Hand Surgery & Microsurgery | Dr. Fang Yousheng (Hand Surgery) | CMCS Shanghai

About Dr. Fang Yousheng

Dr. Fang Yousheng is a senior hand and microsurgeon at Huashan Hospital, Fudan University — one of China's foremost centres for hand surgery, microsurgical reconstruction, and peripheral nerve repair, and a national reference institution for the management of complex hand trauma, replantation surgery, and functional restoration of the upper extremity. He is recognised for his expertise in microsurgical technique, his precision in the diagnosis and operative management of complex wrist disorders, and his success with cases that have failed conservative management at other institutions — particularly ulnar-sided wrist pain syndromes, triangular fibrocartilage complex (TFCC) injuries, and carpal instability. Dr. Fang's clinical philosophy holds that complex wrist disorders require a systematic diagnostic approach that integrates detailed clinical examination, advanced imaging, and intraoperative arthroscopic assessment — and that surgical intervention, when indicated, must be precisely tailored to the individual patient's anatomy, pathology, and functional demands. His department at Huashan Hospital has established one of Shanghai's most comprehensive hand surgery programmes, combining open and arthroscopic surgical techniques, microsurgical reconstruction, and structured postoperative rehabilitation into a unified care pathway for patients with complex hand and wrist conditions.

Case Overview

Mrs. Cui (pseudonym), a 53-year-old Chinese woman, presented with a six-month history of persistent ulnar-sided left wrist pain with no identifiable precipitating event — severe pain on forearm rotation, marked weakness of grip and wrist loading, and significant functional impairment affecting activities of daily living including the inability to wring a towel. Conservative management at multiple institutions had failed to produce symptomatic improvement. Imaging demonstrated left ulnar impaction syndrome with associated triangular fibrocartilage complex (TFCC) injury, small cystic changes in the lunate and triquetrum, and a small left wrist joint effusion. Under the guidance of Prof. Fang Yousheng, the Hand Surgery team at Huashan Hospital designed an individualised surgical plan and performed left ulnar shortening osteotomy. The procedure was completed without complication. At two-month follow-up, the patient had achieved excellent functional recovery with full compliance with postoperative rehabilitation. This case marks a significant milestone for Huashan Hospital's Hand Surgery department — representing a new institutional advance in the surgical management of complex wrist disorders.

Patient Background

• Name / Nationality: Mrs. Cui (pseudonym) — Chinese; 53-year-old woman
• Age / Sex: 53-year-old female
• Chief Complaint: Persistent left ulnar-sided wrist pain for six months, with severe pain on forearm rotation, grip weakness, and significant functional impairment
• History of present illness: Insidious onset of persistent left ulnar-sided wrist pain six months prior with no identifiable precipitating event or trauma. Pain was severe on forearm rotation and wrist loading; grip strength markedly reduced — unable to wring a towel, significantly impairing activities of daily living including personal hygiene and household tasks. The patient had sought evaluation and treatment at multiple institutions; conservative management including analgesia, physiotherapy, and splinting had failed to produce meaningful or sustained symptomatic improvement.
• Past medical history: No significant prior hand or wrist injury; no prior surgery; no relevant systemic medical history
• Functional assessment: Severe limitation of left wrist rotation and loading; grip strength markedly reduced; activities of daily living significantly impaired; quality of life substantially affected

Diagnostic Workup

Clinical Examination

• Tenderness localised to the ulnar aspect of the left wrist; pain reproduced and exacerbated by forearm rotation and ulnar deviation loading; positive ulnar impaction provocation test; reduced grip strength on dynamometry

Imaging Studies

• Plain radiographs: Positive ulnar variance — ulnar head projecting distal to the radial articular surface, consistent with ulnar impaction syndrome
• MRI wrist: Left ulnar impaction syndrome confirmed; associated triangular fibrocartilage complex (TFCC) injury identified; small cystic changes in the lunate and triquetrum consistent with early avascular stress changes from chronic impaction; small left wrist joint effusion

Prof. Fang's pre-operative assessment: The clinical picture is consistent and the imaging confirms what the examination suggests — positive ulnar variance driving chronic impaction of the ulnar head against the proximal carpal row, with the TFCC bearing the brunt of the load and beginning to fail. The cystic changes in the lunate and triquetrum are the early signature of avascular injury from chronic impaction — they tell us that the mechanical problem has been present long enough to begin producing structural bone changes. Conservative management has a role in mild ulnar impaction syndrome, but this patient has failed six months of conservative treatment, has significant functional impairment, and has imaging evidence of progressive structural change. The indication for surgical intervention is clear. Ulnar shortening osteotomy is the definitive procedure for positive ulnar variance — by shortening the ulna to achieve neutral or slightly negative variance, we decompress the ulnocarpal joint, reduce the load on the TFCC, and halt the progression of the lunate and triquetral cystic changes. The TFCC injury in this case does not require separate surgical intervention — decompression of the ulnocarpal joint through the osteotomy will allow the TFCC to heal in a mechanically favourable environment.

Diagnosis and Surgical Treatment Strategy

The diagnosis established by Prof. Fang Yousheng was Left Ulnar Impaction Syndrome with associated Triangular Fibrocartilage Complex (TFCC) Injury, small cystic changes of the lunate and triquetrum, and left wrist joint effusion.

The surgical principle was: ulnar shortening osteotomy to achieve neutral ulnar variance, decompress the ulnocarpal articulation, reduce TFCC loading, and halt progression of carpal avascular change.

Surgical procedure — Left Ulnar Shortening Osteotomy:

• Approach: Longitudinal incision over the distal ulnar shaft; careful dissection through the extensor carpi ulnaris (ECU) interval; periosteal exposure of the distal ulnar diaphysis
• Osteotomy: Precise transverse or oblique osteotomy of the distal ulnar shaft; calculated shortening based on preoperative radiographic measurement of ulnar variance — targeting neutral to slightly negative ulnar variance post-osteotomy
• Fixation: Rigid internal fixation with a low-profile ulnar shortening plate and cortical screws; intraoperative fluoroscopic confirmation of osteotomy reduction, implant position, and achieved ulnar variance
• TFCC: No separate TFCC repair performed — decompression of the ulnocarpal joint through the osteotomy expected to provide a mechanically favourable environment for TFCC healing
• Wound closure and dressing: Layered closure; sterile dressing; postoperative splint immobilisation

Postoperative rehabilitation protocol: Structured progressive rehabilitation programme initiated under physiotherapy supervision — early protected range-of-motion exercises followed by progressive loading and grip strengthening as osteotomy healing confirmed on serial radiographs; full return to activities of daily living targeted at three to six months post-osteotomy.

Treatment Course and Outcomes

Intraoperative

• Left ulnar shortening osteotomy performed without complication under the guidance of Prof. Fang Yousheng; intraoperative fluoroscopy confirmed satisfactory osteotomy reduction, implant position, and achievement of target ulnar variance; estimated blood loss minimal; no intraoperative complications

At Two Months Post-Operatively

• Ulnar-sided wrist pain substantially reduced; forearm rotation pain resolved; grip strength improving with ongoing rehabilitation
• Patient fully compliant with postoperative rehabilitation protocol; progressive range-of-motion and strengthening exercises ongoing
• Radiographic follow-up: osteotomy site showing early consolidation; implant position maintained; ulnar variance at target
• Functional recovery: activities of daily living progressively restored; patient highly satisfied with early outcome

Prof. Fang's clinical reflection: The result at two months is encouraging — the pain on forearm rotation that was the patient's primary complaint has resolved, and she is progressing well through the rehabilitation programme. Ulnar shortening osteotomy is a technically demanding procedure that requires precise preoperative planning, accurate intraoperative execution of the calculated shortening, and rigid fixation to allow early rehabilitation. The key to a good outcome is achieving the target ulnar variance — not simply shortening the ulna, but shortening it by exactly the right amount to decompress the ulnocarpal joint without overcorrecting into negative variance, which can produce its own set of problems. The TFCC injury in this case did not require separate repair — the decompression achieved by the osteotomy is the primary therapeutic intervention, and the TFCC will heal in a mechanically favourable environment once the impaction load is removed. We will continue to follow this patient closely through the osteotomy consolidation phase and the progressive rehabilitation programme. The institutional significance of this case — as the first ulnar shortening osteotomy performed at Huashan Hospital's Hand Surgery department — reflects the ongoing development of our complex wrist surgery programme and our commitment to offering international patients access to the full spectrum of advanced hand surgical techniques.

Expert Commentary — Prof. Fang Yousheng

1. Ulnar Impaction Syndrome: Pathomechanics, Diagnosis, and the Rationale for Surgical Decompression

Ulnar impaction syndrome — also termed ulnocarpal abutment syndrome — is a degenerative condition of the ulnar wrist caused by excessive load transmission across the ulnocarpal joint, typically in the setting of positive ulnar variance. In the normal wrist with neutral ulnar variance, approximately 20% of axial load is transmitted through the ulnocarpal joint — across the TFCC, the lunate, and the triquetrum. For every millimetre of positive ulnar variance, the proportion of load transmitted through the ulnocarpal joint increases substantially — at +2.5 mm of positive variance, ulnocarpal load transmission increases to approximately 42% of total axial load. This chronic mechanical overload produces a predictable sequence of pathological changes: TFCC central perforation or degeneration; chondromalacia of the ulnar head articular surface, the proximal lunate, and the triquetrum; and, in advanced cases, subchondral cystic change and avascular necrosis of the lunate and triquetrum — the changes identified on MRI in this patient. The clinical presentation is characteristic: ulnar-sided wrist pain exacerbated by forearm rotation and ulnar deviation loading; positive ulnar impaction provocation test; and, on imaging, positive ulnar variance with the associated TFCC and carpal changes described above. The diagnosis is clinical and radiographic — the combination of the characteristic symptom pattern, positive provocation testing, and imaging confirmation of positive ulnar variance with ulnocarpal pathological change establishes the diagnosis with high confidence. Conservative management — activity modification, splinting, corticosteroid injection — has a role in mild cases and in patients who are not surgical candidates, but the evidence for sustained benefit is limited, and patients with significant positive variance, established TFCC injury, and carpal cystic change — as in this case — are unlikely to achieve durable relief without surgical decompression.

2. Ulnar Shortening Osteotomy: Surgical Technique, Precision Planning, and Fixation Principles

Ulnar shortening osteotomy is the gold-standard surgical procedure for ulnar impaction syndrome with positive ulnar variance. The procedure addresses the primary pathomechanical driver of the condition — the excessive ulnar variance — by shortening the ulnar diaphysis to achieve neutral or slightly negative ulnar variance, thereby reducing ulnocarpal load transmission, decompressing the TFCC, and creating a mechanically favourable environment for healing of the TFCC and the carpal subchondral changes. Precise preoperative planning is essential: the target shortening is calculated from weight-bearing posteroanterior radiographs with the forearm in neutral rotation, measuring the ulnar variance and determining the amount of shortening required to achieve the target variance. Overcorrection into significant negative variance must be avoided — negative ulnar variance shifts load to the radioscaphoid and radiolunate articulations and can produce its own pattern of degenerative change. The osteotomy is performed through a longitudinal approach to the distal ulnar diaphysis; the calculated shortening is executed with precision using an oscillating saw and an osteotomy guide; and rigid internal fixation is achieved with a low-profile ulnar shortening plate and cortical screws. Rigid fixation is not merely a technical preference — it is a prerequisite for early postoperative rehabilitation, which is essential for preventing stiffness and achieving the functional outcomes that justify the procedure. Intraoperative fluoroscopic confirmation of the achieved variance and implant position is mandatory before wound closure. The technical demands of the procedure — precise planning, accurate execution of the calculated shortening, and rigid fixation — require a surgeon with specific expertise in complex wrist surgery and a thorough understanding of ulnocarpal biomechanics.

3. TFCC Injury in the Context of Ulnar Impaction Syndrome: When to Repair and When to Decompress

The triangular fibrocartilage complex is the primary stabiliser of the distal radioulnar joint and the principal load-bearing structure of the ulnocarpal articulation. TFCC injury in the context of ulnar impaction syndrome is typically a degenerative central perforation — a consequence of chronic mechanical overload rather than acute traumatic disruption — and is classified as a Palmer Type II lesion. The management of TFCC injury in ulnar impaction syndrome is one of the most debated topics in wrist surgery: should the TFCC be repaired at the time of ulnar shortening osteotomy, or is decompression of the ulnocarpal joint through the osteotomy sufficient to allow the TFCC to heal without direct repair? The current evidence supports a selective approach: for Palmer Type II degenerative TFCC perforations in the setting of positive ulnar variance, ulnar shortening osteotomy alone — without TFCC repair — produces excellent outcomes in the majority of patients, because the primary pathological driver is the mechanical overload rather than the structural disruption of the TFCC. Once the overload is removed by the osteotomy, the TFCC degenerative changes stabilise and the residual perforation does not produce ongoing symptoms in most patients. Direct TFCC repair is reserved for cases with associated peripheral TFCC tears, distal radioulnar joint instability, or cases where arthroscopic assessment demonstrates a repairable lesion that is unlikely to heal with decompression alone. In this patient, the decision to proceed with ulnar shortening osteotomy without separate TFCC repair was based on the degenerative nature of the TFCC injury, the absence of distal radioulnar joint instability, and the expectation that decompression of the ulnocarpal joint would provide a mechanically favourable environment for TFCC stabilisation — a decision supported by the early clinical outcome.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported Mrs. Cui and her family throughout the diagnostic and surgical pathway at Huashan Hospital, Fudan University, including: priority appointment coordination with Prof. Fang Yousheng's Hand Surgery clinic with bilingual review of all prior imaging, clinical records, and conservative treatment history; bilingual interpretation throughout the clinical examination, diagnostic discussion, surgical planning consultation, and postoperative review appointments; coordination of plain radiograph and MRI wrist studies with bilingual results communication and clinical summary; bilingual surgical consent process — ensuring the patient and family had a complete understanding of the procedure, the expected recovery timeline, the rehabilitation requirements, and the potential risks and complications of ulnar shortening osteotomy; postoperative rehabilitation coordination — bilingual liaison with the physiotherapy team, written rehabilitation schedule provided in the patient's preferred language, and structured follow-up appointment coordination; and ongoing postoperative monitoring with bilingual communication of radiographic and functional progress to the patient and family.

For international patients with ulnar-sided wrist pain, ulnar impaction syndrome, TFCC injury, or other complex hand and wrist conditions seeking surgical evaluation and management in Shanghai, Prof. Fang Yousheng's team at Huashan Hospital offers a clinically rigorous, technically advanced approach — combining precise surgical planning, expert operative technique, and structured postoperative rehabilitation to achieve optimal functional outcomes. CMCS ensures that expertise is accessible: in the patient's language, with every step of the surgical and rehabilitation pathway coordinated and communicated clearly, from the first consultation through full functional recovery.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.