Wrist Assesment


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

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  • Hi Sean, Just Curious To Know Where You Found My Disabled Left Hand/Wrist,Arm. Disability Photo In Your Article Page 30 Of 48 ?. As Its My Disabled Hand/Wrist,Arm, & Belongs To Me & Is Me, Just Curious To Know Where Ya Found It ?. Interesting Article Too :)
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Wrist Assesment

  1. 1. By Sean Dadswell September 2010
  2. 2. ContentAimsRefresh anatomyBiomechanicsDiagnosisPathologyTestingTreatment
  3. 3. AimsTo refresh and improve knowledge of wrist anatomy and biomechanics and improve knowledge of wrist testing and treatments
  4. 4. Anatomy
  5. 5. Anatomy
  6. 6. Palmar Aspect Dorsal Aspect
  7. 7. Wrist Fundamentals for wrist stability Biomechanics difficult to  Distal radius, Triangular discuss without knowledge of anatomy Fibrocartilage 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 interosseous wrist dysfunction 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)
  8. 8. Forces through Wrist55% force transmitted through Radioscaphoid Joint35% through Radiolunate joint10% through TFCC 55% 35%Biomechanics and 10% instability can alter this significantly
  9. 9. StabilityWrist highly mobileDepends 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
  10. 10. Extrinsic Ligaments Palmar‘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 Dorsum 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
  11. 11. MovementsDistal 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
  12. 12. Movement cont.Proximal row moves into flex Ulna deviation (UD): when distal row ext unless  Head of capitate translates SLL insufficiency then the dorsally lunate will follow triquetrum  Extends lunate (and into extension and scaphoid therefore scaph) flexes excessively  Further UD causes contactConversely if LTL insufficient between hamate and triq then lunate follows which slides up and extends scahphoid into flex and triq => further lunate ext. (palpable during movement) extends Radial 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. 13. InstabilityResults from insufficiency of soft Scaphoid tissue restraints leading Lunate to abnormal movementsDifferent classificationsVISI or DISI  Volar or Dorsal intercalated segment instability  Relative lunate position to scaphoid  Intercalated ref to capitate and lunate connecting proximal and distal carpal rows
  14. 14. 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)
  15. 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 central and dorsal or volar), loss of function, treatments Grip strength Presence of click or snapping with or without pain Previous wrist injury’s or fractures Paresthesia Xray Arthroscopy gold standard
  16. 16. X Ray findingsTerry Thomas sign Positive Terry Thomas sign indicative scapholunate instability
  17. 17. X Ray findings contRing signPositive ring sign indicates scaphoid flexion (left) Normal (right)
  18. 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. 19. X Ray findings contGilula’s arcDisruption of the first arc indicates luno triquetral instability via fractureor ligamentous instability
  20. 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. 21. X Ray findings cont Disruption of the third arc indicates capitohamate joint
  22. 22. Xray findings contKeinbock’s disease Kienbock’s disease caused by AVN of the Lunate
  23. 23. PathologyCauses of wrist pain: OA (1st cmc, piso-triq) DRUJ disruption RA Ulnar impaction #’s CRPS TFCC injury DeQuervain’s Carpal tunnel syndrome Ulnar nerve entrapment ANV scaphoid/Lunate ECU subluxation Nerve root Pronator teres trigger points
  24. 24. TestingWatson’s Scaphoid Shift TestTo 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
  25. 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. 26. Luno-triquetral Ballotment Test(Regan’s Test)Identifies laxity of luno-triquetral ligSensitivity 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)
  27. 27. Regan’s Test cont Simple PA of triquetrum on fixed Lunate MUST BE COMPARED LEFT 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 distal of laxity felt compared to the crest lies the triquetrohamate space to opposite side The lunotriquetral ballottement test (Reagans test)
  28. 28. Dorsal Wrist SyndromeGoldberg et al 2006Palpation base 3rd MC and drop off capitate into fossa over scaphoidIndicated scaph OA or scapholunate injury/instabilityNo spec or sens
  29. 29. Pivot Shift Test for Mid-carpal JointTest 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 radialDescribed in textbooks deviation only there no spec or Pain or ‘clunk’ indicates sens positive testMid carpal joints most likely falling onto flexed wrist
  30. 30. Anterior DrawReddy and Compson (2005) discuss lack of specificity in terms of individual structureMay indicate CIC Anterior Draw test
  31. 31. Piano Key TestTest for Distal radioulnar joint (DRUJ) instabilityNo spec or sensAlthough Moriya (2009) found it to be valid in cadarvic studyDisruption of dorsal or palmar radioulnar ligPositive with more than 5mm difference in Piano Key Test movement compared to asymptomatic side
  32. 32. 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 OATextbook description only
  33. 33. Shear Test for TFCC•TFCC most common source of ulnar sided wrist pain and are eithertraumatic of degenerative•Occur with falls onto ulnarly deviated extended wrist or at extreme rotation•Often related to +ve ulnar variance (Osteotomy required) 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 Sachar (2005) discusses Positive test click or pain pronation leading to ulnar abutment as increases positive ulnar variance
  34. 34. Palpation TFCCSachar (2008) found Specificity 87% Sensitvity 95%Indicative of ulnotriquetral lig injury or TFCC injury/degeneration
  35. 35. Ulnomeniscotriquetral Dorsal Glide(UMTDG)Indicateds TFCC injury Radius stabilised by66% sensitive examiner then using64% specific pinching motion between thumb andIdentified in study index finger of the tested against opposite hand the piso- arthroscopy (La Stayo triquetral complex is and Howell, 1995) moved dorsally whistMay be beneficial to use the ulnar is squeezed multiple tests palmarly
  36. 36. Piso-Triquetral Grind TestIndicates 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 Piso-trquetral grind test:Nakamura (2001) describes Examiner grips pisiform principle as accurate but between thumb and index offers no spec or sens and rotates whilst compressing joint. Positive result is pain
  37. 37. Finklestein’s TestIndicates 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
  38. 38. CMC Grind TestIndicates 1st CMC joint OANo spec or sens availableNeed 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
  39. 39. Carpal TunnelsyndromeMost common nerve entrapment with prevalence upto 6%Compression of median nerve beneath the transverse carpal LigPredominantly 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)
  40. 40. Phalen’s TestSensitivity 64-75%Specificity 75-94%(Boland and Kiernan, 2008; Tetro et al, 1998)Both studies reportPositive test reproduction of pt S&S Phalan’ s test position held for 60 seconds
  41. 41. Tinel’s TestSensitivity 74%Specificity 91%Direct tapping over transverse carpal lig with finger or reflex hammerNo conscensous on number of taps Tinel’s testPositive with reproduction of S&S
  42. 42. Carpal Compression TestSensitivity 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)
  43. 43. Ulnar Nerve EntrapmentGuyons canal syndrome is an entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyons 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
  44. 44. Treatment for Instability(Minimal RCT evidence for concervative treatments)Incomplete lig tears can be Carlsen and Shin (2008) splinted for 6-8/52 recommend stages to repairsGoldberg (2006) reported depend on soft tissue quality:  Lig repairs/Anatomical 500 hand surgeons agreed reconstruction for acute acute or chronic wrist injury with good soft tissue instability should be treated  Salvage* ops where tissue is surgically poorMain surgery are:  Salvages ops where  Lig repairs significant OA or non  With or without K Wire reducable deformity exsists  With or Without *Salvage ops ref to intercarpal Capsulodesis arthrodesis, total wrist arthrodesis
  45. 45. Other Surgical Options (not specific toinstability) Ulnar osteotomy: can If non-union occurs tighten TFCC complex or further options are: reduce positive ulnar  Radial styloidectomy variance  Excision of the proximal Pisiformectomy: for OA fragment CTS release  Proximal row Scaphoid ORIF: necessary carpalectomy  Bone graft in unstable prox pole #’s as  Total or partial 55-95% => AVN arthrodesis  Vascular bone graft (to revascularise scaphoid)
  46. 46. Conservative treamentsCTS TFCC injuries Splinting (night) Avoid aggs Oral steroids Rest Wrist mobs Splinting Injections Injection All offer good short Arthroscopic term outcomes debridment (66-87% success increased to 87-(O’conner et al, 2003; 99% with ulnar Marshall et al, 2007) osteotomy)Surgery better than splinting (Verdugo et al, 2008)
  47. 47. 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)