Ulnar-sided Wrist Pain- Diagnosis and Treatment

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Washington University School of Medicine

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Ulnar-sided wrist pain: Diagnosis and treatmentAlexander Y. ShinMayo Clinic

Mark A. DeitchJohns Hopkins Bayview Medical Center

Kavi SacharUniversity of Colorado School of Medicine and Hand Surgery Associates

Martin I. BoyerWashington University School of Medicine in St. Louis

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T HE J OURNALOF B ON E & JOINTS URGERY JBJS .OR G

VOLUME86-A NUMBER7 JUL Y 2004

ULNAR-S IDEDWRIST P AI N

Ulnar-Sided Wrist PainDIAGNOSIS AND TREATMENT

BYALEXANDERY. SHIN, MD, MARKA. DEITCH, MD, KAVISACHAR, MD, ANDMARTINI. BOYER, MD, MSC, FRCS(C)

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Ulnar-sided wrist pain has often beenequated with low back pain because ofits insidious onset, vague and chronicnature, intermittent symptoms, andfrustration that it induces in patients.Chronic ulnar-sided wrist pain may beaccompanied by a history of WorkersCompensation claims and unrelentingand irresolvable pain, and it may occurin patients with difficult personalities.Despite these issues, many patients withulnar-sided wrist pain do have patho-logic lesions that may be amenable tosurgical treatment.

The anatomy of the ulnar side ofthe wrist is complex, with many over-lapping areas that may be a cause ofpain. A clear understanding of the nor-mal anatomy of the ulnar side of thewrist in addition to a systematic evalua-tion with both physical examinationand radiographic imaging can oftenelucidate the etiology, and thus thetreatment, of ulnar-sided wrist pain.

The differential diagnosis of ulnar-sided wrist pain can be divided into sixelements: osseous, ligamentous, tendi-

nous, vascular, neurologic, and miscel-laneous. Osseous injuries include thesequelae of fractures (i.e., nonunion ormalunion) and degenerative processes.Fracture nonunions of the hamate1-4,pisiform5-10, triquetrum11-13, base of thefifth metacarpal14-17, ulnar styloid pro-cess, and distal part of the ulna or radiushave been reported to cause ulnar-sidedwrist pain. Degenerative processes atthe pisotriquetral joint18, midcarpal(triquetrohamate) articulation, fifth

carpometacarpal joint14-17, or distalradioulnar joint can also result in sub-stantial ulnar-sided wrist pain. Ulnarimpaction or abutment into the radiusor carpus has been reported as well19-21.Ligamentous injuries can occur in anyof the ulnar-sided intrinsic (lunotri-quetral or capitohamate) or extrinsic(ulnolunate, triquetrocapitate, or tri-quetrohamate) ligaments as well as thetriangular fibrocartilage complex1,18,19,22-27.Tendinopathies of the extensor carpiulnaris18,28-30or flexor carpi ulnaris31-34aswell as vascular lesions such as ulnar ar-

tery thrombosis or hemangiomas canalso cause ulnar-sided wrist pain35-38.Neurologic processes such as entrap-ment of the ulnar nerve in Guyons canal,neuritis of the dorsal sensory branch ofthe ulnar nerve, and complex regionalpain syndromes may be present39,40. Fi-nally, the miscellaneous group includesthe very unusual etiologies such astumors, including osteoid osteomas,chondroblastomas, and aneurysmalbone cysts.

The focus of this article is to pro-

vide a clear understanding of the anat-omy of the ulnar side of the wrist andto discuss physical examination, imag-ing techniques, and treatment of someof the more common causes of ulnar-sided wrist pain.

Anatomy of the

Ulnar Side of the Wrist

Extrinsic and IntrinsicCarpal LigamentsThe ulnar portion of the carpus has sev-

eral intrinsic and extrinsic ligamentsthat are important to the stability of thewrist. The intrinsic ligaments includethe capitohamate and lunotriquetralligaments (Fig. 1). The lunotriquetralligament is a c-shaped ligament withthree parts: the dorsal, volar, and in-tramembranous portions. Histologi-cally, the dorsal and volar ligaments aretrue ligaments, and the volar portion issubstantially thicker than the dorsalportion. The intramembranous liga-ment is not a true ligament histologi-cally, and it has little mechanical

strength. The capitohamate ligamentcomplex is formed by three distinct lig-aments: the dorsal, volar, and deepcomponents.

The extrinsic ligaments on the ul-nar side include the ulnotriquetral andulnolunate ligaments (Fig. 2). These lig-aments act as primary stabilizers of therelationship between the distal part ofthe ulna and the volar part of the car-pus. The fibers originate from the volarmargin of the triangular fibrocartilagecomplex, with a contribution from the

base of the ulnar styloid, and insertonto the palmar aspect of the tri-quetrum, lunate, and lunotriquetral lig-ament (Fig. 3). The fibers are blendedintimately with the volar margin of thetriangular fibrocartilage complex. Themeniscus homologue attaches proxi-mally to the dorsal end of the distalmargin of the sigmoid notch and thedorsal border of the triangular disk. Itextends volarly and distally to insert atthe ulnar aspects of the triquetrum, lu-


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nate, and lunotriquetral ligament. Theulnar fibers commingle with those ofthe subsheath of the extensor carpi ul-naris and continue to the base of thefifth metacarpal.

Distal Radioulnar JointThe curvature of the sigmoid notch ofthe radius is larger than the ulnar seatand therefore provides little osseousstability to the distal radioulnar joint.In addition, a dorsal-palmar transla-tion occurs between the joint surfacesduring forearm rotation.

It is understood that, with forearmrotation, motion occurs at the distal ra-dioulnar joint in three planes: rotationabout the longitudinal axis of the fore-

arm, dorsal-palmar translation, andproximal-distal translation. The osseousarchitecture of the distal radioulnar jointaffords decreasing stability with increas-ing forearm pronation or supination, asthe ulnar head contacts only the volarmargin of the sigmoid notch in fullsupination and the dorsal margin of thesigmoid notch in full pronation. The lig-aments of the triangular fibrocartilagecomplex, therefore, provide the primaryintrinsic stabilization of the distal radi-

oulnar joint, with supplemental stabilitybeing provided by the interosseousmembrane, the extensor retinaculum,and the muscle-tendon units that cross

the longitudinal axis of rotation of theforearm. The tendon of the extensorcarpi ulnaris serves as a dynamic stabi-lizer. Static stability is provided by thesubsheath of the extensor carpi ulnaris.

The volar and dorsal radioulnarligaments originate from the dorsal andvolar margins of the medial aspect ofthe radius adjacent to the sigmoidnotch (Fig. 3). They conjoin just me-dial to the pole of the distal part of theulna, forming a triangle that surroundsthe articular disk. There are two sepa-rate sites of insertion on the distal partof the ulna, separated by a band of vas-cularized loose connective tissue: thedeep fibers of the conjoined ligamentsinsert into the ulnar fovea as the liga-mentum subcruentum, while the super-ficial fibers insert into the base of theulnar styloid.

Fig. 1

The intrinsic ligaments of the wrist as viewed from the dorsal aspect of the carpus. C = capitate,

H = hamate, L = lunate, S = scaphoid, T = triquetrum, Tm = trapezium, I = first metacarpal, and

V = fifth metacarpal. (Reprinted with permission of the Mayo Foundation.)

Fig. 2

The extrinsic ligaments of the wrist as seen from the volar perspective of the carpus. C = capi-

tate, H = hamate, L = lunate, P = pisiform, R = radius, S = distal pole of scaphoid, Td = trape-

zoid, Tm = trapezium, U = ulna, I = first metacarpal, and V = fifth metacarpal. (Reprinted with

permission of the Mayo Foundation.)


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Triangular Fibrocartilage ComplexThe triangular fibrocartilage complex isthe complex of soft tissues interposedbetween the distal part of the ulna andthe ulnar side of the carpus, arisingfrom the distal part of the radius andextending across the ulnar pole to insertinto the fovea and the base of the ulnarstyloid (Fig. 3). Considered the pri-mary stabilizer of the distal radioulnar

joint, the term triangular fibrocartilage

complexemphasizes both the func-tional and the anatomic interdepen-dence of its elements. Palmer andWerner described the different compo-nents of the triangular fibrocartilagecomplex41as the triangular fibrocarti-lage proper (the articular disk), the pal-mar and dorsal radioulnar ligaments,the meniscus homologue, the ulnar col-lateral ligament, and the subsheath ofthe extensor carpi ulnaris tendon.

The vascular supply of the trian-

gular fibrocartilage complex has beenwell described42. Supplied by terminalportions of both the anterior and theposterior interosseous arteries, the pal-mar, ulnar, and dorsal components ofthe disk and radioulnar ligaments arewell vascularized, whereas the centraland radial portions are avascular. Thispattern of supply has direct implica-tions with regard to the healing poten-tial of the disk and the radioulnar

ligaments following injury, with pe-ripheral ulnar-sided detachments dem-onstrating a superior capacity to healfollowing repair when compared withradial-sided detachments.

Examination and Diagnostic

Tools for Ulnar-Sided Wrist Pain

The etiology of ulnar-sided wrist paincan often be determined on the basis ofa complete history, a detailed clinicalexamination, and appropriate diagnos-

tic tests. Once a firm diagnosis has beenestablished, treatment can ensue.

Ulnar-sided wrist pain can be di-vided into three categories: acute trau-

matic injuries, chronic overuse injuries,and chronic degenerative problems.Acute injuries typically result

from a notable traumatic event. Thismay be a fall from either a height or astanding position, or it may be a hyper-extension injury from a heavy objectfalling against the wrist. Most injuriesinvolve a hyperextension, ulnar devia-tion moment, although flexion injuriesand direct blows may also result inulnar-sided lesions. Patients may re-port hearing a pop and noticing im-mediate swelling or pain. Injuries suchas a fracture or distal radioulnar jointdislocation may lead the patient to seekimmediate attention, whereas it maytake several months for a patient topresent with an injury such as a tear ofthe lunotriquetral ligament or the tri-angular fibrocartilage complex. The pa-tient, however, will typically rememberthe index event.

Chronic overuse injuries mayhave a more indolent presentation.Patients with chronic repetitive ulnarloading, such as mechanics and plumb-

ers, may present with vague ulnar-sidedpain without a history of specific injury.Patients with low-grade repetitive load-ing, such as assembly workers andcomputer operators, may present withextensor carpi ulnaris tendinitis follow-ing an increase or change in activity.

Chronic degenerative problemsmay result from previous acute trau-matic events, previous injuries that havealtered the anatomy, and abnormalitiesthat arise from anatomic or congenitalvariations. Examples include ulnar-sided

wrist pain resulting from a maluniteddistal radial fracture, a previous radialhead fracture with subsequent radialshortening, congenital radial head dis-location, and pisotriquetral arthritis.

A detailed history is essential todetermine which of these categories ap-plies to a particular patient. It must in-clude a detailed medical history as wellas a history of previous injuries andprevious surgical procedures involvingnot only the wrist but the elbow as well.

Fig. 3

The distal part of the radius and the radiocarpal capsule and ligaments from a dorsal view. The

dorsal and palmar radioulnar ligament as well as the ulnar border of the radius form the margins

for the triangular disk, and all together they form the triangular fibrocartilage complex. Note how

the ulnotriquetral and ulnolunate ligaments arise from the portions of the palmar radioulnar liga-

ment and how the dorsal and palmar radiolunate ligaments attach to the styloid recess. The ex-

tensor carpi ulnaris tendon sheath is intimately associated with the dorsal aspect of the ulna.

(Reprinted with permission of the Mayo Foundation.)


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Asking the patient about his orher symptoms will often help to nar-row the differential diagnosis of ulnar-sided wrist pain. The patient can be

asked whether the pain is ulnar or radialto an imaginary line drawn through thecenter of the dorsal aspect of the wrist.Patients with ulnar-sided lesions areusually able to localize the pain to theulnar side of the wrist. Patients oftenreport pain with ulnar deviation andloading of the wrist such as occurswhen they elevate themselves out of achair or swing a hammer. Patients mayalso report pain with hyperextensionof the wrist. Occasionally, they reportcatching or clicking in the wrist, andthis must be further investigated witha physical examination since noisewith wrist motion can be normal. Ul-nar nerve symptoms may point to diag-noses such as a fracture of the hook ofthe hamate or more proximal ulnarnerve compression. Vascular symptomspoint to diagnoses such as ulnar arterythrombosis.

The physical examination be-gins with inspection. The wrist and el-bow should be examined for previoussurgical scars. Prominence of the ulnaeither volarly or dorsally may indicate

some degree of instability of the distalradioulnar joint. A volar sag and supi-nation of the wrist may indicate thecapsuloligamentous instability that oc-curs in rheumatoid arthritis. Intrinsicatrophy and clawing may indicate ul-nar nerve neuropathy. Splinter hemor-rhages beneath the nails and decreasedturgor in the volar digital pads suggestvascular insufficiency.

Palpation should proceed in asystematic fashion by isolating ana-tomic structures. The examination

should be performed with the pa-tients elbow resting on the table, thehand pointing toward the ceiling, andthe forearm in neutral as if the patientis about to arm wrestle with the exam-iner. Tenderness over any anatomicstructure suggests a specific clinical di-agnosis. The lunotriquetral interval ispalpated between the fourth and fifthcompartments one fingerbreadth dis-tal to the distal radioulnar joint withthe wrist in 30 of flexion. The exten-

sor carpi ulnaris tendon is palpatedalong the distal part of the ulna and ismost palpable just distal to the ulnarhead. The extensor carpi ulnaris inser-

tion is at the base of the fifth metacar-pal, well away from the wrist joint (Fig.4). The fifth carpometacarpal joint is

just proximal to the extensor carpi ul-naris insertion. The tr iangular fibro-cartilage complex is best palpatedmidway between the extensor carpi ul-naris and the flexor carpi ulnaris in thesoft recess just distal to the ulnar sty-loid (Fig. 5). The pisotriquetral joint ispalpated volar to the triangular fibro-cartilage complex, and the pisiformcan be moved between the examinersthumb and index finger. The distal ra-dioulnar joint is palpated dorsally invarious degrees of forearm rotation.

The differential diagnosis ofulnar-sided wrist pain can be nar-rowed further by performing provoca-tive maneuvesrs.

Abnormalities of the lunotrique-tral joint can be assessed with three sep-arate stress maneuvers. Lunotriquetralballottement can be achieved by com-pressing the lunate against the tri-quetrum. This is performed with theexaminers thumb placed against the

lateral border of the triquetrum andcompressing the triquetrum againstthe lunate.

The Regan shuck test is per-formed by the examiner placing his orher thumb and index finger on the tri-quetrum and pisiform, respectively,and placing the other hand on the ra-dial carpus and lunate. The examinermoves his or her right and left hand inopposing (volar and dorsal) directions,placing shear stress across the luno-triquetral joint. Since the lunate and

triquetrum are the only bones not sta-bilized, the force is transmitted acrossthe lunotriquetral joint, with pain in-dicating a pathologic condition.

The Kleinman shear test allowsa more subtle application of force andis considered the most specific provoc-ative test for lunotriquetral disorders.The examiner places his or her thumbon the pisiform volarly and the re-maining fingers of the same hand dor-sally along the ulnar carpus. The other

hand is used to stabilize the lunateand the radial side of the carpus. Forceis generated across the pisiform in adorsal-to-volar direction while the

other hand is held still. This allowsfor controlled stress across the luno-triquetral joint (Fig. 6). Prior to thismaneuver, the pisotriquetral jointshould be palpated in the ulnar-to-radial plane to rule out pathologicchanges in this joint.

Pathologic changes in the tri-angular fibrocartilage complex canbe isolated with the ulnocarpal im-paction maneuver. This is again per-formed with the patients elbow flexedand hand pointing toward the ceiling.The examiner moves the ulnarly devi-ated wrist in a volar-to-dorsal direc-tion while applying an axial loadacross the ulnar side of the wrist(Fig. 7). This maneuver translatesload across the triangular fibrocarti-lage complex, which may cause grind-ing and reproduce pain.

The piano key test is performedto isolate disorders of the distal radioul-nar joint. Ballottement of the ulna isperformed by the examiner applying adorsal-to-volar load with his or herhand 4 cm proximal to the distal radi-

oulnar joint. This isolates abnormali-ties of the distal radioulnar joint byavoiding pressure on the overlyingstructures such as the extensor digitiminimi tendon.

Selective anesthetic injectionsare an important adjunct to confirmpathologic changes suspected on clini-cal examination. If a corticosteroid isadded to the anesthetic injection, ther-apeutic benefits may also be achieved.Injections should be performed in

joints or along tendons that are sus-

pected of being injured. If a lesion ofthe triangular fibrocartilage complex issuspected, the injection should be per-formed in the ulnocarpal joint. If ex-tensor carpi ulnaris tendinitis is theworking diagnosis, then the injectionshould be performed in the extensorcarpi ulnaris tendon sheath, withavoidance of the ulnocarpal joint. Suchselective injections can be used to dis-tinguish intra-articular from extra-articular lesions.


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Techniques and Indications

for Imaging of the Ulnar

Side of the Wrist

Numerous imaging modalities are

available for the evaluation of ulnar-sided wrist pain. In almost all cases,plain radiographs are made first. Thedecision to use more advanced imagingmodalities is based on the suspecteddiagnosis.

Standard RadiographsInitial radiographic evaluation shouldinclude neutral rotation posteroante-rior, neutral rotation lateral, and ob-lique plain radiographs of the wrist.These views are useful as a generalscreening tool to look for evidence offractures, arthritic changes, and bonelesions. Numerous indices can be mea-sured on these radiographs43.

On the posteroanterior radio-graph, particular attention should bepaid to Gilulas lines, ulnar variance, thecarpal height ratio, and evidence of car-pal instability. The lateral radiograph ismost useful for measurements of carpalinstability, including the scapholunate,capitolunate, and lunotriquetral angles.

It is important that the poster-oanterior and lateral radiographs are

made with the forearm in neutral rota-tion, as changes in forearm rotation caninfluence the measurement of variousradiographic indices. For example, pr-onation increases ulnar variance andsupination decreases it44. On the poster-oanterior radiograph, neutral rotationcan be confirmed by visualizing thegroove of the extensor carpi ulnaris ten-don adjacent to the ulnar styloid. Onthe lateral radiograph, the anterior sur-face of the pisiform should project mid-way between the anterior aspect of the

capitate head and the distal pole of thescaphoid.

Special ViewsIn addition to the standard views de-scribed above, there are special plainradiographic views that can provideadditional diagnostic information. Thedecision to obtain additional views isbased on the suspected diagnosis.

Comparison of standard postero-anterior, ulnar deviation posteroanterior,

Fig. 4

Surface anatomy of the ulnar side of the wrist. The extensor carpi ulnaris tendon inser tion, the

lunate, and the triquetrum are shown. Note that the extensor carpi ulnaris insertion is well away

from the radiocarpal and midcarpal joints. The lunotriquetral interval is one fingerbreadth distal

to the distal radioulnar joint.

Fig. 5

The triangular fibrocartilage complex is best palpated midway between the extensor carpi ulnaris

and the flexor carpi ulnaris in the soft recess just distal to the ulnar styloid.


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and radial deviation posteroanterior ra-diographs may provide indications ofabnormal radiocarpal or midcarpalmotion. An ulnar deviation posteroan-

terior radiograph, commonly used toshow an elongated view of the scaphoid,may also reveal lunotriquetral instabilityor evidence of ulnocarpal abutment,especially when it is compared with astandard posteroanterior radiograph.If ulnocarpal abutment is suspected, itis often useful to make a posteroanteriorradiograph with the forearm in prona-tion and the fist clenched, which in-creases ulnar variance. Other stressradiographs, such as those made withdorsal or volar stress on the distal part ofthe ulna of patients with suspected insta-bility of the distal radioulnar joint, mayalso assist in confirming the diagnosis.

The scaphoid tubercle, the pisi-form, and the hook of the hamate areoften difficult to visualize on standardradiographs. A 30 supinated obliqueradiograph is useful to visualize thesestructures, especially the pisotriquetral

joint and the hamate. A carpal tunnelradiograph is also useful. However, it isoften difficult to make a proper carpaltunnel radiograph of a patient with anacute wrist injury, as it requires posi-

tioning the wrist in full extension.

Computed TomographyComputed tomography scans providebetter osseous detail than do plain ra-diographs. They are very useful in theevaluation of suspected fractures ofbones that are difficult to visualize onplain radiographs, such as the hamatehook (Fig. 8). Computed tomographyscanning is a very effective modality forthe evaluation of a healing fracture (Fig.8). In addition to providing thin-slice

axial views of the bones, computer re-construction can provide images in anydesired plane or can generate three-dimensional images if needed (Fig. 8).

Computed tomography is the im-aging modality of choice for the evalua-tion of subluxation of the distalradioulnar joint. The congruity of thedistal radioulnar articular surfaces canalso be evaluated accurately. In a studyof computed tomography criteria forthe determination of subluxation of the

Fig. 6

The Kleinman shear test. One of the examiners hands holds the radial side stable while

a volar-to-dorsal force is applied across the pisiform with the thumb of the examiners other

hand.

Fig. 7

The ulnocarpal impaction maneuver. The examiner moves the ulnarly deviated wrist in a volar-to-

dorsal direction while applying an axial load across the ulnar side of the wrist.


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distal radioulnar joint, Wechsler et al.emphasized the need to obtain simulta-neous views of both extremities withthe forearms in neutral rotation, full su-

pination, and full pronation

45

.

ArthrographyIn the past, arthrography had been thefavored imaging modality for the evalua-tion of ruptures of the interosseous liga-ments and tears of the triangularfibrocartilage complex. Triple-injectionarthrography had been considered thegold standard for detecting perfora-tions of the triangular fibrocartilagecomplex. However, several authors havemaintained that arthrography of thewrist is much less accurate than arthros-

copy and that it has a relatively highrate of false-negative findings20,46. Othershave pointed out the poor correlationbetween arthrographic findings and

symptoms reported by patients

47-49

.Zanetti et al. suggested that this poorcorrelation is due to a dependence on thedetection of communicating defects ofthe triangular fibrocartilage complex50.Those authors suggested that carefulattention to detail allows detection ofnoncommunicating defects of the tri-angular fibrocartilage complex, whichhave a more reliable association withsymptomatic ulnar-sided lesions of thetriangular fibrocartilage complex50.

Over the past several years, ar-thrography has been largely supplanted

by magnetic resonance imaging for theevaluation of lesions of the triangularfibrocartilage complex. However, ar-thrography continues to be used to

evaluate the integrity of the scapholu-nate and lunotriquetral interosseousligaments (Fig. 9). The value of arthrog-raphy may be increased by the simulta-neous use of real-time fluoroscopicimaging.

FluoroscopyAbnormal motion of the carpal bonescan be most accurately demonstratedwith real-time fluoroscopic imaging. Inparticular, in patients who demonstratea sudden shift or clunk with wrist devi-ation, the site of the pathologic entitycan often be identified fluoroscopically.When a patient has an injury of thelunotriquetral interosseous ligament,fluoroscopy may demonstrate the so-called catch-up of the triquetrum mov-ing into extension as the wrist movesfrom radial to ulnar deviation19. Fluo-roscopy is similarly useful for demon-strating dynamic instabilities in patientswith instability of the scapholunate,midcarpal, or distal radioulnar joint.

Radionuclide Imaging

Radionuclide imaging, or bone-scanning, provides excellent sensitivityfor the detection of occult or nondis-placed fractures. A single-phase scan issufficient for the detection of fracturesif additional information, such as thestatus of osseous blood flow, is not re-quired. Bone scans are very sensitive tothe locations of pathologic lesions ofbone, but they often do not provide adefinite diagnosis. The modality is auseful, relatively low-cost screening toolfor the evaluation of occult fractures,

osteonecrosis, and osteomyelitis. Therelative value of bone-scanning com-pared with computed tomography forthe evaluation of occult fractures on theulnar side of the wrist has not been de-termined, and some have suggested thatmagnetic resonance imaging is as usefulas bone-scanning for detecting an oc-cult lesion51. If such a lesion is found, asubsequent computed tomography scanis the most accurate modality for evalu-ating the osseous details of the fracture,

Fig. 8

A,Posteroanterior radiograph of a wrist with a fracture of the hamate hook (arrow). The fracture is

difficult to visualize because the hamate hook overlaps the fourth and fifth carpometacarpal joints

on this view. B,Computed tomography image of the same wrist. The axial view clearly demon-

strates the fracture of the hamate hook (arrow). C,Computed tomography image demonstrating a

healed fracture of the base of the hamate hook (arrow). D,Three-dimensional reconstruction per-

formed from computed tomography data demonstrating a nonunion of the hamate hook (thick

black arrow) and also demonstrating the pisotriquetral joint (thin white arrow).


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if that information is needed. Radio-nuclide imaging may also be usefulfor the evaluation of complex regionalpain syndromes.

Magnetic Resonance ImagingMagnetic resonance imaging is the pro-cedure of choice for the assessment of awide range of soft-tissue lesions, in-cluding ligament and cartilage lesions,soft-tissue tumors, tendinitis, and jointeffusions. While computed tomogra-phy provides superior osseous detail,magnetic resonance imaging may havegreater sensitivity for the detection ofsubtle changes such as bone edema andis therefore particularly useful for theevaluation of occult fractures and stressfractures. Magnetic resonance imagingclearly provides a great deal more ana-tomic detail than does arthrographyalone. Magnetic resonance imagingwith use of a dedicated wrist coil andcombined with arthrography may sup-plant magnetic resonance imagingalone for the diagnosis of intercarpaland triangular fibrocartilage complexabnormalities. Recently, techniquescombining magnetic resonance imagingwith single-injection gadolinium ar-thrography have been developed (Figs.

10-A and 10-B), but their use has notbeen thoroughly studied. After injec-tion of gadolinium into the radiocarpalor the midcarpal joint, contrast me-dium leaking into the distal radioulnar

joint or into the radiocarpal joint canbe indicative of a tear of the triangularfibrocartilage complex or an injury ofthe intercarpal ligament. Magnetic res-onance imaging can also provide infor-mation concerning the vascular statusof the lunate and the ulnar head, whichis valuable in the diagnosis of ulnocar-

pal abutment21

.Magnetic resonance imaging has

become widely used for the evaluationof tears of the triangular fibrocartilagecomplex. Early studies demonstratedthat magnetic resonance imaging hadpoor accuracy for predicting the lo-cation of such tears seen at arthros-copy52,53. In one recent study, magneticresonance imaging had an accuracy of92% for predicting tears of the triangu-lar fibrocartilage complex54; however,

other authors have suggested that thislevel of accuracy may be somewhatlower in most clinical settings and ishighly dependent on the experience ofthe individual interpreting the mag-netic resonance imaging scans55. Mag-netic resonance imaging has not yetproven reliable for the detection oftears of the lunotriquetral ligament19,56.

Wrist ArthroscopyArthroscopy can serve as an importanttool in the diagnosis and treatment ofulnar-sided wrist pain. Although diag-nostic modalities such as magnetic res-onance imaging and arthrography arehelpful, arthroscopy is considered thegold standard for diagnosing and stag-ing of intra-articular lesions. Tears ofthe scapholunate and lunotriquetral lig-aments can be graded by visualizingthem through both the radiocarpal and

the midcarpal portal. Partial tears canbe appropriately dbrided, and com-plete tears can be prepared for recon-struction. Central tears of the triangularfibrocartilage complex can be dbridedarthroscopically, and peripheral tearscan be repaired with arthroscopic assis-tance. Isolated areas of arthritis are of-ten difficult to diagnose with othermodalities. Arthroscopy allows the stag-

ing of degenerative or posttraumatic ar-thritis and can help the surgeon todetermine which reconstructive proce-dures or limited fusions are appropri-ate. Arthroscopy of the distal radioulnar

joint allows staging of arthritis of thatjoint. Furthermore, loose bodies andcartilage flaps that are difficult to visu-alize with other modalities can be seenand removed. Finally, normal arthro-scopic findings allow the examiner toexclude intercarpal ligament, triangular

Fig. 9

An arthrogram of the midcarpal and distal radioulnar joints, demonstrating a perforation through

the lunotriquetral ligament (small arrow) as well as the triangular fibrocartilage complex (large ar-

row). (Reprinted with permission of A.Y. Shin, owner of copyright.)


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fibrocartilage complex, and articularlesions as sources of pain and should

lead him or her to look for pathologicchanges elsewhere.

Treatment

Triangular Fibrocartilage Complexand Distal Radioulnar JointPalmer classified lesions of the triangu-lar fibrocartilage complex as eithertraumatic (Type 1) or atraumatic (Type2) (Fig. 11)57. Division of each groupinto subtypes, with Type-1 lesions clas-sified on the basis of the structure thatis disrupted and Type-2 lesions classi-

fied on the basis of the extent of thedegenerative process, can direct treat-ment. Definitive treatment of trau-matic or degenerative lesions of thetriangular fibrocartilage complex re-mains controversial. Although there areexceptions, in general Type-1 lesions aretreated either with immobilization orsurgical repair, whereas Type-2 lesionscan be treated either with a splint, anti-inflammatory drugs, or cortisone injec-tion or with arthroscopic dbridement

or ulnar shortening osteotomy.Chronic radial or ulnar-sided de-

tachment of the triangular fibrocarti-lage complex can lead to symptomaticinstability (clunking on forearm rota-tion) or pain in the distal radioulnar

joint secondary to degeneration of thearticular cartilage of the sigmoid notch

and the ulnar seat. Previous injury tothe distal part of the radius (intra-articular fracture of the sigmoid notch)or to the ulnar seat can likewise lead to

cartilage degeneration and symptom-atic arthritis. Patients experience painwith forearm rotation and tendernesson palpation of the distal radioulnar

joint. Surgical treatment should at-tempt to address both the arthritis ofthe distal radioulnar joint and the dis-tal ulnar instability.

Lunotriquetral InstabilitySeveral factors should be consideredwhen choosing the optimal treatmentfor lunotriquetral injuries19. These in-clude the amount of instability (staticor dynamic), the elapsed time betweenthe injury and treatment (acute orchronic), and the presence of associ-ated injury or degenerative changes.Pain associated with lunotriquetraltears may be due to dynamic instabilityand/or local synovitis. The initial man-agement of almost all acute and chronictears without a dissociation or volar in-tercalated segmental instability shouldprobably be conservative, with cast orsplint immobilization. Careful cast-molding with a pad underneath the

pisiform maintains optimal alignmentas healing progresses. Midcarpal corti-costeroid injections can be helpful todecrease synovitis. Operative treatmentis indicated for acute and chronic disso-ciations that demonstrate a volar inter-

Fig. 10-A

Magnetic resonance arthrogram (T1-weighted fat-suppression image made after injection of gad-

olinium into the distal radioulnar joint) demonstrating a tear of the triangular fibrocartilage com-

plex near its radial insertion (arrow).

Fig. 10-B

Photograph made during wrist

arthroscopy, demonstrating a

tear of the triangular fibrocar-

tilage complex near its radial

attachment (arrow). The le-

sion corresponds to the tear

identified on the magnetic res-

onance image.


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calated segmental collapse and chronictears that are unresponsive to conserva-tive management. The goal of surgicalintervention is realignment of the luno-

capitate axis and reestablishment of therotational integrity of the proximal car-pal row. A variety of procedures havebeen described, including lunotrique-tral arthrodesis, ligament repair, andligament reconstruction. If concomi-tant ulnar negative or positive varianceor midcarpal or radiocarpal arthrosis ispresent, additional procedures such asulnar lengthening or shortening, mid-carpal arthrodesis, or proximal rowcarpectomy may be indicated. Total

wrist arthrodesis may be indicatedwhen degenerative changes make othersalvage procedures impossible.

Repair of the lunotriquetral liga-

ment has been described by severalauthors58,59. The lunotriquetral interos-seous ligament is reattached to the siteof its avulsion, which is generally the tri-quetrum. As the strong volar ligament isalso disrupted, a combined dorsal andvolar approach as well as augmentationof the repair by plication of the dorsal ra-diotriquetral and dorsal scaphotriquetralligaments may be of some value. Pro-tracted immobilization is then necessary.

Patients who engage in strenuous

pursuits or have chronic instability or apoor-quality lunotriquetral ligamentmay be best managed with ligament re-construction rather than repair. Liga-

ment reconstruction with a distallybased strip of extensor carpi ulnaris ten-don graft is one option. Unlike recon-struction of the scapholunate ligament,this technique, although demanding, has

yielded uniformly good results in twostudies58,59. Unlike lunotriquetral arthro-desis, reconstruction preserves lunotri-quetral motion and provides the optimalchance for restoration of normal carpalinteractions.

The observation of asymptomatic

Fig. 11

Diagrammatic representation of the different types of injuries of the triangular fibrocartilage complex as described by Palmer57.A,Type 1A, a central

traumatic tear, usually in the sagittal plane, 1 to 2 mm from the ar ticular surface of the radius. B,Type 1B, a medial avulsion that may or may not

be associated with an ulnar styloid fracture. C,Type 1C, distal avulsions involving disruption of the ulnocarpal ligaments. D,Type 1D, lateral avul-

sions involving disruption of the radioulnar ligament and the articular disk attachments to the radius. This injury may or may not be associated with

a fracture of the sigmoid notch. E,Type 2, degenerative perforations occurring centrally. (Reprinted, with permission, from: Chidgey LK. The distal ra-

dioulnar joint: problems and solutions. J Am Acad Orthop Surg. 1995;3:95-109.)


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congenital lunotriquetral coalitions andthe relatively little relative motion thatnormally occurs between the lunate andtriquetrum led to the concept of luno-

triquetral arthrodesis. It may be techni-cally less demanding than ligamentreconstruction or repair, and it has be-come the technique of choice of manysurgeons. However, the method is notwithout substantial problems. The re-ported nonunion rate has ranged from0% to 57%19. Use of Kirschner wires hasbeen shown to result in an unacceptablyhigh nonunion rate of 47%19,59. Use ofcompression screws may improve re-sults, but nonunion remains a majorproblem. A 9% nonunion rate has beenreported with the Herbert screw, andthe use of conventional cortical screwsmay be associated with nonunion ratesas high as 57%19,59. Ulnocarpal impinge-ment required additional surgery in23% (five) of twenty-two patientstreated with lunotriquetral arthrodesisin one series59. This complication wasnot seen with lunotriquetral repair orreconstruction. A comparison of theresults following arthrodesis, ligamentrepair, and reconstruction at the MayoClinic demonstrated that repair and

reconstruction were superior to arthro-desis59. The lower complication rates,higher patient satisfaction, greater rangeof motion, and fewer subsequent reop-

erations led the Mayo Clinic group toprefer repair or reconstruction of thelunotriquetral ligament as their pri-mary method of treatment for lunotri-quetral injuries that require surgicalintervention (Fig. 12).

TendinopathiesTendinopathies of the wrist are rela-tively common causes of ulnar-sidedwrist pain. On the dorsal side of thewrist, the extensor carpi ulnaris and,less commonly, the extensor digiti min-imi may be involved; on the flexor sur-face, the flexor carpi ulnaris and/or thepisiform may be involved.

An understanding of the anat-omy of the extensor carpi ulnaris and itssurrounding structures is essential forthe diagnosis and management of ex-tensor carpi ulnaris tendinitis60. The ex-tensor carpi ulnaris tendon sits in agroove, or sulcus, at the distal part ofthe ulna. It is maintained within thisgroove during forearm rotation by theextensor retinaculum and a subsheath,

which forms a fibro-osseous tunnel.The linea jugata connects the sub-sheath to the epimysium and preventssubluxation of the extensor carpi ul-

naris in a palmar direction during fullsupination. Normally, the extensorcarpi ulnaris tendon sits in the ulnarsulcus and helps to stabilize the distalradioulnar joint as the forearm movesfrom pronation to supination. If the ex-tensor carpi ulnaris displaces in a volardirection during supination, it maycause the tendon to move out of the sul-cus, often resulting in a painful snap-ping sensation and inflammation. Thedepth of the ulnar sulcus varies, andsubluxation is more likely to occur if itis shallow. In the case of a traumaticdorsal subluxation or dislocation of theulnar head, the extensor carpi ulnarismay be forcibly displaced volarly andthere is often disruption of the triangu-lar fibrocartilage complex. In addition,the extensor carpi ulnaris subsheathmay rupture, with or without disrup-tion of the extensor retinaculum. Thismay happen with forceful radial devia-tion with flexion of the wrist, which isseen in patients participating in activi-ties such as baseball and rodeo. In pa-

Fig. 12

On the basis of the lower complication rate, improved survivorship, and higher patient satisfaction, repair of an avulsed lunotriquetral ligament (if

possible) (A, B, and C) or reconstruction with a distally based strip of extensor carpi ulnaris tendon (D, E,and F) is preferred over arthrodesis. The

techniques used in repair and reconstruction of the lunotriquetral ligament are illustrated. (Reprinted with permission of the Mayo Foundation.)


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tients with inflammatory disorders suchas rheumatoid arthritis, attritional wearof the supporting structures may lead tosubluxation of the extensor carpi ul-naris and extensor digiti minimi with-out a specific traumatic event.

Patients with extensor carpi ul-naris tendinitis due to subluxation maypresent with a painful snap or click dur-ing forearm rotation18,28-30. Often, thereis tendinitis without detectable instabil-

ity. In such cases, there may be tender-ness at the distal part of the ulna, overthe fifth (extensor digiti minimi) orsixth (extensor carpi ulnaris) dorsalcompartment. Extensor digiti minimitendinitis presents with pain or tender-ness over the fifth dorsal compartmentof the wrist. Less commonly, there is in-flammation at the insertion of the ex-tensor carpi ulnaris, which presentswith pain and inflammation at thedorsal base of the fifth metacarpal.

Acute treatment of a traumaticinjury involving the extensor carpi ul-naris tendon includes reduction of adistal radioulnar joint dislocation, ifpresent, followed by immobilizationof the wrist and forearm, rest, applica-tion of ice, and use of nonsteroidal anti-inflammatory medications. The fore-arm is usually immobilized in the neu-tral position, although it is sometimesnecessary to immobilize it in supination

to maintain reduction of the distal radi-oulnar joint after a dorsal dislocation.Subsequently, the distal radioulnar jointis stabilized by repair of the triangularfibrocartilage complex. The extensorcarpi ulnaris tendon is stabilized by re-construction of the extensor carpi ul-naris subsheath, with use of a flap ofextensor retinaculum passed aroundthe tendon as described by Spinner andKaplan60. This procedure allows the ex-tensor carpi ulnaris tendon to remain

within the ulnar sulcus during forearmand wrist rotation.

In patients with subluxation of theextensor carpi ulnaris due to inflamma-

tory arthritis, dorsal subluxation of theulnar head often must be addressed inaddition to reconstruction of the exten-sor carpi ulnaris subsheath. Numerousprocedures have been described for thispurpose, and the choice of procedure isdetermined by the clinical presentationand the surgeons preference.

In the case of nontraumatic ten-dinitis of the extensor carpi ulnaris orextensor digiti minimi tendon, themainstay of treatment is rest, brief peri-ods of immobilization, nonsteroidalanti-inflammatory drugs, and judi-cious use of corticosteroid injections.Surgery is rare and is reserved forchronic, recalcitrant cases. Insertionaltendinitis of the extensor carpi ulnarisis treated with transfer of the extensorcarpi ulnaris to the dorsum of thehamate. Tendovaginitis within the ex-tensor sheath is treated with release ofthe extensor carpi ulnaris subsheathand reconstruction, as described above.If the extensor digiti minimi is involved,simple release of the fifth dorsal com-partment has excellent results.

Treatment of tendinitis of theflexor carpi ulnaris similarly requires anunderstanding of the local anatomicstructures31,32. The ulnar neurovascularbundle lies on the radial side of theflexor carpi ulnaris tendon just proxi-mal to the wrist joint. It passes radial tothe pisiform at Guyons canal. Theflexor carpi ulnaris is a large muscle andthe most powerful wrist motor. It doesnot have a synovial sheath. It insertsinto the proximal and anterior aspect ofthe pisiform, a sesamoid bone located

within the flexor carpi ulnaris tendonthat has a single articular surface, whicharticulates with the volar surface of thetriquetrum. As there is no inherent sta-bility of the pisotriquetral joint, stabil-ity depends on the pisohamate andpisometacarpal ligaments, which attachto the pisiform like spokes on a wheel61.Flexor carpi ulnaris tendinitis has an in-sidious onset. Patients present with ach-ing pain on the ulnar flexor side of thewrist. The symptoms may be related to

Fig. 13

A magnetic resonance image of the wrist demonstrates a ganglion in Guyons space with

compression of the ulnar nerve at the level of the wrist. (Reprinted with permission of A.Y.

Shin, owner of copyright.)


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repetitive or overuse activities. Thereis tenderness near the insertion of theflexor carpi ulnaris on the pisiform andpain on resisted wrist flexion and ulnardeviation. Patients may present with as-

sociated ulnar nerve symptoms.Pisotriquetral arthritis and, less

commonly, pisotriquetral instabilityare causes of ulnar-sided wrist painthat may be misdiagnosed as flexorcarpi ulnaris tendinitis. Pisotriquetralarthritis is associated with local painand tenderness, which are exacerbatedby grinding of the pisiform dorsallyagainst the triquetrum. Instability maybe subtle and more difficult to diag-nose. A diagnostic injection of localanesthetic in combination with appro-

priate radiographic imaging will con-firm both diagnoses.

Flexor carpi ulnaris tendinitisis most commonly treated nonopera-tively31,32. As is the case for other soft-tissue conditions, it usually can betreated with rest, immobilization, non-steroidal anti-inflammatory drugs, and,rarely, corticosteroid injection. Surgicaltreatment is rare and, if it is under-taken, the ulnar neurovascular bundlemust be identified and protected. Flexor

carpi ulnaris tendinitis that does not re-spond to nonoperative treatment maybe relieved by z-plasty lengthening ofthe tendon proximal to its insertion onthe pisiform. If the pathologic process

primarily involves the pisiform, exci-sion of the pisiform is the most com-monly used surgical procedure.

Unusual Causes

Unusual causes of ulnar-sided wristpain include those of neurogenicorigin, vascular origin, and atypicalfractures.

Ulnar nerve compression atGuyons canal typically presents with fa-tigue, weakness, and the feeling of lossof coordination with fine motor

activities62

. Patients may have decreasedsensation in the ring and small fingersbut not on the dorsum of the handsince the dorsal sensory nerve branchoriginates more proximally. The diag-nosis is made with nerve conductionstudies and electromyography. Com-pression of the ulnar nerve in Guyonscanal may result from a mass effect,thrombosis of the ulnar artery, or afracture of the hook of the hamate.Magnetic resonance imaging should be

considered to determine if any of thesefactors, which can be treated with surgi-cal decompression, are contributing tothe ulnar nerve compression (Fig. 13).

Thrombosis of the ulnar artery(Fig. 14) otherwise known as hypothe-nar hammer syndrome, typically resultsfrom repetitive force against the ulnarartery as is seen in plumbers or otherworkers who use high-impact equip-ment35. More unusual causes includesystemic conditions or a more proximalvascular event. Patients present withpain associated with cold exposure,splinter hemorrhages, and decreasedturgor in the ulnar digits. The diagnosisis suspected on the basis of abnormalresults of the Allen test and can be con-firmed with Doppler studies. Surgicalplanning requires an arteriogram. Surgi-cal treatment consists of either resectionalone or resection combined with vascu-lar reconstruction.

Conclusion

Although ulnar-sided wrist pain can beintimidating and confusing, it can bebroken down into the fundamental ele-ments and evaluated in a systematicfashion. A probable diagnosis can bemade on the basis of a detailed history

and a clinical examination of all of theentities that can cause ulnar-sided wristpain. The diagnosis is then confirmedby appropriately selected radiographicstudies. Anesthetic injections (with cor-ticosteroids) can be utilized as a diag-nostic tool as well as a therapeuticmeasure. Once the diagnosis is made,treatment (both conservative and oper-ative) should be directed at restoringnormal anatomy whenever possible.

Alexander Y. Shin, MDMayo Clinic, 200 First Street S.W., Rochester,MN 55905

Mark A. Deitch, MDJohns Hopkins Bayview Medical Center, 4940Eastern Avenue, Baltimore, MD 21224

Kavi Sachar, MDUniversity of Colorado School of Medicine andHand Surgery Associates, 2535 South Down-ing Street, Suite 500, Denver, CO 80210

Fig. 14

An operative view of the thrombosed ulnar artery secondary to chronic trauma in the hypothenar

area, also known as hypothenar hammer syndrome. The ulnar artery in this area is damaged by

chronic trauma and can often present as a vague ulnar-sided wrist pain associated with ulnar

digit ischemia. (Reprinted with permission of the Mayo Foundation.)


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Martin I. Boyer, MD, MSc, FRCS(C)Department of Orthopaedic Surgery, Washing-ton University School of Medicine, Barnes-Jewish Hospital at Washington University,Suite 11300, West Pavilion, One Barnes-Jewish

Hospital Plaza, St. Louis, MO 63110

The authors did not receive grants or outsidefunding in support of their research or prepa-

ration of this manuscript. They did not receivepayments or other benefits or a commitmentor agreement to provide such benefits from acommercial entity. No commercial entity paidor directed, or agreed to pay or direct, any

benefits to any research fund, foundation,educational institution, or other charitable ornonprofit organization with which the authorsare affiliated or associated.

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. This ar-ticle, as well as other lectures presented atthe Academys Annual Meeting, will be avail-able in February 2005 in Instructional Course

Lectures,Volume 54. The complete volumecan be ordered online at www.aaos.org, or bycalling 800-626-6726 (8 A.M.-5 P.M., Centraltime).

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