Positive Ulnar Variance Research Articles

Modified oblique ulnar shortening osteotomy combined with arthroscopic synovectomy for treatment of ulnar impingement syndrome

Objective To introduce a modified oblique ulnar shortening technique combined with arthroscopic synovectomy for treating ulnar impingement syndrome without the Rayhack system,and to evaluate the outcomes.Methods From March 2010 to July 2013,11 cases of ulnar positive variance with consistent ulnar wrist pain were treated with oblique osteotomy of the ulna and intemal fixation with a volar Zimmer compression plate.Arthroscopic debridement of the triangular fibrous cartilage complex (TFCC) was also done simultaneously.Postoperatively bone union,wrist pain and wrist function were followed.Results All the cases were follow-up for 6 to 24 months,with an average of 14 months.Average bone union time was 10 weeks.There was no non-union.Postoperative VAS for pain dropped from 5.6 to 1.2.According to Modified Mayo wrist score,the wrist function was excellent in 6 cases,good in 4 cases and fair in 1 case.Wrist range of motion and grip strength recovered well.All the patients went back to previous work in 3 months.Conclusion The modified oblique osteotomy with volar compression plate and lag screw fixation for ulnar shortening combined with arthroscopic synovectomy is an effective treatment for ulnar impingement syndrome.It decreases the incidence of bone nonunion and dorsal implant protruding. Key words: Arthroscopes; Surgical procedures, operative ; Ulnar impingement syndrome; Ulnar shortening

Ulnar Shortening Osteotomy Utilizing a TriMed Ulnar Osteotomy System

Ulnar impaction syndrome (UIS) is a degenerative condition of the ulnar wrist typically seen in patients with static or dynamic ulnar-positive variance. Impaction of the distal ulna on the proximal lunate and triquetrum leads to degeneration of the triangular fibrocartilage complex and/or the chondral surfaces of the lunate and triquetrum. Patients with UIS present with pain in the ulnar aspect of the wrist. In cases of UIS refractory to nonoperative treatment, several surgical techniques have been described, including arthroscopic triangular fibrocartilage complex debridement, arthroscopic wafer procedure, and ulnar shortening osteotomy (USO). USO has gained favor as a reliable technique to offload the forces seen at the ulnar wrist extra-articularly while preserving the distal radioulnar joint stabilizing structures. We describe a technique utilizing a jig-facilitated, oblique, diaphyseal USO and fixed with a TriMed ulnar osteotomy compression plate. This system allows for precise measured ulnar shortening and reliable compression across the osteotomy site, and has been shown to decrease operative times and achieve to high union rates. Plate prominence is minimized by utilizing the volar surface of the ulna, although plate prominence and subsequent need for hardware removal remain a relatively common complication.

Ulnar Impaction Syndrome: Ulnar Shortening vs. Arthroscopic Wafer Procedure.

The outcome of ulnar shortenings was compared with that of arthroscopic wafer resections for ulnar impaction (or abutment) syndrome in patients with a positive ulnar variance. The outcome was measured by DASH score, visual analog scale for pain, and working incapacity. The mean DASH score in the ulnar shortening group was 26; in the wafer group it was 36. The VAS scores were respectively 4.4 and 4.6. The working incapacity was 7?months in the ulnar shortening group and 6.1 months in the wafer group. The differences between the two groups were not statistically significant.

Ulnocarpal impaction syndrome: treatment with a transverse ulnar shortening osteotomy from an ulnodorsal approach

Ulnocarpal impaction syndrome is a common cause of chronic ulnar-sided wrist pain. The distal ulnar shortening osteotomy addresses the often present positive ulnar variance and therefore relieves the excessive load on the ulnocarpal joint. In the present study, the results of a technique that uses an ulnodorsal approach with a compression device and a transverse osteotomy are presented and compared to other techniques. This retrospective study includes 92 wrists with an ulnocarpal impaction syndrome, which were treated with an ulnar shortening osteotomy. The mean duration of postoperative follow-up was 50 months. The mean ulnar variance was 2.17 ± 1.56 mm preoperatively and after the ulnar shortening osteotomy -1.36 ± 1.67 mm (p < 0.05). Radiological consolidation of the osteotomy could be shown in 91 wrists 6 months postoperatively. Patients rated the preoperative pain level at a VAS 7.9 ± 1.7 which decreased to a of VAS 2.4 ± 2.5 (p < 0.05). 19 patients complained of mechanical irritation. There was no neurological irritation. It could be shown that the distal ulnar shortening osteotomy by a transverse osteotomy using a compression device and an ulnodorsal approach has a low complication rate. It is comparable to the oblique osteotomy in effectiveness and safety.

Pediatric Distal Forearm and Wrist Injury: An Imaging Review

Injuries to the pediatric distal forearm and wrist have myriad manifestations. Growth plate injuries can occur in the skeletally immature child. An unfused growth plate is less robust than ligamentous complexes and therefore is more easily injured. The Salter-Harris fracture classification system is used to grade physeal injuries based on their imaging appearance. This grading has prognostic significance: higher grades imply an increased likelihood of eventual growth disturbance. A disrupted distal radioulnar joint characterizes Galeazzi-type injuries at all ages; however, before skeletal maturity is attained, a disrupted radioulnar joint can manifest as a distal ulnar physeal separation with associated epiphysiolysis of the distal ulna, termed a Galeazzi-equivalent fracture. Bone contusions can be diagnosed using fluid-sensitive fat-suppressed magnetic resonance imaging, and their detection can alter the prognosis. The unique cartilaginous cushion of the developing bony carpus imparts resilience to fracture and dislocation until carpal maturity is reached. Chronic compressive forces to the wrist in a skeletally immature gymnast can result in a distinct pattern of bone and soft-tissue injury referred to as gymnast wrist. If the distal radial physis fuses prematurely, ulnar growth will outpace radial growth, leading to positive ulnar variance and consequent chronic wrist pain from ulnar impaction.

Osteotomy for Sigmoid Notch Obliquity and Ulnar Positive Variance

Background Several causes of ulnar wrist pain have been described. One uncommon cause is ulnar carpal abutment associated with a notable distally facing sigmoid notch (reverse obliquity). Such an abnormality cannot be treated with ulnar shortening alone because it will result in incongruity of the distal radioulnar joint (DRUJ). Case Description A 23-year-old woman presented with ulnar wrist pain aggravated by forearm rotation. Ten years earlier she had sustained a distal radius fracture that was conservatively treated. Examination revealed mild tenderness at the DRUJ and decreased wrist flexion and grip strength on the affected side. Radiographic examination demonstrated 1 cm ulnar positive variance, ulnar styloid nonunion, and a 37° reverse obliquity of the sigmoid notch. The patient was treated with ulnar shortening and rotation sigmoid notch osteotomy to realign the sigmoid notch with the ulnar head. Literature Review Sigmoid notch incongruity is one of several causes of wrist pain after distal radius fracture. Traditional salvage options for DRUJ arthritis may result in loss of grip strength, painful ulnar shaft instability, or reossification and are not acceptable options in the young patient. Sigmoid notch osteotomy or osteoplasty have been described to correct the shape of the sigmoid notch in the axial plane. Clinical Relevance We report a coronal plane osteotomy of the sigmoid notch to treat reverse obliquity of the sigmoid notch associated with ulnar carpal abutment. The rotation osteotomy described is particularly useful for patients in whom a salvage procedure is not warranted.

Arthroscopic Wafer Procedure for Ulnar Impaction Syndrome

Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.

Study protocol: non-displaced distal radial fractures in adult patients: three weeks vs. five weeks of cast immobilization: a randomized trial

BackgroundUp to 30% of patients suffer from long-term functional restrictions following conservative treatment of distal radius fractures. Whether duration of cast immobilisation influences functional outcome remains unclear.Methods/DesignThe aim of the study is to evaluate whether the duration of immobilization of non or minimally displaced distal radial fractures can be safely reduced. We will compare three weeks of plaster cast immobilization with five weeks of plaster cast immobilization in adult patient with non or minimally displaced distal radial fractures.Study design: a prospective randomized clinical trial.Study population: adult (>18 years) (independent in activities of daily living) patients with a non/minimal displaced distal radius fracture (dorsal angulation <15°, volar tilt <20°, radial inclination >15°, ulnar positive variance <5 mm and an articular step off <2 mm).Intervention: three weeks of plaster cast immobilization versus five weeks of plaster cast immobilization.Main study parameters: primary outcome parameters: Patient related wrist evaluation (PRWE) Quick Disability of Arm, Shoulder and Hand (QUICKDASH) score after a one year follow-up, and secondary parameters: range of motion, pain level (VAS) and complications.DiscussionThe expectation of this study is that shorter duration of plaster cast immobilisation is beneficial for the patient with a distal radius fracture. This risk of specific complications is low and generally similar in both treatment options. Moreover, the burden of the study is not much higher compared to standard treatment. Follow-up is standardized according to current trauma guidelines. Literature indicates that both treatment options from the study are accepted for displaced distal radius fractures. No clear advantage for one treatment options is found at present in the literature, although there is no level I evidence present. This trial will provide level-1 evidence for the comparison of consolidation and functional outcome between two treatment options for non-displaced distal radial fractures. The gathered data may support the development of a clinical guideline for conservative treatment of distal radial fractures.Trial registrationNetherlands National Trial Register NTR3552.

A comparison of 3-D computed tomography versus 2-D radiography measurements of ulnar variance and ulnolunate distance during forearm rotation

Positive ulnar variance is associated with ulnar impaction syndrome and ulnar variance is reported to increase with pronation. However, radiographic measurement can be affected markedly by the incident angle of the X-ray beam. We performed three-dimensional (3-D) computed tomography measurements of ulnar variance and ulnolunate distance during forearm rotation and compared these with plain radiographic measurements in 15 healthy wrists. From supination to pronation, ulnar variance increased in all cases on the radiographs; mean ulnar variance increased significantly and mean ulnolunate distance decreased significantly. However on 3-D imaging, ulna variance decreased in 12 cases on moving into pronation and increased in three cases; neither the mean ulnar variance nor mean ulnolunate distance changed significantly. Our results suggest that the forearm position in which ulnar variance increased varies among individuals. This may explain why some patients with ulnar impaction syndrome complain of wrist pain exacerbated by forearm supination. It also suggests that standard radiographic assessments of ulnar variance are unreliable.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius' angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance. For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6-8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one. Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly. Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

Functional results of arthroscopic triangular fibrocartilage complex reconstruction in chronic distal radioulnar joint instability

PurposeTears in the triangular fibrocartilage complex (TFCC) often manifest as ulnar wrist pain and limited wrist function. In chronic cases, the treatment of large tears with irreparable TFCC degeneration combined with distal radioulnar joint (DRUJ) instability is difficult. In the current report, we describe the outcomes of a mini-invasive technique for TFCC reconstruction using the palmaris longus (PL) tendon via arthroscopy. MethodsWe examined the cases of 21 adult patients [20 men and 1 woman; age range, 19−24 years (mean age, 22.4 years)] treated for chronic and irreparable TFCC tears from September 1999 to September 2011. We used the arthroscopic TFCC reconstruction method with the PL tendon for all chronic and irreparable TFCC injuries with DRUJ instability in our clinic. Thereafter, the patients underwent a rehabilitation program, which included wrist motion and occupational therapy. The time period from the event causing the tear to the operation ranged from 14 months to 28 months (mean duration, 22.6 months). All the patients had negative, zero, or mildly positive (<2 mm) ulnar variance. ResultsThe results were graded using the Mayo modified wrist score. Of the 21 patients, 11 rated their wrists as “excellent,” 9 as “good,” and 1 as “fair.” None of the patients developed wound infections or complications. ConclusionsThe results of this study suggest that arthroscopic TFCC reconstruction using the PL tendon is an effective method for treating chronic and irreparable TFCC tears with DRUJ instability.

Madelung Deformity

Madelung deformity is a rare congenital anomaly of the wrist caused by asymmetric growth at the distal radial physis secondary to a partial ulnar-sided arrest. The deformity is characterized by ulnar and palmar curvature of the distal radius, positive ulnar variance, and proximal subsidence of the lunate. It more commonly occurs in females than males and typically affects both wrists. The deformity can occur in isolation or as part of a genetic syndrome. The pattern of inheritance varies, with some cases following a pseudoautosomal pattern and many others lacking a clear family history. Nonsurgical management is typically advocated in asymptomatic patients. Few studies exist on the natural history of the condition; however, extensor tendon ruptures have been reported in severe and chronic cases. Stiffness, pain, and patient concerns regarding wrist cosmesis have been cited as indications for surgery. Various techniques for surgical management of Madelung deformity have been described, but clear evidence to support the use of any single approach is lacking.

Translating Carpal Biomechanics to Triangular Fibrocartilage Complex Injury: Significance of Ulnar Variance in Predicting TFCC Lesions

Ulnar variance (UV) describes the cranio‐caudal position of the distal ulna in relation to the distal radius at the wrist. Neutral ulnar variance (ulna and radius articulating at the carpus at exactly the same level) transmits 20% of the compressive load across the wrist to the distal ulna and 80% to the distal radius. A +2.5mm positive UV has been shown to increase the ulnocarpal load to 40%. The triangular fibrocartilage complex (TFCC) acts as a cushion for the ulnar carpus and transmits axial loads from the wrist to the ulna in a longitudinal direction across the ulnar column of the wrist. Consequently, a positive ulnar variance implicates a greater risk of TFCC injury. This study sought to calculate the prevalence of traumatic TFCC injury in those with a positive UV versus those with a negative UV. 20 cadaveric wrists aged 50 – 90 were assessed for TFCC damage via gross examination and classified according to Palmer's schema. A plain film PA radiograph of each wrist was then taken to measure the degree of UV. Results showed that all wrists had degenerative Class II lesions of the TFCC, while traumatic Class I lesions of the TFCC were found in 69% of wrists with positive UV as compared to 0% of wrists with negative UV (p&lt;0.05). Our investigation prompts further research exploring a “dose‐response” relationship between UV and TFCC damage as well as between the degree of TFCC damage and clinical symptoms or diminished quality of life.Grant Funding Source: SUNY Downstate College of Medicine Alumni Association

Reconstructed animation from four-phase grip MRI of the wrist with ulnar-sided pain

In order to visualize dynamic variations related to ulnar-sided wrist pain, animation was reconstructed from T2* coronal-sectioned magnetic resonance imaging in each of the four phases of grip motion for nine wrists in patients with ulnar pain. Eight of the nine wrists showed a positive ulnar variance of less than 2 mm. Ulnocarpal impaction and triangular fibrocartilage complex injury were assessed on the basis of animation and arthroscopy, respectively. Animation revealed ulnocarpal impaction in four wrists. In one of the four wrists, the torn portion of the articular disc was impinged between the ulnar head and ulnar proximal side of the lunate. In another wrist, the ulnar head impacted the lunate directly through the defect in the articular disc that had previously been excised. An ulnar shortening osteotomy successfully relieved ulnar wrist pain in all four cases with both ulnocarpal impaction and Palmer's Class II triangular fibrocartilage complex tears. This method demonstrated impairment of the articular disc and longitudinal instability of the distal radioulnar joint simultaneously and should be of value in investigating dynamic pathophysiology causing ulnar wrist pain.

Radiological Investigation of Relationship Between Lunate type and Ulnar Variance

Some variances and anatomical proportions of the wrist may contribute to development of avascular necrosis of the lunate. Kienböck's disease is more often encountered in young males, who suffer, among others, from type II of the lunate (with two joint surfaces for the capitate and hamate) and/or negative variance of ulna in relation to radius. The aim of the study was to investigate whether there exists interdependence between the simultaneous occurrence of individual types of the lunate with one of the variances of ulna in both genders. A retrospective analysis of 394 (n=394) radiological tests of the wrist in 174 (44%) women and 220 (56%) males aged 18-83 years (average age 39 years). From the entire pool, 265 X-rays were educed in 104 females and 161 males, and no fractures or wrist instability features were could be observed. The X-rays were obtained from computer lab and archive data base at St Hedwig Hospital in Trzebnica from the beginning of January 2011 to the end of December 2012. 196 cases (74%) were found with type I of the lunate and 69 cases (26%) with type II. Ulnar variance amounted to from +4.7 mm to -4.2 mm (mean value +0.9 mm). Positive ulnar variance was stated in 44 patients (16.6%), negative in 63 (23.7%) and neutral accounted for the biggest group of other 158 (59.7%) patients. Neutral variance of ulna is the one that occurs most often in the Polish population. There is no correlation between gender and ulnar variance. There is also lack of direct connection between occurrence of individual lunate types and ulnar variance.

Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fractures in Elderly Patients

ABSTRACT Purpose To evaluate the use of internal distraction plating for the management of comminuted, intra-articular distal radius fractures in patients over 60 years of age at two level one trauma centers. Our hypothesis was that distraction plating of comminuted distal radius fractures in the elderly would result in acceptable outcomes regarding range of motion, disabilities of the arm, shoulder and hand (DASH) score, and radiographic parameters and would thereby provide the upper extremity surgeon with another option for the treatment of these fractures. Materials and methods A retrospective review was performed on 33 patients over 60 years of age with comminuted distal radius fractures treated by internal distraction plating at two level 1 trauma centers. Patients were treated with internal distraction plating across the radiocarpal joint. At the time of final follow-up, radiographs were evaluated for ulnar variance, radial inclination, and palmar tilt. Range of motion, complications and DASH scores were also obtained. Results Thirty-three patients with a mean age of 70 years were treated with distraction plating for comminuted distal radius fractures. At final follow-up, all fractures had healed and radiographs demonstrated mean palmar tilt of 5° and mean positive ulnar variance of 0.6 mm. Mean radial inclination was 20°. Mean values for wrist flexion and extension were 46° and 50° respectively. Mean pronation and supination were 79° and 77° respectively. At the final follow-up, the mean DASH score was 32. Conclusion In the elderly, distraction plating is an effective method of treatment for comminuted, osteoporotic distal radius fractures. Level of evidence Therapeutic, Level IV (Retrospective case series). Richard MJ, Katolik LI, Hanel DP, Wartinbee DA, Ruch D. Distraction Plating for the Treatment of Highly Comminuted Distal Radius Fractures in Elderly Patients. The Duke Orthop J 2013;3(1):93-98.

The association of Kienböck’s disease and ulnar variance in the Iranian population

We retrospectively determined the distribution of ulnar variance in 60 patients with Kienböck's disease. We also measured the ulnar variances in 400 standard wrist radiographs in the normal adult population. The mean ulnar variance of the Kienböck's group was -1.1 mm (SD 1.7) and the mean ulnar variance of the general population was +0.7 (SD 1.5), which was significantly different. In the Kienböck's disease group there were 38 (63%) with ulnar negative, 16 (27%) neutral and six (10%) with ulnar positive variance. The preponderance of ulnar negative variance was statistically significant. There was an association between ulnar negative variance and the development of Kienböck's disease in this study.

Ulnar Shortening for Adolescent Ulnar Impaction Syndrome: Radiological and Clinical Outcomes

To determine the amount of shortening needed in an ulna to achieve final neutral ulnar variance in adolescents with ulnar impaction syndrome. Radiological and clinical outcomes were evaluated after ulnar shortening and after growth had stopped. From February 2006 to February 2009, we prospectively followed 16 consecutive patients treated with a shortening osteotomy for positive ulnar variance. The study group included 10 boys and 6 girls with an average age of 16.1 years. The closed medial half-side of the physis of the distal radius was used to measure the variance as a reference for the ulna. Based on the radius without any growth potential, the amount of shortening was determined for the ulna with potential for further growth. The preoperative, postoperative, and final ulnar variances were evaluated. The clinical results were compared before surgery and at the time of growth termination. Preoperative ulnar variance was 3.4 mm ± 0.6 mm and the amount to be shortened was 6.1 mm ± 1 mm. The final ulnar variance was 0.2 mm ± 0.3 mm. The mean visual analog scale pain score improved from 6.6 ± 1.0 before surgery to 2.2 ± 0.5 after surgery. The mean range of forearm rotation increased from 132° ± 11° before surgery to 170° ± 16° at final follow-up. In addition, grip strength was 15.3 kg ± 7.6 kg (71% of grip strength on the unaffected side) before surgery and 19.8 kg ± 4.9 kg (90% of grip strength on the unaffected side) at final follow-up. The modified Mayo Wrist Score was 85 ± 8 at the final follow-up. No cases of complications or treatment failure occurred. Ulnar shortening was considered a useful procedure for adolescents with ulnar impaction syndrome, particularly if the measurement for the shortening amount was determined using the physis of the distal radius and ulna.

Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

A 46-year-old right hand–dominant woman presents with left ulnar-sided wrist pain following a fall from a standing height onto her outstretched hand 6 months before. The examination is normal except for pain with ulnar deviation and axial loading of the wrist. A posteroanterior radiograph of the wrist taken with the forearm in full pronation demonstrates ulnar-positive variance measuring 4 mm. Magnetic resonance imaging reveals increased signal intensity over the proximal ulnar aspect of the lunate and distal ulna along with a central defect of the triangular fibrocartilage complex.

Corrective Radial and Ulnar Osteotomies for Distal Radial Fracture Malunion.

We describe a technique consisting of simultaneous radial closing-wedge and ulnar shortening osteotomy to treat malunion of distal radial fractures. Plan the radial closing-wedge osteotomy to correct the volar tilt angle to 8.5° to 15.5° and the ulnar shortening osteotomy to restore ulnar variance to -2.5 to 0.5 mm. Remove the wedge of bone from the radius and reduce the distal fragment, keeping the dorsal cortex as a hinge. Resect the section of the ulna equivalent to the positive ulnar variance with transverse osteotomies. Hold together the two fragments of the radius with a Kirschner wire and fix the osteotomy site with a volar locking plate. Evaluate residual ulnar positive variance with fluoroscopy and restore the ulnar variance to within a normal range by removing additional bone from the proximal fragment. Use a compression device to close and fix the ulnar osteotomy site. Allow early motion immediately after the operation. We retrospectively evaluated forty-two patients at a minimum of one year after treatment of an extra-articular distal radial malunion with a radial corrective osteotomy. IndicationsContraindicationsPitfalls & Challenges.