Indications and complications

The ulnocarpal conflict is not a rare condition and should be taken into account in the event of ulnocarpal pain. The conflict is created by too narrow a space of the ulnar head and the ulnar edge of the lunate and the triquetrum. During loading and ulnar deviation of the wrist, a direct contact between these bones is produced. This leads to degenerative changes on the cartilage and produces pain. The origin may be a congenital positive ulnar situation, or a trauma impairing the natural leveling of the forearm bones. We distinguish a fresh traumatic condition (ulnar impaction syndrome) from a chronic condition (ulnar impingement syndrome). The midcarpal bones may also suffer from a similar condition, which is the hamate tip syndrome.
Diagnosis is made by clinical examination including the ulnocarpal stress test, standard X-rays, MRI enhanced with endovenous contrast and subsequent wrist arthroscopy.

Therapeutic options include the ulnar shortening osteotomy and the resection of the distal head of the ulna. Decision can be made depending on the state of the TFCC, the age of the patient and the collateral changes in the wrist. If the lesion occurs in young patients without any concomitant lesion, a shortening osteotomy is more often chosen.

In all other conditions, the less invasive choice for the minimal resection of the distal ulnar head is made by arthroscopic and open surgery. The camera is introduced through the 3-4 portal and the burr through the 6R portal. At the beginning, a 3.5 burr —in more trained hands a 4.2 burr— is used to resect about 2-3 mm of the distal ulnar head during supination and pronation movements. Care is taken not to resect the foveal area or the DRUJ.

After the operation, a comfort splint can be adapted for 3-4 days, and immediate physiotherapy is initiated.

Instability of the distal radioulnar joint (DRUJ) results from injury or laxity of the ligaments responsible for stabilizing the joint. Of note, the triangular fibrocartilage complex (TFCC) plays a crucial role in maintaining DRUJ stability. Sometimes, it may be impossible to repair the TFCC due to degenerative changes in the TFCC. In such cases, DRUJ reconstruction is possible provided that there are no arthritic changes in the DRUJ with the use of tendon graft. The aim of this procedure is to reconstruct the ligament and restore function, thus providing multidirectional stability. This procedure uses a tendon graft, preferably the Palmaris Longus (PL), which is woven through trans-osseous tunnels in the distal radius, converging at the fovea through a distal ulnar trans-osseous tunnel.

In this authoritative lecture, Dr. Baur goes over arthroscopic distal ulna resection in the management of ulnar impaction syndrome.

In this key lecture, Dr. Caroline Leclercq goes over the complications of wrist arthroscopy with an extensive survey of 10,107 cases.

The volar midcarpal instability results from the post-traumatic distension (or rupture) of the palmar strap of the extrinsic ligaments. The second row of the bones of the carp will gradually slip on the first which will find itself subluxed back. Arthroscopic suture of extrinsic volar ligaments can be performed to restore the normal anatomy of the carpal bones.

In this lecture, Dr. Tse discusses the techniques used to remove a volar synovial cyst.

In this key lecture, Dr. Wong presents the different techniques and portals used in wrist arthroscopy.

In this key lecture, Dr. Cohen covers the arthroscopic interposition strategy for basal joint arthritis.

In this key lecture, Dr. Van Hoonacker focuses on the arthroscopic treatment of scapholunate disruptions.

In this key lecture, Dr. Garret outlines a MRI study for dorsal ganglion cyst.