Distal radioulnar joint injuries

Abstract

Distal radioulnar joint is a trochoid joint relatively new in evolution. Along with proximal radioulnar joint, forearm bones and interosseous membrane, it allows pronosupination and load transmission across the wrist. Injuries around distal radioulnar joint are not uncommon, and are usually associated with distal radius fractures,fractures of the ulnar styloid and with the eponymous Galeazzi or Essex_Lopresti fractures. The injury can be purely involving the soft tissue especially the triangular fibrocartilage or the radioulnar ligaments. The patients usually present with ulnar sided wrist pain, features of instability, or restriction of rotation. Difficulty in carrying loads in the hand is a major constraint for these patients. Thorough clinical examination to localize point of tenderness and appropriate provocative tests help in diagnosis. Radiology and MRI are extremely useful, while arthroscopy is the gold standard for evaluation. The treatment protocols are continuously evolving and range from conservative, arthroscopic to open surgical methods. Isolated dislocation are uncommon. Basal fractures of the ulnar styloid tend to make the joint unstable and may require operative intervention. Chronic instability requires reconstruction of the stabilizing ligaments to avoid onset of arthritis. Prosthetic replacement in arthritis is gaining acceptance in the management of arthritis.

Keywords: DRUJ arthroplasty; DRUJ injuries; Distal radioulnar joint; TFCC; distal radius fracture.

Figure 1

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

Figure 2

(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

Figure 3

(a) X-ray evaluation of DRUJ. 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 (Scheker-weighted PA view is useful for diagnosis of ulna impingement syndrome following Darrach procedure if there is instability). [Picture courtesy, with permission: Dr Luis Scheker, Christine M Kleinert institute of Hand Surgery and Microsurgery, Louisville, KY, USA]

Figure 4

(a) MRI T2-weighted fat suppression image, showing a radial TFCC tear, fluid seen adjacent to DRUJ. In the sequence of MRI pictures (not shown here), the fluid is seen within the joint, (b) Proton density–weighted MRI, coronal view suggestive of ulnar impaction syndrome. Ulnar styloid process measures 8 mm (normal 2-6 mm), increased ulnar styloid index 0.61 (normal, 0.14–0.28). There is articular cartilage loss with erosion, marrow edema, subchondral cyst, and sclerosis of triquetrum and lunate

Figure 5

Arthroscopic evaluation of TFCC showing (a) Central TFCC tear, (b) Foveal detachment of the TFCC, (c) Reattachment of TFCC, and (d) Degenerative tears of TFCC. [Picture courtesy with permission: Dr Tuna Ozyerukoglu, Christine M Kleinert Institute of Hand and Microsurgery, Louisville, KY, USA.]

Figure 6

X-ray of wrist with distal forearm and hand anteroposterior and lateral views showing (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

Figure 7

(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

Figure 8

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

Figure 9

Diagrammatic representation of Adams–Berger procedure for chronic DRUJ instability. The dorsal and volar radioulnar ligaments are reconstructed with a palmaris longus graft. (Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am. 2002 Mar;27(2):243-51)

Figure 10

(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

Figure 11

Postoperation X-ray of a 48-year-old female patient who underwent Sauve–Kapandji procedure for chronic instability of DRUJ with painful arthrosis

Figure 12 (a-d)

Bowers hemiresection interposition arthroplasty (HITE) for DRUJ arthrosis and minimal impingement, preoperative X-ray, intraoperative images and postoperative X-ray

Figure 13

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

Figure 14 (a-c)

Scheker total DRUJ arthroplasty (APTIS DRUJ prosthesis) for DRUJ arthritis: (continued from Figure 13) 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 (Picture series 13 and 14, courtesy, with permission: Dr. Luis Scheker, Christine M Kleinert institute of Hand Surgery and Microsurgery, Louisville, KY, USA)