Managing elbow, wrist, and hand injuries

The elbow, wrist, and hand are complex multipoint systems. They work synchronously as a kinetic chain, transferring effector response to the brain and generating torque at the elbow to generate well-coordinated volitional upper limb movements.

Elbow-wrist-hand control is essential in coordinating fine motor tasks and gross movements of the upper extremity. The bony structures are surrounded by muscles, ligaments, tendons, and nerves. They are prone to soft tissue, orthopedic, musculoskeletal, and rheumatological injuries.

According to research, the elbow and wrist are most affected by soft tissue injuries, accounting for 70% of mild soft tissue injuries and 10% of severe soft tissue injuries. This greatly impacts hand function.

What are soft tissue injuries?

Soft tissue injuries are defined as any oxidative/compressive damage to the tendons, muscles, and ligaments. These types of injuries commonly occur as a result of overuse. The surrounding soft tissue is inflamed in response to repeated traumatic stimuli over time. In most cases, this compresses the nerve, leading to severe pain, numbness, paresthesia, and partial loss of strength and function.

The common soft tissue injuries are:

• Ganglion cyst
• Golfer's, tennis elbow
• Carpal tunnel syndrome
• Cubital tunnel syndrome
• De Quervain's tenosynovitis
• Ulnar collateral ligament (UCL) injury

What are other conditions in which the elbow, wrist, and hand will be affected?

Nerve dysfunctions

Nerve entrapments at the elbow and wrist level are most common. The patient presents with electric sharp pain, numbness, paresthesia, and difficulty in performing fine motor tasks.

• Ulnar nerve is the most common nerve trapped at the guyon canal and cubital tunnel in the elbow and forearm. The ulnar nerve symptoms usually occur due to compression, traction, or friction loads.
• Median nerve compression usually occurs at the proximal forearm and wrist. It arises due to repetitive tasks or overuse injuries. Median nerve neuropathy, carpal tunnel, and pronator teres syndrome are seen in outpatient departments.
• Radial and musculocutaneous nerve neuropathies are mostly seen in patients whose occupation requires repetitive forceful extension at the elbow and wrist simultaneously.

Fractures and trauma

Elbow, wrist, and hand, injuries are most common in adolescents and young adults, especially while playing contact sports. Patients also sustain trauma to the elbow, wrist, and hand in accidents. Injuries to the distal compartment of the upper limb are of serious concern as the patient is unable to perform their day-to-day activities. The scaphoid fracture is more common in hand and wrist injuries, while distal radius fracture is more common in injuries of the elbow and wrist.

Arthritis

Rheumatoid arthritis (RA) is an autoimmune condition that primarily affects small joints, especially the hand. Over time, RA causes severe hand deformities (Boutonniere and Swan neck deformities). In 20% of patients, the hand joints are swollen and have nodules. The patient is unable to perform basic ADLS due to prolonged pain, tenderness, and stiffness in the joints.

Managing various elbow, wrist, and hand problems

Soft tissue injuries

Soft tissue injuries rarely require surgery. These are managed by physiotherapy and conservative treatment management. Medications (NSAIDS) are used to reduce pain. The physician uses an exercise-based regimen to strengthen the weakened muscles and improve functionality.

Nerve dysfunction

Neuropathic nerve dysfunctions are common overuse injuries that can be easily managed by physiotherapy. If a patient has severe pain, numbness, and reduced nerve function shown in NCS, only then are they classified for corticosteroid injection and surgery (arthroscopy), such as in carpal tunnel syndrome, in which hand function is severely impaired.

Fractures

The first line of treatment consists of elevating the limb, using painkillers like ibuprofen, bracing the area with a splint or sling, and administering ice to minimise swelling.

• Severe or displaced fractures require surgical intervention, open reduction, and internal fixation (ORIF).
• Non-displaced fractures are typically treated with closed reduction and immobilisation using a cast or splint.
• Following post-op immobilisation, physical therapy uses progressive exercise to restore range of motion, strength, and function and prevent nerve and soft tissue damage.

Arthritis

The primary objective in treating arthritis in the elbow, wrist, or hand is to slow down the progression of the condition, improve joint function, and lessen pain.

• Lifestyle changes, such as avoiding joint-stressing activities and using ergonomic gadgets to lessen the tension in afflicted areas, are part of first-line treatment.
• NSAIDs, topical analgesics, and corticosteroid injections are some examples of drugs that can be used to treat pain and inflammation.
• Physical therapy is essential to prevent aggravating symptoms, preserve range of motion, strengthen surrounding muscles, and enhance joint stability.
• Splints or bracing may be used in more severe situations to relieve pain and offer support.

The elbow, wrist, and hand are the most common sites for injury in the upper extremities, as their dysfunction impacts the overall upper limb functionality. Timely diagnosis and effective management can prevent injury or help treat the cause, helping to preserve normal joint range of motion and strength so patients can return to normal activities.

- Dr Humda, Physiotherapist

Learn more about this topic in the HealthCert Professional Diploma program in Musculoskeletal & Sports Medicine - fully online or with optional practical workshops.

References

https://idp.springer.com/authorize/casa?redirect_uri=https://link.springer.com/article/10.1007/s10926-021-09997-0&casa_token=z7OeXBXeNmIAAAAA:AdMspeBKVDsm5bzGyyfDMjitvc37MrLOTf86x4aD40jVX0GajNNh6fi61jrwYb5YQ7ufco8LyD5sQaCs

https://www.tandfonline.com/doi/abs/10.2147/OAJSM.S246414

https://pubmed.ncbi.nlm.nih.gov/23218630/#:~:text=Complex%20lesions%2C%20including%20the%20association,patients%20with%20complex%20elbow%20instability.

https://pubmed.ncbi.nlm.nih.gov/7900737/

https://www.sciencedirect.com/science/article/abs/pii/S0278591920302301