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Ulnar Sided Wrist Pain

Arthritis-RA, OA, post-traumatic, gout, pseudogout Lunotriquetral Instability
Distal Radius Fracture  with sigmoid notch involvement Pisiform Fx
Dorsoulnar sensory nerve neuritis TFCC Tear  (traumatic, degenerative)
DRUJ Arthritis / Incongruity Triquetral avulsion fracture
Essex-Lopresti Injury Ulnar Artery Thrombosis (Guyons canal)
Extensor Carpi Ulnaris Subluxation Ulnar Styloid Fracture
Extensor Carpi Ulnaris Tendonitis Ulnar Tunnel Syndrome
FCU Tendonitis Ulnocarpal Impaction Syndrome
Ganglion Cyst Other=Congenital Madelung’s deformity, fixed forearm contracture, tumor
Hamate Fracture  
Keinbock's Disease  
Lunate Fracture  

 

Ulnar Sided Wrist Pain Anatomy

  • TFCC=triangular fibrocartilage complex=articular disc, dorsal and palmer radioulnar ligaments, meniscus homologue and extensor carpi ulnaris sheath(the floor of which is called the ulnar collateral ligament)
  • 82% of compressive loads are carried by radiocarpal joint, 18% by ulnocarpal joint while in neutral ulnar variance (Palmer AK, CORR 187:26;1984), positive ulnar variance increases load born by ulnocarpal joint.
  • ulnar variance increases with full pronation and power grip and decreases with full suppination

Ulnar sided Wrist Pain Clincal Evaluation

  • age, hand dominence, vocational and recreational demands
  • compare to uninvolved side
  • ROM suppination / pronation
  • Identify point of maximal tenderness
  • TFCC grind: deviate wrist ulnarly and apply axial load and rotation. Painful clicking that reproduces patients symptoms indicates TFCC injury.
  • Shuck and lunotriquetral ballottement indicate LT injury.
  • Shear test: indicates pisotriquetral arthrosis
  • Assess DRUJ stability
  • Assess grip strength

Ulnar Sided Wrist Pain Xray

  • PA  (PA=neutral pro/sup, shoulder abducted 90, elbow flexed 90, neutral wrist flex/ext); lunate should be 1/2 on ulnar border of radius, with full ulnar deviation lunate should be entirely over radius (if not suspect radiocarpal arthritis)
  • lateral (shoulder adducted at side, elbow at 90, neutral sup/pro) pisiform overlies distal 1/3-1/4 of distal pole of scaphoid
  • ulnar variance-measured on PA xray; line drawn perpendicular to longitudinal axis of radius at level of the subchondral bone of the palmar lip of the lunate fossa; distance the lunar head is above(positive) or below(negative)=the ulnar variance
  • Clenched fist ulnar deviation view: evaluate for dynamic ulnar impingement.
  • CT prone of bilateral wrists at level of Lister’s tubercle in neutral, full suppination, and full pronation useful for DRUJ subluxation/dislocation, evaluating articular surface,
  • triple injection arthrography; evaluate TFCC tears; radiocarpal injection, followed by DRUJ and midcarpal injections 3 hrs later
  • MRI-nearly as good as arthrography for TFCC tear.  Traumatic tears seen on T2-weighted coronal images.  80% sensitivity, 100% specificity for tears.  By 60 yrs old @50% of people have asymptomatic articular disc perforations. Marrow changes in the lunate, ulnar head or triquetrum indicated ulnar impaction.