Ulnar Impaction Syndrome
- Fysiobasen
- Oct 6
- 6 min read
Ulnar Impaction Syndrome is a degenerative condition affecting the ulnar side of the wrist, leading to pain and functional impairment. The syndrome results from increased load transmission between the ulna and the ulnar carpal bones – primarily the lunate and triquetrum – as well as the triangular fibrocartilage complex (TFCC).
Over time, this causes TFCC degeneration, chondromalacia of the ulna and lunate, and ligament damage, particularly to the lunotriquetral ligament¹–⁵.
Epidemiology and Etiology
The main predisposing factor for ulnar impaction syndrome is positive ulnar variance, meaning the ulna extends more distally than the radius.This can be congenital or acquired – for example after fractures, radial shortening, or surgical removal of the radial head.Positive ulnar variance increases compression on the TFCC and ulnar carpal structures, particularly during pronation and power grip² ³ ⁶ ⁷.
Even in neutral or negative ulnar variance, the syndrome can develop under dynamic load, especially during pronation and gripping, as the ulna shifts distally and increases pressure on the TFCC and lunate⁶ ⁸ ⁹.
Clinical Presentation
The condition develops gradually, and symptoms can range from mild to severe. Common clinical features include:
• Ulnar wrist pain, often diffuse or localized distal to the ulnar head
• Tenderness dorsally and volarly to the ulnar styloid process
• Swelling and reduced wrist motion, especially during ulnar deviation and pronation
• Pain during gripping and repetitive load-bearing (e.g., lifting, screwdriver motions)
Patients may also exhibit restricted forearm rotation, reduced grip strength, and occasional clicking. Symptoms typically worsen with physical activity or manual labor.
Differential Diagnoses
Palpation
Tenderness is typically noted:
• Dorsal to the ulnar head
• Volar to the ulnar styloid process
• Pain is often reproduced during active pronation and ulnar deviation
Movement
Typical findings include:
• Reduced flexion, extension, and deviation of the wrist
• Pain during passive ulnar deviation
Strength Testing
• Decreased grip strength measured using a dynamometer
• GRIT test (Gripping Rotary Impaction Test): a GRIT ratio greater than 1 indicates Ulnar Impaction Syndrome⁶
Specific Tests
• Ulnocarpal Stress Test:– Ulnar-deviate the wrist– Apply axial compression– Passively pronate and supinate– Pain reproduction indicates a positive test¹⁵
Imaging
• X-ray:– PA view in both neutral and pronated rotation– Reveals ulnar variance, sclerosis, cysts, or osteophytes¹ ⁸ ¹⁴
• MRI:– Demonstrates degeneration of the TFCC, lunatum, and associated soft-tissue structures⁸ ¹³ ¹⁶
• Arthrography:– Previously the gold standard for TFCC assessment, now largely replaced by MRI due to false negatives
• CT:– Indicated when evaluating osteoarthritis or DRUJ instability
• Arthroscopy:– Remains the gold standard for assessing osseous lesions and TFCC integrity
Diagnostic Criteria for Ulnar Impaction Syndrome
• Pain located distal to the ulnar head
• Radiological findings showing cystic changes in lunatum or ulna, or TFCC degeneration (Palmer class 2)
Outcome Measures
• DASH / QuickDASH
• GRIT ratio
• Patient-reported pain and grip strength
• Range of motion and ADL functional status
Medical Treatment
Conservative treatment should always be the first approach and includes:
• Immobilization for 6–12 weeks with a splint or cast
• NSAIDs
• Corticosteroid injections
• Reduction or avoidance of provocative activities such as pronation, power gripping, and ulnar deviation
If symptoms persist despite conservative management, surgical treatment is indicated¹ ⁶ ⁷.
Surgical Options
Ulnar Shortening Osteotomy
• 2–3 mm of the ulnar shaft is resected and fixed with a plate
Indications:
• Positive ulnar variance
• Pain during pronation and ulnar deviation
• Positive stress test
Contraindication:
• Advanced osteoarthritis in the distal radioulnar joint (DRUJ)
Results:
• Significant improvement in modified Gartland and Werley scores⁶
• Reduction of subluxation and cystic degeneration
• 100% bone union reported within 6–8 weeks in several studies
Arthroscopic Wafer Procedure
• Removal of up to 2.3 mm from the distal ulna
• Often combined with TFCC debridement
Indications:
• TFCC degeneration
• Mild positive ulnar variance (<4 mm)
Results:
• 85–100% reduction in pain
• Possible mild loss of grip strength, especially in patients with previous radius fracture⁹
Other Surgical Procedures
Bowers Procedure:
• Resection of the ulnar articular surface if TFCC remains intact
Darrach Procedure:
• Excision of the ulnar head if TFCC cannot be reconstructed
Sauvé-Kapandji Procedure:
• Resection of the distal ulna combined with radioulnar arthrodesis to preserve forearm rotation
Complications
• Scarring and infection
• Injury to the dorsal sensory branch of the ulnar nerve
• Numbness, complex regional pain syndrome, or ECU tendinitis
• Delayed or non-union
• Smoking delays bone healing after osteotomy
Postoperative Rehabilitation and Follow-Up
0–2 weeks:
• Immobilization with a sugar-tong splint or cast
• Focus on pain and edema control
2–6 weeks:
• Transition to removable brace
• Gradual range-of-motion exercises for the elbow, wrist, and fingers
• Avoid loaded rotational movements
6–8 weeks:
• Begin isometric strengthening
• Full range of motion without load
12–16 weeks:
• Progressive strengthening and manual mobilization if joints are stable
Expected recovery:
• Full bone healing after ulnar shortening within 3 months
• Return to full activity within 6 months
• Return after wafer procedure typically within 8–12 weeks
Physiotherapy After Surgery
The physiotherapist’s role is to:
• Reduce postoperative pain and swelling
• Restore range of motion in the elbow, forearm, and wrist
• Rebuild strength and functional capacity
• Improve proprioception and joint control
Particularly important when managing:
• TFCC insufficiency
• DRUJ instability
• Stiffness following immobilization
Example interventions include:
• Low-load, high-repetition exercises
• Early active and passive movement of adjacent joints
• Isometric strengthening
• Soft-tissue and scar mobilization
• Gentle joint mobilization when stability permits
Clinical Summary
Ulnar Impaction Syndrome is an important differential diagnosis for ulnar-sided wrist pain. It requires careful clinical assessment and appropriate imaging for a reliable diagnosis. When conservative management fails, surgical treatment provides good outcomes if properly indicated. Interdisciplinary follow-up and targeted physiotherapy are crucial for restoring wrist function and preventing long-term disability.
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