Washington University School of Medicine Digital Commons@Becker Open Access Publications 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 Follow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubs Part of the Medicine and Health Sciences Commons 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 This Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in Open Access Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact [email protected]. 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- THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004 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 stabi- lizer. 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 me- dial 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 vas- cularized 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 ul- naris 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 transla- tion occurs between the joint surfaces during forearm rotation. It is understood that, with forearm rotation, motion occurs at the distal ra- dioulnar joint in three planes: rotation about the longitudinal axis of the fore- arm, 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.) THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG ULNAR-SIDED WRIST PAIN VOLUME 86-A · NUMBER 7 · JULY 2004 tic tests. Once a firm diagnosis has been established, 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. This may be a fall from either a height or a standing position, or it may be a hyper- extension injury from a heavy object falling against the wrist. Most injuries involve a hyperextension, ulnar devia- tion moment, although flexion injuries and direct blows may also result in ulnar-sided lesions. Patients may re- port hearing a pop and noticing im- mediate 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.