01 - RS3580 Wrist Dysfunction & PT MGT

For personal use only
RS3580 Wrist Dysfunction and

Physiotherapy Management
Raymond TSANG
Professor of Practice (Physiotherapy)
All rights reserved
Outline
• Wrist functions
• Anatomy
• Assessment
• Some common wrist conditions and
management, e.g.
• Wrist fractures
• Carpal instability
• de Quervain’s disease
• TFCC injuries
• Carpal tunnel syndrome
All rights reserved 2
Wrist Functions

• In order for the hand to be functional,
proximal articulations must be both mobile
and stable
• Functions of wrist
• Placing the hand in best possible position to
manipulate objects
• Controlling moment arms of most extrinsic
tendons of hand (carpal tunnel as pulley for
flexor tendons; dorsal compartments for
extensor tendons)
(Garcia‐Elias, 2021)
Anatomy
Wrist complex (condyloid/biaxial joint)
• Radiocarpal, ulnocarpal, mid‐carpal,
carpometacarpal & distal radioulnar joints (DRUJ)
• 15 bones with 20 articulations – 8 carpi, 5
metacarpals, radius & ulna
• 15‐20 named ligaments
• 24 tendons passing through
• 2 major blood vessels (radial & ulnar arteries)
• 3 major peripheral nerves
4
Wrist Complex

小多角骨
Joints and Bones
鉤骨
頭狀骨大多角骨
豆骨 (Schuenke et al, 2020, p.255)
Carpometacarpal
三角骨舟骨 joints
月骨
舟月豆角、大小頭鉤
(DRUJ)
(Steinberg, 2002)
Radius, Ulna and Carpal Bones

(Srinivas Reddy & Compson, 2005a)

Radius, Ulna and Carpal Bones

Wrist – 3 columns
1. Radial column – radial
styloid process, scaphoid
facet, base of Lister’s
tubercle
2. Intermediate/middle/
central column – lunate
facet, sigmoid notch
3. Ulnar column –
triangular fibrocartilage
complex (TFCC), ulnar (Schuenke et al, 2020, p.256)
styloid process All rights reserved 7
Distal Radius
(Loredo et al, 2005) For personal use only
110
220

Carpal Ligaments

Extrinsic ligaments
• those that cross the radiocarpal and ulnocarpal
joints and connect the forearm bones with the
carpus
Intrinsic ligaments
• may be interosseous or intercarpal, may connect
two or more carpal bones, and may cross the mid‐
carpal joint
(Wolfe & Kakar, 2022, p.490‐1)
Carpal Ligaments
Volar ligaments: For personal use only
extrinsic & intrinsic (poor ligamentous support
between capitate and lunate 
Arcuate or perilunate dislocation)
Ulnar side: Triquetral‐hamate‐

capitate ligament
(strongest)
(Steinberg, 2002)
Carpal Ligaments

Carpal intrinsic ligaments
Proximal row:
• Scapholunate interosseous ligament – dorsal region
thickest and strongest, palmar segment thin and
obliquely oriented, proximal segment made up of
fibrocartilage
• Lunotriquetral interosseous ligament – thickest
volarly, interdigitates with fibres of ulnocapitate
ligament, dorsal region thin and proximal portion
made up of fibrocartilage
Carpal Ligaments
Carpal intrinsic ligaments
Distal row:
• Trapeziotrapezoid,
trapezocapitate and
capitohamate
ligaments – dorsal,
palmar, and deep
portions
(Moriatis & Shin, 2010, p.6)

Carpal Ligaments

Dorsal ligaments
– extrinsic
Failure with loading: Dorsal radiolunate ligament

Interosseous ligament ~300N Dorsal radioscaphoid ligament
Extrinsic ligament ~200N
(Oatis, 2009, p.272)
(Cardoso & Szabo, 2007)
Carpal Ligaments
Abundant
mechanoreceptors &
nerves in:
1. Dorsal radiotriquetral
2. Dorsal intercarpal
3. Scaphotriquetral
4. Scapholunate
(Hagert, 2010, p.14)

Carpal Kinematics

• Extremely complex motion of 8 carpal bones
• flexion/extension, radioulnar deviations, rotation
• Distal row
• very little motion between bones
• Proximal row
• more mobile with one another
• as an intercalated segment between radius &
ulna and distal row
Intercalated segment
• There is no direct control over proximal carpal row
• Motion is governed by extraneous factors – geometry of articular surfaces,
forces applied and integrity of ligaments
Carpal Stability
A: Triquetrocapitate
B: Scaphocapitate
C: Scapholunate
D: Lunotriquetral
(Hirt et al, 2017, p.24)
(Wolfe & Kakar, 2022, p.494)

Mobile 4th & 5th MC

Deep transverse
metacarpal or
inter‐volar plate
ligaments
Mobile 4th &

Immobile 2nd, 3rd CMCJ 5th CMCJ White line indicates the relaxed position of the
& distal intercarpal distal metacarpals; red line indicates their position
joints  forming fixed after the fist is clenched
longitudinal arch &
transverse carpal arch (Neumann, 2017, p.257)
(Schreuders et al, 2019, p.5) All rights reserved 17
Carpal Kinematics
A simplified central column model of wrist flexion and

extension – roughly equal contributions of radiocarpal joint
and mid‐carpal joint in flexion and extension
(Neumann, 2017, p.230)
Carpal Kinematics

Wrist ulnar deviation and radial deviation – more
contributions from mid‐carpal joint than radiocarpal joint,
especially in radial deviation
(Neumann, 2017, p.230‐1)
Carpal Kinematics
• Physiological motions in oblique plane of wrist are
common in ADL, e.g. hammering a nail, combing
hair  dart‐throwing motion with minimal
motion between scaphoid and lunate
(Magee & Manske , 2021, p.506)
Wrist extension with radial deviation All rights reserved Wrist flexion with ulnar deviation 20
DRUJ

(Kleinman, 2010, p.43)
Pivot
joint
DRUJ Kinematics

DRUJ Kinematics

• As the radius rotates
from full supination
to full pronation
around a fixed ulna,
the radiocarpal unit
shortens relative to
the ulna, resulting in
a positive ulnar
variance in the
pronated position
(pronated position,
ulna becomes more
distal or “longer”)
DRUJ Kinematics
Negative ulnar
variance
(Loredo et al, 2005) Positive ulnar

variance
DRUJ Stabilizers

ECU
Extrinsic DRUJ
stabilizers
6th dorsal
compartment
Intrinsic DRUJ subsheath
stabilizers
 Pronator
quadratus
(Srinivas Reddy & Compson, 2005b)

Interosseous
Triangular fibrocartilage complex (TFCC) membrane
is the primary soft tissue stabilizer for
ulnocarpal joint and DRUJ (Kleinman, 2010, p.44)
Triangular Fibrocartilage Complex

Circulation to
TFC at periphery

Triangular Fibrocartilage Complex

TFCC – TFC, meniscal homologue, ulnolunate and ulnotriquetral ligaments, dorsal &
palmar radioulnar ligaments, ulnar collateral ligament, and ECU subsheath
(superficial radioulnar ligament)
Fovea
UT – Ulnotriquetral ligament (deep radioulnar ligament)

UL – Ulnolunate ligament
(Thomas & Sreekanth, 2012)
Wrist Loading
84%

Wrist Loading

Neutral position:
Radiocarpal joint
~80% (radio‐
scaphoid ~50%;
radio‐lunate
~30%)
Ulnocarpal joint
~20%
(Krukhaug, 2014, p.34‐35)

Wrist Loading

Surface Anatomy 4 5

3
2
6
1
12 3 4 56
(2, 2, 1, 2, 1, 1) All rights reserved 31

Surface Anatomy
Lunate as most prominent
bone in wrist flexion
(Srinivas Reddy & Compson, 2005a)

History

• What and where are the symptoms?
• Acute vs gradual or chronic onset
• What is the mechanism of injury? Find out
the exact nature of force transmission
• Establish the site of pain, related to
underlying structures
• Behaviour of symptoms and irritability
• Past medical history or health
History
• Trauma e.g. fall on out‐stretched hand
• Wrist fractures
• Fractures of distal radius – Colles’ fracture or
intra‐articular fracture
• Scaphoid fracture
• Carpal instability – a symptomatic dysfunction
with inability to bear loads and abnormal wrist
kinematics during motion
• Overuse syndrome, e.g.
• De Quervain’s disease
• Carpal tunnel syndrome
Inspection

Wrist Deformities
Colles’ fracture – dorsal displacement of fragment
Dinner fork deformity For personal use only
(Iyer, 2006)
Wrist ganglion cyst
Smith’s fracture – volar displacement of fragment

https://www.osc‐ortho.com/blog/ganglion‐
cyst‐of‐the‐wrist‐robert‐j‐snyder‐md/
(Seeley et al, 2020, p.257)
Movements

Movements

Palpation

3 Main Principles (Young et al, 2007)
• The exact point of local tenderness is the
location of pathology
• If one knows the exact location, i.e. the
anatomical structure, one likely knows the
diagnosis
• The diagnosis is arrived at by a summation of
positive and negative physical findings
Location of Wrist Pain

Entrapment of superficial sensory

branch of radial nerve
(Newton et al, 2017)

Palpation

5 zones:
• Radial dorsal zone (radial to Lister’s tubercle)
• Central dorsal zone (Lister’s tubercle to
DRUJ)
• Ulnar dorsal zone (ulnar to DRUJ)
• Radial volar zone (radial to PL tendon)
• Ulnar volar zone (ulnar to PL tendon)
Palpation
Radial Dorsal Zone (Srinivas Reddy &
• Radial styloid Compson, 2005a)
• Scaphoid
• Scapho‐Trapezial Joint &
Trapezium
• 1st MC base & 1st CMCJ
• EPB, APL & EPL tendons
• Dorsal radial sensory
nerve
1 Lister’s tubercle
2 Scapholunate interval
All rights reserved
3 Radial styloid 42
Sensory Distribution

(https://semmelweis.hu/anatomia/files/2020/09/20201019_Katz_en.pdf)
Palpation
Central Dorsal Zone (Srinivas Reddy &
• Lister’s tubercle Compson, 2005a)
• Scapho‐lunate interval
• Lunate (ulnar to 2)
• Capitate
• 2nd & 3rd MC and
CMCJs
• ECRL, ECRB & EDC
tendon
1 Lister’s tubercle
2 Scapholunate interval
All rights reserved
3 Radial styloid 44
Palpation

Ulnar Dorsal Zone (Srinivas Reddy &
• Ulna head Compson, 2005a)
• Ulnar styloid process

• DRUJ (between 1 & 11)
• TFCC
• Hamate
• Triquetrum
• Luno‐Triquetral interval
• 4th & 5th CMCJs 11 Ulnar head
12 Ulnar styloid process
• ECU tendon All rights reserved
13 Triquetral 45
Palpation
Radial Volar Zone
• Scaphoid tuberosity (Srinivas Reddy &
Compson, 2005a)
• Radial styloid – volar
aspect
• Trapezial ridge
• Volar 1st CMCJ
• FCR tendon
• Palmaris longus tendon
• Median nerve and palmar/
superficial branch 7 Scaphoid tuberosity
8 Trapezial ridge
• Radial artery All rights reserved 46
Sensory Distribution

(Outside Guyon canal / (Outside carpal tunnel)
ulnar tunnel)
(https://semmelweis.hu/anatomia/files/2020/09/20201019_Katz_en.pdf)
Palpation
Ulnar Volar Zone
• Pisiform (9) (Srinivas Reddy &
Compson, 2005a)
• Hook of hamate (10)
• Ulnar nerve and
palmar/superficial
branch & artery
• FCU tendon
• TFCC
9 Pisiform
10 Hook of hamate
Wrist Fractures

• Fractures of distal radius
• Extra‐articular fracture, e.g. Colles’
fracture, Smith’s fracture
• Intra‐articular fracture
• Carpal fractures
• Scaphoid fracture
Fractures of Distal Radius

(Lindau & Ekholm, 2014, p.5)

Colles’ Fracture

• Characteristics: extra‐articular fracture with dorsal
angulation and dorsal displacement (dinner fork
deformity), within 2‐3cm of articular surface
• Age: older adults, likely with osteoporosis, i.e. one
of the most common fragility fractures
• Aetiology: fall on out‐stretched hand (FOOSH)
• Treatment: usually closed reduction required with
immobilization in short‐arm cast/plaster of Paris
(POP) for 6 weeks
Colles’ Fracture
• Physiotherapy with cast in first 6 weeks
• Active mobilization of affected fingers, elbow
and shoulder
• Reduction of oedema with advice on elevation
• Assessment of the following possible
complications:
• Cast loosening after first week of cast application
• Delayed rupture of extensor pollicis longus
• Complex regional pain syndrome (CRPS)

Colles’ Fracture

• Physiotherapy after cast removal
• Active wrist mobilization and gentle hand
gripping exercise begin
• Gentle passive wrist mobilization and gentle
resistive exercises after 8 weeks
• Active and passive wrist mobilization , and
progressive resistive exercises after 10 weeks
Intra‐articular Fracture of Distal Radius

• Characteristics: intra‐articular fracture, usually
with comminution
• Age: young adults
• Aetiology: high‐energy trauma, e.g. motor bike
accident
• Treatment:
• Closed reduction and immobilization with long‐arm
cast/POP
• Open reduction with internal fixation (± bone graft)
• External fixator for open fracture ± significant soft
tissue trauma

• Closed reduction and immobilization with long‐arm
cast/PoP
• Active mobilization of affected fingers and shoulder
• 3 weeks after closed reduction, long‐arm cast can be changed
to short‐arm cast with radiological confirmation of reduction
maintained
• Then active elbow mobilization can be started, withouth
forearm supination and pronation mobilization which may lead
to loss of reduction
• Short‐arm cast may be removed after 6 weeks of closed
reduction, with active wrist mobilization begins
• Gentle passive wrist mobilization and gentle resistive exercises
after 8 weeks
• Active and passive wrist mobilization , and progressive resistive
exercises after 10 weeks All rights reserved 55

• Open reduction with internal fixation (± bone
graft)
• There may be temporary immobilization of wrist with
POP slab
• Active mobilization of affected fingers, elbow and
shoulder
• Active wrist mobilization after slab removal
• Gentle passive wrist mobilization and gentle resistive
exercises after 8 weeks
• Active and passive wrist mobilization , and progressive
resistive exercises after 10 weeks
Scaphoid Fracture

• Age: usually young
adults, with fall on
out‐stretched hand
• Symptoms: may
not be obvious;
tenderness at (Schuenke et al, 2020,
anatomic snuff p.259)
box, pain on axial
compression
(Magee & Manske , 2021, p.490, 527)

Scaphoid Fracture
Scaphoid fracture (a) subtle contour deformity of the lateral cortex of scaphoid
(arrow) with signet ring sign; (b) wrist in ulnar deviation showing waist fracture
of scaphoid (scaphoid view) (Resnik, 2000)
Scaphoid Fracture

• Complications: delayed or non‐union because of
delayed treatment and poor circulation to
proximal pole; avascular necrosis (AVN); collapse
(https://www.nationwidechildrens.org/conditions/scaphoid‐fractures)
SLAC or SNAC
(Ankarath, 2006)
Scaphoid Fracture

• Treatment
• Prompt identification of fracture after injury – if
scaphoid fracture is not obvious in initial x‐ray, x‐ray
should be repeated about 1 to 2 weeks to allow
adequate resorption of fractured bones to identify
fracture line; or MRI / CT scan within 3‐4 days of injury
• Fracture without displacement: scaphoid cast (short‐
arm cast with 1st CMCJ, thumb MPJ and IPJ
immobilized) for 6‐10 weeks (see algorithm); active
mobilization of other finger joints, elbow and shoulder
• Wrist mobilization after cast removal
• Strengthening exercise after 12 weeks with evidence of
union in x‐ray
(e.g. Herbert screw)
(Clementson et al, 2020)

Scaphoid Fracture

• Treatment
• Fracture with displacement: open reduction and
internal fixation (e.g. Herbert screw)
• Postoperative protection with short‐arm thumb spica
slab or splint; active mobilization of other fingers,
elbow and shoulder
• Removal of short‐arm slab/splint after 6 weeks if there
is radiological evidence of bone healing
• Gentle active wrist and thumb mobilization starts
• Strengthening exercise after 12 weeks
Carpal Instability
• As a wrist condition showing symptomatic
dysfunction, inability to bear loads without
normal kinematics during any portion of its arc of
motion (Trail et al, 2007)
• Mostly resulted from an injury such as a fall on
outstretched hand with wrist in hyperextension
• 4 major patterns (Lee & Elfar, 2015; Wolfe & Kakar, 2022)
• Carpal instability dissociative (CID)
• Carpal instability non‐dissociative (CIND)
• Carpal instability complex (CIC)
• Carpal instability adaptive (CIA)
Carpal Instability Dissociative

• CID as predominant dysfunction between carpal
bones of proximal row: (Wolfe & Kakar, 2022)
• Scapholunate instability  DISI
• Lunotriquetral instability  VISI
Dorsal intercalated Volar intercalated

segmental instability segmental instability
‐ lunate angulated ‐ lunate angulated
dorsally volarly
(Wolfe & Kakar, 2022, p.500)

Scapholunate Dissociation
Normal:
300‐600
Scapholunate dissociation – Terry Thomas sign, ring sign & increased

scapholunate angle (Resnik, 2000)
Scapholunate Instability
Watson’s Scaphoid Shift Test

Scapholunate Instability
Watson’s Scaphoid Shift Test For personal use only

Lunotriquetral Instability
Lunotriquetral Ballottement Test

Lunotriquetral Instability
Lunotriquetral Ballottement Test For personal use only

Carpal Instability Non‐Dissociative

• CIND as symptomatic disruption between radius
and proximal row or proximal and distal carpal
rows: (Lee & Elfar, 2015; Wolfe & Kakar, 2022)
• Radiocarpal instability – entire carpus translocated
with respect to radius in any direction
• Combined radiocarpal‐mid‐carpal or proximal
row instability – proximal carpal row collapse with
instability in flexion or extension
• Mid‐carpal instability – dysfunction at mid‐carpal
level with normal alignment of proximal row, e.g.
capitolunate instability pattern (CLIP), chronic
capitolunate instability (CCI)
Mid‐carpal Instability
Anteroposterior Drawer Test For personal use only

Anteroposterior Drawer Test

Mid‐carpal Ulnar Pronation Test For personal use only

Catch‐up Clunk Test

Catch‐up Clunk Test For personal use only

Carpal Instability Complex

• CIC as carpal dysfunction that alters linkage both
between bones of same carpal row (CID) and
between carpal rows (CIND): (Lee & Elfar, 2015)
• Perilunate dislocations
• Axial dislocations
Perilunate Dislocation
(Loredo et al, 2005) For personal use only

Perilunate Dislocation

(Navaratnam et al, 2012) Spilled teacup sign
Perilunate dislocations
• typically caused by axial loading of the carpus
from high energy trauma (eg, road traffic
incidents, industrial injuries, falls from height),
resulting in hyperextension, ulnar deviation, For personal use only
and intercarpal supination
Mayfield classification – applied force progresses

in a sequential manner, increasingly disrupting
carpal ligaments and resulting in dislocation and
rotation of the lunate
Stage I: disruption of the scapholunate ligament
(black line) and radioscaphocapitate ligament
(black dashed line), or trans‐scaphoid fracture
Stage II: disruption of the lunocapitate
articulation (grey line) or capitate fracture
Stage III: disruption of the lunotriquetral
interosseous ligaments (blue line) or triquetrum
fracture
Stage IV: disruption of the radiolunate ligament
(blue dashed line)
(Ahmad & Vashista, 2021)

Carpal Instability Complex
Axial Loading Test

Carpal Instability Adaptive

• CIA as cases of carpal malalignment secondary to
injuries not involving carpal bones, e.g. mal‐united
non‐articular distal radius fracture (Wolfe & Kakar, 2022)

Carpal Instability – Interventions

• Evidence to support interventions for carpal
instability is limited (Mee, 2020)
• Appropriate interventions (operative or non‐
operative) would depend on individual conditions,
taking into consideration of aetiology, chronicity,
symptom severity, location and instability pattern
(Wei et al, 2023)
• In general, rehabilitation programme after

operative or non‐operative interventions should
achieve stable wrist with functional ROM and
include: (Mee, 2020)

• Managing oedema and pain
• Maintaining ROM of unaffected joints
• Initiating controlled, protected mobilization to
involved structures based on tissue healing,
potential tension to repaired structures, and
symptoms
• Avoiding exercise or activity that could
compromise tissue healing or place undue load to
healing structures (e.g. strong hand gripping,
weight bearing activities)

• Initiating individualized, clinically reasoned wrist
ROM and strengthening exercises (e.g. dart‐
throwing motion for scapholunate instability)
However, recent study showed that

there is motion between scaphoid
and lunate during dart‐throwing
motion; therefore aggressive dart‐
throwing exercises should not be
implemented early after
scapholunate repair (Schriever et
(Mee, 2020, p.281) al, 2021)

• Avoiding painful end‐range or excessive active
ROM exercises
Functional wrist ROM: (Mee, 2020, p.274)

• Flexion 400
• Extension 400
• Combined deviation 400
• Pronation and supination 75%

de Quervain’s Disease

• As stenosing tenovaginitis or stenosing
tenosynovitis due to overuse pathology involving
impaired gliding of APL and EPB in first dorsal
compartment of radial wrist (McQueen & Pemberton, 2020)
• Aetiology: (McQueen & Pemberton, 2020)
• Thickening of extensor retinaculum over first dorsal
compartment likely as a result of forceful or repetitive
grasp combined with ulnar deviation, repetitive thumb
abduction, and/or repetitive thumb MPJ flexion
• Sex and age: higher incidence in females; peak
incidence between 40‐59; pregnancy as a risk
factor (Currie et al, 2022)
Differential diagnosis For personal use only
Intersection syndrome
(Kay, 2000)
Eichhoff’s Test

(Ahuja & Chung, 2004)
de Quervain’s
disease
Finkelstein’s Test
(Ahuja & Chung, 2004)
de Quervain’s
disease

Testing for Painful 1st CMCJ
1st CMCJ Grind Test

Testing for Painful 1st CMCJ

1st CMCJ Grind Test For personal use only


• Non‐operative intervention (McQueen & Pemberton,
2020)
• Activity modification, e.g. avoiding holding
heavy object with forearm in mid‐prone
• Thumb spica splint with IPJ free at night  day
time (as much as possible) for 4‐6 weeks
• With symptom improvement after wearing
splint and activity modification, active and
passive ROM and stretching started to promote
tendon gliding without exacerbating symptoms
• Steroid injection + thumb spica splint
• Operative intervention (McQueen & Pemberton, 2020)
• Surgical release of extensor retinaculum if
condition does not improve with non‐operative
intervention

TFCC Injuries

• Injuries from (Pitts et al, 2016)
• Trauma – rotational torque stress of DRUJ
• Degeneration from overuse – exposure to
repetitive compressive forces on central
portion of TFCC from weight bearing, overhead
lifting, and ulnar deviation with force
• Indications for intervention – pain and/or
instability from ulnocarpal joint or DRUJ
(traumatic injuries), or lunotriquetral joint
(degenerative injuries)
Palpation for TFCC Injuries

• Ulnar fovea sign –
tenderness at interval
between ulnar styloid
process and FCU tendon,
between volar surface of
ulnar head and pisiform 
foveal disruption of DRUJ
ligaments (deep radioulnar
ligaments  DRUJ instability)
and/or ulnotriquetral
ligament (no DRUJ instability)
injuries (Tay et al, 2007)
(Schmauss et al, 2016)
Sign of DRUJ Instability

Stress Test for DRUJ Instability






Dorsal
Testing deep dorsal fibres of TFC

(dorsal deep radioulnar ligament)
(Kleinman, 2010, p.50‐51)

Dorsal
Dorsal
Testing deep palmar fibres of TFC

(palmar deep radioulnar ligament)
(Kleinman, 2010, p.50‐51)
Dorsal
Other Test for DRUJ Instability

Piano Keys Test For personal use only

Testing for Painful TFCC
McMurray’s Grind Test /

Ulnocarpal Stress Test / Ulnar Impaction Test

Test for TFCC Injuries

McMurray’s Grind Test / For personal use only
Ulnocarpal Stress Test / Ulnar Impaction Test

Ulnomeniscal Triquetral Dorsal Glide Test


Ulnomeniscal Triquetral Dorsal Glide Test For personal use only

TFCC Injuries

• Non‐operative interventions (Pitts et al, 2016)
• Immobilization 6 weeks
• Long‐arm splint with elbow flexion 70‐900 ( hinged
elbow) with forearm and wrist in neutral for 18‐24
hours daily
• Finger and shoulder mobilization exercises
• After 6 weeks
• Wrist and forearm active and active assisted
mobilization
• Wrist in neutral position with ADL tasks
TFCC Injuries
• Non‐operative interventions (Pitts et al, 2016)
• After 8 weeks
• Progressive strengthening exercises if no increase in
pain
• After 10‐12 weeks
• Overhead and weight‐bearing activities if
asymptomatic

TFCC Injuries

• Operative interventions (Pitts et al, 2016)
• Arthroscopic debridement of TFCC
• For horizontal tear in avascular portion of TFCC
• Postop with protective splint
• Postop D3‐5: gentle wrist active ROM (neutral
position) out of splint 5‐10min/hour
• Postop D10‐12: part‐time splint up to 4 weeks;
continue active ROM and self‐care ADL
• Postop 4‐6 weeks: gentle wrist passive ROM; gentle
isotonic strengthening with light putty
• After postop 6 weeks: progressive strengthening
with putty; isotonic wrist flexion/extension with
light weight
TFCC Injuries
• Operative interventions (Pitts et al, 2016)
• Peripheral tear repair of TFCC
• Postop D0‐14 with protective splint; active finger
mobilization
• Postop 3‐4 weeks: DRUJ pin removed; gentle wrist
flexion/extension; passive ROM exercise with
supination to 450‐600 depending on tear, repair and
surgeon’s preference
• Postop 6‐8 weeks: full active ROM for flexion,
extension, pronation and supination as goal
• Postop 8‐12 weeks: isotonic strengthening with
putty, isometric grip and isotonic wrist flex/ext
Carpal Tunnel Syndrome

• Definition: compression of median nerve under
transverse carpal ligament in carpal tunnel/canal
• It is the most common compressive neuropathy in
upper limb, affecting hand sensation (pain,
numbness, decreased sensation) and thenar
muscles supplied by median nerve
• It can be progressive with ischaemic changes,
blood‐nerve barrier breakdown, perineural
oedema, focal demyelination, and eventually
axonal loss (Currie et al, 2022)

(Currie et al, 2022)

Tests for Carpal Tunnel Syndrome

Durkan’s Compression test – 30s
Phalen’s test – 60s
(Boscheinen‐Morrin &
Conolly, 2001, p.85)
(Ceruso et al, 2002, p.65)

(Currie et al, 2022)

Hand elevation test – 2 min
(Ahn, 2001)


Pooled Diagnostic Accuracy of Tests
Test n Sensitivity Specificity
(studies) (95% CI) (95% CI)
Phalen test 32 68% 71%
(63%‐74%) (63%‐80%)
Durkan test 14 62% 77%
(49%‐77%) (63%‐93%)
Tinel test 28 55% 75%
(48%‐63%) (67%‐83%)
Hand elevation test 5 85% 95%
(77%‐94%) (86%‐100%)
(Núñez de Arenas‐Arroyo , 2022)

Mild: intermittent symptoms
Moderate: constant symptoms Non‐operative For personal use only
Severe: thenar muscle atrophy
(Carpal tunnel syndrome: a summary of clinical practice guideline recommendations‐using the evidence to guide
physical therapist practice, 2019)

• Operative interventions
• Carpal tunnel release for decompression of
median nerve – open or endoscopic
• Reconstructive surgery – Camitz transfer (Rymer &
Thomas, 2016)
• transfer of the insertion of palmaris longus tendon
with a strip of the palmar aponeurosis to the
insertion of abductor pollicis brevis in order to
improve thumb opposition for severe thenar
muscle atrophy
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for diagnosis and treatment. EFORT Open Rev 2020; 5(2): 96‐103. doi:
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RS3580 Wrist Dysfunction and

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For personal use only

Radius, Ulna and Carpal Bones

(Srinivas Reddy & Compson, 2005a)

For personal use only

All rights reserved 8

For personal use only

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Ulnar side: Triquetral‐hamate‐

For personal use only

All rights reserved 11

(Moriatis & Shin, 2010, p.6)

All rights reserved 12

For personal use only

Failure with loading: Dorsal radiolunate ligament

(Hagert, 2010, p.14)

For personal use only

(Hirt et al, 2017, p.24)

(Wolfe & Kakar, 2022, p.494)

For personal use only

Mobile 4th &

A simplified central column model of wrist flexion and

For personal use only

(Magee & Manske , 2021, p.506)

For personal use only

All rights reserved 21

(Kleinman, 2010, p.41)

All rights reserved 22

For personal use only

All rights reserved 23

(Loredo et al, 2005) Positive ulnar

For personal use only

(Srinivas Reddy & Compson, 2005b)

Triangular Fibrocartilage Complex

(Kleinman, 2010, p.45)

For personal use only

(superficial radioulnar ligament)

UT – Ulnotriquetral ligament (deep radioulnar ligament)

(Kleinman, 2010, p.46)

All rights reserved 28

For personal use only

(Krukhaug, 2014, p.34‐35)

(Kleinman, 2010, p.46)

All rights reserved 30

For personal use only

(2, 2, 1, 2, 1, 1) All rights reserved 31

(Srinivas Reddy & Compson, 2005a)

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For personal use only

For personal use only

Wrist ganglion cyst

Smith’s fracture – volar displacement of fragment

For personal use only

(Srinivas Reddy & Compson, 2005b)

For personal use only

All rights reserved 39