DISTAL RADIOULNAR JOINT INJURIES

Presented by Dr Sunil poonia, PGT, Orthopaedics, SMCH

Moderated by Dr S. K. Das, Assoc. Prof of Orthopaedics, SMCH

Binu P Thomas, Raveendran Sreekanth

Dr. Paul Brand Centre for Hand Surgery, CMC Hospital,

Vellore, Tamil Nadu, India

DISTAL RADIOULNAR JOINT (DRUJ)

Part of the complex forearm articulation

Functionally and anatomically integrated with the

ulnocarpal articulation of wrist.

Important joint in pronosupination and load transmission

EVOLUTION OF DRUJ

From the syndesmotic DRUJ of brachiating

primates with limited forearm rotation, three major

changes occurred

(a) development of a distinctly separate DRUJ,

(b) recession of the distal ulna from the ulnar carpus,

(c) development of a distinct ulnocarpal meniscus

the primitive pectoral fin of early fish

the bipedal primate wrist

Current human wrist

Distal radioulnar

joint injuries

Acute injury Chronic

instabilty or arthritis

Isolated injuries

along with fractures

ANATOMY

diarthrodial trochoid synovial joint

two parts

the bony radioulnar articulation and

soft tissue stabilizers.

Transverse section

through the DRUJ

in a cadaver,

showing the

sigmoid notch of

the radius (white

arrow) and the

head of the ulna

along with the

radioulnar

ligaments

THE RADIOULNAR ARTICULATION

ANATOMY

The shape of sigmoid notch is not uniform and has been classified into-

1) flat face,

2) ski slope,

3) C type, and

4) S type

The distal articular surface of the ulna (dome or pole) is mostly covered by articular cartilage.

At the base of the ulnar styloid is a depression called fovea, which is devoid of cartilage.

Differential arc of curvature of ulna and sigmoid notch

In pronation, the ulna translates 2.8 mm dorsally and distally from a neutral position

in supination, the ulna translates 5.4 mm volarly and proximally from a neutral position

TRIANGULAR FIBROCARTILAGINOUS COMPLEX

(TFCC).

also known as as ulnoligamentous complex

It consists of

The triangular fibrocartilage (TFC or articular disk),

Meniscal homologue,

Ulnocarpal [ulnolunate (UL) and lunotriquetral] ligaments,

The dorsal and volar radioulnar ligaments,

Ulnar collateral ligament, and

The extensor carpi ulnaris (ECU) subsheath.

The radioulnar ligaments (dorsal and volar) are the

primary stabilizers of the DRUJ.

TRIANGULAR FIBROCARTILAGINOUS COMPLEX (TFCC).

(a) Diagrammatic

representation of the

TFCC, superimposed on a

dissected specimen,

(b) Diagrammatic

representation of

triangular fibrocartilage

(TFC) inserting into the

fovea (deep layer) and

ulnar styloid (superficial

layer), RUL: Radioulnar

ligament, TFC: triangular

fibrocartilage, UL:

ulnolunate ligament, UT:

Ulnotriquetral ligament,

ECU: extensor carpi

ulnaris in its subsheath,

SP: styloid process of ulna

providing attachment to

these structures-R:

Radius, U: Ulna, S:

scaphoid, L: lunate, T:

triquetrum

CLINICAL EVALUATION

trauma, eg, a fall on the outstretched hand

(FOOSH).

ulnar-sided wrist pain (USWP), especially on

loading the hand and rotating the forearm,

Persistence of USWP and stiffness following distal

radius fractures (DRF)

Clicking sounds

Obvious instability

SPECIAL TESTS

Impingement sign

The ulna fovea sign

The piano-key test

The table top test

The Grind test

Ulnar deviation of the wrist with the forearm in neutral produces ulnar wrist pain and occasional clicking

A painful click may be elicited by having the patient clench and ulnarly deviate the wrist and then repeatedly pronate and supinate the wrist

The ulnar impaction test—wrist hyperextension and ulnar deviation with axial compression—also will elicit pain.

The “press test” is another useful provocative test: the seated patient is asked to push the body weight up off a chair using the affected wrist, creating an axial ulnar load. If this reproduces the patient’s pain, the test is considered positive

With the wrist in pronation, an unstable distal ulna may translate dorsally and can be manually reduced with dorsal thumb pressure (“piano key test”).

Tenderness and pain identified when external pressure is applied to the area of the fovea (fovea sign) is indicative of an ulnocarpal ligament lesion.

TFCC instability also is suggested by excessive motion with the “shuck test”—with the radial aspect of the wrist stabilized, anteroposterior stress is applied to the ulnar side of the wrist

RADIOLOGICAL INVESTIGATIONS

Radiographs

Posteroanterior (PA)

True lateral X-ray

Pronation and supination views

A clenched fist PA view in pronation

Weighted lateral stress view in pronation

X-RAY EVALUATION OF DRUJ

a)True PA views should

show the groove for

ECU radial to the ulnar

styloid (red arrow). True

lateral view should show

the palmar edge of

pisiform (red dotted line)

midway between palmar

borders of distal pole of

scaphoid and capitate

(yellow lines);

(b) Scheker-weighted

lateral view with patient

holding 3 lb weight in the

hand showing dorsal

instability of the distal

ulna. Weighted views

provide loading of the

DRUJ, bringing out

instability, which may not

be visible in routine X-

rays

COMPUTED TOMOGRAPHY

Useful to delineate sigmoid notch fractures and

DRUJ injuries

Ligament injuries can be assessed indirectly by

assessing the radioulnar articulation in various

positions and also by loading views

Three-dimensional (3D) reconstructions are helpful

in assessing spatial relationship between the radius

and ulna

MRI HAS 86% SENSITIVITY FOR DETECTION OF TFCC

TEARS.

a) MRI T2-weighted

fat suppression

image, showing a

radial TFCC tear,

fluid seen adjacent to

DRUJ.

b) Proton density-

weighted MRI,

coronal view

suggestive of ulnar

impaction syndrome.

There is articular

cartilage loss with

erosion, marrow

edema, subchondral

cyst, and sclerosis of

triquetrum and lunate

ARTHROSCOPY IS THE GOLD STANDARD FOR EVALUATION

OF TFCC INJURIES.

(a)Central TFCC

tear,

(b) Foveal

detachment of

the TFCC,

(c) Reattachment of

TFCC, and

(d) Degenerative

tears of TFCC.

INJURIES OF DRUJ AND TFCC- A WORKING

CLASSIFICATION

TRIANGULAR FIBROCARTILAGINOUS COMPLEX

INJURY

“the traumatic TFCC disruption as a continuum of

injury”– Melone

It was classified into five stages of increasing severity

Stage I: detachment of TFC from ulnar styloid,

stage II: ECU subsheath injury,

stage III: ulnocarpal ligament disruption,

stage IV: lunotriquetral ligament injury, and

stage V: midcarpal ligament injury

PALMER’S CLASSIFICATION OF TFCC INJURIES

Currently, management of class 1A TFCC (central perforation)

lesions includes nonoperative measures initially. If significant

symptoms persist, arthroscopic débridement may provide relief

For class 1B lesions (avulsion from the ulna, with or without

ulnar styloid fracture), immobilization for 6 weeks followed

by rehabilitation may be sufficient

If symptoms persist, and if there is DRUJ instability,

arthroscopic repair using either an inside-out or an outside-in

technique may produce satisfactory relief of pain and

improvemen

class 1C lesions (distal avulsion of ulnocarpal ligaments), which

result in a volar ulnar “sag” of the carpus, late open or

arthroscopic repair may relieve symptoms

TREATMENT OF TFCC INJURIES

Non operative

splinting or AE cast

Pharmacological

NSAIDSSteroid

injections

modification of activity

occupational therapy

Operative

arthroscopicOpen

techniques

ISOLATED DRUJ DISLOCATIONS

Uncommon injuries

Dorsal or volar

Simple or complex

The dorsal dislocation is more common

closed manipulation and reduction under anesthesia is

usually successful.

Once the joint is reduced, stability must be verified

ISOLATED DRUJ DISLOCATIONS

Immobilize dorsal dislocations in an above elbow plaster

of Paris (POP) cast in supination, and volar dislocations

in pronation for a period of 6 weeks

If instability persists after reduction, radioulnar pinning is

done in reduced position to allow soft tissue healing

TFCC repair, either open or arthroscopic, needs to be

also considered in case of severe disruptions

Soft tissue interposition can result in irreducibility

DRUJ INJURIES ASSOCIATED WITH FRACTURES AND

FRACTURE-DISLOCATIONS

The most common cause of residual wrist disability after

DRF is the DRUJ involvement

Three basic causes that result in radioulnar pain and

limitation of forearm rotation are

instability,

joint incongruence, and

ulnocarpal abutment

it is found that severely displaced DRF result in disruption of

TFCC in the absence of ulna styloid fractures

USF through the base results in DRUJ instability if the

fragment involves the foveal insertion of the TFCC.

DRUJ INJURIES ASSOCIATED WITH FRACTURES

AND FRACTURE-DISLOCATIONS

Fractures through the sigmoid notch produce stiffness and

late onset arthritis of the DRUJ.

Despite the severity of these injuries, with proper diagnosis

and reduction, most patients will have a satisfactory outcome

Assessment of DRUJ stability following DRF are best done

intraoperatively after fixation of the radius fracture by

translation of the ulna in a dorsopalmar direction

DRUJ INJURIES ASSOCIATED WITH FRACTURES

AND FRACTURE-DISLOCATIONS

Careful assessment of the preoperative X-rays can

indicate a possibility of DRUJ instability

1) shortening of radius >5 mm relative to ulna,

2) fracture of the base of ulnar styloid,

3) widening of the DRUJ interval on PA view,

4) dislocation of the DRUJ on lateral view.

Computed tomography scans subluxation and

fractures of the ligamentous margins of radius and

ulna

DRUJ INJURIES ASSOCIATED WITH FRACTURES

AND FRACTURE-DISLOCATIONS

Fragment-specific fixation is helpful

About 61% of DRF are associated with ulna styloid fractures

No significant relationship between functional outcome and

ulnar styloid fractures (USF), which were not fixed following

stable fixation of distal radius fracture

ULNA STYLOID FRACTURES

may also be seen in isolation

While styloid tip fractures are stable, basal fractures of the styloid are associated with DRUJ instability

Fixation of styloid fracture makes the DRUJ stable, provided the TFCC is not otherwise injured

various fixation techniques

closed pinning,

tension band wiring

compression screw fixation,

suture anchor technique

symptomatic nonunions of styloid?

Comminuted, unstable, or displaced distal ulna neck fractures?

GALEAZZI FRACTURE-DISLOCATION

Palmer Type IB TFCC injury is classically seen

80% of these injuries presented with complete

dislocation of DRUJ

operative fixation of the radius is necessary due to

inherent instability.

When the radius fracture is within 7.5 cm of the distal

radius, DRUJ injury is highly likely

GALEAZZI FRACTURE-DISLOCATION

Stabilize radiusDRUJ reduced

spontaneously check instability

soft tissue interposition

DRUJ is pinned

open reduction

X-RAY OF WRIST WITH DISTAL FOREARM AND HAND

ANTEROPOSTERIOR AND LATERAL VIEWS

(a) Ulnar styloid

with DRUJ

instability

(b) treated by open

reduction and

tension band

fixation. Joint

was stable

following union

of fracture.

(c) Pre- and

postoperative X-

rays of a patient

with fracture of

the ulnar head

(d) treated by

ORIF with

screws

(a)Acute fracture

involving the sigmoid

notch with DRUJ

instability and ulnar

translation of carpus.

(b) Open reduction,

internal fixation (ORIF)

of the fragment and

repair of volar wrist

ligaments

(radioscaphocapitate

ligament) were done.

Galeazzi fracture-

dislocation with ulnar

styloid fracture and

grossly unstable DRUJ

treated by ORIF of

radius and trans fixation

of radius and ulna.

DRUJ was stable

following POP removal

after 6 weeks

THE ESSEX-LOPRESTI INJURY

A hard fall on the outstretched hand can result in a fracture of the radial

head or neck, disruption of the distal radioulnar joint, and tearing of the

interosseous membrane for a considerable distance proximally

if the radial head is resected, rapid proximal migration of the radius can

occur, resulting in wrist pain from ulnar carpal impingement and elbow

pain from radiocapitellar impingement

Pain in the distal radioulnar joint with a displaced fracture of the radial

head or neck should alert the surgeon to the possibility of this injury

combination

MRI and ultrasound evaluation of soft tissue damage of IOM is helpful

Excision of radial head is contraindicated in these injuries.

CLASSIFICATION OF ESSEX-LOPRESTI AND

SUGGESTED MANAGEMENT

CHRONIC DRUJ INSTABILITY

Chronic DRUJ instability can result from fractures of the

distal radius and ulna following inadequate treatment or

malunion

If untreated, these lead to chronic pain and disability due to

stiffness, decreased grip strength, and arthritis

There are reports suggesting that anatomical reduction of

DRF is more critical in avoiding persistent DRUJ issues

rather than associated fixing or union of ulna styloid

fractures.

MANAGEMENT

Management of chronic DRUJ instability depends

primarily on the underlying cause

Correct malunion, length discrepancies first

Soft tissue reconstruction indicated in symptomatic

patients in whom TFCC is irreparable & sigmoid notch

incompetent

Arthritis of DRUJ requires salvage procedures

X-ray anteroposterior and

lateral views

(a) Malunited distal radius

fracture following an old

gunshot injury with gross

deformity and relative

ulnar lengthening, treated

by corrective osteotomy

and bone grafting of

radius using a volar

approach, and volar plate

fixation. Intraoperatively,

a distractor was used to

correct the deformity,

(b) Postoperation follow-

up X-rays showing

deformity correction, the

restitution of DRUJ and

correction of radial

inclination and height

MANAGEMENT

Various soft tissue procedures directed at stabilizing the

DRUJ

1) extrinsic radioulnar tether (Fulkerson & Watson)

2) extensor retinaculum capsulorrhaphy (Herbert sling procedure)

3) ulnocarpal sling (Hui & Linshead)

4) reconstruction of volar and dorsal radioulnar ligaments.

Adams identified three categories of soft tissue reconstruction for

chronic DRUJ instability: (1) distal ulnar tenodesis, with the extensor

carpi ulnaris or flexor carpi ulnaris tendon; (2) ulnocarpal tether; and

(3) radioulnar tether.

Diagrammatic

representation of

Adams-Berger

procedure for

chronic DRUJ

instability. The

dorsal and volar

radioulnar

ligaments are

reconstructed with

a palmaris longus

graft.

ULNAR IMPACTION SYNDROME

Due to repetitive loading of the ulnocarpal joint, especially in

the presence of ulna plus variance, degenerative changes

occur in the TFC,ulnar head, lunate and triquetral surface,

lunotriquetral articulation and is referred to as ulnar

impaction or ulnocarpal abutment syndrome

progressive wear of TFCC perforation ulnocarpal

arthritis

the most common cause acquired ulna plus variance and

dorsal tilt caused by malunited distal radius fracture

ulna impingement

syndrome??

ULNAR IMPACTION SYNDROME

Typical clinical features are ulnar-sided wrist pain,

especially on loading and rotation movement

Investigations

The PA view demonstrates the ulna plus.

MRI is useful for observing changes in the lunate and

triquetrum

Arthroscopy demonstrates the classical stages described by

Palmer.

TREATMENT

Splinting

NSAIDs

Modification of

activities

wafer resection of the

distal ulna as described

by Feldon

ulna shortening

osteotomy

conservative Surgical

Author prefers an ulna shortening osteotomy

and compression plate fixation

(a) X-ray, and computed

tomography

reconstruction showing

the impingement to the

lunate and triquetrum

ulnar impaction syndrome

secondary to long-

standing malunited distal

radius fracture presenting

as USWP with painful

supination/pronation on

loading the wrist, a

positive impingement

sign.

(b) X-ray posteroanterior

and lateral views showing

Ulna was shortened by

cuff resection and

compression plating with

relief of pain and

improved movement

DRUJ ARTHRITIS

Causes

DRF through the sigmoid notch or the distal ulna

Malunions

chronic instability of DRUJ

failed reconstruction of the DRUJ

Various options are available

Resection of distal ulna (Darrach procedure)

Sauve-Kapandji procedure

Hemiresection-interposition arthroplasty

DRUJ implant arthroplasty

DARRACH PROCEDURE

removes the distal articular surface of

the ulna

useful in the elderly and in patients with

limited activity

FCU or ECU tendon slings have been

fashioned to attach to the distal ulna to

address the ulna instability

Complications

ulna impingement syndrome

loss of grip strength

possible ulnar translation of carpus

SAUVE-KAPANDJI PROCEDURE

Originally described in 1936

DRUJ arthrodesis + surgical pseudarthrosisof the distal ulna

Prefered procedure in young active adults

painful instability of the proximal ulna stump can be a problem

HEMIRESECTION-INTERPOSITION

ARTHROPLASTY-BOWER

partial resection of the articular surface of ulna

interposing a capsular flap

Ulnocarpal impaction is a relative contraindication

Preferred for DRUJ arthrosis with mild degree of ulna plus variance

DRUJ IMPLANT ARTHROPLASTY

Indications

primary DRUJ arthrosis

failed DRUJ surgery

Prosthesis commonly used

Swanson and Herbert prosthesis for distal ulna replacement.

Scheker’s semiconstrained modular implant for total

replacement of the DRUJ (APTIS DRUJ prosthesis)

Though long term results are still awaited, the implant

shows great promise

SCHEKER TOTAL DRUJ ARTHROPLASTY (APTIS DRUJ

PROSTHESIS) FOR DRUJ ARTHRITIS

(a) Peroperative

photograph

showing incision

mark.

(b) X-rays lateral

and posteroanterior

views showing

degenerative

changes in the

DRUJ.

(c) Peroperative

photograph

showing ulnar head

devoid of cartilage

with sigmoid notch

osteophytes

SCHEKER TOTAL DRUJ ARTHROPLASTY (APTIS DRUJ

PROSTHESIS) FOR DRUJ ARTHRITIS

Ulnar head was

excised and DRUJ

replacement with

APTIS size 20

radial plate

assembly and a 4.0

mm diameter 1-cm

ulnar stem. The

patient had

excellent recovery

with full range of

motion and is able

to lift weight without

any pain. She

returned to her

regular occupation

CONCLUSION

The DRUJ injuries presents as ulna sided wrist pain

resulting most commonly from traumatic episodes

Clinical examination provide information regarding

the anatomical structures injured

Arthroscopy is considered the gold standard in

diagnosis

Treatment include splinting, ORIF of fractures and

repair of torn ligaments and TFCC by arthroscopy

or open methods

DRUJ arthroplasty is emerging as a treatment in

cases of arthrosis of the joint.

CARPAL LIGAMENT INJURIES AND INSTABILITY PATTERNS

Linscheid et al. grouped carpal instabilities into four types:

(1) dorsiflexion instability

(2) palmar-flexion instability

(3) ulnar translocation

(4) dorsal subluxation

Instability in the carpus has been considered to be static if

the radiographic intercarpal relationships do not change with

motion and dynamic if the intercarpal relationships change

with manipulation and motion

Radiographic evaluation of the proximal carpal row in the lateral projection in which the radius, lunate, capitate, and third metacarpal should have collinear axes within an approximately 15-degree tolerance.

On this projection, the wrist-collapse patterns include (1) patterns in which the distal articular surface of the lunate is tilted to face dorsally, known as dorsal intercalated segment instability (2) patterns in which the distal articular surface of the lunate faces toward the palm, known as volar intercalated segment instability.

Linscheid et al. advocated the concept of dissociative and nondissociative instabilities in the wrist. Dissociative carpal instabilities are those in which there is disruption of the intrinsic interosseous ligaments between the bones of the proximal carpal row. Nondissociative instabilities are those in which the extrinsic radiocarpal ligaments may be disrupted, with intact intrinsic ligaments between the carpal bones.

PROGRESSIVE PERILUNAR INSTABILITY Mayfield, Johnson, and Kilcoyne described four stages of

progressive disruption of ligament attachments and anatomical relationships to the lunate resulting from forced wrist hyperextension

Stage I represents scapholunate failure;

stage II, capitolunate failure

III, triquetrolunate failure

IV, dorsal radiocarpal ligament failure, allowing lunate

dislocation

ROTARY SUBLUXATION OF THE SCAPHOID Injuries to the dorsal and volar portions of the scapholunate

interosseous ligament, the long radiolunate ligament, and the radioscaphocapitate ligament allow the proximal pole of the scaphoid to rotate dorsally. The scaphoid assumes a more vertical orientation, and eventually the scaphoid separates from the lunate .

Watson and Black observed that rotary subluxation of the scaphoid may manifest in four types: (1) dynamic, (2) static, (3) with degenerative arthritis, and (4) secondary to a condition such as Kienböck osteochondrosis.

a fall on the extended wrist is the usual cause.

On examination, pain and tenderness are present along the dorsal radiocarpal articulation at the scapholunate area.

Edema may be present with limitation of motion, particularly in flexion.

The following maneuvers are considered to be helpful in evaluating rotary instability of the scaphoid

“scaphoid test,” in which the examiner places four fingers on the dorsum of the radius with the thumb on the scaphoid tuberosity, using the right hand for the right wrist and the left hand for the left wrist. Ulnar deviation of the wrist aligns the scaphoid with the long axis of the forearm. Applying thumb pressure to the scaphoid tuberosity, the wrist is returned to radial deviation, maintaining the thumb pressure on the scaphoid tuberosity. If the scaphoid is sufficiently unstable, the proximal pole is driven dorsally, and pain results

As the wrist under load progresses from radial deviation to ulnar deviation, the scaphoid normally moves smoothly into extension, aligning with the forearm axis. If scaphoid rotary subluxation is present, the lunate remains in a volar-flexed and dorsal position until sufficient pressure is applied, so that it suddenly shifts from the volar-flexed position and “catches up” with the scaphoid with a “clunking” sensation

the diagnosis of static rotary subluxation of the scaphoid can be made on an anteroposterior radiographic view when a gap of more than 2 mm is noted between the scaphoid and the lunate bones. This gap is seen to increase with an anteroposterior view taken with the fist clenched. Other findings on the anteroposterior view include apparent shortening of the scaphoid and the so-called cortical ring appearance of the axial projection of the scaphoid.

MANAGEMENT

Closed treatment of acute rotary subluxation of the scaphoid consists of attempting reduction by placing the wrist in neutral flexion and a few degrees of ulnar deviation.

Percutaneous pinning can be done with one 0.045-inch (1.16-mm) Kirschner wire placed through the scaphoid into the capitate and a second placed through the scaphoid into the lunate.

If closed reduction is unsuccessful, arthroscopic reduction and percutaneous pin fixation can be attempted

open reduction through a dorsal approach with closure of the scapholunate gap, Kirschner wire internal fixation of the lunate to the scaphoid, and ligament repair usually are indicated.

Management of an old rotary subluxation of the scaphoid may require reconstruction of the scapholunate interosseous ligament with a segment of the extensor carpi radialis brevis tendon plus Kirschner wire fixation

ANTERIOR DISLOCATION OF THE LUNATE

The most common carpal dislocation is anterior dislocation of the lunate

On a lateral radiographic view of the normal wrist, the half-moon–shaped profile of the lunate articulates with the cup of the distal radius proximally and with the rounded proximal capitate distally

AP view, the normal rectangular profile of the lunate when dislocated becomes triangular because of its tilt.

An anteriorly dislocated lunate can cause acute compression of the median nerve

When the injury is treated early, manipulative reduction usually is possible and immobilization for 3 weeks with the wrist in slight flexion is required.

When treated after 3 weeks, the injury can be difficult to reduce by manipulation, and open reduction may be necessary. A dorsal approach has been recommended

TREATMENT OPTIONS FOR WRIST LIGAMENT

INJURIES AND INSTABILITY

For acute injuries, options include closed or arthroscopically

controlled manipulation and percutaneous pinning

If closed methods are unsuccessful, open repair or

reconstruction of ligaments may be required

For late diagnosed problem – limited arthrodesis

Dorsal capsulodesis can be added to limit scaphoid flexion

Excision arthroplasty – proximal raw carpectomy