Case of Posttraumatic Ulnar Translocation of the Carpus: A Report

M. Nasra et al reported a case of Posttraumatic ulnar translocation (PTUT) in a 71-year-old-man who presented to Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. Conservative treatment was successful in managing symptoms.

Ulnar translocation (UT) of the carpus is a rare pattern of radiocarpal instability. Posttraumatic ulnar translocation (PTUT) is an infrequent event that is often missed on initial presentation. As a result, there can be a considerable delay in diagnosis and treatment with poorer outcomes. An optimal treatment method has not yet been established.

A 71-year-old right-handed man presented with multiple injuries following a mechanical fall from a ladder sustained while hanging Christmas lights. The patient fell forward onto his face and outstretched hands. He sustained various facial fractures that were emergently treated. Additionally, he complained of left wrist pain.

Initial examination revealed the left upper extremity to be neurovascularly intact, swelling about the base of the first metacarpal joint, and tenderness to palpation over the anatomical snuffbox. Initial plain radiographs of the left wrist were read as normal. The patient's left upper extremity was placed in a thumb spica splint for a suspected nondisplaced scaphoid fracture, and he was told to follow up outpatient.

At the 7-week follow-up visit, the patient had continued mild left-sided wrist pain, which prompted a reevaluation of the initial radiographs. A retrospective diagnosis of volar ligament injury was made. A small volar fleck fracture was associated with the ulnar translation of the proximal carpal row. The hand attending physician, hand surgery resident, and radiologists missed this diagnosis on the initial presentation.

New radiographs taken at this visit demonstrated that the entire carpus had translocated ulnarly. Because of the minimal symptoms and delay in diagnosis, he continued to be managed nonsurgically.

At the 14-week follow-up, he again had minimal pain and a slight cosmetic ulnar deformity. Wrist examination revealed 600 of extension, 450 of flexion, 250 of ulnar deviation, 100 of radial deviation, symmetrical rotation to the uninjured side, and a full fist.

At 6 months, the patient denied any pain symptoms. He used a splint when he occasionally did yard work but otherwise did not use immobilization. Examination of the affected wrist revealed 60 of wrist extension, 50 of wrist flexion, 250 of ulnar deviation, 100 of radial deviation, and the contralateral wrist had 800, 700, 400, 200, respectively. Grip strength at level 3 of the Jamar dynamometer was 18.1 kgf on the injured side and 29.5 kgf on the uninjured side. There was no evidence of functional carpal instability or degenerative radiographic changes.

At 10 months postinjury, the patient was contacted by phone. He mentioned having mild pain with heavy activities such as yard work. However, using a cock-up wrist splint while doing strenuous activities allowed him to work without pain. He takes no pain medication for his wrist and is satisfied with his current upper extremity function.

The authors recommended that - Clinicians should maintain a high index of suspicion for PTUT in the setting of high-energy injuries with signs of ligamentous injury on imaging, such as the volar fleck sign, and strongly consider contralateral imaging. Surgical repair is favored in cases diagnosed acutely. Conservative management may be considered for chronic cases if the patient presents with minimal symptoms, particularly if elderly and low demand. Otherwise, ligamentous reconstruction or limited wrist fusion may be warranted.

Further reading :

Posttraumatic Ulnar Translocation of the Carpus: A Case Report and Brief Review of the Literature

Matthew Nasra et al

Journal of Hand Surgery Global Online 4 (2022) 49-52

https://doi.org/10.1016/j.jhsg.2021.10.002