Fovea Sign

Original Editors - Rachael Lowe

Top Contributors - Claire Knott, Rachael Lowe, Evan Thomas, Kim Jackson, Joyce Timmermans, Wanda van Niekerk and Chelsea Mclene

Search strategy:

Following databases were searched: Pubmed, Google Scholar
Useful information was found by combining the different keywords: fovea sign, ulnar fovea sign, foveal disruption, distal radioulnar ligament, ulnotriquetral ligament, distal radioulnar joint stability.

Purpose

The ulnar fovea sign is a clinical test to specify the cause of ulnar-sided wrist pain. Foveal disruption of the distal radioulnar ligaments and ulnotriquetral ligament injuries are the two conceivable possibilities when a positive ulnar fovea sign is determined. This positive ulnar fovea sign is sensitive and characteristic to examine the presence or absence of ulnar fovea disruption.
It is a provocative test to provoke an irregular soreness in the fovea region of the wrist.
A ulnar fovea sign is accomplished when the patient has complaints about the ulnar side of the wrist. The characteristics of a positive ulnar fovea sign is an irregular soreness in the fovea region of the wrist.
The hypothesis was that overdone traction of the ulnocarpal ligaments, eliciting through hyper – radial extension or hyperextension of the wrist in combination with axial loading and/or forearm rotation, could transcribe forces at the fovea region. When the ulnotriquetral ligament suffers to an extreme traction, the ulnar styloid attachment breaks down before the foveal attachment does.
The hypothesis stating that the ulnar fovea sign is a utile clinical test to locate foveal disruption and ulnotriquetral ligament injuries is propped.
In a validation study, in the clinical observation to locate foveal disruption and ulnotriquetral ligament injuries the ulnar fovea sign was 95% sensitive and 87% specific. In detecting longitudinal split tears of the ulnotriquetral ligament, the ulnar fovea sign was 90% sensitive and 88% specific.

(Shian-Chao Tay et al.).
In the research “The Ulnar Fovea Sign for Defining Ulnar Wrist Pain: An analysis of Sensitivity and Specificity” was the ulnar fovea sign positive in 156 patients. 90 patients received the diagnosis of foveal disruption and 68 patients of UT ligament injuries. So two patients had a positive ulnar fovea sign, but none of the two possible pathologies (Shian-Chao Tay et al.).

Technique

The fovea is situated among the ulnar styloid process and the flexor carpi ulnaris tendon.
Ligamentous structures in the fovea region during neutral forearm position are the foveal attachments of the conjoined palmar and dorsal radioulnar ligaments and the ulnocarpal ligaments.

The place of the fovea sign should be objective and well found by an experienced surgeon. The dose and capacity of the soreness are dependent from the patient, so the personal opinion of the surgeon is not applicable. It is at the most utile in a symptomatic patient who has no other clear evidence of pathology in the wrist and who continues to suffer pain despite affective nonsurgical interventions and for whom wrist arthroscopy should be the following examination. The ulnar fovea sign is not utile on patients who have global soreness of the wrist.

For this purpose the patient’s facing the therapist with the elbow on the table. The elbow has to stay in 90° to 110° of flexion, the forearm and the wrist in neutral position.

http://www.youtube.com/watch?v=6nElItvL1dU
The thumb of the therapist has to be pressed deep into the soft space among the ulnar styloid process and the flexor carpi ulnaris tendon distally, between the palmair surface of the ulnar head and the pisiform.
A positive ulnar fovea sign is indicated when the patient senses a aesthetic tenderness replying the pain, equalizing with the contrary side. When there is a positive ulnar fovea sign, the patient shows facial expressions during the test. The soreness of a positive ulnar fovea sign copies the disorders of the patient (Shian-Chao Tay et al.).

After eliciting the positive ulnar fovea sign, the stability of the distal radioulnar joint has to be identified. The stability of the distal radioulnar joint is completed when the congruent articulating surfaces and the radioulnar ligaments are strong and fixed. A radiograph or a CT scan can identify the extent of injury and the area of instability. If it’s stable, the following possibility is the longitudinal split tear of the ulnotriquetral ligament. If it’s unstable,
Using a consistent gold standard is important to criticize the intention of the ulnar fovea sign (Shian-Chao Tay et al.).
A wrist examination should be accomplished in all cases of ulnar sided wrist pain. Grip strength of the wrist, range of motion of the wrist, forearm pronation and supination should be gauged.

Differential diagnosis
When a positive ulnar fovea sign is established there is a possibility of two wrist conditions, the longitudinal split tear of the ulnotriquetral ligament and foveal disruption. The positive ulnar fovea sign has a stable dorsal radioulnar ligament joint or a unstable dorsal radioulnar ligament joint. When it’s unstable, a longitudinal split tear of ulnotriqutral ligament is the statement. When the stable dorsal radioulnar ligament joint is determined, it’s a foveal disruption. The difference between the two conditions is made clinically, radiographic or with a CT scan.

Evidence

Kavi Sachar. Ulnar – Sided Wrist Pain: Evaluation and Treatment of Triangular Fibrocartilage Complex Tears, Ulnocarpal Impaction Syndrome, and Lunotriquetral Ligament Tears. American society for Surgery of the Hand. 2008

Shian Chao Tay, Richard A. Berger. Longitudinal Split Tears of the Ulnotriquetral Ligament. Division of Hand Surgery. 2010

Shian Chao Tay, Richard A. Berger. The “Ulnar Fovea Sign” for Defining Ulnar Wrist Pain: An Analysis of Sensitivity and Specificity. American Society of the Hand. 2007

Claire A. Coggins. Imaging of Ulnar – sided Wrist Pain. Virginia Commonwealth University. 2006

References

1. Kavi Sachar, MD., Ulnar – Sided Wrist Pain: Evaluation and Treatment of Triangular Fibrocartilage Complex Tears, Ulnocarpal Impaction Syndrome, and Lunotriquetral Ligament Tears, American society for Surgery of the Hand, 2008
Level of evidence: 2B

2. Shian Chao Tay, Richard A. Berger. Longitudinal Split Tears of the Ulnotriquetral Ligament, Division of Hand Surgery, 2010
Level of evidence: 1B

3. Shian Chao Tay, Richard A. Berger. The “Ulnar Fovea Sign” for Defining Ulnar Wrist Pain: An Analysis of Sensitivity and Specificity, American Society of the Hand, 2007
Level of evidence: 1B

4. Claire A. Coggins, MD. Imaging of Ulnar – sided Wrist Pain, Virginia Commonwealth University, 2006
Level of evidence: 2B