Ulnar-Sided Wrist Pain in the Athlete

Ulnar-sided wrist pain is a common problem in athletes that can be challenging owing to its frequent combination of overuse in conjunction with acute injury. Repetitive pronosupination, wrist flexion and extension, as well as radial and ulnar deviation can predispose the athlete to injury of ulnar structures. Careful understanding of the sport-specific injuries as well as the underlying biomechanics are key to understanding and treating the athlete. In this article, we discuss the most frequent causes of ulnar-sided wrist pain in the athlete and focus on anatomy and pathophysiology, presentation, and diagnosis, as well as nonoperative and operative treatment options.

Key points

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The athlete’s wrist is subjected to high loads during activities that involve pronation/supination, radial/ulnar deviation, and flexion/extension.
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These activities stress stabilizing elements of the ulnar side of the wrist, including the triangular fibrocartilage complex, distal radioulnar joint, as well as the ulnocarpal region.
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Pathology along the ulnar side of the athlete’s wrist can lead to pain, dysfunction, and difficulty participating in sport.

Introduction

Ulnar-sided wrist pain is a common problem in athletes that can be challenging owing to its frequent combination of overuse in conjunction with acute injury. Forceful forearm rotation, wrist flexion and extension, as well as radial and ulnar deviation can predispose the athlete to injury of ulnar stabilizing structures. Careful understanding of the sport-specific injuries as well as the underlying biomechanics are key to understanding and treating the athlete. In this article, we discuss the most frequent causes of ulnar-sided wrist pain in the athlete and focus on the anatomy and pathophysiology, presentation and diagnosis, as well as nonoperative and operative treatment options of:

1.

Triangular fibrocartilage complex (TFCC)/distal radioulnar joint (DRUJ) injuries
2.

Ulnocarpal impaction
3.

Extensor carpi ulnaris (ECU) conditions
4.

Flexor carpi ulnaris (FCU) calcific tendonitis

The management of hook of hamate fractures are not discussed in this article because it is detailed within Bilal Mahmood and Steve K. Lee’s article, “ Carpal Fractures Other than Scaphoid in the Athlete ,” in this issue.

Triangular Fibrocartilage Complex and Distal Radioulnar Joint Injuries

Ulnar-sided wrist pain in athletes can be caused by injury to the TFCC. The TFCC is a group of interrelated anatomic structures that are integral to stability of the DRUJ. Traumatic injuries of the TFCC may occur from fall or hyper-rotational injuries to the forearm. Repetitive forceful movement of the athlete’s wrist from supination to pronation can cause overload stress affecting components of the TFCC.

Anatomy and biomechanics

The TFCC is a group of structures that assist with load transmission from the hand and carpus, and is the primary stabilizer of the DRUJ. There are 6 main components of the TFCC that provide stability to the DRUJ ( Box 1 , Fig. 1 ). The volar and dorsal radioulnar ligaments are the major supportive structures of the joint. In particular, the deep ligamentum subcruentum fibers are the main stabilizing component of the DRUJ. These fibers insert at the fovea at a relatively obtuse angle of attachment onto the volar and dorsal margins of the sigmoid notch, facilitating rotational stability. The superficial radioulnar ligaments insert at a more acute angle onto the styloid and provide secondary stability to the DRUJ, as well as support to the articular disc.

Box 1

Components of the TFCC

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Central disc
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  Bound by the volar and dorsal superficial radioulnar ligaments and the distal sigmoid notch of the radius
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  Relative avascular central portion with significant peripheral vascularity
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Superficial radioulnar ligaments: volar and dorsal
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  Attach to the distal volar/dorsal edges of the sigmoid notch and the ulnar styloid
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  Narrow angle of attachment
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Deep radioulnar ligaments: volar and dorsal
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  Also attach to the distal volar/dorsal edges of the sigmoid notch, but at the fovea near the base of the ulnar styloid
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  Wide angle of attachment
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Ulnotriquetral and ulnolunate ligaments
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  Actually attach at the ulnar and volar aspect of the disc, not the ulna
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ECU subsheath
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  Course dorsally similar to the volar ulnocarpal ligaments
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Meniscal homologue
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  Ulnar side of the complex; a reflection of the joint capsule

Volarly, the TFCC is linked to the ulnar carpus through strong attachments to the lunotriquetral ligament and the ulnar extrinsic ligaments, as well as to the hamate and base of the fifth metacarpal. Dorsally, there are weak attachments of the TFCC to the carpus, except where the TFCC blends with the ECU subsheath. The ulnar collateral ligament is a capsular structure that arises from the base of the ulnar styloid. The ulnocarpal meniscal homologue travels from the discoid section of the TFCC to the triquetrum, lunate, and fifth metacarpal. Both of these structures form the remainder of the TFCC in addition to the ECU subsheath and the articular disc. The TFCC and distal ulna receive about 16% to 20% of wrist load in neutral variance, which increases with ulnar deviation of the hand and ulnar positive morphology. Heavy gripping activities, as well as the increased ulnar positive variance that occurs with wrist pronation, both serve to increase load transmission to the TFCC. ^,

The TFCC is supplied by terminal branches of the ulnar artery; in particular, the anterior and posterior interosseous arteries that insert around the periphery and provide a rich blood supply to the fovea. The central articular disc, which can be likened to the central portion of the meniscus of the knee, is avascular and has limited healing potential.

The DRUJ is inherently unstable through its bony configuration, where the sigmoid notch has a greater radius of curvature than the ulnar seat, providing approximately 20% of the stability. The stability of the joint is achieved through extrinsic structures including the ECU tendon and its subsheath, the deep head of the pronator quadratus, and the distal interosseous ligament, which includes the distal oblique bundle that provides isometric stability during pronosupination. Intrinsic stability of the DRUJ is provided largely by the radioulnar ligamentous components of the TFCC.

Patient history

Athletes who participate in sports that use racquets, clubs, or bats are at risk for TFCC or DRUJ injures owing to the high torque loads transmitted, especially when moving from supination to pronation. Traumatic injuries from a fall with an extended and deviated wrist may cause an acute injury. The athlete may recall a specific event in which they experienced acute pain, or may have a more insidious onset. They may report a variety of symptoms:

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Mechanical symptoms of the ulnar wrist
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Pain located over the dorsal and ulnar wrist
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Pain with wrist loading
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Pain with forearm pronation or supination
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Pain with ulnar deviation
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Pain and feelings of instability

Physical examination

Knowledge of the anatomy of the TFCC is important to localize areas of pathology through the physical examination. Physical examination begins with examination of the wrist to assess for swelling or visual abnormality compared with the contralateral wrist. The patient is seated at the hand table with the elbow at 90° and fingers toward the ceiling. Range of motion, including flexion/extension, pronation/supination, and radial/ulnar deviation, is then assessed. The examination should be compared with the contralateral uninjured wrist. Tenderness to palpation over various components of the TFCC can help to focus on the pathologic area and should be performed in a stepwise fashion over each anatomic component. Dorsally, the TFCC is intimately associated with the ECU subsheath, which can make tenderness at this region difficult to isolate.

Tenderness at the ulnar fovea is a both highly sensitive and specific test for TFCC injuries or ulnotriquetral ligament injuries, with a sensitivity of 95% and specificity of 86% for detecting foveal disruptions or ulnotriquetral ligament tears. The ulnar fovea is a soft spot that lies between the ulnar styloid process, the ECU and the FCU tendons, which is easily palpable with the forearm in neutral rotation. This test is positive when pain is elicited and replicates the patient’s pain when compared with the contralateral side. It is important to isolate the TFCC as the location of pain during the physical examination. The ECU synergy test, discussed within the ECU Tendonitis section, is helpful for distinguishing between intra-articular and extra-articular pathology.

Testing of the lunatotriquetral (LT) interval is important to determine LT instability as a cause of ulnar-sided pain. The LT shear test, as described by Kleinman, is performed with the wrist and fingers in the standard examining position. ^, To examine the patient’s right hand, the examiner’s left thumb is placed over the dorsal surface of the lunate with the remaining 4 fingers wrapping around the radial wrist to stabilize the hand–forearm unit. The right thumb is then placed over the pisiform, applying a dorsally directed force while the left thumb applies a volarly directed force across the lunate, to cause shearing at the LT interval and detect even mild pain.

The LT compression test, as described by Linscheid, is performed with the hand and wrist in the standard position. The forearm is stabilized along the radial border, and the thumb of the examining hand pushes firmly on the triquetrum in an ulnar to radial direction. This causes compression across the LT joint and elicits pain in a positive test. ^,

As described by Kleinman, the dorsal fibers of the deep ligamentum subcruentum are under maximum tension with the forearm in supination. Conversely, the palmar fibers of the deep ligamentum subcruentum are under maximum tension with the forearm in pronation. Testing of the dorsal fibers is performed by rotating the forearm to full supination, loading the distal ulna toward the patient and pulling the radiocarpal unit toward the examiner ( Fig. 2 ). In an injury to these dorsal fibers, this maneuver causes pain or increased translation, depending on the degree of injury to the stabilizing complex. Palmar fiber testing is done similarly, with the forearm in full pronation. A dorsally directed force is then placed along the distal ulna while the radiocarpal unit is again pulled toward the examiner ( Fig. 3 ). Pain or increased translation when compared with the contralateral arm results if there is an injury to the palmar fibers of the ligamentum subcruentum.

The DRUJ compression test identifies inflammation or articular pathology within the DRUJ. With the wrist and forearm in neutral rotation and fingertips toward the ceiling, the wrist is grasped proximal to the DRUJ at the junction of the distal and middle thirds of the forearm. The forearm is squeezed together to compress the radius and ulna, and the forearm is rotated. Pain elicited when compared with the opposite side indicates a positive test.

Imaging

Plain radiographs are part of the initial workup and typically consist of zero-rotation posteroanterior and lateral radiographs ( Figs. 4 and 5 ). In particular, ulnar variance, morphology, and degenerative changes of the DRUJ are assessed. It is important to also identify the presence of an ulnar styloid fracture or nonunion. MRI is commonly used for evaluation of the TFCC and associated soft tissues or for assistance in differentiating between extra-articular and intra-articular pathology. Conventional MRI has been shown to have sensitivity ranging from 44% to 100% and specificity of 60% to 100% in identifying TFCC injuries, depending on whether a 1.5 T or 3.0 T magnet is used. ^, MR arthrography has been shown to have increased accuracy in diagnosing both central and peripheral TFCC tears when compared with MRI, with sensitivity of up to 94% in central TFCC tears, 93% in peripheral tears, and specificity of 97% to 100% in a single study. A systematic review of 21 studies demonstrated a pooled sensitivity of 75% and specificity of 81% for MRI in detecting full-thickness TFCC tears compared with 84% sensitivity and 95% specificity for MR arthography. Arthroscopy, however, is considered to be the gold standard for diagnosing TFCC injuries. Confirmation of a tear can be performed with the assistance of arthroscopic tests. The trampoline test is done by using a probe to ballotte the articular disc and evaluate for loss of tension of the disc, which may occur with a peripheral tear. The hook test assesses the TFCC at its foveal insertion. This is done by placing a probe into the prestyloid recess and applying a radial traction force. Displacement of the TFC off the ulnar head can be demonstrated when an unstable foveal tear is present. A recent cadaveric study demonstrated increased sensitivity, specificity, and reliability of the hook test in diagnosing TFCC tears when compared with the trampoline test. Recently, the suction test has been described to identify peripheral TFCC tears as well as confirm integrity of a repair. A shaver is placed arthroscopically and applies periodic suction, demonstrating a loss of tension along the TFCC in the presence of a tear, which is not seen after repair.

Treatment

Nonoperative treatment

In patients with an acute TFCC injury and a stable DRUJ, an initial period of nonoperative management should be initiated. This consists of the use of bracing to prevent forearm rotation. Taping of the DRUJ and the use of anti-inflammatories or intra-articular corticosteroid injections can be helpful for athletes that are trying to continue training. A retrospective study identified 57% of patients treated successfully with nonoperative treatment in 1 month in a volar wrist splint or cast. Consideration of the athlete’s activity level as well as time remaining in their season, as well as future career endeavors, must be taken into account when considering the duration of nonoperative treatment.

Operative treatment

Operative treatment is considered for failure of nonoperative management or TFCC tears in the presence of DRUJ instability. Arthroscopic evaluation of the ulnar wrist is important for diagnosis and treatment of TFCC lesions. The Palmer classification is commonly used to describe TFCC injuries and is separated into both traumatic (class 1) and degenerative (class 2) injuries. Class 2 injuries are often associated with ulnocarpal impaction and will be discussed further in that section.

Class 1: Traumatic
- 1A: Central perforation
- 1B: Ulnar avulsion, with or without ulnar styloid fracture
- 1C: Distal avulsion
- 1D: Radial avulsion, with or without sigmoid notch fracture
Class 2: Degenerative
- 2A: TFCC wear without perforation or chondromalacia
- 2B: TFCC wear with chondromalacia of the lunate or ulnar head, or both
- 2C: TFCC perforation, with lunate/ulnar chondromalacia
- 2D: TFCC perforation, with lunate/ulnar chondromalacia and lunotriquetral ligament perforation
- 2E: TFCC perforation, with lunate/ulnar chondromalacia, lunotriquetral ligament perforation, and ulnocarpal arthritis

Class 1A lesions are the most common type of traumatic tears and are rarely associated with the instability that can be seen in class 1B and 1C injuries. Although the Palmer classification is widely used, it does not offer a treatment-oriented approach. Atzei and Luchetti described a classification system for peripheral TFCC injuries that incorporates stability of the DRUJ as well as offers a treatment algorithm ( Table 1 ). This classification system divides the TFCC into the proximal component, which is composed of the proximal triangular ligament and ligament subcruentum, and the distal component, which is made up of the ulnar collateral ligament and distal hammock structure.

Table 1

Atzei and Luchetti classification of peripheral TFCC tears

From Atzei A, Luchetti R. Foveal TFCC Tear Classification and Treatment. Hand Clin . 2011;27(3):263-272; with permission.

Class	Injury Pattern	Treatment
0	Isolated ulnar styloid fracture without TFCC tear	Nonoperative (splinting) or fragment removal
1	Distal peripheral TFCC tear without DRUJ instability	TFCC suture or splinting acutely
2	Complete peripheral TFCC tear of both the proximal and distal components, with DRUJ instability	Fixation of TFCC to fovea
3	Proximal peripheral TFCC tear with DRUJ instability	Fixation of TFCC to fovea or styloid fixation if associated with avulsion fracture
4	Nonrepairable TFCC tear owing to large size or poor healing potential	Tendon graft reconstruction
5	TFCC tear and DRUJ arthritis	Arthroplasty

For patients who have class 1A or traumatic central tears and fail nonoperative management, arthroscopic debridement is considered. Central tears of the TFCC lack the healing potential that is seen with peripheral tears owing to the relative avascularity of the central portion of the disc. The goals of debridement are resection of the central portion back to a stable rim and removal of any loose flaps that may cause mechanical symptoms or irritation. Limited arthroscopic debridement for traumatic central tears has been shown to have good clinical results with success rates from 66% to 95%, without destabilization of the TFCC. A biomechanical study demonstrated that partial excisions that compromised less than two-thirds of the disc region and left the peripheral 2 mm of the disc intact did not result in any significant biomechanical changes. In the setting of ulnar-positive variance, ulnar shortening osteotomy may also be considered. This will be discussed further in the Ulnocarpal Impaction section.

Peripheral tears, or type 1B lesions, are in the vascular region of the TFCC and are amenable to arthroscopic or open repair. A variety of arthroscopic techniques have been described and are often preferred in athletes to an open repair. Fixation options include repair of the torn fibers to capsule or to bone with suture anchors or transosseus fixation, the latter of which is performed if there is concomitant foveal injury resulting in DRUJ instability. Peripheral tears affecting the superficial fibers only have been described by Wysocki and colleagues to have good results in treatment with outside-in repair of the TFCC to the ulnar capsule, with improvement in mean Disability of Arm Shoulder and Hand (DASH) scores from 38 to 9 at an average final follow-up of 31 months. Additionally, 64% of high-level athletes returned to sport at a similar level of competition. McAdams and colleagues described arthroscopic repair of unstable TFCC tears in competitive athletes using an inside-out repair with good results and return to sport in all athletes at an average of 3.3 months. All-arthroscopic, all-inside fixation has also recently been described to decrease disadvantages such as extra incisions or prominent suture knots. ^, However, in our experience, peripheral stable tears are best treated with an arthroscopic repair using an outside-in suture tying technique. The postoperative protocol includes 6 weeks of immobilization followed by gradual return to activity. We have found that athletes are usually able to return to sport at 3 to 6 months postoperatively with the addition of circumferential compression support during activity.

For unstable peripheral tears associated with DRUJ instability or disruption of the deep radioulnar ligament, we feel that these injuries are best treated in an open fashion. This technique allows direct, secure fixation of the deep radioulnar ligaments to their anatomic site of bony origin. However, when comparing open versus arthroscopic repair of unstable peripheral TFCC repairs, neither approach has proven to be superior. A retrospective review comparing arthroscopic versus open foveal repairs showed no difference in pain, range of motion, grasping power, stability, or DASH scores. Luchetti and colleagues found no difference in postoperative outcomes when comparing functional outcomes of arthroscopic versus open repairs except for superior DASH scores in the arthroscopically treated group. Likewise, Anderson and colleagues found no statistically significant differences between the 2 groups, but did observe a higher rate of postoperative superficial ulnar nerve pain in the open group as well as a slightly increased wrist range of motion.

Open Triangular Fibrocartilage Complex Repair

Preparation and patient positioning

The patient is placed supine and the operative extremity is prepped and draped. A sterile tourniquet is applied before placing the wrist in a commercial traction tower. Folded towels are used to pad the skin against the tower. Initial evaluation begins with establishment of a standard 3-4 portal; however, multiple portals are used depending on the site of pathology.

Surgical approach

Diagnostic arthroscopy is performed and confirmation of TFCC tear is visualized. The arm is then removed from the traction tower and placed onto the hand table in a pronated position. A longitudinal incision is made centered over the ECU tendon, with an ulnar angulation at the level of the DRUJ. Full-thickness skin flaps are then raised off the extensor retinaculum with care taken to identify and protect the dorsal sensory branch of the ulnar nerve. The retinaculum and dorsal ECU sheath are then opened sharply, the ECU is retracted ulnarly, the extensor digiti quinti proprius is retracted through the fifth dorsal compartment, and the location of the TFCC is localized with the placement of an 18-gauge needle distal to the pole of the distal ulna ( Fig. 6 ). Proximally, the dorsal DRUJ capsule is elevated off the ulnar head using a radially based rectangular flap. Elevation of this exposes the proximal undersurface of the TFCC at its articulation with the pole of the ulna.