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2/4/2019
1
Hand Therapy Management of Wrist Instability
Aviva Wolff, EdD, OTR, CHT Clinician Scientist
Leon Root, MD Motion Analysis Laboratory Hospital for Special Surgery Impairment Mechanism
Design
Testing
Functional Improvement
Development of Rehabilitation Approach
Impairment
Mechanism
Design and testing
Improvement in function
Science informs practice
WRIST INSTABILITY
Rehabilitation
Science of proprioception
E Hagert
Roles of the muscles in carpal
stability
M Garcia-Elias
Wrist Kinematics and DTM
Wolfe
Individual occupational
needs/expectations
Mancuso
How can an understanding of wrist motion lead to better
treatment and rehab?
Why is it important to understand carpal motion?
• Understand effect of injury on motion
Surgical planning
• Surgical approach selected based on motion
Early rehab
• Minimize motion at repaired/injured structures
Late rehab
• Maximize path of motion
First, Know and Understand the SCIENCE
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Anatomy Biomechanics Kinematic
Studies (DTM)
Proprioception Dynamic
Carpal Stability
ANATOMY
Scapho-Lunate
Mid-carpal DRUJ
Instability Patterns
Courtesy of Primal Pictures
carpus
DRUJ
metacarpals
radius ulna
R wrist,
palmar
view
Distal row
Proximal row
RC Joint
MC Joint
1. Motion occurs primarily at RC and MC joints 2. Ligaments are important primary stabilizers
Proximal Row = “intercalated segment” Motion is dependent on mechanical signals from ligaments
Courtesy of Scott Wolfe, MD
Scapho-lunate interosseous ligament (SLIL): Primary stabilizer
• ACL of carpus
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Know thy S-L Ligament
Scaphoid Lunate
Scapholunate ligament
Photo courtesy of Eugene Ek, MD
Resected
Photo courtesy of Eugene Ek, MD
Dissociation
Photo courtesy of Eugene Ek, MD
Repair
Photo courtesy of Eugene Ek, MD
Photos courtesy of Eugene Ek, MD
Know and understand the anatomy Scapho-lunate interosseous ligament (SLIL): Primary stabilizer
• ACL of carpus
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Scapho-lunate Ligament
S L Dorsal 260N***
Volar 118N
Fibrocart 63N
Courtesy of Eugene Ek, MD and Christopher Dy, MD
Take home points: Scapho lunate Interosseous Ligament (SLIL):
SLIL is a primary wrist stabilizer - mechanics
SLIL is richly innervated
• Protective reflex function causing diminished dynamic stability
Traumatic partial SLIL tears result in impaired proprioception
Traumatic complete disruption leads to SL dissociation
Anatomy Biomechanics Kinematic
Studies (DTM)
Proprioception Dynamic
Carpal Stability
Biomechanics
Scapho-Lunate
Mid-carpal DRUJ
Instability Patterns Carpal Motion
scaphoid
lunate
triquetrum
SLIL LT Courtesy of Scott Wolfe, MD
Distal carpal motion follows fingers
Scaphoid follows distal motion
Lunate follows passively (SLIL)
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KINEMATICS: “The promiscuous lunate” Ken Flowers
scaphoid
lunate
triquetrum
SLIL LT
Courtesy of Scott Wolfe, MD
KINEMATICS: SL Dissociation
scaphoid
lunate
triquetrum
SLIL LT
Courtesy of Scott Wolfe, MD
KINEMATICS: SL Dissociation
scaphoid
lunate
triquetrum
SLIL LT
Kitay, A., Wolfe, S.W. Scapholunate instability. JHS 2012
DISI
KINEMATICS: LT Dissociation
scaphoid
lunate
triquetrum
SLIL LT Courtesy of Scott Wolfe, MD
KINEMATICS: LT Dissociation
scaphoid
lunate
triquetrum
SLIL LT
VISI
Spectrum of disability
DISI Dissociation Diastasis Disaster
Kitay, A., Wolfe, S.W. Scapholunate instability. JHS 2012
Complete disruption of SLIL and distal STT support
Pathologic extension of lunate Dorsal interacalated segmental instability
DISI
Scapholunate Adavanced Collapse SLAC
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Take Away Points For pain relief and further degeneration
• No good options
Salvage procedures limit motion
• Proximal row carpectomy
• Range of intercarpal fusions
• 4 corner fusion/midcarpal arthrodesis
• STT fusion
Better strategy = prevention, early diagnosis
Early repair of SL ligament prevents further degeneration
Instability Midcarpal
Midcarpal Instability
• Involves both MC and RC joints • Entire row is mal-aligned • Involves multiple ligaments
Midcarpal Instability: Types
CIND-VISI CINC-DISI
CIND-Combined
CIND-Adaptive
Palmar
(Ulnar MCI)
(CIND-VISI)
Dorsal
(CLIP)
(CIND-DISI) Combined Adaptive
Midcarpal Instability: Variants CIND VISI Most common
No specific injury
“snapping” wrist
“catch-up Clunk”
Midcarpal shift test
70% ligament laxity
Non-operative treatment
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Anatomy Biomechanics Kinematic
Studies (DTM)
Proprioception Dynamic
Carpal Stability
Kinematics: Carpal Movement
in DTM Plane
Kinematics Studies: HSS, Brown University
Micro Kinematics - Brown Study of individual carpal motion
– Micro Kinematics Cadaveric studies (Crisco and
Wolfe) In Vivo – CT – Markerless bone
registration (Crisco and Wolfe)
Macro Kinematics - HSS Development of biomechanical
and kinematic model and solution to measure wrist motion
Study of functional wrist motion – motion lab
Kinematics Studies: Take Away
• Dart-thrower’s motion (DTM)
• Minimal scaphoid and lunate motion during DTM plane
• Early DTM safe in protected range
• DTM impact on functional activities
• Circumduction Envelope – task specific quadrants of motion
Coupled Wrist Motion
• Alters kinematics and functional task performance
• Findings from PRC and 4 CF patients
Surgical reconstruction of SLAC
Identification of task specific
quadrants of motion
Singh, JHS, 2014 Wolff, JHT, 2014
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Anatomy Biomechanics Kinematic
Studies (DTM)
Proprioception Dynamic
Carpal Stability
Proprioception
Dr Elisabet Hagert Karolinska Institute, Stockholm
Seminal work in identifying innervation patterns in the wrist ligaments
• Used advanced staining techniques and immunohistochemical markers to identify presence of mechano receptors in each of the 15 wrist ligaments
• US and fine wire electrode to stimulate ligaments in healthy volunteers
Ligamento-muscular reflexes
Sensorimotor control of the wrist
Proprioceptive Pathways Dialogue between muscles and ligaments
Hagert, E JHT 2010
Immediate Pathway
Spinal level
Stimulation of mechanoreceptors in
intra-articular ligaments
Activates control of muscles around the
joint
Secondary Pathway
Supraspinal
Cerebellar unconscious
integration of somatosensation and
proprioception
Cortical- conscious
Innervation Distribution in the Wrist
Hagert, E JHT 2010
Intrinsic ligaments
Richly innervated
Triquetral, dorsal
Dorsal SLIL (Mataliotakis,
JHS, 2009)
Important sensory
Extrinsic ligaments
Radio-volar
Collagenase, dense
Poorly innervated
mechanically important
Dynamic Carpal Stability
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Can the proximal row be dynamically stabilized? Role of Muscles in Carpal Stability • SL INJURY Flexion and Pronation of
Scaphoid
• Scapholunate “friendly” structures = SUPINATE – FCU, FCR, APB, ECRL FCR
• Scapholunate “unfriendly” structures =
PRONATE – ECU
Garcia-Elias et al
Indications/Contraindications
• Indication – Predynamic/Partial SL Injury
(secondary ligaments intact – dorsal)
– Post-Surgical repair
• Contra-Indication – Complete SL tears – Dorsal translation of scaphoid
Then, apply that knowledge to your TREATMENT
Anatomy Biomechanics Kinematic
Studies (DTM)
Proprioception Dynamic
Carpal Stability
Cautionary Tale
Garcia Elias et al 2014
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Cautionary Tale
Garcia Elias et al 2014
Limit motion at S-L joint (biomechanics) Splints that limits motion to DT plane ONLY radial extension to neutral in SL acute injury and early post-repair
Courtesy of Hamish Anderson Lynn Feehan, JHT 2016 Federica Braidotti, JHT 2015
Rigid tape for pre-dynamic S-L instability
Poretto-Lourke, JHT 2016
Limit activities to DT plane Limit to radial extension to neutral in early phase
Proprioception
Begin proprioceptive training for injured ligaments
Goal:
Increase/develop proprioceptive awareness
and joint position sense
Mirror therapy
Contralateral
Creates illusion of motion
Stimulates somatosensory
cortex
Visual occlusion exercises
Eliminate visual and auditory
cues
Motor imagery
Hagert, JHT 2010
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Smartphone Apps
Alger and Valdes, JHT 2016
Dynamic Muscle Stability
Case Example 1
56 y/o, female
10 months radial wrist
pain
Full ROM
Her midcarpal joint is only
minimally maligned
Isometric stabilization exercises in PRONATION
ECRB APL
FCU
Case Example 2
60 y/o, male, Orthopedic Surgeon
6 month old injury to non-dominant right wrist, hit backhand shot, felt sharp pain
Pain with resistive activities, able to work with moderate ache, and able play golf.
Worried about progression and potential inability to play sports during retirement Left and right wrist neutral laterals,
both demonstrate 10 deg RLA, 70 deg SLA and no dorsal scaphoid translation
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Right injured wrist PA
Right injured ulnar dev PA
Right injured grip
Template
vSLIL intact but stretched
dSLIL intact but stretched RSC and LRL intact and robust
Consecutive cuts of radioscaphoid fossa showing no dorsal translation
Cartilage-sensitive sequencing showing no cartilage loss
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DRC intact and robust.
DIC attenuated but intact and lunate and scaphoid attachments on sagittal images appear to be intact.
DIC
DRC
Template
DIC attenuated but intact and lunate and scaphoid attachments on sagittal images appear to be intact. Distal band of DIC robust and intact
DIC distal band. dST?
Later Phase
Later phase (stable joint and healed ligaments)
Biomechanics
Activities that maximize
circumduction envelope
Begin strengthening in DT plane
Proprioception
Isokinetic – BTE CPM PRIMUS
Isokinetic exercises
Neuromuscular Rehab
Reactive muscle activation (RMA)
Perturbation exercises
(plyometrics)
Oscillatory Devices (body blade, weighted
pipe, power ball (Balan et al 2008)
Circumduction
Maximizing Circumduction Envelope
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Strengthening in DT plane
Holmes et al, 2016
Proprioception
Kinesthetic awareness
Smallest change in joint angle needed to
elicit a conscious awareness of joint
motion
BTE PRIMUS – CPM
Passive mode
Isokinetic mode
• Performed at constant angular speed
Neuromuscular Purpose
Promote motion in muscles that are joint protective while avoiding activation of muscles that are joint damaging
Use dynamic muscular compression
Regain smooth motion after trauma or surgery
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Oscillatory devices
Power Ball (Balan et al
2008)
Body Blade
Weighted pipe
Perturbation exercises
plyometrics
Reactive muscle activation (RMA)
Neuromuscular Rehab (unconscious) Wrist Stabilization Exercises
Dynamic Muscle Stability
Holmes et al 2016
Neuromuscular Rehab Neuromuscular rehab: closed chain
Karagiannapolous, JHT, 2016
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Closed Chain Sports Specific
Multiplanar movements
Position specific maneuvers - shooting guard, power forward, center position etc..
Flexible protective wrist support Holmes, HT, 2016
Summary
Need clinical studies in large cohorts to compare these treatments to previous standards of care
Many unanswered questions
Great progress in understanding role of proprioception and neuromuscular joint control
Great progress in understanding role of muscles in dynamic carpal stability
Great progress in understanding link between kinematics and carpal function
Challenge
• Hincapie, JHT 2016
• Anderson, JHT 2016
• Holmes, Hand Therapy 2016 (n=7)
Small case reports n=1 studies
Let’s begin to report our outcomes
Or we will never know….
Treatment recommendations For Mid-Carpal Instability
Stabilization Splint
Direct dorsal force on pisiform and triquetrum
Depress ulnar head
Mid-Carpal Instability
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Splinting for midcarpal instability (CIND – VISI)
Courtesy of Emily Altman, CHT, DPT
Splinting for midcarpal instability (CIND – VISI)
• Why this works?
• Proximal row is in VISI
• Splint directs dorsal force on pisiform/triquetrum and depress ulnar head
• Shift row into dorsal alignment
Courtesy of Emily Altman, CHT, DPT
Dynamic Splint
Courtesy of Emily Altman, CHT, DPT
Ulnar boost splint
Ulnar boost splint Challenges
Difficult to fabricate
Hard to control VISI with static splint
Skin cannot tolerate the pressure required to push these bones into proper alignment
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Selected References • Esplugas M, Garcia Elias M, Lluch A, et al. Role of muscles in the
stabilization of ligament-deficient wrists. J Hand Ther 2016; 29:166-74. • Hagert E, Lluch A, Rein S. The role of proprioception and neuromuscular
stability in carpal instabilities. J Hand Surg Eur Vol. 2016; 41: 94-101. • Kitay A, Wolfe SW. Scapholunate instability: current concepts in diagnosis
and management. J Hand Surg. 2012;37(10):2175-2196 • Rainbow MJ, Wolff AL, Crisco JJ, Wolfe SW. Functional kinematics of the
wrist. J Hand Surg Eur Vol. 2016;41(1):7-21 • Salva-Coll G, Garcia-Elias M, Hagert E. Scapholunate instability:
proprioception and neuromuscular control. J Wrist Surg 2013; 2:136-40 • Wolfe AL, Wolfe SW: Rehabilitation for scapholunate injury: application of
scientific and clinical evidence to practice. J Hand Ther 2016; 29:146-153.
HSS Wrist Biomechanics Team
LRMALab
Scott Wolfe, MD
Howard Hillstrom, PhD
Aviva Wolff, EdD
Andrew Kraszewski, PhD
Andreas Kontaxis, PhD
Sherry Backus, PT
Thank you