Ulnar Deviation or Ulnar Drift is the name given to a deformity of the hands in which there is gradual shifting of the wrist and fingers in an ulnar direction. The ulna is a bone of forearm, which is present on the side of little finger. The deviation is caused by chronic inflammation resulting in wear and tear of capsule and ligament of the joint in the hand and fingers. The joint inflammation mostly affects the metacarpophalangeal joints as a result of usually Rheumatoid Arthritis.1 In this article, we will read in detail about the causes, symptoms, treatments rendered, and some of the exercises done for Ulnar Deviation/Drift.
What is Ulnar Deviation or Ulnar Drift?
Ulnar Deviation or Ulnar Drift as stated is a deformity of the hands in which the metacarpophalangeal joints bends or deviate towards the little finger. The ulna is a bone, which is present in forearm and contributes in elbow and wrist joint. Ulnar bone lies on the side of little finger. Ulnar Deviation or Ulnar Drift is usually seen in people who are suffering from Rheumatoid Arthritis. Some consideration is also given to a medical condition called Pigmented Villonodular Synovitis, which is also associated with Ulnar Deviation or Ulnar Drift. Ulnar Deviation or Ulnar Drift is a medical disorder, which also causes weakness of flexor muscles. Flexor muscles are innervated by ulnar nerve. Muscles innervated by median nerve function normal.
Causes of Ulnar Deviation or Ulnar Drift
The main cause of Ulnar Deviation or Ulnar Drift is Rheumatoid Arthritis. Rheumatoid Arthritis causes the inflammation of metacarpo-phalangeal joints. The synovial membrane and ligaments supporting the joint become extremely lax and joint subluxated. Partial subluxation and joint laxity causes repositioning of the extensor and flexor muscles. Repositioning of the extensor and flexor muscles and its tendon causes pull of the finger and hand toward ulnar side resulting in ulnar deviation. In several cases tendon and ligaments are ruptured resulting in rapid deterioration of the joint and deviation.
Symptoms of Ulnar Deviation or Ulnar Drift
- Pain is mild to moderate in the beginning and later pain often becomes severe.
- Pain intensity is worst in the morning.
- Pain responds to NSAIDs during the initial phase.
Tingling and Numbness-
- Few cases may suggest sensory nerve damage.
- Sensory nerve damage results in tingling and numbness.
- Ulnar deviation or ulnar drift between 11 to 25 degree shows visible deviation.D
- It is a chronic irreversible condition
- Ulnar Deviation or Ulnar Drift is a chronic condition and it could take several months to observe the optimum deviation.
- The bend or deviation depends on severity of rheumatoid arthritis.
- Metacarpo-phalangeal (MP) joints are swollen and edematous.
- MP joints feel spongy and soft.
- Decreased grip and pinch strength is also observed in Ulnar Deviation or Ulnar Drift.
- The grip strength is less affected in patient suffering with rheumatoid arthritis when only ulnar deviation is observed in peripheral joint.A
- There is also diminution of the overall hand function, which starts worsening with time.
Diagnosis of Ulnar Deviation or Ulnar Drift
- Examination indicates characteristics of ulnar deviation and joint deformity.
- Observe for presence of warmth over the joint
- Look for swelling over the joint
- Look for presence of effusion over the joint
- Look for presence of palpable tenderness
- Confirms the deviation of the hand, inflammatory changes of the joint and hypertrophy of the ligament and capsule.
- Osteoarticular destruction
CAT Scan and MRI-
- Osteoarticular destruction
- Synovial membrane thickness is observed
- Subluxation of metacarpophalangeal and interphalangeal joint is observed.
Treatments for Ulnar Deviation or Ulnar Drift
The following are some of the treatments rendered for Ulnar Deviation/Ulnar Drift:
Conservative Treatment for Ulnar Deviation or Ulnar Drift-
- Cold compression therapy
- Heating pad
- Hand and wrist braces
- Use of contrast baths for control of swelling
- Use of moist heat at end of possible range to help with stretch
- Use of laser therapy for control of pain
- Use of ultrasound for reduction of tenderness
- Stretching Exercises- Such exercises for this condition needs to be avoided when there is inflammation of the joint as there is decreased tissue strength as a result of the inflammation hence if stretching exercises are done it may result in overstretching and rupture of the tissue.
Therapeutic Treatment for Ulnar Deviation or Ulnar Drift -
- NSAIDS- Cymbalta, Naproxen or Motrin
- Treat rheumatoid arthritis
Physical Therapy (PT) for Ulnar Deviation or Ulnar Drift -
- Supervised Exercises for Ulnar Deviation/Ulnar Drift
- The affected individual should do active and passive range of motion exercises for the MCP, DIP, and PIP joints
Intrinsic Supervised Physiotherapy Stretches For Ulnar Deviation or Ulnar Drift:
- Lumbricals: To actively stretch lumbricals, the individual should actively flex the DIP and PIP joints keeping the MCP joint in extension. This stretch should be held for about half a minute and should be done three to four times at least thrice daily for about a week
- Interossei: To passively stretch the interossei, the individual should hold the MCP in hyperextension and passively flex the PIP joint as much as possible. This stretch should be held for about half a minute and should be done about four times daily for about a week.
- Isometric Strengthening of Radial Intrinsic: To do this exercise, the palm should be kept flat on an even surface. Now, a pen should be placed on the radial side of each finger and the individual should try to resist the movement of the finger radially. This position should be held for about 10 seconds and should be done at least once a day in repetitions of five.
- Radial “Finger Walking”: To do this exercise, the palm should be placed flat on an even surface, then extend the thumb and to actively move the fingers towards the thumb.
- Tendon Gliding: To do this exercise, first of all the fingers should be kept straight and now try and flex the MCP joints keeping the PIP and the DIP joints straight all the while to form a type of a tabletop. Come back to the starting position. Now, flex the PIP and DIP joints keeping the MCP joint straight and again return to the starting position. Now, flex the PIP and MCP joints keeping the DIP joint straight to form a type of a straight fist.
Splinting Therapy for Ulnar Deviation or Ulnar Drift -
- Hand Resting Splint for Ulnar Deviation or Ulnar Drift:The purpose of this splint is to reduce pain by providing rest and support to wrist and the joints. It also reduces subluxation at the wrist. These splints are extremely useful for individuals who sleep with their hands flexed at night.
- MPAP-MCP Protection Splint for Ulnar Deviation or Ulnar Drift:This type of splint is useful in providing support and improvement of alignment of MCP joints at times of rest and activity.
Surgical Treatment for Ulnar Deviation or Ulnar Drift -
- Arthroplasty- Several studies has suggested Silicone metacarpophalangeal joint Arthroplasty has better results of functional improvements. B
- Reconstruction Surgery- Reconstruction of the metacarpophalangeal and interphalangeal joint has better results following surgery. C
Prevention of Ulnar Deviation or Ulnar Drift
Joint Protection Techniques
- One should not place too much stress on the MCP joints and to reduce the stress one should use the palms instead of fingers to grasp objects like a book or tray.
- Avoid activities like turning a key, a doorknob or opening the lid of a jars.
- One should not put direct pressure on MCP joints especially when joint is inflamed in hands and wrist.
- Avoid hand positioning, which puts the MCP joints in flexion. Example holding a book or working on computer keyboard.
- Avoid activities that put extra stress on the MCP joints like holding a heavy mug with its handle or carrying object. Instead, one should try and use both hands to use the mug.
1. Rheumatoid wrist deformities and their relation to ulnar drift.
Hastings DE, Evans JA,
J Bone Joint Surg Am. 1975 Oct;57(7):930-4.
2. Ulnar deviation of the fingers as a clinical sign in the elderly.
Age Ageing. 1976 Aug;5(3):132-40.2
3. Grip strength characteristics using force-time curves in rheumatoid hands.
Dias JJ1, Singh HP, Taub N, Thompson J.
J Hand Surg Eur Vol. 2013 Feb;38(2):170-7. 3
4. Long-term followup for rheumatoid arthritis patients in a multicenter outcomes study of silicone metacarpophalangeal joint Arthroplasty.
Chung KC1, Burns PB, Kim HM, Burke FD, Wilgis EF, Fox DA. 4
Arthritis Care Res (Hoboken). 2012 Sep;64(9):1292-300.
5. A prospective study comparing outcomes after reconstruction in rheumatoid arthritis patients with severe ulnardrift deformities.
Chung KC1, Burke FD, Wilgis EF, Regan M, Kim HM, Fox DA.
Plast Reconstr Surg. 2009 Jun;123(6):1769-77. 5