Post on 13-Jul-2015
Nickolaos A. Darlis, MD
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“Forearm Joint”“Forearm Joint”
One functional unit
“Forearm Joint”“Forearm Joint”
The forearm as a ring
Anatomy Distal RadiusAnatomy Distal Radius
DRUJ AnatomyDRUJ Anatomy
• Radii of curvature differ – 10mm vs 15mm– Full congruity impossible
DRUJ anatomyDRUJ anatomy
• Congruity of DRUJ– Neutral rotation: 60% of
sigmoid notch in contact– Extremes of rotation: 10%– Dorsal and palmar rims
important
• Little osseous stability
TFCC componentsTFCC components
VRULDRUL
ARTICULARDISC
UL, UTr ECU sub sheath
Volar & Dorsal RU lig.-Deep bundleVolar & Dorsal RU lig.-Deep bundle
Distal Radio-ulnar ligamentsDistal Radio-ulnar ligaments
Exact role disputed for years• Primary constraint to volar dislocation?• Primary constraint to dorsal dislocation?
However, most common explanation:However, most common explanation:
• Pronation– Ulnar head dorsal– DRUL taut– If PRUL ruptures,
dislocates dorsally• Supination– Ulnar head volar– PRUL taut– If DRUL ruptures,
dislocates volarly
Deep bundle, Foveal attachmentDeep bundle, Foveal attachment
The Iceberg Concept Atzei &Lucetti 2011The Iceberg Concept Atzei &Lucetti 2011
TFCC anatomyTFCC anatomy
• Vascular supply– Central portion• avascular
– Periphery (dorsal and palmar radio-ulnar ligaments)• vascularized
DRUJDRUJ
• Rotation• Load transmission• Stability
KinematicsKinematics
• Radius rotates about the distal ulna• “Ulnar head dislocation” by convention• Axis of rotation
Load transmission (RH intact )Load transmission (RH intact )
80%
20%
40% 60%
Halls 1964, Palmer 1984, Birkbeck 1997
U
U
R
R
Load TransmissionLoad TransmissionExplains common fracture patterns
Galeazzi
Forearm
Monteggia
Essex-Lopresti
Interosseous Membrane AnatomyInterosseous Membrane Anatomy
Two main bands:• Central Band (volar)• Proximal Interosseous
Band (dorsal)
• Accessory bands (1-5)• Membranous portion
Skahen 1997
CB
PIOB
IOM-Central BandIOM-Central Band
• 70% of forearm stability
• Injury of other elements of IOM (partial tears), increase CB strains
Hotchkiss,1989, Lafferty 1990, Rabinowitz, 1994, Skahen III 1997
Radius
Ulna
CB
IOM AnatomyIOM Anatomy
60%
40%
35%
75%250120mm
outlineoutline
Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti
TFCC management
Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti
TFCC management
Common misconceptionsCommon misconceptions
• TFCC tear ≠ DRUJ instability– In fact: most tears don’t cause instability
• Ulnar styloid fracture ≠ DRUJ instability– Styloid fractures may co-excist with TFCC tears
Acute Ulnar head Dislocation
without fracture
Acute Ulnar head Dislocation
without fracture• Dorsal: reduce in supination• Palmar: reduce in pronation• Global instability: usually requires
stabilization
• If stable: immobilize in stable position– Sugartongue splint for 6 weeks
• Failed closed reduction may result from trapped ECU, capsule, ulnar styloid, extensor tendon
• Open reduction dorsal - 5th compt.
• TFCC repair if avulsed
Acute Ulnar head Dislocation
without fracture
Acute Ulnar head Dislocation
without fracture
DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• 1777 Desault isolated DRUJ dislocation• 1814 Colles: DRUJ with distal radius– “at some remote period again enjoy perfect freedom”
• 1837- Diday– “the problem is really the overriding ulna”
• 1934 Galeazzi • 1951 Essex-Lopresti• 1967 Frykman– “Disturbances of the DRUJ make for worse results”
DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• “Most common source of pain following distal radius Fx”
Fernandez &Geissler JHS 1992
• Loss of supination most common functional complaint following distal radius Fx
Hanel AAOS ICL 2004
• Residual depression of the lunate facet ≥2mm results in articular incongruity and arthrosis
Jupiter JBJS 1986
DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
DRUJ injury in distal radius FxDRUJ injury in distal radius Fx
Highly possible when:• shortening >5-7mm• displaced fx base of the
ulnar styloid, • angulation >25-300 any
plane• DRUJ diastasis in PA Rö
projection
DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• Accurate osseus reduction first– Ulnar column stabilization
Common pitfallsCommon pitfalls
• Radial translocation- sigmoid notch malreduction
Common pitfallsCommon pitfalls
• Excessive volar tilt/ translocation
DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• Geissler and Fernandez Instabilty classification AFTER radius reduction– Type I: Stable– Type II: Unstable– Type III: Potentially Unstable
Type I: StableType I: Stable
• minimally displaced avulsion tip of the ulnar styloid
• fracture of the neck of the ulna
(just fix)
Type III: Potentially UnstableType III: Potentially Unstable
• Fx through sigmoid notch (4-part fracture) or• Ulnar head fracture
(fix & test)
Type II: UnstableType II: Unstable
• avulsion Fx base of the ulnar styloid or• massive tear of the TFCC and/or secondary
stabilizers
Ulnar styloid FxUlnar styloid Fx
• Management controversial• May be fixed or tends to reduce in supination• Fix when DRUJ unstable, usually base.• Make sure TFCC attaches to fragment
Ulnar styloid FxUlnar styloid Fx
• CRIF: easier said than done; supinate
• Re-check stability
Ulnar styloid FxUlnar styloid Fx
• ORIF: ample skin incision– Kirschner wires,– tension band wire– screw– suture anchors
• Re-check stability
Ulnar styloid FxUlnar styloid Fx
• ORIF– Dedicated plates
• Re-check stability
Ulnar styloid FxUlnar styloid Fx
• However, if no clinical instability, value of fixation questionable
152 pts with displaced fx involving 75% of ulnar styloid
– 76 treated and 76 untreated
• The fracture itself trended to worse outcomes than if there was no fracture
• No differences noted between the treated group and the untreated group
The unsolved questionThe unsolved question• How do you define and test DRUJ stability in
the acute setting?
DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
If DRUJ stable after osseus fixation (distal radius ± ulna):
• Immobilize in stable position for 4-6 weeks– Sugartongue splint– Avoid excessive pronation (DRUJ stable but
associated w loss of forearm motion)
DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
Congruent reduction with an unstable joint, consider:
• Cross pinning– Pin breakage
• TFCC repair• External fixation
Galeazzi Fx DlGaleazzi Fx Dl
• Accurate ORIF first• Same principles for DRUJ as for distal radius Fx
Essex Lopresti injuryEssex Lopresti injury
Failure of the IOM• Acute• Secondary to overload following Radial Head Excision
Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis
• Distal Radioulnar Joint pain and dissociation
• Distraction-compression X-rays
• Intraoperative manual testing
Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis
• MRI
• Ultrasound
• Radial Head Reconstruction- Replacement (Titanium-Vitallium-Allograft)
• DRUJ reduction- pinning in supination
• TFCC repair
Mayhall 1981, Morrey 1981, Gordon 1982
Acute Essex Lopresti injury-TreatmentAcute Essex Lopresti injury-Treatment
Essex Lopresti injury- complicationsEssex Lopresti injury- complications
• Proximal radial migration• Symptomatic DRUJ
subluxation
Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency
• Ulnar shortening • Radial Head Replacement
Results inconsistent
Bowers 1999
Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency
• Attempts at IOM reconstruction
60%
40%
35%
75%250
120mm
BPTB
IOM
FCR
Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti
TFCC management
The unsolved questionThe unsolved question• How do you define and test DRUJ stability in
the acute setting?
Wrist arthroscopy in distal radius FxWrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)
• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)
Arthroscopically assisted reduction Arthroscopically assisted reduction
• Currently indicated in selected injuries– Radial styloid Fx– Die Punch Fx– Three & Four part Fx– DRUJ instability
Especially in young, high demand patients
1. Radial styloid
1. Radial styloid
1. Radial styloid
2. die punch2. die punch
3. Three & Four part fractures3. Three & Four part fractures
3. Three & Four part fractures3. Three & Four part fractures
Palmer ClassificationPalmer Classification• Traumatic (Class 1)
• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome
Central tear
Peripheral tear)
Radial tear
Tear locationTear location
Deep bundle of TFCC
Volar radioulnar lig.
radius
ulna
N.D
1. Central TFCC lesions1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of
articular disc
• Debridement ± pinning
1. Central TFCC lesions1. Central TFCC lesions
• Debridement ± pinning
Darlis & Sotereanos, JHS(A), 2006
1. Central TFCC lesions1. Central TFCC lesions
1. Central TFCC lesions1. Central TFCC lesions
• Often degenerative and associated with ulnocarpal impaction syndrome
• Ulnar recession procedure to prevent symptom recurrence
Arthroscopic Wafer procedureArthroscopic Wafer procedure
• Preferred when modest shortening needed
2. Radial TFCC tears2. Radial TFCC tears• Repair or debridement?
2. Radial TFCC tears2. Radial TFCC tears• Repair if:
– VRUL or DRUL are involved– DRUJ instability
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
• Well vascularized• Repairable
Usual location of peripheral tearsUsual location of peripheral tears
Dorsal
Usual location of peripheral tearsUsual location of peripheral tears
REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
REATTACH TO FOVEA
OR
3. Peripheral (ulnar) TFCC tears
Hook test
REPAIR TO CAPSULE
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REPAIR TO CAPSULE
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
TFCC managementTFCC management
REATTACH TO FOVEA
TFCC
TFCC managementTFCC management
REATTACH TO FOVEA
TFCC
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears
Alternative: Mini open
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
Arthroscopically assisted reduction Arthroscopically assisted reduction
Need for routine TFCC repair unproven
But repair if:• DRUJ unstable• Young active patient
Take Home MessagesTake Home Messages
• Much known about biology and biomechanics of DRUJ
• Little known about treatment outcomes from DRUJ disruption
• Restore osseous anatomy first• Address residual instability with soft tissue
procedures• TFCC has capacity to heal- IOM does not
Take Home MessagesTake Home Messages
• In young active patients tend to:– Fix styloid base fx– Repair TFCC
Whatever you doWhatever you do• Remenber Vit C for disproportionate pain• Reassess ligaments and TFCC status after
fracture healing– Still window of opportunity
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
THANK YOUTHANK YOU
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