Ulnar Impaction Syndrome

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Search Strategy

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Definition/Description

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Epidemiology/Etiology

Asians have a higher incidence of ulnar variance than Whites, and since ulnar variance is a risk factor for ulnar impaction, ulnar impaction syndrome may be present more often in Asians. However, ulnar impaction is more commonly from an acquired variance rather than congenital. Acquired variance can be due to distal radial fracture malunion, radial head excision, premature physeal closure of the radius, and increased ulnar length. Any of these predisposing factors can lead to excess load across the ulnocarpal joint, resulting in ulnar impaction syndrome.

Characteristics/Clinical Presentation

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Differential Diagnosis

Differential Diagnosis (Sammer 2010):
- Ulnar impaction syndrome
     o Ulnar impaction test
- Pisotriquetral arthritis
- Distal radioulnar joint arthrosis
- Extensor carpi ulnaris subluxation or tendonitis
- Neuritis of dorsal cutaneous branch of ulnar nerve
- Lunotriquetra-Interval (LTIL) injury
     o Hogar shuck test
     o Kleinman shear test
- Triangular Fibrocartilage Complex (TFCC) injury
     o TFCC compression test
     o Piano key sign
     o Supination assessment (assess for volar ulnar subluxation with supination)
- Distal radioulnar joint instability and pain
     o Distal radioulnar joint mobility assessment

Outcome Measures

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Examination

To diagnose ulnar impaction syndrome,a comprehensive wrist exam must be completed. Diagnostic imaging should be performed to support the findings from the clinical exam. The physical therapist should pay specific attention to the following:

• Palpation (Vezeridis, Webb)
     o Tenderness dorsally just distal to ulnar head
     o Tenderness just volar to the ulnar styloid process
     o Positive ulnar variance, while static or dynamic

• Range of Motion (Tatebe, Vezeridis, Webb)
     o Painful passive ulnar deviation and forceful pronation
     o Decreased flexion, extension, radial & ulnar deviation

• Strength (Tomaino, Vezeridis, Webb)
     o Decreased grip strength, using dynamometer

• Ulnocarpal stress test (Nakamura)
     o Place wrist in maximum ulnar deviation
     o Apply axial load to wrist
     o Passively rotate forearm through supination and pronation
     o + Test = reproduction of patient’s pain
     NOTE- Test is sensitive for UIS but can get positive with other pathologies, such as LTIL injury, TFCC injury or isolated arthritis.

• Gripping Rotary Impaction Test (GRIT) (LaStayo)
     o Place arm by side and elbow in 90 degrees of flexion
     o Using a grip dynamometer, measure grip in 3 positions: neutral, full supination, full pronation
     o GRIT Ratio=(supinated grip strength)/(pronated grip strength)
           GRIT ratio is greater than 1.0 indicates UIS

• Imaging – used to support physical examination findings

    o Radiograph (Sammer, Tatebe, Webb, Watanabe)
           Views:
             • Neutral rotation P-A radiograph with elbow in 90° flexion
             • Pronated grip P-A radiograph
           May have subchondral sclerosis, cystic changes, or osteophyte formation
           Positive ulnar variance is the hallmark of UIS
     o MRI (Vezeridis, Webb, Watanabe)
           Detects tears to TFCC and other soft tissue injuries
           May detect decrease in vascular profusion of the lunate and ulnar head or anatomical abnormalities
     o Arthrography (Webb, Watanabe, Shin)
           Currently, considered “gold standard” at detecting damage to TFCC
           Although, recent research is refuting this because of high rates of false-negatives and poor correlation between findings and patient presentation, and stating MRI is more effective

Criteria for Ulnocarpal Abutment Syndrome (Nakamura 1997)
1. Ulnar wrist pain with tenderness just distal to the ulnar head (dorsal and/or palmar)
2. Ulceration or cystic lesion of the lunate ulnar base and/or ulnar head of radiography, OR low signal intensity of the lunate ulnar base on T1-weighted images of MRI, OR degenerative lesions of the TFCC on arthroscopy (Palmer’s class 2 lesion).

Medical Management

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Physical Therapy Management

Conservative treatment should be attempted before surgery. (Sammer & Rizzo 2010).

Treatment is symptom based and can include immobilization for 6-12 weeks, NSAIDs, corticosteroid injection and limiting aggravating movements such as pronation, gripping and ulnar deviation. Lack of improvement with conservative management is an indication for surgery (Sachar 2008, Sammer & Rizzo 2010, LaStayo 2001).

UIS can be associated with class 2 TFCC injury and treatment should also address this if present (Sacher 2008, EORIF.com, Wantanabe 2010) as well as impairments resulting from immobilization.

Example Post-Surgery Protocol(EORIF.com, Sammer 2010, PNCL)
Goals

• Control pain and swelling
• Protect surgical site
• Maintain ROM in unaffected joints (shoulder, elbow, digits)
• Minimize deconditioning

Initial

• Immobilization in sugar-tong splint or long-arm cast x 2wks
• NWB
• Elevation for edema management as needed
• Digit ROM

2 wks Post-Sx

• Sugar-tong splint removed
• Removable splint based on surgery type

           o Ulnar-Shortening Osteotomy - Elbow-hinged long arm splint Munster splint
           o Wafer Procedure - Wrist cock-up brace

• Limited wrist & forearm ROM outside splint
• Avoid loaded pronation & supination

6 – 8 wks Post-Sx

• Full AROM allowed
• Begin STR training – dependent on evidence of bony union (EORIF)
• Isometric elbow flex/ext and pronation/supinatio

12-16 wks Post-Sx

• UE Strength training
• Remaining ROM deficits addressed
• Full union expected by 3 months

6 Months to 1 Year Post-Sx

• Return to unrestricted activity

Post-immobilization therapy should include low-load, high-rep wrist & elbow ROM

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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