Updated: 5/20/2021

Ulnocarpal Abutment Syndrome

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Questions
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Evidence
11
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  • Summary
    • Ulnocarpal Abutment Syndrome is a common source of ulnar sided wrist pain secondary to excessive impact stress between the ulna and the carpal bones (primarily lunate).
    • Diagnosis is made with PA wrist radiographs showing positive ulnar variance and sclerosis of the lunate.
    • Treatment includes a trial of rest and splinting for minimally symptomatic patients. Operative ulnar shortening procedures are indicated depending on severity of symptoms.
  • Etiology
    • 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 styloid impaction syndrome 
    • 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
      • approach
        • subcutaneous to ulna
      • technique
        • often combined with arthroscopic TFCC repair
Flashcards (0)
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1 of 0
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:

QID: 3042
FIGURES:
1

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

2%

(67/4327)

2

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

51%

(2225/4327)

3

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

2%

(87/4327)

4

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

11%

(464/4327)

5

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

34%

(1464/4327)

L 4 C

Select Answer to see Preferred Response

(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:

QID: 82
FIGURES:
1

Repair of the ulnar styloid nonunion

0%

(18/3632)

2

Darrach resection of the distal ulna

16%

(594/3632)

3

Complete ulnar head resection

3%

(97/3632)

4

Ulnar hemiresection arthroplasty and TFCC reconstruction/repair

74%

(2682/3632)

5

Isolated arthroscopic TFCC reconstruction

6%

(218/3632)

L 2 D

Select Answer to see Preferred Response

(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?

QID: 1371
1

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

1%

(14/2679)

2

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

88%

(2357/2679)

3

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

2%

(53/2679)

4

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

9%

(229/2679)

5

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

0%

(8/2679)

L 1 C

Select Answer to see Preferred Response

Evidence (11)
VIDEOS & PODCASTS (5)
EXPERT COMMENTS (14)
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