1
|
Jones SW, Campbell FC, Campbell DA. Revision of Failed Nonanatomic Extensor Retinacular Stabilization of the Unstable ECU Tendon: Surgical Technique and Case Series. Tech Hand Up Extrem Surg 2024; 28:67-73. [PMID: 38088179 DOI: 10.1097/bth.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
Nonanatomic surgical stabilization of the unstable extensor carpi ulnaris (ECU) tendon (where the subluxing tendon is re-routed away from the bony groove in the distal ulna) utilizes a flap of extensor retinaculum to create a new retaining sheath that will stabilize the tendon during forearm rotation movements. When this surgery fails, the extensor retinaculum tissue does not regenerate with sufficient structural strength to be used again. Previously, a different approach has then been needed for revision surgery, often using more complex surgical techniques with a substantially greater impact on recovery. We describe a highly reliable yet simple method of using local soft tissue to adequately restabilize the subluxing ECU tendon in cases where an extensor retinacular flap has already been used. We report the results of this technique in 4 patients, all of whom returned to jobs/hobbies where ECU instability was a considerable functional risk.
Collapse
Affiliation(s)
- Stuart W Jones
- Department of Trauma & Orthopaedic Surgery, Airedale NHS Foundation Trust, Keighley
| | - Fiona C Campbell
- Department of Acute and General Medicine, Harrogate NHS Foundation Trust, Harrogate
| | | |
Collapse
|
2
|
Shoap SC, Dennis ER, Lombardi JM, Wilkerson J, Wahood M, Rosenwasser MP. An Analysis of Extensor Carpi Ulnaris Groove Morphology and Tendon Instability. Hand (N Y) 2024; 19:400-406. [PMID: 35815616 PMCID: PMC11067848 DOI: 10.1177/15589447221105539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The extensor carpi ulnaris (ECU) tendon has a distinct subsheath at the distal ulna. Symptomatic tears of this subsheath and subluxation of the ECU tendon often require reconstruction. We sought to determine the anatomical constraints of the ECU subsheath. METHODS The ECU subsheath was exposed on 12 fresh-frozen upper extremities. The tip of the ulnar styloid, the distal ulnar joint surface, and the proximal extent of the distal radio-ulnar joint were identified and dimensions measured. Subluxation of the tendon was then assessed with and without an intact subsheath in 9 specimens. The travel of the tendon was measured in pronation through supination and flexion before and after sectioning of the subsheath. RESULTS The ECU subsheath is 8.9 mm (standard deviation [SD] = 0.8 mm) wide proximally and 9.0 mm (SD = 1.2 mm) distally. The distal ulnar insertion is 0.5 mm (SD = 0.8 mm) proximal to the tip of the styloid, and stretches 10.2 mm (SD = 2.7 mm) proximally. From maximum pronation to maximum supination and flexion, the ECU tendon traveled 3.32 mm (SD = 4.24) medially when the subsheath was intact and 5.42 mm (SD = 5.0 mm) after sectioning. The maximum depth of the ulnar groove was 2.5 mm (1.59-3.56 mm). There was no significant association between changes in ECU subluxation and the depth of the ECU groove (Spearman's rho = 0.25). CONCLUSION The ECU subsheath is roughly 1 cm square stretching proximally from the ulnar styloid. ECU groove depth is not a significant independent predictor of tendon subluxation.
Collapse
Affiliation(s)
- Seth C. Shoap
- Columbia University Irving Medical Center, New York City, NY, USA
| | | | | | - James Wilkerson
- Columbia University Irving Medical Center, New York City, NY, USA
| | | | | |
Collapse
|
3
|
Burda R, Morochovič R, Rudnay M, Špaková T. A new comprehensive Classification Scheme for ECU Tendon Problems at the Wrist. HANDCHIR MIKROCHIR P 2022; 54:427-433. [PMID: 36037819 DOI: 10.1055/a-1740-4020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Based on a systematic review of the literature, description of previous classification schemes and new anatomical knowledge, a new comprehensive classification scheme for ECU tendon problems at the wrist is described.
Collapse
Affiliation(s)
- Rastislav Burda
- Pavol Jozef Šafárik University in Košice, Department of Trauma Surgery
| | | | - Maroš Rudnay
- Pavol Jozef Šafárik University in Košice, Department of Radiology
| | - Timea Špaková
- Pavol Jozef Šafárik University in Košice, Associated Tissue Bank of Faculty of Medicine
| |
Collapse
|
4
|
Abstract
Extensor carpi ulnaris tendon subluxation can be a challenging diagnosis as a cause of wrist pain. The tendon is stabilized by a tough subsheath. This subsheath is vulnerable to tears in acute wrist movements, especially those combining supination, flexion, and ulnar deviation. The patient presenting acutely may experience swelling, tenderness, and pain. In a chronic setting, the complaint is often an unstable wrist. The diagnosis can be made with a thorough examination, and ultrasonography can be used to evaluate the dynamics of the tendon. Surgical repair with a flap of extensor retinaculum to re-create the tendon's stabilizing subsheath is recommended.
Collapse
Affiliation(s)
- Jacqueline N Byrd
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 122W, Ann Arbor, MI 48109, USA; Department of Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Sarah E Sasor
- Department of Plastic Surgery, Medical College of Wisconsin, Tosa Center, South Entry, Suite T2500, 1155 N Mayfair Road, Wauwatosa, WI 53226, USA
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 122W, Ann Arbor, MI 48109, USA.
| |
Collapse
|
5
|
Omokawa S, Gumpangseth T, Komutrattananont P, Inchai C, Mahakkanukrauh P. Anatomical Study of Stabilizing Structures of the Extensor Carpi Ulnaris Tendon Around the Wrist. J Hand Surg Am 2021; 46:930.e1-930.e9. [PMID: 33846027 DOI: 10.1016/j.jhsa.2021.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 11/26/2020] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The sixth dorsal extensor compartment is a relatively common site of stenosing tenosynovitis in the upper extremity, but the exact location of stenosis is not fully understood. The objective of this study was to investigate the detailed anatomy of structures surrounding the extensor carpi ulnaris (ECU) tendon around the wrist. METHODS Fifty fresh human cadaveric wrists were used for gross observation and morphology measurements of the sixth dorsal compartment and the ECU subsheath. An additional 13 wrists were used for histological examination. We evaluated the morphology of supporting structures in 3 regions: the ulnar groove (zone I), the ulnar styloid process (zone II), and the triquetrum (zone III). RESULTS The fibro-osseous tunnel comprising the ulnar groove and the overlying subsheath (zone I) stabilized the ECU tendon, and the subsheath had thin membranous collagen fibers attached to the periosteum. We consistently found the distal extension of ECU subsheath (zone II), which connected the ulnar styloid process and the dorsal radioulnar ligament. Variations in the length of the distal extension increased with the forearm in pronation. Collagen fiber thickness around the ECU tendon in zone II was greater than that of zone I. In zone III, the overlying extensor retinaculum and septa, which were composed of thick circumferential collagen structures, supported the ECU tendon by attaching to the triquetrum on both sides of the ECU tendon. We found the presence of an ulnar septum of the sixth compartment attached to the triquetrum in 84% of dissected wrists. CONCLUSIONS The ECU tendon was supported by the ECU subsheath, which had thin and elastic collagen fibers over the ulnar groove. Distal extension of the subsheath and surrounding radial and ulnar extensor retinaculum septa attached to the triquetrum provided thicker supporting structures. CLINICAL RELEVANCE Stenosing ECU tenosynovitis may occur not only in the ulnar groove but also in the more distal ulnar styloid process and triquetrum areas.
Collapse
Affiliation(s)
- Shohei Omokawa
- Department of Hand Surgery, Nara Medical University, Kashihara Nara, Japan
| | | | | | - Chirapat Inchai
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Thailand
| | - Pasuk Mahakkanukrauh
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Thailand; Excellence in Osteology Research and Training Center, Chiang Mai University, Thailand; Department of Hand Surgery, Nara Medical University, Kashihara Nara, Japan.
| |
Collapse
|
6
|
Kim JN, Kwon ST, Shin HD. Subluxation of the extensor carpi ulnaris on magnetic resonance imaging on neutral wrist position: correlation with tenosynovitis of the extensor carpi ulnaris and translation of the distal radioulnar joint. Skeletal Radiol 2021; 50:1593-1603. [PMID: 33432435 DOI: 10.1007/s00256-020-03705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/23/2020] [Accepted: 12/27/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify the subluxation degrees of extensor carpi ulnaris (ECU) tendon on neutral wrist MRI in patients with ulnar-sided wrist pain and to evaluate the relationships of ECU subluxation with accompanying imaging findings such as ECU tenosynovitis, distal radioulnar joint (DRUJ) stability, and triangular fibrocartilage complex (TFCC) pathology. MATERIALS AND METHODS A total of 297 MRIs of 292 patients having ulnar side pain were reviewed retrospectively. Degrees of ECU subluxation was classified into four grades: grade 0, no subluxation; grade 1, tendon displacement < 50% of the tendon width; grade 2, tendon displacement 51 to 99% of the tendon width; and grade 3, tendon displacement of 100% of the tendon width. ECU tenosynovitis, ECU tendinosis, injuries of triangular fibrocartilage and distal radioulnar ligaments (DRUL), translation ratio of the DRUJ, rotation angle of the DRUJ, and the width, depth, and length of the ulnar groove were assessed on wrist MRI. The relationships between degree of ECU subluxation and these imaging findings were investigated. RESULTS Women had higher subluxation degrees of the ECU tendon (p = 0.001). Tenosynovitis of the ECU, sprain of the dorsal DRUL, dorsovolar translation ratio and rotation angle of the DRUJ, and depth and length of the ulnar groove were statistically significantly related to the subluxation degree of the ECU tendon (p = 0.000). CONCLUSION High-grade subluxation of the ECU tendon was strongly correlated with ECU tenosynovitis and DRUJ translation. Clinicians and radiologists should scrutinize imaging findings, particularly when patients with ulnar-sided wrist pain have high-grade subluxation of the ECU tendon.
Collapse
Affiliation(s)
- Ji Na Kim
- Department of Radiology, Kangbuk Samsung Hospital, 29 Saemunan-ro, Jongno-gu, 03181, Seoul, Republic of Korea
| | - Soon Tae Kwon
- Department of Radiology, Chungnam National University Hospital, Chungnam National University School of Medicine, 282 Munwha-ro Jung-gu, 35015, Daejeon, Republic of Korea.
| | - Hyun Dae Shin
- Department of Orthopaedic Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, 282 Munwha-ro Jung-gu, 35015, Daejeon, Republic of Korea
| |
Collapse
|
7
|
An Evidence-Based Review of Overuse Wrist Injuries in Athletes. Orthop Clin North Am 2020; 51:499-509. [PMID: 32950219 DOI: 10.1016/j.ocl.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Overuse wrist injuries are a common problem in athletes and can be related to tendinopathies or osteoarticular pathology. Fortunately, athletes rarely miss time from their sport due to these conditions because many can be treated nonoperatively. For refractory cases, there often is a curative surgical procedure that can be done during the off-season.
Collapse
|
8
|
Long-Term Outcomes After Extensor Carpi Ulnaris Subsheath Reconstruction With Extensor Retinaculum. Tech Hand Up Extrem Surg 2019; 24:2-6. [PMID: 31343594 DOI: 10.1097/bth.0000000000000257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study assessed the long-term outcomes and complications of patients that underwent operative treatment for extensor carpi ulnaris subluxation. Fifteen patients underwent extensor carpi ulnaris subsheath reconstruction at a median of 5.9 weeks nonoperative treatment interval (interquartile range: 2.4 to 13). Reconstruction consisted of using the extensor retinaculum as a sling reconstruction. We found that about 1 in 3 patients had a complication or reoperation. At a median of 8 years follow-up, many patients had some residual symptoms, but in general, most patients were satisfied.
Collapse
|
9
|
Peter K, Luzian H, Markus G, Ansgar R, Andrea K, Arora R. Mid-term outcome (11-90 months) of the extensor retinaculum flap procedure for extensor carpi ulnaris tendon instability. Arch Orthop Trauma Surg 2019; 139:1323-1328. [PMID: 31222435 PMCID: PMC6687678 DOI: 10.1007/s00402-019-03227-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The aim of our study was the assessment of the mid-term outcome of patients treated with a pediculated extensor retinaculum flap for extensor carpi ulnaris (ECU) tendon subluxation including postoperative tendon stability control. MATERIALS AND METHODS Twelve patients treated with an extensor retinaculum flap for symptomatic ECU tendon instability were retrospectively evaluated. Follow-up examinations included functional and radiologic assessment. The range of motion, grip strength, DASH score, PRWE score, Krimmer score and subjective satisfaction were recorded. A rotation-movie MRI was conducted before and after surgery to visualize tendon displacement. RESULTS Wrist extension was 65.8° (SD 10.0°), flexion 64.2° (SD 12.2°), radial deviation 15.8° (SD 6.0°), ulnar deviation 32.1° (SD 7.2°), pronation 82.5° (SD 9.4°) and supination 85.0° (SD 9.0°). Mean grip strength was 30.5 kg (SD 8.9 kg). Six patients presented an excellent, four a good, one a fair and one a poor result on the Krimmer score. The DASH and PRWE scores showed a mean of 24.2 (SD 25.1) and 32.2 (SD 29.4) points. MRI showed a dislocation (n = 7) or subluxation (n = 5) of the ECU tendon preoperatively. Five patients showed an unchanged displacement pattern postoperatively. CONCLUSION The pediculated extensor retinaculum flap as a treatment for a symptomatic ECU instability shows good to excellent results and a high subjective satisfaction independent of postoperative ECU tendon displacement.
Collapse
Affiliation(s)
- Kaiser Peter
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Haug Luzian
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
- Department for Plastic, Reconstructive and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gabl Markus
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Rudisch Ansgar
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klauser Andrea
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rohit Arora
- Department of Trauma Surgery, Medical University of Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria.
| |
Collapse
|