Conservative management of palmer mid-carpal instability

Peter BelwardPhysiotherapist

UHS NHSFT

Key messages

●Restore patient confidence

●Regain strength and control in a position of stability

●Reduce dependency on over protection and splintage

Patient history

+/- Minor injuryPain and apprehension

Protection and reduced activity

Increased weakness

Loss of dynamic control

Pseudo-diagnosis WRULD (RSI)

Ave age 27

Patient confidence

●A clear diagnosis with a positive outcome

●Understanding and recognition

●Reassurance, clicks and clunks

●Attainable goals (strength and function)

Position of stabilitysupination

●Effect of relative ulna shortening and dorsal translation of the radius

●Increased tension in:

● Extrinsic and intrinsic wrist ligaments

● Extensor carpi ulnaris(ECU) (sub sheath)

● Flexor carpi ulnaris(FCU) (increased radial length)

1mm

pronation supination

Position of stability

●In radial deviation ● lunate and scaphoid in flexion with capitate and the

distal carpals in extension

●Capito-lunate palmer subluxation●Potential instability

Position of stability

●Stability achieved in ulnar deviation

● proximal carpal row extends as the distal carpal row flexes

●Ligaments tighten and midcarpal joint achieves congruent stability

Catch up clunk

Strength and control

●Muscle weakness results in:● Loss of muscle endurance● Slower reflex motor control● Impaired co-contraction● Loss of dynamic control

Dynamic control is imperative in patients who have poor

static control due to ligamentous laxity

Strength and controlsensory-motor system

●Radio-volar ligaments are dense collagenous structures; poorly innervated

●Dorsal and triquetral ligaments highly innervated

Strength and controlsensory motor system

●Fusimotor effect

●Theoretical concept of local reflex driven by Gamma motor neurones

●Stimulation of wrist ligaments producing direct reflex response with forearm muscles (Hegert E)Reflex via dorsal horn, with higher

control and co-contraction

Proprioception

Sudden alterations in joint position

Stimulate reflex muscular stabilisation

Kinematics

●Coupling movements● Flexion with ulnar deviation

● Extension with radial deviation

● Supination with flexion

● Pronation with extension

Strength and control

●Start with:●Strengthen in supination with flexion and ulnar deviation

● Propreoception

Eccentric ECU

Concentric FCU

Hypothenar muscles

Strength and control

●Progression:●Into forearm neutral

● Eccentric and concentric ECU

● Concentric FCU●General strength●Co-contraction●Dart throwers motion

● ECRB and FCU

Co-contraction

FCU ECU

A B

Strength and control

●End stage: 6/12+●Strengthening in pronation●Spinball●Load bearing

When to splint

●Never ?●Control splints

Ulnar boost

Off the shelfManutrain

Dynamic control

Classification

●Litchmans grading: shift test I. No palmer translation no clunk II. Minimal palmer translation minimal clunk III. Moderate palmer translation moderate clunk IV. Maximum palmer translation significant clunk Increasing degrees of normal mid-carpal laxity

V. Self induced palmer translation and clunk

Pathological condition of mid-carpal instability, often associated with general hypermobility

V. Self induced palmer translation and clunk

●Clinical sub categories seen in UHSA. As above in pronationB. Reproducible in forearm neutralC. Reproducible in supination

Increasing severity of instability

Splints may be the only way to relieve symptoms and open the door to muscle re-education in sub type C

Strength and controlDart throwers motion

●Scaphoid and lunate motion significantly less than with any other plane of wrist motion

●Scapholunate ligament (SLL) elongation is minimal, so strengthen ECRB and FCU in SLL injury

NB. ECU increases the stress at the SLL, ok in palmer mid-carpal instabilityECU rehab to be avoided in SLL injury

Present in the majority of functional tasks

The future

●Improvement in diagnosis and grading

●? Correlation between degree of instability, symptoms, strength and function

●Research to clarify conservative treatment● Hegart E, call for case studies (a start)

Case study

●Five patients with mid-carpal instability treated with POP cast for four weeks●Two patients had further protection in splints●All patients reported short term benefit in pain●No long term benefit, only one patient returned to their chosen occupation

Journal of hand surgery (Edinburgh, Scotland), April 1996, vol./is. 21/2(197-201), 0266-7681:Ono H,Gilula LA,Evanoff BA,Grand D

Case study

●21yr old right handed female student●5 yr hx of bilateral wrist pain R > L●Clunky wrists forearm pains on writing

RSI

●No general joint laxity, flexible wrists●Grip strength R =14kg L=16kg●Litchmans V (b)

Case study

●In supination strength and control exercise● After one month grip R= 20kg ● L= 26kg (asymptomatic)

●Progression to forearm neutral● One month later grip R= 24kg, 75% improved● At 6/12 maintaining improvement

●Tried spinball,● increased symptoms - ‘crepitus++’

Case study

●Reverted to forearm neutral and supination theraband work

●One month back to 75% improvement

●6/12 later maintaining gains but felt she needed to continue with maintenance strengthening programme

Case study●Locked wrist, A/E visits ++

● 16yr old female● Generalised joint laxity● Symptoms often occurred over night

Taught, self traction, flexion, with dorsal lunate pressure during extension to relocate

References

●Lichtman DM, Schneider JR, Swafford AR, Mack GR: Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg [Am] 6:515-523, 1981. ●Wright TW, Dobyns JH, Linscheid RL, et al: Carpal instability non-dissociative. J Hand Surg [Br] 19:763-773, 1994. ●Brown DE, Lichtman DM: Midcarpal instability. Hand Clin 3:135-140, 1987.●Mason WT, and Hargreaves DG: Arthrosopic thermal capulorraphy for palmer midcarpal instability. Journal of Hand Surgery (European Volume, 2007) 32E: 4: 411–416●Hagert E, Persson JKE, Werner M, Ljung B-O. Evidence of wrist proprioceptive reflexes elicited after stimulation of the scapholunate interosseous ligament. J Hand Surg Am. 2009; 34:642–51.

References

●Hagert E, Forsgren S, Ljung BO. Differences in the presence of mechanoreceptors and nerve structures between wrist ligaments may imply differential roles in wrist stabilization. J Orthop Res. 2005;23:757–63.

●Moritomo H, Apergis EP, Herzberg G,Werner FW,Wolfe SW,Garcia-Elias M. 2007 IFSSH report of wrist biomechanics committee: biomechanics of the so-called dart throwing motion of the wrist. J Hand Surg [Am]. 2007;32:1447–53.27.

●Prosser R, et al. Current Practice in the Diagnosis and Treatment of Carpal Instability—Results of a Survey of Australian Hand Therapists. J Hand Therapy. 2007;20:239–43.