CHAPTER 14
The Elbow, Wrist
and Hand
Introduction
Over the last century, the use of thrust manipulation to treat upper extremity pathologies has increased progressively. Today manipulation is now used as an adjunctive therapy for a range of upper limb disorders, including lateral epicondylitis, nursemaid’s elbow, post-traumatic elbow stiffness, carpal tunnel syndrome, cubital tunnel syndrome and many more (Lason and Peeters, 2014). Advocates of manual therapy consider manipulation a relatively safe and effective approach to treat upper extremity disorders. In addition, they claim that a great majority of patients with musculoskeletal pathologies can benefit from manipulative procedures (Paterson and Burn, 2012).
Practitioners of manipulative therapy use various techniques depending on the upper extremity joint and/or lesion being treated. The therapeutic goal of these practitioners is to apply a procedure that is well tolerated by the recipient and yields the best result. They primarily aim to reduce inflammation, alleviate spasticity, correct malalignment of bones, decrease overload of forces, promote faster healing and increase upper extremity strength, endurance and flexibility (Saunders et al., 2015). In general, they usually utilise two manipulation approaches for manual correction of upper extremity abnormalities: high-velocity, low-amplitude thrust (HVLAT) and mobilisation.
However, despite many positive claims by the advocates of manual therapy, there has been a lack of quality research and evidence in support of manipulation of the upper extremity (Bronfort et al., 2010). Given the limited evidence with regard to the therapy, the benefits and risks associated with upper extremity manipulation are yet not explored (Brantingham et al., 2013; McHardy et al., 2008). Therefore, before deciding to perform a manipulative procedure, a practitioner must make sure that no absolute contraindication or red flag for serious pathology is present. Moreover, because adequate knowledge, good technical skill, extensive experience and sound clinical reasoning play an important role in preventing incidence of adverse events following manipulation, it is of critical importance for practitioners to have appropriate training and education (World Health Organization, 2005; Ernst, 2007; Brantingham et al., 2013).
The purpose of this chapter is to help practitioners diagnose serious pathologies of the upper extremity. However, as we have already discussed the shoulder region in a separate chapter, this chapter will particularly focus on the elbow, wrist and hand. In addition, this chapter will also describe the various joints of these structures, the range of motion in these joints, some common injuries to the regions and the red flags for manipulation.
Joints
In human anatomy, the upper extremity is the region that extends from the deltoid region to the hand. It includes all the structures from the shoulder to the hand. The elbow acts as a mechanical link between the shoulder and the hand. The major functions of the elbow comprise placing the hand in space, serving as a hinge or support for the forearm and affording fine movements of the hand and wrist (Alcid, Ahmad and Lee, 2004).
In contrast, the hand and wrist comprise a complex system of static and dynamic structures, consisting of bones, muscles, tendons, ligaments and skin. Together they perform a variety of complex tasks, including object handling, providing oppositional grip, communicating and various other tasks in daily life (Doyle, 2003).
Table 14.1 The joints of the elbow, wrist and hand | ||
Joint name | Description | Function |
Elbow joint | •A highly congruous and stable joint •Forms a complex hinge between three bones: the humerus, the ulna and the radius •Involves three separate articulations: the humeroulnar joint, the humeroradial joint and the superior radioulnar joint •Surrounded by a single fibrous capsule that encloses the entire joint complex | •Provides the arm with much of its versatility and allows the hand to move towards and away from the body •Allows flexion and extension of the upper arm as well as supination and pronation of the forearm and wrist |
Humeroulnar joint | •A synovial hinge joint, which is one of the three joints that constitute the elbow •Composed of two bones: the humerus and the ulna •Originates from the trochlear notch of the ulna to the trochlear of the humeral condyle •Involves articulation between the humerus and the ulna | •Allows flexion and extension of the elbow |
Humeroradial joint | •A ball-and-socket joint, which is one of the three joints that constitute the elbow •Originates from the superior aspect of the radial head to the capitulum of the humeral condyle •Involves articulation between the humerus and the radius | •Allows flexion and extension of the elbow with rotation of the radial head on the capitellum |
•A pivot-type synovial joint that is encapsulated within the elbow’s synovial tissue •Originates from the head of the radius to the radial notch of the ulna | •Allows pronation or supination movement of the elbow | |
Radiocarpal joint | •A major synovial joint formed between the forearm and the hand •Connects the distal radius to the scaphoid, lunate and triquetrum | •Contributes to the stability of the wrist •Allows the wrist to move along two axes •Supports flexion, extension, adduction and abduction of the wrist |
Intercarpal joints | •Synovial joints that involve articulations between the individual carpal bones of the wrist •Subdivided into three sets of articulations: joints of the proximal row, joints of the distal row and joints between these two rows | •Contribute to total wrist mobility |
Midcarpal joint | •A synovial, S-shaped joint formed between the proximal and distal carpal rows •Composed of a very extensive and irregular joint cavity | •Allows the initial phase of wrist flexion and extension |
Carpometacarpal joints | •Synovial joints formed between the distal row of carpal bones and the proximal row of metacarpal bones •Supported by some strong ligaments, including the carpometacarpal and pisometacarpal ligaments | •Contribute to the palmar arch system in the hand |
Intermetacarpal joints | •Plane synovial joints formed between the metacarpals •Occur between the bases of the second, third, fourth and fifth metacarpal bones •Strengthened by a group of ligaments, including the dorsal, palmar and interosseous metacarpal ligaments | •Permit some flexion-extension and adjunct rotation |
Metacarpophalangeal joints | •Condyloid-type joints that connect the distal head of metacarpals to the proximal phalanges of the fingers •Supported by a number of ligaments, including the strong palmar and collateral ligaments | •Allow movement of the fingers in different directions (e.g. flexion, extension, abduction, adduction and circumduction) |
Interphalangeal joints | •Hinge joints formed between the phalanges of the fingers •Connect the heads of the phalanges to the bases of the next distal phalanges •Subdivided into two sets of articulations: proximal interphalangeal joints and distal interphalangeal joints | •Allow flexion and extension movements |
Sources: Alcid et al. (2004); Kuxhaus (2008); Fornalski, Gupta and Lee (2003); McCann and Wise (2011); Standring (2008); Doyle (2003) | ||
Range of Motion
The elbow joint is a complex hinge between three bones and thus involves three separate articulations: the humeroulnar joint, the humeroradial joint and the radioulnar joint. These three joints comprise a single compound joint and work in coordination to allow flexion and extension of the upper arm and, at the same time, supination and pronation of the forearm and wrist (Villaseñor-Ovies et al., 2012).
Table 14.2 Normal range of motion of the elbow joint | |
Movement type | Range of motion |
Flexion | 140–150° |
Extension | 0° |
Pronation | 76–84° |
Supination | 80° |
Source: Norkin and White (2009) | |
Table 14.3 Range of motion of elbow for activities of daily living | |
Movement type | Range of motion |
Flexion | 75–120° |
Extension | 0° |
Pronation | 50° |
Supination | 50° |
Sources: Vasen et al. (1995); Morrey, Askew and Chao (1981) | |
In contrast to the elbow joint, the hand and wrist have an incredible range of motion and help assist in a wide range of activities of daily living.
Table 14.4 Normal range of motion of the wrist | |
Movement type | Range of motion |
Flexion | 60–80° |
Extension | 60–75° |
Radial deviation | 20–25° |
Ulnar deviation | 30–39° |
Source: Norkin and White (2009) | |
Table 14.5 Functional and average range of motion of the wrist | ||
Motion unit | Range of motion | Reference |
Functional range of motion in ADL | •45° of flexion •50° of extension •15° of radial deviation •40° of ulnar deviation | Brigstocke et al. (2013) |
Average range of motion in ADL | •50° of flexion •51° of extension •12° of radial deviation •40° of ulnar deviation | Nelson et al. (1994) |
Table 14.6 Normal range of motion of the finger joints | ||
Joint name | Motion type | Average |
Metacarpophalangeal joint | Flexion | 90–100° |
Extension | 20–45° | |
Proximal interphalangeal joint | Flexion | 90–120° |
Extension | 0° | |
Distal interphalangeal joint |
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