abc's of treatment strategies for upper extremity instabilities

1

ABCrsquos of Treatment Strategies for Upper Extremity Instabilities

Tambra Marik OTD OTL CHT

Secrets to Stabilization Part 1 1

Objectivesbull Describe the basic functional anatomy and

biomechanics of the shoulder wrist and elbow

bull Implement the concepts of functional rehabilitation

bull Assess pathomechanics of instabilities of the shoulder elbow and wrist

bull Utilize evaluation tests and interpret diagnostic values of tests for application to daily clinical practice

bull Implement neuromuscular training and core strengthening to treatment strategies


THEMES

bull Rehabilitation concepts

ndash Themes of stabilization functional rehabilitation

ndash Rest and immobilization required for healing

ndash Specific structures require protection

ndash Gradual ROM progressions based on soft tissue healing

ndash The core matters

ndash Gradual progression towards strengthening and return to previous level of function

ndash Proximal and distal joint movement patterns addressed to avoid further injury

ndash Proprioception trainingsensorimotor activities


2

THEMES Secrets to Stabilization

Functional Rehabilitation

Core

Motor Control

Dynamic Stability

Static StabilitySecrets to Stabilization Part 1 4


Function

Rehabilitation

Core Stability

Static Stability

Motor Control

DynamicStability

Local

Stabilizers

Global

Stabilizers

Global Mobilizers

bull Abnormal

movement at 1

segment

bull Reflex inhibition

bull Poor response to

load

bull Poor movement

patterns at

segment

Dysfunction

bull Decreased force

production


bull Dysfunctional

recruitment

pattern


Local

StabilizersGlobal

Stabilizers

Global

Mobilizers

bull Overactive amp

tight muscles

bull Spasms

bull Results in

decreased

movement

patterns at

several joints

3

GLENOHUMERAL STABILIZERS

STATIC

bull LigamentsCapsule

bull Geometry of GH joint

bull Glenoid Labrum

bull Negative intra-articular

pressures

7

Finnoff J Doucette S Hicken G Glenohumeral instability and dislocation Phys Med and

Rebab Clinics of N Amer 200415575-605Secrets to Stabilization Part 1

Static Stability

Motor Control

Pacinian Ruffini

Extreme Motion

Compressive Strength

Extreme Motion

Tensile Strength

Glenohumeral Static Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect

httpwwwithacaedufacultylahrLE2000UE_Ind_Stud

y_99shouldereditedglenoid_fossajpeg

8Secrets to Stabilization Part 1

Static Stability

Ligaments of the Shoulder Girdle

bull Sternoclavicular (SC)ndash Anterior Posterior

ndash Costoclavicular

bull Acromio-clavicular (AC)ndash Coracoacromial

ndash Coracoclavicular (conoid trapzoid)

bull Superior Transverse Ligament

bull Coracohumeral ligament (CHL)

bull Glenohumeral ligament (superior middle inferior)

9

httpuploadwikimediaorgwik

ipediacommons33bGray326

pngSecrets to Stabilization Part 1

4


Sternoclavicular

bull Interclavicular inferior displacement

(holds shoulder up)

bull Anteriorposterior antpost displacement

bull Costoclavicular excessive rotation and

mediallateral displacement

Retrieved on 81515 from httpclassconnections3amazonawscom535flashcards3547535pngsternoclavicular_j

14105C8D3116E509030png

restrains

restrains

restrains

Secrets to Stabilization Part 1

Mechanism of Injury SC ligament

Direct or Indirect force

Anterior dislocationbull 8 wks in sling

bull Elbowwrist ROM

8 wks ROM below 90deg(gradual reduce sling wear)

12 wks Full ROM and strengtheningGuan J J amp Wolf B R (2013) Reconstruction for anterior sternoclavicular joint dislocation and instability Journal of Shoulder and Elbow Surgery 22(6) 775-781

Posterior dislocation

bull Posterior dislocation 6-8

wks figure of eight clavicle

strap and gentle

pendelums Avoid flex and

abduction above 90

Groh G I Wirth M A amp Rockwood C A (2011) Treatment of traumatic

posterior sternoclavicular dislocations Journal of Shoulder and Elbow Surgery

20(1) 107-113



bull Acromio-clavicular

12

Retrieved on 81515 from

httpssyimgcomfzapires12nRAxT99C962Y7olZJXIcWw--

YXBwaWQ9c3JjaGRkO2g9NjEyO3E9OTU7dz02MjU-

httpclassconnections3amazonawscom184flashcards1904184jpg

11353982940540jpg

bull Acromoclavicular antpost

translation provides horizontal stabilization

bull Coracoacromial antpost translation

bull Coracoclavicular vertical

displacement

restrains

restrains

restrains


5

Mechanism of Injury AC ligament

Fall directly on shoulder

Types I amp IIbull 1 to 3 wks wear sling

(discharge as pain subsides)

bull ROM and strengthening

Type III (conservative)

bull 3 to 4 wks wear sling

bull Progress ROM amp strength

Types IV V (Reconstruction

Procedures)

bull 6-8 wks Gunslinger Shoulder Orthosis

bull AROM elbow wrist and hand

bull 7 to 10 days PROM to 90deg flexion supine

bull AROM 6 to 8 wks

bull Strengthening at 12 wks if no pain with

arom

bull 12 to 16 wks gradual return to pre-

injury activity levelJohansen J A Grutter P W McFarland E G amp Petersen S A (2011) Acromioclavicular joint injuries indications

for treatment and treatment options Journal of Shoulder and Elbow Surgery 20(2) S70-S82Secrets to Stabilization Part 1 13

Glenohumeral

Ligaments

14




Ligaments of the Glenohumeral Joint


bull Superior glenohumeral ligament (SGHL)

bull Middle glenohumeral ligament (MGHL)

bull Inferior glenohumeral ligament (IGHL)

bull Posterior band glenohumeral ligament

httpuploadwikimediaorg

wikiped

Iacommons33bGray326

png


6

Ligaments of the Glenohumeral

JointCoracohumeral


Connects coracoid process to greater and lesser

tuberosities of the humerus

httpuploadwikimediaorgwikipediacommons33bGray326png



(SGHL MGHL IGHL)bull Superior glenohumeral ligament

(SGHL)

Connects anterosuperior edge of the glenoid to the lesser tubercle of the humerus


Connects supra-glenoid tubercle superior labrum or scapular neck to lesser tuberosity


Connects anteroinferior labrum and glenoid lip to lesser tuberosity

httpuploadwikimediaorgwikipediacom

mons33bGray326png

Axillary

Pouch

SGHL

MGHL

IGHL


Stabilizers Against Anterior Translations

bull Humerus adducted Subscapularis

bull Humerus abducted 45deg Subscapularis middle

anterior GH ligament and superior portion of

inferior anterior GH ligament

bull Humerus at 90deg abduction Inferior anterior GH

ligament

18Turkel et al 1981

Retrieved from httpwwwradsource

us_images0909_6jpgSecrets to Stabilization Part 1

7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum

Fibrocartilage Structure

bull ^ depth of glenoid

fossa by 50

bull Provides attachment of

GH ligaments

bull Firmly attached in all

regions except loosely

superiorly

22

Illustration retrieved fromrdquohttpwwwsportsinjuryclinicnet

galleryshoulderglenoid_labrum2jpgSecrets to Stabilization Part 1


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers

Negative Intra-articular Pressure

bull Creates a vacuum effect across GH joint

bull Primary stabilizer against inferior instability

bull Also prevents instability in other directions

24Illustration retrieved on 22612 from

httpwwwshoulderdoccoukimagesuploadedlabrum_depthjpgSecrets to Stabilization Part 1

9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect

Il lustration retrieved on 41110 from

httpwwwacta-orthogrv57t3U1jpg


bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg

Defining Shoulder Instability

bull Shoulder instability is the inability to maintain

the humeral head in the glenoid fossa

Dislocation the humeral head is forced

completely out of its normal position in the

glenoid fossa

Subluxation the humeral head slips partially out

of glenoid fossa causing symptoms

Laxity partial lost of glenohumeral articulation

without symptoms


10

Circle Concept of the Shoulder

bull Capsuloligamentous restraints act in a ring fashion

bull Translations of the humerus create tension on the same and opposite

sides Therefore translation in one direction may require damage to

restraints on the same and opposite sides of the joint

bull Contra-coup concept is injury can occur to the opposite side of the

injuryLevine et al 2000

Humeral

Head

Ant Capsule

Humeral

Head

Anterior Translation

Ant Capsule


Epidemiology of Shoulder Dislocations

Acutebull Approximately 24 out of 100000 are estimated to have acute

shoulder dislocations

bull 4 to 8 of all injuries sustained by active population (Zebas et al 1995)

bull TUBS traumatic unilateral bankart

bull High Risk Factors

Young males (ages 15 to 29 years old)

Dislocations most often occur from sports or recreation

Most frequently seen as a result of a fall

The estimated incident is on the rise(Zacchili amp Owns 2010)


Acute Shoulder Dislocations

bull High recurrent rate in younger population

(Zacchili amp Owns 2010)

lt 20 yrs 20-40 yrs gt40 yrs

No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on

Holevius et al 2008Secrets to Stabilization Part 1 30

11

Sensorimotor Insufficiencies

bull Recurrent anterior instability sensorimotor

insufficiency increase with dominant side

involvement (Edouard Gasq Calmes amp Degache 2014)


Etiology of Traumatic Shoulder

Dislocationsbull Unidirectional from traumatic event (anterior is the most

common)

Most commonly caused by a fall on an outstretched hand or a sudden forceful motion in the abder position

Bankhart

Superior Labrum Anterior Posterior (SLAP)

Most common direction of instability is anteriorinferior from falling in 9090 position (ABDER)



Special Tests Anterior Instability

Apprehension amp Relocation

Sensitivity 81 Specificity 98 (Farber et al 2006)

Apprehension Test Relocation Test


12

Pathomechanics

Bankart LesionAnterior Instability

bull Instability of the anterior-

inferior glenohumeral joint

capsule

OR

bull Detachment of the

anterior-inferior glenoid

labrum from the glenoid

rim

34

httpimagesconquestchroniclescomimagesadmin

shoulder_bankart_lesion_85905_2jpg

Bankart Lesion

I l lustration from

httpwwwptcliniccommedlibrary

imagesv2slapbankartgif


Boney Bankart Lesions

Photo retrieved from Millet et al 2009


Superior Labrum Anterior-Posterior

SLAPbull Fall on an outstretched

abducted arm or sudden

contraction of biceps

tendon or repetitive

stress Or repetitive

injury related to

eccentric deceleration

ldquopeel back

36

Illustration retrieved on 3512

fromhttphealingartscecomimagessh20SLAP20lesionjpg

Illustration from httpwwwptcliniccommedlibrary



13

Pathomechanics Peel Back

Mechanism in Throwing Athletes

37

Retrieved from http2bpblogspotcom_

BsgqbRhgCnQSRtejHI0PvIAAAAAAAAANA

vMjopqYdgrss400SLAP-peel-backjpg

Retrieved from Braun S Kokmeyer

D Millett P

Current Concepts Review Shoulder

Injuries in the

Throwing Athlete Jour Bone amp Jt

Surg 200991(4)

bull High eccentric activity of the biceps during arm

deceleration

bull Torsional peel back force detaching labral anchor

Photo retrieved from Braun S

Kokmeyer D amp Mi llett P J (2009)

Shoulder injuries in the throwing athlete

The Journal of Bone amp Joint Surgery 91(4) 966-978


Pathomechanics SLAP

bull Type IFraying

bull Type IIBiceps amp Labrum are

becoming detached

bull Type IIIBiceps amp Labrum are

stable on glenoid but a flap

hangs down

bull Type IVBucket handle tear

extending into the bicepsRetrieved on 7-4-10

fromhttpwwwathleticadvisorcomimagesshoulderSLAPSLAP_types2

gif


Special Tests for Superior Labrum

Anterior Posterior (SLAP)

Active Compression amp Passive Distraction

Sensitivity 70 Specificity 90 (Hegedus et al 2012)

ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14



Etiology Atraumatic Shoulder

Multidirectional Instabilities

bull Instability from mirco-trauma from repetitive motions in one direction or multi-directional

Voluntary Individual subluxes or dislocates volitionally

AMBRI atraumatic multidirectional bilateral rehabilitation inferior shift

Involuntary Subluxes or dislocates involuntary


15

Poll Question

Is the posterior inferior direction the most

common dislocation of the shoulder

a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION


REHABILITATION of Shoulder

Dislocations Protective Phase

bull Glenohumeral joint is reduced and the arm is placed in a sling

bull Current evidence does not support ER to avoid recurrent shoulder dislocation (Vavken etal 2014)

bull Duration of immobilization (Patternson et al 2010)

bull ER with ABD may reduce the rate of recurrent dislocation3 wk (Heidari 2014)

Photo retrieved fro Heirdari et

al 2014


16

Important Considerations with Surgical Procedures

PROTECT HEALING STRUCTURES

Arthroscopic Repair Bankart

bull Remain in sling except for table slides and passive flexion to 90deg

bull Gradual external rotation during reparative phase (passive ER gradual stress at 3 to 4 wks post-op) Sperber et al 2001

bull No combined ER and ABD during reparative phase

bull Gradual progression of ROM and light strengthening during remodeling (no forceful stretching)

bull Progress strengthening during maturation phase

Image retrieved from

httpwwwtheshoulderdoccomcontentassetsbankart_layoutgif


Important Considerations with Concomitant

Procedures


Arthroscopic Repair SLAP Type II

Protect repair (1000-200)

bull Slow ER progressions limiting

passive ER to 40deg in scapular

plane during reparative phase

bull Avoid extension and horizontal

abduction for ~4 wks PO remain

in sling

bull Avoid resistance to elbow

(extension and supination)

httpkneeandshouldercliniccomauwp-contentuploadsSlapTear-

pic2png



Dislocations Reparative Phase

bull Continue immobilization

bull Maintain elbow and forearm motion

bull Maintain grip strength

bull Active assist to 90deg in flexion and 60deg scaption

bull Begin isometrics when sling is removed for external rotators

bull Avoid motions of abduction and external rotation


17

FUNCTIONAL EXERCISES REMODELING

TO MATURE PHASE


bull Lumbopelvic region (inferiorly)

bull Abdominals (anteriorly)ndash Transversus abdominis (TA)

ndash Internal amp external obliques

ndash Rectus abdominus

bull Diaphragm (superiorly)

bull Paraspinals and gluteals (posteriorly)

TA is the first muscle that activates when lifting arm overhead (Richardson 2014)


Core Stability

Transfers

forces to limbs(Beckman amp Bachman 1995)

bull Peate Bates Lunda Francis amp Bellamy (2007)ndash Core strengthening resulted in 62 reduction of lost time

and 42 reduction of injuries

bull Behm Drinkwater Willardson amp Cowley (2011)ndash Stabilization exercises prevent low back dysfunction

bull Emery De Serres McMillan amp Cote (2009)ndash Core training improved thoracic posture abdominal

strength and stabilized core posture with shoulder flexion

bull Miyake Kobayashi Kobayashi amp Nakajima (2012)ndash Core strengthening improved upper extremity function

bull Nagai et al 2012ndash Trunk rotation improves scapula kinematicsSecrets to Stabilization Part 1 51

Core Stability

18

SHOULDER STABILIZERS

DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52

Finnoff J Doucette S Hicken G Glenohumeral instability and dislocation Phys Med and Rebab Clinics of N Amer 200415575-605


DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception

Conscious Sensations

Proprioception Conscious Sensation

Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort


Neuromuscular ControlUnconscious

Stability

bull Force couples of glenohumeral joint provide

information on compression

ndash Muscle spindles provide information on position

sense and reflexive muscle contraction

ndash Golgi tendons are tension sensitive and signal

agonist to relax

bull Compliment input from capsuligamentous input to

extreme motions (Ruffini) and compressive (Pacinian)

19


Stability

Image retrieved fromhttpimageslidesharecdncom

anatomyofshoulderjoint2-130318210432-phpapp01

95anatomy-of-shoulder-joint-vamshi-kiran-32-638jpgcb=1363640800

Shoulder Dynamic Stabilizers(GibbonsMottram amp Comerford 2001)

Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive

bull Type IIaSecrets to Stabilization Part 1 56

Global Mobilizer

bull Superficial

bull Force wlength changes

bull Primarily concentric

bull Recruited with high load

amp high speed in open

kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids

bull Pectoalis minor

bull Levator scapula

bull Latissumus dorsi

bull Pectoralis major

bull Short head of biceps

bull Long head of triceps

bull Latissimus dorsi

-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern

bull Overactive amp tight muscles

bull Spasms

bull Results in decreased movement

patterns at several joints

20

Early isometrics of external rotators


Isometric contraction side-lying

(pushing down in table)


Dislocations Remodeling Phase

bull Gradual motion and strengthening to 90deg90deg(ERABD)

bull Progress positions as pain decreases

bull Proprioception training

Scaption 45deg Scaption 90deg


Progress Position


21



Progressing Proprioception Training



22


bull SERAPE EFFECT

ndash Transfers stored energy into potential energy

ndash Transverse abdominus will activate before the

initiation of movement to brace the body before

the core generates power

Hodges amp Richardson 1996)

Core Stability


Decreased scapular upward

rotation and increased scapular

internal rotation in subjects with

shoulder instabilities (Struyf Ni js Baeyens Mottaram amp Meeusen

2011)

23

Gradually Add Increased Challenges


Mature Phase Work towards

functional strengthening for return to

previous activity level


Proprioception

Proprioception

Musculotendinous

Golgi Tendon

Muscle contractionJoint

position

(signals agonist to relax)

Muscle SpindlesJoint movement

positions sense reflex

muscle contraction

Capsuloligamentous

Pacinian type receptorsExtreme

MotionCompressive

Strength

Ruffini ReceptorsExtreme Motions Tensile

Strength


24


Poll Question

1 Is limiting passive external rotation

appropriate after a SLAP or Bankart surgery

a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC

ndashBoney Congruency

ndashCapsule

ndashMedial Collateral Ligament

ndash Lateral Collateral Ligament Complex

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashBrachioradialis

ndashECRL

ndashTriceps

ndashAnconeusSecrets to Stabilization Part 1 73

httpwwwdaviddarlinginfoimageshumerus

gifSecrets to Stabilization Part 1 74

Other Stabilizers

Elbow Capsule

bull Small contributor as a passive soft tissue stabilizer (questionable)

bull Most lax at 80 degrees of flexion (consider this extensible meaning the capsule is not restraining)

bull Position of comfort after injury

bull Risk of flexion contracture


26

Static Stabilizers

bull Medial collateral ligament (MCL)

bull Lateral collateral ligament(LCL)

bull Humeroulnar JointFrom Advanced Concepts of Hand

Pathology and Surgery

Subliime tubercle

of proximal ulna

bull Anterior Capsule

(taut with elbow ext)


Adapted on 22011 from Callaway G Field L Deng X Torzilli P Obrien S Altchek D Warren

R (1997)

Bilomechanics of the Medial Collateral Ligament of the Elbow J Bone Joint Surg AM

Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles


Medial Collateral Ligaments

bull Elbow extension stability to valgus stress

ndash MCL contributes 30

ndash Anterior capsule 30

ndash Bony Articulation 40

bull Elbow at 90 degree flexion stability to valgus stress



ndash Bony articulation 35


27

Lateral Collateral Ligaments


Lateral Collateral Ligaments bull Annular ligament

bull Radial collateral ligament

bull Lateral ulnar collateral

ligament (LUCL)

ndashProvides stability to

posterolateral rotation

bull Accessory lateral collateral ligament


httpwwwbiomechcomfilesarticle

_imagesPainMgmt-Elbw_3jpg



bull Elbow extension stability to varus stress

ndash LCL contributes 15



bull Elbow at 90 degree flexion stability to varus stress





28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos


ndashWristdigit extensors amp flexors

ndashTriceps


Elbow Dynamic Stabilizers(GibbonsMottram amp Comerford 2001)

Local Stabilizers

bull Anconeus(deep fibers)

bull Pronator

Quadratus(deep fibers)

bull Supinator(deep fibers)

Global Stabilizers

bull Brachialis

bull Brachioradialis

bull Triceps (medial amp

lateral heads)

bull Anconeous

(superficial fibers)

bull Supinator


bull Pronator

Quadratus(superficial fibers)

bull ECU (ulnar head)

bull FCU (ulnar head)

bull APL


Global Mobilizer

Biceps Brachii (long amp short heads)

Triceps Brachii (long head)

Wrist amp Digit Extensors

Pronator Teres

Wrist amp Digit Flexors

I Elbow Pathology Ligamentous

Lateral Collateral Ligament (LCL)

bull Ligamentous

ndash Lateral collateral ligament sprain

or tear is also associated with trauma

and often occurs with a fracture

ndashMechanism of injury

bull Fall on outstretched hand (FOOSH)

bull Forced twisting of the arm with varus

(lateral) forces

OrsquoDriscoll 1992Secrets to Stabilization Part 1 84

29

Elbow pathology ndash ligamentous (LCL)

bull Ligamentous stress tests

bull Lateral Collateral Ligament (LCL) injury =

Varus Stress Test

bull Elbow 20-30deg flexion forearm

supinated

bull Examiner places one hand on medial

elbow the other on distal radial wrist

bull Apply medial force to wrist ndash this

translates varus force to the elbow

bull Positive if painful or more lax than

contralateral Secrets to Stabilization Part 1 85

Elbow pathology ndash ligamentous (LCL)bull Movement without stability is usually painful

bull Elbow typically becomes more unstable as it

moves into extension

bull Placing the elbow in 20-30 degrees of flexion

unlocks the olecranon from the humerus

bull Should be rehabilitated in pronation bc the

elbow is more stable from varus forces in

pronation



bull Not all tears are repaired sometimes they are left to heal on their own

bull This can lead to chronic instability

bull Ligament repair can occur if surgery is performed within 2-3 weeks of injury

bull Ligament reconstruction is chosen if injury is more than 3 weeks old

bull Palmaris longus is usually used for reconstruction

bull If not repairedhellip


30

Posterolateral Rotatory Instability (PLRI)

Can result from a FOOSH with forearm supinated

Leads to ulna (moving with radius due to annular ligament) externally rotating away from trochlea(Picture resourced from Radsource httpwwwradsourceusclinic0901)


I ldquosnappingrdquoII varus instability

III Post Dislocation

Iv Complete instability

Special Tests Lateral Elbow

Posterolateral Rotary Instability

Push-up and Stand-up tests

Sensitivity 875

Specificity 100 (Regan et al 2006)


Rehab PLRI (LCL complex)

Elbow pathology - ligamentous

bull General Post-op LCL Reconstruction

Guidelines

ndash Splint 90deg flexion pronated

ndash AROM extensionflexion extension limited to 60deg

initially and gradually increased

ndash Forearm rotation from pronation to neutral only

for 6 weeks

ndash DC splint at 6 weeks

ndash Gradually resume supination


31


bull Flexion and pronation increase the contact between the radial head and capitellum

bull Studies have shown that the LCL deficient elbow is more stable in pronation

bull Shoulder AB and IR increase varus stress to the elbowndashso avoid this position with exercises

bull If both medial and collateral ligaments have been repaired elbow should be splinted in neutral rotation

(Armstrong 2000 Dunning 2001)Secrets to Stabilization Part 1 91

Dynamic Stabilizers Against Varus Stress

bull Isometric strengthening EDC ECRB amp

ECRU (An Kaufman amp Chao 1989)

Schickendantz M (2002)

Bindra amp Bringer 2010

Dynamic Stabilizers ent

Elbow pathology - MCL

Medial collateral ligament injury

bull May have spontaneous failure characterized by a

ldquopoprdquobull Onset may be vague characterized by failure to

perform at less than normal ability

bull Decreased accuracy

bull Decreased velocity

bull Decreased endurance


32


MCL Injury

bull If no specific ldquopoprdquo or rupture is noted conservative management consisting of strengthening the muscles

surrounding the joint is pursued

bull If surgery is required ligament repair may be

possible in nonprofessional athletes

bull Most professional athletes require ligament

reconstruction aka ldquoTommy John Procedurerdquo


Special Tests Medial Elbow

Medial Collateral Ligament Instability

Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60

Elbow VideosMoving valgusAVISecrets to Stabilization Part 1 95


33



Conservative Management MCL Injury

bull Protect ndash no overhead activity

bull AROM - sagittal plane

bull Strengthening - core shoulder elbow and wrist

bull Throwerrsquos Ten Program for shoulder elbow

forearm and wrist

bull Evaluation of throwing technique

bull Advanced Throwerrsquos Ten Program



bull Post-operative management of MCL injury

bull Splint in neutral rotation 90deg flexion

bull Active elbow extension and flexion with full extension limited initially

bull AROM digits and wrist ok to grip

bull Isometric strengthening of shoulder No external rotation of shoulder as it creates valgus stress at elbow

bull Splint DCrsquod at 6 weeksbull Progress through full ROM and into Throwerrsquos Ten


34

MCL Strengthening Considerations

CLINICAL PEARL

bull Strengthen flexor carpi ulnaris and flexor digitorum superficialis to increase stability

bull Radial head contributes to stability



bull Start exercises in supination and

progress to pronated position


Intermediate Phase

Sub-Maximal IsometricsMedial Collateral Ligament Rehab

bull Strengthen with forearm in supination FCU amp FDS and isometric pronation


Advance to Mature Phase

Motor Control Proprioception

TrainingLubiatowski et al 2014 Elbow joint position

sense after elbow arthroplasty Jour of Shoulder

amp Elbow Surgery 23693-700

Decreased joint position sense compared

healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures

Dislocation Classification bull Simple

ndash Small osseous fractures not affecting joint stability

ndashDescribed as posterior anterior medial lateral

bull Complex

ndashDescribed as posterior anterior medial lateral or divergent

bull Acute (less than 2 weeks)

bull Subacute (2 to 4 weeks)

bull Chronic (6 weeks ore more)

Sheps et al 2004

Medial Lateral DivergentRetrieved on 22211 fromhttpboneandspinecomwp-contentuploads200902lateral-dislocation-elbowgif

PosteriorNormalRetrieved on 22211 fromhttpimgmedscapecompiemedckbemergency_medicine756148-821994-823277-1671248jpg

36

Evidence for Early Motion in Simple

Posterior Dislocations

bull Loss of extension is the most frequent

complication

bull Ross et al protocol Immediate active motion

combined with modalities to reduce pain and

swelling and UE strengthening Results of

nearly full ROM within 5 degrees of extensionRoss et al (1999)

Sheps et al 2004

ELBOW TRAUMA


Radial Head Fractures in Elbow

Trauma

bull Terrible Triadndash Posterior or posterolateral dislocation of ulnohumeral

joint with fractures of the radial head and coronoid process Avulsion of medial collateral ligament (MCL) and lateral collateral ligament (LCL)

ndash Coronoid process provides stabilitybull Buttress against posterior displacement of the ulna and

contributes to varus stability (Budoff 2012)

bull Essex Lopresti radial head fracture rupture of the interosseous membrane (IOM) resulting in forearm instability and proximal migration of the radius

37

Radial Head Fractures

Internal Fixation or Radial Head

Replacement

bull Fragmentation of less than 3 fragments have improved results with fixation (Ring amp Jupiter 2001)

bull Lateral collateral ligament protection may be required if ligament re-attached or involved reattached after surgery (pronation) at 2 days post-op allow prosup with elbow flexed at 90

Internal Fixationbull Phase I

ndash Early mobilization 3 to 5 days post-opPROM gentle

ndash Posterior elbow orthosis 90deg flexion with forearm

neutral

ndash Regain motion 1 to 3 wks post-op AAROM (flexext

prosup)

ndash CPM

bull Phase II (4 to 6 wks post-op)

ndash Regain full motion and gradual strengthening

bull Phase III (6 to 12 wks)

ndash Advance strengthening and closed chain exercises

ndash Joint mobilizations

ndash End range strengthening

Radial Head Replacementbull Phase I (Week 1 to 3 post-op)

ndash Early mobilization (orthosis CPM (forearm pronated or neutral) AROM wrist and hand during 1st week

ndash Hinged elbow orthosis worn at all times

ndash Advance elbow and forearm motion exercises Elbow AAROM with gravity assisted extension Position elbow at 90deg flexion during forearm exercises

ndash Consider edema glove for hand

bull Phase II (Week 3-6 post-op)

ndash Begin AAROM prosup PROM elbow stretching to tolerance initiate orthosis to increase flexext if needed advance to AROM forearm rotation and elbow motion

bull Phase III (Week 6-8 post-op)

ndash Discharge hinged orthosis begin isometrics continue

mobilization orthosis

bull Phase IV (Week 8-12 post-op)ndash Light resistance gradually upgrade strengthening

38

Distal Humerus Intra-articular

FracturesFixation Plating (post-op 1 week)

bull Edema control

bull Long arm orthosis alternating between elbow flexion daily and elbow extension nightly

bull Elbow shoulder forearm wrist hand AROM every 1 to 2 hours

Post-op 2 weeks

bull Initiate scar management

bull Progress ROM each week

bull Non-weight-bearing until fracture healed

bull Strengthening when fractured healed

CHALLENGE

39

Customizing Therapy to Patient

Should I incorporate CPM

bull Indicated to prevent post-traumatic stiffness based on rationale ndash Acute bleeding and edema result in

swelling of peri-articular tissues limiting joint motion and uarrrsquoing pain

ndash Moving the joint through its entire range can empirically prevent stiffness and edema

ndash Subacute stage deposition of extracellular matrix and granulation tissue cpm used to accomplish full ROM (1 week to 4 weeks)

Should I Incorporate CPM

bull Phase I

ndash Prevent joint stiffness

ndash Minimize edema

ndash Minimize hydrostatic

joint pressures(OrsquoDriscoll amp Giori 2000)

bull Evidence Controversial

ndash CPM vs no CPM post open

contracture release Lindenhovius et

al 2009)

ndash CPM vs no CPM total knee

arthroplasty (MacDonald et al 2000)

How do I protect soft tissue structures

bull Lateral collateral ligament (LCL) protection may be required if ligament reattached or involved

bull Protect LCL with the patient supine and placing forearm in pronation during ROM

bull May allow prosup with elbow flexed at 90 at 2 days post-op

bull Avoid adduction and internal rotation of the shoulder limiting varus stress (Dunning et al 2001)

Hand on forehead

maintaining pronation


40

What muscles can I begin isometric

strengthening for stability








bull Medial collateral ligament (MCL)l Hinged orthosis with forearm in supination to block end range extension gradually add ~10degextension weekly

bull Elbow motion performed within safe arc and forearm supinated

bull Avoid external rotation and abducted positions of the shoulder during early phases of healing limiting valgus stress


What muscles can I begin isometric strengthening for stability

Dynamic Stabilizers Against Valgus Stress

bull Isometric strengthening flexor pronator mass flexor carpi ulnaris and flexor digitorum superficialis to increase stability (Park amp Ahmad 2004)




41

How should I position the forearm during

elbow ROM


Protect LCL wforearm pronated

Protect MCL wforearm supinated

Poll Question

Which of the following shoulder motions will

place the most stress on a healing medial

collateral ligament

a Adduction combined with internal rotation

b Abduction combined with external rotation

c Forward flexion

d Extension with internal rotation

122

What are the signs of heterotopic ossification

bull Risk Factors gt 1 reduction (Shukla et al 2015) head injuries (Garland amp OrsquoHollaren 1982) burns operative care gt 48 hours after injury (McLauglin1955) floating fractures (Bauer et al 2012)

bull Signs amp Symptoms ndash Decreased ROM

ndash Increased pain

ndash Localized edema

ndash Increase in temperature (Hinck 1994)


42

What are the symptoms of ulnar nerve involvement

Clinical Presentation

bull Paraesthesia at ring and small fingers

bull Elbow pain

bull Weakness in grip

Clinical Management

bull Nerve gliding elbow orthosis nocturnally protect cubital tunnel


bull What type of orthosis should I use when contracture has developed static progressive or dynamic


Elbow Static Progressive vs Dynamic Orthosis

Lindenhovius A Doomberg J Brouwer K Jupiter J Mudgal C Ring D (2012) Dynamic

Versus Static Progressive Elbow Splinting for Posttraumatic Elbow Stiffness Jour of Bone amp

Joint Surg Amer 94A(8)694-700

Picture retreived from

httpwwwdynasplintcomuploadspages36_originaljpg

Photo retrieved from

httpwwwremingtonmedicalcomContentimgproductsdetailbig1-

T55jpg

43

bull Lindenhovius A et al 2012

Results

3 months No significant differences

6 months DASH scores significantly improved in static progressive group

12 months No significant difference between groups for ROM and DASH scores

bull 6 month results

bull Dynamic orthosis ROM improved 40degbull Static progressive ROM improved 39degbull 12 month results

bull Dynamic orthosis ROM improved 47degbull Static progressive ROM improved 49deg

ndash Most gains are in the first 3 months

ndash No statistical significant difference for elbow ROM between the

static progressive and dynamic orthosis

ndash Regaining elbow motion factors

Comfort optimism confidence ampself-efficacy to

perform elbow stretching

Patients can continue to make ROM gains for 12

months

Patients with an elbow contracture uncommonly

request surgery


bull PROS

129

bull Custom fabrication allows for

improved fit

bull Easy to make adjustments for

patientrsquos comfortbull Easy dondoffing amp cleaning

bull Hinge placement can be

modified

CONS

bull Fabrication time between 30

and 60 minutes depending on

experience level

bull Elbow flexion and extension

motion limited to length of

hinge


Custom or pre-fabricated

44

d

bull PROS

130

bull Pre-fab short wearing time

bull Light weight amp easy fitting with

measurements

bull Easy dondoffing amp cleaning

bull Results can reach up to 170deg of

flexion and -10deg of extension

bull Patient can track progress on

CONS

bull Could be limited by insurance

authorization

bull Modifications to orthosis could

be more timely

bull Can be high profile depending

on order




Poll Question

Is it safe to begin early ROM in a type one radial

head fracture that is minimally displaced

a Yes

b No

132

45

WRISTHAND INSTABILITIES

Bony Anatomy

bull 2 long bones

ndashRadius amp Ulna

bull 8 carpal bones

ndashProximal amp distal rows

bull 14 phalanges

bull 5 metacarpals 134

FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION

bull RADIAL DEVIATION

bull ULNAR DEVIATION

bull CIRCUMDUCTION

bull DART THROW AXIS Retrieved on 050109 from

wwwdkimagescomDarts

Darts-15html

46

Carpal Row Movements during

FlexionExtensionbull Distal carpal row follows the

direction of movement of metacarpals 23

bull Proximal row moves with the distal row but there is more motion between the individual bones

bull Flexion Proximal row glides dorsally and capitate glides dorsally on lunate

bull Extension Proximal row glides volarly and capitate glide volarly


httpwwwandysleighcom

WristAndForearmtutorial

wristpage5ahtml


RadialUlnar Deviation

Reciprocal Motion

bull Ulnar Deviation Distal row moves ulnarly and the proxmialrow extends and translate radially

bull Radial deviation Distal row moves radially and the proximal row flexes and translate ulnarly Retrieved on 050109 from

wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996

Osseous Morphology amp Kinematics

Radius amp Ulna

bull Distal radius articulates with proximal row at scaphoid fossa and lunate fossa

bull Ulna does not articulate with the carpus Triangular disc articulates with carpus at distal ulna

Retrieved on 050109

fromwwwanswerscomtopicu

lna

Retrieved on 50309From wwwhughstoncom

hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of

bull Radiocarpal Joint

bull Midcarpal Joint

bull Distal Radioulnar

Joint

bull Interosseous Joints


httpwwwmedmuncaanatomytsmsk

xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments

bull Intrinsic ligaments

exist between carpal

bones in capsule

bull Extrinsic ligaments

oblique orientation b-

w peripheral of wrist

to carpal bone amp

superficial to capsule

bull Radioulnar ligament

Volar View

Picture retrieved on 020809 from

wwwuphsupenneduhtmloj12sp99p27html

Important StabilizersIntrinsic

bull Scaphoid-lunate

bull Lunotriquetral

Extrinsic

Volar Radioschapocapitate radiolunotriquetral short radiolunate ligaments

Dorsal dorsal radiocarpal ligament

Photo from Lichtmen amp Wroten

Jour Hand Surgery 2006

48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist

bull THUMB CMC OA Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)

Dorsal CentralbullScaphoid-Lunate Tear

THUMB CARPAL

METACARPAL

OSTEOARTRHITIS

(THUMB CMC OA BASAL JOINT OA

DEGENERATIVE JOINT DISEASE)

49

DEFORMITY PATTERNS

Zig Zag

(most common)

MP hyper-extension IP

hyper-flexion resulting

in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers

bull Anterior ObliquedAOL (Beak Ligament)

bull Posterior ObliquePOL

bull IntermetacarpalIML

bull Dorsal IntermetacarpalDIML

bull Dorsal radiocarpalDRLPhoto modified from Tan J Xu J Zie R Deng A Tang J In vivo length and changes

of l igaments stabilizing the thumb carpometacarpal joint J Hand Surg 201136A420-427

Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished

Proprioception TM Joint

50

CMC Grind Test1 Stabilize the trapezium

with one hand

2 Grasp the first

metacarpal

3 Compress the metacarpal

base to the trapezium

while applying an axial

load to the metacarpal

4 Pain is a positive test


Conservative Treatment

bull Soft Tissue Release of Adductor

bull Mobilize CMC joint

ndashGentle Distraction

Arm behind back Hold involved thumb while the weight of arms provides distraction

Technique from OrsquoBrien V Albrecht J Fine Tuning the Care of the Painful Thumb ASHT Instructional Course Webinar 2012

51

Conservative Management

bull Neuromuscular re-

education and

strengthening for thumb

stabilizers

bull Strengthen thumb

intrinisics

bull Strengthen thumb and

wrist extensors

bull Teach Functional Pinch

Poll Question

Which of the following exercise is most

appropriate to strengthen for individuals with

thumb CMC osteoarthritis

a Flexor pollicis longus

b Adductor pollicis

c Adductor digiti minimi

d Extensor pollicis brevis opponens pollicis

abductor pollicis brevis 1st dorsal interossei

152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52

Tendencies of the Scaphoid and Lunate

bull Triquetrum extends

bull Without ligament resort it will tilt dorsal

bull Volar intercalculated instability

VISI

bull Scaphoid flexes

bull Without ligament support it will tilt volar

bull Dorsal intercalculated instability

DISI

Dorsal Central Wrist

Scaphoid-Lunate Dissociative

bull History amp Clinical presentation

ndash Hyper-ext UD injury

ndash Radial sided pain

ndash Click andor clunk

ndashWeakness of grip

ndash Limited wrist ROM

ndash Positive Watsonrsquos testndash Ring sign on AP view

155

Scapholunate Dissociation

Dorsiflexion Intercalculated Segment

Instability (DISI)

53

Watsonrsquos test Provocative test for scaphoid instability

Procedure

bull Ulnar deviate the

wrist with ext

bull Pressure to palmar

aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion

Positive Test Proximal pole

of scaphoid shifts or jumps

dorsally within the

scaphoid fossa

158

Ballotment Test for S-L Instabilitybull Stabilize the lunate bw the

thumb and index finger of one hand

bull Stabilize the scaphoid between the thumb and index finger of the other hand

bull Push the scaphoid in a volar to dorsal direction

Positive Test Discomfort may suggest injury to S-L ligament

159

54

Rehabilitation of S-L InstabilityGrade I Sprain

bull Follow the stages of soft tissue healing

bull Inflammatory to proliferation Immobilize in thumb spica with light AROM (dart throwers) amp neuro-muscular re-ed

bull ProliferationRemodeling AROM PROM with emphasis on dart throwerrsquos position

bull Mature Strengthening with emphasis on dart thrower muscles

160

Poll Question

A dorsal inter-calculated instability (DISI) is

described as

a Lunate and triquetrum tilts dorsally

b Scaphoid and lunate tilt dorsally

c Scaphoid and trapezium tilts dorsally

d Hook of the hamate tilts dorsally

161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA

bull SCAPHOID FRACTURE

bull DISTAL RADIUS FRACTURE

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist

Lunotriquetral Dissociation

bull Clinical presentation

ndashPain with ulnar and supination of

the fa

ndashTender at L-T joint

ndashPatient co weakness and giving

away

ndashUnable to lift heavy items

ndashPositive ballotment of lunotriquetralIl lustration retrieved on 12212

From httpwwwexpertconsultbook

comexpertconsultbbbmapAsset

appID=NGEampisbn=978-1-4160-5279-

1ampeid=4-u10-B978-1-4160-5279-1

00015-0f19ampassetType=full

Dissociative Lunate-Triquetrum

VISI

Volar Intercalated Instability

Mechanism of Injury

bull Fall on outstretched hand

bull Shoulder ER forearm supinated and wrist extended and radial deviated

164

Il lustration retrieved on 12212From httpwwwexpertconsultbook

comexpertconsultbbbmapAsset appID=NGEampisbn=978-1-4160-5279-

1ampeid=4-u10-B978-1-4160-5279-100015-0f19ampassetType=full

Lunotriquetral ballottement test

(Regan Shuck)bull Procedure Stabilize the

lunate with the thumb and index fingers of one hand while the other hand attempts to displace the pisotriquetral unit volarly then dorsally

Sensitivity 33-100

Specificity no valuePositive result

Laxity pain

or crepitus

56


Rehabilitation of LT InstabilityGrade I Sprain


bull Inflammatory to proliferation Immobilize in wrist orthosis light arom amp

bull neuro-muscular re-ed



Consider taping for neuromuscular re-ed

167

Ulnar Sided Wrist Pain

Clinical Presentation of TFCC Tearbull Ulnar sided wrist pain

bull Pain with palpation in region of TFCC

bull Pain with active ulnar deviation

bull Positive TFCC load test

bull Pain with forearm rotation

bull Audible click with rotation

bull Pain with pronated grip

168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57

bull Normal axial load of radius is 80 and ulna is 20

bull The TFCC functions to transmit 20 of the axially applied load from the ulnar carpus to the distal ulna It is a major stabilizer of the distal radial ulnar joint

169

Illustration from Palmer A Bille B Anderson A

Acute Injuries of the Distal Radioulnar Joint

Tears by the Triangular Fibrocartilage

Distal Radiouulnar Joint Chapter 24

TRIANGULAR FIBROCARTILAGE COMPLEX

(TFCC)

Stabilizers of the Ulnar Wrist

bull Static Stabilizers

ndash Sigmoid Notch

ndashDorsalVolar radioulnar ligaments

ndashTFCC

bull Dynamic Stabilizers

ndashPronator Quadratus

ndashECU

ndash FCU

170Image fromhttpuploadwikimediaorgwikipedia

commons115Gray424png

Triangular Fibrocartilage Complex

(TFCC)

bull Palpate for

tenderness

171

Fovea sign Tenderness bw

FCU tendon and ulnar styloid

process

58

TFCC or Ulnocarpal Abutment

TESTING

Ulnocarpal Stress

Test

bull Axial load compression

with wrist in ulnar

deviation Glide volar

and dorsally

Positive Test

Reproduction of pain

clicking or crepitus

173

Poll Question

Which is the following best describes the triangular fibro-cartilage complex

a Redistributes force from the ulna to the radius

b Is highly vascular in the central portion

c Re-distributes 20 of the force from the ulnar carpus to the distal ulna and is contributor to the stability of the distal radioulnar joint

d Clinically presents as radial wrist pain174

59

Rehabilitation for Ulnar Wrist Pain


bull Inflammatory to proliferation Immobilize in wrist orthosis light arom amp neuro-muscular re-ed

bull ProliferationRemodeling AROM PROM

bull Mature Strengthening with emphasis on dynamic stabilizers


175

Isometric contraction of

pronator quadratus in

supination for DRUJ stability

Picture retrieved on

41011 from

httpwwwwristwidgetco

muploads188518855

523998400jpg164x203

Phase I (~6 wks) Long arm removeable orthotic with forearm and wrist in neutral Gentle AROM

Phase II (~6 to 8 wks) Removable wrist splint with periodic gentle ROMYOSHIAKI et al 2004 (cuff vs ulnar gutter)

Progressive ROM and gentle strengthening

Phase III (~12 weeks) Gradual return to sport or work as pain is decreased

Injuries to the central region are not amenable to repair due to avascularity

Trial Ulnar Wrist Support

1Cut 3-4rdquo piece of velcro2Cut hole and 2 tails

3Apply hook to each tail

60

Procedures for Distal Radial

Ulnar Joint (DRUJ) Instability

bull Soft tissue reconstruction

bull Suave Kapandje

bull Darrah

bull Hemiresection-Interposition Arthroplasty (HIT)

bull Implant arthroplasty


httpwwworthoteersorg

imagesuploadedSauvejpg

Retrieved on 121011f from Fornalski S Hay Q Gupta R Chronic Instability of the

Dis tal Radioulnar Joint A Review Univ Of Penn Ortho Jour 20001343-52

Photo retrieved from Ka iser et a l 2008

General Progression Concepts with

Stabilization

ProliferationRegeneration Phases

bull Gradual return to AROM and gentle PROM at wrist and forearm (gradual progression to end range prosup)

Maturation Phase (6 to 12 weeks)

bull Gentle strengthening and activity as tolerated

bull Full activity as tolerated

GENERAL REHAB CONSIDERATIONS

bull Which orthotic limits forearm rotation best

ndashMuenster

ndashSugartong

ndashAntipronationSlaughter et al 2010

61

Conclusionbull Sugartong restricts pronation significantly better

than all other orthotics

bull Anti-pronation demonstrated significantly better

results limiting forearm pronation as compared to

the wrist orthotic

bull Anti-pronation splint may be uncomfortable due

to placement on ulnar styloid

bull Neither Muenster or Sugartong completely

immobilized rotation

bull 3 subjects reported Sugartong most comfortable

and 2 reported Muenster most comfortableSlaughter et al 2010

Poll Question

Should forearm rotatiion strength and ROM be

phased in gradually as the patient gains strength

following a surgical reconstruction of the distal

radial ulnar joint

a Yes

b No

182

General Concepts for

Wrist Rehabilitation

62

Proprioception Training

Conscious RehabilitationPhase I Conscious joint control

Phase II Sense joint motion without audiovisual

cues

Phase III Strengthening specific muscles to enhance

joint stability

Phase IV Unconscious RehabilitationHagert E (2010)

bull Edema Control

bull Pain Control (visual analog scale)

bull Promote Safe Motion

Conscious Rehabilitation

Phase I

Diagram retrieved on 71511 from http0tqncomdergonomics10C---

painscalejpg


Phase II amp III

Conscious joint controlbull Mirror therapy

bull Active reproduction of joint angle accuracy of joint re-positioning

Hagert E (2010)

63


Phase IV

Sense Joint Motion without

Audiovisual Cuesbull Motion detection (detection of passive motion)

ndash Degree of joint angle at which motion is detected

Hagert E (2010)


Phase V

Strengthen specific muscles to enhance joint

stability

bull Eccentric training

bull Co-activation training

Hagert E (2010)

Phase VIUNCONSCIOUS NEUROMUSCULAR

REHABILITATION

Reactive muscle activation

Hagert E (2010)

64


REHABILITATION Hagert E (2010)


Oscillating Technique Isometric

Stabilization

Light Ball Toss

Gentle Oscillations

Sensori-motor Re-training

191

Image retrieved from httpniveapsychouniv-paris5fr

CogSysZurich2010How20to20build20a20robot20t

hat20feels_

fichiersimage153png

Sensorimotor Retraining

1 Use chopsticks to pickup varying items and separate items

2 Finding dry beans in putty

3 Molding specific shapes

4 Card turning

5 Rhythmic stabilization

Research pediatric sensorimotor activities for more ideas

192

65

THANK YOU


References1 Angst F Schwyzer H K Aeschlimann A Simmen B R amp Goldhahn J (2011) Measures of adult shoulder function Disabilities of

the Arm Shoulder and Hand Questionnaire (DASH) and its short version (QuickDASH) Shoulder Pain and Disability Index (SPADI) American

Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form Constant (Murley) Score (CS) Simple Shoulder Test (SST)

Oxford Shoulder Score (OSS) Shoulder Disability Questionnaire (SDQ) and Western Ontario Shoulder Instability Index (WOSI) Arthritis care amp

research 63(S11) S174-S188

2 Bot S D M Terwee C B Van der Windt D A W M Bouter L M Dekker J amp De Vet H C W (2004) Clinimetric evaluation of shoulder

disability questionnaires a systematic review of the literature Annals of the rheumatic diseases 63(4) 335-341

3 Braun S Kokmeyer D amp Millett P J (2009) Shoulder injuries in the throwing athlete The Journal of Bone amp Joint Surgery 91(4) 966-978

4 Crisco J J Heard W M Rich R R Paller D J amp Wolfe S W (2011) The mechanical axes of the wrist are oriented obliquely to the

anatomical axes The Journal of Bone amp Joint Surgery 93(2) 169-177

5 Hagert E Proprioception of the Wrist Joint A ReviewmOf Current Concepts and Possible Impllications on the Rehabilitation of the Wrist Jour

Hand Ther 2010232-17

6 Heidari K Asadollahi S Vafaee R Barfehei A Kamalifar H Chaboksavar Z A amp Sabbaghi M (2014) Immobilization in external rotation

combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation Journal of Shoulder and Elbow Surgery

23(6) 759-766

7 Itoi E Hatakeyama Y Kido T Sato T Minagawa H Wakabayashi I amp Kobayashi M (2003) A new method of immobilization after

traumatic anterior dislocation of the shoulder a preliminary study Journal of shoulder and elbow surgery 12(5) 413-415

8 Levine W N amp Flatow E L (2000) The pathophysiology of shoulder instability The American journal of sports medicine 28(6) 910-917

9 Kocher M S Horan M P Briggs K K Richardson T R OHolleran J amp Hawkins R J (2005) Reliability validity and responsiveness of the

American Shoulder and Elbow Surgeons subjective shoulder scale in patients with shoulder instability rotator cuff disease and glenohumeral

arthritis The Journal of Bone amp Joint Surgery 87(9) 2006-2011

10 Millett P J amp Braun S (2009) The ldquobony Bankart bridgerdquo procedure A new arthroscopic technique for reduction and internal fixation of a

bony Bankart lesion Arthroscopy The Journal of Arthroscopic amp Related Surgery 25(1) 102-105

11 Vavken P Sadoghi P Quidde J Lucas R Delaney R Mueller A M amp Valderrabano V (2014) Immobilization in internal or external

rotation does not change recurrence rates after traumatic anterior shoulder dislocation Journal of Shoulder and Elbow Surgery 23(1) 13-19

12 Paterson W H Throckmorton T W Koester M Azar F M amp Kuhn J E (2010) Position and duration of immobilization after primary

anterior shoulder dislocation The Journal of Bone amp Joint Surgery 92(18) 2924-2933

13 Paschos N K Mitsionis G I Vasiliadis H S amp Georgoulis A D (2013) Comparison of early mobilization protocols in radial head fractures

Journal of orthopaedic trauma 27(3) 134-139

14 Slaughter A Miles L Fleming J amp McPhail S (2010) A comparative study of splint effectiveness in limiting forearm rotation Journal of Hand

Therapy 23(3) 241-248

15 Wright R W amp Baumgarten K M (2010) Shoulder outcomes measures Journal of the American Academy of Orthopaedic Surgeons 18(7)

436-444

References Angst F Schwyzer H K Aeschlimann A Simmen B R amp Goldhahn J (2011) Measures of adult

shoulder function Disabilities of the Arm Shoulder and Hand Questionnaire (DASH) and its short

version (QuickDASH) Shoulder Pain and Disability Index (SPADI) American Shoulder and Elbow Surgeons

(ASES) Society standardized shoulder assessment form Constant (Murley) Score (CS) Simple Shoulder

Test (SST) Oxford Shoulder Score (OSS) Shoulder Disability Questionnaire (SDQ) and Western Ontario

Shoulder Instability Index (WOSI) Arthritis care amp research 63(S11) S174-S188

Bot S D M Terwee C B Van der Windt D A W M Bouter L M Dekker J amp De Vet H C W

(2004) Clinimetric evaluation of shoulder disability questionnaires a systematic review of the literature

Annals of the rheumatic diseases 63(4) 335-341

Braun S Kokmeyer D amp Millett P J (2009) Shoulder injuries in the throwing athlete The Journal of

Bone amp Joint Surgery 91(4) 966-978

Crisco J J Heard W M Rich R R Paller D J amp Wolfe S W (2011) The mechanical axes of the wrist

are oriented obliquely to the anatomical axes The Journal of Bone amp Joint Surgery 93(2) 169-177

Groh G I Wirth M A amp Rockwood C A (2011) Treatment of traumatic posterior sternoclavicular

dislocations Journal of Shoulder and Elbow Surgery 20(1) 107-113

Guan J J amp Wolf B R (2013) Reconstruction for anterior sternoclavicular joint dislocation and

instability Journal of Shoulder and Elbow Surgery 22(6) 775-781

Hagert E Proprioception of the Wrist Joint A ReviewmOf Current Concepts and Possible Impllications

on the Rehabilitation of the Wrist Jour Hand Ther 2010232-17

Heidari K Asadollahi S Vafaee R Barfehei A Kamalifar H Chaboksavar Z A amp Sabbaghi M

(2014) Immobilization in external rotation combined with abduction reduces the risk of recurrence after

primary anterior shoulder dislocation Journal of Shoulder and Elbow Surgery 23(6) 759-766Secrets to Stabilization Part 1 195

66

bull Hodges P W amp Richardson C A (1996) Inefficient muscular stabilization of the lumbar spine

associated with low back pain a motor control evaluation of transversus abdominis Spine 21(22) 2640-

2650

bull Itoi E Hatakeyama Y Kido T Sato T Minagawa H Wakabayashi I amp Kobayashi M (2003) A new

method of immobilization after traumatic anterior dislocation of the shoulder a preliminary study

Journal of shoulder and elbow surgery 12(5) 413-415

bull Johansen J A Grutter P W McFarland E G amp Petersen S A (2011) Acromioclavicular joint injuries

indications for treatment and treatment options Journal of Shoulder and Elbow Surgery 20(2) S70-S82

bull Levine W N amp Flatow E L (2000) The pathophysiology of shoulder instability The American journal of

sports medicine 28(6) 910-917

bull Liemohn WP Baumgartner TA Gagnon LH (2005) Measuring core stability J Strength Cond Res

19(3)583-6

bull Lubiatowski P Olczak I Lisiewicz E Ogrodowicz P Bręborowicz M amp Romanowski L (2014) Elbow

joint position sense after total elbow arthroplasty Journal of Shoulder and Elbow Surgery 23(5) 693-

700

bull Kocher M S Horan M P Briggs K K Richardson T R OHolleran J amp Hawkins R J (2005)

Reliability validity and responsiveness of the American Shoulder and Elbow Surgeons subjective

shoulder scale in patients with shoulder instability rotator cuff disease and glenohumeral arthritis The

Journal of Bone amp Joint Surgery 87(9) 2006-2011

bull Millett P J amp Braun S (2009) The ldquobony Bankart bridgerdquo procedure A new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion Arthroscopy The Journal of Arthroscopic amp

Related Surgery 25(1) 102-105

bull Miyake Y Kobayashi R Kelepecz D amp Nakajima M (2013) Core exercises elevate trunk stability to

facilitate skilled motor behavior of the upper extremities Journal of bodywork and movement therapies

17(2) 259-265 Secrets to Stabilization Part 1 196

bull Nagai K Tateuchi H Takashima S Miyasaka J Hasegawa S Arai R amp Ichihashi N (2013) Effects of trunk rotation

on scapular kinematics and muscle activity during humeral elevation Journal of Electromyography and Kinesiology 23(3)

679-687

bull Paterson W H Throckmorton T W Koester M Azar F M amp Kuhn J E (2010) Position and duration of immobilization

after primary anterior shoulder dislocation The Journal of Bone amp Joint Surgery 92(18) 2924-2933

bull Peate W F Bates G Lunda K Francis S amp Bellamy K (2007) Core strength a new model for injury prediction and

prevention J Occup Med Toxicol 2(3) 1-9

bull Pizzari T Wickham J Balster S Ganderton C amp Watson L (2014) Modifying a shrug exercise can facilitate the upward

rotator muscles of the scapula Clinical Biomechanics 29(2) 201-205

bull Potvin JR Brown SH An equation to calculate individual muscle contributions to joint stability (2005) J Biomech 38(5)973-

80

bull Struyf F Nijs J Baeyens J P Mottram S amp Meeusen R (2011) Scapular positioning and movement in unimpaired

shoulders shoulder impingement syndrome and glenohumeral instability Scandinavian journal of medicine amp science in

sports 21(3) 352-358

bull Vavken P Sadoghi P Quidde J Lucas R Delaney R Mueller A M amp Valderrabano V (2014) Immobilization in

internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation Journal of

Shoulder and Elbow Surgery 23(1) 13-19

bull Wright R W amp Baumgarten K M (2010) Shoulder outcomes measures Journal of the American Academy of Orthopaedic

Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444


Patient Function and Goals

bull Patientrsquos functional activity ndash Validated outcome assessments for shoulder

instabilities include

bull Oxford shoulder instability questionnaire

bull Shoulder instability questionnaire

bull Western Ontario shoulder instability index

bull The American Shoulder and Elbow Surgeons subjective

scale

bull Disability of the arm shoulder and hand (DASH)

bull Constant Murley shoulder assessment

bull Shoulder pain and disability indexSecrets to Stabilization Part 1 201

68

Elbow Joints KinesiologyHumeroulnar Joint

Hinge-joint that flexes and extends

Open Pack 70deg flex10deg supination

Closed Pack extsupination

Humeroradial Joint


Open Pack extsup

Closed Pack 90deg flex5deg sup

Proximal Radioulnar Joint

Pronation and supination

Open Pack 70deg flex35degSup

Closed Pack 5degsupext httpuploadwikimediaorgwikipediacom

nsthumb221Gray330png271px-

Gray330png 202Secrets to Stabilization Part 1

2

THEMES Secrets to Stabilization

Functional Rehabilitation

Core

Motor Control

Dynamic Stability

Static StabilitySecrets to Stabilization Part 1 4


Function

Rehabilitation

Core Stability

Static Stability

Motor Control

DynamicStability

Local

Stabilizers

Global

Stabilizers

Global Mobilizers

bull Abnormal

movement at 1

segment


bull Poor response to

load

bull Poor movement

patterns at

segment

Dysfunction

bull Decreased force

production


bull Dysfunctional

recruitment

pattern


Local

StabilizersGlobal

Stabilizers

Global

Mobilizers

bull Overactive amp

tight muscles

bull Spasms

bull Results in

decreased

movement

patterns at

several joints

3


STATIC



bull Glenoid Labrum


pressures

7



Static Stability

Motor Control

Pacinian Ruffini

Extreme Motion


Extreme Motion

Tensile Strength


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability









9




4


Sternoclavicular


(holds shoulder up)





14105C8D3116E509030png

restrains

restrains

restrains





bull Elbowwrist ROM






strap and gentle


abduction above 90



20(1) 107-113




12





11353982940540jpg





displacement

restrains

restrains

restrains


5










Procedures)






arom




Glenohumeral

Ligaments

14











wikiped

Iacommons33bGray326

png


6


JointCoracohumeral








(SGHL)







mons33bGray326png

Axillary

Pouch

SGHL

MGHL

IGHL








ligament

18Turkel et al 1981



7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








3


STATIC



bull Glenoid Labrum


pressures

7



Static Stability

Motor Control

Pacinian Ruffini

Extreme Motion


Extreme Motion

Tensile Strength


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability









9




4


Sternoclavicular


(holds shoulder up)





14105C8D3116E509030png

restrains

restrains

restrains





bull Elbowwrist ROM






strap and gentle


abduction above 90



20(1) 107-113




12





11353982940540jpg





displacement

restrains

restrains

restrains


5










Procedures)






arom




Glenohumeral

Ligaments

14











wikiped

Iacommons33bGray326

png


6


JointCoracohumeral








(SGHL)







mons33bGray326png

Axillary

Pouch

SGHL

MGHL

IGHL








ligament

18Turkel et al 1981



7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








4


Sternoclavicular


(holds shoulder up)





14105C8D3116E509030png

restrains

restrains

restrains





bull Elbowwrist ROM






strap and gentle


abduction above 90



20(1) 107-113




12





11353982940540jpg





displacement

restrains

restrains

restrains


5










Procedures)






arom




Glenohumeral

Ligaments

14











wikiped

Iacommons33bGray326

png


6


JointCoracohumeral








(SGHL)







mons33bGray326png

Axillary

Pouch

SGHL

MGHL

IGHL








ligament

18Turkel et al 1981



7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








5










Procedures)






arom




Glenohumeral

Ligaments

14











wikiped

Iacommons33bGray326

png


6


JointCoracohumeral








(SGHL)







mons33bGray326png

Axillary

Pouch

SGHL

MGHL

IGHL








ligament

18Turkel et al 1981



7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








6


JointCoracohumeral








(SGHL)







mons33bGray326png

Axillary

Pouch

SGHL

MGHL

IGHL








ligament

18Turkel et al 1981



7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








7

0 to 30 degrees

45 to 60 degrees

90 degrees

Antero-medial force

Boney Architect




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








8

Static Stabilizers

Glenoid Labrum



fossa by 50


GH ligaments



superiorly

22




bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

Static Stabilizers







9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








9


bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




Static Stability

26

Glenohumeral Static

Stabilizers

bull Ligaments

bull Labrum

bull Capsule

bull Boney

Architect




bull Humeral

head to

shaft angle

130deg to

150deg

bull Retroverted

30deg






glenoid fossa




without symptoms


10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








10








Humeral

Head

Ant Capsule

Humeral

Head


Ant Capsule

















No Recurrent

Recurrent

Inci

de

nce

of

Re

curr

en

t D

islo

cati

on


11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








11








common)


Bankhart










12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








12

Pathomechanics




capsule

OR




rim

34



Bankart Lesion

I l lustration from













injury related to


ldquopeel back

36






13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








13



37





D Millett P


Injuries in the


Surg 200991(4)


deceleration







Pathomechanics SLAP

bull Type IFraying


becoming detached



hangs down




gif






ER

Supinate Pronate

Passive Distraction

IR

Active Compression


14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








14










15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








15

Poll Question



a Yes

b No

43

PROTECTIVE PHASE

REHABILITATION









al 2014


16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








16













Procedures









in sling




pic2png











17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








17


TO MATURE PHASE










Core Stability

Transfers









Core Stability

18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








18


DYNAMIC

bull Muscles

ndash Scapular

Stabilizers

ndash Rotator Cuff

Muscles

ndash Long head of

the biceps

52



DynamicStability

Motor

Control

Golgi Tendon

-Muscle contraction

-Joint position

-Signals agonist to

relax

Muscle

Spindles

-Joint movement

-Positions sense

-Reflex muscle

contraction

Proprioception



Kinesthesia

PositionMovement

Tension or Force

Sense of Balance

Sense of Effort



Stability






agonist to relax



19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








19


Stability





Local Stabilizers

bull Deepclose

to axis of

movement

bull Constantly

modulating

bull Constantly

modulates

force output

bull Highly

proprio-

ceptive

bull Type I

Global Stabilizers

bull Deep or

superficial

bull Controls

inner and

outer range

bull Controls

eccentric

motions

bull Highly

proprio-

ceptive


Global Mobilizer

bull Superficial





kinetic chain


Local Stabilizers

bull Rotator cuff

bull Long head

of the

biceps

bull Lower and

middle

trapezius

Global Stabilizers

bull Teres major

deltoids

coraco-

brachialis

upper amp

middle

trapeziusser

ratus

anterior


Global Mobilizer

bull Rhomboids








-Abnormal movement

at 1 segment

-Reflex inhibition

-Poor response to

load

-Poor movement

patterns at segment

Decreased force

production

Reflex inhibition

Dysfunctional

recruitment pattern


bull Spasms



20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








20












Progress Position


21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








21






22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








22


bull SERAPE EFFECT






Core Stability






2011)

23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








23







Proprioception

Proprioception

Musculotendinous

Golgi Tendon


position




muscle contraction

Capsuloligamentous


MotionCompressive

Strength


Strength


24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








24


Poll Question



a Yes

b No

71

ELBOW INSTABILITIES


25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








25

ELBOW STABILIZERS

bull STATIC


ndashCapsule



bull DYNAMIC

ndashBiceps

ndashBrachialis


ndashECRL

ndashTriceps




Other Stabilizers

Elbow Capsule






26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








26

Static Stabilizers





Subliime tubercle

of proximal ulna





R (1997)


Post Bundle

taut in max

flexion

Anterior

Bundle 3

functional

fiber bundles












27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








27






ligament (LUCL)


















28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








28

ELBOW STABILIZERS

bull DYNAMIC

ndashBiceps

ndashBrachialis

ndashPronators

ndash Supinatos



ndashTriceps



Local Stabilizers


bull Pronator



Global Stabilizers

bull Brachialis



lateral heads)

bull Anconeous


bull Supinator


bull Pronator




bull APL


Global Mobilizer




Pronator Teres




bull Ligamentous







(lateral) forces


29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








29




Varus Stress Test


supinated














pronation










30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








30











Sensitivity 875






Guidelines





for 6 weeks




31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








31






















32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








32


MCL Injury










Moving Valgus

Sensitivity 100

Specificity 75

Valgus Stress Test

Sensitvity 66

Specificity 60



33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








33








forearm and wrist












34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








34


CLINICAL PEARL








Intermediate Phase










healthy elbows


35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








35

Elbow Trauma

Dislocations amp

Fractures




bull Complex





Sheps et al 2004



36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








36




complication





Sheps et al 2004

ELBOW TRAUMA



Trauma






37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








37



Replacement






neutral


prosup)

ndash CPM


















38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








38



bull Edema control



Post-op 2 weeks





CHALLENGE

39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








39








bull Phase I








al 2009)








Hand on forehead



40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








40




















41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








41


elbow ROM




Poll Question



collateral ligament



c Forward flexion


122








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








42




bull Elbow pain


Clinical Management













T55jpg

43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








43


Results














months


request surgery


bull PROS

129


improved fit




modified

CONS



experience level



hinge



44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








44

d

bull PROS

130



measurements





CONS


authorization


be more timely


on order




Poll Question



a Yes

b No

132

45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








45


Bony Anatomy

bull 2 long bones


bull 8 carpal bones


bull 14 phalanges


FUNCTIONAL MOTIONS

bull FLEXION

bull EXTENSION



bull CIRCUMDUCTION


wwwdkimagescomDarts

Darts-15html

46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








46










wristpage5ahtml



Reciprocal Motion



wwwdavidlnelsonmd

Lichtman_talkhtm

Berger 1996


Radius amp Ulna



Retrieved on 050109


lna


hhaa_13_3_1htm

47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








47

WRIST

ARTICULATIONS

Consists of




Joint




xarpusgif

Radiocarpal

Joint

Midcarpal

Joint

Distal

Radioulnar Joint

Wrist Ligaments



bones in capsule




to carpal bone amp



Volar View





bull Lunotriquetral

Extrinsic





48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








48

Examining the Wrist

Column Concept

Radial

Lateral Column

Scaphoid

Trapezium

Trapezoid

Lateral Radius142

Dorsal Central

Central Column

Lunate

Capitate

Hamate

Medial Radius

Ulnar

Medial Column

Triquetrum

Ulna

Radial Wrist


bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


THUMB CARPAL

METACARPAL

OSTEOARTRHITIS



49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








49

DEFORMITY PATTERNS

Zig Zag

(most common)



in CMC instability

MP hyper-flexion IP

hyperextension

resulting in CMC

instability

Reverse

Zig Zag

Static Thumb

Stabilizers







Photo retrieve from

httpwwweatonhandcom

musthumbmusgif

Thumb Adduction

MP Hyper-ext

FPL Primary Flexor

MP volar plate

stretcheddAOL lax

Diminished


50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








50


with one hand

2 Grasp the first

metacarpal













51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








51



education and


stabilizers


intrinisics


wrist extensors


Poll Question





b Adductor pollicis




152

Radial Wrist

bull THUMB CMC OA

Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








52





VISI




DISI










155



Instability (DISI)

53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








53


Procedure


wrist with ext


aspect of distal

scaphoid

bull Then radial

deviate the wrist

with flexion



dorsally within the

scaphoid fossa

158






159

54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








54






160

Poll Question


described as





161

Radial Wrist

bull DE QUERVAINS

bull THUMB CMC OA



Ulnar Wrist

bull Lunotriquetral

Tear

(Dissociative)

bull Triangular

Fibrocartilage

Complex Tear

(TFCC)


55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








55

Ulnar Wrist




the fa



away






1ampeid=4-u10-B978-1-4160-5279-1



VISI


Mechanism of Injury



164







Sensitivity 33-100


Laxity pain

or crepitus

56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








56









167









168

Retrieved from

wwwhughstoncom

hhaa_13_3_1htm

57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








57



169






(TFCC)



ndash Sigmoid Notch


ndashTFCC



ndashECU

ndash FCU




(TFCC)

bull Palpate for

tenderness

171



process

58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








58


TESTING

Ulnocarpal Stress

Test


with wrist in ulnar


and dorsally

Positive Test



173

Poll Question






59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








59







175





41011 from


muploads188518855

523998400jpg164x203









60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








60




bull Suave Kapandje

bull Darrah










Stabilization








ndashMuenster

ndashSugartong


61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








61





the wrist orthotic







Poll Question




radial ulnar joint

a Yes

b No

182



62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








62




cues


joint stability


bull Edema Control




Phase I


painscalejpg


Phase II amp III



Hagert E (2010)

63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








63


Phase IV




Hagert E (2010)


Phase V


stability



Hagert E (2010)


REHABILITATION


Hagert E (2010)

64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








64





Stabilization

Light Ball Toss

Gentle Oscillations


191



hat20feels_

fichiersimage153png





4 Card turning



192

65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








65

THANK YOU
















23(6) 759-766
















Therapy 23(3) 241-248


436-444























66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








66



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444
























67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








67



2650









19(3)583-6



700












679-687








80



sports 21(3) 352-358





Surgeons 18(7) 436-444









scale




68





Humeroradial Joint


Open Pack extsup








68





Humeroradial Joint


Open Pack extsup








abc's of treatment strategies for upper extremity instabilities

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