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Extensor Carpi Ulnaris Subluxation in a Workplace Accident: A Case ReportJosh G. Meyer, ATSClearfield, UTObjective: To present the case of an acute traumatic Extensor Carpi Ulnaris (ECU) subluxation as the result of a direct blow in the workplace.Background: The patient was driven to the ground during a work activity causing a direct blow to the lateral wrist. No initial pain and/or signs and symptoms were present. Consequently no doctor visit was immediately thought necessary. Differential Diagnosis: ECU Tendinopathy, Triangular Fibrocartilage Complex (TFCC) tear, Ulnar Collateral Ligament (UCL) sprain, Lunotriquetral instability, Pisotriquetral instability.Treatment: Once signs and symptoms emerged the patient went to see a doctor. First conservative methods were used but ultimately surgery was required to ensure proper healing. Following surgery the patient was required to undergo physical therapy before being cleared for all activities. Uniqueness: ECU subluxations are fairly rare but because of the complexity of MOI’s and misdiagnosis it’s hard to pinpoint exactly how rare. They generally happen it sports such as tennis, golf, basketball, and baseball.Conclusions: Popping and clicking from the ulnar sided wrist is the first sign of a possible ECU subluxation. The sooner you contact you doctor with this symptom the better chance you have of being correctly diagnosed and healed with non-surgical methods.Key Words: Extensor Carpi Ulnaris (ECU), Subluxation, Tendon, Retinaculum______________________________________________________________________________Intro:54343302647315003267075101409500The ECU, sometimes considered a part of the triangular fibrocartilage complex (TFCC) is a muscle in the forearm that helps with wrist extension and ulnar deviation.1 The ECU travels down the forearm from its origin at the lateral epicondyle via the common extensor tendon to its insertion on the ulnar side of the fifth metacarpal.2 The ECU tendon itself lies in the wrist’s sixth compartment. The compartment is comprised of the ECU sub-sheath or where the antebrachial fascia inserts into the osseous groove. The wrist’s dorsal retinaculum which holds down the other five compartments actually doesn’t hold down the sixth compartment.3 It instead runs above and allows for pronation and supination movements.4 The most common mechanism of injury (MOI) for the ECU is one that involves ECU contraction, forced supination, palmar flexion, and ulnar deviation. Injuries from this kind of trauma include small amount of weakening ECU contraction all the way to complete rupture of the ECU and its surrounding sheath.5 Data compiled using Ultra-Sound (US) as a way to disrupt the articulation of the ECU tendon with the ulnar groove suggests that ECU subluxation may result in individuals that are completely asymptomatic just as often as those individuals that have had ulnar sided wrist pain in the past. Dislocation however is more common in those that have previous ulnar sided wrist pain.6 Case Report:Our patient is a 25 year old male who works as a counselor. The injury was sustained while working in a youth home April 15th 2013. During a case that needed restraint the patient was called to action. As he struggled to control the situation he was thrown off balance where he fell to the floor causing a direct blow to the medial wrist. His wrist was in a flexed and ulnar deviated position as he landed with not only his own weight but the weight of the adolescence driving the wrist, into the ground. There was no initial pain or other signs and symptoms until later that night when the patient felt pain and realized as he supinated his wrist he could feel something pop back and forth on the lateral side. The pain subsided over the next week but the popping in the lateral wrist still bothered the patient. After about a week of continued popping the patient decided to go get checked out by a physician. Once at the doctor, the patient revealed that he had no previous history with any type of wrist injuries. After re-counting what happened and describing his symptoms, the doctor initially thought he was dealing with a case of TFCC. Considering there was clicking on the medial wrist and somewhat of a robotic carrying of the hand this pathology made sense. He went on to perform Fovea Sign, Over Supination, and TFCC Press/Supinated Lift special tests. Once all of them turned up negative, he was forced to reconsider other pathologies.Prior to going to the doctor the patient became curious and actually researched into his injury. He also came across TFCC but instead landed on the idea that he had an ECU subluxation, the exact injury the doctor tested for next. To rule out any other pathology an X-ray and MRI were also taken, revealing no further injury. It was then the patient was officially diagnosed with and acute ECU subluxation.Course of Treatment:Initial treatment consisted of six weeks in a long cast. The patient was cast in wrist pronation in hope scar tissue would build up and fix the problem without invasive techniques. After six weeks in cast and two weeks of physical therapy (PT) another MRI was taken and it was determined that surgery would be needed to ensure proper healing and future function.In the procedure the distal ulnar groove was deepened allowing for more articulation with the ECU. Dorsally, the surgeon went in and peeled back the retinaculum allowing for easier access to the ECU and surrounding structures. They next placed the hand in supination pulling the tendon away from the ulna. They then expanded the ulnar groove allowing the tendon to sit down nice and snug. Sutures were placed from the ulnar side of the tendon sheath down through the bone to anchor it. Post-surgery the patient was required to go another six weeks in a long cast, keeping his elbow flexed and preventing his wrist from any supination. Following this set of six weeks, another MRI was taken and after doctor approval the patient was moved into a short cast allowing both elbow flexion and wrist supination. Yet another six weeks were then required to ensure complete healing. Before returning to all daily activities the patient will be required to wear a splint and complete a PT stint in which they will use progressive active range of motion (ROM) exercises to help rehab the tendon back to full strength.Discussion:-47625-321627500Traumatic injuries to the ECU that result in dislocation or subluxation are fairly rare because of the usual complexity of the MOI that must take place in order for injury to occur.6 However, recent studies have shown that they may not be as rare as originally thought. Most true ECU subluxations are misdiagnosed as it was initially in this scenario. Generally they become irritating enough that further testing proves correct diagnosis but this delayed treatment time hinders any studies from getting a better grasp on just exactly how rare ECU subluxations are.8 Most commonly ECU subluxations occur in sports such as tennis, golf, basketball, and baseball. The diagnosis in sports in usually straightforward but with the complexity of ulnar wrist pain, this is not always the case. Ulnar sided sports injuries increase the difficulty in pinpointing just how common.9-85979058737500Usual treatment for acute cases involves surgery followed by six weeks in a long arm cast.10 Most doctors will choose to try non-invasive techniques before attempting surgery. They usually involve some sort of cast or splint in hope that avoiding any supination motions scar tissue will build up and lock down the tendon.5 However, this is usually unsuccessful and only lengthens recovery time. It’s been shown that surgery is relatively quick, pain free and successful. There are two main types of repairs for an ECU subluxation. The first was previously described and performed on the patient. It is when the surgeon goes in dorsally, pulls aside the retinaculum and tendon followed by the deepening of the ulnar groove and suturing the tendon sheath back down. The second is rarely done and is only slightly different as it includes shortening of the ulna to help with TFCC problems. Two years post-recovery, roughly 80% of patients forgot that they had the typical surgery until reminded. Reversely 6% needed the surgery again. The alternate option fares similarly as 76% of patients receive no ill effects but 20% reported mild to moderate pain following shortening of the ulna.11,12 The two most common pathologies that ECU subluxations are mistaken for are TFCC and ulnar collateral ligament sprain.8 The TFCC is comprised of three components with the proximal component residing next to fovea of the ulna. This explains why it is sometimes confused for an ECU subluxation as it lies very close to where the ECU tendon sits. However it can be differentiated because only the TFCC provides true stabilization to the distal ulna. TFCC will also cause intense pain when the wrist is compressed and deviated to the ulnar side.13,14 The ulnar collateral ligament adds little support to the wrist but again is very close in proximity to the ECU tendon and is why it can be mistaken for an ECU subluxation as well.15 Conclusions: Although ECU subluxations are generally rare there are some key signs that should alert you to the pathology. Clicking or popping on the ulnar sided wrist especially when the hand is supinated. TFCC also presents this way but should be accompanied by pain with ulnar deviation and compression. The best thing you can do if you present with this is to see your doctor right away so you can hopefully use non-surgical methods before defaulting on surgery.ReferencesSasao S, Beppu M, Kihara H, Hirata K, Takagi M. An Anatomical Study of the Ligaments of the Ulnar Compartment of the Wrist. Hand Surgery. December 2003;8(2):219-226.Starkey C, Brown S, Ryan J, ed 3. Examination of Orthopedic and Athletic Injuries. Philadelphia: E.A. Davis Company; 2010.Montalvan B, Parier J, Brasseur J, LeViet D, Drape J. Extensor Carpi Ulnaris Injuries in Tennis Players: A Study of 28 Cases. British Journal of Sports Medicine. May 2006;40(5):424-429.Cift Hak, Ozkan K, Soylemez S, Ozkan F, Cift Hac. Ulnar-Sided Pain Due to Extensor Carpi Ulnaris Tendon Subluxation: A Case Report. Journal of Medical Case Reports. November 2012;6:394.MacDonald D, Hunt III T, vol 3. Operative Techniques in Orthopaedic Surgery. Surgical Treatment for Extensor Carpi Ulnaris Subluxation (chap 65). Lippincott Williams & Wilkins; 2012.Pratt R, Hoy G, Bass Franzcr C. Extensor Carpi Ulnaris Subluxation or Dislocation? Ultrasound Measurement of Tendon Excursion and Normal Values. Hand Surgery. December 2004;9(2):137-143.Oka Y, Handa A. Recurrent Dislocation of the ECU Tendon in a Golf Player: Release of the Extensor Retinaculum and Partial Resection of the Ulno-Dorsal Ridge of the Ulnar Head. Hand Surgery. December 2001;6(2):227-230.Patterson S, Picconatto W, Alexander J, Johnson R. Conservative Treatment of an Acute Traumatic Extensor Carpi Ulnaris Tendon Subluxation in a Collegiate Basketball Player: A Case Report. Journal Of Athletic Training. September 2011;46(5):574-576.Buterbaugh G, Brown T, Horn P. Ulnar-Sided Wrist Pain in Athletes. Clinics in Sports Medicine. July 1998;17(3)567-583.Rowland S. Acute Traumatic Subluxation of the Extensor Carpi Ulnaris Tendon at the Wrist. Hand Surgery. November 1986;11(6)809-811.Allende C, Le Viet D. Extensor Carpi Ulnaris Problems at the Wrist—Classification, Surgical Treatment and Results. Hand Surgery. June 2005;30(3)265-272.Jui-Tien S, Hung-Maan L. Functional Results Post-Triangular Fibrocartilage Complex Reconstruction With Extensor Carpi Ulnaris With or Without Ulnar Shortening in Chronic Distal Radioulnar Joint Instability. Hand Surgery. December 2005;10(2/3):169-176.Tagliafico A, Ameri P, Michaud J. Wrist Injuries in Nonprofessional Tennis Players: Relaionships with Different Grips. American Journal of Sports Medicine. March 2009; 37(4) 760-767.Nakamura T, Horiuchi Y. Functional Anatomy of the Triangular Fibrocartilage Complex. Hand Surgery. October 1996;21(5)581-586.Taleisnik J. The Ligaments of the Wrist. Hand Surgery. September 1976;1(2)110-118. ................
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