➢ Injuries to the extensor carpi ulnaris tendon are most commonly tendinitis, tendinosis, and tenosynovitis, followed by injuries to the extensor carpi ulnaris subsheath. Extensor carpi ulnaris tendon ruptures are rare.
➢ In most cases, a period of several weeks of wrist immobilization and activity modification will lead to a favorable outcome.
➢ In patients reporting continued pain and functional limitation, magnetic resonance imaging (MRI) or ultrasound may be a useful clinical adjunct in establishing a diagnosis.
➢ Surgical exploration with synovectomy, debridement of necrotic tissue or anomalous tendons, release of the extensor carpi ulnaris, or a combination of these procedures may be indicated.
➢ In cases of extensor carpi ulnaris subluxation, operative treatment should consist of direct repair of the torn extensor carpi ulnaris subsheath, reconstruction with extensor retinaculum, or suture-anchor repair of periosteal attachments of the extensor carpi ulnaris subsheath, depending on the type of injury and the surgeon’s preferred technique.
➢ In cases of extensor carpi ulnaris rupture, reconstruction with a tendon graft with reconstruction of the extensor carpi ulnaris subsheath may be indicated.
Injury of the extensor carpi ulnaris tendon in the sixth dorsal compartment represents a frequent source of ulnar-sided wrist pain and commonly results from forces applied to the wrist while held in a position of flexion and ulnar deviation. This frequently occurs as a sudden rotational force against the forearm in supination, as follows swinging a racquet or club, and produces opposition against the extensor carpi ulnaris tendon and stabilizing structures over the ulnar aspect of the wrist and dorsal aspect of the ulna1. As such, racquets, bats, and golf clubs serve to extend the lever arm of forces applied to the extensor carpi ulnaris, and injuries are usually reported as an acute sensation of pain, popping, or instability over the ulnar aspect of the wrist2. Although many injuries to the extensor carpi ulnaris are traumatic, degenerative pathology may also produce injury at the extensor carpi ulnaris tendon.
The ability to diagnose and differentiate injuries to the tendon or fibro-osseous subsheath of the extensor carpi ulnaris relies on an understanding of the biomechanics, pathoanatomy, and potential treatment options following extensor carpi ulnaris injury. It is the goal of this review to provide a comprehensive algorithm of extensor carpi ulnaris tendon injury patterns and potential treatment solutions and to grade the quality of the evidence that supports recommendations for the care of these conditions.
Biomechanics and Pathoanatomy
The extensor carpi ulnaris muscle originates from the lateral epicondyle of the humerus, posterior proximal aspect of the ulna, and antebrachial fascia and inserts at the base of the fifth metacarpal3. At the distal aspect of the forearm, the extensor carpi ulnaris tendon travels beneath both the extensor retinaculum and a separate fibro-osseous tunnel along the dorsal aspect of the ulna termed the extensor carpi ulnaris subsheath4. In full pronation, the extensor carpi ulnaris tendon travels a straight course through its subsheath into its insertion at the base of the small finger metacarpal. As the forearm moves through neutral to supination, the extensor carpi ulnaris exits the subsheath at an increasingly acute angle, reaching its maximum at approximately 30° of supination1. Ulnar deviation accentuates this angle and the resultant ulnar translational force applied by the tendon to the extensor carpi ulnaris subsheath1,2. The extensor carpi ulnaris subsheath and its location on the dorsal aspect of the ulna are critical to wrist and distal radioulnar joint stability and should be examined carefully in injuries that put the stability of these structures at risk.
The extensor carpi ulnaris acts as a dynamic stabilizer of the distal radioulnar joint. Spinner and Kaplan were the first to describe the role of the extensor carpi ulnaris in distal radioulnar joint stability with cases of dorsal dislocation when the extensor carpi ulnaris was not maintained in the ulnar groove4. The floor of the extensor carpi ulnaris subsheath is continuous with the distal radioulnar joint capsule and distal radioulnar ligaments of the triangular fibrocartilage complex2. Contribution of the extensor carpi ulnaris tendon and its subsheath to triangular fibrocartilage complex stability was confirmed by Iida et al., using a cadaveric biomechanical model5. They found that dorsal ulnar translation relative to the radius peaks in the neutral forearm position and nearly doubles when the triangular fibrocartilage complex has been damaged5. When activated, the extensor carpi ulnaris tendon can reduce dorsal translation of the ulna by nearly 30%; however, this mitigating force was neutralized when the extensor carpi ulnaris subsheath was sectioned from its attachments at the distal aspect of the ulna5.
Salva-Coll et al. found that the extensor carpi ulnaris also pronates the scaphoid, triquetrum, and capitate bones when it is activated6. This pronation was reduced when the extensor carpi ulnaris subsheath was sectioned (p < 0.01), implying that the extensor carpi ulnaris in its intact sheath acts as an important antagonist to carpal supinators (namely, the flexor carpi ulnaris, the extensor carpi radialis longus, and the abductor pollicis brevis)6.
Some authors have suggested that distal ulnar morphology may be predictive of extensor carpi ulnaris instability. Nakashima et al. performed a cadaveric study of 240 limbs to analyze variations in the depth of the extensor carpi ulnaris groove as well as to quantify the frequency of the extensor carpi ulnaris groove subtypes (Table I)3. Grade I, with a deep sulcus groove, was the most frequently encountered, followed by grade II, a shallower sulcus with a prominent ulnar styloid3. Grade III is a shallow sulcus without a prominent ulnar styloid. Grade IV, a completely flat sulcus, was found in only 1.3% of dissected limbs3. A retrospective review correlating ulnar morphology to extensor carpi ulnaris pathology found a trend toward shallower extensor carpi ulnaris grooves in subjects with known extensor carpi ulnaris subluxation, but this finding did not reach significance7. However, the extensor carpi ulnaris groove length was significantly shorter (p < 0.0001) in subjects with extensor carpi ulnaris subluxation (5.2 mm) than in those without (9.6 mm)7. There was significantly greater negative ulnar variance (p < 0.0001) in subjects with extensor carpi ulnaris subluxation (−3.4 mm) compared with controls (−1.2 mm)7.
The presence of an accessory extensor carpi ulnaris or extensor digiti minimi tendon slip traveling within the extensor carpi ulnaris subsheath has been documented to be present in 5.6% to 34.2% of patients8-10. It has been suggested that this accessory tendon may contribute to stenosing tenosynovitis, as it may increase the size of the bundle that must pass through the extensor carpi ulnaris subsheath8,10. Futami and Itoman found that two of three patients who failed conservative treatment of extensor carpi ulnaris tendinitis had accessory tendons that were successfully treated with surgical excision and release of the sixth dorsal compartment10. Barfred and Adamsen also reported three cases of ulnar-sided wrist pain that resolved after excision of the accessory slip of the extensor carpi ulnaris tendon11.
A classification scheme for injuries to the extensor carpi ulnaris tendon formulated by Allende and Le Viet addresses conditions of both the tendon, graded as 0 to 5b, and the subsheath, graded as A to D12. Grade 0 represents an uninjured tendon, grade 1 represents tenosynovitis, grade 2 represents tendinopathy with longitudinal lesions and thickening of the tendon, grade 3 represents a partial rupture, grade 4 represents a complete rupture, grade 5a represents insertion tenosynovitis or tendinopathy, and grade 5b represents a tendon avulsion12. For the extensor carpi ulnaris subsheath, grade A is a normal subsheath, grade B is a false sheath formed by stripping periosteum at the ulnar insertion of the fibro-osseous sheath, grade C1 is an ulnar-wall rupture, grade C2 is a radial-wall rupture, and grade D is a preserved but contracted subsheath12. Although it is comprehensive, the system has been criticized as cumbersome2. Inoue and Tamura described a simpler classification for extensor carpi ulnaris instability, which divides disruption of the fibro-osseous sheath into three types: type A, which is an ulnar rupture of the sheath; type B, which is a radial rupture of the sheath; and type C, which is a detachment of the intact sheath from the inferior periosteum13. Of twelve extensor carpi ulnaris subsheath injuries, five were type A, three were type B, and four were type C13. Although Inoue and Tamura suggested that type-B injuries may be treated with immobilization, Allende and Le Viet recommended operative treatment for all acute cases of extensor carpi ulnaris instability as it can be difficult to distinguish the type of injury preoperatively, and surgical treatment produced excellent results while nonoperative management sometimes failed12,13.
Radiographs of the wrist and forearm are generally normal in extensor carpi ulnaris pathology; however, some authors have noted erosion of the ulnar styloid with extensor carpi ulnaris tenosynovitis14. Both ultrasound and MRI have been used to better evaluate the relationship of the tendon to the distal aspect of the ulna and subsheath. A Level-III retrospective analysis examined sixteen patients with known extensor carpi ulnaris pathology and compared four MRI sequences with those in a group of thirty matched controls; two radiologists interpreted the MRIs and rated the diagnostic value of each sequence15. Kappa statistics were reported for concordance of diagnoses. T1-weighted images had the lowest kappa statistic (0.26), short tau inversion recovery (STIR) fared slightly better at 0.69, and gadolinium-enhanced, fat-saturated, T1-weighted transverse sequences in both pronation (kappa, 0.61) and supination (kappa, 0.73) were rated as significantly more valuable (p = 0.01). Jeantroux et al. also assessed subluxation or dislocation of the extensor carpi ulnaris tendon within the ulnar groove in both pronation and supination and determined the presence of ulnar head edema, extensor retinaculum injury, tendinosis, and tenosynovitis. Sensitivity or specificity of MRI for these findings was not specifically examined, as all patients were treated conservatively without operative confirmation of findings15.
A Level-IV study evaluated the utility of ultrasound to assess the extensor carpi ulnaris as the wrist was brought through full flexion and extension in ten healthy volunteers16. Normal extensor carpi ulnaris tendons may subluxate up to 40% beyond the volar lip of the extensor carpi ulnaris groove in flexion and 33% beyond the dorsal lip in extension16. Another prospective study of forty normal wrists held in twelve different positions used the same method to calculate the percentage of displacement17. In all cases, the extensor carpi ulnaris tendon remained within the ulnar groove in full pronation regardless of wrist position. Extensor carpi ulnaris subluxation peaked in full supination, with 50% displacement over the ulnar border of the extensor carpi ulnaris groove17. The maximum absolute displacement from the volar edge of the tendon to the volar edge of the extensor carpi ulnaris groove was 5 mm17. In both studies, there were no cases of normal wrists in which the tendon displaced entirely out of the ulnar groove16,17. A Level-IV, uncontrolled retrospective review of twenty-one patients with extensor carpi ulnaris subluxation correlated ultrasound findings of subluxation to intraoperative findings of type-C injuries in all cases18. That study was criticized for its lack of normal ultrasound controls, nonstandardized imaging technique, and lack of criteria to define abnormal subluxation19. Dynamic ultrasound may be useful in diagnosing extensor carpi ulnaris subluxation; however, studies comparing ultrasound with a gold-standard diagnostic test are currently unavailable to our knowledge.
In contrast to a subsheath injury, patients with extensor carpi ulnaris tendinitis or stenosing tenosynovitis usually report a gradual, insidious onset of ulnar-sided wrist pain over the course of weeks to months10,20. Patients present most commonly without a history of trauma, but a specific injury may be given10,14,20. Pain is generally worsened with activity and may be elicited with resisted radial deviation or active ulnar deviation against resistance14,20.
The extensor carpi ulnaris synergy test was developed to help the examiner distinguish between intra-articular ulnar-sided pain and pain originating with the tendon21. The test is performed with the patient’s elbow on the examination table, flexed at 90° and in full supination. The examiner grasps the patient’s thumb and long finger between his or her thumb and index fingers. With the other hand, the examiner palpates the extensor carpi ulnaris. The patient is then asked to abduct the thumb against the examiner’s provided resistance, which isometrically activates the extensor carpi ulnaris. Activation is verified by the examiner’s contralateral hand. Pain with this maneuver favors extensor carpi ulnaris tendinitis over an intra-articular cause such as a triangular fibrocartilage complex tear21. In a series of fifty-four consecutive patients reviewed over a two-year period, a positive extensor carpi ulnaris synergy test in the absence of other positive examination maneuvers for intra-articular pathology correctly identified ten of eleven patients with isolated extensor carpi ulnaris tendinitis and correctly ruled out extensor carpi ulnaris tendinitis in all twenty-one patients with a negative test21. Of the twenty-two patients with both a positive extensor carpi ulnaris synergy test and at least one other positive examination maneuver, eleven had confirmed intra-articular pathology on either MRI or wrist arthroscopy, seven had complete resolution of their pain with extensor carpi ulnaris corticosteroid injection, and four did not have their symptoms relieved but also did not undergo a confirmatory test21. The authors have been criticized for use of MRI findings or resolution of symptoms with corticosteroid injection as the gold standard with which the test was compared, as many causes of pain will resolve over time without intervention and asymptomatic extensor carpi ulnaris tendon edema and tenosynovitis may be seen on MRI21,22.
Nonoperative management is through splinting, activity modification, and local corticosteroid injections. In a Level-IV case series, fifteen consecutive patients were reviewed over a four-year period: eight responded well to nonoperative management with splinting and corticosteroid injection and seven went on to surgical release of the sixth dorsal compartment14. Another Level-IV review of seventy-two cases over a five-year period found that only nine patients obtained relief with corticosteroids20. In a review of patients treated with a combination of immobilization, oral nonsteroidal anti-inflammatory drugs, and local corticosteroids, forty of forty-three patients responded with resolution of their symptoms10. Up to three corticosteroid injections were given, which may account for the higher rates of success with nonoperative therapy compared with other studies. Of the three patients who failed this management, two were found at the time of the operation to have accessory tendon slips that were removed10. A review of injuries in tennis players found that, of fourteen patients diagnosed with extensor carpi ulnaris tendinitis, ten recovered within two to twenty-four weeks with nonoperative management and four were lost to follow-up23. Variability in success rates for nonoperative management may be due to varying numbers of injections, length and type of immobilization, and patient compliance.
Tendinosis, or degenerative tendinopathy, may be difficult to clinically distinguish from tendinitis24. Because tendinosis is a noninflammatory overuse syndrome, the role of steroidal and nonsteroidal anti-inflammatory treatments remains controversial24. Both nonsteroidal anti-inflammatory drugs and local corticosteroid injections have been shown to inhibit collagen repair in vitro, and their utility in the treatment of tendinosis has been called into question25. Campbell et al. recommended consideration of local corticosteroid injection after at least three weeks of rest and immobilization and a period of rehabilitation with increasing load and isometric exercises; they also recommended compartment release for patients with persistent tendinosis1.
Surgical options for treatment of tenosynovitis include release of the extensor carpi ulnaris subsheath, with or without reconstruction of the subsheath, or synovectomy10,12,26. A review of twenty-two patients who underwent release of the extensor carpi ulnaris subsheath reported no cases of tendon instability at a follow-up of forty-three months (range, fifteen to 106 months)26. Outcomes from synovectomy alone were not reported12. Chronic tendinopathy may be treated by longitudinal division of the fibers and debridement of the necrotic tissues12. Anomalous tendon slips should be removed as their volume effect may contribute to stenosis8,10,12. All studies showing outcomes for tendinitis and stenosing tenosynovitis are Level IV. A summary of treatment recommendations can be found in Table II.
Extensor Carpi Ulnaris Subluxation and Dislocation
Extensor carpi ulnaris subluxation usually presents with a painful snapping or clicking sensation over the dorsoulnar aspect of the wrist reproducible on supination27. Most patients give a history of sudden onset of pain due to injury, commonly from sporting activities, a fall, or a twisting injury13,23,28. Montalvan et al. reported that five of five patients with acute extensor carpi ulnaris instability returned to sport within six months after a three-month immobilization in a short arm splint with the wrist at 15° of extension23. Other authors have strongly advocated for operative treatment of acute injuries; in one case, operative findings were reported of a 7-mm gap between torn edges of the extensor carpi ulnaris subsheath in all wrist positions, implying that subsheath apposition within the extensor carpi ulnaris groove through immobilization alone would not have been achieved and healing would have been unlikely29. In this case, direct repair of the subsheath was performed29. In a retrospective case series, Burkhart et al. reported five cases of extensor carpi ulnaris instability, of which two were acute27. One of the latter cases was managed with a radial-based sling made from extensor retinaculum, and the other case was managed by passing a slip of the flexor carpi ulnaris through an osseous tunnel, from palmar to dorsal, to reconstruct the ulnar wall and roof of the extensor carpi ulnaris subsheath27. Both patients were asymptomatic, the first case at the one-year follow-up and the second case at the seven-month follow-up27.
Inoue and Tamura advocated selecting an operative technique based on injury type. Type-A tears (ulnar-sided rupture) were reconstructed with a strip of extensor retinaculum because of contracture of the subsheath remnant13. Type-B (radial-sided) tears of the extensor carpi ulnaris subsheath were repaired directly, because the flap of extensor carpi ulnaris subsheath was found underneath the tendon lying on the floor of the compartment13. Type-C injuries, in which the periosteum is stripped from the ulna to form a false pouch into which the extensor carpi ulnaris could dislocate, were repaired by using suture anchors to tack the periosteum down to the ulnar side of the extensor carpi ulnaris groove and to eliminate the false pouch13. At an average follow-up of twenty months, all patients recovered a normal, painless range of motion and returned to previous work and sport13. Other authors have reported successful reconstruction of the extensor carpi ulnaris subsheath with a free graft of extensor retinaculum30.
The deepening of the extensor carpi ulnaris groove has been reported in several techniques. MacLennan et al. reported a series of twenty-one patients with type-C injuries causing extensor carpi ulnaris instability18. In these patients, the extensor carpi ulnaris subsheath was elevated intact subperiosteally; a burr was then used to deepen the extensor carpi ulnaris groove. Suture anchors were placed along the ulnar margin to secure the extensor carpi ulnaris subsheath and to reduce its size and further stabilize the extensor carpi ulnaris tendon18. At a minimum two-year follow-up, all patients returned to some form of employment and twenty of twenty-one patients returned to the activity during which the injury occurred18. There were no patient-reported recurrences of subluxation18. Although the average forearm and wrist range of motion increased significantly following reconstruction (p < 0.04), the clinical importance was minimal, as the increase was a mere 3° or 4° in all measures18,19. A similar technique was used by Kim et al. in a case study31. This technique has been criticized because, in combination with suture anchors, the ulnar wall of the groove is weakened, putting the repair at risk for failure2. Erosion of the floor of the sixth dorsal compartment was identified as the source of pain in two case series on refractory stenosing tenosynovitis14,32. Three of seven patients in one series and four of four patients in another series were found to have exposed bone at the floor of the extensor carpi ulnaris subsheath that was contributing to tendon inflammation14,32. In both case series, a portion of retinaculum was used to reconstruct the floor of the sixth dorsal compartment to protect the tendon from further damage14,32.
Another proposed technique for treatment of acute subluxation involves the release of the extensor carpi ulnaris subsheath, resection of the ulnar side of the extensor carpi ulnaris groove, and incision and reapproximation of the extensor retinaculum underneath the extensor carpi ulnaris tendon33. Oka and Handa pointed out that this technique allows a speedy return to play for athletes; they reported that a professional golfer was able to return to practice one month after surgery and was able to compete only two months after surgery, and, at the fifty-two-month follow-up, he had slight bowstringing of the extensor carpi ulnaris tendon but had full strength and full, painless range of motion33. One disadvantage of the technique is that patients requiring revision surgery would not have the option for another reconstruction technique that makes use of the extensor carpi ulnaris groove2. Other authors have proposed securing the extensor retinaculum to the ulnar groove to produce an ulnar-sided buttress2,28. Simply securing the extensor retinaculum to the ulnar groove runs the risk of limiting pronation and supination4. To avoid this, Graham recommended an ulnar-based retinaculum flap that is secured to the ulnar side of the extensor carpi ulnaris groove and to the edge of the fifth dorsal compartment radially2. This flap is incised radially so that the remainder of the extensor retinaculum moves freely while the flap serves to secure the extensor carpi ulnaris tendon in its groove2. Radial-based flaps or slings similarly prevent subluxation of the tendon in the ulnar direction, but have been criticized for either weakening the ulnar side of the groove with suture anchors or preventing the extensor carpi ulnaris from resting within the groove2. Ulnar-based flaps have the advantage of more closely approximating native anatomy while possibly avoiding the pitfalls of a radial-based flap2. Treatment recommendations for extensor carpi ulnaris instability are Level-IV and V evidence, consisting of case series and expert opinion.
Extensor Carpi Ulnaris Rupture and Salvage Procedures
Rupture of the extensor carpi ulnaris tendon is thought to be the product of repeated trauma over time. Treatment with local corticosteroid injection may contribute to the ultimate rupture of the tendon23,34. Montalvan et al. described a typical pattern of an elite athlete with an initial violent trauma, several episodes of ulnar-sided wrist pain treated with local corticosteroid injection, and eventual complete rupture of the tendon with continued use23. On examination, the extensor carpi ulnaris tendon could not be palpated in its sheath. Although daily activities were relatively unhindered, the patient lacked power in the wrist23. Montalvan et al. reported two cases of extensor carpi ulnaris rupture and reconstruction with palmaris longus tendon in combination with reconstruction of the extensor carpi ulnaris subsheath; both patients were able to return to sport six months postoperatively23. Another case study described reconstruction of the extensor carpi ulnaris using a palmaris longus tendon interposition graft and a free retinacular graft reconstruction of the subsheath; at the three-year follow-up, the patient had returned to professional tennis34. Finally, Wang et al. reported a professional hockey player with an extensor carpi ulnaris tendon rupture at the myotendinous junction, with an intact extensor carpi ulnaris subsheath, treated successfully with a palmaris tendon graft35.
The Darrach procedure and the Sauvé-Kapandji procedure are both commonly performed for the treatment of distal radioulnar joint disorders, but may be complicated by instability of the ulnar stump or radioulnar convergence36,37. The extensor carpi ulnaris tendon may be woven through the ulnar stump to provide stabilization36-38. Minami et al. first described a modification of the Sauvé-Kapandji procedure by using a half-slip of the extensor carpi ulnaris for stabilization36. A segment of ulnar shaft proximal to the ulnar head is resected and a distal radioulnar joint fusion is performed between the radius and the remnant ulnar head36. A 3.5-mm drill-hole is created on the dorsal cortex of the ulna; the extensor carpi ulnaris is split longitudinally and the radial half of the tendon is released at the ulnocarpal level, preserving its attachment at the musculotendinous junction36. This strip is then passed through the drill-hole and is retrieved from the medullary canal, is tensioned, and then is sutured back on itself36. A retrospective review of twelve patients followed for an average of ninety-five months revealed improved pain, range of motion, and grip strength at thirty-five months, which was maintained at ninety-five months39. At the time of the latest follow-up, pain was found to be moderate in one patient, mild in three patients, and absent in eight patients39. Three patients had broken drill-holes in the proximal ulnar stump; however, there was no related proximal ulnar instability39.
A similar modification to the Darrach procedure, using a half-slip of extensor carpi ulnaris for stabilization, was described by Sotereanos and Leit in 199637. The extensor carpi ulnaris tendon is split longitudinally, preserving its attachment at the base of the fifth metacarpal37. A 1/8-in (3.2-mm) bicortical drill-hole is created from dorsal to volar in the distal aspect of the ulna, and the tendon slip is passed from volar to dorsal and tensioned with the wrist in ulnar deviation37. The tendon is then sutured back on itself37. A retrospective review of sixteen patients who underwent this modified procedure demonstrated marked alleviation of pain in fifteen of sixteen wrists at a follow-up of thirty-seven-months (range, twenty-eight to forty-seven months)37. Chu et al. performed a Level-III comparative retrospective review of nineteen wrists with stabilization of the ulnar stump following the modified Darrach or Sauvé-Kapandji procedures40. Ulnar stability was assessed radiographically by asking the patient to hold a 5-lb (2.2-kg) cylinder with the shoulder abducted and elbow flexed at 90° and the forearm in neutral rotation40. No patients reported pain or symptoms due to stump instability. A retrospective comparison of the Sauvé-Kapandji procedure with and without ulnar stabilization with the extensor carpi ulnaris found that, initially, pain at the ulnar stump was more common when stabilization was not performed; two (9%) of twenty-two patients who had undergone the procedure with ulnar stabilization and seven (37%) of nineteen patients who had undergone the procedure without ulnar stabilization reported pain41. This difference had disappeared by the latest follow-up at an average of fifty-eight months (range, twelve to ninety-nine months)41. Jupiter described a similar modification utilizing both a proximally based slip of the extensor carpi ulnaris tendon to provide dorsal stabilization and a distally based slip of the flexor carpi ulnaris tendon to provide palmar stabilization42. All of the longer-term outcome studies using all or a portion of the extensor carpi ulnaris are retrospective, Level-IV evidence except where noted.
Of the available evidence for subsequent extensor carpi ulnaris pathology treatment, prospective and randomized trials are unavailable, with only Level-IV uncontrolled retrospective case series or Level-V expert opinion. Treatment recommendations are subsequently grade C (Table II).
Injury to the extensor carpi ulnaris tendon can be complicated by a vague history of trauma or repetitive overuse. Regardless of the etiology, most cases of extensor carpi ulnaris pathology benefit from a period of several weeks of wrist immobilization and activity modification. However, in those patients who report continued pain and functional limitation, MRI or ultrasound may be a useful clinical adjunct to establishing a diagnosis.
Failing relief, operative exploration with an appropriate combination of synovectomy, debridement of necrotic tissue or anomalous tendons, or release of the extensor carpi ulnaris may be indicated. In cases of suspected extensor carpi ulnaris subluxation, operative treatment should consist of direct repair of the torn extensor carpi ulnaris subsheath, reconstruction with extensor retinaculum, or suture-anchor repair of periosteal attachments of the extensor carpi ulnaris subsheath, depending on the type of injury and the surgeon’s preferred technique. No single technique has been shown to be superior; however, tacking the extensor retinaculum to the ulnar border of the extensor carpi ulnaris groove may limit range of motion and is to be avoided. Finally, in cases of extensor carpi ulnaris rupture, reconstruction with tendon graft with reconstruction of the extensor carpi ulnaris subsheath may be appropriate.
Source of Funding: There was no source of external funding for this study.
Investigation performed at the Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, Washington
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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