Dnyanesh Lad

DRUJ + PRUJ = Longitudinal rotations = Special type

Bicondylar joint

Structural & Functional separation btw DRUJ and carpal bones = pronation-supination without affecting grasping

ANATOMY Triangular Fibro cartilage of Palmar and

Werner Ulna to radius and ulnar side of carpus TFCC includes1. Dorsal & Volar Radio-ulnar ligs( Primary

Restraint)2. Volar Ulno-lunar lig.3. Ulno-triquetral lig.4. Ulnar collateral lig.5. Articular disc6. Extensor Carpi Ulnaris Sheath

TFCC AnatomyOrigin: Ulnar side of lunate fossa of radius

(base-5mm thick)Insertion: Head of ulna & base of ulnar styloid

(apex-1mm thick)Joined by ulnar collateral ligDorsal Insertions:1. Triquetral2. Hamate3. Base of 5th metacarpal

FUNCTIONS OF TFCC1. Gliding surface at distal face of forearm

bones

2. Provides flexible mechanism for stable rotational movements of the radiocarpal unit around ulnar axis

3. Suspends the ulnar carpus from the dorsal ulnar face of the radius

4. Cushions forces transmitted through ulnocarpal axis

5. Connects ulnar axis to volar carpus

ADDITIONAL STABILITY TO DRUJ1. Contour of sigmoid notch

2. Interosseous membrane

3. Extensor Retinaculum

4. Dynamic forces of ECU and pronator quadratus

In Ulna neutral Position of Wrist20% applied load – Ulna80% applied load – Radius

Imp: Ulnar variance affects load distribution

TFCC thinner in wrists with +ve ulna variance

TFCC thicker in wrists with –ve ulna variance

a. Full Supination – Full pronation 1mm apparent increase in length of ulna

b. Head of ulna also dorsally displaced relative to lunate and triuetrum in full pronation

a. +b. = Minimal affect on axial force transmission

IN PRONATION: DORSAL RUL under tension

IN SUPINATION: VOLAR RUL under tension

“PIANO KEY SIGN”Avulsion of RUL from radial or ulnar

attachments

Increased mobility of ulnar head on radius

Appreciated by ballottement test

DRUJ DISORDERS

ACUTE # Ulnar head/styloid # Radius/carpal

bones Dislocation/

subluxation DRUJ carpal bones

TFCC & ECU subluxation

Symptomatic TFCC tears & perforations

CHRONIC Non unions/malunions

/incongruity of wrist jt. Including subluxation/dislocation of DRUJ, ulnocarpal region, carpal bones, TFCC

Arthritis of pisotriquetral, lunotriquetral jts

DRUJ arthritisSYMPTOMS: Pain-

weakness-instability-loss of motion

INVESTIGATIONS RADIOGRAPHSa. AP or PA wrist- semipronated (45*)USE: for dorso ulnar structures

b. Semisupinated/ Reverse Oblique/Ball catcher view

(30-45* supination)USE: Volar ulnar quadrant of the wrist

especially pisotriquetral jt and hook of hamate

c. Dynamic/Provocative/ Loaded viewsPt. made to make a fist/ squeeze an

objectCompare with opposite sideUSE: To recognize instability

d. Loaded PA radial and ulnar deviation views

USE: Movt. Of proximal row in relation with distal radius and TFC.

TOMOGRAPHYUSE: accurate for DRUJ

subluxation/dislocationADVANTAGES:1. Does not require precise positioning2. Can be done through a plaster cast3. Sigmoid notch abnormalities assessed

best

MRIUSE: location of ECU tendon, joint capsule, TFCC tears.

ARTHROSCOPYUSE: Small joint arthroscope- -TFCC tears-Synovitis-Erosion areas- Rim avulsion of radial head of TFCC

TREATMENT

For acceptable redn-intra articular # must be anatomically aligned and jt. congruity restored

Ulnar articular surface must not be translated in any direction

COMMINUTED STABLE #: Closed reduction and External fixation SEVERELY COMMINUTED+ UNSTABLE ORIF and Bone graft

Ulnar articular #: Open fix with k-wire or screw

Comminuted # ulna head: 1* resection of the head preserving shaft axis

Minimal displacement Rx with BE cast immobilization with interosseous moulding and avoiding more than mid pronation. Wrist neutral and slight ulnar deviation.

ESSEX- LOPRESTI INJURY DRUJ disruption + displaced radial head +

Proximal migration of radius ~ 5-10mmDISRUPTION OF:1. DRUJ ligament2. Interosseeos membrane3. Radiocapitular articular surfaceRADIOGRAPH: X ray Elbow+forearm+wristCT: Comparison of DRUJMRI: Interosseous haematoma

Rx: Fixation of large radial head fragment+ Reducn repair fixn of DRUJ

Radial head comminuted-Excise itUlnocarpal impaction: hemiresection and

arthroplasty

Isolated TFCC disruption=Periulnar dislocation of radiocarpal mass/Dislocation of lower end of ulna -ulna in N position at elbow

Volar Ulnar dislocation-reduced by pronation

Dorsal Ulnar dislocation-reduced by supination

AE cast x 6 weeksGreen recommends neutral rotation +

ulnar deviation for both

Direct TFCC Repair-intraosseous wire technique 24 gauge wire

Isolated TFCC damage without Instability

OPTION A: complete excision

OPTION B: Repair of tear if it is in Peripheral vascular zone; debridement if in central avascular zone.

BUNNEL-BOYES RECONSTRUCTION OF DRUJ

For dorsal dislocationDistally based FCU harvested proximally,

stripped distally to pisiform attachmentNew ligament woven through the volar capsuleStress on pisotriquetral jt relievedNew lig. Passed through drill hole in styloid to

exit in axilla of ulnar styloid processImbrication with dorsal capsuleC/I: VOLAR DISLOCATION

Moving pronator quadratus to a more lateral and dorsal insertion for stability-Johnson

Fascia lata used to stabilise DRUJ Fernandez Osteotomy: Osteotomy of distal radius re-establishes length, volar tilt and

ulnar inclination of radius

IMPINGEMENT ULNOCARPAL IMPACTION SYNDROMEUlnar head impinges against carpusLimitation of Rotation-ligaments relax

around wristSymptoms: 1. Ulnar wrist pain2. Rotation/Ulnar deviation3. Clicks/crepitus in TFCC region4. Long ulna relative to radius

X RAYS: Sclerotic/cystic changes in ulnar head & lunate

PREDISPOSING CONDITIONS1. Premature closure radial epiphysis 2* to

trauma (Acquired Madelung’s deformity)2. Premature wrist fusion3. Excision of radial head or shaft4. Fracture malunions with shortening of radius5. Normal variant long ulna

TFCC examined with MRI & Arthroscopy

Ulnar unloading-Feldon, Belsky and Torrono “Wafer” Osteotomy-2-4mm wafer of cartilage & bone from ulnar articular dome under TFC.

FOR DRUJ INCONGRUITY1. Darrach and modifications-Ulna head

excision

2. Sauve-kapandji Procedure: Ulnar recession & fusion ulnar head with radius

+ proximal pseudo arthrosis for restoration of forearm motion

3. Bowers resection-hemiresection

arthroplasty with shortening

4. Swanson resection and replacement arthroplasty

INDICATION-HEMIRESECTION ARTHROPLASTY

1. RA a. Early: Bower’s arthroplasty b. Late: Modified Darrach’s procedure

2. OA of DRUJ along with osteophyte resection

3. Ulnocarpal impaction Syndrome

4. Painful Instability of DRUJ

5. Rotational Contractures with radio ulnar disease

DISADVANTAGES OF BOWER’S ARTHROPLASTY1. Fails if TFCC is not functioning (trauma/severe RA)

2. Cannot restore stability in an unstable painful DRUJ

3. Unsuccessful if stylocarpal impingement is not anticipated.

4. In long standing contractures may not restore rotation

C/I TO BOWER’S OSTEOTOMY1. Unreconstructable TFCC

2. Advanced RA

3. Ulnocarpal translation (post traumatic/arthritic)

DARRACH’S PROCEDUREIncision proximal from ulnar styloidSeparate ECU and FCUBEWARE: Dorsal cutaneous br. Ulnar nerveOsteotomy 2.5cm proximal to styloidMobilization encouraged within 24 hrs.

DISADVANTAGES:1. Increased Ulnocarpal

translocation/instability2. Decreased Grip Strength

MODIFIED DARRACH’S PROCEDURES1. Blatt and Ashworth: flap of volar capsule

to dorsal ulnar stump2. O’Donovan and Ruby: tethering distal

ulnar stump with distally based strip of ECU3. Kessler and Hecht: dynamic stabilisation

looping tendon around distal ulnar stump and the ECU

4. Goldner and Hayes: ECU through drill hole in ulnar stump –forearm in supination

5. Tsai and Stilwel: FCU to stabilise ulnar stump and ECU

6. Johnson: Pronator advancement

SAUVE KAPANDJI POCEDURE

Radio ulnar jt. Fusion Creation of pseudoarthrosis proximal to fusion INDICATIONS:1. OA/Chondromalacia of DRUJ2. Post traumatic ulno carpal impingement a/w

DRUJ arthrosis3. Yong RA pt. with ulnar translocation + DRUJ

disease4. RA pt. who may need a stable radioulnar

surface for support of an arthroplasty or implant