Διάγνωση και αντιμετώπιση της οξείας ασταθειας της απω κερκιδωλενικής. Acute distal radioulnar joint Instability, isolated and with concommitan fracture, diagnosis and treatment
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Οξεία Αστάθεια της Άπω Κερκιδωλενικής 016/ Acute DRUJ Instability 016
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?
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
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
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
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
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
41.
42.
43.
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
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
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
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
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