EXAMINATION OF THE WRIST BEYOND THE BASICS OMA SPORT MED 2019 Janice Harvey MD CCFP CFFP Dip. Sp Med.
CFPC CoI Templates: Slide 1 used in Faculty presentation only. FACULTY/PRESENTER DISCLOSURE Faculty: Janice Harvey Relationships with financial sponsors: Receive speaker honoraria from OCFP
CFPC CoI Templates: Slide 2 DISCLOSURE OF FINANCIAL SUPPORT This program has received NO financial support This program has received NO in-kind support Potential for conflict(s) of interest: Paid employee of the CFPC
1ST THE BASICS 1ST THE BASICS
WRIST STABILITY Dependent on 3 factors Skeletal alignment Passive restraint from ligaments Muscular compressive forces require sensorimotor input from mechanoreceptors
WRIST STABILITY Ligaments of the radial column constrain and guide the wrist, while richly innervated dorsal intercarpal and volar triquetral ligaments provide sensory feedback to muscles for actions like throwing Injury results in disruption of the sensory input and disrupts transmission of proprioceptive input functional impairment and a feeling that the wrist doesn t feel like their own
LIGAMENTS
INSPECTION Both wrists surfaces (swelling, incisions, erythema etc.) Alignment of hand with the wrist ulnar styloid Ulnar variance difficult to assess in inspection need an x-ray to determine Malunited distal radial # - whole hand drops off on the radial side when radial inclination is lost Carpal Boss (? Ganglion) Base of 2 nd + 3 rd metacarpals Articulate with the trapezoid on the index finger and the capitate on the long finger Extensor tendons of 4 th compartment can ride over this and cause a tendonitis Plastics can do a cheilectomy
ROM + RESISTED ROM Grip Strength Flexion radial deviation 10-15 deg ulnar deviation 25 50 deg Ulnar Deviation Extension Radial Deviation Supination Pronation
PALPATION Start at one side + move circumferentially Dorsal Radial side Proximal Carpal Row 1 st compartment Radial styloid Snuff box best with thumb extended scaphoid body Lister s tubercle just distal to snuff box on radius (extend thumb, follow EPL tendon as it wraps around the bony prominence Scapholunate interval distal to Lister s tubercle Base of Long finger lunate just radial to this is the SL interval Ulnar styloid process volar aspect is the FOVEAL Region tender in TFCC injuries
VOLAR ASPECT Ulnar Side Pisiform can do Pisiform translation on the triquetrum to look for instability/pain Hook of Hamate distal and radial to Pisiform lay crease of 1 st MP jt on Pisiform, pad will be on Hook of Hamate Distal Ulnar nerve compression in Guyan s canal will be felt in same region Carpal Tunnel Tinels tap test, modified Phalens (compress and flex the wrist with one hand may also elevate wrist above the pt s shoulder to look for median nerve paresthesias Scaphoid tuberosity 1 st extensor compartment
THE SNUFFBOX Palpation snuff box Palpation of volar aspect Ulnar deviation while palpating radiocarpal jt space to feel the waist of the scaphoid Axial load of 1 st mcp jt Resisted supination
BEYOND THE BASICS -SPECIAL TESTS- Ligament Instability Tests + Impaction Tests
WATSON S Scapholunate Instability Test SL ligament tear or scaphoid # Place examining thumb on volar scaphoid tuberosity and press dorsally while passively deviating ulnar and radial As the wrist extends, there is a tendency for the scaphoid to supinate and the lunate to pronate, which effectively separates the palmar surfaces of the 2 bones With a full tear ulnar deviation can sublux the proximal pole of the scaphoid off the radius, radial deviation will let the scaphoid reduce back in place - clunk
MID CARPAL INSTABILITY Mid carpal shift test (Lichtman) Just distal to capitate at 3 rd cmc jt. Is the midcarpal jt area (between the distal and proximal carpal rows) 2 Types: Non dissociative instability between carpal rows - (usually volar; dorsal is rare) Dissociative instability within a carpal row between 2 carpals (SL, lig LT lig) Maneuver: R wrist grasp pronated mid forearm with L hand and distally grip metacarpals with R hand Translate mid carpals volar-dorsally (volar slight twist due to more natural laxity on ulnar aspect of the metacarpals vs radial side which is more rigid (palmar mid carpal instability) Radioulnar deviation ulnar direction will accentuate the translation but radial deviation puts tension through the ulnar capsule Tx Midcarpal instability - if conservative Tx fails (splint in extension to rest the capsule, PT, proprioception 4-6 wks) End stage - dorsoulnar capsular plication
DISSOCIATIVE INSTABILITY LT Shuck Test For LT ligament instability: Base of long finger lunate grasp with right thumb and fingers, L hand grasp the Pisiform and triquetrum - translate dorsal/volar Compare to the other wrist for degree of mov t. Reverse Watson s Push on the Pisiform while deviating ulnar radial
DRUJ INSTABILITY Distal Radioulnar Joint Testing DRUJ located just radial to TFCC (distal to dorsal ulnar head) Line up forearm with elbow resting on the desk and hand in pronation - grasp the radius with the R hand and ulna with the L - translate the ulna on the radius dorsal/volar Repeat in Neutral rotation and in Supination Check for asymmetry between wrists If instability unidirectional (volar or dorsal ) usually equates to bidirectional instability due to the anatomy of the TFCC Superficial and Deep Ulnar ligaments: one attachment of the TFCC superficially onto the ulnar styloid and a deeper attachment on to the fovea ( at the base of volar ulnar styloid)
ULNOCARPAL IMPACTION Ulnar Grind Test - Ulnar head - Lunate impaction Maneuver: Place arm in pronation - this puts the ulna in a position of dynamic positive variance (ulna longer) allowing the ulnar head to impact on the carpals most commonly the lunate Elbow on solid surface grasp forearm with L hand and metacarpals with R hand Put wrist into Ulnar deviation to see if there is pain in the dorsal ulnar region Then while grasping the metacarpals grind the hand passively in dorsal and volar (flexion/extension) directions while keeping middle finger of R examining hand over the dorsal ulnar aspect of the wrist to pick any click/clunk or grind Flap tear of the TFCC (not a bony grind), or head of ulna on lunate (bony grind) Tx injection of steroid into TFCC 2mm distal to ulnar head 22g needle 40 mg depo, 0.5cc of 0.25% bupivacaine
U L N A R S T Y L O I D T R I Q U E T RU M I M PAC T I O N USTI Similar orientation to UCI (ulnar to radial) but more ulnar in location Often a result of a longer ulna or ulnar hypertrophy from a distal radial # or ulnar styloid #s *** Radius pivots around the ulna in movement. In pronation the radius will be relatively shortened relative to the ulna. So this is why impaction can happen (ulnar styloid on triquetrum) Maneuver: Put elbow on solid surface, hand is in the Stop position (extension) Grasp the humerus just above the elbow with L hand + place R hand loading on the pt s palm Rotate the forearm into supination while loading
USTI Most pain of impaction will be experienced in the dorsal ulnar aspect of the last 10-20 deg. X-rays: pronated PA, pronated PA Grip view (gripping compresses the carpals and that compresses the radius which shows a relative elongated ulna dynamic change into a positive 3mm variance from neutral ulnar variance in pronation) Tx: Conservative Tx (rest, physio, splinting) If pain on ADL persists MRA, scope Wafer from ulnar head or a shortening osteotomy
SOFT TISSUE TESTS De quervain's tenosynovitis Extensor pollicis brevis (EPB) and the abductor pollicis longus (ABL) tendons, which extend the joints of the thumb Intersection Syndrome Outcropper muscles of 1 st extensor compartment muscles Abductor Pollicis Longus, EPB, as they cross over the common extensors ECRL, ECRB
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