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MIDTERM IS WEEK 5
bring fasting info page for Thea
don't mobilize hands/wrists in case of arthritis until you have a firm dx
know the disease process
don't do grade 3+ if inflamed


COURSE OVERVIEW
extremities: evaluation and mobilization
helluva lot easier than spinal mobilization
therapeutics are similar to evaluation skills
most emphasis on hypermobile segments/instability
as opposed to hypomobility common in spine
how to stabilize joint: taping, exercise, other skills
this class will include reviews of orthopedic tests
esp of shoulders, knees

MODEL SKELETONS
not true to life, pisiform is fused to triquetrium
orientation of bones slightly off
encourages us to keep a model and an anatomy source close at hand

PARTS:
pain
asymmetry
ROM: active, passive, resisted, pain
tissue changes
special tests

***********************************************************************

WRIST AND HAND PROCEDURES

DISTRACTION OF THE WRIST
evaluate "PARTS" first
pt position sitting or supine, most relaxed if arm/hand are resting on something
don't drape body parts across yourself
mb indicated for many reasons: limited ROM, FOOSH injury, interosseous membrane involvement, repetitive injury, colles fracture, bicycling, compression of carpals, gymnastics
create space in radiocarpal joint
hand contacts close together
stabilize radius and ulna with one hand
and pull on proximal row of carpal bones with thumb and index finger of other hand
if there's a lot of resistance, one side doesn't pull apart as easily, is that restricted?
compare sides, evaluation is rather subjective
pain relief with distraction: common
1) hold distraction in neutral
2) apply P-->A force (flexion)
3) A-->P force (extension)
4) lateral glide (ulnar and radial deviation)
5) circumduction
for mobilization do same procedure therapeutically

COLLES FRACTURE



APPROXIMATION OF DISTAL RADIO-ULNAR JOINT
pt arm on firm surface
rest forearm and hand on tabletop with thumb up
protect radial styloid
hand contact is hand that would shake (ipsilateral hand)
use that hand to locate radial styloid
then place other index finger crossways on styloid, use as marker for next hand placement
hand on radius just proximal to styloid mark,
other hand on wrist of that hand (support)
press downward (lateral to medial relative to anatomy)
should feel springy and be pain free
may have cavitations here

if interosseous membrane is injured, feels better w compression-->tape wrist
she tapes first and checks response for a few days,
if pos response then prescribes wrist brace
6-8 weeks to fully heal, brace easier than taping

DISTRACTION OF THE RADIOULNAR-CARPAL JOINT
find ulnar and radial styloids and hold both firmly
with other hand grab proximal carpals and distract
hold for a while, any clicking or cracking or instability
push hand A-->P, then return to neutral
P-->A glide
glide hand medially (toward floor)
and laterally (toward ceiling)

CARPALS

acronyms for wrist bones
simply learn the parts that the carpus has
some lovers try positions that they can't handle
scaphoid, lunate, triquetrium, pisiform, trapezium, trapezoid, capitate, hamate
(proximal row thumb to pinkie, then distal row)
where are they?

triquetrium is by pinkie
hamate artic w/ 4th metacarpal
capitate is landlocked in distal row, harder to locate
hook of hamate in palm

GLIDE OF THE CARPALS
anterior and posterior only
if pt cannot pronate forearm doc relocate to push not pull
no wiggle back and forth, focus on each movement sequentially
outer rows are more mobile than "landlocked" lunate and capitate
if a true rstrx noted, bony block, using grades 1-4 use same technique
grade 5 thrust then need to change approach

FOR GRADE 5
if P-A restriction of capitate (not too uncommon)
put write in full extension
stack mid fingers on bone
use thumbs to extend hand
ask pt to hold shoulder tight so not too much give there
pull capitate toward you using midfingers

for A-P glide
posterior glide restriction
change body position
stack midfingers on bone
use thumbs to flex wrist
pull toward self in thrust to mobilize

POSITION FOR WRIST ASSESSMENT AND ADJUSTMENT
sitting across a narrow table from patient is good way to work on wrists
she likes having small table top so she can move around it
or be at end of table

SCAPHOID
anatomic snuffbox-->scaphoid is base
scaphoid articulates with many bones incl radius
if tender to palpation do finkelstein's test, for dequervain's tenosynovitis
(pt hold thumb in fist and ulnar deviate wrist to tension tendons)
trap trapezium to move scaphoid
stabilize radius and slide scaphoid both directions
stabilize trapezium and slide scaph or vv
scapholunate is a commonly aggravated joint
push rather than pulling

LUNATE
hyperflex wrist and it is most prominent on back of wrist
common extensor tendons run over it but don't flick them, work around them
stabilize scaphoid and move lunate
"landlocked" expect less mobility than outer rows

TRIQUETRIUM
articulates mainly with 5th but some with 4th metacarpal
also with ulna, lunate, hamate
stabilize lunate and move triquet alone

PISIFORM
is floater on top of triquetium
wiggles more laterally than P-A
won't move if wrist extended, keep neutral or (better) flexed

TRAPEZIUM
distal carpal at thumb
trapezium articulates with the thumb
z brothers hang out together (trapezium and trapezoid artic w#2)

TRAPEZOID
articulates with index finger
sandwiched between trapezium, capitate, scaphoid

CAPITATE
"landlocked" between digit #3, hamate, lunate, scaphoid, trapezoid
stabilize hamate, test it

HAMATE
at pinkie
hook of hamate is in hypothenar eminence
mb tender in bicyclists, massage therapists, those who use it
stabilize capitate and triquetrium? to test it

*************************************************

METACARPALS
1st metacarp--stabilize trapezium
2nd--trapezoid
3rd--capitate
4th & 5th--hamate

METACARPAL SHEAR
a-p only: do hand bones move normally?
if grade 4-5 must overlap midfingers and flex/ext to adjust
extend to push on dorsum
flax to push on palm



INTERPHALANGEAL GLIDE
check glide in four directions in each joint
metacarpal phalangeal medial-lateral glide is minimal esp at 3rd & 4th digits
hand contacts along sides of bones to check lateral glide, close to jt line
move distal on proximal
avoid valgus or varus stress, can do damage
she doesn't recommend grade 5's into extension dt risk of damage
if restrx then mobilize with pull
using stacked midfingers to pull and thumbs to stabilize

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