after Carpal Ligament Injury

Published on 18/03/2015 by admin

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W8 Rehabilitation after Carpal Ligament Injury

Terri M. Skirven, OTR/L, CHT, Lauren M. DeTullio, MS, OTR/L

The rehabilitation program for the wrist after carpal ligament injury is based on consideration of the specific injury; the stage of healing; the nature of any surgical procedures, whether reparative or salvage; and any resultant alteration in the biomechanics or load-bearing capacity or both of the wrist. Added to these considerations are the patient’s functional requirements, including work, self-care, leisure, and family and household responsibilities.

The goal of rehabilitation for the injured wrist is the return of motion and strength adequate for function with a relative absence of symptoms. In some, but not all, cases, this may mean that the wrist range of motion (ROM) and grip strength after rehabilitation may not reach the preinjury level. It can be ill-advised to set as a goal the achievement of arbitrary measurements of wrist ROM and grip readings at the expense of comfort and without regard for what the patient needs for function. The goal should be a symptom-free, stable wrist that is capable of withstanding the forces involved in the activities that the patient needs to perform for work, leisure, and other activities of daily living (ADL).

Relevant to this approach are the studies of functional ROM that were published in the 1980s, which illustrate that the wrist ROM required to perform most ADL tasks is less than what is considered normal ROM. Palmer and colleagues,¹ in a study evaluating wrist motion used by normal subjects in the performance of standardized tasks, found that functional wrist ROM is between 5 degrees of flexion and 30 degrees of extension, 10 degrees of radial deviation, and 15 degrees of ulnar deviation. In this study, Palmer and colleagues¹ described a “dart thrower’s motion” pattern (i.e., extension/radial deviation to flexion/ulnar deviation) that was used to perform many of the tasks. Ryu and associates² found that 40 degrees of wrist extension, 40 degrees of wrist flexion, and a total of 40 degrees of radial and ulnar deviation are needed to perform most ADL.

Throughout the rehabilitation program, the therapist must closely monitor and use the patient’s symptom response to therapy as an indicator of the capacity of the wrist to handle load. The “no pain, no gain” philosophy has no place in the rehabilitation program. Aggressive and repetitive wrist mobilization and isotonic strengthening may trigger persistent symptoms and potentially undermine the stability of the wrist and either should be used with caution or should be avoided altogether, depending on the diagnosis and the patient’s functional requirements. General goals of rehabilitation after wrist injury include the following:

• Control of edema and pain

• Maintenance of the ROM of uninvolved joints

• Achievement of functional motion of the wrist when healing permits

• Preservation of wrist stability

• Avoidance of activity and exercise that adversely load the wrist and undermine recovery of function and healing

• Return to previous level of function when healing permits

Wrist Evaluation Procedures

The foundation for a wrist rehabilitation program is a thorough assessment. The components of the wrist assessment include a detailed history; visual inspection; objective measurements of ROM, strength, and sensibility; palpation and provocative testing; a functional assessment; and administration of an outcome measure appropriate for the wrist, such as MacDermid’s patient-rated wrist evaluation.³ If the patient has been referred to therapy from a nonspecialized practitioner with a vague diagnosis such as wrist pain or sprain, the clinical examination takes on even greater importance. In this instance, undiagnosed pathology may exist, therapy may not be indicated, and the patient may need to be referred to a hand surgeon for definitive diagnosis.

The history includes details pertaining to the onset of the problem, such as when the problem started, and whether the condition occurred as a result of a single traumatic event, or whether it started gradually and worsened over time. It is important to determine what treatment has been provided, including surgical and nonsurgical management, and the efficacy of the treatment provided. This information helps in the treatment planning process by avoiding approaches that have proved not to be helpful.

A careful exploration of the patient’s symptoms is included—when symptoms occur, whether in response to a specific activity or related to use in general; whether symptoms occur at rest; what relieves the symptoms; and what makes the symptoms worse. In some cases, it may be helpful to use a numeric pain rating or other type of pain measurement that establishes a baseline for later comparison when evaluating the patient’s response to therapy. The impact of the patient’s symptoms and condition on ADL and work and leisure activities is important to determine the degree of disability caused by the wrist problem. An ADL checklist or questionnaire can be used to document a baseline of functional performance and to identify problem areas.

Visual inspection of the wrist and hand with comparison to the uninvolved side can give clues about the nature and extent of the problem. Spontaneous use, wrist posture and alignment, nail and skin color and condition, signs of use or disuse, and muscle bulk or atrophy all are important to note.

A baseline of the patient’s status and function is established with specific measurements of active ROM and passive ROM of all planes of wrist motion and of supination and pronation. Care must be taken when measuring passive ROM to stay within the patient’s comfort range and to avoid forceful end range overpressure. In some cases, passive ROM measurements may be deferred at the initial evaluation depending on the patient’s pain level and healing status. A goniometer is used to insure accuracy of measurement. The most reliable method for measuring wrist flexion and extension is with the goniometer placed on the dorsum of the wrist for flexion and on the volar aspect of the wrist for extension.⁴ Wrist ROM varies in the normal wrist; measurements of the uninvolved side should be taken for comparison.

The size of the wrist can be documented with circumference and volumetric measurements. For more acute conditions, the size of the wrist compared with the uninvolved side may be larger reflecting the presence of swelling, and with more chronic conditions, it may be smaller reflecting disuse and loss of muscle bulk. van Velze and colleagues ⁵ found that the left nondominant side was 3.3% smaller than the dominant side with volume measurement in a study of 263 male laborers. The volumeter has been found to be reliable to within 1% of the total volume when one examiner performs the measurement.⁶

Grip strength measurement is performed with the use of a dynamometer. In some instances, measurement of grip strength may be deferred. In the case of a patient with an incompletely healed condition, referred after cast removal for early phase rehabilitation, grip testing would not be relevant and if attempted could potentially overstress the healing wrist. Guidelines for the recommended method of measurement have been published by the American Society of Hand Therapists.⁷ Regular calibration and maintenance of grip gauges is important to ensure accuracy and comparability of repeated measurements.

A sensibility screen is performed to help detect the presence of nerve compressions. The median, ulnar, and dorsal radial sensory nerve can be compressed or irritated with a wrist injury, and the cutaneous distribution of these nerves is examined. Semmes-Weinstein light touch threshold testing has been found to be the most sensitive clinical test for detecting nerve compression.⁸

In cases with a nonspecific diagnosis, such as “wrist pain or strain,” referred from a nonspecialized practitioner, a physical examination with palpation and provocative testing should be performed to identify the symptomatic regions and structures, and to determine if the patient should be referred to a hand surgeon for definitive diagnosis. Important for the performance of a physical examination is a thorough knowledge of surface anatomy and an understanding of the biomechanics and pathomechanics of the wrist and of the common conditions that may occur as a result of injury. Piecing together details from the history of the mechanism or onset of the injury or condition, and correlating this information with the physical findings can help in the process of determining what structures may be involved. The provocative clinical tests are used to identify the clicks, clunks, snaps, and pops of the various instability patterns and conditions that can occur. Examples of provocative tests include the scaphoid shift test, also referred to as the Watson test or radial stress test, used to assess scaphoid stability.⁹ The midcarpal shift test is performed to detect midcarpal instability,¹⁰ and the lunotriquetral ballottement test is used to detect lunotriquetral instability.¹¹ These are only a few of a plethora of clinical provocative maneuvers that have been described and are helpful in the evaluation of a painful wrist.¹² The importance of an accurate diagnosis cannot be overstated. If the therapist has any suspicion that more than a minor soft tissue strain has occurred, or the patient fails to improve after an initial brief trial of therapy, the patient should be referred to a specialist for further evaluation.

Selected Conditions and Guidelines for Rehabilitation

Scapholunate Instability

Scapholunate instability is an example of carpal instability dissociative, and is the most frequent form of carpal instability.¹³ Carpal instability dissociative refers to instability between carpal bones of the same carpal row.¹⁴ This instability is caused by partial or complete disruption of the intrinsic interosseous ligaments. Scapholunate instability refers to a spectrum of conditions, including subtle instability without overt anatomical disruption, but with insufficient load-bearing capacity; dynamic instability that occurs only under load; static instability with full dislocation/rotary subluxation of the scaphoid; and scapholunate advanced collapse.¹⁵ Rehabilitation for scapholunate ligament injuries depends on whether the injury is acute or chronic, the presence and degree of instability, and whether the therapy is to be provided preoperatively or postoperatively. A clinical provocative test for scapholunate instability is the scaphoid shift test, also known as the Watson test and the radial stress test.⁹ The scaphoid shift test is performed by the application of pressure over the volar prominence of the scaphoid as the wrist is moved from ulnar to radial deviation with slight flexion. A positive test reproduces the patient’s symptoms, usually a painful clunk.¹⁶

Nonoperative Management

Acute scapholunate ligament injuries treated nonoperatively are typically immobilized for up to 8 weeks with either a short arm cast or a thermoplastic splint. During this initial period of immobilization, the patient performs finger ROM exercises and digital tendon gliding exercises. After the immobilization phase and during the early phases of rehabilitation from 2 to 4 weeks, the wrist is protected intermittently with a removable splint to protect against inadvertent stresses to the wrist from ADL. Active ROM exercises are begun to resolve stiffness and promote recovery of motion lost secondary to cast immobilization.

ROM exercises in the “dart thrower’s”¹⁷ pattern may be better tolerated initially because during this pattern of motion there is minimal scaphoid and lunate motion and minimal scapholunate interosseous ligament elongation.^18,¹⁹ This pattern involves the combined motions of wrist extension and radial deviation to wrist flexion and ulnar deviation. The dart thrower’s path of wrist motion allows a degree of radiocarpal stability; this direction, rather than the anatomical directions of flexion/extension and radial/ulnar deviation, may be the primary functional direction of the radiocarpal joint (Fig. W8-1).²⁰ As the patient exhibits tolerance for this pattern of motion, standard wrist ROM exercises can be introduced.