Diagnosis of the Wrist

00:01 Osteopathic evaluation of the wrist and hands.

00:04 So we're gonna start by following our mantra of look-feel-move So we're gonna observe the hands bilaterally, you wanna check both surfaces - the palmar and the dorsal surface.

00:13 What you wanna do is look for any sort of gross abnormalites, sometimes you may have nodules in the fingers, sometimes you may have deviations due to arthritis or degeneration You wanna check the muscles and muscles tone, Sometimes you have wasting of the muscles.

00:28 if you have the innervation of the nerves innervating the hand.

00:31 So through observation, we check first for any asymmetries then we're gonne feel and palpate So when we're palpating, we're gonna feel for the carpal bones and see if there's any tenderness sometimes.

00:43 We could feel for the muscles of the hand, you could check the intactness of the fingers and the tendons, sometimes I'll ask them to check wrist grip strength and have them make a tight fist and don't let me pull.

00:54 Good.

00:55 and so that's a way to quickly check grip strength in the hand So we're gonna feel and see, check our different landmarks You do wanna check the scaphoid and the lunate cause these two bones are the most commonly injured bones in the wrist So be comfortable with understanding your landmarks and where you're finding your carpals and your metacarpals and your phalanges.

01:20 After palpation, we're gonna do some motion testing.

01:23 So at the wrist, we have in the saggital plane, a flexion and extension so you should be able to fully flex the wrist and extend the wrist, if there's any restrictions there, you could note decreased extension or flexion At the wrist we could also have ABduction going out to the thumb and ADduction going towards the pinkie.

01:49 So another word for AB- and ADduction of the wrist is also radial deviation cause you're deviating towards the radial bone and ulnar deviation cause you're going towards the ulnar bone There's limited internal and external rotation at the wrist due to the the tendons and the ligaments around the wrist.

02:10 You could also have motions at the fingers and the thumb, so make sure that all the motions at the thumb and the fingers are intact especially when the patients are complaining of any specific finger joint pains there is more flexion available than extension to the attachments of the flexor tendons but if the tendons are ever disrupted, that could potentially decrease the amount of motion or the finger may be abnormally not able to move.

02:36 So if we find a motion restriction at the wrist, so if the patient is able to ulnar deviate but not able to radial deviate, then you name it for the freedoms that'll be ulnar deviation wrist dysfunction If a patient is able to flex but not fully extend then that will be a wrist flexion dysfunction so you wanna name the somatic dysfunction based on the freedom of motion that you find when you're motion testing the wrist and hand and the fingers.

03:06 There are several tests that we could perform to help narrow down certain pathologies in the hand and wrist.

03:13 So if someone has a fall or some sort of trauma to the wrist and hand, a lot of times there may be injury to the scaphoid bone.

03:24 and so there's a test called the Watson's test, in this test, check for the stability of the scaphoid bone.

03:30 So we start by really stabilizing the scaphoid bone underneath our hands.

03:35 You wanna find the thumb and find the base of the thumb then you'll find the bone underneath the thumb.

03:40 We're gonna hold on to the bone and then we're gonna ask the patient with their fingers straight to try to bring their hand from ulnar to radial.

03:50 So I'm gonna hold this here and go ahead and try to bring your hand from ulnar to radial. Good.

03:55 As the patient does that, that is checking for the stability of the scapholunate ligaments if there's pain, if the patient's unable to do that, that will be a positive Watson's test.

04:09 If patients have pain in the wrist and it's more central and you're worried about something going on with the lunate bone, there's a test check for perilunate stability.

04:19 So here, what we're gonna do is we'er gonna do a Shuck test.

04:22 We're going to flex the wrist and then monitoring over the lunate, we're gonna have the patient try to extend their wrist or bring their hands straight forward against resistance.

04:32 So as they do that, if there's any pain in the area, tenderness as they're trying to straighten out their wrist then that might signify some sort of perilunate instability.

04:45 If you're concerned about the patency of the vasculature in the hand, our hand receives arterial supply from the radial and ulnar side and so if you you're doing a blood draw, if you're doing arterial blood draw, sometimes you wanna make sure that both sides are patent, we could do an Allen's test.

05:09 So an Allen's test checks for the patency of the blood vessels supplying the hand.

05:15 What we're gonna do is we're gonna initially compress on those blood vessels and have the patient open and close their hands several times or you could tell them to kinda hold their fist and after a couple of seconds the blood will go through the venous return and you're holding the arteries compressed And so now, the patient's gonna open their hand, you could see that it's more pale and we're gonna release one side.

05:39 So here, I release the ulnar side you could see how the hand pinked up, so that means the blood vessel is intact 'cause the blood is rushing through.

05:50 we could do the same thing for the opposite side, go ahead and make a fist and hold it and open your hand and you see it's pale and then I release the radial side and you could see that it starts to pink up.

06:02 So the Allen's test is negative when the hand returns to its normal color upon releasing each of the blood vessels.

06:12 If I release the blood vessel and the hand does not pink up then there may be an issue with the blood vessel and it may tell you to further investigate or not to draw blood from that wrist.

06:26 Patients that complain of numbness and tingling in the hand especially with the medial portion of the hand numbs and tingling and maybe they may have a thenar wasting when it becomes more severe, may suffer from carpal tunnel.

06:42 So carpal tunnel disease is a impingement of the median nerve as it passes through the tunnel.

06:48 So the tunnel has a roof, the attachments of the flexor retinaculum include the scaphoid and the trapezium and the hook of hamate and the pisiform So across this ligament and underneath it are a lot of your flexor tendons and running along with those flexor tendons is your median nerve.

07:08 and the median nerve comes and innervates the medial aspect of your hand up to halfway of your forefinger.

07:13 So numbness and tingling in the hand due to certain repetitive motions or injuries or swelling could cause a carpal tunnel syndrome.

07:21 So how could we assess for carpal tunnel syndrome? Well you could perform a Tinel's test.

07:26 Tinel's test is when you tap over the median nerve as it passes through the carpal tunnel and if you tap and it recreates the numbness and tingling and symptoms then that is a positive test for carpal tunnel syndrome.

07:39 So to perform it, you're gonna find that region between the two bones where the carpal tunnel lies and you're gonna apply a little bit of a gentle tap there and if it recreates the pain, then that's a positive test.

07:51 Another test you could do to assess for carpal tunnel syndrome is called the Phalen's test.

07:57 Here, we're gonna have the patient bring their hands together and their elbows up to 90 degrees.

08:02 And so what that does is it really compresses in that carpal region here and the patient should be able to hold this up for at least a minute.

08:12 If they're unable to hold this position for more that a minute then that would be a positive test especially if they're getting numbness, tingling in the side that they were complaining of hand pain.

08:23 (You can put your hands down) Patients that complain about pain along their thumb especially along their lateral aspect to their forearm may have DeQuarvain's tenosynovitis.

08:35 So it is inflammation of the tendon helping to move your thumb has been definitely more common now that people have been texting or gaming or using more precise motion with their thumb.

08:47 So to perform the test, what we're going to do is we're gonna have the patient take their thumb and put it in their fist and then we're gonna have them slowly ulnar deviate their wrist.

09:00 So you're gonna take their thumbs in your hand and kinda put your hand down towards the floor There you go.

09:05 and so that is Finkelstein's test and what you're doing is you're really stretching that tendon and a positive test would be pain or the inability for the patient to try to ulnar deviate their hand.