CHAPTER 9 The Wrist and Hand
CHAPTER 9
Clinical Chiropractic: The Wrist and Hand



This is Chapter 9 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Clinical Chiropractic: Upper Body Complaints”


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Clinical Briefing
  Structural Considerations 
  Basic Wrist and Finger Biomechanics 
  Clinical Analysis

Carpal Tunnel Syndrome

De Quervain's Disease

Hand and Finger Contractures

Gouty Arthritis

Osteoarthritis

Rheumatoid Arthritis

Raynaud's Phenomenon

Sudeck's Atrophy

Traumatic Inflammation

Ulnar Nerve Compression Syndrome at the Wrist

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 pro cess of the ulna restricts motion when the hand is supinated. During adduc tion, 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 deli cate 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.


     Table 9.1. Common Causes of Wrist, Hand, or Finger Pain
                                                                         Endocrine
Traumatic     Inflammatory         Neurologic       Vascular             Metabolic   
Contusion     Abscess              Carpal tunnel    Arteriosclerosis     Acromegaly
Dislocation   Arthritis             syndrome        Gangrene             Diabetes mel-
Fracture      Cellulitis           Cervical IVD     Ischemic neuritis     litus
Hematoma      Felon                 syndrome        Macroglobulinemia    Gout
Laceration    Folliculitis         Cubital tunnel   Myocardial infarc-   Menopause
Sprain        Gonorrhea             syndrome         tion                Myxedema
Strain        Herpes               IVD syndrome     Scalenus anticus
Subluxation   Infection            Neuritis          syndrome
              Myositis             Peripheral       Vasculitis
              Pneumonia             neuralgia
              Shoulder or elbow    Subluxation
               bursitis             complex
              Spondylitis          Trigger point
              Subacute bacterial   Vasospasm
               endocarditis
              Syphilis
              Tendinitis
              Thrombophlebitis
              Tuberculosis
              Ulcer

                    Degenerative                     Allergic
Neoplastic          Deficiency       Congenital      Autoimmune             Toxic   
Dermal carcinoma    Cervical spon-   Amyloidosis     Allergic dermatitis    Arsenic
Multiple myeloma     dylosis         Buerger's       Erythema multiform     Lead
Pancoast's tumor    Osteoarthritis    disease        Lupus erythematosus    Vasocon-
Spinal cord tumor   Stenosing        Cervical rib    Periarteritis nodosa    stric-
Subcutaneous sar-    tenosynovitis                  Rheumatoid arthritis    tors
 coma               Syringomyelia                   Scleroderma

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 stiff ness 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.

      Background

The characteristics of carpal tunnel syndrome are pain, grip and supination weakness, tender wrist transverse ligaments, volar swelling at the wrist, numbness, and burning or tingling in the first two or three digits and/or the area proximal to the wrist. Pain often awakens the patient, which is relieved by hanging the involved arm toward the floor while prone. Light touch, temperature, and position perception is diminished or absent. Phalen's test and hyperextension of the wrist will aggravate the pain. Thenar atrophy; anesthesia of the lateral fingers; inhibited forearm pronation and supination; and a "flat-hand" deformity appear when the disorder becomes chronic. A neuroma may form proximal to the tunnel. Similar to that seen in muscle hypertrophy or tenosynovitis, venous engorgement and a bulge may be seen in the flexor mass of the distal wrist. Note that impairment of the radial or ulna arteries will exhibit similar features. Symptoms usually appear distal to the lesion, but they also may radiate upward -possibly as far as the neck.

The history may tell of a scaphoid fracture, paralunar dislocation, or wrist tendinitis. The patient may describe a sudden fall that was stopped abruptly by the palm of the hand when the wrist was acutely dorsiflexed. Repetitive microtrauma from long hours of wrist manipulation such as in typing or playing computer games is another precipitating factor that has had a rising incidence in recent years. Referral for surgical decompression may be necessary if conservative treatment fails.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential     Hemoglobin level           Shoulder x-ray
    Chest x-ray              Nerve conduction studies   Spinal roentgenography
    ECG                      Peripheral vascular        Thermography
    Elbow x-ray              R-A test                   Urinalysis
    EMG                      Sedimentation rate         Wrist/hand x-ray
    Glucose tolerance test   Serum electrolytes

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). In carpal tunnel syndrome, supination weakness that improves when the radius and ulnar are compressed distally is a confirmatory sign that also shows that a radioulnar separation subluxation exists. Perform tests for auto nomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C6-T1 and 1st rib. Release fixations found in the fingers, wrist, elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7-T4 for 1-2 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI-11, GB-20, GB-34, TH-5, ST-36, PC-7 (Table 16.21).

  • Treat auriculopoints 37, 55, 67, 106 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, LI-5, SI-3, TH-4 (Fig. 16.5).

  • If the Valleix cervical spine, heart, or kidney reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the wrist flexors and extensors, forearm supinators, subscapularis, infraspinatus, and upper trapezius and latissimus dorsi muscles (Tables 16.28-31).

  • If Chapman's heart, kidney, or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.1.

      Nutritional Therapy

Supplemental nutrients B6, C, niacin, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin factors (Table 16.56).

      Elective Procedures

Other helpful forms of treatment include rest, anti-inflammatory therapy, and spray-and-stretch therapy for trigger points during the acute stage, followed by moist heat (Tables 16.34 35) or pulsed diathermy (Table 16.36), warm whirlpool hand baths, iontophoresis with niacin (Table 16.43), mild alternating current (Table 16.27) for passive exercise, or tendon friction massage of involved muscles (except in the elderly). After the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

During a severe attack, temporary immobilization of the wrist in the neutral position may be necessary to relieve the pain. Anything that might impair the circulation of the hand must be avoided (eg, tight wrist watch strap, bracelet, elastic bandage, tight shirt or blouse cuffs, etc).



     De Quervain's Disease

This is a particular type of painful stenosing tenosynovitis near the styloid process of the radius due to narrowing of the tendon sheaths of the abductor pollicus longus and brevis and the extensor pollicus brevis.

      Background

Persistent irritating movements produce chronic tendinitis of the thumb extensors as they pass through the narrow tunnel on the lateral wrist. The first signs are wrist pain on movement, styloid tenderness, and tendon thickening on the dorsum of the hand at the base of the thumb. Tendon crepitus during thumb motion may exist. Repetitive wrist and thumb exercise usually initiates the pain, which is perceived in the distal radius. Turning a key in a lock, unscrewing the lid of a jaw, piano playing, golf, bowling, racket sports, knitting, hedge clipping, and opening a car door are difficult. A dull ache may persist at rest.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential     Nerve conduction studies    Spinal roentgenog-
    ECG                      Peripheral vascular tests    raphy
    Elbow x-ray              R-A test                    Thermography
    EMG                      Sedimentation rate          Urinalysis
    Glucose tolerance test   Serum electrolytes          Wrist/hand x-ray
    Hemoglobin level         Shoulder x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C6-T1 and 1st rib. Release fixations found in the fingers, wrist, elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7-T4 for 1-2 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI-11, GB-20, GB-34, TH-5, PC-7 (Table 16.21).

  • Treat auriculopoints 37, 55, 67, 62, 106 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, LI-5, SI-3, TH-4 (Fig. 16.5).

  • If the Valleix cervical spine and heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the wrist flexors and extensors, subscapularis, infraspinatus, and upper trapezius and latissimus dorsi muscles (Tables 16.28-31).

  • If Chapman's heart or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.2.

      Nutritional Therapy

Supplemental nutrients B1, B6, C, niacin, rutin, and zinc are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include rest, cryotherapy (Tables 16.32 16.33), and spray-and-stretch therapy for trigger points during the acute stage, followed by moist heat (Tables 16.34 35) or pulsed diathermy (Table 16.36), warm whirlpool hand baths, iontophoresis with hydrocortisone (Table 16.43), alternating current (Table 16.27) for passive exercise, tendon friction massage of involved muscles (except in the elderly). Temporary TENS is often helpful in situations of intractable pain (Table 16.49). After the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Hand and Finger Contractures

Contractures in the hand and fingers are due to tight intrinsic muscles, shortened fascia or ligaments, or taut capsules -all which lead to deformity and some degree of disability. The cause may be trauma, infection, or a degen- erative process (local or systemic). These deformities are stubborn to treat conservatively unless seen very early in the process.

      Background

Dupuytren's contracture. Chronic contraction of palmar fascia is often seen in adult males. A white-race hereditary factor may be involved. The deformity arises gradually and leads to painless fixed flexion of the little finger (less often, the ring finger) in one or both hands. Males are affected more often than females. Palpation will reveal a tense band that is preceded by tender nodular thickening on the ulnar aspect of the palm (proliferative fibroplasia). Common causes are burns, lacerations, shoulder-hand syndrome, diabetes mellitus, and chronic alcoholism. Epileptics often manifest such contractures, but the reason for the association is unknown.

Volkmann's Contracture in the Hand. This flexor compartment syndrome of the forearm is characterized by ischemic fibrosis of the finger long flexors, degenerative neuritis, muscle hypertonia, atrophy of the forearm muscles, and hand pronation and flexion as the result of circulatory impairment and radial nerve damage. The tissues distal to the lesion are abruptly painful, swollen, numb to light touch, cold, and cyanotic. Prolonged pressure from a cast, tourniquet, or bandage is a frequent cause. Supracondylar fractures of the humerus involving the brachial artery also may be the origin. An emergency exists if a pulse cannot be found.

Trigger Finger. This is an entrapment syndrome produced by scar tissue compressing an extensor tendon and often part of the clinical picture of DeQuervain's syndrome, infection, or finger trauma. After the finger has been actively flexed, any effort to extend it passively will produce a snapping sound. Pain and tenderness just proximal to the palmar aspect of the involved metacarpophalangeal joint may exist.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood calcium level     Glucose tolerance test    Spinal roentgenography
    CBC and differential    Hemoglobin level          Spirometry
    Chest x-ray             R-A test                  Thermography
    ECG                     Peripheral vascular       Urinalysis
    EEG                     Sedimentation rate        VD serology
    Elbow x-ray             Serum electrolytes        Wrist/hand x-ray
    EMG                     Shoulder x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C6-T1 and 1st rib. Release fixations found in the fingers, wrist, elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7-T4 for 1-2 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI-11, GB-20, TH-5, HT-7, SP-6 (Table 16.21).

  • Treat auriculopoints 19, 37, 55, 67, 106 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, LI-5, SI-3, TH-4 (Fig. 16.5).

  • If the Valleix cervical spine or heart reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the wrist flexors and extensors, subscapularis, infraspinatus, and upper trapezius (Tables 16.28-31).

  • If Chapman's heart or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.3.

      Nutritional Therapy

Supplemental nutrients B-complex, C, calcium, inositol, manganese, magnesium, pangamic acid, rutin, and zinc are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include moist heat (Tables 16.34 35) or pulsed diathermy (Table 16.36), warm whirlpool hand baths, interferential therapy (Tables 16.39 41), iontophoresis with SOD or salicylate (Table 16.43), alternating current (Table 16.27) for passive exercise, spray-and- stretch therapy for trigger points, or tendon friction massage of involved muscles (except in the elderly). After the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Gouty Arthritis

Gouty arthritis is the effect of hyperuricemia depositing monosodium urates in distal tissues (fingers, toes). Movement upon the jagged crystals creates an acute inflammatory reaction. When prolonged, gout is usually associated with rheumatoid arthritis, suggesting that an immunologic factor as well as a purine metabolism defect is involved.

      Background

Involved joint(s) become swollen and excruciatingly painful in episodes of varying duration. The overlying skin becomes hot, deep red, and shiny. Emotional overstress, fatigue, overindulgence, or drugs may precipitate an attack. No position affords relief. Primary treatment must be directed at the cause of the hyperuricemia.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood calcium level     Kidney function studies   Shoulder x-ray
    Blood urea level        Liver function studies    Spinal roentgenography
    CBC and differential    Peripheral vascular       Thermography
    ECG                       studies                 Urinalysis
    Elbow x-ray             R-A test                  Wrist/hand x-ray
    Hemoglobin level        Sedimentation rate

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Perform tests for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C3-C4, T9-L1. Release unankylosed fixations found in the elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the unankylosed subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 and T9-L1 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints SP-3, SP-6, LV-3, LU-7, ST-36 (Table 16.21).

  • Treat auriculopoints 62, 76, 95, 97, 107 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, SI-3 (Fig. 16.5).

  • If the Valleix cervical spine, kidney, and liver reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the forearms, subscapularis, infraspinatus, and upper trapezius muscles (Tables 16.28-31).

  • If Chapman's kidney, liver, or intrinsic spinal muscles points are tender, massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.4.

      Nutritional Therapy

Supplemental nutrients B6, C, niacin, P, sulphur, and zinc are recommended. Fluid intake must be increased to avoid uric acid kidney stones. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58). Protein, white sugar, and caffeine intake should be greatly reduced during an attack and controlled between attacks.

      Elective Procedures

Besides rest of the involved joint(s) and forced fluids, helpful forms of treatment include moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), warm whirlpool hand baths, ultrasound in water (Table 16.37), or interferential therapy (Tables 16.39 41). Aspirin must be avoided because salicylates interfere with uricosuric action.



     Osteoarthritis

Degenerative joint disease is characterized by deterioration and abrasion of articular cartilage with new bone formation at the borders of the articula tion. It is the most common form of arthritis and found in all mammals. Wear of aging, trauma, and the abuse of weight bearing is usually attributed, but this seems an oversimplification for the disruption of collagen, decreased ground substance, microscopic changes, and frequent increase in water content of the involved cartilage. A trophic deficit is likely involved.

      Background

Morning stiffness that eases with activity, pain on prolonged exercise, slight joint swelling from fluid accumulation, crepitus on movement, disuse atrophy, and joint deformity are characteristic.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood gases            EMG                    Spinal roentgenography
    Blood calcium level    Hemoglobin level       Spirometry
    CBC and differential   Peripheral vascular    Thermography
    Chest x-ray             studies               Urinalysis
    ECG                    Sedimentation rate     VD serology
    Elbow x-ray            Serum electrolytes     Wrist/hand x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C1, C5-T1, and T11-L2. Release unankylosed fixations found in the fingers, wrist, elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the unankylosed subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over segments C7-T4 and T11-L2 for 1-2 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints TH-5, ST-36, UB-11, UB-60, GB-41, SP-6 (Table 16.21).

  • Treat auriculopoints 37, 55, 62 (Figs 16.3 4).

  • Treat hand points LI-4, SI-3, TH-4 (Fig. 16.5).

  • If the Valleix cervical spine, kidney, and liver reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the wrist flexors and extensors, upper trapezius, and latissimus dorsi muscles (Tables 16.28-31).

  • If Chapman's kidney, liver, or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.5.

      Nutritional Therapy

Supplemental nutrients A, B-complex, C, D, rutin, and sulphur are recommended. The diet should be rich in fiber. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58). Honey, apple cider vinegar, ginger ale, and ginger tea shoulder be used frequently.

      Elective Procedures

Other helpful forms of treatment include spray-and-stretch therapy for trigger points, moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), warm whirlpool hand baths, ultrasound (Table 16.37), interferential therapy (Tables 16.39 41), alternating current (Table 16.27) for passive exercise, high-voltage therapy (Table 16.38), or tendon friction massage of involved muscles (except in the elderly). After the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Rheumatoid Arthritis

Rheumatoid arthritis is a chronic inflammatory disease of systemic origin that chiefly affects joint synovia. The direct cause is unknown, but it is generally classified as a defect in the autoimmunologic system. Granulomas develop in periarticular tissues. They also are found in the dura matter, myocardium, heart valves, lungs, eyes, somatic muscles, and peripheral nerves.

      Background

The hands are often the first parts of the body to manifest this syndrome: first the metacarpophalangeal joints, next the proximal interphalangeal joints, then the bones of the wrist. Deformity occurs late in the disease, involving joint architecture (bone erosion and cystic changes) and changes in tendons, muscles, and ligaments.

Early symptoms are myalgia and morning stiffness aggravated by motion. Joint swelling, tenderness, and limited motion are common. Late features are pain at rest increased by motion, disability, and subluxation leading to ankylosis and deformity.

If recognized early, this disorder can be resolved in 5-7 weeks but followup long-term maintenance care 3-4 times a year should be recommended. Once deformity has occurred, however, the best that can be expected is to retard the progress. In some cases, joint function will improve greatly even if deformity remains.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood gases             EMG                    Shoulder x-ray
    Blood calcium level     Hemoglobin level       Spinal roentgenography
    Blood urea level        Peripheral vascular    Thermography
    CBC and differential     studies               Urinalysis
    Chest x-ray             R-A test               VD serology
    ECG                     Sedimentation rate     Wrist/hand x-ray
    Elbow x-ray             Serum electrolytes

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7) if suspicions of vagotonia or sympathicotonia arise.

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

The spinal major will likely be found at C1 and T11; however, do not adjust by direct manipulation if advanced ankylosis or instability exists at this level. Release unankylosed fixations found in the noninvolved spinal segments, fingers, wrist, elbow, shoulder, and shoulder girdle. After relaxing the tissues and adjusting the unankylosed subluxated/fixated segments, apply deep low-velocity percussion spondylotherapy over the entire thoracic spine for 1-2 minutes (Table 16.20). It is the author's opinion that ankylosed rheumatoid joints should not be mobilized as they are compensatory.

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints TH-5, LI-11 (Table 16.21).

  • Treat auriculopoints 22, 29, 55, 95, 108 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, SI-3, TH-3 (Fig. 16.5).

  • If the Valleix cervical spine, heart, kidney, and liver reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the wrist extensors, brachioradialis, rhomboids, trapezius, latissimus dorsi, and abdominal muscles (Tables 16.28-31).

  • If Chapman's heart, kidney, or liver points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.6.

      Nutritional Therapy

Supplemental thymus extract and nutrients B-complex, C, F, niacin, P, pantothenic acid, pyridoxine, and sulphur are recommended. Licorice and cod liver oil should be added to a high-fiber diet. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58). Ginseng, cumin, ginger, eucalyptus tea, onions, and apple cider vinegar should be used frequently in the diet.

      Elective Procedures

Other helpful forms of treatment include cryotherapy (Tables 16.32 16.33) and spray-and-stretch therapy for trigger points during the acute stage, followed by moist heat (Tables 16.34 35), warm whirlpool hand baths, warm sulphur baths, ultrasound in water (Table 16.37), high-voltage therapy in water (Table 16.38), interferential therapy (Tables 16.39 41), or alternating current (Table 16.27) for passive exercise.

After the acute stage has passed, demonstrate mild therapeutic exercises to work weak muscles and/or stretch contractures. This is best accomplished in water (eg, a pool). Note: Excessive exertion or strenuous exercise of involved joints will increase the inflammatory process.



     Raynaud's Phenomenon

Raynaud's phenomenon is a vasomotor disturbance that manifests in the fingers. The patient is asymptomatic between attacks. It often precedes the development of rheumatoid arthritis or scleroderma. Young adult females (18-30 years of age) have a high incidence. It is also linked to peripheral vascular disease, thoracic outlet syndrome, pulmonary hypertension, myxedema, poisoning (ergot, carbon monoxide), and trauma (eg, frostbite).

      Background

This episodic disorder (usually bilateral) features intermittent attacks of digital pallor (reflex vasospasm) followed by cyanosis and then redness (reflex vasodilation) before returning to normal. Sensations of throbbing, numbness, or tingling are also common during an attack. The radial and ulnar pulses remain normal. Exposure to cold or emotional stress often precipitates an attack. Infrequently, untreated cases progress to gangrene of the finger tips.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential   Hemoglobin level           Sedimentation rate
    Chest x-ray            Nerve conduction studies   Spinal roentgenography
    ECG                    Peripheral vascular        Thermography
    Elbow x-ray             studies                   Urinalysis
    EMG                    R-A test                   Wrist/hand x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C7-T1 and 1st rib. Release fixations found in the fingers, wrist, elbow, shoulder, shoulder girdle, and anterior thorax. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints HT-5, HT-6, TH-5, GV-14, GB-20 (Table 16.21).

  • Treat auriculopoints 13, 22, 37, 62, 106 (Figs 16.3 4).

  • Treat hand points LI-4, LU-10, SI-3 (Fig. 16.5).

  • If the Valleix cervical spine, heart, and kidney reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the deltoid, wrist extensors, subscapularis, sternocleidomastoideus, upper trapezius, rhomboids, and upper-thoracic multifidi muscles (Tables 16.28-31).

  • If Chapman's heart, kidney, or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.7.

      Nutritional Therapy

Supplemental nutrients B12, niacin, folic acid, pangamic acid, and calcium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58). Nicotine and other vasoconstric tors should be avoided.

      Elective Procedures

Other helpful forms of treatment include spray-and-stretch therapy for trigger points, shortwave diathermy of the trunk (Table 16.36), paraspinal ultrasound (Table 16.37), pulsating alternating current (Table 16.27) for passive exercise, or interferential therapy (Table 16.39). Temporary TENS is often helpful in situations of intractable pain (Table 16.49).

Demonstrate aerobic therapeutic exercises to strengthen weak muscles and/or stretch contractures. Vigorous circumducting exercise of the upper extremity may stop an impending attack. Encourage warm bromine-valerian baths and the avoidance of stimulating showers.



     Sudeck's Atrophy

This disorder is a manifestation of upper-extremity vasomotor reflex spasm that leads to osteodystrophy and bone resorption. It is unusual in that the associated pain is far out of proportion to clinical findings. A periarticular inflammatory reaction is involved that spreads to underlying bone. Trauma is often in the history.

      Background

Related features include hand and finger pain, paresthesia, swelling, stiffness, intolerance to cold, tenderness, limb trigger-point development, and decreased joint motion. Skin color and texture changes, nail ridges, hyperhidrosis, and local temperature changes are often associated. Diagnosis is confirmed by roentgenography, but this is only possible in the advanced stage.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    Blood calcium level    EMG                        Sedimentation rate
    CBC and differential   Glucose tolerance test     Serum electrolytes
    Chest x-ray            Hemoglobin level           Spinal roentgenography
    Drug screen            Nerve conduction studies   Thermography
    ECG                    Peripheral vascular        Urinalysis
    Elbow x-ray             studies                   Wrist/hand x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6). Test for autonomic imbalance (Table 16.7).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C6-T1 and 1st rib. Release fixations found in the fingers, wrist, elbow, shoulder, shoulder girdle, and anterior thorax. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints UB-11, HT-5, TH-5, GV-14, KI-27 (Table 16.21).

  • Treat auriculopoints 13, 22, 62, 106 (Figs 16.3 4).

  • Treat hand points LI-4, LU-10, SI-3 (Fig. 16.5).

  • If the Valleix cervical spine, heart, and kidney reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the deltoid, wrist extensors, subscapularis, sternocleidomastoideus, upper trapezius, rhomboids, and upper-thoracic multifidi muscles (Tables 16.28-31).

  • If Chapman's heart, kidney, or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.8.

      Nutritional Therapy

Supplemental nutrients B12, E, niacin, potassium, and calcium are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58). Nicotine and antihistamines should be avoided.

      Elective Procedures

Other helpful forms of treatment include spray-and-stretch therapy for trigger points, shortwave diathermy of the trunk (Table 16.36), paraspinal ultrasound (Table 16.37), pulsating alternating current (Table 16.27) for passive exercise, or interferential therapy (Table 16.39). Temporary TENS is often helpful in situations of intractable pain (Table 16.49). Demonstrate aerobic therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Traumatic Inflammation

Wrist and finger strains, sprains, and contusions fall in this category. The symptoms are typical of such trauma: tenderness, painful motion, swelling, and possibly superficial warmth overlying injured tissues.

      Background

A priority is to differentiate traumatic from infectious inflammation of the wrist or hand. Traumatic arthritis of the wrist usually has a clear history of severe sprain, strain, fracture (especially scaphoid) or dislocation of the carpals (especially lunate). Physical signs and symptoms are often misleading; roentgenography is required for diagnosis.

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential   EMG                   Spinal roentgenography
    Chest x-ray            Sedimentation rate    Thermography
    ECG                    Serum electrolytes    Urinalysis
    Elbow x-ray            Shoulder x-ray        Wrist/hand x-ray

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13?, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved and adjacent joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C6-T1 and 1st rib. Also release fixations found in the fingers, wrist, elbow, shoulder, and shoulder girdle. Temporarily avoid involved acute joints. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints LI-11, GB-21, GB-34, TH-5, ST-36, PC-7 (Table 16.21).

  • Treat auriculopoints 37, 55, 62, 67, 106 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, LI-5, SI-3, TH-4 (Fig. 16.5).

  • If the Valleix cervical spine, kidney, and liver reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the wrist flexors and extensors, subscapularis, infraspinatus, and upper trapezius and latissimus dorsi muscles (Tables 16.28-31).

  • If Chapman's kidney, liver, or intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.9.

      Nutritional Therapy

Supplemental nutrients B-complex, C, niacin, pantothenic acid, and zinc are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Other helpful forms of treatment include rest, temporary support, comfrey ointment, cryotherapy (Tables 16.32 16.33), and spray-and-stretch therapy for trigger points during the acute stage, followed by moist heat (Tables 16.34 35) or shortwave diathermy (Table 16.36), warm whirlpool hand baths, ultrasound in water (Table 16.37), interferential therapy (Tables 16.39 41), pulsating alternating current (Table 16.27) for passive exercise, high-voltage therapy in water (Table 16.38), or tendon friction massage of involved muscles (except in the debilitated or elderly). After the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.



     Ulnar Nerve Compression Syndrome at the Wrist

The two nerves most likely to become trapped in the wrist are the median (carpal tunnel syndrome) and the ulnar. Ulnar compression may involve either the superficial or deep branch of the nerve, but the superficial branch is rarely involved alone. Entrapment usually occurs in the canal of Guyon. As in carpal tunnel syndrome, the cause may be in the wrist or far more proximal (eg, in the spine, thoracic outlet, shoulder, or elbow).

      Background

Compression of the deep branch of the ulnar nerve features a motor deficit such as interoseous atrophy, a weak pinch, weak little finger and thumb abduction, and inability to actively flex the metacarpophalangeal joints. Froment's cone sign will be positive.

Entrapment of the superficial branch exhibits acute tenderness over the pisiform-hamate tunnel and burning sensations in the 4th and 5th digits. Roentgnography may reveal a hamate fracture or pisiform dislocation. Repetitive microtrauma also may be involved (eg, DCs who practice upper-cervical recoil adjusting exclusively).

      Diagnostic Workup

Conduct a thorough physical examination and consider the following workups according to clinical judgment:

    CBC and differential    Peripheral vascular        Spinal roentgenography
    Elbow x-ray              studies                   Thermography
    EMG                     Sedimentation rate         Wrist x-ray
    Nerve conduction        Shoulder x-ray             VD serology

Motion palpate the spine, and relate findings with the patient's complaints. Confirm findings with appropriate orthopedic and neurologic tests (Tables 16.13, 16.16; Fig. 16.1). Check pertinent tendon and superficial reflexes (Tables 16.2), and grade the reaction (Table 16.3). Check involved joint motion and muscle strength against resistance, and grade resistance strength (Table 16.9). Interpret resisted motion signs (Table 16.6).

      Eclectic Diagnostic Aids

Check alarm points (Table 16.15), visceral Valleix areas of the foot (Fig. 16.2), Chapman's points (Fig. 16.6), and potential contributing trigger points (Tables 16.28 16.31).

      Articular Adjustment

Associated spinal majors will likely be found at C5-T1. Also release fixations found at the nonacute elbow, shoulder, or wrist. After relaxing the tissues and adjusting the subluxated/fixated segments, apply deep high-velocity percussion spondylotherapy over segments C7-T4 for 3-4 minutes (Table 16.20).

      Adjunctive Therapy

To restore further neurologic homeostasis and enhance healing:

  • Treat acupoints TH-5, LI-15, LU-5, PC-3, TH-10 (Table 16.21).

  • Treat auriculopoints 22, 37, 55, 67 (Figs 16.3 4).

  • Treat contralateral hand points LI-4, LI-5 (Fig. 16.5).

  • If the Valleix cervical spine reflex areas in the feet are tender, massage each to patient's tolerance for 20 seconds (Fig. 16.2).

  • Treat trigger points discovered, especially those found in the anconeus, triceps, brachialis, brachioradialis, and extensor and pronator muscles (Tables 16.28-31).

  • If Chapman's intrinsic spinal muscles points are tender, deeply massage each to patient's tolerance for 10 seconds while simultaneously holding firm fingertip contact against the respective spinal area with your other hand (Fig. 16.6).

These points are summarized in Figure 9.10.

      Nutritional Therapy

Supplemental nutrients B1, B6, C, niacin, P, manganese, zinc, and rutin are recommended. Counsel the patient to avoid appropriate antivitamin and antimineral factors (Tables 16.56 and 16.58).

      Elective Procedures

Helpful modalities include cryotherapy (Tables 16.32 16.33), spray-and-stretch trigger point therapy, interferential therapy (Tables 16.39 41), ion tophoresis with magnesium (Table 16.43), alternating current (Table 16.27) for passive exercise and pain control, or high-voltage therapy in water (Table 16.38). When the acute stage has passed, demonstrate therapeutic exercises to strengthen weak muscles and/or stretch contractures.

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