1. Therapy for Challenging Wrist Conditions
Marianne Williams B.Sc.P.T., CHT

2. Objectives:
To discuss the therapy interventions for some wrist instability patterns

3. ANATOMY Intrinsic wrist ligaments Extrinsic wrist ligaments Volar
Dorsal
Extrinsic wrist ligaments

4. Intrinsic Wrist Ligaments-Volar

5. Intrinsic Wrist Ligaments-Dorsal

6. Extrinsic Wrist Ligaments-Volar
Capito-triquetral lig
Radio-scapho--capitate lig

7. Extrinsic Wrist Ligaments-Dorsal
Radio-triquetral lig

8. Classification Carpal Instability Dissociative (CID)
A dissociation within the interosseous ligaments
Carpal Instability Non-dissociative (CIND)
Instability of a carpal row as a whole
Carpal Instability Complex (CIC)
A combination of the 2 dissociations
Carpal Injury Adaptive (CIA)
Secondary changes in the carpus which results from a non-union or malunion of the distal radius or carpal bones

9. CID - Pathomechanics The proximal carpal row is the most common site
The scapho-lunate ligament disruption and subsequent scaphoid rotatory subluxation is the most common ligament injury pattern of the wrist
The clinical picture may range from complete dislocation to a subtle form of dynamic instability
The carpal mal-alignment results in increased stresses on the radio-scaphoid and capito-lunate joints

10. Clinical Evaluation ROM Grip Strength
Palpation over the Scapho-lunate(SL) ligament
Special tests :Watson’s test, SL Ballottement test
X-ray

11. Therapy Considerations
Kinematics:
As the wrist extends, there is a tendency for the scaphoid to supinate and the lunate to pronate, which effectively separates the palmar surfaces of the 2 bones.
The reverse occurs in palmar flexion
Berger 1996

12. Therapy Considerations (cont’d)
Kinetics:
The radial side of the wrist is responsible for the major load transfers across the wrist. In wrist neutral and neutral forearm rotation, 80% of the force is transmitted across the radiocarpal joint and 20% across the ulnocarpal joint with gripping.
Berger 1996

13. CID-Therapy Intervention
Comfortable AROM
No PROM into end range
No repetitive gripping
Isometric vs isotonic strengthening

14. Post-Operative Therapy
When ligaments are repaired, the patient may be immobilized for up to 8 weeks
Length of immobilization after a partial fusion is dependent upon radiographic healing
Initially AROM is started then PROM for extension sooner than flexion. PROM is for physiological range not accessory motion.
Therapy goals need to parallel the surgeon’s goals

15. Post-Operative Therapy (cont’d)
Functional wrist ROM is 40/40 for flexion and extension.
Wright et al, 1996
Principles of strengthening are based on the kinetics. Initially start with isometrics and retraining the wrist extensors. Gradually progress to concentric strengthening. Grip strengthening is introduced judiciously.

16. Luno-triquetral Instability
Less common than the SL ligament dissociation
Alter the special tests in your clinical examination to this region
Similar approach by Surgeon and Therapist for both conservative and post-operative interventions as in SL dissociation

17. CIND: Clinical Characteristics
Volar sag on the ulnar side of the wrist
Painful clunk which occurs at the end range of ulnar deviation
Tenderness over the triquetral-hamate and capito-lunate intervals
Weakness of grip

18. Pathoanatomy
Ligamentous laxity or disruption results in the following:
Volar flexed orientation of the proximal carpal row in neutral deviation
Palmar translation of the distal carpal row
Ligaments involved:
Ulnar arm of the volar arcuate ligament
Dorsal radio-triquetral ligament

19. Pathomechanics Loss of intimate midcarpal joint contact
Loss of the smooth transition of the proximal carpal row from a flexed to extended position as the wrist moves from radial to ulnar deviation
As the wrist moves from radial to ulnar deviation, the proximal carpal row stays flexed and the distal carpal row remains palmarly subluxed until the end range of ulnar deviation

20. Pathomechanics (cont’d)
A painful “clunk” occurs at the end range of ulnar deviation which represents abrupt snapping of the proximal carpal row into extension and reduction of the palmar translation of the distal carpal row.
Wright et al ,1984

22. Clinical Evaluation
Palpation over the triquetral-hamate and the capito-lunate intervals
Midcarpal shift test (Lichtman)
Passive translation of the midcarpal joint while stabilizing the distal forearm and applying a palmar or dorsal directed force to the carpus

23. CIND-Conservative Management
This is attempted initially
Immobilize – cast for 6 weeks
Then wrist cock-up splint and initiation of AROM
PROM OFTEN NOT NECCESSARY

24. Midcarpal Stabilization Splint
Dorsally directed pressure on the pisiform reduces the ulnar sag and corrects the volar flexed position of the proximal carpal row
Midcarpal dynamics are corrected and wrist clunk is eliminated

25. Midcarpal Stabilization Splint
Splint allows nearly full extension, radial and ulnar deviation and limits flexion

26. Midcarpal Stabilization Splint Pattern

27. Exercise Approach
Midcarpal joint pathomechanics might also be corrected by dynamic muscle action
Dynamic muscle compression achieved by activation of the flexor carpi ulnaris (FCU) and the hypothenar muscles reproduces the normal joint contact forces in the absence of adequate ligament support

28. Abd DM
FCU
ECU

29. Abd DM
ECU
FCU

30. Exercise Approach (cont’d)
Strengthening of both FCU and ECU, would seem to be important in counteracting the volar sag that occurs prior to moving into ulnar deviation
Position of the forearm – supination
Isometric vs Isotonic exercises

31. Case Presentation
22 year old right-handed cashier with idiopathic right dorsal wrist pain
Diagnosis: Midcarpal Instability
Right wrist was immobilized in a cast x6/52
April 22, 2003 Right wrist cock-up splint fabricated and patient initiated AROM exercises
Sept 17,2003 midcarpal stabilization splint made for the right wrist

33. PRWE Results Sept. 17,2003 Pain: 37/50 Function: 29.5/50
Total: 66.5/100
Right midcarpal stabilization splint made
Nov. 4, Pain: 22/ Function: 11.5/50
Total: 33.5/100

34. Surgical Intervention
At our centre the approach is dorsal
The Hand Therapist should be cognizant that if a procedure is designed to stabilize tissue and the prolonged post-operative immobilization is to limit motion, then therapy principles should parallel these goals.

35. CIC-Perilunate Dislocation
Surgery is the most successful form of medical management
Post-operative therapy is similar to that of SL or LT repair
However, ligament repairs are more extensive and more dissection required
Therefore, long extensor adhesions are more common
Significant wrist motion is lost post-operatively

36. CIA-Carpal Injury Adaptive
Secondary changes in the carpus have developed from a non-union or malunion of the distla radius or carpal bone
The pattern is treated by correcting the deformity eg Distal radius corrective osteotomy
This post-operative therapy focuses on early AROM

37. Conclusion
“A good axiom to keep in mind is that a painless, stable wrist with functional ROM is superior to one with full ROM that is unstable and painful”
Hendrycks et al, 2001