[Treatment of the ulnar impingement syndrome in the distal radioulnar joint]

Computer-assisted correction of incongruent distal radioulnar joints in patients with symptomatic ulnar-minus variance

Our study described a computer-assisted, three-dimensional (3-D), planned surgical technique of a radial shortening osteotomy. The osteotomy of the distal radius was planned with computer assistance on 3-D bone models based on computed tomography data. The objective was to maximize the contact zone of the sigmoid notch with the ulnar head. Between 2012 and 2020 we treated 14 wrists in 11 patients with symptomatic ulnar-minus variance with a mean follow-up of 44 months (range 8 to 98) and a mean age of 28 years (range 19 to 38). Postoperatively, patients showed a decrease in pain at rest and during effort (numeric rating scale from 4.4 to 0 and 7.5 to 4.5, respectively). The range of motion postoperatively was similar to the contralateral side. Grip strength increased from 24 kg to 30 kg. The Disability of the Arm, Shoulder, and Hand and the Patient-Rated Wrist Evaluation scores were 28 and 35 postoperatively, respectively. Our technique of 3-D computer-assisted distal radioulnar joint reconstruction led to a pain reduction and improvement of the hand function in patients with symptomatic ulnar-minus variance.Level of evidence: IV.

Long-term outcome after arthroscopic debridement of Palmer type 2C central degenerative lesions of the triangular fibrocartilage complex

PURPOSE

The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions.

METHODS

A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done.

RESULTS

Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred.

CONCLUSION

Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance.

LEVEL OF EVIDENCE

Therapeutic IV.

[The Painful Wrist]

The Painful Wrist Abstract. Wrist pain is a problem that can significantly limit patients in their daily activities. The causes are manifold, and treatment is often challenging. A systematic approach is therefore helpful in working up the correct diagnosis. This article aims to demonstrate a straightforward approach to the evaluation of wrist pain in adults.

Treatment of Mild Ulnar Longitudinal Deficiency with a Z-Shaped Ulna Lengthening Osteotomy: A Report of 2 Cases

CASE

Two adolescent patients with therapy-refractory ulnocarpal wrist pain because of mild ulnar longitudinal deficiency (ULD; ulna hypoplasia type I according to Bayne) underwent surgical treatment with a Z-shaped ulna lengthening osteotomy and interposition of the iliac crest bone graft. Long-term ULD correction and pain-free motion were maintained in both patients.

CONCLUSION

Pediatric patients with symptomatic mild ULD are often mistaken for ulnar negative variance with radioulnar impingement and may be successfully treated using this newly described technique. The ulnar malangulation is corrected at the apex of the deformity, and the clinical and radiographic outcomes have been successful.

Three-dimensional kinematics of the flexor pollicis longus tendon in relation to the position of the FPL plate and distal radius width

INTRODUCTION

The standard therapy of intra-articular and extra-articular distal radius fractures consists of open reduction and stabilization using palmar osteosynthesis with an angularly stable plate. The integrity of the flexor pollicis longus tendon (FPLT) may be mechanically affected by the plate, with rupture rates between 1 and 12% reported in the literature, occurring during a postoperative time period from 4 to 120 months. The aim of this study was to investigate the position of the tendon in relation to the distal edge of the plate using high-resolution ultrasonic imaging.

MATERIALS AND METHODS

Nineteen patients undergoing osteosynthesis for distal radius fracture in 2015 with the Medartis^® APTUS^® FPL plate were included in this study. Of these, seven dropped out for various reasons. Therefore,  twelve patients with a median age of 52 years (range 24-82 years) were included in the final analysis. High-frequency ultrasound was performed within a median of 28 (range 10-52) weeks by an experienced radiology specialist to locate the FPLT position in two separate wrist positions: (1) wrist held in 0° position and fingers extended and (2) wrist held in 45° of dorsal extension and actively flexed fingers II to V (functional position). For analysis, we used the axial ultrasound videos. Postoperative X-rays and CT scans were included for the analysis, especially the soft-tissue CT scan window for the exact localization of the FPLT.  Dynamic ultrasound scanning was used to localize the FPLT in relation to the plate in 0° and functional position of the hand. Using CT scanning, the position of the plate relative to the bone was determined. In this way, we were able to correlate the functional FPLT position with the osseous structures of the distal radius.

RESULTS

In all cases, the FPLT was positioned closer to the volar distal edge of the FPL plate in functional position than in 0° position. In four cases, the FPLT did not touch the plate at all and was shown to shift diagonally from radio-volar in ulno-dorsal direction during wrist movement from 0° to functional position, similarly to the sliding of the tendon in the assumed physiological motion sequence. In these cases, in the functional position the center of the FPLT was positioned slightly ulnarly of the center of the distal radius (i.e., less than 50% of the distal radius width measured from the radial border of DRUJ), and positioned more ulnarly than in all other cases (i.e., in which the FPLT came into contact with the plate). In the remaining two-thirds of the cases (eight patients), the FPLT touched the plate during wrist movement from 0° to functional position, shifted in dorsal direction and slid into the plate indentation, irrespective of whether the tendon entered the indentation from the radial or the ulnar side, and independent of the ulnoradial position of the plate. No signs of tendinopathy of the FPLT were found in any of the cases.

CONCLUSION

The results show that the indentation of the Medartis^® APTUS^® FPL plate reduces the tendon-plate contact and ideally even prevents it entirely. In particular, ulnar positioning of the plate lowers the risk of tendon-plate contact. If the FPLT touches the plate, the tendon pulls into the plate indentation, thus lowering the contact. Consequently, the Soong criteria are not applicable when a FPL plate is used.