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HAND, WRIST, AND ELBOW
Taking Care of Your Hand, Wrist, and Elbow
A vast range of human activities- from playing the piano,
to laying bricks, to opening a can of soda- would be
impossible without the healthy functioning of the elbow,
wrist, and hand. And yet this area is one of the most
intricate- and one of the most vulnerable to injury-
in the human body.
In this article you will learn about:
the basic anatomy of the elbow, wrist, and hand;
common ailments;
ways to reduce risk and injury;
exercises to do at home; and
physical therapy treatments.
Sometimes all it takes is some simple preventive measures
and exercises to keep your hand, wrist, and elbow in
good shape.
Anatomy of the Hand, Wrist, and Elbow
The elbow is a hinge joint connecting the upper arm
bone (humerus) with the bones of the forearm (the radius
and the ulna). It consists of three joints enclosed
within a capsule and held together by muscles, tendons,
and ligaments. Tendons are strong fibrous cords that
attach muscles to bones. Ligaments are bandage-like
sheaths of fibrous tissue that keep the joints and bones
in alignment.
The wrist and hand are far more complex than the elbow.
The eight wrist bones are known as carpals, and they
support the carpal tunnel, a "tube" which
runs through the wrist. The carpal tunnel contains tendons
and the median nerve, and it is covered by the transverse
carpal ligament (a flat, bandage-like ligament).
The hand itself is more intricate. The metacarpals
form the structure for the "body" of the hand,
and the phalanges are the finger bones. There are three
phalanges in each finger, except for the thumb, which
has two.
Each finger is supplied with two types of tendons:
an extensor tendon on top, which straightens the finger,
and a flexor tendon on bottom, which bends it.
The interphalangeal (IP) joints are the joints between
the different sections of the finger. Metacarpal phalangeal
(MP) joints connect the fingers and the hand.
In all, there are 27 bones in the hand, including the
wrist. In addition, the hand contains an intricate network
of muscles, tendons, nerves, and blood vessels, all
packed into a very tight space.
Traumatic Injuries vs. Repetitive Motion Injuries
Physical therapists deal with two main groups of hand,
wrist, and elbow injuries- traumatic injuries and repetitive
motion injuries.
Traumatic injuries- fractures, lacerations, amputations,
etc.- always require immediate medical intervention.
Repetitive motion injuries develop over time and are
often the result of computer work, assembly line tasks,
or other tasks which require the repetitive use of the
arms and hands. Physical therapists can treat repetitive
motion injuries by developing long-range plans of treatment
which address muscle and joint stress and weakness.
Many physical therapists are also involved in preventing
repetitive motion injuries by helping redesign workstations
and tools.
Repetitive Motion Ailments
One example of a repetitive motion injury is "trigger
finger," a form of tendinitis brought on by repeatedly
grasping an object. This condition is an inflammation
of the flexor tendon in any of the fingers (including
the thumb). This swelling makes it difficult for the
flexor tendon to glide easily through the tendon sheath
which surrounds it. As a result, there may be a popping
or clicking sensation when moving the finger. At times
the finger locks in a curled position. If the finger
locks, surgery will probably be required. If, however,
the joint can be palpated (very gently examined) and
mobilized (passively moved), the condition can often
be treated with anti-inflammatory injections (administered
by a physician), splinting, and other therapies.
DeQuervain's Disease is a painful condition that involves
the tendon of the thumb and the distal radius. (The
distal radius is the end of the forearm bone that lines
up with your thumb.) As with trigger finger, the tendon
swells and is unable to move freely within the sheath
located at the wrist near the base of the thumb.
DeQuervain's falls into the repetitive motion category
of problems, though it can also be brought on by traumatic
injury or aging. Options for treating DeQuervain's are
similar to those for trigger finger.
Traumatic Injuries
Physical therapists regularly see patients who have
suffered traumatic injuries- such as in a car collision-
in addition to less severe injuries such as sprains
and fractures. In the more serious cases the physician
and physical therapist will work together to plan a
course of therapy for the patient after his or her condition
has stabilized.
Common Elbow Ailments
Tennis elbow does not occur only in tennis players.
In fact, whatever the activity involved, there's a potential
for tennis elbow developing anytime you twist your elbow
repeatedly so that the radius and the ulna (the lower
arm bones) criss-cross each other.
This repetitive motion puts strain on the cartilage,
ligaments, and tendons surrounding the elbow joint and
can lead to swelling, inflammation, or tissue damage.
Inflammation of the tendons, or tendinitis, is a common
problem in these conditions. Physical therapists can
treat tennis elbow and tendinitis with a variety of
modalities, including ice, and exercises.
A sprain occurs when a ligament is stretched beyond
its normal limits. Sometimes the ligament tears. The
most common hand sprain is the ulnar collateral ligament
sprain, in which the ligaments at the base of the thumb
(the MP joint) are torn or partially torn.
Common Hand Ailments
Sprains often happen while playing sports. People
often minimize the seriousness of a sprain, using the
word as a generic term for any minor injury to the extremities.
An actual sprain can take weeks to heal properly, while
most minor injuries heal quickly with little or no physical
therapy. For a sprain, a physical therapist will focus
on restoring full strength and mobility and on preventing
the creation of adverse scar tissue, which can permanently
affect the functioning of the hand or any joint.
If you fall on your outstretched hand, you may suffer
a Colles' fracture, a fracture of the bones of the forearm
(the radius and the ulna) near the wrist. A physician
can treat a "clean" or uncomplicated break
by simply "setting" the bones and keeping
the area immobile for a period of time by means of a
cast or splint. In other cases, surgery may be required,
with pins inserted around the fracture site before the
arm is immobilized. In either case, a physical therapy
will be an integral part of the rehabilitation program,
before and after the cast or splint is removed. For
example, your physical therapist might consult with
your physician to determine how the cast should fit
so that it does not unduly limit your mobility and thus
slow your recovery.
Some of the most common injuries physical therapists
see these days- and not just in children and teens-
are the result of in-line skating accidents. Simple
protective equipment can mean the difference between
many hours in a physical therapist's office and many
hours zipping around town. So take some good advice:
if you participate in in-line skating, wear wrist protectors,
elbow pads, knee pads, and a helmet.
The DIP Joint
DIP joint stands for "distal interphalangeal joint"-
in other words, the finger joints closest to the fingernails.
DIP joint injuries are common in sports, occurring most
often when a baseball or basketball jams into the end
of the finger, injuring the DIP joint and causing the
finger to droop. This tearing of the tendon and subsequent
drooping of the finger usually requires splinting for
6-8 weeks; otherwise, the finger may droop permanently.
Carpal tunnel syndrome (CTS) is probably the best-known
of the repetitive motion disorders. Briefly, CTS is
an ailment caused by the swelling of the tendons within
the carpal tunnel, a narrow channel running through
the wrist. The carpal tunnel also contains the median
nerve, which transmits impulses directly from the brain,
or the spinal cord, to the hand. When the tendons swell
and put pressure on the median nerve, the result can
be symptoms of numbness, weakness, tingling, and burning
in the fingers and hands.
Some people seem to be genetically inclined to CTS,
but others at risk include those who work at computer
keyboards for long periods, assembly-line workers, and
jackhammer operators. Prevention is paramount in dealing
with CTS: regular rest breaks, on-the-job exercises,
posture, and ergonomically correct tools and instruments
are all crucial.
The cubital tunnel is a bony tunnel in the inside of
the elbow which contains the ulnar nerve. Because there
is very little room for movement within the cubital
tunnel, inflammation of the ulnar nerve can cause tingling
or pain that radiates from the elbow down to the fingers.
These symptoms are often seen in people who habitually
rest their elbow on the window edge in a car or prop
their elbow up on their desk at work, thus putting pressure
on the ulnar nerve.
The "Funny Bone"
The "funny bone" is not a bone at all, but
rather the ulnar nerve, which runs along the outer edge
of the elbow. This nerve is close to the surface of
the skin, and even a minor blow can cause sharp pain
and tingling. This sensation usually subsides after
a few seconds and almost never requires professional
attention.
The Role of the Physical Therapist
Your physical therapist can help you regain function
in your elbow, wrist, or hand as quickly as possible
through a combination of manual techniques such as exercise,
massage and mobilization, and training to help you use
your hand for maximal function. Physical therapists
emphasize the need to get the affected area moving as
quickly as is safe after an injury. The longer a joint
remains immobile, the greater the possibility that excess
swelling may lead to decreased use of the area.
It is especially important to minimize edema (swelling)
in the hand. The hand is so compact, and so intricately
constructed with its many small bones and joints, that
the natural swelling that accompanies an injury can
be a serious problem in itself. The back of the hand
is the most common place for swelling to occur, and
if the fluid that accompanies the edema is not displaced,
the tissue inside the hand can become almost like glue
in texture. When scarring sets in, the capsules around
the joints shrink and the ligaments tighten, causing
loss of function in the hand.
Moving the hand as soon as is safely possible displaces
the fluid that causes swelling. It also lessens the
chance that the hand's range of motion will be permanently
diminished.
Traditional Therapies and High-Tech Horizons
Your physical therapist has many options available
to treat your condition, from ice packs and splints
to the most advanced technology. Often working in consultation
with a physician, your physical therapist will design
a treatment regimen tailored to your individual problem,
working to restore flexibility and ease discomfort.
Treatment may emphasize exercises for relaxation, conditioning,
restoring range of motion, strength, endurance, and
coordination. Specialized treatments, or modalities,
include heat, cold, massage, ultrasound, electrical
stimulation, and traction.
Medical technology today can often diagnose ailments
without surgery. Using a process called arthroscopy,
orthopedic surgeons can now insert miniature video cameras
into the affected area (the wrist, for example). This
can allow the physician to pinpoint the problem and
treat it immediately. This procedure is far less traumatic
to the patient than is surgery, and it allows the patient
to begin sessions with the physical therapist days or
weeks earlier than might have been possible before.
Prevention
Many of the problems that physical therapists see every
day could have been easily prevented with a little education
and awareness. For instance, virtually all repetitive
motion disorders can be avoided through rest breaks,
exercise, proper posture, proper technique, use of protective
equipment, and properly designed work stations.
Overuse is certainly the most avoidable cause of hand,
wrist, or elbow problems. Taking regular breaks from
your computer keyboard- or your tennis game, or your
electric drill, or your sewing machine- for a few minutes
each hour can go a long way in preventing common overuse
injuries.
Exercise builds strength and increases your mobility
and range of motion. Depending on how it's used, exercise
can prevent problems or bring them on: the key is proper
form and moderation. We've included some simple hand
and wrist exercises in this brochure to get you started.
In addition, correct posture is essential to healthy,
harmonious functioning of the elbow, wrist, and hand.
The muscles and tendons of the wrist and hand are not
designed to carry a great deal of weight. The position
and alignment of your body when you carry heavy objects
can make the difference between developing a chronic,
painful condition and years of trouble-free use. You
can learn more about posture by ordering APTA's brochure
The Secret of Good Posture (listed below).
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