ELBOW, FIST AND HAND

The elbow is the joint in the middle of the upper limb. It allows us to move our hand at various distances from the body, and for this reason, a restriction of movement in the elbow joint can be a serious handicap. The elbow consists of the humerus (the arm bone), radius, and ulna (the forearm bones).

The lateral collateral ligament is the main stabilizer of the elbow, while the medial collateral ligament controls flexion and extension. The joint capsule provides the necessary space for elbow movement, and the muscles inserting in the elbow area ensure its functionality. Elbow pathologies can permanently affect the use of the entire upper limb. Almost all sports activities can affect the elbow to a greater or lesser extent.

The anatomy of the wrist joint is extremely complex, probably one of the most complex in the human body. It is made up of the forearm bones (radius and ulna) and 8 carpal bones (scaphoid, lunate, triquetral, pisiform, trapezium, trapezoid, capitate, hamate). These bones and their associated joints allow us to use our hands in a very diverse manner. The wrist is a very versatile joint that allows us to lift, support, and manipulate objects around us.

The hand consists of 5 metacarpal bones forming the palm's skeleton and 14 phalanges forming the fingers. Hand injuries are less common than those of the shoulder and elbow, but due to their nature, they can become very frustrating.

Contents

Common Conditions

• Radial head fracture
• Distal humerus fracture
• Radius and ulna fracture

Chronic Conditions

• Epicondylitis (tennis elbow)

Surgical Interventions

• Distal humerus fracture
• Epicondylitis (tennis elbow)
• Radial head fractures
• Scaphoid fracture
• Elbow dislocation
• Finger dislocation
• Carpal tunnel syndrome

Common Conditions

• Radial Head Fracture

  
  

  Out of all elbow fractures, the radial head is involved in over 20% of problems. This fracture is usually caused by indirect trauma, such as falling on the upper limb with the elbow and hand in extension. Acute pain can lead to a limitation of movement and a decrease in hand strength.

  To best highlight a radial head fracture, an oblique position X-ray may be necessary, but the best imaging method remains MRI.

  Non-displaced fractures are usually immobilized with a rigid brace for 10 days. Therapeutic treatment should begin as soon as possible and carefully, but early mobilizations of the joint are essential to avoid the risk of subsequent stiffness, which tends to develop quite frequently.

  Displaced fractures are usually treated non-surgically and immobilized for 2 weeks, accompanied only by flexion and extension mobilizations. After the 2 weeks, a radiological examination confirms healing in over 70% of cases.

• Distal Humerus Fracture

  
  

  Fracturing the distal end of the humerus predominantly occurs in children, but sometimes it can also happen to adults. It usually occurs through indirect trauma such as falling on the upper limb with the elbow extended, but it can also break as a result of a direct blow.

  The pain is intense and encompasses the entire elbow joint, and the very high intensity of this pain impedes all elbow movements except for slight flexion.

  The doctor recommends an X-ray examination, and if he considers that there may be vascular or neurological complications, he may request more complex tests such as an electromyography or arteriography.

  Conservative treatment with a cast is rarely recommended to avoid elbow stiffness that can occur in such situations. For this reason, early resumption of movement is also recommended after surgical fixation.

• Radius and Ulna Fracture

  
  

  The most common fracture of the distal end of the radius is the one that also affects the COLLE bone, with the main cause being a direct fall on the hand in hyperextension. 60-70% of people with this type of fracture are postmenopausal women because this type of fracture predominantly occurs on an osteoporotic background.

  The same type of trauma causes scaphoid fractures in young people and "greenstick" fractures of the radius in children.

  This fracture is extremely painful and causes a noticeable deformity of the area, which is why analgesics are usually prescribed.

  A standard X-ray together with an oblique X-ray are sufficient to make an exact diagnosis. In some cases, an electromyogram can be performed to assess the presence of neurological conditions.

  After administering painkillers, which aim to manage the pain, the fracture is reduced by manipulation under anesthesia or surgical intervention for stabilization. Residual deformities are quite common, and during immobilization, a compression syndrome may appear due to a too-tight cast.

  After removing the cast, even if the joint is protected, recovery can begin by mobilizing the shoulder, elbow, and finger joints. After a few days, the actual mobilization of the wrist and forearm joints, both passive and active, can begin.

  Despite an adequate therapeutic process, 20-30% of these types of fractures remain unstable.

Chronic Conditions

• Epicondylitis (Tennis Elbow)

  
  

Epicondylitis starts with pain only during effort or when palpating the lateral epicondyle, then the pain occurs even at rest and becomes bothersome during daily activities: shaking hands, lifting a bottle of water, twisting a handle, etc.

The diagnosis is mainly clinical. During the consultation, the doctor will perform specific tests and may request a tissue ultrasound or an MRI (magnetic resonance imaging) for confirmation.

The first treatment choice is always a conservative one. In the acute phase, you will be advised to avoid movements that cause you pain for 20 days and to follow a physiotherapy program accompanied by both analytical and global stretching and relaxing massage. TECAR therapy works very well for such conditions due to its diathermy effect, which will accelerate the body's healing capacity. This, combined with eccentric exercises, will help you manage the problem very well in the long term.

Resuming sports activities is recommended only after strengthening the flexor muscles of the shoulder to release the entire motor chain. In case of recurrent chronic pain, shock wave therapy can be added to the treatment.

Surgical Interventions

• Distal Humerus Fracture

  
  

  A wide variety of surgical techniques are used to stabilize such a fracture: from internally fixed plates and screws to external fixations, all aimed at stabilizing the fracture and preventing displacement of the bone ends.

  The main objective of recovery is to mobilize the joint as quickly as possible without causing further complications that could lead to subsequent surgical treatment.

  Management of physiotherapeutic treatment will be done together with the surgeon, who will recommend resuming pronation and supination movements only after radiological confirmation of bone fixation.

• Epicondylitis (Tennis Elbow)

  
  

  Surgical treatment for this condition is considered only in disabling cases or in very persistent chronic forms.

  The surgical intervention aims to lengthen the myo-tendinous structures. There is both the classic open intervention and the minimally invasive arthroscopic variant.

  After surgical intervention, the segment may be immobilized in a mobile brace for 2-3 days, and after a maximum of 10 days, it is important to start physiotherapy to regain full range of motion. Physiotherapy aims to increase muscle strength and resume sports activities 50 days after the intervention.

• Radial Head Fractures

  
  

  These are usually fixed through a classic surgical intervention aimed at reducing and fixing the fracture with screws, rods, etc.

  The trauma caused by the surgical intervention in addition to the initial trauma that caused the fracture creates a debilitating stiffness of the joint, and for this reason, it is essential to start physiotherapy as soon as possible.

• Scaphoid Fracture

  
  

  A scaphoid fracture is the most common fracture among the carpal bones (almost 90% of cases). These fractures occur only as a result of falling on an outstretched hand and may also be associated with injuries to the small ligaments that stabilize the scaphoid, especially those near the lunate bone.

  Typically, the fracture causes sharp pain and significant swelling localized near the anatomical snuffbox (the small triangular area at the base of the thumb). The pain limits movement in all planes.

  To simplify, fractures are categorized into three types based on location: proximal, distal, and waist. The location of the fracture is very important for choosing therapeutic modalities and for long-term prognoses. In conclusion, fractures with the longest healing time and highest risk of complications are the proximal ones, as blood supply goes from distal to proximal, and children usually have much more significant vascularization of the distal two-thirds compared to the proximal third.

  To diagnose the fracture, the doctor will rely on both the patient's history and clinical signs; the diagnosis is usually confirmed by an X-ray of the wrist, taken in specific positions for the scaphoid. There are cases where a fracture may go unnoticed on the first X-ray; if suspicion of fracture persists, it is advisable to repeat the X-ray after 15 days or to perform a CT scan immediately to confirm the diagnosis.

  A late diagnosis or too short immobilization can be the most common causes of complications such as osteonecrosis of the proximal end or pseudoarthrosis (false joints).

  Immobilization with a cast includes the thumb, and the cast must be kept for 6 to 10 weeks. If proximal fractures are treated surgically with osteosynthesis material through a small incision (Herbert's approach), immobilization will be with a brace and will last only 2 weeks.

  Upon removal of the cast or brace (which comes after radiological confirmation of healing), it is appropriate to start a cycle of physical therapy aimed at recovering movement and intrinsic and extrinsic muscle strength of the hand. The recovery program will be supplemented with specific occupational therapy exercises to restore manual dexterity according to individual needs.

• Elbow Dislocation

  
  

  The most common hand injury is falling on an outstretched and externally rotated hand. This leads to stretching of the joint capsule structures.

  You will go to the doctor with typical pain throughout the joint and significant swelling.

  Swelling may appear behind the wrist, but usually a 10-day rest period with ice applications and a brace to limit movement are sufficient to manage the pain.

  After this period, physical therapy is needed to regain the full range of motion and muscle strength. We will do proprioception and coordination exercises together to restore the full function of the hand.

• Finger Dislocation

  
  

  Ligament injuries of the phalangeal joints are usually first or second degree and mainly affect the 4th and 5th fingers (ring and little fingers), which are the most vulnerable.

  The dislocation causes immediate sharp pain that tends to diminish within the next 2-3 minutes after the trauma and generally allows the resumption of hand activity. Movement limitation is mostly due to the level of swelling, which also makes it difficult to clench the fist.

  In many cases, there are also unknown fractures at this level that can cause joint stiffness and early arthritis. For this reason, an X-ray is usually recommended. The doctor will likely recommend a protective bandage for 7-10 days.

  If you play sports, the fingers can be immobilized by taping them to the adjacent finger. Splint immobilizations are recommended only for third-degree injuries with a slight degree of joint instability. Due to the location of the injury, analgesic treatment may be recommended during immobilization. After removing the splint, mobilizations and exercises should be performed to regain the function of the affected finger and increase the strength of the hand muscles.

• Carpal Tunnel Syndrome

  
  

  This syndrome is caused by a mechanical conflict between the container (carpal tunnel) and the contents (vascular-nervous bundle and tendons passing through the carpal tunnel). More precisely, the median nerve is pushed into the transverse carpal ligament, causing pain and motor deficiencies in the hand.

  There is a common pathology (more frequently encountered) caused by synovial hypertrophy of the flexor tendons and a secondary pathology caused by a systemic disease (amyloidosis, rheumatoid arthritis, diabetes) or narrowing of the carpal tunnel due to previous injuries: dislocations, fractures, etc.

  The syndrome occurs much more frequently in women during their fertile period and is usually bilateral.

  It is suspected that hormonal factors play an important role in the appearance of this pathology, but research is ongoing in this direction. This would explain the recurrence of symptoms during pregnancy and menopause.

  In the common (primitive) form, carpal tunnel syndrome is characterized by a tingling or numbness sensation in the palm and the first 4 fingers, especially occurring at night. In secondary pathologies, pain usually appears and tends to worsen with movement, making it predominantly a daytime problem.

  Diagnosing this issue is done through specific clinical tests supported by an electromyography (EMG) that confirms the degeneration of the median nerve's activity. Additional tests (blood tests, X-rays, or MRI) are useful for diagnosing secondary pathologies.