Ulnocarpal Abutment Syndrome

Author: Jason McKean

Topic updated on 06/07/13 7:05pm

Introduction

Syndrome cause by excessive impact stress between ulna and carpal bones (primarily lunate)
- positive ulnar variance
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 caused by
  - scapholunaite 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
  - palpation of the ulnar wrist between the styloid and FCU tendon to

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
- CU 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 psuedoarthrosis 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
- approach
  - subcutaneous to ulna
- technique
  - often combined with arthroscopic TFCC repair

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Qbank (3 Questions)

TAG

(OBQ09.229) A 32-year-old carpenter has a 6 month history of ulnar 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: Topic

Review Topic

FIGURES: A

1. Care should be taken to avoid the dorsal sensory branch of the ulnar nerve
2. Indicated for patients with concomitant Madelung deformity
3. Placement of the plate to the dorsal surface of the ulna can cause tendinitis of the extensor carpi ulnaris
4. Concomitant arthroscopy is indicated for patients who are seen to have cystic changes of the carpus on radiographs
5. Degenerative cystic changes of the ulnar carpal bones resolve after the ulnar shortening osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: Ulnocarpal impaction syndrome results from abutment of the ulnar head into the proximal ulnar aspect of the lunate. 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. In the absence of structural abnormalities, such as a Madelung deformity or DRUJ arthrosis, the most commonly performed procedure is an ulnar shortening osteotomy. Coexisting central TFCC tears are common and can be addressed by arthroscopic or open débridement. The Level 4 study by 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. The Level 4 study by Chun et al showed very good outcomes with minimal complications and no ulnar nonunions.

REFERENCES:

1. Baek GH, Chung MS, Lee YH, Gong HS, Lee S, Kim HH. Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome. Surgical technique. J Bone Joint Surg Am 2006 Sep;88 Suppl 1 Pt 2:212-20. PMID:16951094 (Link to Abstract)

2. Chun S, Palmer AK. The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. J Hand Surg Am. 1993 Jan;18(1):46-53. PMID:8423317 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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TAG

(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: Topic

Review Topic

FIGURES: A

1. Repair of the ulnar styloid nonunion
2. Darrach resection of the distal ulna
3. Complete ulnar head resection
4. Ulnar hemiresection arthroplasty and TFCC repair
5. Isolated arthroscopic TFCC reconstruction

PREFERRED RESPONSE ▶

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

While there are multiple treatment options, the ulnar hemiresection arthroplasty with concurrent TFCC reconstruction 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 laborers. 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 Suave-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.

Illustrations: A

REFERENCES:

1. Scheker LR, Severo A. Ulnar shortening for the treatment of early post-traumatic osteoarthritis at the distal radioulnar joint. J Hand Surg Br. 2001 Feb;26(1):41-4. PMID:11162014 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, Sanj Kakar MD, Bobby Chhabra M.D.,

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TAG

(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? Topic

Review Topic

1. 34-year-old female with an ulnar neutral wrist and distal radioulnar joint incongruity
2. 34-year-old female with an ulnar positive wrist and distal radioulnar joint incongruity
3. 34-year-old female with an ulnar negative wrist and distal radioulnar joint incongruity
4. 78-year-old female with ulnar positive wrist and distal radioulnar joint arthritis
5. 78-year-old female with ulnar negative wrist and distal radioulnar joint arthritis

PREFERRED RESPONSE ▶

DISCUSSION: 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

Illustrations: A

REFERENCES:

1. Manske PR(ed): Hand Surgery Update. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 105-115.

2. Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society of Surgery of the Hand, 2003, pp 147-157.

Question Authors:

David Abbasi MD, John Badylak MD, Ben Taylor MD,

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Videos

	Ballottement test Hand - Physical Exam - Ulnocarpal Abutment Syndrome Physical exam showing Ballottement test	2/27/2013 382 views 5
	Ulnar Shortening Osteotomy for Ulna Positive Variance - Dr. Jack Choueka Hand - Surgical Techniques - Ulnocarpal Abutment Syndrome Dr. Jack Choueka performs an ulnar shortening osteotomy for a TFCC tear with uln...	10/14/2012 268 views 4
	TFCC Repair Hand - Surgical Cases - Ulnocarpal Abutment Syndrome TFCC Repair using anchors	1/24/2012 1038 views 1

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Baek GH, Chung MS, Lee YH, Gong HS, Lee S, Kim HH. Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome. Surgical technique. J Bone Joint Surg Am 2006 Sep;88 Suppl 1 Pt 2:212-20. PMID:16951094 (Link to Abstract)
Chun S, Palmer AK. The ulnar impaction syndrome: follow-up of ulnar shortening osteotomy. J Hand Surg Am. 1993 Jan;18(1):46-53. PMID:8423317 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Manske PR(ed): Hand Surgery Update. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 105-115.
Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society of Surgery of the Hand, 2003, pp 147-157.

Undefined

Scheker LR, Severo A. Ulnar shortening for the treatment of early post-traumatic osteoarthritis at the distal radioulnar joint. J Hand Surg Br. 2001 Feb;26(1):41-4. PMID:11162014 (Link to Abstract)

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Ulnocarpal Abutment Syndrome

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