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Ulnar Nerve – triangular fibrocartilage complex

Wrist pain on the ulnar side is pain on the side of your wrist opposite your thumb. It may come as the result of acute injury or it may be the product of degenerative wear and tear. It is especially painful in athletes or workers during gripping as in a gold club, a tennis racquet, or tool or in any activity where turning or twisting the wring is needed, which for some people may be just about everything they do. Some patients may hear a clicking or popping sound coming from their wrist. The problem with ulnar wrist pain is getting the right diagnosis. As we will see in the research below, even after diagnostic imaging, the diagnosis may be wrong and an incorrect surgery may be performed.

Regardless of what may be causing your wrist pain traditional conservative treatments may be employed including a splint, wrist brace, more rigid casting, activity modification, physical therapy and the possible use of corticosteroid injection and pain management. If none of these treatments or remedies are successful, wrist arthroscopic surgery may be recommended.

The Ulnar Nerve in Sports Injury – Loss of strength in the elbow, forearm, and pinky side of the arm and hand

A paper in the journal Seminars in musculoskeletal radiology (1) describes . “Ulnar-sided wrist pain is one of the most common symptoms in athletes of baseball, racket sports, golf, and wrestling where there is frequent use of the hands as well as in soccer and running, where hand use is minimal. Compared with all wrist injuries, ulnar-sided wrist injury is a relatively serious condition for athletes because it plays an important role in performing a strong grip and in the rotation of the forearm. Ulnar-sided wrist pain in athletes can be related to acute trauma or chronic overuse. Acute trauma can lead to bone fractures and sprains/tears of ligaments. Repetitive mechanical stresses to tendons, ligaments, and the joint structures can lead to tendinitis or osteoarthrosis. Diagnosis of the ulnar-sided wrist pain is challenging both for hand surgeons and radiologists because of the small and complex anatomy.”

Part of this complex anatomy can confuse a diagnosis when  a patient  complains of pain from the elbow to the pinky, for most doctors a flag goes up that says UCL! The UCL or ulnar collateral ligament is a main culprit in elbow problems in pitchers. Usually when a trainer discovers a UCL sprain or tear, often the result is “Tommy John” or elbow reconstruction surgery. But if you are not a pitcher, UCL causing pain can become a chronic problem because of the “standard of care.”

The triangular fibrocartilage complex

Especially troubling in the confused UCL diagnosis is the subsequent recommendation to “Tommy John” or elbow ligament reconstruction surgery. Yet the elbow may not be the true problem. This may be more true in the adolescent athlete.

Make sure the diagnosis is right before agreeing to arthroscopic surgery

A November 2021 study (2) examined data on asymptomatic patients aged 12-18 years. What they were looking for was a better way to confirm a diagnosis of triangular fibrocartilage complex injury or other problems. The group consisted of 23 asymptomatic adolescents (12 girls and 11 boys). Average age was 13.5 years (the youngest being 12 the oldest being 17). MRI findings, whether normal variation or asymptomatic abnormality, can be observed in triangular fibrocartilage complex and triangular fibrocartilage complex-related features of asymptomatic adolescents. The rather low inter-observer agreement underscores the challenges in interpreting these small structures on MRI. This should be taken into consideration when interpreting clinical MRIs and deciding upon arthroscopy.”

In October 2021 a paper in the ANZ journal of surgery (3) described the difficulties of accurate diagnosis of wrist pain. “Identifying the cause of pain on the ulnar side of the wrist can be challenging. The outcome and recovery following surgery can be unpredictable. The aim of this study was to document and analyze the clinical tests used to evaluate the cause of ulnar-sided wrist pain and determine their diagnostic relevance.”

In this study 110 patients who had pain on the ulnar side of the wrist were assessed. What was found was 17 different diagnoses. Eighty-five percent of the diagnoses were triangular fibrocartilage complex (TFCC) injuries, ulnocarpal abutment syndrome (UCAS), pisotriquetral arthritis (PTA), triquetral fracture or non-union, distal radioulnar joint arthritis and extensor carpi ulnaris (ECU) pathology. . . “Diagnosis of TFCC injuries, ulnocarpal abutment syndrome, distal radioulnar joint arthritis and ECU injuries are challenging as the clinical symptoms and signs for the four diagnoses were similar and required either magnetic resonance imaging or computed tomography for diagnostic confirmation after clinical examination.”

The Pisotriquetral joint

The pisotriquetral joint is a leading culprit for pain on the ulnar side of the wrist.

Pain drives patients to surgery – but is it the right surgery?

A July 2020 study (4) writes:  “The clinical picture of ulnar-sided wrist pain is oftentimes confusing because various pathologies may be coexistent.” In this study, the researchers aimed to:

“(1) to compare the prevalence of potential causes of ulnar-sided wrist pain on magnetic resonance imaging (MRI) in patients who underwent triangular fibrocartilage complex (TFCC) repair and control subjects: and

(2) to evaluate whether inferior clinical results were associated with specific patient characteristics or other potential causes of ulnar-sided wrist pain.”

In the study, 67 patients who underwent a TFCC repair were compared to 67 control subjects. The MRI scans were examined for sources of ulnar-sided wrist pain.

  • After TFCC repair, 42 patients (63%) completed survey.
  • The researchers found significantly higher rates of distal radioulnar joint arthritis, extensor carpi ulnaris (ECU) pathology, and ulnar styloid fractures in patients with TFCC repairs.
    • With increasing age, increasing pathology in the pisotriquetral joint, more ulnocarpal abutment, and more degenerative tears   were seen in both groups.

Conclusions: The researchers observed higher rates of distal radioulnar joint arthritis arthritis and ECU pathology in patients with TFCC tears undergoing repair compared with age- and sex-matched controls. This may be due to damage to the TFCC itself altering relationships of the distal radioulnar joint arthritis and the ECU subsheath, or it may reflect various pathologies that cause ulnar-sided wrist pain and drive patients toward surgery.”

We have seen many patients over the years looking for options to an arthroscopic wrist surgery. Like the discussions above, these people may not have been able to pinpoint their diagnosis and their doctors recommended an exploratory arthroscopic surgery may help find this pain. Equally, the goal was to find damage and repairable damage at that.

Sometimes an eager parent will push to keep their young athlete on schedule during seasonal changes. Sometimes the surgical outlook will give them a time frame that is appealing, more often they get a recovery time frame that is not so appealing.

Conservative care options

An October 2023 patient history (5) published in the Journal of bodywork and movement therapies offered the case of a 36-year-old Jiu-Jitsu black belt athlete with left-sided diffuse ulnar pain (numeric pain scale 5/10)  treated with forearm and grip strength exercises to rehabilitate the pain and strength loss. Following 6 visits and a home exercise program for 8 weeks, his numeric pain scale decreased to 0/10. The authors suggested “Triangular fibrocartilage complex injury was successfully treated conservatively without the need for surgical intervention or passive care modalities.”

1 Yamabe E, Nakamura T, Pham P, Yoshioka H. The Athlete’s Wrist: Ulnar-Sided Pain. Semin Musculoskelet Radiol. 2012 Sep;16(4):331-7. doi: 10.1055/s-0032-1327006. Epub 2012 Oct 9.
2 van der Post AS, Jens S, Smithuis FF, Obdeijn MC, Oostra RJ, Maas M. The triangular fibrocartilage complex on high-resolution 3 T MRI in healthy adolescents: the thin line between asymptomatic findings and pathology. Skeletal radiology. 2021 Nov;50(11):2195-204.
3 Ou Yang O, McCombe DB, Keating C, Maloney PP, Berger AC, Tham SK. Ulnar‐sided wrist pain: a prospective analysis of diagnostic clinical tests. ANZ Journal of Surgery. 2021 Oct;91(10):2159-62.
4 Verhiel SH, Blackburn J, Ritt MJ, Simeone FJ, Chen NC. MRI Findings in Patients Undergoing Triangular Fibrocartilage Complex Repairs Versus Patients Without Ulnar-Sided Wrist Pain. Hand. 2020 Jan 1:1558944720937369.
5 Sergent A, Shaw T, Richardson M. Conservative management of a suspected triangular fibrocartilage complex injury utilizing strength training exercises: A case report. Journal of Bodywork and Movement Therapies. 2023 Oct 1;36:210-2.

 

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