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 Trapezium

• Palpate the dorsal scaphoid. • Deviate the wrist to reveal ST joint. • Distal is the trapezium. Trapezoid

• Smallest bone in the distal row • Notch like structure were it articulates with the capitate where the deep trapezoid carpal ligament is located Trapazoid

• Palpate the capitate. • Move radially until you feel the 2nd mc base. • Move proximally. • Flex and ulnarly deviate to confirm. Capitate

• Largest carpal. • Divided into head, neck and body. • The body is covered entirely with ligamentous insertions. Capitate

• Palpate the base of the 3rd MC for a depression. • Flex wrist and the depression disappears as the capitate moves from under the lunate Hamate

• Divided into proximal pole, hook and body regions. • Proximal pole is covered in articular cartilage • The hook is covered in ligamentus attachments including the flexor retinaculum. Hammate

• Palpate the base of the 4th and 5th MC for the dorsum. • Hook of the hamate is 2 cm distal and radial of the pisoform. The Dynamic Wrist “The Carpal Condyle”

• Smaller diameter of curvature • Less osseous stability medially and volarly create a dependence on ligamentus stabilizers and the joint capsule. • The carpus is more stable in flexion than extension. • Each of the 8 carpals have their own degree of movement in flex/ext and thus are not a single stable unit. • Distal row is more rigid while the proximal has greater individual movement. • The distance between the distal radius and the metacarpals is constant • The carpals shift to maintain the balance. Why Are There So Many Ligaments Going in So Many Directions? Ligaments

• They are named for the bones they attach to. • Proximal to distal • Radial to ulnar • Significant source of information for proprioception via abundant mechanoreceptors. Ligaments of the Wrist

• Function to stabilize the carpals • Those that stabilize the scaphoid, lunate and Triquetrum are most important. Extrinsic Ligaments/Capsular

• Attach the carpus to the forearm • Course toward the midline • Capsular • Articular surface is covered in synovial lamina • Superficial surface consists of Fibrous lamina The extrinsic /capsular ligaments orient to midline providing a balance of stability and mobility. 3 categories

• Palmar radio carpal • Palmar ulno carpal • Dorsal radio carpal • There are no dorsal ulno carpal Palmar Radio Carpal

1. Radioscaphoid 2. Radioscaphoid- capitate**acts as a 5 seatbelt for the scaphoid 2 1 3. Long radiolunate 3 4. Short radiolunate 4 5. Space of Poirier-weak point that is vulnerable to perilunate dislocation R-L short and Long

• Frequently injured • Pronated FOOSH with wrist extension, ulnar deviation and intercarpal supination • Also called ligament of Testut and Kuenz • Important neurovascular support to scaphoid and lunate • Provides radiolunate stability to aid scaphoid mobility Palmar Ulnocarpal Ligaments

1. Ulnocapitate 2. Ulnotriquertum 3. Ulnolunate

1 2 3

Dorsal Radiocarpal Ligament/ DRL

RT, RL, RS components Intrinsic Ligaments/ Articular

• Carpal to carpal attachments. • Course transversely. • Function to attach carpals within a row or one row to another. Schapholunate Interosseous Ligaments (Volar Surface) • Obliquely oriented fibers • Allows significant sagittal rotation relative to the lunate • Less of a stabilizer • Yield str. 118N Dorsal

• Thick slightly oblique fibers • Purpose is stability • Yield Str. 260N Lunotriqutral Interosseous Ligaments- Volar • Stronger • When intact prevents communication between radiocarpal and midcarpal joint spaces Dorsal

• More Mobile • Overall more taut throughout ranges compared to S-L Midcarpal Ligaments

• Link the first and second rows. Dorsal Midpalmar

• Originates on the triquetrum and inserts on the scaphoid, trapezium and trapezoid. • Stabilizes L-C joint Palmar

1. Triquetrum-Hamate- Capitate complex 2. Scaphoid capitate

1 2 ligament • Dorsolateral STT • It and the scaphocapitate maintain normal scaphoid alignment Distal Carpal Row Interosseous Ligaments 1. Protect the contents of the carpal tunnel 2. Taut and have dorsal, deep and volar components 3. CH, TC, TT What Don’t We Have?

• No ligaments between the lunate and the capitate. • No true collateral ligaments Comparable durability

• Interosseous ligaments are very strong requiring up to 300N to fail • Capsular ligaments are weaker at 100N • The radioscapholunate ligament will fail at less than 50N and is best considered a neurovascular pedicle. The Extensors Extensor Retinaculum

• Attaches to the lateral margin of the radius and extends obliquely to the pisiform and triquetrum. • Acts as a pulley for the extensors. • Radial styloid • Lister’s tubrical 1st Dorsal Compartment

APL originates on the distal 1/3 of the radius and insert on the dorsum of the 1st MC base EPB

• Originates on the medial border of the radius. • Inserts at the base of the 1st phalanx of the thumb • Palpable with thumb abduction 2nd Dorsal Compartment

• ECRL distal 1/3 of the supercondular ridge to the base of the 2nd MC • ECRB Lateral epicondyle to the base of the 3rd MC • Palpate insertion during fisting 3rd Dorsal Compartment

• EPL originates from the posterior lateral ulna and inserts on the proximal phalanx of the thumb (1st compartment). Redirected at a 45 degree angle at Lister's tubrical. 4th Dorsal Compartment

• EIP distal 1/3 of the ulna to EDC of index. • Deep and medial of EDC IF • EDC from the common extensor tendon to the digital extensor mechanism. 5th dorsal Compartment

• Common extensor tendon to proximal phalanx of v. • Runs radial of the EDC 6th dorsal Compartment

• ECU from the common extensor tendon to the dorsoulnar portion of the 5th MC. The anatomic snuff box

• Hollow created by bowstringing of the 1st and 3rd compartments. • The scaphoid is palpable within it • Lister’s or the dorsal tubrical of the radius. • Radial styloid Flexor Pollicus Longus

• Arises from the anterior groove of the radius and extends to the IP of the thumb. • It passes through and it redirected in the carpal tunnel by the trapezium. • It runs between the ABPB and the FPB Flexor Carpi Radialis

• Medial epicondyle to the base of the 2nd MC • Also some fibers to 3rd MC and trapezium. Palmaris Longus

• Originates on the medial epicondyle , passes over the extensor retinaculum and into the palmar aponeurosis. • Some fibers insert into the retinaculum. • Palpate by touching thumb to SF with a flexed wrist Flexor Digitorum Superficialis

• 2 heads-humeroulnar and radial. • Median nerve goes between • Bifurcates and inserts on P II • Palpate medial of PL with digital flex Flexor Carpi Ulnaris

• Originates with 2 heads from the medial epicondyle and the olecranon. • Inserts into the pisoform then becomes part of the pisohamate and pisometacapal ligaments. Flexor Retinaculum/Transverse Carpal Ligament • Attaches radially to the superficial tubricals of the scaphoid an trapezium. • Ulnarly to the hook of the hamate and pisoform. • FCR passes between layers. • Tubrical of the Scaphoid • Crest of the trapezium • Hook of the Hamate • Pisoform Bony Landmarks of the Radial Wrist

• Scaphoid palpable in the anatomic snuff box. • Palpate distally to locate the joint between scaphoid and trapezium. • Thumb add/abd aids in palpation. • 6-7 mm more distal is the joint between the trapezium and the 1st metacarpal. DRUJ

• Palpable by grasping the Distal radius and the distal ulna and gliding in opposing directions. Radio Carpal Ligament

• Place the wrist in radial deviation and the radio carpal ligament is palpable. Carpal Kinematics

The first row is a dynamic unit not a stable articular surface for the radius.

Movement must be addressed in multiple axes. Longitudinal Columns The Radial Column

• Radius>Scaphoid> Trapezium> Trapezoid >Thumb. • “Column of The Thumb” The Middle Column

• The “Flexion Extension Column.” • Articulates with the radial column mediated by the S-L ligament. • A small amount of the lunate is in contact with on the triangular ligament. Ulnar Column

• Hamate and Triquetrum • “Column of Rotation” • The distal row may also be considered a single functional unit during flexion and extension of the wrist. • Scaphoid and lunate move as part of the lateral and medial columns. Normal

• The lunate and the capitate are intercalary bones between the radius and 3rd metacarpal. • The distance of C1 remains constant throughout ROM. Lateral Movements Radial Deviation

• Ulnar displacement of the proximal row. • The scaphoid is compressed between the trapezium and the radius. • The triquetrum prevents the lunate from shifting ulnarly. • The capitate is pulled distally making room for the lunate. • Overall the proximal row does a pronation/flexion movement and the distal row a supination/extension movement. Ulnar Deviation

• Trapezium moves distally restricted by the radial collateral ligament. • Scaphoid moves into a vertical position. • Triquitrum moves against the ulnar head and the TFCC. • The capitate compresses the lunate which tilts volarly. • Overall the proximal row does a supination/extension movement and the distal row moves into pronation and flexion • These accessory motions cancel each other out-Neat! Flexion

• Dorsal ligaments are stretched. • Triquetrum moves toward the hamate. • Significant midcarpal flexion occurs. Extension

• Palmar ligament, RLT and RC stretch. • The RC causes scaphoid and capitate extension • The SL ligament. Brings the lunate into extension. • Lunate and the capitate keep extending as a unit for 30 degrees after scaphoid stops. Carpal Instability

• Carpal instability, • Intrinsic ligament injury. dissociative. CID • Carpal instability, non- • Extrinsic ligament dissociative. CIND incompetence. • Carpal Instability , • Both! i.e.. perilunate Combined. CIC dislocation. • Carpal instability, • Misalignment proximal adaptive. CIA or distal to the wrist. Consistency

• Pre dynamic- stable with movement • Dynamic Instabilities-unstable with movement • Static instabilities-unstable at rest Direct

• Crush • Torsion Indirect

• Extreme wrist extension. • Ulnar deviation. • Midcarpal supination. • Typical but can be caused by a variety of impacts. Extrinsic Ligament Injuries

• Difficult to diagnose • Think wrist pain! Conservative Intervention For Instability • Non operative treatment may involve up to 8 weeks in a cast. • Thumb spica orthosis 2-4 weeks. • Digital ROM • Tendon gliding • Edema management • Shoulder ROM • Progress to pain free wrist ROM. VISI DISI What’s it all About? Carpal Instability, dissociative CID • The intrinsic S-L and L-T ligaments ensure that the proximal row moves as a unit. DISI-Dorsal Intercalated Segment Instability • Results after S-L injury and is most common. • Normally from ulnar deviation into radial the scaphoid rotates into palmar flexion. • With S-L disruption the scaphoid assumes a flexed position. • *Lunate assumes an extended position* S-L Tears

• Hyperextension • STT scaphocapitate ligaments tighten. • Scaphoid forced into extension. • Lunate secured by the radiolunate ligaments. • And “POP!” • With radial deviation scaphoid may fracture instead. • And then there was a gap! Watson’s Scaphoid Shift Test

• Subjects elbow rests on the table and the forearm is pronated. • Tester moves the subjects wrist into ulnar deviation and slight extension while supporting the metacarpals. • Tester then compresses the distal pole of the Scaphoid on the palmar side-this prevents palmar movement of the Scaphoid. • The wrist is then moved into radial deviation and slight flexion. Watson Shift Test • If unstable the scaphoid will sublux over the dorsal rim of the radius. • Sometimes just the thumb pressure will cause subluxation and a painful clunk when pressure is removed and it returns to place. • Specificity 66% • Sensitivity 69%

• LaStayo P, Howell J:Clinical proactive tests used in evaluating wrist pain : a descriptive study. J of Hand Surgery 9:222-226, 1984 VISI- Volar Intercalated Segment instability • Occurs with L-T tear • Lunate assumes a flexed position. • Long standing injuries will show radiographic evidence of degenerative changes Normal- It’s a Tug of War

Anterior/ palmar

Scaphoid Lunate Triquetrum DISI- S-L Angle greater than 60

Scaphoid Lunate Triquetrum VISI- S-L Angle < 60

Scaphoid Lunate Triquetrum

What if you had a scaphoid fx? Dorsal Perilunate Dislocation

• Uncommon • Severe • High energy OUCH!

Scapholunate Jt.

Lunocapitate

Lunotriquetral Jt.

Complete lunate dislocation SLAC Wrist Scapho-Lunate Advanced Collapse • Progressive instability caused by arthritis following a DISI deformity. • Radial styloidectomy • PIN, AIN denervation • PRC • Four corner fusion • Wrist fusion

Dart Throwers Motion

• 40 degrees of extension and 20 degrees of radial deviation to 0 degrees of flexion and 20 degrees of ulnar deviation requires minimal S-L stress and motion. • Earlier, safer more stable motion. Shuck Test

• Stabilize the lunate. • Perform radial and ulnar deviation. • L-T pain indicates L-T instability. Lunotriquetral Ballottement (Reagan’s Test) • Grasp triquetrum between thumb and index of one hand. • Grasp the lunate with the other. • Move the lunate up and down. • Laxity or crepitus indicates a tear of the L-T interosseous ligament. • Specificity 44% Sensitivity 64% Lunotriquetral Shear Test

• Grasp the wrist so that the testers thumb rests in the patients and fingers support the dorsal lunate. • Load the pisotriquetral joint with the contra lateral thumb. • Minimal support in literature. Pain, crepitus or abnormal movement indicate lunotriqutral instability.

LaStayo P, Howell J:Clinical proactive tests used in evaluating wrist pain : a descriptive study. J of Hand Surgery 9:222-226, 1984 Carpal Salvage Procedures S-L Repair

• Sometimes Augmented by dorsal capsular flap-Blatt. • Scaphoid is held extended with K-wires. • 2 weeks Long Arm Cast, 6 weeks SAC. • Orthosis 4 more weeks to wean. • Alternative treatment 4 weeks in a spica, 4weeks SAC. • Goal is to limit scaphoid rotation.

• Blatt G:Dorsal capsulodesis for rotary subluxation of the carpal schaphoid. New orleans 1986 • Klienman WB: amnagment of chronic rotary subluxation od the schaphoid by schaphotrapezialtrapazoid arthrodesis. J Hand Surg 7:125-136,1985.

• Control edema and pain • Maintain ROM of uninvolved joints. • Increase ROM as healing allows. • PRESERVE WRIST STABILITY. • Initial exercises include. – EDC glide – Dart throwers motion – Scar massage – STM/MEM – Fluido – Cold corn AROM • Avoid loading activities. • Avoid aggressive stretching. • Avoid heavy gripping and pushing. Strengthening? • What is weak? • Intrinsic function. • Extrinsic function. • Healing tissues tolerance to force. • Start isometric and progress to isotonic. Stress Over Strength?

• Stress loading • On a ball • Table brushing • UBE • Elliptical • Sled • Putty Stress Activities

• Stress loading • Distraction • Gripping*** • Lifting/carrying • Putty-mixed movement Putty

• Prefer combined action tasks. -Roll, pinch, snail pancake. • Sustainer grip with varied size dowels. • Object hunt • Lid turning • Scrapes • Pulls Techniques for the High Activity Demand Individual • BTE • Rebounder • Box lifts a carries • Dips • Cable column-Punches and bow pulls • Theraband stretches Exercise Based Intervention

• Focus on proprioceptive reeducation. • Wrist mechanoreceptors. • Ligamento-muscular loading. • Dart throwers motion. • Isometrics Timeline Considerations

• Age • Length of immobilization • Tobacco • Activity level • Secondary medical conditions • Compliance • Procedure knowledge or lack of it Therapists’ Management of Carpal Fusion Procedures • For a limited fusion up to 12 weeks of immobility. • 8-12 for a repair. • May be shorter with compression screws. • Great variability between surgeons and ligament injury degree. STT Fusion

• Ideal for Kienbock’s. • 6 weeks LSC. • Up to a year to reach maximal strength and tolerance. Partial Wrist Fusions

• CLHT • “Four corner fusion” • Indicated for pain and instability. • Spider plate • Flower plate • Compression screws • Typically immobilized 12 weeks. • Begin A/PROM to unaffected joints early. • Do not push through pain. • Gentle PROM 2-4 weeks after cast is removed. • Graded strengthening after. Carpal Stress and Resistance

• Pay attention to the biomechanics! • Think in terms of stress instead of strength. • Intrinsic vs extrinsic strength- Where is the issue? • Consider the tolerance of the soft tissue vs. the lack of muscular strength. • Do as the tissue indicates. • Initiate isometrics in the plane least stressful to the repair or neutral. • As tolerance increased theraband bar isometrics are a good stepping stone to dynamic Str. • Be reserved with gross gripping Proximal Row Carpectomy

• Early AROM to unaffected digits. • AROM initiated at 4 weeks, orthosis between sessions. • PROM at 6 weeks. • Strengthening at 8 weeks. • NO PAIN! Complete Wrist Fusion

• Indicated for pain due to RA, crush injuries or severe SLAC wrist. • Early A/P ROM to unaffected joints. • Focused EIP, EPL, EDC gliding to prevent adherence. • SA Orthosis with weaning starting at 6 and by 12 weeks. • Generally tolerate strengthening well, starting at the 8 week mark for elbow and shoulder. • Hold off on torsion activities until 10-12 weeks. • Significant scar management considerations due to dorsal incision. Manual Techniques

They’ve been around awhile Joint Stiffness Happens So How Do We Address It? • Pain and edema are part of the normal post immobilization or traumatic inflammatory response. The Disorganization of Fibroplasia- Sometimes It Just Needs to Be Immobilized, Sometimes People Do Not Move

-With immobilization joint changes occur -Disorganization of fibrous and cellular components. -Adhesions between capsular folds -Development of fibro-fatty tissue inside the jt. -Rate of collagen synthesis and degradation speeds up. “Motion is Lotion”-and Organization

• Fibers synthesized during fibroplasia are organized and replaced based on tensile load. • Are we stretching collagen? • “Hand therapy is the behavioral modification of fibroblasts”-Weber D (1978) Why We Use Manual Techniques- Effects • Biomechanical • Neurophysiological • Psychophysiological Plan of Attack Purpose/ Intent

Direction of movement

Position in the range where technique will be performed

Manner of application

Position of the patient, therapist, manual contacts Smart Hands and Good judgment

• Proper assessment of the tissues is vital. • What is restricting movement? – Ankylosed – Unstable • What is the quality of the tissue? • What is the first priority for intervention? • Never mobilize from a closed pack position. Body Mechanics

• Patient and therapist must be relaxed • Hand/ finger pressure should be distributed over as large an area as possible • Skin lock • Distal parts should not dangle • Use your core • Cleanest direction of pressure possible Force

• One bone of the joint is stabilized • Only one joint at a time • Motions are controlled • Either perpendicular or parallel to the joint line Grades of Movement-Maitland

• Grade I-Small amplitude at the beginning of the available range. • Grade II- Large amplitude movement performed in the resistance –free part of the range. • Grade III- Large amplitude movement performed into resistance or up to the limit of the available range. • Grade IV- Small amplitude movement performed into resistance or up to the limit of available range. • Grade V-Small Amplitude, High velocity thrust performed usually at end range. Roll vs. Glide

• A new point on one surface will always be in contact with a new point on the other surface. • One point of one surface will be in contact with a new point on the other surface. They may Be Combined to Influence Desired Tissue Distraction vs. Glide

• Perpendicular vs. Parallel Convex vs. Concave

Concave joint moves in the same direction Convex moves the opposite direction as the motion you hope to improve as the motion you hope to improve Mobilization

Passive Active • Sustained-Traction • Self mobilization • Articulation-rhythmic repeated passive joint movements. – Distraction – Glide • Manipulation-high velocity, short amplitude thrust at end range. Grades of Movement-Maitland

• Grade I-Small amplitude at the beginning of the available range. • Grade II- Large amplitude movement performed in the resistance –free part of the range. • Grade III- Large amplitude movement performed into resistance or up to the limit of the available range. • Grade IV- Small amplitude movement performed into resistance or up to the limit of available range. • Grade V-Small Amplitude, High velocity thrust performed usually at end range. Pain

• Pain is limiting motion. • May be accompanied by other factors: inflammation, peripheral sensitization. • Fear and anxiety They Have Been Told You Are Cruel and Want to Hurt Them! * *****Pain is not part of the process First Make Them Feel Better

• Position. • Supportive physical contact. • Gauge how much information they want. • Low amplitude movements, slow rhythmic. • Increase amplitude as pain decreases. • Assess response as you go. • Build patient confidence that they will move more with less pain with your help. Mobilization With Movement-Mulligan

• Sustained accessory glide with normally painful movement completed actively or passively. • Positional fault. • Possibly hypoalgesic. • Sympathoexitation Mobilization With Movement

Normal joint

Injury

Disrupted Proprioception

Positional fault

Pain stiffness weakness Treatment

Pain free accessory motion

Assess comparable signs-loss of jt. movement, pain with movement

Complete accessory glide

Perform comparable sign while sustaining glide I Immediate improvement..or not Is this the Correct Technique? •P- Pain free. •I- Instant result. •LL- Long Lasting. Distraction

• Improve mobility • Grasp radius and ulna to stabilize • Grasp proximal row and distract perpendicular to the joint plane • Cross index squeeze technique Volar Glide of the Radiocarpal Jt.

• Improve extension • Grasp radius and ulna from the dorsal side. • Grasp carpus glide first carpal row volarly. Dorsal Glide of the Radiocarpal Jt.

• Improve flexion. • Place in comfortable rotation. • Grasp radius and ulna to stabilize. • Grasp carpus and glide dorsally. Ulnar Glide

• Improve radial deviation • In neutral rotation grasp RU and the carpus. • Glide ulnarly. Volar Glide of Capitate on the Lunate

• Improve wrist extension and radial deviation. Dorsal Glide of the capitate on the Lunate • Improve wrist flexion • 3 ulnar fingers of each hand support the thenar and hypothenar eminences. • Index fingers are placed on the volar lunate. • Thumbs are placed on the capitate. • Glide the capitate volarly*. Volar/ Dorsal Glide of the Triquetrum on the Ulna • Improve pronation and supination • Position in pronation • Stabilize ulna between index finger and thumb. • Grasp triquetrum between index and thumb. • Glide dorsally and volarly. Volar/Dorsal Glide of the Hamate on the Triquetrum • Volar glide to increase wrist extension and ulnar deviation. • Dorsal glide to increase wrist flexion and ulnar deviation. • One index and thumb stabilize hamate the other the triquetrum. • Glide dorsally and volarly. Midcarpal Mobilization

• Stabilize the ulnar carpus • Position the wrist in neutral pronation • Grasp the STT • Mobilize obliquely • The capitate follows the stt and the hamate the capitate Questions? Comments?