What are the treatment options for ulnar variance?

Treatment Options for Ulnar Variance

The treatment of ulnar variance should be based on symptom severity, associated pathology, and functional limitations rather than the radiographic finding alone. 1

Diagnostic Approach

• Standard radiographs are necessary for accurate measurement of ulnar variance and should be performed in neutral position and rotation 2
• Pronated grip x-ray views should be included as they can reveal dynamic increases in ulnar variance that may be missed on neutral rotation views 3
• For persistent symptoms with normal or nonspecific radiographs, MRI without IV contrast or CT without IV contrast is recommended 1
• MRI is particularly valuable for detecting soft tissue abnormalities and bone marrow edema that occurs more frequently in symptomatic patients 1
• Lateral radiographs are essential to differentiate true shortening from apparent shortening due to articular surface tilting 4

Conservative Management

• For asymptomatic or mildly symptomatic cases, observation alone may be sufficient 1
• Activity modification to avoid 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
• Rigid immobilization may be preferred over removable splints for better symptom control 1
• Paracetamol (up to 4g/day) is the first-line oral analgesic due to its efficacy and safety profile 1
• Topical NSAIDs can effectively treat localized pain with fewer systemic side effects 1
• Oral NSAIDs at the lowest effective dose for the shortest duration may be considered for inadequate response to paracetamol 1
• Range of motion and strengthening exercises help maintain wrist function 1
• Local heat application before exercise may provide additional benefit 1

Surgical Interventions

For Positive Ulnar Variance (Long Ulna)

• Distal ulna recession (ulnar shortening osteotomy) is indicated for symptomatic ulnocarpal impaction syndrome 5, 6
• Arthroscopic assessment of the wrist allows evaluation of TFCC integrity and helps determine the most appropriate surgical approach 5
• TFCC debridement or repair may be necessary if perforation is present 5, 6

For Negative Ulnar Variance (Short Ulna)

• Radial shortening osteotomy may be considered to address ulnar negative variance, particularly when associated with Kienböck's disease 1, 6
• Joint-leveling procedures may be appropriate in certain cases 1

Special Considerations

• Ulnar variance can change with wrist and forearm position - supination increases negative variance while pronation decreases it 7
• Acquired positive ulnar variance can occur due to premature physeal closure in young athletes, particularly gymnasts, requiring careful assessment and management 5
• In distal radius fractures, assessment of ulnar variance on lateral radiographs helps differentiate true shortening from apparent shortening due to articular surface tilting 4
• Positive ulnar variance has been associated with degeneration and perforation of the TFCC and cartilaginous wear of carpal bones (ulnar impaction syndrome) 6

Monitoring and Follow-up

• Regular radiographic follow-up is recommended to monitor for progression to conditions associated with ulnar variance 1
• Clinical assessment should include testing for ulnocarpal impingement 5
• Treatment decisions should consider symptoms, functional limitations, and evidence of associated pathology rather than the radiographic finding alone 1