The ulnar impaction syndrome

The ulnar impaction syndrome can be defined as the impaction of the ulnar head against the triangular fibrocartilage complex and ulnar carpus resulting in progressive degeneration of those structures. The differential diagnosis in patients who present with ulnar wrist pain and limitation of motion can also include ulnar impingement syndrome and arthrosis or incongruity of the distal radioulnar joint. Structural abnormalities involving the distal radioulnar joint, distal radius, and ulnar carpus must be carefully elucidated prior to developing a treatment plan. When such abnormalities are identified and appropriately addressed, surgical treatment can be expected to be effective in the majority of cases. It is important to remember that in the absence of obvious structural abnormalities, the ulnar impaction syndrome may result from daily activities that result in excessive intermittent loading of the ulnar carpus. In this group of patients, treatment is directed at decreasing ulnar load by shortening the distal ulna in any of several ways. If relative instability of the ulnar ligamentous complex is a factor, then ulnar shortening by recession is the treatment of choice. Malunion of the distal radius resulting in ulnar impaction syndrome is best treated by addressing the deformity; that is, corrective radial osteotomy. Patients who present with a combination of ulnar impaction syndrome along with distal radioulnar joint, abnormalities must have both of these abnormalities addressed at the time of surgery. The matched ulnar resection and the hemiresection interposition arthroplasty are both effective procedures; however, the Suave-Kapandji procedure also can be used to address relative ligamentous laxity at the ulnar aspect of the wrist. The Darrach procedure is presently not recommended as a first-line treatment in these cases; however, when used as a salvage procedure, satisfactory results can be obtained in properly selected patients. Careful preoperative evaluation and planning are therefore the key to successful treatment of the ulnar impaction syndrome.     

Der ulnare Handgelenkschmerz

The distal radioulnar joint (DRUJ), the ulnocarpal joint and the ulnar carpus form an functional anatomical complex, as the head of the ulna is an articulated part of DRUJ as well as having a stabilising action and acting as an abutment due to its direct attachment to the triangular fibrocartilage complex. Pain in this area poses a diagnostic problem due to the close proximity of these structures. In addition to describing the standard clinical examination, the major pathologies of these ulnar hand components, their symptomatology and the basis of their therapy are discussed.     

Distal radioulnar joint replacement

The resection of the ulnar head, as described by Darrach, has unfortunately become the standard of care despite the frequent problems of ulnar stump instability following this procedure. To offer better treatment to our patients, we have to appreciate the various roles and the importance of the ulnar head for the function of the distal radioulnar joint (DRUJ) in mechanically loaded forearm rotation. The ulnar head forms the load-bearing keystone of the DRUJ and the distal forearm, important for maintaining adequate tension within the radioulnar ligaments and the interosseous membrane. A DRUJ implant replacing the ulnar head should and has to be the fixed point and load-bearing part of the joint and will be exerted to large mechanical loads making a neutralization of these forces necessary. A partial resurfacing implant for the DRUJ can be used for primary procedures. The resection is minimal, and further, the attachments of the stabilizing ligaments, the triangular fibrocartilage complex in particular, are preserved with a maintained anatomy and stability. For revision and salvage procedure, a modular ulnar head can be used, which restores the ulnar head offset and stabilizes the ulnar stump, restoring a pain-free DRUJ. The modularity of these 2 implants addresses the majority of indications for prosthesis in the DRUJ.     

TFCC injuries: How we treat?

The triangular fibrocartilage complex (TFCC) is a well defined anatomical entity located on the ulnar aspect of the wrist joint functioning primarily to stabilize the distal radio –ulnar joint (DRUJ) and also to act as a shock absorber across the ulno-carpal joint.Palmer and Werner were first to explain the anatomic details of the TFCC and to describe its biomechanical role at the wrist. The TFCC comprises of the fibro-cartilagenous disc, the dorsal and palmar ligaments spanning across radius and ulna, the ulno-carpal ligaments, a meniscal homolog, and the sub sheath of ulnar extensor of the wrist. The intricate anatomy of this area and complex load transmission kinematics renders it vulnerable to injury and attrition. Both traumatic and degenerative insults produce specific injury patterns which can present as vague ulnar-sided wrist pain particularly during forearm rotation.These injuries are managed initially by modification of daily activities to avoid aggravation of pain and injury, by complete abstinence from sporting/gym/yoga maneuvers which involve stressing the wrist joints, temporary splint or cast immobilisation are also used along with non-steroidal anti-inflammatory medication.Corticosteriod injection are also used in conjunction with physical therapy in grossly symptomatic patients.Surgical treatment is advocated if conservative management fails to provide relief, or in cases presenting initially with frank instability of the DRUJ or with unstable and displaced fractures. Choice of operative treatment is guided by type and extent of injury and may include debridement, repair and in TFCC injuries associated with degenerative changes, ulnar unloading procedures like shortening or Wafer procedure. With current understanding of arthroscopic anatomy of the wrist, availability of instrumentation as well as familiarity of surgeons with this tool, arthroscopic management can be instituted successfully in most if not all conditions afflicting the TFCC.     

Indikation und Ergebnisse der Ulnaverkürzungsosteotomie bei ulnokarpalem Handgelenksschmerz

The ulnar impaction syndrome is proven to be a common source of ulnar sided wrist pain. Ulna-shortening osteotomy represents a successful therapy for this kind of problem, both congenital or posttraumatic positive ulnar variance. Positive variance resulting from a distal radius fracture needs correct dorsal and radial angulation of the radius. In case of congenital positive variance arthroscopic debridement for decompression of the TFCC should be performed first. The adequate correction of the length is the major problem. Disorders of the distal radioulnar joint may result due to overcorrection. Oblique osteotomy using 7-hole-plates is our preferred treatment.     

Pollex valgus: orthopaedic management for ulnar instability of the metacarpophalangeal joint of the thumb

This article describes pollex valgus, the condition of ulnar instability of the thumb's rnetacarpophalangeal joint, relevant to the field of physical therapy. Following a discussion of the normal anatomy and biomechanics of the metacarpophalangeal joint and its component structures, the joint capsule, ulnar collateral ligament, accessory ulnar collateral ligament, volar plate, and adductor aponeurosis, the author details pollex valgus pathology. Emphasis is given to mechanisms of injury and the specific lesions, including ligament sprain and rupture, avulsion, joint locking, and the Kaplan and Stener lesions. Orthopaedic management of pollex valgus is presented in terms of evaluation, via the case history and clinical examination, and treatment, by tape strapping and surgical repair. The author concludes with mention of active exercise and joint mobilization for the rehabilitation of pollex valgus lesions. J Orthop Sports Phys Ther 1986;6(6):334-342.     

Early and late surgical treatment of complete rupture of the radial collateral ligament of the first metacarpophalangeal joint

Stability of the first metacarpophalangeal joint is important for daily activities. Rupture of the radial collateral ligament of the first metacarpophalangeal joint (RCL) is less common than rupture of the ulnar collateral ligament, but serious ruptures of the radial ligament are as debilitating as those of the ulnar ligament. Consistent guidelines for treatment of complete RCL rupture have not yet been established. We recommend 4 weeks of immobilization by two K-wires, followed by extensive hand therapy, as primary treatment of complete RCL rupture. As late treatment of complete RCL rupture, we recommend surgical repair using a bone anchor, 4 weeks of immobilization, and subsequent hand therapy. Two patients with a complete RCL rupture are presented. One was treated early and the other received treatment 2 months after injury. These two cases illustrate the methods of early and late treatment. Received: 1 December 1999 / Accepted: 2 February 2000     

微型骨锚一期重建急性拇指掌指关节尺侧副韧带损伤

目的 评估应用微型骨锚对急性拇指掌指关节尺侧副韧带损伤进行手术修补的临床疗效.方法 2004年7月至2009年5月,对11例急性拇指掌指关节尺侧副韧带完全损伤的患者,采用Mitek micro微型带线骨锚一期植入第一掌骨头或拇指近节指骨基底侧方尺侧副韧带断裂的附着处,用锚尾部的缝合线缝合撕脱的侧副韧带重建起止点.结果 术后随访6个月至4年,平均2.4年.按Saetta标准评定:优7例,良3例,可1例;优良率为90.9%.X线片显示骨锚未见松动、脱落.结论 应用骨锚对急性拇指掌指关节尺侧副韧带损伤进行手术修补不仅操作简便,而且容易掌握,疗效可靠.     

Das Caput-ulnae-Syndrom

The ulnar head has a central function in stabilizing the wrist. In the treatment of caput ulnae syndrome, the radiocarpal joint must, therefore, always be considered. The integrity of the ulnar head and TFCC are of major importance for the rheumatoid wrist. Therefore, surgical treatment should be carried out early, and is indicated for drug-resistant synovitis and monarthritis of the wrist. Early synovectomy of the radiocarpal and distal radioulnar joint (DRUJ) can be done as an open procedure or, when extensor tendon synovitis is absent, as an arthroscopic procedure. In most cases, however, treatment of manifest caput ulnae syndrome, sometimes even with rupture of the extensor tendons, is necessary. In these cases, resection of the ulnar head together with a dorsal wrist stabilization is indicated. Less often, arthrodesis of the DRUJ with segmental resection of the ulna or an arthroplasty are indicated. When choosing the procedure, the type and stage of wrist changes have to be considered. The DRUJ usually has to be treated together with the radiocarpal joint. Its isolated treatment is rarely indicated.     

Surgical management of the hyperflexed thumb interphalangeal joint in the hand with ulnar intrinsic palsy

A great deal of attention has been paid to the need to restore balance about the metacarpophalangeal joint when clawing complicates ulnar nerve palsy. Less commonly addressed but perhaps more disabling are the consequences of ulnar palsy on function of the thumb. The hyperflexion of the thumb’s interphalangeal joint (IPJ), popularly termed Froment’s sign, leads to an unstable pinch. When surgically addressed, a common recommendation is fusion of this joint. A simple operative procedure, introduced to provide stability to the tetraplegic hand as part of key grip reconstruction can be equally well applied to the hyperflexed thumb of ulnar nerve palsy. Tenodesis of one half of the flexor pollicis longus into the extensor pollicis longus provides a check-rein against excessive IPJ flexion, promotes a more stable pinch posture, and avoids fusion of the joint.     

Pressures in the distal radioulnar joint: effect of surgical procedures used for Kienbock's disease

Radial shortening and ulnar lengthening are two accepted surgical methods for treating Kienbock's disease. The effect of these procedures on the pressure within the distal radioulnar joint between the ulnar head and the sigmoid notch of the radius was experimentally evaluated in six fresh cadaver forearms. Radical shortening and ulnar lengthening led to increased pressure at the distal radioulnar articulation and caused shifting of the location of the center of pressure distally within the sigmoid notch. Radial displacement of the distal radial fragment at the time of radial shortening, however, decreased the peak pressures. Based on these experimental data, ulnar lengthening and radial shortening can be expected to alter the normal biomechanics of the distal radioulnar joint.     

Arthroplasty at themetacarpophalangeal joints

Rheumatoid arthritis frequently affects the metacarpophalangeal joints in the hand. When joint disruption isassociated with extensor lag and ulnar drift, implant arthroplasty has been shown to improve metacarpophalangeal joint function in a reliable manner. The soft tissue procedures attendant to the replacement are as important as the implant placement itself. Attention to the details of the procedure and closely monitored postoperative therapy are essential to the success of the procedure.     

尺骨头切除对腕关节稳定性影响的实验研究

本实验研究采用12个新鲜尸体标本,在尺骨头切除(Darrach's procedure)前后进行一系列X线照片和腕关节造影,研究尺骨头切除后腕关节稳定性的影响。实验结果显示:尺骨头切除后,腕关节桡编斜度增加3°(P〈0.01);尺偏斜度增加11.92°(P〈0.001);月骨位置无变化。12个腕关节造影中有11个显示三角纤维软骨损伤。尺骨头切除后腕关节的稳定性受到一定影响。     

兔肘关节尺侧副韧带急性损伤手术与非手术治疗后负载和强度的比较

目的 比较兔急性肘关节尺侧副韧带损伤后手术修复与非手术治疗的差异.方法 新西兰兔81只按随机数学表法分为三组(n=27),正常对照组(A组):暴露右尺侧副韧带后,但不切断;韧带缝合组(B组):切断右尺侧副韧带后随即缝合韧带;韧带不缝合组(C组):切断右尺侧副韧带后不缝合.分别于术后3、6、12周三个阶段取材,进行生物力学检测.结果 术后12周B组断裂时的最大载荷[(68.23±5.64)N]与C组[(42.45±3.66)N]比较,差异有统计学意义(P<0.05);B组与A组[(72.86±2.99)N]比较,差异无统计学意义(P>0.05).B组应力强度[(3.84±0.47)N/mm2]与C组[(2.84±0.17)N/mm2]比较,差异有统计学意义(P<0.05);B组与A组[(4.09±0.15)N/mm2]比较,差异尤统计学意义(P>0.05).结论 肘关节尺侧副韧带急性损伤后手术治疗明显优于非手术治疗.     

掌指关节置换术治疗类风湿关节炎尺偏畸形的疗效

目的总结掌指关节置换术治疗类风湿关节炎(RA)尺偏畸形的临床疗效。方法对40例RA尺偏畸形患者采用Swanson假体掌指关节置换术。评价患者术后尺偏角度、握力、关节活动度及关节功能等指标。结果患者切口均一期愈合,无感染或坏死等早期并发症。患者均获得随访,时间4~6个月。术后3个月,尺偏角度明显纠正,掌指关节活动度及握力明显增加,MHQ评分、AIMS2评分明显改善,各项指标与术前比较差异均有统计学意义(P<0.05)。无假体断裂、脱位及假体周围骨折等并发症。结论掌指关节置换术治疗RA尺偏畸形安全有效,可有效改善手的外观,减轻疼痛,改善关节功能。     

Endoscopic approach to cubital tunnel syndrome

The cubital tunnel syndrome is one of the most common entrapment neuropathy of the upper limb. The ulnar nerve can be compressed in the oteofibrous tunnel by the bone structures, the Osborne's ligament, the fascia of the ulnar flexor muscle of the carpus or of the aponeurosis of the deep flexor of the fingers. Pressure values in the cubital tunnel >50 mm Hg induce blocking of intraneural circulation with electrodiagnostic modifications, clinical signs and histological changes including demyelinazion of the nerve proximal to the cubital tunnel. Surgery becomes essential in case of failure of conservative and physical therapy. Various surgical techniques have been described in the literature for the treatment of the ulnar neuropathy at the elbow. In this paper the authors report a new endoscopic technique for the treatment of ulnar nerve entrapment at the elbow which requires respect of specific electrodiagnostic and clinical criteria of inclusion. The restored joint active motion following elbow arthroscopy in osteoarthritis can induce or get worse a ulnar nerve neuropathy; endoscopy neurolysis is essential to remove perineural adherences and reduces the nerve stress. Immediate well-being of the patient, lesser invasiveness and minimum vascular complications are clear advantages of the endoscopic approach, while the treatment of the pathologies proximal and distal to the Struther's arcade is a limit of the technique.     

Injury of the dorsal sensory branch of the ulnar nerve as a complication of arthroscopic repair of the triangular fibrocartilage

This report presents a case of direct injury to the dorsal sensory branch of the ulnar nerve caused by arthroscopic repair of the triangular fibrocartilage complex. The dorsal sensory branch of the ulnar nerve was strangulated by one of the three pull-out sutures of the joint capsule, just ulnar to the extensor carpi ulnaris tendon. Pain and dysaesthesia of the ulnar side of the wrist was completely relieved after excision of the injured nerve segment. This complication can be avoided by careful exploration of the dorsal sensory branch of the ulnar nerve prior to suturing or passage of instruments during arthroscopy.     

Ulnar neuropathies in rheumatoid arthritis.

A loss of functional motor axons in the median and ulnar nerves occurred in half of thirty-three patients with rheumatoid arthritis. Weakness of small hand muscles may predispose to the development of ulnar deviation of the fingers in patients with joint disease at the radio-ulnar and metacarpophalangeal joints. There is no evidence that spasm of small hand muscles is a significant cause of ulnar deviation of the fingers in rheumatoid arthritis. Ulnar deviation of the fingers in rheumatoid arthritis is not due to selective impairment of the ulnar nerve or the deep palmar branch of the ulnar nerve even though ulnar deviation of the fingers can occur in association with such lesions and in the absence of joint disease.     

Biepicondylar fracture dislocation of the elbow joint concomitant with ulnar nerve injury

In this article, we present a case of humeral biepicondylar fracture dislocation concomitant with ulnar nerve injury in a seventeen year-old male patient. Physical examination of our patient in the emergency room revealed a painful, edematous and deformed-looking left elbow joint. Hypoesthesia of the little finger was also diagnosed on the left hand. Radiological assessment ended up with a posterior fracture dislocation of the elbow joint accompanied by intra-articular loose bodies. Open reduction-Internal fixation of the fracture dislocation and ulnar nerve exploration were performed under general anesthesia at the same session as surgical treatment of our patient. Physical therapy and rehabilitation protocol was implemented at the end of two weeks post-operatively. Union of the fracture lines, as well as the olecranon osteotomy site, was achieved at the end of four months post-operatively. Ulnar nerve function was fully restored without any sensory or motor loss. Range of motion at the elbow joint was 20-120 degrees at the latest follow-up.