Distal radioulnar joint injuries( DRUJ) and carpal instability

Distal radioulnar joint injuries( DRUJ) and carpal instability

1. 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 Sreekanth Dr. Paul Brand Centre for Hand Surgery, CMC Hospital, Vellore, Tamil Nadu, India

2. 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

3. 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

4. Anatomy diarthrodial trochoid synovial joint two parts the bony radioulnar articulation and soft tissue stabilizers.

5. 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

6. 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

7. 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 .

8. triangular fibrocartilaginous complex (TFCC). Diagrammatic representation of the TFCC, superimposed on a dissected specimen, 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

9. 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

10. Special tests Impingement sign The ulna fovea sign The piano-key test The table top test The Grind test

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. Injuries of DRUJ and TFCC- A working classification

18. 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

19. Palmer’s Classification of TFCC injuries

20. 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

21. Treatment of TFCC injuries

22. 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

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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?

29. Galeazzi fracture-dislocation Palmer Type IB TFCC injury is classically seen 80% of t hese 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

30. Galeazzi fracture-dislocation Stabilize radius DRUJ reduced spontaneously check instability soft tissue interposition DRUJ is pinned open reduction

31. 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

32. (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

33. 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.

34. Classification of Essex- Lopresti and suggested management

35. 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.

36. 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

37. 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

38. 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 .

39. Diagrammatic representation of Adams-Berger procedure for chronic DRUJ instability. The dorsal and volar radioulnar ligaments are reconstructed with a palmaris longus graft.

40. 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??

41. 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.

42. 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

43. (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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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.

52. Thank you

53. 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

54. 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.

55. 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

56. 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.

57. 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

58. 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.

59. 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

60. 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

61. 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