Διάγνωση και αντιμετώπιση της οξείας ασταθειας της απω κερκιδωλενικής. Acute distal radioulnar joint Instability, isolated and with concommitan fracture, diagnosis and treatment

1. Nickolaos A. Darlis, MD
Acute DRUJ
Instability
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2. DRUJ Instability is a clinical diagnosis
Radioulnar ballottement test
(Neutral- pronation- supination) DRUJ compression test
Piano- Key sign
ECU subluxiation in supination-
ulnar deviation

3. The unsolved questionThe unsolved question
• How do you define and test DRUJ stability in
the acute setting?

4. The unsolved questionThe unsolved question
• How do you define and test DRUJ stability in
the acute setting?

5. “Forearm Joint”
One functional unit

6. “Forearm Joint”
The forearm as a ring

7. Anatomy Distal Radius

8. DRUJ Anatomy
• Radii of curvature differ
– 10mm vs 15mm
– Full congruity impossible

9. DRUJ anatomy
• Congruity of DRUJ
– Neutral rotation: 60% of
sigmoid notch in contact
– Extremes of rotation: 10%
– Dorsal and palmar rims
important
• Little osseous stability

10. The Iceberg Concept Atzei &Lucetti 2011

11. radius
ulna
N.D

12. radius
ulna
N.D

13. radius
ulna
N.D
Volar & Dorsal Radioulnar Lig
Foveal attachment

14. TFC MENISCUS
radius
ulna
N.D

15. radius
ulna
N.D
TFC CRUCIATE Lig

16. Volar & Dorsal RU lig.-Foveal
Attachment

17. TFCC anatomy
• Vascular supply
– Central portion
• avascular
– Periphery (dorsal and
palmar radio-ulnar
ligaments)
• vascularized

18. DRUJ
• Rotation
• Load transmission
• Stability

19. Kinematics
• Radius rotates about the distal ulna
• “Ulnar head dislocation” by convention
• Axis of rotation

20. Load transmission (RH intact )
80%
20%
40% 60%
U
U
R
R

21. Load Transmission
Explains common fracture patterns
Galeazzi
Forearm
Monteggia
Essex-
Lopresti

22. Interosseous Membrane Anatomy
Two main bands:
• Central Band (volar)
• Proximal Interosseous
Band (dorsal)
• Accessory bands (1-5)
• Membranous portion CB
PIOB

23. IOM-Central Band
• 70% of forearm
stability
• Injury of other elements
of IOM (partial tears),
increase CB strains
Radius
Ulna
CB

24. IOM Anatomy
60%
40%
35%
75%
250
120mm

25. Essex –Lopresti injury
Acute TFCC tear management
Galeazzi Fracture /Dislocation
Distal Radius Fractures
Isolated Ulnar head dislocation
Acute DRUJ Instability:

26. Isolated Ulnar head DislocationIsolated Ulnar head Dislocation
• Dorsal: reduce in supination
• Palmar: reduce in pronation
• Global instability: usually requires
stabilization
• If stable: immobilize in stable
position
– Sugartongue splint for 6 weeks

27. • Failed closed reduction may result from
trapped ECU, capsule, ulnar styloid, extensor
tendon
• Open reduction dorsal - 5th compt.
• TFCC repair if avulsed
Isolated Ulnar head DislocationIsolated Ulnar head Dislocation

28. DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• 1777 Desault isolated DRUJ dislocation
• 1814 Colles: DRUJ with distal radius
– “at some remote period again enjoy perfect freedom”
• 1837- Diday
– “the problem is really the overriding ulna”
• 1934 Galeazzi
• 1951 Essex-Lopresti
• 1967 Frykman
– “Disturbances of the DRUJ make for worse results”

29. DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• “Most common source of pain following distal
radius Fx”
Fernandez &Geissler JHS 1992
• Loss of supination most common functional
complaint following distal radius Fx
Hanel AAOS ICL 2004
• Residual depression of the lunate facet ≥2mm
results in articular incongruity and arthrosis
Jupiter JBJS 1986

30. Highly possible when:
• shortening >5-7mm

31. Highly possible when:
• shortening >5-7mm
• radialy displaced fx base
of the ulnar styloid

32. Highly possible when:
• shortening >5-7mm
• radialy displaced fx base
of the ulnar styloid,
• angulation >25-300
any
plane

33. Highly possible when:
• shortening >5-7mm
• radialy displaced fx base
of the ulnar styloid
• angulation >25-300
any
plane
• DRUJ diastasis in PA Rö
projection

34. DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• Accurate osseus reduction first
– Ulnar column stabilization

35. Common pitfallsCommon pitfalls
• Radial translocation- sigmoid notch
malreduction

36. Common pitfallsCommon pitfalls
• Excessive volar tilt/ translocation

37. DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
• Geissler and Fernandez Instabilty classification
AFTER radius reduction
– Type I: Stable
– Type II: Unstable
– Type III: Potentially Unstable

38. Type I: Stable
• minimally displaced avulsion tip of the ulnar
styloid
• fracture of the neck of the ulna
(just fix)

39. Type III: Potentially Unstable
• Fx through sigmoid notch (4-part fracture) or
• Ulnar head fracture
(fix & test)

40. Type II: Unstable
• avulsion Fx base of the ulnar styloid or
• massive tear of the TFCC and/or secondary
stabilizers

44. Ulnar styloid FxUlnar styloid Fx
• Management controversial
• May be fixed or tends to reduce in supination
• Fix when DRUJ unstable, usually base.
• Make sure TFCC attaches to fragment

45. Ulnar styloid FxUlnar styloid Fx
• CRIF: easier said than done; supinate
• Re-check stability

46. Ulnar styloid FxUlnar styloid Fx
• ORIF: ample skin incision
– Kirschner wires,
– tension band wire
– screw
– suture anchors
• Re-check stability

47. Ulnar styloid FxUlnar styloid Fx
• ORIF
– Dedicated plates
• Re-check stability

48. Ulnar styloid FxUlnar styloid Fx
• However, if no clinical instability, value of
fixation questionable
152 pts with displaced fx involving 75% of ulnar styloid
– 76 treated and 76 untreated
• The fracture itself trended to worse outcomes than if there
was no fracture
• No differences noted between the treated group and the
untreated group

49. Ulnar styloid non-unionsUlnar styloid non-unions
• Type I- tip - stable → excision
• Type II- base – unstable →ORIF ± TFCC repair

50. DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
If DRUJ stable after osseus fixation (distal radius
± ulna):
• Immobilize in stable position for 4-6 weeks
– Sugartongue splint
– Avoid excessive pronation (DRUJ stable but
associated w loss of forearm motion)

51. DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures
Congruent reduction with an unstable joint,
consider:
• Cross pinning
– Pin breakage
• TFCC repair
• External fixation

52. Galeazzi fracture/dislocationGaleazzi fracture/dislocation
• Accurate ORIF first
• Same principles for DRUJ as for distal radius Fx

53. Essex Lopresti injuryEssex Lopresti injury
Failure of the IOM
• Acute
• Secondary to overload following Radial Head Excision

54. Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis
• Distal Radioulnar Joint pain
and dissociation
• Distraction-compression X-
rays
• Intraoperative manual
testing

55. Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis
• MRI
• Ultrasound

56. • Radial Head Reconstruction-
Replacement
• DRUJ reduction- pinning
• TFCC repair?
Acute Essex Lopresti injury-TreatmentAcute Essex Lopresti injury-Treatment

59. Essex Lopresti injury- complicationsEssex Lopresti injury- complications
• Proximal radial migration
• Symptomatic DRUJ
subluxation

60. Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency
• Ulnar shortening
• Radial Head Replacement
Results inconsistent

61. Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency
• Attempts at IOM reconstruction
60%
40%
35%
75%
250
120mm
BPTB
IOM
FCR

62. Acute TFCC tearsAcute TFCC tears
ISOLATED WITH DISTAL RADIUS Fx

63. Wrist arthroscopy in distal radius FxWrist arthroscopy in distal radius Fx
Concomitant lesions increasingly recognized:
• ΤFCC ≈60% (43-78%)
• SL lig.≈ 40% (32-75%)
• LT lig. ≈20% (15-61%)
• Chondral lesions ≈20% (19-32%)

65. Common misconceptionsCommon misconceptions
• TFCC tear ≠ DRUJ instability
– In fact: most tears do not have evident instability
• Ulnar styloid fracture ≠ DRUJ instability
– Styloid fractures may co-excist with TFCC tears

66. Acute TFCC treatmentAcute TFCC treatment
“Initial conservative treatment for
8 -12 weeks”

67. Literature, Conservative treatmentLiterature, Conservative treatment

68. Literature, TFCC with Distal Radius FxLiterature, TFCC with Distal Radius Fx
• Contradicting …

69. Treatment algorithmTreatment algorithm
Isolated TearIsolated Tear ConservativeConservative
Distal Radius Fx Conservative Conservative
Distal Radius Fx OperativeDistal Radius Fx Operative Consider Arthroscopy*Consider Arthroscopy*
DRUJ Instability Consider Arthroscopy*/
Cross pinning
* Especially in young, high demand patients
Follow-up all conservative patients closely

70. Timing of operative repairTiming of operative repair
ACUTE
Good Healing Potential
SUBACUTE
Unpredictable
CHRONIC
Poor Healing Potential
0 6 months 1 year
3mo 6mo

71. Conservative treatmentConservative treatment
• Sugartongue or Long Arm splint 3-4 weeks
• Short Arm Splint 1-2 weeks

72. Palmer Classification
Class 1: Traumatic Injuries
A Central perforation of the disk proper
B Peripheral avulsion from the ulna
Without styloid fracture
With styloid fracture
C Distal avulsion from the carpus
D Radial avulsion
Without sigmoid notch fracture
With sigmoid notch fracture
D TFCC perforation + lunate and/or head chondromalacia +
lunotriquetral ligament perforation
E TFCC perforation + ulnocarpal arthritis
Class 2: Degenerative Injuries
A TFCC wear
B TFCC wear + lunate and/or head
chondromalacia
C TFCC perforation + lunate
and/or head chondromalacia

73. Central tear
Peripheral tear)
Radial tear
Tear locationTear location
Deep bundle
of TFCC
Volar radioulnar
lig.
radius
ulna
N.D

74. Central TFCC lesionsCentral TFCC lesions
• Poorly vascularized- healing potential minimal
• Arthroscopic debridement up to 2/3 of
articular disc

75. Shaver debridement
Central TFCC lesionsCentral TFCC lesions

76. Arthroscopic TFCC debridement using radiofrequency probes
Darlis NA & Sotereanos DG, JHS(B)2005
Central TFCC lesionsCentral TFCC lesions

77. 1. Central TFCC lesions1. Central TFCC lesions
• Often degenerative and
associated with ulnocarpal
impaction syndrome
• Ulnar recession procedure to
prevent symptom recurrence

78. Ulnocarpal Impaction SyndromeUlnocarpal Impaction Syndrome
Clinical features:
• Ulnar sided wrist pain
• Associated degenerative changes:
– Ulnar side of the lunate
– Radial side of the ulnar dome
– TFCC central tear
– Triquetrum- LunoTriquetrum lig.
• Usually positive or neutral ulnar

79. Arthroscopic Wafer procedureArthroscopic Wafer procedure

80. Arthroscopic Wafer procedureArthroscopic Wafer procedure

81. Open Ulna Recession ProceduresOpen Ulna Recession Procedures
• Several options…

82. Open Ulna Recession ProceduresOpen Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis & Sotereanos JHS(A), 2005

83. Peripheral (ulnar) TFCC tearsPeripheral (ulnar) TFCC tears
• Well vascularized
• Repairable

84. Usual location of peripheral tearsUsual location of peripheral tears
Dorsal

85. Usual location of peripheral tearsUsual location of peripheral tears

86. REPAIR TO CAPSULE REATTACH TO FOVEAOR
TFCC TFCC
3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears

87. REPAIR TO CAPSULE
REATTACH TO FOVEA
3. Peripheral (ulnar) TFCC tears

88. • Clinical DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal
Arthroscopy
Foveal attachment involvement

89. Hook test

90. REPAIR TO CAPSULE

91. REPAIR TO CAPSULE

92. 1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA

93. 2. All Arthroscopic, Knotless: Geissler
REATTACH TO FOVEA

95. TFCC
6R
ACC 6R

96. TFCC
6R
ACC 6R

97. TFCC
6R
ACC 6R

99. TFCC
6R
ACC 6R

100. TFCC
6R
ACC 6R

102. Take Home MessagesTake Home Messages

103. Take Home MessagesTake Home Messages

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