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1.  Case report of right hamate hook fracture in a patient with previous fracture history of left hamate hook: is it hamate bipartite? 
Background
Hamate hook fracture is a common fracture in golfers and others who play sports that involve rackets or sticks such as tennis or hockey. This patient had a previous hamate fracture in the opposing wrist along with potential features of hamate bipartite.
Case presentation
A 19 year old male presented with a complaint of right wrist pain on the ulnar side of the wrist with no apparent mechanism of injury. The pain came on gradually one week before being seen in the office and he reported no prior care for the complaint. His history includes traumatic left hamate hook fracture with surgical excision.
Conclusion
The patient was found to have marked tenderness over the hamate and with a prior fracture to the other wrist, computed tomography of the wrist was ordered revealing a fracture to the hamate hook in the right wrist. He was referred for surgical evaluation and the hook of the hamate was excised. Post-surgically, the patient was able to return to normal activity within eight weeks. This case is indicative of fracture rather than hamate bipartite. This fracture should be considered in a case of ulnar sided wrist pain where marked tenderness is noted over the hamate, especially after participation in club or racket sports.
doi:10.1186/1746-1340-14-22
PMCID: PMC1618845  PMID: 17038179
2.  Position Change of the Neurovascular Structures around the Carpal Tunnel with Dynamic Wrist Motion 
Objective
The purpose of this study was to determine the anatomic relationships between neurovascular structures and the transverse carpal ligament so as to avoid complications during endoscopic carpal tunnel surgery.
Methods
Twenty-eight patients (age range, 35-69 years) with carpal tunnel syndrome were entered into the study. We examined through wrist magnetic resonance imaging in three different positions (neutral, radial flexion, and ulnar flexion) and determined several anatomic landmark (distance from the hamate hook to the median nerve, ulnar nerve, and ulnar vessel) based on the lateral margin of the hook of the hamate. The median nerve and ulnar neurovascular structure were studied with the wrist in the neutral, ulnar, and radial flexion positions.
Results
The ulnar neurovascular structures usually passed just over or ulnar to the hook of the hamate. However, in 12 hands, a looped ulnar artery coursed 0.6-3.3 mm radial to the hook of the hamate and continued to the superficial palmar arch. The looped ulnar artery migrates on the ulnar side of Guyon's canal (-5.2-1.8 mm radial to the hook of the hamate) with the wrist in radial flexion. During ulnar flexion of the wrist, the ulnar artery shifts more radially beyond the hook of the hamate (-2.5-5.7 mm).
Conclusion
It is appropriate to transect the ligament greater than 4 mm apart from the lateral margin of the hook of the hamate without placing the edge of the scalpel toward the ulnar side. We would also recommend not transecting the transverse carpal ligament in the ulnar flexed wrist position to protect the ulnar neurovascular structure.
doi:10.3340/jkns.2011.50.4.377
PMCID: PMC3243843  PMID: 22200022
Carpal tunnel syndrome; Ulnar neurovascular structures; Wrist position
3.  Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome 
Ulnar-sided wrist pain is a common problem and can be difficult to manage due to the wide range of etiologies, and the fact that significant pain can be present without radiographic evidence. A common cause of ulnar-sided wrist pain is ulnar impaction syndrome, for which several factors must be considered when choosing from among the many available treatment options. Ulnar shortening osteotomy is the most commonly performed surgical procedure for ulnar impaction syndrome at the largest hand surgery unit in Canada. In addition to objective radiological and range of motion measurements, this study used a visual analogue scale and the Disabilities of the Arm and Shoulder survey to characterize self-reported outcomes of ulnar shortening osteotomy.
BACKGROUND:
Ulnar-sided wrist pain is a common problem in the upper extremity. It affects a broad patient population and can be difficult to treat. Ulnar impaction syndrome (UIS) is major cause of ulnar-sided wrist pain and a number of different operations have been used to correct it, including ulnar shortening osteotomy (USO).
OBJECTIVE:
To retrospectively review functional outcomes and complication rates of USO for UIS at the Hand and Upper Limb Centre (London, Ontario) over a two-year period.
METHODS:
Twenty-eight patients who underwent USO between 2007 and 2009 participated in the present study. Ulnar variance pre- and post-surgery was assessed using standard radiographic examination. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) survey for functional outcomes. Objective grip strength and range of motion were compared with the contralateral extremity.
RESULTS:
On average, USO achieved a 3.11 mm reduction in ulnar variance. Nonunion occurred in five patients and required a secondary bone grafting procedure. All USO eventually healed. Overall, pain improved by 47.2% and the mean DASH score after surgery was 37.21. Flexion, extension and supination range of motion decreased by 10° compared with the unaffected side. Eleven patients (39%) elected to undergo a second surgery for hardware removal. Patients receiving compensation from the Workplace Safety and Insurance Board experienced significantly higher residual pain (VSA 5.24 versus 1.97) and disability levels (DASH 60.23 versus 25.70). Smokers also experienced worse outcomes in terms of pain (VSA 4.43 versus 2.36) and disability (DASH 51.06 versus 29.67). In this cohort, smoking was not associated with a higher rate of nonunion.
CONCLUSION:
USO is effective in reducing pain in UIS and improves disability, at the price of a small decrease in range of motion. Smokers and people receiving compensation from the Workplace Safety and Insurance Board, however, have significantly worse subjective outcomes (VAS and DASH), but similar objective outcomes (range of motion).
PMCID: PMC3307684  PMID: 23598767
Ulnar impaction syndrome (UIS); Ulnar shortening osteotomy (USO); Ulnar wrist pain
4.  The prevalence, variety and impact of wrist problems in elite professional golfers on the European Tour 
British Journal of Sports Medicine  2013;47(17):1075-1079.
Objectives
Golf is a popular sport played by an estimated 57 million people. Previous studies on wrist injuries in elite golfers have been of simple design and have demonstrated such injuries to be frequent, although no studies report the incidence, variety, severity or impact on the activity of wrist injuries in detail. This prospective cross-sectional study assesses these factors in a cohort of elite professional golfers.
Methods
European Tour golfers eligible to compete at the 2009 BMW PGA Championship at Wentworth were studied. Study design involved the completion of a structured questionnaire supplemented by interview and examination when required, with performance statistics provided by the European Tour. The severity of injury was assessed by the number of missed tournaments and the amount of time of missed practice.
Results
128 of 153 eligible golfers, (84%) completed the study with 38 golfers (30%) reporting 43 problems. The majority of injuries (67%) occurred in the leading wrist at the most common location, the ulnar side of the wrist (35%). 87% of all ulnar-sided and 100% of radial-sided problems were in the leading wrist.
Conclusions
There were clear side differences reported by the players with the lead wrist demonstrating much higher injury rates in all areas. The most significant injury, in terms of absence from competition, was extensor carpi ulnaris tendon subluxation. Specific injuries are explained in relation to the biomechanics of the golf swing. Most structural injuries have a specific treatment and rehabilitation plan, which can involve significant periods of time away from the sport, while the management of many of the more minor problems is through alterations in technique or practice regimes, aiming to keep a golfer playing during recovery.
doi:10.1136/bjsports-2012-091917
PMCID: PMC3812892  PMID: 24014125
Elite Performance; Wrist Injuries; Golf; Sporting Injuries
5.  Hook of hamate fractures in competitive baseball players 
Hand (New York, N.Y.)  2013;8(3):302-307.
Background
Baseball players are susceptible to a number of specific upper extremity injuries secondary to batting, pitching, or fielding. Fractures of the hook of hamate have been known to occur in batters. The purpose of this study is to present our experience with the surgical management of hook of hamate fractures and their short-term impact on the playing capability of competitive baseball players.
Methods
A retrospective chart review was performed on patients with hook of hamate fractures between the years 2000 and 2012. The inclusion criteria were (1) hook of hamate fracture, (2) competitive baseball players, and (3) surgical treatment of the injury. Patient demographics, mechanism of injury, surgical treatment, and outcome were collected from the medical records. Information on return to play was collected from the Internet when applicable.
Results
There were seven male patients that underwent eight procedures. The mechanism of injury was attributed to batting in six cases and rogue pitches in two cases. All surgeries consisted of hamate hook excision and ulnar tunnel decompression. One patient had concomitant carpal tunnel release. The median time between surgery and return to play was 5.7 weeks (range, 4.3 to 10.4 weeks).
Conclusions
The mechanism of hook of hamate fractures in baseball players is predictable, most often developing secondary to repetitive swinging. This injury may occur at all levels of competition. Ulnar tunnel decompression with hook of hamate excision provides good outcomes, with minimal complications and early return to play.
doi:10.1007/s11552-013-9527-4
PMCID: PMC3745239  PMID: 24426938
Baseball; Fracture; Hook of hamate
6.  Will the untreated ulnar styloid fracture influence the outcome of unstable distal radial fracture treated with external fixation when the distal radioulnar joint is stable 
Background
The ulnar styloid is an important supportive structure for the triangular fibrocartilage complex. However, it remains inconclusive whether or not a fractured ulnar styloid should be fixed in an unstable distal radius fracture (DRF) with a stable distal radioulnar joint (DRUJ). The purpose of this study is to evaluate the effect of an untreated ulnar styloid fracture on the outcome of unstable DRF treated with transarticular external fixation when the DRUJ is stable.
Methods
106 patients with an unstable DRF and a stable DRUJ were included in this study following external fixation. The patients were divided into the non-fracture, the tip-fracture and the base-fracture groups according to the location of the ulnar styloid fracture at the time of injury. Postoperative evaluation included the range of wrist motion, the radiological index, the grip strength, the PRWE-HK scores, the wrist pain scores, and the instability of DRUJ at the external fixator removal time, three months postoperatively and the final follow-up visit.
Results
The patients were followed for 12 to 24 months (15 months in average). Sixty-two of 106 patients (58%) had ulnar styloid fracture and 16 patients (26%) showed radiographic evidence of union of ulnar styloid fractures at the final follow-up visit. No significant difference in the radiological findings, the range of wrist motion, the grip strength, the PRWE-HK scores, and the wrist pain scores among three patient groups was detected at the external fixator removal time, three months postoperatively, or the final follow-up visit. Six of the 106 patients (5.7%) complained of persistent ulnar-side wrist pain during daily activities. One patient (0.9%) showed a positive sign in a stress-test, three patients (2.8%) showed a positive sign in a provocative-test, and five patients (4.7%) showed a positive sign in a press-test. There was no significant difference in the percentages of patients who complained of persistent ulnar-side wrist pain or showed a positive sign in the physical examination of the distal radioulnar joint among the three groups at the final follow-up time points.
Conclusion
When the DRUJ is stable, an untreated ulnar styloid fracture does not affect the wrist outcome of the patient with an unstable DRF treated with external fixation.
doi:10.1186/1471-2474-14-186
PMCID: PMC3686660  PMID: 23758986
Distal radius fracture; Ulnar styloid fracture; External fixation
7.  Kienbock’s disease in a varsity football player: a case report and review of the literature 
Objective:
To present the diagnostic, clinical features, and management of Kienbock’s disease and create awareness of the differential diagnosis of this condition in patients presenting with insidious, progressive dorsal wrist pain.
Clinical Features:
A 23-year old male varsity football player presented with insidious progressive dorsal sided wrist pain with reduced wrist flexion and extension. A diagnosis of Kienbock’s disease was made based on radiographs and magnetic resonance imaging.
Intervention and Outcome:
A 3mm ulnar-minus variance was found and a joint leveling procedure to shorten the radius was performed. Conservative therapy was provided pre and post surgical management.
Summary:
This case report demonstrates the importance of findings on radiographs, MRI, and clinical examination in the accurate diagnosis and management of a patient with wrist pain.
PMCID: PMC3501914  PMID: 23204571
Kienbock; Kienbock’s disease; lunatomalacia; avascular necrosis; osteonecrosis; lunate; Kienböck; maladie de Kienböck; malacie du semi-lunaire; nécrose avasculaire; ostéonécrose; os semi-lunaire
8.  The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player – MR, US and Sonoelastography Evaluation 
Polish Journal of Radiology  2014;79:467-471.
Summary
Background
Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography.
Case Report
A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3–0.6% in males and 0–3–1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head.
Discussion
Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more “snapping reasons” is rare but should be always taken under consideration.
Conclusions
There are no sonoelastography studies describing golfers elbow syndrome, additional triceps band and ulnar neuritis. Our data suggest that the sonoelastography signs are similar to those seen in well described lateral epicondylitis syndrome, Achilles tendinitis and medial nerve neuralgia.
doi:10.12659/PJR.891393
PMCID: PMC4269067  PMID: 25525475
Elasticity Imaging Techniques; Elbow Joint; Ulnar Nerve Compression Syndromes
9.  Carpal contusions in an elite platform diver 
BMJ Case Reports  2011;2011:bcr0120113691.
Wrist and hand injuries are common in elite divers, as all correctly performed dives end with a head first entry into the water with the hands extended above the head. This case presentation was an Olympic level diver with 3 months of persistent dorsal wrist pain. MRI findings showed contiguous contusions to the lunate, capitate, hamate and distal radius and also a peripheral tear of the ulnar attachment of the triangular fibrocartilage complex (TFCC). The repeated dorsiflexion stress of entry into the water likely caused these injuries. Although the authors had suspected a TFCC injury and did find an isolated ulnar-sided peripheral tear, the complicating carpal contusions led us to choose a conservative treatment plan, which was the only intervention the patient ultimately required.
doi:10.1136/bcr.01.2011.3691
PMCID: PMC3063257  PMID: 22707598
10.  Percutaneous Pinning of Fifth Carpal–Metacarpal Fracture–Dislocations: An Alternative Pin Trajectory 
Hand (New York, N.Y.)  2008;3(3):251-256.
Traditional management of unstable fourth and fifth carpal–metacarpal (CMC) fracture–dislocations (fx–dislocs) of the hand includes closed reduction and percutaneous pinning (CRPP) versus open reduction internal fixation (ORIF). Traditional trajectory of pin placement is toward the base of the hook of the hamate. Our case series of CMC fx–dislocs treated with this trajectory led to the development of ulnar deep motor branch symptoms (sxs). We attempt to propose an alternative trajectory that could lower the chance of iatrogenic injury. Five fresh frozen cadaveric specimens underwent percutaneous pinning of the fifth CMC joint using fluoroscopic guidance. Each cadaver was dissected, and the proximity of the deep motor branch of the ulnar nerve was measured in relation to a pin that penetrated the volar cortex. Our results confirm the close proximity of the deep motor branch of the ulnar nerve to the volar cortex of the hamate and demonstrate the potential for iatrogenic injury during CRPP of the fifth CMC fx–dislocs, especially with penetration of the volar cortex. By demonstrating the close proximity of the deep motor branch to the volar cortex of the hamate in cadavers, we highlight the potential for iatrogenic injury with CRPP of CMC fx–dislocs as seen in our case series. We recommend a more midaxial starting point on the proximal metacarpal with a trajectory aimed at the midbody of the hamate to prevent penetration of the hamate volar cortex and limit the chances of iatrogenic injury.
doi:10.1007/s11552-008-9092-4
PMCID: PMC2525872  PMID: 18780105
Carpal–metacarpal fracture–dislocations; CMC fx–dislocs; Fifth CMC fx–dislocs; Deep motor branch ulnar nerve; Percutaneous pinning fifth carpal–metacarpal
11.  Minimally invasive plate osteosynthesis for distal radius fractures 
Indian Journal of Orthopaedics  2014;48(1):20-24.
Background:
Fractures of distal radius are common injury in all age groups. Cast treatment with or without close reduction is a viable option. However, the results are often unsatisfactory with restricted function. The open reduction and internal fixation often results in extensive soft tissue dissection and associated high rates of infect and delayed/nonunion. The distractor/external fixator have reported good functional and anatomical results but the incidence of pin traction infection nerve injury and cosmedic deformity are high. We introduced a modified operative technique for minimally invasive plate osteosynthesis (MIPO) for distal radial fracture and evaluated the functional outcomes and complications.
Materials and Methods:
22 distal radial fractures (10 left, 12 right) were treated using the MIPO technique and two small incisions with a palmar locking plate from August 2009 to August 2010. The wrist function was assessed according to Dienst wrist rating system, and postoperative complications were recorded.
Results:
According to Dienst wrist rating system, 13 patients showed excellent results, 6 cases showed good results and 3 patients had moderate results. No patient had poor results. Thus, the excellent and good rate was 86.4%. One patient had anesthesia in the thenar eminence and this symptom disappeared after 3 months. One patient had delayed healing in the proximal wrist crease. Two patients had mild pain on the ulnar side of the wrist and two patients had limited wrist joint function.
Conclusion:
The MIPO technique by using two small palmar incisions is safe and effective for treatment of distal radial fractures.
doi:10.4103/0019-5413.125483
PMCID: PMC3931148  PMID: 24600058
Distal radius fracture; minimally invasive plate fixation; palmar locking plate
12.  Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals 
This case report describes the effectiveness of thrust manipulation to the elbow and carpals in the management of a patient referred with a medical diagnosis of cubital tunnel syndrome (CuTS). The patient was a 45-year-old woman with a 6-week history of right medial elbow pain, ulnar wrist pain, and intermittent paresthesia in the ulnar nerve distribution. Upon initial assessment, she presented with a positive elbow flexion test and upper limb neurodynamic test with ulnar nerve bias. A biomechanical assessment of the elbow and carpals revealed a loss of lateral glide of the humerus on the ulna and a loss of palmar glide of the triquetral on the hamate. After the patient received two thrust manipulations of the elbow and one thrust manipulation of the carpals over the course of four sessions, her pain and paresthesia were resolved. This case demonstrates that the use of thrust manipulation to the elbow and carpals may be an effective approach in the management of insidious onset CuTS. This patient was successfully treated with thrust manipulation when joint dysfunction of the elbow and wrist were appropriately identified. This case report may shed light on the examination and management of insidious onset CuTS.
doi:10.1179/2042618611Y.0000000019
PMCID: PMC3360489  PMID: 23633888
Elbow pain; Ulnar nerve neuropathy; Biomechanical dysfunction; Humeroulnar joint manipulation; Neurodynamic
13.  Madelung Deformity in a Collegiate Gymnast: A Case Report 
Journal of Athletic Training  2001;36(2):170-173.
Objective:
To present the case of a 21-year-old female collegiate gymnast with acute left wrist pain.
Background:
Madelung deformity is a developmental abnormality of the wrist. It is characterized by anatomic changes in the radius, ulna, and carpal bones, leading to palmar and ulnar wrist subluxation. It is more common in female patients and is usually present bilaterally. The deformity usually becomes evident clinically between the ages of 6 and 13 years.
Differential Diagnosis:
Traumatic distal radius physeal arrest, congenital anatomic variant.
Treatment:
The athlete was treated with symptomatic therapeutic modalities and nonsteroidal anti-inflammatory medication for pain. She was able to continue to participate successfully in competitive gymnastics, minimally restricted, with the aid of palmar wrist tape and a commercially available wrist brace to prevent end-range wrist extension.
Uniqueness:
Madelung deformity can result in wrist pain and loss of forearm rotation, leading to decreased function of the wrist and hand. This patient was able to participate successfully in elite- and college-level gymnastics with no wrist pain or injury until the age of 21 years. Furthermore, she was able to continue to participate, experiencing only periodic pain, with the aid of taping and bracing support and without the need for reconstructive surgery.
Conclusions:
Although rare, Madelung deformity is typically corrected surgically in athletes with chronic pain and disability. This case demonstrates an example of successful conservative management in which the athlete continued to participate in sport.
PMCID: PMC155529  PMID: 12937458
traumatic physeal arrest; triangular fibrocartilage complex
14.  MR Arthrography of the Wrist: Controversies and Concepts 
Hand (New York, N.Y.)  2008;4(1):66-73.
Magnetic resonance arthrography (MRA) has become the preferred modality for imaging patients with internal derangement of the wrist. However, several aspects of MRA use need to be clarified before a standardized approach to the imaging of internal derangement of the wrist can be developed. The objective of the study is to evaluate the efficiency of different magnetic resonance (MR) sequences in the detection of lesions of the triangular fibrocartilage complex (TFCC) and scapholunate and lunotriquetral ligaments on direct MRA. Thirty-one consecutive direct magnetic resonance arthrographic examinations of the wrist using a wrist surface coil were performed for the assessment of the TFCC and intrinsic ligaments on a 1.5-T MR imaging system (Signa; 16 channel, Excite, GE Healthcare, Milwaukee, WI, USA). All patients had wrist pain, and in six cases, there was associated clinical carpal instability. The presence, location, and extent of TFCC, scapholunate ligament (SLL), and lunotriquetral ligament (LTL) lesions on T1 fat-saturated, multiplanar gradient recalled (MPGR) and short tau inversion recovery (STIR) images were identified, compared, and analyzed. Forty-one lesions of the TFCC, SLL, and LTL were visualized on contrast-sensitive (T1 fat-saturated) images in 23/31 (74.2%) patients. Twenty-one lesions of the TFCC and intrinsic ligaments were visualized on noncontrast-sensitive (MPGR and STIR) images (15 tears of the TFCC and six tears of the SLL and LTL). All of these lesions were seen on T1 fat-saturated images; 48.8% (20/41) lesions seen on T1 fat-saturated images (eight tears of TFCC and 12 tears of SLL and LTT) were not seen on MPGR and/or STIR images. Superior contrast resolution, joint distention, and the flow of contrast facilitate the diagnosis of lesions of the TFCC and intrinsic ligaments on contrast-sensitive sequences making MRA the preferred modality for imaging internal derangements of the wrist. Little agreement exists regarding the value and location of perforations of the intrinsic ligaments given that both traumatic and degenerative perforations may be symptomatic. Noncommunicating defects of the ulnar attachments of the triangular fibrocartilage (TFC), tears of the dorsal segment of the SLL, and defects at the lunate attachment of the SLL have a higher likelihood of being symptomatic and caused by trauma rather than by degenerative perforation. Although no consensus exists, it would appear that most arthrographies should be started with a radiocarpal injection. Injection into the distal radioulnar joint should be added if no communicational defects are visualized following radiocarpal injection in patients with ulnar-sided wrist pain.
doi:10.1007/s11552-008-9149-4
PMCID: PMC2654947  PMID: 19048349
Magnetic resonance imaging; Arthrography; Wrist
15.  Ulnar-sided wrist pain. Part I: anatomy and physical examination 
Skeletal Radiology  2009;39(8):733-745.
Ulnar-sided wrist pain is a common complaint, and it presents a diagnostic challenge for hand surgeons and radiologists. The complex anatomy of this region, combined with the small size of structures and subtle imaging findings, compound this problem. A thorough understanding of ulnar-sided wrist anatomy and a systematic clinical examination of this region are essential in arriving at an accurate diagnosis. In part I of this review, ulnar-sided wrist anatomy and clinical examination are discussed for a more comprehensive understanding of ulnar-sided wrist pain.
doi:10.1007/s00256-009-0775-x
PMCID: PMC2895881  PMID: 19722104
Wrist; Anatomy; Clinical examination; Magnetic resonance imaging (MRI)
16.  Distal radioulnar joint injuries 
Indian Journal of Orthopaedics  2012;46(5):493-504.
Distal radioulnar joint is a trochoid joint relatively new in evolution. Along with proximal radioulnar joint, forearm bones and interosseous membrane, it allows pronosupination and load transmission across the wrist. Injuries around distal radioulnar joint are not uncommon, and are usually associated with distal radius fractures,fractures of the ulnar styloid and with the eponymous Galeazzi or Essex_Lopresti fractures. The injury can be purely involving the soft tissue especially the triangular fibrocartilage or the radioulnar ligaments. The patients usually present with ulnar sided wrist pain, features of instability, or restriction of rotation. Difficulty in carrying loads in the hand is a major constraint for these patients. Thorough clinical examination to localize point of tenderness and appropriate provocative tests help in diagnosis. Radiology and MRI are extremely useful, while arthroscopy is the gold standard for evaluation. The treatment protocols are continuously evolving and range from conservative, arthroscopic to open surgical methods. Isolated dislocation are uncommon. Basal fractures of the ulnar styloid tend to make the joint unstable and may require operative intervention. Chronic instability requires reconstruction of the stabilizing ligaments to avoid onset of arthritis. Prosthetic replacement in arthritis is gaining acceptance in the management of arthritis.
doi:10.4103/0019-5413.101031
PMCID: PMC3491781  PMID: 23162140
Distal radioulnar joint; TFCC; distal radius fracture; DRUJ injuries; DRUJ arthroplasty
17.  Results of ulnar shortening osteotomy with a new plate compression system 
Hand (New York, N.Y.)  2012;7(3):281-285.
Purpose
The gold standard for treatment of ulnar impaction has become ulnar shortening osteotomy. Previous reports in the literature have shown not only good results with relief of ulnar-sided wrist pain but also significant nonunion rates and painful hardware necessitating further surgery and potentially, metal removal. The purpose of this paper is to review the success rate of ulnar shortening osteotomy utilizing a low profile compression plate designed specifically for ulnar shortening osteotomy.
Methods
Ninety-three patients with ulnar abutment syndrome underwent ulnar shortening osteotomy with the low profile osteotomy plate. There were 47 males and 46 females. The Acumed’s ulnar shortening system was utilized in all cases. The patients were evaluated for pain, range of motion, grip strength, return to work, time to union, and hardware removal. The patients’ results were validated using the Mayo Wrist Score.
Results
There was a 100 % union rate in the 93 patients. There were no nonunions or delayed unions, or any hardware removal. All patients noted an improvement in their ulnar-sided wrist pain. Utilizing the Mayo wrist classification, the average postoperative score was 84.5. The average preoperative Mayo score was 49.4, for an average increase of 35.1 points.
Conclusion
The Acumed’s low-contact plate designed specifically for ulnar shortening osteotomy demonstrated 100 % union rate and no implant removal in our series. This is the largest study to our knowledge of a series of ulnar shortening osteotomies and successful healing without the removal of any implants. Furthermore, the specifically designed ulnar shortening osteotomy plate significantly simplifies the procedure for the surgeon and improves patient outcomes with relief of ulnar-sided wrist pain.
doi:10.1007/s11552-012-9417-1
PMCID: PMC3418351  PMID: 23997733
Ulnar osteotomy; Compression plate; Positive ulnar variance
18.  Isolated displaced non-union of a triquetral body fracture: a case report 
Introduction
Fractures of the body of the triquetral bone are the second most common carpal fractures, and these fractures can be missed on plain X-ray. Although non-union of triquetral body fractures is very rare, such cases are associated with considerable morbidity and reduction in functional activity.
Case presentation
We report the case of a 29-year-old Caucasian British man who sustained an isolated displaced triquetral body fracture that resulted in non-union, who was treated surgically. We describe an original operative management for this debilitating injury. An open reduction and internal fixation using double headed compression screws was performed, without bone grafting, and with early immobilization of the wrist.
Conclusions
We propose this novel approach and advocate early clinical suspicion of triquetral body fractures in patients with a history of fall on an outstretched hand and ulnar sided wrist pain. We recommend evaluation using computed tomography or magnetic resonance imaging scanning.
doi:10.1186/1752-1947-6-54
PMCID: PMC3293004  PMID: 22325450
19.  Ulnar Impaction Syndrome: A case series investigating the appropriate diagnosis, management, and post-operative considerations 
Ulnar sided wrist pain is a common site for upper extremity disability. Ulnar impaction syndrome results in a spectrum of triangular fibrocartilage complex (TFCC) injuries and associated lunate, triquetrum, and ligamentous damage. Patients commonly present with insidious ulnar sided wrist pain and clicking, and a history of trauma or repetitive axial loading and rotation. In this case series, three patients presented to a sports chiropractor for evaluation and were subsequently diagnosed with ulnar impaction syndrome. Treatment strategies consist of conservative management, arthroscopic debridement or repair, arthroscopic wafer procedure, or ulnar shortening osteotomy. For the athlete, intervention should be individualized and sport-specific, considering athletic priorities, healing potential, return to play, and long-term health concerns.
PMCID: PMC4262812  PMID: 25550665
ulnar impaction; abutment; TFCC injury; athlete(s); management; chiropractic; impaction cubitale; soutien; lésions TFCC; athlète; traitement; chiropratique
20.  Arthroscopic Wafer Procedure for Ulnar Impaction Syndrome 
Arthroscopy Techniques  2014;3(1):e123-e125.
Ulnar impaction syndrome is abutment of the ulna on the lunate and triquetrum that increases stress and load, causing ulnar-sided wrist pain. Typically, ulnar-positive or -neutral variance is seen on a posteroanterior radiograph of the wrist. The management of ulnar impaction syndrome varies from conservative, symptomatic treatment to open procedures to shorten the ulna. Arthroscopic management has become increasingly popular for management of ulnar impaction with ulnar-positive variance of less than 3 mm and concomitant central triangular fibrocartilage complex tears. This method avoids complications associated with open procedures, such as nonunion and symptomatic hardware. The arthroscopic wafer procedure involves debridement of the central triangular fibrocartilage complex tear, along with debridement of the distal pole of the ulna causing the impaction. Debridement of the ulna arthroscopically is taken down to a level at which the patient is ulnar neutral or slightly ulnar negative. Previous studies have shown good results with relief of patient symptoms while avoiding complications seen with open procedures.
doi:10.1016/j.eats.2013.09.008
PMCID: PMC3986578  PMID: 24749031
21.  Chronic volar distal radioulnar joint instability: joint capsular plication to restore function 
Canadian Journal of Surgery  2009;52(2):112-118.
Background
Volar instability of the distal radioulnar joint (DRUJ) is uncommon, and there is little written about it. The purpose of this study is to describe a new procedure to treat volar DRUJ instability and to present the outcomes of patients who received this unique surgical repair at a minimum of 1 year follow-up.
Methods
We performed a retrospective case series of 6 consecutive patients treated with a volar and dorsal capsular plication procedure by an upper extremity specialist surgeon at a teaching hospital between April 1999 and October 2004. We evaluated measures, including wrist range of motion, grip strength, radiographs, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and Patient-Rated Wrist Evaluation (PRWE), at final follow-up.
Results
Five of 6 patients had resolution of pain and instability symptoms. The average difference in range of motion between operative and contralateral sides was –7° flexion, 2° extension, 4° radial deviation, 2° ulnar deviation, –17° supination and –2° pronation. Average grip strength measured 83% of the uninjured side. The average DASH score was 13.5 (range 0–46.7), and the average PRWE score was 26.7 (range 0–70). One patient had a low ulnar neuropathy, which resolved. One patient fractured the temporary DRUJ stabilization screw and had radiographic evidence of nonbridging heterotopic ossification.
Conclusion
Joint capsular plication for DRUJ has not yet been described in the literature. It is less elaborate in that it does not require a tendon graft with bone tunnels. The results at an average 16.5 months postoperatively are promising.
PMCID: PMC2663503  PMID: 19399205
22.  Ulnar-sided wrist pain. II. Clinical imaging and treatment 
Skeletal Radiology  2009;39(9):837-857.
Pain at the ulnar aspect of the wrist is a diagnostic challenge for hand surgeons and radiologists due to the small and complex anatomical structures involved. In this article, imaging modalities including radiography, arthrography, ultrasound (US), computed tomography (CT), CT arthrography, magnetic resonance (MR) imaging, and MR arthrography are compared with regard to differential diagnosis. Clinical imaging findings are reviewed for a more comprehensive understanding of this disorder. Treatments for the common diseases that cause the ulnar-sided wrist pain including extensor carpi ulnaris (ECU) tendonitis, flexor carpi ulnaris (FCU) tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex (TFCC) lesions, ulnar impaction, lunotriquetral (LT) instability, and distal radioulnar joint (DRUJ) instability are reviewed.
doi:10.1007/s00256-009-0842-3
PMCID: PMC2904904  PMID: 20012039
Wrist pain; Ulnar side; Imaging; Treatment
23.  A Guyon's canal ganglion presenting as occupational overuse syndrome: A case report 
Background
Occupational overuse syndrome (OOS) can present as Guyon's canal syndrome in computer keyboard users. We report a case of Guyon's canal syndrome caused by a ganglion in a computer user that was misdiagnosed as OOS.
Case presentation
A 54-year-old female secretary was referred with a six-month history of right little finger weakness and difficulty with adduction. Prior to her referral, she was diagnosed by her general practitioner and physiotherapist with a right ulnar nerve neuropraxia at the level of the Guyon's canal. This was thought to be secondary to computer keyboard use and direct pressure exerted on a wrist support. There was obvious atrophy of the hypothenar eminence and the first dorsal interosseous muscle. Both Froment's and Wartenberg's signs were positive. A nerve conduction study revealed that both the abductor digiti minimi and the first dorsal interosseus muscles showed prolonged motor latency. Ulnar conduction across the right elbow was normal. Ulnar sensory amplitude across the right wrist to the fifth digit was reduced while the dorsal cutaneous nerve response was normal. Magnetic resonance imaging of the right wrist showed a ganglion in Guyon's canal. Decompression of the Guyon's canal was performed and histological examination confirmed a ganglion. The patient's symptoms and signs resolved completely at four-month follow-up.
Conclusion
Clinical history, occupational history and examination alone could potentially lead to misdiagnosis of OOS when a computer user presents with these symptoms and we recommend that nerve conduction or imaging studies be performed.
doi:10.1186/1749-7221-3-4
PMCID: PMC2275269  PMID: 18269753
24.  Posttraumatic distal ulnar physeal arrest: a case report and review of the literature 
Hand (New York, N.Y.)  2012;8(1):115-119.
We report the case of a 12-year-old male who sustained a Salter–Harris (SH) type IV physeal fracture of the distal ulna and a SH type II fracture of the distal radius. At 34 months later, he presented with activity-related wrist pain and ulnar variance of −17 mm. He successfully underwent ulnar distraction osteogenesis with radial closing wedge osteotomy. At 16-month follow-up, the patient denied wrist pain with activity, and imaging demonstrated ulnar variance of −3 mm. Epiphyseal fracture separations of the distal radius and ulna have the potential to cause early growth arrest and may become symptomatic as a result. High-energy mechanism, open fracture, number of reduction attempts, and age at injury can all increase the risk of premature closure. Therefore, we recommend longitudinal follow-up of patients with these injuries as earlier intervention may improve outcomes. When premature physeal closure is discovered early, treatment may include resection of the physeal bar, osteotomy with or without epiphysiodesis, and distraction osteogenesis.
doi:10.1007/s11552-012-9464-7
PMCID: PMC3574474  PMID: 24426906
25.  Differences between radial and ulnar deviation of the wrist in the study of the intrinsic intercarpal ligaments: magnetic resonance imaging and gross anatomic inspection in cadavers 
Skeletal Radiology  2009;39(8):799-805.
Objective
To demonstrate how radial and ulnar deviation of the wrist can affect the visualization of the intrinsic intercarpal ligaments using magnetic resonance (MR) imaging, MR arthrography and gross anatomic inspection in cadavers.
Materials and methods
The detectability of the intrinsic intercarpal ligaments of ten fresh human wrists was analyzed in coronal, axial and sagittal images in the neutral position and in radial and ulnar deviation with MR imaging and MR arthrography. The findings were then correlated with gross anatomic inspection. Additionally, quantitative measurements including the radiocarpal distances and capitate angles were performed.
Results
Differences were noted in the visual conspicuity of only the intercarpal ligaments of the proximal carpal row with different techniques and wrist positions. The average width of the radiocarpal joint was 0.62 mm, 1.55 mm and 2.0 mm (radial side) and 3.78 mm, 2.25 mm and 1.16 mm (ulnar side) in radial deviation, neutral position, and ulnar deviation of the wrist, respectively. Statistically, these maneuvers produced significant opening in the ulnar side during radial deviation (Student’s t-test; P = 0.0005) and in the radial side in ulnar deviation (P = 0.007).
Conclusion
Significant differences in the width of the radiocarpal joint were observed during radial and ulnar deviation of the wrist, influencing the visualization of the intrinsic ligaments, mainly the scapholunate and lunotriquetral ligaments. The use of MR arthrography with radial and/or ulnar deviation has the potential to improve diagnosis in clinical cases in which injury to one or both of these ligaments is suggested.
doi:10.1007/s00256-009-0796-5
PMCID: PMC2895879  PMID: 19820928
Wrist; MRI; Ligaments; Arthography

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