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The Pathology of the Long Ulna: Anatomy and TreatmentInstitut Français de Chirurgie de la Main, Paris, France Correspondence: Dr Philippe Saffar, Institut Français de Chirurgie de la Main, 5, rue du Dôme Paris 75116, France. Tel.:+33 1 53 65 53 53; fax:+33 1 53 65 53 53. E-mail:psaffar{at}ifcm.org
A long ulna, as a result of congenital differential growth, such as Madelung’s disease, or injury, commonly a consequence of a malunited distal radial fracture, may present clinically as pain, decreased motion, mainly of pronosupination, and weakness of grip. Secondary effects may include perforations and tears of the triangular fibrocartilage complex, cartilage wear of the proximal surface of lunate and triquetrum and tears of the lunotriquetral ligament. Positive ulnar variance may be evident on X-rays but a prominent ulnar head cannot always be excluded when there is neutral ulnar variance and further investigations, such as an arthroCTscan or arthroscopy, may be necessary. The two principle treatment options are (a) resection of the distal ulna (Darrach’s and Sauvé –Kapandji’s techniques are commonly used) and (b) techniques preserving the ulnar head, including different modalities of shortening osteotomy. The aim is to regain a congruent distal radioulnar joint, restore painless and normal pronosupination and prevent onset of osteoarthritis of this joint.
Key Words: ulna • ulnar variance • shortening • osteotomy The anatomy of the distal radioulnar joint (DRUJ) is known to be complex. This joint has to be both mobile and stable. It works in coordination with the proximal radioulnar joint to allow pronosupination. The local ligamentous anatomy is well described. These ligaments contribute to the stabilisation of this joint. Other stabilisers include the interosseous membrane, the pronator quadratus muscle and the tendon of the extensor carpi ulnaris muscle. Ulnar variance measurement assesses the relative length of the ulna and radius. Several methods have been described to estimate the relationship between the two bones (Coleman et al., 1987; Hulten, 1928; Palmer et al., 1982) (Fig 1). There is a physiological variation of ulnar variance at the end of the growth period which generally varies between – 2 and +2 mm, but this can be significantly more in a small group of individuals.
Pathological positive ulnar variance (ulna +) can be classified into (a) congenital – occurring congenitally as a result of differential growth, such as may occur in Madelung’s disease and (b) acquired – arising after injury. It is commonly a consequence of a malunited distal radial fracture or a sequel to childhood fracture, infection or growth arrest, as is seen in the pseudo-Madelung deformity in young gymnasts (Tolat et al., 1992).
The distal radioulnar joint is a trochoid joint, composed of (a) the radial notch of the distal radius, of which the range of the curvature is variable with the joint being less stable if the curvature of the notch is too wide (b) the distal articular head of the ulna which articulates with the radial notch. A crescent-shaped cartilage occupies 2/3 of the medial circumference of the ulnar head and is about 4 mm thick. This cartilage is in continuity with the rounded distal aspect of the head, which is completely covered by cartilage. The ulnar styloid process is an apophysis located distally on the dorso-medial part of the ulnar head. This joint is stabilised by (a) the radioulnar palmar and dorsal ligaments, (b) the triangular fibro cartilage complex (TFCC), (c) the sheath of the extensor carpi ulnaris tendon passing through a gutter in the ulnar head, (d) the pronator quadratus muscle and the interosseous membrane and (e) the proximal radioulnar joint. Special attention should be paid to: (a) the shape of the distal surface of the ulna, which may be relatively flat or domed. In the latter case, it may abut against the carpus, when this convexity of the distal ulna may cause damage to the TFCC. In addition, it may cause erosion of the cartilage of the proximal carpus, even although the X-rays show an apparently normal ulnar variance. This is seen in more than half of the presenting cases (Fig 2). (b) The volume of the distal radioulnar joint. This may be conical, cylindrical or spherical (Fig 3). A spherical shape is the usual shape of the ulnar head in a wrist with positive ulnar variance of congenital origin. (c) Contact between the two bones, which may have been reduced by an injury (Fig 4). (d) The length of the ulnar styloid, as a long styloid may create a localised arthrosis on the triquetrum (Fig 5).
Proportionally, 80% of the forces pass from the hand to the forearm through the radius, especially when the exerting force passes through the central column of the carpus (lunate and capitate). Where there is ulnar positive variance, the transmission of force increases through the ulnar column, causing the ulna to abut against the ulnar carpus (Tencer et al., 1988). This is particularly true when the ulna is aligned with the carpus in the sagittal plane. When a posterior or anterior subluxation is present, the compressive forces are dissipated. The compression associated with the abutment increases with grasp, in pronation and with age. Ulno-carpal abutment syndrome may create changes in the TFCC, the cartilage of the proximal lunate and triquetrum and the lunotriquetral ligament. Disturbances of the distal radioulnar joint are common after distal radius fractures, particularly after fractures involving the radiocarpal joint or distal radioulnar joint with distal radioulnar joint incongruity. In congenital long ulna, repeated pronosupination movements may result in degenerative injuries of the avascular central part of the TFCC along with a variable central tear and also cartilage wear on the proximal carpus. There may also be a combination of traumatic and degenerative injuries.
Past injuries, usually distal radial fractures or fractures during childhood, are recorded. A rheumatological disease, such as osteoarthritis or chondrocalcinosis, may exist and rheumatoid arthritis may also be present, with localisation of pain at the level of the DRUJ. A congenital wrist deformity, such as Madelung’s deformity, may be apparent clinically to the naked eye (Fig 6).
The magnitude of the pain during movement, mainly pronosupination, spontaneous or provoked by manipulation, is assessed. Ulnar deviation may also be painful (Fig 7). Distal stump pain and posterior displacement may be predicted after ulnar distal bone resection, if there is a posterior dislocation of this bone.
Wrist range of motion, in flexion–extension, ulnar and radial deviation and pronosupination, and its strength, using the opposite side for comparison, are noted. Decrease of pronosupination, especially of supination, is often present when there is an ulnar posterior subluxation. More rarely, pronation is decreased when there is an anterior subluxation. These problems may have been overlooked as a result of limitations of the standard X-rays. However, clinical examination localises the symptoms to the distal radioulnar joint, where the distal ulna is often protruding and painful with motion. Decrease of ulnar deviation and, sometimes, a permanent radial deviation are present. These signs may be sufficient to suspect a long ulna and its pathology on clinical grounds alone. Arthritis may be present after a long period of time (Fig 8).
The first assessment is to highlight the fact that the long ulna is congenital or acquired, because the mechanism and evolution of the two possibilities are different. In congenital long ulna, the injuries of the TFCC and the carpus are degenerative and progressive, while post-traumatic injuries are more acute in their evolution. Any previous injury should be noted and can usually be identified on plain X-ray. Posteroanterior X-rays should be performed, with the forearm in neutral pronosupination, with the shoulder at 90° of abduction and the elbow at 90° of flexion. The axis of the radius should be aligned with the central column of the carpus. A true lateral X-ray is obtained with the dorsal radius and the dorsal aspect of the hand aligned. A small board applied to the dorsal aspect of the distal radius and hand is helpful to maintain a longitudinal alignment. In a true lateral view, the pisiform projects on the distal scaphoid. Anatomical features on plain X-rays to be noted are:
Other investigations which may be performed include:
Possible results of investigation:
The pathology of a long ulna is often evident, but may sometimes be difficult to identify. ArthroCTscan is the most useful investigation in respect of analysis of all of the features of this complex joint.
Two types of treatments are possible, viz. techniques removing the distal radioulnar joint and techniques retaining this joint.
Techniques removing the distal radioulnar joint Of these techniques, only four are currently used:
The advantages and disadvantages of these various procedures are as follows:
In our experience, the Darrach’s procedure is indicated for elderly patients and the Sauvé–Kapandji is preferred for young patients, in whom it provides the best results. However, an unstable distal ulna stump may occur in approximately 30% of patients following either of these two procedures. How painful and disturbing this radioulnar impingement is varies widely in the scientific papers. Stabilisation may be performed systematically during the primary procedure to prevent this problem (Couturier et al., 2002; Minami et al., 2000) or later, if the distal stump becomes painful and/or the extensor tendons are perceived to be at risk from attrition. This may be predicted if the distal ulnar stump is protruding dorsally and suspected pre-operatively if there is dorsal displacement of the ulna relative to the radius on lateral plain X-ray views of the forearm. The procedures most frequently performed under these circumstances are stabilisation of the ulnar stump with the flexor carpi ulnaris (Tsai and Stilwell, 1984) or with the extensor carpi ulnaris (Webber and Maser, 1991) or a combination of these two procedures (Breen and Jupiter, 1989).
Techniques retaining the distal radioulnar joint 1. The "Wafer" procedure (Fig 16), described by Feldon et al. (1992), consists in resection of the distal end of the ulnar head. It may be performed surgically or arthroscopically (Wnorowski et al., 1992). Three to four millimeter of the distal dome of the ulnar head are resected, preserving the ulnar styloid process. A disadvantage of this procedure is that the wrist may remain painful for a significant period of time (often 3–6 months postoperatively), probably because the distal dome of the ulnar head is devoid of cartilage. After having used this technique for a time, I have abandoned it.
2. Ulnar shortening: This operation has been used for many years since its first description by Milch (1963). It preserves the distal radioulnar joint and should achieve good radioulnar congruity. If a discrepancy still remains, osteoarthritis may develop in the longterm. Many variants have been described, viz: (a) A transverse osteotomy, usually at the distal third of the forearm, with resection of a cylinder of bone, the height of which corresponds to the shortening required (Boulas and Milek, 1990). Fixation is done with a plate, preferably a compression plate. (b) A step osteotomy with resection of two hemi cylinders of bone of equal size and reduction of the two parts (Figs 17a and b) (Darlis et al., 2005). This is technically more difficult but the surface of contact of the two parts is larger than for a transverse osteotomy and the chances of healing better. Shortening should correspond to the plus variance of the ulna. Fixation is done using screws or, preferably, a plate. Again, a compression plate is preferable.
(c) A short oblique osteotomy, usually at the distal third of the ulna. This is used to increase the contact of the two parts of the bone and different devices tend to make the adjustment between them better (Kapandji, 1998; Loh et al.,1999; Rayhack et al., 1993). This osteotomy may be localised at the diaphyseal or diaphysoepiphyseal site (Roux, 2005). (d) The osteotomy may be directional if one wants to change the direction of the distal ulna to regain a good alignment of the two diaphyses of the radius and ulna. A volar wedge resection should be included to correct the subluxation of the distal ulna. Two further osteotomy techniques have been described recently: (e) Comtet et al. (1982) have described a hemiepiphyseal osteotomy of the distal ulna. This is an oblique osteotomy of the intraarticular part of the ulnar head, beginning 1 mm radial to the base of the ulnar styloid process and running proximally in a 45° direction to the radial cortex of the ulna, as when performing a Bowers procedure. Instead of resecting this fragment, it is proximally and obliquely displaced and fixed by two screws (Fig 18), inserted by a small ulnar incision. This osteotomy is in a cancellous area and healing is almost certain. This osteotomy allows a shortening of a maximum of 4 mm, which is not sufficient when the ulna + variance is more significant.
(f) A long oblique osteotomy (Saffar, 2006). This technique is one which we have used since 1994. It is an osteotomy beginning at the radial side of the distal ulna, one or two cm proximal to the distal radioulnar joint, and extending proximally to the ulnar side of the ulna. The length of the osteotomy is calculated on the X-rays, depending on the shortening to be obtained and is usually 10–15 cm long. Sliding the distal on the proximal fragment allows the necessary shortening. An advantage of this technique is that (a) it allows the distal fragment to slide in a distal-proximal direction in the sagittal plane to shorten the ulna, and (b) it allows realignment of the distal ulnar fragment with the sigmoid notch of the radius to obtain congruity of this joint by sliding of the distal fragment in an anteroposterior direction It is a directional osteotomy (Fig 19a and b). Fixation is done with only three to four screws. We have used this osteotomy for correction of Madelung’s disease (Fig 20) and also for post-traumatic cases (Fig 21).
Any length of shortening is possible with this technique. Healing is assured because of the very large length of bone contact of the two fragments. Our personal choice of these various osteotomies is the Comtet technique for shortening of less than 4 mm and our long oblique osteotomy for shortening of more than 4 mm (Saffar, 2006). The amount of shortening is variable, especially for distal radial fractures, in which impaction may be moderate or significant.The other techniques may be used in particular cases. In performing these osteotomies, various anatomical features have to be considered, viz. the angle and depth of the sigmoid notch, the decrease of the surface of contact of the DRUJ and achieving good anatomical correction of the ulnar length. Dorsalisation of the tendon of the extensor carpi ulnaris should always be performed to further stabilise the ulna head.
There is a reduction in ulno-carpal loading with shortening the ulna and the forces now pass through the radiocarpal joint in a nearly normal manner. This usually reduces pain at the distal radioulnar joint. A certain amount of pain during pronosupination motion may still be present after surgery at the distal radioulnar joint. Exact reduction of this joint is very difficult to restore using the different osteotomies. The contact between the two articular surfaces of the distal radioulnar joint may be incomplete or with an orientation that may not be exactly parallel. The height of this contact may also be incomplete. Because of these difficulties in achieving perfect congruity of the distal radioulnar joint, a painful secondary osteoarthritis may appear in the joint with time, usually after several years, depending on the use of this joint. Improvement in the range of pronosupination is unpredictable. The best results are obtained with a cylindrical shape of the joint, as discussed earlier in the anatomical section (Fig 3). Whatever the technique used, there is a risk of non-union, which varies from 10% to 25% in the literature. If there is more than 1 cm of shortening, it may be difficult to move the distal fragment proximally because of the ligamentous structures and the interosseous membrane.
Diagnosis of these injuries is by MRI or arthroCTscan. Treatment may be indicated and may be surgical or arthroscopic. Central perforation is the usual lesion of congenital or post-traumatic injuries. This is accessible to the arthroscope and debridement of the central part of the TFCC may be indicated. Reinsertion of the ulnar part of the ligament is possible using an open or arthroscopic technique and may heal. If tears at other locations are reinserted, they have no chance to heal for vascular reasons. Isolated or combined treatment is indicated when this pathology contributes to the pain or dysfunction of the joint.
These cartilage defects are not repairable. However, pain caused by onset of osteoarthritis may be reduced by reduction of the pressure on the two bones when the ulnar positive variance is corrected. Others surgical indications may be chosen, such as proximal row carpectomy if the cartilage wear is significant.
Attrition of this ligament may cause lunotriquetral instability with its own signs, such as carpal pain, clicking and decrease of strength. Treatment of this ligament injury may be performed by reinsertion, ligamentoplasty or limited lunotriquetral arthrodesis. Indication for these treatments are based on carpal symptoms and these should be distinguished from the other associated problems.
The pathology associated with a long ulna is often evident, but ease of identification of the problem is not invariable. We have found ArthroCTscan to be the most useful investigation in respect of analysing all of the complex features of the distal radioulnar joint. A number of techniques have been described above which may restore the balance of forces at the wrist joint. Each has its own special indications. Therefore, careful pre-operative assessment to establish the precise pathology is essential in order to make the appropriate choice of surgical treatment and to ensure the best chance of an acceptable result. Unfortunately, an article of this length cannot cover the nuances of pre-operative assessment or the methodology of choice of operation fully and can only point the interested surgeon in the appropriate directions. As with many complex parts of hand surgery, further reading and visits to surgeons experienced in the field are a necessity for training surgeons. Ttreatment generally achieves a reduction in ulno-carpal loading and the forces now pass through the radiocarpal joint. Loading of the carpus should be restored to near normality. This usually reduces pain in the wrist. Improvement in the range of pronosupination is unpredictable, because it depends not only on exact reduction of the joint but, also, on the postoperative rehabilitation and the degree of muscle atrophy after a long period of absence from use of the muscles involved in pronosupination, especially in congenital cases.
Manuscript received January 18, 2007. Accepted for publication August 8, 2007.
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Journal of Hand Surgery (European Volume), Vol. 32, No. 6,
608-619 (2007)
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Abstract
ANATOMICAL FEATURES
