Ulnar dorsal zone Flashcards
Ulnar dorsal zone
- Ulnar styloid
- Ulnar head
- DRU jt
- TFCC
- ECU
Ulnar dorsal most common
- ulnar styloid fracture/nonunion
- DRU jt instability
- TFCC injurt
- ECU tendinitis, subluxation
DRU jt instability
DRUJ is a synovial pivot joint • Intrinsic stabilizers: -the volar and dorsal radioulnar ligaments -the triangular fibrocartilage (TFC) -the capsule - the ulnar collateral ligament. • Extrinsic stability is achieved through static and dynamic forces: 1) Dynamic stabilizers: -the extensor carpi ulnaris (ECU) - the pronator quadratus 2) Static stabilizers: -Soft tissues: interosseous membrane
Prevalence
• Tennis player
Patient history
• MOI
o Acute fall/twisting injury tears radioulnar ligament = Extreme pronation and extension
o Degenerative: repetitive manual work/sport e.g. tennis
Ax Physical exam • Palpation - between radius and ulnar o Local tenderness + pain on pronation/supination o Snapping or subluxation of ulna • Movement exam: Pronation and supination • Positive tests: Differential diagnosis • TFCC tear
Ballottment test - DRU instability
o stabalise radius, Glide ulna in P/A, A/P directions in various ranges of pronation and supination including end range pronation and supination
o Normally there is no AP or PA movement at end range
o Positive sign: pain or excessive mobility compared to the other side
DRU instability Mx
Splinting
• In an above elbow cast for 6-8 weeks
• Work on extrinsic and intrinsic (?) stabilisers
Strengthening and ROM exercises the prevent stiffness and atrophy from bracing
Low-volume muscular endurance and strength training during 3-week forearm immobilization was effective in preventing functional deterioration.
TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) TEARS
Pathophysiology
• TFCC =shock absorber for carpus
• Applied loading events induce an inflammatory response > causes decreased healing capacity = pain and discomfort
• Can cause DRUJ instability
• Consists of articular disc, radioulnar ligaments, ulnocarpal ligaments, ulna collateral ligaments.
Prevalence
• Sports: tennis, gymnastics, diving
• Aged >30 years for degenerative and younger than 30 years for acute traumatic
• Occupational: manual work, vibrating tools
Patient History
• MOI
o FOOSH/ traumatic: fall/twisting/rotation injury (<30 years)
- Usually compression and ulnar deviation
o Degenerative tear: overuse UD - sport/work
- Vibration from drilling**
• Complains of:
o Activity dependent ulnar sided wrist pain
o Tenderness in the region of FCU and ulnar styloid
o Prolonged discomfort and instability at the wrist
o Pain, clicking, snapping on the ulnar side of the wrist with AROM
TFCC Ax
Physical exam
• Palpation
1. Palpate the ulnar fovea – between the ulnar head and pisiform. Tenderness indicates local inflammation
2. UD the wrist and axially load. Move the wrist from flexion into extension
• Movement examination
o AROM limited by pain
• Positive tests: TFCC load test, TFCC integrity test, Press test
Differential diagnosis
• ECU tendinopathy
• Ulnar styloid fracture
• DRUJ arthritis/instability
Other assessment
• MRI scan and arthroscopy to confirm
• X-ray will show good bony integrity
TFCC tests
TFCC load test
o Ulnar deviate the wrist, axially load and move wrist into flexion and extension
o Positive sign: pain, clicking, snapping
• Positive test: TFCC integrity test
o Wrist in extension/ulnar deviation and then apply overpressure
o Positive sign: pain and clicking
• Positive test: press test
o Push self up off chair.
o Positive sign: pain in TFCC
TFCC Mx
Management
Conservative management
- Rest/immobilisation 2-3 weeks in wrist splint
- progressive painfree ROM and avoidance of aggravating activities
- isometric loading - PQ
- Restricted sports activity 4-6 weeks
- Strapping as needed
- Wrist widget
- HCLA
• 4-6 weeks of immobilisation (+/- LIMIT ROTATION +/- ELBOW FLEXED)
• Progressive strengthening over 3 months
Treatment aims: • Grip strength • ROM ADLs • Return to work
Surgery
• Indications
o Longstanding (>6 weeks), failure to respond to conservative Mx or markedly positive ulnar variance
o If +ive ulnar variance, or instability ulna shortening
• Patients who underwent arthroscopic intervention reported 91% rate f good to excellent outcomes
Prognosis
• If DRUJ is stable, 3 months of conservative management (4-6 weeks of immobilisation + physiotherapy) restores normal function
• If DRUJ is unstable or if conservative Mx fails, = surgical intervention from which recovery is approx. 3 months
EXTENSOR CARPI ULNARIS SUBLUXATION
- TENIIS PLAYERS
• Origin: common extensor tendon on the lateral epicondyle of the humerus
• Insertion: posterior surface of the base of the fifth metacarpal
• Innervated by the posterior interosseous nerve
• In a normal wrist, the ECU lies ulnar to the ulna head in pronation and moves dorsal over the ulna head during supination.
o ECU has its own fibro-osseous tunnel in the wrist
o Subluxation of the tendon is secondary to rupture of the ECU sheath
• In pronation tendon lies ulnar to the ulnar head
• In supination tendon moves to dorsal aspect of ulna
Ax Physical exam • Observation o Subluxes in volar and ulnar direction • Palpation: on ulnar side of wrist between ulna and the base of the 5th metacarpal o May have tenderness and mild swelling
• Movement exam - resist ECU in pronation & and ask the patient to supinate while maintaining ECU resistance
o Dislocates with supination
o Relocates with pronation
• Positive test
o Place wrist in supination and then flex the wrist a visible or palpable snap of the tendon over the ulna head = positive sign.
EXTENSOR CARPI ULNARIS SUBLUXATION
Mx Differential diagnosis • ECU tendinopathy • DRUJ instability • TFCC tear
Management
Early
• Immobilisation with the forearm in pronation and the wrist in radial deviation
• Surgery may be needed in some cases by reconstruction of the pulley by using the extensor retinaculum
ECU TENDINOPATHY
- Palpate between ulna and 5th MC
- Resist wrist extension with UD
OR
Resist thumb abduction in neutral wrist position (creates an isometric ECU contraction with no loading of the ulnar sided structures)
Patient history
• MOI
o Overuse
Ax
• Pain on palpation of ulnar side between the distal ulna and base of the 5th metacarpal
• Movement exam
o Pain after repeated movement with stiffness after a period of rest
- Pain in resisted wrist extension/ulnar deviation
- Resist thumb abduction in neutral wrist position (creates an isometric ECU contraction with no loading of the ulnar sided structures)
Mx • deload • address biomechanics • ADL modifications • Gradually reload to facilitate healing
Ulnar fracture/ulnar styloid frac or contusion
Observe and palpate:
- Ulnar head
- Ulnar styloid
Ulnar head: Observe prominence, Notes changes from supination to pronation: More evident in pronation
Ulnar styloid: May indicate a fracture or confusion
