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Introduction
  • 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
Presentation
  • 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
Imaging
  • 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
Differential
  • Ulnar sided wrist pain
    • DRUJ instability or arthritis
    • TFCC tear
    • LT ligament tear
    • pisotriquetral arthritis
    • ECU tendonitis or instability
Treatment
  • 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
Techniques
  • Ulnar shortening osteotomy post
    • approach
      • subcutaneous to ulna
    • technique
      • often combined with arthroscopic TFCC repair post
 

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