DISTAL RADIOULNAR JOINT INJURIES

Presented by Dr Sunil poonia, PGT, Orthopaedics, SMCH

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

Binu P Thomas, Raveendran SreekanthDr. Paul Brand Centre for Hand Surgery, CMC Hospital, Vellore, Tamil Nadu, India

DISTAL RADIOULNAR JOINT (DRUJ)

Part of the complex forearm articulation

Functionally and anatomically integrated with the

ulnocarpal articulation of wrist.

Important joint in pronosupination and load

transmission

EVOLUTION OF DRUJ

From the syndesmotic DRUJ of brachiating primates with limited forearm rotation, three major changes occurred (a) development of a distinctly separate DRUJ, (b) recession of the distal ulna from the ulnar

carpus, (c) development of a distinct ulnocarpal

meniscus

the primitive pectoral fin of early fish

the bipedal primate wrist

Current human wrist

Distal radioulnar joint injuries

Acute injury

ANATOMY

diarthrodial trochoid synovial joint

two parts the bony radioulnar articulation and soft tissue stabilizers.

Transverse section through the DRUJ in a

cadaver, showing the sigmoid notch of the radius (white

arrow) and the head of the ulna along with the

radioulnar ligaments

THE RADIOULNAR ARTICULATION

ANATOMY The shape of sigmoid notch is not uniform and

has been classified into- 1) flat face, 2) ski slope, 3) C type, and 4) S type

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

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

Differential arc of curvature of ulna and sigmoid notch In pronation, the ulna translates 2.8 mm dorsally and

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

proximally from a neutral position

TRIANGULAR FIBROCARTILAGINOUS COMPLEX

(TFCC). also known as as ulnoligamentous complex It consists of

The triangular fibrocartilage (TFC or articular disk), Meniscal homologue, Ulnocarpal [ulnolunate (UL) and lunotriquetral]

ligaments, The dorsal and volar radioulnar ligaments, Ulnar collateral ligament, and The extensor carpi ulnaris (ECU) subsheath.

The radioulnar ligaments (dorsal and volar) are the primary stabilizers of the DRUJ.

TRIANGULAR FIBROCARTILAGINOUS COMPLEX (TFCC).

(a) Diagrammatic representation of the TFCC, superimposed on a dissected specimen,

(b) Diagrammatic representation of triangular fibrocartilage (TFC) inserting into the fovea (deep layer) and ulnar styloid (superficial layer), RUL: Radioulnar ligament, TFC: triangular fibrocartilage, UL: ulnolunate ligament, UT: Ulnotriquetral ligament, ECU: extensor carpi ulnaris in its subsheath, SP: styloid process of ulna providing attachment to these structures-R: Radius, U: Ulna, S: scaphoid, L: lunate, T: triquetrum

CLINICAL EVALUATION

trauma, eg, a fall on the outstretched hand (FOOSH).

ulnar-sided wrist pain (USWP), especially on loading the hand and rotating the forearm,

Persistence of USWP and stiffness following distal radius fractures (DRF)

Clicking sounds Obvious instability

SPECIAL TESTS

Impingement sign The ulna fovea sign The piano-key test The table top test The Grind test

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

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

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

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

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

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

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

RADIOLOGICAL INVESTIGATIONS

Radiographs

Posteroanterior (PA)

True lateral X-ray

Pronation and supination views

A clenched fist PA view in pronation

Weighted lateral stress view in pronation

X-RAY EVALUATION OF DRUJ

a)True PA views should show the groove for ECU radial to the ulnar styloid (red arrow). True lateral view should show the palmar edge of pisiform (red dotted line) midway between palmar borders of distal pole of scaphoid and capitate (yellow lines);

(b) Scheker-weighted lateral view with patient holding 3 lb weight in the hand showing dorsal instability of the distal ulna. Weighted views provide loading of the DRUJ, bringing out instability, which may not be visible in routine X-rays

COMPUTED TOMOGRAPHY

Useful to delineate sigmoid notch fractures and DRUJ injuries

Ligament injuries can be assessed indirectly by assessing the radioulnar articulation in various positions and also by loading views

Three-dimensional (3D) reconstructions are helpful in assessing spatial relationship between the radius and ulna

MRI HAS 86% SENSITIVITY FOR DETECTION OF TFCC TEARS.

a) MRI T2-weighted fat suppression image, showing a radial TFCC tear, fluid seen adjacent to DRUJ.

b) Proton density-weighted MRI, coronal view suggestive of ulnar impaction syndrome. There is articular cartilage loss with erosion, marrow edema, subchondral cyst, and sclerosis of triquetrum and lunate

ARTHROSCOPY IS THE GOLD STANDARD FOR EVALUATION OF TFCC INJURIES.

(a)Central TFCC tear,

(b) Foveal detachment of the TFCC,

(c) Reattachment of TFCC, and

(d) Degenerative tears of TFCC.

INJURIES OF DRUJ AND TFCC- A WORKING CLASSIFICATION

TRIANGULAR FIBROCARTILAGINOUS COMPLEX

INJURY

“the traumatic TFCC disruption as a continuum of injury”– Melone

It was classified into five stages of increasing severity Stage I: detachment of TFC from ulnar styloid, stage II: ECU subsheath injury, stage III: ulnocarpal ligament disruption, stage IV: lunotriquetral ligament injury, and stage V: midcarpal ligament injury

PALMER’S CLASSIFICATION OF TFCC INJURIES

Currently, management of class 1A TFCC (central perforation) lesions includes nonoperative measures initially. If significant symptoms persist, arthroscopic débridement may provide relief

For class 1B lesions (avulsion from the ulna, with or without ulnar styloid fracture), immobilization for 6 weeks followed by rehabilitation may be sufficient

If symptoms persist, and if there is DRUJ instability, arthroscopic repair using either an inside-out or an outside-in technique may produce satisfactory relief of pain and improvemen

class 1C lesions (distal avulsion of ulnocarpal ligaments), which result in a volar ulnar “sag” of the carpus, late open or arthroscopic repair may relieve symptoms

TREATMENT OF TFCC INJURIES

Non operative

splinting or AE cast

Pharmacological

NSAIDS

Steroid injections

modification of

activity

occupational

therapy

Operative

arthroscopicOpen

techniques

ISOLATED DRUJ DISLOCATIONS

Uncommon injuries

Dorsal or volar

Simple or complex

The dorsal dislocation is more common

closed manipulation and reduction under

anesthesia is usually successful.

Once the joint is reduced, stability must be

verified

ISOLATED DRUJ DISLOCATIONS

Immobilize dorsal dislocations in an above elbow plaster of Paris (POP) cast in supination, and volar dislocations in pronation for a period of 6 weeks

If instability persists after reduction, radioulnar pinning is done in reduced position to allow soft tissue healing

TFCC repair, either open or arthroscopic, needs to be also considered in case of severe disruptions

Soft tissue interposition can result in irreducibility

DRUJ INJURIES ASSOCIATED WITH FRACTURES AND FRACTURE-DISLOCATIONS

The most common cause of residual wrist disability after DRF is the DRUJ involvement

Three basic causes that result in radioulnar pain and limitation of forearm rotation are instability, joint incongruence, and ulnocarpal abutment

it is found that severely displaced DRF result in disruption of TFCC in the absence of ulna styloid fractures

USF through the base results in DRUJ instability if the fragment involves the foveal insertion of the TFCC.

DRUJ INJURIES ASSOCIATED WITH FRACTURES AND FRACTURE-DISLOCATIONS

Fractures through the sigmoid notch produce stiffness

and late onset arthritis of the DRUJ.

Despite the severity of these injuries, with proper

diagnosis and reduction, most patients will have a

satisfactory outcome

Assessment of DRUJ stability following DRF are best

done intraoperatively after fixation of the radius

fracture by translation of the ulna in a dorsopalmar

direction

DRUJ INJURIES ASSOCIATED WITH FRACTURES AND FRACTURE-DISLOCATIONS

Careful assessment of the preoperative X-rays

can indicate a possibility of DRUJ instability

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

2) fracture of the base of ulnar styloid,

3) widening of the DRUJ interval on PA view,

4) dislocation of the DRUJ on lateral view.

Computed tomography scans subluxation and

fractures of the ligamentous margins of radius

and ulna

DRUJ INJURIES ASSOCIATED WITH FRACTURES AND FRACTURE-DISLOCATIONS

Fragment-specific fixation is helpful

About 61% of DRF are associated with ulna styloid

fractures

No significant relationship between functional

outcome and ulnar styloid fractures (USF), which were

not fixed following stable fixation of distal radius

fracture

ULNA STYLOID FRACTURES

may also be seen in isolation While styloid tip fractures are stable, basal fractures

of the styloid are associated with DRUJ instability Fixation of styloid fracture makes the DRUJ stable,

provided the TFCC is not otherwise injured various fixation techniques

closed pinning, tension band wiring compression screw fixation, suture anchor technique

symptomatic nonunions of styloid? Comminuted, unstable, or displaced distal ulna

neck fractures?

GALEAZZI FRACTURE-DISLOCATION

Palmer Type IB TFCC injury is classically seen

80% of these injuries presented with

complete dislocation of DRUJ

operative fixation of the radius is necessary

due to inherent instability.

When the radius fracture is within 7.5 cm of

the distal radius, DRUJ injury is highly likely

GALEAZZI FRACTURE-DISLOCATION

Stabilize radiusDRUJ reduced spontaneously check

instability

soft tissue interposition DRUJ is

pinned

open reduction

X-RAY OF WRIST WITH DISTAL FOREARM AND HAND ANTEROPOSTERIOR AND LATERAL VIEWS

(a) Ulnar styloid with DRUJ instability

(b) treated by open reduction and tension band fixation. Joint was stable following union of fracture.

(c) Pre- and postoperative X-rays of a patient with fracture of the ulnar head

(d) treated by ORIF with screws

(a)Acute fracture involving the sigmoid notch with DRUJ instability and ulnar translation of carpus.

(b) Open reduction, internal fixation (ORIF) of the fragment and repair of volar wrist ligaments (radioscaphocapitate ligament) were done.

Galeazzi fracture-dislocation with ulnar styloid fracture and grossly unstable DRUJ treated by ORIF of radius and trans fixation of radius and ulna. DRUJ was stable following POP removal after 6 weeks

THE ESSEX-LOPRESTI INJURY

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

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

tearing of the interosseous membrane for a considerable distance

proximally

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

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

elbow pain from radiocapitellar impingement

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

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

combination

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

Excision of radial head is contraindicated in these injuries.

CLASSIFICATION OF ESSEX-LOPRESTI AND SUGGESTED MANAGEMENT

CHRONIC DRUJ INSTABILITY

Chronic DRUJ instability can result from fractures of

the distal radius and ulna following inadequate

treatment or malunion

If untreated, these lead to chronic pain and disability

due to stiffness, decreased grip strength, and

arthritis

There are reports suggesting that anatomical

reduction of DRF is more critical in avoiding

persistent DRUJ issues rather than associated fixing

or union of ulna styloid fractures.

MANAGEMENT

Management of chronic DRUJ instability depends

primarily on the underlying cause

Correct malunion, length discrepancies first

Soft tissue reconstruction indicated in

symptomatic patients in whom TFCC is

irreparable & sigmoid notch incompetent

Arthritis of DRUJ requires salvage procedures

X-ray anteroposterior and lateral views

(a) Malunited distal radius fracture following an old gunshot injury with gross deformity and relative ulnar lengthening, treated by corrective osteotomy and bone grafting of radius using a volar approach, and volar plate fixation. Intraoperatively, a distractor was used to correct the deformity,

(b) Postoperation follow-up X-rays showing deformity correction, the restitution of DRUJ and correction of radial inclination and height

MANAGEMENT

Various soft tissue procedures directed at stabilizing

the DRUJ

1) extrinsic radioulnar tether (Fulkerson & Watson)

2) extensor retinaculum capsulorrhaphy (Herbert sling

procedure)

3) ulnocarpal sling (Hui & Linshead)

4) reconstruction of volar and dorsal radioulnar ligaments.

Adams identified three categories of soft tissue

reconstruction for chronic DRUJ instability: (1) distal ulnar

tenodesis, with the extensor carpi ulnaris or flexor carpi

ulnaris tendon; (2) ulnocarpal tether; and (3) radioulnar

tether.

Diagrammatic representation of

Adams-Berger procedure for chronic DRUJ

instability. The dorsal and volar

radioulnar ligaments are reconstructed

with a palmaris longus graft.

ULNAR IMPACTION SYNDROME

Due to repetitive loading of the ulnocarpal joint, especially in the presence of ulna plus variance, degenerative changes occur in the TFC,ulnar head, lunate and triquetral surface, lunotriquetral articulation and is referred to as ulnar impaction or ulnocarpal abutment syndrome

progressive wear of TFCC perforation ulnocarpal arthritis

the most common cause acquired ulna plus variance and dorsal tilt caused by malunited distal radius fracture

ulna impingement syndrome??

ULNAR IMPACTION SYNDROME

Typical clinical features are ulnar-sided wrist

pain, especially on loading and rotation

movement

Investigations

The PA view demonstrates the ulna plus.

MRI is useful for observing changes in the lunate

and triquetrum

Arthroscopy demonstrates the classical stages

described by Palmer.

TREATMENT

Splinting NSAIDs Modification of

activities

wafer resection of the distal ulna as described by Feldon

ulna shortening osteotomy

conservative Surgical

Author prefers an ulna shortening osteotomy and compression plate fixation

(a) X-ray, and computed tomography reconstruction showing the impingement to the lunate and triquetrum ulnar impaction syndrome secondary to long-standing malunited distal radius fracture presenting as USWP with painful supination/pronation on loading the wrist, a positive impingement sign.

(b) X-ray posteroanterior and lateral views showing Ulna was shortened by cuff resection and compression plating with relief of pain and improved movement

DRUJ ARTHRITIS

Causes DRF through the sigmoid notch or the distal ulna Malunions chronic instability of DRUJ failed reconstruction of the DRUJ

Various options are available Resection of distal ulna (Darrach procedure) Sauve-Kapandji procedure Hemiresection-interposition arthroplasty DRUJ implant arthroplasty

DARRACH PROCEDURE

removes the distal articular surface of the ulna

useful in the elderly and in patients with limited activity

FCU or ECU tendon slings have been fashioned to attach to the distal ulna to address the ulna instability

Complications ulna impingement syndrome loss of grip strength possible ulnar translation of carpus

SAUVE-KAPANDJI PROCEDURE

Originally described in 1936

DRUJ arthrodesis + surgical pseudarthrosis of the distal ulna

Prefered procedure in young active adults

painful instability of the proximal ulna stump can be a problem

HEMIRESECTION-INTERPOSITION ARTHROPLASTY-BOWER

partial resection of the articular surface of ulna

interposing a capsular flap

Ulnocarpal impaction is a relative contraindication

Preferred for DRUJ arthrosis with mild degree of ulna plus variance

DRUJ IMPLANT ARTHROPLASTY

Indications primary DRUJ arthrosis failed DRUJ surgery

Prosthesis commonly used Swanson and Herbert prosthesis for distal ulna

replacement. Scheker’s semiconstrained modular implant for total

replacement of the DRUJ (APTIS DRUJ prosthesis) Though long term results are still awaited, the

implant shows great promise

SCHEKER TOTAL DRUJ ARTHROPLASTY (APTIS DRUJ PROSTHESIS) FOR DRUJ ARTHRITIS

(a) Peroperative photograph showing incision mark.

(b) X-rays lateral and posteroanterior views showing degenerative changes in the DRUJ.

(c) Peroperative photograph showing ulnar head devoid of cartilage with sigmoid notch osteophytes

SCHEKER TOTAL DRUJ ARTHROPLASTY (APTIS DRUJ PROSTHESIS) FOR DRUJ ARTHRITIS

Ulnar head was excised and DRUJ replacement with APTIS size 20 radial plate assembly and a 4.0 mm diameter 1-cm ulnar stem. The patient had excellent recovery with full range of motion and is able to lift weight without any pain. She returned to her regular occupation

CONCLUSION

The DRUJ injuries presents as ulna sided wrist pain resulting most commonly from traumatic episodes

Clinical examination provide information regarding the anatomical structures injured

Arthroscopy is considered the gold standard in diagnosis

Treatment include splinting, ORIF of fractures and repair of torn ligaments and TFCC by arthroscopy or open methods

DRUJ arthroplasty is emerging as a treatment in cases of arthrosis of the joint.

THANK YOU

CARPAL LIGAMENT INJURIES AND INSTABILITY PATTERNS

Linscheid et al. grouped carpal instabilities into four types:

(1) dorsiflexion instability (2) palmar-flexion instability (3) ulnar translocation (4) dorsal subluxation Instability in the carpus has been considered to be static if the radiographic intercarpal relationships do not change with motion and dynamic if the intercarpal relationships change with manipulation and motion

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

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

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

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

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

Stage I represents scapholunate failure;

stage II, capitolunate failure

III, triquetrolunate failure

IV, dorsal radiocarpal ligament failure, allowing lunate

dislocation

ROTARY SUBLUXATION OF THE SCAPHOID

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

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

a fall on the extended wrist is the usual cause.

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

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

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

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

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

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

MANAGEMENT Closed treatment of acute rotary subluxation of the scaphoid

consists of attempting reduction by placing the wrist in neutral flexion and a few degrees of ulnar deviation.

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

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

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

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

ANTERIOR DISLOCATION OF THE LUNATE

The most common carpal dislocation is anterior dislocation of the lunate

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

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

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

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

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

TREATMENT OPTIONS FOR WRIST LIGAMENT INJURIES AND INSTABILITY

For acute injuries, options include closed or arthroscopically controlled manipulation and percutaneous pinning

If closed methods are unsuccessful, open repair or reconstruction of ligaments may be required

For late diagnosed problem – limited arthrodesis Dorsal capsulodesis can be added to limit scaphoid

flexion Excision arthroplasty – proximal raw carpectomy