Ulna Variance and Ulna Shortening
Oftentimes when speaking with patients, they report that their doctor states that they have a positive ulnar variance. They are discouraged as it sounds permanent and only resolved with ulnar shortening surgery. I thought it was an important topic to discuss. Ulnar variance is a measurement that is taken from X-rays to define the length of the ulna bone relative to the radius.
This is an important measurement because the dynamics of the wrist are dependent on the ulna and radius translating force through the wrist. Normally, the translation of forces 80/20. 80% translates to the radius and 20% to the ulna. This is one of the reasons we see more radius fractures than ulna fractures.
I have found that the interpretation of X-rays is highly variable amongst radiologists. Anyone with this diagnosis should understand some important dynamics. Firstly, the analysis of ulnar variance is quite detailed - a mm difference is a big deal. Anytime we are dealing with mm, there is a lot of room for error.
The best discussion about ulnar variance and radiographic imaging of the wrist can be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193630/
I would highly recommend that you read this article thoroughly and consider printing it for your next visit.
Although not yet done, I have often hypothesized that when the TFCC is disrupted, there is a spreading of the distal radius and ulna. This spreading lends to a view of a longer ulna. Is it the long ulna that caused the tear or the tear that caused the view of a long ulna? A simple research study would include imaging the wrist with and without the WristWidget®. If a blinded radiologist could view the ulna variance change with the WristWidget® on, it would support the theory of the TFCC causing an ulnar variance.
In an interesting article published by PubMed.gov, the authors write, "The relationship between triangular fibrocartilage complex (TFCC) tear and ulnar impaction syndrome has not been fully understood. We hypothesized that a TFCC tear could change the ulnar variance, which may be the cause of ulnar impaction syndrome." They concluded, "Ulnar variance may be changed after a TFCC tear. In our study, it decreased after TFCC foveal repair. However, as time went on, the ulnar variance increased again, which could be one of the causes of ulnar impaction syndrome and ulnar-sided wrist pain."
Also of note, the position of the elbow matters. The article above clearly shows the changes to the ulna variance when the elbow is positioned in neutral, pronation and supination with grip. Look closely at the time frame of 2009-2011. This is new knowledge and takes a while to infiltrate into the world of medicine. The importance of the pronated grip view cannot be underestimated in the evaluation of the wrist. When I ask patients about their X-rays, few describe receiving a pronated grip view!
Positive ulnar variance is when the ulna extends past the radius 1-4 mm. 4 mm is serious and needs surgical repair. I think the positive ulnar variance is a consequence of a tfcc tear.
There is only one genetic disease where one is born with an ulnar variance, Madelung's deformity. Radiopedia states,
"Madelung deformity is due to defective development of ulnar third of the epiphysis of the distal radius, which results in a radial shaft that is bowed with an increased interosseous space, and dorsal subluxation of the distal ulna.
It can be bilateral in 50-66% of patients. It often occurs as rare congenital deformity and does not usually manifest until 10-14 years. It may also be seen as an acquired consequence of trauma to the growth plate, e.g. Salter V fracture. The congenital form has an autosomal dominant inheritance with a variable penetrance."
For the rest of us, there are many reasons that one acquires an ulnar variance, but in my humble opinion, the sharp increase of diagnosis of positive ulnar variance is suspicious.
In every TFCC case, the elbow should not be excluded. Every patient should understand the value of knowledge in your own care.
Here is another article on ulnar shortening surgery. When Wendy was asked about it, she replied that she completely agrees with it. https://regenexx.com/blog/
Wendy devoted a recent Instagram session to this frustrating condition. Here is the cheat sheet and video link.
Episode 22: Ulnar Variance
0:49 Difficult to define alignment
2:06 What is ulnar variance?
2:29 Positive ulnar variance
3:40 Relation of ulna to radius
4:17 Distribution of force
5:26 Measurement of ulnar variance
5:43 Standard procedures for measuring ulnar variance
6:47 How pronation/supination changes ulnar variance
6:53 Grip and ulnar variance
6:56 Position of the elbow changes ulnar variance
7:17 Device to standardize assessment
7:47 Doctors range in their assessment/definition of ulnar variance
8:35 Why MRIs are not a good way to measure ulnar variance
9:13 What happens when your positive ulnar variance is above 4mm?
9:37 Kienbock's disease and negative ulnar variance
9:40 LT tears and negative ulnar variance
10:06 Abutment syndrome
10:20 Wrist and elbow fractures effect on ulnar variance
11:39 Ulna shortening
12:14 TFCC tear and ulnar variance
14:58 What's the best treatment for ulnar variance?
16:27 Effects due to prolonged wrist stability less than 45 lbs
17:05 How weight bearing test can help with ulnar variance
17:22 Grip strength and ulnar variance
19:53 Timeline for surgical procedure and recovery
24:10 Important to get multiple opinions
26:11 Differences in male/female and small/large wrists
27:27 How can you make the xray tech position you correctly?
29:00 Ask Dr. to order xray with elbow at 90 degrees and wrist is neutral
30:04 Ask Dr. to xray other wrist as well
31:00 Does TFCC injury cause ulnar variance or vice versa?