hand therapy management of wrist...

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Hand Therapy Management of Wrist Instability

Aviva Wolff, EdD, OTR, CHT Clinician Scientist

Leon Root, MD Motion Analysis Laboratory Hospital for Special Surgery Impairment Mechanism

Design

Testing

Functional Improvement

Development of Rehabilitation Approach

Impairment

Mechanism

Design and testing

Improvement in function

Science informs practice

WRIST INSTABILITY

Rehabilitation

Science of proprioception

E Hagert

Roles of the muscles in carpal

stability

M Garcia-Elias

Wrist Kinematics and DTM

Wolfe

Individual occupational

needs/expectations

Mancuso

How can an understanding of wrist motion lead to better

treatment and rehab?

Why is it important to understand carpal motion?

• Understand effect of injury on motion

Surgical planning

• Surgical approach selected based on motion

Early rehab

• Minimize motion at repaired/injured structures

Late rehab

• Maximize path of motion

First, Know and Understand the SCIENCE

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Anatomy Biomechanics Kinematic

Studies (DTM)

Proprioception Dynamic

Carpal Stability

ANATOMY

Scapho-Lunate

Mid-carpal DRUJ

Instability Patterns

Courtesy of Primal Pictures

carpus

DRUJ

metacarpals

radius ulna

R wrist,

palmar

view

Distal row

Proximal row

RC Joint

MC Joint

1. Motion occurs primarily at RC and MC joints 2. Ligaments are important primary stabilizers

Proximal Row = “intercalated segment” Motion is dependent on mechanical signals from ligaments

Courtesy of Scott Wolfe, MD

Scapho-lunate interosseous ligament (SLIL): Primary stabilizer

• ACL of carpus

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Know thy S-L Ligament

Scaphoid Lunate

Scapholunate ligament

Photo courtesy of Eugene Ek, MD

Resected


Dissociation


Repair


Photos courtesy of Eugene Ek, MD

Know and understand the anatomy Scapho-lunate interosseous ligament (SLIL): Primary stabilizer

• ACL of carpus

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Scapho-lunate Ligament

S L Dorsal 260N***

Volar 118N

Fibrocart 63N

Courtesy of Eugene Ek, MD and Christopher Dy, MD

Take home points: Scapho lunate Interosseous Ligament (SLIL):

SLIL is a primary wrist stabilizer - mechanics

SLIL is richly innervated

• Protective reflex function causing diminished dynamic stability

Traumatic partial SLIL tears result in impaired proprioception

Traumatic complete disruption leads to SL dissociation


Studies (DTM)


Carpal Stability

Biomechanics

Scapho-Lunate

Mid-carpal DRUJ

Instability Patterns Carpal Motion

scaphoid

lunate

triquetrum

SLIL LT Courtesy of Scott Wolfe, MD

Distal carpal motion follows fingers

Scaphoid follows distal motion

Lunate follows passively (SLIL)

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KINEMATICS: “The promiscuous lunate” Ken Flowers

scaphoid

lunate

triquetrum

SLIL LT


KINEMATICS: SL Dissociation

scaphoid

lunate

triquetrum

SLIL LT


KINEMATICS: SL Dissociation

scaphoid

lunate

triquetrum

SLIL LT

Kitay, A., Wolfe, S.W. Scapholunate instability. JHS 2012

DISI

KINEMATICS: LT Dissociation

scaphoid

lunate

triquetrum

SLIL LT Courtesy of Scott Wolfe, MD

KINEMATICS: LT Dissociation

scaphoid

lunate

triquetrum

SLIL LT

VISI

Spectrum of disability

DISI Dissociation Diastasis Disaster

Kitay, A., Wolfe, S.W. Scapholunate instability. JHS 2012

Complete disruption of SLIL and distal STT support

Pathologic extension of lunate Dorsal interacalated segmental instability

DISI

Scapholunate Adavanced Collapse SLAC

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Take Away Points For pain relief and further degeneration

• No good options

Salvage procedures limit motion

• Proximal row carpectomy

• Range of intercarpal fusions

• 4 corner fusion/midcarpal arthrodesis

• STT fusion

Better strategy = prevention, early diagnosis

Early repair of SL ligament prevents further degeneration

Instability Midcarpal

Midcarpal Instability

• Involves both MC and RC joints • Entire row is mal-aligned • Involves multiple ligaments

Midcarpal Instability: Types

CIND-VISI CINC-DISI

CIND-Combined

CIND-Adaptive

Palmar

(Ulnar MCI)

(CIND-VISI)

Dorsal

(CLIP)

(CIND-DISI) Combined Adaptive

Midcarpal Instability: Variants CIND VISI Most common

No specific injury

“snapping” wrist

“catch-up Clunk”

Midcarpal shift test

70% ligament laxity

Non-operative treatment

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Studies (DTM)


Carpal Stability

Kinematics: Carpal Movement

in DTM Plane

Kinematics Studies: HSS, Brown University

Micro Kinematics - Brown Study of individual carpal motion

– Micro Kinematics Cadaveric studies (Crisco and

Wolfe) In Vivo – CT – Markerless bone

registration (Crisco and Wolfe)

Macro Kinematics - HSS Development of biomechanical

and kinematic model and solution to measure wrist motion

Study of functional wrist motion – motion lab

Kinematics Studies: Take Away

• Dart-thrower’s motion (DTM)

• Minimal scaphoid and lunate motion during DTM plane

• Early DTM safe in protected range

• DTM impact on functional activities

• Circumduction Envelope – task specific quadrants of motion

Coupled Wrist Motion

• Alters kinematics and functional task performance

• Findings from PRC and 4 CF patients

Surgical reconstruction of SLAC

Identification of task specific

quadrants of motion

Singh, JHS, 2014 Wolff, JHT, 2014

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Studies (DTM)


Carpal Stability

Proprioception

Dr Elisabet Hagert Karolinska Institute, Stockholm

Seminal work in identifying innervation patterns in the wrist ligaments

• Used advanced staining techniques and immunohistochemical markers to identify presence of mechano receptors in each of the 15 wrist ligaments

• US and fine wire electrode to stimulate ligaments in healthy volunteers

Ligamento-muscular reflexes

Sensorimotor control of the wrist

Proprioceptive Pathways Dialogue between muscles and ligaments

Hagert, E JHT 2010

Immediate Pathway

Spinal level

Stimulation of mechanoreceptors in

intra-articular ligaments

Activates control of muscles around the

joint

Secondary Pathway

Supraspinal

Cerebellar unconscious

integration of somatosensation and

proprioception

Cortical- conscious

Innervation Distribution in the Wrist

Hagert, E JHT 2010

Intrinsic ligaments

Richly innervated

Triquetral, dorsal

Dorsal SLIL (Mataliotakis,

JHS, 2009)

Important sensory

Extrinsic ligaments

Radio-volar

Collagenase, dense

Poorly innervated

mechanically important

Dynamic Carpal Stability

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Can the proximal row be dynamically stabilized? Role of Muscles in Carpal Stability • SL INJURY Flexion and Pronation of

Scaphoid

• Scapholunate “friendly” structures = SUPINATE – FCU, FCR, APB, ECRL FCR

• Scapholunate “unfriendly” structures =

PRONATE – ECU

Garcia-Elias et al

Indications/Contraindications

• Indication – Predynamic/Partial SL Injury

(secondary ligaments intact – dorsal)

– Post-Surgical repair

• Contra-Indication – Complete SL tears – Dorsal translation of scaphoid

Then, apply that knowledge to your TREATMENT


Studies (DTM)


Carpal Stability

Cautionary Tale

Garcia Elias et al 2014

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Cautionary Tale

Garcia Elias et al 2014

Limit motion at S-L joint (biomechanics) Splints that limits motion to DT plane ONLY radial extension to neutral in SL acute injury and early post-repair

Courtesy of Hamish Anderson Lynn Feehan, JHT 2016 Federica Braidotti, JHT 2015

Rigid tape for pre-dynamic S-L instability

Poretto-Lourke, JHT 2016

Limit activities to DT plane Limit to radial extension to neutral in early phase

Proprioception

Begin proprioceptive training for injured ligaments

Goal:

Increase/develop proprioceptive awareness

and joint position sense

Mirror therapy

Contralateral

Creates illusion of motion

Stimulates somatosensory

cortex

Visual occlusion exercises

Eliminate visual and auditory

cues

Motor imagery

Hagert, JHT 2010

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Smartphone Apps

Alger and Valdes, JHT 2016

Dynamic Muscle Stability

Case Example 1

56 y/o, female

10 months radial wrist

pain

Full ROM

Her midcarpal joint is only

minimally maligned

Isometric stabilization exercises in PRONATION

ECRB APL

FCU

Case Example 2

60 y/o, male, Orthopedic Surgeon

6 month old injury to non-dominant right wrist, hit backhand shot, felt sharp pain

Pain with resistive activities, able to work with moderate ache, and able play golf.

Worried about progression and potential inability to play sports during retirement Left and right wrist neutral laterals,

both demonstrate 10 deg RLA, 70 deg SLA and no dorsal scaphoid translation

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Right injured wrist PA

Right injured ulnar dev PA

Right injured grip

Template

vSLIL intact but stretched

dSLIL intact but stretched RSC and LRL intact and robust

Consecutive cuts of radioscaphoid fossa showing no dorsal translation

Cartilage-sensitive sequencing showing no cartilage loss

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DRC intact and robust.

DIC attenuated but intact and lunate and scaphoid attachments on sagittal images appear to be intact.

DIC

DRC

Template

DIC attenuated but intact and lunate and scaphoid attachments on sagittal images appear to be intact. Distal band of DIC robust and intact

DIC distal band. dST?

Later Phase

Later phase (stable joint and healed ligaments)

Biomechanics

Activities that maximize

circumduction envelope

Begin strengthening in DT plane

Proprioception

Isokinetic – BTE CPM PRIMUS

Isokinetic exercises

Neuromuscular Rehab

Reactive muscle activation (RMA)

Perturbation exercises

(plyometrics)

Oscillatory Devices (body blade, weighted

pipe, power ball (Balan et al 2008)

Circumduction

Maximizing Circumduction Envelope

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Strengthening in DT plane

Holmes et al, 2016

Proprioception

Kinesthetic awareness

Smallest change in joint angle needed to

elicit a conscious awareness of joint

motion

BTE PRIMUS – CPM

Passive mode

Isokinetic mode

• Performed at constant angular speed

Neuromuscular Purpose

Promote motion in muscles that are joint protective while avoiding activation of muscles that are joint damaging

Use dynamic muscular compression

Regain smooth motion after trauma or surgery

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Oscillatory devices

Power Ball (Balan et al

2008)

Body Blade

Weighted pipe

Perturbation exercises

plyometrics

Reactive muscle activation (RMA)

Neuromuscular Rehab (unconscious) Wrist Stabilization Exercises

Dynamic Muscle Stability

Holmes et al 2016

Neuromuscular Rehab Neuromuscular rehab: closed chain

Karagiannapolous, JHT, 2016

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Closed Chain Sports Specific

Multiplanar movements

Position specific maneuvers - shooting guard, power forward, center position etc..

Flexible protective wrist support Holmes, HT, 2016

Summary

Need clinical studies in large cohorts to compare these treatments to previous standards of care

Many unanswered questions

Great progress in understanding role of proprioception and neuromuscular joint control

Great progress in understanding role of muscles in dynamic carpal stability

Great progress in understanding link between kinematics and carpal function

Challenge

• Hincapie, JHT 2016

• Anderson, JHT 2016

• Holmes, Hand Therapy 2016 (n=7)

Small case reports n=1 studies

Let’s begin to report our outcomes

Or we will never know….

Treatment recommendations For Mid-Carpal Instability

Stabilization Splint

Direct dorsal force on pisiform and triquetrum

Depress ulnar head

Mid-Carpal Instability

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Splinting for midcarpal instability (CIND – VISI)

Courtesy of Emily Altman, CHT, DPT

Splinting for midcarpal instability (CIND – VISI)

• Why this works?

• Proximal row is in VISI

• Splint directs dorsal force on pisiform/triquetrum and depress ulnar head

• Shift row into dorsal alignment


Dynamic Splint


Ulnar boost splint

Ulnar boost splint Challenges

Difficult to fabricate

Hard to control VISI with static splint

Skin cannot tolerate the pressure required to push these bones into proper alignment

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Selected References • Esplugas M, Garcia Elias M, Lluch A, et al. Role of muscles in the

stabilization of ligament-deficient wrists. J Hand Ther 2016; 29:166-74. • Hagert E, Lluch A, Rein S. The role of proprioception and neuromuscular

stability in carpal instabilities. J Hand Surg Eur Vol. 2016; 41: 94-101. • Kitay A, Wolfe SW. Scapholunate instability: current concepts in diagnosis

and management. J Hand Surg. 2012;37(10):2175-2196 • Rainbow MJ, Wolff AL, Crisco JJ, Wolfe SW. Functional kinematics of the

wrist. J Hand Surg Eur Vol. 2016;41(1):7-21 • Salva-Coll G, Garcia-Elias M, Hagert E. Scapholunate instability:

proprioception and neuromuscular control. J Wrist Surg 2013; 2:136-40 • Wolfe AL, Wolfe SW: Rehabilitation for scapholunate injury: application of

scientific and clinical evidence to practice. J Hand Ther 2016; 29:146-153.

HSS Wrist Biomechanics Team

LRMALab

Scott Wolfe, MD

Howard Hillstrom, PhD

Aviva Wolff, EdD

Andrew Kraszewski, PhD

Andreas Kontaxis, PhD

Sherry Backus, PT

Thank you

[email protected]

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