulna & radius, and to
◦ 5 Metacarpals the proximal metacarpals
◦ 14 Phalanx Bones ◦ Wrist: UCL & RCL
◦ Volar aspect of wrist is
Transverse Carpal Ligament
◦ Each Joint in the fingers has
MCL & LCL ligaments

Muscles of the
Hand Motions of the Wrist
Extrinsic Flexion
muscles: originate Extension
Radial Deviation
outside of the hand
Ulnar Deviation
Motions of the
Intrinsic Muscles: Fingers
originate inside of the Flexion
hand Extension
Abduction
Adduction
Motions of the
Thumb
Opposition
Flexion
Extension
Abduction
Metacarpal
Fracture
Cause: The most common
◦ Direct Axial force metacarpal fracture is a 5 th
metacarpal fracture, aka
◦ Trauma Boxer’s Fracture
◦ Contact
Signs & Symptoms:
◦ Pain
◦ Point Tenderness
◦ Defect
◦ Rapid Swelling
Care:
◦ Physician referral for x-ray &
evaluation
◦ If the fracture is not displaced,
they injury is casted
◦ If the fracture is displaced,
surgical reduction may be
necessary
Metacarpal Fracture

Boxer’s Fracture
Fracture of the 5th
Metacarpal

Mallet Finger
Rupture of the Extensor Tendon at the Distal
Interphalangeal Joint
Bony Avulsion of that tendon
Must be splinted in extension splint for 6-8
weeks, 24 hours a day

Mallet
Finger

Boutonniere Deformity
AKA Buttonhole Deformity
Rupture of the extensor tendon over the middle
phalanx at the Proximal Interphalangeal Joint
Caused by forcing the DIP into extension & the
PIP into flexion
Splint in extension for 6-8 weeks
If not treated properly a boutonniere deformity
will be permanent

Swan Neck Deformity
In a swan neck deformity, the PIP joint
is hyperextended with flexion at the
distal interphalangeal (DIP) joint.
In a boutonniere deformity, there is
flexion the PIP joint with
hyperextension of the DIP joint.

Boutonniere
Deformity

Jersey Finger
Cause:
◦ Rupture of the Flexor
Digitorum Profundus from
distal phalanx (DIP Joint)
◦ May occur with an avulsion
Signs & Symptoms:
◦ Finger cannot be flexed
◦ Finger stuck in extension
◦ Pain & point tenderness
over the distal phalanx
Care:
◦ Surgery is required for
flexion to be restored
◦ Surgery must be done
within 7-10 days. Recovery
is approx 12 weeks

Jammed Finger
Cause: forced axial
load to the tip of the
finger. Incredibly
common in sports.
Signs & Symptoms:
severe point
tenderness, lateral
instability, swelling
Care: x-ray to rule
out fracture, ice, &
splint, tape to return
to play

Collateral Ligament Sprain
“Jammed Finger”

Gamekeeper’s Thumb
Cause:
◦ Ulnar Collateral Ligament
Strain at MCP Joint
Signs & Symptoms:
◦ Pain over UCL
◦ Weakness & pain with
pinch
◦ Swelling over medial
aspect of thumb
◦ Joint instability
Care:
◦ X-ray to rule out fracture
◦ Splint or Cast 4-6 weeks
◦ Surgery can be required if
not protected properly

Gamekeeper’s Thumb

Dislocated Finger
Cause: Blow to the
tip of the finger
Signs & Symptoms:
Deformity, tearing of
capsule resulting in
hemorrhage, swelling
Care: x-ray to rule
out fracture,
reduction of
dislocation, splint
for 3-4 weeks, tape
to return to play

Phalanx Fracture
Cause:
Trauma such as being
stepped on, hit, mashed
between two objects,
twisting, forced
dislocation
Signs &
Symptoms:
pain, swelling, point
tenderness, deformity
Care:
Splint, refer for x-ray &
physician evaluation
Phalanx Fracture

Subungual
Hematoma
Cause:
◦ Contusion or crushing injury to
the first phalanx that causes
blood to accumulate under the nail
Signs & Symptoms:

◦ Extreme pain, blood under nail,
more than 25% fracture needs to
be ruled out
Care:
◦ Drain within 12 to 24 hours, ice,
elevate, clean once drilled, may
have to be drilled twice, keep
clean & covered. DO NOT DRILL
THE NAIL IF A FRACTURE IS
SUSPECTED!!!

Wrist
Sprain
Cause: a wrist sprain is
caused by Hyperextension
most often, but it can be
caused by violent flexion
or torsion
Make sure the athlete

gets an x-ray to rule
out a fracture.
Care: ice, splinting &

analgesics, strengthening
exercises, & taping to
return to play

Wrist Tenosynovitis
(Tendinitis)
Cause: repetitive wrist
acceleration &
deceleration
Signs & Symptoms:

Pain with use or pain with
passive stretching. Point
tender with swelling over
the tendon
Care: Ice massage,

NSAIDs, rest, & splint
injured tendon

Carpal Tunnel Syndrome
Cause: Care:
◦ Carpal Tunnel is caused ◦ Rest
by inflammation of the ◦ Wrist splint
flexor tendons that ◦ NSAIDS
compress the median ◦ Injection of corticosteroid
nerve
◦ Surgery
Signs & Symptoms:
◦ Sensory & motor deficits
◦ Tingling & numbness
◦ Paresthesia of thumb,
index & middle fingers.
◦ Weakness in thumb,
index & middle fingers
◦ Aching in hand

Carpal Tunnel
Syndrome

Dislocated Lunate
Caused by forceful
hyperextension
Not very common in
sports
Pain, swelling, deformity,
difficulty with flexion
May have numbness or
paralysis due to
pressure on the median
nerve
See physician
immediately for x-ray
and reduction. Cast for
4-8 weeks

Dislocated Lunate

Scaphoid Fracture
Scaphoid is found in the anatomical snuff box
Typically caused by falling on outstretched hand
Signs & symptoms include swelling & severe point
tenderness, loss of grip strength, weakness with thumb
movement
Athlete should be x-rayed immediately, immobilized in a cast
◦ Re-xray athlete every 2 weeks, & remain in splint if fx.
Shows up.
◦ If a fracture is present, immobilization period is typically
around 6 weeks
◦ The scaphoid doesn’t have good blood supply, which can
result in a non-union
◦ Non-union fracture healing must be repaired with surgery
◦ When athlete returns to play once out of cast, they must be
taped for 8-12 weeks

Scaphoid Fracture

Hamate Fracture
Cause: Care:
◦ A fall ◦ Cast the wrist
◦ Contact while ◦ Doughnut pad over
holding a sports hook of hamate
implement such as
the handle of a
tennis racket, bat,
golf club.
Signs & Symptoms:
◦ Wrist pain &
weakness
◦ Point tenderness
◦ Numbness &
tingling (ulnar nerve)
Hamate
Fracture

Wrist Ganglion
Cause: Care:
◦ Damage to joint capsule, ◦ Old: Pressure pad
synovial sheath or a cyst ◦ New: Combined
◦ Typically occurs after a treatment. Aspiration,
trauma Cauterization, pressure
◦ Usually found on dorsal pad
side of wrist ◦ Only sure way to remove
Signs & Symptoms: ganglion cyst is surgery
◦ Pain
◦ Lump at the site of pain
that is palpable
◦ Pain with wrist extension

Wrist
Ganglion


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Lecture No. 5 The Wrist, Hand, Forearm & Elbow by DR Chaman Lal PT

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MS PT 2S Lecture# 5

The Wrist, Hand,

By: Dr Chaman Lal PT 2

By: Dr Chaman Lal PT 3

By: Dr Chaman Lal PT 4

By: Dr Chaman Lal PT 5

By: Dr Chaman Lal PT 6

By: Dr Chaman Lal PT 8

By: Dr Chaman Lal PT 9

By: Dr Chaman Lal PT 10

By: Dr Chaman Lal PT 11

By: Dr Chaman Lal PT 12

By: Dr Chaman Lal PT 13

By: Dr Chaman Lal PT 14

By: Dr Chaman Lal PT 15

Using Palmaris Longus

By: Dr Chaman Lal PT 16

Signs & Symptoms:

Care: treat conservatively by

By: Dr Chaman Lal PT 17

By: Dr Chaman Lal PT 18

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By: Dr Chaman Lal PT 20

By: Dr Chaman Lal PT 21

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Signs & Symptoms: May not

Care: Ice, sling or splint,

By: Dr Chaman Lal PT 28

By: Dr Chaman Lal PT 29

By: Dr Chaman Lal PT 31

By: Dr Chaman Lal PT 32

By: Dr Chaman Lal PT 33

Observation : swelling, deformity, discoloration,

Palpation : tenderness, edema, deformity, skin

By: Dr Chaman Lal PT 35

By: Dr Chaman Lal PT 36

By: Dr Chaman Lal PT 38

The recovery time is 6–12 weeks. A mild

Posterior interosseous nerve palsy is the most

All Monteggia fractures

For Monteggia fracture-

By: Dr Chaman Lal PT 43

Signs & Symptoms: visible

Care: Splint & immediately refer

By: Dr Chaman Lal PT 47

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