Fovea Sign
Original Editors - Rachael Lowe
Top Contributors - Claire Knott, Rachael Lowe, Mmesoma Eyisi, Kim Jackson, Evan Thomas, Joyce Timmermans, Wanda van Niekerk, Chelsea Mclene, Mohamed A Hassanin and Stacy Lawrence
Purpose
The ulnar fovea sign is a clinical test that specifies the cause of ulnar-sided wrist pain.[1]
The ulnar fovea sign is used clinically to determine the cause of pain on the ulnar side of the wrist. A positive test is usually considered specific for foveal disruption of the distal radioulnar ligaments and ulnotriquetral ligament injuries.[2] The ulnar fovea sign test can form an important part of the objective examination when the patient complains about the ulnar side of the wrist.[3] It is a provocative test to give the patient an irregular soreness in the fovea region of the wrist.
The mechanism of injury for foveal injury is excessive traction of the ulnocarpal ligaments, elicited through hyper-radial extension or hyperextension of the wrist in combination with axial loading and/or forearm rotation. This mechanism transcribes forces at the fovea region. When the ulnotriquetral ligament suffers from extreme traction, the ulnar styloid attachment will break down before the foveal attachment does.[4]
The test is sensitive and examines the presence (or absence if negative) of ulnar fovea disruption.[2]
Anatomy
The fovea is situated between the ulnar styloid process and the flexor carpi ulnaris tendon.
Ligamentous structures in the fovea region, when the forearm is in a neutral position, form the foveal attachments of the conjoined palmar and dorsal radioulnar ligaments and the ulnocarpal ligaments.[3]
Technique
For the purposes of this test, the patient is facing the therapist with the elbow on a table or plinth. The elbow has to stay in 90° to 110° of flexion with the forearm and the wrist in a neutral position. The thumb of the therapist has to be pressed deep into the soft space between the ulnar styloid process and the flexor carpi ulnaris tendon distally, between the palmar surface of the ulnar head and the pisiform.
When there is a positive ulnar fovea sign, the pain may make the patient grimace during the test. The severity of the soreness of a positive ulnar fovea sign copies the disorders of the patient [6]
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 intact 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[7]
A comprehensive wrist examination should be completed in conjunction with the fovea sign test in cases of ulnar-sided wrist pain. Objective components should include active strength in all functional movements, grip strength, and range of motion of the wrist and forearm pronation and supination.
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. A positive ulnar fovea sign test has either a stable dorsal radioulnar ligament joint or an unstable dorsal radioulnar ligament joint. When it’s unstable, a longitudinal split tear of ulnotriqutral ligament is the probable diagnosis. When the stable dorsal radioulnar ligament joint is present, the probable diagnosis is foveal disruption [6]. The difference between the two conditions is made clinically, radiographic or with a CT scan[7].
Evidence
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.[6]
In another study, the analysis of diagnostic clinical tests was done to analyze the clinical tests used to evaluate the cause of ulnar-sided wrist pain and determine their diagnostic relevance, the Fovea sign had a sensitivity and specificity of 89% and 48% for triangular fibrocartilage complex (TFCC) injuries, and 85% and 37% for ulnocarpal abutment syndrome (UCAS).[8]
A study also indicates that the ulnar foveal signs were not sufficiently specific clinical tests used to evaluate the cause of ulnar-sided wrist pain, therefore there is a need for MRI and CT for diagnostic confirmation after clinical examination.[5]
Also, a correlation study between clinical tests and MRI findings in the diagnosis of chronic ulnar pain revealed that the Fovea sign gives significant results in the diagnosis of chronic ulnar-sided wrist pain[9]
References
- ↑ Tay SC, Tomita K, Berger RA. The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg Am. 2007 Apr;32(4):438-44. doi: 10.1016/j.jhsa.2007.01.022. PMID: 17398352.
- ↑ 2.0 2.1 Choudhury MM, Ling AA, Yap RT. Is the ulnar fovea sign positive only in foveal tears of the triangular fibrocartilage complex?. Journal of Hand Surgery (European Volume). 2024 Sep 24:17531934241279921.
- ↑ 3.0 3.1 Vezeridis PS, Yoshioka H, Han R, Blazar P. Ulnar-sided wrist pain. Part I: Anatomy and physical examination. Skeletal Radiol 2009;39(8):733.
- ↑ Moritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K. Change in the length of the ulnocarpal ligaments during radiocarpal motion: possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg Am 2008 Oct;33(8):1278-86. doi: 10.1016/j.jhsa.2008.04.033. PMID: 18929189.
- ↑ 5.0 5.1 IAOMUSVIDEO. The Fovea Sign. Available from https://www.youtube.com/watch?v=q_Q_n7Adg9g
- ↑ 6.0 6.1 6.2 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
- ↑ 7.0 7.1 Claire A. Coggins, MD. Imaging of Ulnar – sided Wrist Pain, Virginia Commonwealth University, 2006
- ↑ Ou Yang O, McCombe DB, Keating C, Maloney PP, Berger AC, Tham SK. Ulnar‐sided wrist pain: a prospective analysis of diagnostic clinical tests. ANZ Journal of Surgery. 2021 Oct;91(10):2159-62.
- ↑ Lashin MF, Megahed EA, Emran AM, Attia IT. Correlation between Clinical Tests and Magnetic Resonance Imaging Finding in Diagnosis of Chronic Ulnar-sided Wrist Pain. Journal of Advances in Medicine and Medical Research. 2021 Sep 7;33(19):64-70.