What is ulnar variance?
- LENGTH OF THE ULNA CF RADIUS
Measured on PA wrist- with shoulder in 90o abduction/elbow felxion 90o, forearm neutral , hand aligned w forearm
How do you measure ulnar variance?
on PA wrist- shoulder 90, elbow flexed 90, neutral forearm rotation
Draw- 1 line tangential to articular surface of the ulna- pink
1 line tangential to articular surface of radius- green
if ulnar tangent is distal to radial = +ve
If ulnar is proximal to radial= -ve
What is the length difference in a ulnar positive variance?
How does this affect the load thru the wrist?
- Ulnar- radial Length difference +2.5mm
- Normal is 0 (<1mm)
- normal load thru radius = 80%, ulna 20%
- +Ve UV= radius 60%, ulna 40%
What is the length difference in an ulnar negative variance ? How does this affect the mechanical load thru the wrist?
Ulnar- radial length difference -2.5mm
normal is 0 (<1mm)
normal load thru radius = 80%, ulna is 20%
-Ve UV= 95% thru radius, 5% ulna
What is the epidemiology of ulnar variance?
- UV is lower in males than Females
- UV increases with age
- Risk Factor- Positive UV present in child gymnast- distal radial plate injury->premature closure of distal radial physis
Described the pathophysiology of Ulnar variance?
Congential - Madelung's deformity ( +UV), reverse Madelung's deformity ( -UV)
Trauma/Mechanical- distal radius Frac w shortening, growth arrest SH frac, DRUJ ( galeazzi/Essex-Lopresti)
Iatrogenic- joint leveling procedures( radial/ulnar shortening/lengthening),Radial head excision
- Trauma/Mechanical- distal radius Frac w shortening, growth arrest SH frac, DRUJ ( galeazzi/Essex-Lopresti)
- Iatrogenic- joint leveling procedures( radial/ulnar shortening/lengthening),Radial head excision
Name some associated conditions of positive Ulnar variance?
- Ulnar abutment syndrome
- TFCC tears
- arthrosis- radial head, lunate, triquetrum
- Lunotriquetral ligament tears
Name some associated conditions of negative Ulnar variance?
Ulnar impingment syndrome- ulna impinges on radius prox to sigmoid notch
Describe the problems with Positive UV?
Ulnar sided wrist pain from increased impact stress on lunate and triquetrum
- UV increases in Pronation/ during Grip
What is the tx of ulnar variance?
Depends on specific condition
ulnar abutment syndrome
What is ulnocarpal abument syndrome?
- Syndrome caused by excessive impact stress between the ulna and carpal bones ( primarily the lunate)
- Positive ulnar variance
What is the pathoanatomy of ulnocarpal abutment syndrome?
Abnormal loading thru ulna
In +ve ulnar variance wrist -
- 40% load thru ulna
- 60% thru radius
- cf normal wrist radius 80% , ulna 20%
Can you name the associated conditions?
- Scapholunate dissociation
- TFCC tears
- Lunotriquetral ligament tears
- Radial shortening from previous trauma
What are the symptoms of ulnocarpal abutment syndrome?
- Pain on dorsal side of DRUJ
Increased pain w ulna deviation of the wrist
- Pain with axial loading
- ULNA sided wrist pain
What are the signs at examination of the ulnocarpal abutment syndrome?
Ballottement test- for lunotriquetral instability- examiners holds lunate between thumb and second finger and triquetrium between thumb adn second finger and sees if they can move and cause pain
Fovea test- use to evaluate the TFCC- palpation of the wirst between styloid and FCU tendon
What xrays views are useful in DX of ulnocarpal abutment syndrome?
- Ap radiographs w wrist in Neutral supination/pronation adn zero rotation
- Pronated grip view- increase radiographic impaction
- See ulnar positive wrist
- Sclerosis of the lunate
To evaluate TFCC tear- caused by ulnocarpal impingement
What is the DDx of ulnar sided wirst pain?
- DRUJ instability or arthritis
- TFCC tear
- LT ligament tear
- Pisotriqeutral arthritis
- CU tendonitis or instability
What is the tx of ulnocarpal abutment syndrome?
supportive measures- nsaids, splint
- Ulnar shortening osteotomy- most cases of +ulnar variance/ DRUJ incongruity often with arthroscopy of wrist to repair TFCC
- Wafer procedure- 2-4mm of cartilage and bone removed under TFCC arthroscopy
- Darrach Procedure- ulnar haead resection- low demand pts-> ulnar stump instability
- SAuve-KApandji- gd option for labourers- create a radioulna fusion and a pseudoarthrosis proximal to fusion.
- Ulnar hemiresection arthroplasty-intact TFCC required- post traumatic DRUJ with distal ulnar degeneration
- Ulnar head prosthesis- severe ulnocarpal arthrosis/salavge fo rfailed darrach
What is Kienbock's Disease?
Avascular necrosis of the lunate -> to abnormal carpal motion
Describe the epidemiology of Kienbock's disease?
Incidence- most common Men 20-40 yrs
Risk Factors- Hx of Trauma
Describe the pathophysiology of Kienbock's?
- ULNA Negative Variance- > increase radial lunate contact stress
- Repetitive Trauma
Geometry of lunate
Vascular supply to lunate- different patterns of arterial blood
Describe the blood supply to lunate?
- Y pattern
- X pattern
- I pattern- 31% of pts highest risk of AVN
Name and describe the classification of Kienbock's Disease?
- Stage 1- No change on xray. Changes on MRI = Immobilisation and NSAIDs
- Stage 2- Sclerosis of lunate xray- Joint levelling procedure- ulna negative
Radial wedge osteotomy/STT fusion - ulna +ve
Core decompression/revascularisation procedures
- Stage 3A= Lunate COLLAPSE, no scaphoid rotation- TX same as above
- Stage 3B= lunate collapse, FIXED SCAPHOID Rotation= Proximal row carpectomy
- Stage 4- Degenerative adj intercarpal joints= Wrist fusion/proximal row carpectomy limited intercarpal fusion
What are the symptoms of Kienboch's?
DORSAL Wrist PAIN
- Usually Activity related
- More often Dominant hand
- Wrist swelling
- Tender over Radiocarpal joint
- Decreased Flexion/extension
- Decreased grip strength
What investigations are useful in Kienboch's?
Xrays- AP, Lateral and oblique view
CT most helful when lunate collapse- extent of necrosis, trabecular destruction, lunate geometry
MRI - best in early disease- Increase intensity T1 weighted image, reduced vascularity
Describe the tx of Kienboch's disease?
Immobilisation/nsaids- stage 1 disease
adolscent w xray changes= Temporary Scaphotrapeziotrapezoidal pinning
- Joint Levelling- for UV negative
- Radial wedge osteotomy- UV positive
- vascularised bone graft- early result promising. gd results stage 2
- Distal radius core decompression-> local healing response
- STT fusion - must address DISI collapse
Stage IIIB/ IV
- Proximal row carpectomy- superior results over STT fusion in studies of type IIIb
- Wrist fusion
- Total wrist Arthroplasty- long term results not available
Can you describe a technique for vascularised bone grafts?
many have been described
- Transfer of pisiform
- Transfer of distal radius on a vassculasired pedicle of Poronator quadratus
- transfer branchies of 1st,2nd, 3rd dorsal metacarpal arteries
- Temporary pinning of STT joint, SC joint or external fixation may be used to unloas lunate after revascularisation
What is avn of the scaphoid aka?
What is the epidemiology of Preiser's disease?
- Rare condition
- Av Age onset 45 yrs
Symptoms of Preiser's Disease?
Dorsal wrist pain
What investigations are useful in Preiser's disease?
- Radiographs= sclerosis and fragmentation of PROXIMAL POLE
- MRI- confirms complete or partial involvement
What is the TX for Preiser's disease?
Immobilisation- effective in 20% cases
- Microfracture drilling, revascularisation procedure or allograft replacement
- Salvage procedure= proximal row carpectomy or scaphoid excision with 4 corner fusion
What is Gymnat's wrist?
What is the epidemiology?
Distal Radial Phsyeal Stress Syndrome
where overuse of the wrist primarily in young gymnasts -> premature closure of distal radial physis
Up to 25% in NON elite gymnasts
What is the Pathophysiology of gymnasts's wrist?
- wrist undergoes supraphysiological loads due to use as Weight bearing joint
- Repetitive stress-> inflammation at growth plate of distal radius
- Microtrauma can lead to premature closure of distal radius physis -> secondary overgrowth of ulna and positive ulnar variance
What are the signs and symptoms of gymnast's wrist?
- Radial sided wrist pain
- ? chronic in nature
- Swelling at wrist
- Tenderness to palpation at distal radius
- Decreased flexion/extension
What investigations are useful in Gymnasts wrist?
- Xrays- ap and lateral= widening of distal radial growth plate with ill defined borders
Positive ulna variance in chronic cases
- MRI= paraphsyeal oedema
Early physeal bridging
Brusing of radius
What is the tx of gymnast's wrist?
- NSaids, rest immobilisation for 3-6 months
Resection of Physeal Bridge- small physeal closures
Ulnar epiphysiodesis and shortening with radial osteotomy - of physeal closure >50%
What are the mechanism of TFCC tear
- Type 1- Mechanical
Fall onto extended wrist w pronated forearm- most common
Traction injury to wrist
- Type 2- Degenerative
- assoc Positive UV- ulnocarpal impaction
What is the TFCC made up of?
- Dorsal radioulnar ligament
- Volar radioulnar ligament
- Central Articular disc
- Meniscus Homolog
- Ulnar collateral ligament
- ECU subsheath
- Orgin of ulnolunate and ulnotriquetral ligaments
Name the TFCC blood supply?
Can you name the origin adn insertion of the FFCC?
Peripheral is well Vascularised
Central portion is ASVASCULAR
Origin= dorsal and volar radioulnar ligaments originate at Sigmoid notch of radius
Insertion= dorsal and volar radioulnar ligaments converge at base of ulnar styloid
Can you describe the classification of TFCC tears?
Class 1- Traumatic
1A= Central perforation tear
1B= Ulnar avulsion ( wout ulnar styloid)
1C= Distal Avulsion ( origin of UL and UT ligaments)
1D= Radial Avulsion
Class 2- Degenerative
2A- TFCC wear and thining
2B- Lunate +/- Ulnar chrondormalacia + 2A
2C- TFCC perforation +2B
2D- Ligament disrutpion + 2C
2E- Ulnocarpal and DRUJ arthritis + 2d
What are the symptoms and signs of TFCC tear?
- Wrist pain- turning a door key
Positive Fovea sign- tenderness in soft spot between ulnar styloid and FCU, between the volar surface of the ulnar head and pisiform
Pain w ulnar deviation (TFCC compression)
Pain w radial deviation (TFCC tension)
Investigations used in TFCC tear idenfication are?
- Radiographs- usually negative, may show ulnar variance
- Arthrography- shows extravasation
- MRI- replaced arthrography- tear at ulnar indicates ulnocarpal impaction, sensitivity 74-100%
- Arthroscopy- most accurate method of dx
- indicated in pt who fail consx tx
What is DDX of ulnar sided wrist pain?
- TFCC tear
- Ulnacarpal abutment syndrome
- Ulnar styloid impaction syndrome
- Fracture- Ulnar styloid
Hook of hamate
- Ulnar nerve entrapment at Gyon's canal
- ECU subluxation
- Pisotriquetral arthritis
NB= The Unopened Umbrella Fell Under Eve's Purse
TX of TFCC tears
Type 1 and 2 acute = Immobilistion/ NSAIDs/Steriod injections
Types 1B, 1C, 1D= Arthroscopic repair- generall y acute- reagin 80% motion/ grip strength if acute ( <3/12)
- Ulnar disaphyseal shortening- +UV >2mm - tightens the ulnocarpal ligaments
- Wafer procedure- +UV <2mm- types 2A-C
- Limited Ulnar head resection- Type 2D
- Darrach - CI due to problems of ulnar stump INSTABILITY !!!
Can you describe the anatomical location for a wrist athroscopy?
Arthroscopic approach to the wrist thru portals 3/4 and 6R