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Ulnar sided wrist pain

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Injured my left wrist at work in June. I have been seeing a specialist since the first of July, and at this point I think workman's comp is going to send me to someone else. As a nurse, I am tired of waiting and having no answers. Hoping someone may have some ideas.

Mechanism of injury. (something doctor's aren't paying attention to). Transfering a patient, left arm was under his arm pit, he buckled his knees and full weight dropped on myself and cna. Felt pain and pulling in my wrist, so I grabbed my left wrist with my right hand until we could safely transfer him. (so his weight was fully on my arm pushing ulna out as I was pulling inward with my right hand).

Swelling on ulnar side of wrist since injury. Pain until recently, (will explain next) with ulnar deviation and suplination, or if you press down on my ulnar from the inner forearm. Generally didn't ache or hurt at rest until end of day. In beginning also had pain radiating to elbow and ulnar nerve tingling at night. Was in a short arm cast after MRI for 4 weeks. Out of cast and splint with rom PT only for 4 weeks then placed in munstor splint. Which has now made it hurt all the time (think because pressure on ulna at both ends). Radiation to elbow has come back with the use of the splint. Since about the third or fourth week no longer have ulnar nerve tingling daily, just occasionally.

Arthrogram was negative for TFCC injury. Doctor said my MRI showed an effusion and a bone contusion on the Triquetrum (? spelling). I got the reports today and I don't have a bone contusion. What the MRI says is I have a type 2 lunate and a bony exotosis on the Ulnar aspect of the triquetrum. Both of these would be chronic and I had no pain before this happened. NOr did I have the pretty much constant popping (without pain) I have now. I have had some very big pops since I have been in the munstor splint.

The swelling is mostly between the Ulnar Styloid and Triquestrum on the lateral aspect of my hand. The ulnar styloid is noticeably higher on the affected extremity when compared to the other wrist, and there is play when you push on the ulna. I also have swelling proximal to the joint on my anterior arm. I measured my wrists, and the affected extremity (non dominant arm) is 0.6 cm bigger just below the styloid portion of the wrist, and over this portion of the wrist (directly over the ulnar styloid), and 1 inch proximal to the wrist.

Now all this sounds like a tear to me. Why the normal arthrogram?

So frustrated, because I have had limited use (10 lbs or less) for four months now. It still is swollen, and it still hurts when I lift anything over 2 lbs (if I lift with ulnar deviation).

Thanks Jen
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replied October 17th, 2012
Especially eHealthy

Sorry about your problems.

Unfortunately, ulnar sided wrist pain is very difficult to diagnose and treat. It is called the "back pain of hand surgery", because it is very common and very difficult to manage.

First, if the Munster splint is making you worse, why wear it? Contact the surgeon who put you it and explain that is not doing anything, making things worse, and you are going to discontinue it. There is no reason to continue to wear an appliance that makes your symptoms worse. You do just as well with a regular wrist splint for activity. A Munster is mainly to prevent pronosupination.

As to the arthorgram, it is a flow study, designed to look for tears which allow the contrast to move from one compartment to another. Though they are usually very accurate, there are cases where the study is a false negative. There can be a flap tear, which seals under the pressure of the injected contrast, and as a result the contrast does not flow through the tear. But, these are rare.

The Type II lunate just refers to its morphology, its shape. The Veigas classification is probably the most commonly used. There is roughly an even prevalence of Type I and II lunates in the general population.

> Type I lunates have a single distal articular facet for the capitate
> Type II lunates have an additional distal articular facet medially for the hamate

Type I lunates are associated with higher prevalence of dorsal intercalated segment instability (DISI) deformity in the setting of scaphoid fracture non-union (~ 75 vs 20%). Type II lunates are associated with hamatolunate impingement syndrome leading to a higher prevalence of hamatolunate degenerative arthritis. These are just generalizations, and do not mean that any one person with either type WILL develop these conditions.

Small bone spurs, exostoses, are very common in the wrist. They are most common on the radial and ulnar sides of the wrist, off the radial styloid, scaphoid, triquetrum, and sometimes the ulnar styloid. As you have noted, they are usually chronic and do not cause any specific problems themselves. But, they can signal that a problem does exist. When seen on the radial side, they are usually associated with degeneration of the radioscaphoid joint. On the ulnar side, you have to look at what is going on to see if there are any associated problems.

As to the bone contusion, did the surgeon look at the film? Many times orthopedic or hand surgeons will pick up subtle things that the radiologist does not (and vise versa). Which is why most surgeons will not only read the report, but also look at the films themselves. A contusion of the triquetrum would not be unexpected in the injury you describe.

From your description of the popping in the wrist, you could have one of the many dynamic carpal instabilities. But, a disclaimer, popping, snapping, etc is very common in the wrist, and does not absolutely indicate that there is a pathological conditon. However, that said, popping can be from abnormal motion of the carpal bones on themselves or abnormal motion of the carpals on the forearm bones. There are so many intrinsic ligaments in the wrist, it is difficult to count all of them.

Unfortuantely, dynamic instabilities usually do not show up on any study, until very late, after degenerative changes have occurred. This type of problem has to be picked up by a thorough physical examination of the wrist.

There are also several tendons which pass by the ulnar side of the wrist, the closest associated one is the ECU (extensor carpi ulnaris). It goes through the sixth extensor compartment, whose subsheath actually makes up part of the TFCC ligamentous sling. The ECU can sublux in and out of its groove, causing ulnar sided wrist pain and swelling.

You can have DRUJ (distal radioulnar joint) instability, with an intact TFCC. This can cause popping and pain on the ulnar side of the wrist, though it is usually more located on the dorsal aspect of the wrist.

As to the ulnar nerve symptoms, those may or may not be associated with your wrist problem. Most of the time, they are not. If it was, it would probably be at Guyon’s canal in the wrist. However, many patients develop numbness and tingling in the ulnar two digits when sleeping, mainly from the position of the arm during sleep. We tend to flex the elbow, putting the hands around the chin or behind the head, and this can compress the ulnar nerve. If you think that you are developing significant neuropathy of the ulnar nerve, then electrical studies may have to be done. There are cases of “double crush”, where the nerve is compressed in two locations along its course.

So, again, not all ulnar sided wrist pain is from the TFCC. And, trying to figure out what it is can be very difficult. Sometimes, a diagnostic arthroscopy has to be done. That is avoided if at all possible, because it is a surgical procedure.

But, a thorough evaulation by a hand surgeon should be able to ferret out what is going on.

Hope that you find out what is going on with your wrist. Good luck.
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