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Understanding Wrist Instability

Understanding Wrist Instability

Ann Porretto-Loehrke, PT, DPT, CHT, COMT

June 5, 2013

This text base course is a transcript of a live seminar titled "Understanding Wrist Instability" by Ann Porretto-Loehrke, PT, DPT, CHT, COMT.  It is strongly recommended to follow along with the course handout to ensure understanding of the course material.

>> Ann Porreto-Loehrke: 

We are going to talk about a tough topic especially for PTs because it is something that not a lot of you treat on a regular basis.  We learn about it in school and then it goes by the wayside. Then all of the sudden someone asks you to see a patient who has a wrist issue and their insurance does not cover OT. I am going to go through this material fairly slowly.  Wrist instability is a very complicated topic.  I will also talk about, some of the surgical aspects of how they address it.  We find with wrist instability that there is only a small portion of patients that we are able to treat conservatively.  Unfortunately the remainder is something that is more of a surgical issue. 

The Bony Anatomy of the Wrist

Let’s first go through and talk about the bony anatomy of the wrist.  Everyone remembers in school that we had that nice little mnemonic to remember all the carpal bones, but I would like to go through and talk about the orientation of the wrist itself and how the carpal bones fit together as well as their function.  That helps us build when we talk about the ligamentous support. 

Distal Radius

When we look at the distal radius, we have what is called the radial declination.  (Figure 1)  If we look on the radial aspect of the distal radius, we have the styloid process and we see we have this sloping that comes down where it meets the ulna.  This is roughly a 25-degree angle.  In some literature it is called an ulnar tilt and in some others radial declination.  If we look at it from a side view, we also have a volar declination.  (Figure 2) If we see the dorsal aspect of the distal radius, we note that  it is sloping downward.  Normal volar tilt, if we draw a line down, should be anywhere from 10 to 15 degrees.  This can be problematic with a distal radius fracture where we lose that volar tilt.  I will talk a little bit about that later.

Figure 1 – Slide 8

Figure 2 – Slide 9

Carpal Bones

Let’s talk about the bony anatomy of the wrist itself.  The wrist is a kinematic chain.  This means we cannot ask our patient to move the scaphoid on their lunate.  As the wrist moves, we have small motions that happen between the carpals, at the radiocarpal joint, as well as the mid carpal joint.  When there is a disruption and we have too much motion in one area, we are going to have issues with the surrounding or adjacent joints stiffening up.  We see this happen in the spine as well.  This can be very problematic for the wrist as far as loading, gripping or weight bearing activities. 

If we look at the cross section of the wrist, (Figure 3) we see we have a very tight articulation.  Here we have the scaphoid.  Here we have the lunate, and what you also notice is there is not much space in between and a very thick layer of cartilage throughout and between each of the carpal bones. 

Figure 3 - Slide 11

Scaphoid. (Figure 4) The scaphoid articulates with the distal radius proximally and the trapezium and trapezoid bones distally.  It is our most frequently fractured carpal bone, and some of that is due to blood supply and healing potential, but the biggest reason this is fractured is because we have this large bone spanning two rows.  We have the proximal pull the scaphoid within the proximal row, but then it also transverses down and is considered part of the distal row.  We have opposing forces of one force pushing up and one force pushing down.  We end up often getting fractures right in the waist of that scaphoid.  The scaphoid is shaped like a peanut.  Here is an example showing a scaphoid waist fracture.  (Figure 5)  Depending upon where the fracture is, sometimes this can lead to instability.  When someone has an injury to their wrist and we do a radiograph, we treat it as a scaphoid fracture even if the radiograph is initially negative, because oftentimes it is does not show up for three weeks.  With these type of patients that say they had a fall on an outstretched hand, they have tenderness in that anatomical snuff box (the area just proximal to the CMC joint), we treat it as a fracture to avoid issues later down the road because these two opposing forces that may limit healing.  A scaphoid fracture that is a malunion or nonunion is a really icky situation and it happens a lot because people injure themselves with sporting activities and they just keep playing.  Then these people end up being 35 years old with a wrist fusion because their scaphoid has collapsed and their whole proximal row has disintegrated because of that fracture.  With people who have a fall on outstretched hand and tenderness in the snuffbox, we want them to go into a thumb spica, splint or cast.  A thumb spica splint just includes the thumb and the wrist.  We keep it relatively immobilized for three weeks and then get repeat x-rays to see if they did fracture their scaphoid.  If it looks fine, they can stop their immobilization.  This can be a really difficult issue.

Figure 4 – Slide 12

Figure 5 – Slide 13

Lunate  From this AP view, (Figure 6) the lunate looks like a very small bone, but when I show it from a proximal aspect it is really quite large.  This always looks like a little square, but it is a very large bone.  This is the one that is going to be most involved with carpal instabilities, and what we are going to find is the proximal row of the wrist is prone to more instabilities than the distal row.  I will talk about that in the next group of slides when we talk about the ligamentous support.  This bone is also prone to avascular necrosis also called lunatomalacia or Kienbock’s disease.  If there is an issue with the end of the ulna versus the end of the radius, if that end of the ulna is what we call an ulnar minus or we have a shorter ulna versus the distal radius, the corner of the lunate can bang on that radius and can also cause issues.  That is what they find is the most common reason people develop Kienbock’s disease or lunatomalacia. 

Figure 6 – Slide 14

The lunate has vessels, dorsal and palmar, but unfortunately in 20% of patients, they only have a single vessel that enters from the volar or the palmar side making it more susceptible to disruption of the blood flow.  Kienbock’s disease typically happens in young males.  It is a mess to treat because when you look at the literature, you have 20 different ways to treat Kienbock’s disease.  This tells us that there is just not a good way.  It is tough because these people are young, usually male (but it does happen in females) and they have lots of pain.  Sometimes there is not a lot that can be done to prevent the lunate from disintegrating. 

There are two types of lunates when we look at the shape of the bones.  (Figure 7) We have a type 1 lunate where we have no articulation between the corner of the lunate and the hamate.  It only has one facet where it articulates with the capitate.  A type 2 lunate actually has two facets.  It has one for the capitate and one for the hamate.  Right through here is where they articulate.  The majority of the population has a type 2 lunate, which is a more stable position for the wrist.  However, patients can also develop arthritic changes.  Sometimes you will see patients who have what is called the HALT syndrome which is hamatal arthrosis lunotriquetral instability.  They develop instability between the lunate and triquetrum, and we have arthritic changes that happen at the proximal pole of the hamate bone.  Oftentimes that is treated by putting a pin through the lunate and triquetrum.  They will take off the small corner of the hamate just enough to unload that area.  That makes a significant difference in the patient’s pain.  Oftentimes this type of procedure would be done on someone in their 50s who is maybe a manual laborer. 

Figure 7 – Slide 16

As far as looking at instability, the type 2 lunate is actually a much more stable situation. I have up here DISI and VISI.  (Figure 8) DISI stands for dorsal intercalated segmental instability.  That is referring to which way the lunate is facing.  When we talk about an intercalated segment, it means a very loose articulation or more mobile articulation between two stable structures.  This is a side view of a wrist, here we have a very stable distal radius and ulna and we have a very stable distal carpal row.  Here we have a very loose or hypermobile proximal row.  If we look at the lunate, we can see that the lunate is lined up with the capitate and it all moves in a line.  If we look at the distal radius, here is the lunate and then the capitate head right here.  A DISI is talking about which way the lunate is facing.  If we see this little tea cup, it is facing backwards or dorsally.  It is a dorsal intercalated segmental instability.  We are going to talk today about the two types of DISIs, one where we have a disruption between the scaphoid and lunate interval, and the other is a mid carpal instability.  The good news is if you have a type 2 lunate, which the majority of people do, it serves as a protective mechanism to keep that lunate stable. 

Figure 8 – Slide 17

Triquetrum  (Figure 9) The scaphoid has the tendency to stay in a flexed position.  The triquetrum, on the other hand, likes to extend.  It tends to locks in with the hamate which pulls the triquetrum up into extension and then it takes the lunate with it.  The triquetrum also serves as an attachment for the pisiform.  We think of the pisiform as being a pea, a tiny little bone, but it is actually quite a large bone that serves as a sesamoid bone for the flexor carpi ulnaris muscle which comes down, goes through here at the pisiform and attaches at the base of the fifth metacarpal.  Our flexor carpi ulnaris is our strongest wrist muscle.  We liken it to the quadriceps muscle with the patella and the patellar tendon. 

Figure 9 – Slide 18

We know the triquetrum likes to extend.  It also serves as an attachment for a system of ligaments at the ulnar wrist called the triangular fibrocartilage complex or TFCC.  I am not going to get into great detail with that today.  That is a whole lecture in and of itself.  There are issues that can happen with the TFCC as far as the articular disk, the volar and dorsal radioulnar ligaments as well as some of the corresponding ligaments that attach to the lunate.  The focus of my talk is going to be more on intrinsic ligament issues with the scapholunate and lunotriquetral ligaments, as well as mid carpal instability. 

The pisiform as we discussed is a sesamoid bone for the flexor carpi ulnaris and it does not play a direct role in the arthrokinematics at the radiocarpal or mid carpal joints.  You can develop arthritic changes between the pisiform and the triquetrum, and that is called pisiotriquetral arthrosis.  People have pain at the pisiform sometimes caused by less than full weight bearing.  Sometimes it is just placing the hand on the steering wheel that bothers them.  Again, this happens more with people in their 50s and 60s.  Sometimes what happens is this bone is completely taken out.  What will that do to the strength of flexor carpi ulnaris?  You do lose some strength, but it is not a dramatic amount.  I have had three to four patients over the course of the last 10 years who have had a pisiformectomy.  One was actually a pediatric PT.  People actually do fairly well considering you are taking out the pisiform.  It changes a little bit, as far as their ability to weight bear because now they feel like there is nothing there.  Oftentimes these people have pretty heavy scarring, but if someone develops arthritic changes there, there is not a whole lot conservatively that you can do for that.  The literature supports this, and I agree.  That is something that you would want to refer to a surgeon.  Sometimes they will do cortisone injections which can be somewhat helpful for a short period of time, but often these patients go on to need a pisiformectomy.  The pisiform serves as an attachment to the transverse carpal ligament which forms the carpal tunnel. 

Trapezium  The trapezium gets a lot of press, especially with thumb issues.  (Figure 10) It is the trapezial metacarpal joint or CMC joint of the thumb.  Lots of arthritic changes can happen there.  What we find with the trapezium is it will form a very tight articulation with the trapezoid and the scaphoid.  They are going to move functionally more as one unit.  The trapezoid is a bone we do not really think about a whole lot, but it is most involved with helping with thumb extension.  Thumb retroposition is a combination of radial abduction and extension.  If you lay your hand flat and you lift your thumb off the table, this is thumb retroposition.  The trapezoid has a significant role.  What we see happen as we develop arthritic changes here is we also get stiffness  which ends up causing a lot of issues with the patient’s ability even to lay their hand flat.  The trapezoid and the trapezium are important because they are tightly bound with the scaphoid. 

Figure 10 – Slide 22

When we look at the STT or the scaphotrapezial trapezoid joint, we look at the orientation and we have to remember that the carpals are shaped in an arch form.  They are not flat and in a one dimensional plane.  How they move is in this plane that is approximately in a 45-degree angle.  This scaphoid likes to rest in a flexed position.  If we were doing any joint specific testing, we have to follow that angle.  Here we look at the axis of rotation.  The scaphoid on the radius has a lot of mobility, 5 degrees of freedom.  It flexes and extends.  It radially and ulnarly deviates, and it has a supination component, but when we look at the articulation between the trapezium, trapezoid, and scaphoid, it has a single degree of freedom.  There is not a lot of mobility there.  This is more prone to arthritic changes especially with issues with the scapholunate ligament.  When there is a problem here, you end up getting the majority of your load at the scaphoid.  The lunate kind of takes a little vacation.  That is another reason that we see more arthritic changes at the radial column of the wrist. 

Capitate  The capitate is the largest carpal bone.  It is also called the keystone of the wrist.  (Figure 11) If you have a problem between the scaphoid and the lunate, the capitate can actually work as a wedge to force these two bones even further apart.  That is one thing to consider when we talk about grip strengthening with patients.  If you have someone who has a laxity or instability at the scapholunate ligament, you do not want to be having them do weight bearing or gripping because that will force the capitate even further between these two bones.  Gripping activities is something you can do later down the road, but early on, we want to avoid that.  We do not want to force that and put even more stress.  If the ligament is partially torn, the secondary stabilizers can end up getting more compromised. 

Figure 11 – Slide 26

Hamate  The hamate is going to be important as far as providing stability at the ulnar side of our wrist. (Figure 12) It is going to lock into the triquetrum and it is going to encourage that extension moment at the proximal row.  It also has a hook on it, the hook of the hamate, where we have the neurovascular bundle and the ulnar nerve and artery that come through.  Sometimes that can get fractured and can cause issues with ulnar nerve symptoms. 

Figure 12 – Slide 27

Rows and Columns

Let’s now talk about the arthrokinematics or the kinesiology of the wrist as far as in rows and columns.  In rows, I mean talking about the proximal row versus the distal row. We have already kind of started talking about the radial column, the middle column or central column, and the ulnar column.  This is a proximal view of the proximal carpal row. (Figure 13) Remember I had said that the lunate does not look that big from an AP view, but look at the lunate here.  It is huge.  It is a large bone.  We can appreciate the waist of the scaphoid.  You can see where the blood vessels enter the distal portion of the scaphoid and see that the waist is the most common site of fracture.  What you notice is the scaphoid is in a flexed position.  Here we have on the other side of the wrist is the pisiform.  What spans this area here is our transverse carpal ligament for our carpal tunnel. I want you to appreciate the shape of these bones. They are more rounded off and there is not a very tight articulation between the two.  Here we have scaphoid and lunate where we find the scapholunate ligament.  Here between the lunate and triquetrum where we find the LT or the lunotriquetral ligament.  We have large bones and a very small surface area where they attach. 

Figure 13 – Slide 29

(Figure 14) Note the hamate and this great picture of the hook of the hamate.  The trapezium is shown as well.  You can see the saddle joint for the trapezial metacarpal joint or the CMC joint and the trapezium tubercle.  They function as the attachment for the transverse carpal ligament.  You can imagine proximally that the tunnel is a lot wider here and then as you go distally, that tunnel narrows just before the median nerve exits.  Take a look at the shape of these bones for the distal row.  They are more wedge-shaped and have a tight articulation.  Look at that between hamate and capitate.  Look at the tight articulation of the trapezoid between the two bones.  The distal row is a very solid structure and they are very tightly bound to the base of the metacarpals.  When we think about the attachment of the wrist flexors and extensors, they do not attach to the carpals.  They bypass the carpals and attach to the base of the metacarpals.  Our one exception is our flexor carpi ulnaris invests the pisiform as that sesamoid bone, but then it continues on to the base of the fifth metacarpal.  It is important to understand that the distal row is very stable.  It is extremely rare that you would ever have an issue with an instability at the distal row because of this tight articulation.  People with end up with issues at the proximal row much more commonly because that row is much looser.  As we are going to find out with the ligaments, they are more elastic and stretchier. 

Figure 14 – Slide 30

The Joints

When we look at the arthrokinematics of the radiocarpal versus the mid carpal joint, (Figure 15) here we have a convex proximal carpal row, moving on a concave distal radius and ulna.  We have a roll and slide that happen in an opposite direction.  If we are rolling to ulnar deviation, we are going to roll ulnarly and we are going to slide radially.  When we look at the mid carpal joint, we have a little different scenario.  We have a concave on convex relationship where the trapezium and trapezoid articulate with the scaphoid and then that reverses.  Now we have a large convex capitate and hamate moving on the concave lunate and triquetrum.  It is important to understand that this very tight articulation is going to move a little bit differently as far as at the mid carpal versus the radiocarpal, and what we find is issues here, we end up with a lot of stiffness that can promote increased mobility at the ulnar side of the wrist.  The ulnar side of our wrist is more lax than the radial side.  It is designed for more cupping and power gripping activities. 

Figure 15 – Slide 31

The radiocarpal joint has a very stable distal ulna, radius, and articular disk which are part of that triangular fibrocartilage complex, and a very mobile scaphoid, lunate, and triquetrum.  At the mid carpal joint, we have that S-shaped structure.  We have a very stiff distal row and we have a very loose or lax proximal row. 

When we think about radial and ulnar deviation of the wrist, if we just look at the orientation of the radiocarpal versus the mid carpal joint, we would think that the mid carpal joint cannot help much with radial and ulnar deviation because of the S-shape.  We would think that the majority of motion comes at the radiocarpal, but in fact, that is opposite.  We have the most motion for radially and ulnar deviation coming from the mid carpal row because of a flexion-extension motion.  It is going to help with radial and ulnar deviation by flexing and extending which is fascinating to me. 

Capsuloligamentous Considerations of the Wrist

Now we are going to talk about the ligaments that support the wrist.  This is where I really want you to stay with me.  This is heavy stuff.  Understanding wrist instability is a tricky thing, but I am going to summarize as we go and try to help you to point out what are the most important things to know.  When you look at the ligaments of the wrist, it is overwhelming.  I do not remember all the names.  I think about the orientation and which direction those ligaments are going and what they are doing.  Now over the course of many years, I have them memorized, but it is because I understand what they do and not just thinking about the names.

There are two types of ligaments at the wrist.  There are intracapsular ligaments and intra-articular ligaments.  The intracapsular ligaments are within that capsular sheath and that loose connective tissue.  That applies to all of them except for three.  The Transverse Carpal Ligament spans the volar side of the wrist and makes up the carpal canal and is a separate ligament from the capsular sheath.  The connection between the pisiform and hamate is also separate as well as the connection between the pisiform and the base of the fifth metacarpal.  The majority of the ligaments though are within the capsular thickenings. 

Intracapsular Ligaments  When we take a look at the intracapsular wrist ligaments, we have two types.  We have the extrinsic, which start outside of the wrist and come through, and the intrinsics, which start and end within the wrist.  If we look at the extrinsic ligaments and keep in mind the radial declination we talked about earlier, the ligaments in general start on the radial side and span ulnarly and distally.  If you think about the carpals wanting to slide down that slope, these ligaments are helping to support it in that ulnar distal direction.  We are going to talk a lot more about the intrinsics especially the muscles that rest between the scaphoid and lunate, and the lunate and triquetrum. 

Extrinsic Ligaments  Next, we look at the extrinsic ligaments, ligaments that start at the distal radius and travel into the carpals.  They are stiffer and there are three major groups of them.  There is the volar radiocarpal, volar ulnocarpal, and dorsal radiocarpal.  We do not have any ligamentous support dorsally between the ulna and the carpus, and that allows for pronation and supination.  If we did, we would have a limitation with our forearm rotation. 

Look at the orientation here.  (Figure 16) Again do not get caught up in the names.  Look at the orientation of these ligaments.  They start on the proximal radial side of the distal radius and they travel in a distal ulnar direction.  Here is the radioscaphocapitate.  It starts at the radius, goes through the scaphoid, attaches to the capitate.  We have the long and short radial lunate ligaments, again starting from the radius, attaching to the lunate.  This ligament right here, the radioscaphoid ligament also serves as our collateral ligament for the wrist, or radial collateral ligament. 

Figure 16 – Slide 39

Next, we look at the ulnar side.  (Figure 17) These are involved with the TFCC or the ulnar side of the wrist.  We have the ulnolunate and ulnocapitate ligaments, but we also have the ulnotriquetal ligament.  This ligament right here is the ulnar collateral ligament.  Although hard to appreciate here, it is a bifid or v-shaped ligament.  Here we have a view looking at the ulnotriquetral ligament or the ulnar collateral.  (Figure 18) You can appreciate that v shape.  Here we have the radioscaphoid ligament.  That is also a kind of a v-shaped structure as well.  Because the wrist is not circular, they are not true collateral ligaments, but that is how we refer to them as they provide some support in a radial-ulnar plane. 

Figure 17 – Slide 40

Figure 18 – Slide 41

We also have the ulnar collateral ligament even though I just talked about the fact that there is no true collateral ligament because the wrist is not a true hinge joint.  We also have the radial collateral ligament, starting from the radial styloid and then attaching to the scaphoid. 

When we look at support of the wrist, we also have support from the muscles as they cross the wrist.  What I am looking at here is the dorsal aspect of the wrist and hand.  (Figure 19) The extensor carpi ulnaris or ECU tendon is the one that is most prominent by the ulnar head.  The ECU tendon comes down and attaches to the base of the fifth metacarpal.   If you have any issue with instability or laxity at the ulnar side of the wrist, whether it is the distal radioulnar joint or the TFCC, oftentimes you will see problems with the ECU.  You may see ECU tendinitis or tendinosis, or ECU tenosynovitis.  Tenosynovitis is an inflammation between the tendon and the sheath around it versus tendinitis being more an issue of the insertion into the base of the fifth metacarpal.  That is a sign.  If you have someone with ongoing ECU tenosynovitis or tendinitis, you do your modalities to calm it down, you look at their positioning, and you start to strengthen, and they end up with the problems again, that is your sign that maybe something else is going on underneath that needs to be addressed.  When we look at the radial side, it is our abductor pollicis longus or APL.  That is the tendon that is involved with de Quervain’s.  That is part of our first dorsal compartment.  Again we can see issues here with the APL as far as tenosynovitis in patients that have the positive Finklestein’s test, or you can see issues sometimes with APL if there is a problem with the CMC joint.  The take home message here is that our wrist ligaments are dynamized or assisted by muscles around it.  If you have someone with an ongoing tenosynovitis or an ongoing tendinosis, there may be other issues underlying requiring the muscles to work harder to provide support. 

Figure 19 – Slide 44

Now we will go back to the volar side of the wrist.  (Figure 20)  There are two layers.  Here we see that fan-shaped structure coming from the radial side and moving in a distal ulnar direction.  Again it is to help prevent that wrist from sliding down that slope.  There is an issue with the deeper portion.  We do not have any ligamentous support between the capitate and the lunate.  That is called the Space of Poirier.  That is one reason why we end up with more instability issues at the lunate because we do not have any connection between the capitate and lunate. 

Figure 20 – Slide 45

Here on the right we see that V or fan-shaped structure.  The deep extrinsic ligaments are what we call an arcuate complex because it is shaped in an arch.  We have a big hole in the middle where we have the Space of Poirier, where we have no ligamentous support.  Again, this makes that central column, or the capitate on the lunate, more prone to instability issues.  What we have discussed so far is that we know the distal row has a very tight articulation.  It is tightly bound to the base of the metacarpals, and we have a very strong distal radius and ulnar, and a very loose, more bulbous bones with not as good of an attachment at the proximal row.  From that aspect, the lunate is more prone to issues and from a central column aspect, it is more prone to issues because of that Space of Poirier. 

Let’s talk now about the dorsal radiocarpal ligament.  (Figure 21) Now we are on the dorsal side of the wrist.  For many years, people thought that the dorsal side of the wrist really was not important.  If someone had an injury and their dorsal wrist capsule was torn, it was not that big of a deal.  Surgeons did not really repair it on a consistent basis because no one realized the biomechanical importance of it.  Well now we find that it is important, and there is a surgeon named Steve Viegas who had done a lot of research in the late ‘90s and found that this is really an important structure.  It provides a lot of support, not only to the whole wrist itself, but especially to the proximal row.  I had the honor of seeing Dr. Viegas present at the ASHT (American Society of Hand Therapists) conference two weeks ago in San Diego.  He was great.  He is a great educator and a great researcher and that sometimes does not happen together.  He really helped me to drive home why the scaphoid ends up getting more issues with arthritic changes.  I will talk about that in a few slides with his example that helped really drive it home.  He did a lot of research and we found out that these are really important.  What they do is help prevent the translation of the carpus down that radial declination.  They indirectly stabilize the scaphoid.  You can see they are crossing right over.  They are going to contribute to stability of that proximal row. 

Figure 21 – Slide 50

What he also found was that there is a lot of variation with the dorsal extrinsic wrist ligaments.  Some patients, half the population, have a little wispy type 1 dorsal radiocarpal ligament, where others, 9%, have a very strong one. The rest of us fall somewhere in the middle. That helps us to understand why some patients have a huge fall onto an outstretched hand and do not have many issues whereas someone that has the type 1 ligament may have a minor trauma but they are hurting all the time and cannot do anything. We wonder if they are just being a baby or is there something else going on. It is important for us to keep in mind that there is a lot of variability with these wrist ligaments.  That can play a huge role in how fast or slow that you can rehab them. 

Intrinsic Ligaments  Now I am going to shift gears and I am going to talk about the intrinsic ligaments.  When we talk about the intrinsics, they are the ligaments that start and end within the carpals.  The main ligaments we are going to talk about are the scapholunate ligament, which attaches between the scaphoid and lunate, and the lunotriquetral ligament.  We are also going to talk about the mid carpal ligaments of which there are many.  I have the names listed, but it is not as critical as just looking at the connection between the distal and proximal rows.  Then we also have a very strong set of ligaments that attach the distal row to the base of the metacarpals. 

The scapholunate ligament is most important.  (Figure 22) The dorsal portion is the thickest and the most important.  Here we see the dorsal view and here is the volar view.  Let’s think about what the carpal bones are doing.  The scaphoid bone wants to flex, so it tends to stay in a flexed position.  The lunate is kind of fickle.  It is going to go either way, wherever it wants to go.  In Figure 22, we see the flexed scaphoid.  Here is the lunate next to it.  Whenever there is an issue between the scaphoid and lunate, the scaphoid is always going to flex.  It is always going to go further into flexion.  If they separate, the lunate is going to follow the triquetrum into an extended position. 

Figure 22 – Slide 55

The lunotriquetral ligament attaches the triquetrum here and the triquetrum wants to extend.  (Figure 23) That is its goal.  It locks with the hamate and it goes into extension.  Where the lunate again is going to be fickle, it will go either way.  If there is an issue with the LT ligament where it disrupts and we lose the support of the other ligaments, the dorsal intercarpal ligament especially, the lunate will then follow the scaphoid into flexion.  The lunate is going to follow whichever it is still connected to. 

Figure 23 – Slide 56

Let’s talk about these deep intrinsic ligaments.  (Figure 24) The most mobility is coming from the scapholunate and lunotriquetral ligaments.  There are highly elastic, very mobile, very different from these distal ligaments where we have a very strong articulation.  There is not much movement that occurs, for example, between the trapezoid and capitate and capitate and hamate. 

Figure 24 – Slide 57

Look at the deep intrinsic ligaments, here is our nice picture.  (Figure 25) I love this picture showing the intercalated segment.  What is the intercalated segment?  Here we have a very rigid distal row and rigid distal radius and ulna.  We have a very loose slippery proximal row.  I remember an article I had read where they showed this as a slippery banana, sliding back and forth between two very rigid structures.  This whole area is considered an intercalated segment, meaning it is a very loose structure sitting in between two very rigid structures.

Figure 25 – Slide 58

Let’s look at issues with what we call DISI and VISI. (Figure 26)  DISI is dorsal intercalated segmental instability and VISI is volar intercalated segmental instability.  This is in reference to where the lunate is facing.  Let’s say that you have disruption of the scapholunate ligament.  The scaphoid always wants to flex, and it normally sits in 40 to 60 degrees of flexion, but it can flex even further up to 80 to 90 degrees if it is not attached to the lunate and the rest of the proximal row.  Let’s say a patient had a fall and we disrupted that ligament.  The scaphoid will further flex.  What is the lunate going to do?  Remember the lunate is fickle.  It is going to go with whomever it is still attached to.  The lunate will follow the triquetrum into extension.  From a side view, what you are going to see is the lunate is going to follow or look up into an extended position, but we have arthrokinematically a convex lunate moving on a concave distal radius.  As that lunate tips back dorsally, it is going to slide down volarly.  That can be problematic because what is sitting right here underneath the lunate is the carpal canal and the median nerve.  There are some cases where if someone has a disruption of the scapholunate ligament they can end up with median nerve symptoms.  Did they develop carpal tunnel over time?  No this would be an acute carpal tunnel because now the lunate has looked up and slid down, and now you have decreased that area of the carpal canal. 

Figure 26 – Slide 59

VISI, again, is volar intercalated segmental instability.  Now the lunate is going to look volarly or forward.  What happens here?  Here is the disruption of the lunotriquetral ligament.  The triquetrum is going to extend by itself and the lunate is now going to follow the scaphoid.  Which way is it going to go?  The scaphoid wants to flex, so the lunate will now follow the scaphoid into flexion.  What happens here from a side view is the lunate is going to look down and it is going to slide up because of that convex and concave articulation.  What happens then is the carpus, in this case, appears dropped.  If you look at the patient’s wrist from a side view, you are going to see the whole hand kind of drop down.   What we are going to find to be able to help treat that is something that will boost the carpal row up.  We can do that by placing pressure on the pisiform and the triquetrum to help lift it up as well as the scaphoid tubercle to help prevent that flexion.  I will talk about that in our last section for today. 

How I show this when I teach this live is I will have three people standing up and holding hands.  I will have one person be the scaphoid and flex, and I will have the other person on the other end be the triquetrum and extend.  They are all happily holding hands.  Then,  I will have a fall on an outstretched hand where the scaphoid and lunate separate.  What happens there is the person that is leaning forward is going to lean forward further, and the person that is the lunate and is joining hands with the triquetrum is going to extend into that extended position following the triquetrum where it is going to roll dorsally, so dorsal intercalated segmental instability.  For the second scenario, we have those three people joining hands.  When we have an issue or a disruption of the LT ligament, now they stop holding hands.  The scaphoid wants to flex so the lunate will stay with the scaphoid and it will flex further.  That is how we get that volar flexion where the lunate is looking downward and sliding up.  Hopefully this make more sense as we go through. 

I want to talk a little bit now about the mid carpal ligaments because they are going to be our most important secondary stabilizers for the proximal row.  If someone has a disruption of the scapholunate ligament, they may not show an instability pattern until they have started to stretch this dorsal intercarpal ligament.  (Figure 27)  Because in and of itself, that dorsal intercarpal ligament can stabilize the wrist and you will not see an instability pattern. 

Figure 27 – Slide 61

Viegas, again, did a study to find out what are the variations in the dorsal intercarpal ligament.  There are quite a few.  We have type A where it has a wisp coming across the dorsal aspect of the proximal row.  Thankfully, the majority have a medium (type B), where they have a little bit more.  Type C has a lot of support and is in 26% of the population.  Most patients have a third of a chance that they are going to have a decent amount of support here. 

The dorsal intercarpal ligament is thicker and is going to contribute to stability of the wrist.  When it gets compromised or when its stretched, it is going to cause issues at either the scapholunate or lunotriquetral interval.   It is a very strong stabilizer, so we have some backup if we end up blowing out our scapholunate ligament. 

It is important to talk about the dorsal intercarpal ligament and its relationship to the scaphoid.  (Figure 28)  It is going to attach to the scaphoid right at the waist area of the scaphoid.  So if you have a fracture that is proximal to the waist, it is going to actually provide stability because of this dorsal intercarpal ligament.  The dorsal scapholunate interosseous ligament is the scapholunate ligament.  If you have a fracture though distally, you can end up with issues of instability.  This is a very important ligament. 

In Figure 29, I want you to think about the fact that there are a lot of different ligaments that help support the mid carpal joint.  If you look at the orientation, they are kind of in a star-shaped pattern.  Don’t worry about the names of them, just think about the orientation.  These ligaments are providing support for the mid carpal region.  Look at the distal carpal row and the interosseous ligaments.  We have a very stable structure.  This is the strong connection between the distal row and the base of the metacarpals.  There is nothing that is going to disrupt those.  You can disrupt the CMC joints, but I have never seen a disruption between those distal carpals unless it is a very high energy trauma or a partial amputation. 

Figure 29 – Slide 64

I have a patient right now who I am interested to see.  The hand surgeon told him that all of his carpals were like a cup of dice and he rolled the dice.  He was racing trucks off-road.  His truck flipped over many times and the safety device that holds the arms in let loose and his hand came out of the truck, and the truck rolled on his hand.  He has multiple K-wires through his wrist.  They are coming out next week.  I am really curious to see how he is doing pain-wise.  Normally K-wires are not that stable.  They are great for finger fractures, but not as great for the wrist.  I am curious to see how he does with the disruption because he completely disrupted all of his carpals.Let’s talk about the distal row.  (Figure 30) Here we have a very tight articulation between the trapezoid and capitate and the capitate and hamate.  They are not moving.  They are very dense.  They are not elastic.  This is very different from what we see in the proximal row. 

Figure 30 – Slide 65

Analysis of Carpal Instability

This is where we start to talk about carpal instability as there are many different names for different stages.  I am going to go through that and try to help delineate.  All of this that I am showing is in the handout.  So if you have not done so already, print out the handouts and take a look at it.  That will be a big help. 

When we talk about stability of the wrist, it is a balance because the wrist is a load transfer system.  Every time we grip or every time we weight bear, load gets transmitted through all of the bones, and there are different stages as we are going to find.  You can have a lax wrist which is sometimes what we see in young females.  You can have patients that have trauma where they have full disruption of the ligaments.  When we look at the classification, unfortunately, there is really none that is ideal.  We have a lot of different names and I am going to go through - all the different types and what they refer to. 

When we talk about carpal instability, we can look at it from six means.  Chronicity looks at “how long did it happen?”  Oftentimes we do not get these patients right away.  We get them when it has become chronic.  We also have the constancy, the etiology (this is where we are going to talk about some of the systemic disorders that can cause wrist issues as well), the location, the direction and the pattern.   


We are going to first talk about chronicity. There is acute which means trauma less than a week ago, which we hardly get in the clinic.  We usually see people in the subacute or chronic phases.  The acute phase is the best phase for healing potential.  If you have someone that just had their issue, you test them, you realize they need a Wrist Restore splint, and you brace them.  They will have a good potential for healing.  Let’s say that patient had a car accident.  I think about one of my patients who had her hand on the shifter in the middle of the car and she was rear-ended.  She had a huge force or load through her wrist.  She is still having issues with it.  She thought like most people that she could take a little ibuprofen and it will get better, but it has not gotten better.  It is continuing to get worse.  Now we look at their healing potential.  The ligaments may have retracted, and we may have some issues of the remnants of that becoming necrotic.  Now the healing potential is more limited.  Chronically, our primary ligaments are unlikely to heal except if it is an avulsion.  Sometimes that does happen when the ligament fractures a portion of the bone.  That has good healing potential, but the majority, if they have torn in the center part of the ligament, it is very unlikely that you can do a direct repair.  Those are people who sometimes have ligament reconstructions. 


The idea of Constancy is something that we will see more in the literature.  There are categories of Pre-dynamic, Dynamic, Static Reducible and Static Irreducible.  I would like for you in your handouts to put a star by predynamic because that is the only one that we can really treat conservatively.  The rest of these are ones that we are going to need to refer to a hand surgeon or orthopedic specialist.   

Pre-dynamic refers to a partial ligament tear.  When you stress that joint, meaning if you do a clenched fist x-ray or something to load, we are going to find no malalignment.  How do we find out what is going on?  It is with our clinical exam.  I will be talking about how to do some of the tests to help rule things out. 

Dynamic is where we have complete rupture of the ligament itself.  The problem is that on static x-ray, it does not show up.  Unless the ligament is loaded during the x-ray, i.e., a clenched fist or clenched pencil, the instability pattern will not be seen.  The majority of people are dynamic. 

Static instability is the complete rupture of the ligament with permanent alteration of carpal alignment.  A static x-ray will show this.  These two people typically are not therapy candidates.  I think a lot of people out there have that predynamic.  They may have a partial ligament tear and there are things that we can definitely do for them.  I will be talking about treatment later.  There are some prefabricated braces that work well for these patients.  There are some motions that we want to focus on as well.  We are going to talk about the dart-thrower’s motion because that motion actually minimizes stress between the scapholunate and lunotriquetral ligament.  There are things that can be done, but our role as therapists is that we need to determine what is going to help them.  If they are at a point where they have a dynamic or static instability, they are past what we can do conservatively for them.  We do not want to waste visits by seeing them for weeks and weeks and then find out that things have not changed drastically. 

Pre-dynamic Instability With our pre-dynamic instability, the partial ligament is causing the pain.  There are no alignment issues, but our only way to determine what is going on is by clinical exam. 

Dynamic Instability  Dynamic instability comprises 88% of all cases when comparing dynamic and static instability.  The pre-dynamic instability is not in the picture.  I think there is a lot more predynamic out there then we know because the research is often done on what is operated on.  What is operated on is static and sometimes dynamic instability.  With dynamic, we have a partial or full interosseous ligament injury, but we have no changes or minimal changes with a static radiograph.  When we ask them to do loaded positions, we will then see the instability pattern. 

This is the traditional clenched fist radiograph.  (Figure 31) What we are looking at, outlined in a yellow, is a case where we are evaluating whether or not someone has a scapholunate instability.  Here we are looking at the distance between the scaphoid and the lunate.  Remember with a scapholunate ligament disruption, we have the scaphoid further flexing and the lunate extending.  We are going to see, not only further flexion, but we are also going to see an increase in gap between the scaphoid and the lunate.  In this position, the patient is going to actively make a fist and they are going to shoot the x-ray. 

Figure 31 – Slide 75

The Clinched Pencil Radiograph came out in 2003, and I think it is a great idea.  (Figure 32) The patient grasps a pencil.  What happens is that you get an increase in pronation of the forearm and carpal pronation.  Our most stable position for the wrist is in a supinated position where the carpals are the closest together.  Holding the pencil ends up causing more pronation of the wrist, which is in more of a maximal loose position, and here you can see the difference.  Look back to Figure 31 so that you can compare.  Look at the gapping here on Figure 31. Then we come back and look at the gapping on Figure 32.  You can see a much wider gap on Figure 32 and that may be important for someone that has an issue that maybe a very mild dynamic instability. 

Figure 32 – Slide 76

What is static instability?  That is the late stage of instability, where we have scapholunate dissociation or lunotriquetral dissociation.  What we see is a permanent position where that scaphoid is flexed forward and it is staying there statically.  This is oftentimes where we see the initiation of more arthritic changes.  We are going to talk about that.  Here we have that gap.  (Figure 33)  Can everyone appreciate that here is the scaphoid and here is the lunate?  This is really nice because you can really see that shape of the lunate, how it is shaped like a moon.  Sometimes you will see with the scaphoid in marked flexion what is called a cortical ring sign, where you will see a ring right through here.  This one is not as profound.  That is where the scaphoid has further flexed and you see a radial lucency here that is shaped like a little ring.  Sometimes you will see that also in reports.  That is telling you that the scaphoid is flexed.  What we see here is often called Terry Thomas sign.  He was a British comedian that had a big gap between his front teeth.  It is now called more like the David Letterman sign, like the big gap between his teeth.  This is definitely something that we will not be able to treat as therapists. 

Figure 33 – Slide 78

Another way to look at analyzing the alignment of the carpals is looking at what is called Gilula’s arcs.  (Figure 34) We should see some concentric rings here at the proximal border of the proximal row, at the distal border of the proximal row, and then following here the capitate and the hamate.  Now over here on the right we can see we have the Terry Thomas or David Letterman sign.  Look at this.  We have that disruption.  We do not have that nice concentric ring that we do in the first scenario.  That is another thing that physicians will look at as they evaluate those radiographs. 

Figure 34 – Slide 79


Now we have gone through and talked about chronicity and constancy.  Now I am going to talk a little bit about etiology.  Most of the things we would see in the clinic are more traumatic based, but there are other issues, more systemic issues, that can cause instability issues.  We can have congenital issues that are present at birth.  An example is Madelung’s deformity.  This is where the distal ulna is longer than distal radius.  We can end up with the distal ulna pushing on the proximal row which can cause TFCC problems and problems at the lunotriquetral interval.  We can have carpal synostosis where we have the carpal bones fused together.  You can get what is called an LT coalition where the lunotriquetral bones are actually somewhat connected.  Sometimes it is fibrous and sometimes it is fully bone.  Sometimes the fibrous ones can loosen with time and cause issues.  There are some congenital reasons. 

Most often we see issues from trauma, sometimes due to a crush injury like the gentleman who rolled his truck.  He said it was all his fault because he likes to race trucks.  He is not doing it anymore per his wife, he said.  Again it could be from a crush injury or a FOOSH (fall on an outstretched hand) which is a hyperextension injury.  We see that a lot especially if you are living up North when the first ice storm comes.  Everyone comes in with distal radius fractures or if you treat the lower extremities, hip fractures. 

The mechanism of injury can be direct where the direct blow comes to the bone dislocating it, and you see this more in industrial issues where you have wringer type injuries or power press.  We get a lot of issues with crush injuries.  Where I live, the paper industry is strong so you get a lot of people whose hand gets caught in a paper machine and is rolled.  Then it is the combined mechanism of traction as well as direct force.  The indirect injury is where the deforming load is applied at a distance.  That is the fall on an outstretched hand.  They may fall more on their fingertips and the front part of their wrist, but then that injury is translated because of the kinetic forces through the wrist. 

Now we are looking at the stages of a hyperextension injury looking at perilunate instability. What happens first is the scapholunate dissociates, so we have an issue between the scaphoid and lunate.  Then it travels up between the lunate and capitate, then to the LT ligament and finally the lunate dislocates.  That is the pattern.  It starts at the radial side of the wrist.  That is the pattern for arthritis as well.  It always starts at the radial side of the wrist. 

Under inflammatory etiologies you will find rheumatoid arthritis.  We think about rheumatoid arthritis being more of a joint issue, but it is really a synovial issue.  The synovial issue can cause joint issues, but think about the radial declination and volar declination.  Think about those ligaments and their orientation.  They are going proximal-radial and distal-ulnar.  As those ligaments start to stretch, we will have the sliding down of the carpus.  It will slide in a ulnar direction and a volar direction. 

Under neoplastic etiology we have to realize that sometimes tumors can, although not frequently, cause carpal instability.  We can also have instability caused by a healthcare provider.  A well-meaning physician or surgeon trying to help one condition can sometimes cause other issues.  Other causes could be an infection or avascular necrosis or Kienbock’s disease with the lunate. 


I have some pictures that will help make a little more sense as we talk about location.  (Figure 35) We can have instability at the radiocarpal versus proximal intercarpal, mid carpal, distal intercarpal, the CMC which is more due to trauma or specific bones. 

Figure 35 – Slide 87

Location, location, location!  When we look at the radiocarpal, we are talking about something that we will see more with a rheumatoid arthritis case.  Remember the direction of those ligaments.  As those ligaments stretch due to the synovitis, it is going to slide ulnarly and volarly.  Because those ligaments have just slowly started to stretch out we can have issues also between the carpals, scapholunate or lunotriquetral.  We can also have issues at the mid carpal joint because as we recall between the capitate and lunate there is no direct ligamentous support.  That is called the space of Poirier.  There is nothing there to help us so that is one reason why we see issues at the mid carpal joint with instability.  Sometimes we can have issues at the CMC.  Which one is the most common?  The first CMC, our thumb.  I know that our thumb is near and dear to us as therapists because we use our hands a lot, so we have to protect it so that we do not end up with subluxation or resultant arthritic changes in specific bones themselves.  Oftentimes what we see, as we talked about earlier, is that it is the lunate that gets dislocated. 

Radiocarpal Joint  Looking at the radiocarpal joint, what are our stabilizing mechanisms?  (Figure 36) These are the ligaments we talked about earlier.  We have the dorsal and volar ligaments.  Look at the orientation, again proximal-radial and distal-ulnar.  With an ulnar declination, because everything is tending to want to slide, we can end up with issues at the radiocarpal joint.  As in a rheumatoid arthritis case, everything slides over.  These people will present with a radial deviated wrist because of that ulnar translocation.  If you are trying to make a splint for them, you would need to first relocate the wrist and that provides alignment.  You may have to put more padding or support here to prevent the proximal row from sliding ulnarly.  We also see issues with volar translocation.  We can see that whole proximal row sliding down because of the volar tilt of the wrist. 

Figure 36 – Slide 88

Proximal Intercarpal Joints  When we look at the proximal intercarpal joints we have SL or scapholunate ligament and the LT or lunotriquetral ligament.  (Figure 37) What are our deforming forces?  We have fall on an outstretched hand, our wrist hyperextends, ulnarly deviates, and the carpals supinate.  Now we end up with a direct force on these ligaments.  We can also end up with a hyperpronated injury where you have someone who falls with their hand behind them.  Most people fall with their hand out in front, but sometimes people fall backwards in a more pronated position.  It is not as common. 

Figure 37 – Slide 90

Failure of the scapholunate ligament (Figure 38) can lead to a DISI or dorsal intercalated segmental instability. The LT or lunotriquetral failure will cause the lunate to flex with the scaphoid.  The lunate will look volarly and slides dorsally.  That comes back a couple of times because that is a really important concept. 

Figure 38 – Slide 91

Midcarpal Joint  Now the mid carpal joint.  What are our stabilizers?  Here are those mid carpal ligaments that help us stabilize.  (Figure 39) Axial compressive forces can cause that scaphoid to flex and that can cause a disruption between the capitate and the lunate because we do not have the stability there.  Mid carpal issues can also be seen more with young girls that have a lot of laxity in their ligaments.  Unfortunately those are the ones that choose to go out for gymnastics or they do cheerleading or dance where they do a lot of loading and tumbling type activities.  I am going to go through some things as far as treatment, but these are a hard bunch to treat.  One person I think about is someone I saw about three months ago.  She is a 16-year-old and is very lax to the point where when she radially and ulnar deviated her wrist, her scaphoid subluxed dorsally out of her distal radius.  You could feel it and it was clicking.  She was so lax, but she wanted to go back to tumbling and weight bearing.  She is 16.  She is not going to make dance her career.  So, I wonder why she would go back.  It is so hard to treat because as soon as she started getting better, she wanted to tumble and weight bear again.  I think it also becomes an issue with gymnastics and sports.  People are doing contact sports at a much younger age.  Looking the distance of the distal ulna versus the radius, we call it an ulnar positive or ulnar negative wrist.  We are seeing more people with ulnar plus wrists because of the weight bearing early on and that growth plate for the radius closing early, but the ulna keeps growing.  We are seeing more people with ulnar wrist issues because they have an ulnar positive wrist.  It is because they are getting involved with karate at 3 or 4 years old and loading this joint which is not meant to be loaded that much, and closing that growth plate early. 

Figure 39 – Slide 92

Back on topic, we can also have a DISI or VISI that is not associated with a problem with the scapholunate or lunotriquetral ligaments.  This is higher level stuff because there are not a lot of hand therapists that understand this.  This is big stuff.  Again we look at the definition of a DISI or VISI we are looking at what happens and where is the lunate facing.  What happens here is a disruption between the capitate and lunate so the mid carpal joint causes the issue and the lunate then looks dorsally.  (Figure 40) This can happen with our young girls that have a lot of ligamentous laxity.  I will talk about that a little more when I talk about the carpal instability combined and complex. 

Figure 40 – Slide 93

Distal Intercarpal Joints  Let’s talk about the distal intercarpal joints.  (Figure 41) Again we do not see a whole lot of issues with this.  What is the stabilizing mechanism?  Here is the transverse carpal ligament and we have dorsally, the dorsal intercarpal ligament, and interosseous ligaments.  They are going to help stabilize between the carpals here at the distal row and the proximal row.  The deforming forces can be muscles, FPL and flexor tendon of the small finger, as well as crush injuries.  Again, this is not as common as far as with falls on outstretched hand.  You are going to see more scapholunate and lunotriquetral, but it can happen. 

Figure 41 – Slide 94


VISI and DISI  Now we are going to go back to our VISI and DISI.  With a DISI, again, the lunate is extended.  I think I have probably driven this home enough.  In VISI, the lunate is flexed. 

Keep in mind that with a DISI, what is happening with the scaphoid.  The scaphoid is normally at 40 to 60 degrees of flexion.  When you have a DISI and a disruption between the scaphoid and lunate, the lunate is going to further flex.  It can flex 80 to 90 degrees.  The lunate will follow the triquetrum in extension.  We treat that conservatively by having some kind of support at the distal end of the scaphoid to bring it up in a more extended position.  So the majority of issues between the scapholunate versus lunotriquetral involved the scapholunate ligament.  75% of intercalated segmental instabilities are DISI.  The test we are going to use to help determine if there is a disruption of the scapholunate ligament and its supporting dorsal intercarpal ligament is the scaphoid shift of the Watson’s test. 

Let’s take a look at Figure 42.  Normal angulation of the scaphoid is 30 to 60 degrees.  How we look at that is you can either bisect the bone, here I am bisecting the scaphoid, or here I am going through the lunate.  That angle right here should be 30 to 60 degrees.  There is also an article that came out and found that tangential method is actually a little better since you are on top of the bone and measuring.  You may find that is a little more accurate.  Look what happens when you have disruption between the scaphoid and lunate.  The lunate is going to extend.  You can see it is not coming straight up, but how it is facing now in extension with the capitate and the triquetrum.  Look at the scaphoid.  Where is it?  It is really flexed with 92 degrees of flexion.  Now look at this.  This is our scapholunate angle which is 92 degrees.  If you have a patient on lateral x-ray that has a very large angle between the scaphoid and lunate ligament, that is indicative of a DISI or disruption between the scapholunate ligament. 

Figure 42 – Slide 99

The mechanics of it are typically the fall on an outstretched hand.  Injury to the scapholunate ligament can cause predynamic instability or occult instability.  This is something we can treat.  If it gets to the point that it stretches out the other supporting structures like the dorsal intercarpal ligament, then we are going to have more problems because they are going to be passed what we can do as far as conservative treatment.  When we completely section the scapholunate ligament, what we have is a dynamic instability, but when we section everything, the secondary stabilizers, we have a static instability.  That is where we can end up with more issues with arthritic changes. 

Next we will talk about a SLAC wrist. SLAC stands for scapholunate advanced collapse.  That is the arthritic changes that happen as a result of a static DISI due to scapholunate disruption.  We have arthritic changes starting more between the scaphoid and radius, then they go into the mid carpal joint, and I am going to show some pictures here.  They start here at the radial styloid.  (Figure 43)  What drove it home for me is what Steve Viegas said a few weeks ago with a cute illustration of a scaphoid and lunate bone as little characters.  They were holding this big weight, a 50 pound bar bell, between the two of them.  He showed that this is what normally should happen.  The two should share the load, scaphoid and lunate.  He said and this is what happens if you have a disruption between the scaphoid and lunate.  He showed the scaphoid sweating, working hard and holding the weight, with the lunate sitting back on a patio chair sipping something under an umbrella because the lunate was not really doing anything, and the scaphoid had all the load.  He said this is the reason the scaphoid ends up getting arthritic changes, that the lunate is the last to come because the lunate does not have the force that is involved when you disrupt that ligament that the scaphoid does.  If you can picture that nice peanut-shaped bone, the scaphoid, holding with all its might holding up that weight, it helps us understand why we see arthritic changes here first when you have a scapholunate disruption. 

Figure 43 – Slide 103

Now (Figure 44) it travels more throughout the whole scaphoid where it articulates with the radius.  Then it goes to the mid carpal joint.  (Figure 45) The lunate is sipping a nice drink and is not involved.  Then eventually, we will get the entire mid carpal joint.  (Figure 46)  Then we can get issues at the distal radioulnar joint right here.  So when you have someone with a SLAC wrist, you are looking at a salvage procedure as far as for surgery.  There is not a lot, you know you cannot just go in here and say we are going to clean up some of the arthritic changes.  The scaphoid has flexed to the point it is a fixed deformity.  You cannot just prop it up and put some pins in here and think that it is going to work.  Over time, it will not and patients are not going to happy. 

Figure 44 – Slide 104

Figure 45 – Slide 105

Figure 46 – Slide 106

What do they do surgically for this? There are a few options.  One, you could do a total wrist fusion where you just put plate through the whole thing.  That is really not done as commonly anymore.  There are two procedures that they use.  One is called a four corner fusion where they will take out the scaphoid and fuse the capitate, hamate, lunate, and triquetrum.  Sometimes they will use a plate with bone grafts; sometimes they will just use a bone graft.  What that leaves the patient as far as function is usually about 50% of their range.  You can expect 30 to 40 degrees of flexion and 30 to 40 degrees of extension.  The one issue with this is that sometimes there are problems with the fusion.  If you have someone who is a smoker, most surgeons will not operate on them until they agree to stop smoking and stay not smoking.  The four corner fusion is something that you will often see if someone has a SLAC wrist.  There is usually not a whole lot of therapy that you have to do with them, but some people are a little stiff.  You do not really want to go in and mobilize this area because that is the only joint they have and it will loosen with time.  Just doing gentle active motion is great for these people. 

The other procedure to address a SLAC wrist is called a PRC or proximal row carpectomy.  In this procedure, they take out the scaphoid, lunate, triquetrum, and pisiform bones.  They take out that whole row.  Now that works if you have a good articulation of the capitate.  If the capitate has gotten to the point where it is arthritic, then you will either have to do the four corner or a full fusion.  If you do not have arthritic changes here, the proximal row carpectomy is a nice option.  What they have found, comparing the studies between PRCs and four corner fusions, is that they get roughly the same outcomes.  The difference is with the PRC, the whole wrist shortens because obviously you lose these bones, and it takes usually about a year to build up their strength to the point where it would be their maximum because you have wait for the muscles to myostatically contract, to be able to have that length-tension relationship restored.  Most patients, whether they have a PRC or a four corner fusion, will get about 80% of their grip back and about 50% of their range of motion.  The PRC is the same deal as far as 30 to 40 degrees of flexion and 30 to 40 degrees of extension.  These are salvage procedures.  People do well and are functional, but their wrist is never the same.  You are going to lose half of your range, and you are going to lose about 20% of your strength.  However for someone who is in significant pain and cannot do their activities of daily living, it may be a good option. 

Figure 47 is showing a picture of a stage 2 SLAC wrist.  Where is the joint space here?  There’s not much.  You could even see here there are some arthritic changes at the distal radius.  It is really hard to delineate where the scaphoid is in relation to the lunate because of those arthritic changes.  The majority of these people that develop SLAC wrists is due to a trauma.  I talked earlier about the scaphoid fracture that does not get treated, and ends up being 34 years old, and has one of these procedures.  That is called a SNAC wrist.  It is scaphoid nonunion advanced collapse.  So if the scaphoid fractures and you have a nonunion, you develop a SNAC wrist.  The SNAC wrist is very similar in its pattern to a SLAC wrist.  The treatment is also the same.  That was preventable if they would have done something about it at the time it happened.  I remember talking to this 32-year-old guy who was right dominant hand and had a four corner fusion because of a SNAC wrist.  I asked him if it was worth it.  He said it was because he got to football all four years of high school.  That is what can happen with a scaphoid fracture that is not properly treated, it goes on to malunion, and it collapses.   Again this is the reason, if you have someone with a fall on an outstretched hand and tenderness in the snuff box, to treat them and immobilize them early, and ensure that they do not have a fracture.

Figure 47 – Slide 107

Here is our VISI again.  (Figure 48)  We know our lunate is going to flex forward and the whole carpal row is going to appear dropped.  Here is that lateral view in x-ray.  Again we want that lunate and capitate to be lined up, and it should be straight on with the distal radius.  Here you can see it has dropped.  The whole carpus has dropped down.  What is it going to look like?  (Figure 49) If you have a VISI, your scapholunate angle is going to be less than 30 degrees because what we see is the lunate now looking down.  It is falling forward and now we have less of an angle at the scapholunate interval.  If it is more than 60 degrees, it is a scapholunate ligament problem.  If it is less than 30 degrees, it is a lunotriquetral problem. 

Figure 48 – Slide 109

Figure 49 – Slide 110

What can happen with LT dissociation?  Patients can develop progressive perilunate instability where they can have any injury causing an issue at the LT which eventually causes arthritic changes, or they can have the ulnar plus variant.  That is what I talked about earlier.  If a patient has a longer ulna than distal radius, this can wear and push on the LT interval and cause arthritic changes.  The proximal row slides ulnarly.  A carpal instability can be both at the radiocarpal and mid carpal joints, and then a dorsal translocation where the carpal condyle passively subluxes in the dorsal direction.  That happens more because of distal radius fractures, but sometimes you can see it subluxing if you have people who are really hypermobile. 

So here we are with everything is shifting ulnarly. (Figure 50) We talked about this with systemic disorders, especially rheumatoid arthritis. Here we have disruption of the scapholunate ligament, so we just have the ulnar side of the wrist that is sliding, (Figure 51) but everything is staying intact on the radial side including the radioscaphoid or the radial collateral ligament and the radioscaphocapitate ligament.  Those stay intact.  That CIC is carpal instability combined.   I will talk about that in our last section.

Figure 50 – Slide 113

Figure 51 – Slide 114 

As we can see, this is heavy stuff.  Understanding wrist instability is a huge topic and there is a lot of different variables.  I have, at the end of this course, my email address so if you have questions, please feel free to email me.  This is tricky stuff.

Normally the proximal row moves into extension and the distal row moves dorsally with ulnar deviation.  That is the normal movement pattern that happens.  But what can happen with mid carpal instability is that you can have a VISI where you flexion of the scaphoid and whole proximal row, and sometimes you can have a DISI, where you have hyperlaxity, where the lunate comes back.  There is no problem between the LT or scapholunate ligaments; the issue comes from the mid carpal joint.  Why am I talking about this?  We are going to go through a test as far as how to examine it.  It is called the Load and Shift test where we will be looking for mid carpal instability, but we will be able to define whether it is a VISI or a DISI. 

Looking at the VISI pattern, it is going to reduce in ulnar deviation.  (Figure 52)  If you are going to load this wrist, so if you are doing your load and shift test, you are going to axially compress the wrist.  I have pictures of this that I am going to show.  Then ulnarly deviate and that VISI pattern will actually reduce.  It goes into a normal position in ulnar deviation.  The DISI pattern actually subluxes.  (Figure 53) You can see here we have the capitate pushing up when you ulnarly deviate.  That is a big deal.  If someone subluxes when they ulnarly deviate, we would want to treat that by limiting ulnar deviation versus this other case, the VISI pattern.  If they reduce in ulnar deviation, that is a good thing. 

Figure 52 – Slide 116


Figure 53 – Slide 117

Carpal Instability  There are two forms of carpal instability.  There is the intrinsic, secondary to laxity of the wrist ligaments and the extrinsic.  The intrinsic examples are scapholunate and lunotriquetral.  The extrinsic is secondary to boney abnormalities outside of the carpus.  Sometimes we see this with distal radius fractures or if we have a change between the distal radius and the ulna, whether an ulnar plus or ulnar minus variant. 

Radial translocation  The proximal row can be passively displaced radially.  I talked about that with rheumatoid arthritis.  If you have a badly malunited distal radius fracture where you have more of a radial inclination, you can end up with issues with instability because now you have some of your ligaments more on slack and others are more on stretch.  You have changed the forces. 

Dorsal translocation  That can happen when you have a dorsal mid carpal instability (MCI).  There really is not a problem with the carpals themselves, but it is adapted to the distal radius issue.  This is why it is important when someone has a distal radius fracture, the surgeon tries to restore that volar tilt and radial declination.  If he or she does not, it is going to end up causing issues with the extrinsic ligaments of the wrist and people can end up with wrist instability issues. 

Pattern  So this is looking at carpal instability which is referred to as dissociative, non-dissociative, combined and adaptive patterns.  You can see how these patterns are coming back again and again with different descriptions.  What is carpal instability dissociative?  It is an instability that occurs within the same row.  Scapholunate/lunotriquetral.  Carpal instability combined is a dysfunction between the rows or between the radius.  This is involving more our extrinsic ligaments where carpal instability dissociative is our intrinsic ligaments.  Sometimes you can get the combined where there is both.  The adaptive is the malunited distal radius fracture, so something from outside of it. 

Carpal Instability Dissociative  Here are the causes of carpal instability dissociative, where you have a scapholunate dissociation or SLD and that is because of disruption of the scapholunate ligament and stretching of the dorsal intercarpal ligament.  The LT dissociation again is another form of a carpal instability dissociative.  More common is scapholunate.  Unstable scaphoid fractures can also cause instability, again within the carpal row.  Non-unions or malunions, especially the scaphoid, and advanced Kienbock’s disease is also a cause because that is going to change the dynamics within the carpal row. 

Carpal Instability Nondissociative   Here we have the radiocarpal where we can picture now the ulnar translocation and radial translocation, or a pure radiocarpal dislocation.  Again more systemic issues.  The mid carpal where we can have a volar mid carpal instability or a dorsal mid carpal instability.  The root of the problem is the extrinsic ligaments.  It is not involving the intrinsic.  You can have DISI because of mid carpal instability, but you can also have a DISI within the carpal row due to scapholunate. 

Radiocarpal instability nondissociative is an insufficiency of those obliquely oriented radiocarpal ligaments. That is our systemic disorders, the Madelung’s deformity, where the ulna is longer than the radius. People are born with that, but sometimes they get that translocation if the surgeon removes too much of the distal ulna to help correct the problem. Then we have another issue. 

Mid carpal instability. There is no dissociation between the bones of the proximal row, but the dysfunction is between that proximal and distal row at the mid carpal region. Again volar and dorsal, and you can have laxity with both or due to a malunited radius, so an adaptive. 


Special Tests

We have talked about that continuum of having microtrauma all the way up to an open dislocation.  Oftentimes these patients do not show up on x-ray or any kind of MRI imaging, so our clinical exam is going to be critical.  What do these people complain of?  They complain of local sharp or shooting pain with active motion, a feeling of weakness often difficulty weight bearing, and they may come in using their other hand to hold their wrist, saying it feels better if they hold it.  This is sometimes called the clamp sign. 

Radial Side

Let’s go through our test for the radial side of the wrist.  There are three tests that we are going to look at.  One is the Scaphoid Shift Test, or Watson’s Test.  One is our Resisted Finger Extension Test which is looking for occult ganglia with the scaphoid and lunate interval.  Then we have the Scapholunate Ballottement Test. 

Scaphoid Shift Test  (Figure 54) Normally when the wrist goes from ulnar deviation to radial deviation, the scaphoid flexes so that it gets out of the way of the radial styloid or it is going to bang into the radial styloid.  What we are doing is in the test is passively positioning our patient’s wrist in ulnar deviation.  My thumb here is on the scaphoid tubercle.  To find the scaphoid tubercle, look at your own right wrist along the wrist crease.  If you put your finger right at the wrist crease and actively radially deviate, you can feel that prominence or bump coming into your finger.  That is the scaphoid tubercle.  We are putting pressure on the scaphoid tubercle and then ulnarly deviating.  (Figure 55) If the test is negative, the scaphoid tubercle pushes my thumb out of the way.  That means that the scaphoid and lunate are bound together or connected.  If, however, when I radially deviate, I am able to push the scaphoid tubercle and my thumb wins, meaning I am able to prevent it from pushing my thumb out of the way, what is happening is that pressure is causing the scaphoid to dorsally dislocate over the distal rim over the distal radius.  Ideally what we want is to have the patient push your thumb out of the way.  That is telling us that the test is negative. 

Figure 54 – Slide 132

Figure 55 – Slide 133

Now this test has good sensitivity but low specificity.  We want to compare it to the opposite side because the problem is that some people who are really lax may have a positive test on both sides.  What we are looking for is a painful click/pop if it is positive.  If you ever have a chance to feel one of these, remember that you only get one shot as they will not let you do this again.  It is very painful, but you always want to test the uninvolved side to see what the normal is.  If this test is positive, they are not a therapy candidate.  That is someone you need to refer to a hand surgeon.  If they tell you their history, you find a positive scaphoid shift, you need to refer them to a hand surgeon. 

Resisted Finger Extension  What we are doing is looking for an occult wrist ganglia.  Ganglion form where you have excessive motion between articular surfaces.  You can get an occult ganglia where it is sitting within the scapholunate interosseus ligament or underneath it where it is not prominent and they do not have a big bump on their wrist.  What we are doing here is looking at if they have a positive test here that is telling us that the scaphoid and lunate are moving too much on each other.  What we do is place the patient’s fingers in flexion at the middle and ring, and we give resistance to them.  (Figure 56) What we are looking for is a reproduction of pain.  This maneuver is not specific, but it is sensitive.  This is why we like to use a cluster of tests and not just one.  When you look at the literature and the tests, we do not always have a pure 95% sensitive and 95% specific test.  It is not the case.  You have to look at history and you have to look at a combination of tests.  This maneuver helps to diagnose an occult wrist ganglion, telling us there is increased motion between the scaphoid and lunate interval.  

Figure 56 – Slide 135

Ballottement Test  Here I have drawn out the scaphoid and the lunate.  (Figure 57) As you look at the lunate, the lunate is a little more ulnar than we expect.  It is not smack dab in the middle of the wrist; it is offset.  We find the lunate by finding the distal radioulnar joint, and that is the ulnar border of the lunate.  What we do here is test with the wrist in slight flexion and ulnar deviation which is maximal loose-pack position.  (Figure 58) We are going to stabilize the lunate and move that scaphoid in a dorsal and volar direction, kind of like we are shucking it.  We are looking for a reproduction of pain.  We are also checking the mobility, but we are going to test their uninvolved side to make sure we know.  Some people are really loose, and they may have tons of motion on both sides. 

Figure 57 – Slide 137

Figure 58 – Slide 138

Ulnar Side

For the ulnar side of the wrist, we are going to talk about just a couple of tests.  We are not going to through.  There are a lot of tests referring to the TFCC and the distal radioulnar joint.  Those are the tests that I have listed in the handout, but we are not going to cover it today because we had so much to cover with mid carpal instability and with scapholunate and lunotriquetral.  There are a whole other slew of tests. 

Ballottement Test  Looking at the ulnar aspect of the wrist, we are doing the ballottement test.  This time we are stabilizing the lunate and moving the triquetrum, again in a dorsal volar fashion, looking for provocation of pain and looking at mobility, comparing it to their uninvolved side. 

Shear Test  What you are doing here is stabilizing the lunate from the dorsal side and applying pressure on the volar side at the trapezium.  Here is the lunate stabilized.  (Figure 60) With pressure on the pisiform, you are basically trying to pinch your fingers together to shuck that LT interval.  (Figure 61) You are looking for provocation of pain.  You hold and you push on the pisiform.

Figure 60 – Slide 143

Figure 61 – Slide 144

The Derby Test (Figure 62) What you are doing here is placing a load on the pisiform.  Remember that the lunate is looking volarly so that the whole carpus is dropped down.  By putting pressure on the pisiform you are actually realigning the joint.  You are bringing it back up where it needs to be.  You push here and they go into what is called a dart-throwing motion which is radial deviation with extension and they go into ulnar deviation and flexion.  By putting that dorsal-based pressure on the pisiform, you are reducing that subluxation and their feeling of instability and strength should improve with this.  We treat this by providing pressure with a splint to boost that wrist and help provide alignment. 

Figure 62 – Slide 145

Ulnar Snuff Box Test  (Figure 63) Here is the extensor carpi ulnaris and flexor carpi ulnaris.  Here is the snuff box where we are going to place pressure.  Here is the ulnar styloid.  Here is the triquetrum.  We are going to be placing pressure here with the triquetrum against the lunate.  (Figure 64) Then we are going to radially deviate the wrist.  We think arthrokinematically about what happens with radial deviation.  We roll into radial deviation and we slide ulnarly.  By providing that pressure, we are increasing the load on that LT interval. 

Figure 63 – Slide 147

Figure 64 – Slide 148

The nice thing in the wrist is that there is not a lot of referred pain.  Where they hurt is where the problem is.  It is a lot different from the shoulder.  If their pain is radial, I do my radial tests.  If their pain is ulnar, I do my ulnar tests.  I do not have to do all of the tests.  With the ulnar snuff box, we are looking for an LT issue or an issue with the ulnar styloid and triquetrum where the ulnar styloid may be pushing into the triquetrum. 

Mid Carpal Shift Test  (Figure 65) In the mid carpal shift, we are loading it and ulnarly deviating.  What happens if you have an volar mid carpal instability?  When you load and you ulnarly deviate, you are getting what is called a catch-up and clunk.  That proximal row is going to extend.  Is that a good thing or bad thing?  Actually in this case it is a good thing because it is going to allow that proximal row to catch-up and extend, and that is the more stable position.  Here we see the lunate is looking forward in a VISI.  It should be facing more up through here and cupping the capitate, and it is forward. 

Figure 65 – Slide 152

This test looks like this. We come in and we grasp the distal forearm.  (Figure 66)  We provide a downward pressure on the capitate and we are going to load. (Figure 67) We provide an axial load and then we are going to ulnarly deviate, bringing the wrist into ulnar deviation, maintaining that volar pressure, as we maintain the axial compression. A positive result is if we have a painful clunk that reproduces the patient’s symptoms.  Again it is very important to test both sides. 

Figure 66 – Slide 153

Figure 67 – Slide 154

Grip and Pinch Strength One thing that I use with grip testing is a Wrist Restore splint.  I will test their grip with and without the Wrist Restore.  That will help give me a better idea.  I have seen as much as 25 pounds difference in strength with the Wrist Restore on versus without it with testing.  That is another good objective weigh in.  It is a way for the patient also to say that it feels better and they feel stronger but getting that external support. 


Conservative Mangagement

As we know, there are only a few wrist conditions that we can treat conservatively for instability.  The key is really recognition so we are not wasting their time in therapy visits to figure out whether or not this is something we can help.  We know already by our clinical exam if they are too far gone. 

Carpal Instability

This is the one we can help the most with, the predynamic.  What are our clinical findings of predynamic dissociative instability if it is a DISI?  We know that the scapholunate ligament is involved.  We may have a positive resisted finger extension test and positive Scapholunate Ballottement.  They may have pain with end range of wrist flexion.  Why is that?  When you have the scaphoid and lunate not talking to each other, the lunate looks up in extension and it slides down.  Sliding down is going to cause a limitation with wrist flexion.  For treatment, we are going to provide support to the scapholunate ligament and educate the patient on proper biomechanics.  Later on in the rehab, 10+ weeks, we can work on re-education with wrist proprioception, grip strength and then strenuous activities we wait typically 6 months. 

This is an excellent brace to use for someone with a scapholunate or lunotriquetral or mid carpal instability.  (Figure 68) The good news is you can use the same brace for a lot of different things.  This is a Wrist Restore.  It is from  I have no financial relationship with them.  This is just a nice brace to use.  It supports the distal pole of the scaphoid and the pisiform and triquetrum.  (Figure 69) You put it on with the wrist in a supinated position, and you are going to have them grasp their thumb and ulnarly deviate.  That brings the scaphoid into extension.  You will lay down the first strap then the second third and fourth.  These help prevent it from sliding.  A great way to test their strength is with this Wrist Restore on and without.  The brace is pretty cheap.  I think it is $18.00.  You can order it from 

Figure 68 – Slide 163

Figure 69 - Slide 164

If you have a VISI, you will have a positive LT ballottement test, positive ulnar snuff box, negative mid carpal shift test, but they may have pain with wrist extension because now the lunate is looking volarly and sliding up, and actually blocking wrist extension.  So we brace them, educate them on biomechanics, and stop doing weight bearing.  We are going to go through the wrist proprioception program, grip strength is initiated later on, three months, and strenuous activity is to begin in six months.  This we base more on what we found with SL. 

When you don the Wrist Restore here it is similar to a DISI, but is what happening now is that we are using more of the ulnar pull, and it is boosting up the pisiform.  The pisiform boost provides that realignment. (Figure 70)

Figure 70 – Slide 167

Volar Mid Carpal Non Dissociative

We have a negative LT ballottement, but we may have a positive Derby test, negative snuff box, and here our mid carpal shift test is going to be positive.  Here we have everything sagging down.  It is because of a problem with the extrinsic ligaments, not the intrinsic.  The treatment is to use an ulnar boost splint.  (Figure 71) I have found that the Wrist Restore splint works great as long as you are getting that boost or push on the pisiform.  I love using this splint and I use it a ton.  The nice thing is if you do not do custom splinting, you do not need to.  We will also need to work on contraction of flexor carpi ulnaris because that pushes the pisiform dorsally. 

Figure 71 - Slide 170

Ulnar Translocation

That is when it is sliding off in an ulnar direction.  What do we use for our treatment?  You can use a prefabricated splint, this is one option from Ossur.  (Figure 72) Sometimes if it is a milder case, I will use the Wrist Restore for this as well. 

Figure 72 – Slide 175

The Dart-Thrower’s Motion

This one is important.  What they have found is biomechanically going in that dart-thrower’s motion,  radial wrist extension with ulnar deviation and wrist flexion, actually minimizes stress on the proximal row.  So if you have a scapholunate or lunotriquetral problem, you are going to end up with less stress on there if you are working in that dart-thrower’s plane.  (Figure 73) You can actually have them strengthen in that dart-thrower’s motion.  If it is an SL or LT problem, you want them to work in the dart-thrower’s motion.  It utilizes more of the mid carpal joint and that is why you are not getting the stress on the proximal row.  If someone has mid carpal instability, you do not want to do this.

Figure 73 – Slide 177 

Proprioceptive Training

Things have changed a lot with wrist instability as far as the treatment.  We used to have people do a lot of gripping and grasping and we have found that that actually makes things worse.  You have to wait and we want to focus on improving their proprioception.  With our training, we want to improve the kinesthesia or looking at the wrist proprioception and joint position sense.  What we are looking at is their ability to know where their wrist is in space and you can do that with having them blindfolded and having them replicate on their uninvolved hand.  Have them replicate in their involved hand what they are doing as far as their position.  Work on their neuromuscular control at a subconscious level.  That starts to assist with the dynamic control of their wrist.  You can use isokinetic as well and isometric.  I will go through the isometric.  A nice early way to start with their fingers relaxed so you are not getting a lot of loading through their fingertips.  We know if it is an ulnar and mid carpal instability, we want to focus on flexor carpi ulnaris, because that will push the pisiform dorsally.  If it is a scapholunate problem, we want to focus on flexor carpi radialis because that is going to help bring the scaphoid in an extended position.   (Figure 74) The one exception to that is if the scapholunate ligament is completely blown, you do not want to work on FCR because it will cause complete dorsal translation of the scaphoid.   

Figure 74 – Slide 193

Figure 75 is showing how the proximal pole of the scaphoid can sublux dorsally if the scapholunate is blown.  If you have a positive scaphoid shift, this is not someone you will treat conservatively.  You do not want them to do FCR strengthening because that can make it worse. 

Figure 75 – Slide 194

Here is a nice example of some proprioceptive exercises isometrically.  (Figure 76)  I have patients do just a swooping motion.  They are holding on to, in this case, a two-pound weight and move their wrist in different positions or move their arm to get the load in different positions.  But it is comfortable.  They are not gripping that for dear life. 

Figure 76 – Slide 195

Here is an example of some isometrics you can have them do.  (Figure 77) I usually have people start doing this early on.  For conservative treatment, I will have them come into the clinic once every three to four weeks, recheck them and progress their program. 

Figure 77 – Slide 196

Eccentric can be an important component as well.  You can have them doing eccentric.  (Figure 78)  I usually start with isometric for three to four weeks and then move on to eccentric for three to four weeks.  Again that is just my own clinical experience.  Unfortunately, there is nothing in the research to show exactly how long you need to do at a certain point. 

Figure 78 – Slide 198

The flex bar can be helpful, but again later stages, more like at three months post injury.  (Figure 79)  This is a nice eccentric where it is just a dowel and they are lowering it. 

Figure 79 – Slide 199

If you are working on the conscious proprioception or co-activation, here are some examples of holding a ball similar to the use of a BAPS board for the ankle.  (Figure 80)

Figure 80 – Slide 201

We can do some perturbation exercises.  That is an important thing to help us with our dynamic control of the wrist.  Here are some examples.  This is a B.O.I.N.G. from  (Figure 81)  The next is from  This is just having the patient whip ropes.  You can use a rebounder.  That works as well.  Again this is for later stages, more than 3 months.  This is a nice thing. I use this. It is a Powerball.  (Figure 82) It is like a gyroscope and they are holding it so that is again increasing that reactive muscle activation.  You can also use other things like mirrors for mirror therapy to stimulate the somatosensory cortex especially if they have been really afraid to move because of pain.  (Figure 83)

Figure 81 – Slide 205

Figure 82 – Slide 206

Figure 83 – Slide 209

Afferents to the skin can be helpful to enhance proper proprioceptive feedback.  You can have them put some rice in a bowl and they can search for things in the bin, and that type of thing.  That is a very hand therapy thing to do, but that can also be helpful.  (Figure 84)

Figure 84 – Slide 211

When do you progress from immobilizing to start mobilizing?  With the Wrist Restore, I will actually have them use that for all of their exercises up to the point where they are doing grip strengthening and then I will gradually decrease the use of that Wrist Restore.  They are probably using that six to eight months for those activities that are really provoking their symptoms. 

Figure 85 is showing the stages of Proprioceptive Re-Education.  This is from an excellent article by Elizabeth Hagert who is a physician somewhere in Northern Europe I think.  It is a good thing to help us think differently about how you treat instability. 

Figure 85 – Slide 213

All of this information is in the handouts.  If you have questions, please feel free to email me.  The biggest thing is you want to avoid gripping and weight bearing with these patients early on.  You want to wait about three months and focus on the proprioceptive aspect before you progress to strengthening. 

Questions and Answers:

You mentioned that they should avoid gripping early on, what do you tell your patients about driving, gripping the steering wheel?  How long they are able to drive, or do you put any limitations on that?

That is a good question.  I would typically start them in the brace - usually the Wrist Restore Brace works well.  I do not want them to do any kind of loading on their wrist at least initially.  Even grasping the steering wheel, people tend to grip harder than they need to.  If you can avoid them do that for six to eight weeks, it will be better for them.  It is hard with the younger people that I see that are the gymnasts.  They want to get back to doing their thing.  It is really helpful if you see the difference in their strength with and without the brace to help them realize that the brace is pretending to be their ligaments, and they have a lot of work to do to allow those ligaments to tighten up.  If you can avoid having to do some of those prolonged grasping tasks, it is better. 




ann porretto loehrke

Ann Porretto-Loehrke, PT, DPT, CHT, COMT

Ann Porretto-Loehrke is a Certified Hand Therapist (CHT) and a Certified Orthopedic Manual Therapist (COMT) for treatment of the upper quadrant through the International Academy of Orthopedic Medicine-United States (IAOM-US). She earned a post-professional Doctorate in Physical Therapy (DPT) degree from Drexel University with a specialty in hand and upper quarter rehabilitation. Ann co-authored the chapter “Therapist’s Management of Other Nerve Compressions About the Elbow and Wrist” in the most recent edition of Rehabilitation of the Hand & Upper Extremity.  She is a therapy manager of a large department at the Hand to Shoulder Center of Wisconsin, located in Appleton, Wisconsin.  She is a dynamic, passionate instructor who loves teaching and providing patient care.

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CEUs/Hours Offered: See All State Associations
AK/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DC/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0; MA/2.0; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NV/0.2; NY/2.0; OR/2.0; RI/2.0; SD/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0
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CEUs/Hours Offered: See All State Associations
AK/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DC/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0; MA/2.0; MD/0.2; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NY/2.0; OR/2.0; RI/2.0; SD/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0
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CEUs/Hours Offered: See All State Associations
AK/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DC/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0; MA/2.0; MD/0.2; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NY/2.0; OR/2.0; RI/2.0; SD/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0
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CEUs/Hours Offered: See All State Associations
AK/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; MA/2.0; MD/0.2; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NY/2.0; OR/2.0; RI/2.0; SD/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0
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CEUs/Hours Offered: See All State Associations
AK/2.0; AR/2.0; AZ/2.0; CA/2.0; CO/2.0; CT/2.0; DC/2.0; DE/2.0; GA/2.0; HI/2.0; IA/2.0; ID/2.0; IL/2.0; IN/2.0; KY/2.0; MA/2.0; MD/0.2; ME/2.0; MI/2.0; MO/2.0; MT/2.0; NC/2.0; ND/2.0; NE/2.0; NH/2.0; NY/2.0; OR/2.0; RI/2.0; SD/2.0; UT/2.0; VA/2.0; VT/2.0; WA/2.0; WI/2.0; WY/2.0
Course Details

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