Ulnar-Sided Wrist Pain: A Diagnostic Evaluation Guide From 30-Plus Years of Experience

INTRODUCTION

While multiple ulnar-sided wrist pain (USWP) diagnostic evaluation guides have been presented, none have included original clinical data or statistical analysis. The purpose of this study is to provide a diagnostic evaluation guide derived from original clinical data and analysis to help clinicians arrive at a differential diagnosis for USWP.

METHODS

Using a computer search of patients presenting with sprains, instability, and laxity of the wrist, 385 patient charts were identified. Patient demographics, mechanism of injury, subjective complaints, physical findings, and diagnostic test findings were reviewed. Statistical analysis was performed to determine sensitivity and specificity of diagnostic methods on their ability to identify lunotriquetral ligament tears, triangular fibrocartilage complex (TFCC) tears, and ulnar impaction syndrome. Diagnostic arthroscopy was used as the reference standard.

RESULTS

Ninety-three patients, comprising 101 cases of USWP, were included in the study. The onset of injury was traumatic in 83 out of 101 cases with motor vehicle accidents (N=46) being the most common, followed by overuse (N=18), and a fall onto an outstretched hand (N=16). The ulnocarpal tenderness test exhibited sensitivity/specificity of 72%/33%; lunotriquetral ligament laxity test of 42%/62%; bone scan of 80%/33%; radiocarpal arthrogram of 90%/98% for TFCC tears and 50%/91% for lunotriquetral ligament tears; midcarpal arthrogram of 82%/86% for lunotriquetral ligament tears. The mean ulnar variance on standard posteroanterior view radiograph was 0.95 mm, increasing to 2.67 mm on gripping posteroanterior view.

CONCLUSION

Physicians should suspect a lunotriquetral ligament and/or TFCC tear with the acute onset of USWP following a loaded dorsiflexed mechanism of injury. Ulnocarpal tenderness tests and pre-operative ulnar variance measures are effective for increasing suspicion of USW pathology. Bone scans are helpful in diagnosing ulnar impaction syndrome in conjunction with radiographic findings. A combination of midcarpal arthrogram for lunotriquetral ligament tears and radiocarpal arthrogram for TFCC tears should be employed.

Minimial clinically important difference values in distal metaphyseal ulnar shortening for ulnar impaction syndrome and assessment of the relationship between level of the osteotomy and bone union time

OBJECTIVE

We aimed to define minimal clinically important difference (MCID) values of patient-reported outcome measures (PROMs) for distal metaphyseal ulnar shortening and to assess the relationship between level of the osteotomy and time to bone union.

METHODS

20 patients who had distal metaphyseal ulnar shortening osteotomies due to ulnar impaction syndrome and had at least 6 months of follow-ups were included in this study. The mean follow-up period was 12.3 ± 7.01 months. The PROMs which consisted of patient-rated wrist evaluation (PRWE) and quick disabilities of arm, shoulder, and hand (QDASH) were recorded on the day before the surgery and at follow-up assessments. Grip strength and range of motion were recorded for operated and contralateral wrists at postoperative assessments. Postoperative radiological evaluations of distance of the osteotomy from the distal ulnar articular surface (osteotomy level), the union of osteotomy site; preoperative and postoperative evaluations of styloid-triquetral distance, and ulnar variance were performed using AP wrist x-rays. The MCID values for PRWE and QDASH were calculated using ROC curve analysis.

RESULTS

Mean PRWE and QDASH scores decreased statistically significantly. The mean grip strength of contralateral wrists was higher. Mean ulnar variance decreased, whereas styloid-triquetral distance increased postoperatively. Patients with osteotomy levels of greater than 13.7 mm had a longer time from surgery to bone union. Furthermore, patients with time from surgery to bone union shorter than 7 weeks had an osteotomy closer to the ulnar articular surface. The MCID values for PRWE and QDASH were analyzed and calculated through the ROC curve as 22.25 and 20.45, respectively.

CONCLUSION

This study has shown us that the osteotomy level affects the time to bone union and an osteotomy closer than 13.7 mm to the ulnar articular surface seems to result in shorter union time. Furthermore, MCID values were defined for PRWE and QDASH as 22.25 and 20.45, respectively.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Is ulnar shortening osteotomy or the wafer procedure better for ulnar impaction syndrome?: A systematic review and meta-analysis

BACKGROUND

Wrist pain on the ulnar side is often caused by ulnar impaction syndrome (UIS). Idiopathic UIS requires surgical treatment when conservative treatment fails. The 2 main surgical procedures used are the wafer procedure and ulnar shortening osteotomy (USO) of the metaphysis or diaphysis. This review aimed to analyze comparative studies of the 2 procedures in UIS to determine clinical outcomes and complications.

METHODS

One prospective and 5 retrospective comparison trials were retrieved from the PubMed, Embase, and Cochrane Library databases. The primary outcomes were treatment effectiveness; pain visual analog scale (VAS), disabilities of the arm, shoulder, and hand (DASH) score, Mayo wrist, and Darrow scores. The incidence of postoperative complications formed the secondary outcome.

RESULTS

The selected studies included 107 patients who underwent the wafer procedure (G1) and 117 patients who underwent USO (G2). The wafer procedure had the benefits of less postoperative immobilization and an early return to work. However, there were no significant differences in the postoperative pain improvement and functional scores. All 6 studies reported high total complication rates and reoperation with USO. The most frequent complication was implant-related discomfort or irritation; subsequent plate removal was the most common reason for a secondary operation.

CONCLUSIONS

There was no difference in pain improvement or the postoperative functional score between the groups. Nevertheless, postoperative complications were the major pitfalls of USO. As the specialized shortening system advances further, a high-level study will be necessary to determine the surgical option in UIS.

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.

Risk Factors for Complications in Ulnar Shortening Osteotomies: A Multicenter Retrospective Review

PURPOSE

Ulnar shortening osteotomy (USO) is commonly performed to alleviate pathologies causing ulnar-sided wrist pain. Surgical complications include nonunion and hardware removal, with rates up to 18% and 45%, respectively. The primary objective of the study was to report the overall complication rate of USO. The secondary objective was to identify risk factors for complications.

METHODS

A retrospective multicenter cohort review was undertaken, including six Canadian cities over a 6-year period (January 2013-December 2018). Chart review was used to collect demographic data, surgical technique, implant used, and postoperative complications. Descriptive statistics of demographics and operative characteristics, including plate positioning, type of osteotomy, plate type, and ulnar variance (mm), were analyzed. Univariate analyses were used to select predictor variables for nonunion and hardware removal. These predictor variables were then entered into an adjusted multivariable logistic regression model.

RESULTS

A total of 361 USOs were performed. Mean age was 46 ± 16 years (60.7% men). The overall complication rate was 37.1%, hardware removal rate was 29.6%, and nonunion rate was 9.4%. There was a workers' compensation claim associated with 21.6% of all complications, and it was a risk factor for both hardware removal (odds ratio [OR] = 3.81) and nonunion (OR = 2.88). Neither smoking nor diabetes was associated with complication rates. Seventy percent of plates were placed volarly, 25.5% dorsally, and 3.9% directly ulnar. Osteotomies were oblique in 83.7% of cases and transverse in 15.5%. Adjusted multivariate regression analysis revealed that younger age (OR = 0.98) was a risk factor for hardware removal and male sex (OR = 0.40) was a risk factor for nonunion. A surgical factor associated with hardware removal was direct ulnar plate placement (OR = 9.93). No surgical factors were associated with nonunions.

CONCLUSIONS

There are substantial rates of complications with USOs. Direct ulnar plate placement should be avoided. Patients should be thoroughly counseled on the risks of complications prior to proceeding with USO.

LEVEL OF EVIDENCE

Therapeutic IV.

Distal Metaphyseal Ulnar Shortening Osteotomy Fixation: A Biomechanical Analysis

PURPOSE

Ulnar shortening osteotomy can be used to treat ulnar impaction syndrome and other causes of ulnar wrist pain. Distal metaphyseal ulnar shortening osteotomy (DMUSO) is one technique that has been proposed to reduce the complications seen with a diaphyseal USO or a wafer resection. However, to our knowledge, the optimal fixation construct for DMUSO has not been studied. We sought to characterize the biomechanical stiffness and rotational stability of different DMUSO constructs.

METHODS

A DMUSO was performed on 40 human cadaveric ulnas using 4 different fixation constructs (10 specimens per group): one 3.0 mm antegrade screw; two 2.2 mm antegrade screws; one 3.0 mm retrograde screw; and two 2.2 mm retrograde screws. Biaxial testing using axial load and cyclical axial torque was performed until failure, defined as 10° of rotation or 2 mm displacement. Specimens were assessed for stiffness at failure. Bone density was assessed using the second metacarpal cortical percentage.

RESULTS

Bone density was similar between all 4 testing groups. Of the 4 groups, the 2 antegrade screw group exhibited the highest rotational stiffness of 232 ± 102 Nm/deg. In paired analysis, this was significantly greater than 1 retrograde screw constructs. In multivariable analysis, 2-screw constructs were significantly stiffer than 1 screw and antegrade constructs were significantly stiffer than retrograde. Maximum failure torque did not differ with orientation, but 2 screws failed at significantly higher torques.

CONCLUSION

Using 2 screws for DMUSO fixation constructs may provide higher stiffness and maximum failure torque, and antegrade screw constructs may provide more stiffness than retrograde constructs.

CLINICAL RELEVANCE

Antegrade screw fixation using 2 screws may provide the strongest construct for DMUSO. Antegrade fixation may be preferred because it avoids violating the distal radioulnar joint capsule and articular surface of the ulna.

Evaluating Immediate and Short-Term Postoperative Clinical Outcomes of Patients Undergoing Ulnar Shortening for Ulnar Impaction Syndrome Using PROMIS

Background  The early recovery trajectory of patients undergoing ulnar shortening for ulnar impaction syndrome using the Patient-Reported Outcomes Measurement Information System (PROMIS) is unknown. Questions/Purposes  Using PROMIS Upper Extremity (UE), Physical Function (PF), Pain Interference (PI), and Depression, we asked (1) do patients undergoing operative management for ulnar impaction syndrome present at their preoperative visit with notable impairment?; (2) At immediate follow-up, do patients present with a clinically appreciable change in symptom severity?; and (3) At short-term follow-up, do patients present with a clinically appreciable change in symptom severity? Materials and Methods  We identified patients from 01/2017 to 12/2019 at our institution undergoing ulnar shortening for ulnar impaction syndrome who completed all PROMIS domains at a preoperative visit and at least one postoperative time point (i.e., less than 4 weeks and/or greater than 12 weeks). Distribution- and anchor-based minimal clinically important difference estimates were used to evaluate clinically appreciable changes in symptoms over time. Results  A total of 38 patients met our inclusion criteria. The average change in PROMIS UE, PF, PI, and Depression scores from preoperative to immediate postoperative follow-up were -3.8, -4.3, 3.2, and 0.5, respectively. However, by short-term follow-up, the average change in PROMIS UE, PF, PI, and Depression scores were 3.7, 3.2, -4.7, and -3.9, respectively. Conclusions  Patients have worsening function at the immediate postoperative follow-up. By short-term postoperative follow-up, functional status and PI levels improve. Our findings can help hand surgeons provide evidence-based guidance on expected initial recovery following operative management for ulnar impaction syndrome. Level of Evidence  This is a level II, prognostic study.

Distal Metaphyseal Osteotomy Allows for Greater Ulnar Shortening Compared to Diaphyseal Osteotomy for Ulnar Impaction Syndrome: A Biomechanical Study

Purpose  To compare the biomechanical characteristics between diaphyseal and metaphyseal ulnar-shortening osteotomy with respect to (1) maximal shortening achieved at each osteotomy site and (2) force required to achieve shortening at each site. Methods  Nine fresh frozen cadaveric upper extremities were affixed through the proximal ulna to a wooden surgical board. A metaphyseal 20-mm bone wedge was resected from the distal ulna and sequential shortening was performed. A load cell was attached to a distal post that was clamped to the surgical board and used to measure the force required for each sequential 5-mm of shortening until maximal shortening was achieved. The resected bone was reinserted, and plate fixation was used to restore normal anatomy. A 20-mm diaphyseal osteotomy was performed, and force measurements were recorded in the same manner with (1) interosseous membrane intact, (2) central band released, and (3) extensive interosseous membrane and muscular attachments released. Results  Metaphyseal osteotomy allowed greater maximal shortening than diaphyseal osteotomy with the interosseous membrane intact and with central band release but similar shortening when extensive interosseous membrane and muscle release was performed. Force at maximal shortening was similar between metaphyseal and diaphyseal osteotomy. Sequential soft tissue release at the diaphysis allowed for increased shortening with slightly decreased shortening force with sequential release. Conclusion  Metaphyseal ulnar osteotomy allows greater maximal shortening but requires similar force compared with diaphyseal osteotomy. Sequential release of the interosseous membrane permits increased shortening at the diaphysis but requires extensive soft tissue release. Clinical Relevance  Both sites of osteotomy can achieve sufficient shortening to decompress the ulnocarpal joint for most cases of ulnar impaction syndrome. The greater shortening from metaphyseal ulnar osteotomy may be reserved for severe cases of shortening, especially after distal radius malunion or in the setting of distal radius growth arrest in the pediatric population. Level of Evidence  This is a Level V, basic science study.

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Background  The purpose of this study is to characterize patient- and surgery-specific factors associated with perioperative pain level in patients undergoing ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS). We hypothesize that preoperative opiate consumption, tobacco utilization, and severity of ulnar variance will be associated with less postoperative pain relief. Methods  All cases of USO between January 2010 and December 2016 for management of UIS were retrospectively reviewed. Patient demographics, smoking status, type of labor, and opioid utilization before surgery were recorded. Radiographic measurements for ulnar variance, radial tilt and inclination, as well as triangular fibrocartilage complex and distal radial-ulnar joint (DRUJ) morphology were assessed. Pre- and postoperative pain score were recorded. Regression analysis was performed to determine predictors of pain scores. Results  A total of 69 patients were included for the final analysis with a mean age of 44 years (range 17-73 years). Seventeen patients reported use of daily opioid medications at the time of surgery (25%). Patients who used opioid analgesics daily, active laborers, smokers, and patients involved in worker compensation claims had significantly less pain relief after surgery. Patients with osteotomy performed at the metaphysis had significantly more pain relief than patients that had diaphyseal osteotomy. Regression analysis identified tobacco utilization and anatomic site of osteotomy as independent predictors of postoperative pain. Conclusion  The results from this study identified smoking and location of osteotomy as independent predictors of postoperative pain relief. While smoking cessation is paramount to prevent delayed/nonunion it may also help improve pain relief following USO. The potential to achieve greater shortening with a metaphyseal osteotomy suggests that in addition to the mechanical unloading the carpus, pain relief after USO may also stem from tensioning the ulnar collateral ligaments of the wrist, the ECU subsheath, and the radioulnar ligaments. Level of Evidence  This is a Level III, therapeutic study.

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.

Distal radioulnar joint configurations in three-dimensional computed tomography in patients with idiopathic ulnar impaction syndrome

We retrospectively reviewed 26 patients diagnosed with idiopathic ulnar impaction syndrome and measured the slopes of the sigmoid notch and ulnar head at their centre using their preoperative three-dimensional computed tomography. We found that the slope of the sigmoid notch and that of the ulnar head were not parallel to each other. There was a significant linear relation between the slope of the ulnar head and the changes in the closest joint space of the distal radioulnar joint at the centre of the sigmoid notch after ulnar shortening. We conclude that the slope of the ulnar head is more strongly correlated with changes in the closest joint space in the distal radioulnar joint than that of the sigmoid notch. Our findings suggest that slope of the ulnar head might be as important a predisposing factor as that of the sigmoid notch for the progression of distal radioulnar joint arthritis after ulnar-shortening osteotomy. We should consider the slopes of both the sigmoid notch and ulnar head before the osteotomy. Level of evidence: IV.

Changes in Ulnar Variance after a Triangular Fibrocartilage Complex Tear

Purpose  The relationship between triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood. We hypothesized that a TFCC tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome. Patients and Methods  A total of 72 patients who underwent TFCC foveal repair between January 2011 and June 2016 were included in this retrospective study. Among them, 44 patients diagnosed with TFCC foveal tear with distal radioulnar joint instability and no ulnar impaction syndrome underwent TFCC foveal repair only (group A) and 28 patients diagnosed with TFCC foveal tear with ulnar impaction syndrome underwent TFCC foveal repair and ulnar shortening osteotomy simultaneously (group B). We measured their ulnar variances in preoperative, postoperative, and last follow-up plain radiography. We also compared them with the ulnar variance of the contralateral (uninjured) wrist. Postoperative clinical outcomes, such as range of motions of the wrist, the visual analog scale (VAS) for pain, grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, were assessed. Results  Ulnar variance increased after TFCC tears compared with that on the uninjured side in both groups (group A: 0.98 vs. 0.52 mm, p  = 0.013; group B: 2.71 vs. 2.13 mm, p  = 0.001). Once the TFCC was repaired, ulnar variance decreased (group A: 0.98 to 0.01 mm, p  < 0.01; group B: 2.71 to 0.64 mm, p  < 0.01). However, it was increased on the last follow-up radiograph (group A: 0.01 to 0.81 mm, p  < 0.01; group B: 0.64 to 1.05 mm, p  = 0.004). There were no significant improvement of range of motion, except for pronation-supination motion ( p  = 0.04). Mean grip strength increased from 56.8 to 70.8% of the contralateral unaffected hand at the last assessment ( p  = 0.01). Mean VAS for pain decreased from 7.4 ± 2.5 preoperatively to 2.7 ± 2 postoperatively ( p  = 0.001). The QuickDASH score significantly improved from 45 to 9 ( p  = 0.001). Conclusion  Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain. Level of Evidence  This is a therapeutic Level IV study.

The Parallelogram Effect: The Association Between Central Band and Positive Ulnar Variance

PURPOSE

Ulnar impaction syndrome is a poorly understood degenerative wrist condition characterized by symptoms of pain thought to be caused by increased loads between the ulnar head and the carpals. Radiographic evaluation often reveals an ulnar-positive wrist. We hypothesize that progressive elongation of the central band of the forearm interosseous ligaments changes the longitudinal radial-ulnar relationships, resulting in an ulnar-positive wrist. The objective of the study was to identify a relationship between the loss of integrity of the forearm interosseous ligaments and increased ulnar variance.

METHODS

Six cadaveric human forearms were used to measure displacement of the radius relative to the ulna during axial loading of the lunate fossa of the radius. Radial heights were measured in supination and pronation under a 5-lbF (22-N) preload. Gradual axial loads were applied up to 50 lbF (222N); the resultant axial displacement was measured in supination and pronation. All measurements were evaluated with the interosseous ligament intact and repeated with the central band cut.

RESULTS

With an applied 5-lbF preload, cutting the central band increased ulnar variance by 3.02 ± 0.80 mm in supination and by 2.15 ± 0.79 mm in pronation. In supination, when the loads were increased from the 5-lbF preload to 50 lbF, the radius displaced 2.1 times further after the central band was cut (3.00 mm) compared with the group with the intact forearm construct (1.41 mm). In pronation, when the loads were increased from the 5-lbF preload to 50 lbF, the radius displaced 1.8 times further when the central band was cut (2.84 mm) than with the intact forearm construct (1.57 mm).

CONCLUSIONS

Because of a parallelogram effect, the radius shifted proximally under a 5-lbF preload, creating an ulnar-positive wrist relationship. Dynamic loading of the forearm after ligament excision resulted in significant additional radial displacement relative to the intact forearm.

CLINICAL RELEVANCE

Deficiency in the ligamentous restraints of the central band leads to positive ulnar variance, which could be a factor (among others) that contributes to idiopathic ulnar impaction syndrome.

A Dorsal Approach for Ulnar Shortening Osteotomy

Aim  This study aims to evaluate the long-term complications, results, and patient satisfaction rates of a dorsally approached ulnar shortening osteotomy for ulnar impaction syndrome. Methods  A retrospective chart review of 20 patients was performed. Primary outcomes of interest were subjective, measured using the Patient-Rated Wrist Evaluation (PRWE) score, Disability of the Arm, Shoulder, and Hand (DASH) score, and the third questionnaire about patient satisfaction, composed by the authors. Secondary outcomes included hardware removal due to irritation and other complications. Results  Mean postoperative functional score of PRWE was 28 (standard deviation [SD], 30) and DASH 20 (SD, 26), respectively. Fifteen patients were satisfied with the operation. Removal of hardware was noted in six patients. In one patient plate breakage occurred. Conclusion  Similar postoperative functional scores and complications were seen in patients undergoing an ulnar shortening osteotomy with a dorsally placed plate for ulnar impaction syndrome, compared with other plate placement localizations. The incidence of plate removal is also comparable to previously described results. As the dorsally placed plate and freehand technique, are relatively easy, we feel that it has a place in the treatment of ulnar impaction syndrome. Level of Evidence  Level IV, retrospective cohort study.

Outcomes of the Ulnar Shortening Osteotomy Using a Dynamic Compression Plate on the Ulnar Surface of the Ulna

Background  The purpose of this study is to evaluate the results of patients with ulnar impaction syndrome treated with diaphyseal osteotomy using freehand technique and fixation with ulnar osteotomy compression plate placed on the ulnar surface of the ulna. Materials and Methods  A retrospective chart review of patients with ulnar impaction syndrome between 2010 and 2014 identified 38 patients. The following clinical data were observed: patient age, sex, range of motion, grip strength, visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiological assessment, and complications. The mean follow-up period is 30 months. Eleven patients were excluded from the study. Results  Compared with the contralateral side, the 27 patients included in this study attained 93 to 96% of wrist and forearm motion and 81% of the grip strength. The average DASH score was 18 in a mean follow-up period of 30 months. Three patients required plate removal and one case showed nonunion and a further operation was needed. Two patients reported persistent ulnar-sided wrist pain. Conclusion  We concluded that placing the ulnar osteotomy plate on the ulnar surface of the ulna is a quicker procedure, with less soft tissue dissection and irritation, and very high union rate. Level of Evidence  Level IV.

[Combined ulnar shortening osteotomy and elastic suspended fixation in treatment of ulnar impaction syndrome]

Objective

To investigate the effectiveness of ulnar shortening osteotomy combined with elastic suspension fixation for ulnar impaction syndrome caused by relatively long ulna.

Methods

Between October 2015 and August 2016, 3 cases of ulnar impaction syndrome were treated. One patient was male and 2 patients were females. The age was 32, 29, and 59 years, respectively. One patient was dislocation and impaction of distal radioulnar joint for more than 1 year after internal fixation due to ulnar and radial open fractures. Other patients had no trauma and surgery, but long-term manual history. The visual analogue scale (VAS) scores were 7, 5, and 5, respectively. Cooney wrist function scores were rated as poor. Preoperative X-ray measurements of the ulnar variance was 12.7, 9.0, and 8.7 mm, respectively. The ulna was transversely osteotomy and fixed with plate and screws. The distal radioulnar joint was elastic suspension fixed with mini plate.

Results

Postoperative X-ray film showed that the matching of the distal radioulnar joint had no significant difference compared with the contralateral side. All the incisions healed by first intention without complication such as neurovascular injury, infection, and dislocation of the distal radioulnar joint. The patients were followed up 27, 17, and 23 months, respectively. At last follow-up, X-ray film showed that all osteotomy segments achieved bony union without internal fixation failure. The VAS scores were 2, 0, and 1, respectively, and the Cooney wrist function scores were rated as excellent.

Conclusion

The ulnar shortening osteotomy combined with elastic suspension fixation can correct the ulna variation, avoid the instability of the distal radioulnar joint caused by the extensive dissection of the tissue around the ulnar, and avoid stiffness of the joints caused by rigid fixation. It is an ideal treatment for ulna impaction syndrome.

Treatment of Ulnar Impaction Syndrome with and without Central TFC Lesion

Background  Arthroscopic debridement of the triangular fibrocartilage (TFC) is well accepted in patients with ulnar impaction syndrome with central TFC lesions. Treatment remains controversial, however, when there is no such lesion from radiocarpal view. Purpose  This study assessed the clinical outcome of arthroscopic central TFC resection and debridement and secondary ulnar shortening in patients with ulnar impaction with central TFC lesion compared with patients without TFC lesion. Patients and Methods  Thirty-two consecutive patients with ulnar impaction syndrome were arthroscopically treated, 16 of whom had a central lesion of the TFC that was debrided. In the 16 patients with no lesion from the radiocarpal view, the TFC was centrally resected and debrided to decompress the ulnocarpal joint. Persisting symptoms necessitated ulnar shortening in four patients in each group. Two patients underwent repeat arthroscopic TFC debridement. All patients were examined at 3, 6, and 12 months, and at final follow-up (mean: 1.7 years) following arthroscopy, respectively ulnar shortening or hardware removal. Results  In both groups, pain, Krimmer, and DASH scores significantly improved. Improvements of DASH scores were significantly higher in patients without lesion at 12 months and at final follow-up. For other parameters, no significant difference was found between the two groups. Conclusion  In both situations, with and without central TFC lesion, resection and debridement sufficiently reduced the ulnar-sided wrist pain and improved function in three out of four patients, and therefore qualified as the first-line treatment of ulnar impaction syndrome as arthroscopy is performed, anyway. Those patients who complained of persisting or recurrent ulnar-sided wrist pain finally benefitted from ulnar shortening osteotomy as the secondary procedure. Level of Evidence  Therapeutic III, case-control study.

Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series

BACKGROUND

This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons' experiences.

METHODS

Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form.

RESULTS

ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union.

CONCLUSIONS

In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.

Significance of Scapholunate Gap Width as Measured by Probe from Midcarpal

Background  Geissler's classification is widely accepted in arthroscopic diagnostics of scapholunate (SL) ligament injury. Thereby, probe insertion into the SL gap from the midcarpal would indicate treatment necessity in patients with SL tear as seen from radiocarpal view. Purpose  In this review, the SL gap width, examined by the probe from midcarpal, was arthroscopically assessed in patients with intact SL ligaments, who were treated for ulnar impaction syndrome. The review examined how often lax SL joints can be found in patients with no complaints with respect to the SL ligaments and in which the SL ligaments were proven to be intact from radiocarpal view. We suspected that probe insertion, as an indicator for a lax joint, does not affect the outcome in ulnar impaction treatment. Patients and Methods  A total of 32 patients with clinically diagnosed ulnar impaction syndrome were arthroscopically treated by central resection and debridement of the triangular fibrocartilage; 8 patients underwent concurrent ulnar shortening, and 4 of them finally hardware removal. All patients were examined preoperatively as well as after 3, 6, and 12 months following arthroscopy, respectively, after ulnar shortening or hardware removal. Results  In 14 patients, the probe could not, in 18 patients, the probe could be inserted into the SL gap. There was neither any significant difference in the improvement of pain, grip strength, Krimmer, or DASH score, nor for any of the radiographic angles between the two groups. Conclusion  Laxity of the SL ligament allows the probe to be inserted into the SL gap from midcarpal in some patients. This finding, therefore, does not necessarily imply the necessity of treatment when there is partial rupture seen from radiocarpal view. Level of Evidence  Level III, case-control study.

Metaphyseal Versus Diaphyseal Ulnar Shortening Osteotomy for Treatment of Ulnar Impaction Syndrome: A Comparative Study

PURPOSE

To compare the clinical and radiographic outcomes and complication rates of diaphyseal and metaphyseal ulnar shortening osteotomies for the treatment of ulnar abutment syndrome.

METHODS

We performed a retrospective study comparing 35 patients who underwent either a metaphyseal (n = 14) or diaphyseal (n = 21) osteotomy. Radiographic and clinical outcomes were compared. Complication rates including infection, hardware removal, and reoperations were also assessed.

RESULTS

There were no differences in patient characteristics, ulnar variance, or pain and functional scores between groups. Metaphyseal osteotomy surgery time was shorter (45.5 vs 71.7 minutes) and resulted in greater ulnar shortening (4.8 vs 3.4 mm) compared with diaphyseal osteotomies. At an average 19.2-month follow-up, metaphyseal osteotomies were associated with greater improvement in pain and Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire scores. The need for implant removal was the same in both groups. There were no complications in either group.

CONCLUSIONS

Results from this study suggest that metaphyseal osteotomies are a safe and effective alternative to diaphyseal osteotomies for the management of ulnar abutment syndrome. Although improved surgical time and postoperative outcomes are encouraging, further large-scale and properly powered studies with long-term outcomes will help characterize the benefit of one technique over another. Ultimately, the decision between a metaphyseal and diaphyseal osteotomy may be surgeon preference.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy

This study examined the reliability of surgeons' estimations as to whether central lesions of the triangular fibrocartilage complex were traumatic or degenerative. A total of 50 consecutive central triangular fibrocartilage complex lesions were independently rated by ten experienced wrist surgeons viewing high-quality arthroscopy videos. The videos were reassessed after intervals of 3 months; at the second assessment surgeons were given the patient's history, radiographs and both, each in a randomized order. Finally, the surgeons assessed the histories and radiographs without the videos. Kappa statistics revealed fair interrater agreement when the histories were added to the videos. The other four modalities demonstrated moderate agreement, with lower Kappa values for the assessment without videos. Intra-rater reliability showed fair agreement for three surgeons, moderate agreement for two surgeons and substantial agreement for five surgeons. It appears that classification of central triangular fibrocartilage complex lesions depends on the information provided upon viewing the triangular fibrocartilage complex at arthroscopy.

LEVEL OF EVIDENCE

II.

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.

Freehand technique with the predrilled hole method for ulnar-shortening osteotomy

BACKGROUND

Ulnar shortening is a common and useful method for treating ulnar wrist pain from many causes. Many devices used to perform osteotomy have been introduced in the literature; however, the devices are not universally available. The standard freehand technique is still commonly used in clinical practice; however, it is associated with several complications and is time-consuming. We present a freehand technique for ulnar-shortening osteotomy using a predrilled hole method.

METHODS

From 2011 to 2013, we performed the predrilled hole method for ulnar shortening in 18 cases using the six-hole limited-contact dynamic compression plate (LC-DCP) and in two cases using the Acumed six-hole Locking Midshaft Ulna Plate.

RESULTS

All patients had uneventful union, and the average operative time was 39.7 minutes (range, 32-50 minutes). The average follow-up period was 21 months (range, 12-30 months). There were no complications except in three patients in the LC-DCP group who complained of implant irritation. Good functional outcomes were achieved with this method.

CONCLUSION

Our technique is easy and quick to use and can minimize soft-tissue manipulation. The union rate is high and complications are few.

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.

Soft tissue complications of dorsal versus volar plating for ulnar shortening osteotomy

PURPOSE

To compare the results and complications of fixed-angle dorsal locking plate fixation for ulnar shortening osteotomy (USO) with the conventional technique of volar plating.

METHODS

We performed a retrospective review of 32 patients undergoing USO on 34 wrists and compared the outcomes of 16 consecutive cases with dorsal 2.4/2.7-mm fixed-angle plating and 18 consecutive cases with volar 3.5-mm plating. A minimum of 12 months' follow-up was used to assess outcomes. Primary outcomes were painful hardware and removal of symptomatic implants. Secondary outcomes were pain, Patient-Rated Wrist Evaluation, range of motion, time to union, grip strength, and complications.

RESULTS

There were no significant differences in Patient-Rated Wrist Evaluation, pain score, range of motion, or time to union. Relative grip strength compared with the contralateral upper extremity in the dorsal group was higher than the volar group. After adjusting for hand dominance, dorsal plating was significantly associated with higher relative grip strength. There were 2 complications in the dorsal group, including one case with painful hardware. This was significantly lower than in the volar group, which had 10 complications including 2 nonunions and 6 cases of hardware-related soft tissue irritation.

CONCLUSIONS

Both volar and dorsal plating techniques for USO yielded good functional outcomes. There was a higher incidence of painful hardware requiring removal of implants in the volar group. Based on these findings, we advocate dorsal plate position using a smaller fixed-angle plate for USO in ulnar impaction syndrome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Ulnar impaction syndrome with different operative methods: a comparative biomechanical study

OBJECTIVE

Ulnar impaction syndrome seriously impairs wrist and hand function. Three main treatment procedures are available; however, little systematic research on the post-operation changes in wrist biomechanics currently exists. This study aimed to determine the long-term effects of these procedures and the optimal treatment methods for ulnar impaction syndrome.

METHODS

Twenty-four cases of fresh upper limb specimens were randomized into four groups: (1) the control group, (2) the ulnar-shortening operation group, (3) the Sauvé-Kapandji procedure group (distal radioulnar arthrodesis and intentional distal ulnar pseudoarthrosis), and (4) the Darrach procedure group (distal ulna resection). After keeping the wrist in a neutral position, a pressure sensitive film was applied. Starting at 0 N, the load was increased gradually at a speed of 0.1 N/s until reaching 200 N and then maintained for 60 s by the CSS-44020 series biomechanical machine. Then, the pressure sensitive films from each group were measured, and the results were analyzed with SPSS software.

RESULTS

The mean pressure and force on the ulna in the groups followed a decreasing trend from the control group, Sauvé-Kapandji procedure group and ulnar-shortening operation group. The mean pressure of the scaphoid fossa and the force on distal aspect of the radius in the groups followed an increasing trend from the control group, Sauvé-Kapandji procedure group, ulnar-shortening operation group and Darrach procedure group. This study found no significant differences in the mean pressure of the scaphoid fossa and the force on distal aspect of the radius between the Sauvé-Kapandji procedure group and the ulnar-shortening operation group. The Sauvé-Kapandji procedure group showed the greatest mean pressure on lunate fossa.

CONCLUSIONS

In this comprehensive analysis of wrist biomechanics, the ulnar-shortening operation was superior to the Sauvé-Kapandji procedure and Darrach procedure, which adequately maintained the anatomical relationships of the wrist.

Comparison of compression screw and perpendicular clamp in ulnar shortening osteotomy

PURPOSE

To biomechanically quantify 2 techniques, compression screw and perpendicular clamp, for generating compression during ulnar shortening osteotomy (USO) in order to promote reliable primary bone healing.

METHODS

Fourteen fresh-frozen cadaveric human forearms were randomly assigned to 1 of 2 groups. Group I (n = 7) underwent USO according to the traditional AO plate fixation technique using a screw placed eccentrically in an oblong hole to generate compression at the osteotomy site. Group II (n = 7) underwent USO with a commercially available USO plating system using a clamp placed perpendicular to the osteotomy site to generate compression. Both techniques involved a 2-mm resection osteotomy performed with cutting jigs to minimize variability and an interfragmentary lag screw to augment compression. A digital pressure sensor measured contact area at the osteotomy site and average pressure in the observed contact area; these values were used to calculate force across the osteotomy site. Measurements were obtained after the following steps: reduction of osteotomy, compression screw placement (group 1 only), lag screw placement, and final construct with all clamps removed.

RESULTS

Group II demonstrated significantly greater force than group I, and lag screw placement resulted in significantly increased force independent of fixation technique. The effect of the lag screw on force was maintained after clamp removal. Although technique of fixation did not significantly influence contact area, lag screw placement significantly increased contact area independent of fixation method. However, this effect was not maintained after clamp removal. Average pressure in the observed contact area was not significantly influenced by fixation technique or stage of fixation.

CONCLUSIONS

Perpendicular clamp compression significantly increased force as compared with traditional compression screw technique, and lag screw placement significantly increased force in both constructs.

CLINICAL RELEVANCE

Larger compressive forces across the osteotomy may promote primary bone union and decrease the rates of delayed union or nonunion.

Distal metaphyseal ulnar shortening osteotomy: technique, pearls, and outcomes

Background Ulnar sided wrist pain is a commonly encountered complaint of the hand surgeon, and ulnar impaction is a common cause. Surgical treatment aims to reduce the force transmitted through the ulna and traditionally includes diaphyseal ulnar shortening osteotomy and the "wafer" procedure. These procedures have known shortcomings. We describe an alternative option known as the distal metaphyseal ulnar shortening osteotomy (DMUSO). Materials and Methods Retrospective review of eight procedures was undertaken to assess radiographic healing, objective measurements of wrist and forearm motion, grip and pinch strength, and subjective measures of Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Rated Wrist Evaluation (PRWE), and Michigan Hand Outcomes Questionnaire (MHQ) at a minimum of 12 months following surgery. Description of Technique A wedge osteotomy is made in the osteochondral region of the distal metaphysis of the ulna, and a headless compression screw is used for fixation. Results Five women and three men underwent DMUSO with average follow up at 13 months; the dominant wrist was affected in 7 of 8 patients. The affected wrist had less motion in all planes, and grip and pinch strength was also less in the affected wrist, but only wrist extension was significantly different from the contralateral side. These findings likely did not have an effect on the clinical outcome. Subjective outcomes included average DASH score of 13 (0-35), PRWE 19 (40-11), and MHQ score of 88 (85-100). Conclusions DMUSO is a viable option for patients with ulnar impaction syndrome. It requires intra-articular exposure of the distal radioulnar joint (DRUJ) but is less invasive then diaphyseal shortening. It permits early and reliable return of joint motion and function while avoiding the potential need for hardware removal by using a buried screw.

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.

Ulnar shortening osteotomy for ulnar impaction syndrome

Background Ulnar impaction syndrome is a condition in which the ulna impacts on the ulnar carpus. This most commonly occurs when the ulna is longer than the radius, but it can also occur in wrists with ulnar neutral and ulnar negative variance. Materials and Methods In this paper we outline our surgical technique for ulnar shortening osteotomy. A previously published retrospective case series of 28 patients treated at our center is presented. Fifty consecutive patients who underwent ulnar shortening osteotomy (USO) for ulnar impaction syndrome were approached for study, and 28 consented to review. Mean preoperative ulnar variance was +2.3 mm, and mean postoperative ulnar variance was -0.8 mm. Mean follow-up time was 21.2 months (8 to 41 months) and ten of 28 were receiving workers' compensation. Mean preoperative pain score (visual analog scale; VAS) was 7.9. Univariate analysis was performed to assess clinical and demographic data. In addition, subgroup analysis of workers' compensation patients and smokers was performed. Description of Technique A longitudinal incision over the subcutaneous border of the ulna is used to expose the ulna between the distal and middle third of the ulna from the ulna styloid. Preoperative posteroanterior (PA) X-rays are reviewed to determine the amount of shortening required, with a goal of creating -2 mm variance postoperatively. A 6-hole dynamic compression plate is predrilled distally prior to performing two oblique osteotomies separated by the desired shortening length. The fragments are reduced, controlling for rotation, and plated using compression. In some cases, a lag screw is employed across the oblique osteotomy site. Results Mean pain scores were significantly reduced postoperatively (VAS 7.9 versus 3.1, P < 0.0001). The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 37.2 postoperatively. Flexion, extension, and supination were reduced compared with the contralateral unaffected extremity (84.6%, 85.3%, and 86.9% of normal). Patients receiving workers' compensation and smokers had significantly more pain postoperatively (VAS 5.2 vs. 2.0, P = 0.0002 and VAS 4.4 vs 2.4, P < 0.05, respectively). Eleven of 28 patients required hardware removal for plate irritation, and five of 28 patients had a nonunion. Conclusion We present our surgical technique for ulnar shortening osteotomy. Pain was significantly improved in our population; however, patients receiving workers' compensation and smokers had less improvement in pain and higher disability scores.

Arthroscopic distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome: a different technique

Ulnar impaction syndrome generally occurs with positive ulnar variance. The solution to the problem is to unload the ulnocarpal joint. Effective surgical options include diaphyseal ulnar shortening osteotomy, open wafer osteotomy, and arthroscopic wafer osteotomy. Recently, Slade and Gillon described an open procedure of ulnar shortening in the osteochondral region of the ulnar head. The procedure minimizes the risk of hemarthrosis and does not require hardware removal, which are problems with other surgical options. This article introduces a new arthroscopic technique of distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome. This technique offers the advantages of minimizing surgical injury to the dorsal capsule of the distal radoulnar joint and so protects its stability.

Distal ulna hook plate: angular stable implant for fixation of distal ulna

Distal ulna fractures, especially styloid injuries, classically have not been repaired, and only recently have these injuries been considered important. Certain fracture patterns of the distal ulna contribute to distal radioulnar joint (DRUJ) incongruity and potential instability. Appropriate fixation of the distal ulna is frequently difficult for several reasons: (1) high incidence of osteoporois in the affected patient population, (2) proximity of the injury to articular surfaces, and (3) lack of a proper implant to treat these injuries. The 2.0-mm locking compression distal ulna plate (LC-DUP) is an anatomically contoured implant with a low profile and fixed angle that provides proper stability to treat injuries of the distal ulna. The plate was designed for the treatment of distal ulna fractures, but its success has led to an extension of its indications to be used in treating symptomatic basistyloid ulnar nonunions and in ulnar shortening osteotomy for ulnocarpal abutment syndrome. The authors' description of the techniques used for each indication as well as their perspectives in the treatment of distal ulna injuries are described in detail in this report.