Wrist Conditions Flashcards
ulnar variance TFcc injury Ulnocarpal abuntment Ulnar styloid impaction Keinbock's disease Preiser's Disease Distal radial physeal stress syndrome
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)
- Acquired
- 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?
Positive UV
- Ulnar abutment syndrome
- SLD
- TFCC tears
- arthrosis- radial head, lunate, triquetrum
- Lunotriquetral ligament tears
Name some associated conditions of negative Ulnar variance?
Negative UV
- Keinbocks disease
- 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
Tfcc tears
Keinbock’s disease
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
MRI
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?
Non operative
supportive measures- nsaids, splint
Operative
- 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?
Multiple factors
Biomechanical factors
- ULNA Negative Variance- > increase radial lunate contact stress
- Repetitive Trauma
Anatomic Factors
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?
Lichtman
- 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
STT fusion
- 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
Signs:
- Wrist swelling
- Tender over Radiocarpal joint
- Decreased Flexion/extension
- Decreased grip strength
