What is the treatment for ulnar variation?

Treatment for Ulnar Variation

The treatment for ulnar variation should be based on symptom severity, with conservative management as first-line therapy for mild to moderate cases, including activity modification, splinting, and pain management, while surgical interventions should be reserved for cases with progressive symptoms or associated conditions like Kienböck's disease. 1

Diagnostic Approach

• For persistent symptoms with normal or nonspecific radiographs, MRI without IV contrast or CT without IV contrast is recommended to evaluate for associated conditions 2
• MRI is particularly valuable for detecting soft tissue and bone marrow edema that occurs more frequently in symptomatic patients 2
• Ultrasound can be used to assess ulnar collateral ligament integrity with high accuracy (sensitivity 77-79%, specificity 94-98%) 2

Conservative Management

First-Line Interventions

• For asymptomatic or mildly symptomatic cases, observation alone may be sufficient 1
• Avoiding activities that place excessive load on the wrist is recommended to prevent symptom exacerbation 1
• Splints or orthoses provide symptom relief, especially with associated thumb base or wrist pain 1, 3
• Rigid immobilization may be preferred over removable splints for better symptom control 1
• Night splinting has shown effectiveness in improving subjective discomfort 4

Pain Management

• Paracetamol (up to 4g/day) is the oral analgesic of first choice due to its efficacy and safety profile 1
• Topical NSAIDs can be effective for localized pain with fewer systemic side effects 1
• For inadequate response to paracetamol, oral NSAIDs at the lowest effective dose for the shortest duration may be considered 1

Physical Therapy

• Range of motion and strengthening exercises help maintain wrist function 1
• Nerve mobilization techniques have demonstrated long-term positive results in cases of ulnar nerve entrapment 5
• Local application of heat before exercise may provide additional benefit 1

Surgical Interventions

Indications for Surgery

• Surgical options are typically reserved for cases where conservative management fails or when there is progression to conditions like Kienböck's disease 1
• Motor weakness, muscle atrophy, or fixed sensory changes are indications for surgical intervention 6

Surgical Options

• Simple in situ decompression is the treatment of choice for primary cubital tunnel syndrome when ulnar variation affects the nerve 6
• Radial shortening osteotomy may be considered to address ulnar negative variance 1
• Joint-leveling procedures may be appropriate in certain cases 1
• For ulnar nerve compression with painful subluxation, subcutaneous anterior transposition may be performed 6
• In cases of severe bone or tissue changes, anterior transposition of the ulnar nerve may be indicated 6

Special Considerations

Ulnar Nerve Compression

• When ulnar variation leads to nerve compression, simple decompression and decompression with transposition are equally effective based on moderate-quality evidence 4
• Decompression with transposition is associated with more wound infections than simple decompression 4
• Endoscopic approaches may be considered but carry a higher risk of hematoma formation 4

Anatomical Variations

• Approximately 8% of individuals may have anatomical variations related to the ulnar nerve that could affect treatment outcomes 7
• These variations may include abnormal communications with neighboring nerves or variations in nerve formation 7

Monitoring and Follow-up

• Regular radiographic follow-up is recommended to monitor for progression to conditions associated with ulnar variation 1
• Treatment decisions should consider the presence of symptoms, functional limitations, and evidence of associated pathology rather than the radiographic finding alone 1
• Periodic assessment of upper extremity position during procedures is recommended to prevent complications related to ulnar nerve positioning 2

Prevention of Complications

• Avoid extension of the elbow beyond the comfortable range to prevent stretching of the median nerve 2
• Avoid prolonged pressure on the radial nerve in the spiral groove of the humerus 2
• When positioning patients during procedures, limit arm abduction in supine patients to 90° to reduce the risk of brachial plexus neuropathy 2