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Ulnocarpal Abutment Syndrome

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Topic updated on 02/13/14 4:48pm
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 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 post
    • approach
      • subcutaneous to ulna
    • technique
      • often combined with arthroscopic TFCC repair post

 

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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   B   C      

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 ▶
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 ▶
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 ▶



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