Rev. bras. ortop. vol.52 número5

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rev bras ortop.2017;52(5):621–624

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Case

Report

Dynamic

ulnar

impaction

syndrome

in

tennis

players:

report

of

two

cases

夽

Edgard

de

Novaes

Franc¸a

Bisneto

UniversidadedeSãoPaulo,HospitaldasClínicas,InstitutodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil

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Articlehistory:

Received5August2016 Accepted22August2016 Availableonline16August2017

Keywords: Wristinjuries Tennis/injuries Fibrocartilage/injuries Ulnocarpalimpaction

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Inthisreport,twotennisplayerswithsymptomsofulnarimpactionsyndromearereviewed. Bothplayershaveneutralulnarvariance.Thesecasesrepresentdynamiculnarimpaction syndrome,whentheimpactbetweenulnaandcarpusoccursduringconditionsofpronated grip.Theliteratureandthetreatmentofthesetwocasesarediscussed.

creativecommons.org/licenses/by-nc-nd/4.0/).

Síndrome

do

impacto

ulnocarpal

dinâmico

em

tenistas:

relato

de

dois

casos

Palavras-chave:

Traumatismosdopunho

Tênis/lesões

Fibrocartilagem/lesões Impactoulnocarpal

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Orelatoapresentaoscasosdedoistenistasportadoresdedornobordoulnardocarpo comsinaisdeimpactonosemilunar.Ambossãoportadoresdeulnaneutra.Essescasos representamumaentidadedenominadasíndromedoimpactoulnocarpaldinâmiconaqual ocorreoimpactoentreacabeçadaulnaeocarpoemsituaçãodepronaçãocompunho fechadoduranteaatividadefísica.Aliteraturaeotratamentodosdoiscasossãodiscutidos noartigo.

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

PaperdevelopedatUniversidadedeSãoPaulo,HospitaldasClínicas,InstitutodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil. E-mail:[email protected]

http://dx.doi.org/10.1016/j.rboe.2017.08.003

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rev bras ortop.2017;52(5):621–624

Introduction

Ulnocarpal impaction syndrome (UCIS) is a degenerative

lesion characterizedbycompression or impactofthe ulna

head against the semilunar bone and/or the pyramidal

bone,withor withoutlesionofthetriangularfibrocartilage complex.1–3

Generallyassociatedwiththepresenceofulnaplus,UCIS may alsooccur inthe presenceofneutralorminus ulna.4 Duringpronationthereisarelativeshorteningbetweenthe radiusandtheulna,andinsituationsofneutralorminusulna

shorterthan2mmanimpactcanoccurbetweenthecarpus

andtheulnahead,thisconditioniscalleddynamiculnocarpal impactionsyndrome(UCIS).4

UCISinthepresenceofneutralorminusulnaisdescribed inpronationsituationsassociatedwithgripstrength,common insportsactivitiessuchastennisorbaseball.5

Inthisreport,twocasesoftennisplayerswithUCISwill bepresented,andtreatedarthroscopically.Afterthe presen-tation of the cases, a discussion of the literature will be performed.

Case

report

1

A20-year-old female patient, who isa tennis playerat an Americanuniversity,witharightwristtriangular fibrocarti-lagelesion,diagnosedattheuniversity.

Whensheunderwentarthroscopyatthatmedicalservice withfibrocartilagedebridementandwristsynovectomy,

asso-ciatedsemilunarchondromalaciawasdiagnosed.

Aftersevenmonthsofsurgery,andintenserehabilitation, thepainpersistedpreventingherfromplaying.

Onphysicalexamination,sheshowedpainatmaximum

supination;positivefoveasign(painatulnarvolarpalpation oftheulnahead);absenceofinstabilityofthedistalradioulnar joint(DRUJ);normalwristROMandlowpaintoulnardeviation againstresistance.

Imaging demonstrates triangular fibrocartilage lesion, intensesynovitisandedemaofthesemilunarandpyramidal bones.Presenceofneutralulna(Fig.1)wasalsonoted.

Patientunderwentnewarthroscopyofthewristwith evi-dentsituationofimpactionseenintheintraoperativeperiod duringpronosupinationofthewrist.Arthroscopicwafer pro-cedure,aswellasdebridementoftriangularfibrocartilageand loosecartilageofthesemilunar(Fig.2),wasperformed.

The patient remained immobilized with an

antebra-chiopalmar orthesis with epicondylar block during three

weeks. She was referred to rehabilitation, and returned

to her sports activities with no pain four months after

surgery.

Case

report

2

A49-year-oldmalepatient,amateurtennisplayer,whoplayed

every weekend, presented with chronic, progressive pain,

mainly when performing forehand technique while playing

tennis.

Onphysicalexamination,hepresentedwithpainat max-imumsupination;positivefoveasign,absenceofinstability ofthedistalradioulnarjoint(DRUJ);normalwristROMand no pain at ulnar deviationagainst resistance.This patient

also presented pain on palpation of the projection of the

interosseousscaphosemilunarligament(SLL),buttheWatson testwasnegative.

Magneticresonanceimagingshowedsemilunarand

pyra-midalboneedema,triangular fibrocartilagelesionand sus-picionofpartiallesiononthescaphosemilunarinterosseous ligament,confirmedintraoperatively(GeisslerIII_type_lesion). Neutralulna(Fig.3)wasalsonoted.

Thepatientunderwentwristarthroscopy,andulnocarpal

impactionwasalsoobservedduringpronosupinationofthe

wrist(Fig.4).Arthroscopicwaferanddebridementoftriangular fibrocartilage,therewasnolooselunarcartilage.Inthiscase,

SLL debridementwasperformed,alongwith

scaphosemilu-narandscaphocapitatepercutaneousfixationwithKirschner wires.Inthiscase,duetoSLLtreatment,immobilizationwas maintainedfor6weeks.

Discussion

Whenconsideringpainfulsyndromesinathleteswrists, sev-eralaffectionscanbementioned4–7_:

• Fractures ofthedistalextremity oftheradius, scaphoid,

hamate,pisiform.

• Temporaryorpermanenttraumaticepiphysiodesis.

• Synovitis(dorsalwristimpactionsyndrome).

• Ligament lesions, scaphosemilunar ligament, triangular

fibrocartilagecomplex.

• Pseudoarthrosisofthehamatehook.

• Tendinopathyorcarpalulnarextensortendondislocations.

• Degeneration,duetoimpact,ofthetriangularfibrocartilage

complex.

Regardingthedynamiculnar-carpalimpact,thisshouldbe consideredwhenthereispainattheulnaredgeofthecarpus, inthepresenceofneutralorminusulna,insituationsof fore-armpronationgrip.Onphysicalexaminationthesignalofthe foveamaybepositive,associatedwithulnarpainatmaximum pronation.Wristrangeofmotionisgenerallypreservedand theremaybenopainfordailyactivitieswithnoload.

Magnetic resonance imaging (MRI) or radiographs on

pronationwithpalmargrip(pronatedgripviews)canhelpwith diagnosis8₍_Fig.₅_).

Jang etal.9 _state_that_UCIS _is_one_of_the _most_common causesofarthroscopyreviewofthewristduetopersistence ofpain.

Thedynamicvisualizationoftheinsinuationoftheulna headabovetheradiusjointobservedbytheportals3–4,4–5 and6Rwasfundamentalinthediagnosisinthesetwocases, especiallyincase1,inwhichthemagneticresonanceimaging

showed no clearsigns ofulnocarpal impaction. The

chon-drallesioninthesemilunarisalsoasignificantfindingofthe UCIS.

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Fig.1–Imagesofcase1.(A)MRIevidencingsynovitisandsemilunarandpyramidaledema;(B)lesionofthetriangular fibrocartilageinthedistalportiononly;and(C)tomographydemonstratingneutralulna.

Fig.2–Arthroscopicwaferprocedure.(A)lesionoffibrocartilagewithulnaheadexposure;(B)semilunarcondrallesion;(C) insinuationoftheulnaheadduringpronationabovetheradiusjointline;and(D)arthroscopicwafer.

Fig.3–(A)MRIevidencestriangularfibrocartilagelesion;(B)edemaontheulnahead;and(C)semilunaredema.

Fig.4–Wafer-likeprocedure.(A)Fibrocartilagelesionwithulnaheadexposure;(B)fibrocartilagebulging(arrow)onwrist

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Fig.5–Radiographinpronationwithpalmargrip(pronatedgripviews).8_(A)_With_no_pronation;_and_(B)_pronation_with

palmargripthatalterstheulna-radiusrelation.Source:TomainoandElfar(2005).

hadadegenerativelesionandtherewasnoneedtousedistal radioulnarportals.Noneofthepatientspresentedinstability ofthedistalradioulnarjoint.

Thisauthor considers the postoperative immobilization

important after any arthroscopic procedure of the wrist,

for pain control and stabilization of the inflammatory

process.Immobilizationwithawristorthoticswithor

with-out epicondyle block is generally used for three to six

weeks,depending on concomitant procedures.Thepatient

referred to functional limb rehabilitation for four to eight weeks.

TheimportanceofUCISisinthepossibilityofbeingmuch moreprevalentthanisimaginedduetotheimmensenumber ofpeoplewhopractisesportsthatusepalmargripassociated withforearmpronation,suchastennis,golf,baseball, bowl-ing,canoeing,etc.Therecognitionandearlytreatmentofthis syndromeisfundamentalforthereintroductionoftheathlete tohis/hersportspractice.

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

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