Slideshow
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Figure 1. Anteroposterior radiographic view of injured wrist.
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Figure 2. Lateral view of wrist.
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Figure 3. Coronal MRI of wrist.
A 24-year-old man presents with a 4-month history of right wrist pain on the ulnar side. The patient notes that the pain developed after a fall where he landed on an outstretched hand. On physical examination, he has tenderness to palpation over the ulnar fovea and increased pain with ulnar deviation of the wrist. He has full strength and sensation in the hand. A period of rest and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) over 3 months was followed by intra-articular injection with no pain relief. More recently, the wrist was immobilized in a cast for 6-weeks without relief. Radiographs are negative for fractures or degenerative changes (Figures 1 and 2). Coronal magnetic resonance imaging (MRI, Figure 3) shows a partial tear vs a sprain of the triangular fibrocartilage complex (TFCC).
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Ulnar-sided wrist pain is a common presenting symptom but it can be difficult to determine a cause. Common causes may include TFCC tears, a ligament sprain, distal radial ulnar joint (DRUJ) arthritis and instability, fractures, and tendinitis. The TFCC is a ligament structure that supports the carpus and DRUJ. Injuries to the TFCC can occur with a traumatic fall or because of degeneration over time.1,2
Injuries to the TFCC present with ulnar-sided wrist pain when opening a doorknob or turning a key. The most common mechanism of injury is a fall with the wrist in extension and the forearm in pronation. On physical examination, patients will have pain over the soft spot between the ulnar styloid process and flexor carpi ulnaris tendon (fovea sign).
Radiographic imaging will be negative for TFCC injuries, therefore an MRI is the study of choice to confirm the diagnosis. Diagnostic wrist arthroscopy with repair or debridement is the recommended surgical approach when conservative treatments have failed.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. DaSilva MF, Goodman AD, Gil JA, Akelman E. Evaluation of ulnar-sided wrist pain. J Am Acad Orthop Surg. 2017;25(8):e150-e156. doi:10.5435/JAAOS-D-16-00407
2. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011;27(3):263-272. doi:10.1016/j.hcl.2011.05.014.
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