Hand Therapy Exam Prep | Finger & Hand Injuries
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[00:00:00] So are you guys ready? All right, so I've been getting great questions from you guys, by the way.
[00:00:05] Thank you. That always helps me. It really helps me to know where you guys are at cuz then that allows me to help you better. So everyone's everyone's at a different place, everyone's studying a little differently. And that's okay. That's okay. Part of this group is just, getting together, knowing that you're gonna cover certain topics.
[00:00:24] So it just keeps you going, right? It's that little nudge, keep going. Because this is now buckle downtime and you wanna make sure you're doing everything that you need to do and stay focused. One of the biggest things is staying disciplined and staying focused.
[00:00:39] Believe it or not, that is my mantra right now as well. Yeah, so saying discipline, saying focus, and then, so everyone's at different phases. Everyone's got a different story to tell. Whether it be your first time, if you've done this before and doing it again, it's okay if you don't wanna share it openly.
[00:00:59] It's. [00:01:00] Fine. Please email me, let me know because now when I get your feedback, I can change and make sure that I'm getting everyone's needs met. So if you're shy, you don't wanna share your face and you're like, I don't wanna answer, I don't wanna ask questions it's okay. You can ask me questions probably if that's what helps.
[00:01:19] So I just wanna make sure that I'm here to answer your questions. You can email me and. And we're making videos. And even if I've gone through it again and you're like, I still don't get it. Just tell me I'll do it. I'll make sure that you get the support that you need. Okay. Always with these kind of tests, it's really important to understand that when you're studying, don't just study for memorization.
[00:01:46] There's certain things that you are memorizing, but you want to memorize certain things, but really the memorization is to understand it. So some things you're just pure memorization, right? But so much of it's if I [00:02:00] understand how this joint moves or if I understand how this muscle moves then I can understand what normal motion is.
[00:02:07] And then, and I always say we're lucky. We've got two hands. Look at how your hand moves. Look at how it's posturing, how it's positioned and then just make it a daily thing. Like I do. You guys look at people's hands. I look at people's hands all the freaking time. I watch how they stand.
[00:02:26] I watch how they reach. I watch how people walk. I watch how people get dressed. I watch how people get undressed. Like I watch how people eat. But when you. See normal movement pattern. It's also going to help you easily spot abnormal movement patterns. If you understand how things are supposed to move, then you'll understand to a certain extent why.
[00:02:54] The protocols or the protocols? So I always teach, I teach beginners in [00:03:00] between my clinic and in different classes that I teach. If you don't know all the protocol just understand what that joint is about. Understand some of complications of what that joint's about.
[00:03:14] Like last week, we talked about, we could talk about pips for the 12 weeks. Okay. But we're not, we're talk about freaking pips all day long, or fractures all day long. What we know about Pips is that it gets. Stuck in flex. If it gets stuck in flex, then what do we do as therapists? We need to put it into extension.
[00:03:35] So when you think about what kind of splinting, what kind of protocols, like if you're confused about some of that, just really think back to the principles of stuff. And that's gonna help you be the problem solver and the decision maker. So everything about this test is not going to be, I'm gonna have to bring you in the a letter that I got from the hand therapy commission because they are quite aware that I'm doing this mentorship program.[00:04:00]
[00:04:00] And even before this I got a letter with them, stating the stipulations of the test and stuff like that. Because there's rules around this test, it's rules around this test cuz you know, you're not supposed to be, telling people the questions and stuff like that. It's been like a million years since I took this exam, so I'm fucking no questions.
[00:04:21] All I know is how I teach my own staff to become the problem solvers and the decision makers when it comes to the different injuries that we see. And we see surgical cases, we see non-surgical cases, and we have to be the ones that say, okay, this is a problem. This is how we're gonna do it, this is how we're gonna treat it.
[00:04:43] And of course, sometimes when you're working with doctors, you also are the ones. That talk to them like actually when we go a little bit more into like tendon injuries and stuff like that and nerve stuff, I'll bring on a case that we have a really severe case crush [00:05:00] injury fractures.
[00:05:01] It's a wrist fractures tendon laceration and then nerve compressions like the works. And I've got to be able to look at this hand and I've got to say, what are we doing first, second, and third? I've got to be able to look at it and say, okay, first thing we're gonna do is we're gonna heal the fractures first.
[00:05:21] We're gonna protect what we need to protect. But I can see there's certain problems that are going to be coming down the pipeline. When we talk about pmp When we talk about MP stiffness, we talk about collateral ligaments, those ligaments get really short when they're in extent, when the mps are extended.
[00:05:41] So when you look at safe positions, everything is about a safe position. Why? They need to be in a safe position because of those collateral ligaments. So when you understand that, you can then take that and apply it and say, I don't care. Like I might not know like 100%, but I know damn those mps should be able to be [00:06:00] inflection, and then how do I do the next step and the next step? And so it's so critical when you're studying that you understand the anatomy and all those things too. But then you understand why, because then when you're in the test, you're gonna be a lot more confident, problem solving through and then making a decision about what you need to do next.
[00:06:23] Cuz that's what you do in real life. I was able to sit there and then go I tell him like, okay, I see this nerve problem. I see mps are stuck. Mps are stuck, inflection can't get them down. What kind of surgery do I recommend next? They rely on us just as much as we are relying on them to let us know like, when is it safe, when is it stable?
[00:06:48] So much about when you're studying for this, it gives you the confidence to be able to make these decisions. And it's gonna take you in the test in a different [00:07:00] mindset. It's really important. Half this test is about mindset people. All right, so thank you so much for the emails. It lets me it lets me know where to meet you at and lets me help you much better.
[00:07:11] So if anyone of you guys have not emailed me questions or haven't told me their stories, or haven't said to me like, Hey, I, I need this from you, then please feel free to, cuz the whole point of this mentorship is you have access to me. You have access to me. Let me know what you need. And for some people this is gonna be like an affirmation, which is great, right?
[00:07:33] It's gonna be an affirmation like, Ooh, I know that. Ooh, I understand that. And that's a great thing because when you know that you got something right, and when you know that you've got something, it's gonna boost your confidence. And when you get your confidence boosted, what happens? You can go into the next subject and the next subject.
[00:07:53] With your confidence boosted and each level of the way, it's really gonna help you. Confidence is a [00:08:00] huge thing. And that's part of the mindset. Alright I want to encourage you to think where's the gap? When it comes to studying, what do I know? What don't I know? What don't, I don't understand.
[00:08:12] And then that's where usually that's why I tell mys like that's where I can come in and fill the gap for you. Alright, so think about your questions. Am I go over thumb? Are we good with me going over thumb? Cuz that's what I studied and I wrote, I read some chapters, I wrote some things and I said, Let me think about when I read this, like what are some of the things that you should keep in mind, right?
[00:08:38] I'm a huge fan of the rehab of the handbook. I think it's essential in studying and it's not as, I know a lot of people think, oh my guys, it's so hard to read. It's really thick. But they do, they do put it like relatively easy in most parts. But just like anything else when you're studying, it's [00:09:00] weeding in the most important and weeding weeding in the most important and weeding out the unimportant things.
[00:09:08] I think everyone's on mute. Can you make sure everyone's on mute? Can you do that?
[00:09:18] I think everyone's oh. Everyone put yourself on mute unless you wanna talk. All right. All right. So yeah, read the chat. So you might wanna tell them. All right, man. You're making it sound like I'm saying it. No, I'm kidding. It's okay. It's all right. I'm thank God for Vanessa. All so what so I'm gonna talk about.
[00:09:42] Thumb and I talk about the cmc and why it's so important, right? I love drawing my thumbs. Okay. I love drawing my bones cuz I'm, really don't have to be fancy. This is the, can you see it? Oof so small. Why am I drawing so small? So [00:10:00] here is,
[00:10:03] The metacarpal. So it's the first metacarpal, right? And here is the trapezium. So this right here is essentially your cmc, right? All right. And believe it or not, for the most part, it's pretty much the same. It's pretty much the same as the fingers. The only, the biggest difference is the C M C. So the C M C is basically the base. Of the metacarpal and the trapezium. And it's shaped like the, I know that a lot of people were asking about the saddle joint issue.
[00:10:43] Yes. So don't overthink it, except for that it's a saddle, like it's a saddle joint. So both it can go in both directions. So if you take a look at your thumb, right? This is your,[00:11:00]
[00:11:00] this is your metacarpal, right? So I can feel the base of my metacarpal.
[00:11:10] All right? And then right underneath the, it's touching is a trapezium. So the most important thing, if you look at your thumb has the most amount of motion. All right? So what the saddle joint and the concave and the convex. Thing really is just to tell you that it can move in both directions.
[00:11:31] It could move in flexion and extension, and it could move in abduction and abduction. That's all that means. So what does that mean? It means that it has a lot of ability to move. So anytime you have a lot of motion, what do you sacrifice? You? Yeah, you sacrifice a certain amount of stability, right?
[00:11:54] So if you understand that, you know what, some of our problems tend to be with the cmc, [00:12:00] right? So we get a lot of motion. The some keywords or some keywords that they might throw at you are the planes. So how do you say Corona plane? I was. Yeah. Corona plane. I was calling it something else, like beer.
[00:12:17] So Corona play is your, flexion and extension, right? And then your sagittal plane is your abduction, and your abduction. You couldn't see your thumb. Oh, I'm sorry. You can't see my thumb. Your abduction and your abduction. So those are just some key little things to think about cuz they might throw that out there.
[00:12:39] And then opposition. So opposition is also known as pronation. Nobody calls it pronation. But it's pronation. And then so when you have opposition to come out of opposition, it's retro position. So it's considered sup nation. So I thought, it's always good to know [00:13:00] both terminologies cuz they might just throw it out there, right?
[00:13:04] But what the saddle joint part of it, because you have so much motion in it. It's what gives us so much function. So literally without literally without the The motion without the thumb, there's not that much you can do. So think about all your types of patients that have arthritis and their joint falls in to their palm, or they have any kind of thumb injury, then they're gonna lose motion.
[00:13:38] So what happens when you have a lot of pain due to instability or bony changes, which cause instability, and you have a lot of pain. When you have a lot of pain, you lose your ability to functionally use it, right? So you tend to u lose the grip and you tend to lose your [00:14:00] pinch, right? So imagine, look, your thumb does 50% of the work of your hand.
[00:14:04] So imagine if you're trying to pinch and you don't have a thumb you, it's very hard to pinch, okay? If you're trying to grip. You're still using your thumb. Your thumb gives you your grip. So you're on your side and your thumb is the things that give you the strength in your hands. So without your thumb, you're really not very functional.
[00:14:28] So think about your thumb in that sense. So we know that the bones sit a certain way, so as long as they sit where they're supposed to sit, you're fine. So what gives it stability? So we know that muscles get long and muscles get short, and that's what moves the thumb. But between bone to bone, you're gonna have your ligament.
[00:14:54] Now the ligaments of the MP and the ligaments of the IP are pretty much the [00:15:00] same as the finger. So if you know it for the fingers, you really do know it for the thumb. But when it comes to the cmc, it's just a little different.
[00:15:12] Okay. The abduction plane and then Scott answered, oh, can you use a different color for the ligament? Oh, as you go? No, just difference. But the red, everyone's complaining. Can't. Oh no, the blue. You can't see the red, right? You can't see the I'm gonna need like a spotlight.
[00:15:33] You can't see a spotlight. Let me see. Can you guys see the blue better? Let's see. Blue. No, it's okay. They're ligaments. What do ligaments do? Ligaments attach bone to bone and give stability, right? But in the thumb they. What? Oh shit man. I can't fucking win to say my, that's all right. You guys know where it's at?[00:16:00]
[00:16:00] Or you should so I've gotta put you on mute, girl. Stop coming outta mute. She just wanted to laugh. Oh, you did? You just wanted to laugh out loud. So yeah, I gotta put everyone on mute cuz otherwise when you come on to talk, which you should but when I'm lecturing and you come on to talk, then you take me away and and everyone apparently wants to see me.
[00:16:21] I don't know why, but they wanna see me. So remember, ligaments give stability, but in the thumb it has to be lax enough to have movement, right? So that's the most important thing of the cmc. So I'm just challenge you to. Think of it that way so that you can then know how to apply it. So what else?
[00:16:43] So out of all the ligaments, cuz there's, so I'm gonna list them. There's an anterior oblique. So that is a major one to know because it is a major stabilizing ligament, right? And it's taught, it's tight [00:17:00] when the thumb goes into abduction, right? So goes into abduction, extension, opposition, it stretches that anterior oblique ligament.
[00:17:10] So it's a major stabilizing one. Another one that's really important is the ulnar collateral ligament. So the ulnar collateral ligament is a key one to know too, because. It's one where it's easily injured in the thumb. So when you're studying and you're like, oh my God, do I need to know the posterior oblique and the inter metacarpal oblique and the dorsal radio obl please, you need to know that there are all these extra ligaments.
[00:17:41] And if you look at the word posterior oblique, inter metacarpal, dorsal radio, like the names help you with where they're positioned so you can problem solve through the test. If they're talking about something anterior and the choice is dorsal, that [00:18:00] might not be the correct answer. Depending on the question though just challenge you to think so.
[00:18:06] And then the joint caps around completes that so that you can have You can have stability. Carolyn Jackson said. Do you mean the UCL of the MP joint or the cmc? Oh, the, of the MP joint. But yes, you're right. I'm talking I went beyond but in the cmc. In the cmc, the major one to know is the anterior oblique.
[00:18:29] Like everything else is, just a ligament. And then when we go to the thumb, sorry. When we go to the thumb, we're gonna talk about, we're gonna, we are talking about the thumb when we're talking about the mp, right? We're talking about the mp. The MP of the thumb pretty much is the same as any other finger.
[00:18:50] But in your finger let me see your thumbs. Cause I have pretty decent wait. MP, joint. M [00:19:00] not ips, mps. So in the mps we have, Vanessa doesn't have much mp MP flexion. So in the mp, if you take a look it's actually the most varied out of all the joints because it could range from like 10 to 15 degrees to a ton of range of motion, but it's pretty much the same as all the other fingers.
[00:19:23] It has less flexion extension, but pretty much it varies. The biggest difference in the MP of the thumb versus the MP of the thumb versus MP of the fingers is right here at the mp you have two sesamoid bones, right? And those little sesamoids. Holds. So it's it's essentially right here.
[00:19:53] It's what holds one of the tendons, one of the flexor tendons, right? So it it houses the flexor polys is [00:20:00] longest. Okay? So it holds it so that, that tendon can glide through. It's a partial insertion for the abductor pollis. And the. On the ulnar side and the flexor polys is breathless on the radial side.
[00:20:19] Do that again. Okay. So the sesamoid bones on the on the ulnar side, so let's say this is the, let's say this is the radial side and this is the nar side. That part is where partial insertion of the adductor polls is. And then on the radial side that's where the flexor lysis breakfast inserts.
[00:20:48] So when I was reading through, I said, oh, this is important to know because when you have thumb injuries, you wanna know what's going on here and why you might have the problems, why you have, so that you can think through some [00:21:00] of the issues. The modif, there's a modified extensor hood that is stronger on the owner side, which is formed by the tendon and the apron of the adductor pollis.
[00:21:12] So the MP has an extensor hood. The MP has an extensor hood, just like all your other fingers, right? But on the nar side of this, it's much stronger than on the radial side, right? And it's formed by the tendon and the app peroneus of the adductor pollis. And you, when you read that, you're wondering why is that, why is the owner side stronger than the radio side?
[00:21:50] So it's stronger on the owner's side, than the radio side because of the forces that gets applied to the thumb.[00:22:00] So when you're pinching, where are the forces? The forces applied Honorly onto it. So when you were talking about ligament injuries, especially in the thumb, you know what happens, right?
[00:22:18] The function of the MP is to provide stability while you're pinching. And grabbing because the forces applied to it are going to be applied honorably. So that MP has to give it a lot of stability versus the CMC has a lot of motion,
[00:22:39] right? So it's sacrificed stability for motion. And the MP is gives you stability so that it's strong. So it can pinch, can take on the forces of grip and pinch, and in any event, it's better to be stiffer so that you can have greater joint mo, [00:23:00] greater joint stability, right? So if you have too much motion here, if you have too much motion, you might be unstable, but what's the point of this joint?
[00:23:10] It's supposed to be stable. So it's just letting you think, okay, if I'm reading through, like I wanna understand why. It is what it is. So then I would say what happens to, if something happens to this joint right here to the MP joint? What happens to it? So there's the ulnar collateral ligament injury, right?
[00:23:38] And it happens 10 times more often to the ulnar side than to the radial side. Now it's stronger on the NAR side because it has to be, cuz it takes on all the forces. But because it takes on all the forces, it's 10 times likely to get injured versus thenar versus the radial side. Okay, [00:24:00] so what are some of the injuries that there was a question on it.
[00:24:05] So when you have a ulnar collateral ligament, it's also called a skier's thumb, right? So it's called a skier's thumb, but the gamekeeper's thumb is pretty much the same thing. It's the same injury, only a skier's thumb is acute, and a gamekeeper's thumb tends to be more chronic. It's the same injury to the same ligament.
[00:24:34] It's just the skier thumb is called the skier thumb because you usually can, injure it when you're skiing the pole pulls, right? So I have a case where this girl, she was driving and she got in a car accident because of how she was holding. The, when she was hit, somehow it pulled and hyperextended that thumb, right?
[00:24:58] It hyper, it went into [00:25:00] radial deviation and hyperextension. That's how you pull that. So it doesn't have to be skiing. It's just any kind of forces that apply a very forceful radial deviation and hyperextension of your mp and you could tear your on collateral ligament.
[00:25:18] So I would challenge you to think, okay, if I tore it, what. What is going to happen to that joint? So the MP joint is supposed to be, it's supposed to be stable, right? So when you tear that ligament, when you break that ligament, what happens? It becomes unstable. So if you're thinking through a problem, how do you make that stable again?
[00:25:44] And if you try, so in this case, she was in a she was driving, she was holding onto the steering wheel, and when she got in a car accident, it hit her and it pulled her thumb. And what they decided to do was they decided to splint her and they splinted [00:26:00] her for six to eight weeks. To see if they could give her back the stability.
[00:26:07] Cuz when you, when something happens to her and there's a sprain or a tear, then there's instability. And with instability comes pain. So think of it like that if you're gonna apply it and if there's any kind of scenario, that's how you would think through what's the point of this ligament, what does it do?
[00:26:26] And so in her case, she ended up. Trying the conservative method and then they determined that it wasn't really helpful cuz once she got really stiff, then they got motion back and then she was fine. But anytime she would pinch or grip, she had pain again. So because of that, they decide to go ahead and do surgery to correct that on the collateral ligament.
[00:26:52] And they after they pinned her and they left her for six weeks and then afterwards the therapy [00:27:00] process started. So when you know that the MP would rather be stiff than unstable, so in order for you to have a functional pinch and functional grip and all that good stuff, that MP. Needs to be stiff because without the stiffness it's gonna go back to being unstable.
[00:27:21] Does that make sense? Like when I'm going through and talking about this stuff, that's how I want you to think about some of the things that you're studying. It's great to have the Purple Book and it's great to have the black book and stuff like that cuz it allows you to go through different questions and stuff like that.
[00:27:39] But I would really challenge you. To to really, when you're answering some of these questions, to challenge yourself by problem solving forward or problem solving back. Does that make sense? If this is the case and I would do this, so in this case, because I know that the [00:28:00] mp needs to be, the MP of the thumb needs to be stable.
[00:28:05] It needs to, it would rather be stiff so that it can be stable so that I can have pinching abilities. Cuz of the forces that are applied. When would then I make the recommendation essentially that it isn't what is the name of the test for, what is the name of the test for testing for the.
[00:28:33] I dunno. Usually it's just very unstable, like during any kind of pinch. There is a you can test for to stress it. So you just hold down just like any collateral ligament. You would you would hold one bone and then press into the opposite direction to test it. You could do it with, it extended, you could do it with it slightly flex and test it.
[00:28:56] But usually there's pain point, like on that spot where [00:29:00] it's attached. And usually it's not so much of a test, but it's like every time they pinch, they go back into a pain cycle. They just can't get rid of that that pain. Now the name, there's a lesion, it's called the Steiners lesion.
[00:29:14] Which is the same thing as a gamekeeper. So gamekeepers gamekeepers thumb and skier's thumb, they're all ulnar collateral ligaments, but they just have two different names, right? Steiners Lesion is the same injury. Okay. Ulnar collateral ligament. The only thing is it's a complete tear of the ulnar collateral ligament and the distal end of it gets caught underneath.
[00:29:48] Caught on the outside of the ab adductor apron. It's the same thing. It's just got a different [00:30:00] name, but it's still the only collateral ligament. And usually with the signer's lesion, it is like you're trying, but you can't you can't fix it, because it's completely torn. So you have to go surgically.
[00:30:15] To remove imp penant. So then what's your protocol, Karen? What is most important in your experience, in comparison to others? Function, pain or stability? What's my, what's the most important? Pain. Everything comes back to pain. If you have so much pain, you're not gonna be functional, right? If you have pain, then you're not stable.
[00:30:46] So if you think about the function of the mp, the function of the MP is to be really stable. It doesn't move that much like most people's mp. I think this, I did this at the [00:31:00] beginning, or somebody did this at recently. They're like I just can't get her MP moving. I can't, it's stuck at like 10 degrees, so I said let's look at the other thumb. And the MP of that person's thumb was 10 degrees too. So that mp has, it's, tons of people can have varied amounts of motion. You could have from like 10 degrees to 60 degrees. But it's gotta be stable. And stability is the ligaments holding it together.
[00:31:32] So if you know that joint is stable by being stiff, then part of the protocol is stiffness. If you know that the CMC is supposed to be movable, it's supposed to have much, a lot of motion. Then what happens if you lose motion? If you lose motion of the cmc, then you lose function, right? Because it's su it.
[00:31:57] The job of the CMC is to [00:32:00] move. The job of the CMC is to give you opposition. What happens if you no longer have opposition? You can lose opposition one through bony problems of arthritis, fractures or whatever, right? You can have a bony problem. That's how you lose motion, and you can lose motion at the C for opposition through nerve injury.
[00:32:24] But with the C M C you have, you're not going to, the ligaments of the C M C are meant to be loose. So most of the time the problem is gonna be too loose, right? So if you're too loose, then what happens? You're unstable. And if you're unstable, you can have pain. If you're cmc, you're supposed to be loose enough to have motion, but if you too tight and you don't have enough motion, [00:33:00] then what happens?
[00:33:00] You lose function. So when you think about the purpose of these joints and what it's supposed to do for you can help you think through the problems that you have and the problems that you're gonna face, whether it be with your patients or answers, questions on a test.
[00:33:23] Okay. Normally with the protocol of a owner owner collateral ligament for the mp you actually don't, and it depends, like the protocol book will say, between four to six weeks and then you can start active motion. But if there's a question on there, In terms of when do you start, passive motion, the protocol per the hand Indiana hand protocol book.
[00:33:55] It's you can start active motion at six weeks. And then you [00:34:00] don't wanna start passive range of motion until seven, right? And the most important thing is because you want stability, because you want stability. Remember you want stiffness more than you want. Motion is that you don't wanna be so aggressive, right?
[00:34:20] Passive range of motion is pushed a lot later. So seven weeks you keep splinting for the most part for any heavy activities until about eight weeks. But you're not allowed to do any heavy pinching for about 12. And why is it so long when you think about man, if there's a question about that it's because it needs to be stable because you know that when someone pinches, there's forces applied to that nar collateral ligament cuz that nar collateral ligament is.
[00:34:55] Supposed to support it. So if I start [00:35:00] strengthening and I have pain, then what should I do? I should cut it out because I need to be pain free. I need to be stiffer for stability for the surgery to be successful. If you push and push on somebody, especially on a ligament injury, then you can compromise the injury.
[00:35:28] Now, if it was a, Fracture and it was a boney problem. Is there a problem of instability? Tends not to be. When it's a fracture type, so it's a bone problem, then you don't, you're gonna be more concerned about stiffness and you're gonna be more concerned about that stiffness, interfering with function because it's just not moving and you just can't pinch, you can't move that thumb.
[00:35:56] So you don't, if the collateral ligaments are stable.[00:36:00] You don't have to worry about, pushing for, for pain and stuff like that, because that, I have, I keep having a question. Okay. Protocols were passive range of motions prohibited until after active range of motion. Is that because overstretching could disrupt healing tissues and reduce.
[00:36:19] Stability where? So yeah, so in general, right? In general if you think about the purpose of ligaments are supposed to keep you stable. So if something is disrupting your ligament, you've lost ability. So you can't go pushing on people. Does that make sense? If you so you're allowed to do active, like everyone, tons of research and protocols and stuff like that encourage active motion.
[00:36:57] Early active motion or anything like that. [00:37:00] Once things are stable, but when passive range of motion is prohibitive, you take a look and compare all your protocols or as you go and you study through those ligament injuries. Like we're about to get into the wrist and so we're gonna talk a shit ton about ligaments and it's instability.
[00:37:19] And when those ligaments are torn, oh my gosh, huge problems. I had somebody who had ligament tears and it's like this downward spiral. So that can happen. And in In the thumb too. But not all ligaments are created equal ligaments of your finger, can take the brunt of a lot of stuff.
[00:37:42] They tend not to be, they tend not to have the same kind of injuries as like your thumb. Because there aren't those kind of forces. I mean there are, if there's like a high force injury when we talked about collateral ligament types of injuries of the of the P I P and stuff like that.
[00:37:58] But [00:38:00] usually if the ligament is torn then yeah, that's why passive range of motion is prohibited. Did I answer that is why ligaments apply? I was thinking of p I p. Yes. I understand why ligaments apply. As I was thinking about p i p dislocation, V plate is similar to ligaments cuz it's takes longer to heal.
[00:38:18] Yeah. V plate is a ligament. So if it's dislocated, if it's dislocated, Backwards like that, then that roller plate can be disrupted. But so in that sense, we're not pushing anything backwards. We're gonna push it into flexion cuz then that you're not, it again, it's a ligament. It's keeping it from Hyperextending.
[00:38:43] Hyperextending, but it's not the same. It's purpose isn't the same. That's where I was going with it. The purpose of all ligaments aren't the same, but like all ligaments are meant to stabilize bone to bone. It's stabilize the joint. [00:39:00] All right, so there was a couple questions. Anyone else have questions?
[00:39:05] Oh, I, can I say something? Yes. Tell him say it. I just wanna say that it was helpful for you to say, for example you could do this at 12 weeks, but why? We never asked. Okay. Why? And I feel like that helps. Yeah. Why every protocol? Does that help? Different? Yeah. Yeah, it does help. Okay, good.
[00:39:23] All right, so then let's take this knowledge and apply it. So when we're talking, I think we talked about fractures. The d I p and all that finger is pretty much the same as the other fingers, right? And in terms of fractures, it's really just about making sure the fracture is aligned in order to be able to move when it comes to, so take that knowledge that you have apply to arthritis.
[00:39:54] What happens to patients when they have osteoarthritis and there's changes to that, to [00:40:00] this joint right here. So here they have bony changes to the metacarpal, and then of course then arose onto the carpal bones, the trapezium, right? In osteoarthritis what tends to happen, so if there's a lot of pain and there's bone loss and stuff like that, what happens to the full function of the hand?
[00:40:23] When you're studying all of those things and. You're studying what do they tend to do conservatively? What do we do? We splint it. We use heat modalities, that kind of stuff. We work the tissues around it and stuff like that. And then if that doesn't work or if that's used in conjunction with injections, then what happens after injections and then after injections.
[00:40:48] There's a whole chapter on the types of surgeries that are done. And really the main reason of knowing what the types of surgeries are, it's just so you can [00:41:00] now then take that knowledge and apply it for. What you should do as a therapist, so the pro protocols are gonna be there. It says oh yeah, we're gonna reduce the edema, we're gonna reduce the pain, we're gonna get more motion.
[00:41:16] And then when can you start strengthening you all? They're going into surgery for pain. If they're going into surgery for pain then what shouldn't you do? Push on them that's gonna cause them more pain. So when you're studying those, think through why things are done the way they are.
[00:41:37] So that can help you better answer questions cuz you can study the books and you study those questions. I remember like this purple book is twice the size of what it was when I studied, but I remember when I took it. I was like, man, these none of the questions were the same. Obviously, they have a bank of [00:42:00] questions and rotate them around, they add to them and stuff like that.
[00:42:03] And what they do is there, there's gonna be questions about scenarios. If this is a case, this is a case story and we could do that too, like I said I'll introduce some of my nerve and my more complicated cases and stuff like that, and even non-surgical cases.
[00:42:21] When we talk about like different tendonitis and stuff like that, like how do you think through this problem so that when you're, whether it's on the test or in a clinic and you're saying, this patient is coming in at this number of weeks and they present with a painful thumb at the MP on the owner.
[00:42:44] On the on their side of the thumb, every single time they pinch, and their complaint is they can't open a jar. They can't turn the key, things like that. What could this possibly be? And then they're, there's gonna, they're [00:43:00] gonna give you, different things and then you have to pick it.
[00:43:03] And then, because then from a clinical standpoint what would you do, X, Y, and Z? And that could be your question. That could be the person that comes in my particular case, she came in, she had already gone through two months worth of therapy somewhere else, and then she moved down to Miami.
[00:43:26] We saw her for one day and I was like, Ooh, if you've already been doing therapy and you're still having pain let's, let's see. In the next couple of visits, like where we're at, cuz she's already got majority of her motion. We didn't wanna push because it was better for her to be stiff.
[00:43:41] Cuz we knew that on the collateral ligament was injured, we just didn't know to what extent. And then within what was it, the second visit. The doctor that she had transferred here already decided, okay, you've already tried long enough cuz we already stiffened you for six to eight [00:44:00] weeks. We tried a therapy for a month or two and you're still having pain with any kind of pinching or gripping, then we need to do the surgery.
[00:44:08] So then she went and had the surgery. She was pinned for six weeks. Then when she came to us, she was six weeks out, she was about seven weeks. So technically seven weeks we're allowed to start pushing her, but why push her? Even though you're allowed to push her, but why push her? Why not wait until, we start active motion, we start, we did scar edema, all that good stuff.
[00:44:30] Stuff, reduce the pain. And then we started to do passive range of motion in a pain free, at a pain-free pace to not increase the pain cycle. And there's no heavy gripping. But does that mean like we don't introduce light, I isometric types of functional stuff that allow her to use all the muscles of her hand?
[00:44:50] Yes. How can you do it? You can do it in a pain-free way so that we maintain the integrity of that [00:45:00] repair, but not reentering, not causing her to go back into that pain. So at 12 weeks we can say, okay, technically speaking at 12 weeks, You know you're healed. There's no precautions. You can do everything as long as you're in a pain-free way, because we know that joint is supposed to stay stable and it's better for it to be a little stiffer than to be too loose and get you back into that pain, which means that maybe that surgery didn't, wasn't successful.
[00:45:26] So how do you explain that to people? You tell them your joint MP is better to be stiffer, so it's better not to push it. You just wanna actively move it. So that's how you would apply the knowledge that you have here. To that type of case, then you have someone you know with arthritis. Okay. What do we know about CMC or, cmc joint, it's supposed to have a certain amount of stability.
[00:45:50] It's supposed to have a certain amount of mobility. And the mo the most functional thing is this halfway point between radial. [00:46:00] Abduction and Palmer abduction. You wanna be in the middle cause you want that cupped position, right? So what happens in arthritis when that joint starts to fall?
[00:46:11] They start to lose function and they have a lot of pain. What do you do? So that's how I want, when you're studying and you're thinking through and you're answering some of these questions, go back to that and think through. Cause I think that's really gonna help you, problem solve through any kind of scenario you have.
[00:46:26] And be able to pick the best possible answer.
[00:46:32] Does that help anybody? There was a question on sagittal bands. So Sagittal, the Sagal band is a ligament and all it does is it, Stabilizes and keeps the extensor tendon. So if you make a fist, you're gonna see that extensor tendon, right? And all your fingers. So the sagittal band just keeps it centered.
[00:46:54] And when there's a disruption to that sagal band that tendon falls [00:47:00] off track. So every time it moves, it's gonna click and pop all over the place. So there's supposed to be a certain amount of motion with it so that you can move. But if it moves too much, then you're in pain. And that actually falls into a zone five x extensor tendon type of injury.
[00:47:15] And we'll go over more of that and we'll go over more. Anything having to do with the extensor extensor mechanism kind of issues, but extensor mechanisms basically. It's just it's not part of it, it's just, it's what helps. With the motion of the D I p and the p i p and it's usually explained when things go wrong cuz there's all these mesh of ligaments and stuff like that.
[00:47:40] So we can go through more of that if we need to, like in the tendon stuff. But that's what SAG bands are for the most part. Is Sagittal Bend, like the extensor hood or It's the same, it's just a ligament. Just a ligament. Boop. And it just, on both [00:48:00] sides it just holds it just holds these tendons in place.
[00:48:03] Don't get fancy. Don't like. Oh, what else is it? No, it just holds those tenants in place. That's it. So if it's job is to hold the extensor tenant in place, what happens if you cut it? Don't answer. We're gonna go over during tenant, cuz we actually have another case. Lacerated that, and it's a, what zone does it fall in and what do you do and how do you split it all that is in tendon zone, tendon week.
[00:48:32] Right.
[00:48:37] So another, what was I gonna say? Is that good? Anything else? Oh my god, drink.
[00:48:48] Okay. So I had a question about the van also. No. No. Okay. So on this page right here, say it extend, it says extensor expansion hood. Is that the [00:49:00] same thing? The sagittal band? I don't dunno. Vanessa, why? You wanna come chime in? No, I don't. Okay. So expansion hood is, it's a fancy word for saying it's part of the sagittal band, but yeah it's the.
[00:49:17] In a similar place I would Yeah, they're Look it up. Yeah. Can you remember that question? Sure. So the SAG band, it's its own band and then it becomes the extensor mechanism, sensor mechanism. Extensor hood. I think it's all the same shit. Think it's all the same thing.
[00:49:41] I can answer that in in an email. Email, yes. Anyone else have a question? Did I cover Mostly everyone's questions. Let me see.
[00:49:53] Oh yeah, I know. She can't answer that. Juan says, fucking shit. [00:50:00] Sorry. What kind of NA says is this? No, don't get me in trouble. I'm gonna lose my CHC lesson. Can you imagine, damnit? Wait, what was, where was I gonna go? I was going to answer some questions and see. Were the last couple of videos really good.
[00:50:19] So I'm be making more videos to help you guys with the questions and stuff like that. Anyone? Anyone? Okay. Yeah, the videos are good. Okay, good. I have another one. It's 20 minutes long. I think I'm talking. I don't, I think I just posted it. I know. I haven't posted it. I was video, I was editing. I should post it.
[00:50:44] Oh, you know what I was gonna say? I said something wrong the other day. Please feel free to correct me. I do not know everything. What I'm really good about is like taking it back down and explaining it in a simple way so you can understand it [00:51:00] really, when you're studying, try to think like, how can I make this easy for myself?
[00:51:06] Honestly, how can I make it easy for myself? I think last time I said something incorrectly, so the fractures, when it's a in, I'm gonna write this shit down. All right,
[00:51:24] so this is the capsule, right? Oh, that looks terrible. That looks real. Okay. I'm just gonna, that part. Okay, so this is a capsule and any, so when you say intra, I said it backwards. Intra versus extra
[00:51:52] articular. So articular is the joint, right? Intra is you're going into the [00:52:00] joint. You broke it inside into the joint. Intra extra is is in like in the bone. You didn't go into the joint. Is that how I think I said it. Backwards. Don't listen to me. So extra-articular. So extra-articular is is outside of the joint, so it's outside of the joint, meaning it's just in the bone part.
[00:52:27] Intraarticular went into the joint, so it's inside. So it does break through the articular cartilage. So if you have the bone and then on top of that is the cartilage, which makes it move nice and smooth when you break into it. It's an intraarticular. I think I said it backwards the other day.
[00:52:56] Yeah. What do you want? Yeah, go ahead and then we'll [00:53:00] move on. Cause I know it's not for this week. Okay, good. What happened? That's why I said, she said she's confirming. That's what I said. I don't know why I thought I said it backwards. I was like, holy shit, I'm gonna mess people up, but I'm, seriously.
[00:53:14] So we have another question, but before we get to that, okay. I'm just gonna say something real quick. All right. Okay. I'm gonna give Wong a break. She needs to drink some water. Just take a moment. But so Chelsea and Fay I think had the question about the sagittal bands. Okay, so I'm gonna say two things.
[00:53:34] So what I found on online right now, just like looking at sagittal bands, cuz I think one of the things we need to remember is like, all right, how can we figure this out for ourselves? So one thing like that came to my head was like, Looking up where the sagittal ban inserts and originates and then that can anatomically help you decide.
[00:53:54] Is that the same thing as the expansion hood? So if you ever have a question like, what is this? Maybe think about that. And I know I've [00:54:00] gotten questions about the extensor mechanism the same way like. If the ligament attaches to a tendon somehow. So think about the origin and the insertion of what you're asking about the, that ligament or that tendon.
[00:54:13] So the sagittal bands arise from the v plate of the MP joint, the inter, okay. So then it says, and then it inserts on the extensor hood. And I was able to find a picture that is not that clear, but you can see that they're pointing to two different things. So the extensor expansion hood is separate from the sagittal band.
[00:54:39] Okay. But they get together. So I think I can somehow share this picture with you if that helps you. And I'll look it up in the rehab of the hands exactly where I got that information. But I, I was like talking to Wong. I think that's helpful is to always ask ourselves like, why, and know how to [00:55:00] problem solve for ourselves as we're going through this.
[00:55:03] Does that make sense? Okay.
[00:55:09] Somebody said hi, difference between Rolando. Oh, maybe she's answering. Kari is answering Shauna's. Come on. Unmute yourself and answer.
[00:55:26] What was the question? Okay, I have a question. I have a question from the Purple Book. 2 55.
[00:55:42] That question isn't from me. It is actually, somebody sent it to me on accident. I think it's from whoever's on the iPhone. Oh, okay.
[00:55:57] Maybe she wants to ask you, Harry, [00:56:00] maybe you know some stuff. Yes. I dunno. Yes. You do know, man. It's all mindset. Like I know. I was just gosh, what was it? I was at this thing and it talks about what we say to ourselves, like self-talk. Cuz I can be pretty nasty to myself.
[00:56:18] You wouldn't say this to other people, the shit that you say to yourself. So change the conversation that you're having with yourself. Change it. It's a big difference. Question. I know it gotta be positive. 2 55. Question 58, about rheumatoid arthritis. 58. In a person with rheumatoid arthritis, the ligaments typically loosen on their ulnar aspect of their radiocarpal joints resulting in a radial displacement of the proximal carpal row.
[00:56:52] True or false, following this ulnar deviation of the hand in the forearm [00:57:00] occurs. So before we answer this, what do we know about RA in the hand, right? So let's go back and say, this is where you kind of problem solving backwards, RA has a tendency to loosen the joints and has a zigzag type of pattern, right?
[00:57:25] So it has a zig type of pattern. So when the ligaments loosen on the radio as. Suspect of the radiocarpal joint, ulnar displacement of the carpal row will occur. So if this is your proximal
[00:57:44] row's, your proximal row, hold your dear Lord. And then this is your distal row,
[00:57:58] right? Yeah. [00:58:00] This's your distal row, distal proximal. And ra patient the mps. Will go into the fingers will go into ulnar deviation resulting in this going into into the opposite direction. So if the fingers go ulnar, then the metacarpals will go radially. And then the distal row will go ulnar too.
[00:58:36] So following this, so a person with rheumatoid arthritis, the ligaments typically loosen in the ulnar aspect of the radiocarpal joint, resulting in a radial displacement of the proximal carpal row. True or false, following this ulnar deviation. Of the hand on the forearm [00:59:00] occurs on the deviation notes.
[00:59:01] This goes narcos radial. So the ligaments loosen on the radial aspect of the radial carpal joint, so ulnar displacement of the proximal will occurs, so radial deviation of the hand occurs secondarily on the forearm. An associate subluxation of D R U J often occurs is causing a loss of stability in the ulnar aspect of the wrist.
[00:59:31] A Palmer subluxation of the proximal row on the radius also is commonly seen. So when it comes to that question what is some of the issues that you're having with thinking through it? Can you hear me? Yeah. Okay. Yeah I just don't understand like what they're talking about regarding like the hand or the forearm.
[00:59:55] Are they talking about the, like I don't understand I told 'em understand [01:00:00] the MP going ulnar and the metacarpal going radial. I get that, but I got confused for the whole rest of the situation and the carpal go and then the hand deviation on the forearm. So in a person, I can't see it. I just don't understand.
[01:00:15] Yeah. Yeah. That one's a really hard one. In a person with rheumatoid arthritis, the ligaments typically loosen on the ulnar aspect, so the radiocarpal joint. So the radius. The radius carpal joint, loosens on the ulnar aspect resulting in a radial displacement of the proximal row. True or false? So say that, the simple thing on that question to me, if it loosened on the ulnar aspect then your medical or your radiocarpal joints are going to deviate, radially, not narly. So I had to think about that and I had to take it back to that they're talking about the [01:01:00] radiocarpal, they're not talking about like everything. So take it back to the radiocarpal. So we're gonna go over some our risk next week.
[01:01:09] Would that help if we talked about. The kinematics of that and then we could tie it to arthritis and the language that they're talking about. Would that help? Yeah. Okay. All right. Can you make a note of that? All right, cool. All right. So when you guys send me questions let me know where you find it, because then that helps me.
[01:01:31] It's almost like you're sometimes the questions if they're real specific, like what you did right there the, okay, this question on this, and I don't understand in that way, that, that way it gives me a better idea of how to, make, create something for you that will help explain it.
[01:01:50] All right, thank you. All right. So the difference between a Rolando fracture and benef versus, I don't know what a reverse Bennett fracture is. I can, [01:02:00] I know what a Bennetts fracture is, which is the base. It's a fracture and dislocation but a reverse. Is that a boxer's fracture?
[01:02:13] No, I wouldn't think so. Boxer fracture is on the MP and the fifth generally from hunching. Yeah, but it's but it's on the it's on this side. It's on the distal end of the metacarpal. A boxer's fracture. Yeah, it's here on the neck versus like a bennets fracture is on the proximal end of the metacarpal.
[01:02:37] So that's the reverse. The reverse could, the reverse could be opposite too, but I'll look it up. Because I hadn't I hadn't seen that one when I was reading through. Yeah. So you said, I guess you're saying the reverse Bennett could be a boxer fracture Cause it's the opposite end Yeah.
[01:02:54] Of the metacarpal. I've never heard of that, but I can look into that. Cuz usually a boxer's fracture is a, [01:03:00] is called a boxer's fracture. Yeah, just like a bend fracture. But like I said, it's always important to know, just like when we were talking about skier thumb and gamekeepers, like the same thing, just has different words.
[01:03:14] And it could be that, but I'll look into that. And see if there is any real difference between it. Did you read it on any particular or you just saw it in one of the questions,
[01:03:28] Carolyn? Yeah. I, oh, sorry. Oh I just remember reading something like that when I was reviewing the purple book. Okay. A while back. I'll look it up. Quang, if it helps you, it's on page four 15 maybe of the on the first volume
[01:03:52] it has like that fracture, aros fracture. I didn't see the reverse though. [01:04:00] Okay. Four 15. Oh, sorry.
[01:04:08] Oh, but I do remember seeing that on one of the questions. So Caroline was right. Okay, so let's think about four 15. Oh, hello? You did read that. It was right there. So the Bennetts fracture is a fracture and dislocation. The fracture is mechanically similar to peer dislocations in an unopposed pull of the APL and the E P L and the adductor lysis axle compression in the less flexion. It tends to cause a palon injury to the metacarpal base with three or more. These injuries have been termed even though the original description.
[01:04:50] Okay, so it seems like it's the same type of fracture only in in three or more fragments with [01:05:00] axi. So axi compression and less flexion tends to cause a palon injury to the metacarpal with three or more fragments. And these injuries have been termed rolando's fracture. So a Bennet's fracture and a rolando's fracture is essentially in the same area, only a rolando's fracture has three or more pieces of fracture, and then I'll look up the reverse.
[01:05:22] Bennett's. Sound good? All right. What I know is it happens in, yeah. And the reverse. The reverse. Can you hear me? Yeah. Hey, Scott, I think is what they're saying is the Bennett's fracture is actually on the first metacarpal and the reverse Bennett is actually at the fifth metacarpal.
[01:05:43] Okay. This would be, the reverse metacarpal would be cool what happens on the fifth metacarpal, but but on the base, right? On the base, I think that's what they're saying is the reverse. Okay. Okay. [01:06:00] All right. We'll double check that and make sure. All right. Everyone had a good call? Yeah. Thank you. Good, I'm glad.
[01:06:08] So we're gonna talk about risks. For the next two weeks. And wrist is really hard, right? So please study wrist kinematics. You guys have to know the wrist bones and you wanna know which ones are the ones have that have the most problems. Like scaphoid is a really huge one and it tends to have a ton of different problems.
[01:06:37] And then you have to know ligaments stuff because ligaments again, ligaments give stability. So study over. Which ligaments are like the most important ones? Usually like the SL ligaments, stuff like that. And it's really important, I always find like when you're studying wrists to know the muscles that are actually [01:07:00] attached to any of the carpal any of the carpal bones, because when there's a fracture, there's going to be a pull on it, right?
[01:07:08] So there's the wrist bones in the sense that there's carpal issues and carpal instability and stuff like that. And also included in the wrist is your distal radius, your dis onna, your D R U J, which is this joint right here in the middle that gives you supination, pronation, stuff like that.
[01:07:27] And how some of those so know your basis and then that way we can, and if you're having any trouble with that, then email me cuz then I can make you a little videos and I can explain it better. And then we can talk through some of those kind of similar to what we did today and go backwards and forwards and think about like certain problems.
[01:07:49] And this is where, we talked splinting a little bit in the other injuries, but it's, you don't have to make the splint on the test, I promise. You just have to, [01:08:00] don't roll your eyes. Carrie. I saw that. It's my favorite thing splinting. But you wanna know, like positioning, you wanna know principles of splinting.
[01:08:12] That's pretty much the most important part. You don't have to make anything, you just have to know the principles of it. Like when would you splint when would you use X, Y, and Z? What's the position? And when it comes to the wrist, there's. There's all sorts of stuff, so very good. Thank you so much.
[01:08:28] You guys are rocking it, you guys are studying, showing up is half, showing up is half the battle. I'm telling you. We had 23 people. What? It's amazing. It's awesome. Everyone came, I, everyone participated. I want to, get questions from you. Majority of you guys put your videos on.
[01:08:45] I'd like that, see faces normally I teach, in a classroom and stuff like that. And it's a little different feel on camera, but imagine if you guys came to Miami for 12 weeks, you might wanna kill me. So even though it's a very fun town, you might [01:09:00] guys wanna kill me. So thanks everyone.
[01:09:02] Good night, happy studying, and say nice things to yourselves. Pat yourself in the back. Good job. Good job. Until next time, cheers. I'll post this soon. All right, have a great night.
