NOW PLAYING THE WRIST. David Costa, OTR/L October 20, 2007

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1 NOW PLAYING THE WRIST David Costa, OTR/L October 20, 2007

2 Starring Radius Ulna Scaphoid Lunate Triquetrum Trapezium Trapezoid Capitate Hamate Pisiform TFCC Transverse Carpal Ligament Scapholunate Ligament Lunotriquetral Ligament Median Nerve Flexor Carpi Unlaris Flexor Carpi Radialis Palmaris Longus Flexor Digitorum Superficialis Flexor Digitorum Profundus Lumbrical Extensor Carpi Ulnaris Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Digitorum Communis Abductor Pollicis Longus Extensor Pollicis Brevis Flexor Pollicis Brevis Extensor Digiti Minimi Extensor Indicis

3 Starring Radius Ulna Scaphoid Lunate Triquetrum Trapezium Trapezoid Capitate Hamate Pisiform TFCC Scapholunate Ligament Lunotriquetral Ligament Median Nerve Transverse Carpal Ligament Flexor Carpi Unlaris Flexor Carpi Radialis Palmaris Longus Flexor Digitorum Superficialis Flexor Digitorum Profundus Lumbrical Extensor Carpi Ulnaris Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Digitorum Communis Abductor Pollicis Longus Extensor Pollicis Brevis Flexor Pollicis Brevis Extensor Digiti Minimi Extensor Indicis

4 With Special Guest Wrist Pain- playing the roles of Wrist Strain Wrist Sprain Fracture

5 With Special Guest Wrist Pain- playing the roles of Wrist Strain Wrist Sprain Fracture

6 Objectives Identify anatomical structures associate with the most common wrist injuries Understand the basic biomechanics and arthrokinematics of the wrist Palpate obvious tendons and bony prominences Become familiar with special tests used for assessment Identify differences between tendinous and ligamentous injuries Identify treatment techniques for common wrist injuries

7 The Basics Anatomy

8 The Wrist Joints Radiocarpal Ulna-Meniscal-Triquetral Midcarpal Intracarpal Intermetacarpal Distal Radio-ulnar

9 Carpals

10 Ligaments

11 Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Carpi Ulnaris Extrinsic Digit/Thumb Extensors

12 Flexor Carpi Ulnaris Flexor Carpi Radialis Palmaris Longus Extrinsic Digit/Thumb Flexors

13 Wrist ROM Flexion- 70 degrees Extension- 60 degrees Ulnar deviation- 30 degrees Radial deviation- 20 degrees Pronation- 80 degrees Supination- 70 degrees

14 Palpation Ulnar head/styloid Radial styloid Lister s tubercle Lunate Scaphoid Pisiform Hook of Hamate Distal Radio-ulnar joint Abductor pollicis longus/extensor pollicis brevis Extensor pollicis longus Flexor pollicis longus

15 Wrist Biomechanics Wrist Extension: movement largely occuring at the midcarpal joint Wrist Flexion: movement largely occuring at the radiocarpal joint

16 Carpal Kinematics Wrist Flexion Proximal row glides dorsally, distal row glides volarly, radius moves caudally on the ulna Wrist Extension Proximal row glides volarly, distal row glides dorsally, radius moves cephalically on ulna Radial Deviation Proximal row flexes, glides dorsally and translates ulnarly Lunate pronates Ulnar Deviation Proximal row extends, rides volarly, and translates radially Lunate supinates

17 Radio-ulnar Kinematics Pronation Ulna displaces dorsally on radius Ulna Moves distally on radius Supination Ulna displaces volarly on radius Ulna moves proximally on radius

18 Nerve compressions at wrist Median nerve at carpal tunnel Ulnar nerve at Guyon s Canal Bordered radially by hook of hamate Bordered ulnarly by pisiform Numbness in ulnar half of 4 th digit and all of 5 th May see clawing due to intrinsic weakness

19 Featurette CARPAL TUNNEL SYDNROME

20 Carpal Tunnel Syndrome

21 CTS Evaluation Symptoms Numbness (where), Pain, Weakness How often Time of day Activity exacerbation How long experienced

22 CTS Evaluation (cont) PMH-medications, diabetes Diagnostic tests Grip/pinch strength Semmes-Weinstein & other sensory testing Tinel s and Phalen s Occupational/Avocational activities Visual assessment Atrophy Quality of movement/motor function

23 CTS Conservative Treatment Splinting Ergonomic considerations Posture Microbreaks/stretching Tool use and design Median nerve glides Hands on treatment (?) Avoid forceful gripping Avoid tight fist Avoid sustained wrist flexion

24 Lumbricals

25 CTS Post-surgical Weeks 1-4 Wound/Scar management Edema management Median nerve and tendon glides AROM wrist Gradual return to ADL s Weeks 4+ Scar management Strengthening Gradual return to lifting and heavy work

26 Median Nerve Glides With your left hand in front of you, palm down, start with a gentle fist, wrist bent down. Open and splay your fingers. Extend your wrist. Simultaneously turn your palm upward. Try to turn your wrist as far counterclockwise as you can. With your other hand, reach under your hand and grab the base of your thumb. Gently pull downward, trying to extend the rotation a little. Make sure to pull from the base of the thumb, not the joints. Repeat 7 times. Repeat with the other hand.

27 And Now Your Feature Presentation THE WRIST DX: PAIN

28 History History, History, History your patient will tell you what is wrong with them Sudden onset/trauma vs Chronic Vocational/avocational activities Previous injuries

29 Activity

30 Acute Edema Color Changes Usually specific episode of injury Special tests can be difficult Chronic Likely no edema or color changes Specific activity likely contributing to symptoms Pain can be widespread or local (treat to localize pain) Special tests more accurate

31 Acute Chronic

32 Observation Just look Compare right vs left Volar and dorsal Creases Bony Prominences

33 Look for the obvious

34 I m going to get arthritis So what do we always hear broken bone or other injuries. I m going to have arthritis now huh? Patients feel any injury will lead to an arthritic condition With wrist injuries absolutely true if mismanaged. Prolonged injury not found, patient continuing to be active and sucking up pain. Performing aggressive therapy through specific wrist pain. Always respect specific wrist pain!

35 Static Assessment Compare right to left Bony prominences Creases Edema Atrophy

36 Kinematic Assessment ROM Movement patterns Clicking/clunking Pain Compensatory movement Special Tests

37 Special Tests Finkelstein s TFCC load test CMC grind Luno-triquetral shear Scaphoid shift Piano-key test ECU subluxation Hamate fx

38 Ulnar sided vs Radial Side Once this is narrowed down, you can typically rule out some dx Common ulnar side pain TFCC disruption, Lunotriquetral ligament disruption, DRUJ instability, ECU subluxation, ECU/FCU tendinitis Common radial side pain Scaphoid fx, Scapho-lunate ligament disruption, 1 st CMC arthritis, DeQuervain s, FCR tendinitis

39 Chronic Tendinitis Crepitus Pain with: Passive stretch of tendon Active contraction of involved muscle Manual resistance in specific plane Tenderness to palpation of tendon (muscle belly) Ligamentous Clunking Younger peopleligamentous laxity Pain with: Motion in multiple plains Specific deep joint pain Forceful grip

40 CMC Arthritis Prolonged pain Age Activity specific Stitchers, therapists CMC Grind Palpation to base of thumb Conditions with similar symptoms: DeQuervain s, Scaphoid fx, radial styloid fx X-ray is THE diagnostic tool Treatment Splinting Joint protection instruction Strengthening proximal to wrist

41 DeQuervain s Tenosynovitis 1 st Dorsal Compartment Abductor Pollicis Longus Extensor Pollicis Brevis Finkelstein s Test Resistance of APL/EPB

42 Distal Radioulnar Joint Instability Distal radius fractures Torque injuries More prominent ulnar head compared with unaffected side Piano-key test Pain with pronation/supination Ulnar sided wrist pain

43 TFCC Disruption Ulnar sided pain Pain with pronation/supination Pain with P/A and A/P glides of DRUJ TFCC Load test

44 Scapholunate disruption Pain with all wrist motions Pain to palpation of scaphoid both volar and dorsal Scaphoid shift test

45 Luno-triquetral ligament disruption Pain with all wrist motions Pain to palpation of lunate and triquetrum volar and dorsal Luno-triquetral shear test

46 Tendinitis Treatment Education RESPECT PAIN Avoid painful activity Splinting with muscle/tendon neutral/slack Heat muscle belly/ice tendon-joint Ultrasound-continuous muscle belly, pulsed to tendon STM muscle belly and surrounding musculature DFM Iontophoresis Dexamethasone for acute Acetic acid for chronic

47 Tendinitis Treatment(continued) Strengthening of proximal musculature Shoulder girdle and postural muscle strengthening critical Strengthening of distal musculature Only when pain subsides Initiate with isometric strengthening in different plains (monitor pain) Stability Exercises (discussed shortly)

48 Treatment Ligamentous Education---RESPECT PAIN Splinting-thumb included for radial side pain ROM unaffected joints Maintain pain free wrist and forearm motion Gradual introduction to isometric strengthening Progress to pain free isotonic strengthening Stability exercises

49 Stability Exercises Consider patient age, condition, and prior activity level Scapula musculature exercises Medicine ball activity Spontaneous movements Entire extremity involvement Muscle endurance Impact Weight bearing Static weight bearing beginning with wrists in neutral UE step-ups on platform Bosu ball Theraball Grip challenge activites All above are progressed pain free

50 Other things to look for Hamate fx FCU tendonitis ECU subluxation Pisotriquetral arthritis Positive/Negative ulnar variance

51 Surgeries ORIF Ligament repair Arthroplasty Carpectomy Partial wrist fusions Total wrist fusion Tendon releases

52 Post-surgical Treatment-general Protocol/physician specific Immobilization through cast or splint Can be 6-20 weeks Edema control ROM unaffected digits Pin care Treatment follows nonsurgical guidelines when AROM can be initiated Likely some permanent restrictions in motion

53 Distal Radius Fx s Many different classifications Can be associated with ligamentous instabilities, carpal tunnel syndrome Usually appear as bone heals and patient begins ROM and function Surgical ORIF Pro-Stability, Early mobilization Con-Infection risk, tendon-scar adherance, tendon-hardware interference

54 Distal Radius Fx s Treatment Splinting/Casting until healing noted by radiograph Typically 6 weeks Edema control Digit ROM! Emphasize HEP Shoulder and elbow ROM Nonsurgical-typically AROM wrist and forearm at 4-6 weeks, PROM after 6 weeks ORIF plate fixation-arom within first week, PROM at week 2 (monitor pain) Strengthening at 8 weeks (earlier or later per MD) Shoulder to Digits Isometric strengthening of wrist/forearm musculature within pain limits at week6

55 Summary Thorough history (most important part of evaluation) Observe Palpate Utilize resources based on symptoms Respect pain- in therapy and educate (most important part of therapy) Strengthening from shoulder girdle to digits Stability exercises

56 Typical patient I would see

57 Thank You

58 Go Sox!

59 Credits Lichtman,, D.M. (1988). The Wrist and its Disorders. Philadelphia: WB Saunders Skirven,, Terry: Clinical Examination Of The Wrist. Journal of Hand Therapy April 1996 Essentials Of Interactive Functional Anatomy CD/DVD ROM. Primal. Human Kinetics Eradiography.org Lichtman,, D.M.: Ulnar-Sided Wrist Pain. Emedicine.com February 2006

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