Getting a Grip on Ulnar Sided Wrist Pain
By Ather Mirza, MD
Being in practice for over 30 years, I have seen a progressive and dynamic shift in procedural approaches over time. As techniques have evolved, our field and the larger medical community have greatly benefited from the pearls and pitfalls shared among colleagues. When a potential breakthrough emerges in the field of medicine, onlooking physicians owe due diligence on the subject at the very least. At times, these breakthroughs result in the adoption of new methods, but more often than not our understanding of the subject is broadened. Certain pathologies may require entirely new protocols to be investigated, while others may just need to be viewed from a different perspective.
For many clinicians, ulnar sided wrist pain has proven to be a daunting opponent when discerning a differential diagnosis. The biomechanical complexity of the ulnar sided wrist joint, coupled with the small structural sizes of pertinent anatomy further complicate the diagnostic process. With over 30 years of experience diagnosing ulnar sided wrist pain and performing ulnar shortening osteotomies, my approach has undoubtedly changed over time (Figure 1).
When seeing and evaluating patients presenting with ulnar sided wrist pain, gripping posteroanterior view x-ray has become a mainstay in our practice. Incorporating this view in the evaluation process has yielded considerable success. While standard posteroanterior view is a staple of evaluation, it often fails to account for dynamic changes in ulnar variance that may be contributing to ulnar sided wrist pathology (Figures 2 & 3).
In addition to gripping posteroanterior view x-rays, arthrograms have proven to be more helpful than MRI in the diagnostic process. This has been especially true for the diagnosis of lunotriquetral tears, which are often missed in general orthopedic practice without the use of midcarpal arthrogram (Figure 4). Regarding the diagnosis of triangular fibrocartilage complex tears, MRI and radiocarpal arthrogram have both served useful.
Moving from diagnosis to treatment, I have seen my approach with operative technique subtly evolve. Utilizing finger traps while hanging a 12lb weight has made arthroscopy significantly easier to perform. Following arthroscopy and proceeding with ulnar shortening osteotomy, the hand is left in traction and the weight is decreased to 5lbs. This approach makes exposing the ulna relatively easy and taking x-rays during the procedure less cumbersome. During the procedure, we use 4 Hohmann (Baby Bennett) retractors. These retractors are placed subperiosteally on either side of the ulna, tied with a kling on the opposite side to make function like self-retaining retractors (Figure 5).
For new and seasoned physicians alike, mainstay approaches and historical techniques serve as fertile learning grounds for success. As the advancement of technology continually ushers in new approaches of evaluation and treatment, it is our duty to vet these methods. Whether incorporated as a whole, in part, or not at all, our attempts to shape the landscape of medicine broaden our colleagues understanding and often spark further ingenuity. While many novel approaches fail, you never know when the next breakthrough is going to be.
Figure 1: Ulnar Shortening Osteotomy
Figure 2: Standard PA View
Figure 3: Gripping PA View
Figure 4: LT Tear Observed Under Arthroscopy
Figure 5: Retraction Method Utilized