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Instabilities in the Wrist

Presented by: Ben Cunningham

Andrew Ellis BSc (Ex. Sci), M. Phty

Ben Cunningham Member of the Australian Hand Therapy Association

Ben Cunningham BOT, M Clin Sci (Hand & Upper Limb)

Member of the Australian Hand Therapy Association

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• Incredibly complex and unstable

• The Main functions of the wrist are;

- Movement

- Positioning of the hand for function

- Positioning to make the most of muscle function

• Distal radioulnar joint

• Radiocarpal joint

• Midcarpal joint

• CMCJ’s

• Stable and unstable!

• Distal radius/TFCC

• Loosely congruent surfaces

• Prestyloid recess on ulnar styloid – artic with carpus

• Includes lunotriquetral joint

• Main joint for wrist extension

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• Proximal carpal row and distal carpal row

• Distal scaphoid pole artics with 2 trapezial bones to form gliding joint

• Proximal scaphoid, lunate and triquetrum form concave surface for capitate and hamate

• Main joint for wrist flexion, capitate flexes on the lunate

• Guide motion between carpus

• Afferent input for proprioception

• Dorsal and ulnar ligaments have most innervation, vascularity and proprioception for maximum information re movement

• The most innervated ligs attach to triquetrum

• Volar ligs stronger collagen, less innervation but strong mechanics for stability

RTq Dorsal radio carpal

Dorsal Intercarpal

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RTq Dorsal radio carpal

Dorsal Intercarpal

Stop slip

down slope

CHTq

RSC

RLT / long radiolunate

UL

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1.Dorsal • thickestTrue ligament thickness

averaging 3mm • Highest failure threshold

STRONGEST • Stabilises traction and torsion

forces between scaphoid and lunate

2. Volar/palmar • True ligament thickness averaging

1mm • Stabilises rotational forces

between scaphoid and lunate 3. Proximal/membranous • Fibro cartilage, thin • Lowest failure threshold

WEAKEST

Source: Bodor, D (2009).

Volar

• RSC - radioscaphocapitate ligament – Meade et al (1990) in Manuel & Moran (2010) found that sectioning RSC with dorsal SLIL increased the scapholunate interval to 4.1mm compared to 2.6mm when dorsal SLIL alone was sectioned.

• Long radiolunate

• Scaphotrapezial

• Scaphocapitate

Dorsal

• Dorsal capsule – Ruby et al (1997) sectioned entire SLIL and dorsal capsule and measured a scapholunate interval of 5mm.

• DIC – dorsal intercarpal ligament – Stabilises the lunate. Short et al (2002)in Manuel & Moran and Mitsuyasu et al (2004) found that sectioning SLIL from its connection with DIC causes DISI.

• DRC – dorsal radiocarpal ligament

Source: Gelberman, Cooney III and Szabo (2000)

Figure 3, p 578.

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Triangular Fibro Cartilage Complex.

1. ECU tendon

2. Ulnar styloid

3. Distal radio-ulnar ligaments

4. Ulnar lunotriquetral ligament

5. Ulnar collateral ligament

• 78% of axial load via radius

– 46% via radioscaphoid

– 32% via radiolunate

• 14% via ulnolunate joint

• 8% via ulnotriquetral joint

• Ulnar variance alters load

Gilula’s Lines

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• Ulnar Deviation

– The trapezium moves distally checked by the radial collateral ligament

– Scaphoid assumes more vertical position and the “ring” theory causes the triquetrum to compress the lunate which then tilts volarly

• Radial Deviation

– Ulnar displacement of the proximal row causes

the “ring” to continue to turn the scaphoid

– Capitate pulled distally allows greater space for the lunate which tilts dorsally which in turn offers greater functional distance

Carpal height

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• Minimal mid carpal joint movement.

• Pronation and supination of the forearm allow for tool use in any position and is a key to our development.

• Dart throwers motion refines this concept

• The two radioulnar joints are coaxial – they share the same axis.

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+/- 15

• Ligaments direct carpal movements either stabilising or allowing shift of a bone within the extent of the length of the ligaments involved.

• Laxity or rupture of these ligaments will alter patterns of movement of the wrist.

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• Scaphoid is

– the main stabilising bone in ROM

– has greatest ROM

– takes most axial force through the wrist.

• The lunate has least movement of PCR

• PCR has greater capacity for the bones to move independently of each other

• DCR moves as one unit with MC’s at CMCJ’s

• Movement initiated by the ECRL,ECRB, ECU at insertions on MC’s

• Ligaments between trapezial bones/capitate and scaphoid become taut.

• Continuing forces of the extensor muscles now pull DCR and scaphoid into extension in relation to the lunate and triquetrum

• PCR then moves into extension at RCJ

• The opposite occurs with each section flexing in sequence

• Movement initially occurs

– at MCJ

– then RCJ

– end of range at MCJ

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RSC

• As discussed 78% of the axial loading is at radiocarpal joint and 22% through the ulnocarpal joint on direct loading

• In function, about 20% of proximal carpal row total contact area is in direct contact in any one position of the wrist

• Scaphoid takes 50% of contact in any position • % of bony contacts change with different wrist positions. • At the mid carpal joint the actual contact is less than 40% • Capitate takes up to 50% of the total contact area of the

mid carpal joint.

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Dual x-rays

• PA – shoulder 90, elbow 90

• Lateral

Scapholunate Gap Normal = 2-4mm

Radiolunate Angle Normal = 10 - 12°

Scapholunate Angle Normal = 40 - 70°

• Ring sign of the scaphoid

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Source: L Funk (2003). Wrist examination p 3

Source: L Funk (2003). Wrist examination p 2

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• MRI

• Schadel-Hopfner et al (2001) 103 wrist with suspected scapholunate tears 75% correctly diagnosed, overall specificity 86% sensitivity 65%.

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The final level of SL dissociation is scapholunate advanced collapse (SLAC). The SLAC wrist starts with SL plus DISI and degenerates with arthritis to become SLAC.

• Types of conservative treatment

• Splinting Wrist brace or Long Opponens brace.

• Isometric strengthening?

• Dart throwers motion?

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FCR acts as a hinge toward the distal insertion into the second metacarpal.

When the FCR muscle contracts, the scaphoid tuberosity is pushed laterally/supination, thus creating a moment that counteracts the flexion/pronation tendency that the scaphoid has when axially loaded.

• Damage to TFCC is common. • Its role is to stabilise the distal radius. • Only a 20% boney stability so gets 80% of its

stability via soft tissue and dynamic attachments. • Holds the radius and ulnar together allowing the

radius to move over the ulnar without subluxation.

• Tightest in mid prone giving the forearm most stability in usually the best position for hand function.

In supination the deep dorsal DRUJ ligaments are taut.

In pronation the deep volar DRUJ ligaments are taut.

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• Symptoms:

• Pain around ulnocarpal area

• Tenderness at ulnocarpal area

• Pain aggravated by strenuous activity

• Pain increased by ulnar deviation and rot.

• Diagnosis:

• Ballottement of ulnar head in ulnar deviation – TFC compression test

• X-Ray

• Cortical sclerosis- may be confused with Keinbock’s

• Galeazzi # - fracture of the distal 1/3 of the radius with dislocation of the DRUJ

• High energy injury • Hyper extension and

rotation • Surgical Treatment

– ORIF and reduction and pinning of the DRUJ

– Complex therapy!

• Mechanism - if any • Previous

fractures/dislocations • OA or RA? • Wrist Pain – Ulnar sided

burning pain radiating up the forearm

• Feeling of instability • Grinding, Clicking or

Snapping. • Weight bearing aggravating

the condition

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• Arthroscopy

– Gold standard!

– Accurate location of pathology

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• X-ray

• Variance +ve or negative?

• Traumatic - depending on the significance of the ulnar styloid fragment it may impact on the integrity of the DRUJ.

• CT – more costly but more effective assessment of the disruption of the DRUJ.

• CT through Lister’s tubercle

• A - symptomatic

• B - asymptomatic

• T1 water suppressed MRI showing the intact TFCC.

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• MRI

• T2 constants show the inflammation of the torn DRUJ complex.

• Class 1; Acute Traumatic

• Class 2; Chronic Degenerative

• TFCC tears associated with ulno carpal impaction are considered degenerative

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• Acute UNSTABLE DRUJ Palmers 1B 1C and 1D

• Conservative – Sugartong/Munster 6-8 weeks

Peripheral repairs +/- fractures and DRUJ instability

• Arthroscopic - All inside

• Arthroscopically Assisted

• Tendon Grafts for stability

• Open repair - Outside in technique

• Fixations Type dependant on fracture.

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• Goal: Optimise pain free wrist and forearm movement

• Oedema and Scar Management

• Use of supportive splint for comfort

• Minimise supination and pronation

• Isometric strengthening and progress as able

• Once stable……….

• Often pronation is limited for a period but is gained in function more easily

• Proprioceptive training ++

• Limit end range in function if clunk or click

• Avoid end range flexion as this can stretch ulnar TFCC tissues (Mead and Prosser 2003)

• Use splints with straps, Kinesio Taping, mechanical taping, wrist widget or custom wrist warrior.

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• Abductor Digiti Minimi is a much forgotten muscle of the ulnar side of the wrist.

• Remember any strengthening program for FCU must include the AbDM.

• Anatomically and biomechanically wrists are designed for function but not stability

• We need a stable structure to function

• Injury leads to instability

• Hand therapy or surgical role is to provide stability

• Equal strength = stability

• Congruence = stability

• Stability = function

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• Learn mechanism of injury

• Check xray PA and lateral

• MRI and arthroscopy are most sensitive

• Assess the stability!!!

• Decide on the splint

• Consider the treatment program +/- DTM

• Strengthen slowly and avoid UD

• Remember the wrist is proprioceptive

• CLINICALLY REASON!!!!

Thank you

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