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Current Practice in the Diagnosis and Treatment of Carpal Instability—Results of a Survey of Australian Hand Therapists
SCIENTIFIC/CLINICAL ARTICLES JHT READ
FOR
CREDIT ARTICLE #061
Current Practice in the Diagnosis and Treatment of Carpal Instability—Results of a Survey of Australian Hand Therapists Rosemary Prosser, MSc, BApSc(Phty), CHT Sydney Hand Therapy & Rehabilitation Centre, Sydney, Australia School of Physiotherapy, University of Sydney, Sydney, Australia
Rob Herbert, PhD, BApert D. MAppSc, pSc(Phty) School of Physiotherapy, University of Sydney, Sydney, Australia
Paul C. LaStayo, PhD, PT, CHT Division of Physical Therapy, Department of Orthopedics and Department of Exercise and Sport Sciences, University of Utah, Salt Lake City, Utah, USA
Wrist instability is a common cause of pain and impairment at the wrist. Frequently reported symptoms include both generalized and focal pain, weak gripping abilities, and the inability to stabilize the wrist under load.1e4 A fall on the outstretched hand with a resultant ligamentous tear or attenuation is the typical cause of this pain and impairment. Other diagnoses are associated with wrist instability including malalignment of a distal radius following fracture, which may produce relative length changes in the wrist ligaments leading to wrist instability. Watson et al.5 and Filan and Herbert6 have also described an early-stage dynamic wrist instability resulting from an underlying minor ligament lesion associated with wrist ganglions. Numerous tests of carpal joint ligaments and the related wrist stability have been described. Collectively, they are termed provocative tests as they are designed to reproduce the wrist pain and Correspondence and reprint requests to Rosemary Prosser, MSc, Sydney Hand Therapy & Rehabilitation Centre, 187 Macquarie St, Sydney NSW 2000, Australia; e-mail:. 0894-1130/$ e see front matter Ó 2007 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. doi:10.1197/j.jht.2007.04.006
ABSTRACT: A postal survey of all 85 full Australian Hand Therapy Association (AHTA) members was carried out to determine the current practice of the diagnosis and treatment of carpal instability by AHTA members. There was an 87% return rate. On average therapists saw 3.8 patients/month with carpal instability. Time from onset of pain or injury was a median of eight weeks (interquartile range 0e26 weeks). Ulnar pain was reported in 39% of patients, central pain in 17%, radial pain in 13%, and combined in 34%. Mean pain intensity at rest was 3.5/10 (SD 2.8), and with aggravating activity was 7.7 (SD 2.2). Forty-seven percent of patients reported difficulties with grip-related activities. Mean grip strength was 67% of the contralateral side. The most commonly used tests used were scaphoid shift, lunotriquetral ballotment, triangular fibrocartilage complex, and midcarpal stress tests. The most used treatments were patient education (advice and activity modification), splinting the wrist, and isometric exercising of the wrist musculature. J HAND THER. 2007;20:239–43.
assess the instability. In 1988, Watson et al.7 described a test for scaphoid stability and the primary stabilizing ligament, the scapholunate ligament. Lunotriquetral joint stability tests have also been described by Reagan et al.8 and others.9 Several authors have discussed gross stress tests for the triangular fibrocartilage complex (TFCC) though many lack specific operational details. In 1973, Rana and Taylor10 described a test for the distal radioulnar joint (DRUJ). LaStayo and Howell11 modified a joint mobilization maneuver by Hertling and Kesser12 to specifically stress the TFCC. The Gripping Rotatory Impaction Test (GRIT) test for ulnar impaction syndrome13 is the most recent addition (2001) to this battery of provocative tests of the wrist and DRUJ. In the past 15 years, our understanding of wrist biomechanics and the role of these ligaments has lead to a wider acceptance of ligament testing as part of routine wrist examination. Despite a large body of literature reporting on wrist tests, ligament lesions and surgical management, there is little written on the diagnostic accuracy or predictive validity of these provocative wrist tests. The purpose of this paper is to report a recent survey that catalogs the clinical presentation of patients with wrist instability seen by Australian JulyeSeptember 2007 239
hand therapists (physiotherapists and occupational therapists), and to describe the current clinical practice patterns of hand therapists in the evaluation and conservative management of carpal instability patients in Australia.
METHOD A mail survey of all 85 full members of the Australian Hand Therapy Association was carried out in 2004. Therapists were asked to review their records of one or two recent cases of wrist instability. Wrist instability included scapholunate, ulnar carpal (including the TFCC), lunotriquetral, or midcarpal instability. Wrist ganglions were also included as they are considered a symptom of early wrist instability. This survey asked specifically about conservative management of carpal instability of those patients who would not be considered severe enough for surgery or those not appropriate for surgery. Generally, these patients are those with a predynamic or dynamic instability where there are no signs of instability on X-ray. The survey questionnaire was developed specifically for this study. Preliminary versions of the questionnaire were pilot tested on three hand therapists and then revised before final implementation. Therapists were asked about their patients’ mechanisms of injury, pain, functional loss, joint range of motion (ROM), grip strength, and the presence of global hypermobility. They were also asked to indicate what diagnostic and provocative tests they used in assessment and their therapy for this condition.
RESULTS There was an 87% return rate of the survey. A total of 75 therapists returned questionnaires. Thirty-five (46%) of the 75 returned questionnaires indicated that the therapist assessed and treated patients with carpal instability in the past month. Of these 35 therapists, each therapist saw an average of 3.8 patients with carpal instability each month. The therapists described 59 cases among their 75 responses. The most common reported mechanism of injury was a wrist extension injury (17 of 59 patients, 29%). No clear mechanism was reported to be the next most common finding (16/59, 27%). Other mechanisms were lifting and twisting maneuvers (9/59, 15%), wrist fracture (8/59, 14%), overuse of the wrist (7/59, 12%), and arthritis (2/59, 0.03%). The time from onset of pain or injury to the therapist’s initial assessment varied from immediate to 30 years with a median of eight weeks (IQR 0e26 weeks). Pain was located on the ulnar side of the wrist in 39% of cases, centrally in 17%, radially in 13%, and a central-combined presentation in 30% 240
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(with ulnar component 8%, with radial component 12%, and general 10%). Mean pain intensity at rest on a visual analog scale was 3.5/10 (SD 2.8) and mean pain in the most aggravating activity was 7.7/10 (SD 2.2). Twenty-five percent reported difficulties with self-care or domestic use, 22% had difficulty specifically with grip, and 17% reported difficulty with weight bearing. At initial presentation, most patients had a functional wrist ROM.14e16 Eighty-nine percent had 458 of flexion or better and 90% had 408 of extension or better. Twenty-eight percent were globally hypermobile. Mean grip strength was 67% of the uninjured contralateral side in 30 of the 59 patients for whom grip measures were reported. Table 1 shows that the most commonly used provocative tests were the scaphoid shift test, lunotriquetral ballotment test, TFCC stress test, and the midcarpal stress test. The most used treatments were patient education (advice and activity modification), wrist splinting, and isometric exercising of the wrist musculature (Table 2).
DISCUSSION Therapists in this survey reported on the conservative management of carpal instability, which included assessment and treatment. These are patients who after assessment were not considered surgical candidates; because they had no signs of instability on X-ray, a period of conservative management was deemed appropriate. Generally, these are the patients who have a predynamic or dynamic instability. The literature generally describes carpal instability symptoms as wrist pain coupled with a painful or giving way episode under load. This is usually associated with a normal ROM and a weak grip.1,3,17 Data from this survey are consistent with this description. Pain with aggravating activity was considerable (mean 7.7/10), indicating that pain is an important clinical component of carpal instability that should be addressed by therapists. This supports North and Myer’s18 data in which 96.3% of patients with longer-term wrist instability had pain with
TABLE 1. Counts and Proportions of Therapists Who Reported Using Wrist Ligament Tests Test Scaphoid shift test Lunotriquetral ballotment test Triquetroulnar critical test Triangular fibrocartilage complex stress test Midcarpal stress test GRIT22
Count (Proportion) of Therapists Using the Test 28/35 27/35 13/35 29/35
(80%) (77%) (37%) (83%)
19/35 (54%) 10/35 (29%)
TABLE 2. Counts (Proportions) of Therapists Who Reported Using Specific Treatments for Conservative Management of Carpal Instability Treatment Advice or activity modification Strengthening grip Strengthening wrist Strengthening—isometric Strengthening—isotonic Strengthening—eccentric Splinting—rigid Splinting—semiflexible Peripheral joint mobilization Electrotherapy
Count (Proportion) of Therapists Using the Treatment 34/35 (97%) 16/35 17/35 19/35 11/35 14/35 19/35 24/35 8/35 13/35
(46%) (49%) (54%) (31%) (40%) (54%) (69%) (23%) (37%)
activity. Surprisingly, only 17% of subjects in this survey reported an inability to bear weight through the affected wrist. However 47% had problems with grip-related activities. The mechanism of injury and site of pain may indicate particular lesions. Our data show the mechanism of injury was usually an extension injury or there was no clear mechanism of injury. This supports North and Myer’s18 1990 data. It is generally thought that a fall on the extended wrist (hyperextension injury) primarily gives rise to a scapholunate injury.3,18e21 A TFCC injury would be more likely following a twisting or ulnar deviation stress, which may also be combined with a fall on the hand.17,22 Twisting injuries accounted for only 15% of the 59 injuries. Perhaps a rotary component in a fall on the hand was not recognized by the patient at the time of the injury. ROM for these patients is often reported as normal.1,3,17,20 Our data showed that while most patients had a functional ROM few had a normal ROM compared to the other side. Previous descriptive literature reports grip strength as close to normal20,23 or weak, 10e45% less than the contralateral side.17 A 33% reduction in grip strength as measured in our data suggests weakness is also a major impairment and it has implications for function, which is likely to decline. The functional implication of an unstable wrist has not been reported in the literature. Twenty-five percent of patients in this survey had difficulties with self-care and domestic duties. An additional 22% had difficulty with grip activity and 17% with weight bearing. The triquetroulnar critical test was designed to assess ulnotriquetral stability and to give an indication if realignment of the carpus (triquetrum) on the ulna into a more anatomical position relieved pain.17 It has been suggested that if pain is relieved by carpal elevation then a splint mimicking this may be helpful in treatment.17,24,25 Only 37% of therapists used this test. Ulnar carpal elevation has also been
suggested24,25 for improving stability and pain in palmar midcarpal instability. Provocative wrist tests can be viewed as an important aspect of wrist examination to determine the location and severity of pain and possible structures involved. Most therapists (77e83%) used proximal row wrist tests (scapholunate ligament test [SST], lunotriquetral ligament test [LTB], and TFCC testing) for wrist stability. Only 54% tested the midcarpal joint, 37% tested the ulnotriquetral ligament, and 29% used the GRIT test for ulnar impaction syndrome. How important are these tests to our treatment and management? Only one study11 has reported on the sensitivity and specificity of these tests. The sensitivities, specificities, and positive and negative likelihood ratios of the tests are given in Table 3. All three tests appear to be of limited clinical utility. However, even though the limited available evidence suggests these tests are not predictive, there are currently no alternative tests that are known to give a more accurate indication of what is occurring in the wrist joint. The tests should be interpreted in combination with information about mechanisms of injury, ROM, grip strength, functional deficits, and available imaging tests. Patient education (advice and activity modification) was the most used treatment technique in the conservative management of carpal instability. Given the high pain scores reported with aggravating activity this is to be expected. Some form of splinting was the second most used treatment. It is believed that this decreases wrist pain and aggravation, which may improve the healing environment. Some types of splinting may help to stabilize the wrist thereby improving hand function. Grip strengthening exercises (mostly isometric or eccentric exercise) were used by approximately 50% of therapists. Given that grip strength was, on average, only 67% of the strength of the contralateral side, and that difficulty with grip activities was reported as a functional problem (directly in 22% and indirectly, self-care and domestic tasks, in 25%), this is perhaps a little surprising. Generally, a graded pain-free exercise program would be advocated.26 Moderate grip
TABLE 3. Diagnostic Accuracy of Wrist Ligament Tests Reported by LaStayo and Howell (1995)11 Test Scaphoid shift test Lunotriquetral ballotment test Triangular fibrocartilage complex test
Sensitivity Specificity LR (%) (%) LRþ 69 64
66 45
2.0 0.47 1.2 0.80
66
64
1.8 0.53
LRþ ¼ positive likelihood ratio, calculated from data in paper; LR ¼ negative likelihood ratio, calculated from data in paper.
JulyeSeptember 2007 241
strength is vital for functional hand use. The effectiveness of all of these interventions (advice, splinting, and grip strengthening exercises) has not been rigorously tested. Twenty-eight percent of patients were considered globally hypermobile by therapists. Many therapists believe that hypermobile individuals are more likely to experience scaphoid instability.
CONCLUSION Wrist instability following a carpal ligament lesion often manifests as wrist pain, difficulty with grip activities, and sometimes difficulty bearing weight through the wrist. ROM may be limited but is generally in the functional range. Grip strength is generally decreased compared with the contralateral side. The tests most commonly used by Australian hand therapists are the SST, the LTB, and the TFCC test. The most common treatments are patient education, splinting, and grip or wrist strengthening.
REFERENCES 1. Herbert TJ. Carpal instability. Proceedings of the Sydney hospital hand symposium—Update on the wrist joint. Sydney, 1991: 2e6. 2. Garcia-Elias M. The treatment of wrist instability. J Bone Joint Surg. 1997;79:684–90. 3. Ashe M. Management of carpal instability: a therapists’ perspective. Br J Hand Ther. 2001;6:9–14. 4. Bowers WH. Instability of the distal radioulnar articulation. Hand Clin. 1991;7:311–27. 5. Watson HK, Rogers WD, Ashmead D. Reevaluation of the cause of the wrist ganglion. J Hand Surg. 1989;14A:812–7. 6. Filan S, Herbert TJ. Recurrent dorsal wrist ganglion: aetiology and treatment. Hand Surg. 1996;1:7–9. 7. Watson HK, Ashmead D, Makhlouf MV. Examination of the scaphoid. J Hand Surg [Am]. 1988;13A:657–60. 8. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg [Am]. 1984;9A:502–14.
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9. Bishop A, Reagan DS. Lunotriquetral sprains. In: Cooney WP, Linscneid RL, Dobyns JH (eds). The Wrist—Diagnosis and Operative Treatment. St. Louis, MO: Mosby, 1998, pp 527–49. 10. Rana NA, Taylor AR. Excision of the distal end of the ulna in rheumatoid arthritis. J. Bone Joint Surg. 1973;55B:96–105. 11. LaStayo P, Howell J. Clinical provocative tests used in evaluating wrist pain: a descriptive study. J Hand Ther. 1995;8:10–7. 12. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia, PA: J P Lippincott, 1990; 105. 13. LaStayo P, Weiss S. The GRIT: a quantitative measure of ulnar impaction syndrome. J Hand Ther. 2001;14:173–9. 14. Brumfield RH, Champoux JA. A biomechanical study of normal functional wrist motion. Clin Orthop Relat Res. 1984;187: 23–5. 15. Palmer AK, Werner FW, Murphy D, Glison R. Functional wrist motion: a biomechanical study. J Hand Surg [Am]. 1985;10A: 39–46. 16. Nelson DL. Functional wrist motion. Hand Clin. 1997;13:83–92. 17. Prosser R. Conservative management of ulnar carpal instability. Aust J Physiother. 1995;41:41–6. 18. North ER, Myer S. Wrist injuries: a correlation of clinical and arthroscopic findings. J Hand Surg [Am]. 1990;15A:915–20. 19. Blatt G. Scapholunate instability. In: Lichtman DM (ed). The Wrist and Its Disorders. Philadelphia, PA: W B Saunders, 1988, pp 25–273. 20. Talesneik J, Linscheid RL. Scapholunate instability. In: Cooney WP, Linscneid RL, Dobyns JH (eds). The Wrist—Diagnosis and Operative Treatment. St. Louis, MO: Mosby, 1998, pp 501–26. 21. Mayfield JK. Pathogenesis of wrist ligament instability. In: Lichtman DM (ed). The Wrist and Its Disorders. Philadelphia, PA: W B Saunders, 1988, pp 53–73. 22. Cooney WP. Tears of the triangular fibrocartilage of the wrist. In: Cooney WP, Linscneid RL, Dobyns JH (eds). The Wrist—Diagnosis and Operative Treatment. St. Louis, MO: Mosby, 1998, pp 710–42. 23. Taleisnik J. Scapholunate dissociation: medial carpal instability. In: Taleisnik J (ed). Wrist Instability. New York: Churchill Livingstone, 1985, pp 239–305. 24. Alexander CE, Lichtman DM. Triquetrolunate and midcarpal instability. In: Lichtman DM (ed). The Wrist and Its Disorders. Philadelphia, PA: W B Saunders, 1988, pp 274–85. 25. Gaenslen ES, Lichtman DM. Midcarpal instability: description, classification, and treatment. In: Buchler U (ed). Wrist Instability. London: Martin Dunitz, 1996, pp 163–74. 26. Prosser R. Management of carpal instabilities. In: Prosser R, Conolly WB (eds). Rehabilitation of the Hand and Upper Limb. Edinburgh: Butterworth Heinemann, 2003, pp 148–59.
JHT Read for Credit Quiz: Article #061 Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue. There is only one best answer for each question. #1. Pain was most frequently reported on the______ aspect of the wrist a. radial b. ulnar c. central d. combined #2. The typical patient profiled in the survey responses was a. not amenable to conservative management b. postsurgical c. likely a surgical candidate d. likely a nonsurgical candidate #3. A surprise finding was a. the most common mechanism of injury was a fall on the outstretched hand b. that most patients had functional ROM c. only 17% reported difficulty with weight bearing through the wrist
d. that only 50% of those surveyed responded to the survey #4. The most commonly reported mechanism of injury was a. a fall with a twisting component applied to the wrist b. a fall with an extension force applied to the wrist c. blunt trauma to the dorsum of the wrist d. blunt trauma to the volar wrist #5. The most common intervention by the therapists was a. advice b. splinting c. home exercises d. physical agent modalities When submitting to the HTCC for recertification, please batch your JHT RFC certificates in groups of three or more to get full credit.
JulyeSeptember 2007 243
FOR
CREDIT ARTICLE #061
Current Practice in the Diagnosis and Treatment of Carpal Instability—Results of a Survey of Australian Hand Therapists Rosemary Prosser, MSc, BApSc(Phty), CHT Sydney Hand Therapy & Rehabilitation Centre, Sydney, Australia School of Physiotherapy, University of Sydney, Sydney, Australia
Rob Herbert, PhD, BApert D. MAppSc, pSc(Phty) School of Physiotherapy, University of Sydney, Sydney, Australia
Paul C. LaStayo, PhD, PT, CHT Division of Physical Therapy, Department of Orthopedics and Department of Exercise and Sport Sciences, University of Utah, Salt Lake City, Utah, USA
Wrist instability is a common cause of pain and impairment at the wrist. Frequently reported symptoms include both generalized and focal pain, weak gripping abilities, and the inability to stabilize the wrist under load.1e4 A fall on the outstretched hand with a resultant ligamentous tear or attenuation is the typical cause of this pain and impairment. Other diagnoses are associated with wrist instability including malalignment of a distal radius following fracture, which may produce relative length changes in the wrist ligaments leading to wrist instability. Watson et al.5 and Filan and Herbert6 have also described an early-stage dynamic wrist instability resulting from an underlying minor ligament lesion associated with wrist ganglions. Numerous tests of carpal joint ligaments and the related wrist stability have been described. Collectively, they are termed provocative tests as they are designed to reproduce the wrist pain and Correspondence and reprint requests to Rosemary Prosser, MSc, Sydney Hand Therapy & Rehabilitation Centre, 187 Macquarie St, Sydney NSW 2000, Australia; e-mail:
ABSTRACT: A postal survey of all 85 full Australian Hand Therapy Association (AHTA) members was carried out to determine the current practice of the diagnosis and treatment of carpal instability by AHTA members. There was an 87% return rate. On average therapists saw 3.8 patients/month with carpal instability. Time from onset of pain or injury was a median of eight weeks (interquartile range 0e26 weeks). Ulnar pain was reported in 39% of patients, central pain in 17%, radial pain in 13%, and combined in 34%. Mean pain intensity at rest was 3.5/10 (SD 2.8), and with aggravating activity was 7.7 (SD 2.2). Forty-seven percent of patients reported difficulties with grip-related activities. Mean grip strength was 67% of the contralateral side. The most commonly used tests used were scaphoid shift, lunotriquetral ballotment, triangular fibrocartilage complex, and midcarpal stress tests. The most used treatments were patient education (advice and activity modification), splinting the wrist, and isometric exercising of the wrist musculature. J HAND THER. 2007;20:239–43.
assess the instability. In 1988, Watson et al.7 described a test for scaphoid stability and the primary stabilizing ligament, the scapholunate ligament. Lunotriquetral joint stability tests have also been described by Reagan et al.8 and others.9 Several authors have discussed gross stress tests for the triangular fibrocartilage complex (TFCC) though many lack specific operational details. In 1973, Rana and Taylor10 described a test for the distal radioulnar joint (DRUJ). LaStayo and Howell11 modified a joint mobilization maneuver by Hertling and Kesser12 to specifically stress the TFCC. The Gripping Rotatory Impaction Test (GRIT) test for ulnar impaction syndrome13 is the most recent addition (2001) to this battery of provocative tests of the wrist and DRUJ. In the past 15 years, our understanding of wrist biomechanics and the role of these ligaments has lead to a wider acceptance of ligament testing as part of routine wrist examination. Despite a large body of literature reporting on wrist tests, ligament lesions and surgical management, there is little written on the diagnostic accuracy or predictive validity of these provocative wrist tests. The purpose of this paper is to report a recent survey that catalogs the clinical presentation of patients with wrist instability seen by Australian JulyeSeptember 2007 239
hand therapists (physiotherapists and occupational therapists), and to describe the current clinical practice patterns of hand therapists in the evaluation and conservative management of carpal instability patients in Australia.
METHOD A mail survey of all 85 full members of the Australian Hand Therapy Association was carried out in 2004. Therapists were asked to review their records of one or two recent cases of wrist instability. Wrist instability included scapholunate, ulnar carpal (including the TFCC), lunotriquetral, or midcarpal instability. Wrist ganglions were also included as they are considered a symptom of early wrist instability. This survey asked specifically about conservative management of carpal instability of those patients who would not be considered severe enough for surgery or those not appropriate for surgery. Generally, these patients are those with a predynamic or dynamic instability where there are no signs of instability on X-ray. The survey questionnaire was developed specifically for this study. Preliminary versions of the questionnaire were pilot tested on three hand therapists and then revised before final implementation. Therapists were asked about their patients’ mechanisms of injury, pain, functional loss, joint range of motion (ROM), grip strength, and the presence of global hypermobility. They were also asked to indicate what diagnostic and provocative tests they used in assessment and their therapy for this condition.
RESULTS There was an 87% return rate of the survey. A total of 75 therapists returned questionnaires. Thirty-five (46%) of the 75 returned questionnaires indicated that the therapist assessed and treated patients with carpal instability in the past month. Of these 35 therapists, each therapist saw an average of 3.8 patients with carpal instability each month. The therapists described 59 cases among their 75 responses. The most common reported mechanism of injury was a wrist extension injury (17 of 59 patients, 29%). No clear mechanism was reported to be the next most common finding (16/59, 27%). Other mechanisms were lifting and twisting maneuvers (9/59, 15%), wrist fracture (8/59, 14%), overuse of the wrist (7/59, 12%), and arthritis (2/59, 0.03%). The time from onset of pain or injury to the therapist’s initial assessment varied from immediate to 30 years with a median of eight weeks (IQR 0e26 weeks). Pain was located on the ulnar side of the wrist in 39% of cases, centrally in 17%, radially in 13%, and a central-combined presentation in 30% 240
JOURNAL OF HAND THERAPY
(with ulnar component 8%, with radial component 12%, and general 10%). Mean pain intensity at rest on a visual analog scale was 3.5/10 (SD 2.8) and mean pain in the most aggravating activity was 7.7/10 (SD 2.2). Twenty-five percent reported difficulties with self-care or domestic use, 22% had difficulty specifically with grip, and 17% reported difficulty with weight bearing. At initial presentation, most patients had a functional wrist ROM.14e16 Eighty-nine percent had 458 of flexion or better and 90% had 408 of extension or better. Twenty-eight percent were globally hypermobile. Mean grip strength was 67% of the uninjured contralateral side in 30 of the 59 patients for whom grip measures were reported. Table 1 shows that the most commonly used provocative tests were the scaphoid shift test, lunotriquetral ballotment test, TFCC stress test, and the midcarpal stress test. The most used treatments were patient education (advice and activity modification), wrist splinting, and isometric exercising of the wrist musculature (Table 2).
DISCUSSION Therapists in this survey reported on the conservative management of carpal instability, which included assessment and treatment. These are patients who after assessment were not considered surgical candidates; because they had no signs of instability on X-ray, a period of conservative management was deemed appropriate. Generally, these are the patients who have a predynamic or dynamic instability. The literature generally describes carpal instability symptoms as wrist pain coupled with a painful or giving way episode under load. This is usually associated with a normal ROM and a weak grip.1,3,17 Data from this survey are consistent with this description. Pain with aggravating activity was considerable (mean 7.7/10), indicating that pain is an important clinical component of carpal instability that should be addressed by therapists. This supports North and Myer’s18 data in which 96.3% of patients with longer-term wrist instability had pain with
TABLE 1. Counts and Proportions of Therapists Who Reported Using Wrist Ligament Tests Test Scaphoid shift test Lunotriquetral ballotment test Triquetroulnar critical test Triangular fibrocartilage complex stress test Midcarpal stress test GRIT22
Count (Proportion) of Therapists Using the Test 28/35 27/35 13/35 29/35
(80%) (77%) (37%) (83%)
19/35 (54%) 10/35 (29%)
TABLE 2. Counts (Proportions) of Therapists Who Reported Using Specific Treatments for Conservative Management of Carpal Instability Treatment Advice or activity modification Strengthening grip Strengthening wrist Strengthening—isometric Strengthening—isotonic Strengthening—eccentric Splinting—rigid Splinting—semiflexible Peripheral joint mobilization Electrotherapy
Count (Proportion) of Therapists Using the Treatment 34/35 (97%) 16/35 17/35 19/35 11/35 14/35 19/35 24/35 8/35 13/35
(46%) (49%) (54%) (31%) (40%) (54%) (69%) (23%) (37%)
activity. Surprisingly, only 17% of subjects in this survey reported an inability to bear weight through the affected wrist. However 47% had problems with grip-related activities. The mechanism of injury and site of pain may indicate particular lesions. Our data show the mechanism of injury was usually an extension injury or there was no clear mechanism of injury. This supports North and Myer’s18 1990 data. It is generally thought that a fall on the extended wrist (hyperextension injury) primarily gives rise to a scapholunate injury.3,18e21 A TFCC injury would be more likely following a twisting or ulnar deviation stress, which may also be combined with a fall on the hand.17,22 Twisting injuries accounted for only 15% of the 59 injuries. Perhaps a rotary component in a fall on the hand was not recognized by the patient at the time of the injury. ROM for these patients is often reported as normal.1,3,17,20 Our data showed that while most patients had a functional ROM few had a normal ROM compared to the other side. Previous descriptive literature reports grip strength as close to normal20,23 or weak, 10e45% less than the contralateral side.17 A 33% reduction in grip strength as measured in our data suggests weakness is also a major impairment and it has implications for function, which is likely to decline. The functional implication of an unstable wrist has not been reported in the literature. Twenty-five percent of patients in this survey had difficulties with self-care and domestic duties. An additional 22% had difficulty with grip activity and 17% with weight bearing. The triquetroulnar critical test was designed to assess ulnotriquetral stability and to give an indication if realignment of the carpus (triquetrum) on the ulna into a more anatomical position relieved pain.17 It has been suggested that if pain is relieved by carpal elevation then a splint mimicking this may be helpful in treatment.17,24,25 Only 37% of therapists used this test. Ulnar carpal elevation has also been
suggested24,25 for improving stability and pain in palmar midcarpal instability. Provocative wrist tests can be viewed as an important aspect of wrist examination to determine the location and severity of pain and possible structures involved. Most therapists (77e83%) used proximal row wrist tests (scapholunate ligament test [SST], lunotriquetral ligament test [LTB], and TFCC testing) for wrist stability. Only 54% tested the midcarpal joint, 37% tested the ulnotriquetral ligament, and 29% used the GRIT test for ulnar impaction syndrome. How important are these tests to our treatment and management? Only one study11 has reported on the sensitivity and specificity of these tests. The sensitivities, specificities, and positive and negative likelihood ratios of the tests are given in Table 3. All three tests appear to be of limited clinical utility. However, even though the limited available evidence suggests these tests are not predictive, there are currently no alternative tests that are known to give a more accurate indication of what is occurring in the wrist joint. The tests should be interpreted in combination with information about mechanisms of injury, ROM, grip strength, functional deficits, and available imaging tests. Patient education (advice and activity modification) was the most used treatment technique in the conservative management of carpal instability. Given the high pain scores reported with aggravating activity this is to be expected. Some form of splinting was the second most used treatment. It is believed that this decreases wrist pain and aggravation, which may improve the healing environment. Some types of splinting may help to stabilize the wrist thereby improving hand function. Grip strengthening exercises (mostly isometric or eccentric exercise) were used by approximately 50% of therapists. Given that grip strength was, on average, only 67% of the strength of the contralateral side, and that difficulty with grip activities was reported as a functional problem (directly in 22% and indirectly, self-care and domestic tasks, in 25%), this is perhaps a little surprising. Generally, a graded pain-free exercise program would be advocated.26 Moderate grip
TABLE 3. Diagnostic Accuracy of Wrist Ligament Tests Reported by LaStayo and Howell (1995)11 Test Scaphoid shift test Lunotriquetral ballotment test Triangular fibrocartilage complex test
Sensitivity Specificity LR (%) (%) LRþ 69 64
66 45
2.0 0.47 1.2 0.80
66
64
1.8 0.53
LRþ ¼ positive likelihood ratio, calculated from data in paper; LR ¼ negative likelihood ratio, calculated from data in paper.
JulyeSeptember 2007 241
strength is vital for functional hand use. The effectiveness of all of these interventions (advice, splinting, and grip strengthening exercises) has not been rigorously tested. Twenty-eight percent of patients were considered globally hypermobile by therapists. Many therapists believe that hypermobile individuals are more likely to experience scaphoid instability.
CONCLUSION Wrist instability following a carpal ligament lesion often manifests as wrist pain, difficulty with grip activities, and sometimes difficulty bearing weight through the wrist. ROM may be limited but is generally in the functional range. Grip strength is generally decreased compared with the contralateral side. The tests most commonly used by Australian hand therapists are the SST, the LTB, and the TFCC test. The most common treatments are patient education, splinting, and grip or wrist strengthening.
REFERENCES 1. Herbert TJ. Carpal instability. Proceedings of the Sydney hospital hand symposium—Update on the wrist joint. Sydney, 1991: 2e6. 2. Garcia-Elias M. The treatment of wrist instability. J Bone Joint Surg. 1997;79:684–90. 3. Ashe M. Management of carpal instability: a therapists’ perspective. Br J Hand Ther. 2001;6:9–14. 4. Bowers WH. Instability of the distal radioulnar articulation. Hand Clin. 1991;7:311–27. 5. Watson HK, Rogers WD, Ashmead D. Reevaluation of the cause of the wrist ganglion. J Hand Surg. 1989;14A:812–7. 6. Filan S, Herbert TJ. Recurrent dorsal wrist ganglion: aetiology and treatment. Hand Surg. 1996;1:7–9. 7. Watson HK, Ashmead D, Makhlouf MV. Examination of the scaphoid. J Hand Surg [Am]. 1988;13A:657–60. 8. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg [Am]. 1984;9A:502–14.
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9. Bishop A, Reagan DS. Lunotriquetral sprains. In: Cooney WP, Linscneid RL, Dobyns JH (eds). The Wrist—Diagnosis and Operative Treatment. St. Louis, MO: Mosby, 1998, pp 527–49. 10. Rana NA, Taylor AR. Excision of the distal end of the ulna in rheumatoid arthritis. J. Bone Joint Surg. 1973;55B:96–105. 11. LaStayo P, Howell J. Clinical provocative tests used in evaluating wrist pain: a descriptive study. J Hand Ther. 1995;8:10–7. 12. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods. Philadelphia, PA: J P Lippincott, 1990; 105. 13. LaStayo P, Weiss S. The GRIT: a quantitative measure of ulnar impaction syndrome. J Hand Ther. 2001;14:173–9. 14. Brumfield RH, Champoux JA. A biomechanical study of normal functional wrist motion. Clin Orthop Relat Res. 1984;187: 23–5. 15. Palmer AK, Werner FW, Murphy D, Glison R. Functional wrist motion: a biomechanical study. J Hand Surg [Am]. 1985;10A: 39–46. 16. Nelson DL. Functional wrist motion. Hand Clin. 1997;13:83–92. 17. Prosser R. Conservative management of ulnar carpal instability. Aust J Physiother. 1995;41:41–6. 18. North ER, Myer S. Wrist injuries: a correlation of clinical and arthroscopic findings. J Hand Surg [Am]. 1990;15A:915–20. 19. Blatt G. Scapholunate instability. In: Lichtman DM (ed). The Wrist and Its Disorders. Philadelphia, PA: W B Saunders, 1988, pp 25–273. 20. Talesneik J, Linscheid RL. Scapholunate instability. In: Cooney WP, Linscneid RL, Dobyns JH (eds). The Wrist—Diagnosis and Operative Treatment. St. Louis, MO: Mosby, 1998, pp 501–26. 21. Mayfield JK. Pathogenesis of wrist ligament instability. In: Lichtman DM (ed). The Wrist and Its Disorders. Philadelphia, PA: W B Saunders, 1988, pp 53–73. 22. Cooney WP. Tears of the triangular fibrocartilage of the wrist. In: Cooney WP, Linscneid RL, Dobyns JH (eds). The Wrist—Diagnosis and Operative Treatment. St. Louis, MO: Mosby, 1998, pp 710–42. 23. Taleisnik J. Scapholunate dissociation: medial carpal instability. In: Taleisnik J (ed). Wrist Instability. New York: Churchill Livingstone, 1985, pp 239–305. 24. Alexander CE, Lichtman DM. Triquetrolunate and midcarpal instability. In: Lichtman DM (ed). The Wrist and Its Disorders. Philadelphia, PA: W B Saunders, 1988, pp 274–85. 25. Gaenslen ES, Lichtman DM. Midcarpal instability: description, classification, and treatment. In: Buchler U (ed). Wrist Instability. London: Martin Dunitz, 1996, pp 163–74. 26. Prosser R. Management of carpal instabilities. In: Prosser R, Conolly WB (eds). Rehabilitation of the Hand and Upper Limb. Edinburgh: Butterworth Heinemann, 2003, pp 148–59.
JHT Read for Credit Quiz: Article #061 Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue. There is only one best answer for each question. #1. Pain was most frequently reported on the______ aspect of the wrist a. radial b. ulnar c. central d. combined #2. The typical patient profiled in the survey responses was a. not amenable to conservative management b. postsurgical c. likely a surgical candidate d. likely a nonsurgical candidate #3. A surprise finding was a. the most common mechanism of injury was a fall on the outstretched hand b. that most patients had functional ROM c. only 17% reported difficulty with weight bearing through the wrist
d. that only 50% of those surveyed responded to the survey #4. The most commonly reported mechanism of injury was a. a fall with a twisting component applied to the wrist b. a fall with an extension force applied to the wrist c. blunt trauma to the dorsum of the wrist d. blunt trauma to the volar wrist #5. The most common intervention by the therapists was a. advice b. splinting c. home exercises d. physical agent modalities When submitting to the HTCC for recertification, please batch your JHT RFC certificates in groups of three or more to get full credit.
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