Abstract
Purpose of review
The goal of this manuscript is to review key historic and recent literature regarding extensor carpi ulnaris (ECU), triangular fibrocartilage complex (TFCC) and distal radioulnar joint (DRUJ) injuries, particularly in athletes.
Recent findings
Many recent studies examining the ECU focus on clinical and radiographic diagnosis. Several physical exam findings are described in addition to the use of MRI and US. Imaging studies must be clinically correlated due to high incidence of findings in asymptomatic patients.
In regard to the TFCC/DRUJ, there are numerous recent studies that support the use of MRA as an adjunctive diagnostic study. There are also a number of repair constructs that are described for the various different kinds of TFCC pathology reviewed here.
Summary
In summary, there are a number of options for the diagnosis and treatment of ulnar-sided wrist pain. Patient factors, especially in the athletic population, must be taken into account when approaching any patient with these pathologies.
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References
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Patterson SM, Picconatto WJ, Alexander JA, Johnson RL. Conservative treatment of an acute traumatic extensor carpi ulnaris tendon subluxation in a collegiate basketball player: a case report. J Athl Train. 2011;46(5):574.
Hawkes R, O’Connor P, Campbell D. The prevalence, variety and impact of wrist problems in elite professional golfers on the European Tour. Br J Sports Med. 2013;47(17):1075–9.
Campbell D, Campbell R, O’Connor P, Hawkes R. Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. Br J Sports Med. 2013;47(17):1105–11.
Wang C, Gill TJ, Zarins B, Herndon JH. Extensor carpi ulnaris tendon rupture in an ice hockey player a case report. Am J Sports Med. 2003;31(3):459–61.
Montalvan B. Extensor carpi ulnaris injuries in tennis players: a study of 28 cases. Br J Sports Med. 2006;40(5):424–9.
Baratz ME. Central TFCC tears in baseball players. Hand Clin. 2012;28(3):339.
Wiedrich TA. The treatment of TFCC injuries in football players. Hand Clin. 2012;28(3):327–8.
Howard TC. Elite athlete: chronic DRUJ instability or central TFC tears. Hand Clin. 2012;28(3):341–2.
Spinner M, Kaplan E. Extensor carpi ulnaris. Its relationship to the stability of the distal radio-ulnar joint. Clin Orthop Relat Res. 1970;68:124–9.
• Ghatan AC, Puri SG, Morse KW, Hearns KA, von Althann C, Carlson MG. Relative contribution of the subsheath to extensor carpi ulnaris tendon stability: implications for surgical reconstruction and rehabilitation. J Hand Surg. 2016;41(2):225–32. Cadaveric biomechanical study demonstrates the distal half o the ECU subsheath contributes more to ECU stability than the proximal half. Authors propose that this should be emphasized during reconstructive procedure.
Taleisnik J, Gelberman R, Miller B, Szabo R. The extensor retinaculum of the wrist. J Hand Surg [Am]. 1984;9(4):495–501.
Horii E, An KN, Linscheid RL. Excursion of prime wrist tendons. J Hand Surg. 1993;18(1):83–90.
• Chang CY, Huang AJ, Bredella MA, Kattapuram SV, Torriani M. Association between distal ulnar morphology and extensor carpi ulnaris tendon pathology. Skelet Radiol. 2014;43(6):793–800. Retrospective MRI study looking at anatomical variants in association with ECU pathology. Authors report relationship between ulnar negative variance and ECU instability. Depth of the ECU groove trended towards a relationship but did not reach significance.
Sanmartín-Fernández M, Couceiro-Otero J, Costas-Alvarez M, Sotelo-Garcia A. Extensor carpi ulnaris tenosynovitis caused by the tip of an oversized ulnar styloid: a case report. J Wrist Surg. 2015;04(01):065–7.
Inoue G, Tamura Y. Recurrent dislocation of the extensor carpi ulnaris tendon. Br J Sports Med. 1998;32(2):172–4.
Inoue G, Tamura Y. Surgical treatment for recurrent dislocation of the extensor carpi ulnaris tendon. J Hand Surg Br Eur Vol. 2001;26(6):556–9.
Allende C, Le Viet D. Extensor carpi ulnaris problems at the wrist—classification, surgical treatment and results. J Hand Surg Br Eur Vol. 2005;30(3):265–72.
• Kataoka T, Moritomo H, Omori S, Iida A, Omokawa S, Suzuki D, et al. Pressure and tendon strain in the sixth extensor compartment of the wrist during simulated provocative maneuvers for diagnosing extensor carpi ulnaris tendinitis. J Orthop Sci. 2015;20(6):993–8. Cadaveric study demonstrating pressure within the 6th extensor compartment is highest when the wrist and forearm are supinated and patients with tendinopathy will experience pain in this position.
Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg Eur Vol. 2008;33(10):1777–82.
Ng C, Hayton M. Ice cream scoop test: a novel clinical test to diagnose extensor carpi ulnaris instability. J Hand Surg Eur Vol. 2013;38(5):569–70.
•• Kuntz MT, Janssen SJ, Ring D. Incidental signal changes in the extensor carpi ulnaris on MRI. HAND. 2015;10(4):750–5. Study examining the incidental findings of ECU pathology on MRI. When compared against a clinical diagnosis of ECU pathology, MRI was shown to have sensitivity of 57% and specificity of 88%.
Jeantroux J, Becce F, Guerini H, Montalvan B, Le Viet D, Drapé J-L. Athletic injuries of the extensor carpi ulnaris subsheath: MRI findings and utility of gadolinium-enhanced fat-saturated T1-weighted sequences with wrist pronation and supination. Eur Radiol. 2011;21(1):160–6.
Spicer P, Romesberg A, Kamineni S, Beaman F. Ultrasound of extensor carpi ulnaris tendon subluxation in a tennis player. Ultrasound Q. 2016;32(2):191–3.
Lee KS, Ablove RH, Singh S, De Smet AA, Haaland B, Fine JP. Ultrasound imaging of normal displacement of the extensor carpi ulnaris tendon within the ulnar groove in 12 forearm–wrist positions. Am J Roentgenol. 2009;193(3):651–5.
Pratt RK, Hoy GA, Bass FC. Extensor carpi ulnaris subluxation or dislocation? Ultrasound measurement of tendon excursion and normal values. Hand Surg. 2004;9(02):137–43.
•• Sole JS, Wisniewski SJ, Newcomer KL, Maida E, Smith J. Sonographic evaluation of the extensor carpi ulnaris in asymptomatic tennis players. PM&R. 2015;7(3):255–63. Cross sectional ultrasound study of asymptomatic tennis players. The authors report that 75% of studied wrists had ECU pathology on ultrasound.
Hajj A, Wood M. Stenosing tenosynovitis of the extensor carpi ulnaris. J Hand Surg [Am]. 1986;11(4):519–20.
Stathopoulos IP, Raptis K, Ballas EG, Spyridonos S-PG. Recurrent dislocation of the extensor carpi ulnaris tendon in a water-polo athlete. Trauma Mon [Internet]. 2016 Feb 6 [cited 2016 Jun 16];21(1). Available from: http://www.traumamon.com/?page=article&article_id=19551
Burkhart S, Wood M, Linscheid R. Posttraumatic recurrent subluxation of the extensor carpi ulnaris tendon. J Hand Surg [Am]. 1982;7(1):1–3.
Eckhardt WA, Palmer AK. Recurrent dislocation of extensor carpi ulnaris tendon. J Hand Surg Eur Vol. 1981;6(6):629–31.
Palmer A, Werner F. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg [Am]. 1981;6(2):153–62.
Palmer A, Werner F. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984;187:26–35.
Werner FW, Palmer AK, Fortino MD, Short WH. Force transmission through the distal ulna: effect of ulnar variance, lunate fossa angulation, and radial and palmar tilt of the distal radius. J Hand Surg Eur Vol. 1992;17(3):423–8.
• Harley BJ, Pereria ML, Werner FW, Kinney DA, Sutton LG. Force variations in the distal radius and ulna: effect of ulnar variance and forearm motion. J Hand Surg. 2015;40(2):211–6. Cadaveric study demonstrating force across the distal ulnar is greatest with the forearm in pronation. Interestingly, there was no association with ulnar variance found in this study.
Palmer A, Glisson R, Werner F. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg [Am]. 1984;9:681–2.
Bednar M, Arnoezky S, Weiland A. The microvasculature of the triangular fibrocartilage complex—its clinical significance. J Hand Surg [Am]. 1991;16(6):1101–5.
• LaPorte DM, Hashemi SS, Dellon AL. Sensory innervation of the triangular fibrocartilage complex: a cadaveric study. J Hand Surg. 2014;39(6):1122–4. Cadaveric study demonstrating innervation of the TFCC primarily from the dorsal cutaneous branch of the ulnar nerve, medial antebrachial cutaneous nerve, and branch of the palmar cutaneous nerve.
Hagert C. Distal radius fracture and the distal radioulnar joint—anatomical considerations. Handchir Mikrochir Plast Chir. 1994;26(1):22–6.
Palmer A. Triangular fibrocartilage complex lesions—a classification. J Hand Surg [Am]. 1989;14(4):594–606.
Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011;27(3):263–72.
Lester B, Halbrecht J, Levy I, Gaudinez R. “Press test” for office diagnosis of triangular fibrocartilage complex tears of the wrist. Ann Plast Surg. 1995;35(1):41–5.
Onishi T, Omokawa S, Iida A, Nakanishi Y, Kira T, Moritomo H, et al. Biomechanical study of distal radioulnar joint ballottement test. J Orthop Res. 2016 Jun 29
Hahn P, Wolf MB, Unglaub F. Bilateral test for potential subluxation of the DRUJ. Arch Orthop Trauma Surg. 2013;133(10):1459–61.
Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg Eur Vol. 2007;32(4):438–44.
Hess F, Farshad M, Sutter R, Nagy L, Schweizer A. A novel technique for detecting instability of the distal radioulnar joint in complete triangular fibrocartilage complex lesions. J Wrist Surg. 2012;01(02):153–8.
Tomaino MM. The importance of the pronated grip X-ray view in evaluating ulnar variance. J Hand Surg Eur Vol. 2000;25(2):352–7.
Iida A, Omokawa S, Akahane M, Kawamura K, Takayama K, Tanaka Y. Distal radioulnar joint stress radiography for detecting radioulnar ligament injury. J Hand Surg Eur Vol. 2012;37(5):968–74.
May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg Eur Vol. 2002;27(6):965–71.
•• Nakamura T, Iwamoto T, Matsumura N, Sato K, Toyama Y. Radiographic and arthroscopic assessment of DRUJ instability due to foveal avulsion of the radioulnar ligament in distal radius fractures. J Wrist Surg. 2014;03(01):012–7. Retrospective study of patients with distal radius fractures and subsequent wrist arthroscopy for the diagnosis of foveal TFCC injuries. Univariate analysis demonstrates a relationship between increased radial translation, decreased radial inclination, increased radial shortening, and ulnar styloid fragment radial displacement of >4mm.
•• Lee YH, Choi YR, Kim S, Song HT, Suh JS. Intrinsic ligament and triangular fibrocartilage complex (TFCC) tears of the wrist: comparison of isovolumetric 3D-THRIVE sequence MR arthrography and conventional MR image at 3 T. Magn Reson Imaging. 2013;31(2):221–6. Study examining MRI vs MRA, the authors report an increased accuracy in the MRA group compared to MRI alone in the diagnosis of central TFCC tears (95.8 vs 77.1%) and peripheral TFCC tears (95.8 vs. 87.5%).
Iordache SD, Rowan R, Garvin GJ, Osman S, Grewal R, Faber KJ. Prevalence of triangular fibrocartilage complex abnormalities on MRI scans of asymptomatic wrists. J Hand Surg Eur Vol. 2012;37(1):98–103.
• Pahwa S, Srivastava D, Sharma R, Gamanagatti S, Kotwal P, Sharma V. Comparison of conventional MRI and MR arthrography in the evaluation wrist ligament tears: a preliminary experience. Ind J Radiol Imaging. 2014;24(3):259. Preliminary report of 16 patients reporting 100% accuracy of MRA compared to 75% in MRI alone for the diagnosis TFCC tear.
• Cerny M, Marlois R, Theumann N, Bollmann C, Wehrli L, Richarme D, et al. 3-T direct MR arthrography of the wrist: value of finger trap distraction to assess intrinsic ligament and triangular fibrocartilage complex tears. Eur J Radiol. 2013;82(10):e582–9. MRI study looking at the utility of traction. With the use of 4 kg distraction the authors did not find a significant effect on the visualization of the TFCC.
•• Lee RKL, Griffith JF, Ng AWH, Nung RCH, Yeung DKW. Wrist traction during MR arthrography improves detection of triangular fibrocartilage complex and intrinsic ligament tears and visibility of articular cartilage. Am J Roentgenol. 2016;206(1):155–61. MRI study examining the benefit of traction during MRI. With the use of 7 kg for men and 5 kg for women the authors report increased visualization and diagnostic accuracy for TFCC tears.
•• Lee RKL, Ng AWH, Tong CSL, Griffith JF, Tse WL, Wong C, et al. Intrinsic ligament and triangular fibrocartilage complex tears of the wrist: comparison of MDCT arthrography, conventional 3-T MRI, and MR arthrography. Skeletal Radiol. 2013;42(9):1277–85. A cadaveric study demonstrating 100% sensitivity, specificity, and accuracy of CTA in the diagnosis of TFCC tears.
•• Moritomo H, Arimitsu S, Kubo N, Masatomi T, Yukioka M. Computed tomography arthrography using a radial plane view for the detection of triangular fibrocartilage complex foveal tears. J Hand Surg. 2015;40(2):245–51. The authors describe a specific CTA sequence for examining the TFCC using a radial axis. They reported 83% sensitivity, 40% specificity, and 76% positive predictive value.
Jarrett CD, Baratz ME. The management of ulnocarpal abutment and degenerative triangular fibrocartilage complex tears in the competitive athlete. Hand Clin. 2012;28(3):329–37.
Park MJ, Jagadish A, Yao J. The rate of triangular fibrocartilage injuries requiring surgical intervention. Orthopedics [Internet]. 2010 Nov 2 [cited 2016 Jul 28] 10.3928/01477447-20100924-03
Howard TC. The elite athlete: triangular fibrocartilage tears in basketball players. Hand Clin. 2012;28(3):325.
Garcia-Lopez I, Delgado PJ, Abad JM, DE LUCAS FG. Thermal energy for the arthroscopic treatment of tears of the triangular fibrocartilage of the wrist. Acta Orthopa Edica Belg. 2012;78(6):719.
•• Pirolo JM, Le W, Yao J. Effect of electrothermal treatment on nerve tissue within the triangular fibrocartilage complex, scapholunate, and lunotriquetral interosseous ligaments. Arthrosc J Arthrosc Relat Surg. 2016;32(5):773–8. Cadaveric study examining the effect of electrothermal treatment to the TFCC. This study demonstrates a denervation effect to the treated tissues.
Griska A, Feldon P. Wafer resection of the distal ulna. J Hand Surg. 2015;40(11):2283–8.
Smet L, Vandenberghe L, Degreef I. Ulnar impaction syndrome: ulnar shortening vs arthroscopic wafer procedure. J Wrist Surg. 2014;03(02):098–100.
Bernstein MA, Nagle DJ, Martinez A, Stogin JM, Wiedrich TA. A comparison of combined arthroscopic triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome. Arthrosc J Arthrosc Relat Surg. 2004;20(4):392–401.
Stockton DJ, Pelletier M-E, Pike JM. Operative treatment of ulnar impaction syndrome: a systematic review. J Hand Surg Eur Vol. 2015;40(5):470–6.
• Pouliot M, Yao J. Ulnar shortening osteotomy utilizing a trimed ulnar osteotomy system. Tech Hand Up Extrem Surg. 2014;18(2):72–6. Technique guide to the use of a ulnar shortening osteotomy specific plate and system.
Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand Clin. 2011;27(3):281–90.
Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg. 2008;33(5):675–82.
•• Luchetti R, Atzei A, Cozzolino R, Fairplay T, Badur N. Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability. J Hand Surg Eur. 2014;39(8):845–55. Study comparing open and arthroscopic treatment of DRUJ instability due to TFCC injury. Both groups showed improvement of DASH and PRWE scores compared to preoperative scores. However, the arthroscopic group was found to have greater improvements when compared to the open group.
• Atzei A, Luchetti R, Braidotti F. Arthroscopic foveal repair of the triangular fibrocartilage complex. J Wrist Surg. 2015;04(01):022–30. A retrospective review of patients with class 2 and 3 tears that were arthroscopically repaired using suture anchors They showed significant improvement in MMWS and DASH scores as well as resolution of DRUJ instability in 91.7% of their cohort.
• Kim B, Yoon HK, Nho JH, Park KH, Park SY, Yoon JH, et al. Arthroscopically assisted reconstruction of triangular fibrocartilage complex foveal avulsion in the ulnar variance-positive patient. Arthrosc J Arthrosc Relat Surg. 2013;29(11):1762–8. Retrospective review of the treatment of foveal avulsions in ulnar positive patients using an arthroscopically assisted reconstruction with the use of a suture anchor. The authors report significant improvement in MMWS scores as well as decreased dorsal ulnar subluxation postoperatively.
• Geissler W. Arthroscopic knotless peripheral ulnar-sided TFCC repair. J Wrist Surg. 2015;04(02):143–7. Description of a knotless fixation technique for peripheral TFCC tears. The authors propose decreased irritation with the use of knotless constructs.
Woo S, Jegal M, Park M. Arthroscopic-assisted repair of triangular fibrocartilage complex foveal avulsion in distal radioulnar joint injury. Indian J Orthop. 2016;50(3):263–8.
Yao J, Lee AT. All-arthroscopic repair of palmer 1B triangular fibrocartilage complex tears using the FasT-Fix device. J Hand Surg. 2011;36(5):836–42.
Yao J. All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a traditional outside-in technique in cadavers. J Hand Surg. 2009;34(4):671–6.
• Desai MJ, Hutton WC, Jarrett CD. Arthroscopic repair of triangular fibrocartilage tears: a biomechanical comparison of a knotless suture anchor and the traditional outside-in repairs. J Hand Surg. 2013;38(11):2193–7. Cadaveric biomechanical study comparing knotless suture anchors with traditional outside in repair constructs for peripheral TFCC tears. The authors report significantly greater strength of knotless suture anchor constructs.
• Bain GI, McGuire D, Lee YC, Eng K, Zumstein M. Anatomic foveal reconstruction of the triangular fibrocartilage complex with a tendon graft. Tech Hand Up Extrem Surg. 2014;18(2):92–7. Authors describe a technique for reconstruction of chronic DRUJ instability due to TFCC injury using a palmaris longus autograft.
• Bain G, Eng K, Lee Y, Mcguire D, Zumstein M. Reconstruction of chronic foveal TFCC tears with an autologous tendon graft. J Wrist Surg. 2015;04(01):009–14. Retrospective report of nine patients who underwent palmaris longus autograft reconstruction of the DRUJ due to TFCC injury. The authors report increased patient satisfaction and improved pain post operatively.
• Nakamura T. Anatomical reattachment of the TFCC to the ulnar fovea using an ECU half-slip. J Wrist Surg. 2015;04(01):015–21. Case series of patients undergoing TFCC reconstruction with ECU half-slip. The authors report 21/25 patients with excellent outcomes and 22/25 with stable DRUJ.
Sagerman S, Short W. Arthroscopic repair of radial-sided triangular fibrocartilage complex tears. Arthroscopy. 1996;12(3):339–42.
Cho C-H, Lee Y-K, Sin H-K. Arthroscopic direct repair for radial tear of the triangular fibrocartilage complex. Hand Surg. 2012;17(03):429–32.
McAdams TR, Swan J, Yao J. Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med. 2009;37(2):291–7.
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Eric Quan Pang declares that he has no conflict of interest.
Jeffrey Yao reports personal fees from Smith and Nephew Endoscopy during the conduct of study. He also reports personal fees from Arthrex, BME, McGinley Orthopedics, and Trimed, as well as a grant from Medartis, outside of the submitted work.
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Pang, E.Q., Yao, J. Ulnar-sided wrist pain in the athlete (TFCC/DRUJ/ECU). Curr Rev Musculoskelet Med 10, 53–61 (2017). https://doi.org/10.1007/s12178-017-9384-9
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DOI: https://doi.org/10.1007/s12178-017-9384-9