Distal radioulnar joint

1. DISTAL
RADIOULNAR
JOINT
Dnyanesh Lad

2. DRUJ + PRUJ = Longitudinal rotations
= Special type Bicondylar joint
Structural & Functional separation btw DRUJ
and carpal bones = pronation-supination
without affecting grasping

3. ANATOMY
Triangular Fibro cartilage of Palmar and Werner
Ulna to radius and ulnar side of carpus
TFCC includes
1.Dorsal & Volar Radio-ulnar ligs( Primary Restraint)
2.Volar Ulno-lunar lig.
3.Ulno-triquetral lig.
4.Ulnar collateral lig.
5.Articular disc
6.Extensor Carpi Ulnaris Sheath

4. TFCC Anatomy
Origin: 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 lig
Dorsal Insertions:
1.Triquetral
2.Hamate
3.Base of 5
th
metacarpal

5. FUNCTIONS OF TFCC
1.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

6. ADDITIONAL STABILITY TO DRUJ
1.Contour of sigmoid notch
2.Interosseous membrane
3.Extensor Retinaculum
4.Dynamic forces of ECU and pronator quadratus

7. In Ulna neutral Position of Wrist
20% applied load –Ulna
80% 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

8. 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

9. 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

10. 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, lunotriquetr
al jts
DRUJ arthritis
SYMPTOMS: Pain-
weakness-instability-loss
of motion

11. INVESTIGATIONS
RADIOGRAPHS
a. 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

12. c. Dynamic/Provocative/ Loaded views
Pt. made to make a fist/ squeeze an object
Compare with opposite side
USE: To recognize instability
d. Loaded PA radial and ulnar deviation views
USE: Movt. Of proximal row in relation with distal
radius and TFC.

13. TOMOGRAPHY
USE: accurate for DRUJ subluxation/dislocation
ADVANTAGES:
1.Does not require precise positioning
2.Can be done through a plaster cast
3.Sigmoid notch abnormalities assessed best
MRI
USE: location of ECU tendon, joint capsule,
TFCC tears.

14. ARTHROSCOPY
USE: Small joint arthroscope-
-TFCC tears
-Synovitis
-Erosion areas
-Rim avulsion of radial head of TFCC

15. 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

16. 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.

17. ESSEX-LOPRESTI INJURY
DRUJ disruption + displaced radial head + Proximal
migration of radius ~ 5-10mm
DISRUPTION OF:
1.DRUJ ligament
2.Interosseeos membrane
3.Radiocapitular articular surface
RADIOGRAPH: X ray Elbow+forearm+wrist
CT: Comparison of DRUJ
MRI: Interosseous haematoma
Rx: Fixation of large radial head fragment+ Reducn repair
fixn of DRUJ
Radial head comminuted-Excise it
Ulnocarpal impaction: hemiresection and arthroplasty

18. 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 weeks
Green recommends neutral rotation + ulnar
deviation for both
Direct TFCC Repair-intraosseous wire technique 24
gauge wire

19. 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.

20. BUNNEL-BOYES RECONSTRUCTION
OF DRUJ
For dorsal dislocation
Distally based FCU harvested proximally, stripped
distally to pisiform attachment
New ligament woven through the volar capsule
Stress on pisotriquetral jt relieved
New lig. Passed through drill hole in styloid to exit in
axilla of ulnar styloid process
Imbrication with dorsal capsule
C/I: VOLAR DISLOCATION

21. 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

22. IMPINGEMENT
ULNOCARPAL IMPACTION SYNDROME
Ulnar head impinges against carpus
Limitation of Rotation-ligaments relax around wrist
Symptoms:
1.Ulnar wrist pain
2.Rotation/Ulnar deviation
3.Clicks/crepitus in TFCC region
4.Long ulna relative to radius
X RAYS: Sclerotic/cystic changes in ulnar head &
lunate

23. PREDISPOSING CONDITIONS
1. Premature closure radial epiphysis 2* to trauma
(Acquired Madelung’s deformity)
2. Premature wrist fusion
3. Excision of radial head or shaft
4. Fracture malunions with shortening of radius
5. 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.

24. FOR DRUJ INCONGRUITY
1.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

25. 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

26. DISADVANTAGES OF BOWER’S ARTHROPLASTY
1.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 OSTEOTOMY
1.Unreconstructable TFCC
2.Advanced RA
3.Ulnocarpal translation (post traumatic/arthritic)

27. DARRACH’S PROCEDURE
Incision proximal from ulnar styloid
Separate ECU and FCU
BEWARE: Dorsal cutaneous br. Ulnar nerve
Osteotomy 2.5cm proximal to styloid
Mobilization encouraged within 24 hrs.
DISADVANTAGES:
1. Increased Ulnocarpal translocation/instability
2. Decreased Grip Strength

28. MODIFIED DARRACH’S PROCEDURES
1.Blatt and Ashworth: flap of volar capsule to dorsal
ulnar stump
2.O’Donovan and Ruby: tethering distal ulnar stump
with distally based strip of ECU
3.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

29. SAUVE KAPANDJI POCEDURE
Radio ulnar jt. Fusion
Creation of pseudoarthrosis proximal to fusion
INDICATIONS:
1.OA/Chondromalacia of DRUJ
2.Post traumatic ulno carpal impingement a/w
DRUJ arthrosis
3.Yong RA pt. with ulnar translocation + DRUJ
disease
4.RA pt. who may need a stable radioulnar
surface for support of an arthroplasty or
implant