Case Example Wrist Release

Transcription

1 THERAPY Sheri B Feldscher OT, CHT Wrist Release The Ideal Patient: Joint stiffness is due to capsular contracture Articular cartilage is normal Normal joint congruity Wrist Release 55 yo RHD disabled landscaper diagnosed with OA of L Lunate/ Ulnar impaction syndrome Underwent L ulnar shortening osteotomy and Lunate arthroplasty using OATS procedure from L knee Cartilaginous resurfacing method Therapy Wrist orthosis 0-4 weeks Gentle wrist AROM initiated at week 4 Rotation held until week 8 to allow for osteotomy to heal Strengthening at week 10 Significant stiffness L wrist contracture Wrist ex/flex 55 /25 Grip: R 38 L 18 lbs Wrist Release 8 months later underwent a L wrist capsulectomy with arthroscopic debridement of intraarticular adhesions OATS procedure on lunate had excellent survival of cartilage S-L, L-T, radial and ulnar extrinsic ligaments intact Articular and ligamentous structures of midcarpal joint intact 65 /60 wrist extension/flexion Wrist Release AROM initiated post op day 1 (Wrist ex/flex 40 /30 ) Treatment was progressed to include heat, dfm, A/P/AAROM, edema control, functional activities Strengthening initiated at 6 wks D/C at 7 weeks Wrist ex/flex 55 /55 ; Rd/Ud 15 /22 Pro/sup 85 /85 Grip at level II Jamar Dynamometer R 60 L 40 lbs (66%) I ADL s; resumed quilting activities; able to lift ½ gallon containers 1

2 Wrist Link between the hand and the UE Requires mobility for positioning Requires stability for force transfer Proper function depends upon Intact ligaments Proper bony alignment of articular surfaces Untreated injuries can lead to carpal malalignment Places abnormal stress on articular surfaces of wrist Results in progressive degeneration Pain, weakness, loss of motion, loss of function Treatment: Reconstruction; Arthrodesis Wrist Salvage Procedures Goals: Create a stable wrist Maintain functional ROM Palmer et al evaluated 10 normal wrists performing 52 standardized tasks Wrist ex/flex 30 0 /5 0, RD/UD 10 0 /15 0 Ryu et al studied 40 subjects performing 31 activities Wrist ex/flex 40 0 /40 0, RD/UD 10 0 /30 0 All ADL s except rising from chair and perineal care If functional ROM can t be maintained extension and ulnar deviation must be maintained with arthrodesis Implications for Therapy Therapeutic Management Postoperative therapy goals Pain-free functional wrist motion A stable wrist with a painfree arc of limited ROM is more functional than an unstable, painful wrist that has full motion Less is More 1. Protective Phase 2. ROM Phase 3. Strengthening th Phase Protective Phase Protective Phase Varies with procedure and type of fixation used Compression screws Provide increased stability and allow for early motion K-wire fixation Provides minimal stability & no compression Requires 8-10 weeks to achieve fusion ORIF Allows for early motion within 1 st 2 postop weeks Delayed Union Requires longer period of immobilization Protective Orthotics/Casting Patient Education Orthosis use and care Precautions AROM uninvolved joints Edema Control ADL Performance Encourage one-handed or adapted ADL s Wound Care Scar Management 2

3 ROM Phase Wrist and forearm AROM are initiated when x-rays indicate sufficient healing Gentle Performed frequently Requires minimal force Pain free Emphasize isolated motion Wrist extension with finger flexion Wrist flexion with fingers relaxed/extended Goal Pain- free ROM in a functional range ROM Phase Protective orthotics continue between exercises Treatment as indicated: Modalities, edema control, desensitization, scar management, light functional activities As ROM increases and pain decreases Progress to gentle isometrics and AAROM Precautions: Avoid undue stress at the repair site Grip strengthening exercises Testing that significantly load the carpus Forceful manipulations and joint mobilizations are not appropriate Strengthening Phase Begins with surgeon approval when X-rays confirm bony healing Begin gentle PROM if needed to increase ROM Avoid forceful manipulations and joint mobilizations Protocols provide guidelines for expected ROM Progressive Loading Graded grip strengthening Isotonic exercise Progressive resistive exercises Closed chain activities and light job simulations Strenuous activity is avoided until there is evidence of solid healing May vary from 8-16 weeks Strengthening Phase Wean orthosis Step down orthotics for additional light support Wrist wraps and gloves as needed for comfort Consider Adaptive equipment Ergonomic adjustments Task modifications Patient education Joint protection techniques Full symptomatic and strength recovery may require 6-12 months 3

4 Intercarpal Arthrodesis Goal: To provide stability by fusing certain carpal bones Maintain functional ROM Pathology and secondary pattern of degeneration determine which bones are fused Common diagnosis treated Chronic SL instability Lunate AVN Degenerative/ Posttraumatic arthritis Intercarpal Arthrodesis 47 year old RHD Account Executive Presented for evaluation of L wrist pain PMH + for motorcycle accident & sports injuries Diagnosed with: L wrist SLAC deformity Underwent: L Radial Carpal Arthrodesis Distal radius bone graft Radius, Scaphoid, Lunate Intercarpal Arthrodesis Postoperative Therapy Protective Phase (0-4 weeks) Short arm cast ROM Phase (4 weeks) Thumb spica orthosis Therapy initiated: iti t A/AAROM 6 Weeks- developed crepitus at ulnar wrist with UD/ Pro HEP modified and pt educated re: pain free ROM F-T orthosis use resumed when symptoms persisted Referred to MD for evaluation - X-rays: no hardware loosening but DRUJ DJD - Therapy restarted within limited range wrist ex and 20 0 wrist flex in sup Intercarpal Arthrodesis Strengthening Phase Isometrics at 7 ½ Weeks Strengthening at 9 ½ Weeks Orthosis weaned to neoprene support Avoid heavy activity x 3 months D/C at 12 ½ Weeks Wrist ex/flex 50 0 /45 0 By 8 weeks, expect flexionextension arc of motion RD/UD 15 0 /30 0 Pro/sup 90 0 /70 0 Grip strength Level II Jamar R 67 L 65 lbs. (97%) Full symptomatic and strength recovery may require 6-12 months Outcomes Data Intercarpal Arthrodesis Minami et al (1999) 4/12 radiocarpal Achieved wrist ex/flex 33 /32 at both 22 and 89 months postop Grip strength was nearly identical at both visits Concluded Clinical/radiographic results were maintained at final follow up The effect of limited wrist fusion does not deteriorate Honkanen et al (2007)- prospectively reviewed 20 radiocarpal arthrodesis in unstable RA wrists Achieved wrist ex/flex 34 /29 Concluded Radiolunate arthrodesis with inclusion of the scaphoid produces a functional pain free wrist while preserving mobility and bone stock in pts with sig. disease 4

5 Four-bone Arthrodesis Procedure Lunate, capitate, hamate, & triquetrum fusion Stabilize the wrist Scaphoid excision Eliminates the degeneration Prevents further capitate migration Maintains carpal height Indications SLAC wrist RC arthritis from scaphoid nonunion Scaphoid AVN Benefits Maintains 50-60% of normal wrist motion 80% grip strength of contralateral side Four-Bone Arthrodesis 61yo RHD retired male who sustained injury of his R cervical spine and R wrist when drilling 7 months prior Underwent cervical fusion C3-7 Wore bone stimulator throughout course of therapy Presented for treatment when wrist pain worsened Diagnosis SLAC Wrist Deformity Traumatic Arthritis R wrist Wrist ex/flex 30 /20 Thumb spica Four-Bone Arthrodesis Underwent intercarpal arthrodesis with local bone graft and excision R Scaphoid with CTR Postoperative Therapy Protective Phase Placed in a thumb spica cast x 4 weeks ROM Phase (4 weeks) Thumb spica orthoses remolded Therapy initiated Moist heat, scar mgt, AROM thumb, gentle AROM wrist, DIP joint blocking, and TGE Treatment progressed to include light functional activities ROM Goals: Expect wrist ex/flex RD/UD arc Four-Bone Arthrodesis Wrist isometrics at 6 weeks Strengthening Phase 8 weeks Thumb spica weaned to a Neoprene wrist/thumb wrap Strengthening initiated Four-Bone Arthrodesis D/C at 12 weeks Wrist ex/flex 45 /35 Improved from pre op RD/UD 20 /20 Grip level II Jamar R 47 L 62 lbs (75%) Pinch Key pinch = B at 10 lbs 3 pt pinch R 4 L 10 lbs (40%) Expect 80% grip strength and 82% pinch strength uninvolved UE Quick DASH 11% Improved from 75% on IE Outcomes Data Four-Bone Arthrodesis High patient satisfaction and good pain relief are documented in the literature Ashmead et al 1994 Cohen and Kozin 2001 El-Mowafi et al 2007 Ozyurekoglu and Turker 2012 Winkler et al 2010 In a cohort study performed by Bain and Watts (2010) following 31 pts for up to 10 years s/p surgery Found favorable outcome at 1 year that does not deteriorate significantly between 1 and 10 years Low conversion rate to total wrist arthrodesis Reduced pain but at expense of reduced wrist flexion (ave of 22%) 5

6 Proximal-Row Carpectomy Procedure Scaphoid, lunate, and triquetrum are removed Radioscaphocapitate ligament is preserved to maintain stability Indications Disease affecting the PCR Scaphoid nonunion Radioscaphoid arthritis SL instability AVN of the lunate or scaphoid Advantages over arthrodesis Increased motion Decreased period of immobilization No internal fixation or bone grafting Proximal Row Carpectomy 44 year old RHD Account Executive Presented for evaluation of R wrist C/o pain, swelling, popping, & paresthesias PMH + for motorcycle accident & sports injuries Diagnosed with: R wrist midcarpal instability with scapholunate ligament injury Underwent: R Proximal Row Carpectomy Proximal Row Carpectomy Protective Phase (0-3 weeks) Immobilization in 10 0 wrist extension in short arm cast Provides relative shortening of lengthened extrinsics AROM thumb and digits Digital flexion is often limited because of the altered length-tension relationship of the flexor tendons AROM of the fingers and thumb in the orthosis provide isometric contractions that will later contribute to grip strength recovery Edema control as indicated Proximal Row Carpectomy ROM Phase (3 weeks) Wrist orthosis fabricated Used F-T with removal for hygiene and exercise Gentle wrist AROM initiated Precaution- Avoid composite wrist/digit ex/flex during the first 12 postop weeks Prevents stretching of the extrinsic muscles 6 weeks Increased pain and inflammation due to overuse Placed in thumb spica orthosis x 1 week 7 weeks therapy resumed Moist heat, U/S, DFM, A/AAROM Proximal Row Carpectomy Strengthening Phase (8 weeks) Wrist isometrics, graded grip strengthening, isotonics, PRE s D/C at 4 months Pain-free with excellent function Wrist ex/flex 64 0 /48 0; RD/UD 16 0 /20 0; Pro/Sup WNL Expect Average wrist flex-ex arc 52-84% contralateral wrist Radial deviation Ulnar deviation Grip Level III Jamar: R 55 L 65 lbs. (85%) 1 year s/p repair on L 4 years s/p repair on R 6

7 Proximal Row Carpectomy PRC results in weakness of grip with strength averaging 50-87% of the contralateral side Grip strength deficits may be more marked initially Due to altered length-tension relationship of tendons Potential for active insufficiency Studies indicate that as much as % of contralateral grip strength may be regained May take up to 1 year Return to work Sedentary work- as early as 3 months Heavy labor- usually requires up to 6 months Imbriglia (1990) Culp (1993) Tomaino (1994) Elfar and Stern (2011) - PRC should be used selectively in laborers Outcomes Data Proximal-Row Carpectomy Chim and Moran (2012) conducted a SR to determine best evidence on long term outcomes following PRC 147 pts from 6 studies Found no sig difference between preop and long- term post op motion Post op grip strength was 68.4% compared with contralateral side DASH, PRWE, and Mayo wrist scores were comparable to those reported for 4 corner arthrodesis 21 failures (14.3%) Conclusions: Confirms long- term durability of PRC when used for treatment of wrist arthritis Poorer long term outcomes are likely to result in pts engaged in heavy manual labor PRC vs Four-Corner Fusion Outcomes Data Saltzman et al (2014) conducted a SR of 7 level I-III studies (240 pts) reporting clinical outcomes after PRC or 4CF for SNAC or SL AC pts Found sig different postop values for 2 procedures 4 corner vs PRC Wrist extension 39 vs 43 Wi Wrist tflexion 32 vs 36 Flexion -extension arc 62 vs 75 Radial deviation 14 vs 10 Grip strength 74% vs 67% Complication rate 29% (nonunion) vs 14% (synovitis & edema) Conclusions RD/ grip strength were sig better s/p 4CF Wrist flex/ex and flex-ex arc of motion were better after PRC Lower complication rate Historically limited to patients with RA & low demand wrist Now extended to include post traumatic arthritis Patients must have functioning wrist extensor tendons Objectives To maintain wrist motion and function While relieving gpain & correcting deformity Indications RA patients with bilateral wrist involvement Wrist arthroplasty for function with limited ROM & dexterity on one side Wrist arthrodesis on the other extremity for strength Permanent restrictions Lifting no > than 10 pounds Limited repetitive activity No weight bearing or impact sports 70 yo R hd female who presented with very painful limited wrist ROM Diagnosed with End-stage SLAC deformity R wrist/ Extensor tenosynovitis Underwentent Total Wrist Replacement R wrist Extensor tenosynovectomy Postoperative Therapy Protective Phase Casted 1 st 2 postop weeks then volar Wrist orthosis was fabricated Pt instructed to treat as a cast x 3 weeks AROM uninvolved joints Edema Control 7

8 ROM Phase Gentle wrist AROM initiated at week 5 Time frames depend on prosthetic fit and soft tissue integrity Scar management Desensitization Edema control Functional activities Contraindications Avoid regular use of the UE for support during ambulation or transfers Pt ambulated with cane Continued wrist orthosis; did not wean to soft support Strengthening Phase 8 weeks Wrist orthosis was weaned to neoprene support Gentle strengthening was initiated Isometric grip As early as 6 weeks Putty ex Isotonics Education regarding adaptive devices and techniques, joint protection, and energy conservation D/C at 13 weeks Pain persisted but was improved Crepitus and pain at DRUJ TENS unit for pain Wrist ex/flex 30 /45 ; RD/UD 10 /30 Pro/sup WNL Grip at Level II Jamar R 30 lbs L 40 lbs (75%) Grip= pre op mm at 30 lbs Expect 60º wrist ex/flex arc of motion 10 /25 RD/UD Maximum motion is not expected until 6 months postoperatively DRUJ replacement 1 year later Outcomes Data- 2 Systematic Reviews Boeckstyns ME (2014) SR literature on 2 nd, 3 rd, and 4 th generation implants Concluded T/PWA has good potential to improve function through pain reduction and preservation of mobility Risk of severe complications is small Implant survival is % at 5 years but declines 5-8 years Yeoh and Tourret (2014) SR evidence from past 5 years Concluded that wrist arthroplasty preserves some ROM Functional scores improved and were maintained Complication rates were higher than for wrist fusion Evidence does not support widespread use of arthroplasty over arthrodesis Careful pt selection is essential Total Wrist Arthrodesis Final salvage procedure All motion is sacrificed for stability and pain relief Pronation and supination are preserved Indications Posttraumatic arthritis involving midcarpal and radiocarpal joints Failed intercarpal fusion RA Joints always included in the fusion: Radioscaphoid, Scapholunate Scaphocapitate, Lunocapitate Capitate, Long finger metacarpal If ulnar wrist involvement: Lunate hamate and triquetrum are included in the fusion 8

9 Total Wrist Arthrodesis 63 yo RHD Utilities worker Presented with severe R wrist pain limiting daily use Diagnosis: SLAC wrist/cts Preoperative Treatment Volar/dorsal wrist orthosis fabricated Determine the best individual wrist position Allow the patient to become accustomed to an immobile wrist The wrist is usually fused in extension and slight ulnar deviation to optimize hand function Total Wrist Arthrodesis Underwent R Total Wrist Arthrodesis/ CTR Postoperative Therapy Protective Phase (0 to 6-8 weeks) Immobilized in a short arm cast 0-4 weeks Previously fabricated clam shell orthosis was remolded for post op use weeks 4-8 Treatment: Edema control Digit PROM, TGE, and blocking - EDC gliding exercises - To minimize scar adherence over the extensor tendons - Isolated MP joint flexion exercises Scar management/ desensitization Fine motor tasks Total Wrist Arthrodesis Strengthening Phase (weeks 8-12) 5 pound weight restriction first 8 weeks Wrist orthosis weaned to a neoprene wrist wrap Isometric grip strengthening exercises Progressed to graded grip strengthening D/C at 12 weeks Pain-free Full digit/thumb AROM Pro/sup WNL Grip Strength Level II Jamar (50%) R 28 lbs L 55 lbs Total Wrist Arthrodesis Outcomes Data Cavaliere and Chung (2008) performed a SR of total wrist arthroplasty (18) compared to total wrist arthrodesis (20) for RA Total wrist fusion provides more reliable relief than arthroplasty Complication and revision rates were higher for total wrist arthroplasty Satisfaction was high in both groups Of 14 arthroplasty studies reporting appropriate data only 3 showed ave. arc of motion within functional range Concluded: Outcomes for fusion were comparable & possibly better than those for arthroplasty in RA pts Implications: Expensive intervention does not demonstrate superior outcomes No support for widespread use of arthroplasty In Conclusion Less is More Therapy Goal Functional pain-free wrist motion Unless a total wrist fusion was performed The patient, surgeon, and therapist must work together to achieve optimal, pain-free function References Bain GI and Watts AC. The outcome of scaphoid excision and four-corner arthrodesis for advanced carpal collapse at a minimum of 10 years. J Hand Surg. 2010; 35(5): Bednar JM, Feldscher SB, and Seftchick J. Wrist Reconstruction: Salvage Procedures. In Skirven TM., Osterman AL., Fedorczyk J, and Amadio PC. (Eds) Rehabilitation of the Hand and Upper Extremity, 6th Edition. Elsevier: Boeckstyns ME. Wrist arthroplasty- a systematic review. Dan Med J May; 61(5):A4834. Cavaliere CM and Chung KC. A systematic review of total wrist arthroplasty compared with total wrist arthrodesis for RA. Plast Reconstr Surg Sep; 122(3)

10 References Chim H and Moran SL. Long-term outcomes of proximal row carpectomy: a systematic review of the literature. J Wrist Surg Nov 1(2): Elfar JC and Stern PJ. Proximal row carpectomy for scapholunate dissociation. J Hand Surg Eur (2): Honkanen PB et al (2007). Radiocarpal arthrodesis in the treatment of the rheumatoid wrist. A prospective midterm follow-up. J Hand Surg Eur. 32(4): Ozyurekoglu T. and Turker T. Results of a method of 4- corner arthrodesis using headless compression screws. J Hand Surg (3): References Saltzman BM et al. Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: A systematic Review. J Hand Surg Eur Vol 2014, Oct 7. Yeoh E and Tourret L. Total wrist arthroplasty: A systematic review of the evidence from the last 5 years. J Hand Surg Eur Vol June 23 (Epub ahead of print) Winkler et al. Mid-term results after scaphoid excision and four-corner wrist arthrodesis using K-wires for advanced carpal collapse. Z Orthop Unfall (3):