Distal Radioulnar Joint Subluxation Research Articles

The Natural History of Non-operatively Treated Traumatic Triangular Fibrocartilage Complex Tears: A Systematic Review

Abstract Purpose Operative treatment of triangular fibrocartilage complex (TFCC) tears has been well researched; however, data regarding nonoperative management is mixed and scarce. Our review aimed to utilize available data to formulate conclusions regarding treatment algorithms for this heterogeneous injury group. Methods A thorough literature review was performed in Medline (OVID), Embase, Cochrane Library, and PubMed databases with search terms including “triangular fibrocartilage complex” and variations on the full term including “triangular fibrocartilage” or “TFCC,” alongside “non-operative” and “conservative.” Results were then subject to inclusion criteria, ultimately identifying eight studies. Results The studies involved a total of 425 patients and 427 wrists for analysis. The mean age ranged from 30.7 years to 60.4 years. 53.6% of patients were male. The mean follow-up ranged from 12 months to 7 years, with an overall mean follow-up period of 27 months. Primary endpoints focused on various functional outcome scores, range of motion, grip strength, and pain. The nonoperative management of TFCC tears resulted in noninferior and comparable outcomes to operative management. Conclusion Our review identified that the nonoperative management of Palmer-type IB tears with a short period of above-elbow immobilization was an effective treatment option with good functional outcome scores. The nonoperative management of general TFCC tears resulted in comparable functional outcomes when viewed alongside results from other systematic reviews. Risk factors for developing a poor functional outcome or requiring operative management included distal radioulnar joint subluxation, short-arm immobilization, and full tears of the foveal attachment. However, further randomized controlled trials with homogenous data collection are required to make further conclusions regarding the management of this condition.

Displaced sigmoid notch fracture and higher patient age are associated with distal radioulnar joint subluxation.

Distal radius fractures (DRFs) are frequently associated with distal radioulnar joint (DRUJ) instability. The purpose of this study is to evaluate the effect of the sigmoid notch and ulna styloid fracture types on DRUJ subluxation following closed reduction and casting of DRFs via calculating radioulnar ratio (RUR) on postreduction computed tomography (CT) images. In our study, postreduction CT images of 202 patients with distal radius fractures were evaluated retrospectively. CT images were evaluated for RUR, sigmoid notch fracture, and ulna styloid types. Sigmoid notch fractures were classified as nondisplaced in the sigmoid notch fractures (NDS) and displaced sigmoid notch (DS) fractures; ulna styloid fractures were grouped as the proximal half ulna styloid (PHUS) and distal half ulna styloid (DHUS) fractures. The mean age of Rozental type 3b (62.8 years) was significantly higher among others. The mean RUR value was significantly higher in Rozental type 3a in compared to type 1a and type 2 fractures. PHUS fractures were more common with DS fractures than DHUS fractures. DS fractures and higher patient age are associated with DRUJ subluxation on postreduction CT images following DRFs. DS fractures are seen more commonly with PHUS fractures than DHUS. Patients with PHUS should be carefully assessed for sigmoid notch fractures and DRUJ congruency. These findings could be helpful for preoperative decision making in the treatment of DRFs.

Styloid Ulna Window Approach for Repair of Avulsed Foveal Attachment of Triangular Fibrocartilage Complex

To describe a surgical approach for open repair of the triangular fibrocartilage complex foveal avulsion via ulnar styloid osteotomy, and to assess its clinical results. We reviewed 12 patients with distal radioulnar joint (DRUJ) instability due to isolated foveal avulsion of DRUJ ligaments. Wrist arthroscopy was conducted for all patients to exclude the presence of concomitant tear of the superficial part of the triangular fibrocartilage complex and to corroborate the diagnosis with a positive hook test. Through an ulnar approach between flexor and extensor carpi ulnaris, an ulnar styloid osteotomy was performed under image intensifier control just ulnar to the fovea of the head of the ulna. The avulsed foveal attachment was anchored through transosseous sutures passing from the fovea to the neck of the ulna. The ulnar styloid was fixed by means of screws or tension band wires. Outcome measures included clinical assessment of pain (visual analog scale), grip strength, DRUJ instability, range of motion of the wrist, and modified Mayo wrist score. Radiographic assessment was done to determine union of the ulnar styloid osteotomy, DRUJ subluxation, and any hardware-related problems. Outcome measures were evaluated after a mean follow-up of 21 months. Healing of the osteotomy was obtained in all cases by 11 weeks. The DRUJ laxity, visual analog scale, and modified Mayo wrist score improved, while grip strength and range of motion remained unchanged. One patient had prominent hardware necessitating removal after union of the osteotomy. There were no reported cases of injury or neuropraxia of the dorsal cutaneous branch of the ulnar nerve. Open repair of an avulsed foveal attachment of the triangular fibrocartilage complex using an ulnar styloid osteotomy is an alternative to either open or arthroscopic repair approaches. Therapeutic IV.

Predictors for poor outcome for conservatively treated traumatic triangular fibrocartilage complex tears.

The primary aim of this study was to assess if traumatic triangular fibrocartilage complex (TFCC) tears can be treated successfully with immobilization alone. Our secondary aims were to identify clinical factors that may predict a poor prognosis. This was a retrospective analysis of 89 wrists in 88 patients between January 2015 and January 2019. All patients were managed conservatively initially with either a short-arm or above-elbow custom-moulded thermoplastic splint for six weeks. Outcome measures recorded included a visual analogue scale for pain, Patient-Rated Wrist Evaluation, Disabilities of the Arm, Shoulder and Hand score, and the modified Mayo Wrist Score (MMWS). Patients were considered to have had a poor outcome if their final MMWS was less than 80 points, or if they required eventual surgical intervention. Univariate and logistic regression analyses were used to identify independent predictors for a poor outcome. In total, 76% of wrists (42/55) treated with an above-elbow splint had a good outcome, compared to only 29% (10/34) with a short-arm splint (p < 0.001). The presence of a complete foveal TFCC tear (p = 0.009) and a dorsally subluxated distal radioulnar joint (DRUJ) (p = 0.032) were significantly associated with a poor outcome on univariate analysis. Sex, age, energy of injury, hand dominance, manual occupation, ulnar variance, and a delay in initial treatment demonstrated no significant association. Multiple logistic regression revealed that short-arm immobilization (p < 0.001) and DRUJ subluxation (p = 0.020) were significant independent predictive factors of an eventual poor outcome. Nonoperative management of traumatic TFCC injuries with above-elbow immobilization is a viable treatment method, particularly in patients without DRUJ subluxation. Early surgery should be considered for patients with dorsal ulnar subluxation treated with short-arm splints to prevent prolonged morbidity. Cite this article: Bone Joint J2021;103-B(8):1386-1391.

Hemiresection Interposition Arthroplasty of the Distal Radioulnar Joint: A Long-term Outcome Study.

Background: The aim of this study was to assess factors associated with long-term patient-reported functional, pain, and satisfaction scores in patients who underwent (Bowers) hemiresection interposition technique (HIT) arthroplasty of the distal radioulnar joint (DRUJ). The secondary aims were to determine the complication and reoperation rates. Methods: A retrospective study with long-term follow-up of patients undergoing HIT arthroplasty was performed. Demographic, disease, and treatment characteristics were collected for the 66 included patients. Thirty-one patients completed all surveys, which were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), our custom-made HIT arthroplasty questionnaire, Numeric Rating Scale (NRS) for pain, and NRS for satisfaction. The mean interval between surgery and follow-up by means of questionnaires was 8.6 ± 3.4 years. Results: The mean QuickDASH score was 31.0 ± 20.2. The mean score of the HIT arthroplasty questionnaire was 2 ± 2. The median NRS for pain was 1 (interquartile range [IQR], 0-3), and the median NRS for satisfaction was 9 (IQR, 8-10). The complication rate and reoperation rate were 14% and 8%, respectively. Conclusion: Overall, patients expressed satisfaction with HIT arthroplasty, despite a mean QuickDASH score of 31.0. In our cohort, patients with inflammatory arthritis had higher satisfaction and lower pain scores. Patients who had prior trauma, prior surgery, or DRUJ subluxation are generally less satisfied. Men, older patients, and posttraumatic patients had higher long-term pain scores; however, posterior interosseous nerve neurectomy is associated with improved pain scores. Our findings support the use of HIT arthroplasty in patients with inflammatory arthritis.

Impact of Distal Ulnar Fracture Malunion on Distal Radioulnar Joint Instability: A Biomechanical Study of the Distal Interosseous Membrane Using a Cadaver Model

Certain distal ulna fractures may contribute to distal radioulnar joint (DRUJ) instability. We hypothesized that residual distal ulna translation could affect DRUJ stability by slackening the distal interosseous membrane (DIOM). We aimed to test this hypothesis in a cadaver model. We created an ulnar translated distal ulna fracture model in 6 cadavers. Dorsal and palmar displacements of the ulna relative to the radius were measured and DRUJ instability was staged under the following conditions: (1) 0-, 2-, and 4-mm ulnar translation of the distal ulna with an intact triangular fibrocartilage complex (TFCC) and DIOM; (2) 0-, 2-, and 4-mm translations with TFCC divided and an intact DIOM; and (3) a 0-mm translation with TFCC and DIOM divided. With an intact TFCC, dorsal and palmar displacements were not increased with any amount of distal ulna translation. After TFCC division with 0-mm translation, dorsal displacement increased significantly with DRUJ dislocation, whereas palmar displacement increased to a lesser extent with DRUJ subluxation. Palmar displacement gradually increased as the translation increased, and with 4-mm translation the ulnar head displaced to a perched position off the sigmoid notch. With TFCC and DIOM division, displacements increased markedly with DRUJ dislocation both dorsally and palmarly. Dorsal dislocation occurred when the TFCC was divided regardless of the amount of distal ulna translation. Palmar subluxation occurred when the TFCC alone was divided. Palmar displacement to a perched position occurred because of slackening of the DIOM as a result of translation of the distal ulna. Bidirectional DRUJ instability with dorsal dislocation and palmar displacement to a perched position occurred when the TFCC was divided and the distal ulna was ulnarly translated. Bidirectional DRUJ instability might occur when distal ulna translation deformity is associated with TFCC injury because the DIOM loses its function as a secondary stabilizer.

Ulnar head fracture malunion with distal radioulnar joint subluxation: A case report and literature review

The distal radioulnar joint (DRUJ) is a very important component of normal forearm rotation. Any bony incongruence of the DRUJ could result in the blockade of forearm rotation. Meanwhile, isolated ulnar head fracture is a rare condition among all reported wrist injuries. In this report, we present a case featuring the blockade of forearm rotation as a result of neglected ulnar head fracture and malunion. Satisfactory results with restored forearm rotation are achieved after performing ulnar head corrective osteotomy.

Outcome of Distal Radioulnar Joint in Galeazzi Lesions

Objective: To evaluate clinical, radiological, and tomographic long-term evolution of the distal radioulnar joint in Galeazzi lesions treated with open reduction and internal fixation of the radius component and indirect reduction of distal radioulnar joint dislocation. Material and Methods: We retrospectively evaluated patients with Galeazzi lesions; the inclusion criteria were patients older than 18 years, treated with open reduction, and internal fixation of radial fracture and nonsurgical reduction of distal radioulnar joint dislocation, with postoperative immobilization in slight supination for 3 weeks. All cases with open reduction of the distal radioulnar joint and follow-up of less than 6 years were excluded. We evaluated pain using the visual analogue scale and Swanson scale; function was assessed by Disabilities of the Arm, Shoulder and Hand (DASH) score. Wrist range of motion—flexion-extension, lateral deviation, and pronosupination—was measured bilaterally with a manual goniometer. Bilateral grip strength was recorded with a Jamar Dynamometer. Distal radioulnar piano key sign was tested bilaterally with the wrist in neutral rotation, maximum pronation, and maximum supination to evaluate joint stability. Bilateral true anterior-posterior (AP) and lateral x-rays were taken at final follow-up; ulnar dorsal subluxation was measured with respect to the radial axis on lateral x-rays. Radial shortening was measured by taking the ulnar variance on AP x-rays. Distal radioulnar joint arthritis signs were classified following Knirk and Jupiter scale. Computed tomography (CT) scans of both wrists were taken in 3 positions—neutral rotation, supination, and pronation. On the axial slices, distal radioulnar joint subluxation was evaluated using the Mino and radioulnar ratio methods. Arthritis signs in the distal radioulnar joint were also recorded. Results: Fourteen patients met the inclusion criteria; average follow-up was 11.5 years (6-18 years). Twelve were male and the mean age at the time of lesion was 38 years (18-59). The final evaluation revealed 9 patients without pain, 3 had pain with heavy tasks, and 2 with moderate efforts. Final pain intensity according to the visual analogue scale was on average 0.3 (0-3). Average DASH was 3 (0-9). Wrist flexion-extension was 98%, lateral deviation 95%, and pronosupination 97%; grip strength was 77%, and 3 patients had piano key sign positive for instability, but none produced pain. All these measurements were recorded comparative to the contralateral wrist. Final lateral x-rays showed one patient with dorsal radioulnar subluxation. However, CT scans showed no cases of distal radioulnar joint subluxation. The average final ulnar variance was 0 mm on the injured side and −0.5 mm on the contralateral wrist. Six patients had radiologic arthritis grade II and 2 had grade I. The remaining 6 patients had no signs of arthritis either in x-rays or CT scans. Conclusions: Clinical and radiological long-term results showed a stable distal radioulnar joint. Even when almost half of the patients had arthritic changes in the distal radioulnar joint on the lesion side, they had no significant clinical repercussions, giving a painless joint with an excellent range of motion.

Intra-articular Fractures of the Sigmoid Notch of the Distal Radius: Analysis of Progression to Distal Radial Ulnar Joint Arthritis and Impact on Upper Extremity Function in Surgically Treated Fractures.

Background Studies have established an increased risk of radiocarpal joint posttraumatic arthritis in patients with displaced intra-articular fractures of the distal radius, although this phenomenon has yet to be evaluated in the distal radioulnar joint (DRUJ). Purpose We hypothesized that patients with displaced intra-articular fractures of the sigmoid notch would have a higher prevalence of DRUJ arthritis and greater upper extremity dysfunction after operative treatment of distal radius fractures compared with fractures without sigmoid notch involvement. We also hypothesized that the degree of sigmoid notch incongruity would be correlated with the grade of DRUJ arthritis and the severity of upper extremity dysfunction. Patients and Methods A retrospective review was conducted on surgically treated patients with distal radius fractures with pre- and/or postoperative computed tomography (CT) scans. Patients were divided into groups based on presence or absence of fracture extension into the sigmoid notch. Within the sigmoid notch group, postoperative CT scans were used to measure sigmoid notch fracture step-off and diastasis (mm), as well as volar or dorsal DRUJ subluxation (%). Patients were administered Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires and radiographs were obtained to grade DRUJ arthritis using the Kellgren-Lawrence (KL) radiographic criteria. Results Thirty-three patients were included (19 with sigmoid notch involvement and 14 without) with an average radiographic follow-up of 6.3 years (range: 3.5-10.1 years). DASH scores were available for all patients, and radiographic follow-up was available in 24 patients (73%). A trend toward higher grade of DRUJ arthritis and poorer average DASH was found in those with sigmoid notch involvement, but was not statistically different. In the sigmoid notch group there were poorer DASH scores in patients with coronal step-off > 1.0-mm (p < 0.05). There were no significant correlations between sigmoid notch step-off, diastasis or DRUJ subluxation and either KL grade of arthritis or DASH scores. Conclusion Fractures involving the sigmoid notch did not appear to have a greater prevalence of DRUJ posttraumatic arthritis in operatively treated patients at greater than 6 years of follow-up. Postoperative sigmoid notch step-off, diastasis or DRUJ subluxation had a minimal effect on upper extremity function, but fractures with a coronal step-off of > 1.0-mm exhibited higher levels of upper extremity dysfunction. Level of Evidence Prognostic, Level III-Case control.

A Case Report of Isolated Fracture-Dislocation of the Radial Head with Distal Radioulnar Joint Subluxation

A Case Report of Isolated Fracture-Dislocation of the Radial Head with Distal Radioulnar Joint Subluxation

Arthroscopy for Galeazzi fractures, a way to demonstrate TFCC damage in extra-articular radius fracture: A series of 7 cases

Galeazzi fracture is a trauma associating diaphysal radius fracture and dislocation or subluxation of the distal radio-ulnar joint (DRUJ). Despite an anatomic reduction of the radius, DRUJ impairment, especially injury of triangular fibrocartilage complex (TFCC) may lead to partial instability with secondary pain and stiffness. This prospective case series proposes to perform wrist arthroscopy for Galeazzi fractures in order to diagnose ligamentous injuries and to enable their reparations. Over a period of 18 months, 7 recent Galeazzi closed fractures were operated on with wrist arthroscopy. We used a locking compression plate, a 1.9 mm arthroscope with 3 radio-carpal portals: 3-4, 4-5 and 6U. A dorsal forearm splint was kept for 3 weeks followed by an active/passive physiotherapy. Physical examination and X-ray were performed after 3, 6 and 12 weeks. Analysis criteria were: – perioperative: ligament impairment, duration of surgery; – postoperative: pain, wrist motion (flexion/extension; prono/suppination), grasp strength, time off work and sports, X-ray analysis (reduction, consolidation, secondary displacement). All patients were reviewed 3 times. The triangular ligament was injured in all cases, 3 cases in the radial part, 3 cases in the ulnar part and one both side. All ulnar injuries were repaired systematically. The radial TFCC injuries were only repaired when DRUJ instability persisted despite good reduction of the radius. After osteosynthesis of the radius, DRUJ remained instable in 3 cases, one ulnar lesion, one radial and one both side. The reparation of the triangular ligament improved stability of the DRUJ in 2 cases, one case remained instable despite TFCC reparation. About strength and mobility: – after 3 weeks: F/E: 50/60°, P/S 45°/45°, grasp 20%; – after 6 weeks: F/E: 80/80°, P/S 70°/60°, grasp 45%; – after 12 weeks: F/E: 85/80°, P/S 80°/75°, grasp 80%. We noticed 7 anatomic radius reductions and no secondary displacement. A dorsal DRUJ subluxation was noticed despite the ulnar TFCC repair; none nonunion was reported. Time off work was 7 weeks (4–10). Functional mobility was regained after 6 weeks, accompanied by good strength. TFCC reparation participate in DRUJ stabilization but was not always sufficient to fully stabilize the DRUJ. A next study with DRUJ MRI and prono-supination strength measurement should participate to demonstrate further benefits of TFCC reparation in Galeazzi fractures. A lesion of the TFCC was noticed in all cases suggesting that TFCC lesion could occur in some other extra-articular distal radius fractures.

New perspectives on treatment of both bone forearm malunions

Diaphyseal fractures of the forearm can present challenges not encountered with other fractures in the body. This is due to the complex relationship between the radius and ulna. The complexity increases when both the radius and ulna are fractured. Restoration of the length, radial bow, rotational alignment, and relationship of the two bones are essential for optimizing forearm rotation, strength, and pain-free function of the entire upper extremity. Often, unsatisfactory results are obtained after fixation of forearm fractures. This is because of malunion of either bone in the forearm in any plane or heterotopic ossification. As the severity of the malunion increases, the risk of distal radioulnar joint subluxation or radial head dislocation becomes a concern. Traditional approaches to reconstruction of forearm malunions have used radiographs or CT scans, with attempts intraoperatively to recreate normal anatomy. While previous studies have demonstrated improvement in motion after traditional osteotomies, recent advances in three dimensional (3-D) imaging, and additive manufacturing (also known as 3-D printing) have shown promise in simplifying reconstructions of these deformities. A review of recent articles on 3-D modeling is included in this paper as well as a case example from the author and instructions on how to use this new technology.

Traumatic Separation of the Distal Ulnar Physis in Children

To propose a new fracture classification according to the direction of epiphysis displacement and to compare clinical findings and surgical outcomes between these subtypes. Retrospective study. A tertiary referral hospital. Twelve adolescents (mean age, 13.4 ± 1.3 years) who experienced separation of the distal ulnar physis were identified from the pediatric trauma database. Closed reduction was attempted for all injuries. If a satisfactory alignment could not be achieved, an open reduction was performed. The clinical outcome was evaluated with Mikic's criteria (union, alignment, length, distal radioulnar joint subluxation, limitations of elbow/wrist function, and degree of supination/pronation). The impacts of fracture patterns and locations of wrist abrasions on treatment decisions and clinical outcomes were tested with Fisher exact tests (unadjusted) and logistic regression analyses (adjusted for age and gender) with the bootstrap method. Five orthopedic surgeons used the new classification, and the reproducibility was tested with multirater kappa. The injury patterns included 6 dorsally-tilted distal ulnas (type 1) and 6 volarly-tilted distal ulnas [type 2-A (n = 1), type 2-B (n = 3), and type 2-C (n = 2)]. All type 1 fractures were successfully treated with closed reduction. Five of 6 cases with type 2 injuries failed closed reduction because of entrapment of the extensor carpi ulnaris tendon in the fracture site. Eleven of the patients' outcomes were excellent. One patient with a type 2-C injury experienced ulnar growth arrest. The multirater kappa for the new classification equals to 0.94, and P < 0.001. A majority of volar-flexion injuries require surgery to reduce the entrapped soft tissue. This new classification is easy to understand with a good interrater reproducibility. It is useful in identifying the injury mechanism and correlated with the likelihood of open reduction. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Real-time magnetic resonance imaging (MRI) during active wrist motion--initial observations.

BackgroundNon-invasive imaging techniques such as magnetic resonance imaging (MRI) provide the ability to evaluate the complex anatomy of bone and soft tissues of the wrist without the use of ionizing radiation. Dynamic instability of wrist – occurring during joint motion – is a complex condition that has assumed increased importance in musculoskeletal medicine. The objective of this study was to develop an MRI protocol for evaluating the wrist during continuous active motion, to show that dynamic imaging of the wrist is realizable, and to demonstrate that the resulting anatomical images enable the measurement of metrics commonly evaluated for dynamic wrist instability.MethodsA 3-Tesla “active-MRI” protocol was developed using a bSSFP sequence with 475 ms temporal resolution for continuous imaging of the moving wrist. Fifteen wrists of 10 asymptomatic volunteers were scanned during active supination/pronation, radial/ulnar deviation, “clenched-fist”, and volarflexion/dorsiflexion maneuvers. Two physicians evaluated distal radioulnar joint (DRUJ) congruity, extensor carpi ulnaris (ECU) tendon translation, the scapholunate (SL) interval, and the SL, radiolunate (RL) and capitolunate (CL) angles from the resulting images.ResultsThe mean DRUJ subluxation ratio was 0.04 in supination, 0.10 in neutral, and 0.14 in pronation. The ECU tendon was subluxated or translated out of its groove in 3 wrists in pronation, 9 wrists in neutral, and 11 wrists in supination. The mean SL interval was 1.43 mm for neutral, ulnar deviation, radial deviation positions, and increased to 1.64 mm during the clenched-fist maneuver. Measurement of SL, RL and CL angles in neutral and dorsiflexion was also accomplished.ConclusionThis study demonstrates the initial performance of active-MRI, which may be useful in the investigation of dynamic wrist instability in vivo.

Delayed distal radio-ulnar joint instability after Galeazzi type fracture fixation in a child.

We report a rare case of delayed distal radio-ulnar joint instability with malunion of a Galeazzi-type radius fracture in a 10- year-old boy. He underwent operative intervention with flexible intramedullary nailing of the radius. He had careful clinical and intra-operative evaluation under image intensifier, and regular clinical and radiological assessments subsequently in clinic, and his distal radio-ulnar joint (DRUJ) was stable. He nonetheless developed DRUJ instability with malunion of radial midshaft fracture at 4 months. Corrective osteotomy for forearm fracture malunion is an uncommon procedure in children. He underwent a corrective radial osteotomy at the site of malunion, held with a Pennig external fixator, with reconstruction of the DRUJ subluxation. He made a good recovery with full restoration of wrist and forearm function, which was maintained at 17 months.

Diagnosis of distal radioulnar joint subluxation in patients with rheumatoid wrist by computed tomography

Subluxation of the distal radioulnar joint (DRUJ) is associated with extensor tendon rupture in patients with rheumatoid arthritis (RA). However, it remains difficult to quantitatively evaluate DRUJ subluxation in RA wrist. We devised a new method for assessing DRUJ subluxation. This study investigated whether the new method, known as the RA subluxation ratio (RASR), or a conventional method was superior for detecting extensor tendon rupture in the RA wrist. Thirty-five RA wrists and 10 wrists of healthy volunteers were scanned using computed tomography. The RA wrists were divided into a tendon rupture group and a nonrupture group. The dorsal surface of the distal radius from Lister's tubercle to the ulnar aspect of the distal radius maintains a planar surface in the RA wrist. Therefore, we defined the RASR as the extent of dorsal subluxation of the ulna relative to this plane. We quantified subluxation of the DRUJ by using the RASR or the modified radioulnar line method, and compared the two methods. The RASR was 0.440 in the rupture group, 0.333 in the nonrupture group, and 0.106 in the healthy volunteers. The RASR was significantly higher than the modified radioulnar line method in the sensitivity of diagnosing tendon rupture.

Diagnosis of distal radioulnar joint subluxation in patients with rheumatoid wrist by computed tomography

Subluxation of the distal radioulnar joint (DRUJ) is associated with extensor tendon rupture in patients with rheumatoid arthritis (RA). However, it remains difficult to quantitatively evaluate DRUJ subluxation in RA wrist. We devised a new method for assessing DRUJ subluxation. This study investigated whether the new method, known as the RA subluxation ratio (RASR), or a conventional method was superior for detecting extensor tendon rupture in the RA wrist. Thirty-five RA wrists and 10 wrists of healthy volunteers were scanned using computed tomography. The RA wrists were divided into a tendon rupture group and a nonrupture group. The dorsal surface of the distal radius from Lister's tubercle to the ulnar aspect of the distal radius maintains a planar surface in the RA wrist. Therefore, we defined the RASR as the extent of dorsal subluxation of the ulna relative to this plane. We quantified subluxation of the DRUJ by using the RASR or the modified radioulnar line method, and compared the two methods. The RASR was 0.440 in the rupture group, 0.333 in the nonrupture group, and 0.106 in the healthy volunteers. The RASR was significantly higher than the modified radioulnar line method in the sensitivity of diagnosing tendon rupture.

Chronic Wrist Pain - Rock Climbing

HISTROTY: 32yo female rock climber with a history of increasing left wrist pain. As a teen ager she had FOOSH injury to her right wrist while rock climbing and had xrays of both wrists demonstrating “bony abnormalities” needing a “cast.” Since, she has had pain while rock climbing. She never taped or braced. Currently, pain located dorsolateral/medial at the wrist and worse with hyperdorsiflexion such as pushing off and opening doors. No swelling or redness. No mechanical symptoms. No numbness or tingling. Elbow, shoulders and neck negative. Tried ibuprofen as needed but no physical therapy or bracing. History of patellar subluxation. PHYSICAL EXAMINATION: Inspection - no bony deformities, effusions or erythema. Symmetric active range of motion in all planes. Left wrist tender with terminal ulnar deviation. Palpation no nodules or masses but at the dorsal and volar ulnar aspects elicits some tenderness. Clicking at the ulnar aspect occurs with passive radial to ulnar deviation reported as uncomfortable. TFCC loading and table lift off test produces tenderness. Watson's scaphoid shift does not produce clicking or pain. Anatomic snuffbox palpation is negative. Tinel's is negative. Radial and ulnar pulses and sensation is intact and symmetric. Finger opposition strength is full. Hyper extension and abduction indicates laxity. DIFFERENTIAL DIAGNOSIS: TFCC tear. Carpal stress fracture. Scaphoid fracture non-union. Carpal instability. Distal radioulnar junction instability. TEST AND RESULTS: Plain film radiographs show lunotriquetral carpal coaltion. No scapholunate widening. MR Arthrography shows partial tears of ulnar attachment of TFCC without positive ulnar variance. Volar radioulnar ligament disruption with dorsal distal radioulnar joint subluxation. Lunotriquetral coalition, ulnar impaction. FINAL WORKING DIAGNOSIS: TFCC tear. DRUJ instability with dorsal subluxation. Lunotriquetral coalition. Ulnar impaction. Hyperlaxity. TREATMENT AND OUTCOMES: High dose NSAIDS and bracing. Cast immobilization deferred. Relative rest from rock climbing. At 4 months, intermittent pain with hyper dorsiflexion left greater than right. Refer to hand PT. At 6 months, improvement with relative rest but some symptoms with ADL's. Ortho Hand. Wrist taping for rock climbing.

Distal radio-ulnar joint subluxation following intramedullary nailing of the radius in a child

We describe a patient with fractures of both bones of the forearm in whom flexible intramedullary nail fixation of the radius alone led to ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Criteria for diagnosing distal radioulnar joint subluxation by computed tomography.

Bilateral wrist computed tomography (CT) was performed in 30 patients with suspected unilateral distal radioulnar joint (DRUJ) subluxation to evaluate dynamic DRUJ CT scanning with a straight elbow. Five CT criteria for diagnosing dorsovolar subluxation were examined. Maximum active supination and pronation on a conventional scanning table yielded satisfactory rotation (mean +/- SD, 119 degrees +/- 29 degrees) at the DRUJ, thus permitting a dynamic diagnosis of DRUJ subluxation. The radioulnar line method and the congruity method frequently yielded false positive results compared with bilateral diagnosis and were unreliable. Modifications of these two methods achieved sensitivity and specificity comparable to the epicenter method. We recommended the modified radioulnar line method for diagnosing dorsovolar subluxation using unilateral CT because of its excellent sensitivity and specificity combined with ease of technique.