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Updated: May 20 2021

Ulnocarpal Abutment Syndrome

  • 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
    • Lunotriquetral coalition 
  • 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
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