ic05-l: ulnar wrist pain - assh
Post on 23-Jul-2022
4 Views
Preview:
TRANSCRIPT
All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
IC05-L: Ulnar Wrist Pain
Moderator(s): William B. Kleinman, MD
Faculty: Nancy M. Cannon, OTR, CHT, Thomas J. Fischer, MD, Sanjeev Kakar, MD,
FAOA, and David S. Zelouf, MD
Session Handouts
Thursday, October 01, 2020
75TH VIRTUAL ANNUAL MEETING OF THE ASSH
OCTOBER 1-3, 2020
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: meetings@assh.org
9/24/2020
1
IC05: Ulnar Wrist Pain
William B. Kleinman, MD
Speaker has no relevant financial relationships with commercial interest to disclose.
IC05L - Advanced
ANATOMY and BIOMECHANICS at the DISTAL END of the ULNA, as UNDERSTOOD in 2020
Moderator – William B. Kleinman, M.D.The Indiana Hand to Shoulder Center
Indianapolis
1
2
3
9/24/2020
2
FOREARM AXIS-OF-ROTATION
RADIUS HEAD TO ULNA FOVEA
HINGED, GINGLYMUS
ULNO-TROCHLEAR JOINT
FOREARM AXIS-OF-ROTATION
RADIUS HEAD TO ULNA FOVEA
4
5
6
9/24/2020
3
ULNA FOVEA
Axis-of-
Rotation
THE “BOWED” RADIUS
7
8
9
9/24/2020
4
ULNA
MINUS
VARIANCE
ULNA
PLUS
VARIANCE
10
11
12
9/24/2020
5
(Radius Shorter)
(Radius Longer)
13
14
15
9/24/2020
6
16
17
18
9/24/2020
7
19
20
21
9/24/2020
8
22
23
24
9/24/2020
9
ULNA
RADIUS/CARPUS/HAND
25
26
27
9/24/2020
10
DEEP FIBERS OF THE TFC(Ligamentum Subcruentum)
28
29
30
9/24/2020
11
CARL-GORAN HAGERT
Scand J Plast Reconstr Surg: 1994
31
32
33
9/24/2020
12
SUPINATION
34
35
36
9/24/2020
13
DIAGNOSTIC WORK-UP FOR SUSPECTED INJURIES OF THE TFC
o HISTORYo PHYSICAL EXAMINATION
- POINT TENDERNESS- SHUCKING INSTABILITY- PIANO KEY SIGN- STRESS-TESTING THE DEEP FIBERS (Ligamentum subcruentum)
o PLAIN X-RAYSo BONE SCANo MRIo ARTHROSCOPY
GOLD STANDARD
37
38
39
9/24/2020
14
40
41
42
9/24/2020
15
43
44
45
9/24/2020
16
WHAT ABOUT AVULSION OF THE CRITICAL DEEP PORTION?
46
47
48
9/24/2020
17
Superficial TFCC INTACT
Ligamentum Subcruentum TORN
Superficial TFCC INTACT
Ligamentum Subcruentum TORN
49
50
51
9/24/2020
18
52
53
54
9/24/2020
19
RIGHT WRIST
PROXIMAL
DISTAL
55
56
57
9/24/2020
20
THE UNSALVAGEABLE TFC
58
59
60
9/24/2020
21
Nancy Cannon, OTR, CHTIndianapolis, IN
Indiana Hand to Shoulder Center
Sanj Kakar, M.D.Rochester, MN
The Mayo Clinic
Dave Zelouf, M.D.Philadelphia, PA
Philadelphia Hand Center
Tom Fischer, M.D.Indianapolis, IN
Indiana Hand to Shoulder Center
61
62
63
9/24/2020
22
Sanjeev Kakar, MD, FAOA
Royalty: Arthrex
Consulting Fees: Arthrex
Ownership Interests: Sonex
My Preferred Surgical Approach to Repair or
Reconstruct the Damaged, Dysfunctional Triangular
Fibrocartilage Complex
A Case Based Approach
Sanj Kakar MD, FAOA
Professor of Orthopaedic Surgery
Mayo Clinic
Rochester, MN USA
Acknowledgements
▪ Marc Garcia-Elias MD, PhD
▪ Richard Berger MD, PhD
64
65
66
9/24/2020
23
35F RHD s/p rt wrist fusion & failed foveal
TFCC repair with ulnar wrist pain
Three Key Questions To Ask
Yourself When Managing Ulnar
Wrist Pain?
67
68
69
9/24/2020
24
Categorization Of Ulnar Wrist Pain
• Pain
• Pain with instability
• Pain with arthritis
Distal Radioulnar Joint Pathology
A Difficult Problem To Treat !!!!
▪ LOW BACK PAIN OF THE WRIST
▪ Multifactorial pathology
• Bony Deformity
• Cartilage injury
• TFCC disorders
• Soft tissue injury e.g. ECU instability
▪ These are NOT mutually exclusive
• Failure to recognize this → suboptimal results
70
71
72
9/24/2020
25
✓ Bone deformity ? YES / NO
✓ Cartilage damage ? YES / NO
✓ TFCC injury ? YES / NO
✓ Unstable ECU tendon ? YES / NO
Unstable
ECU
Cartilage
defect
Bone deformity
TFCC
injury
Four Important Questions To Ask
Forget About The Acuity Of The
Injury When Deciding Upon Repair
Or Reconstruction
Is The Quality Of The Tissue Able To
Withstand The Repair?
73
74
75
9/24/2020
26
How Do You Test Foveal
Attachment?
▪Arthroscopic assessment
• Hook test Ruch et al.
• Trampoline test Hermansdorfer & Kleinman
• DRUJ arthroscopy Nakamura
– But what if it’s scarred down peripherally?
Hook Test
76
77
78
9/24/2020
27
Trampoline Test
79
80
81
9/24/2020
28
DRUJ Arthroscopy
Easier Way
▪ Scope (1.9 mm) in 3-4 portal
▪ Needle in presumed DRUJ portal under
TFCC
• Incise skin
in under
TFCC
▪ Scope in DRUJ portal
DRUJ Arthroscopy
82
83
84
9/24/2020
29
Case
RHD s/p ATV accident
CRPP (paeds ortho)
85
86
87
9/24/2020
30
4 months later
88
89
90
9/24/2020
31
✓ Bone deformity ? YES / NO
✓ Cartilage damage ? YES / NO
✓ TFCC injury ? YES / NO
✓ Unstable ECU tendon ? YES / NO
Unstable
ECU
Cartilage
defect
Bone deformity
TFCC
injury
One of Four Factors Injured & must be Addressed
Negative Trampoline Sign & Hook Test
91
92
93
9/24/2020
32
Making DRUJ Portal
DRUJ Arthroscopy Showing Foveal Deatachment
Working DRUJ Portal
94
95
96
9/24/2020
33
Debridement of Fovea
Needle Through Ulnar Tunnel
Foveal Repair
97
98
99
9/24/2020
34
Immediate Stability
100
101
102
9/24/2020
35
RHD s/p fall
103
104
105
9/24/2020
36
8 months later, ↑ ulnar wrist pain refractory to
non operative treatmentUlnar impaction & TFCC tenderness
DRUJ Examination
✓ Bone deformity ? YES / NO
✓ Cartilage damage ? YES / NO
✓ TFCC injury ? YES / NO
✓ Unstable ECU tendon ? YES / NO
Unstable
ECU
Cartilage
defect
Bone deformity
TFCC
injury
Four Important Questions To Ask
106
107
108
9/24/2020
37
109
110
111
9/24/2020
38
Wafer Procedure
112
113
114
9/24/2020
39
Indications
▪ Failed conservative treatment
▪ DRUJ instability
▪ Reparable TFCC with foveal disruption
Contra- indications
▪ Irreparable TFCC
▪ DRUJ arthritis
115
116
117
9/24/2020
40
What If The TFCC Is Irreparable?
118
119
120
9/24/2020
41
3 drill holes
- Ulnar tunnel
- Volar margin of
sigmoid notch to BR
footprint on radius
- Dorsal margin of
sigmoid notch to BR
footprint
121
122
123
9/24/2020
42
Back To Our Case
35F RHD s/p rt wrist fusion & failed foveal
TFCC repair with ulnar wrist pain
124
125
126
9/24/2020
43
1.35 mm Fibertack Anchors
Ulnar Head Within Calamari
127
128
130
9/24/2020
44
132
133
134
9/24/2020
45
▪ 4 pts
• 10 DRUJ arthritis
▪ Follow up: 15M-26M
▪ ROM:
• Pronosupination: 1580
• Flexion-extension: 1230
• ↑ function & ↓ pain
• NO revisions
Summary
Forget About The Acuity
It’s The Quality Of The Tissue That
Determines Repair Versus
Reconstruction?
135
136
137
9/24/2020
46
Thank You For The Privilege Of Your Time
Email: Kakar.sanjeev@mayo.edu
DISCLOSURES
Thomas J. Fischer, MD
Consulting Fees: Synthes/Depuy
When Is an Arthroscopic TFCC
Repair Indicated, and When Do I
Feel That Only an Open TFCC
Repair Should Be Performed
Thomas J. Fischer, M.D.
Clinical Associate Professor,
Department of Orthopedic Surgery
Indiana University School of Medicine
The Indiana Hand Center
138
139
140
9/24/2020
47
Conflict of Interest
• Depuy-Synthes (DPS) technical writer and consultant
(Contract)
• AO International Foundation, Technical Commission,
Chair, Hand Expert Group, developers of plates and
screws of the distal radius and hand (Per Diem)
• None apply to this topic
Gratitude - Spanning the Start
• My partner of 33 years, Bill Kleinman who
taught me how to love anatomy and especially
for this convo, TFCC anatomy and function
• Andy Palmer, who brought TFCC pathology
into a collective understanding and shaped
mine
• Gary Poehling, Terry Whipple and Champ
Baker, whose principled teaching of the subject
of wrist arthroscopy allowed me to take the
leap into the small joint world of arthroscopy
A Postage Stamp Size Piece of Real Estate
141
142
143
9/24/2020
48
Unifying Concept – Forearm Axis
Preserve Forearm Function
• Distal Radius
• Distal Radioulnar Joint (DRUJ)
• Distal Ulna
• Ulna Shaft
• Olecranon
• Proximal Radioulnar Joint
• Radiocapitellar Joint
• Radial Head
• Radial Shaft
I fix the TFCC when the hinge is broken
144
145
146
9/24/2020
49
Disclaimer - Central Flap Tears
• Not a source of instability
• These are not part of the discussion today
• Only if they occur in conjunction with other instabilities
are they included for this discussion
Two Kinds of Instability – pain generators
• Minor Instabilities, not unlike tennis elbow, just enough
pathology and load to create soft tissue pain, pain
inhibition and dysfunction, no gross instability
- Dorsal marginal tears, red zone tears
- Subsheath tears of ECU, detaching TFCC disc from the
influence of the ECU
- Partial foveal tears, secondary stabilizers keep the joint
from subluxating
Two Kinds of Instability – pain generators
• Major Instabilities, subtle and gross instability, ulna
loses its domain on the radius, subluxation and
dislocation
- Complete or near complete foveal disruptions with or
without intact secondary stabilizers (ECU, DOB)
- Gross instability of ECU with subluxation accompanied by
detatchment from TFCC
147
148
149
9/24/2020
50
Source: Journal of Hand Surgery 2009; 34:415-422 (DOI:10.1016/j.jhsa.2008.10.025 )
Copyright © 2009 Terms and Conditions
JHS 2009
2 articles
Osaka Japan
Noda
Moritomo
Yoshikawa
Sugimoto
IOM
5 components
• 3 distal
• Isometric
• Central band
• Acc Band
• DOB, distal oblique
band***
• 2 Prox
• Off axis
• NOT Isometric
I do not know how the DOB plays
into minor vs major instabilities
Surface Contact: not unlike the glenohumeral
joint
10% in
Extreme
Supination
10% in
Extreme
Pronation
60% in
Neutral
Berger’s radiographic method for
determining instability
Open repair
150
151
152
9/24/2020
51
Ulna Fovea– is the location for a
“spot weld” of the TFCC onto the
distal end of the ulna
FZ – Fusion Zone
The Scene of the Crime
KLEINMAN/SCHNITZ
My 4 Repairs for TFCC
1. Ulna Fovea tears, partial and complete
2. Dorsal Marginal tears, aka ECU
subsheath tears, retinacular tears, red
zone tears
3. Palmar Ulno Carpal ligament tears, rare
4. Combinations of 1,2,3
153
154
155
9/24/2020
52
OPEN vs CLOSED Repair
• Any foveal repair is an open repair for me
- Determined by:
• Physical exam
• MRI
• Radiographic subluxation criteria
• Arthroscopic determination by probe, hook, manipulation
• Previous failed instability surgery
Foveal Repairs
• Open, palmar approach along subQ border
of ulna
• Debride granulation tissue
• Large diameter drill hole for bone anchor
du jour
• Three sutures – attached to single anchor
- Disc, absorbable suture (placed with scope)
- Dorsal limb TFCC, fiberwire
- Palmar limb TFCC, fiberwire type
Drill Hole Placement - Crucial
156
157
158
9/24/2020
53
The Anchor
Anchor Characteristics
• Static, not necessarily absorbable
• Free shackle to place secondary surtures of various
diameters
• Free running of suture through eyelet of anchor
• Subsheath tears, dorsal marginal tears can be repaired
this way for combination injuries extending dorsally.
159
160
161
9/24/2020
54
1 Dorsal ligaments
deep and
superficial
2 Ventral limb of
TFCC
3 Central disc,
absorbable
Dorsal Marginal Repairs
• Arthroscopic assisted with placement of
sutures in dorsal rim TFCC outside in
• Can be done with a myriad of soft tissue
fixation techniques, absorbable sutures
• Avoid DSBrUN, transverse branch
• Don’t include ECU tendon in repair,
respect the sheath
• Re integrate the vertical septum between
5th and 6th Dorsal compartments to TFCC
LUNATE FOSSA
OF RADIUS
DISTALLY
• Retinaculum of
the 6th
compartment
• ECU subsheath
• Vertical septum
between 5th and
6h compartment
• Vertical septum
of 6U
162
163
164
9/24/2020
55
Inside out technique – taken from
lateral meniscus repair techniques
THE WRIST STABLE
PLATFORM OF LOAD
How it transmits that load to the
ulna hence to the elbow starts at
the DRUJ
SUMMARY
165
166
167
9/24/2020
56
DISCLOSURES
David S. Zelouf, MD
Speaker has no relevant financial relationships
with commercial interest to disclose.
What do I do when a Surgical TFC Repair or
Reconstruction Fails?
ASSH 2020, ICL 05
David S. Zelouf, MD
I have nothing to disclose
168
169
170
9/24/2020
57
How does one define “failed surgery?”
There are always lawyers who want to help out…
How does one define “failed” surgery?
◼ No meaningful improvement or worsening of one’s symptoms at
final follow/up
◼ It can be subjective, as in ongoing pain and reported dysfunction
◼ It can be objective, with a loss of motion, strength or both
◼ Just remember, there isn’t anything surgery can’t make worse
171
172
173
9/24/2020
58
How about “outcome measures?”
◼ QuickDASH score
◼ I find it very useful preop,
and I have all new patients
complete it
PRWE
Modified Mayo Wrist Score
174
175
176
9/24/2020
59
Four main reasons for failed TFCC surgery
◼ Improper patient selection
◼ Improper diagnosis
◼ Complications leading to failure
◼ Technical issues
Improper patient selection
◼ Beware of patients with very high QuickDASH scores
◼ Beware of patients with significant anxiety, depression and
catastrophizing behavior
177
178
179
9/24/2020
60
Improper patient selection
◼ Patients in litigation
◼ Workers’ compensation patients,
especially those with legal representation
◼ MVA cases
◼ “Slip and falls”
◼ Other third-party litigation
Improper diagnosis
◼ Not all ulnar sided wrist pain is
secondary to TFCC pathology
◼ Take care to really examine the
patient
Failure to address…
◼ ECU tendinopathy
180
181
182
9/24/2020
61
Failure to address…
◼ ECU instability
◼ Can be isolated or associated with peripheral TFCC pathology
The ECU is properly located in its groove in pronation…
But dislocates or “snaps” out of its groove in supination
183
184
185
9/24/2020
62
Failure to address…
◼ Pisotriquetral arthritis
◼ Be sure to perform the pisotriquetral shear test
Failure to address…
◼ Hamate chondromalacia (HALT)
◼ Always scope the midcarpal joint!
Failure to address…
◼ Hamate hook non-union
◼ Patients often present with dorsal ulnar wrist pain
186
187
188
9/24/2020
63
Failure to address…
◼ Ulnocarpal impaction
◼ Obtain grip loaded pronated x-rays pre-op
◼ May need to perform an ulnar shortening osteotomy in addition
to addressing TFCC pathology
Failure to address…
◼ DRUJ instability, either isolated or in association with a radius
malunion
◼ Take care to examine for DRUJ instability
◼ An arthroscopic peripheral TFC repair to capsule may not
address DRUJ instability as a foveal repair is typically necessary
EH
◼ 25 y/o RHD man with long standing ulnar sided right wrist pain
◼ Sustained a right distal radius fracture at age 15 treated with a
closed reduction and casting
◼ Subsequently developed ulnar sided wrist pain
189
190
191
9/24/2020
64
EH
◼ Underwent TFCC repair by another hand surgeon 5 years ago
with no improvement
◼ PE: mature 3cm longitudinal ulnar scar
◼ Near full rotation, flexion 45 vs 60, extension 60/60
◼ Grip 130/150
◼ “Click” noted from neutral to supination
192
193
194
9/24/2020
65
195
196
197
9/24/2020
66
Supination dissociation: Radius malunion
◼ Apex volar radius malunion which results in displacement of
the ulna in supination
198
199
200
9/24/2020
67
Forearm fracture malunions and their effect on DRUJ stability
◼ Childhood radius fractures are forgiving but there is a limit
◼ Some will lead to problems at the DRUJ including decreased rotation and
DRUJ instability
◼ The fracture may have occurred many years ago, and the problem is often late
in developing
◼ Be mindful of subtle malunions and always obtain forearm films, including the
opposite side
10+ cm
2.5c
m
Repair of childhood forearm malunions and DRUJ instability
◼ A 10 degree flexion osteotomy 10cm from the growth plate will create a spatial change of 2.5cm at the joint
◼ With advanced diaphyseal remodeling the corrective osteotomy will appear overly angulated
◼ A TFCC repair for an unstable DRUJ without correcting the angular malunion will fail!
Preo
pPosto
p
201
202
203
9/24/2020
68
Failure to address…
◼ DRUJ arthrosis
Failure to address…
◼ Associated LT tears
◼ Ulnar extrinsic ligament tears
◼ Associated SL instability
204
205
206
9/24/2020
69
Complications leading to failure
◼ Neuroma formation secondary to portal placement during wrist
arthroscopy
◼ If one chooses a 1-2 portal, place it within the “safe zone”
◼ Avoid 6U portal as a working portal due to its proximity to the dorsal
cutaneous branch of the ulnar nerve
◼ Look for the dorsal cutaneous branch of the ulnar nerve if an open
incision is utilized about the ulnar side of the wrist
Complications leading to failure
◼ Infection
◼ Prophylactic antibiotics somewhat controversial
◼ Have a low threshold for a return to the OR for a wash
out if a postop infection develops
Complications leading to failure
◼ Stiffness
◼ Avoid prolonged immobilization following TFCC debridement
◼ No more than 4-6 weeks of immobilization post TFCC repair
while allowing elbow flexion/extension
◼ Early use of hand therapy is recommended, particularly in those
patients with early identified stiffness
207
208
209
9/24/2020
70
Complications leading to failure
◼ Iatrogenic tendon, cartilage and ligament injury from poorly
positioned portals and forceful insertion of instruments
Technical issues
◼ Inadequate debridement of central TFCC tears
◼ Failure to diagnose peripheral tears in need of repair back to
capsule
◼ Failure to diagnose foveal disruption; consider DRUJ arthroscopy
◼ Avoid excessive use of a heat probe without adequate outflow
that may result in chondrolysis
Summary
◼ Failed TFCC surgery may result from:
◼ Poor patient selection
◼ Improper or incomplete diagnosis
◼Avoidable and unavoidable complications
◼Technical issues
210
211
212
9/24/2020
71
Summary
◼ Whether to perform further surgery in the setting of “failed TFC
repair or reconstruction” depends on the identified reason for said
failure
◼ Patients with an “agenda” may may not improve with further
surgery unless a clear reason for the failure is identified, and even
then, success is unpredictable
Summary
◼ If a clear cause of the surgical failure is identified, revision surgery
may be successful
◼ Goals should be clearly outlined to the patient and both the
surgeon and patient must be realistic
◼ Revision surgery may include a procedure to address previously
unaddressed pathology, or possibly reconstructive surgery as in the
use of a tendon graft for ongoing DRUJ instability following TFC
repair, or a salvage procedure in selected cases deemed “non-
repairable”
Thank you
David S. Zelouf, MD
213
214
215
9/24/2020
72
DISCLOSURES
Nancy M. Cannon, OTR, CHT
Speaker has no relevant financial relationships
with commercial interest to disclose.
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Maximizing Post-Operative Function following TFCC Repairs
& Reconstructions
Nancy M. Cannon, OTR,CHT
~ No Disclosures ~ ASSH Annual Meeting
2020
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Focus…
▪Therapy for TFCC Ligament Repairs
▪Key Exercises – Favorably Influence Outcomes
▪Orthoses – Immobilization and Exercise
▪Research
216
217
218
9/24/2020
73
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Valuable Information – Therapist
▪ Initial Therapy Orders…and…
▪Operative Note & MRI Report ▪Specific structures involved
▪Specific procedures performed
▪Stability – DRUJ pre-op, intra-op
▪Favorably Influence▪Quality – therapy program
▪Quality – patient outcome
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Initial Therapy Visit
▪10–14 Days Post-op [Arthroscopic or Open Repair]
▪Bulky dressing & sutures removed
▪Scar massage & manual desensitization
▪Edema control – light compression stockinette
Patients often wearing at discharge!Appreciate circumferential support
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Post-Op Immobilization Orthosis
▪Bivalve Wrist Immobilization Orthosis
▪Long Arm Orthosis▪ Forearm neutral
▪Preferred position
▪ Shortest length of the volar & dorsal radioulnar ligaments▪ Position surgery – repair tight (stability)
219
220
221
9/24/2020
74
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Post-Op Immobilization Orthosis
▪Muenster Orthosis [IHTSC design]
▪ Full elbow motion, prevents supination/pronation
▪Sugar Tong Orthosis or Short-Long Arm Cast
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Period of Immobilization – Literature
▪Arthroscopic Debridement▪ 5 – 7 days
▪Arthroscopic Repair▪ 4 – 6 wks
▪Open Repair▪ 6 – 8 wks [grafts +1-4 wks]
▪Priority – Stability Arthrex.com
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Pull-Out Strengths – Suture Anchors
▪2.9 PushLock Anchor: 105N
▪Mini 2.5 PushLock Anchor: 73N
▪5.0 Titanium Corkscrew: 110N
▪Priority – Stability▪Early motion – risks lengthening
effect on the ligament or gapping repair site Arthrex.com
222
223
224
9/24/2020
75
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Wrist Exercises ± 4 – 6 weeks post-op
▪Short to Mid-Arc Flexion & Extension Initially▪ Forearm neutral (light fist) – slide wrist on tabletop
▪ Transition to full arc – ± 1 week later
▪Avoid Ulnar & Radial Deviation
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Ulnar Deviation – Compression Ulnar Wrist
▪Scaphoid-Lunate-Triquetrium – Slide Radially▪Compression – hamate against the triquetrium
▪Compression – triquetrium against the articular disc & ulnar styloid
Neumann, Kinesiology of theMusculoskeletal SystemMosby , 2002
Supination
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Forearm Exercises ± 6 weeks post-op
▪Short to Mid-Arc Motion Initially
▪Elbow Flexed 90, Forearm Neutral▪Supination & pronation (light fist)
▪ ± 1week later… full arc motion
225
226
227
9/24/2020
76
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Rationale – Short to Mid-Arc Motion
▪Gently Elongate & Mobilize Adhesions
▪Slowly Introduce Tension, Compression & Distraction on DRUJ, TFCC, IOM, and PRUJ
▪Maximize Contact Area –between the Ulna and Sigmoid Notch for DRUJ stability
ClinicalGate.com
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Rotation & Translation Exercise Important!
▪Reproduces Normal Biomechanics of the DRUJ – Forearm Rotation▪Radius – translation as it rotates
around the fixed ulna
▪Supination: radius – distal & dorsal to the ulna
▪Pronation: radius – proximal & volar to the ulna
ClinicalGate.com
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Rotation & Translation – Therapist
▪Supination:▪ Fingertips on the dorsal distal
ulna; apply volar-directed pressure (lifting effect)
▪ Thumb applies pressure on the distal radius to rotate the radius around the fixed distal ulna
228
229
230
9/24/2020
77
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Rotation & Translation – Therapist
▪Pronation▪ Fingertips on the volar distal ulna;
apply dorsal-directed pressure on the ulna (lifting effect)
▪ Thumb applies pressure to the distal radius to rotate the radius around the fixed distal ulna
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Rotation & Translation – Patient
▪Supination▪Volar-directed pressure on
the dorsal ulna (fingertips)
▪ Thumb rotates distal radius around ulna
▪Pronation
▪Upward pressure on the ulna (fingertips)
▪ Thumb rotates distal radius around ulna
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Exercise Orthoses – Wrist Straps
▪Beneficial – TFCC Repairs
▪ Indications – Clinical Perspective▪Pain with motion
▪Catching-clicking (wrist or forearm motion)
▪ROM plateaus – stops progressing
▪Proactively – external support – course of therapy
231
232
233
9/24/2020
78
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Exercise Orthoses – Wrist Straps
▪Pre-Fabricated ▪Bulls Eye Wrist Band
▪P.O.P – 3-Points Product
▪Wrist Squeeze –Ulnar Compression Wrap
▪WristWidget
~ Examples ~
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Exercise Orthoses – Wrist Straps
▪Custom-Fabricated▪Elastic strap + orthotic material (ulna &/or radius)
▪O’Brien & Thurn design [JHT, 2013]
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Rationale – Clinical Perspective
▪Provide Lateral, Circumferential or Targeted Support [dependent on orthosis design]
▪May influence dorsal/volar translation
▪May ↓ tension/strain – TFCC ligaments
▪Pressure effect may stimulate sensory nerve fibers (A) to dampen pain [Gate control theory]
▪Circumferential support – “reassuring”! Slideserve.com
234
235
236
9/24/2020
79
I N D I A N A H A N D T O S H O U L D E R C E N T E R • I N D I A N A P O L I S , I N D I A N A
Closing…
▪Post-op Immobilization – Prioritize Stability
▪Exercises▪Gradually restore motion [short – mid – full arc]
▪Research▪Optimal therapy program – excellent outcomes
▪Wrist straps – influence DRUJ structures & pain
237
top related