Clinical Chiropractic: The Wrist and Hand

Clinical Chiropractic: The Wrist and Hand

The Chiro.Org Blog

We would all like to thank Dr. Richard C. Schafer, DC, PhD, FICC for his lifetime commitment to the profession. In the future we will continue to add materials from RC’s copyrighted books for your use.

This is Chapter 9 from RC’s best-selling book:

“Clinical Chiropractic: Upper Body Complaints”

These materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.

Chapter 9:   The Wrist and Hand

CLINICAL BRIEFING

Structural Considerations

Clinically, the most important articulation in the elbow is formed by the proximal ulna and the distal radius forms the most important articulation in the wrist. The carpals articulate with the ulna only during extreme wrist adduction.

The distal row of carpals forms a complex joint with the proximal row. Because they are loosely connected, the navicular and trapezium spread during wrist abduction and approximate during adduction. The proximal carpals rock and glide toward the ulna during wrist abduction and toward the radius during adduction. Adduction is slightly greater in pronation because the styloid process of the ulna restricts motion when the hand is supinated. During adduction, the styloid swings backward out of the way. As the A-P curve of the proximal carpals is more acute than the transverse curve, greater excursion is allowed in wrist flexion and extension than in lateral motion. The more delicate the patient’s bone structure, the greater the mobility.

The intricate anatomical architecture of the wrist allows flexion (80°), extension (70°), radial deviation (30°), ulnar deviation (20°), supination and pronation of the forearm.

Basic Wrist and Finger Biomechanics

The muscles of the wrist course obliquely to the parts to be moved. This requires coordination with other muscles whenever the wrist is moved. Wrist strength in flexion is nearly double that in extension, and the power of extension is greatly lessened when the wrist is fully flexed. During extreme flexion of the wrist, it is impossible to strongly curl the fingers in full flexion because the flexor tendons are slack. When the wrist is hyperextended, the extensors relax and the fingers cannot hyperextend fully. These are two important considerations during examination.

Clinical Analysis

Besides posttraumatic deformity, hypertrophic osteoarthropathy is a common deformity seen in the wrist. It is often a distal manifestation of chronic pulmonary or pleural disease featuring enlarged distal ends of the radius and ulnar and prominent finger clubbing. It is readily recognized by inspection and confirmed by roentgenography. Bronchiectasis, tuberculosis, and empyema are common causes.

The alert diagnostician will have a habit of greeting the patient new to the practice with a gentle handshake for it may reveal much to the observer. The weak grip of the myopathic, the cool damp hand of the thyroid patient, the stains of paint on house painters (eg, potential chemical, abrasive, or lead poisoning), the stiff calloused hands of the laborer, the flattened and calloused fingertips of the violinist, and the worn fingers of the seamstress, for example, may reveal much to complete the patient’s later profile. The nervous, limp, or hearty handshake also reflects the patient’s current temperament. The “claw hand” of nerve palsy, the “flipper hand” caused by contractures, and the spastic “hemiplegic hand” of the stroke victim are important diagnostic clues gained solely by observation.

Pain. As an aid to differentiation, the common causes of wrist, hand, and finger pain are shown in Table 9.1. The location of hand pain frequently points to the nerve involved if neuropathy is present. Note, however, that the cause may be at any point from the thumb to the cervical cord. The median nerve supplies the radial side of the palm and the thenar muscles. Pain radiating to the ulnar aspect of the hand and the ring and little fingers is characteristic of an ulnar nerve lesion.

Weakness. Hand weakness progressing to paralysis with repetitive muscle contractions suggests myasthenia gravis. Neuropathic hand weakness is often a part of the clinical picture of diabetes mellitus. If the weakness exhibited is associated with pain, the radial nerve can be excluded because it lacks sensory fibers in the hand.

Absent hand and finger weakness when weakness exists elsewhere may be an important sign. Selective proximal weakness excluding the hands, forearms, and lower legs, for example, suggests cancer or an endocrine myopathy (eg, adrenal insufficiency, hyperthyroidism, hypothyroidism, or Cushing’s syndrome).

Stiffness. A patient with early rheumatoid arthritis will complain of hand and finger stiffness in the morning that eases with activity. Elderly patients with advanced osteoarthritis, however, will report that initial morning stiffness becomes painful with daily activity.

Carpal Tunnel Syndrome

This is the most common nerve entrapment syndrome of the wrist. It is difficult to injure any of the flexors on the anteromedial aspect of the wrist without damaging the median nerve in this area. Nevertheless, neurologic, vasomotor, or vascular interference at the spine, thoracic outlet, shoulder, or elbow is just as frequent a cause and still exhibit symptoms only in the hand and fingers. In wrist lesions, the cause can be any local or systemic disorder narrowing or crowding the carpal tunnel. It is five times more prevalent in women than men.