Rehabilitation of distal radioulnar joint instability

tREatment of trIaNgular FibrOcaRtilage ComplEx Ruptures (REINFORCER): protocol for randomised, controlled, blinded, efficacy trial of triangular fibrocartilage complex tears

INTRODUCTION

Triangular fibrocartilage complex (TFCC) tear is often considered to be the cause of ulnar wrist pain. The primary treatment typically involves non-operative methods; however, in cases of persistent symptoms, operative intervention has been proposed as a viable option. Depending on the tear's morphology, treatment may involve debridement (central or radial tear) or repair (peripheral tear). Efficacy of operative treatment has not been studied in a randomised controlled trial.

METHODS AND ANALYSIS

This is a prospective, randomised, controlled, blinded multicentre trial, with two randomisation stratums. The first stratum includes central or radial TFCC tears, while the second stratum comprises peripheral TFCC tears. Each stratum consists of two parallel 1:1 arms, comparing the efficacy of (1) debridement of central or radial tear with placebo surgery and (2) repair of peripheral tear with physiotherapy. Participants are recruited from secondary and tertiary referral hospitals in Denmark, Finland and Sweden.Primary outcome is the Patient-Rated Wrist Evaluation (PRWE) at 1 year. Secondary outcomes include subjective and objective outcome measures at 6 months, 1, 2, 5 and 10 years follow-ups.

ETHICS AND DISSEMINATION

The trial was approved by the Pirkanmaa Hospital District Institutional Review Board in March 2020. All participants will be asked to give a written informed consent. The results of the trial will be disseminated as published articles in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04576169.

Exercise-based intervention as a nonsurgical treatment for patients with carpal instability: A case series

BACKGROUND

Although the important roles of proprioception and neuromuscular control in carpal instabilities under laboratory conditions have been recognized, only a few studies have translated this knowledge into a routine clinical practice.

PURPOSE

This study aimed to evaluate the results of a personalized rehabilitation in patients with carpal instability on functionality and pain intensity.

STUDY DESIGN

This was a case series study.

METHODS

This case series included 39 adults (mean age: 38.2 ± 14.0 years; 16/23 females/males) diagnosed with carpal instability (radial or ulnar) with indication for orthopedic treatment. The disabilities of the arm, shoulder, and hand questionnaire was used to assess upper limb functionality. Pain perception was assessed using a visual analog scale. Exercise-based physiotherapy interventions were performed according to the clinical needs of the patients for at least 6 weeks (2-3 sessions per week). For the treatment of radial instability (n = 13), strengthening exercises of the abductor pollicis longus, extensor carpi radialis longus, flexor carpi radialis, and pronator quadratus muscles were prescribed. For the treatment of ulnar instability (n = 24), extensor carpi ulnaris and pronator quadratus were trained. All patients underwent proprioceptive training in open kinetic chain and closed kinetic chain, as well as strengthening of the unaffected hand. Changes before and after treatment were compared using the nonparametric Wilcoxon signed rank test.

RESULTS

A significant improvement with a large effect size in disabilities of the arm, shoulder, and hand (P < .001; d = 2.9) and visual analog scale (P < .001; d = 3.2) scores were obtained after treatment. Moreover, the changes were greater than the minimal clinically important difference of 10.8 and 1.4, respectively. Similar results were found when patients with radial instability and ulnar instability were analyzed separately.

CONCLUSIONS

Personalized training with specific proprioception and strengthening exercises produces improvements in functionality and pain perception in our cohort of people with carpal instability. These results highlight the importance of multicomponent exercise in the treatment of wrist instability. Future randomized clinical trials should further investigate the effectiveness of this protocol.

Proprioception evaluation and treatment: Hand therapist practice patterns

BACKGROUND

Little is known about how hand therapists assess proprioception and treat deficits in clinical practice and what types of diagnoses they see most often. To our knowledge, no survey has been completed regarding proprioception practice patterns among hand therapists.

PURPOSE

The purpose of this study was to examine current practice patterns related to the treatment and assessment of proprioception deficits by hand therapists in the United States.

STUDY DESIGN

This was a cross-sectional study using a survey instrument.

METHODS

The survey was sent to occupational and physical therapists identified as certified hand therapists or members of the American Society of Hand Therapists. The Checklist for Reporting Results of Internet E-Surveys was used in reporting results.

RESULTS

Members of American Society of Hand Therapists (n=152) responded to the survey. The participants were asked if they provided rehabilitation services to people who have proprioceptive deficits, and 122 (82%) responded yes, and 27 (18%) responded no. Most therapists use a standardized technique for assessing proprioceptive deficits. Hand therapists' mean confidence level in treating proprioception deficits was 7.2 out of 10 compared to the mean confidence level reported evaluating them, which was 6.1 out of 10.

CONCLUSIONS

Most hand therapists evaluate and treat proprioception deficits across a variety of diagnoses. While the frequency and duration of proprioception treatment varies, most hand therapists reported high use of open- and closed-chain exercises and activities along with elastic taping as part of their intervention approach.

Weight-bearing test of traumatic triangular fibrocartilage complex lesion with unstable radioulnar joint

BACKGROUND

Ulnar-sided wrist pain might be caused by a lesion of the triangular fibrocartilage complex (TFCC). Patients with TFCC lesion may show an instability of the distal radioulnar joint (DRUJ). Before arthroscopic assessment, conservative therapy using a brace or splint may result in alleviation of symptoms. The results of our previous study showed that patients with a traumatic TFCC lesion and instability of the DRUJ had the smallest weight-bearing capacity and had the largest increase in application of the wrist brace (WristWidget).

PURPOSE

In this prospective study, we wanted to test if the weight-bearing capacity with and without the wrist brace can be used as a diagnostic tool to differentiate between patients with traumatic TFCC lesion and instability of the DRUJ. We tested if patients with traumatic TFCC lesion and instability of the DRUJ (1) have a lower weight-bearing capacity and (2) show a higher increase of weight-bearing capacity after application of a wrist brace compared to all other types of injury.

STUDY DESIGN

This was a prospective cohort study.

METHODS

Forty-eight patients presented to an outpatient clinic with suspected TFCC lesion. We measured the dynamic weight-bearing capacity of both hands with and without the wrist brace (WristWidget) by letting the patients lean on an analog scale with extended arm and wrist. The stability of the DRUJ was assessed by clinical examination by a hand surgeon preoperatively and intraoperatively. Forty-five patients received an arthroscopy and were included in the analysis. During arthroscopy, the surgeon determined if there was a traumatic TFCC lesion and DRUJ instability. Patients with a traumatic lesion of the TFCC and DRUJ instability were compared to all other cases. We used the t-test for normally distributed values, Mann-Whitney U test for nonnormally distributed values, and the Chi-square test for categorical variables, respectively Fisher's exact if the expected cell count was less than five.

RESULTS

Patients with a traumatic TFCC lesion and DRUJ instability had a higher weight-bearing capacity (22.8 kg) than all other cases (13.8 kg; p < 0.01). This is in contrast to our previous study, in which patients with a traumatic lesion of the TFCC had the tendency to show lower values of weight-bearing capacity than those with a degenerative lesion. While the wrist brace was worn, the relative gain was not significantly lower in patients with traumatic TFCC lesions and DRUJ instability compared to all other cases (21% vs 54%, p = 0.16). All included cases showed the same absolute increase of about 4 kg in weight-bearing capacity with the wrist brace (p = 0.93) CONCLUSIONS: The weight-bearing test cannot be used to identify patients with traumatic TFCC lesion and DRUJ instability among those with suspected TFCC lesion. The results of our previous study could be confirmed that the weight-bearing capacity on the injured side was higher with brace than without.

A structured non-operative treatment program for traumatic triangular fibrocartilage complex tear: A quasi-experimental study

OBJECTIVES

Triangular fibrocartilage complex (TFCC) injury is a common cause of ulnar-sided wrist pain. However, treatment protocols vary across clinical settings and a standardized treatment protocol is needed to improve quality of care. We devised a rehabilitation regime which comprised both orthoses and exercises. We hypothesized that the program can effectively reduce pain and improve functional performance.

MATERIALS AND METHODS

Thirty-two subjects participated in the 5-phase rehabilitation program. Progress was monitored every 3 weeks. Outcome measures comprised numeric pain rating scale (NPRS), activities of daily living (ADL) pain score, wrist range of motion (ROM), ADL performance score, patient-rated wrist evaluation (PRWE), power grip and distal radioulnar joint (DRUJ) instability grade.

RESULTS

NPRS decreased from 5.3/10 to 0.5/10 while the ADL pain score improved from 10/20 to 19.1/20. ROM in flexion/extension and supination/pronation improved by 35%. Functional performance on ADL performance score and PRWE improved from 21/40 to 38/40 and 49.5/100 to 14.6/100, respectively. Power grip increased by 59.5%, and DRUJ stability improved.

DISCUSSION

The combination of orthoses and progressive strengthening and proprioception training was effective in re-establishing DRUJ stability, and improving wrist strength and functional performance.

CONCLUSIONS

This study provided insight for the development of a rehabilitation protocol for patients with TFCC injury.

Rehabilitation in Triangular Fibrocartilage Complex Injuries: Treatment Algorithm

Injuries to the triangular fibrocartilage complex (TFCC) can lead to instability of the distal radioulnar joint (DRUJ). In fact, they are the most frequent cause of it. But, in other cases, depending on the type of injury, the DRUJ remains stable. This will condition different types of treatments, from conservative management to the different options of surgical treatment. Since a controversy persists regarding the management of these lesions, our purpose is to disclose the foundations of the rehabilitation treatment and propose an algorithm of treatment according to the different types of injuries and their repairs.

Clinical evaluation of a wrist sensorimotor rehabilitation program for triangular fibrocartilage complex injuries

Introduction

Triangular fibrocartilage complex (TFCC) injuries are associated with distal radioulnar joint (DRUJ) instability and impaired wrist proprioception. Sensorimotor training of extensor carpi ulnaris (ECU) and pronator quadratus (PQ) can enhance DRUJ stability. With limited evidence on effectiveness of TFCC sensorimotor rehabilitation, this study aimed to evaluate the effects and feasibility of a novel wrist sensorimotor rehabilitation program (WSRP) for TFCC injuries.

Methods

Patients diagnosed with TFCC injuries were recruited from May 2018 to January 2020 at an outpatient hand clinic in Singapore General Hospital. There are four stages in WSRP: (1) pain control, (2) muscle re-education and joint awareness, (3) neuromuscular rehabilitation, and (4) movement normalization and function. WSRP also incorporated dart throwing motion and proprioceptive neuromuscular facilitation. Outcome measures included grip strength measured with grip dynamometer, numerical pain rating scale, joint position sense (JPS) measurement, weight bearing measured with the 'push-off' test, and wrist function reported on the Patient Rated Wrist Hand Evaluation.

Results

Ten patients completed the WSRP. Mean changes were compared with minimal clinically important differences (MCID) for outcomes. All patients achieved MCID on pain, 70% of patients achieved MCID on grip strength, weight bearing and wrist function. Paired t-tests and Cohen's D for outcome measures were calculated. There were large effect sizes of 2.47, 1.35, and 2.81 for function, grip strength and pain respectively, and moderate effect sizes of 0.72 and 0.39 for axial loading and JPS respectively.

Discussion

WSRP presents a potential treatment approach in TFCC rehabilitation. There is a need for future prospective clinical trials with control groups.

SMoC-Wrist: a sensorimotor control-based exercise program for patients with chronic wrist pain

STUDY DESIGN

This is a narrative review.

INTRODUCTION

Chronic wrist pain is a common disorder that can lead to considerable disability in performing activities in daily living and at work. Patients with nonspecific chronic wrist pain are regularly referred to a physiotherapist/hand therapist. Immobilization, avoiding excessive wrist load, steroid injections, and various physical therapy methods predominantly focus on the pain itself. However, these methods often do not result in a satisfactory long-term pain relief.

PURPOSE OF THE STUDY

In this article, we will describe the principles behind and content of a sensorimotor control-based exercise program as introduced by Videler et al., modified and substantiated by current insights into sensorimotor control training and wrist kinetics.

METHODS

Both structure and content of the modified exercise program (SMoC-wrist) are substantiated by recent scientific literature.

RESULTS

A clear 4-level exercise model based on sensorimotor principles is presented, that is, proprioceptive level, conscious static/isometric level, conscious dynamic level, and unconscious dynamic level. The content of each level and the transition toward the next level are described in detail.

DISCUSSION

Besides the substantiation of the exercise program, possible outcome measures for joint position sense and kinesthesia of the wrist are discussed.

CONCLUSION

We modified and substantiated a widely used exercise program for patients with nonspecific chronic wrist pain based on recent insights into sensorimotor control principles and wrist kinematics. The presented exercise program (SMoC-wrist) is not primarily focused on reducing pain but on functional reeducation and strengthening of the neuromusculoskeletal system on the basis of sensorimotor control principles.

Radioulnar joint reconstruction: a novel surgical technique and biomechanical assessment for chronic instability

Purpose

This study aims to describe and biomechanically evaluate a novel technique using a strip of the flexor carpi ulnaris tendon for distal radioulnar joint reconstruction.

Methods

Surgical technique was thoroughly detailed, and a cadaveric biomechanical test was conducted to evaluate sagittal plane stability. Pronosupination range of motion was measured before and after the procedure. Dorsal and volar translation resistances were checked in three situations: with the uninjured triangular fibrocartilage complex, after its complete resection and after the surgical procedure.

Results

For distal radioulnar joint translation, higher values were found both in dorsal and volar translation in situations with an injured triangular fibrocartilage complex, with means equal to 25.4 mm (SD: 9.4 mm) and 26.1 mm (SD: 8.0 mm), respectively. For intact triangular fibrocartilage complex, both dorsal and volar translations averages were 3.4 mm (SD: 0.9 mm) and 4.5 mm (SD: 1.8 mm), respectively. Finally, when evaluating dorsal and volar translations after surgical reconstruction, means were 6.3 mm (SD: 1.3 mm) and 6.8 mm (SD: 0.9 mm), respectively. Regarding supination and pronation range of motion, which ranged from 57.9 to 63.4^o, there were no differences in mean and median measures, when the cadavers with intact and reconstructed triangular fibrocartilage complex were compared (p > 0.05).

Conclusion

Promising mechanical evaluations encourage us to hypothesize that the technique effectively reconstructs the dorsal and volar radioulnar ligaments, preserving pronosupination and maintaining the physiological characteristics of the wrist joint. Clinical comparative studies are still necessary to fully validate this procedure.

Level of evidence

Therapeutic - Level V.

[Retrospective study of Galeazzi fractures in adults hospitalized in the Department of Orthopaedics at the Habib Bourguiba University Hospital, Sfax, Tunisia: about 45 cases]

Galeazzi fracture is defined as the association of radius fracture and inferior radioulnar joint dislocation. Its diagnosis is often unrecognized initially. The purpose of our study is to determine the epidemioclinical features of Galeazzi fracture-dislocations in adults and to assess the functional and radiological outcomes of our case series. We conducted a retrospective descriptive study of 45 patients with Galeazzi fractures treated surgically whose data were collected in the Department of Orthopaedics at the Habib Bourguiba University Hospital, Sfax, Tunisia, over a period ranging from 2009 to 2018. We used Mestdagh score for the clinical evaluation of the results. The mean time between fracture and treatment initiation was 5.35 days. Fixation of the radius was performed using screwed plate in 39 cases and fixation of the radio-ulnar joint using a plug in 13 cases. The average time for union was 10.5 weeks. Outcomes were excellent in 35 patients, good in 3 patients, medium in 6 patients and adverse in a patient. We had 3 cases of sepsis at the level of the plug and two cases of malunions. Galeazzi fracture-dislocation is an under diagnosed disorder in some cases. Dynamic intraoperative examination after solid fixation of the radius can allow for good functional results.

A novel staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex injury: A case report

STUDY DESIGN

Case report.

INTRODUCTION

Studies have highlighted the sensory innervations and stabilizing role of forearm muscles on wrist joint and implications to wrist sensorimotor rehabilitation. This case explored the novel incorporation of dart-throwing motion and proprioceptive neuromuscular facilitation in wrist sensorimotor rehabilitation.

PURPOSE OF THE STUDY

To describe and evaluate a staged wrist sensorimotor rehabilitation program for a patient with triangular fibrocartilage complex (TFCC) injury.

METHODS

The patient participated in the staged program for 9 sessions over a 3-month period. Treatment involved neuromuscular strengthening at the wrist and movement normalization of the upper extremity. Outcome measures were grip strength, visual analog scale, joint position sense, Quick Disabilities of the Arm, Shoulder and Hand, and patient-rated wrist evaluation.

RESULTS

The patient showed improvement in all outcome measures. Most outcomes exceeded the established minimal clinically important difference values.

DISCUSSION

The results suggest that dart-throwing motion and proprioceptive neuromuscular facilitation are beneficial in rehabilitation of TFCC injury.

CONCLUSIONS

This is the first study that incorporated dart-throwing motion and proprioceptive neuromuscular facilitation in the sensorimotor rehabilitation of TFCC injury and yielded promising results. There is a need to further evaluate the program in prospective randomized controlled trial recruiting a larger group of patients with TFCC injury.