Case of Posttraumatic Ulnar Translocation of the Carpus: A Report

Written By : Dr Supreeth D R |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2022-06-07T19:30:50+05:30 | Updated On 7 Jun 2022 7:31 PM IST

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.

MBBS, Dip. Ortho, DNB ortho, MNAMS

Dr Supreeth D R (MBBS, Dip. Ortho, DNB ortho, MNAMS) is a practicing orthopedician with interest in medical research and publishing articles. He completed MBBS from mysore medical college, dip ortho from Trivandrum medical college and sec. DNB from Manipal Hospital, Bengaluru. He has expirence of 7years in the field of orthopedics. He has presented scientific papers & posters in various state, national and international conferences. His interest in writing articles lead the way to join medical dialogues. He can be contacted at editorial@medicaldialogues.in.

Dr. Kamal Kant Kohli

Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751