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Wrist Anatomy and Kinesiology

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Wrist Complex Anatomy and Kinesiology Laura Conway OTR/L, CHT COMT UE Or is it “ Complex Wrist”? The Importance of the Wrist It is a Tool for Communication Protection Sensory- Motor Organ Your Hand is a Valuable Tool For Assessment of Your Environment • Temperature • Thickness • Texture • Depth • Shape • Speed • Weight Kinetic Chain The Interosseous Membrane • Forearm stabilizer that provides longitudinal and transverse stability. • Transfers force from the radius to the ulna. • Secondary stabilizer of the DRUJ • Tears are often undiagnosed and difficult to treat. • Rotated 180 but able to bear substantial loads. • Key to functional hand position • Distal Oblique Bundle- DOB. Stabilizer of DRUJ. • Accessory Band-AB • Central Band-CB • Dorsal Oblique Accessory Cord- DOAC • Proximal Oblique Cord- POC. May restrain excessive supination. • Significant individual anatomic variation. Central Band • Restrains radius from proximal migration (TFCC helps too) • Transfers force from the radius to the ulna • Largest and strongest portion Injuries • Frequently unrecognized • Typically occur with displaced radial head fractures with wrist pain. • Central band may be surgically repaired- R-U k-wire fixation to unload Matthias R. Interosseous membrane of the forearm. J wrist surg. 2016 Aug, 5(3):188-193 So Long as it is Competent the DRUJ Will Not Disassociate*Essex lopresti Load 40% 60% 80% 20% Sigmoid Notch • The articular function of pro/sup occurs between the head of the ulna and the sigmoid notch. • Notch is shallow (allows for translation) but the rims contribute significantly to stability. • Sigmoid notch: average size is 15mmx 10mm; volar and dorsal translation between 8-9 mm • In neutral about 60% of the available surface area is in contact with the ulna • At extremes of pronation and supination 2mm at the rims of the notch. The Ulna • Begins with a triangular shape and becomes cylindrical distally- rotatory shape like radius proximally • Articulated with the TFCC not the lunate or triquetrum Ulnar styloid • Extends the subcutaneous ridge 2-6 mm distal of the pole. • Provides additional attachment space for soft tissue. • Attachment surface for ECU tendon sheath. • Secondary attachment for radioulnar ligaments. • At the base of the styloid there is a shallow concavity called the fovea. • It is devoid of cartilage which creates access to the TFCC from the vascular foramina. • Also the attachment point for the radiocarpal and ulnocarpal ligaments The Distal Radius Lister’s / Dorsal Tubercle Sigmoid/ Ulnar Notch Radial Styloid • Lister’s tubercle acts as a pulley to the EPL. • Used as an anatomic landmark for arthroscopy/ 3rd dorsal compartment. • Has a double obliquity, it is concave in both sagittal and coronal planes • 12-15 degrees in the lateral view • 15- 20 degrees in the AP • Posterior lip and radial styloid have a buttressing effect • Lunate Fossa- LF • Scaphoid Fossa- SF • Interfossal Ridge-IR • Scapholunate Interosseous Ligament- SLI • Ulnolunate Ligament-UL • The radial fossa or scaphoid fossa is triangular with its apex directed radially. • The lunate fossa is quadrangular. • Separated by a sagittal oriented fibro cartilage ridge • Preservation of the sigmoid notch angle may affect rotation and impingement. • Normally the DRUJ is isolated from the radio carpal joint, but defects in the articular disc will allow direct communication. DRUJ Stabilizers • Pronator Quadratus • TFCC • ECU • IOM • Sigmoid notch • Capsule- Palmar more than dorsal *Mostly soft tissue The TFCC 1. Extend the smooth articular surface of the distal radius to cover the ulnar head. 2. Transmit axial force across the ulnocarpal joint with some load absorption. 3. Provide a strong and flexible connection between the radius and ulna allowing pronation and supination. 4. Support the ulnar portion of the carpus. • The TFCC bears 22% of the force load of the wrist. • Complexity and function results in frequent injury and degeneration. Dorsal and Palmar Radioulnar Ligaments • Primary stabilizers of • Originate from the volar the DRUJ. and dorsal portions of • Good vascular supply. the sigmoid notch and • Strong ligaments. converge on the ulna. • The deep limb into the fovea and the superficial into the ulnar styloid • As the ulna translates through rotation the RU ligaments both stabilize with a primary tension and drive the head of the ulna into the stabilizing rims of the sigmoid notch. • The DRUL restrains the ulna from dorsal displacement in supination • The PRUL restrains the ulna from volar displacement during pronation • Both insert in multiple locations and may play multiple roles. Articular Disk • Widest at ulnar edge of lunate fossa • Blends with the radioulnar Ligaments • Fibers are oriented to bear weight in the center of the disk Vascularity • Periphery (outer 15%) is well supplied and has good healing potential. • Central portion essentially avascular. Poor potential for healing. • Primary suppliers UA AIA. Innervations • Volar and ulnar portions from the ulnar n. • Dorsal From the PIN Load Transmission Some of this force is translated into a splaying effect that is partially constrained by the radioulnar ligaments • The disc goes through significant deformation throughout rotation. • The increase in force is concentrated on the radial portion especially during pronation. • Reason for location of many tears ECU tendon Sheath • Extends from the dorsal groove of the ulnar head and the dorsal radioulnar groove to the carpus. • Accurate prehension. ECU as a Stabilizer • In pronation the ECU elevates the ulnar carpus dorsally. • With the PQ is responsible for dynamic stability. TFCC Exam-Palpation • Tender Ulnar fovea • Tender just volar to ulnar styloid process • Resisted radial deviation often painful • Painful passive ulnar deviation especially when gripping • End range Pro/Sup painful • Often have a painful click with ROM • Decreased Grip Strength Ulnar Fovea Sign • The tester presses a thumb in the fovea between the ulnar styloid, the FCU tendon and the pisoform. Pain indicates disruption of ulnotriquitral and distal radioulnar ligaments vs. a L-T tear. Indicates instability of the DRUJ. Piano Key Test • Place both wrists in pronation. • Stabilize the wrist and compress the ulna with the index finger. • Compare to the contra lateral wrist. • “Positive” finding if the ulna return to its original position S Vezeridis, Peter & Yoshioka, Hiroshi & Han, Roger & • “Negative” Indicates Blazar, Philip. (2009). Ulnar-sided wrist pain. Part I: Anatomy and physical examination. Skeletal radiology. 39. pathology 733-45. GRIT Test • Grip strength assessed in neutral, pronation and supination. • Calculate ratio of pro vs. sup. Greater than 1.0 indicates ulnar impaction Supination/Pronation • 75/90= .83 neg • 90/75= 1.2 pos Supination Lift Test • Flex elbows to 90 degrees with forearms supinated. • Place palms under the table and ask them to lift. • Ulnar sided wrist pain indicates dorsal TFCC tear Sharpey’s Test/TFCC Load Test • Tester stabilized forearm with one hand. • Grasp the patient’s hand and axially load the wrist . • Ulnarly deviate the wrist while maintaining axial load. • Then shift the wrist volarly and dorsally (may also rotate). • Positive pain and crepitus indicate TFCC pathology. Ulnomeniscotriquitral Dorsal Glide • Place arm in pronation. • Examiner places a thumb over the dorsal ulna and the PIP of their index finger over the pisotriquetral joint. • Posterior force is applied to the pisotriquetral complex. Laxity or pain indicates TFCC pathology. Specificity 64% Sensitivity 66% LaStayo P, Howell J:Clinical proactive tests used in evaluating wrist pain : a descriptive study. J of Hand Surgery 9:222-226, 1984 Wrist Stability Exercises • Isometric magazine • Isometric bar • Isometric band • Rhythmic stabilization, with water bottle • Short arc wrist rom with grip • Towel isometrics The Carpus Scaphoid • Vulnerable blood supply • Especially the proximal pole • Also called the Navicular • 2nd largest carpal • Has a proximal and distal pole • Dorsal ridge provides capsular attachment at the waist and assists in nutrition Carpals-Scaphoid • Place wrist in ulnar deviation • Palpate the radial styloid with your index. • Distal is the dorsal scaphoid • Palpate distal of the mid volar radius with your thumb to feel the tuberosity. • Radially deviate to feel its flexion The Lunate • Dorsal and Palmer pole • Flat medial and lateral to articulate with the scaphoid and triquetrum • Concave distal surface articulates with the capitate and sometimes the hamate • Proximal surface in convex and articulates with the radius • Vulnerable blood supply Lunate • Flex wrist. • Locate lister’s tubrical. • Palpate prominence. • Extend wrist and it is no longer palpable. • Palpate radially to appreciate the S-L interval. The Triquetral • Triquetrum, Cuneform, Pyramidal bone • Many ligamentus attachments • Flat surface articulates with the lunate • Concave volar surface articulates with the pisoform • Articulation with the hamate is an irregular “helicoid” shape (spiral Triquetrum • Palpate the ulnar styloid. • Radially deviate wrist. • Palpate distal of the fovea. • Palpate the dorsal portion and move radially to appreciate the L-T interval. Pisoform • Sesimoid within the FCU. • Prone to traumatic arthritis. Pisoform • Base of hypothenar eminence. • Laterally and medially mobilize with wrist flexion. Trapezium • Concave as it articulates with the scaphoid • Saddle configuration to articulate with the 1st metacarpal • Attachment point for all Carpometacarpal ligaments
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