carpal instabilities - Hand Rehabilitation Section

CARPAL
INSTABILITIES
Elizabeth Byrne MPT, OCS, CHT, ATc
Linda de Haas MPT, OCS, CHT
lmbyrnie2011@yahoo.com
lldehaas@msn.com
Objectives
Upon completion of this course, you'll be able to:
1) Gain an understanding of the complexity of the anatomy,
biomechanics of the wrist and carpals
2) Gain and understanding of the pathoanatomy and pathokinematics
of various wrist/ carpal instabilities including- CID (carpal instability
dissociative), CIND (carpal instability non dissociative), CIC (carpal
instability complex) and Palmer's classification of both traumatic and
degenerative changes.
3) Describe current interventions on surgical and conservative
management.
Contributors to a
functional stable
wrist...
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Bones (8 carpals of
varied shape,
radius, ulna,
metacarpals that
articulate with DCR)
Ligamentous
structures (intrinsic
and extrinsic)
Proprioception
Muscle contraction
as stabilizer
Wrist Anatomy
Bone Anatomy
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•
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•
Complex
shapes
Intricate
articulations
with each
other
Radius to
carpus
Carpal
bones with
one another
Joints of wrist and carpals
•
•
•
Radiocarpal Joint
Ulno carpal articulation
Midcarpal Joint
Radial articulations
STT
SC
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•
•
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Central articulations
LC
•
Ulnar articulations
TqH
•
Triangular Fibrocartilage Complex
(TFCC)
Stabilizes the DRUJ
and separates it
from carpus
Originates of
sigmoid notch on
radius and attaches
to ulnar fovea
Triangular Fibrocartilage Complex
(TFCC)
Includes dorsal and
palmar radioulnar
ligaments,
ulnocarpal
ligaments, ECU
tendon sheath/ulnar
collateral ligaments,
meniscus
homologue,
articular disc
(TFC proper)
DRUJ and TFCC
ECU
MH
UL
UT
PRUL
DRUL
DORSAL
Articular Disc
PALMAR
Extrinsic Carpal Ligaments
RSC
UTq
DRC
Dorsal
UC
UL
SRL
Palmar
LRL
Intrinsic Carpal Ligaments
CT
TT
CT
CH
CH
TT
STT
TqHC
SC
DIC
SLIL
LT
Dorsal
LT
SLIL
Palmar
Mechanoreceptor- Dense
Carpal Ligaments
TqHC
DIC
SLIL
LT
DRC
PRUL
DRUL
Dorsal
Palmar
Muscles as Stabilizers
FCU, APL, ECRL were found by Hagert & GaricaElias to act as dynamic stabilizers of the SLIL while FCR,
FCU, APL reduce stress at SLIL.
Garcia-Elias found FCU and hypothenar muscles
stabilizes LT and MCI. Litchman added ECU to stabilize
MCI
Force Transmission
Force travels through a neutral positioned wrist from 3rd metacarpal to
Capitate/Scaphoid/Lunate joint at Mid-carpal joint (~50%) to
Radio-carpal joint ~80% (RS 46%+ RL 32%) and ulnocarpal joint/TFCC
~20% (14% UL + 8%UT)
Force Transmission
With axial compressive loading
(gripping), PCR tends to rotate into
flexion and pronation that is checked
by mid carpal ligaments
Carpal Kinematic Therapy
Historical Timeline
Navarro
Gifford
Linscheid &
Dobyns
Mennell
Mayo Clinic
Taleisnik
Lichtman
Wrist Kinematics
• Columnar Theory
of Navarro, 1919
• 3 vertical columns
Links and Cranks
Gifford’s Link Theory
Linscheid/Dobyn’s crank analogy
Mennell’s 2 Row Theory
Refuting the 2 Row Theory
Flexion occurs mostly at
midcarpal joint
Extension occurs mostly
at radiocarpal joint
Mayo Clinic
Wrist Kinematics
Taleisnik’s
vertical
columns
Distal row
considered
fixed by now
Wrist Kinematics
Lichtman’s Oval Ring
• 4 Links:
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•
•
•
Triquetrum
Lunate
Scaphoid
Distal carpal row
Kinematic
Concepts
The scaphoid is strategically positioned to add stability
to a naturally unstable mid carpal joint line
The scaphoid has a tendency towards flexion,
the triquetrum towards extension
Proximal row has more mobility between the individual
carpals compared to the distal carpal row
Ligaments are the key to the stability of the “intercalated
segment”
DCR secured firmly
to hand unit (MC and Phalanges)
by articular interlocking
and strong ligaments.
PCR are not as secured
due to mid carpal joint
Proximal Carpal Row Kinematics
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•
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Scaphoid wants to move into flexion
Triquetrum wants to move into extension
Scaphoid and triquetrum maintain balance through the SLIL and LT
ligament
The result in normal circumstances is a balanced lunate in the PCR.
With wrist in neutral, scapho-lunate angle averages 45-47%
Normal Carpal
Alignment
C-C-C
Normal S-L angle of 47°
WRIST MOTION KINEMATICS
Overall motion of the wrist is the
sum of carpal bones moving on
each other, influenced by their
articulations and ligamentous
attachments.
Grossly, wrist motion is
combination of motion at:
Radiocarpal Joint and Midcarpal
Joint
Carpal Kinematics
Wrist Flexion/Extension
Center of motion lies within the
head of the capitate
Extension occurs more at
midcarpal joint with proximal
row gliding volarly and
capitate gliding volarly on
lunate
Flexion occurs more at
radiocarpal joint with proximal
row gliding dorsally on carpus
and capitate glides dorsally on
lunate
Mayo Clinic
Carpal Kinematics
Wrist Radial Deviation
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•
PCR flexes
PCR glides dorsally
PRC translates
ulnarly
Lunate pronates
Triquetrum rides
proximally & dorsally
on the hamate
Carpal Kinematics
Wrist Ulnar Deviation
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•
•
•
•
PCR extends
PCR glides volarly
PCR translates radially
Lunate supinates
Triquetrum distally
rides distally & volarly
on hamate
Dart Throwers Motion
Most functional tasks are
performed in this plane of motion
More action is at midcarpal joint
thus limiting stress to radiocarpal
joint
Less motion of the scaphoid and
lunate
May have future implications for
early motion protocols for
fractures, SLIL injuries, and
ligament repairs
Radial extension
40⁰ ext, 20⁰ RD
Ulnar flexion
0⁰ flexion, 20⁰ UD
Dart Throwing Motion
What is functional motion
in the wrist?
Palmer et al: 30° extension, 5° flexion,
10° radial deviation, 15°ulnar deviation
Ryu et al: 40° extension, 40° flexion,
40° combined radial/ulnar deviation
Gartland and Werley: 45°extension, 30° flexion,
15° radial deviation, 15°ulnar deviation and
50° degrees of each supination and pronation
Carpal Instabilities
CARPAL INSTABILITIY DISSOCIATIVE
(CID)
Instability between
carpal bones in same
row
Static dissociation or
gap between carpals
due to ligament
insufficiency (SLIL and
L-T tears) or collapse
deformity
“LOOSEY” LUNATE
(CID)
VISI
Lunate goes with carpal bone to which it is still
connected ...
Scaphoid tends to flex so if lunate is
connected to scaphoid (intact SLIL), the
lunate will flex
Triquetrum tends to extend so if lunate is
connected to triquetrum (intact L-T), the
lunate will extend
Dorsal
Volar
If the lunate flexes, because the T-L is deficit,
then lunate faces volarly= VISI. S-L angle <
30 deg
If the lunate extends because the SLIL is
deficit, the lunate faces dorsally= DISI. S-L
angle > 70 deg
DISI
DISI & VISI Instability Patterns
Dorsal Intercalated Segmental Instability vs.
Volar Intercalated Segmental Instability
DISI
Volar aspect
VISI
Dorsal aspect
Volar aspect
Dorsal aspect
Scapho-Lunate
Dissociation
Most Common Carpal
Instability
History of FOOSH-wrist
hyperextension, UD and MC
supination
Presents w/ wrist weakness
and pain with loading
Scapho-Lunate
Dissociation
Timing is crucial.< 3 weeks, healing
potential is good
Pre-dynamic: presents w/dorsal wrist pain
(+) Watson’s
x-rays unremarkable
Most commonly diagnosed through
arthroscope
S-L Dissociation
Dynamic
Isolated complete
or partial SLIL tear
Can be seen radiographically with
stress views
Clenched fist view
Static
Ruptured SLIL and
palmar ligaments
(+) Terry Thomas
sign
Ring Sign
Ring Sign of the Scaphoid
DISI
Scapho-Lunate Advanced Collapse
End result of
long standing
SLIL rupture is
SLAC
http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/hand/scapholunate_diss.htm
Scapho-Lunate Nonunion Advanced Collapse
(SNAC)
Seen with long standing scaphoid nonunion- distal portion
of the scaphoid palmar flexes and lunate dorsiflexes
Static & Dynamic Instabilities
Resting posture
Grip view
Lunotriquetral
Dissociation
Can be confused w/ other
ulnar sided wrist problems
Often seen with peripheral
tears of TFCC, avulsion of
ulnocarpal ligaments, ulnar
nerve paresthesias
MOI: backward FOOSH w/
arm ER’d, forearm supinated,
wrist E& RD
May be combined w/ TFCC
tear & avulsion UC ligament
VISI
More about Lunotriquetral
Dissociation
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•
•
•
(+) palmar sagging of the
ulnar column
(+) L-T Instability tests
Painful crepitus w/ UD
(+) giving away sensation
w/supination/UD/E
Triangular Fibrocartilage Complex (TFCC)
TFCC is an articular fibrocartilage disc
Analogous to meniscus in knee
Improves joint congruency
Cushions against compressive forces
Transmits ~20% axial load –hand to forearm
TFCC lesion may be combined with L-T
disruption
Lesions- 80% central, 20% periphery
Central tears are usually degenerative in nature
and not repairable due to poor vascularity
Tears on the periphery are repairable
www.mikereinold.com
Palmar Classification TFCC
Lesions
Mechanism of Injury:
FOOSH or forearm rotation w/
wrist extended
Class I – traumatic
A. central perforation
B. ulnar avulsion w/ or w/o distal
ulnar fx
C. distal avulsion
D. radial avulsion w/ or w/o
sigmoid notch fx
www.dme-direct.com
Palmer Classification of TFCC Abnormalities
Class 2: degenerative
(ulnocarpal abutment
syndrome)
A. TFCC wear
B. TFCC wear + lunate and/or ulnar chondromalacia
C. TFCC perforation + lunate and/or ulnar chondromalacia
D. TFCC perforation + lunate and/or ulnar chondromalacia +
L-T ligament perforation
E. TFCC perforation + lunate and/or ulnar chondromalacia +
L-T ligament perforation + ulnocarpal arthritis
Palmar 1989
Carpal Instability Non-Dissociative
(CIND)
Instability of proximal row between either radiocarpal or mid-carpal joint w/o instability between
the individual carpal bones in the proximal row
Seen w/ loading in patients with ligamentous
laxity, or history of trauma. Static collapse pattern
not yet established
Example: Mid carpal instabilities (palmer > dorsal)
Midcarpal Instability
(CIND)
Dysfunction between proximal and distal rows
Palmar- most common form of mid carpal instability
Proximal row does not move smoothly from flexion to extension going
from RD to UD. VISI pattern maintained until extreme end of motion
Wrist will exhibit a characteristic clunking in which proximal row
suddenly jumps from flexion to extension as wrist moves into UD.
Head of capitate and hamate relocate- (+) MC shift test
Primarily a laxity issue- (+) palmar sag
Results: wrist unable to bear axial loads w/o collapsing into VISI
position
Carpal Instability Complex
(CIC)
Combination of CID and CIND
Often caused by acute hyperextension w/ UD and
intercarpal supination (fall onto thenar eminence)
SL, CL, LT joints are disrupted and lunate can rotate
into carpal tunnel
May be associated w/ fractures of carpals, radial and
ulnar styloids
Example: perilunate dislocations, fracture/dislocations
http://www.wikem.org/wiki/Perilunate_
and_Lunate_Dislocations
Mayfield: introduced concept of progressive perilunate
instability. Injury caused by compressive forces with
hyperextension of the wrist, forearm pronation and
ulnar deviation.
Perilunate Pattern
of Instability
Stage 1:partial disruption of S-L
joint
Stage 2:complete disruption of
S-L joint
Stage3:disruption of S-L, C-L,
Tq-L joints
Stage 4:disruption of all above +
dorsal radiocarpal ligaments,
allowing lunate dislocation
Associated fxs of radial styloid
&/or triquetrum
Mayfield 4 Stages of progressive perilunate
instability:
Stage I: Disruption of S-L and RSC
Stage II: Capitate and scaphoid separate from the lunate and
triquetrum (capitolunate)
Stage III: Injury continues ulnarly and separates the triquetrum
from the lunate, the carpus is completely separated from the
lunate resulting in perilunate dislocation (triquetrolunate)
Stage IV: Complete lunate dislocation. May occur in a dorsal or
palmar direction (radiolunate)
Carpal Instability Adaptive
(CIA)
Secondary instability due to malunion or bony
deformity
Example: dorsally malunited distal radial
fracture that makes the PCR conform to the
abnormal radial tilt
Medical Management
of Wrist Instabilities
Scapholunate Dissociation
(Chronicity)
Timing is everything
Acute < 1 week
Healing potential is optimal
Subacute 1-6 weeks
The ligaments may not heal as well as a consequence of
necrosis and retraction of their remnants.
Chronic > 6 weeks (poor healing potential)
Primary ligament healing, although possible, is very
unlikely.
Classification of Scapholunate
Ligament Injuries
Garcia-Elias, et al, 2006: JHS 31A:1, 125-134
Scapholunate Dissociation
Stage 1 - Pre dynamic
Injured ligaments: partial
scapholunate interosseous ligament
(SLIL)
Description: diagnosed acutely,
dorsal wrist pain or dysfunction with
mechanical loading
Arthroscopy confirms diagnosis
No abnormalities of scaphoid or
lunate on static or stress radiographs.
Scapholunate Dissociation
Stage 1 Pre-Dynamic
Conservative treatment:
casting splinting, NSAIDs
and therapy
Surgical treatment:
debridement with pinning
or capsulodesis, open or
arthroscopic
Scapholunate Dissociation
Stage 2 Dynamic
Caused by higher energy
trauma
Isolated complete or partial
SL tear
Can be seen radiographically
with stress views
Static x-ray is negative
Clenched Fist View
http://www.wheelessonline.com/image5/sld3.jpg
Scapholunate Dissociation
Stage 2 - Dynamic
Episodic instances of carpal
subluxation only under certain
loading conditions
Treatment: SLIL repair with
capsulodesis (re-anchor capsule
into the lunate)
Scapholunate Dissociation
Stage 3 Static Reducible
Instability
Ruptured SLIL
Ruptured palmar ligaments
Gap between scaphoid and lunate
appears on X-ray without stress
Immediate surgical repair favored as
subluxation is easily reducible
Bone-ligament-bone graft is
indicated or tri-ligament
reconstruction
Scapholunate Dissociation
Stage 4 –Static Irreducible Instability
Complete loss of SL linkage (SLIL, STT, and SC) Ligaments all
torn
Scapholunate Angle Increases > 45° and joint deformity or intraarticular fibrosis does not allow reduction of the subluxation
Lunate rotates dorsally to reduce capitolunate angle to 15° or less.
Tendon reconstruction of the scaphoid stabilizers (Brunelli)
Three ligament tenodesis
Reduction Association of the SL joint (RASL Procedure)
Static Arthritic Instability
Stage 5 – Complete SLIL Injury with Irreducible
Malalignment but Normal Cartilage.
A chronic subluxation has induced degenerative
changes in the joint cartilage increasing wrist stiffness
No soft tissue procedures can achieve full stability
unless the fibrosis is excised effectively.
A partial fusion with the aim of reestablishing an
adequate load-bearing column is recommended
Scaphoid-trapezium-trapezoid
Scaphoid-lunate
Scaphoid-capitate
Radius-scaphoid-lunate fusion
Scapholunate Dissociation
Stage 6 - Complete SLIL Injury with Irreducible
Malalignment and Cartilage Degeneration
Chronic dysfunctional wrists tend to develop cartilage
degeneration (SLAC)
The goal of treatment is to relieve pain with minimal
functional loss.
Excision of the scaphoid plus midcarpal “four corner”
fusion
Proximal-row carpectomy
Conservative Treatment of SLIL
Tears
Grade I and II
Immobilize 3-12 weeks
Thumb Spica orthosis
Patient performs finger ROM ex and
digital tendon-gliding exercises
Then immobilize intermittently
between exercises
After immobilization period initiate
gentle AROM in DTM (goal is
stability over mobility)
Strength
Isometrics
Be cautious with power grip strength
Rehabilitation
Debridement and Thermal Shrinkage
0-3 weeks - Immobilize in a short-arm thumb
spica cast or splint
3-6 weeks post op - Protected motion therapy is
performed.
6 weeks DC immobilization and begin resistive
strengthening and functional therapy.
Treatment of SLIL Tears
Scapholunate Ligament Repair
Dorsal Approach
SLIL attached to lunate
Rehab after repair/reconstruction
ROM – flexion and extension
approximately 80% of pre-op
Grip strength 80%
Goal = stability > mobility
Dorsal Scapholunate Ligament
Repair
Expected Outcomes
Direct Repair
75% as compared with contralateral side
80-85% return of grip strength
70% of patients have significant improvement in pain
Full recovery may take up to 4-6 months
Ligament Reconstruction
20-30% loss of wrist flexion
20% loss of wrist extension
75-80% return of grip strength
Treatment SLIL Tear
Blatt Dorsal Capsulodesis
One of the more common
indirect ligament reconstruction
techniques.
Uses a flap of remaining dorsal
capsule attached to distal radius
to reposition scaphoid. It is
pinned through scaphoid and
capitate then woven into
scaphoid and anchored.
Because the flap is attached to
the distal radius, wrist flexion is
reduced by ~ 20%.
Treatment of SLIL Tear
Chronic injuries (>6 weeks)
Dorsal Capsulodesis
Bone-Ligament-Bone Grafts
Dynamic instability
Tendon weaves
RASL
Arthrodesis
Treatment SLIL Tear
Bone-Ligament-Bone Grafts
Portion of SLIL cut out along with
bone attachments to create space
for a bone-tendon-bone graft.
Common donor sites
Dorsal capitate-hamate ligament
Navicular – 1st cuneiform of ankle
Treatment of SLIL Tear
Bone-Ligament-Bone Grafts Rehabilitation
Thumb Spica Orthosis
Avoid early loading which can cause failure
After pin removal, gentle AROM in DTM
4-6 months return to normal functional use
Treatment of SLIL Tear
Tendon Weaves/Soft Tissue Reconstruction
Brunelli Reconstruction
Most common weave used
Uses half of FCR tendon
which is woven through
the scaphoid
Use of Palmaris Longus
also in the literature
Rehabilitation after Brunelli
Reconstruction
0-8 weeks: Well molded wrist and
thumb immobilization
8 weeks: AROM starting with dart
thrower’s motion, interval
splinting
12 weeks: Light strengthening
starting with isometrics
6 months: Full activity resumed
RASL Procedure
Reduction and
Association of the
Scaphoid and
Lunate
Temporary Herbert screw fixation following
primary repair of SL
Motion can begin earlier than SL repair – 4-6
weeks
Rosenwasser et al. (1997) reported good results using this approach.
Follow-up of ~ 54 months, 20 patients with a static SLD treated with
RASL exhibited 91% of their normal motion and 87% grip strength.
Rehabilitation RASL Procedure
0-3 weeks post op immobilize in short-arm
thumb spica cast.
3-6 weeks - Removable wrist orthosis as
exercise begins
6 weeks DC orthosis and begin resistive
ex.
STT Arthrodesis
Treatment of SLIL Tear
Salvage Procedures
Proximal Row Carpectomy
Scaphoid Excision with 4
Corner Fusion
Four-Corner Fusion
Scaphoid Excision
Rehabilitation of Proximal Row
Carpectomy (PRC)
Wrist AROM at post op week 4
Wrist PROM at post op week 6
Strengthening at post op week 6
Expectations:
30-50% reduction in wrist motion
50-60% ROM for flexion/extension
8° of radial deviation
20° of ulnar deviation
20-50% reduction in grip strength
Capitate sits in lunate facet
Proximal Row Carpectomy
Two longitudinal studies > 10 years average follow up, offer insight into the
durability, patient satisfaction and performance after PRC.
Jebsen et al, evaluated 20 patients at average follow up of thirteen years
found a flexion/extension arc of 72 °. Radial deviation 9° and ulnar
deviation averaged 31°
DiDonna et al, evaluated 22 patients with a follow up >14 years found an
average flexion/extension arc of 76°. Radial deviation 12° and ulnar
deviation averaged 22 °.
Grip strengths in the two studies were 93% (Jebson) and 81% (DiDonna) of
the contralateral arm.
Thirty-five of the combined 42 patients reported a satisfactory outcome.
Only six patients (14%) eventually required conversion to wrist arthrodesis.
Treatment of SLIL Tear
Partial Wrist Fusion Rehabilitation
Long or short arm cast – until solid 6-12 weeks
Pins removed after immobilization period and referral to therapy
Short arm thumb spica orthosis for 2-4 weeks then wean
A/AAROM (DTM) of wrist 6+ weeks
Gentle PROM after healed (8-10 weeks)
Strengthening 10-12 weeks
Work Hardening after 16 weeks
Results: decreased ROM by 40-60%
Treatment of LT Tears
Initial non-operative management of partial LT
injury without dissociation
6 weeks of cast or splint immobilization above
the elbow with a pisiform boost
NSAIDS or steroid injections into midcarpal
joint to decrease synovitis
Treatment of LT Tears
Chronic tears: Immobilization
(ulnar boost orthosis), activity
modification, exercises
Supervised therapy
Re-establish proprioceptive
control of FCU, ECU,
hypothenar muscles
Isometric contraction
generates dorsally directed
force on Tq via pisiform
Treatment of LT Tears
Surgical reconstruction for chronic
tears. May be done in conjunction
with wafer procedure or ulnar
shortening
Arthroscopic exam and
debridement
Reconstruction of L-T with slip of
ECU
L-T fusion
Radiolunate fusion
PRC
Treatment of LT Tears
Rehabilitation after debridement
Wrist orthosis for 1-3 weeks post op
Initiation of movement is dictated by comfort
and can start as early as week one
Progress to light loading and increased
functional use as tolerated
Treatment of LT Tears
Rehab after direct repair
0-2 weeks - Post op dressing- AROM and PROM
of fingers, elbow and shoulder
6-8 weeks - Long arm cast in neutral rotation
8-10 weeks – Pins removed and splint used
during rehab period
12 weeks begin strengthening
Impact loading avoided for 4-6 months
Mid Carpal Instabilities (MCI)
Clinical significance
Exact incidence is unknown
Complaints of ulnar sided wrist pain
Do not use their hand normally because they are
afraid of sudden painful clunk
Afraid to use hand functionally
Loose grip when clunk occurs
Avoidance and abnormal use occurs
Conservative Management
Immobilization, anti-inflammatories,
activity modification
Pisiform boost orthosis/Midcarpal
stabilization orthosis
Skirven
Exercises similar to L-T injury: FCU, ECU,
hypothenar muscles. Avoid isotonics, power grip
and repetitive wrist motion. Include proprioceptive
training
Supination is more stable, decreases ulnar variance
Splinting
Pisiform Boost Splints
Treatment of MCI
Operative Management- Aims to prevent
pathologic motion and stabilize PCR
Types:
Arthroscopic palmar MC capsular shrinkage
Tendon reconstruction of ligaments
MC fusion
Radiolunate fusion
Post op Rehabilitation of MCI
After soft tissue repair/pinning and 8 weeks of
immobilization
Volar wrist orthosis is used intermittently after
this period of immobilization
Initiate conservative management exercises
Avoid heavy loading, power grip, and weight
bearing for 6 months
Physical Therapy
Management
of Wrist Instabilities
Provocative Maneuvers
SLIL Provocative Test
Scaphoid Shift Test/Watson’s
Patients wrist placed in ulnar deviation and slight extension.
Examiner places thumb on tubercle of scaphoid and flexion
of scaphoid is blocked as patients wrist is moved into radial
deviation and slight flexion.
Instability will cause scaphoid to sublux dorsally.
When pressure is removed a painful clunk will be noted in
positive test
There is a 30% rate of false positives.
False positives can be decreased by clenching fist during
testing
Watson’s/Scaphoid Shift Test
Lunotriquetral Shear Test
Grasp the Pisiform and Triquetrum
The contralateral thumb and index
finger hold the Lunate and radial
carpus.
Move the Triquetrum while the
lunate and radial wrist remain
stationary.
The force is transmitted across the
lunotriquetral joint.
If this maneuver produces pain, the
result is considered positive
Sensitivity .66
Specificity .44
Reagan/Ballottement/Shuck Test
Grasp the whole piso-triquetral
unit.
The contralateral thumb and
index finger hold the lunate.
Apply a dorsally directed force
with one hand and volarly
directed force with the other
hand.
This force is switched in the
opposite directions in both
hands.
This creates a shear stress at
the lunotriquetral joint, and if
painful, the result is positive.
Sensitivity .69
Specificity .44
Linscheid Compression Test
Examiners thumb along
ulnar border of the
Triquetrum
Push in radial direction
Compression force across
the lunotriquetral joint.
If this maneuver produces
pain, the result is
considered positive
Lichtman’s Midcarpal Shift test
Pt’s wrist placed in neutral with
forearm pronated
A palmar force is applied to the
hand at the base of the third
metacarpal
The wrist is deviated ulnarly.
Test is + if a painful clunk occurs
as the distal row snaps back into
its physiologic position and
reproduces symptoms.
Ulna Fovea Sign
The elbow is in flexion, forearm in
neutral rotation and wrist in
neutral position.
The examiner’s thumb tip is then
pressed distally and deep into the
interval “soft spot”
The ulnar fovea sign is positive
when there is exquisite
tenderness compared with the
contralateral side.
95.2% sensitivity
86.5% specificity
TFCC Load Test
Ulnar deviation
Axial load
Rotation
http://www.physiopedia.com/Triangular_Fibrocartilage_Complex_Injuries
Gripping Rotatory Impaction Test
Quantifiable measurement
Three forearm test
positions: neutral,
supination, and pronation
Expressed as a ratio:
Supination strength
Pronation strength
1.0 is normal, > 1.0 predicts
ulnar impaction problems
Friends and Enemies of the SLIL
FCR is a dynamic stabilizer of
the scaphoid
Scaphoid will rotate into flexion
but also supinate
Supination of the scaphoid
causes distal row pronation via
the trapezium
Opposite rotation of the carpal
rows may have a protective
effect on SLIL dynamic
instabilities
Proprioceptive Training
for
Wrist Ligament Injuries
Proprioception Training?
Proprioceptive training may prevent a stage I
scapho-lunate ligament injury from progressing.
Surgery often recommended for all levels of
injury but outcomes extremely variable.
Proprioception
Hagert discussed findings of innervation
patterns in ligaments of the wrist.
She proposed how these findings can translate
to therapeutic innervation in wrist injuries.
“A carpal ligament injury, therefore, should be
regarded as a trauma affecting the whole wrist, with
implications not only on the internal carpal
kinematics, but possibly also on the coordination and
proprioception of the entire wrist joint”
Proprioception
Proprioceptive training is based on principle that
SLIL is protected by the co-contraction of the
FCR, FCU, ECRB and ECU
Injury disrupts the feedback loop
Exercises improve awareness of joint position
Exercises increase stabilization by cocontraction of muscles that reduce strain on the
SLIL (APL, FCR, FCU supinate the scaphoid to
reduce SLIL tension)
Working Proprioception Into
The Treatment Plan
Working on joint position sense, kinesthesia
Moving joint to a specific position, mirror therapy
Neuromuscular control
Exercises targeting specific muscles dependent
on ligaments involved in instability which is
present
Perturbation training, reactive muscle activation
Muscles as Stabilizers
Strengthening begins at ~ 12 weeks
Start w/ isometrics progress to co-contraction,
isotonics. Focus strengthening to specific
muscles supporting ligament stability.
Hagert & Garcia-Elias found FCU, APL, ECRL
as dynamic stabilizers of SL. FCR, FCU, APL
reduce stress @ SL
Garcia-Elias found FCU, hypothenar stabilizes
LT and MCI. Litchman added ECU to stabilize
MCI
Avoid repeated power gripping, repetitive ROM,
wrist curls
Scaphoid supination/Triquetrum
pronation
Medicine Ball Wrist Curls
During rehab, isolate the actions of wrist extensors from finger
extensors
Limits cheating with finger extensors
Consider supinated position to start grip strengthening
exercises in those with ulnar impaction syndrome.
Proprioceptive
Exercises
Neuromuscular Proprioceptive
Training Protocol Hagert
Stages
Plan
Purpose
Technique
1
Basic
rehabilitation
2
Proprioception
awareness
Conscious joint
control
Mirror therapy
VAS
ROM
3
Joint position
sense
Replicate joint
angle
Blinded
Passive/active
Goniometer,
joint angle
4
Kinesthesia
Sense joint
motion
Motion detection
Machine - manual
TTDPM
5
Conscious
neuromuscular
rehab
Train specific
muscles to
enhance
stability
Isometric
Co-activation
Strength
Stability
6
Unconscious
neuromuscular
rehab
Reactive
muscle
activation
Perturbation
training (machine,
powerball)
EMG
Oedema/pain
control
Basic hand therapy
Motion
Assessment
VAS
ROM
Training Proprioception
Stage I: The basics
Edema/pain control, ROM
Stage II: Proprioception awareness
Conscious joint control
Mirror box therapy
Training Proprioception
Stage III: Joint position sense
Replicate a joint angle, active & passive,
blinded
Get patient to replicate a joint angle, progress
from with visual cues to without v.c.
Stage IV: Kinesthesia
Sensing joint position
Motion detection machine (? availability)
Training Proprioception
Stage V: Conscious neuromuscular rehab
Train specific muscles to enhance stability
Increase co-activation
Strengthen supinating muscles (FCU, ECRL)
Stage VI: Unconscious neuromuscular rehab:
Responsible for posture, joint stability,
anticipatory control, intact nerve function
With PIN denervation, there are significant
changes in reflex patterns in the wrist
Reflex muscle activation with Power Ball
In Summary
What is the injured structure?
What are the established guidelines to promote healing
of the structure?
What are the needs of your patient? Athlete vs.
accountant
Is there an arc of motion that limits stress to the injured
structure?
Is there a muscle contraction that has been shown to
improve stability for injured structures?
How can we work on improving proprioception lost
during immobilization?
Is there an arc of motion that limits stress to the
injured structure?
Is there a muscle contraction that has been
shown to improve stability for injured
structures?
How can we work on improving proprioception
lost during immobilization?
Thank You
Questions?
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