Elsevier

Journal of Hand Therapy

Volume 28, Issue 4, October–December 2015, Pages 369-374
Journal of Hand Therapy

Scientific/Clinical Article
Multiplanar wrist joint proprioception: The effect of anesthetic blockade of the posterior interosseous nerve or skin envelope surrounding the joint

https://doi.org/10.1016/j.jht.2015.03.003Get rights and content

Abstract

Purpose

Contribution of the posterior interosseous nerve (PIN) and surrounding skin envelope to wrist proprioception is a topic of debate and the primary focus of this research.

Methods

We performed a double-blinded, placebo control study in which subjects underwent baseline multiplanar testing of wrist proprioception. They were randomized to receive either anesthetic blockade of the PIN within the fourth dorsal compartment, or circumferential topical anesthetic blockade of skin surrounding the wrist. Corresponding opposite wrists underwent placebo intervention with saline injection or inert ultrasound gel. Subjects repeated proprioceptive testing.

Results

Eighty subjects, 45 male and 35 female, mean age 33 years (range, 19–64 years), completed testing. The percentage of measurements falling outside a ±18° range did not differ between pre-treatment and post-treatment PIN blockade or for circumferential skin anesthesia.

Conclusions

Wrist proprioception appears to be a multifactorial phenomenon. Surgeons may sacrifice the PIN without concern for effect on joint proprioception.

Level of evidence

Level I

Introduction

Joint proprioception contributes to the conscious awareness of that particular extremity in space.1 It significantly affects coordinated movement and the maintenance of static balance.2, 3, 4, 5 In his seminal paper, Moberg wrote of the multifactorial contribution of joint, muscle and cutaneous receptors to joint position sense, kinesthesia and motor function of the hand.6 The contribution of capsular branches of the posterior interosseous nerve (PIN) and the surrounding skin envelope to wrist joint proprioception is a topic of debate and the focus of several recent scientific publications.5, 7, 8, 9, 10, 11 Studies of other joints have further questioned the isolated role of joint capsule innervation.12, 13, 14

There are potential implications in surgery about the wrist as well as subsequent rehabilitation. The terminal capsular branch of the PIN is often excised in an effort to decrease postoperative dorsal wrist pain15, 16, 17 and subsequently improve measured grip strength18 and return to employment.19 Physical and occupational therapists often address deficiencies of proprioception through rehabilitative protocols.20 Many studies on this topic pertain to rehabilitation of the shoulder,21 knee22 and ankle,23 in which proprioceptive feedback facilitates joint stability. The relevance of joint proprioception to therapeutic exercise in the wrist includes the stabilizing effect of static co-activation of wrist antagonists, dynamic reactive muscle activation and in voluntary movement employing mirror therapy in preventing and rehabilitating injuries in patients with high functional demand of this joint complex.20

The primary objective of this research was to determine which factors contribute to wrist joint proprioception. A secondary objective was to develop a standardized tool to assess wrist proprioception in the clinical setting. We hypothesized temporary anesthesia of the posterior interosseous nerve has no measureable effect on multiplanar wrist joint proprioception. We further suspected temporary anesthesia of the skin envelope surrounding the wrist joint would have a measurable effect. This study introduces an efficient way to assess wrist proprioception in the clinical setting. The results also provide valuable information to clinicians making decisions regarding the operative management of the PIN and subsequent rehabilitation of these patients.

Section snippets

Methods

We performed an Institutional Review Board (Department of Clinical Investigation, Tripler Army Medical Center) approved prospective, randomized study to compare wrist proprioception accuracy and precision between pre- and post-treatment measurements. We obtained informed consent as well as HIPAA consent from each subject. Potential subjects were excluded from this study if (1) they were outside of the inclusion age range of 18–65 years-old; (2) had a history of neuromuscular disorder affecting

Results

Eighty subjects, 45 male and 35 female, mean age 33 years (range, 19–64 years), completed testing. Overall accuracy and precision were generally good regardless of treatment, with approximately 90% of measurements falling within the acceptable range of ±18° of the target value (Table 1). Females were more likely than males to have an observation outside the acceptable range (11% vs. 8%, p = 0.035 at pre-treatment, Table 2), and non-dominant wrists were more likely than dominant wrists to miss

Discussion

Proprioception is an important component of conscious movement involving intricate ascending and descending neural pathways.1, 2, 3, 4, 20 In its absence, synchronized movements become difficult. Proprioception has been studied in various joints of the body. However, wrist proprioception is a relatively recent topic of investigation. Given the impact on functional performance, wrist proprioception is an appropriate topic for continued research.

Terminal branches of the PIN arborize into the

Acknowledgments

The authors acknowledge the contributions of Robert J. Lachky, MD for participating in the collection of subject data.

Quiz: #381

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.

  • #1.

    The study design was

    • a.

      a retrospective cohort

    • b.

      RCT

    • c.

      a case series

    • d.

      an n = 1

  • #2.

    The PIN was anesthetized in the __________ dorsal compartment

    • a.

      1st

    • b.

      2nd

    • c.

      3rd

    • d.

      4th

  • #3.

    The primary purpose of the study was to identify the

    • a.

      contribution of the PIN to wrist pain

    • b.

      contribution of the PIN to grip strength

    • c.

      factors

References (26)

Cited by (0)

Study performed at Tripler Army Medical Center, Honolulu, Hawaii.

Disclaimer: The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense or the U.S. Government.

Conflict of interest: All authors hereby declare that they have no conflicts of interest related to this study.

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