Avoid Ulnar Shortening Surgery: What’s Causing My Pain if It’s Not My Ulna Bone?
A few years back, I blogged on the barbaric procedure known as ulnar shortening. A patient who was about to pull the trigger on this surgery wrote me and wanted me to blog on what could be causing the pain he experiences. Hence, this morning’s blog.
What Is Ulnar Variance or a Long Ulna?
The forearm has two bones—one is the ulna and the other the radius. The main idea here is that someone is born with a long ulna bone and that this causes too much force on the little-finger side of the wrist, leading to arthritis and soft-tissue injury. All of this eventually causes pain, which leads patients to need an ulnar shortening surgery where a piece of that bone is cut out. But what if this idea, that a long ulna causes this pain, was wrong? The patient would be exposed to a major and invasive surgery for no gain.
Request a Regenexx AppointmentThe Lowdown on Invasive Ulnar Shortening Surgery
This blog is meant as a companion blog to an earlier piece I did on why this surgery has no high-level evidence to support that it works and is loaded with complications. To read that first blog, click on its image below:
As a side note, I just performed an updated search on the research that supports this procedure. There is still not a single high-level study showing that it works or is even advisable.
Why Your Long Ulna Is Unlikely to Be Causing Pain
First, you need to understand that pain generation is a combination of three factors: structure, nerve irritation or damage, and the local chemical environment. Meaning, we have many, many studies showing that patients who seem to have structural abnormalities on X-rays or MRI that should be causing pain often have none. In addition, we have studies that show that patients with normal anatomy can be in severe pain. How is this possible? MRIs and X-rays don’t show the status of nerve irritation or the local chemicals that can lead to pain. So in many cases, while the anatomy is bad, the nerves are fine and the local chemicals are normal, hence, no pain. Or on the other side of that coin, the anatomy is fine, but the local nerves are irritated and are surrounded by toxic and inflammatory chemicals, so the patient hurts.
So right off the bat, you can see why any physician who understands this would be very wary of the idea that an X-ray showing a long ulna bone could ever make an accurate diagnosis of why someone has pain. It’s simply not enough information. So if this can’t be nailed as a cause, despite all of the surgeons wanting to cut off a chunk of your ulna, what might be the real cause? Let’s review a few.
Wrist Instability
One of the more common things I see in painful wrists is that they’re unstable. Meaning, at some point in someone’s life, a fall on an outstretched hand or catching a ball the wrong way stretched some of the many ligaments that hold the many wrist carpal bones in place (see pic to the left). This often goes unnoticed for many years while these bones move around too much. This extra motion causes wear and tear on the small joints, with pain and swelling. Since most doctors aren’t trained on how to find small amounts of instability, this often goes undiagnosed. In addition, an MRI is a static image (without movement), and this diagnosis can only be made when the wrist bones are moved. How is it usually fixed? Precise ultrasound-guided injections of platelet-rich plasma into the stretched ligaments to get them to heal and tighten down will usually provide stability.
Ulnar Nerve
TFCC
Tendonitis/Tenosynovitis
Why Do Famous Surgeons Want to Operate and How Could They Miss These Diagnoses?
Surgeons view the world in terms of surgery. Meaning their physical exam and review of imaging and history in a patient all revolves around whether there is a surgery that may help. In particular, because of the old adage if all you have is a hammer, everything looks like a nail, they commonly miss these other diagnoses. Interventional orthopedics is different. Here the treatments are broader and encompass a much wider number of diagnoses; hence, our job is to find this stuff that the surgeons miss and fix it without surgery. What is interventional orthopedics? See my video below:
The upshot? Please don’t let someone remove a piece of your ulna bone when there may be other wrist problems that have been missed and will go untreated. If you do end up with this extremely invasive surgery, make sure it’s only after all of the above have been ruled out or treated by an experienced interventional orthopedics physician.
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Your always mention when you are treating an irritated nerve to inject around the nerve. What happens if you hit the nerve during the injection? Does this cause further damage/irritation and prevent healing?
Donna, this is why we use ultrasound guidance and small needles. So, no, in experienced hands, the nerve is not hit.
I would like to find a specialist in mybarea. I live in north central Idaho, near Lewiston.
Alannah,
Please call 855 622 7838, and our team can assist in getting you set up at the right location.
My ulna is longer due to wrist break
I still recommended for therapy my break was on September 20th and I had a reduction at that time
I had a soft cast and hard cast and a brace
I have been doing therapy since November I feel and in
I still don’t have full range of motion
I had the surgery in 2017 due to a ruptured tendon along with wrist pain. Prior to that I never had elbow pain. It wasn’t until 2 weeks after the surgery I started experiencing pain in my elbow. I still have constant pain and cannot straighen my arm.
Dear regenexx,
My ulna is too long. But for some reason it never caused any pain. However, it looks awful. My ulnahead and styloid process protudes so much out of my hand that I am considering Ulna shortening.
My qeustion is: Can you recommend Ulna shortening when it is for cosmetica reasons and having little/none burden of the wrist?
No, this is a high-risk surgical procedure that can lead to serious nerve damage, so shortening your ulna for cosmetic reasons is not a good idea.
I had a TFCC tear in 2016. The ulnar bone in my left arm was diagnosed to be the issue. I was told that I was born this way. I had the ulnar shortening surgery and no other issues arose—until now! 2020! The right arm has the same issues. AND the left is now experiencing a different pain in the same area. Should I waste my time on the right wrist surgery then go back to the left after the right heals? Any advice is appreciated. Oh! Typing is my livelihood.
These surgeries, in my opinion are a waste of time. There is likely another cause for your TFCC issue that has yet to be diagnosed.