With wrist and hand anatomy,
the hand is a closed space.
Knowing the bones and knowing
the muscles are important,
being able to differentiate the carpals and the
metacarpals from the phalanges is your first step.
So you deal with the carpal bones on
the wrist and the metacarpal bones
which are the fingers hidden by the
hand and the phalanges of the fingers.
Learning the ligaments is also gonna be critical
to being able to talk with the hand surgeon
or somebody who may be able to help
you with issues related to the hand.
The nerve distribution is very clear and can tell
you where you may have impingements everywhere.
So the hand is a good
harbinger of illness elsewhere
and knowing the median nerve disrtibution
and ulnar nerve distribution
will help you separate
out those pathologies.
The range of motion of the hand is that you
can have extension to 70, flexion to 80.
You'll have radial deviation up to 20
and ulnar deviation to 30 degrees.
and you have finger adduction
and abduction as well.
So complicated movement, lots of movement
and lots of trauma to the hand as well.
If somebody has decreased range of
motion, it could be secondary to spasm,
it could be secondary to
tendon or ligament issues
and doing the test to figure
out which it is, is important
because again, damage to the hand can occur
quickly and needs to be taken seriously.
We do a lot of motion testing of the
hand to see if there's a loss of hand
or whether people just
have overuse injuries
which are also very common with
spasm and pain in the hand.
It is not unusual to use
muscle energy techniques
to help with muscle pain and the
hand pain as a way of helping.
One of the more chronic issues we see
a lot is De Quervain's tenosynovitis
which is a contracture of the ligaments
and a loss of use of the hand
because of the contracture.
It also causes instability of some
of the bones and the wrist area.
So it's something that needs
to be paid attention to.
The physiology of De Quervain's or
inflammation of the extensor pollicis brevis
and the abductor pollicis longus
tendons which can contract
and can stay contracted and you can
have a loss of some of the motion.
The test is called Finkelstein's test
where you put the thumb
inside the hand and squeeze.
Severe pain is a positive test.
The osteopathic treatment of De Quervain's
is to increase the radial deviation,
helping with the motion by restoring motion
either by muscle energy or counterstrain.
Other injuries to worry about
are ligamentous injuries
that could affect the scapholunate
stability or perilunate stability.
Ligamentous strain or rupture
can cause a gap in the area
and this thing should be
watched for and monitored for.
So you wanna do a good
hand exam and again,
knowing the anatomy and knowing
where you're testing them
is going to be a big help.
We're gonna go through Watson's test,
there'll be a separate video on that,
so you'll have a short video to be able to
test for ligamentous injury of the hand.
The test for perilunate instability
is called the Shuck test and again,
we'll do a separate video looking at the Shuck
test for hand instability and finger instability.
Severe pain is going to indicate this
instability and needs to be looked up further.
We are gonna have a separate
talk on carpal tunnel syndrome
and we'll talk a little bit
about injury to the ulnar nerve
interosseous nerve syndrome
and a vascular compromise to the hand.
Carpal tunnel is a very common condition and
it's letting people come to for treatment for.
Because we've got good treatments
and interventions that will help.
The physiology of carpal tunnel syndrome
is this is an entrapment syndrome.
It's a neuropathy of the median nerve as
it passess through the carpal
And the flexor tendons tend to get
taught, limit motion and tend to spasm.
If you can reproduce pain
with the Tinel's test,
just tapping on the carpal tunnel and
you get shooting pain to the fingers,
that's a positive Tinel's sign and can
be indicative of carpal tunnel syndrome.
The osteopathic management is
stretching and relief of symptoms.
And what I do is I put my hand between the 4th
digit and the 1st digit, stretch out the hand,
pull the carpal tunnel and help
induce increased motion that way.
You will keep the hand dosriflexed at the
wrist and splaying the fingers and stretching.
and we'll have a separate
video on that as well.
Osteopathic management focuses on the
carpal bones and the carpal tunnel.
Some people do do HVLA, it is an
easier, quicker way of doing it
but with the pain, some patients
are uncomfortable with it.
and what you do is you get a
good grip of the carpal bones
and when you have a restriction, you
find the area where the restriction is
and then work through that restriction.
It helps to have the hand dorsiflexed
until you engage the barrier.
And then employ immobilization with a thrust
moving towards the wrist, to
the floor with the hand down.
The palmar flexor barrier
can be engaged as well,
if you wanna do a high velocity, low amplitude
thrust technique, to treat a carpal tunnel syndrome.
We can treat it in other ways as well.
If you wanna treat it
with joint mobilization,
you will grasp the hand and it can be
done either pronated or supinated,
find the area where the restriction is
and once you've engaged the restriction,
work through the barrier.
You can apply an upward force
if you got the hand supinated
in order to engage and treat
the carpal tunnel syndrome.
There will be a more thorough discussion of
carpal tunnel syndrome in another lecture.
If you have injury to the ulnar
nerve through Guyon's canal,
that's a compression of the ulnar nerve as it passess
between the pisiform and the hook of hamate.
Also very serious, it happens with trauma and
it is something that needs to be treated.
The Tinel's test will also tell you if
there is an impingement of this nerve.
Positive test is when you have the
radiation of pain down the nerve root.
Management is activity modification and
splinting beacause this is an overuse injury
and at times, steroid or
corticosteroid injections will help.
From the osteopathic perspective, we'll do some
myofascial release to help ease the symptoms
and help relieve the pain of Guyon's canal
syndrome and the ulnar nerve impingement.
For the distal posterior
interosseous nerve syndrome,
the physiology is one of entrapment
of the posterior interosseous nerve
and it can cause finger weakness and difficulties
with wrist extension with preserved sensation.
We will treat this as other impingement
syndromes with positioning and bracing as well.
From Osteopathic perspective, we can use myofascial
release to help ease up with the symptoms
and help make people feel better.
So if you grasp the patient's distal
forearm and hold them by the thumbs,
that's one way to help stretching
and the myofascial release.
You'll do some effleurage, you'll do some
massage and free up the tissues that way.
And the last nerve vascular issue
is gonna be vascular compromise.
Again, this could be a medical emergency
and needs immediate intervention.
If there's a change in the
vasculature supply in the hand,
there'll be ischemic pain and
severe pain immediately.
We do the Allen test to see if you have a good
pulse in both the radial and ulnar arteries
And what you do is you have the
patient open and close the fist
and you occlude the radial
and ulnar arteries,
and then you release one at a time,
making sure that the hand fills with blood,
that you have increased perfussion after relaxing
or relieving each the radial and ulnar vessels.
If it stays pale when you release the artery, it's
a sign that there might not be good perfussion
and you may need further intervention.
So if the palm does not flush,
that's a positive Allen's test.
Those are the probs of the upper extremity.
Thank you for listening.