Ulnar impaction syndrome in the ulnar negative and neutral wrist. Diagnosis and pathoanatomy

Treatment of Hand and Wrist Cartilage Defects in Athletes

Cartilage injuries of the hand and wrist can be debilitating in the athlete. Diagnosis is difficult given the broad spectrum of presenting symptomatology. History and physical examination is crucial to achieve the correct diagnosis, and advanced imaging can offer helpful assistance to the clinician as well. TFCC injuries and ulnar impaction syndrome are among the most common conditions in athletes with hand and wrist pain. Treatment of these injuries is initially nonoperative, but elite athletes may elect to bypass nonoperative treatment in favor of earlier return to sport. Surgical treatment varies but can include open and arthroscopic methods. The clinician should tailor treatment plans to each athlete based on level of competition, type of sport, and individual preferences and goals.

Reverse Wafer Procedure for Ulnar Impaction Syndrome

Ulnar impaction syndrome occurs when excessive load across the ulnocarpal joints results in pathologic changes, especially over the articular surface of the ulnar head and proximal ulnar corner of the lunate. The 2 main surgical options in ulnar impaction syndrome are ulnar shortening osteotomy and wafer procedure, whether open or arthroscopically, to decompress the ulnocarpal joint load. However, all of these techniques have their shortcomings and drawbacks. The current study demonstrates a novel technique to decompress the ulnocarpal joint load: the "reverse wafer procedure" for ulnar impaction syndrome. In this surgical technique, we resected the proximal ulnar side of the lunate instead of partial resection of the thin wafer of the distal ulnar head dome in the standard wafer procedure. This technique avoids iatrogenic central tear of triangular fibrocartilage and distal radioulnar joint portal arthroscopy, which is technically demanding while preserving the distal radioulnar joint.

Arthroscopic wafer procedure versus ulnar shortening osteotomy for ulnar impaction syndrome: a systematic review and meta-analysis

PURPOSE

This study aimed to systematically compare the efficacy and safety of arthroscopic wafer procedure (AWP) versus ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS) treatment.

METHODS

All the studies included in this meta-analysis compared the efficacy of AWP to USO for UIS and were acquired through a comprehensive search across multiple databases. The meta-analysis was performed by calculating the effect sizes with the Cochrane Collaboration's RevMan 5.4 software.

RESULTS

A total of 8 articles were included in this analysis, comprising 148 cases in the AWP group and 163 cases in the USO group. The pooled estimates indicated no significant differences in combined Darrow's Criteria or Modified Mayo Wrist Score, Modified Mayo Wrist Score, DASH scores, grip strength, VAS score, and postoperative ulnar variation. On the other hand, the patients in the AWP group exhibited fewer complications (OR = 0.17, 95%CI 0.05-0.54, P = 0.003) and a lower reoperation rate (OR = 0.12, 95%CI 0.05-0.28, P < 0.00001) than those in the USO group.

CONCLUSIONS

The two surgical techniques were both effective in treating UIS but the AWP group showed fewer complications and a lower reoperation rate. Therefore, AWP may present a superior alternative for UIS treatment.

Altered Ulnar Variance With Full-Body Weight-bearing During Handstands With Upper Extremity Weight-bearing CT

PURPOSE

Ulnar variance (UV) is a radiographic measurement relating the articular surface heights of the distal radius and ulna. Abnormal UV increases the risk for wrist pathology; however, it only provides a static measurement of an inherently dynamic bony relationship that changes with wrist position and loading. The purpose of this study was to investigate how full-body weight-bearing affects UV using weight-bearing computed tomography (WBCT).

METHODS

Ten gymnasts completed two 45-second scans inside a WBCT machine while performing a handstand on a flat platform (H) and parallettes (P). A non-weight-bearing CT scan was collected to match clinical practice (N). Differences in UV between weight-bearing conditions were evaluated separately for dominant and nondominant sides, and then, UV was compared between weight-bearing conditions on pooled dominant/nondominant data.

RESULTS

Pooled analyses comparing weight-bearing conditions revealed a significant increase in UV for H versus N (0.58 mm) and P versus N (1.00 mm), but no significant change in UV for H versus P (0.43 mm). Significant differences in UV were detected for H versus N, P versus N, and H versus P for dominant and nondominant extremities. The change from N to H was significantly greater in the dominant versus nondominant side, but greater in the nondominant side from N to P.

CONCLUSIONS

Ulnar variance changed with the application of load and position of the wrist. Differences in UV were found between dominant and nondominant extremities.

CLINICAL RELEVANCE

Upper extremity loading patterns are affected by hand dominance as defined by a cartwheel and suggest skeletal consequences from repetitive load on a dominantly used wrist. Although statistically significant, subtle changes detected in this investigational study do not necessarily bear clinical significance. Future WBCT research can lead to improved diagnostic measures for wrist pathologies affected by active loading and rotational wrist behavior.

Ulnar-Sided Sclerosis of the Lunate Does Not Affect Outcomes in Patients Undergoing Volar Locking Plate Fixation for Distal Radius Fracture

BACKGROUND AND AIM

Radial shortening after distal radius fracture causes ulnar impaction, and a mild reduction loss of radial height occurs even after volar locking plate fixation. This study aimed to determine whether preoperative ulnar-sided sclerosis affects clinical outcomes after volar locking plate fixation for distal radius fracture (DRF).

METHOD

Among 369 patients who underwent volar locking plate fixation for DRF, 18 with preoperative ulnar-sided sclerosis of the lunate were included in Group A and compared to a 1:4 age-, sex- and fracture-pattern-matched cohort without sclerosis (72 patients, Group B). The visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and grip strength were assessed as clinical outcomes. Ulnar variance (UV), radial inclination, radial length, and volar tilt at two weeks after surgery and the final follow-up were measured as radiographic outcomes.

RESULTS

The mean VAS and DASH scores and grip strength did not differ between the two groups. The mean UV at two weeks after surgery and the last follow-up was significantly higher in Group A. The mean changes in UV were +0.62 mm in Group A and +0.48 mm in Group B. There were no significant intergroup differences. Neither UV nor its changes showed any association with DASH and VAS scores.

CONCLUSIONS

Preoperative ulnar-sided sclerosis of the lunate did not affect clinical outcomes after volar locking plate fixation, even if UV increased postoperatively.

Pronated Grip View With Wrist Deviation: A Pilot Study on the Effect on Ulnocarpal Relationships

BACKGROUND

We hypothesize that different positions of the wrist in the coronal plane makes the carpus susceptible to ulnar impaction.

METHODS

We prospectively enrolled 10 adult volunteers and obtained fluoroscopic images of each wrist in 12 different positions using a standardized protocol. Distances from the ulna to the lunate (UL) and ulna to the triquetrum (UT) were digitally measured as was the portion of the lunate surface area that was uncovered (LUR) with wrist deviation.

RESULTS

A wrist position of Pronation, Neutral Deviation, and Grip (P-ND-G) significantly shortened the ulnocarpal distance when compared to a position of Neutral Rotation, Neutral Deviation, and No Grip (NR-ND-NG). Radial deviation during pronation and gripping (Pronated, Radial Deviation, Gripping [P-RD-G]) resulted in the lowest mean UL distance (1.2 mm). UT distance was minimized by a position of ulnar deviation during a pronated grip (Pronated, Ulnar Deviation, Gripping [P-UD-G]) (3.1 mm). The lunate becomes more uncovered with radial deviation.

CONCLUSION

Radial deviation minimizes the UL distance while ulnar deviation minimizes the UT distance during a wrist position of pronation and gripping. Further, there is more proximal lunate surface area uncoverage during all positions of radial deviation compared to ulnar deviation.

Is metaphyseal ulnar shortening osteotomy superior to diaphyseal ulnar shortening osteotomy in the treatment of ulnar impaction syndrome? A meta-analysis

BACKGROUND

Although metaphyseal ulnar shortening osteotomy (MUSO) is safer for the treatment of ulnar impaction syndrome (UIS) than diaphyseal ulnar shortening osteotomy (DUSO), DUSO is widely used for UIS treatment.

AIM

To evaluate the effectiveness of DUSO and MUSO for UIS treatment and determine the factors that should be considered when choosing surgical treatment for UIS.

METHODS

Articles comparing the effectiveness of DUSO and MUSO for UIS treatment were systematically retrieved from MEDLINE (Ovid), PubMed, EMBASE, and Cochrane Library. The demography, incidence of complications, secondary operation rate, postoperative DASH score, wrist pain on the visual analogue scale, and grip strength improvement were also evaluated. In addition, the correlation between the improvement of grip strength and the shortening of osteotomy length of ulna was analyzed. The outcome of the patient was discontinuous, and the odds ratio, risk ratio (RR), and 95%CI were calculated and analyzed via RevMan5.3 software.

RESULTS

Six studies, including 83 patients receiving MUSO (experimental group) and 112 patients receiving DUSO (control group), were included in the meta-analysis. The second operation rate was significantly higher after DUSO than after MUSO. The DASH scores were slightly lower in the MUSO group than in the DUSO group. The patients receiving MUSO had slightly better pain relief effect than patients receiving DUSO. However, the incidence of complications and improvement of grip strength were not significantly different between the two groups.

CONCLUSION

Although DUSO and MUSO provide similar effects for UIS, MUSO is associated with a lower secondary operation rate, slightly lower postoperative DASH scores and slightly better pain relief effect than DUSO, indicating that MUSO can effectively be used for UIS treatment.

Ulnar shortening osteotomy for posttraumatic ulnar impaction syndrome in adolescent (younger than 18 years) - Based on the Cha & Shin assessment

PURPOSE

We performed ordinary ulnar shortening osteotomy (USO) in patients younger than 18 years old with secondary ulnar impaction syndrome (UIS) after traumatic events. Here, we report the clinical and radiologic outcomes with a review of the previous literature through a retrospective case series.

METHODS

Twenty-two adolescents treated by USOs from 2006 to 2018 were investigated. The amount of shortening was classified into three categories. The first category was for a still open physis on the medial half of the radius in those younger than 15. In this category, we osteotomized the ulna for the physis level to be left neutral or negative by 1-2 mm. The second category had no growth potency in the radius. If the patient was younger than 15, we considered only residual growth of the ulna, thus performing USO for the ordinary UV to be negative by 2-3 mm. For patients aged 15-18 years old, if growth potency was nearly absent in the ulna, we performed traditional USO with a neutral ulnar variance (UV).

RESULTS

Categories 1, 2, and 3 for the amount of USO were determined for 4, 4, and 14 patients, respectively. All USOs properly healed without substantial complications. The mean preoperative UV was 2.91 mm, and the final value decreased to 0.23 with statistical significance (p < 0.001). The range of wrist motion was improved after USO from 133.86° and 132.73° to 154.77° and 160.68° (all, p < 0.001 in flexion-extension and pronation-supination arcs, respectively). The preoperative VAS and MMWS scores also improved from 2.77 to 75.00 to 0.18 and 88.86, respectively, at the final follow-up (all, p < 0.001).

CONCLUSIONS

UIS in adolescent populations after trauma in their children/younger adolescents could be properly treated by USO. Even with an open physis at the ulna, neutral UVs could be achieved, and the clinical outcomes were satisfactory. However, long-term follow-up is still needed regarding TFCC and DRUJ status.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Ulnar shortening osteotomy vs. wafer resection for ulnar impaction syndrome: A systematic review and meta-analysis

BACKGROUND

Ulnar shortening osteotomy (USO) is the most common operation to treat ulnar impaction syndrome (UIS). An alternative to USO is the arthroscopic wafer procedure (AWP). Few studies have directly compared USO and AWP in patients with UIS. This study compared ulnar shortening osteotomy (USO) versus arthroscopic wafer procedure (AWP) for UIS treatment.

MATERIALS AND METHODS

PubMed, EMBASE, the Cochrane Library, Wanfang, and CNKI were systematically searched for reports published before March 2021. The outcomes included Modified Mayo Wrist Score, Darrow's Criteria, Disability of Arm, Shoulder, and Hand (DASH), grip strength, visual analog scale (VAS) score, and time to resume manual occupation.

RESULTS

Seven studies (133 and 118 patients with USO and AWP, respectively) were included. There were no differences in combined Darrow's Criteria or Modified Mayo Wrist Score, Modified Mayo Wrist Score, Darrow's Criteria, revision rate, DASH score, VAS score, and time to resume manual occupation. Grip strength was better with AWP (SMD = -0.73, 95%CI: -1.36, -0.11, P = 0.022). Differences were seen for ulna positive variation, favoring USO (WMD = -2.75, 95%CI: -5.17, -0.33, P = 0.026).

CONCLUSIONS

In the surgical treatment of UIS, AWP might be associated with improved grip strength, while USO seems to show better results in treating pronounced ulna positive variation. Only evidence of moderate quality could be included in this meta-analysis.

Bone Morphology in Ulnar Impaction Syndrome: A Radiographic Evaluation

Background: Positive ulnar variance (UV) may be associated with a higher incidence of ulnar impaction syndrome (UIS). However, neutral and/or negative UV has also been associated with the development of UIS; therefore, other risk factors may be involved. The purpose of this study was to compare radiological bone morphology in patients with UIS and asymptomatic controls. Methods: Between 2009 and 2018, posteroanterior wrist radiographs of 47 wrists in 45 patients diagnosed with UIS were compared with those of 163 wrists in 93 asymptomatic patients from the control group. The following parameters were obtained: ulnar variance (UV); ulnar head top-fovea distance (UTFD); capitate-triquetrum distance (CTD); radio-lunate distance (RLD) and lunate coverage ratio (LCR). The morphology of the lunate was classified based on the absence (type I) or presence (type II) of a medial facet that articulates with the hamate. The radiographic parameters and lunate types were compared between the two groups. We then divided the groups into two subgroups: the positive UV subgroup and the neutral/negative UV subgroup. In each subgroup, the radiographic parameters and lunate types were compared between the UIS and control groups. Results: In the UIS group, the UV and UTFD were significantly increased compared to those in the control group. The proportion of type II lunates was significantly higher in the UIS group than in the control group. In addition, the type II lunate was more common in the UIS group in both the positive UV and negative UV groups. Conclusions: Our study suggests that in addition to positive UV, ulnar head morphology with an increased UTFD and type II lunate morphology may be associated with the development of ulnar impaction syndrome. Level of Evidence: Level III (Diagnostic).

Arthroscopic Anatomy of the TFCC with Relevance to Function and Pathology

Introduction  The authors present a new comprehensive arthroscopic anatomical description of the fibrocartilage complex "TFCC" which is related to the current TFCC functional and pathological knowledge. Methods  Our description of the TFCC is based on an arthroscopic view from the 3-4 portal as observed in more than 100 wrist arthroscopies in fresh cadavers and more than 1000 diagnostic and/or therapeutic wrist arthroscopies. Results  TFCC is considered as a 3-D-3-part box-like structure (Reins, Wall and Disc). The first TFCC component ("R") corresponds to 2 strong radio-ulnar ligamentous Reins, one dorsal (DRUL) and one palmar (PRUL). This "V-shaped" RUL reins diverge from the fovea and ulnar styloid to the volar and dorsal edges of the sigmoid notch. It is a main stabilizer of the DRUJ. The second TFCC component ("W") is a continuous, radially concave Peripheral Capsular Wall attached and perpendicular to the RUL reins. It surrounds the ulnar aspect of the ulno-carpal interval while attaching to the RUL reins proximally and to the medial carpus distally. Along with the radiocarpal ligaments, the TFCC peripheral capsular wall contributes to the stability of the carpus with respect to the radius-ulna entity. This is especially true for the thick volar TFCC capsular wall. The third TFCC component ("D") is the disc proper which is a static and dynamic shock absorber intercalated between the ulnar head and the medial proximal row in the coronal/sagittal planes and between the two strands of the RUL in the axial plane. Its pathology is influenced and related to the ulnar variance. Discussion  This new arthroscopic description of the TFCC provides a comprehensive anatomical, functional ant pathological background for TFCC disorders analysis and treatment. Currently known disorders are included as "R 1,2,3,4", "W 1, 2, 3, 4", and "D 1, 2". Combined TFCC disorders and further new pathology descriptions may be included in this open classification.

Ulnocarpal Impaction

Ulnocarpal impaction syndrome is a common cause for ulnarsided wrist pain caused by an abutment between the ulnar head and the lunotriquetral complex. This pain is typically triggered by load bearing and rotation of the forearm. Radiographic examination is often associated with positive ulnar variance and cysts in the lunate, edema of the ulnoproximal lunate is shown in MRI. Operative treatment aims to reduce load on the lunate, either by open ulnar shortening osteotomy or arthroscopic wafer procedure.

Stress distribution pattern in the distal radioulnar joint before and after ulnar shortening osteotomy in patients with ulnar impaction syndrome

Ulnar shortening osteotomy (USO) for ulnar impaction syndrome potentially leads to degenerative changes of the distal radioulnar joint (DRUJ). This study was performed to evaluate the effect of the sigmoid notch morphology on the stress distribution pattern of the DRUJ using computed tomography (CT) osteoabsorptiometry (CT-OAM). We reviewed the pre- and postoperative transverse CT images of 15 wrists that had undergone USO. The examined wrists were classified into two groups based on the sigmoid notch morphology: the linear-type notch (type L) and the curved-type notch (type C). We calculated and statistically compared the percentage of the high-density area (%HDA) in each divided region of the sigmoid notch. In type L, %HDA was significantly larger in the distal-dorsal region of the sigmoid notch before USO. Postoperatively, in type L, no specific regions showed a significantly different %HDA. In type C, %HDA was significantly larger in the distal-volar region of the sigmoid notch before USO. Postoperatively, %HDA of type C was significantly larger in the proximal-volar region. Our results suggest that in patients with ulnar impaction syndrome, morphological evaluation of the sigmoid notch can serve as a predictor of osteoarthritis in the DRUJ with or without USO.

Influence of TFCC foveal tear on the location of lunate chondromalacia in ulnar impaction syndrome

OBJECTIVE

The purpose of this study was to identify the location of lunate chondromalacia and to compare the difference in location according to presence or absence of triangular fibrocartilage complex (TFCC) foveal tear, which induces distal radioulnar joint (DRUJ) instability.

METHODS

We performed a retrospective study of 97 patients (102 wrists) who were diagnosed with and treated for idiopathic ulnar impaction syndrome (UIS) between 2014 and 2018. Subjects were divided into two groups according to presence or absence of TFCC foveal tear with DRUJ instability. Group I had UIS without a TFCC foveal tear (52 wrists, mean age of 43.2 years), while Group II had UIS with a TFCC foveal tear (50 wrists, mean age of 45.3 years). There was no significant difference in age, sex, or duration of symptoms between the two groups. All patients underwent wrist MR Arthrography (MRA) in the same gantry, and all scanned coronal sections of the lunate were standardized into 10 slices, including the whole anteroposterior width of the lunate. Each slice was sequentially numbered from dorsal to volar side, and the location of chondromalacia was marked in each numbered section. Radiological parameters including ulnar variance and ulnolunate distance (ULD), which indicated the distance between the ulnar head and lunate, were measured in the wrist series.

RESULTS

The most frequent location of lunate chondromalacia was slightly to the volar side of the lunate in both groups. Group I showed a higher frequency of chondromalacia in the volar side of the lunate. In Group II, chondromalacia was identified with high frequency not only on the volar side of the lunate but also on the dorsal side. In other words, Group II showed broader chondromalacia in the lunate. There was no significant difference in ulnar variance (Group I, 3.19 ± 1.42 mm; Group II, 2.76 mm ± 1.67 mm) or ulnolunate distance (Group I, 1.66 ± 0.94 mm; Group II, 2.05 mm ± 0.87 mm). The average ULD decreased during radial deviation but increased during ulnar deviation.

CONCLUSION

This study showed that lunate chondromalacia associated with idiopathic ulnar impaction syndrome occurs more frequently on the volar side of the lunate. Also, TFCC foveal tear, which causes DRUJ instability, leads to broader lunate chondromalacia in idiopathic ulnar impaction syndrome. Therefore, further analysis of the pattern of lunate chondromalacia can provide a clue for DRUJ instability.

Outcomes following Distal Radius Fractures with Preexisting Ulnocarpal Abutment

Background  Due to the commonality of distal radius fractures (DRFs), the potential impact of ulnocarpal abutment (UA) on patient outcomes is significant, whether it developed after or prior to injury. It is, therefore, important to consider whether preexisting UA has any impact on outcomes after an acute DRF. Questions/Purpose  The aims of this study were to determine if differences were present in (1) pain at final follow-up, (2) complications, and (3) unintended operations in patients with DRFs and either without or with preexisting radiographic UA. Methods  A single institution retrospective cohort study comparing patients treated either nonoperatively (43 patients) or operatively (473 patients) for DRFs between 5/1/2008 to 5/1/2018 was performed. Data included demographics, prior wrist pain or surgery, ulnar variance, select treatment data, and presence of pain, complication, or unintended operation by final follow-up. Statistical testing used Fisher's exact test and chi-squared test, with a significance level of 0.05. Results  The prevalence of preexisting UA was 14.0 and 15.6% in the nonoperatively- and operatively treated groups, respectively. In nonoperatively treated patients without or with UA, no differences in pain (37.8 vs. 33.3%, p  = 1.00) or complications were seen (13.5 vs. 50.0%, p  = 0.07). A higher unintended operation rate for nonoperatively treated DRFs with UA, compared with those without, UA was seen (5.4 vs. 50.0%, p  = 0.01). No differences in pain, complications, or unintended operations were seen between those without and with UA in the operatively treated group. Conclusion  Preexisting UA is not associated with pain, complications, or unintended operations after operative treatment of DRFs. Prospective studies further evaluating outcomes in nonoperatively treated DRFs with UA may be beneficial.

Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome

Post-traumatic or constitutional ulnar impaction syndrome can be treated by shortening the ulna. This can be achieved by diaphyseal or metaphyseal osteotomy, or by arthroscopic epiphyseal resection. The objective of this study was to compare the results of the diaphyseal shortening osteotomy (USO) and arthroscopic wafer procedure (AWP) of the ulna in this indication. This was a retrospective case series of 33 patients operated for ulnar impaction syndrome by the same surgeon between 1997 and 2017. The diagnosis was made based on pain on the ulnar edge of the wrist with positive provocative tests. Radiographs were made and CT arthrography or MRI were used to confirm the diagnosis. Per-and post-operative assessments were functional (DASH and PRWE scores), clinical (pain, range of motion and grip strength) and radiographic. Diaphyseal ulnar shortening osteotomy (USO) was performed in 9 patients using a volar plate and a cutting guide. Twenty-four patients underwent an arthroscopic wafer procedure. Mean follow-up was 103 ± 8 months in the USO group versus 55 ± 4 months in the AWP group. There was no significant difference between groups in pain levels (1.2/10 in the USO group versus 0.9/10 in the AWP group, p = 0.88), grip strength (39 Kg in the USO group versus 34 Kg in the AWP group, p = 0.27) and PRWE score (5,8/100 in the USO group versus 11,2 in the AWP group, p = 0.34), and DASH score (25/100 in the USO group versus 28 in the AWP group, p = 0.63). The time away from work was long in the USO group than in the AWP group (7.86 months versus 3.75 months) (p = 0.002). Seven patients were reoperated in the USO group (5 plate removal, 1 nonunion and 1 delayed union) versus 3 in the AWP group (1 ECU stabilization, 1 ablation for painful ulnar styloid due to nonunion and 1 wrist denervation) (p = 0.0004). The study found no clinical differences between these two techniques except the return to work time. In our series, diaphyseal USO was associated with a greater number of reoperations than the AWP.

Wrist Arthroscopy in Athletes

Arthroscopy is a surgical technique whose indication for wrist injuries has grown in recent years. Athletes are subject to traumatic injury to the wrist due to training overload or the intensity of the activity during competition. The need of a quick return to sports practice makes arthroscopy a very useful minimally invasive technique in these situations. The authors present indications of sports-related injuries to the wrist that can be treated by arthroscopy. A literature review is also presented.

An In Vitro Study to Determine the Effect of Ulnar Shortening on Distal Forearm Loading During Wrist and Forearm Motion: Implications in the Treatment of Ulnocarpal Impaction

PURPOSE

To evaluate the effect of ulnar shortening on distal forearm loading following simulated dynamic motion.

METHODS

Ulnar shortening was simulated using a custom-built adjustable implant to simulate up to 4 mm of ulnar shortening (-4 mm) in 9 cadaveric extremities. Load cells were placed in the distal ulna and radius to quantify axial loading. Using a wrist and forearm motion simulator, absolute and percentage loads were measured during dynamic flexion, ulnar deviation (UD), flexion dart throw (DT), and pronation.

RESULTS

There was a significant decrease in absolute and percentage distal ulnar loads at each interval of ulnar shortening during flexion, UD, DT, and pronation. The distal ulna bore no compressive loads, and in fact, tensile loads were measured in the ulna at 2 mm of ulnar shortening during DT and pronation, at 3 mm during flexion, and at 4 mm during UD.

CONCLUSIONS

A progressive decrease in distal ulnar loads with generation of tensile loads was observed with sequential ulnar shortening.

CLINICAL RELEVANCE

Ulnar shortening greater than 2 mm can result in tensile loading in the distal ulna. When managing ulnar impaction syndrome, excessive shortening may not be required to provide relief of symptoms.

Nonunion Rates Among Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome: A Systematic Review

PURPOSE

The purpose of this study was to systematically review all available literature reporting nonunion rates of ulnar-shortening osteotomies (USO) used for the treatment of ulnar impaction syndrome (UIS) and to compare those rates among transverse versus oblique cuts for the osteotomy.

METHODS

Electronic databases including PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies that evaluated outcomes of both transverse and oblique USO for UIS. Level of evidence was determined by 2 independent reviewers. Studies were screened based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and inclusion and exclusion criteria were applied. A total of 37 studies (1,423 patients) were included in final analysis. The average rate of nonunion and delayed union for each group (transverse and oblique osteotomy) was calculated.

RESULTS

The average rate of nonunion among all osteotomies was 4.0%. The average rate of nonunion was 4.16% and 3.86% in transverse osteotomies and oblique osteotomies, respectively. This difference was not statistically significant. The average rate of delayed union, in those studies that reported delayed union, was 5.7%. The average rate of delayed union was 7.41% and 4.1% in transverse osteotomies and oblique osteotomies, respectively.

CONCLUSIONS

Based on our review of the literature, there is no difference in the rate of nonunion between transverse and oblique osteotomies. Therefore, the decision of which of the 2 surgical techniques should not be based on rate of nonunion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Lunate subchondral cysts: Are there specific radiologic findings for patients with symptomatic ulnocarpal impaction?

BACKGROUND

There are few clinical studies evaluating the relationship between lunate cysts and symptomatic ulnar impaction syndrome (UIS). The purpose of this study was to investigate the prevalence and relationship between lunate cysts and UIS by comparing data from patients with UIS against those without.

MATERIALS AND METHODS

From March 2012 to January 2015, 375 patients who had undergone MRI or CT for reasons other than ulnar-sided wrist pain were classified into the 'asymptomatic group' (Group I). Thirty three patients who had been diagnosed with UIS were classified in the 'UIS group' (Group II). We determined whether any differences were present between the two groups and evaluated prognostic factors for lunate cysts.

RESULTS

The prevalence of lunate cysts was significantly higher in Group II but only reached just above 50% (10.4% vs. 57.6%, p < 0.001]. Dorsal-side lunate cysts were more frequent than palmar side in Group I, while Group II had more cysts on the palmar side (74.4% vs. 52.6%, p = 0.001). Logistic regression analysis revealed that UIS and patient age was a significant factor for the presence of lunate cysts (odds ratio: 11.692, p < 0.001; odds ratio: 1.063, p < 0.001, respectively). However, positive ulnar variance or duration of symptom in Group II was not a predisposing factor for lunate cysts (odds ratio: 1.035, p = 0.598; odds ratio: 1.007, p = 0.877, respectively).

CONCLUSION

Since positive ulnar variance or duration of symptom did not affect the formation of the lunate cyst and only slightly more than 50% (57.6%) of patients with UIS had a lunate cyst, it seems unlikely that these cysts are a pathognomonic finding. Surgeons can obtain some evidence from lunate cysts on radiographic exams, but care must be taken that this diagnosis is not made hastily or without due consideration.

During forearm rotation the three-dimensional ulnolunate distance is affected more by translation of the ulnar head than change in ulnar variance

Ulnolunate abutment has been thought to be aggravated by pronation because of an increase in ulnar variance. We hypothesized that the ulnolunate distance might be greater in pronation because the ulnar head is dorsally translated. Twenty-one three-dimensional reconstructions of computed tomographic scans of wrists taken in supination and pronation were investigated. The ulnolunate distance was measured in each position, and the change in ulnolunate distance from supination to pronation was calculated. The changes in ulnar variance from supination to pronation and the amount of translation of the ulnar head were measured directly by superimposing three-dimensional reconstructions. The mean ulnolunate distance in pronation was significantly greater than in supination. There was no significant correlation between the changes in ulnolunate distance and in the ulnar variance. The change in ulnolunate distance had a significant positive linear relationship with the amount of translation of the ulnar head. The change in ulnolunate distance during forearm rotation is determined by the amount of translation of the ulnar head rather than by change in ulnar variance. Level of evidence: IV.

Current perspectives in conventional and advanced imaging of the distal radioulnar joint dysfunction: review for the musculoskeletal radiologist

Distal radioulnar joint (DRUJ) dysfunction is a common cause of ulnar sided wrist pain. Physical examination yields only subtle clues towards the underlying etiology. Thus, imaging is commonly obtained towards an improved characterization of DRUJ pathology, especially multimodality imaging, which is frequently resorted to arrive at an accurate diagnosis. With increasing use of advanced MRI and CT techniques, DRUJ imaging has become an important part of a musculoskeletal radiologist's practice. This article discusses the normal anatomy and biomechanics of the DRUJ, illustrates common clinical abnormalities, and provides a comprehensive overview of the imaging evaluation with an insight into the role of advanced cross-sectional modalities in this domain.

The severity of ulnar variance compared with contralateral hand: its significance on postoperative wrist function in patients with distal radius fracture

The aim of this study was to detect the severity of ulnar variance (UV) compared with contralateral hand on postoperative wrist function in patients with distal radius fracture. 116 cases with unilateral distal radius fracture were retrospectively analyzed and divided into high or low UV severity groups (Dividing value = 2.5 mm). The following parameters were used to evaluate the effect: palmar tilt, radial inclination, VAS score, DASH score and wrist function. The severity of UV existed widely, accounting for 93.1% (108 cases). The severity of UV correlated with palmar tilt, radial inclination, grip strength, VAS score, DASH score and the wrist function (P < 0.05). Log-rank analysis showed that the severity of UV, palmar tilt, radial inclination were important factors influencing the joint function postoperatively (P < 0.0 5). Multivariate analysis confirmed that the severity of UV was an independent and significant factor on wrist function (P = 0.010). And the palmar tilt was also an important factor influencing wrist function (P = 0.047). The severity of ulnar variance compared with contralateral hand is an independent and significant factor on wrist function, which should be considered as an important step during preoperative plan.

The Role of Triangular Fibrocartilage Complex in Axial Stability of the Forearm

Background  The triangular fibrocartilage complex (TFCC) provides stability to the wrist and disruption of this complex can result in axial instability which can lead to ulnocarpal abutment. Purpose  This article determines the individual contributions of the volar radioulnar ligament (VRUL), dorsal radioulnar ligament (DRUL), and foveal attachment of the TFCC to longitudinal stability of the forearm under axial load. Materials and Methods  Eighteen cadaveric specimens were randomly assigned into three groups representing the component of the TFCC to be initially transected: VRUL, DRUL, and foveal attachment. Prior to transection, posterioranterior radiographs of the wrist were obtained at 0, 44.5, and 90 N of axial load. Serial transection of the TFCC components were performed with radiographs obtained at each of the aforementioned loads. Ulnar variance was assessed with two-way repeated measures analysis of variance and paired t -tests. Results  Transection of the foveal attachment demonstrated a significant change in ulnar variance of 1.5 and 0.6 mm under 45 and 90 N of load, respectively. At 0 N of load, there was no significant change in ulnar variance between an intact wrist and a wrist with all three ligaments transected; however, a significant change in ulnar variance, 1.0 mm, was observed under 90 N of load. Conclusion  The foveal attachment of the TFCC provides the largest contribution to axial stability. Clinical Relevance  The TFCC provides axial stability to the wrist and disruption of the TFCC may result in change in ulnar variance observed on an axial loaded wrist radiograph.

Ulnar variance according to gender and side during aging: An analysis of 600 wrists

BACKGROUND

Ulnar variance, or the difference in height between the joint surfaces of the distal radius and ulna, may play a role in several diseases of the wrist.

HYPOTHESIS

This study was to conduct a detailed analysis of ulnar variance in a wider case series by dividing the patients' radiographs into groups according to age, gender, and side.

MATERIALS AND METHODS

Twenty groups were created in order to investigate the change of ulnar variance according to age, gender, and side. Each group was planned to have 30 wrists. Wrist radiographs were scanned retrospectively, and ulnar variance was measured using the method of perpendiculars. Patients with any arthritic conditions, avascular necrosis, congenital deformities, bone and soft tissue tumors, and previous fractures or surgeries, and those radiographs, which were not at the exact anteroposterior position, and with insufficient technique were not included the study.

RESULTS

Six hundrends wrists (300 males [150 right, and 150 left wrists], and 300 females [150 right, and 150 left wrists]) were included in this study. There was a significant difference between the males (median: 0.4, minimum: -3.8, maximum: 5.1) and females (median: 0.85, minimum: -4.8, maximum: 5.7), regardless of the age and side (p=0.043). In the right wrists only (regardless of age), there was also a significant difference between the males (median: 0, minimum: -3.8, maximum: 5.1) and females (median: 0.8, minimum: -3.9, maximum: 5.7) (p=0.025). No statistically significant differences were found within the males and females with regard to aging, or between the sides in the same sex in any decade. In addition, there were no significant differences between the same sides in the males and females in any decade.

DISCUSSION

Although this study has one of the larger series in the literature, further studies should be done in different populations and ethnicities to obtain more accurate results, and to understand the relationship between ulnar variance and specific wrist disorders.

LEVEL OF EVIDENCE

Level III.

The Effect of Axial Loading on Ulnar Variance

Background  Forearm rotation results in change in ulnar variance. Axial loading of the wrist is required to maintain daily activities. Change in ulnar variance during axial loading has not been investigated previously. Purpose  To measure the change in ulnar variance on axially loaded wrists. Patients and Methods  We examined 21 asymptomatic individuals and 24 patients with unilateral ulnar-sided wrist pain. All patients underwent standard neutral posteroanterior wrist radiographs without load and under axial loading on bilateral wrists. Axial loading was standardized at 18.1 kgf using an analog weight scale. A magnetic resonance (MR) arthrogram was obtained only in patients with ulnar-sided wrist pain. Beighton flexibility score was recorded on healthy volunteers. Change in ulnar variance between 0 and 18.1 kgf was compared for each wrist among all subjects. A correlation was sought between the change in ulnar variance, MR arthrogram findings, and physical examination. Results  In individuals without wrist pain, on average, 0.4 mm increase in ulnar variance was measured between 0 and 18.1 kgf. There was no difference between the dominant and nondominant side. No correlation was found with increasing age. In contrast, patients with ulnar-sided wrist pain displayed an average increase of 0.8 mm in ulnar variance. Compared with the contralateral wrist, more than 1 mm increase in ulnar variance was correlated with intra-articular pathologies including dorsoulnar ligament disruption, central triangular fibrocartilage complex (TFCC) perforation, and foveal detachment. Conclusion  Compared with contralateral side, more than 1 mm increase in ulnar variance is suggestive of longitudinal instability or TFCC pathology. Level of Evidence  Level II, diagnostic.

Editorial Commentary: Wrist Ulnar Impaction Syndrome: When I Use the Wafer Procedure and When I Do Not

Ulnar impaction syndrome is fundamentally a clinical diagnosis, which can be confirmed by magnetic resonance imaging. All palmer stages are amenable to surgical treatment with either arthroscopic wafer procedure (AWP) or ulnar shortening osteotomy, and neither the absence of a triangular fibrocartilage complex perforation nor neutral or negative variance contraindicate either. Because of its minimally invasive value proposition and likely success, there are few clinical scenarios for which I do not perform AWP preferentially. Furthermore, AWP is always preferable in smokers and in wrists in which a divergent orientation of the sigmoid notch and ulnar articular surfaces portend arthritic complication after ulnar shortening.

Arthroscopic Wafer Procedure Versus Ulnar Shortening Osteotomy as a Surgical Treatment for Idiopathic Ulnar Impaction Syndrome

PURPOSE

To compare clinical and radiologic outcomes and complication rates of the arthroscopic wafer procedure (AWP) and ulnar shortening osteotomy (USO) for idiopathic ulnar impaction syndrome (UIS).

METHODS

From May 2009 to June 2014, 42 patients who were aged 45 years or older with idiopathic UIS underwent either the AWP or USO under the following identical surgical indications: (1) less than 4 mm of positive ulnar variance, (2) Palmer classification 2C or 2D lesion of the triangular fibrocartilage complex, (3) stable distal radioulnar joint (DRUJ) and/or lunotriquetral joint, and (4) no evidence of osteoarthritis of the DRUJ or ulnocarpal joint. The patient assignment was not randomized. Were used a visual analog scale for ulnar wrist pain; grip strength; range of motion; the Mayo Wrist Score (MWS); and the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3, 6, 12, and 24 months after surgery to compare clinical outcomes. Ulnar variance, cystic changes of the lunate and triquetrum, and DRUJ arthritis on radiographs and operation-related complications were compared.

RESULTS

This study evaluated 19 patients after the AWP and 23 patients after USO. At 3 months, the AWP produced significantly better outcomes than USO regarding grip strength (79.6% ± 14.3% vs 62.7% ± 12.6%, P < .001), MWS (81.8 ± 7.9 points vs 71.3 ± 14.2 points, P = .005), and DASH score (19.4 ± 8.4 vs 31.5 ± 14.0, P = .001); clinical outcomes were similar at 6, 12, and 24 months. The complication rates were 34.8% for USO and 10.5% for the AWP; complications included DRUJ arthritis (n = 4), implant irritation (n = 6), and refracture after implant removal (n = 2) in the USO group and secondary surgery (n = 1) and tendinopathy (n = 1) in the AWP group.

CONCLUSIONS

The AWP and USO for idiopathic UIS with subtle positive ulnar variance achieved similar clinical and radiologic outcomes at 2 years after surgery. However, compared with USO, the AWP showed lower complication rates and better grip strength, MWS values, and DASH scores at 3 months after surgery.

LEVEL OF EVIDENCE

Level III, comparative trial.

Arthroscopic Management of Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome

Both ulnocarpal impaction syndrome and ulnar styloid impaction syndrome can produce ulnar wrist pain. The definition and clinical differentiation are explained. The relevant anatomy, biomechanics, causes, diagnosis, and arthroscopic treatments, as well as the surgical indications, techniques, and outcomes of these syndromes are discussed in detail.

Dynamic ulnar impaction syndrome in tennis players: report of two cases

In this report, two tennis players with symptoms of ulnar impaction syndrome are reviewed. Both players have neutral ulnar variance. These cases represent dynamic ulnar impaction syndrome, when the impact between ulna and carpus occurs during conditions of pronated grip. The literature and the treatment of these two cases are discussed.

Microfracture for Ulnar Impaction Syndrome: Surgical Technique and Outcomes with Minimum 2-Year Follow-up

Purpose The purpose of this study is to assess functional and patient-reported outcomes after lunate microfracture for management of lunate chondral lesions in the setting of ulnar impaction syndrome. Methods This was a retrospective review of all patients undergoing wrist arthroscopy for triangular fibrocartilage complex pathology by one surgeon from 2007 until 2010. Disabilities of the arm, shoulder, and hand (DASH) scores were assessed preoperatively and at minimum 2-year follow-up. Patient-rated wrist evaluation and bilateral wrist range of motion, grip strength, and key pinch strength were assessed at final follow-up. Results A total of 22 patients underwent microfracture of the carpus during the study period, of which 7 met all inclusion and exclusion criteria. Mean DASH scores improved significantly (p < 0.001), from 58.3 (standard deviation: 13.5) before the procedure to 15.1 (standard deviation: 8.6) at minimum 2-year follow-up. Operative wrist pronation and supination showed equivalence with the contralateral wrist at final follow-up (p < 0.05, E = 15 degrees, standard deviation pronation: 3.25, supination: 3.49). Discussion This study suggests that lunate microfracture may be a useful technique for treating articular defects of the lunate in the setting of ulnar impaction syndrome. Type of Study/Level of Evidence Therapeutic, level IV.

The Shape of the Triangular Fibrocartilage During Pronation–Supination

We studied the changes in the shape of the triangular fibrocatilage (TFC: disc proper) which occur during forearm rotation in disarticulated and articulated wrists. The influence of artificial 3 mm ulnar lengthening on distortion of the disc was also examined. In the disarticulated wrists, slight distortion of the central and radial portions of the TFC was observed in the ulnar neutral variance specimens. More distortion was noted in the radial and central portions of the TFC in specimens with positive ulnar variance or with the ulna lengthened. However, in the articulated wrist, the TFC demonstrated little change in shape during pronosupination even in the ulnar positive variance wrists or with the ulna lengthened. There was no significant change in palmar and dorsal peripheral lengths of the TFC in ulnar neutral, ulnar positive or ulna-lengthened specimens at three rotatory positions of the forearm. These findings suggest that changes in ulnar variance which occur during forearm rotation can produce distortion on the TFC, but the carpus helps to maintain the shape of the TFC during pronation–supination, even with positive ulnar variance.

Imaging of Sports-related Hand and Wrist Injuries: Sports Imaging Series

Hand and wrist injuries are common occurrences in amateur and professional sports and many of them are sport-specific. These can be divided into two categories: traumatic injuries and overuse injuries. The aim of this article is to review the most common hand and wrist sports-related lesions. Acute wrist injuries are predominantly bone fractures, such as those of the scaphoid, hamate hook, and ulnar styloid. Ligament lesions are more challenging for radiologists and may lead to carpal instability if undiagnosed. Overuse wrist injuries are mainly represented by tendinous disorders, with De Quervain syndrome and extensor carpi ulnaris tendon disorders being the most common among them; however, there are other possible disorders such as impaction syndromes, stress fractures, and neurovascular lesions. Finally, finger lesions, including closed-tendon injuries (mallet and boutonniere injuries, jersey finger, and boxer's knuckle), flexor pulley injuries, and skier's thumb, should also be detected. (©) RSNA, 2016 Online supplemental material is available for this article.

Ulnar-Sided Wrist Pain due to Long Ulnar Styloid: A Case Report

Ulnar styloid impaction syndrome involves repetitive friction between an excessively long ulnar styloid and the carpus, resulting in chondromalacia, synovitis, and pain. The arthroscopic diagnosis, evaluation, and management of this syndrome are not well characterized. We present a patient with chronic wrist pain of unknown origin, culminating with arthroscopic findings demonstrating substantial loss of articular cartilage on both the lunate and triquetrum. The patient successfully underwent operative ulnar styloid excision, ultimately resolving chronic wrist pain symptomology.

Ulnar impaction syndrome: Managed by wrist arthroscopy

BACKGROUND

The development of handicraft industry and increase of various such works that need a large amount of repeated wrist ulnar deviation strength, the incidence of ulnar impaction syndrome (UIS) is increasing, but the traditional simple ulnar shortening osteotomy has more complications. This study aimed to explore the early diagnostic criteria of UIS and its wrist arthroscopic treatment experience.

MATERIALS AND METHODS

9 UIS patients were enrolled in this study. According to magnetic resonance imaging, X-ray and endoscopic features, the diagnostic criteria of UIS were summarized and the individualized treatment schedule was made. If the ulnar positive variance was less than 4 mm, the arthroscopic wafer resection was performed. If the ulnar positive variance was more than 4 mm, the arthroscopic resection of injury and degenerative triangular fibrocartilage complex and ulnar osteotomy were conducted.

RESULTS

In all patients, the wound healed without any complications. All patients returned to normal life and work, with no ulnar wrist pain again. One patient had wrist weakness. There was a significant difference of the wrist activity between the last followup and before operation (P < 0.05). According to the modified wrist function scoring system of Green and O'Brien, there were 6 cases of excellent, 2 cases of good and 1 case of appropriate and the overall excellent and good rate was 92.3%.

CONCLUSION

In the treatment of UIS, the arthroscopy can improve the diagnosis rate, optimize the treatment plan, shorten the treatment cycle, with good treatment results.

Operative treatment of ulnar impaction syndrome: a systematic review

This article critically and systematically reviews the surgical treatments for ulnar impaction syndrome. Three types of treatments currently exist: arthroscopic wafer procedure, open wafer procedure, and ulna shortening osteotomy. A total of 36 articles were included from searching the electronic databases PubMed MEDLINE, Ovid MEDLINE, and Ovid EMBASE. Studies were evaluated for quality using the Modified Detsky Score. Of these, 14 articles had a Modified Detsky Score of 6/10 or higher. Satisfaction rates were 100% for arthroscopic wafer procedure, 89% for open wafer procedure, and 84% for ulna shortening osteotomy. The percentage of participants reporting an excellent or good outcome was 82% for arthroscopic wafer procedure, 87% for open wafer procedure, and 76% for ulna shortening osteotomy. In conclusion, available evidence shows that arthroscopic wafer procedure and open wafer procedure may be viable alternatives to the more popular ulna shortening osteotomy, but clinical superiority is yet to be established. Future research should focus on prospective cohort methods and should report participant outcomes using validated scoring methods.

A comparison of 3-D computed tomography versus 2-D radiography measurements of ulnar variance and ulnolunate distance during forearm rotation

Positive ulnar variance is associated with ulnar impaction syndrome and ulnar variance is reported to increase with pronation. However, radiographic measurement can be affected markedly by the incident angle of the X-ray beam. We performed three-dimensional (3-D) computed tomography measurements of ulnar variance and ulnolunate distance during forearm rotation and compared these with plain radiographic measurements in 15 healthy wrists. From supination to pronation, ulnar variance increased in all cases on the radiographs; mean ulnar variance increased significantly and mean ulnolunate distance decreased significantly. However on 3-D imaging, ulna variance decreased in 12 cases on moving into pronation and increased in three cases; neither the mean ulnar variance nor mean ulnolunate distance changed significantly. Our results suggest that the forearm position in which ulnar variance increased varies among individuals. This may explain why some patients with ulnar impaction syndrome complain of wrist pain exacerbated by forearm supination. It also suggests that standard radiographic assessments of ulnar variance are unreliable.

Ulnar impaction syndrome: incidence of lunotriquetral ligament degeneration and outcome of ulnar-shortening osteotomy

PURPOSE

We hypothesized that most patients with ulnar impaction syndrome have degenerative changes of the proximal lunotriquetral (LT) membrane and that ulnar-shortening osteotomy is an effective procedure in these patients.

METHODS

We retrospectively reviewed 50 wrists of 49 patients with idiopathic ulnar impaction syndrome who underwent an arthroscopic evaluation at the time of ulnar-shortening osteotomy, and subsequently at plate removal. Based on the Geissler classification, patients were divided into group A, normal, and group B, grades I to IV. The degree of degeneration of the proximal LT membrane at first-look arthroscopy was compared with that at second-look arthroscopy.

RESULTS

After ulnar-shortening osteotomy, both groups improved significantly in wrist range of motion and grip strength. According to the Mayo wrist score, 29, 18, and 3 patients showed excellent, good, and fair results, respectively. Of the 50 wrists, 25 had degenerative changes (group B) in the proximal LT membrane at the time of first-look arthroscopy. Of the 25 wrists in group B, 11 wrists improved based on the Geissler grade, 9 wrists showed no changes, and 2 wrists became worse. Clinically, patients demonstrated improvement after ulnar-shortening osteotomy regardless of the degree of degenerative LT ligament changes.

CONCLUSIONS

Degenerative LT membrane changes that were seen in about half of our patients were mostly of a mild nature, and the clinical outcomes of ulnar-shortening osteotomy were acceptable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Arthroscopy during ulnar shortening for idiopathic ulnar impaction syndrome

Arthroscopy during ulnar shortening osteotomy for ulnar impaction syndrome is subject to debate regarding its clinical usefulness. The purposes of this study were to analyze the arthroscopic findings in patients who underwent ulnar shortening osteotomy and to assess the role of arthroscopic evaluation during osteotomy. Medical records and arthroscopic findings of 50 consecutive patients who had been diagnosed with idiopathic ulnar impaction syndrome were retrospectively evaluated. Pathologic changes of the articular disk of the triangular fibrocartilage complex (TFCC), chondromalacia of the lunate and triquetrum, and tears of the lunotriquetral interosseous ligament (LTIL) were evaluated during arthroscopy. Palmer’s classification was used to classify the TFCC lesions. Perforation of the TFCC was observed in 20 patients, and central tears were observed in 10. Thirty-eight patients exhibited chondromalacia of the lunate, including 4 unstable cartilage flaps. Partial tears of the LTIL were detected in 24 patients, including 9 unstable flap tears. In 21 (42%) of 50 patients, arthroscopic findings were not appropriate to define the disease stage with Palmer’s original description. Eight wrists exhibited tears or perforations of the TFCC without evidence of chondromalacia. Seven patients had an LTIL tear without perforation of the TFCC. Lunotriquetral interosseous ligament tears without lunate chondromalacia were found in 7 patients. Arthroscopic debridement was performed in 23 patients based on the clinical judgment that the procedure would help alleviate symptoms postoperatively. Arthroscopy during ulnar shortening osteotomy addresses intra-articular pathologies and may be helpful for symptom improvement.

Reconstructed animation from four-phase grip MRI of the wrist with ulnar-sided pain

In order to visualize dynamic variations related to ulnar-sided wrist pain, animation was reconstructed from T2* coronal-sectioned magnetic resonance imaging in each of the four phases of grip motion for nine wrists in patients with ulnar pain. Eight of the nine wrists showed a positive ulnar variance of less than 2 mm. Ulnocarpal impaction and triangular fibrocartilage complex injury were assessed on the basis of animation and arthroscopy, respectively. Animation revealed ulnocarpal impaction in four wrists. In one of the four wrists, the torn portion of the articular disc was impinged between the ulnar head and ulnar proximal side of the lunate. In another wrist, the ulnar head impacted the lunate directly through the defect in the articular disc that had previously been excised. An ulnar shortening osteotomy successfully relieved ulnar wrist pain in all four cases with both ulnocarpal impaction and Palmer's Class II triangular fibrocartilage complex tears. This method demonstrated impairment of the articular disc and longitudinal instability of the distal radioulnar joint simultaneously and should be of value in investigating dynamic pathophysiology causing ulnar wrist pain.

Positive or negative ulnar variance after ulnar shortening for ulnar impaction syndrome: a retrospective study

Background

The goal of this study was to compare simple radiographic findings and clinical results according to residual ulnar variance following ulnar shortening for ulnar impaction syndrome.

Methods

Forty-five cases of ulnar impaction syndrome, which were treated with ulnar shortening from 2005 to 2008, were studied retrospectively. Group I included 13 cases with positive residual variance after ulnar shortening and group II included 32 cases with negative variance after shortening. The presence of a lunate cystic lesion both preoperatively and at final follow-up and assessments of wrist function based on the modified Mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, as well as the Chun and Palmer score were evaluated.

Results

A cystic lesion of the lunate was present in 4 cases preoperatively and the size decreased in 2 cases at final follow-up in group I, and in 10 and 5 cases, respectively, in group II. No statistical difference was observed between the groups. The modified Mayo wrist score, DASH score, as well as the Chun and Palmer score improved significantly in both groups. No significant differences were observed between the two groups in terms of the proportion of positive cystic lesions at final follow-up or the functional scores.

Conclusions

After ulnar shortening, the degree of radiological change in the cystic lunate lesions and clinical improvement did not differ significantly between the groups with unintended residual positive and negative variance after shortening.

Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.

Ulnar impaction

Ulnar impaction syndrome is a common source of ulnar-sided wrist pain. It is a degenerative condition that occurs secondary to excessive load across the ulnocarpal joint, resulting in a spectrum of pathologic changes and symptoms. It may occur in any wrist but is usually associated with positive ulnar variance, whether congenital or acquired. The diagnosis of ulnar impaction syndrome is made by clinical examination and is supported by radiographic studies. Surgery is indicated if nonoperative treatment fails. Although a number of alternatives exist, the 2 primary surgical options are ulnar-shortening osteotomy or partial resection of the distal dome of the ulna (wafer procedure). This article discusses the etiology of ulnar impaction syndrome, and its diagnosis and treatment.

The relationship between stress positions and pain intensity in triangular fibrocartilage lesions

We investigated the relationship between stress applied in several positions of the wrist and pain intensity in triangular fibrocartilage lesions in sixty-one patients who were diagnosed as having triangular fibrocartilage lesions and had a wrist arthroscopy. Before arthroscopy, we stressed the wrist with an axial load applied in four different wrist positions, and the evoked pain was graded into four levels. The patients who had a triangular fibrocartilage lesion on arthroscopy were divided into those with a traumatic tear and those with degenerative changes. While hypersupination and extension of wrist position evoked the most severe pain in patients with a traumatic tear, the intensity of pain did not relate to wrist rotation in patients with degenerative changes.

Ulnar-sided wrist pain. II. Clinical imaging and treatment

Pain at the ulnar aspect of the wrist is a diagnostic challenge for hand surgeons and radiologists due to the small and complex anatomical structures involved. In this article, imaging modalities including radiography, arthrography, ultrasound (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography are compared with regard to differential diagnosis. Clinical imaging findings are reviewed for a more comprehensive understanding of this disorder. Treatments for the common diseases that cause the ulnar-sided wrist pain including extensor carpi ulnaris (ECU) tendonitis, flexor carpi ulnaris (FCU) tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex (TFCC) lesions, ulnar impaction, lunotriquetral (LT) instability, and distal radioulnar joint (DRUJ) instability are reviewed.