This study aimed to (1) introduce a simple and reproducible method to assess severe radial translation of distal radius fractures (DRF) which is a potential cause of distal radioulnar joint (DRUJ) instability, and (2) to construct a treatment-oriented classification. From 2018 to 2023, stress test (ballottement test) was performed to detect DRUJ instability associated with DRF after treatment with locking plate fixation. Potential radiographic predictors of DRUJ instability focus on radial translation were accessed. The severity of radial translation was described by a readily and easily technique as 'point- baseline' method. According to this method, radial translation was categorized into three grades: no translation (the marking points not moved), moderate translation (the marking points moved, but were located on the ulnar side of the baseline), and severe translation (the marking points moved and reached the baseline position, or even completely moved to the radial side of the baseline). All these fractures were divided into two groups, namely Group A (cases with no translation or moderate translation) and Group B (cases with severe translation). Relationships between DRUJ instability and the radiographic parameter of radial translation were analyzed. To investigate the causes of DRUJ instability, all of the cases with DRUJ instability were further divided into two subgroups: subgroup A (cases with DRUJ instability in Group A) and subgroup B (cases with DRUJ instability in Group B). Practices to address DRUJ instability at the time of DRF fixation were explored. There were 226 patients enrolled in this study. According to 'point- baseline' method, there were 174 wrists in Group A and 52 wrists in Group B. There were 34 cases (19.54%) diagnosed as having DRUJ instability intraoperatively via manual stress testing in Group A, while 36 cases (69.23%) in Group B. There was significant difference in the incidence of DRUJ instability between the two groups (p < 0.0001). Of the 70 cases with DRUJ instability, 18 cases regained stability by ulnar styloid fracture fixation, 12 cases by dorsal ulnar corner fragment (sigmoid notch fracture) fixation, and 40 cases by arthroscopy-assisted triangular fibrocartilage complex (TFCC) repair. To investigate the causes of DRUJ instability, there were 34 wrists in subgroup A, while 36 wrists in subgroup B. There were no significant differences between the two subgroups regarding the causes of DRUJ instability including ulnar styloid process fracture, dorsal ulnar corner fragment (sigmoid notch fracture), and traumatic TFCC injury. This study helped establish a 'point- baseline' method which can be readily and easily used to identify the severity of radial translation, which was a significant predictor of DRUJ instability. On the other hand, whether or not severe radial translation, treatment of DRUJ instability by the three major ways: (1) the ulnar styloid fracture fixation; (2) the dorsal ulnar corner fragment fixation; and (3) traumatic TFCC injuries repairing.

Introduction:Galeazzi fractures, defined as fractures of the radial shaft with associated dislocation of the distal radioulnar joint (DRUJ), are uncommon injuries typically caused by high-energy blunt trauma or falls onto an outstretched hand. Ballistic mechanisms rarely produce this fracture pattern because they lack the torsional forces usually required to disrupt the DRUJ. Only isolated case reports of such injuries exist in the literature. This report presents the largest known case series of Galeazzi fractures resulting from gunshot wounds, providing new insight into their mechanism, management, and outcomes.Case Series:Six patients, four males and two females, between 25 and 52 years of age, sustained Galeazzi fractures following low-velocity gunshot wounds. Several were polytraumatized with concomitant injuries to other extremities or the abdomen. All patients underwent operative fixation of the radial shaft using rigid internal fixation constructs. In each case, the DRUJ was evaluated intraoperatively after fixation and was found to be stable without the need for additional surgical stabilization. Post-operative immobilization consisted of short-term splinting followed by early mobilization. At follow-up, all patients demonstrated fracture healing and functional forearm rotation without pain or DRUJ instability. Despite an average of 10.9 mm of initial radial shortening relative to the ulna, no patient developed instability requiring further surgical intervention.Conclusion:This case series expands current understanding of Galeazzi fracture patterns by demonstrating that ballistic mechanisms, though uncommon, can produce this distinctive injury without the classic torsional loading. These findings suggest that stable DRUJ alignment can often be achieved through rigid fixation of the radial shaft alone, even in the setting of significant shortening from ballistic trauma. This report adds novel evidence to the orthopedic literature by highlighting a previously underrecognized mechanism of Galeazzi injury. It supports the importance of thorough intraoperative assessment of DRUJ stability following fixation. The clinical impact extends beyond trauma surgery by reinforcing that fracture pattern, rather than mechanism alone, should guide management decisions.

Outcomes Following Retrograde Intramedullary Threaded Nail Fixation of Distal Ulnar Neck Fractures.

Postoperative Immobilization After Foveal Triangular Fibrocartilage Complex Repair: A Systematic Review and Meta-Analysis of Comparative Studies.

Carpal instability is fundamentally a dynamic disorder that may not be detected using conventional static imaging modalities such as radiography, CT, and MRI. This diagnostic limitation may delay diagnosis and treatment, potentially leading to progressive instability and degenerative changes. Four-dimensional CT enables dynamic, in vivo visualisation and quantitative analysis of wrist kinematics by acquiring sequential volumetric datasets during active motion. This allows identification of abnormal motion patterns, including altered intercarpal coordination and subluxations, which cannot be detected using static imaging. Clinical applications include evaluation of scapholunate instability, distal radioulnar joint instability, midcarpal instability, and altered carpal kinematics in conditions such as Kienböck disease. Four-dimensional CT may also be valuable for preoperative planning and postoperative assessment by enabling objective evaluation of treatment-related changes in wrist motion. Comparison with the contralateral wrist provides an internal physiological reference and may improve diagnostic confidence by distinguishing pathological motion from normal anatomical variation. Four-dimensional CT complements conventional imaging and arthroscopy by providing functional information on wrist biomechanics. It should be used selectively when dynamic instability is suspected and conventional imaging is inconclusive. Ongoing advances in automated analysis, dose optimisation, and protocol standardisation are expected to further improve clinical applicability and support broader integration into clinical practice.

Abstract Malunion of a distal radius fracture may lead to persistent pain and functional limitation. Traditionally, the indication for corrective osteotomy is based on two-dimensional radiographic criteria. However, a subset of patients with radiographically subtle malunions—defined as cases in which all radiographic parameters fall within the acceptable limits outlined by current guidelines—may still experience significant symptoms that impair activities of daily living or occupational performance. Notably, rotational deformities are typically not evaluated, despite their potential clinical relevance. The objective of this retrospective cohort study was to evaluate the clinical outcomes of corrective osteotomy using a three-dimensional-printed patient-specific implant in patients with a minimal malunion of the distal radius. Surgical outcomes were assessed using patient-reported outcome measures, including the Patient-Rated Wrist/Hand Evaluation (PRWHE), as well as clinical evaluation of distal radioulnar joint (DRUJ) stability. Fourteen patients were included. The PRWHE improved from 72 (interquartile range [IQR]: 56, 81) to 35 (IQR: 8, 57), p = 0.004, after a follow-up of 11 months (IQR: 10, 13). Preoperatively, 12 patients had DRUJ instability. Postoperatively, only one patient exhibited asymptomatic DRUJ instability. No postoperative complications were observed. Patients with subtle malunions of the distal radius may benefit from corrective osteotomy. Standard guideline parameters may not be sufficient to identify all patients who could benefit from surgical intervention. Moreover, DRUJ instability following a distal radius fracture should be considered a manifestation of malunion until proven otherwise. IV.

Abstract Distal radioulnar joint instability secondary to triangular fibrocartilage complex (TFCC) injury remains a major challenge in wrist surgery. Traditional tendon graft–based reconstruction techniques, such as the Adams‐Berger procedure, though effective, require extensive soft tissue dissection and tendon harvesting, resulting in significant surgical morbidity. Meanwhile, isolated arthroscopic TFCC repairs often fail to achieve durable stabilization in chronic or degenerative cases due to poor tissue quality and insufficient fixation strength. To overcome these limitations, we present a modified minimally invasive technique that combines arthroscopic TFCC repair using FiberTape with an anatomic augmentation of the distal radioulnar ligament based on the Adams‐Berger concept. A small volar incision is made over the distal radioulnar joint to create a bone tunnel at the radial insertion of the TFCC, through which FiberTape is introduced and routed along the volar and dorsal aspects of the joint capsule to the ulnar side. Under direct arthroscopic visualization, a suture lasso is used to shuttle the FiberTape through the TFCC and across its anatomic attachment at the ulnar fovea. Final tensioning and knot tying are performed at the ulnar tunnel outlet, forming a circumferential internal brace that anatomically replicates the deep distal radioulnar ligament configuration. This technique provides immediate biomechanical stability without the need for tendon harvesting, minimizes soft tissue disruption, and enables early postoperative mobilization. It offers a reproducible, low‐morbidity, and anatomically faithful method for distal radioulnar joint augmentation.

Isolated Distal Ulnar Salter-Harris IV Fracture in an Adolescent Male With Distal Radioulnar Joint Injury: A Case Report and Review of the Literature

The triangular fibrocartilage complex (TFCC) is a key stabilizer of the ulnar wrist, integrating both the distal radioulnar and ulnocarpal joints. Recent advances in arthroscopic anatomy have led to a three-dimensional, tripartite conceptualization of the TFCC, describing it as comprising three interconnected components: the articular disc, the distal radioulnar ligaments providing primary stability, and a continuous peripheral capsular structure, or "peripheral wall," which encompasses the palmar and dorsal ulnocarpal ligaments, the meniscus homologue, and the extensor carpi ulnaris tendon sheath. Vascular supply is concentrated at the peripheral insertions, while the central disc is relatively avascular, influencing its healing potential. Functionally, the TFCC contributes to both rotational and translational stability of the radioulnocarpal articulation, with the distal radioulnar ligaments serving as the primary stabilizers and the ulnocarpal ligament complex, extensor carpi ulnaris tendon sheath, and interosseous membrane providing secondary support. MRI, particularly three-dimensional isotropic sequences and MR arthrography, allows detailed visualization of the TFCC components, detection of partial or complete tears, and differentiation between normal anatomic variants and pathologic abnormalities. Recognition of normal variations and positional changes related to forearm rotation is essential to avoid diagnostic errors. This review integrates arthroscopic, anatomical, biomechanical, and imaging perspectives, providing a comprehensive understanding of the TFCC and its updated conceptual framework, with direct implications for clinical assessment, surgical planning, and post-treatment follow-up of ulnar wrist injuries.

Distal radioulnar joint (DRUJ) instability is commonly assessed clinically via physical examination, such as a ballottement test, which evaluates palmar-dorsal translation of the radius relative to the ulna. However, the normal physiological range of translation and the factors influencing it remain poorly defined, limiting the test's diagnostic precision. This study aimed to quantify the normal range of DRUJ translation and identify its associated factors in a healthy population. Healthy adult participants were recruited between January 1, 2025, and April 30, 2025. Data on occupation, gender, age, height, weight, handedness, wrist circumference, forearm length, and grip strength were recorded. A custom-designed device was used to measure the palmar, dorsal, and combined DRUJ translations in forearm pronation, supination, and neutral positions. Univariate and multivariate analyses were performed to identify factors influencing translation. The mean (±SD) combined DRUJ translation was 11.9 ± 4.2 mm in pronation, 12.4 ± 3.9 mm in supination, and 13.3 ± 4.6 mm in the neutral position. Significant side-to-side differences were observed for all translations in pronation and for both palmar and dorsal translations in the neutral position. No significant side-to-side difference was found in supination. Compared to pronation and supination, combined and palmar translations were significantly greater in the neutral position. Conversely, dorsal translation was greatest in supination. Multivariate analysis revealed that combined DRUJ translation in supination was significantly influenced by grip strength, forearm length, weight, and age. Our findings establish reference values for DRUJ translation and demonstrate that it is influenced by forearm position and multiple factors. To improve the clinical utility of the ballottement test, we recommend performing it in forearm supination while comparing both limbs. Specifically, combined DRUJ translation with forearm supinated is significantly affected by grip strength, forearm length, weight, and age.

Distal radioulnar joint (DRUJ) balance is essential for forearm rotation, load transmission, and overall wrist function. Traumatic injuries - including foveal triangular fibrocartilage complex (TFCC) tears, distal radius malunions and disruption of the distal oblique bundle - represent the most common causes of symptomatic DRUJ instability. Accurate differentiation between physiological laxity and clinically relevant instability remains challenging owing to limited reliability of physical examination and the subtle nature of soft-tissue pathology. Comprehensive assessment requires detailed anatomical understanding, structured clinical evaluation, multimodal imaging and, when indicated, diagnostic arthroscopy. Advances in minimally invasive surgical techniques have transformed the management of DRUJ instability. Arthroscopic interventions allow precise identification and treatment of TFCC lesions, enabling foveal repairs, capsular reinforcement, and tendon-graft reconstructions while minimizing soft-tissue disruption. Open yet minimally invasive procedures - including suture-button suspension constructs and distal oblique bundle reinforcement - offer additional options for restoring stability, particularly in chronic or complex cases. Treatment selection depends on underlying pathoanatomy, patient age, severity of instability and associated osseous deformities such as distal radius malunion or ulnar-positive variance. Postoperative recovery requires careful monitoring of stability, range of motion and functional progression, with growing evidence supporting shorter immobilization and early supervised mobilization in stable repairs. A stepwise algorithm integrating anatomical, clinical, radiographic and arthroscopic findings can guide decision-making and optimize outcomes. As diagnostic imaging and arthroscopic techniques continue to evolve, minimally invasive approaches will play an increasingly central role in restoring DRUJ balance, improving function and preventing long-term degenerative change.Level Evidence: V.

Volar Plating Versus Combined Plating For AO Type C Distal Radius Fracture: A Randomized Controlled Study Of 135 Patients With A 5-Year Follow-Up.

IntroductionFractures of the distal radius are frequently accompanied by fractures of the ulnar styloid process. Because the triangular fibrocartilage complex attaches to the base of the ulnar styloid and contributes to the stability of the distal radioulnar joint (DRUJ), the optimal management of these fractures remains controversial. While some surgeons advocate fixation of the ulnar styloid fragment to restore joint stability, others believe that fixation may not significantly influence clinical outcomes.MethodsThis retrospective comparative study included patients presenting with Fernandez type I distal radius fractures associated with a base fracture of the ulnar styloid. Patients were divided into two groups based on the treatment received: those who underwent fixation of the ulnar styloid fragment and those managed without fixation. All distal radius fractures had been stabilized using percutaneous crossed Kirschner wires. In the fixation group, the ulnar styloid fragment had been additionally stabilized using a tension-band wiring technique. Clinical and follow-up data were retrieved from medical records, with a minimum follow-up duration of 12 months. Outcomes were assessed using the Visual Analogue Scale (VAS) for pain, the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire, the Mayo Wrist Performance Score, wrist range of motion, and grip strength.ResultsA total of 121 patients were included (fixation: 63; without fixation: 58). Quick-DASH scores were slightly higher in the fixation group at three months (34.4 ± 13.5 vs. 32.9 ± 5.7, p = 0.027) and six months (29.8 ± 18.2 vs. 19.3 ± 8.2, p = 0.001), but no difference was observed at 12 months (12.7 ± 7.7 vs. 6.4 ± 2.1, p = 0.198). Mayo Wrist Scores, VAS pain scores, wrist range of motion, and grip strength were comparable between the groups at all time points (all p > 0.05).ConclusionFixation of the ulnar styloid fragment did not provide a measurable long-term functional advantage after distal radius fracture stabilization. Routine surgical fixation of the ulnar styloid may therefore be unnecessary in patients with a stable DRUJ.

Background: The stability of the distal radioulnar joint (DRUJ) relies heavily on the osseous congruity of the ulnar (sigmoid) notch. Morphometric variations, particularly anterior-posterior asymmetry, significantly influence joint mechanics and implant design. This study aimed to evaluate the detailed morphometric parameters of the distal radius, specifically analyzing the dimensional asymmetry between the anterior and posterior aspects of the ulnar notch. Materials and Methods: A morphometric study was conducted on 54 dry adult human radii (27 right and 27 left) free of pathology. Using a digital Vernier caliper (0.01-mm precision), measurements were obtained for the anterior and posterior lengths of the ulnar notch, notch width, radial styloid length, and the dimensions of the inferior articular facet. Statistical analysis was performed using paired and independent t -tests. Results: The analysis revealed significant anteroposterior asymmetry. The posterior (dorsal) length of the ulnar notch was consistently greater than the anterior (volar) length. On the right, the mean posterior length (0.77 ± 0.18 cm) significantly exceeded the anterior length (0.46 ± 0.14 cm; P &lt; 0.001). Left-sided specimens showed a similar pattern (0.58 vs. 0.45 cm). Conversely, the inferior articular facet was wider at its anterior margin. The mean radial styloid length was 1.16 cm (right) and 1.12 cm (left). Conclusion: The ulnar notch extends significantly further dorsally than volarly, likely to accommodate the dorsal radioulnar ligament and increase articular surface area. In contrast, the radiocarpal facet is wider anteriorly. These morphometric norms are critical for preoperative planning, radiographic interpretation, and designing anatomical plates that restore DRUJ congruity.

Irreducible distal radioulnar joint (DRUJ) dislocations are often caused by bony impingement rather than soft tissue entrapment alone. Careful analysis of CT scans can identify the specific locking mechanism, allowing for successful closed reduction through a targeted "unlocking" maneuver, thereby avoiding open surgery.

This study aimed to evaluate the clinical outcomes and changes in distal radioulnar joint (DRUJ) stability in patients with ulnar impaction syndrome (UIS) combined with DRUJ instability, treated with ulnar shortening osteotomy (USO) without concomitant triangular fibrocartilage complex (TFCC) repair. Between November 2017 and December 2024, a total of 16 patients (7 males, 9 females; mean age, 40 ± 12 years) underwent USO combined with wrist arthroscopy, followed by structured rehabilitation and regular follow-up. Clinical outcomes were assessed using ulnar variance, the Ballottement test, visual analog scale (VAS) for pain, Disabilities of the Arm, Shoulder, and Hand (DASH) score, modified Mayo wrist score, Patient-Rated Wrist Evaluation (PRWE), grip strength, and wrist range of motion. Preoperatively, all patients had positive Ballottement tests, and TFCC injuries were confirmed by arthroscopy. At the final follow-up (mean, 31 months), ulnar variance was significantly reduced, and VAS, DASH, modified Mayo wrist score, PRWE, and grip strength all showed marked improvement. DRUJ stability was restored in all patients, with the Ballottement test converting to negative. These findings suggest that isolated USO effectively treats UIS with concurrent DRUJ instability and achieves satisfactory clinical outcomes without the need for simultaneous TFCC repair. Therapeutic, Level IV.

Carpal tunnel syndrome (CTS) diagnosis has traditionally relied on electrodiagnosis (EDX) to confirm the diagnosis and to assess severity. Ultrasound has shown potential in measuring median nerve cross-sectional area (CSA) for CTS diagnosis, and magnetic resonance imaging (MRI) can be used for wrist soft-tissue evaluation. This study explored the correlation between CTS diagnosis and median nerve CSA measured on MRI at different wrist levels. A retrospective review of an electronic medical record database identified patients who underwent both wrist MRI and EDX within a 90-day interval between January 2000 and December 2022. Median nerve CSA was measured on axial T2-weighted images at 3 levels: proximal to the carpal tunnel inlet (the distal radioulnar joint [DRUJ]), the inlet, and the outlet. Continuous variables are presented as means ± standard deviations. A logistic regression model was constructed to evaluate the diagnostic accuracy of median nerve CSA, at the 3 anatomical levels, in identifying CTS. Empirical cut point estimation determined optimal cutoffs and corresponding areas under the receiver operating characteristic curve (AUCs). Sixty-eight patients (76 wrists; mean age, 51.4 ± 14.2 years; male-to-female ratio, 26 to 50; 59 White patients, 8 Hispanic patients, and 1 Asian patient) were included. The mean median nerve CSA in the EDX-negative group compared with the EDX-positive group was 10.6 ± 3.4 versus 11.7 ± 4.0 mm2 (p = 0.248) at the DRUJ level, 11.1 ± 3.1 versus 14.4 ± 5.1 mm2 (p = 0.007) at the inlet level, and 9.8 ± 2.4 versus 11.0 ± 5.2 mm2 (p = 0.833) at the outlet level. The inlet CSA cutoff for CTS was 11.3 mm2 (AUC = 0.67), with a sensitivity of 74% and a specificity of 60%. MRI-based measurements of median nerve CSA, particularly at the inlet level, suggest that relying solely on CSA measurements may not be an optimal diagnostic strategy for CTS in patients with equivocal clinical symptoms. Even with MRI and highly standardized measurement protocols, only poor-to-fair diagnostic accuracy was achieved. This study raises questions about the diagnosis of CTS based on CSA measurements. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Despite anatomically successful fixation of distal radius and Galeazzi fractures, a subset of patients develops persistent pain and functional limitation, suggesting that factors beyond osseous alignment influence recovery. Distal radioulnar joint instability has been implicated in unfavorable outcomes, yet intraoperative assessment remains inconsistently standardized and has rarely been validated as a prognostic variable. This prospective multicenter observational cohort study included 120 consecutive patients with distal radius or Galeazzi fractures treated with plate fixation in two tertiary centers. After fracture reduction and stabilization, intraoperative distal radioulnar joint stability was systematically assessed using a previously published classification system comprising Grades I to III, with patients demonstrating no instability serving as the reference group. The primary outcome was the QuickDASH score at 12 months, while secondary outcomes included pain intensity, grip strength, radiographic distal radioulnar joint gap, and postoperative complications. Multivariable linear regression was used to evaluate the association between intraoperative instability grade and outcomes, adjusting for age, sex, fracture type, and treatment center. Increasing instability grade was independently associated with worse functional outcome, higher pain levels, reduced grip strength, and greater postoperative distal radioulnar joint widening at 12 months, with an adjusted increase of approximately 5 to 6 QuickDASH points per grade. Intraoperative distal radioulnar joint instability grading provides clinically relevant prognostic information and supports postoperative risk stratification following distal radius and Galeazzi fractures.

Arthroscopic treatment of TFCC lesions and stabilization of the DRUJ offer a differentiated range of findings-oriented procedures. Theses include central smoothing/partial resection via peripheral capsular sutures to foveal refixation and, in cases of irrepairable damage, anatomical reconstruction of the DRUJ-stabilizing radioulnar ligaments. The Palmer and Atzei classifications are widely used in everyday clinical practice and offer a structured approach to diagnosis and indication, with foveal integrity being the central criterion for DRUJ stability. Medical history, clinical examination, imaging and, in particular, diagnostic arthroscopy ensure precise classification, while standardized follow-up treatment concepts and realistic expectations ensure functional results. The choice of the specific procedure should be injury-specific, patient-related and experience-based.

To investigate the diagnostic value of MRI combined with distal radioulnar joint (DRUJ) stability characteristics and ulnar styloid bone marrow edema (BME) in differentiating peripheral vs. central triangular fibrocartilage complex (TFCC) injuries, and to establish a multiparametric MRI diagnostic model to optimize preoperative classification accuracy. A retrospective analysis of 76 patients with arthroscopically confirmed TFCC injuries (55 peripheral tears, 21 central tears) was conducted. Preoperative MRI evaluated DRUJ stability and BME. Chi-square tests analyzed intergroup differences, binary logistic regression identified predictors, diagnostic efficacy metrics were calculated, and MRI-based classification, DRUJ stability, BME, and combined models were compared using arthroscopy as the gold standard. The peripheral tear group exhibited significantly higher BME positivity (82.9% vs. 11.1%) and DRUJ instability rates (70.9% vs. 9.5%) compared to the central tear group (both p < 0.001). Logistic regression identified BME positivity (OR = 0.140, 95% CI: 0.044-0.444) and DRUJ instability (OR = 0.103, 95% CI: 0.013-0.428) as independent predictors of peripheral tears (p = 0.001). The combined model (MRI+DRUJ+BME) demonstrated superior diagnostic performance (AUC = 0.898, 95% CI: 0.818-0.978; sensitivity = 76.2%, specificity = 94.6%) compared to MRI alone (AUC = 0.810) or DRUJ+BME models (AUC = 0.822). The combined model integrating anatomic stability improves diagnostic specificity, providing critical guidance for preoperative stratification, surgical planning, and personalized treatment. Bone marrow edema (BME) and distal radioulnar joint (DRUJ) stability hold potential as supplementary MRI imaging biomarkers for TFCC injuries classification.