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Problems of the Distal Radioulnar Joint0749-0712/91 $0.00 + .20

Ulnar lmpaction Syndrome

Steven L. Friedman, MD,* and Andrew K. Pahner,

The diagnosis and management of ulnar wristdisorders has historically been a source of con-fusion and frustration among clinicians. Wide-spread interest in the ulnar aspect of the wristand distal radioulnar joint during the past dee-ade has resulted in a much dearer understand-ing of the anatomy, biomeehanies, and patho-logic conditions affecting the distal radioulnarjoint and ulnar carpus. The ulnar impaetionsyndrome has proven to be a relatively commonsource of ulnar wrist pain and limitation ofmotion. This article defines the ulnar impaetionsyndrome and discusses its causes, diagnosis,

associated disorders, and treatment.The ulnar impaetion syndrome can be defined

as a degenerative condition characterized bvulnar wrist pain, swelling, and limitation ~fmotion related to excessive load bearing acrossthe ulnar aspect of the wrist. Chronic impaetionof the ulnar head against the triangular fibfo-cartilage complex and ulnar carpus results inprogressive deterioration of the triangular fibro-cartilage complex, ehondromalaeia of the lunateand ulnar head, and attrition of the lunotrique-tral ligament (Fig. 1). The clinical and patho-logic characteristics of the ulnar impaetion syn-

drome have been well described previously,3.5yet confusion still exists in the literature as aresult of inconsistency in nomenclature. Ulnarimpaetion, ulnar impingement, a. lo ulnoearpal

impingement,6 ulnocarpal abutment,3, ~ and ul-nocarpal loadinga have all been terms used todescribe this syndrome. In some references:,these terms have been used interchangeably;

yet the ulnar impingement syndrome;is a dis-

tinct clinical entity. Bell and associates definedulnar impingement syndrome as "a short ulnaimpinging on the distal radius and causing apainful, disabling pseudarthrosis"e (Fig. 2). definition, therefore, the ulnar impaetion syn-drome and the ulnar impingement svndromeare not only distinct syndromes but’are mu-tually exclusive.

A painful condition resulting from articularincongruity of the distal radioulnar joint canpresent with findings similar to the ulnar im-paetion syndrome. In a substantial number ofcases, in fact, ulnar impaction syndrome maycoexist with distal radioulnar joint abnormali’-ties. The successful surgical treatment of dis-.orders of the ulnar aspect of the wrist dependson accurate assessment of the factors contrib-uting to the disorder. It is important, therefore,to distinguish between the ulnar impaetion syn-drome, the ulnar impingement syndrome, anddisorders of the distal radioulnar joint whenformulating an appropriate surgical tr~--~tmentplan and reporting results of surgical proce-dures.

BIOMECHANICS

The distribution of compressive loads acrossthe wrist joint has been determined in a human

cadaver model in which miniature load ceilswere used to evaluate a fixed force applied tothe wrist joint through the wrist motors. ~, la In

From the State University of New York Health Science Center, Syracuse, New York

*Hand Fellow~Professor of Orthopedic Surgery, and Director, Hand Surgery Service

Hand Clinics--Vol 7, No. "~ ~ ...... ;~2,95

296 Steven L. Friedman and Andrew K. Palmer|

ulnocarpal articulation when the wrist is inneutral alignment with respect to the coronal,sagittal, and axial planes. Under similar condi-tions, relatively small changes in ulnar variancehave a direct relationship to the proportion ofload borne, across the ulnocarpal joint (Fig. 3).A 2.5-ram increase in ulnar length raised theulnar load to 42%, whereas a 2.5-ram lengthdecrease lowered the ulnar load to 4.3%.~a

Removal o~F the triangular fibrocartilage complexresulted in a similar relationship of ulnar lengthversus ulnar load at a lower magnitude. Peakarticular pressure measurements using pres-sure-sensitive film in this human cadaver modelconfirmed these relationships of ulnar length Fversus ulnar load.la ~ We.

Further biomechanieal investigation intowrist load distribution was performed in a hu-man cadaver model to assess the effect of dorsaltilt of the distal radial articular surface on ulnarload and load distribution. ~4 A direct relation-Figure 1. This radiograph demonstrates subchondral

cysts involving the lunate and the ulnar head along with ship was observed bet~veen dorsal radial tilt andpositive ulnar variance, ulnar load (Fig. 4). A change in radial tilt from

11 degrees of volar tilt to 40 degrees of dorsaltilt resulted in an increase in ulnar load from

the ease of neutral ulnar variance, approxi- approximately 21% to 65%. Furthermore, themately 82% of the compressive load is borne increased dorsal tilt of the distal radial articularby the radiocarpal articulation and I8% by the surface resulted in concentration of the pressure

on the ulnar and radial articular surfaces to a Fidista

more dors~,l location, crewRadiographic studies have been performed ~ (Fro,

that demonstrate significant alteration in ulnar

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variance with forearm rotation and with the withpresence or absence of active, powerful grip.7, nMaximum forearm pronation results in an in-crease in positive ulnar variance, whereas max-imum forearm supination decreases ulnar vari-ance (Fig. 5). Ulnar variance increasessignificantly with powerful grip and returns toits original state with cessation of grip (Fig. 6).The magnitude of change in ulnar variance withforearm rotation and grip varies significantly yetis generally in the range of 1 to 2 mm.

It is clear that ulnar variance is not a constantand can be affected by daily activities that resultin repetitive forearm rotation and grip. Thechanges that can be demonstrated in ulnarvariance are relatively small; however, biome ....chanical data demonstrate a substantial changein force distribution throughout the wrist jointwith very small changes in ulnar length and

Fi;;~:r,~.,% :~mpingement ofa short distal ulna on t~e distalco~r:~:’:q~’,..o}" tI:,e d.:.sta! radius, These bio-

is inronal,2ondi-danceion ofig..~d thelength

.3%. ~amplexlength. Peakpres-

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n ulnar~ith thegrip], 11~ an in-,.as max-mr vari-lcreasesturns to(Fig. 6).ace withmtly yet

constant~at result:ip. Thein ulnar, biome-1 changefist joint~gth and

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The Ulnar Impaction Syndrome

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-3.0 -2.0 -I 0 0 +1.0 +2.0 +3.0Change in Ulna Length (ram)

Figure 3. Increasing ulnar length results in a substantial increase in the load borne by the ulna. (From Palmer AK,Werner FW: Bimneehanics of the distal radioulnar joint. Clin Orthop i87:26, 1984; with permission)

PERCENT FORCE THROUGH ULNA70-

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" 0 10 20 3o ~ 5oCHANGE IN DOFIS~L ANGULATIO~I (DtEGREES|

Figure 4. Increasing the absolute dorsal tilt of thedistal radial articular surface results in substantial in-creases in the proportion o£axial load borne by the ulna.(From Palmer AK: Fractures of the distal radius. InGreen DP (ed:): Operative Hand Surgery, vol 2, ed. New York, Churchill-Livingstone, 1988, pp 991-1026;with permission)

F:.:~. -,~ 5. An eyample cff tlze effect of forearm rot~tioe, on b.laar variance. ~ks measured

298 Steven L. Friedman and Andrew K. Palmer

Figure 6, An example of the effect of power ~rip on ulnar variance, as measured radiographically.

causal relationship between repetitious dailyactivities involvi~g forearm rotation and gripand progressive degeneration of the ulnar as_

peer of the wrist joint in the absence of congeo_ital deformity or acute trauma.

PATHOLOGY

The ulnar impa~tion syndrome has been ide~.tiffed in patients with positive ulnar varian%and neutral ulnar Variance. There are presentlyno cases reported in which this syndrome has

developed in a WVist with negative ulnar vari,anee. The most eommon predisposing eondi,tions include congenital positive ulnar variane~(Fig. 7), malunion of the distal radius (Fig.

premature physea/ arrest of the distal radius(Fig. 9), and previous radial head resection Essex-Lopresti injhry (Fig. 10). All of theseconditions result i h a fixed increase in under~lying ulnar loadin~ related to relative length-ening of the ulna ~r increased dorsal tilt of thedistal radius.

Large anatomic studies have looked at the

incidence of degenerative lesions in the humancarpus through gross eadaverie dissection.9. ~. ~v

~erforations o£ ~e tri.’~Z~gular t~broearti]age corn-p ex, rupture ot the lUqotriquetral ligamentous

complex, and eh0ndro~aalacia of the ulnar headand lunate are commonly found in eadavericwrists with no other evidence of previoustrauma~, ~. ~7 (Fig. 11). The presence of trian-

gular fibrocartilage C~tnplex perforations hasbeen shown to be; age related, with virtually no

perforations being identified before the fourthdecade.O, ~7 With increasing age, the incidence

of triangular ~brocartil~e eorn~lex "erforation’-increases rap~dly, such ~hat by the sixth decade,over 50% of speeimen~ demonstrate perfora-tions in some ser:ies.9. ~a The association of ero-sive changes involving the ulnar head and lu-nate with triangular fibroeartilage complex

perforationSluiS~o~iG~high. Furthermore, thepresence of 7 q t~al ligament rupture as-sociated with triangular ffbroeartilage complexperforations has been r~ported to be as high as76%.~’ ~ The assoeiati% between ulnar vari-

ance and presence oF t~:iangular fibroeartilage

.complex perforations, Uinar and lunate cb~on-

auman

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The Ulnar Impaction Syndrome 299

Figure 7. An example of congenitally positive ulnar variance ~vith associated ulnar impaction syndrome.

Figure 8. Malunion of a distal radius fracture resulting in raa,,’i-:,:,~. ~,- <:v;-: ulnar variance mad dorsal tilt of the distalradial articular sur,~aee. Ulnar inapaction syndr,’>m.e


Figure 9. An example of partial physeal arrest of the distal radius in a young gymnast, resulting in the ulnar impactionsyndrome.

Figurespecimen:syndromplex is psubchon~well as p~

dromal~:tures h~disseeti~or positionstratctilage c(similarvariancedata avarelationstion acr~and theas the ul

Figure 10. An example of the ulnar impaction syndrome following resection of the radial head.

The c]syndrom~vcrist pairelievedforearmquentlv

mpaction

Figure 11. A coronal section through a cadaveric wristspecimen demonstrates the features of the ulnar impactionsyndrome. Perforation of the triangular fibrocartitage com-p’lex is present and is associated with chondromalacia andsubchondral cyst formation of the lunate and ulnar head, aswell as perforation of the lunotriquetral ligament.

dromalacia, and lunotriquetral ligament rup-tures has also been demonstrated in cadavericdissections.9’ ~7 Seventy-three percent of neutralor positive ulnar variance specimens have dem-onstrated perforation of the triangular fibroear-tilage complex, whereas only 17% demonstratedsimilar changes in wrists with negative ulnarvariance. 12 The biomeehanical and anatomicaldata available therefore suggest a direct causalrelationship between increased force distribu-tion across the ulnar aspect of the wrist jointand the spectrum of pathologic changes knownas the ulnar impaetion syndrome.

DIAGNOSIS

The clinical presentation of ulnar impactionsyndrome is generally chronic or subacute ulnarwrist pain, often exacerbated by activity andrelieved by rest. Swelling and limitation offorearm rotation and wrist motion are fre-quently concurrent complaints. _Physical exam-


ination reveals swelling and tenderness that isusually localized to the region of the triangularfibrocartilage complex and lunotriquetral joint.Pronation and supination of the forearm withulnar deviation of the wrist generally evokesincreased symptoms.

The clinical presentation of the ulnar im-pingement syndrome and disorders of the distalradioulnar joint can be similar to that of theulnar impaction syndrome; however, the pa-tient will generally experience a great deal morediscomfort with pronation and supination of theforearm. Tenderness in these patients will bemore localized to the distal radioulnar joint ordistal radioulnar pseudarthrosis, and crepituswill be elicited by forearm rotation. Compres-sion of the distal radioulnar joint along withforearm rotation is a very useful sign in identi-fying patients with incongruity of the distalradioulnar joint and symptoms related to thisabnormality.

Radiographic findings in the ulnar impactionsyndrome include neutral or positive ulnar var-iance. Underlying abnormalities, including mal-union of a distal radial fracture with residualradial shortening and abnormal dorsal tilt, maybe present. Other findings may include evi-dence of premature pbyseal arrest of the distalradius or previous Essex-Lopresti or Galeazzifracture. Previous resection of the radial headmay also be evident on plain radiographs. Sec-

..ondary changes in the carpus include subchon-dral sclerosis and cystic changes in the lunateand ulnar head. Arthrography will often revealperforation of the triangular fibroeartilage tom-_plex and, possibly, rupture of the lunotriquetralligament (Fig. 12). Separate injections of theradioearpal joint, midcarpal joint, and distalradioulnar joint are sometimes necessary todemonstrate these lesions on arthrography. In-congruity of the distal radioulnar joint and theulnar impingement syndrome are both usuallyobvious on plain radiographic examination.

Diagnostic arthroseopic examination of thewrist is becoming a more accepted procedurein difficult cases. Although the diagnosis of ulnarimpaction syndrome is usually made by lessinvasive measures, arthroseopy demonstratesthe pathologic characteristics of this disorder.Chondromalacia of the lunate and ulnar headcan be clearly seen, along with perforation of

~ . fib~,~car .......>~ complex and rup-the triangular ..... +:~ .......

302

Figure 12. Lunotriquetral ligament perforation is dem-

onstrated in this patient arthrographica[ly.

ture of the lunotriquetral ligament. Arthro-scopic access to the distal radioulnar joint ismuch more difficult; therefore, arthroscopic ex-amination is less useful in making the diagnosisof distal radioulnar joint arthrosis.

TREATMENT

Initial treatment of the ulnar impaetion syn-drome includes avoidance of activities that ex-acerbate the discomfort, splinting, and anti-inflammatory medication, Patients who do nothave excessive positive ulnar variance and donot have another underlying structural abnor-mality will generally respond to this therapy,Patients with significant structural abnormali-ties and those who cannot abstain from theexacerbating activities will often require sur-gical .intervention ultimately.

The surgical treatment of the ulnar impactionsyndrome needs to be carefully considered andindividualized. Factors that affect surgical de-cision making include ulnar variance, sagittal

Steven L. Friedman and Andrew K. Palmer

and coronal alignment of the distal radial artic-ular surface, status of the triangular fibrocarti-lage complex and lunotriquetral ligament, thedegree of congruence of the distal radioulnararticulation, and the skeletal age of the patient.

Ulnar shortening is a very effective form oftreatment in the majority of patients with theulnar impaction syndrome ~vho do not haveunderlying structural abnormalities other thanpositive ulnar variance. In cases where there issignificant articular incongruity of the distalradioulnar joint or significant deformity of thedistal radius, an alternative should be consid-ered. Advantages of ulnar shortening includepreservation of the ulnocarpal articulation anddistal radioulnar joint while significantly de-creasing ulnar load. Furthermore, the ulnocar-pal ligamentous complex is tightened in thisgroup of patients, who often demonstrate ulnarligamentous laxity. Several surgical techniquesfor ulnar shortening have been proposed in theliterature.5 10 These methods include trans-

verse, step-cut, and oblique osteotomies fixedby plates, screws, cast immobilization, and wirefixation techniques. We currently prefer anoblique ulnar osteotomy with internal fixationusing the compression plate and lag screw tech-nique (Fig. 13).

The junction of the middle and distal thirdsof the ulnar diaphysis is exposed through anincision overlying its subcutaneous border. Softtissue dissection and periosteal stripping is keptto a minimum. A seven-hole, 3.5-ram dynamiccompressiofi plate is slightly prebent and ap-plied to the ulnar cortex. The plate is looselyfixed to the ulna by placing a 3.5-mm corticalscrew through one of its most distal holes andnot tightening the screw completely. The platecan now be rotated, thus exposing the site ofproposed ulnar osteotomy. An oblique osteot-omy is perfi3rmed with orientation suchthat acortical lag screw can be placed through theplate and across the osteotomy site at the com-pletion of the osteotomy. After the first saw cutis partially made, a free saw blade may beplaced in [his cut and used as a guide forperforming the second parallel saw cut (Fig.14). Preoperative planning is necessary to judgethe appropriiate amount of ulnar shortening tobe performed (Fig. 15). In patients with positiveulnar variance, the amount of resection is cho-sen so that neutral ulnar variance or 1 mm ofnegative ulnar variance results. In patients who

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7ormity of the.ld be eonsid-~ning includetieulation andnifiehntly de-, the ulnoear-tened in thisonstrate ulnar?al techniques:oposed in thenelude trans-~otomies fixed.tion, and wiretly prefer anternal fixationag screw teeh-

d distal thirds~d through an~s border. Softripping is kepti-mm dynamic~bent and ap-~late is loosely5-mm corticalistal holes and:ely. The plateing the site of~blique osteot-an such that a:l through the:~te at the eom-le first saw cutblade may bes a guide forsaw cut (Fig.essary to judgeshortening to

:s with positivesection is eho-.’e or 1 mm ofn patients who


Figure 13. An artist’s conception of the sequence ofimportant steps in fixation of an oblique ulnar osteo~:omy.Note that compression at the oblique osteotomv site isinitially obtained through an eccentric screw placed" th:~oughthe dynamic compression plate. Secondary compression atthe osteotomy site is obtained using a lag screw th;oughthe plate.

have neutral ulnar variance to begin with, ap-proximately 2 mm of bone is removed. Theosteotomy cuts are completed and the oblielueopposing surfaces are reduced in anatomic t!ash-ion. The plate is then rotated back into itsproper position with respect to the ulnar ~;haftand is fixed to the distal fragment with thepreviously placed cortical screw. Once anatomicalignment has been confirmed, the gliding holefor the lag screw is drilled through the centralhole of the plate and the 3.5-mm drill guide isinserted in the gliding hole to maintain properposition of the proximal fragment with respectto the plate. A proximal screw is now placedafter appropriate predrilling and tapping in theeccentric mode to provide compression at theosteotomy site. It is important that the osteot-omy has been performed so that the proximalfragment apex is wedged into the acute angleformed by the plate and the distal fragment.Once compression has been obtained across theosteotomy si~e, the threaded hole for the lag

Figure 14, This intraoperative example demonstrates theutility of using a free saw blade as a guide to making twoparallel oblique cuts in the ulnar shaft, Note the preliminaryfixation of the plate distally to facilitate reduction follo~vingosteotomy.

screw is drilled and the lag screw inserted aftertapping. At this time, the remaining screws areplaced in the proximal and distal fragmentsthrough the plate in the neutral mode. Alter-natively, an independent lag screw may beplaced perpendicular to the plane of the plate,rather than through the plate (Fig. 16). Intra-operative radiographs are always used to con-firm satisi~aetory alignment and fixation of theosteotomy (Fig. 17). Following wound closure,a compressive dressing and sugar-tong splintare used. Postoperative care includes immobi-lization in a Munster-type cast for approxi-mately 4 weeks, followed by. protection in. ashort-arm gauntlet orthosis for an additional[ 2weeks. Removal of the ulnar plate and screwsis recommended at 1 or 2 years following sur-gery. Short-arm cast immobilization at t__hat time

Figure 15. A compIeted osteotomy with resected portionof boue is demonstrated.


Figure 16. Completed fixation of the osteotomy is dem-onstrated in this figure. Note that the interfragmentary lagscrew in this case was in the plane perpendicular to thecompression plate.

is routinely used for 6 weeks following plateremoval to prevent stress fracture.

Patients who develop ulnar impaetion syn-drome following malunion of a distal radiusfi’acture may have positive ulnar variance asxvell as excessive dorsal radial tilt contributingto the disorder (see Fig. 8). In cases where

excessive dorsal radial tilt is not a factor, thenulnar shortening alone is a more simple, reliablemethod of treating the problem than lengthen-ing of the radius. When excessive dorsal tilt ofthe distal radius is present with or withoutpositive ulnar variance, osteotomy of the distalradius to restore normal volar tilt, as well asrecreate neutral or negative ulnar variance, isthe treatment of choice. Correction of excessivedorsal[ tilt, loss of ulnar tilt, and positive ulnarvariance can be obtained with a dorsal openingwedge osteotomy in most eases. Preoperativeevaluation is carried out to approximate theamount of correction required in each plane.The distal radius is exposed dorsally betweenthe third and fourth dorsal compartments. Thedorsal, opening wedge osteotomy is performedand iutraoperative radiographs are obtained toassess adequacy of correction while maintainingthe osteotomy in the corrected position using apin or radiolueent template. In the majority ofeases, a trapezoidal corticoeancellous bone graftfrom the distal radius provides satisfactoLv cor-rection of the deformity as described by Watson

Figure 17. The completed osteotomy, as demonstrated radiographically. Note that the interfragmentary lag scre~vtraverses the compression plate in this case.

:tor, then~, reliablelengthen-rsal tilt ofr withoutthe distalis well astriance, is¯ excessiverive ulnard opening~operativeimate thetch plane.~ between~ents. Theperfbrmedbtained to~aintainingon using a.najority ofbone graft~etory eor-by Watson

The Ulnar hnpaction Syndrome 305

and Catle18 (Fig. 18). The advantages of a localcorticocancellous graft include decreased donor’site morbidity as compared to using iliae crest:bone graft; Kirschner wire fixation is generally’adequate for stability. Occasionally excessive..length discrepancy, excessive angular defor-.mity, or inadequate bone stock of the distal[radius require that an iliac crest corticocancel--lous bone graft be used. If the osteotomy siteis substantially destabilized by excessive son:tissue dissection and periosteal stripping, weprefer more rigid internal fixation utilizing AO-ASIF plate and screws. Postoperative care fol.-lowing distal radial osteotomy includes com-pressive dressing after routine wound closureand a sugar-tong splint. Munster cast immobi-lization is then used for approximately 6 weeks,followed by a short-arm east for an additional 9,weeks. If more rigid internal fixation is usedthan Kirsehner wires, the postoperative immo-bilization can often be shortened somewhat:;however, in these eases a second operation isnecessary, for plate removal, and complicationsrelated to irritation of the digital extensor ten-dons are more frequent.

In cases where there is no abnormality of theconfiguration of the distal radial articular surfaceand no abnormality of the distal radioulnararticulation, an alternative to ulnar shorteningas previously described is a partial excision ofthe ulnar head using the wafer procedure asdescribed by Feldon and colleagues,s The ul-nocarpal articulation is approached through adorsal incision between the fifth and sixth dorsalcompartments. The triangular fibrocartilagecomplex is explored and debrided or repaired,if necessary. The portion of the ulnar head thatis in contact with the undersurface of the freesegment of the triangular fibroeartilage is ex-cised, taking great care to preserve the insertionof the triangular fibroeartilage complex andavoiding injury to the portion of the distal ulnaarticulating with the sigmoid notch of the radius(Fig. 19). Postoperative care includes splintimmobilization for 1 to 2 weeks, followed byearly rehabilitation unless triangular fibroearti-lage complex repair has been necessary, inwhich ease a longer period of immobilization isnecessary.. The amount of positive ulnar vari-ance that can be corrected by this method is

:ary lag screw Figure 18. Postoperative radiograph demorv-trat,rw ;:’;,rrectic, a ~d-a distal radial malunion using the trapezoidal cortico-c::mcellous bone graft technique. The preop~:ra::~;’~ "~ ~iio~;~’ap~s are si~own in Figure 8.

306

the ulnar impaction syndrome. Intraoperative and radiographic

Steven L. Friedman and Andrew K. Palmer

Figure 19. Preoperative arthrogram demonstrates perforation of the triangular fibrocartilage complex in this patient ~vithdemonstrations of the wafer procedure are sho~vn.

limited, yet under the proper circumstances,the reported results of this procedure seem tobe satisfactory, at least in the short term. It isimportant to note that recovery following thisprocedure is generally slow and maximal im-provement may require longer than 6 months.

A variation of the wafer procedure that iscurrently under investigation at our institutionis the arthroscopic wafer procedure. The ulno-carpal articulation is visualized through the ar-throscope and, in the presence of a triangularfibrocartilage perforation, the ulnar head can bevisualized through the radiocarpal joint as well.Under these circumstances, the portion of theulnar head that is impacted against the freeportion of the triangular fibrocartilage complexcan be rejected using arthroscopic instruments(Fig. 20), Again, great care must be taken preserve the triangular fibrocartilage insertioninto the distal ulnar fovea and styloid and topreserve the distal radioulnar joint. Debride-ment of a lunotriquetral ligament rupture andarticular cartilage erosive lesions can be carriedout during this procedure. Intraoperative radio-graphs are absolutely essential prior to comple-tion of the arthroscopic procedure to ensureadequate bony resection (Fig. 21). Substantialexperience with arthroscopic techniques as wellas the presence of a triangular fibrocartilageperforation are prerequisites of this procedure.Currently, access to the distal" radioulnar joint

using arthroscopic techniques is problematic. Ifthis obstacle can be resolved in the near future,arthroseopie resection of the distal ulna couldpossibly be carried out even in the absence ofa large triangular fibroeartilage perforation. Theadvantage’, of arthroseopie treatment of the ulnarimpaetion syndrome may be that more rapidrehabilitation and return to xvork are possible.Presently this procedure must be consideredinvestigational, and follow-up is insufficient toallow any,,reeommendations to be made at this

Figure 211. An arthroscopic view of the ~vrist joint dem-onstrates a perforation in the triangular fibrocartilage com-plex (TFCC) through which the ulnar head (UH) is seen. motorized burr is being used to perform an arthroscopicwffer procedure..

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The Ulnar lmpaction Syndronw 307

techniques that can be used to prevent impinge-ment of the ulnar styloid against the ulnarcarpus after the procedure. It should be notedthat both of these procedures fail to address therelative ligamentous laxity that is often presentat the ulnar aspect of the wrist in these patients.

A procedure that can be used to address bothulnar impaction syndrome and distal radioulnarjoint arthrosis is distal radioulnar arthrodesisassociated with creation of a distal ulnar pseud-arthrosis as described by Suave-Kapandji. ~ Thedistal radioulnar joint is exposed through adorsal incision. The articular cartilage and scle-rotic subchondral bone are removed. An extra-periosteal segmental resection of approximately2 cm of bone is performed, leaving approxi-mately 2 cm of the ulnar head distally. The

Figure 21. Intraoperative radiographs are essential inassessing the degree of bony resection attained when per-forming an arthroscopic wafer procedure,

time. Recovery following the arthroscopie waferprocedure seems to be slow, as in the openwafer procedure,

A significant number of patients present withconcurrent ulnar impaction syndrome and distalradioulnar joint incongruity. It is important torecognize the presence of both of these lesion.,;and to consider this in treatment planning. The,ulnar shortening procedures and radial osteot-.omies previously described do not adequately’..address the distal radioulnar joint contributionto symptoms in this group. Resection arthro-plasty or arthrodesis of the distal radioulnarjoint is necessary in addition to correction ofthe positive ulnar variance. The matched ulnarresection as described by Watson and co-authors~ (Fig..22) or the hemiresection inter-positional arthroplasty procedure as describedby Bowers4 (Fig. 23) both are acceptable meth-ods of treating this combination of disorders.Currently there are no convincing data favoringone procedure over the other. The reader isencouraged to review the original literature fordetails of operative techniques. The more im-portant technical points include adequate resec-tion of distal ulna, maintenance of the integrityof the triangular fibrocartilage complex, andprevention of ulnar styloid impaction againstthe ulnar carpus after resection. Interpositionalgrafts or concomifant ulnar shortening are both

Figure 22. The matched ulna resection as described byWatson is seen here radiographically.


rotation have been satisfactory in the majorityof patients reported following this procedure;however, return of motion is somewhat unpre-dictable. Occasionally, symptoms of an ulnarimpingement type may develop at the regionof the ulnar’ pseudarthrosis and the distal radius.

The classic or modified Darraeh procedurehas been used historically for ulnar impactionsyndrome and distal radioulnar joint problemswith varying degrees of success (Fig. 25). currently recommend this procedure for salvageof failed subtotal resection of the ulnar head.Maintenance of ligamentous integrity of theulnar carpus is less predictable following theDarrach procedure and the possibility of ulnarimpingement syndrome exists, especially whenresection has been excessive (Fig. 26). Satisfac-tory result,,; can be obtained, however, when

Figure 23. The beret-interposition resection techniqueas described by Bowers is demonstrated here radiographi-tally. Note the distance maintained between the sigmoidnotch and the remaining distal ulna.

triangular fibrocartilage complex is explored andits insertion carefully preserved. The distal ra-dioulnar joint is reduced so that resulting ulnarvariance is neutral or slightly negative. Internalfixation can be adequately achieved with Kirsch-ner wires (Fig. 24). In the authors’ experience,screw fixation has laeen associated with highermorbidity in terms of soft tissue problems.Correcting the positive ulnar variance in thesepatients does serve to tighten the ulnocarpalligamentous complex. Postoperative care in-eludes Munster cast immobilization for approx-imately 6 weeks, at which time the pins areremoved and active range of motion exercisesbegun. Pain relief and recovery of forearm

Figure 24. Radiograph of a healed Suave-Kapandji pro-cedure for arthrosis of the distal radioulnar joint associated~vith the ulnar impaction syndrome.

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pingem

Figur~followimulnar stpreserve:

majorityocedure;Lt unpre-an nlnare region~1 radius.rocedurenpaetion~roblems"25). We,r salvagear head.y of the~eing theof fllnar

.lly whenSat:sfae-

~r, when


abnormalities involving the distal radioulnarjoint, distal radius, and ulnar carpus must becarefully elucidated prior to developing a treat-ment plan. When such abnormalities are iden-tified and appropriately addressed, surgicaltreatment can be expected to be effective inthe majority of cases. It is important to remem-ber that in the absence of obvious structuralabnormalities, the ulnar impaction syndromemay result from daily activities that result inexcessive intermittent loading of the ulnar car-pus. In this group of patients, treatment isdirected at decreasing ulnar load by shorteningthe distal ulna in any of several ways. If relativeinstability of the ulnar ligamentous complex isa factor, then ulnar shortening by recession isthe treatment of choice. Malunion of the distalradius resulting in ulnar impaction syndrome isbest treated by addressing the deformity; thatis, corrective radial osteotomy. Patients ~vhopresent ~vith a combination of ulnar impactionsyndrome along ~vith distal radioulnar joint ab-normalities must have both of these abnormal-

e w,’anm;pro-associated

Figure 25. Radiographic example of a Darrach procedurefollowing malunion of a distal radius fracture. The remainingulnar styloid demonstrates that an attempt was made topreserve the ulnocarpal ligamentous complex in this case.

this procedure is carefully performed in prop-erly selected patients.~, ~a

SUMMARY

The ulnar impaction syndrome can be definedas the impaction of the ulnar head against thetriangular fibrocartilage complex and ulnar car-pus resulting in progressive degeneration ofthose structures. The differential diagnosis inpatients who present with ulnar wrist pain andlimitation of motion can also include ulnar im-pingement syndrome and arthrosis or incongru-ity of the distal radioulnar joint. Structural

Figure 26. The anaount of bone resected in this case wasa bit excessive and the ulnar ]igamentous complex was notadequately preserved. Note the snggestion of early ulnartranslocation of the carpus.

310 Steven L. Friedman

ities addressed at the time of surgery. Thematched ulnar resection and the hemiresectioninterposition arthroplasty are both effective pro-cedures; however, the Suave-Kapandji proce-dure also can be used to address relative liga-mentous laxity at the ulnar aspect of the wrist.The Darrach procedure is presently not rec-ommended as a first-line treatment in thesecases; however, when used as a salvage proce-dure, satisfactory results can be obtained inproperly selected patients. Careful preoperativeevaluation and planning are therefore the keyto successful treatment of the ulnar impactionsyndrome.

REFERENCES

1. Albanese SA, Palmer AK, Kerr DR, et ah Wrist painand distal gro~vth plate closure of the radius ingymnasts. J Pediatr Orthop 9:23-28, 1989

2. Bell M J, Hill RJ, McMurtry RY: Ulnar impingementsyndrome. J Bone Joint Surg [Br] 67:t26-129, 1985

3. Bowers WH: Distal radioulnar joint. In Green DP (ed):Operative Hand Surgery, ed 2. New York, ChurchillLivingstone, 1988, pp 939-989

4. Boxvers WH: Distal radioulnar joint arthroplasty: Thehemiresection-interposition technique. J Hand Surg[Am] 10:169-178, 1985

5. Darrow JC, Linseheid IlL, Dobyns JH, et al: Distalulna recession for disorders of the distal radioutnarjoint. J Hand Surg [Am] 10:482-491, 1985

6. Dingman PVC: Resection of the distal end of the ulna(Darrach operation). An end result study of twentyfour eases. J Bone Joint Surg [Am] 34:89"3-900, 195

and Andrerw K. Palmer

7. Epner RA, Bowers WH, Guilford WB: Ulna variance:The effect of wrist positioning and roentgen filmingtechnique. J Hand Surg 7:298-305, 1982

8. Feldon P, Belsky MR, Terrono AL: Partial ("wafer")distal ulna resection for triangular fibrocartilage com-plex tears and/or ulnar impaction syndrome (ab-stract). J Hand Surg [Am] 15:826, 1990

9. Mikic ZD: Age changes in the triangular fibrocartilageo~" the wrist joint. J Anat 126:367-384, 1978

10. Milch H: Cuff resection of the ulna for malunitedColles’ fracture. J Bone Joint Surg 23:311-313, 1941

11. Pahner AK, Glisson RR, Werner FW: Ulnar variancedetermination. J Hand Surg 7:376-379, 1982

12. Palmer AK, Werner FW: The triangular fibrocartilagecomplex of the wrist: Anatomy and function, J HandSarg 6:153-172, 1981

13. Palmer AK, Werner FW: Biomechanics of the distalradioulnar joint. Clin Orthop 187:26-35, 1984

14. Short WH, Palmer AK, Werner FW, Murphy DJ: Abilomechanieal study of distal radius fractures. J HandSurg [Am] t2:529-534, 1987

15. Taleisnik J: The Wrist. New York, Churchill Living-stone, 1985, pp 429-432

i6. Tulipan DJ, Eaton RG, Eberhart RE: The Darrachprocedure defended: Technique redefined and long-term follow-up (abstract). J Hand Surg [Am] 15:828,1990

17. Viegas SF, Ballantyne G: Attritional lesions of the wristjoint. J Hand Surg [Am] 12:1025-1029, 1987

18. Watson HK, Catle TH Jr: Trapezoidal osteotomv of thedistal radius for unacceptable articular an~ulationafter Colles’ fracture. J Hand Surg [Am] 13:837~843,1988

19. Watson HK, Ityn J, Burgess RC: Matched distal nlnarresection. J Hand Surg [Am] 11:812-817, 1986

Address reprint requests to

Andrew K. Palmer, MD500 Harrison CenterSyracuse, NY 13202

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