6.2 Elbow, Wrist & Hand Assessment
Key Takeaways
- The anterior bundle of the UCL is the primary valgus restraint from ~30–120°; O'Driscoll's moving valgus stress test is positive when medial pain peaks between 120° and 70° (original 2005 cohort: 100% sensitive, 75% specific, n=21).
- Lateral epicondylalgia (Cozen/Maudsley) must be separated from C6 radiculopathy because C6 also extends the wrist; screen the neck before naming tennis elbow.
- Snuffbox tenderness plus axial thumb load after FOOSH is a scaphoid fracture until proven otherwise: thumb-spica and refer even if the first x-ray is negative—initial films miss about 20%, and the proximal pole is at AVN risk.
- Jersey finger is an FDP avulsion (no active DIP flexion) and is a surgical urgency; mallet finger is the terminal extensor and is usually splinted in DIP extension.
- Little league elbow is medial epicondyle apophysitis in a skeletally immature thrower; little league shoulder is proximal humeral physeal stress—do not interchange the names.
PA8 task 0202 at the elbow, wrist, and hand rewards people who can name the tissue, the joint angle that unmasks it, and the injuries that are surgical clocks. A painful medial elbow in a 12-year-old is not the same disease as a painful medial elbow in a gymnast with closed physes, and a 'negative x-ray' does not clear a snuffbox.
Elbow: Medial Valgus, Lateral Epicondyle, Nerve, and Biceps
The ulnar (medial) collateral ligament (UCL) has anterior, posterior, and transverse bundles. The anterior bundle is the primary valgus restraint from about 30–120° of flexion—the arc of throwing. At 0° the bony olecranon locks; that is why a valgus stress test is done at ~20–30°, not in full extension.
| Test | Structure / construct | Positive finding | What +/− actually means |
|---|---|---|---|
| Valgus stress at ~30° | Anterior bundle UCL | Pain and/or medial gapping vs the other side | Pain without gapping is common in partial injury or flexor-pronator strain. Gross gapping is uncommon even with complete tears. |
| Moving valgus stress (O'Driscoll) | UCL, late-cocking/early-acceleration shear | Reproduction of medial pain that peaks between 120° and 70° | Original 2005 surgical cohort: 100% sensitive, 75% specific (17 of 17 and 3 of 4)—a small sample, but the shear-angle definition is what the exam wants. Pain only at end-range extension is not a positive test. |
| Milking maneuver | Anterior bundle in a flexed, throwing-like position | Medial pain/apprehension when the thumb is pulled into valgus | Complements moving valgus. Later athletic-population work found moving valgus better to rule out and milking more helpful to rule in—use both. |
| Cozen / Maudsley / Mill | Common wrist-extensor origin (ECRB) | Lateral epicondyle pain with resisted wrist or long-finger extension | Lateral epicondylalgia, not a nerve-root diagnosis. C6 also extends the wrist—screen the neck. |
| Tinel at cubital tunnel / elbow-flexion test | Ulnar nerve | Paresthesias in the 4th/5th digits | Cubital tunnel. Differentiate from C8–T1 radiculopathy (neck cluster) and Guyon canal (wrist). |
| Hook test | Distal biceps tendon | Cannot hook the intact tendon from the lateral cubital fossa | Complete distal biceps avulsion. Weak supination > flexion. This is not a proximal Popeye long-head rupture. |
Lateral epicondylalgia versus C6 radiculopathy: Cozen (resisted wrist extension, elbow extended), Maudsley (resisted long-finger extension), and Mill (passive stretch) provoke the common extensor origin. C6 radiculopathy can produce lateral elbow pain and wrist-extensor weakness because C6 innervates that myotome. If there is neck pain, a positive Spurling, dermatomal thumb/index sensory change, or a depressed biceps/brachioradialis reflex, do not call it tennis elbow. Every stubborn 'lateral epi' gets a cervical screen.
Cubital tunnel: ulnar nerve behind the medial epicondyle. Tinel there, and an elbow-flexion test (elbow flexed, often with wrist extension, held up to ~3 minutes) reproducing 4th/5th paresthesias. Secondary ulnar irritability is common next to a UCL injury—treat the ligament question and the nerve question as separate lines.
Distal biceps: sudden eccentric load (deadlift, gymnastics dismount). Hook-test failure, loss of the cubital-fossa contour, and weak supination. Complete tears in active people are a surgical referral, not a wait-and-see biceps tendinopathy.
Olecranon bursitis: extra-articular 'goose egg' over the olecranon. Aseptic: padding and load change. Warmth, fever, or rapid painful swelling: septic bursitis until proven otherwise—do not inject steroids into a possibly infected bursa; refer.
Little league elbow is not little league shoulder
Little league elbow is medial epicondyle apophysitis (and, when more severe, avulsion or UCL failure) in a skeletally immature thrower. Valgus load hits an open medial physis before it hits an adult UCL. Do not crank aggressive moving-valgus stress on an open medial epicondyle; rest from throwing and refer if there is gapping, a mechanical block, or an avulsion on imaging.
Little league shoulder is stress of the proximal humeral physis (widening on comparison radiographs), presenting as lateral shoulder pain in the same age group. The names are not interchangeable. A 12-year-old with medial elbow pain does not have little league shoulder.
Wrist and Hand: The Surgical Clocks
Scaphoid (the FOOSH you cannot 'x-ray clear')
The scaphoid is the most commonly fractured carpal bone. Blood supply is largely retrograde (dorsal carpal branch of the radial artery entering distally), so the proximal pole is at risk for avascular necrosis (AVN) and nonunion.
Exam triad: anatomic snuffbox tenderness, scaphoid tubercle (volar) tenderness, and pain with axial load of the thumb. Snuffbox tenderness is sensitive and not specific—treat the cluster plus FOOSH history. Initial plain films miss on the order of 20% of acute scaphoid fractures (occult). Exam trap: returning a snuffbox-tender athlete because 'the x-ray was negative.' Place a thumb-spica, withhold load, and refer for repeat radiographs in 10–14 days and/or MRI/CT. Do not buddy-tape and play.
TFCC and carpal tunnel
| Test | Structure / construct | Positive finding | What +/− actually means |
|---|---|---|---|
| Press (chair) test | TFCC | Ulnar-sided wrist pain when pushing up from a chair with the wrist extended | Load-bearing TFCC pain. Not a stand-alone surgical indication. |
| Fovea sign | TFCC foveal insertion / ulnocarpal | Point tenderness in the soft spot between the ulnar styloid and FCU | Localizes to the fovea. Pair with DRUJ stability (ulnar piano-key). |
| Phalen | Median nerve at the carpal tunnel | Paresthesias in thumb, index, middle, and radial ring after ~60 s of wrist flexion | Helpful, not perfect. Night pain and median distribution matter more than a stopwatch. |
| Tinel at the wrist | Median nerve | Tapping the tunnel reproduces median paresthesias | Same limitation as Phalen. C6/C7 radiculopathy can mimic—screen the neck. |
| Allen test | Radial and ulnar arterial arches | Delayed reperfusion when one artery is released | Documents dual supply before assuming a single-vessel hand or before procedures. |
TFCC injuries present with ulnar-sided pain, clicking, and pain on weight-bearing through a hyperextended wrist (gymnastics, blocking). Press-test plus fovea plus DRUJ instability is a cluster. Carpal tunnel is a median neuropathy at the wrist, not a cervical root—but you still have to prove it is not C6.
Finger and thumb injuries you cannot 'tape and play'
Jersey finger: forced extension of a flexed fingertip (grabbing a jersey). Flexor digitorum profundus (FDP) avulses from the volar distal phalanx, classically the ring finger. The athlete cannot actively flex the DIP. Leddy–Packer type I (tendon retracted to the palm) disrupts vincula blood supply and needs repair on the order of 7–10 days. All acute jersey fingers need hand-surgery referral; this is not a sprain and not a mallet finger.
Mallet finger: disruption of the terminal extensor tendon (or bony avulsion) so the DIP droops and cannot actively extend. Closed mallet without DIP subluxation is usually a full-time DIP-extension splint for about 6–8 weeks. Obtain a radiograph: large articular fragments or DIP subluxation may need surgery. Do not treat jersey as mallet or mallet as jersey—one cannot flex DIP, the other cannot extend it.
Gamekeeper/skier thumb: ulnar collateral ligament of the thumb MCP. A Stener lesion occurs when the adductor aponeurosis interposes and the UCL cannot heal to bone—that is a surgical problem. Unstable MCP valgus, a palpable displaced stump, or a complete tear goes in a thumb spica and to a hand surgeon; do not assume every skier's thumb is a two-week tape job.
Boxer's fracture: 5th (sometimes 4th) metacarpal neck after a punch. Check rotational deformity (scissoring on fist). Fight bite over the MCP is a human-tooth wound (including Eikenella): do not close it and forget antibiotics/referral. Angulated boxer's fractures need imaging and often reduction/ulnar gutter—not 'buddy tape and start Friday.'
Worked Scenario: Gymnast with Elbow Pain
A 16-year-old gymnast has medial elbow pain that spikes on vault and uneven-bar dismounts (valgus plus extension). No fever, no locking. Observation: no olecranon bursal goose egg, no distal-biceps contour loss. Cervical screen: full rotation, Spurling negative, C6 myotome strong—this is not radiculopathy masquerading as tennis elbow. Cozen is painless (not lateral epicondylalgia). Tinel at the cubital tunnel is mildly sensitive but does not reproduce her vault pain. Hook test is intact (distal biceps is not the problem). Valgus at 30° is painful without a clunk. Moving valgus reproduces her medial pain, maximal between 110° and 80°. Milking is painful. Physes are closed on a recent age-appropriate film, so this is not little league elbow and it is certainly not little league shoulder.
Interpretation: UCL-pain cluster (moving valgus shear arc + milking + 30° valgus pain) in a valgus-loading gymnast. Mild cubital-tunnel irritability is a neighbor, not the primary diagnosis. Hold vault/bars loading, protect valgus, and refer for imaging/orthopedics if there is gapping, recurrent giving-way, or failure of a protected plan. If she were 12 with an open medial epicondyle, you would shift the label to little league elbow (apophysitis) and you would not crank the same valgus stress for sport.
Exam trap: calling every medial elbow 'little league elbow' after physes close, or clearing a snuffbox-tender FOOSH because the first radiograph was negative. Thumb-spica and refer the scaphoid; name the UCL with the 70–120° shear arc; send jersey finger to surgery.
A soccer player FOOSHs, has anatomic-snuffbox and axial-thumb tenderness, and a same-day wrist radiograph is read as negative. What is the appropriate athletic-training decision?
A 16-year-old gymnast has medial elbow pain on vault. Moving valgus reproduces pain that peaks between 110° and 80°, milking is painful, valgus at 30° is painful without a clunk, Cozen is negative, the cervical screen is normal, and physes are closed. What is the best interpretation?
A football player grabs a jersey and immediately cannot flex the DIP of the ring finger. The PIP still flexes. What is the injury and the urgency?