• Syndrome cause by excessive impact stress between ulna and carpal bones (primarily lunate)
  • Pathoanatomy
    • in a wrist with +2 mm ulnar variance approximately 
      • 40% of the load goes to the ulna
      • 60% to the radius
    • in a normal neutral wrist approximately 
      • 20% of the load goes to the ulna
      • 80% to the radius
  • Associated conditions
    • positive ulnar variance can be seen in the setting of:
      • scapholunate dissociation
      • TFCC tears
      • lunotriquetral ligament tears
      • radial shortening from previous Colles fracture
  • Symptoms 
    • pain on dorsal side of DRUJ
    • increased pain with ulnar deviation of wrist
    • pain with axial loading
    • ulna sided wrist pain
  • Physical exam
    • Ballottement test 
      • dorsal and palmar displacement of ulna with wrist in ulnar deviation
      • positive test produces pain
    • Nakamura's ulnar stress test
      • ulnar deviation of pronated wrist while axially loading, flexing and extending the wrist
      • positive test produces pain
    • fovea test 
      • used to evaluate for TFCC tear or ulnotriquetral ligament tear
      • performed by palpation of the ulnar wrist between the styloid and FCU tendon
  • Radiographs
    • recommended views
      • AP radiograph with wrist in neutral supination/pronation and zero rotation
        • required to evaluate ulnar variance
      • pronated grip view
        • increases radiographic impaction 
      • arthrography can show TFCC tear and lunotriquetral ligament tear
    • findings
      • ulna positive variance
      • sclerosis of lunate and ulnar head
  • MRI
    • evaluate for TFCC tears which may be caused by ulnocarpal impingement and often influences treatment
  • Ulnar sided wrist pain
    • DRUJ instability or arthritis
    • TFCC tear
    • LT ligament tear
    • pisotriquetral arthritis
    • ECU tendonitis or instability
  • Nonoperative
    • supportive measures
      • indications
        • may attempt supportive measures as first line of treatment
  • Operative
    • ulnar shortening osteotomy   
      • indications
        • most cases of ulnar positive variance
        • most cases of DRUJ incongruity
    • Wafer procedure  
      • technique
        • 2 to 4mm of cartilage and bone removed from under TFCC arthroscopically
    • Darrach procedure (ulnar head resection) 
      • indications
        • reserved for lower demand patients
      • complications
        • risk of proximal ulna stump instability 
    • Sauvé-Kapandji procedure  
      • indications
        • good option for manual laborers
      • technique
        • creates a distal radioulnar fusion and a ulnar pseudoarthrosis proximal to the fusion site through which rotation can occur
    • ulnar hemiresection arthroplasty  
      • indications
        • usually requires an intact or reconstructed TFCC 
        • appropriate treatment option in the presence of post-traumatic DRUJ with concomitant distal ulnar degenerative changes
    • ulnar head replacement 
      • indications
        • severe ulnocarpal arthrosis
        • salvage for failed Darrach
      • outcomes
        • early results are promising, long-term results pending
  • Ulnar shortening osteotomy post
    • approach
      • subcutaneous to ulna
    • technique
      • often combined with arthroscopic TFCC repair post

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Questions (3)

(OBQ09.229) A 32-year-old carpenter has a 6-month history of ulnar-sided wrist pain that is worsened opening a jar, squeezing a wet towel, typing, or changing a gearshift. Radiograph and MRI images are detailed in Figures A through C. All of the following concerning ulnar shortening osteotomy are true EXCEPT: Review Topic


Care should be taken to avoid the dorsal sensory branch of the ulnar nerve




Results are encouraging even for those with degenerative changes in the distal radioulnar joint




Placement of the plate to the dorsal surface of the ulna can cause tendinitis of the extensor carpi ulnaris




Concomitant arthroscopy may be indicated for patients with concurrent tears of the triangular fibrocartilage complex




Degenerative cystic changes of the ulnar carpal bones can resolve after the ulnar shortening osteotomy



Select Answer to see Preferred Response


For patient's with ulnar impaction syndrome, concomitant arthrosis in the distal radioulnar joint (DRUJ) is a contraindication to ulnar shortening osteotomy.

Ulnar impaction syndrome is caused by abutment of the ulnar head into the carpal bones. It is worsened by activities that have wrist rotation and ulnar deviation. A positive ulnar variance with or without cystic changes of the carpus is often seen on plain radiographs. Coexisting central TFCC tears are common and can be addressed by simultaneous arthroscopic or open d├ębridement.

Baek et al. describes 31 patients that had improved Gartland and Werley scores following ulnar shortening osteotomy. They also noted that all patients with degenerative cystic changes had resolution of the cysts at 1-2 year followup and they include a detailed outline of their surgical technique.

Chun et al. similarly reviewed 30 wrists of 27 patients with ulnar impaction syndrome with very good outcomes with minimal complications and no ulnar nonunions following ulnar shortening osteotomy. Exclusion criteria included any exisiting arthrosis in the DRUJ

Figure A is a plain radiograph noting ulnar positive variance and mild cystic changes in the lunate. Figures B and C are T1 and T2 MRI images of the wrist noting increased signal in both the lunate and ulnar head.

Incorrect answers:
Answer 1, 3, 4, and 5 are all important factors to consider when performing ulnar shortening osteotomy.


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(OBQ05.46) A 42-year-old construction worker presents with pain in his right wrist. A current radiograph of the wrist is shown in Figure A. He reports that rotating activities, such as turning a screw driver, are bothersome and the pain is preventing him from working. A current MRI reveals a TFCC tear, and nonsurgical treatment has failed to provide relief. Treatment should now consist of: Review Topic


Repair of the ulnar styloid nonunion




Darrach resection of the distal ulna




Complete ulnar head resection




Ulnar hemiresection arthroplasty and TFCC reconstruction/repair




Isolated arthroscopic TFCC reconstruction



Select Answer to see Preferred Response


The clinical presentation is consistent with DRUJ arthritis in a heavy laborer. Of the options listed, ulnar hemiresection arthroplasty with concurrent TFCC reconstruction or repair would be the most appropriate treatment.

While there are multiple treatment options, the ulnar hemiresection arthroplasty with concurrent TFCC reconstruction or repair is considered most appropriate in heavy laborers, as it would likely resolve the pain and enable them to return to work sooner. The TFCC should be intact when performing an ulnar hemiresection arthroplasty to prevent distal ulna instability with forearm rotation. One could also consider performing a Suave-Kapandji procedure. This procedure creates a distal radioulnar fusion and an ulnar pseudarthrosis proximal to the fusion site through which rotation can occur. The advantage is that the ulnocarpal joint is not sacrificed, and a stable wrist is created.

Scheker et al reported on the outcome of ulnar shortening performed on 32 wrists with early osteoarthritis of the DRUJ. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32 fair, 5/32 poor, with plate irritation being the most frequent postoperative complication.

Figure A is a radiograph showing significant DRUJ arthritis. Illustration A shows ulnar hemiresection arthroplasty. Illustration B shows a Darrach procedure. Illustration C shows a Sauve-Kapandji procedure. Illustration D is a treatment schematic of TFCC reconstruction.

Incorrect Answers:
Answer 1: There is no obvious ulnar styloid non-union.
Answer 2: As mentioned in Miller's review text, the Darrach procedure is typically reserved for low-demand, elderly patients and may lead to painful proximal ulna stump instability.
Answer 3: Complete ulnar head resection is not indicated.
Answer 5: TFCC reconstruction will not improve or treat the DRUJ arthritic changes.


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Question COMMENTS (7)

(OBQ04.266) An ulnar shortening osteotomy would be MOST indicated for which of the following patients presenting with longstanding ulnar sided wrist pain refractory to conservative measures? Review Topic


34-year-old female with an ulnar neutral wrist and distal radioulnar joint incongruity




34-year-old female with an ulnar positive wrist and distal radioulnar joint incongruity




34-year-old female with an ulnar negative wrist and distal radioulnar joint incongruity




78-year-old female with ulnar positive wrist and distal radioulnar joint arthritis




78-year-old female with ulnar negative wrist and distal radioulnar joint arthritis



Select Answer to see Preferred Response


Ulnar shortening osteotomy is the best procedure for young adults with longstanding ulnar sided wrist pain due to ulnar positive variance and associated distal radioulnar joint (DRUJ) incongruity. Ulnar positive variance causes an "ulnar impaction syndrome" as the distal ulnar styloid can cause damage to the triangular fibrocartilage complex (TFCC), and ulnocarpal joint (illustration A.)

Advantages of an ulnar shortening osteotomy include preservation of ulnar dome articular cartilage and DRUJ joint, and also tightens the TFCC and ulnocarpal ligaments as the distal ulna is translated and fixed proximally after the osteotomy.

It is also important to note that ulnar shortening in the setting of preoperative DRUJ incongruity may simultaneously decrease ulnocarpal abutment and improve congruity at the distal radioulnar articulation. One specific instance in which to avoid an ulnar shortening in an ulnar positive wrist with DRUJ incongruity is a joint with a reverse oblique inclination in the coronal plane. This may create abnormally high radioulnar contact and may lead to joint degeneration


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