This 50-year-old, right hand dominant, recreational player presented with a three month history of ulnar-sided pain in her left wrist. She described an insidious onset of pain and symptoms that are worse with weight bearing through her arms and with movements involving rotation. On examination she had pain with end range wrist extension and with ulnar deviation. A grind test, where the wrist is ulnar deviated and rotated, provoked her symptoms.
A true PA x-ray image of the wrist shows approximately 5mm of positive ulnar variance. The x-ray series is otherwise normal. A subsequent MRI showed that there was thinning of the triangular fibrocartilage (TFCC) disc without a discrete perforation or full-thickness tear. The proximal and distal lamina also appeared intact. A large multiloculated volar ganglion (measuring 6 x 7 x 5 mm) was seen adjacent to the flexor digitorum profundus tendons and deep to the ulnar neurovascular bundle.
This player was managed with a short period of splinting. During this period her symptoms and clinical signs resolved entirely. She was able to return to all normal activities without pain or restriction. It is important to highlight that in some situations, especially when the variance is significant, an ulnar shortening procedure is needed.
A ‘true’ PA x-ray image is needed to adequately assess ulnar variance. This image is taken in zero degrees with the shoulder, elbow and wrist in the same horizontal plane. Careful positioning is important as pronation makes the ulna look longer while supination makes it appear shorter. To determine ulnar variance a line is drawn from the ulnar aspect of the radius to pass through the ulnar styloid. Normal variance is generally considered to be neutral or 1-2mm either side of this line.
Loading at the wrist is normally shared between the radius and ulna at a ratio of 80:20. Ulnar minus variance (shortening of the ulna) by as little as 2.5mm can reduce this load to 4% and is associated with carpal instability. Possible complications may include avascular necrosis of the lunate (Kienbocks) and rupture of the TFCC. Ulnar plus variance (a longer ulna) by 2.5mm increases its load to 42%. Complications include ulnar abutment syndrome (or ulnar impingement), with degenerative changes at the distal ulnar, proximal lunate and proximal triquetrum and rupture of the TFCC.
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