History and Clinical Presentation

A 24-year-old right hand dominant man sustained a dorsiflexion injury to his right wrist while trying to protect himself from a falling shelf at work. He continued to work with pain for about 6 weeks before he presented to an orthopedic surgeon. He was treated nonoperatively for a year and a half, but he continued to complain of ulnar-sided wrist pain and clunking. He had a positive midcarpal clunk with ulnar deviation, but his midcarpal instability was not as dramatic as his symptoms of ulnar abutment. Radiographs demonstrated ulna positive variance and mild VISI deformity. A triple-phase arthrogram revealed tears of the TFCC and lunotriquetral ligament. The patient was thus given a diagnosis of ulnar abutment syndrome. After failing conservative treatment (nonsteroidal antiinflammatory drugs, steroid injections, splinting), he was taken to the operating room for arthroscopic debridement of the torn TFCC and lunotriquetral ligaments, and open wafer excision of the right distal ulna. He did well postoper-atively and progressed with occupational therapy that included range-of-motion exercises, stretching, and later wrist strengthening exercises. However, the clunking sensation remained. At 1 year postoperatively, he had minimal complaints of ulnar abutment; however, the clunking sensation persisted and was associated with pain while gripping in palmar flexion. A pisiform loading volar splint was fabricated and was worn for all activities; however, his symptoms did not improve over the next 2 months.

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