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Presentation of wrist assessment including pathologies, assessment tests and anatomy.
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By Sean DadswellSeptember 2010
ContentAimsRefresh anatomy BiomechanicsDiagnosisPathologyTesting Treatment
AimsTo refresh and improve knowledge of wrist
anatomy and biomechanics and improve knowledge of wrist testing and treatments
Anatomy
Anatomy
Palmar Aspect Dorsal Aspect
WristBiomechanics difficult to
discuss without knowledge of anatomy
3 Planes of movementAll interdependent Instability therefore simply
wrist dysfunction
Distal radius, Triangular Fibrocartilage Complex (TFCC), distal ulna form stable base
Distal carpal row (hamate, capitate,trapizium & trapizoid) Joined by strong interosseous ligs and move as one unit
Proximal row (scaphoid, lunate, triquetrum & pisiform) change position in response to lig attachments and adjacent bone movements
Proximal row has no muscle attachments and is therefore inherently unstable when lig disruption
(Campbell, 1999; Berger 1996)
Fundamentals for wrist stability
Forces through Wrist55% force
transmitted through Radioscaphoid Joint
35% through Radiolunate joint
10% through TFCCBiomechanics and
instability can alter this significantly
55% 35%
10%
StabilityWrist highly mobileDepends on short,
strong intrinsic interosseous ligs and longer extrinsic intercapsular ligs
Intrincis ligs have origin and insertion in same carpal row
Scapho-lunate lig (SLL) and Luno-triquetral lig (LTL) important in proximal row as prevent separation of bones whilst allowing force through wrist and adaptation of bone positions
Extrinsic Ligaments‘V’ shaped volar focusing on
lunate proximally with limbs attaching to ulna and radius and capitate distally attaching to rad and triq via scaphoid
Dorsal aspect also ‘V’ shaped centring on the triquetrum and contains radio-luno-triq segment and trapezium, trapezoid, scaph segments
Other stability offered from flexor and extensor retinaculae and wrist flexors and extensors but these are not sufficient to prevent instability without ligs
Palmar
Dorsum
MovementsDistal row one unit
moves proximally when wrist is loaded
Compresses proximal row which flexes scaophoid 2ndry to palmar extrinsics
SLL then causes lunate flexion as well as capitate pushing into flex
Triquetrum then has flex force from LTL and ext force from distal row attachments. Flex force greater Therefore Triq flexes
Movement cont.Proximal row moves into
flex when distal row ext unless SLL insufficiency then the lunate will follow triquetrum into extension and scaphoid flexes excessively
Conversely if LTL insufficient then lunate follows scahphoid into flex and triq extends
During wrist flex and ext proximal row follows distal row
Ulna deviation (UD):Head of capitate
translates dorsallyExtends lunate (and
therefore scaph)Further UD causes
contact between hamate and triq which slides up and extends => further lunate ext. (palpable during movement)
Radial Deviation (RD):Trapizoid and trapizium
approximate to the radius and push scaph into flexion => lunate flex
InstabilityResults from
insufficiency of soft tissue restraints leading to abnormal movements
Different classifications
VISI or DISIVolar or Dorsal
intercalated segment instability
Relative lunate position to scaphoid
Intercalated ref to capitate and lunate connecting proximal and distal carpal rows
Scaphoid
Lunate
Instability cont. Numerous classifications and
terminology Popular one:
Carpal Instability Dissociative (CID): refers to instability between bones in same row
Carpal Instability Non-dissociative: instability between bones in separate carpal rows
Carpal Instability Complex (CIC): combination of CID and CIND (useful to describe elements of CID and CIND as guides treatment
Carpal Instability Adaptive (CIA): instability 2ndry to adaptation to abnormal bony architecture (eg malunion scap/rad etc)
DiagnosisHistory of trauma not always but most often presentFailed resolution of wrist sprainMechanism of injury (MOI)
Angle of impact (FOOSH or fall backwards)
Force (MPH, Height) Throwing injury
Detailed swelling, location of pain (radial, ulna, global or central and dorsal or volar), loss of function, treatments
Grip strengthPresence of click or snapping with or without painPrevious wrist injury’s or fracturesParesthesiaXrayArthroscopy gold standard
X Ray findingsTerry Thomas sign
Positive Terry Thomas sign indicative scapholunate instability
X Ray findings cont
Ring sign
Positive ring sign indicates scaphoid flexion (left) Normal (right)
X Ray findings cont
Ulnar variance
Positive ulnar varience (middle) and negative ulnar variance (right)
In ulnar neutral wrist 18% load goes through ulnar side of wristIf unlar length increased by 2.5mm force increases to 42%If ulnar length reduced by 2.5mm force reducs to 4.3% (Sachar, 2008)
X Ray findings cont
Gilula’s arc
Disruption of the first arc indicates luno triquetral instability via fracture or ligamentous instability
X Ray findings cont
Disruption of the second arc indicates scapholunate and lunotriqutral instability. Even though there is a gap in the first arc it can still be trace as a smooth arc
X Ray findings cont
Disruption of the third arc indicates capitohamate joint
Xray findings cont
Keinbock’s disease
Kienbock’s disease caused by AVN of the Lunate
PathologyCauses of wrist pain:
OA (1st cmc, piso-triq)RA#’sTFCC injuryCarpal tunnel syndrome Ulnar nerve entrapmentANV scaphoid/LunateECU subluxationNerve rootPronator teres trigger
points
DRUJ disruptionUlnar impactionCRPSDeQuervain’s
TestingWatson’s Scaphoid Shift TestTo identify scapho-lunate instability (scapho-lunate
ligament laxity/rupture)69% sensitive* 66% specific** (La Stayo and
Howell 1995)As almost 1/3 false negatives and 1/3 false
positives not very accurate but no further studies done to validate (Marx et al, 1999)
Needs to consider general hypermobility as more false positives in lax controls (Goldberg, 2006)
*Sensitivity indicated tests ability to predict presence of pathology
**Specificity indicates tests ability to predict true negatives/absence of pathology
Scaphoid shift test cont.
Sitting in an arm wrestling position. Examiner starts with the patients wrist in ulnar deviation and slight ext the applying pressure to the distal pole of the scaphoid to prevent palmar translation. Wrist is then radially deviated and slightly flexed. Pressure is then released.
If positive the scaphoid subluxes over the distal rim of the radius and there will be a click/clunk when pressure is released
In normal wrists the examiner will feel the scaphoidflex forward as the wrist is deviated radially
The Watson's test.
Luno-triquetral Ballotment Test (Regan’s Test)Identifies laxity of luno-triquetral ligSensitivity 64% Specificity 44% (therefore can
be false positive in > 50% of normals) (La Stayo and Howell 1995)
Better at predicting the absence of pathology rather than the presence of it (Marx et al 1999)
Poor validity from research but few attempts to validate
Ballotment testing of carpal mobility showed good inter and intra tester reliability therefore useful is wrist assessment (Staes et al 2009)
Regan’s Test cont
Simple PA of triquetrum on fixed Lunate
MUST BE COMPARED LEFT TO RIGHT
Positive if crepitus, pain of laxity felt compared to opposite side
The posterior side of the triquetrum is easily found as one can palpate the insertional crest of the posterior radiotriquetral ligament. Just distal to the crest lies the triquetrohamate space
The lunotriquetral ballottement test (Reagan's test)
Dorsal Wrist SyndromeGoldberg et al 2006Palpation base 3rd
MC and drop off capitate into fossa over scaphoid
Indicated scaph OA or scapholunate injury/instability
No spec or sens
Pivot Shift Test for Mid-carpal JointTest for ant capsule
and interosseous lig injury leading to capitate instability (Tuiana et al 1998; McGee, 1997)
Described in textbooks only there no spec or sens
Mid carpal joints most likely falling onto flexed wrist
Dorsal to volar pressure applied to capitate with hand in full supination then moved from radial to ulnar to radial deviation
Pain or ‘clunk’ indicates positive test
Anterior Draw Reddy and Compson
(2005) discuss lack of specificity in terms of individual structure
May indicate CICAnterior Draw test
Piano Key TestTest for Distal
radioulnar joint (DRUJ) instability
No spec or sensAlthough Moriya
(2009) found it to be valid in cadarvic study
Disruption of dorsal or palmar radioulnar lig
Positive with more than 5mm difference in movement compared to asymptomatic side
Piano Key Test
DRUJ Compression Test
Compressive force applied to DRUJ in 15-30 degrees supination
Wrist then pro and supinated
Positive with reproduction of pt’s symptoms
Indicates DRUJ OATextbook description
only
Shear Test for TFCC
Reddy and Compson (2005) Mini-symposium describse test but no Spec or Sens although construct validity OK
Indicated TFCC degeneration or injury
DRUJ held by examiner then axial load applied with Unlar deviation followed by passive pro and supination
Positive test click or painSachar (2005) discusses pronation leading to ulnar abutment as increases positive ulnar variance
•TFCC most common source of ulnar sided wrist pain and are either traumatic of degenerative•Occur with falls onto ulnarly deviated extended wrist or at extreme rotation•Often related to +ve ulnar variance (Osteotomy required)
Palpation TFCCSachar (2008) found
Specificity 87% Sensitvity 95%
Indicative of ulnotriquetral lig injury or TFCC injury/degeneration
Ulnomeniscotriquetral Dorsal Glide(UMTDG)Indicateds TFCC
injury66% sensitive64% specificIdentified in study
tested against arthroscopy (La Stayo and Howell, 1995)
May be beneficial to use multiple tests
Radius stabilised by examiner then using pinching motion between thumb and index finger of the opposite hand the piso-triquetral complex is moved dorsally whist the ulnar is squeezed palmarly
Piso-Triquetral Grind TestIndicates Piso-triquetral
OA most frequently but also pisiform instability
Need to differentiate between piso-triq OA and FCU tendon problem. (Palmar, 1995) advises palp FCU whilst resisting wrist flex and unlar deviation for FCU testing
Nakamura (2001) describes principle as accurate but offers no spec or sens
Piso-trquetral grind test:Examiner grips pisiform between thumb and index and rotates whilst compressing joint.Positive result is pain
Finklestein’s TestIndicates De Quervain’s
(Stenosing tendovaginitis /synovitis of 1st extensor compartment )
Batteson et al (2008) reports upto 100% sens and spec when used as part of a De Quervain’s screening tool but otherwise no reports of Sens or Spec
Screening tool included pain, tenderness, thickened APL or EPB, swelling,pain on resisted thumb ext
Finklesein’s test: Positive if pain illicited
CMC Grind TestIndicates 1st CMC
joint OANo spec or sens
availableNeed to differentiate
from De Quervain’s Examiner axially
compresses 1st CMC joint then med and lat rot 1st MC
Positive with pain or crepitus illicited
Carpal Tunnel syndromeMost common nerve entrapment
with prevalence upto 6%Compression of median nerve
beneath the transverse carpal LigPredominantly sensory S&S with
nocturnal S&S a classic feature.Nerve conduction studies often
used even when clinical picture clear to confirm CTS diagnosis (not efficient/cost effective
Using multiple tests can increase accuracy of clinical tests(Boland and Kiernan, 2008)
Phalen’s TestSensitivity 64-75%Specificity 75-94%(Boland and
Kiernan, 2008; Tetro et al, 1998)
Both studies reportPositive test
reproduction of pt S&S Phalan’ s test position held for
60 seconds
Tinel’s TestSensitivity 74%Specificity 91%Direct tapping over
transverse carpal lig with finger or reflex hammer
No conscensous on number of taps
Positive with reproduction of S&S
Tinel’s test
Carpal Compression TestSensitivity 75-90%Specificity 90-93%Direct pressure over
transverse lig for 30 seconds
Spec and Sens may be improved by adding flexion to wrist (up to 99% but evaluating own test) (Tetro et al, 1998)
Ulnar Nerve Entrapment Guyon's canal syndrome
is an entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyon's canal.
Common in cyclists and RSI of ulnar border of hand on desk
Tested by compressing over Guyon’s canal
Nerve conduction studies
Differentiate higher ulnar nerve entrapment
Treatment for Instability
Incomplete lig tears can be splinted for 6-8/52
Goldberg (2006) reported 500 hand surgeons agreed acute or chronic wrist instability should be treated surgically
Main surgery are:Lig repairsWith or without K WireWith or Without
Capsulodesis
Carlsen and Shin (2008) recommend stages to repairs depend on soft tissue quality:Lig repairs/Anatomical
reconstruction for acute injury with good soft tissue
Salvage* ops where tissue is poor
Salvages ops where significant OA or non reducable deformity exsists
*Salvage ops ref to intercarpal arthrodesis, total wrist arthrodesis
(Minimal RCT evidence for concervative treatments)
Other Surgical Options (not specific to instability)
Ulnar osteotomy: can tighten TFCC complex or reduce positive ulnar variance
Pisiformectomy: for OA
CTS releaseScaphoid ORIF:
necessary in unstable prox pole #’s as 55-95% => AVN
If non-union occurs further options are:Radial styloidectomyExcision of the
proximal fragmentProximal row
carpalectomyBone graftTotal or partial
arthrodesisVascular bone graft (to
revascularise scaphoid)
Conservative treamentsCTS
Splinting (night)Oral steroidsWrist mobsInjections
All offer good short term outcomes
(O’conner et al, 2003; Marshall et al, 2007)
Surgery better than splinting (Verdugo et al, 2008)
TFCC injuriesAvoid aggsRestSplintingInjectionArthroscopic
debridment (66-87% success increased to 87-99% with ulnar osteotomy)
Conservative treatments cont.
De Quervain’s: No evidence for splinting rather than injection (Coldham, 2008)
Treatments to increase ROM: HEP better than mob’s but mob’s are helpful (Michovitz et al 2004; Krischak et al 2009)
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