Saturday, May 26, 2012

Ulnar wrist pain: TFCC injury & DD of Ulnar sided wrist pain

Many ulnar wrist pains are obscure & according to Bottke both surgical exploration and nonoperative treatment have been less than satisfying. Most of the times specific physical examination and standard radiographs were unrevealing in these cases. Even with specific diagnostics test such as arthroscopy, treatment results could not be correlated with arthrographic findings (1).

Ulnar wrist pain,Distal RUJ & TFCC:
The distal radioulnar joint (DRUJ) acts in concert with the proximal radioulnar joint to control forearm rotation. The DRUJ is stabilized by the triangular fibrocartilage complex (TFCC). This complex of fibrocartilage and ligaments support the joint through its arc of rotation, as well as provide a smooth surface for the ulnar side of the carpus. TFCC and DRUJ injuries are part of the common pattern of injuries we see with distal radius fractures. While much attention has been paid to the treatment of the distal radius fractures, many of the poor outcomes are due to untreated or unrecognized injuries to the DRUJ and its components (2).
Triangular fibrocartilage complex (TFCC) tears are a common source of ulnar sided wrist pain. Originally described by Palmer, in 1981, as a complex of several structures, our understanding of the anatomy and the function of the TFCC has been refined by histologic studies. The TFCC plays an important role in load bearing across the wrist as well as in distal radioulnar joint (DRUJ) stabilization. A thorough knowledge of the anatomy as well as the Palmer classification system helps to guide treatment options (3).

Palmer’s Classifications of TFCC Lesions (4)
Class 1: Traumatic
A. Central perforation

B. Ulnar avulsion

- With styloid fracture
- Without styloid fracture

C. Distal Avulsion (from carpus)

D. Radial avulsion

- With sigmoid notch fracture
- Without sigmoid notch fracture

Class 2: Degenerative (Ulnar Impaction Syndrome)
A. TFCC wear

B. TFCC wear

+ lunate and/or ulnar head chondromalacia

C. TFCC perforation

+ lunate and/or ulnar head chondromalacia

D. TFCC perforation

+ lunate and/or ulnar head chondromalacia
+ lunotriquetral ligament perforation

E. TFCC perforation

+ lunate and/or ulnar head chondromalacia
+ lunotriquetral ligament perforation
+ Ulnocarpal arthritis

For further reading on TFCC readers are directed to: (5)

Differential diagnosis of Ulnar sided wrist pain (6):
1. TFCC injury:
S/S:  1. Ulnar wrist pain 2. Snapping or clicking
Physical Tests:  1. TFCC compression test  2. Piano key sign 3. Supination lift test 4. Palpation

2. Lunotriquetral Interosseous Ligament (LTIL) Injury:
S/S:  1. Joint tenderness 2. Decreased ROM 3. Decreased grip strength 4. Painful clunk with radial & ulnar deviation
Physical Tests:  1. Ballottement test 2. Shuck test 3. Shear test 4. Ulnar snuffbox test

3. Arthritis (DRUJ /Pisotriquetral):
S/S:  1. Pain & crepitus with loading 2. Decreased ROM 3. Decreased grip strength 4. Localized pain
Physical Tests:  1. Grind tests 2. Palpation of joint lines 3. Ballottement tests 4. ROM

4. DRUJ Instability:
S/S:  1. Pain with forearm rotation
Physical Tests:  1. Grind tests 2. Palpation

5. ECU Pathology:
S/S:  1. Pain specific to ECU tendon 2. ECU subluxation
Physical Tests: 1. Palpation of ECU tendon over ulnar head 2. Resisted wrist extension & ulnar deviation 3. Active forearm supination & ulnar deviation

6. Fracture (Ulnar styloid, Triquetrum, Hamate):
S/S:  1. Tenderness & edema 2. Decreased ROM 3. Decreased wrist strength 4. Pain with motion

Physical Tests: 1. Palpation of bony landmarks 2. DRUJ stability (ulnar styloid) 3. Resisted 5th digit flexion (hamate)

7. Midcarpal Instability:

S/S:  1. Midcarpal clunk with ulnar deviation & pronation 2. Volar sag at ulnar wrist 3. Often bilateral

Physical Tests: 1. Mid carpal shift test

8. Kienbock's Disease:

S/S:  1. Chronic wrist pain without trauma 2. Tender dorsal lunate 3. Decrease ROM 4. Decreased grip strength 5. Arthritis (late stage)

Physical Tests: 1. Palpation of Lunate

9. Ulnar Nerve Entrapment:

S/S:  1. Paresthesia to 4th & 5th digits 2. Hand intrinsic weakness

Physical Tests: 1. Tinel's to Guyon's Canal 2. History/pattern of symptoms

10. Ulnar Artery Thrombosis:

S/S:  1. Night pain 2. Pain with repetitive activity 3. Cold intolerance 4. Exquisite tenderness at site of pathology 5. Dependent rubor or ulceration or 4th or 5th fingertips 6. Sympathetic fiber excitation of ulnar proper digital nerves

Physical Tests: 1. Allen test.

11. Dorsal Ulnar Cutaneous Nerve Neuritis

S/S:  1.  Sensory changes to 4th & 5th digits 2. Pain or sensory changes at elbow and/or hand weakness, indicative of more proximal ulnar nerve pathology .                                                           
Physical Tests: 1. Sensory exam 2. Palpation 3. Wartenburg sign (motor pathology) 4. Froment sign (motor pathology)

Comments on DD of TFCC:
N.B. Acute trauma to the triangular fibrocartilage complex includes tears of the fibrocartilage articular disk substance and meniscal homolog as well as radioulnar ligament avulsions, with or without an associated fracture (7).
The critical distinction is in differentiating injuries that produce instability of the distal radioulnar joint from those that do not. Also important is the recognition of acute injuries in the context of an ongoing degenerative pattern (ie, Palmer class 2 lesions) (7). Subluxation of the ulnar head relative to the sigmoid notch of the radius, as assessed by MRI with the wrist in pronation, is a predictor of tears of the foveal attachment of the TFCC (8). Horizontal tear and fibrillation of TFCC disk without TFCC tear at the radiocarpal joint present with ulnar-sided wrist pain due to isolated triangular fibrocartilage complex. Arthroscopic debridement only relieves pain after surgery and helps in achieving good functional recovery (9).

Patient evaluation includes clinical examination, imaging studies, and wrist arthroscopy (diagnostic). The Palmer classification is typically used to define injuries to the triangular fibrocartilage complex (10).

TFCC management outline:
Both surgical & Non-surgical therapies have claimed success. Nonsurgical management includes temporary splint immobilization of the wrist and forearm, oral nonsteroidal anti-inflammatory medication, corticosteroid joint injection, and physical therapy. Surgical strategies include d├ębridement, acute repair, and subacute repair. Most surgical procedures can be performed arthroscopically. However, open ligament repair may be needed in the setting of distal radioulnar joint instability.

Comments of the author: Manual therapy: Many cases of mild-moderate ulnar sided wrist pain can be helped by MWM technique of Mulligan i.e. Medial glide to intercalar segment with wrist F/E.  

1. Bottke CA et al; Orthopedics. 1989 Aug;12(8):1075-9. Diagnosis and treatment of obscure ulnar-sided wrist pain.

2. Tsai PC et al; Bull NYU Hosp Jt Dis. 2009;67(1):90-6. The distal radioulnar joint.

3. Ahn AK et al;Bull NYU Hosp Jt Dis. 2006;64(3-4):114-8. Triangular fibrocartilage complex tears: a review.

4. Green’s operative hand surgery, fifth edition, Distal radioulnar joint instability, blz: 613-616



7. Henry MH; J Am Acad Orthop Surg. 2008 Jun;16(6):320-9. Management of acute triangular fibrocartilage complex injury of the wrist.

8. Ehman EC et al; J Hand Surg Am. 2011 Nov;36(11):1780-4. Subluxation of the distal radioulnar joint as a predictor of foveal triangular fibrocartilage complex tears.

9. Abe Y et al; Hand Surg. 2011;16(2):177-80. Ulnar-sided wrist pain due to isolated disk tear of triangular fibrocartilage complex within the distal radioulnar joint: two case reports.

10. Henry MH; J Am Acad Orthop Surg. 2008 Jun;16(6):320-9. Management of acute triangular fibrocartilage complex injury of the wrist.

Thursday, May 10, 2012

Differential diagnosis of Anatomic (Radial) snuffbox pain: It is not always DeQuervain’s tenosynovitis.

Tendon, Bone & Ligament causes:
1. DeQuervain’s tenosynovitis:
Swelling of tendon of APL (Abductor pollicis longus) & extensor pollicis brevis at lateral wrist near anatomic snuff box.  The primary complaint is radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb. The pain has been described as a “constant aching, burning, pulling sensation." Pain is often aggravated by repetitive lifting, gripping, or twisting motions of the hand. Swelling in the anatomical snuff box, tenderness at the radial styloid process, decreased CMC abduction ROM of the 1st digit, palpable thickening of the extensor sheaths of the 1st dorsal compartment and crepitus of the tendons moving from the extensor sheath may be found upon examination. Other possible findings include weakness and paresthesia in the hand. Finkelstein’s diagnostic test will present positive provoking the patient’s symptoms.

If left untreated, the inflammation and progressive narrowing (stenosis) can cause scarring that further limits thumb motion.

 2. Carpal Instabilities:
Altered biomechanics of the wrist may produce pain. Scapholunate disassociation, scapho-trapezio-trapezoidal joint degeneratioin, and lunatotriquetral dissociation could all present with radial sided wrist pain.

3. Scaphoid Fracture
A scaphoid fracture commonly present with radial sided wrist pain, tenderness and possible swelling in the anatomical snuff box, and limited ROM with pain especially at end ranges.

4. Osteoarthritis of the 1st CMC
Osteoarthritis of the 1st CMC typically occurs in individuals greater than 50 years old, and will most frequently present with morning stiffness of the 1st CMC joint, a general decrease in ROM of the joint, tenderness along the joint line, and a positive grind test.

Neural Causes:

1. Cheiralgia paresthetica:
Cheiralgia paresthetica is commonly referred to as handcuff neuropathy. It is a neuropathy of the hand generally caused by compression or trauma to the superficial branch of the radial nerve.

The area affected is typically on the back or side of the hand at the base of the thumb, near the anatomical snuffbox, but may extend up the back of the thumb and index finger and across the back of the hand. /S includesnumbness, tingling, burning or pain. Since the nerve branch is sensory there is no motor impairment.

Differentiating point: It may be distinguished from de Quervain syndrome because it is not dependent on motion of the hand or fingers.

2. C6 Cervical Radiculopahy:
Compression on a spinal nerve root can cause sensory disturbances, myotomal weakness, and diminished reflexes throughout the root's distribution. The dermatomal key point for the C6 nerve root is the radial aspect of the 2nd metacarpal and index finger which is close to the area of pain experienced with De Quervain’s. Since a radiculopathy can present much like De Quervain’s a thorough screen of the cervical spine is necessary.