Ulnar Head Research Articles

Shortening of the distal ulna to correct ulnar variance in osteoporotic wrist fractures treated with intra-focal pining.

The aim of this study is to correct the ulnar variance in severe osteoporotic wrist fracture treated with intra-focal pining of the distal radius, with shortening osteotomy of the distal ulna. Thirteen patients, 12 females and one male, 61-83years old, 6-year follow-up, were treated by intra-focal pining (kapandji). When preoperatively the ulnar variance did not return to a normal value comparing to the opposite wrist, a shortening osteotomy of the ulna was performed in one stage, 4cm proximal to the ulnar head. The fractures healed 6-8weeks with stability and normal motion: flexion 70°, extension 60° and pronation/supination 140°. There was no pain upon palpation of distal ulna and no sign of radial impingement. Concerning the ulnar variance and starting with nine neutral values at the normal wrist, we obtained eight negative and one neutral ulnar variance after surgery. In four cases of negative variance at normal wrist, we obtained four negative ulnar variances after surgery and two cases of ulnar non-union. In cases of dorsal comminution in wrist fracture with severe osteoporosis, intra-focal pining technique is able to restore all the radiological parameters, but it could not correct the inversion of ulnar variance relative to shortening of the radius. Avoiding secondary interventions, acute shortening osteotomy of the ulna performed is a procedure which allows restoring the ulnar variance without affecting carpal stability and the mobility.

English

Anomalies of upper limb arteries have got clinical implications for nursing staff, surgeons and medical practitioners. Here we have found superficial ulnar artery arising from brachial artery in the middle 1/3rd of the arm in the Right upper limb. This anomaly was found during routine dissection in the Anatomy Department, Andhra Medical College. Its frequency varies from 0.7% to 7%. Its clinical significance is discussed. INTRODUCTION: Ulnar artery is the larger terminal branch of brachial artery in the cubital fossa 1. It passes downwards, medially and leaves the cubital fossa deep to the ulnar head of pronator teres which separates the artery from the median nerve.2 In the present case the ulnar artery is taking origin from the brachial artery in the middle third of the arm and is running a superficial course. It is passing superficial to the bicipital aponeurosis in the cubital fossa and subjacent to the median cubital vein. It is then passing just lateral to the medial epicondyle of humerus and running superficial to the common flexor origin. Hence it has been named as Superficial Ulnar artery (SUA). CASE REPORT: During routine dissection for the under-graduate students we have come across this anomaly. In the Right upper limb we have noticed that the superficial ulnar artery (SUA) has taken origin from the middle third of the brachial artery in the arm at a distance of 12.3cms from the acromian process of scapula. (Photograph 1) At its origin in the Arm: The SUA along with its venae comitantes is lying lateral to the median nerve. The later on it is crossing to the medial side and comes to lie subjacent to the median nerve. There after it ran a superficial course in the arm, passes just lateral to the medial epicondyle of humerus and superficial to the common flexor origin to enter the cubital fossa. In the cubital Fossa: The SUA is present superficial to the bicipital aponeurosis and subjacent to the median cubital vein where it is most vulnerable to injury while attempting for intra- venous injections and cannulations. In the Forearm: The SUA passed superficial to the flexor muscles of the forearm. It passed superficial to the pronator teres muscle and then ran downwards and medially to run lateral to the ulnar nerve. Both the SUA and ulnar nerve are present lateral to the flexor carpi ulnaris muscle. The SUA has not given any significant branches throughout its course in the arm and the forearm.

Can Total Wrist Arthroplasty Be an Option for Treatment of Highly Comminuted Distal Radius Fracture in Selected Patients? Preliminary Experience with Two Cases.

We present two case reports of successful primary shortening of the forearm and total wrist arthroplasty (TWA) using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year-old male patient with adequate bone stock, insertion of the noncemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year-old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients could resume their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (DASH score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. Further experience is needed to validate this concept.

Exposure of both the radius and ulna through a single posterior incision: a technical note

Fractures of both the radius and ulna are usually treated with two separate incisions and rarely with one single incision. However, both methods have disadvantages. For this we describe a relatively safe single straight posterior incision for exposure of the whole shafts of both the radius and ulna with the forearm rested on a board across the chest. This procedure was used in 116 forearms in 115 patients. The incision was in a straight line from the lateral humeral epicondyle to the ulnar head. The ulna was exposed between the extensor carpi ulnaris muscle and flexor digitorum profundus muscle covered by the aponeurosis of the flexor carpi ulnaris muscle and the radius between the extensor digitorum muscle and the extensor carpi radialis brevis muscle. During operation there was no difficulty in reducing or fixing any of the fractures in the whole shafts of the radius and ulna and at follow-up (average 5.2 years) there was no radioulnar synostosis or neurovascular injury in any of the forearms.

Clinical results of isolated ulna head fracture

Clinical results of isolated ulna head fracture

Load Transfer at the Distal Ulna Following Simulated Distal Radius Fracture Malalignment

To measure the effects of distal radius malalignment on loading at the distal ulna. Using an adjustable mechanism to simulate angulated and translated malalignments, clinically relevant distal radius deformities were simulated in a cadaveric model. A custom-built load cell was inserted just proximal to the native ulna head to measure the resultant force and torque in the distal ulna. Loads were measured before and after transecting the triangular fibrocartilage complex (TFCC). There was an increase in distal ulna load and torque with increasing dorsal translation and angulation. Combined conditions of angulation and translation increased force and torque in the distal ulna to a greater extent than with either condition in isolation. Transecting the TFCC resulted in a reduction in distal ulna load and torque. A progressive increase in load at the distal ulna was observed with increasing severity of malalignment, which may be an important contributor to residual ulnar wrist pain and dysfunction. However, no clear-cut threshold of malalignment of a dorsally angulated and translated distal radius fracture was identified. These observations suggest that radius deformities cause articular incongruity, which increases TFCC tension and distal radioulnar joint load. Cutting of the TFCC decreased distal ulna loading, likely by releasing the articular constraining effect of the TFCC on the distal radioulnar joint, allowing the radius to rotate more freely with respect to the ulna. Anatomical reduction of a distal radius fracture minimizes the forces in the distal ulna and may reduce residual ulnar wrist pain and dysfunction.

Arthroscopy of the distal radioulnar joint

Insertion of a small joint arthroscope into the proximal and distal parts of the distal radioulnar joint (DRUJ) allows visualization of the proximal pouch of the DRUJ, the joint surfaces of the sigmoid notch and the ulnar head, the convexity of the ulnar head and the proximal ulnar-sided surface of the triangular fibrocartilage complex (TFCC). Evaluation of joint pathologies in ulnar-sided wrist pain, especially in cases without diagnostic findings in standard X-rays and MRI, suspected cartilage lesions without osteochondral changes (signs of osteoarthritis), undefined swelling of the DRUJ in suspected synovitis, removal of loose bodies and arthroscopical synovialectomy, suspected lesions of the deep part of the TFCC, respectively foveal avulsions, wear or superficial tears of the proximal TFCC and arthroscopic-assisted ulnar shortening. Significant changes of the local topographical anatomy, extensive scar formation, ulna plus variance, local infection or open wounds, affected sensibility in the area of the dorsal branch of the ulnar nerve, fractures of the sigmoid notch or the ulnar head, capsular tears causing effusion of irrigation fluid. In vertical extension of the wrist, two portals are created on the dorsal side of the DRUJ between the extensor digiti minimi and extensor carpi ulnaris tendons. Partial visualization of the ulnar head, the sigmoid notch, the proximal pouch of the DRUJ, and the proximal surface of the TFCC. Following isolated diagnostic arthroscopies immobilization of the wrist in a semicircular ulnar-sided cast for 1 week. No extensive load to the wrist for 4 weeks. Still rarely performed procedure for diagnosis and therapy of ulnar-sided wrist pain. Technically demanding with a flat learning curve and anatomy-related obstacles. A complete view of the joint is not always accessible. Rare complications are injuries of the extensor digiti minimi tendon as well as contusion or sectioning of the transverse branch of the dorsal branch of the ulnar nerve. In distinct cases this procedure offers valuable additional information about the distal radioulnar joint.

Traitement prothétique des fractures du radius distal irréparables du sujet âgé autonome. Résultats préliminaires, étude prospective de 10 cas

Introduction The purpose of this paper was to define irreparable acute DRF in autonomous elderly patients and to review the current results of a prospective study using a resurfacing implant to treat these injuries. Methods A total of 10 wrists in 10 women were prospectively included. The average age was 75 years (range 64–87). General health status was normal in 3 patients and there were co-morbidities in seven. However, all patients were autonomous at home. Functional needs were high in 3, intermediate in 7. All but one DRF were articular “C” type. Displacement was volar in 4 patients and dorsal in 6 patients. Circumferential comminution was present in all cases. The average intra-articular displacement severity score (Intra-DSS) was 11.5/12. Impaction and cartilage defect were present in all cases. All patients sustained total wrist arthroplasty through a single dorsal approach. An ulnar head resection was combined in 8/10 cases. Post-operative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks, 2, 6, 12 months. A wrist clinical score was used as well as the Quick-Dash and PRWE. Results Reflex sympathetic dystrophy was present in 2 patients. In the 5 patients with more than 3 months of follow-up and no RSD, the average VAS pain was 1.6. Average ranges of active motion were: pronation 65°, supination 66°, wrist extension 28°, and flexion 21°. The average grip strength was 38% of the contralateral side. The average wrist score was 57 pts. Discussion Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder and elbow. This concept recently emerged for DRF as well. Indeed, some DRF in the elderly are beyond any osteosynthesis fixation. Autonomous elderly patients are good candidates to prosthetic surgery. Our preliminary results confirm that there may be a room for prosthetic replacement of the distal radius at the acute stage in selected elderly patients. Further controlled prospective studies are necessary to validate this concept.

Anatomical transosseous fixation of the deep and superficial fibers of the radioulnar ligaments.

The triangular fibrocartilage complex is in conjunction with the interosseous membrane the most important stabilizer of the distal radioulnar joint. Lesions of the triangular fibrocartilage complex may cause instability of the distal radioulnar joint with serious consequences. Therefore, the goal is to reconstruct and provide stability to prevent further harm. Based on the anatomical configuration of the radioulnar ligaments, we present a technique which addresses both the deep and the superficial fibers of the radioulnar ligaments. This surgical procedure can be performed either openly or arthroscopically assisted. Two osseous 2-mm tunnels starting from the ulnar neck to the foveal surface are created. A nonabsorbable suture is passed through the tunnels and the triangular fibrocartilage using a 20-gauge venipuncture needle in order to attach the deep fibers. Then a third osseous tunnel starting from the lateral base of the styloid process to the medial aspect is created. The suture is passed through this tunnel and through the triangular fibrocartilage and around the styloid process palmarily using the same needle as before in order to anchor the superficial fibers anatomically. After reducing the ulna head the sutures are tightened. This technique is quite simple and addresses the anatomical configuration of the radioulnar ligaments.

Intermediate Outcomes of Ulnar Head Arthroplasty

To determine the survivorship and clinical outcomes of ulnar head arthroplasty. The study design included a review of medical records and clinical assessment of all patients who had an ulnar head arthroplasty more than 2 years previously. Survivorship of 79 implants in 74 patients was determined. Forty-seven of these patients participated in a clinical review using the Patient Examination Measure, Patient-Related Wrist Examination, Wrightington Wrist Score, and EQ5D to measure outcomes. Analysis of outcomes was performed for diagnostic subgroups (inflammatory arthritis, posttraumatic, osteoarthritis/impingement, and other), primary versus revision surgery, and whether the procedure was performed for ulnar stump instability (related to either a previous Darrach or Sauvé-Kapandji procedure). The 5- and 15-year survival of the implants was 90% for both, with mean follow-up of 7 ± 4 years. Mean age at surgery was 50 ± 13 years (range, 24-76). Mean range of motion was within the functional range and grip strength was 67% that of the contralateral side. Patient satisfaction was generally high, but outcomes scores indicated substantial residual disability. Overall scores were 41 for the Patient Examination Measure, 52 for the Patient-Related Wrist Examination, and 70 for the WWS. Patients in the "other" category had the worst scores for all measures. Patients with prior wrist surgery had poorer outcomes than those for whom the arthroplasty was a primary procedure. Patients with posttraumatic diagnoses had worse EQ5D scores and were less likely to recommend the procedure to others. Ulnar head arthroplasty had good long-term survival and acceptable patient satisfaction. Substantial disability remained in all groups, with the posttraumatic, "other", and revision groups faring worse. Patients should be counseled about the expected outcomes of this specialized procedure as they pertain to the patient's specific situation. Therapeutic IV.

Traitement prothétique des fractures du radius distal irréparables du sujet âgé autonome. Résultats préliminaires, étude prospective de 10 cas

The purpose of this paper was to define irreparable acute DRF in autonomous elderly patients and to review the current results of a prospective study using a resurfacing implant to treat these injuries. A total of 10 wrists in 10 women were prospectively included. The average age was 75 years (range 64–87). General health status was normal in 3 patients and there were co-morbidities in seven. However, all patients were autonomous at home. Functional needs were high in 3, intermediate in 7. All but one DRF were articular o C O type. Displacement was volar in 4 patients and dorsal in 6 patients. Circumferential comminution was present in all cases. The average intra-articular displacement severity score (Intra-DSS) was 11,5–12. Impaction and cartilage defect were present in all cases. All patients sustained total wrist arthroplasty through a single dorsal approach. An ulnar head resection was combined in 8–10 cases. Postoperative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks, 2, 6, 12 months. A wrist clinical score was used as well as the Quick DASH and PRWE. Reflex sympathetic dystrophy was present in 2 patients. In the 5 patients with more than 3 months of follow-up and no RSD, the average VAS pain was 1,6. Average ranges of active motion were – pronation 65°, supination 66°, wrist extension 28°, flexion 21°. The average grip strength was 38% of the contralateral side. The average wrist score was 57 pts. Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder and elbow. This concept recently emerged for DRF as well. Indeed some DRF in the elderly are beyond any osteosynthesis fixation. Autonomous elderly patients are good candidates to prosthetic surgery. Our preliminary results confirm that there may be a room for prosthetic replacement of the distal radius at the acute stage in selected elderly patients. Further controlled prospective studies are necessary to validate this concept.

Arthroscopy of the distal radioulnar joint.

Wrist arthroscopy is now widely indicated for diagnosis and treatment of acute or chronic wrist pain, especially for triangular fibrocartilage complex (TFCC) lesions, as a gold standard. In most cases radiocarpal and midcarpal arthroscopy was performed, while DRUJ arthroscopy has been rarely performed because of its difficulties. Recent anatomic and biomechanical studies demonstrated that the radioulnar ligament (RUL), which is the proximal component of the TFCC facing to the DRUJ, is the primary stabilizer of the distal radioulnar joint (DRUJ). Rupture of the radioulnar ligament (RUL) at the fovea area, where it is the main attaching portion to the ulna and is the isometric point during forearm rotation as the rotation axis passes, is responsible for DRUJ instability. Although physical examination and imaging diagnosis may indicate a foveal detachment of the TFCC, DRUJ arthroscopy is potential for visualizing the RUL at the fovea. Role of DRUJ arthroscopy should be more important not only for diagnosis of rupture of the RUL but also for decision making of treatment option for RUL tear. DRUJ arthroscopy also demonstrates the joint surface of both the sigmoid notch and ulnar head, and the proximal surface of the TFCC.

Arthroscopic repair for ulnar-sided tears of the TFCC

Accurately performed anatomic and biomechanical studies as well as clinical experience during the last years have widened our knowledge about function and pathology of the distal radioulnar joint (DRUJ) making a differentiated treatment possible. In cases of trauma a rupture of the ulnar part of the triangular fibrocartilaginous complex (TFCC) frequently occurs. An overview is given on the development of different arthroscopic techniques for repair and the state of the art is presented. The ulnar part of the TFCC is constituted of the superficial part which is less important for stability and the deep part which is anchored to the fovea of the ulnar head. This deep part is the most important stabiliser of the DRUJ. Each of these parts may rupture separately or both of them may rupture at the same time. Keystones for diagnosis are clinical examination and arthroscopy. On clinical examination instability of the DRUJ is to be evaluated by comparing it to the contralateral side. Furthermore, the degree of instability should be estimated. Extraarticular associated lesions must also be assessed clinically. On arthroscopy the TFCC may be evaluated from the radiocarpal joint as well as from its undersurface, from the DRUJ. In cases of avulsion from the fovea, an anatomic reconstruction with reinsertion of the deep part to the bone is indicated and may be performed successfully according to the published studies and our own experience. If a severe instability is found on clinical examination it is to be supposed that more stabilising structures - then only the radioulnar ligaments - are affected and reinsertion of the deep fibres to the fovea may not be sufficient.

Síndrome de impactación ulnocarpiano, manejo artroscópico

Ulnocarpal impaction is one of the most common causes of ulnar-sided wrist pain. It is a progressive degenerative condition caused by chronic impaction of the ulnar head against the triangular fibrocartilage (TFC) and the ulnar portion of the carpus. The aim of surgical treatment is to perform a decompression of the ulnar column of the wrist, in the ulnocarpal joint.With the advances in wrist arthroscopic surgery it is possible to shorten the ulnar head (Wafer procedure) by an arthroscopic approach, at the same time as assessing and treating the injuries associated with the ulnar impaction (TFC injuries, chondral injuries, lunopyramidal ligament tears, synovitis, etc.), thus allowing a more complete and accurate treatment, and with some very satisfactory results.

Herbert Ulnar Head Prosthesis Arthroplasty: Satisfactory Midterm Outcomes: Level 4 Evidence

Reports about short-term results following ulnar head arthroplasties have been promising but there is a paucity of mid- and long-term data. To address the concerns about lasting results and late complications we conducted the present study.

Ulnar shortening osteotomy for distal radius malunion.

Background Malunion is a common complication of distal radius fractures. Ulnar shortening osteotomy (USO) may be an effective treatment for distal radius malunion when appropriate indications are observed. Methods The use of USO for treatment of distal radius fracture malunion is described for older patients (typically patients >50 years) with dorsal or volar tilt less than 20 degrees and no carpal malalignment or intercarpal or distal radioulnar joint (DRUJ) arthritis. Description of Technique Preoperative radiographs are examined to ensure there are no contraindications to ulnar shortening osteotomy. The neutral posteroanterior (PA) radiograph is used to measure ulnar variance and to estimate the amount of ulnar shortening required. An ulnar, mid-sagittal incision is used and the dorsal sensory branch of the ulnar nerve is preserved. An USO-specific plating system with cutting jig is used to create parallel oblique osteotomies to facilitate shortening. Intraoperative fluoroscopy and clinical range of motion are checked to ensure adequate shortening and congruous reduction of the ulnar head within the sigmoid notch. Results Previous outcomes evaluation of USO has demonstrated improvement in functional activities, including average flexion-extension and pronosupination motions, and patient reported outcomes. Conclusion The concept and technique of USO are reviewed for the treatment of distal radius malunion when specific indications are observed. Careful attention to detail related to surgical indications and to surgical technique typically will improve range of motion, pain scores, and patient-reported outcomes and will reduce the inherent risks of the procedure, such as ulnar nonunion or the symptoms related to unrecognized joint arthritis. Level IV.

Total Joint Arthroplasty of the Distal Radioulnar Joint for Rheumatoid Arthritis

To evaluate the clinical and radiological results of primary total distal radioulnar joint (DRUJ) replacement as well as reconstruction following ulnar head excision in patients with rheumatoid arthritis (RA). Seventeen patients with RA underwent 19 total DRUJ replacement between 2005 and 2011. Mean age at the time of the surgery was 57 years. Mean follow-up was 39 months (range, 12-79 mo). Pain level was evaluated using a visual analog scale (VAS). Pronation and supination were recorded before and after surgery. A patient satisfaction survey was used, as well as postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Related Wrist Evaluation (PRWE) scores. Ulnar translocation of the carpus was assessed radiographically, and the presence or absence of radiolucent zones around the implant were recorded. The preoperative average VAS score for the 19 joints was 7.3. Pain decreased after surgery to 2.2. Pronation improved from 56° before surgery to 78° afterward, a 39% improvement. Supination improved from 57° before surgery to 71° afterward, a 27% improvement. Final scores were 24 for the DASH and 24 for the PRWE. Fifteen patients reported substantial pain relief. All patients were satisfied with their surgical result. The results of this study suggest that total replacement of the DRUJ is of benefit to the patient with RA. Pronation was significantly increased and supination was increased but did not approach significance. Improvement in VAS score suggests that pain was decreased. Therapeutic IV.

Architectural properties of the neuromuscular compartments in selected forearm skeletal muscles.

The purposes f this study were to (i) explore the possibility of splitting the selected forearm muscles into separate compartments in human subjects; (ii) quantify the architectural properties of each neuromuscular compartment; and (iii) discuss the implication of these properties in split tendon transfer procedures. Twenty upper limbs from 10 fresh human cadavers were used in this study. Ten limbs of five cadavers were used for intramuscular nerve study by modified Sihler's staining technique, which confirmed the neuromuscular compartments. The other 10 limbs were included for architectural analysis of neuromuscular compartments. The architectural features of the compartments including muscle weight, muscle length, fiber length, pennation angle, and sarcomere length were determined. Physiological cross-sectional area and fiber length/muscle length ratio were calculated. Five of the selected forearm muscles were ideal candidates for splitting, including flexor carpi ulnaris, flexor carpi radials, extensor carpi radialis brevis, extensor carpi ulnaris and pronator teres. The humeral head of pronator teres contained the longest fiber length (6.23 ± 0.31 cm), and the radial compartment of extensor carpi ulnaris contained the shortest (2.90 ± 0.28 cm). The ulnar compartment of flexor carpi ulnaris had the largest physiological cross-sectional area (5.17 ± 0.59 cm(2)), and the ulnar head of pronator teres had the smallest (0.67 ± 0.06 cm(2)). Fiber length/muscle length ratios of the neuromuscular compartments were relatively low (average 0.27 ± 0.09, range 0.18-0.39) except for the ulnar head of pronator teres, which had the highest one (0.72 ± 0.05). Using modified Sihler's technique, this research demonstrated that each compartment of these selected forearm muscles has its own neurovascular supply after being split along its central tendon. Data of the architectural properties of each neuromuscular compartment provide insight into the 'design' of their functional capability. In addition to improving our understanding of muscle anatomy and function, elucidation of forearm neuromuscular compartments architecture may ultimately provide information useful for selection of muscle subdivisions used in tendon transfer.

Response to the Letter to the Editor on: Dorsal Capsuloplasty for Dorsal Instability of the Distal Ulna (J Wrist Surg 2013;2(2):168-175).

I would like to thank colleague Christian Spies for his kind and stimulating words regarding our recent article “Dorsal Capsuloplasty for Dorsal Instability of the Distal Ulna” [JWS 2.2]. Indeed, we also characterize this technique as simple and straightforward for regaining stability in the DRU joint. During the many years that we used this capsuloplasty, there was never a situation that prompted us to switch to an alternative technique, even in the few cases of a recurrence. We successfully repeated the capsular reefing, however, with a prolonged regime of postoperative hand therapy. Patients that we select for dorsal capsuloplasty have a history of longstanding ulnar wrist pain with loss of function. We consider a positive Shift Test of the DRUJ essential in staging the instability and deciding if surgery is needed. This test is performed with the wrist in neutral position, with a flexed elbow resting on the table. The patient should relax shoulder and arm. The surgeon stabilizes the distal radius with one hand, moving the distal ulna with the other, in a plane from volar to dorsal. Differences in degree of shift can thus be diagnosed, comparing it with the contralateral wrist. A significant shift means significant instability to us, indicating probable surgery. Further fine tuning for surgery depends on the outcome of arthroscopy. We perform the needle test by inserting the needle just through the skin, volar to the styloid process in a ulnar-volar plane, parallel to the surface of the ulnar head. If the needle is thus not moved too much from volar to dorsal, I do not think it will significantly hurt the deep fibers to the fovea. MRI currently plays no reliable role as a diagnostic, lacking specificity and sensitivity. We recently compared the MRI reports of 15 consecutive patients, experiencing ulnar wrist pain, with the findings of arthroscopy. The results confirmed the lack of sensitivity and specificity in MRI, thus demonstrating the inadequacy of MRI. As in many cases, there is more than one option for treating DRUJ instability. The reason for choosing this technique is the belief that it is mechanically more resistant to stress, as the capsuloplasty stretches all the way over the ulnar head, beginning at DRUJ level. and ending over the styloid process. Only when foveal loosening is diagnosed do I strongly recommend reinsertion. It is technically not very demanding. Roughening of the surface of the fovea is mandatory . Reinsertion in these cases can thus be expected to be durable, adding to the DRUJ stability. We could not find differences in outcome related to the duration of preoperative symptoms.

How to Avoid Ulnar Nerve Injury When Setting the 6U Wrist Arthroscopy Portal

The dorsal sensory branch of the ulnar nerve (DSBUN) is at risk in setting the 6U wrist arthroscopy portal. Although surgeons know the risk and are careful when they set the 6U portal, DSBUN injuries still occur. The purpose of the present anatomical study was to evaluate the possibility that DSBUN undergoes dynamic anatomical variations in its location during wrist arthroscopy. The goal of the study was to clarify (1) whether the nerve-to-portal (NTP) distance changes with flexion/extension wrist and/or hand/forearm rotation, and (2) whether there is any particular combination of flexion-extension/hand-forearm rotation where the NTP distance is maximal. Six fresh cadaver arms were suspended in a traction tower with forearm rotation locked, the skin and subcutaneous tissue around the ulnar head was removed, and the NTP distance measured in three predetermined loading/positional conditions. Of all options, the one that consistently showed the longest and safest NTP distance involved wrist flexion and radiocarpal supination when forearm rotation is limited. In conclusion, when an arthroscopic traction device restricts the forearm rotation, the 6U portal should not be set under traction with the hand passively pronated. Failure to observe this precaution can result in serious neuropathic pain.