非创伤性尺腕撞击综合征的诊断和治疗

目的 探讨无明确创伤病史且X线片表现不典型的尺腕撞击综合征的特点及诊断标准和治疗方法.方法 回顾性研究2003年10月至2010年10月明确诊断和治疗的55例尺腕撞击综合征患者中没有明确创伤病史且X线片表现不典型的25例,在Kostas诊断标准基础上,观察尺腕压力试验、动态尺骨正向变异、MRI检查的阳性率和腕关节镜检查,分析观察指标对诊断结果的影响和临床意义.治疗采取尺骨短缩手术,截骨方式中16例采用水平截骨(Darrow法),9例采用斜行截骨(Rayhack法),加压钢板螺钉内固定.采用Darrow标准作为疗效评价标准.结果 本组25例患者中尺腕压力试验阳性比率为84％,动态尺骨正向变异的发生比率为52％,MRI检查发现腕骨信号改变的比率为82％,以月骨尺侧部近端和三角骨腰部最为常见,腕关节镜检查三角纤维软骨复合体(TFCC)退变及尺骨头和月骨的软骨退变比率为100％.随访时间4～48个月,平均26个月.25例骨折均愈合,水平截骨的平均愈合时间为4.5个月,斜行截骨的平均愈合时间为2.5个月.优7例,良15例,中2例,差1例;总优良率为88％.术后未发生严重并发症,治疗结果满意.结论 非创伤性尺腕撞击综合征由于缺少明确的创伤病史,尤其当X线片表现不典型时同其他引起腕关节尺侧疼痛的病因较难鉴别,应用尺腕压力试验、动态尺骨正向变异检查和早期MRI检查可早期明确诊断,有效提高诊断率.腕关节镜检查可作为诊断困难和鉴别诊断的补充手段.应用尺骨短缩手术可明显改善症状,斜行截骨是值得推荐的截骨方式.     

Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome

A retrospective review was performed that compared the results of 2 different surgical treatments for ulnar impaction syndrome in 22 patients over a 6-year period. Ulnar shortening osteotomy and wafer distal ulna resection (wafer resection procedure) were each performed in 11 patients based on the preference of 3 individual hand surgeons. All patients presented with ulnar wrist pain and positive ulnar variance on either neutral rotation or pronated-grip x-rays and each failed conservative management. At a minimum follow-up time of 18 months, 9 patients had good to excellent results following ulnar shortening osteotomy compared with 8 following the wafer resection procedure. This difference was not statistically significant. All patients regained functional wrist motion and 21 of the 22 patients had satisfactory pain relief. There was 1 poor result in the wafer group that required revision to complete resection of the distal ulna. Five secondary procedures were required in the osteotomy group to remove painful hardware and union was delayed in 2 patients. Although ulnar shortening osteotomy provides effective treatment for ulnar impaction syndrome, the wafer resection procedure provides favorable pain relief and restoration of function but without the potential for nonunion or hardware removal. (J Hand Surg 2000; 25A:55-60.     

Ulnar shortening osteotomy

Objective  Ulnar shortening to unload the ulnocarpal ligamentous complex. Indications  Clinically relevant ulnar impaction syndrome, be it congenital or posttraumatic. Contraindications  Concomitant pronounced malunion of the radius. Osteoarthritis of the distal radioulnar joint. Surgical Technique  Ulnopalmar approach. Oblique osteotomy of the ulna in its distal third. Removal of a bony wafer of predetermined thickness. Internal fixation with a 7-hole LD-DC plate or special plate and lag screw. Results  29 patients (14 men, 15 women, average age 42 years) underwent an ulnar shortening osteotomy for a therapyresistant ulnar impaction syndrome. Follow-up after an average of 25(7–37) months. Average amount of shortening 4.5 (1.5–13) mm. 72% reduction of pain as determined with a visual analog scale. The range of motion was improved by 7% in extension/flexion, by 8% in abduction/adduction, and by 11% in pronation/supination. Grip strength measured with a vigorimeter (balloon size 5) increased by 12%. Complications: three malunions, effectively treated by revision of internal fixation.     

Arthroscopic treatment of ulnar impaction syndrome

Ulnar impaction syndrome occurs in the setting of a central traumatic or degenerative defect in the triangular fibrocartilage complex in patients with ulnar positive variance. Chondral and subchondral edema, mechanical impingement of the articular disc, and chondromalacia of the distal ulna, proximal lunate, and proximal triquetrum produce symptoms with activity that do not improve with rest. Decreasing ulnocarpal load-sharing across the wrist with recession of the distal ulna is necessary to relieve symptoms in the majority of patients. Arthroscopic treatment with triangular fibrocartilage complex debridement and arthroscopic ulnar wafer resection is an effective treatment for ulnar impaction syndrome. It affords a single-stage, minimally invasive approach, with similar efficacy and fewer complications than open wafer resection or ulnar shortening osteotomy.     

Die Ulnaverkürzungsosteotomie

Objective Ulnar shortening to unload the ulnocarpal ligamentous complex. Indications Clinically relevant ulnar impaction syndrome, be it congenital or posttraumatic. Contraindications Concomitant pronounced malunion of the radius.Osteoarthritis of the distal radioulnar joint. Surgical Technique Ulnopalmar approach. Oblique osteotomy of the ulna in its distal third. Removal of a bony wafer of predetermined thickness. Internal fixation with a 7-hole LD-DC plate or special plate and lag screw. Results 29 patients (14 men, 15 women, average age 42 years) underwent an ulnar shortening osteotomy for a therapy-resistant ulnar impaction syndrome.Follow-up after an average of 25 (7–37) months. Average amount of shortening 4.5 (1.5–13) mm. 72% reduction of pain as determined with a visual analog scale. The range of motion was improved by 7% in extension/flexion, by 8% in abduction/adduction and by 11% in pronation/supination. Grip strength measured with a vigorimeter (balloon size 5) increased by 12%.Complications: three malunions, effectively treated by revision of internal fixation.     

Laser-assisted arthroscopic ulnar shortening

The purpose of this study is to evaluate arthroscopic ulnar shortening with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser for the treatment of ulnocarpal abutment syndrome (UAS). This is a retrospective review of the experience of a single surgeon using this technique between 1994 and 2000. Unloading the ulnocarpal joint is the recognized treatment of UAS. Ulnar shortening via a diaphyseal osteotomy and plating (USO) has been used with good results; however, nearly 50% of patients will require hardware removal. Researchers have reported similar results between open distal ulnar resection (the wafer procedure) and USO for the treatment of UAS. Researchers have also reported similar results with mechanical arthroscopic distal ulnar resections (arthroscopic wafer distal ulnar resection [AWP]) for UAS. Eleven patients who underwent Ho:YAG laser-assisted arthroscopic distal ulnar resection were retrospectively evaluated. The average follow-up time was 31 months, with a range of 7 to 61 months. Evaluation using Darrow’s criteria revealed 64% excellent (7 of 11), 18% good (2 of 11), 9% fair (1 of 11), and 9% poor (1 of 11) results. The average return to work time was 4.7 months, with a range of 1.5 to 16 months. Complications included 1 repeat surgery for ulnocarpal scar formation, 2 cases of transient tendonitis, and 1 portal site erythema without drainage that was treated with antibiotics. One patient (the one with a poor result) has not returned to work for unrelated reasons. χ- square analysis (P < .05) was unable to identify a statistical difference between the reported results of arthroscopic wafer procedures, USOs, and open wafer procedures. We concluded that Ho:YAG laser-assisted arthroscopic ulna shortening procedures show similar results to those reported for arthroscopic wafer procedures, open wafer procedures, and USOs. Return to work times are similar to those reported by other researchers, as is the return to preoperative occupation rate. There is no need for late removal of hardware, as is sometimes associated with USO. Our experience has been that the Ho:YAG laser removes hyaline cartilage and subchondral bone rapidly and with little debris, and thus facilitates the ulna shortening procedure.     

Ulnar impaction syndrome

Although Palmer's classification of TFCC lesions differentiates post-traumatic central perforations (IA tears) from degenerative tears secondary to ulnocarpal impaction (IIC) [3], the distinction is not always clear clinically. In the final analysis, the literature suggests that as many as 25% of wrists with TFCC tears have residual symptoms following arthroscopic debridement alone [23], and it is likely that static or dynamic ul-nar positive variance plays a role [2,5,17,25]. The authors' results suggest that combined arthroscopic TFCC debridement and wafer resection are feasible and efficacious as treatment for all stages of ulnar impaction syndrome. When class II A and B changes are observed, that is, when a TFCC perforation has not yet developed, the authors have observed favorable results in most patients following arthroscopic TFCC central disc excision and wafer resection as an alternative to ulnar shortening osteotomy [33] or open wafer excision [10].     

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.     

Mar shortening osteotomy in posttraumatic ulnar impaction syndrome

Twenty-eight patients (average age 45 years) with posttraumatic ulnar impaction syndrome underwent ulnar shortening osteotomy of 3–15 mm. Contributing factors were malunited fractures of the distal radius in 20, diaphyseal fractures of the ulna and radius in 6, resection of the radial head and a traumatic tear of the triangular fibrocartilage in 1 patient each. Evaluation at an average follow-up of 20 months showed a high rate of satisfied patients (89%), but according to Chun's modification of the Gartland-Werley score there were 1 excellent (3.5%), 11 good (39.5%), 11 fair (39.5%) and 5 poor (17.5%) results. Degenerative changes of the distal radioulnar joint were associated with fair and poor results, and ulnar shortening osteotomy is only recommended in ulnocarpal impaction with an intact distal radioulnar joint. Osteotomy fixation with 3.5 mm dynamic compression plates enabled immediate postoperative mobilisation and resulted in a low complication rate. There was no advantage for the technically more demanding oblique as compared with a transverse osteotomy.     

Treatment of ulnar impaction syndrome with the wafer procedure

Our objective was to evaluate the efficacy of wafer resection of the distal ulna (the wafer procedure) as treatment for ulnar impaction syndrome. Between 1995 and 1997, 26 patients were surgically treated for refractory wrist pain secondary to ulnar impaction syndrome. The diagnosis was based on physical examination, radiologic imaging, and wrist arthroscopy, and confirmatory pathoanatomy was identified at the time of surgery in all cases. The study population consisted of 18 women and 8 men, and patient age averaged 42 years. Follow-up averaged 27 months (range, 17-41 months). Twenty-three patients were completely satisfied with pain relief and the functional status of their wrists at final follow-up. Range of motion returned to baseline in the majority of cases, usually by 3 months, and grip strength increased an average of 11 kg (P < or = .005). The wafer procedure is an effective treatment alternative to ulnar-shortening osteotomy for ulnar impaction syndrome and avoids the risk of nonunion and hardware-related complications.     

Subcapital ulnar shortening osteotomy

Ulnar shortening osteotomy is the standard treatment for the condition of ulnocarpal impaction. Traditionally ulnar shortening osteotomy has been performed in the diaphysis and secured with a 3.5 mm plate. Delayed union, nonunion, and symptomatic hardware have been cited as detractors of this technique. A number of alternatives have consequently been proposed that range from different hardware to different patterns of osteotomy to resection of the distal portion of the ulnar head. This article describes one method for ulnar shortening osteotomy that seeks to draw upon the advantages of several of these variations in order to minimize complications.     

Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome.

Twenty-eight patients were treated by ulnar shortening osteotomy for static or dynamic ulnar impaction syndrome. Ulnar variance was measured on a true anteroposterior radiograph. There were 25 wrists that were too long, two neutral, and one that was short. Bones were shortened by a mean of 3.5 mm. Mean follow-up time was 29 months (range 7-60), all with confirmed consolidation. At final follow-up mean grip strength had improved from 67% to 75%, mean Disabilities of the Arm, Shoulder, and Hand (DASH) score from 40 (range 12-83) to 26 (range 0-61) and mean range of movement from 80% (range 40%-100%) to 88% (range 50%-100%). Smoking, age at operation, type of osteotomy (transverse or oblique), dominance of hand, and sex did not influence consolidation or functionality. Special attention was paid to the anatomy of the distal radioulnar joint and the inclination of the sigmoid notch of the radius. There was no correlation between the anatomy and the functional outcome scores. Mean consolidation time (10 months) (range 2-32) and return to work were longer than in similar studies. Our findings confirm the usefulness of ulnar shortening osteotomy in the relief of ulnocarpal impingement symptoms.     

Carpal impaction with the ulnar styloid process: treatment with partial styloid resection

Carpal impaction with the ulnar styloid process (stylocarpal impaction) occurs less frequently than with the ulnar head (ulnocarpal impaction), and more commonly develops in wrists with negative ulnar variance. Physical examination, radiographic evaluation, and wrist arthroscopy are all helpful in excluding alternative causes of ulnar wrist pain. When an ulnocarpal stress test elicits pain, and radiographs suggest that this is due to carpal impaction with the ulnar styloid, partial resection of the styloid process provides successful treatment, so long as the insertion of the triangular fibrocartilage at the base of the styloid is not disrupted.     

The treatment of ulnar impaction syndrome: a systematic review of the literature

Ulnar impaction syndrome is a common cause of ulnar-sided wrist pain that is thought to be a result of abutment between the ulna and the ulnar carpus. A systematic review of the literature was conducted to determine the effectiveness of different treatment options in managing ulnar impaction syndrome. PubMed, the Cochrane database, and secondary references were reviewed to identify all English-language articles with reported results on the treatment of ulnar impaction syndrome. A total of 16 articles met the criteria for review. Three procedures were identified as the most commonly used in treating this syndrome: ulnar shortening osteotomy, the wafer procedure, and the arthroscopic wafer procedure. Mean time to union and percentage nonunion for the osteotomy group was 10.3 weeks and 1.7%, respectively. The overall complication rate for patients in the ulnar shortening osteotomy group, the wafer procedure group, and the arthroscopic wafer group was 30%, 8.8%, and 21%, respectively. The authors were unable to determine a single best treatment option based on the available studies, mainly due to the variability in the reporting of subjective outcome measures. Ulnar shortening osteotomy was associated with a higher complication rate than other procedures.     

Results of the wafer procedure for ulnar impaction syndrome in the ulnar negative and neutral wrist

Thirteen wrists with ulnar neutral or negative variance were treated by open distal ulna excision (the wafer procedure). The mean follow-up was 25 months (range, 12-38). At final follow-up grip strength had increased a mean of 14 kgf and 12 of the 13 patients were very satisfied with the functional outcome and pain relief. In treatment of the ulnar impaction syndrome, the wafer procedure provides excellent pain relief and functional restoration particularly in patients with ulnar neutral or negative wrists in whom triangular fibrocartilage tears have not yet developed.     

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.     

Effects of wafer resection and hemiresection from the distal ulna on load-sharing at the wrist: a cadaveric study

PURPOSE: Ulnar impaction syndrome is commonly the result of a naturally occurring ulnar-positive condition, distal radius fracture malunion, or collapse of a fractured radial head. The Feldon wafer procedure and the Bowers distal hemiresection procedure are designed to decrease force transmitted through the distal ulna. The purpose of this study was to measure the effects of these procedures on distal ulnar loading with varying degrees of ulnar positivity at the wrist. METHODS: Using a specially designed miniature load cell distal ulnar force was measured in 20 fresh-frozen cadaveric forearms as the wrist was loaded axially to 134 N in neutral forearm rotation; tests were performed in valgus alignment with the elbow flexed to 90 degrees . Ulnar positivity (0 mm, +2 mm, +4 mm, and +6 mm) was created by incremental shortening of the distal radius using a sliding plate. The radial neck was sectioned transversely and the radial head fragment was fixed in its anatomic position using cemented metal prongs connected to a rigid bar; this allowed the radial head to be disconnected and tilted out of the loading pathway to simulate an excised radial head. Loading tests (with and without the radial head in place) were repeated after removal of a 3-mm wafer of bone beneath the triangular fibrocartilage complex, and again after a hemiresection of the distal ulna to the base of the ulnar styloid process. RESULTS: For each ulnar status condition (intact, wafer removal, hemiresection) the mean distal ulnar force generally increased as the wrist became more ulnar positive. Both wafer removal and hemiresection significantly decreased mean distal ulnar forces under all conditions of ulnar variance, with or without the radial head in place. With the radial head in place the mean distal ulnar forces (expressed as a percentage of applied wrist force) for the 0-mm condition were 16.9% (intact), 3.8% (wafer removal), and 3.5% (hemiresection); corresponding values for the +6-mm condition were 61.6% (intact), and 39.8% (wafer removal), 15.1% (hemiresection). With the radial head removed the mean distal ulnar forces for the 0-mm condition were 31.7% (intact), 4.6% (wafer removal), and 4.4% (hemiresection); corresponding values for the +6-mm condition were 96.4% (intact), 71.6%, (wafer removal), and 27.2% (hemiresection). The decrease of distal ulnar force resulting from hemiresection was significantly greater than that for wafer removal for all ulnar-positive conditions; force reductions were not significantly different between the 2 procedures with neutral ulnar variance. CONCLUSIONS: The results of the present study can help to offer a biomechanical basis for choosing between a Feldon wafer procedure and a Bowers hemiresection procedure in patients with ulnocarpal impaction syndrome. Both procedures produced equal decreases of distal ulnar force in the intact forearm. With an ulnar-positive wrist, the condition for which the procedure would be performed commonly, the hemiresection was more effective in decreasing force transmitted through the distal ulna.     

Ulnar shortening osteotomy for ulnar ideopathic impaction syndrome

Twenty-eight patients were treated by ulnar shortening osteotomy for static or dynamic ulnar impaction syndrome. Ulnar variance was measured on a true anteroposterior radiograph. There were 25 wrists that were too long, two neutral, and one that was short. Bones were shortened by a mean of 3.5 mm. Mean follow-up time was 29 months (range 7–60), all with confirmed consolidation. At final follow-up mean grip strength had improved from 67% to 75%, mean Disabilities of the Arm, Shoulder, and Hand (DASH) score from 40 (range 12–83) to 26 (range 0–61) and mean range of movement from 80% (range 40%–100%) to 88% (range 50%–100%). Smoking, age at operation, type of osteotomy (transverse or oblique), dominance of hand, and sex did not influence consolidation or functionality. Special attention was paid to the anatomy of the distal radioulnar joint and the inclination of the sigmoid notch of the radius. There was no correlation between the anatomy and the functional outcome scores. Mean consolidation time (10 months) (range 2–32) and return to work were longer than in similar studies. Our findings confirm the usefulness of ulnar shortening osteotomy in the relief of ulnocarpal impingement symptoms.     

Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome

BACKGROUND: Idiopathic ulnar impaction syndrome can be defined as a degenerative condition of the ulnar aspect of the wrist in patients with congenital or dynamic positive ulnar variance without a history of fracture or premature physeal arrest. The purpose of this study was to evaluate the clinical features of idiopathic ulnar impaction syndrome and the outcomes of ulnar shortening osteotomy for this group of patients. METHODS: Thirty-one wrists in twenty-nine patients with idiopathic ulnar impaction syndrome were treated with an ulnar shortening osteotomy. Ulnar variance was measured on an anteroposterior radiograph of the wrist, and radioulnar distance was measured on a lateral radiograph, with the forearm in neutral rotation, to evaluate any displacement of the ulnar head from the distal aspect of the radius. All patients were followed clinically and radiographically for a mean of thirty-two months. RESULTS: An average preoperative ulnar variance of +4.6 mm (range, 2 to 7.5 mm) was reduced to an average of -0.7 mm (range, -4 to +1 mm) postoperatively. Preoperatively, the modified Gartland and Werley score was an average (and standard deviation) of 69.5 +/- 7.6, with twenty-four wrists rated poor and seven rated fair. Postoperatively, the score improved to an average of 92.5 +/- 8.0, with twenty-four wrists rated excellent; five, good; one, fair; and one, poor. Dorsal subluxation of the distal aspect of the ulna was found concomitantly in nine wrists, and it was found to be reduced by the shortening osteotomy. Seven patients had cystic changes in the carpal bones preoperatively, but these were not evident one to two years after the operation. CONCLUSIONS: Ulnar shortening osteotomy improved wrist function in patients with idiopathic ulnar impaction syndrome and reduced the subluxation of the distal radioulnar joint, which is commonly found in these patients. Degenerative cystic changes of the ulnar carpal bones appear to resolve following the shortening osteotomy.     

Die arthroskopische ulnokarpale Dekompression durch Teilresektion des Ulnakopfs

Objective

Arthroscopic decompression (wafer procedure) of the ulnocarpal compartment in patients with ulnar impaction syndrome.

Indications

The arthroscopic wafer procedure is recommended in ulnar-plus situations with up to 3 mm length-excess. To perform this procedure the ulnar head needs to be accessible for the burr through a pre-existing, impaction-related, centroradial lesion of the triangular fibrocartilage complex (TFCC). The additional presence of a distal radioulnar joint (DRUJ) type C confirms the indication.

Contraindications

The wafer procedure is contraindicated if there is no consistent TFCC injury ensuring access to the ulnar head and furthermore in ulna-plus situations of more than 3 mm. Relative contraindications: in young patients due to lack of evidence-based studies.

Surgical technique

Arthroscopic, semicircular, partial resection of the ulnar head in terms of oblique–helicoidal osteotomy using a 4.2 mm burr, while sparing the DRUJ and the dorsal and the palmar radioulnar ligaments.

Postoperative management

Immobilization for 1 week in a palmar splint with immediate intensive exercising of pro- and supination under physiotherapeutic instruction.

Results

Between 2008 and 2010, an arthroscopic wafer procedure was performed in 24 patients. The resection of the ulnar head was 2.5 mm on average. After a mean follow-up time of 13.25 months, very good results were archived in 23 of 24 patients; the ulnar impingement test was negative. On a visual analog scale (0–10) average postoperative pain was 1.16 at rest and 4.5 under stress. The mean postoperative DASH score was 13.4.