Angélica-Almeida, Maria

Borges, Alexandra

Casal, Diogo

O'Neill, João Goyri

Pais, Diogo

English

Repositório da Universidade Nova de Lisboa

ÓRGÃO OF IC IAL DA SOC IEDADE PORTUGUESA DE REUMATOLOGIA - ACTA REUMATOL PORT. 2010;35:110-1110I M A G E N S E M R E U M AT O L O G I AA VA R I A N T O F T H E D I S T A L U L N A I N AP AT I E N T W I T H U L N A R I M P A C T I O N S Y N D R O M EDiogo Casal*,**,Alexandra Borges***, Diogo Pais**, Maria Angélica-Almeida*, João Goyri-O'Neill***Plastic and Reconstructive Surgery Department, São José Hospital **Anatomy Department, Medical Sciences Faculty, New Universityof Lisbon***Radiology Department, Portuguese Institute of Oncology of Lisbon, Lisbon, Portugalneration1. It  is most commonly associated withpeople whose daily activities cause excessive inter-mittent loading of the ulnar carpus, as in this pa-tient, who worked as a carpenter2. The clinical hall-mark of this syndrome consists of chronic or suba-cute ulnar wrist pain, often exacerbated by activityand relieved by rest. Swelling and limitation of fo-rearm rotation and wrist motion are frequent con-current complaints2. The differential diagnosismust include senescent changes, intraosseous gan-glia, true cysts, vascular grooves, Kienböck disea-se, and the lunula accessory ossicle that, someti-mes, can be partially or completed fused with thestyloid process1-3.Several anatomical variants of the ulna havebeen associated with an increased incidence of ul-nar wrist pain syndromes, namely: significant ul-nar positive variance and ulnar impaction syndro-me; an excessively long or prominent ulnar styloidand ulnar styloid impaction syndrome; ulnar nega-tive variance and Kienböck disease, and, in extre-me cases, ulnar impingement syndrome. The va-A 42-year-old man, working as a carpenter, wasseen in the Clinic for the insidious onset in the pre-vious three months of pain in the ulnar side of hisright wrist (dominant hand). The pain was exacer-bated by his working activities, namely using thehammer and grasping heavy objects. Rest and avoi-dance of these activities caused the pain to subsi-de. He denied any previous significant trauma tothat region. The medical history was otherwisenoncontributory. Physical examination revealedpain on palpation of the distal portion of the ulna,as well as limitation of ulnar deviation of the wristagainst resistance, due to complaints of pain. Painwas also elicited by asking the patient to firmlyclasp his hand, and when pressure was exertedfrom proximal to distal against his clenched fist. Radiographs of the right wrist didn't show anysignificant pathological changes. However, an ana-tomical variant of the distal portion of the ulna wasobserved with a prominent ulnar styloid in an ul-nar negative wrist being apparent (Figures 1A andB). This gave the distal ulna a bifid appearance. Ul-trasonography revealed only moderate and unspe-cific swelling in the medial structures of the wrist.A presumptive diagnosis of ulnar impactionsyndrome was made, and the patient was treatedconservatively with a wrist splint and analgesics for4 weeks. The symptoms gradually subsided and 6weeks after the first consultation the patient resu-med his work by his own initiative. He refused tohave an MRI of his wrist done, as well as any otherdiagnostic tests, claiming that he felt better.  The ulnar impaction syndrome is thought to becaused by the impaction of the ulnar head againstthe triangular fibrocartilage complex and ulnar car-pus, provoking excessive load bearing across thesestructures and resulting in their progressive dege-Figure 1. Antero-posterior and lateral right wrist radiographs (Figures A and B, respectively) depicting a variant of the distal ulna in a patient with a clinically ulnarimpaction syndrome.A prominent ulnar styloid in an ulnarnegative wrist is observed, giving a bifid appearance to the distal ulna.ÓRGÃO OF IC IAL DA SOC IEDADE PORTUGUESA DE REUMATOLOGIA - ACTA REUMATOL PORT. 2010;35:110-1111DIOGO CASAL E COL.riant described in this patient, by increasing loadbearing across the ulnar portion of the wrist, couldalso be a predisposing factor for the developmentof ulnar impaction syndrome1-2, 4.Although the authors couldn't determine thefrequency of this variant in the general population,they believe it is rare, as it is not mentioned in theliterature review the authors conducted, includingthe works of Schuind et al. and Hyams et al., whoreviewed wrist radiographs of 120 and 51 normaladults, respectively5-6, and the work of Timins, whoreviewed 208 MRI wrist studies with normal va-riants3.Correspondence toDiogo CasalRua Luís Pastor de Macedo, N 32, 5D, 1750-159,Lisbon, PortugalE-mail: diogo_bogalhao@yahoo.co.ukReferences1. Friedman SL, Palmer AK. The ulnar impactionsyndrome. Hand Clin 1991;7: 295-310.2. Cerezal L, del Pinal F, Abascal F, Garcia-Valtuille R, Pe-reda T, Canga A. Imaging findings in ulnar-sidedwrist impaction syndromes. Radiographics 2002;22:105-121.3. Timins ME. Osseous anatomic variants of the wrist:findings on MR imaging. AJR Am J Roentgenol1999;173: 339-344.4. Mellado JM, Calmet J, Domenech S, Sauri A. Clini-cally significant skeletal variations of the shoulderand the wrist: role of MR imaging. Eur Radiol2003;13:1735-1743.5. Hyams E, Yazaki N, Nakamura R, Nakao E, WatanabeK. Radiographic morphology of the ulnar head. HandSurg 2004;9:175-180.6. Schuind FA, Linscheid RL, An KN, Chao EY. A normaldata base of posteroanterior roentgenographic mea-surements of the wrist. J Bone Joint Surg Am1992;74:1418-1429.

Images in rheumatology. A variant of the distal ulna in a patient with ulnar impaction syndrome

https://run.unl.pt/bitstream/10362/22014/1/ARP_2010_1_110_Impactacaoulnar_ARP2010.pdf

Images in rheumatology. A variant of the distal ulna in a patient with ulnar impaction syndrome

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