This Fast Focus Framework below that I use in my programs with all my students helps critically think through any case:
- Bones
- Muscle/Tendons
- Ligaments
- Nerves
- Skin/Fascia
When it comes to using my Fast Focus Framework, it allows you to identify a primary problem and a secondary problem.
For example, if you broke a bone in the wrist, you would know that that was a bone problem, and that’s why everything might be stiff and painful. If you have a fracture, once it’s stabilized, it’s stabilized, but because of that fracture, it has impacted such and such area.
If it’s a ligament problem, it’s a whole other animal. Because of your ligament injury, you are now directly affecting how the bones move and work together. If those things don’t move and work together, this becomes a problem.
Your patient might have a muscle-tendon imbalance. If that is imbalanced, it will directly affect how the skin, fascia, nerves, and all that glide around.
It’s not that they are not ALL affected and impacting each other. It’s just that when you know what the major problem is, you can understand how to think through that problem, to say, “What am I allowed to do and what am I not allowed to do?”
Now obviously, patient symptoms are a huge concern.
Let’s break down the wrist into bones, including the joints, ligaments, tendons, and muscles. The wrist allows the hand to function and motion and transfers the forces into the forearm, and it’s in all different positions.
Think about your little wrist, which allows forces to transfer to the forearm. It gets to be in a neutral position, gets to be in a supinated position, or gets to be in a pronated position, and then it allows to transfer the forces into the hand. Now, it could be transferred into the hand when it’s supinated, when it’s pronated, or when it’s neutral.
Normally I’ll draw out the eight wrist bones as a visual aid, and I’ll include the radius and ulna too. It doesn’t matter if it’s to scale or not. Make sure you include the DRUJ (distal radius ulna joint). It’s the joint between the distal radius and the ulna because that’s how those two bones move and impact on the wrist, on the carpal bones. Then the TFCC is ulnarly positioned. If you think about it, when the radius and the ulna move, it moves, impacting the DRUJ joint. Every time the wrist moves, it impacts the TFCC. The TFCC, essentially, is like a trampoline on the wrist because every time the joint moves, the TFCC bounces. But it’s very strong because it’s made up of many ligaments and strong tissue.
The most important thing to understand about the wrist is that the bones have to sit in a very particular way. The proximal row, distal row, radius, ulna, and metacarpals move in a very specific way.
The ligaments hold these bones together. They have to hold within their row, and then some ligaments cross each other. These ligaments that hold the two rows together tend to be the most problematic, and the ligaments of the proximal rows tend to be a bit more problematic. The ligaments that hold these together are actually really strong to the metacarpal. They attach themselves to the hand bones (metacarpals) really, really strongly.
When we talk about bone problems, we know that the carpals have to sit in a certain way, the radius has to move in a certain way into the ulna, and the ulna has to move in a certain way which then affects the TFCC. So all of these play a role in each other.
When something happens to the ligament, and something gets broken, then all of a sudden it throws this whole thing outta work, right?
If there is a ligament issue, over time, it starts to mess up with the way the bones are sitting, and then you’ll start to develop muscle-tendon issues, which are like tendonitis or arthritis. And that’s why you’ll see a lot of people have a lot of pain types of symptoms that they’re coming to you with.
Next, think about what the TFCC does. The job of the TFCC is to stabilize the DRUJ. That is the job of the DRUJ. Everyone has a job here and what are they supposed to do? And if they’re not doing it anymore, then something happened. Something went wrong, right?
That’s where you get to come in and figure things out. The TFCC also separates the carpals from the forearm bones. The distal radius just gives it a slight separation. The TFCC actually plays a huge part in promoting the rotation and sliding motion between the radius and the ulna. And that’s how you’re allowed to rotate and turn your palm up and down. So every time you rotate your palm up and down, some forces are applied to this trampoline.
What happens with forearm rotation, is it feels like the ulna is moving, but it’s really not the ulna. The ulna is stable because if you think about where the ulna is, on the olecranons here, bone is stable. It’s the radius that rotates on the ulna. The DRUJ holds everything together. Together, the TFCC must be intact to stabilize this joint. They play a role in helping each other out. When it comes to the ulna, positive ulnar variance, the ulna moves distally with pronation. When your arm is in a pronated position, your ulna moves distally. So if your arm is pronated, your ulna moves distal, and if it’s moving distal, what’s it catching? It’s pushing into that TFCC. When you are supinated, that ulna moves proximally.
Just imagine that these two forearm bones are constantly based on your rotation. And if something stops them from moving the way they should, then there’s going to be a lot of irritation.
What is happening with all of your patients is that you have people who have ligament issues. You have ligament issues in your people. You have TFCC injuries. You have some kind of problem like that. But if this part is not moving well, it’s probably irritating your TFCC.
But what are the muscles that move? You know, some of the wrist muscles that they cross? All the wrist muscles cross to bring the wrist up. Think about the muscles, right? The muscles that move the wrist are the longus, the brevis, and then the ulnaris. You have your wrist extensors, and then you have your wrist flexors, so then you have your wrist flexor, but then you have your wrist flexor, the ulnaris, the flexor carpi ulnaris, which are all on the ulna side.
So anytime I have a patient with ulnar-sided pain, I always want to think about the ECU and the FCU. The muscles are more ulna than you think, and they play a huge role in giving people ulna-sided pain. And it’s so easy to think that potentially it’s a TFCC problem because it’s all around that side.
Your job is to rule in and rule out all the possibilities so that you know what to do and how to guide your patients towards their goals.
If you work with anyone with hand and wrist issues, the key to getting results is the ability to think through why they have the problem and what to do to fix it.
Want help with any type of upper extremity case no matter where you work?
You don’t have to wait your turn to become a Hand Therapist. Get the skills and confidence you deserve to advance your career, help any patients who come your way, and feel sure about what to do and say.
