What is the initial approach to managing productive changes at the ulnar joint?

Management of Productive Changes at the Ulnar Joint

Radiographs should be the initial imaging modality for evaluating productive changes at the distal radioulnar joint, as they can identify fractures, dislocations, arthritis, and other structural abnormalities. 1

Diagnostic Approach

• Conventional radiographs are the first-line imaging modality for assessing ulnar joint pain, providing valuable information about bone alignment, fractures, and arthritic changes 1
• Standard radiographic examination should include posterior-anterior and lateral views in neutral position and rotation, often supplemented by oblique views 1
• Comparison with the contralateral elbow/wrist can be helpful to identify asymmetry and subtle changes 1
• For persistent symptoms with normal or nonspecific radiographs, advanced imaging is recommended 2

Advanced Imaging Options

• MRI without IV contrast is recommended for evaluating soft tissue and bone marrow edema that occurs more frequently in symptomatic patients 2
• CT is the modality of choice for evaluating distal radioulnar joint stability and should include imaging of both wrists in maximal pronation, neutral position, and maximal supination 1
• Ultrasound can be used to assess soft tissue structures with high accuracy (sensitivity 77-79%, specificity 94-98%) 2

Conservative Management

• Avoiding activities that place excessive load on the wrist is recommended to prevent symptom exacerbation 2
• Splints or orthoses provide symptom relief, especially with associated thumb base or wrist pain 2
• Rigid immobilization may be preferred over removable splints for better symptom control 2
• Paracetamol (up to 4g/day) is recommended as first-line oral analgesic for pain management 2, 3
• Topical NSAIDs are recommended for localized pain with fewer systemic side effects 2, 3
• Oral NSAIDs at the lowest effective dose for the shortest duration may be considered if there is inadequate response to paracetamol 2
• Range of motion and strengthening exercises help maintain function 2, 3
• Local heat application before exercise may provide additional benefit 2

Surgical Interventions

When Conservative Management Fails

• Surgical options should be considered when conservative management fails or when there is progression of symptoms or associated conditions 2
• For ulnar impaction syndrome (which may occur with ulna positive variance), ulnar shortening osteotomy should be considered 4, 5
• For chondromalacia of the ulnar head in the sigmoid notch and unstable distal radioulnar joints, ulnar recession may be effective by altering the bearing surface and tightening the ulnocarpal ligamentous complex 5
• For ulnar negative variance associated with conditions like Kienböck's disease, ulnar lengthening may be efficacious by redistributing joint compressive forces 5

Specific Procedures Based on Pathology

• In rheumatoid arthritis affecting the distal radioulnar joint, resection of the distal ulnar head (Darrach's procedure) remains the gold standard treatment 6
• For cases with increased radial slope (>23 degrees) and/or destruction of the ulnar corner of the distal radial epiphysis, the Sauvé-Kapandji procedure is a useful alternative 6
• Joint-leveling procedures may be appropriate in certain cases to address ulnar variance issues 2

Monitoring and Follow-up

• Regular radiographic follow-up is recommended to monitor for progression of productive changes 2
• All patients with unremitting pain during follow-up should be reevaluated 1
• Treatment decisions should consider the presence of symptoms, functional limitations, and evidence of associated pathology rather than radiographic findings alone 2

Pitfalls and Caveats

• Ulnar-sided wrist pain is often misdiagnosed as triangular fibrocartilage complex (TFCC) injury, leading to prolonged inappropriate treatment 7
• The "scallop" sign on radiographs is an alerting sign for tendon attrition in rheumatoid arthritis and requires prompt attention 6
• A common complication of Darrach's procedure (distal ulnar head resection) is instability of the proximal ulnar stump 6
• Ulnar translation of the carpus may progress after ulnar head resection, but evidence suggests this is more likely a consequence of the disease rather than the surgical procedure 6