At the conclusion of this chapter, the reader will be able to:
Identify the key anatomical and biomechanical features of the wrist and hand and their impact on examination and intervention.
List and perform key procedures used in the orthopaedic manual physical therapy (OMPT) examination of the wrist and hand.
Demonstrate sound clinical decision-making in evaluating the results of the OMPT examination.
Use pertinent examination findings to reach a differential diagnosis and prognosis.
Discuss issues related to the safe performance of OMPT interventions for the wrist and hand.
Demonstrate basic competence in the performance of a skill set of joint mobilization techniques for the wrist and hand.
FUNCTIONAL ANATOMY AND KINEMATICS
The wrist-and-hand complex provides an extraordinary example of both the complexity and the precision with which human motion can occur. The compound radiocarpal and midcarpal joints collectively form the wrist-joint complex;1 however, the proximal and distal radioulnar joints also exert an important influence on wrist function. This complex accumulation of bones, muscles, and articulations provides function that ranges from fine motor tasks to the production of substantial force, all of which are accompanied by a great degree of individual variability.1
The Distal Radioulnar (RU) Joint
The distal RU joint forms a compound articulation with the proximal RU joint, which collectively provides the motions of pronation and supination. Although external to the wrist joint proper, the distal RU joint contributes greatly to hand function and is commonly involved in dysfunction of the hand and wrist.2,3 This joint is classified as a pivot joint; however, on closer inspection, one can see that a substantial amount of gliding occurs at this joint as well.3 The degree of joint glide afforded at this joint is due largely to the mismatch in curvature between the ulnar head and the corresponding radial sigmoid notch.2,4
Stability of the Distal Radioulnar Joint
The distal RU joint relies heavily on its noncontractile soft tissue structures for support, with minimal support osteologically.5 The joint capsule and the triangular fibrocartilage complex (TFCC) provide direct support, while the annular ligament, as well as the interosseous membrane, provide indirect support. The joint capsule is more substantial distally and may contribute to axial stability of this joint.6 Although this capsule is weak anteriorly, it contains folds that distend to allow for full supination and to guard against excessive supination.7
The TFCC serves an important role in attenuating axially loaded forces by distributing these forces to the ulna, increasing the articular surface of the wrist, and stabilizing the entire wrist complex.7,8 The TFCC is composed of fibrocartilage, the dorsal and volar radioulnar ligaments, the ulnar collateral ligament, and a meniscus.7 The base of the TFCC inserts ...