Wrist and Hand
MClin Sc
Comprehensive Musculoskeletal
Therapy
Objectives
• Review the functional anatomy of the wrist for the
purpose of application to clinical pathologies of the
region
• Review the classification of wrist instabilities relevant
to the clinical practice of musculoskeletal
physiotherapy
• Review the typical clinical pattern of presentation of
common instabilities of the wrist
• Review the clinical examination of the wrist in a
structured regional approach
• Review the general management approach of
instabilities of the wrist appropriate to the
physiotherapy setting
Anatomy of the Carpus
Ligamentous Anatomy - Classifications
• Subdivided into:
– Extrinsic ligaments i.e. radioscaphocapitate,
radiolunotriquetral (long radiolunate)
– Intrinsic ligaments (interosseous) i.e.
scapholunate, lunotriquetral
Ligamentous Anatomy - Classifications
• Further subdivided into:
– Radial ligaments-palmar surface
•
•
•
•
Radioscaphocapitate
Long radiolunate ligament
Radioscapholunate ligament
Short radiolunate ligament
Ligamentous Anatomy - Classifications
• Further subdivided into:
– Ulnar ligaments-palmar surface
• Ulnolunate ligament
• Ulnotriquetral ligament
• Ulnocapitate ligament
Ligamentous Anatomy - Classifications
• Further subdivided into:
– Dorsal ligaments
• Dorsal radiocarpal ligament
• Dorsal intercarpal ligament
Ligamentous Anatomy
Ligamentous Anatomy – Intrinsic
Ligaments
Ligaments-volar surface
Scapholunate and
Lunotriquetral Interosseous
Ligamentous Anatomy – Intrinsic
Ligaments
Interosseous Ligamentsvolar surface
Scapholunate and
Lunotriquetral
Ligamentous Anatomy – Intrinsic
Ligaments
Scapholunate interosseous
ligament-proximal portion
Scapholunate interosseous
ligament-volar aspect
Ligamentous Anatomy – Intrinsic
Ligaments
Scapholunate interosseous ligament and
Lunotriquetral ligament-distal aspect
Wrist Instabilities
Carpal Instabilities
Dissociative (C.I.D.)
– Scapholunate instability
(DISI)
– Lunotriquetral instability
(VISI)
– Note: Carpal Instability
Combined (C.I.C.)
Carpal Instabilities Non
Dissociative (C.I.N.D.)
– Capitolunate instability
(VISI, DISI)
– Radiocarpal instabilities
• palmar
• dorsal
• ulnar translocation
Wrist Instabilities
C.I.D.
– Instability between two
carpals within the same
carpal row
C.I.N.D.
– Instability between two
bones in different carpal
rows
• Radius and ulna with
proximal row
• Proximal with distal row
DISI or VISI classification based on rotation of lunate i.e. lunate
is dorsalflexed or volarflexed
Scapholunate Instability
• Scapholunate instability
• Rotary subluxation of
the scaphoid
• Scapholunate
dissociation
Scapholunate Instability
Dynamic instability
– apparent on clinical
examination only
– apparent on clinical
examination and
potentially stress
radiographs
Static instability
– apparent on clinical
examination
– apparent on both static
and stress radiographs
Scapholunate Instability
Mechanism of injury:
– force applied to the hypothenar eminence with
the hand in extension and ulnar deviation
– often occurs in the presence of excessive joint
laxity or local carpal weakness
– a force vector is generated which drives the
capitate between the scaphoid and the lunate
Mechanism of Injury
Midcarpal supination ensues leading to:
– stage II-partial perilunate dislocation
– stage III-complete perilunate instability
– stage IV-lunate dislocation
Pathology of Injury
• Interosseous
scapholunate
ligament-palmar and
dorsal
• Repetitious
movement following
injury
• May involve palmar
radiocarpal ligaments
(extrinsic system)
Clinical History
Clinical Pattern
– MOI: traumatic event (FOOSH) sometimes with
minimal initial symptoms
– MOI: microtrauma-repetitive motion, repetitive
loading in extension
– in the presence of other more traumatic events to
the radial side of the wrist (i.e. distal radius
fracture)
– primary degenerative arthritis (rheumatoid)
– Often localized pain dorsally in region of scaphoid/
lunate
– Often aggravated by loading in extension and may
complain of lack of confidence with loading
Clinical Examination
• Scapholunate
interval palpation
with localized
tenderness
• May be localized
swelling of region
Scapholunate Instability
Intermittent painful
loud snap during
motion
– displacement of
the proximal pole
of the scaphoid as
it subluxes past
the dorsal rim of
the radius
Clinical Examination
• Range of motion-may
have some limitation
and pain on end
range but can be
normal
• Grip strength-can
show some reduction
but can be normal
• These findings can be
deceptive and
misleading of the true
underlying pathology
Clinical Examination
Scaphoid shift test
• provocative with
pain and
apprehension in
comparison to
the uninvolved
side
Clinical Examination
• Scaphoid lift test,
scaphoid thrust
test or
• Scapholunate
ballottementincreased pain
and sense of
instability
Clinical Examination
• Normal
radiographfrontal
Clinical Examination
• Radiographsfrontal
– scapholunate gap-A/P
– cortical “ring” sign
– extension of the
lunate (quadrilateral
appearance)
– loss of normal
scapholunotriquetral
correlation
– decrease in the
scaphoid ring
– negative ulna variance
Clinical Examination
Normal
radiograph-lateral
Clinical Examination
Radiograph-lateral
– Scaphoid flexed
(greater than 70°
with respect to
the lunate)-in
some cases the
proximal pole is
subluxed on the
dorsal rim of the
radius
– lunate in
extension
Treatment
• Isolated rotatory
subluxation of the
scaphoid-acute
– conservative vs.
surgical
management
Lunotriquetral Instability
• Lunotriquetral
injury occurs as
continuum from
light perforations
to fixed carpal
instability
• Most severe form
of LT dissociation
forms a static
volar intercalated
instability (VISI)
Lunotriquetral Instability
Associated injuries:
DRUJ instability
arthritis
TFCC injury
TH instability
ulnocarpal
impingement
– ECU tendonitis/
instability
– ulnar neurovascular
syndromes
–
–
–
–
–
Carpal Mechanics
Ulnar deviation:
– distance between the
hamate and ulna
decreases
– triquetrum firmly
engages in the hamate
– triquetrum forced into
extension, supination
and volar glide and
brings the lunate along
Carpal Mechanics
Ulnar deviation
– capitate is dorsal to
the flexion/extension
axis-flexes
– STT articulation
brings the scaphoid
into extension
– RSC ligament
tightens- facilitates
proximal row
extension
Carpal Mechanics
Radial Deviation:
– proximal row
flexion/ distal row
extension
– ulnar translation
– scaphoid under
compression and
RSC ligament
relaxed allows the
scaphoid to flex
Carpal Mechanics
Radial Deviation:
– triquetrum slides
dorsally into flexion
– dorsal RT ligament
becomes taut
increasing
compression of the
LT joint which limits
lunate motion into
flexion
Pathomechanics
Results in:
– lunate flexion in
neutral and in
radial deviation
– diminished TH
contact in ulnar
deviation
Mechanism of Injury
• Force to palmar
radial aspect with
wrist in DF and UDwhich will typically
result in DISI first
• Hypothenar force
with the wrist in
extension and RDintercarpal
pronation
Clinical Findings
Symptoms
– history of specific
injury usually present
– ulnar sided wrist pain
– intermittent and
prominent click with
deviation and
rotation of the wrist
– sense of instability,
weakness, ulnar
nerve symptoms
Clinical Examination
• May be observable
VISI deformity (fork
shaped)
• Palpable painful click
with radioulnar
deviation
• Ulnar deviation in
pronation with axial
compression will elicit
pain and instability
Clinical Examination
• Palpation will reveal
localized tenderness
• Ulnar side
compression test
Clinical Examination
Lunotriquetral
Ballottement
Test
Clinical Examination
• Lunotriquetral
Ballottement
Test or
• Lunotriquetral
dorsal palmar
shear test
Clinical Examination
Other symptoms:
– limited ROM
– decreased grip strength on repeated
testing
– crepitus on radioulnar deviation
– positive ulnocarpal impingement
secondary to associated ulna plus variant
Carpal Instability Nondissociative
(C.I.N.D.)
Often referred to as:
– midcarpal instability
– PCR instability
– capitolunate instability
– triquetrohamate instability
Carpal Instability Nondissociative
(C.I.N.D.)
• Currently incorporates all carpal disruptions that
result in instability between the carpal rows vs.
within the carpal row
• Results from laxity of extrinsic ligamentous system
vs interosseous ligaments
Incidence:
– less common than scapholunate instability
– at least or perhaps more common than lunotriquetral
instability
– long term consequences i.e. degenerative changes
unknown
Pathomechanics
• Proximal carpal row
dependent on
extrinsic ligaments
for smooth
transition of
proximal carpal row
during radial and
ulnar deviation
Pathomechanics
• Proximal carpal
should make a
smooth transition
from flexion to
extension from RDUD
• C.I.N.D. results in
sudden or no
transition of motion
Mechanism of Injury
•
•
•
•
•
•
majority sustain extension injury
flexion
distraction
compression
rotation
no specific history of injury in one
half of these patients
Clinical Findings
Symptoms
– complain of
painful clunk
particularly
during radial
ulnar deviation
or circumduction
– may have
bilateral
complaints
Clinical Findings
Examination
– positive catch up clunk test
Clinical Findings
• Compression of
the ulnar
snuffbox
against the
lunate during
radial to ulnar
deviation will
often eliminate
the clunk
Clinical Findings
• Compression of
the ulnar
snuffbox
against the
lunate during
radial to ulnar
deviation will
often eliminate
the clunk