Flexor Carpi Ulnaris Tendinitis

THE CLINICAL SYNDROME

  • Tendinitis can develop in the flexor carpi ulnaris tendon of the hand as a result of overuse or improper use, and this is especially likely to occur when engaging in tasks that need the hand to be repeatedly bent and extended.
  • The rise in popularity of racquet sports like tennis, baseball, and golf has led to an increase in the incidence of acute flexor carpi ulnaris tendinitis being encountered in clinical practice.
  • This is a direct result of the increased use of racquets in these games.
  • Both the development of flexor carpi ulnaris tendinitis and acute tendon rupture have been linked to improper stretching of the flexor carpi ulnaris muscle and flexor carpi ulnaris tendon prior to activity.
  • When the distal tendon is subjected to direct trauma while it is fully flexed under load or when the wrist is forcibly flexed while the hand is in full radial deviation, tendon injuries that range from partial to complete tears are possible.
  • These injuries can occur either when the distal tendon is flexed fully under load or when the wrist is forcibly flexed while the hand is in full radial deviation.

SIGNS AND SYMPTOMS

  • The pain associated with flexor carpi ulnaris tendinitis is persistent, intense, and confined to the dorsolateral side of the wrist.
  • Those who are afflicted with flexor carpi ulnaris tendinitis frequently report that the discomfort prevents them from getting a good night's rest.
  • Tendinitis of the flexor carpi ulnaris causes patients to experience discomfort during active, resisted flexion of the hand as well as during radial deviation of the wrist.
  • Patients who suffer from flexor carpi ulnaris tendinitis frequently splint the inflamed tendon in an effort to alleviate their discomfort.
  • This is accomplished by reducing the amount of hand flexion and radial deviation of the wrist in order to release strain on the tendon that is inflamed.
  • Patients who are suffering with flexor carpi ulnaris tendinitis may have difficulties performing any activity that needs flexion and adduction of the wrist and hand, such as using a hammer or lifting a large coffee mug, if they do not receive treatment for their condition.
  • In the long run, if the tendinitis is not treated, the patient may experience muscular atrophy and calcific tendinitis, or the distal musculotendinous unit may suddenly rupture.
  • Both of these conditions can be quite painful. Individuals who suffer a complete rupture of the flexor carpi ulnaris tendon will be unable to fully flex the hand or fully adduct the wrist with any amount of force.

TESTING

  • Radiographs of the plain variety should be taken of every patient who comes in complaining of wrist and hand pain.
  • The clinical presentation of the patient may signal the need for additional testing, which may include a total blood cell count, sedimentation rate, and testing for antinuclear antibodies.
  • When tendinopathy or a tear of the flexor carpi ulnaris muscle is suspected, imaging of the wrist and hand with magnetic resonance imaging or ultrasound is recommended.
  • The study of the affected area with magnetic resonance imaging or ultrasound may also be helpful in determining the presence of calcific tendinitis or another form of hand pathology.

DIFFERENTIAL DIAGNOSIS

  • Extensor carpi ulnaris tendonitis, flexor carpi ulnaris tendonitis, pisotriquetral arthritis, triangular fibrocartilage complex lesions, ulnar impaction, lunotriquetral instability, hook of the hamate fracture, hypothenar hammer syndrome, and distal radioulnar joint instability should all be considered in the differential diagnosis of ulnar sided wrist pain.
  • In contrast to extensor carpi ulnaris tendonitis, flexor carpi ulnaris tendonitis is localized to the dorsoulnar portion of the wrist and will deteriorate with flexion.
  • This characteristic helps to differentiate the two conditions.

TREATMENT

  • The initial treatment for the pain and functional disability associated with flexor carpi ulnaris tendinitis consists of a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors.
    • Both of these types of medications reduce inflammation and pain.
  • The administration of heat and cold to specific areas of the body may also be therapeutic.
  • Avoid engaging in any activity that requires a repeated motion and has the potential to make the patient's symptoms worse.
  • Those who do not respond to these therapy modalities may benefit from receiving an injection of a local anesthetic and steroid as the next stage in the treatment process.
  • Before administering an injection to treat flexor carpi ulnaris tendinitis, the patient is positioned in the supine position with the affected arm fully adducted at the patient's side, the elbow flexed, and the dorsum of the hand supported by a towel that has been folded in half.
  • This helps relax the tendons that are being treated.
  • A sterile syringe with a capacity of 5 milliliters is used to draw up a total of 1 milliliter of local anesthetic and 40 milligrams of methylprednisolone.
  • Following the hygienic preparation of the skin that is above the insertion of the flexor carpi ulnaris tendon, the patient is instructed to forcibly extend his or her wrist in order to make it easier to identify the tendon.
  • A needle of 1 inch in length and 25 gauges in diameter is pierced through the surface of the skin and into the subcutaneous tissue that is located directly above the afflicted tendon.
  • If bone is found, the needle is retracted into the subcutaneous tissue and the procedure is repeated.
  • After then, a gentle injection of the contents of the syringe is performed.
  • It ought to feel like there is very little resistance being injected. If there is resistance, the needle is most likely already embedded in the tendon; in this case, it is necessary to extract the needle and wait until the injection can be given without considerable obstruction.
  • After the needle has been removed, a sterile pressure dressing and an ice pack are put to the area that was just given the injection.
  • Recent clinical experience suggests that the injection of type A botulinum toxin and platelet-rich plasma and/or stem cells may provide improved symptom relief and healing of flexor carpi ulnaris tendinitis.

COMPLICATIONS AND PITFALLS

  • Rupture of the inflamed tendon is the most serious complication that can occur in conjunction with flexor carpi ulnaris tendinitis.
  • This can occur as a result of direct injection into the tendon or as a result of recurrent trauma.
  • Before moving on with the injection, the doctor needs to make sure that the needle is positioned outside of the tendon.
  • This will help ensure that the tendon, which may already be inflamed and injured, does not rupture.   Infection is another another potential risk associated with injection, but this should be an extremely remote possibility if proper asepsis procedures are followed.
  • The injection method is risk-free provided that the clinically relevant anatomy is carefully considered.
  • In particular, the ulnar nerve, which is vulnerable to damage near the elbow, should be given special attention.
  • Patients should be made aware of the chance that they may experience a temporary increase in pain after receiving an injection, as this affects approximately one quarter of all patients.