J Korean Orthop Assoc.  2017 Apr;52(2):103-111. 10.4055/jkoa.2017.52.2.103.

Updates on Ulnar Impaction Syndrome

• Kim J
• Gong HS
• Baek GH

• KMID: 2438975
• DOI: http://doi.org/10.4055/jkoa.2017.52.2.103

Abstract

Ulnar impaction syndrome is one of the common causes of ulnar-sided wrist pain. The pain is usually aggravated by ulnar deviation during a power grip, especially when the forearm is in a pronated position. The most common predisposing factor of ulnar impaction syndrome is ulnar positive variance, which is an increased ulnar length relative to the radius of the radiocarpal joint. However, it can also occur in patients with ulnar neutral or negative variance because ulnar variance can increase during functional activities, including pronation and power gripping. In these patients, the triangular fibrocartilage complex (TFCC) may be thickened. If conservative treatments"”lifestyle modification, medication, or wrist splinting"”are unsuccessful, surgical treatments, such as wafer procedure or ulnar shortening osteotomy can be considered. The wafer procedure is an effective treatment for ulnar impaction syndrome. It removes the distal 2 to 4 mm of the ulnar head, while preserving the ulnar styloid process from fracturing via a limited open or an arthroscopic approach. The advantages of the wafer procedure are that it does not require bone healing or internal fixation and provides direct access to TFCC. However, it is a technically demanding procedure and is contraindicated in patients with distal radio-ulnar joint (DRUJ) instability, lunotriquetral instability, ulnar minus variance, and with an ulnar positive variance of more than 4 mm. Ulnar shortening osteotomy is the most popular method for the treatment of ulnar impaction syndrome. It can effectively relieve ulnar impaction symptoms and stabilize DRUJ. However, an excessive amount of shortening may increase the peak pressure at DRUJ, which results in DRUJ arthritis. There is also a possibility of delayed union or nonunion in the osteotomy site. To prevent delayed union or nonunion, we should make an effort to decrease the gap in the osteotomy site during surgery. A serial follow-up is also recommended to evaluate the occurrence of arthritis in DRUJ after ulnar shortening.

Keyword

ulnar impaction syndrome; ulnar shortening osteotomy; wafer procedure

MeSH Terms

Arthritis
Causality
Follow-Up Studies
Forearm
Hand Strength
Head
Humans
Joints
Methods
Osteotomy
Pronation
Radius
Triangular Fibrocartilage
Wrist

Figure

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  Figure 1 Both wrist posteroanterior view with pronation and power grip of a 23-year-old man with ulnar impaction syndrome.

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  Figure 2 (A) Both wrist posteroanterior (PA) view of a 34-year-old woman with ulnar impaction syndrome. (B) Both wrist PA view with pronation and power grip.

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  Figure 3 Ulnar shortening osteotomy is usually performed with the forearm over the chest position.

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  Figure 4 After longitudinal incision on the ulna centered on the distal one third point of the ulna, dissection is performed between the flexor carpi ulnaris and extensor carpi ulnaris to expose the ulna.

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  Figure 5 After placing a six-hole plate (ARIX ulna osteotomy system; Jeil Medical Corporation, Seoul, Korea) on the ulna, a screw is inserted into the 2nd most distal hole of the plate.

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  Figure 6 Two osteotomy sites were marked with a 3.5 mm interval.

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  Figure 7 Screws were inserted on the proximal fragment of the ulna with compression applied by an assistance surgeon.

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  Figure 8 Right wrist posteroanterior and lateral radiographs at 6 weeks after the surgery.

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