We describe outcomes of extensor carpi ulnaris (ECU) subsheath reconstruction with extensor retinaculum at a median of 8 years follow-up.Methods & Materials In this retrospective study, we identified patients who underwent ECU subsheath reconstruction for subluxation of the ECU tendon between January 2003 and December 2016. The tendon is swollen and small interstitial splits are evident as bright foci within the tendon. [1] [2] [3] [4] It may occur as a result of an early or late complication of cataract surgery, prior vitreoretinal surgery, trauma, or an inherent pathological process or connective tissue . Common symptoms indicative of an extensor carpi ulnaris (ECU) subsheath tear may include: Swelling and discomfort Stiffness Snapping or clicking with rotation Decreased range of motion Causes of Extensor Carpi Ulnaris (ECU) Subsheath Tears Traumatic ECU subluxation is commonly reported in association with racket sports, baseball, and golf. Practicing nutritional mindfulness is one of the most successful ways to promote health and wellness. Curr Rev Musculoskelet Med. This allows side-by-side comparison with the asymptomatic wrist and adequately shows the position of the ECU relative to the ulnar osseous groove in all three positions. This can progress to ECU tendinopathy and partial tendon tears. Recovery and rehabilitation Before you leave hospital, a hand therapist may replace the rigid plaster splint (a support designed to protect the hand) fitted during the operation with a lighter and more flexible plastic one. Depending on the severity of injury, immobilization is necessary for six weeks to three months. When diagnostic measures fail to show ECU tendon damage, an accessory of the extensor pollicus brevis may be the source of the snapping sensation (Subramaniyam SD, et al 2017). Abbasi D. Snapping Extensor Carpi Ulnaris (ECU) [Internet]. Coronal T1. The rare ECU ruptures are repaired via a graft from the palmaris longus.9,10 Associated injuries to the ECU subsheath are concurrently repaired. When an individual experiences an ECU subsheath tear, they may become more prone to further injury of the wrist and may have sustained additional damage that often occurs during the same injury. Mild edema is also evident within the palmar aspect of the distal ulna (arrowhead). Your arm will be placed in a splint or cast, depending on the level of protection needed. Treatment may be successful by immobilizing the wrist with the tendon in a proper position to allow the sheath to heal. J Orthop Sports Phys Ther. If necessary we may suggest some movements for you to do at home to aid in your recovery. Rettig AC, Ryan RO, Stone JA. The ECU muscle plays an active role in movements of wrist extension and ulnar deviation. In resisted finger abduction, pain over the wrist and ECU tendon signifies an inflammatory ECU condition, possibly due to subluxation or overuse. (13a) T1-weighted and (13b) STIR axial images following an acute twisting injury with documented ECU tendon dislocation. study identified ECU subluxation with intact sub- Soames RW, Palastanga N. Anatomy and human movement: Structure and function. Reconstruction consisted of using the extensor retinaculum as a sling reconstruction (Figure 1).Medical records of patients were manually reviewed and assessed for complications and unplanned reoperations. Extensor carpi ulnaris (ECU) dislocation or subluxation is a condition in which an athlete notices a recurrent snapping sensation on the dorsum (back) of the wrist. It's held in this position by a ligament. The ECU subsheath (red arrowheads) is diffusely fragmented. Common risk factors for ECU injury are[1]: Acute injuries are commonly associated with some form of 'trauma' that requires high levels of wrist extensor or ulnar deviation forces to be produced, such as: An athlete/patient may report that they felp a "snap", "pop" or a "tear" at the time of the trauma. The sutures will be removed beginning 10-14 days after surgery. The infratendinous retinaculum runs from the radiocarpal to the carpometacarpal joints. In both instances, the ECU tendon is destabilized and subluxates ulnarly and volarly over the distal ulna beneath an intact dorsal retinaculum. distal ulnar resection (Wafer procedure) preserve ulnar attachment of TFCC. Acta Orthopaedica Belgica 2002; 68-4. The extensor carpi ulnaris (ECU) tendon is involved in many pathologies seen in golf, hockey, tennis, and baseball athletes. What is your diagnosis? Palpating the ECU groove will likely elicit pain and tenderness for the patient if the ECU is involved in the mechanism of injury. The overall incidence of wrist injury can be up to 8.9% of all reported sports injuries but data documenting the frequencing of ECU subluxations specifically is limited[2]. Local steroid injections may have provided temporary relief. Crutches and a brace (or splint) are needed for about one month after surgery. Generally speaking, subluxation of the ECU should be treated under the supervision of a medical professional. A cataract causes the lens to become cloudy, which eventually affects your vision. Patients who experience acute ECU subluxation or dislocation often describe a traumatic incident with immediate, searing pain. There are a number of causes of ulnar-sided wrist pain, and one of those are problems with the ECU tendon. If you do require surgery, Dr. Knight is renowned as one of the most talented Upper extremity specialists in the country, and his state-of-the-art surgical facility will provide both the doctor and you, the patient, with the best possible outcome in repairing your ECU subluxation. It is often the result of acute injury or repetitive motion injury but can also be caused by medical conditions that undermine the integrity of ligaments. Injuries to the extensor carpi ulnaris (ECU) are a well recognized but often poorly understood cause of such pain. endobj
Dallas Fort-Worth accessible hand and wrist offices. The resultant force during the 'contact' can result in a tear of the tendons subsheath and a resultant sublaxation, Range of motion (ROM): likely full other except during the acute phase of injury and will potentially present with pain on, active wrist extension and/or ulnar deviation. Nine patients reported no limitations in daily activity.Conclusions The extensor retinacular sling technique demonstrated favorable results at long-term follow-up and allowed the surgeon to address pathology in the tendon sheath.Level of Evidence: level IVFigure 1. People often call it snapping wrist or snapping ECU. Physical therapy to optimize range of motion and strength is recommended. The injury causes damage to the normal tendon sheath and allows the tendon to slide out of its normal location. Objectively, a thorugh wrist assessment should be completed to aid identification of associated pathologies and to rule out any additional differential diagnoses[6]. Subluxation of the tendon in the ulnar groove will proved a snapping sensation with passive supination and ulnar deviation of the wrist. 5, No. Snapping ECU syndrome is a condition due to the ECU tendon sliding in and out of its groove on the side of the wrist. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Disclaimer The treatment for subluxations may include resetting the joint, pain relief, rehabilitation therapy, and, in severe cases, surgery. Three weeks later, a forearm-based splint is provided and the patient slowly progresses back to activities. Hitting a powerful backhand during tennis where the forearm is reuired to create top spin by moving forcefully from pronation to supination, Hitting a solid object during the golf swing whilst the golf club moves from a radially deviated position to neutral, and the ECU contracts isometrically to stabilize the joint, Contact sports like rugby that require the athlete to hold the ball (and thus contract the ECU isometrically in maximal supination) to maintain possession when entering a contact. Am J Sports Med 2205; 33:1910-1913. It also provides stability to the ulnar side of the wrist. Degree of damage dictates restrictions. An overview of the ECU at the level of the distal ulna with a cutaway of the extensor retinaculum reveals the band-like subsheath (red) which serves to stabilize the ECU tendon within its groove at the distal ulna. Uncommon, ruptures are typically repaired using a local graft, primarily the palmaris longus. The subsheath appears disorganized and its palmar attachment is lax and ill defined (arrowheads). Your arm will be placed in a splint or cast, depending on the level of protection needed. The most commonly utilized repair technique is a reconstruction of the subsheath using a strip of extensor retinaculum. ECU subluxation is caused when the fibrous sheath through which the ECU tendon passes upon reaching the wrist joint become injured, whether through trauma or repetitive injury. You will wear this cast or splint for around four weeks. As it takes about 1 hour for the medication to take effect, it is important to stay ahead with your pain medication and avoid having to play catch up for a significant increase in pain. How can Dr. Knight help you with ECU Subluxation? Our cohort consisted of 6 male and 9 female patients. An MRI arthrogram of the wrist may depict a subsheath tear and, therefore, an injury to the peripheral TFCC. Musculoskeletalkey.com. Ultrasound: is useful for assessing the dynamic stability of the ECU tendon as the tendon can be visualised whilst the patient/athlete pronates and supinates their forearm. The pain often occurs at night and may persist for several months despite the lack of any specific injury or trauma. Types of Shoulder Instability Surgery. Am J Roentgen 2007; 189:1502-1507. Radial head fracture with an interosseous membrane injury extending to DRUJ. The chronically unstable tendon, if used repetitively, may even cause osseous erosion of the distal ulna.8. Apparently recovery takes a LONG time. endobj
You will be prescribed occupational therapy after your surgery to restore your range of motion. An athlete/patient may go on to develop co-comittant tenosynovitis/tendinopathy as the tendon becomes irritated by repeated rubbing against the ulna styloid during subluxations. Seldom is a surgical procedure needed for treatment of ECU tendonitis, but if symptoms persist despite appropriate management, a surgical debridement of the tendon can be considered. Surgical repair may be recommended in some cases, especially in situations where an individual has an acute or chronic high-grade injury to the ECU. Chronic subluxation can lead to ECU tendonitis. In addition, the ECU was subluxated volarly in forearm supination with tendon attrition at the level of the ulnar These diagnostic tests will be followed by a thorough physical exam, so that the doctor can see the injury for himself and learn from you just how it affects your activities of daily life. Medication for nausea may also be provided. Following this, the retinaculum was elevated until the extensor carpi ulnaris was identified and it was freed up from surrounding synovium. Injury to the tendon may be acute, chronic, or anatomical based. Hand Anatomy Review and Clinically Relevant Disorders by Compartment. 4 Stoller DW. The OCSM clinic in Metairie, Louisiana, specializes in diagnosis and treatment of Rotator Cuffs. MPFL reconstruction is a surgery in which a new medial patellofemoral ligament is created to stabilize the knee and help protect the joint from additional damage. Altered mechanics lead to chronic irritation, and thus many such patients experience persistent tenosynovitis. The ECU tendon is the tendon that sits in a groove on the outside of the Ulna bone and is covered by a thin sheath that holds it in place. The ECU tendon can be palpated on the dorsal aspect of the wrist with the wrist in resisted extension and ulnar deviation. The treatment can be conservative but sometimes it requires surgical treatment. Provocative maneuvers for lunotriquetral ligament injuries (ie, ballottement test, ulnar snuff box test) have sufficient sensitivity but poor specificity. In such patients, chronic stress upon the tendon results in inflammation of its synovial lining, causing tenosynovitis.4 Over time, stress may also lead to tendon degeneration and altered collagen content, resulting in tendinosis with or without partial tears (8a). Due to the mobility required around the wrist the muscle relies on specific stabilising structures such as the fibro-osseous groove, tendon subsheath and extensor retinaculum to maintain its position at the wrist[1]. Non-surgical treatment of ECU subluxation consists of splinting or casting, as with other wrist tendon injuries, which will hold the joint in place and keep movement from exacerbating the problem and allowing the tendon to rest in its appropriate position while healing. Palpation and movement of the joint may also give a better understanding of the possible nature of the injury. The surgery would put the ECU back in the groove and take some ligament graft to aid the sheath in healing. It ensheathes the ECU and maintains the tendon tightly in the groove (. The tendon itself lies within a bony groove along the dorsal, distal ulna. Bankart Repair. Surgical Intervention Closed reduction of the wrist dislocation can be attempted after a complete neurovascular examination is performed and proper radiographs are obtained. Reconstruction consisted of using the extensor retinaculum as a sling reconstruction (Figure 1). This type of injury is frequently misdiagnosed in high-trained athletes. The dorsal extensor retinaculum of the wrist is composed of two primary layers (. Sometimes your healthcare provider will perform a test by injecting a numbing medication (lidocaine) around the tendon to see if the pain resolves. Ulnar sided ruptures of the subsheath, likely the most common pattern of injury, usually result in dislocation followed by reduction in which the tendon returns to a location deep to the subsheath (12a, 13a,13b). Rowland. At a median follow-up of 8.4 years, the median PROMIS UE Physical Function score among 10 patients was 56, the median score for pain 0.5, and the median score for satisfaction 9.5. Clinical History: A 44 year old recreational tennis player complains of chronic, worsening ulnar sided wrist pain.