EXTENSOR CARPI ULNARIS tendinopathy

EXTENSOR CARPI ULNARIS
TENDINOPATHY
Amanda Cooper
OVERVIEW
• Anatomy
• Biomechanics
• Injury Pathology
• Assessment
• Treatment
Anatomy
• Origin:
− Middle third of the posterior border of
ulna
− Lateral epicondyle of humerus
• Insertion:
− Dorso-ulnar aspect of the base of the 5th
metacarpal
• Innervation:
− Posterior interosseous nerve (C7 & C8), the
continuation of deep branch of radial
nerve
• Main Action:
− Wrist extension and ulnar deviation. It also
assists to provide stability at the wrist.
Anatomy
• Fibro-osseous tunnel
– Distal ulna - ulnar groove
– 1.5 to 2cm length band of connective tissue
(ECU subsheath)
• Stabilises the tendon at the level of the
distal ulna
• ECU subsheath lies deep to the extensor
retinaculum
• The overlying extensor retinaculum
courses over the ECU and distal ulna to
attach to the pisiform and triquetrum.
Does not play a role in stabilising the
ECU tendon.
• Linea jugata provides dynamic stability
Anatomy
• Linea Jugata
Anatomy
• Linea Jugata
Anatomical Variations
• Shallow osseous groove
• Anomalous tendinous slips (EDM)
Biomechanics
• Pronation
– Straight course
– Minimal force on subsheath
• Supination
– ECU radially translates forming ulnar directed obtuse angle
– This angle is further increased with wrist flexion and ulnar deviation
– Maximal force on subsheath
Injury Pathology
1. ECU Subluxation
2. ECU Tenosynovitis
3. ECU Rupture
Differential Diagnosis
• Associated Injuries / Differential Diagnosis
–
–
–
–
TFCC injury
Lunotriquetral instability
DRUJ injury
Ulnar styloid non-union
ECU Subluxation
• Requires an injury to the ECU subsheath
• ECU tendon is no longer maintained within its fibro-osseous
groove
• Usually occurs as a result of acute injury
– Forceful supination, flexion and ulnar deviation
• Tennis, golf, weight lifting, rodeo
• Cricket, forceful twisting of a drill
• Can develop into a chronic injury if left untreated
ECU Subluxation
Injury is classified into three groups:
A. Stripping injury
B. Ulnar sided rupture of subsheath
C. Radial sided rupture of subsheath
ECU Subluxation
A. Stripping injury
− ECU subsheath is stripped at its ulnar attachment, forming a false
pouch into which the ECU tendon can sublux (supination)
Normal subsheath
preventing subluxation
Stripping of subsheath at ulnar attachment
resulting in subluxation during supination
ECU Subluxation
B. Ulnar sided rupture of subsheath
– Likely most common pattern of injury
– Subluxes in supination with relocation of tendon upon pronation
C. Radial sided rupture of subsheath
– Tendon is more likely to relocate lying above the ruptured subsheath.
– Functional healing of the tendon is prevented
Ulnar sided rupture
Relocates beneath
ruptured subsheath
Radial sided rupture
Relocates atop
ruptured subsheath
Supination
Pronation
ECU Tenosynovitis & Tendinosis
• Insidious onset
• Chronic stress is placed upon the tendon resulting in
inflammation of its synovial lining, causing tenosynovitis
– Office workers, Boiler maker, Chicken Treat
• Over time, stress may also lead to tendon degeneration
and altered collagen content, resulting in tendinosis with
or without partial tears.
• Second most common site of wrist tendinopathy in
athletes
– Racquet sports, golf, rowing
• Frequent early finding in patients with RA
ECU Tenosynovitis & Tendinosis
T1 Weighted axial image
STIR axial image
•
Yellow asterisk = Normal ECU tendon
•
Blue arrow = fluid surrounding the ECU tendon
•
Red arrow = ECU subsheath
•
Red asterisk = reactive marrow oedema
•
Blue arrow = extensor retinaculum
ECU Rupture
• Rare
• Characteristic cascade of events
–
–
–
–
Initial acute luxation event
Low grade persistent pain (often with accompanying tenosynovitis)
Local steroid injections (may have provided temporary relief)
Increasing pain limits wrist activity, and subsequent imaging reveals
the tendon rupture
• Decreased grip strength
ECU Rupture
•
•
•
Tendon is absent
Red arrow = subsheath is thickened
Red arrowhead = chronically torn from radial aspect
Assessment
• Location of pain &/or swelling
– Dorso-ulnar wrist
• Onset of symptoms
– Acute vs. gradual onset
• Mechanism of injury
– Forceful supination, flexion, ulnar deviation
– Repetitive ulnar deviation
Clinical Assessment
• Tendon stability
– Painful snapping or clicking sensation of the ECU tendon during
provocative testing
• Active supination
• Passive supination
• Active supination, flexion and ulnar deviation
• MMT
– Resisted wrist extension and ulnar deviation
– ECU synergy test (Ruland & Hogan 2008)
ECU Synergy Test
1.
2.
3.
4.
Elbow flexed 90°; forearm in full
supination; wrist neutral; fingers in full
extension
Examiner grasps patients thumb and
middle finger and palpates the ECU
tendon with the other hand. The
patient then abducts the thumb
against resistance
Presence of both ECU and FCU muscle
contraction is confirmed
Re-creation of pain along the dorsal
ulnar aspect of the wrist is considered
to be a positive test for ECU tendonitis
Imaging
• MRI (supination)
• Dynamic ultrasound
(pronation & supination)
Conservative Management
•
•
•
•
•
Rest
NSAIDs
Immobilisation (splinting or casting)
Ergonomic assessment
Activity modification
Conservative Management
• ECU Subluxation
– Maintain forearm in pronation. Wrist in slight extension and radial
deviation
– 6-12 weeks
– Mixed results in literature
Conservative Management
• ECU Tenosynovitis
– Ulnar gutter to prevent ulnar deviation
– Advise patient to avoid forearm rotation
– 3-6 weeks
Activity Analysis & Modification
• Activity Analysis
– Identification of tasks involving repetitive ulnar
deviation
– Ergonomic assessment
• Activity Modification
– To enable the person to continue with activity
•
•
•
Use other hand
Alternative grip
Assistive devices or equipment
Ergonomic Equipment
• Avoid ulnar deviation
– Whale mouse: designed to promote a relaxed
hand position and neutral deviation at the wrist
– Split keyboard: maintains neutral alignment
Medical Management
• Indications:
– ECU tenosynovitis/tendinosis who remain symptomatic despite
conservative treatment
– Torn subsheath ends widely separated
– Tendon lies outside the torn subsheath (radial sided tears)
– ECU rupture
Medical Management
• Corticosteroid injection (with caution)
Medical Management
• Surgery
– Direct repair
– Subsheath reconstruction
• Radially based extensor retinacular flap
• Free retinacular graft
– Sulcus deepening
– Tenosynovectomy (+/- tendon debridement)
– Tendon graft from palmaris longus for ECU ruptures
• Immobilisation in extension & pronation for 4 weeks post surgery
Conclusion
• Important to have an understanding of the different types of
injuries that can occur as this will affect your treatment plan
– ECU subluxation versus ECU tenosynovitis
– Start by looking at the mechanism of injury
Conclusion
• ECU subluxation
–
–
–
–
Acute injury – forceful supination, flexion, ulnar deviation
Focus is on limiting supination
Sugar tong versus wrist gauntlet
Need for further study into the effectiveness of splinting for ECU
subluxation
• Does the location of the tear have an impact i.e. ulnar versus radial sided
subsheath tears
• Importance of the linea jugata
Conclusion
• ECU tenosynovitis
–
–
–
–
Gradual onset – repetitive ulnar deviation
Focus is limiting ulnar deviation
Importance of OT role in activity analysis and modification.
ECU synergy test
Thank you
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