Ulna shortening osteotomy for persistent wrist pain

I got ulnar shortening osteotomy (USO) 3 weeks ago after persistent wrist pain for the last year. While researching options, it is clear there is a severe lack of info/experience for climbers and so hoping this will help fill the gap so others can make informed decisions. About me: 42f, rhd, climbing for 13 years, combo of lead and bouldering (at home wall of mine and friends). Mom of 3 and 6 year old.

After a year of wrist pain and months of PT (local in person combined with virtual with a climbing specific PT) I got an MRI that revealed a lunate with signs of osteonecrosis throughout the entire bone (as well as other less-concerning findings like a perforation of the TFCC, partial tear of ECU which I believe happened as a separate event, synovitis, ganglion cyst…all pretty common for climbers w/ and w/out symptoms). MRI also showed positive ulnar variance (ulnar ~2-3 mm longer than radius). 

At first docs told me I had Keinbocks because the whole lunate was necrotic. After looking at my MRI and reading report I suggested ulnar impaction and they ultimately agreed. After 6 weeks in a custom brace with no improvement (actually worsening because of the consequent weakness), the doc suggested USO, which is when they cut the ulna in half, take out a slice and secure it back together. I did the literature review (which showed climbers that opted for surgery had far better outcomes than those that did not) and talked to a climbing specific ortho who had gotten the surgery (recommended by my climbing PT who had seen him present at an international conference on wrist injuries in climbers). Asked my doc about the wafer procedure (shaving off the end of the ulnar instead of cutting in half to shorten) and he said he did not do that because of how complex the wrist is - besides my ulna had to be shortened by more than that procedure allows.

Decided that USO was best option and got it 3 weeks ago. Ulna was shortened 3 mm, which transfers over 40% of the force taken on the ulnar side of wrist to the radial side to be more like it should. The surgery is paired with wrist arthroscopy, during which the doc debrided the wrist, including removing synovitis and cleaning up several cartilage flaps. Doc found significant cartilage damage on lunate, so I’ll have to make sure to strengthen well to avoid pain. 

After the first few days, I’ve been completely off all pain meds with very little pain. It was wrapped with a volar cast for first two weeks and is now in custom brace, which can be removed for active range of motion exercises, scar massage and showering. I’ll get an xray at 6 weeks post op to see how the bone is healing.

Looking back, my left hand (non dominant, surgical side) has been significantly weaker than my right (over 20%) for years despite trying to balance it out. This is likely from the ulnar impaction despite no pain until a year ago. Also, I am hyper-mobile (not terrible, but enough I tore my labrum instead of rotator cuff 12 years ago), which may have contributed to the problem.

Happy to update and answer questions. I have a PhD in biology and do research for a living and brought that into my decision-making process by reading literature and figuring out the nature of the problem if that is helpful for anyone.

Kasey FowlerFinn wrote:

I got ulnar shortening osteotomy (USO) 3 weeks ago after persistent wrist pain for the last year. While researching options, it is clear there is a severe lack of info/experience for climbers and so hoping this will help fill the gap so others can make informed decisions. About me: 42f, rhd, climbing for 13 years, combo of lead and bouldering (at home wall of mine and friends). Mom of 3 and 6 year old.

After a year of wrist pain and months of PT (local in person combined with virtual with a climbing specific PT) I got an MRI that revealed a lunate with signs of osteonecrosis throughout the entire bone (as well as other less-concerning findings like a perforation of the TFCC, partial tear of ECU which I believe happened as a separate event, synovitis, ganglion cyst…all pretty common for climbers w/ and w/out symptoms). MRI also showed positive ulnar variance (ulnar ~2-3 mm longer than radius). 

At first docs told me I had Keinbocks because the whole lunate was necrotic. After looking at my MRI and reading report I suggested ulnar impaction and they ultimately agreed. After 6 weeks in a custom brace with no improvement (actually worsening because of the consequent weakness), the doc suggested USO, which is when they cut the ulna in half, take out a slice and secure it back together. I did the literature review (which showed climbers that opted for surgery had far better outcomes than those that did not) and talked to a climbing specific ortho who had gotten the surgery (recommended by my climbing PT who had seen him present at an international conference on wrist injuries in climbers). Asked my doc about the wafer procedure (shaving off the end of the ulnar instead of cutting in half to shorten) and he said he did not do that because of how complex the wrist is - besides my ulna had to be shortened by more than that procedure allows.

Decided that USO was best option and got it 3 weeks ago. Ulna was shortened 3 mm, which transfers over 40% of the force taken on the ulnar side of wrist to the radial side to be more like it should. The surgery is paired with wrist arthroscopy, during which the doc debrided the wrist, including removing synovitis and cleaning up several cartilage flaps. Doc found significant cartilage damage on lunate, so I’ll have to make sure to strengthen well to avoid pain. 

After the first few days, I’ve been completely off all pain meds with very little pain. It was wrapped with a volar cast for first two weeks and is now in custom brace, which can be removed for active range of motion exercises, scar massage and showering. I’ll get an xray at 6 weeks post op to see how the bone is healing.

Looking back, my left hand (non dominant, surgical side) has been significantly weaker than my right (over 20%) for years despite trying to balance it out. This is likely from the ulnar impaction despite no pain until a year ago. Also, I am hyper-mobile (not terrible, but enough I tore my labrum instead of rotator cuff 12 years ago), which may have contributed to the problem.

Happy to update and answer questions. I have a PhD in biology and do research for a living and brought that into my decision-making process by reading literature and figuring out the nature of the problem if that is helpful for anyone.

Fun reading the process and thoughts.  What was the doctors thoughts on returning to climbing? Usually would suspect after the 12 week mark pending bone healing. 

Hi Sydney - glad you found it interesting! I just saw the doc at my 6 weeks post op appt…

My bone has completely healed at 6 weeks. The surgeon can’t even see where the osteotomy is and is shocked because it usually takes 3 months. He said he has never seen anyone heal this quickly. I think i just heal fast but also I stopped drinking, ate a lot of spinach and other nutrient rich foods, walked as much as I could and was very careful about protecting my hand.

Though technically i could start climbing since my bone is healed, we decided that 3 months post surgery would be a good target to start light climbing. This will provide time for rehab focused on strength and flexibility to get my wrist back into climbing shape.

My wrist is still stiff and a hit swollen (during the wrist arthroscopy, the surgeon did substantial debridement), but I have been doing flexibility exercises since 2 weeks postop when the cast came off and the splint went on. I wore the splint religiously except for showering and wrist exercises. At 3-4 weeks post op I started core and leg strengthening again…i honestly didn’t have much energy before that point.

Feeling good about the future! Happy to answer any more questions!

Kasey FowlerFinn wrote:

Hi Sydney - glad you found it interesting! I just saw the doc at my 6 weeks post op appt…

My bone has completely healed at 6 weeks. The surgeon can’t even see where the osteotomy is and is shocked because it usually takes 3 months. He said he has never seen anyone heal this quickly. I think i just heal fast but also I stopped drinking, ate a lot of spinach and other nutrient rich foods, walked as much as I could and was very careful about protecting my hand.

Though technically i could start climbing since my bone is healed, we decided that 3 months post surgery would be a good target to start light climbing. This will provide time for rehab focused on strength and flexibility to get my wrist back into climbing shape.

My wrist is still stiff and a hit swollen (during the wrist arthroscopy, the surgeon did substantial debridement), but I have been doing flexibility exercises since 2 weeks postop when the cast came off and the splint went on. I wore the splint religiously except for showering and wrist exercises. At 3-4 weeks post op I started core and leg strengthening again…i honestly didn’t have much energy before that point.

Feeling good about the future! Happy to answer any more questions!

Kasey,

That is quite impressive to have such good healing at 6 weeks! Glad you are approved for light climbing at the 12 week point. Makes sense to wait. Would light climbing look like easier grades? 5.6/5.7… things that you can use more leg on than arm?

Sounds like you are a stellar patient! Swelling is common for a while in the wrist. For some reason it just likes to hold on to the edema. Thanks for sharing! Hope the recovery continues to go smoothly for you!

Sydney

Well I won’t be warming up on 10s, that’s for sure! I’m working with a climbing-specific PT to help with progression leading up to, and starting, climbing. I suspect like most things it will depend on my pain levels

Kasey FowlerFinn wrote:

Well I won’t be warming up on 10s, that’s for sure! I’m working with a climbing-specific PT to help with progression leading up to, and starting, climbing. I suspect like most things it will depend on my pain levels

Yes pain levels are usually the guide! Awesome! Wishing you all the best!

Kasey FowlerFinn wrote:

Well I won’t be warming up on 10s, that’s for sure! I’m working with a climbing-specific PT to help with progression leading up to, and starting, climbing. I suspect like most things it will depend on my pain levels

Hi Kasey! I hope you are better now. Your story was truly inspiring for me. I have been climbing for 12 years now and i have felt pain on my left wrist for many years. Two years ago my tfcc was broken (becauce of my ulna, i have the same as you) and  climbing has been so limitating since then. Many doctors told me about wafer procedure and ulna shortening but i have always felt insecure about that. I would love to know your experience and how your feelings are now. It would very helpful for me. Thank you so much in advance. 

i had the ulna shortening surgery in 2017 and have had no issues since .  I decked in 2016 and believe that that initiated my wrist pain, but I had stopped climbing for alot of that year so it is hard to say for certain.  I went to one doc who said there is nothing we can do, went to a second, Dr Miyano in seattle, who did a better job and suggested the surgery and it definitely saved my climbing career. I have noticed 0 difference in strength in my L/R arms.  I remember him saying i could have the plate removed which holds the Ulna together, but I never felt the need to (I can barely feel it on the outside of my write.  I thought it could be an issue for jamming, but definitely has not).

Hi Kasey,

If your amenable, I'd love to stay in touch about your continuing experiences during recovery, and any other info you could provide. I've just been diagnosed with almost the exact issues that you had, and USO,  along with joint cleanup, is the recommended treatment. Right now, I've had cortisone shots, which seem to really help for awhile, and I'm leery of having the surgery due to the downtime involved. My pain comes and goes.....when it's bad, it's bad. But I can have weeks of zero pain, so I'm not sure I'm ready to pull the pin on the surgery yet. 

Any advice is extremely welcome and appreciated.

Thanks

Stephen 

Steve, this is a deeply personal choice. I chose to do it right away because it needed to get done at some point, I was not able to climb how I wanted, it was painful to use my keyboard at work, it was clear it had been an issue far before I realized (e.g. my condition had been preventing me from building strength) and my bone was clearly very traumatized (so much so they initially diagnosed me with the wrong pathology). I just climbed for the first time since surgery the other day (4.5 months post surgery) and my hand strength is almost back where it was pre-surgery so i know I am going to be stronger when I’m done healing. I have zero regrets. In fact, I have been working with a trainer to get stronger in other areas and feel I am going to be a better, stronger climber because of the time off that forced me to work on other weaknesses.

If I hadn’t been in constant pain, would I have done it when I did? Not sure. Definitely would recommend doing it before your bone starts to break down and also keep in mind that cortisone shots weaken tendons and are not a good long-term solution. Personally I would only use them if I couldn’t do surgery right away and needed a stop gap to get me through till when i could. USO seems barbaric but it is a super common surgery and the techniques/equipment have improved substantially in the last couple decades.

Happy to answer any questions you have and best if luck with it all!

Thanks for posting Kasey.

I went in for carpel tunnel surgery. In the review process, two different hand surgeons noted that my right ulna was 8mm longer than my right radius.

Both wanted to do the surgery you had. I was/am not noticing significant pain or weakness to my right arm. I do have limited range of motion in a direction not significant to climbing. I elected not to have the surgery at this time. 

I was surprised that neither doc compared my left and right ulna. Did your docs compare one to the other?
In your research, did you come across whether a longer ulna might occur on both arms or is it generally limited to one?

One doc wanted to know if I had done any damage to my right radius while still growing (as a kid) which may explain the difference in length.

Is there any impact to the alignment of the other bones in the wrist when the ulna is shortened? Do the bones have to "re-learn" to work together?

Thanks in advance for any thoughts.

Rocio Martinez wrote:

Hi Kasey! I hope you are better now. Your story was truly inspiring for me. I have been climbing for 12 years now and i have felt pain on my left wrist for many years. Two years ago my tfcc was broken (becauce of my ulna, i have the same as you) and  climbing has been so limitating since then. Many doctors told me about wafer procedure and ulna shortening but i have always felt insecure about that. I would love to know your experience and how your feelings are now. It would very helpful for me. Thank you so much in advance. 

I would not do the wafer procedure. The wrist is incredibly complex and the wafer procedure gets right into the middle of all that. The ulnar shortening is a pretty standard procedure and can accommodate a wider range of ulnar deviation. Im just shy of 5 months out now and my surgery arm grip strength is basically back up to what it was (still significantly weaker than the other side), suggesting my condition was preventing me from building strength. Im back on the (plastic) wall, easing back in. I have zero regrets. I can even use a keyboard pain free. It’s incredible. Can’t wait to see how much further I can take my climbing!

Doug - wow your ulnar deviation is huge and i don’t know how you are not feeling it! No, they did not compare the other but I suspect it is similar based on morphology and limited flexibility. My doctor did tell me that he does not typically see ulnar impaction in both wrists, so even though the morphology is similar, the ultimate impact does not have to be. Interestingly, women tend to get ulnar impaction syndrome on their non-dominant arm (as I did) and men tend to on their dominant arm. I don’t know how this breaks down by profession or sport, but i suspect there is a story there somewhere.

Yes, the wrist articulates differently, though Im not sure how much this is detectable for me. Perhaps taking off 8mm (compare to my 3-4) would be more noticeable! (I did read a pretty in depth blog post by a gymnast who had a similar deviation as you, might be worth seeking that out!) However, people with ulnar shortening tend to get arthritis at the joint between the radius and ulna sooner/more…I would guess because of the changes in biomechanics.

Kasey FowlerFinn wrote:

Doug - wow your ulnar deviation is huge and i don’t know how you are not feeling it! No, they did not compare the other but I suspect it is similar based on morphology and limited flexibility. My doctor did tell me that he does not typically see ulnar impaction in both wrists, so even though the morphology is similar, the ultimate impact does not have to be. Interestingly, women tend to get ulnar impaction syndrome on their non-dominant arm (as I did) and men tend to on their dominant arm. I don’t know how this breaks down by profession or sport, but i suspect there is a story there somewhere.

Yes, the wrist articulates differently, though Im not sure how much this is detectable for me. Perhaps taking off 8mm (compare to my 3-4) would be more noticeable! (I did read a pretty in depth blog post by a gymnast who had a similar deviation as you, might be worth seeking that out!) However, people with ulnar shortening tend to get arthritis at the joint between the radius and ulna sooner/more…I would guess because of the changes in biomechanics.

Thanks for the thoughtful response.