Mobilization of the Wrist Radiocarpal Joint

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Mobilization of the Wrist

2017 EATA Student Conference

Mary L. Mundrane-Zweiacher

MPT, ATC, CHT

[email protected]

Radiocarpal Joint

Radiocarpal Joint Ligaments Distal Radioulnar Joint (DRUJ)

Midcarpal Joint Carpometacarpal Joint

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First CMC Joint

The Extrinsic Hand Muscles: Volar Aspect

• Palmaris longus

• Flexor carpi radialis

• Flexor carpi ulnaris

• Flexor Pollicis Longus

• Flexor Digitorum Profundus (FDP)

• Flexor Digitorum Superficialis (FDS)

The Extrinsic Hand Muscles: Volar Aspect

• Flexor Digitorum Profundus (FDP)

• Flexor Digitorum Superficialis (FDS)

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FDS FDP

The Extrinsic Hand Muscles: Dorsal Aspect

• Extensor Pollicis Longus (EPL)

• Extensor Pollicis Brevis (EPB)

• Abductor Pollicis Longus (APL)

• Extensor indicis• Extensor Digitorum

Communis (EDC)

Visible Extensor Mechanism

The Extrinsic Hand Muscles: Dorsal Aspect

• Extensor carpi radialis longus ( ECRL)

• Extensor carpi radialis brevis (ECRB)

• Extensor carpi ulnaris

• Extensor digiti minimi

The Intrinsic Hand Muscles

• Lumbricales

• Dorsal Interossei

• Palmar (Volar) Interossei

• Thenar Muscles

• Hypothenar Muscles

• Adductor Pollicis

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• Lumbricales



• Thenar Muscles




• Lumbricales



• Thenar Muscles



Volar Plate Pulley Systems of the Hand

The Lymphatic System

• It is the only system that can remove large molecule substances such as excess plasma proteins, hormones, fat cells, and waste products from the interstitium that you see in chronic edema. The lymphatics are tubes which are in the dermis layer of the skin; they rely on changes in interstitial pressure to open and close (pressures>60mmHg will collapse the tubes).

Myofascial/Skin

• The dorsum of the hand is very different than the palm

• The palmar fascia has longitudinal, transverse, and vertical fibers

• The vertical fibers run superficially to stabilize the thick palmar skin

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Nerves

• Median

• Ulnar

• Radial

Phases of Connective Tissue Healing

• Inflammatory Phase

• Fibroplastic Phase

• Remodeling Phase

Inflammatory Phase

• vasodilation

• hyperemia

• increased cell permeability

• increased vascularity

• cell migration

• debris removal

Fibroplastic Phase

• re-epithelialization causing wound closure (skin)• fibroplasia – fibroblasts are activated and move

along the fibrin meshwork to generate new collagen, elastin, GAG’s, proteoglycans, and glycoproteins

• neovascularization – regeneration of small blood vessels

• wound contraction• collagen with random alignment

Remodeling Phase

• consolidation phase

• increased wound strength

• realignment of collagen

• reduction of abnormal cross links

• maturation phase – the scar links change from weak hydrogen bonds to strong covalent bonds

Normal Synovial Joint Mechanics

• Osteokinematics

• Arthrokinematics– Accessory Motion I

– Accessory Motion II

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Osteokinematics

• Movement of the bony segments around a joint axis

• AROM/AAROM/PROM

• Examples – Shoulder flexion

– Knee extension

Arthrokinematics

• Accessory motion I - joint motion that occurs as a result of active contraction of muscle– generally these motions are described as roll,

spin, and slide

• Accessory motion II – these motions are the result of an outside force which takes the joint beyond anatomical ROM

Synovial Joint Dysfunctions

• Arthrosis

• Degeneration

• Capsular Restriction/Tightness

• Relative capsular fibrosis

• Joint Effusion

Mobilization Principles

• Edema Mobilization (Acute versus Chronic)

• Joint Mobilization

• Scar Mobilization

• Tendon Mobilization

• Neural Glides

Edema Mobilization (Acute versus Chronic)

• Acute – the venous system relies on valves, the heart pumping, and muscle pumping to remove low plasma protein swelling (acute edema)- the treatment goal for acute edema is to decrease the fluid flow into the tissue/interstitium by:

-ice-compression/higher pressure devices-elevation

Edema Mobilization (Acute versus Chronic)

• Chronic – the lymphatic system relies on changes in interstitial pressure to remove large molecule substances

• - the treatment goal for chronic edema is to reduce the excess plasma proteins in the interstitium by stimulating the lymphatics by:

-coban/edema glove-contrast bath-edema massage (light) to dorsum

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Light pressure Too much pressure

Chronic Edema Mobilization

• This treatment can also include Manual Edema Mobilization (MEM) which incorporates the following:-light proximal to distal, then distal to proximal massage of the skin-specific pre and post exercises-massaging the lymph node areas proximal to the

edema -the massage must follow the direction of

lymphatic pathways

Joint Mobilization

• Indications for joint mobilization – pain

– swelling/edema

– muscle spasm

– capsular/ligamentous tightness/connective tissue change

**bony or cartilage block may limit joint motion but is not appropriate for joint mobilization

Physiologic Effects of Joint Mobilization

• Decrease edema• Increases capsular extensibility• Nutrition by movement of synovial fluid• Muscle relaxation by the oscillating

rhythm• Decrease pain by increasing

proprioceptive input and inhibiting ongoing nociceptive input

Convex-Concave Rule

• When a convex surface moves on a concave surface, the convex articular surface moves in the opposite direction as the osteokinematic motion

• When a concave surface moves on a convex surface, the concave articular surface moves in the same direction as the osteokinematic motion

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End Feel

• The resistance felt by the clinician at the end range of a passive joint motion.

End Feels that are Normal or Pathologic include:

• capsular

• ligmentous

• bony

• soft-tissue approximation

• muscular

End Feels that are Strictly Pathologic include:

• muscle-spasm

• abnormal capsular

• boggy

• springy rebound

• empty

Grades of joint mobilization

• I – small amplitude at beginning of joint range• II – large amplitude that does not reach limit of

joint range• III – large amplitude that is up to the limit of joint

range• IV – small amplitude at end of joint range• V – small amplitude, high velocity through limit

of joint range (manipulation)• low load stretch at end range

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Criteria for proper mobilization grade selection

• The degree of pain or protective muscle spasmduring joint motion assessment (irritability)

• The degree of restriction of joint play

• skill and experience of the operator

• The greater the irritability, the lower the grade of mobilization used

-Grade I-II – pain, swelling, and muscle spasm

-Grade III-IV – joint capsule limitation

Open-packed/Closed-packed Position

• Open-packed (Loose-packed) – the position of a joint in it’s ROM where the synovial joint surfaces are least congruent

• the capsule will have the most extensibility• the joint surface contact areas are reduced• Closed-packed – the position of the joint where

the two joint surfaces are most congruent • the ligaments and capsule of the joint are

maximally tight

Contraindications

Absolute • an undiagnosed lesion• joint ankylosis• closed packed position• where the integrity of the ligaments has

been compromised (ex. steroid use) **asthmatics**

• active inflammatory and infective arthritis

Contraindications

Relative

-pregnancy

-joint effusion

-rheumatoid arthritis

-metabolic bone disease (TB, etc)

-internal derangement

-hypermobility

-bony malalignment

Guidelines for joint mobilization

• The athlete must be relaxed• The clinician must be comfortable with the

technique• The mobilization should be relatively painfree• One hand must stabilize while the other hand

performs the mobilization• The more surface area that is contacted increases

the comfort of the athlete as long as the clinician’s hand placement is accurate


• Mobilization techniques can be used for assessment or treatment

• Slight distraction while mobilizing the joint allows better glide and comfort

• Gliding mobilizations are applied parallel to the treatment plane and performed in the direction that was shown to be restricted

• One joint and one mobilization should be done at a time

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• mobilization can vary in movement terms of:

• -direction

• -velocity

• -amplitude

• re-assessment must be done before and after mobilization techniques

Scar Mobilization

• A tendon cannot slide if it is stuck to the skin or the tissues underneath

• -a scar that is adhered to tendon adds resistance to the tendon

• -Mild scar restriction – sometimes gentle massage or tendon function is enough to remodel the tissue

Scar Mobilization

• Moderate scar restriction – stabilize the scar with manual contact or other substance (such as elastomere)

• -mobilize the tendon that is adhered by active contraction

• Established scar –

• -low load, long duration stretch

Elastomere

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Tendon Mobilization

• Tendons can get adhered at a fracture site as the bone is healing.

• - with wrist fractures, always work to restore fisting first

• -prevention – start tendon gliding exercises ASAP

• Keeps the mobility of the tendons and fingers while the bone heals

• Prevents swelling from accumulating between the tissue layers

Differential Tendon Gliding

• The 5 tendon gliding positions (see figure 1)

• -extensors sliding proximally

• -maximal excursion between the FDS and FDP

• -maximal FDP tendon excursion

• -intrinsics (lumbricals and interossei)

• -maximal FDS excursion

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It is crucial to do differential tendon gliding exercises in the

case of pip joint injuries because that is where the FDP has to slide

between the split in the FDS

Joints must be moved through their newly acquired range

actively• New motor programs have to be established

• It is easier to teach a new skill than correct an existing one

• The muscle spindles/golgi tendon organs/joint receptors have to be educated about where the new “normal” is

• “Place-holds” at end range

Neural Glides

• Common Median Nerve glides –– See Figure 2

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Joint MobilizationTechniques

Wrist

• Normal wrist anatomy must be considered while mobilizing the component joints (ex. alignment of the 1st CMC joint should be maintained)

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Normal CMC Position

Wrist

• The radiocarpal and ulnomeniscotriquetral joints’ closed packed position is full extension. The midcarpal joint’s closed packed position is full extension as well.

• Normal joint arthrokinematics are as follows:

Wrist

• Wrist flexion – convex on concave – so the distal carpal row glides dorsally on the proximal carpal row, and the proximal carpal row glides dorsally on the radius and ulna. The scaphoid actually glides further than the other proximal carpals causing it to supinate as well.

Dorsal glide of prox carpal row

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Dorsal glide into flexion

Wrist

• Wrist extension – the distal carpal row glides volarly on the proximal carpal row, and the proximal carpal row glides volarly on the radius and ulna. The scaphoid also pronates

Volar glide of prox carpal row

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Wrist

• Radial deviation – the proximal carpal row flexes, glides dorsally, and translates ulnarly. The distal carpal row extends, glides volarly, and translates radially.

• Ulnar deviation – the proximal carpal row extends, glides volarly, and translates radially. The distal carpal row flexes, glides dorsally, and translates ulnarly.

For RD

For UD

Wrist

• Pronation – see DRUJ

• Supination – see DRUJ

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Distal Radioulnar Joint

• The DRUJ closed packed position is 5 degrees supination

• The movement of the radius on the ulna is a combination of rolling and sliding.

Distal Radioulnar Joint

• Pronation-the radius crosses the ulna by gliding volarly and rotating volarly and medially.

• Supination-the radius glides dorsally and rotates dorsally and laterally

Volar Glide For Pronation

Dorsal Glide For Supination

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Poor force distribution

Special Considerations When Treating Hand or Wrist Injuries

• Infection

• Clean laceration versus a crush or shear type injury

• Smoking

• Mobilize the joint and then have them do the function that is limited

Elbow End Range Extension Loss

• The anatomy of the MCL and medial epicondyle must be considered

• The MCL is most elongated when it has to go over the epicondyle at 30deg flexion

Elbow mob 0deg

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Elbow mob 30deg Thank You to My Son, Lee, and the Staff at Bayhealth Rehab Services

Thank YouThe NATA and EATA are OUR

Associations!!

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Mobilization of the Wrist Radiocarpal Joint

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