Wrist Assesment

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Presentation of wrist assessment including pathologies, assessment tests and anatomy.

Transcript of Wrist Assesment

  • 1. By Sean Dadswell September 2010

2. ContentAimsRefresh anatomyBiomechanicsDiagnosisPathologyTestingTreatment 3. AimsTo refresh and improve knowledge of wrist anatomy and biomechanics and improve knowledge of wrist testing and treatments 4. Anatomy 5. Anatomy 6. Palmar Aspect Dorsal Aspect 7. Wrist Fundamentals for wrist stability Biomechanics difficult to Distal radius, Triangulardiscuss without knowledge ofanatomyFibrocartilage Complex (TFCC), distal ulna form stable base 3 Planes of movement Distal carpal row (hamate, All interdependent capitate,trapizium & trapizoid) Instability therefore simply Joined by strong interosseouswrist dysfunctionligs 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) 8. Forces through Wrist55% force transmitted through Radioscaphoid Joint35% through Radiolunate joint10% through TFCC 55%35%Biomechanics and 10% instability can alter this significantly 9. StabilityWrist highly mobileDepends on short, strong intrinsic interosseous ligs and longer extrinsic intercapsular ligsIntrincis ligs have origin and insertion in same carpal rowScapho-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 10. Extrinsic Ligaments PalmarV shaped volar focusing on lunate proximally with limbs attaching to ulna and radius and capitate distally attaching to rad and triq via scaphoidDorsal aspect also V shaped centring on the triquetrum Dorsum and contains radio-luno-triq segment and trapezium, trapezoid, scaph segmentsOther stability offered from flexor and extensor retinaculae and wrist flexors and extensors but these are not sufficient to prevent instability without ligs 11. MovementsDistal row one unit moves proximally when wrist is loadedCompresses proximal row which flexes scaophoid 2ndry to palmar extrinsicsSLL then causes lunate flexion as well as capitate pushing into flexTriquetrum then has flex force from LTL and ext force from distal row attachments. Flex force greater Therefore Triq flexes 12. Movement cont.Proximal row moves into flex Ulna deviation (UD): when distal row ext unless Head of capitate translates SLL insufficiency then thedorsally lunate will follow triquetrum Extends lunate (and into extension and scaphoid therefore scaph) flexes excessively Further UD causes contactConversely if LTL insufficientbetween hamate and triq then lunate follows which slides up and extends scahphoid into flex and triq=> further lunate ext. (palpable during movement) extendsRadial Deviation (RD):During wrist flex and ext Trapizoid and trapizium proximal row follows distal approximate to the radius row and push scaph into flexion => lunate flex 13. InstabilityResults from insufficiency of soft Scaphoid tissue restraints leadingLunate to abnormal movementsDifferent classificationsVISI or DISI Volar or Dorsalintercalated segmentinstability Relative lunate positionto scaphoid Intercalated ref tocapitate and lunateconnecting proximaland distal carpal rows 14. Instability cont. Numerous classifications andterminology 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) 15. Diagnosis History of trauma not always but most often present Failed resolution of wrist sprain Mechanism of injury (MOI) Angle of impact (FOOSH or fall backwards) Force (MPH, Height) Throwing injury Detailed swelling, location of pain (radial, ulna, global or centraland dorsal or volar), loss of function, treatments Grip strength Presence of click or snapping with or without pain Previous wrist injurys or fractures Paresthesia Xray Arthroscopy gold standard 16. X Ray findingsTerry Thomas signPositive Terry Thomas sign indicativescapholunate instability 17. X Ray findings contRing signPositive ring sign indicates scaphoid flexion (left) Normal (right) 18. X Ray findings contUlnar variancePositive ulnar varience (middle) and negative ulnar variance (right) In ulnar neutral wrist 18% load goes through ulnar side of wrist If unlar length increased by 2.5mm force increases to 42% If ulnar length reduced by 2.5mm force reducs to 4.3% (Sachar, 2008) 19. X Ray findings contGilulas arcDisruption of the first arc indicates luno triquetral instability via fractureor ligamentous instability 20. X Ray findings contDisruption of the second arc indicates scapholunate and lunotriqutralinstability. Even though there is a gap in the first arc it can still be trace as asmooth arc 21. X Ray findings contDisruption of the third arc indicates capitohamate joint 22. Xray findings contKeinbocks disease Kienbocks disease caused by AVN of the Lunate 23. PathologyCauses of wrist pain:OA (1st cmc, piso-triq) DRUJ disruptionRAUlnar impaction#s CRPSTFCC injury DeQuervainsCarpal tunnel syndromeUlnar nerve entrapmentANV scaphoid/LunateECU subluxationNerve rootPronator teres triggerpoints 24. TestingWatsons Scaphoid Shift TestTo identify scapho-lunate instability (scapho-lunateligament laxity/rupture)69% sensitive* 66% specific** (La Stayo and Howell 1995)As almost 1/3 false negatives and 1/3 false positives notvery accurate but no further studies done to validate(Marx et al, 1999)Needs to consider general hypermobility as more falsepositives in lax controls (Goldberg, 2006)*Sensitivity indicated tests ability to predict presence ofpathology**Specificity indicates tests ability to predict truenegatives/absence of pathology 25. 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 The Watsons test. will feel the scaphoidflex forward as the wrist is deviated radially 26. Luno-triquetral Ballotment Test(Regans 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 validateBallotment testing of carpal mobility showed good inter and intra tester reliability therefore useful is wrist assessment (Staes et al 2009) 27. Regans Test cont Simple PA of triquetrumon fixed Lunate MUST BE COMPAREDLEFT TO RIGHT The posterior side of the triquetrum is easily Positive if crepitus, pain found as one can palpate the insertional crest of the posterior radiotriquetral ligament. Just distalof laxity felt comparedto the crest lies the triquetrohamate spaceto opposite side The lunotriquetral ballottement test (Reagans test) 28. Dorsal Wrist SyndromeGoldberg et al 2006Palpation base 3rd MC and drop off capitate into fossa over scaphoidIndicated scaph OA or scapholunate injury/instabilityNo spec or sens 29. Pivot Shift Test for Mid-carpal JointTest for ant capsule and Dorsal to volar pressure interosseous lig injury applied to capitate with leading to capitate hand in full supination instability (Tuiana et al then moved from radial 1998; McGee, 1997)to ulnar to radialDescribed in textbooksdeviation only there no spec orPain or clunk indicates senspositive testMid carpal joints most likely falling onto flexed wrist 30. Anterior DrawReddy and Compson (2005) discuss lack of specificity in terms of individual structureMay indicate CICAnterior Draw test 31. Piano Key TestTest for Distal radioulnar joint (DRUJ) instabilityNo spec or sensAlthough Moriya (2009) found it to be valid in cadarvic studyDisruption of dorsal or palmar radioulnar ligPositive with more than 5mm difference in Piano Key Test movement compared to asymptomatic side 32. DRUJ Compression TestCompressive force applied to DRUJ in 15-30 degrees supinationWrist then pro and supinatedPositive with reproduction of pts symptomsIndicates DRUJ OATextbook description only 33. Shear Test for TFCCTFCC most common source of ulnar sided wrist pain and are eithertraumatic of degenerativeOccur with falls onto ulnarly deviated extended wrist or at extreme rotationOften related to +ve ulnar variance (Osteotomy required) Reddy and Compson (2005)Mini-symposium describsetest but no Spec or Sensalthough construct validityOK Indicated TFCCdegeneration or injury DRUJ held by examiner thenaxial load applied withUnlar deviation followed bypassive pro and supination Sachar (2005) discusses Positive test click or painpronation leading to ulnar abutment as increases positive ulnar variance 34. Palpation TFCCSachar (2008) found Specificity 87% Sensitvity 95%Indicative of ulnotriquetral lig injury or TFCC injury/degeneration 35. Ulnomeniscotriquetral Dorsal Glide(UMTDG)Indicateds TFCC injury Radius stabilised by66% sensitive examiner then using64% specificpinching motion between thumb andIdentified in study index finger of the tested againstopposite hand the piso- arthroscopy (La Stayo triquetral complex is and Howell, 1995) moved dorsally whistMay be beneficial to usethe ulnar is squeezed multiple testspalmarly 36. Piso-Triquetral Grind TestIndi