Ulnar-Sided Wrist Pain: Diagnosis and Treatment Alexander Y

Home , Midcarpal joint, Pisiform bone, Trapezium (bone), Triquetral bone

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7-1-2004 Ulnar-sided wrist pain: Diagnosis and treatment Alexander Y. Shin Mayo Clinic

Mark A. Deitch Johns Hopkins Bayview Medical Center

Kavi Sachar University of Colorado School of Medicine and Hand Surgery Associates

Martin I. Boyer Washington University School of Medicine in St. Louis

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Recommended Citation Shin, Alexander Y.; Deitch, Mark A.; Sachar, Kavi; and Boyer, Martin I., ,"Ulnar-sided wrist pain: Diagnosis and treatment." The Journal of Bone and Joint Surgery.,. 1560-1574. (2004). https://digitalcommons.wustl.edu/open_access_pubs/1104

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THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004

Ulnar-Sided Wrist Pain DIAGNOSIS AND TREATMENT

BY ALEXANDER Y. S HIN, MD, MARK A. DEITCH, MD, KAVI SACHAR, MD, AND MARTIN I. BOYER, MD, MSC, FRCS(C) An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Ulnar-sided wrist pain has often been carpometacarpal joint14-17, or distal eral intrinsic and extrinsic ligaments equated with low back pain because of radioulnar joint can also result in sub- that are important to the stability of the its insidious onset, vague and chronic stantial ulnar-sided wrist pain. Ulnar wrist. The intrinsic ligaments include nature, intermittent symptoms, and impaction or abutment into the radius the capitohamate and lunotriquetral frustration that it induces in patients. or carpus has been reported as well19-21. ligaments (Fig. 1). The lunotriquetral Chronic ulnar-sided wrist pain may be Ligamentous injuries can occur in any ligament is a c-shaped ligament with accompanied by a history of Workers’ of the ulnar-sided intrinsic (lunotri- three parts: the dorsal, volar, and in- Compensation claims and unrelenting quetral or capitohamate) or extrinsic tramembranous portions. Histologi- and irresolvable pain, and it may occur (ulnolunate, triquetrocapitate, or tri- cally, the dorsal and volar ligaments are in patients with difficult personalities. quetrohamate) ligaments as well as the true ligaments, and the volar portion is Despite these issues, many patients with triangular fibrocartilage complex1,18,19,22-27. substantially thicker than the dorsal ulnar-sided wrist pain do have patho- Tendinopathies of the extensor carpi portion. The intramembranous liga- logic lesions that may be amenable to ulnaris18,28-30 or flexor carpi ulnaris31-34 as ment is not a true ligament histologi- surgical treatment. well as vascular lesions such as ulnar ar- cally, and it has little mechanical The anatomy of the ulnar side of tery thrombosis or hemangiomas can strength. The capitohamate ligament the wrist is complex, with many over- also cause ulnar-sided wrist pain35-38. complex is formed by three distinct lig- lapping areas that may be a cause of Neurologic processes such as entrap- aments: the dorsal, volar, and deep pain. A clear understanding of the nor- ment of the ulnar nerve in Guyon’s canal, components. mal anatomy of the ulnar side of the neuritis of the dorsal sensory branch of The extrinsic ligaments on the ul- wrist in addition to a systematic evalua- the ulnar nerve, and complex regional nar side include the ulnotriquetral and tion with both physical examination pain syndromes may be present39,40. Fi- ulnolunate ligaments (Fig. 2). These lig- and radiographic imaging can often nally, the miscellaneous group includes aments act as primary stabilizers of the elucidate the etiology, and thus the the very unusual etiologies such as relationship between the distal part of treatment, of ulnar-sided wrist pain. tumors, including osteoid osteomas, the ulna and the volar part of the car- The differential diagnosis of ulnar- chondroblastomas, and aneurysmal pus. The fibers originate from the volar sided wrist pain can be divided into six bone cysts. margin of the triangular fibrocartilage elements: osseous, ligamentous, tendi- The focus of this article is to pro- complex, with a contribution from the nous, vascular, neurologic, and miscel- vide a clear understanding of the anat- base of the ulnar styloid, and insert laneous. Osseous injuries include the omy of the ulnar side of the wrist and onto the palmar aspect of the tri- sequelae of fractures (i.e., nonunion or to discuss physical examination, imag- quetrum, lunate, and lunotriquetral lig- malunion) and degenerative processes. ing techniques, and treatment of some ament (Fig. 3). The fibers are blended Fracture nonunions of the hamate1-4, of the more common causes of ulnar- intimately with the volar margin of the pisiform5-10, triquetrum11-13, base of the sided wrist pain. triangular fibrocartilage complex. The fifth metacarpal14-17, ulnar styloid pro- meniscus homologue attaches proxi- cess, and distal part of the ulna or radius Anatomy of the mally to the dorsal end of the distal have been reported to cause ulnar-sided Ulnar Side of the Wrist margin of the sigmoid notch and the wrist pain. Degenerative processes at Extrinsic and Intrinsic dorsal border of the triangular disk. It the pisotriquetral joint18, midcarpal Carpal Ligaments extends volarly and distally to insert at (triquetrohamate) articulation, fifth The ulnar portion of the carpus has sev- the ulnar aspects of the triquetrum, lu- 

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oulnar joint, with supplemental stability being provided by the interosseous membrane, the extensor retinaculum, and the muscle-tendon units that cross the longitudinal axis of rotation of the forearm. The tendon of the extensor carpi ulnaris serves as a dynamic stabilizer. Static stability is provided by the subsheath of the extensor carpi ulnaris. The volar and dorsal radioulnar ligaments originate from the dorsal and volar margins of the medial aspect of the radius adjacent to the sigmoid notch (Fig. 3). They conjoin just medial to the pole of the distal part of the ulna, forming a triangle that surrounds the articular disk. There are two sepa- rate sites of insertion on the distal part of the ulna, separated by a band of vascularized loose connective tissue: the deep fibers of the conjoined ligaments Fig. 1 insert into the ulnar fovea as the liga- The intrinsic ligaments of the wrist as viewed from the dorsal aspect of the carpus. C = capitate, mentum subcruentum, while the super- H = hamate, L = lunate, S = scaphoid, T = triquetrum, Tm = trapezium, I = first metacarpal, and ficial fibers insert into the base of the V = fifth metacarpal. (Reprinted with permission of the Mayo Foundation.) ulnar styloid. nate, and lunotriquetral ligament. The ulnar fibers commingle with those of the subsheath of the extensor carpi ulnaris and continue to the base of the fifth metacarpal.

Distal Radioulnar Joint The curvature of the sigmoid notch of the radius is larger than the ulnar seat and therefore provides little osseous stability to the distal radioulnar joint. In addition, a dorsal-palmar translation occurs between the joint surfaces during forearm rotation. It is understood that, with forearm rotation, motion occurs at the distal radioulnar joint in three planes: rotation about the longitudinal axis of the forearm, dorsal-palmar translation, and proximal-distal translation. The osseous architecture of the distal radioulnar joint affords decreasing stability with increas- ing forearm pronation or supination, as the ulnar head contacts only the volar margin of the sigmoid notch in full supination and the dorsal margin of the Fig. 2 sigmoid notch in full pronation. The lig- The extrinsic ligaments of the wrist as seen from the volar perspective of the carpus. C = capi- aments of the triangular fibrocartilage tate, H = hamate, L = lunate, P = pisiform, R = radius, S = distal pole of scaphoid, Td = trape- complex, therefore, provide the primary zoid, Tm = trapezium, U = ulna, I = first metacarpal, and V = fifth metacarpal. (Reprinted with intrinsic stabilization of the distal radi- permission of the Mayo Foundation.) 

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tic tests. Once a firm diagnosis has been established, treatment can ensue. Ulnar-sided wrist pain can be divided into three categories: acute traumatic injuries, chronic overuse injuries, and chronic degenerative problems. Acute injuries typically result from a notable traumatic event. This may be a fall from either a height or a standing position, or it may be a hyperextension injury from a heavy object falling against the wrist. Most injuries involve a hyperextension, ulnar deviation moment, although flexion injuries and direct blows may also result in ulnar-sided lesions. Patients may report hearing a pop and noticing immediate swelling or pain. Injuries such as a fracture or distal radioulnar joint dislocation may lead the patient to seek immediate attention, whereas it may take several months for a patient to present with an injury such as a tear of the lunotriquetral ligament or the tri- Fig. 3 The distal part of the radius and the radiocarpal capsule and ligaments from a dorsal view. The angular fibrocartilage complex. The pa- dorsal and palmar radioulnar ligament as well as the ulnar border of the radius form the margins tient, however, will typically remember the index event. for the triangular disk, and all together they form the triangular fibrocartilage complex. Note how Chronic overuse injuries may the ulnotriquetral and ulnolunate ligaments arise from the portions of the palmar radioulnar liga- have a more indolent presentation. ment and how the dorsal and palmar radiolunate ligaments attach to the styloid recess. The ex- Patients with chronic repetitive ulnar tensor carpi ulnaris tendon sheath is intimately associated with the dorsal aspect of the ulna. loading, such as mechanics and plumb- (Reprinted with permission of the Mayo Foundation.) ers, may present with vague ulnar-sided pain without a history of specific injury. Triangular Fibrocartilage Complex gular fibrocartilage complex has been Patients with low-grade repetitive load- The triangular fibrocartilage complex is well described42. Supplied by terminal ing, such as assembly workers and the complex of soft tissues interposed portions of both the anterior and the computer operators, may present with between the distal part of the ulna and posterior interosseous arteries, the pal- extensor carpi ulnaris tendinitis follow- the ulnar side of the carpus, arising mar, ulnar, and dorsal components of ing an increase or change in activity. from the distal part of the radius and the disk and radioulnar ligaments are Chronic degenerative problems extending across the ulnar pole to insert well vascularized, whereas the central may result from previous acute trau- into the fovea and the base of the ulnar and radial portions are avascular. This matic events, previous injuries that have styloid (Fig. 3). Considered the pri- pattern of supply has direct implica- altered the anatomy, and abnormalities mary stabilizer of the distal radioulnar tions with regard to the healing poten- that arise from anatomic or congenital joint, the term triangular fibrocartilage tial of the disk and the radioulnar variations. Examples include ulnar-sided complex emphasizes both the func- ligaments following injury, with pe- wrist pain resulting from a malunited tional and the anatomic interdepen- ripheral ulnar-sided detachments dem- distal radial fracture, a previous radial dence of its elements. Palmer and onstrating a superior capacity to heal head fracture with subsequent radial Werner described the different compo- following repair when compared with shortening, congenital radial head dis- nents of the triangular fibrocartilage radial-sided detachments. location, and pisotriquetral arthritis. complex41 as the triangular fibrocarti- A detailed history is essential to lage proper (the articular disk), the pal- Examination and Diagnostic determine which of these categories ap- mar and dorsal radioulnar ligaments, Tools for Ulnar-Sided Wrist Pain plies to a particular patient. It must in- the meniscus homologue, the ulnar col- The etiology of ulnar-sided wrist pain clude a detailed medical history as well lateral ligament, and the subsheath of can often be determined on the basis of as a history of previous injuries and the extensor carpi ulnaris tendon. a complete history, a detailed clinical previous surgical procedures involving The vascular supply of the trian- examination, and appropriate diagnos- not only the wrist but the elbow as well. 

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Asking the patient about his or sor carpi ulnaris tendon is palpated hand is used to stabilize the lunate her symptoms will often help to nar- along the distal part of the ulna and is and the radial side of the carpus. Force row the differential diagnosis of ulnar- most palpable just distal to the ulnar is generated across the pisiform in a sided wrist pain. The patient can be head. The extensor carpi ulnaris inser- dorsal-to-volar direction while the asked whether the pain is ulnar or radial tion is at the base of the fifth metacar- other hand is held still. This allows to an imaginary line drawn through the pal, well away from the wrist joint (Fig. for controlled stress across the luno- center of the dorsal aspect of the wrist. 4). The fifth carpometacarpal joint is triquetral joint (Fig. 6). Prior to this Patients with ulnar-sided lesions are just proximal to the extensor carpi ul- maneuver, the pisotriquetral joint usually able to localize the pain to the naris insertion. The triangular fibro- should be palpated in the ulnar-to- ulnar side of the wrist. Patients often cartilage complex is best palpated radial plane to rule out pathologic report pain with ulnar deviation and midway between the extensor carpi ul- changes in this joint. loading of the wrist such as occurs naris and the flexor carpi ulnaris in the Pathologic changes in the tri- when they elevate themselves out of a soft recess just distal to the ulnar sty- angular fibrocartilage complex can chair or swing a hammer. Patients may loid (Fig. 5). The pisotriquetral joint is be isolated with the ulnocarpal im- also report pain with hyperextension palpated volar to the triangular fibro- paction maneuver. This is again per- of the wrist. Occasionally, they report cartilage complex, and the pisiform formed with the patient’s elbow flexed catching or clicking in the wrist, and can be moved between the examiner’s and hand pointing toward the ceiling. this must be further investigated with thumb and index finger. The distal ra- The examiner moves the ulnarly devi- a physical examination since noise dioulnar joint is palpated dorsally in ated wrist in a volar-to-dorsal direc- with wrist motion can be normal. Ul- various degrees of forearm rotation. tion while applying an axial load nar nerve symptoms may point to diag- The differential diagnosis of across the ulnar side of the wrist noses such as a fracture of the hook of ulnar-sided wrist pain can be nar- (Fig. 7). This maneuver translates the hamate or more proximal ulnar rowed further by performing provoca- load across the triangular fibrocarti- nerve compression. Vascular symptoms tive maneuvesrs. lage complex, which may cause grind- point to diagnoses such as ulnar artery Abnormalities of the lunotrique- ing and reproduce pain. thrombosis. tral joint can be assessed with three sep- The piano key test is performed The physical examination be- arate stress maneuvers. Lunotriquetral to isolate disorders of the distal radioul- gins with inspection. The wrist and el- ballottement can be achieved by com- nar joint. Ballottement of the ulna is bow should be examined for previous pressing the lunate against the tri- performed by the examiner applying a surgical scars. Prominence of the ulna quetrum. This is performed with the dorsal-to-volar load with his or her either volarly or dorsally may indicate examiner’s thumb placed against the hand 4 cm proximal to the distal radi- some degree of instability of the distal lateral border of the triquetrum and oulnar joint. This isolates abnormali- radioulnar joint. A volar sag and supi- compressing the triquetrum against ties of the distal radioulnar joint by nation of the wrist may indicate the the lunate. avoiding pressure on the overlying capsuloligamentous instability that oc- The Regan “shuck” test is per- structures such as the extensor digiti curs in rheumatoid arthritis. Intrinsic formed by the examiner placing his or minimi tendon. atrophy and clawing may indicate ul- her thumb and index finger on the tri- Selective anesthetic injections nar nerve neuropathy. Splinter hemor- quetrum and pisiform, respectively, are an important adjunct to confirm rhages beneath the nails and decreased and placing the other hand on the ra- pathologic changes suspected on clini- turgor in the volar digital pads suggest dial carpus and lunate. The examiner cal examination. If a corticosteroid is vascular insufficiency. moves his or her right and left hand in added to the anesthetic injection, ther- Palpation should proceed in a opposing (volar and dorsal) directions, apeutic benefits may also be achieved. systematic fashion by isolating ana- placing shear stress across the luno- Injections should be performed in tomic structures. The examination triquetral joint. Since the lunate and joints or along tendons that are sus- should be performed with the pa- triquetrum are the only bones not sta- pected of being injured. If a lesion of tient’s elbow resting on the table, the bilized, the force is transmitted across the triangular fibrocartilage complex is hand pointing toward the ceiling, and the lunotriquetral joint, with pain in- suspected, the injection should be per- the forearm in neutral as if the patient dicating a pathologic condition. formed in the ulnocarpal joint. If ex- is about to arm wrestle with the exam- The Kleinman “shear” test allows tensor carpi ulnaris tendinitis is the iner. Tenderness over any anatomic a more subtle application of force and working diagnosis, then the injection structure suggests a specific clinical di- is considered the most specific provoc- should be performed in the extensor agnosis. The lunotriquetral interval is ative test for lunotriquetral disorders. carpi ulnaris tendon sheath, with palpated between the fourth and fifth The examiner places his or her thumb avoidance of the ulnocarpal joint. Such compartments one fingerbreadth dis- on the pisiform volarly and the re- selective injections can be used to distal to the distal radioulnar joint with maining fingers of the same hand dor- tinguish intra-articular from extra- the wrist in 30° of flexion. The exten- sally along the ulnar carpus. The other articular lesions. 

THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004

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. The decision to use more advanced imaging modalities is based on the suspected diagnosis.

Standard Radiographs Initial radiographic evaluation should include neutral rotation posteroanterior, neutral rotation lateral, and oblique plain radiographs of the wrist. These views are useful as a general screening tool to look for evidence of fractures, arthritic changes, and bone lesions. Numerous indices can be mea- sured on these radiographs43. On the posteroanterior radiograph, particular attention should be paid to Gilula’s lines, ulnar variance, the carpal height ratio, and evidence of car- Fig. 4 pal instability. The lateral radiograph is Surface anatomy of the ulnar side of the wrist. The extensor carpi ulnaris tendon insertion, the most useful for measurements of carpal lunate, and the triquetrum are shown. Note that the extensor carpi ulnaris insertion is well away instability, including the scapholunate, from the radiocarpal and midcarpal joints. The lunotriquetral interval is one fingerbreadth distal capitolunate, and lunotriquetral angles. to the distal radioulnar joint. It is important that the posteroanterior and lateral radiographs are made with the forearm in neutral rotation, as changes in forearm rotation can influence the measurement of various radiographic indices. For example, pronation increases ulnar variance and supination decreases it44. On the posteroanterior radiograph, neutral rotation can be confirmed by visualizing the groove of the extensor carpi ulnaris tendon adjacent to the ulnar styloid. On the lateral radiograph, the anterior surface of the pisiform should project midway between the anterior aspect of the capitate head and the distal pole of the scaphoid.

Special Views In addition to the standard views described above, there are special plain radiographic views that can provide additional diagnostic information. The decision to obtain additional views is based on the suspected diagnosis. Fig. 5 Comparison of standard postero- The triangular fibrocartilage complex is best palpated midway between the extensor carpi ulnaris anterior, ulnar deviation posteroanterior, and the flexor carpi ulnaris in the soft recess just distal to the ulnar styloid. 

THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004

and radial deviation posteroanterior radiographs may provide indications of abnormal radiocarpal or midcarpal motion. An ulnar deviation posteroanterior radiograph, commonly used to show an elongated view of the scaphoid, may also reveal lunotriquetral instability or evidence of ulnocarpal abutment, especially when it is compared with a standard posteroanterior radiograph. If ulnocarpal abutment is suspected, it is often useful to make a posteroanterior radiograph with the forearm in pronation and the fist clenched, which increases ulnar variance. Other stress radiographs, such as those made with dorsal or volar stress on the distal part of the ulna of patients with suspected instability of the distal radioulnar joint, may also assist in confirming the diagnosis. The scaphoid tubercle, the pisiform, and the hook of the hamate are often difficult to visualize on standard radiographs. A 30° supinated oblique Fig. 6 radiograph is useful to visualize these The Kleinman “shear” test. One of the examiner’s hands holds the radial side stable while structures, especially the pisotriquetral a volar-to-dorsal force is applied across the pisiform with the thumb of the examiner’s other joint and the hamate. A carpal tunnel hand. radiograph is also useful. However, it is often difficult to make a proper carpal tunnel radiograph of a patient with an acute wrist injury, as it requires positioning the wrist in full extension.

Computed Tomography Computed tomography scans provide better osseous detail than do plain radiographs. They are very useful in the evaluation of suspected fractures of bones that are difficult to visualize on plain radiographs, such as the hamate hook (Fig. 8). Computed tomography scanning is a very effective modality for the evaluation of a healing fracture (Fig. 8). In addition to providing thin-slice axial views of the bones, computer reconstruction can provide images in any desired plane or can generate three- dimensional images if needed (Fig. 8). Computed tomography is the imaging modality of choice for the evaluation of subluxation of the distal radioulnar joint. The congruity of the distal radioulnar articular surfaces can Fig. 7 also be evaluated accurately. In a study The ulnocarpal impaction maneuver. The examiner moves the ulnarly deviated wrist in a volar-to- of computed tomography criteria for dorsal direction while applying an axial load across the ulnar side of the wrist. the determination of subluxation of the 

THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004 distal radioulnar joint, Wechsler et al. copy and that it has a relatively high by magnetic resonance imaging for the emphasized the need to obtain simulta- rate of false-negative findings20,46. Others evaluation of lesions of the triangular neous views of both extremities with have pointed out the poor correlation fibrocartilage complex. However, ar- the forearms in neutral rotation, full su- between arthrographic findings and thrography continues to be used to pination, and full pronation45. symptoms reported by patients47-49. evaluate the integrity of the scapholu- Zanetti et al. suggested that this poor nate and lunotriquetral interosseous Arthrography correlation is due to a dependence on the ligaments (Fig. 9). The value of arthrog- In the past, arthrography had been the detection of communicating defects of raphy may be increased by the simulta- favored imaging modality for the evalua- the triangular fibrocartilage complex50. neous use of real-time fluoroscopic tion of ruptures of the interosseous liga- Those authors suggested that careful imaging. ments and tears of the triangular attention to detail allows detection of fibrocartilage complex. Triple-injection noncommunicating defects of the tri- Fluoroscopy arthrography had been considered the angular fibrocartilage complex, which Abnormal motion of the carpal bones “gold” standard for detecting perfora- have a more reliable association with can be most accurately demonstrated tions of the triangular fibrocartilage symptomatic ulnar-sided lesions of the with real-time fluoroscopic imaging. In complex. However, several authors have triangular fibrocartilage complex50. particular, in patients who demonstrate maintained that arthrography of the Over the past several years, ar- a sudden shift or clunk with wrist devi- wrist is much less accurate than arthros- thrography has been largely supplanted ation, the site of the pathologic entity can often be identified fluoroscopically. When a patient has an injury of the lunotriquetral interosseous ligament, fluoroscopy may demonstrate the so- called catch-up of the triquetrum mov- ing into extension as the wrist moves from radial to ulnar deviation19. Fluo- roscopy is similarly useful for demonstrating dynamic instabilities in patients with instability of the scapholunate, midcarpal, or distal radioulnar joint.

Radionuclide Imaging Radionuclide imaging, or bone- scanning, provides excellent sensitivity for the detection of occult or nondis- placed fractures. A single-phase scan is sufficient for the detection of fractures if additional information, such as the status of osseous blood flow, is not required. Bone scans are very sensitive to the locations of pathologic lesions of bone, but they often do not provide a definite diagnosis. The modality is a useful, relatively low-cost screening tool for the evaluation of occult fractures, osteonecrosis, and osteomyelitis. The relative value of bone-scanning compared with computed tomography for the evaluation of occult fractures on the Fig. 8 ulnar side of the wrist has not been de- A, Posteroanterior radiograph of a wrist with a fracture of the hamate hook (arrow). The fracture is termined, and some have suggested that difficult to visualize because the hamate hook overlaps the fourth and fifth carpometacarpal joints magnetic resonance imaging is as useful on this view. B, Computed tomography image of the same wrist. The axial view clearly demon- as bone-scanning for detecting an oc- strates the fracture of the hamate hook (arrow). C, Computed tomography image demonstrating a cult lesion51. If such a lesion is found, a healed fracture of the base of the hamate hook (arrow). D, Three-dimensional reconstruction per- subsequent computed tomography scan formed from computed tomography data demonstrating a nonunion of the hamate hook (thick is the most accurate modality for evalu- black arrow) and also demonstrating the pisotriquetral joint (thin white arrow). ating the osseous details of the fracture, 

THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004 if that information is needed. Radio- nuclide imaging may also be useful for the evaluation of complex regional pain syndromes.

Magnetic Resonance Imaging Magnetic resonance imaging is the procedure of choice for the assessment of a wide range of soft-tissue lesions, including ligament and cartilage lesions, soft-tissue tumors, tendinitis, and joint effusions. While computed tomography provides superior osseous detail, magnetic resonance imaging may have greater sensitivity for the detection of subtle changes such as bone edema and is therefore particularly useful for the evaluation of occult fractures and stress fractures. Magnetic resonance imaging clearly provides a great deal more anatomic detail than does arthrography alone. Magnetic resonance imaging with use of a dedicated wrist coil and combined with arthrography may sup- plant magnetic resonance imaging alone for the diagnosis of intercarpal and triangular fibrocartilage complex abnormalities. Recently, techniques combining magnetic resonance imaging Fig. 9 with single-injection gadolinium ar- An arthrogram of the midcarpal and distal radioulnar joints, demonstrating a perforation through thrography have been developed (Figs. the lunotriquetral ligament (small arrow) as well as the triangular fibrocartilage complex (large ar- 10-A and 10-B), but their use has not row). (Reprinted with permission of A.Y. Shin, owner of copyright.) been thoroughly studied. After injection of gadolinium into the radiocarpal or the midcarpal joint, contrast me- other authors have suggested that this the midcarpal portal. Partial tears can dium leaking into the distal radioulnar level of accuracy may be somewhat be appropriately débrided, and com- joint or into the radiocarpal joint can lower in most clinical settings and is plete tears can be prepared for recon- be indicative of a tear of the triangular highly dependent on the experience of struction. Central tears of the triangular fibrocartilage complex or an injury of the individual interpreting the mag- fibrocartilage complex can be débrided the intercarpal ligament. Magnetic res- netic resonance imaging scans55. Mag- arthroscopically, and peripheral tears onance imaging can also provide infor- netic resonance imaging has not yet can be repaired with arthroscopic assis- mation concerning the vascular status proven reliable for the detection of tance. Isolated areas of arthritis are of- of the lunate and the ulnar head, which tears of the lunotriquetral ligament19,56. ten difficult to diagnose with other is valuable in the diagnosis of ulnocar- modalities. Arthroscopy allows the stag- pal abutment21. Wrist Arthroscopy ing of degenerative or posttraumatic ar- Magnetic resonance imaging has Arthroscopy can serve as an important thritis and can help the surgeon to become widely used for the evaluation tool in the diagnosis and treatment of determine which reconstructive proce- of tears of the triangular fibrocartilage ulnar-sided wrist pain. Although diag- dures or limited fusions are appropri- complex. Early studies demonstrated nostic modalities such as magnetic res- ate. Arthroscopy of the distal radioulnar that magnetic resonance imaging had onance imaging and arthrography are joint allows staging of arthritis of that poor accuracy for predicting the lo- helpful, arthroscopy is considered the joint. Furthermore, loose bodies and cation of such tears seen at arthros- gold standard for diagnosing and stag- cartilage flaps that are difficult to visu- copy52,53. In one recent study, magnetic ing of intra-articular lesions. Tears of alize with other modalities can be seen resonance imaging had an accuracy of the scapholunate and lunotriquetral lig- and removed. Finally, normal arthro- 92% for predicting tears of the triangu- aments can be graded by visualizing scopic findings allow the examiner to lar fibrocartilage complex54; however, them through both the radiocarpal and exclude intercarpal ligament, triangular 

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and the ulnar seat. Previous injury to the distal part of the radius (intra- articular fracture of the sigmoid notch) or to the ulnar seat can likewise lead to cartilage degeneration and symptomatic arthritis. Patients experience pain with forearm rotation and tenderness on palpation of the distal radioulnar joint. Surgical treatment should at- tempt to address both the arthritis of the distal radioulnar joint and the distal ulnar instability.

Lunotriquetral Instability Several factors should be considered when choosing the optimal treatment for lunotriquetral injuries19. These include the amount of instability (static or dynamic), the elapsed time between the injury and treatment (acute or chronic), and the presence of associated injury or degenerative changes. Pain associated with lunotriquetral tears may be due to dynamic instability Fig. 10-A and/or local synovitis. The initial man- Magnetic resonance arthrogram (T1-weighted fat-suppression image made after injection of gad- agement of almost all acute and chronic olinium into the distal radioulnar joint) demonstrating a tear of the triangular fibrocartilage com- tears without a dissociation or volar in- plex near its radial insertion (arrow). tercalated segmental instability should probably be conservative, with cast or fibrocartilage complex, and articular or ulnar shortening osteotomy. splint immobilization. Careful cast- lesions as sources of pain and should Chronic radial or ulnar-sided de- molding with a pad underneath the lead him or her to look for pathologic tachment of the triangular fibrocarti- pisiform maintains optimal alignment changes elsewhere. lage complex can lead to symptomatic as healing progresses. Midcarpal corti- instability (clunking on forearm rota- costeroid injections can be helpful to Treatment tion) or pain in the distal radioulnar decrease synovitis. Operative treatment Triangular Fibrocartilage Complex joint secondary to degeneration of the is indicated for acute and chronic disso- and Distal Radioulnar Joint articular cartilage of the sigmoid notch ciations that demonstrate a volar inter- Palmer classified lesions of the triangular fibrocartilage complex as either traumatic (Type 1) or atraumatic (Type Fig. 10-B 57 2) (Fig. 11) . Division of each group Photograph made during wrist into subtypes, with Type-1 lesions clas- arthroscopy, demonstrating a sified on the basis of the structure that tear of the triangular fibrocar- is disrupted and Type-2 lesions classi- tilage complex near its radial fied on the basis of the extent of the attachment (arrow). The le- degenerative process, can direct treatment. Definitive treatment of trau- sion corresponds to the tear matic or degenerative lesions of the identified on the magnetic res- triangular fibrocartilage complex re- onance image. mains controversial. Although there are exceptions, in general Type-1 lesions are treated either with immobilization or surgical repair, whereas Type-2 lesions can be treated either with a splint, anti- inflammatory drugs, or cortisone injection or with arthroscopic débridement 

THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004 calated segmental collapse and chronic wrist arthrodesis may be indicated pursuits or have chronic instability or a tears that are unresponsive to conserva- when degenerative changes make other poor-quality lunotriquetral ligament tive management. The goal of surgical salvage procedures impossible. may be best managed with ligament re- intervention is realignment of the luno- Repair of the lunotriquetral liga- construction rather than repair. Liga- capitate axis and reestablishment of the ment has been described by several ment reconstruction with a distally rotational integrity of the proximal car- authors58,59. The lunotriquetral interos- based strip of extensor carpi ulnaris ten- pal row. A variety of procedures have seous ligament is reattached to the site don graft is one option. Unlike recon- been described, including lunotrique- of its avulsion, which is generally the tri- struction of the scapholunate ligament, tral arthrodesis, ligament repair, and quetrum. As the strong volar ligament is this technique, although demanding, has ligament reconstruction. If concomi- also disrupted, a combined dorsal and yielded uniformly good results in two tant ulnar negative or positive variance volar approach as well as augmentation studies58,59. Unlike lunotriquetral arthro- or midcarpal or radiocarpal arthrosis is of the repair by plication of the dorsal ra- desis, reconstruction preserves lunotri- present, additional procedures such as diotriquetral and dorsal scaphotriquetral quetral motion and provides the optimal ulnar lengthening or shortening, mid- ligaments may be of some value. Pro- chance for restoration of normal carpal carpal arthrodesis, or proximal row tracted immobilization is then necessary. interactions. carpectomy may be indicated. Total Patients who engage in strenuous 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 articular 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 avulsions 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 radioulnar joint: problems and solutions. J Am Acad Orthop Surg. 1995;3:95-109.) 

THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004 congenital lunotriquetral coalitions and reconstruction were superior to arthro- which forms a fibro-osseous tunnel. the relatively little relative motion that desis59. The lower complication rates, The linea jugata connects the sub- normally occurs between the lunate and higher patient satisfaction, greater range sheath to the epimysium and prevents triquetrum led to the concept of luno- of motion, and fewer subsequent reop- subluxation of the extensor carpi ul- triquetral arthrodesis. It may be techni- erations led the Mayo Clinic group to naris in a palmar direction during full cally less demanding than ligament prefer repair or reconstruction of the supination. Normally, the extensor reconstruction or repair, and it has be- lunotriquetral ligament as their pri- carpi ulnaris tendon sits in the ulnar come the technique of choice of many mary method of treatment for lunotri- sulcus and helps to stabilize the distal surgeons. However, the method is not quetral injuries that require surgical radioulnar joint as the forearm moves without substantial problems. The re- intervention (Fig. 12). from pronation to supination. If the ex- ported nonunion rate has ranged from tensor carpi ulnaris displaces in a volar 0% to 57%19. Use of Kirschner wires has Tendinopathies direction during supination, it may been shown to result in an unacceptably Tendinopathies of the wrist are rela- cause the tendon to move out of the sul- high nonunion rate of 47%19,59. Use of tively common causes of ulnar-sided cus, often resulting in a painful snap- compression screws may improve re- wrist pain. On the dorsal side of the ping sensation and inflammation. The sults, but nonunion remains a major wrist, the extensor carpi ulnaris and, depth of the ulnar sulcus varies, and problem. A 9% nonunion rate has been less commonly, the extensor digiti min- subluxation is more likely to occur if it reported with the Herbert screw, and imi may be involved; on the flexor sur- is shallow. In the case of a traumatic the use of conventional cortical screws face, the flexor carpi ulnaris and/or the dorsal subluxation or dislocation of the may be associated with nonunion rates pisiform may be involved. ulnar head, the extensor carpi ulnaris as high as 57%19,59. Ulnocarpal impinge- An understanding of the anat- may be forcibly displaced volarly and ment required additional surgery in omy of the extensor carpi ulnaris and its there is often disruption of the triangu- 23% (five) of twenty-two patients surrounding structures is essential for lar fibrocartilage complex. In addition, treated with lunotriquetral arthrodesis the diagnosis and management of ex- the extensor carpi ulnaris subsheath in one series59. This complication was tensor carpi ulnaris tendinitis60. The ex- may rupture, with or without disrup- not seen with lunotriquetral repair or tensor carpi ulnaris tendon sits in a tion of the extensor retinaculum. This reconstruction. A comparison of the groove, or sulcus, at the distal part of may happen with forceful radial devia- results following arthrodesis, ligament the ulna. It is maintained within this tion with flexion of the wrist, which is repair, and reconstruction at the Mayo groove during forearm rotation by the seen in patients participating in activi- Clinic demonstrated that repair and extensor retinaculum and a subsheath, 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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within the ulnar sulcus during forearm and wrist rotation. In patients with subluxation of the extensor carpi ulnaris due to inflammatory arthritis, dorsal subluxation of the ulnar head often must be addressed in addition to reconstruction of the extensor carpi ulnaris subsheath. Numerous procedures have been described for this purpose, and the choice of procedure is determined by the clinical presentation and the surgeon’s preference. In the case of nontraumatic tendinitis of the extensor carpi ulnaris or extensor digiti minimi tendon, the mainstay of treatment is rest, brief peri- ods of immobilization, nonsteroidal anti-inflammatory drugs, and judi- cious use of corticosteroid injections. Surgery is rare and is reserved for chronic, recalcitrant cases. Insertional tendinitis of the extensor carpi ulnaris is treated with transfer of the extensor carpi ulnaris to the dorsum of the hamate. Tendovaginitis within the extensor sheath is treated with release of the extensor carpi ulnaris subsheath and reconstruction, as described above. Fig. 13 If the extensor digiti minimi is involved, A magnetic resonance image of the wrist demonstrates a ganglion in Guyon’s space with simple release of the fifth dorsal com- compression of the ulnar nerve at the level of the wrist. (Reprinted with permission of A.Y. partment has excellent results. Shin, owner of copyright.) Treatment of tendinitis of the flexor carpi ulnaris similarly requires an tients with inflammatory disorders such Acute treatment of a traumatic understanding of the local anatomic as rheumatoid arthritis, attritional wear injury involving the extensor carpi ul- structures31,32. The ulnar neurovascular of the supporting structures may lead to naris tendon includes reduction of a bundle lies on the radial side of the subluxation of the extensor carpi ul- distal radioulnar joint dislocation, if flexor carpi ulnaris tendon just proxi- naris and extensor digiti minimi with- present, followed by immobilization mal to the wrist joint. It passes radial to out a specific traumatic event. of the wrist and forearm, rest, applica- the pisiform at Guyon’s canal. The Patients with extensor carpi ul- tion of ice, and use of nonsteroidal anti- flexor carpi ulnaris is a large muscle and naris tendinitis due to subluxation may inflammatory medications. The fore- the most powerful wrist motor. It does present with a painful snap or click dur- arm is usually immobilized in the neu- not have a synovial sheath. It inserts ing forearm rotation18,28-30. Often, there tral position, although it is sometimes into the proximal and anterior aspect of is tendinitis without detectable instabil- necessary to immobilize it in supination the pisiform, a sesamoid bone located ity. In such cases, there may be tender- to maintain reduction of the distal radi- within the flexor carpi ulnaris tendon ness at the distal part of the ulna, over oulnar joint after a dorsal dislocation. that has a single articular surface, which the fifth (extensor digiti minimi) or Subsequently, the distal radioulnar joint articulates with the volar surface of the sixth (extensor carpi ulnaris) dorsal is stabilized by repair of the triangular triquetrum. As there is no inherent sta- compartment. Extensor digiti minimi fibrocartilage complex. The extensor bility of the pisotriquetral joint, stabil- tendinitis presents with pain or tender- carpi ulnaris tendon is stabilized by re- ity depends on the pisohamate and ness over the fifth dorsal compartment construction of the extensor carpi ul- pisometacarpal ligaments, which attach of the wrist. Less commonly, there is in- naris subsheath, with use of a flap of to the pisiform like spokes on a wheel61. flammation at the insertion of the ex- extensor retinaculum passed around Flexor carpi ulnaris tendinitis has an in- tensor carpi ulnaris, which presents the tendon as described by Spinner and sidious onset. Patients present with ach- with pain and inflammation at the Kaplan60. This procedure allows the ex- ing pain on the ulnar flexor side of the dorsal base of the fifth metacarpal. tensor carpi ulnaris tendon to remain wrist. The symptoms may be related to 

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considered to determine if any of these factors, which can be treated with surgical decompression, are contributing to the ulnar nerve compression (Fig. 13). Thrombosis of the ulnar artery (Fig. 14) otherwise known as hypothenar hammer syndrome, typically results from repetitive force against the ulnar artery as is seen in plumbers or other workers who use high-impact equip- ment35. More unusual causes include systemic conditions or a more proximal vascular event. Patients present with pain associated with cold exposure, splinter hemorrhages, and decreased turgor in the ulnar digits. The diagnosis is suspected on the basis of abnormal results of the Allen test and can be confirmed with Doppler studies. Surgical planning requires an arteriogram. Surgi- Fig. 14 cal treatment consists of either resection An operative view of the thrombosed ulnar artery secondary to chronic trauma in the hypothenar alone or resection combined with vascu- area, also known as hypothenar hammer syndrome. The ulnar artery in this area is damaged by lar reconstruction. 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.) Conclusion Although ulnar-sided wrist pain can be repetitive or overuse activities. There carpi ulnaris tendinitis that does not re- intimidating and confusing, it can be is tenderness near the insertion of the spond to nonoperative treatment may broken down into the fundamental ele- flexor carpi ulnaris on the pisiform and be relieved by z-plasty lengthening of ments and evaluated in a systematic pain on resisted wrist flexion and ulnar the tendon proximal to its insertion on fashion. A probable diagnosis can be deviation. Patients may present with as- the pisiform. If the pathologic process made on the basis of a detailed history sociated ulnar nerve symptoms. primarily involves the pisiform, exci- and a clinical examination of all of the Pisotriquetral arthritis and, less sion of the pisiform is the most com- entities that can cause ulnar-sided wrist commonly, pisotriquetral instability monly used surgical procedure. pain. The diagnosis is then confirmed are causes of ulnar-sided wrist pain by appropriately selected radiographic that may be misdiagnosed as flexor Unusual Causes studies. Anesthetic injections (with cor- carpi ulnaris tendinitis. Pisotriquetral Unusual causes of ulnar-sided wrist ticosteroids) can be utilized as a diag- arthritis is associated with local pain pain include those of neurogenic nostic tool as well as a therapeutic and tenderness, which are exacerbated origin, vascular origin, and atypical measure. Once the diagnosis is made, by grinding of the pisiform dorsally fractures. treatment (both conservative and oper- against the triquetrum. Instability may Ulnar nerve compression at ative) should be directed at restoring be subtle and more difficult to diag- Guyon’s canal typically presents with fa- normal anatomy whenever possible. nose. A diagnostic injection of local tigue, weakness, and the feeling of loss anesthetic in combination with appro- of coordination with fine motor priate radiographic imaging will con- activities62. Patients may have decreased firm both diagnoses. sensation in the ring and small fingers Alexander Y. Shin, MD Flexor carpi ulnaris tendinitis but not on the dorsum of the hand Mayo Clinic, 200 First Street S.W., Rochester, is most commonly treated nonopera- since the dorsal sensory nerve branch MN 55905 tively31,32. As is the case for other soft- originates more proximally. The diag- tissue conditions, it usually can be nosis is made with nerve conduction Mark A. Deitch, MD treated with rest, immobilization, non- studies and electromyography. Com- Johns Hopkins Bayview Medical Center, 4940 steroidal anti-inflammatory drugs, and, pression of the ulnar nerve in Guyon’s Eastern Avenue, Baltimore, MD 21224 rarely, corticosteroid injection. Surgical canal may result from a mass effect, Kavi Sachar, MD treatment is rare and, if it is under- thrombosis of the ulnar artery, or a University of Colorado School of Medicine and taken, the ulnar neurovascular bundle fracture of the hook of the hamate. Hand Surgery Associates, 2535 South Down- must be identified and protected. Flexor Magnetic resonance imaging should be ing Street, Suite 500, Denver, CO 80210 

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Martin I. Boyer, MD, MSc, FRCS(C) ration of this manuscript. They did not receive Printed with permission of the American Department of Orthopaedic Surgery, Washing- payments or other benefits or a commitment Academy of Orthopaedic Surgeons. This ar- ton University School of Medicine, Barnes- or agreement to provide such benefits from a ticle, as well as other lectures presented at Jewish Hospital at Washington University, commercial entity. No commercial entity paid the Academy’s Annual Meeting, will be avail- Suite 11300, West Pavilion, One Barnes-Jewish or directed, or agreed to pay or direct, any able in February 2005 in Instructional Course Hospital Plaza, St. Louis, MO 63110 benefits to any research fund, foundation, Lectures, Volume 54. The complete volume educational institution, or other charitable or can be ordered online at www.aaos.org, or by The authors did not receive grants or outside nonprofit organization with which the authors calling 800-626-6726 (8 A.M.-5 P.M., Central funding in support of their research or prepa- are affiliated or associated. time).

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