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mtomaino 04-13-2011 04:22 PM

If you have Ulnar Impaction Syndrome, wrist arthroscopy may be a helpful option
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I was stimulated to add this "post" after seeing a patient today who has ulnar wrist pain due to "Ulnar Impaction." He was told that he may benefit from a shortening osteotomy of the ulna---a procedure which involves removing a sliver of bone in order to decrease its length at its distal end. This can shift load away from a torn TFCC ligament and decrease pain---often caused in part due to swelling in the lunate bone ( see xray with red circle delineating the cyst.)

For years I have felt that an ulnar shortening osteotomy is, perhaps, overkill for this problem; thus, I have written about, and clinically assessed the feasibility and efficacy of a less invasive surgery---Arthroscopic TFCC debridement + wafer procedure.

Click on this link for a narrated video:

Why not have an Ulnar shortening osteotomy at the outset?

First--surgery may not be necessary. I have frequently witnessed superb long-term pain relief from 1-2 ulnocarpal cortisone shots. Remember--never just treat the x-ray! What our intervention seeks to provide, fundamentally, is pain relief and improved function. Sometimes "less is more"!

Second, unless you have a prominent ulnar styloid, and concomitant "stylocarpal" impaction--or more than 4-6mm of postive ulnar variance, wrist arthroscopy is an option with fewer potential complications, like nonunion and painful hardware---without burning any bridges. Indeed, as the x-ray attached shows, fixation after osteotomy requires a lengthy plate, which can potentially irritate the soft tissue.

Lastly, if the articular surfaces of the ulnar head and sigmoid notch are not parallel, shortening the ulna can potentially increase joint pain at the distal radioulnar joint (see red and yellow lines on the attached x-ray).

That having been said, if osteotomy is required, newer devices do provide fixation which minimize risk of nonunion and soft tissue discomfort; so if this procedure is needed, it can provide successful resolution of ulnar wrist pain.

mtomaino 01-20-2012 06:40 PM

I agree that your ulna is long, which, ofcourse, is "normal" for you. However, after a distal radius fracture, and when a TFCC tear requires treatment, the outcomes are not as favorable when a "long" ulna is present. A wafer procedure is often helpful, but not always. In such cases, time may help. But--if your ulnar wrist pain is not something that you can "live with"-- there are other options. I always recommend trying to manage this type of persistent pain conservatively, much like I would advise trying to "live with low back pain", but there are indeed situations where surgery is necessary.
In your situation an ulnar shortening osteotomy is one option. Although resecting the end of the ulna or replacing the end of the ulna are options, these are lower on the list of advisable options, in most situations.

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