Ecu Snapping Or Subluxation
Snapping ECU syndrome is a condition due to the ECU tendon sliding in and out of its groove on the side of the wrist. Snapping ECU is more common in athletes, and generally follows a traumatic injury to the wrist. The injury causes damage to the normal tendon sheath and allows the tendon to slide out of its normal location.
Signs of ECU subluxation include:
- Painful snapping of the wrist with twisting movements
- Tendon snapping out of its groove with turning the hand to a palm-up position
- Tendon snaps back into place when the hand is turned palm down
Normally, the ECU tendon runs within a smooth sheath along a groove on the side of the wrist joint. It’s held in this position by a ligament. Sometimes after an injury such as a wrist fracture, this tendon sheath can become disrupted. If the ECU tendon is not held in place, it may “snap” over the bone as the wrist is rotated.
Treatment may be successful by immobilizing the wrist with the tendon in a proper position to allow the sheath to heal. If this is not effective, treatment may require surgical reconstruction of the tendon sheath so the tendon will stay in its proper position.
Pang EQ, Yao J. Ulnar-sided wrist pain in the athlete . Curr Rev Musculoskelet Med. 2017 10:53-61. doi: 10.1007%2Fs12178-017-9384-9
Provocative Testing Of Druj/tfcc
Stress loading tests are used to assess the stability of the distal radioulnar joint /triangular fibrocartilage complex , as well as to distinguish DRUJ/TFCC pathology from lunotriquetral or triquetrohamate joint disease. The piano-key test involves depressing the distal ulna from dorsal to volar with the hand pronated. A positive result is characterized by painful laxity in the affected wrist compared with the contralateral wrist. The results are usually positive in cases of DRUJ synovitis.
The ulnar compression test may reveal degeneration or inflammation of the DRUJ. To perform this test, compress the ulnar head against the sigmoid notch. A positive result is exacerbation of pain, which suggests arthritis or instability. In addition, with ulnar compression, dorsal or volar subluxation may be noted.
See Clinical Presentation for a brief discussion of the ulnar fovea sign.
Will The Ulnar Nerve Heal Itself
The symptoms of the ulnar nerve entrapment can be relieved by proper medication and rest, but the full recovery of the ulnar nerve may take some months. The recovery of ulnar nerve damage depends on its leading cause and the severity of the injury. But with a proper and timely diagnosis, you can make a complete recovery if taken care of properly.
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Subluxation Of Extensor Carpi Ulnaris
The extensor carpi ulnaris courses through the sixth dorsal compartment, where it is held tightly to the ulnar groove by a subsheath, which is separate from the extensor retinaculum. When the ECU tendon subluxes, the subsheath is torn, whereas the retinaculum usually remains intact. The mechanism that causes ECU subluxation is often forced supination, palmar flexion, and ulnar deviation. The ECU tendon is relocated with pronation.
The patient has pain over the dorsal wrist and clicking or snapping with pronation and supination. On evaluation, the subluxation can be reproduced with active forearm supination and ulnar deviation. Tenderness and swelling are often present over the ECU tendon at the ulnar head. Routine radiographic findings are negative. Further studies are often unnecessary. Magnetic resonance imaging can show inflammation about the sheath, as well as malpositioning of the tendon.
In acute subluxation, immobilization for 6 weeks in a long-arm cast with the forearm pronated and the wrist in slight radial deviation and dorsiflexion should be attempted. With chronic and symptomatic subluxation, surgical reconstruction of the subsheath is beneficial.
When Is Surgery Appropriate For Ulnar Sided Wrist Pain
Depending on the cause of your ulnar sided wrist pain and your reaction to less invasive treatment, your doctor may recommend surgery. While full recovery from surgery can take up to three months, doctors usually suggest surgical intervention when other options are ineffective. In cases that involve physical deformities, such as ulnar impaction syndrome, surgery may be your only option.
Your hand surgeon may recommend surgery when your pain is caused by an injury or tear to the triangular fibrocartilage complex , a network of ligaments, tendons, and cartilage between your ulna and radius on the ulnar side of your wrist. During this procedure, your surgeon repairs TFCC damage by inserting special surgical instruments through small incisions on the side of your wrist.
Surgery may also be appropriate to remove a tumor or growth such as a ganglion cyst. These masses can cause nerve compression and persistent pain. Removing the source of the pressure can alleviate your discomfort.
If you have painful arthritis that doesnt respond to standard treatment, your surgeon may advise wrist joint replacement surgery. This procedure removes the damaged parts of your wrist bones and replaces them with artificial implants. Joint replacement surgery can relieve pain and help you retain or recover function of your wrist and hand.
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Wearing A Wrist Brace
Wrist braces are a common form of treatment for managing pain. They can be purchased at most pharmacies and big box stores, even some grocery stores. They are often simple to put on and take off and are fairly inexpensive.
Doctors will often recommend that patients experiencing wrist pain wear a brace, as it allows the joint to remain stabilized. Stabilization of the joint can allow it to heal quicker. When an individual continues activity in the same way that they did before the injury occurred, they could be allowing further damage to occur.
For example, if the wrist pain is caused by a torn ligament, resuming normal activity could tear the ligament further. It is generally recommended that an injury be stabilized to help it heal this is why bone fractures require casts.
It is often recommended that patients wear their brace during sleep, as the wrist is more likely to get bent during this time. Some patients may wear their brace during certain activities as well, especially activities that cause pain or contribute to the injury.
Wearing a brace is often coupled with other treatments such as physical therapy and anti-inflammatory medication.
Alternative treatments may offer a solution to wrist pain as well. The innovative field of regenerative medicine offers a different solution to chronic wrist pain.
Types Of Ulnar Wrist Pain:
Ulnar wrist pain can be acute or chronic depending upon the underlying causes:
- Acute: A painful twist of the wrist tendons or ligaments under a heavy load or a fall can result in a distal radioulnar joint or triangular fibrocartilage complex injury. When the DRUJ is injured, patients may notice a prominence on the backside of their wrist. Small wrist bone cracks may result from a fall onto an extended or overstretched wrist or hand.
- Chronic: Long-term ulnar-sided wrist pain may result from an old injury to the wrist, hand, elbow, or an inflammatory condition. It may also result from congenital disabilities in the shape of the ulnar wrist. Extended overuse of the ulnar wrist can also lead to triangular fibrocartilage complex. Ulnar wrist pain tends to worsen with movement of the hand to the direction of the ulna .
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The Most Common Causes Of Wrist Pain On The Pinky Side
TFCC tearExtensor carpi ulnaris tendon strain
- If the patient overuse the wrist despite having damaged tendons, the patient is more likely to get ulnar wrist pain.
- Various types of growths such as ganglion cysts may cause ulnar wrist pain.
- Ulnar Artery Thrombosis
- When the patient has a blood clot in the ulnar artery, it leads to a painful wrist, causing ulnar wrist pain.
- Infections may also cause ulnar wrist pain if the patient has a prior penetrating injury or even any underlying situation that leads to infections, which results in ulnar wrist pain.
- Kienbocks disease
- In this condition loss of blood supply happens which leads to the death of the lunate bone on the ulnar side of the wrist.
Wrist Anatomy Kinematics Pathomechanics
Because the structures of the wrist are highly interactive in producing normal and abnormal wrist mechanics, a brief review of the anatomy and kinetics of the entire carpus is included here. Refer to standard anatomy textbooks for further details.
The wrist provides an anatomic link between the forearm and the hand. The wrist consists of the distal radius, the ulna, the carpal bones, and the bases of the metacarpals. The mobility of the wrist is determined by the shapes of the bones involved and by the attachments and lengths of the various ligaments.
The distal articular surface of the radius has an average radial inclination or slope of 22°, and it tilts palmarly by an average of 11°. The distal radius has a biconcave articular surface with two articular facets that are separated by an anterior and a posterior ridge. The lateral scaphoid facet is triangular, whereas the medial lunate facet is quadrilateral. The ulnar aspect of the radius has a concavity: the sigmoid notch, which articulates with the convex semicircular head of the distal ulna.
The distal radioulnar joint is the articulation of the distal radius and ulnar head. When the DRUJ is considered, it is important to note that the radius prosupinates upon the ulna. In both pronation and supination, the radius shortens and lengthens in relation to the ulna. In the neutral position, the lengths of the radius and ulna should not differ by more than 1 mm.
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Signs And Symptoms Of The Ulnar Side Of Wrist Pain
Ulnar wrist pain, while at rest or even with movement, is a common sign of many different injuries, accidents, and medical conditions.
The most common signs and symptoms of ulnar wrist pain include:
- Pain occurs on the pinky-finger side of the wrist.
- Popping or clicking noise in the wrist is associated with the sharp pain with the movement.
- Loss of strength in the hand when gripping strongly is associated with pain.
- Loss of motion at the wrist especially with the rotation of the forearm and with the lateral motion of the wrist towards the pinky side .
- Swelling around the wrist joint along with the redness.
Extensor Carpi Ulnaris Tendinosis
It is unclear exactly why it develops. It is analogous to the very common de Quervains tendinosis which occurs almost exclusively in women in the thumb side of the wrist with the first extensor compartment tendons. The extensor carpi ulnaris muscle is very important in lifting the wrist up and tilting it to the ulnar side of the hand, the most functional position for the hand. It is a fairly powerful muscle. In the past, tendinosis of the extensor carpi ulnaris at the wrist was, in my experience, quite rare. In the last few years I have been seeing a few cases a year and it is treated with cortisone injection initially and if that doesnt resolve it within a few days a minor operation through about a 1-inch incision on the top of the wrist as an outpatient eliminates the pain very quickly. No postoperative immobilization is necessary. There is minimal scar. There may be some mild decreased sensitivity in the skin just beyond the incision for a few weeks to a few months in some cases because of the dorsal cutaneous branch of the ulnar nerve which is in the general area and sometimes has to be pulled to the side to protect it during the procedure. This problem does not appear to be any more common in laborers vs. sedentary, stay-at-home people vs. office workers.
Note the swelling in the exterior of the wrist on the left
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What Is The Cause
Commonly injured structures include the TFCC , the tendons , or the joint between the ulnar bone and the radius at the wrist .
Ulnar-sided wrist pain that comes on more gradually can result from inflammation or irritation of the above structures, but can also be caused by arthritis of the wrist bones or sometimes by a condition called ulno-carpal impaction syndrome. This condition relates to the shape of your bones at your wrist.
Provocative Testing For Midcarpal Shift
To test for midcarpal instability on the right wrist, the examiner stabilizes the patient’s forearm, with the left hand in a pronated position. With the patient’s wrist in 15° of ulnar deviation, the examiner’s right thumb exerts volarward pressure at the level of the distal capitate. The wrist is then simultaneously axially loaded at the metacarpals and ulnarly deviated. The result is positive if a painful clunk occurs that reproduces the patient’s symptoms.
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Extensor Carpi Ulnaris Tendinopathy
The extensor carpi ulnaris muscle is another structure that can frequently cause ulnar pain in the wrist. Excessive work of this muscle can cause discomfort that refers to the ulnar aspect, such as in ECU tendinopathy.
To give an overview, the extensor carpi ulnaris tendon runs along the dorsal aspect of the ulna to its most distal end, where it passes through a tendon sheath. This sheath performs an indispensable function of stability of the ECU tendon, which guarantees its correct mechanical work of extension and pronation of the carpus. Once past this structure, the tendon reaches the distal styloid of the ulna, where it produces a pulley effect to redirect itself to the ulnar and volar carpus.
However, we may find situations in which the tendon sheath ruptures, and its function is altered. The patient will have pain and tendon snapping or popping noises during pronation and supination of the forearm.
Extensor Carpi Ulnaris Synergy Test: this manoeuvre aims to test for tendon involvement. For this, with the elbow flexed, forearm supinated and fingers extended, the examiner will perform a compression against the thumb and middle finger, requesting a radial abduction of the thumb.
With this contraction, the extensor carpi ulnaris and flexor carpi ulnaris contract synergistically to stabilise the wrist. The presence of pain along the course of the tendon will be considered positive for extensor carpi ulnaris tendinopathy.
Here Are The Treatment Options For Ulnar Sided Wrist Pain:
- Taking anti-inflammatory medication , such as naproxen or ibuprofen or newer non-steroidal anti-inflammatory drugs , or steroid injections to ease pain
- Casting or splinting to rest the wrist
- Changing your hands position during activities/sport/work
This surgery may involve wrist arthroscopy and/ or open surgery. Please dont feel daunted by the complexity of this area of the wrist, we are very used to managing these conditions.
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Triangular Fibrocartilage Complex Injuries
The Triangular Fibrocartilage complex of the wrist is a structure located at the level of the distal radioulnar joint, composed of several structures: Articular Disk, Ulnocarpal Ligaments, Dorsal and volar radioulnar ligaments, and the Tendon Sheath of the Extensor Carpi Ulnaris.
The involvement of any of these structures should be suspected in cases of a history of fall or trauma associated with pain, stiffness, jumping and/or joint noises, usually related to pronation-supination movements of the forearm.
1) Piano Key Test: this test evaluates the existing stability at the distal radioulnar level, assessing the capacity of the distal radioulnar ligaments, among others.
For this purpose, the patients hand is placed on a table in pronation of the forearm. The assessor stabilises the distal radius with one hand, and with the opposite hand performs dorsal to volar mobilisations of the ulnar head. The test is positive if the ulna returns to its original physiological position, like the movement of a piano key after it has been released.
Vezeridis P et al 2010
2) Radio Ulnar Ligament Stress Test: In this case, we will directly stress the Dorsal and Volar Radio Ulnar ligaments, which are stressed in maximum pronation and supination. These positions will be used in the test. In addition, the elbow will be kept in flexion to cancel the possible muscular involvement.
The appearance of marked pain or instability will be indicative of a distal radioulnar ligament injury.
What Is The Ulnar Wrist Pain
The wrist joint plays a crucial role in almost everything people do with the hand. It comprises lifting objects, operating mobile phones, preparing food, and many other activities. When people feel pain on the side of the wrist, just opposite the thumb, it may be ulnar wrist pain. The ulnar side of the wrist is the side of the little finger. People may often feel pain there.
The ulnar pain is named after the ulna, the arm bone which ends at the wrist on the side of the pinky finger. The word wrist is used to elaborate on the joint where the hand is attached to the forearm. Ulnar wrist pain means pain on the pinky side of the wrist is very common. It may result from injury to bones, cartilage, ligaments, or even tendons. The ulnar wrist pain can worsen with the motion. When an individual grips something or twists the wrist, a person may experience severe pain. However, the time duration and severity of the pain may vary depending on its causes.
The wrist joint is a complex joint that bridges the hand to the forearm. It is mainly a collection of multiple bones as well as joints. The wrist, as well as the hand, are composed of a total of 27 bones: 8 bones of the wrist, 5 metacarpals, and 14 bones of the phalanges. The hand and the wrist form a group of complex, delicately balanced joints which are reviewed as the most active part of the upper extremity.
There are mainly three joints in the wrist:
Hand and wrist bones
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Differential Diagnosis Of Ulnar
The ulnar side of the wrist is composed by a large number of structures that allow us to be functional, and to perform activities as diverse as weight bearing or delicated gestures .
Due to this complexity, It is more necessary than ever to have a thorough knowledge of the anatomy of the carpus and its biomechanical implications. Only in this way will we be able to make a correct assessment of the region and obtain an accurate diagnosis of the patients problem.
We recommend that you take a look at Part 1 of this Blog, where we set out the basic principles before carrying out any kind of wrist assessment: Principles of a successful diagnosis of the wrist.
Also, remember that we have two complementary entries to this one: Differential diagnosis of the Radial-Side Wrist Pain and Central-Side Wrist Pain.