Conservative management of palmer mid-carpal instability

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1 Conservative management of palmer mid-carpal instability Peter Belward Physiotherapist UHS NHSFT

2 Key messages Restore patient confidence Regain strength and control in a position of stability Reduce dependency on over protection and splintage

3 Patient history Ave age 27 +/- Minor injury Pain and apprehension Loss of dynamic control Protection and reduced activity Increased weakness Pseudo-diagnosis WRULD (RSI)

4 Patient confidence A clear diagnosis with a positive outcome Understanding and recognition Reassurance, clicks and clunks Attainable goals (strength and function)

5 Position of stability supination Effect of relative ulna shortening and dorsal translation of the radius 1mm Increased tension in: Extrinsic and intrinsic wrist ligaments Extensor carpi ulnaris(ecu) (sub sheath) Flexor carpi ulnaris(fcu) (increased radial length) pronation supination

6 Position of stability In radial deviation lunate and scaphoid in flexion with capitate and the distal carpals in extension Capito-lunate palmer subluxation Potential instability

7 Position of stability Stability achieved in ulnar deviation proximal carpal row extends as the distal carpal row flexes Ligaments tighten and midcarpal joint achieves congruent stability Catch up clunk

8 Strength and control Muscle weakness results in: Loss of muscle endurance Slower reflex motor control Impaired co-contraction Loss of dynamic control Dynamic control is imperative in patients who have poor static control due to ligamentous laxity

9 Strength and control sensory-motor system Radio-volar ligaments are dense collagenous structures; poorly innervated Dorsal and triquetral ligaments highly innervated

10 Strength and control sensory motor system Fusimotor effect Theoretical concept of local reflex driven by Gamma motor neurones Reflex via dorsal horn, with higher control and co-contraction Stimulation of wrist ligaments producing direct reflex response with forearm muscles (Hegert E)

11 Proprioception Sudden alterations in joint position Stimulate reflex muscular stabilisation

12 Kinematics Coupling movements Flexion with ulnar deviation Extension with radial deviation Supination with flexion Pronation with extension

13 Strength and control Start with: Strengthen in supination with flexion and ulnar deviation Propreoception Concentric FCU Hypothenar muscles Eccentric ECU

14 Strength and control Progression: Into forearm neutral Eccentric and concentric ECU Concentric FCU General strength Co-contraction Dart throwers motion ECRB and FCU

15 Co-contraction A B FCU ECU

16 End stage: 6/12+ Strengthening in pronation Spinball Load bearing Strength and control

17 When to splint Never? Control splints Off the shelf Manutrain Dynamic control Ulnar boost

18 Classification Litchmans grading: shift test I. No palmer translation no clunk II. Minimal palmer translation minimal clunk III. Moderate palmer translation moderate clunk IV. Maximum palmer translation significant clunk Increasing degrees of normal mid-carpal laxity V. Self induced palmer translation and clunk Pathological condition of mid-carpal instability, often associated with general hypermobility

19 V. Self induced palmer translation and clunk Clinical sub categories seen in UHS A. As above in pronation B. Reproducible in forearm neutral C. Reproducible in supination Increasing severity of instability Splints may be the only way to relieve symptoms and open the door to muscle re-education in sub type C

20 Strength and control Dart throwers motion Scaphoid and lunate motion significantly less than with any other plane of wrist motion Scapholunate ligament (SLL) elongation is minimal, so strengthen ECRB and FCU in SLL injury NB. ECU increases the stress at the SLL, ok in palmer mid-carpal instability ECU rehab to be avoided in SLL injury Present in the majority of functional tasks

21 The future Improvement in diagnosis and grading? Correlation between degree of instability, symptoms, strength and function Research to clarify conservative treatment Hegart E, call for case studies (a start)

22 Case study Five patients with mid-carpal instability treated with POP cast for four weeks Two patients had further protection in splints All patients reported short term benefit in pain No long term benefit, only one patient returned to their chosen occupation Journal of hand surgery (Edinburgh, Scotland), April 1996, vol./is. 21/2( ), :Ono H,Gilula LA,Evanoff BA,Grand D

23 Case study 21yr old right handed female student 5 yr hx of bilateral wrist pain R > L Clunky wrists forearm pains on writing RSI No general joint laxity, flexible wrists Grip strength R =14kg L=16kg Litchmans V (b)

24 Case study In supination strength and control exercise After one month grip R= 20kg L= 26kg (asymptomatic) Progression to forearm neutral One month later grip R= 24kg, 75% improved At 6/12 maintaining improvement Tried spinball, increased symptoms - crepitus++

25 Case study Reverted to forearm neutral and supination theraband work One month back to 75% improvement 6/12 later maintaining gains but felt she needed to continue with maintenance strengthening programme

26 Case study Locked wrist, A/E visits ++ 16yr old female Generalised joint laxity Symptoms often occurred over night Taught, self traction, flexion, with dorsal lunate pressure during extension to relocate

27 References Lichtman DM, Schneider JR, Swafford AR, Mack GR: Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg [Am] 6: , Wright TW, Dobyns JH, Linscheid RL, et al: Carpal instability nondissociative. J Hand Surg [Br] 19: , Brown DE, Lichtman DM: Midcarpal instability. Hand Clin 3: , Mason WT, and Hargreaves DG: Arthrosopic thermal capulorraphy for palmer midcarpal instability. Journal of Hand Surgery (European Volume, 2007) 32E: 4: Hagert E, Persson JKE, Werner M, Ljung B-O. Evidence of wrist proprioceptive reflexes elicited after stimulation of the scapholunate interosseous ligament. J Hand Surg Am. 2009; 34:

28 References Hagert E, Forsgren S, Ljung BO. Differences in the presence of mechanoreceptors and nerve structures between wrist ligaments may imply differential roles in wrist stabilization. J Orthop Res. 2005; 23: Moritomo H, Apergis EP, Herzberg G,Werner FW,Wolfe SW,Garcia- Elias M IFSSH report of wrist biomechanics committee: biomechanics of the so-called dart throwing motion of the wrist. J Hand Surg [Am]. 2007;32: Prosser R, et al. Current Practice in the Diagnosis and Treatment of Carpal Instability Results of a Survey of Australian Hand Therapists. J Hand Therapy. 2007;20:

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