Unstable Distal Radioulnar Joint Research Articles

Should distal radioulnar joint be fixed following volar plate fixation of distal radius fracture with unstable distal radioulnar joint?

BackgroundDistal radioulnar joint (DRUJ) instability often accompanies distal radial fractures. The goal of this study was to investigate whether DRUJ should be fixed to prevent recurrent DRUJ instability in distal radius fracture patients with unstable DRUJ following open reduction and volar plate fixation of the radius. MethodsA retrospective chart review was performed on forty-nine consecutive patients presenting distal radius fracture who were diagnosed with distal radioulnar instability after radius fixation with volar plate. Group one consisted of 24 patients whose DRUJs were fixed in neutral for 6weeks with 1∼2 Kirschner wires (8 cases combined with casting), whereas group two consisted of 25 patients without DRUJ fixation. All patients had radiographic evaluation of their wrist and DRUJ for stabilities and underwent functional evaluation using modified Gartland and Werley demerit scoring system (GW score). ResultsAll patients were followed-up for an average of 15months (12–24months) after surgery. No significant difference was noted between the two groups with respect to gender, age, fracture types and damage types (no noteworthy medical comorbidities in either group). At the latest follow-up, patients in both groups had comparable grip strength, wrist motion, and visual analogue scale (VAS) and GW scores. Only one patient (2.4%) demonstrated DRUJ chronic instability, but did not require any additional surgery. ConclusionThe results suggest that in patients with distal radius fractures, fixation of unstable DRUJs in neutral for 6weeks does not have an advantage over non-fixation. Level of evidenceIII.

Distal Oblique Bundle Reconstruction and Distal Radioulnar Joint Instability

Background This study created an anatomic reconstruction of the distal oblique bundle (DOB) of the interosseous membrane to determine its effect on distal radioulnar joint (DRUJ) instability and compare this technique with distal radioulnar ligament (DRUL) reconstruction. Questions/Purposes We hypothesized that this reconstruction would provide equivalent stability to DRUL reconstruction and that combining the two techniques would enhance stability. Methods Six cadaveric upper limbs were affixed to a custom frame. The volar/dorsal translation of the radius relative to the ulna was measured in 60° pronation, neutral, and 60° supination. Translation was sequentially measured with the DRUJ intact, with sectioned DRULs and triangular fibrocartilaginous complex (TFCC), and with sectioned DOBs. Reconstructions were performed on the DRULs, on the DOB tensioned in both neutral and supination, and employing both techniques. Results The DOB reconstruction, tensioned both in the neutral position and in 60° supination, was more stable than the partial and complete instability in 6/6 specimens in pronation and the neutral position and in 5/6 specimens in supination. The DOB reconstruction and the DOB reconstruction tensioned in supination were more stable than the DRUL reconstruction in 4/6 patients. Combining the two techniques did not further reduce translation. Conclusions The DOB reconstruction is capable of improving stability in the unstable DRUJ.

Union of the ulnar styloid fracture as a function of fracture morphology on conventional radiographs

In a retrospective radiological study, the authors aimed to detect the influence of fracture morphology on the union rate of ulnar styloid fractures associated with distal radial fractures. Eighty-two out of 101 ulnar styloid fractures were included in the final statistical analysis. Initially, they were grouped into six different morphological types based on a novel classification system. They were also classified as per the established Fernández and Frykman classification systems. Furthermore, the initial ulnar styloid displacement was measured in conventional anteroposterior radiographs. Union of the ulnar styloid fracture was evaluated after at least 6months of follow-up. The current investigators demonstrated that the various ulnar styloid fracture patterns have no significant predictive value for ulnar styloid union. In contrast, it could be attested, that an initial fragment dislocation of greater than 2.4mm in the conventional AP radiographs has a significantly lower chance of successful union (p = 0.022). Initial displacement of the ulnar styloid should be measured in each distal radial fracture with a concomitant ulnar styloid fracture. This could be useful to inform the decision regarding surgical fixation of the ulnar styloid fragment in patients with an unstable distal radioulnar joint (DRUJ) or persistent symptoms at the ulnar aspect of the wrist.

A Novel Technique for Detecting Instability of the Distal Radioulnar Joint in Complete Triangular Fibrocartilage Complex Lesions

We performed this study to investigate whether discrepancy of bilateral dorsovolar shift of the distal radioulnar joint (DRUJ) is decisive for the diagnosis of DRUJ instability. Although several cadaver studies have quantified the amount of physiological dorsovolar shift, so far, there is no reliable method of quantification of DRUJ mobility in daily practice. The aim was to describe a novel sonographic method of quantifying DRUJ instability and evaluate its reliability and validity. In this study, 40 healthy volunteers and 17 patients with complete rupture of the triangular fibrocartilage complex (TFCC) underwent sonographic quantification of the grade of instability of their DRUJ bilaterally. Dorsovolar ulnar head translation relative to the distal radius was quantified by means of ultrasonography performed in a transversal plane through the ulnar head and Lister tubercle. Measurements were done while actively pressing the volar surface of the hand onto a brick 30 degrees pronated, and after lifting the hand. A quotient Q of the radioulnar distance (distance between the dorsal radius surface and the ulnar head) between the unloaded and loaded wrist was calculated for differentiation of a normal and unstable DRUJ. The Q ratio of the 17 patients with unilateral TFCC lesion was significantly different between the pathologic side and the contralateral wrist (1.19 vs. 0.54, p < 0.001). There was no significant difference in the Q ratio in the 40 healthy volunteers between the right and left side or dominant and nondominant wrist. A Q ratio > 0.8 was found to be a reasonable cut-off for pathologic laxity of the DRUJ with a sensitivity of 88% and a specificity of 81%. A quotient Q > 0.8 determines instability of the DRUJ reliably. This was a level II diagnostic study.

The “Ulnar Fovea Sign” for Defining Ulnar Wrist Pain: An Analysis of Sensitivity and Specificity

Eliciting tenderness in the region of the ulnar fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based on anecdotal observations, a hypothesis was developed stating that ulnar fovea tenderness (positive "ulnar fovea sign") is sensitive and specific in detecting two ulnar-sided wrist conditions: foveal disruption of the distal radioulnar ligaments and ulnotriquetral (UT) ligament injuries. The clinical records of 272 consecutive patients with wrist arthroscopy performed by the senior author from 1998 through to 2005 were reviewed. Relevant clinical and surgical data were abstracted. The ulnar fovea sign test is executed by pressing the examiner's thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive ulnar fovea sign is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side. There were a total of 90 foveal disruptions and 68 UT ligament injuries diagnosed during wrist arthroscopy. The ulnar fovea sign was positive in 156 patients. The sensitivity of the fovea sign in detecting foveal disruptions and/or UT ligament injuries was 95.2%. Its specificity was 86.5%. The hypothesis stating that the ulnar fovea sign is a useful clinical maneuver to detect foveal disruptions and UT ligament tears is supported. The conditions represent 2 common sources of ulnar-sided wrist pain. The differentiation between the 2 conditions may be made clinically, where UT ligament tears are typically associated with a stable distal radioulnar joint and foveal disruptions are typically associated with an unstable distal radioulnar joint. Diagnostic II.

Distal Radius Fractures: A Comparison of Tension Band Wiring Versus Ulnar Outrigger External Fixation for the Management of Distal Radioulnar Instability

To retrospectively compare the results of immobilization of the forearm in supination with the results of tension band fixation of the ulnar styloid in 35 patients with distal radius fractures, fracture of the base of the ulnar styloid, and distal radioulnar joint instability treated with external fixation. Thirty-five patients with fractures of the distal radius, fracture of the base of the ulnar styloid, and unstable distal radioulnar joint had external fixation with adjunctive percutaneous pins and allograft bone to reduce and stabilize the distal radius fracture anatomically. Only those patients with an associated ulnar styloid base fracture displaced over 2 mm with gross distal radioulnar joint instability relative to the contralateral wrist were included in this study. Group 1 consisted of patients in whom the ulnar styloid base fracture was treated with conventional tension band wiring techniques. Group 2 patients were treated with a supplemental outrigger from the external fixator to the ulna and locked in 60 degrees of forearm supination. Groups 1 and 2 had an average follow-up period of 40 and 36 months, respectively. Group 2 had significantly better supination than group 1. In terms of functional outcome it was found that there was no significant difference for the Disabilities of the Arm, Shoulder, and Hand and the Gartland and Werley scores between the 2 treatment groups. There was a lower rate of complications and fewer secondary procedures were required in group 2. The incidence of distal ulna resection was 4 of the 35 patients (2 patients in each group). Our results indicate that patients in whom the ulnar styloid can be reduced and maintained in supination can be treated effectively with fixed supination outrigger external fixation. This method resulted in a statistically significant improvement in supination and a lower rate of distal radioulnar joint complications, and it required fewer secondary procedures.

Comparison of Distal Radioulnar Joint Reconstructions Using an Active Joint Motion Simulator

Distal radioulnar joint (DRUJ) instability can result in pain and functional disability. Numerous DRUJ reconstructive options have been described with minimal biomechanical analysis. The purpose of this study was to evaluate the ability of 4 well-described DRUJ reconstructions to restore joint kinematics using a dynamic, motion-controlled simulator. Eleven cadaveric upper extremities had computer-controlled simulated active forearm rotation. Joint kinematics were quantified by using an electromagnetic tracking system. We compared the passive and simulated active kinematics of the intact, unstable, and reconstructed DRUJ (capsular repair, 2 described radioulnar ligament reconstructions, and a radioulnar tethering procedure). All reconstructions improved significantly the kinematics of the unstable DRUJ. The capsule repair restored simulated active joint kinematics closest to the intact DRUJ. All 4 reconstructions improved DRUJ stability significantly. The capsule repair most closely matched intact DRUJ kinematics and the radioulnar ligament reconstructions were found to be superior to a radioulnar tethering procedure.

The Operative Treatment of the Unstable Distal Radioulnar Joint using Adam's Technique

Purpose: To determine the value of an anatomic distal radio-ulnar joint ligament reconstruction (Adam's technique) in patients who suffer chronic pain related to distal radio-ulnar joint instability. Materials and Methods: Twelve patients who suffered from chronic pain related to distal radio-ulnar instability and underwent a reconstruction of the distal radio-ulnar ligament using a free tendon technique were enrolled in this study. The mean follow up period was at least 1 year. In all cases, injury to the distal radio-ulnar joint was present, which had been previously treated with conservatively. There was no evidence of arthritis on the distal radio-ulnar joint radiologically. The radiological radio-ulnar space and displacement of the ulnar head, clinical pain, stability, the range of motion and the grip power were measured before and after surgery (follow up 1 year). Results: No displacement of the distal radio-ulnar joint or prominence of the ulnar head was observed radiologically in 10 cases, and only partial subluxation was present in 2 cases. Clinically, the pain disappeared in 8 cases and the stability of the joint was recovered in 8. The mean pronation, supination range and grip power increased by an average of 73, 71 degrees and 11.7 kg, respectively. Conclusion: In treating distal radio-ulnar joint instability related to chronic pain, Adam's technique using palmaris longus, which is an operation using a single incision, and by restoring the distal radio-ulnar ligament anatomically can decrease the level of pain and recover the range of motion. Therefore, it is a good method worth considering in this situation.

Stability of the distal radioulnar joint contributed by the joint capsule

The distal radioulnar joint (DRUJ) capsule is assumed to be an important stabilizer of the DRUJ. There are few published data regarding the capsule and its specific contribution to stability of the DRUJ. We analyzed the contribution of the joint capsule to DRUJ stability in a biomechanical study consisting of collection of force/displacement data from 16 adult human cadaveric upper extremities. Each specimen was subjected to anteroposterior translation testing of the radius relative to the ulna in 3 positions of forearm rotation (neutral, 60 degrees pronation, 60 degrees supination) by serial sectioning of the DRUJ capsule. The experimental conditions tested included intact capsule, sectioned dorsal capsule, sectioned volar capsule, and repaired capsule. Isolated dorsal capsule sectioning resulted in volar instability of the radius to the ulna primarily in the maximum pronated position. Significant dorsal instability of the radius was observed after isolated volar capsule sectioning in the maximum supinated position. The restabilizing effect of capsule shortening was observed near the maximums of forearm rotation. The additional stability owing to capsule shortening surpassed that of the distal radioulnar ligament at these positions. We showed the effect of capsular injury on DRUJ joint stability and the restabilizing effect of capsule shortening. The importance of the capsule to DRUJ stability should be considered when planning surgical procedures to restore the unstable DRUJ.

An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability.

Fourteen patients with posttraumatic distal radioulnar joint instability were treated with a reconstruction of the distal radioulnar ligaments. The technique is anatomically accurate, is reproducible, and requires less dissection than previously described techniques. Candidates for the procedure had joint instability and an irreparable triangular fibrocartilage complex. Ten patients had bidirectional instability. Two patients had a concurrent corrective osteotomy of the distal radius for a malunion. The procedure restored stability and relieved symptoms in 12 of 14 patients at 1 to 4 years' follow-up evaluation. One patient with a deficient sigmoid notch and one with ulnocarpal ligament injury did not achieve full stability. All patients attained near full pronation and supination. The procedure is an effective treatment for an unstable distal radioulnar joint when its articular surfaces are intact and the other wrist ligaments are functional, and it can be used in combination with a distal radius corrective osteotomy.

What are the indications for arthroscopic repair of ulnar tears of the TFCC?

A clinical study was performed to assess the outcome after arthroscopic repair of ulnar tears of the TFCC of the wrist, and to determine which factors are of importance for the results. From 1994 until 1998, in 23 patients an ulnar tear of the TFCC of the wrist was found and treated by arthroscopic repair (average age 32 years, range 16 to 56, 11 female, 12 male). The articular disc was sutured by inside-outside-technique with 2/0 PDS to the floor of the sixth extensor compartment. 14 to 54 months (mean 27 months) after the operation, 21 patients were reexamined. The results were graded according to the Mayo-modified wrist score. Several factors which might be of influence were correlated to the results by crosstabs including preoperative clinical assessment of stability of the distal radioulnar joint (DRUJ), time between trauma and repair, mechanism of injury, associated lesions, details of suturing technique, and the amount of loading of the wrist in daily life. In nine patients, the result was rated as excellent, in five patients good, in four patients fair, and in three patients poor. The average preoperative score was 55.7 points, the average postoperative score was 84 points. The difference was statistically significant as calculated by the paired sample t-test (p < 0.05). In preoperative clinical examinations, 13 DRUJs had been assessed as stable, eight as unstable. In the crosstabulation, a significant correlation was found between excellent results and preoperatively preserved stability of the DRUJ, whereas fair and poor results have often been found with clinically unstable DRUJ. The other factors revealed no correlations with the results. Ulnar tears of the TFCC of the wrist without marked instability of the whole DRUJ can be treated by arthroscopic suturing and satisfactory results can be expected. In case of clinical instability of the joint, it is to be assumed that the lesion extends to structures which cannot be seen and sutured arthroscopically. In these cases, open repair after arthroscopic examination must be considered.

Reconstruction of the posttraumatic unstable distal radioulnar joint

Although not a common problem, the posttraumatic unstable distal radioulnar joint can be difficult to treat. This article focuses on the various methods for reconstruction of the unstable distal radioulnar joint. Attention focuses specifically on anatomic reconstruction of distal radioulnar ligaments. The authors' technique is presented in detail.

The Senami Wrist Supporter for patients with rheumatoid arthritis

One of the wrist orthoses, the Senami Wrist Supporter (SWS), was applied to 203 rheumatoid wrists in 112 patients who had persistent wrist pain and restricted forearm rotation due to synovitis and instability at the distal radioulnar joint (DRUJ). The study was performed by sending out a questionnaire to the patients about the use of the SWS at home, and examining grip strength and forearm rotation with and without the use of the SWS. The average age of the patients was 61 years, and the average follow-up period was 18 months. The rate of compliance of wearing the SWS at home was 73% on average. It was higher in wrists of Larsen–Dale–Eek (LDE) grades 0, I, and II (normal, slight, and definite early abnormality) than in those of grades III, and IV (medium and severe destructive abnormality). Decreased pain was noted in 52% of the wrists at the time of applying the SWS. The SWS was not used in 10% of the wrists because of remission of pain at follow-up. Grip strength increased significantly (P < 0.01) and so did forearm rotation (P < 0.05) by the stabilizing effect of the SWS on the unstable DRUJ. The use of the SWS was confirmed to be an efficient measure to treat painful rheumatoid wrists with early stages of disease at the DRUJ.

Distal radio-ulnar ligament motion during supination and pronation

The dorsal and palmar distal radio-ulnar ligaments (DRUL) play an important role in the stability of the distal radio-ulnar joint (DRUJ). Various authorities, however, hold opposite opinions regarding DRUL motion during DRUJ pronation and supination, thus implying opposite techniques for reconstruction of the unstable DRUJ. With the hypothesis that relative displacement would increase in the dorsal DRUL during pronation and would increase in the palmar DRUL during supination, measurements were made of the relative DRUL displacement with a Hall-effect displacement transducer during DRUJ pronation and supination in six fresh cadaver wrists. The hypothesis was confirmed that the dorsal radio-uluar ligament undergoes relative displacement during pronation, while the palmar radio-ulnar ligament undergoes relative displacement during supination.

THE ACUTE CARPAL TUNNEL SYNDROME

Nine cases of acute carpal tunnel syndrome are reported. Etiologies include: bleeding secondary to chronic lymphatic leukemia; Colles' fracture of the wrist (2 cases); Epiphyseal fracture (Salter II) of the distal radius; Bleeding secondary to giant cell tumor of the tendon sheath; Unstable distal radio-ulnar joint; Displaced intra-articular fracture of the distal radius; Rheumatoid synovitis and vasculitis; Trans-scaphoid, perilunar fracture dislocation of the wrist. Early recognition of median nerve compression in the carpal tunnel is vital. The signs of median nerve compression should be looked for in all cases of wrist trauma. In our opinion, immediate surgical decompression is frequently indicated.