This document provides an overview of distal radioulnar joint (DRUJ) issues and management. It discusses the anatomy and biomechanics of the DRUJ and its primary stabilizer, the triangular fibrocartilage complex (TFCC). It describes common injuries to the TFCC, including Palmer classification types 1A and 1B tears. Imaging options for evaluating the DRUJ are outlined. Initial conservative treatment is typically recommended for type 1A tears while type 1B tears often require arthroscopic or open repair depending on chronicity of the injury.

1. P R E S E N T E D B Y :
D R . N . B E N T H U N G O T U N G O E
P O S T G R A D U A T E
M . S ( O R T H O P E D I C S )
C E N T R A L I N S T I T U T E O F O R T H O P E D I C S
V M M C & S A F D A R J U N G H O S P I T A L
N E W D E L H I
DISTAL RADIO ULNAR
JOINT(DRUJ) ISSUES AND
MANAGEMENT

3. INTRODUCTION
 The distal radioulnar joint (DRUJ) is a diarthrodial, synovial
articulation that provides the distal link between the radius and the
ulna and a pivot for pronation-supination .
 Because the ulna and radius articular surfaces have different radii
of curvature, the soft tissues play a substantia role in guiding and
restraining the joint.
 During forearm motion, the DRUJ moves synchronously with the
proximal radioulnar joint, and any injury or deformity involving the
radius or ulna can alter the function of both joints.
 The DRUJ and ulnocarpal joint are also anatomically and
functionally integrated, so that both are affected by traumatic and
arthritic conditions.

4. BIOMECHANICS
 The normal arc of pronation and supination ranges among
individuals from 150 to 180 degrees. Additional rotation of up to
30 degrees occurs through the radiocarpal joint
 During forearm rotation, translation occurs between the ulnar
head and sigmoid notch, resulting in a combination of rolling
and sliding movements at the articular surface.
 when the unloaded forearm is in the neutral position, articular
contact is maximal, reaching 60% of the available surface area.
At the extremes of pronation and supination, there may be only 2
mm of articular contact at the rims of the notch (<10% of the
articular surface area).
 Translation can occur because the sigmoid notch is shallow, and
its radius of curvature is 50% to 100% greater than that of the
ulnar head.

5. In the transverse plane, the average sigmoid notch
subtends an arc of approximately 50 degrees

6.  Based on an anatomic study of 50 cadavers, four different
sigmoid notch shapes were found:
 flat face (42%),
 ski slope (14%),
 “C” type (30%), and
 “S” type (14%)
 NOTE: A flat sigmoid notch may be more prone to instability and
less responsive to treatment by soft tissue repair alone
 The ulna is the stable unit of the forearm and supports loads
transmitted from the radius and carpus. The ulnar head serves as
the articular seat for the sigmoid notch around which the radius
rotates. The surface of the ulnar head that faces the sigmoid notch
forms a slightly asymmetric, partial cylinder of about a 130-
degree arc.

8.  At the base of the ULNAR styloid and encompassing the geometric center
of the head, is a shallow concavity called the fovea that is devoid of
cartilage and replete with vascular foramina that supply vessels to the
TFCC .
 The fovea is the primary attachment site for the radioulnar and ulnocarpal
ligaments.
 The ulnar styloid is a continuation of the subcutaneous ridge of the ulna,
projecting 2 to 6 mm distally. It provides an increased area for soft tissue
attachments, including the extensor carpi ulnaris (ECU) tendon sheath and
thesecondary attachments of the radioulnar ligaments.
 Ulnar variance is the term used to relate the difference in lengths of the
radius and ulna. Ulna plus (or positive) and ulna minus (or negative)
describe the ulna as longer or shorter than the radius, respectively.

9. TFCC
 The TFCC, named by Palmer and Werner,is the most commonly used term for the
interconnected soft tissues that span and support the DRUJ and ulnocarpal
articulations.
 The primary functions of the TFCC are:
(1) extend the smooth articular surface of the distal radius to cover the ulnar head;
(2) transmit axial force across the ulnocarpal joint, while partially absorbing the load;
(3) provide a strong but flexible connection between the distal radius and ulna that
allows forearm rotation; and
(4) support the ulnar portion of the carpus through connections to the ulna and the
radius.
 The TFCC/ articular disk extends from the ulnar edge of the lunate fossa at the distal
rim of the sigmoid notch and blends peripherally with the radioulnar ligaments
 The radioulnar ligaments(PALMAR AND DORSAL) are the principal stabilizers of
the DRUJ. The ligaments extend from the palmar and dorsal distal margins of the
sigmoid notch and converge in a triangular configuration to attach to the ulna. the
palmar ligament prevents dorsal displacement in pronation, and the dorsal ligament
restrains palmar displacement in supination.

10. TFCC ANATOMY

11.  Because its skeletal architecture imparts minimal stability to
the DRUJ, the soft tissues are the prime stabilizers.
 Several soft tissue structures contribute to DRUJ stability,
including
 the pronator quadratus,
 ECU,
 interosseous membrane (IOM),
 DRUJ capsule,
 articular disk/TFCC,
 and palmar and dorsal radioulnar ligaments.
 Although multiple structures contribute to DRUJ stability,
the TFCC is generally accepted as the primary static stabilizer
in the transverse plane.

12. BLOOD AND VASCULAR SUPPLY OF TFCC
 Its vascular supply is primarily via the anterior interosseous
artery and ulnar artery.
 Vascular penetration into the disk extends only to its outer
15%, leaving the central portion essentially avascular.
 Similar to its vascular distribution, the neural supply of the
TFCC excludes the central portion of the disk.
 The volar and ulnar portions of the TFCC receive innervation
from the ulnar nerve, and the dorsal portion receives
innervation from the posterior interosseous nerve.

13. PHYSICAL EXAMINATION
 Symptoms are due to instability, stiffness, or degeneration,
 Tenderness in the soft depression between the flexorcarpi
ulnaris (FCU) tendon, ulnar styloid, and triquetrum is
suggestive of a TFCC injury.
 Decreased motion and crepitus during pronation-supination
are signs of DRUJ arthritis, which may be accentuated by
manually compressing the joint.
 Increased anteroposterior translation of the ulna on the
radius during passive manipulation is evidence of DRUJ
instability.

14. IMAGING
 A standard posteroanterior radiograph (neutral forearm rotation) is taken with
the shoulder abducted 90 degrees, the elbow flexed 90 degrees, the forearm and
palm flat on the cassette, and the wrist in neutral flexion-extension and neutral
radioulnar deviation.
 Measure the Ulnar Variance
 The standard lateral radiograph is taken with the shoulder at the patient’s side (0
degrees abduction), the elbow flexed 90 degrees, and the wrist in a neutral
position. An accurate view is marked by the palmar surface of the pisiform
visualized midway between the palmar surfaces of the distal pole of the scaphoid
and the capitate (the so-called SPC lateral).
 Evidence of DRUJ instability can be accentuated in a lateral stress view in which
the patient holds a 5-lb weight with the forearm in pronation and the x-ray beam
is directed “cross-table.”
 Semisupinated and semipronated views better show the rims of the sigmoid
notch and the dorsal and volar aspects of the ulnar head and are useful to
evaluate for fractures and arthritis.

17. Imaging: CT
 Several measurement methods have been used to
assess DRUJ instability, including use of dorsal and
palmar radioulnar lines described by Mino and
associates,
1. epicenter and congruency methods proposed by
Wechsler and colleagues,
2. radioulnar ratio described by Lo and co-workers

19. IMAGING : MRI
More useful in the diagnosis of TFCC tears, with
improved sensitivity, specificity, and accuracy in
addition to making anatomic measurements and
assessing stability.

21. Other imaging modalities
Arthrography: used less frequently
Scintigraphy: It is most useful in diagnosing ulnar
impaction syndrome, in which the ulnar head, lunate,
and triquetrum show increased uptake consistent with
chronic inflammation in the bone and soft tissues.
Arthroscopy:
 Arthroscopy is sensitive for identifying traumatic TFCC tears or
degeneration in the central portion of the disk, chondromalacia, and
ulnocarpal ligament injuries.
 A lax or hypermobile TFCC under direct probing—the socalled
trampoline effect—is indicative of an unstable TFCC.Arthrography

22. TFCC LESIONS
 PALMER CLASSIFICATION
 Traumatic TFCC Lesions: Mostly due to acute
rotational injury to the forearm, a combined axial
load and distraction injury to the ulnar border of
the forearm, or a fall on the pronated outstretched
hand.
 Degenerative TFCC Lesions: due to chronic,
excessive loading through the ulnocarpal joint and
are a component of ulnar impaction syndrome.

23. Palmer classification

24. Palmer Class 1-A tear/ central perforation
 Signs and Symptoms:
 ulnar-sided wrist pain that is aggravated by power grip, especially with ulnar deviation or
forearm rotation. It is a relatively common injury that produces pain and clicking.
 Does not cause DRUJ instability and does not require acute treatment.
 This tear is confined to the disk, located 2 to 3 mm ulnar to its radial
attachment, and oriented volar to dorsal.
 MANAGEMENT:
 These tears should initially be managed conservatively by rest, immobilization, anti-
inflammatory medications, and corticosteroid injection, but patients with ulnar-neutral
wrists and especially patients with ulnarpositive wrists are less likely to respond to
conservative management.
 Arthroscopic débridement is the preferred treatment for traumatic TFCC tears when
symptoms persist .

25. PALMER CLASS 1-B TEAR
 Partial or complete avulsion of the TFCC from its ulnar
attachments, with or without an ulnar styloid fracture
 .
 DRUJ instability may or may not be present.
 SIGNS AND SYMPTOMS:
 similar to a class 1A tear, but a click is usually absent, and tenderness is more
ulnar, with point tenderness directly volar to the ulnar styloid. This site overlies
the fovea, and tenderness located here has been termed the fovea sign
 MANAGEMENT:
 CONSERVATIVE: treated initially by above-elbow immobilization
for 4 to 6 weeks with the forearm in neutral rotation with
subsequent hand therapy.
 Arthroscopic repair or Open repair(in chronic cases especially if
there is an ulnar styloid nonunion)

27. Palmer class 1C Tears
Partial or complete tear of the ulnocarpal Ligaments, either within their substance or
at their attachments to the lunate and triquetrum.
These injuries can occur in combination with class 1B tears or lunotriquetral ligament
tears or both.
They are reported much less frequently than other TFCC injuries,
 probably because they are more difficult
 to diagnose and perhaps because they heal more reliably
 owing to their good vascular supply
 The most obvious sign of injury is a volar “sag” of the carpus relative to the ulnar
head, analogous to the “caput ulnae” syndrome in rheumatoid arthritis.
 There is little published literature concerning treatment of these injuries.
 Generally, these injuries should be managed conservatively, unless mechanical
instability is present

28. PALMER CLASS 1D TEARS
 Partial or complete traumatic avulsion of the TFCC
from the radius, with or without a bone fragment,
and may involve one or both radioulnar ligaments
 TREATMENT:
 frequently associated with a distal radius fracture and usually
respond to accurate fracture reduction of the radius
 Cooney’s repair using an open technique through a dorsal
approach

31. Cooney’s repair

33. ACUTE DISTAL RADIOULNAR
JOINT INSTABILITY
 Causes:
 DRUJ dislocation: dorsal more common than volar
 Distal radius fracture/Galaezzi
 Ulnar styloid fractures
 The radioulnar ligaments can tolerate no more than 5 to 7 mm of
radial shortening before one or both ligaments tear.
 In most cases, the secondary stabilizers of the DRUJ, including
the IOM, ECU subsheath, ulnocarpal ligaments, and
lunotriquetral interosseous ligament, maintain sufficient stability
during healing to result in a stable joint.
 Fracture reduction and maintenance of alignment of the radius
are the most important factors to allow stable healing of the
disrupted DRUJ

35. Evaluation
 An acute dislocation usually produces an obvious deformity
with the ulnar head locked over a rim of the sigmoid notch.
 Local tenderness, swelling, and limited motion are the
characteristic findings on presentation.
 Deep tenderness along the IOM and swelling or pain at the
proximal radioulnar joint may indicate a concomitant Essex-
Lopresti injury.
 Instability after reduction is marked by increased translation
of the ulnar head in neutral forearm rotation and may be
present in supination or pronation depending on the injured
soft tissue stabilizers.

36. Simple Dislocations of DRUJ
 Isolated dorsal DRUJ dislocation is more common than
palmar dislocation.
 Management:
 gentle pressure is applied over the ulnar head while the radius is
rotated toward the prominent ulna. After reduction, the joint should
be tested over the full range of forearm rotation to determine the
stable arc. Typically, a dorsal dislocation is most stable in supination,
and a palmar dislocation is most stable in pronation.
 If the joint is stable only in extreme pronation or supination,
additional treatment should be considered, such as radioulnar
pinning in the position of greatest stability or TFCC repair.
 If the joint is stable in an acceptable position of forearm rotation, it
is treated with an above-elbow cast in this position for 3 to 4 weeks
followed by use of a well-molded short arm cast for 2 to 3 weeks

38. Ulnar Styloid Fractures and Nonunions
 Frykman reported that ulnar styloid fractures occurred in approximately 61% of distal
radius Fractures.
 Fractures through the styloid base, especially when displaced, are associated with a
higher risk of DRUJ instability. Fixation of the styloid restores DRUJ stability, provided
that the TFCC is not otherwise damaged.
 Indications OF ULNAR STYLOID FRACTURE FIXATION: Isolated displaced
fracture through base of styloid, associated with unstable DRUJ, Persistent DRUJ
instability after accurate reduction of radius fracture
 Contraindications: Small fragment through its tip ,Nondisplaced fracture without
DRUJ instability
 METHODS OF FIXATION:
 fixation of the ulnar Styloid fracture , including Kirschner wires, tension band wiring,
compression screw, variable-pitch headless screws, mini-fragment plates, and suture
anchors
 Symptomatic nonunion of the ulnar styloid is an uncommon problem that is usually
best treated by simple subperiosteal excision. If the fragment is large, and the TFCC is
unstable, the periphery of the TFCC is repaired to the styloid base after fragment
excision with transosseous sutures

40. POST-TRAUMATIC (CHRONIC) DISTAL
RADIOULNAR JOINT INSTABILITY
 CAUSES:
 isolated trauma to the DRUJ
 fractures of the distal radius and ulna
 Madelung deformity
 unsuccessful attempts to repair the TFCC,
 inflammatory arthritis.
 DRUJ instability after a distal radius or forearm malunion
usually manifests as loss of forearm rotation, prominence of
the ulnar head, and ulnar-sided wrist pain.
 Complaints are caused by a combination of effects of the
malunion on the radiocarpal joint, ulnocarpal joint, and
DRUJ.

41.  Management:
 Conservative: less preferred/poor outcomes
 Surgical:
 Restoration of stability and a full, painless arc of motion are the goals
of surgical treatment for a post-traumatic unstable DRUJ.
 In established DRUJ instability without malunion or arthritis, the
ideal surgical option is late repair of the TFCC.
 A soft tissue reconstructive procedure is indicated when the TFCC is
irreparable and the sigmoid notch is competent.
 Fixation of a basilar fracture of the ulnar styloid alone in chronic
instability is usually ineffective because the soft tissues are
attenuated

42. DRUJ instability related to malunited distal radial fractures
can be treated with distal radial osteotomy and bone grafting
to correct shortening and angulation

44. Adams identified three categories
of soft tissue reconstruction for chronic DRUJ instability
 Soft tissue Reconstructive techniques can be
classified into three categories:
(1) a direct radioulnar tether that is extrinsic to the
joint,
(2) an indirect radioulnar link via an ulnocarpal sling
or a tenodesis,
(3) reconstruction of the distal radioulnar ligaments

45. Soft tissue Reconstructive techniques
1. Boyes and Bunnell:
-reconstructs volar ulnocarpal ligaments and creates a tether
between the distal radius and ulna).
2. Hui and Linscheid:
-reconstructs volar ulnocarpal ligament using strip of
FCU tendon.
3. Johnston Jones and Sanders:
-reconstruction of both radioulnar ligaments with a
palmaris tendon graft

46. Boyes and Bunnell technique

47. Hui and Linscheid technique

48. Johnston Jones and Sanders technique

49. Sigmoid notch osteoplasty
 To improve the mechanical buttressing effect of the
rim of the sigmoid notch, an osteoplasty can be
considered as an isolated procedure or to
complement a ligament reconstruction.

50. Wallwork and Bain’s Sigmoid Notch Osteoplasty
Technique

51.  Hermansdorfer and Kleinman found reattachment of the
TFCC effective for minimal subluxation.
 The reports of Bach et al. and of Scheker et al. suggested
that tenodesis augmentation of TFCC repair with
extensor carpi ulnaris (Bach) or tendon graft
reconstruction through radioulnar drill holes (Scheker)
helped to stabilize the DRUJ.
 Adams emphasized the importance of reconstruction of
the distal radioulnar ligaments to restore DRUJ stability
and to preserve DRUJ motion

52. In patients with posttraumatic
DRUJ instability, Adams and Berger found that anatomical
reconstruction of the distal radioulnar ligaments restored
stability, preserved motion, and relieved pain

53. SCHEKAR TECHNIQUE

54. ULNAR IMPACTION-ABUTMENT AND DISTAL
RADIOULNAR JOINT ARTHRITIS
 Patients with acquired or developmental ulnar-positive variation
may develop degenerative changes in the triangular fibrocartilage,
ulnar head, articular surfaces of the lunate and triquetrum, and
lunotriquetral interosseous ligament.
 Symptoms: ulnar wrist pain aggravated by ulnar deviation with
forearm rotation
 CAUSES of Positive ulnar variation:
 may be a normal finding
 Madelung deformity.
 Shortening of the radius after fracture
 radial head fracture-dislocation with interosseous membrane injury (Essex-
Lopresti),
 traumatic growth arrest of the distal radius

55. MANAGEMENT
CONSERVATIVE: activity modification,
splinting,oral medications, and injections of
corticosteroids.
SURGICAL: Arthroscopic joint débridement, open or
arthroscopic distal ulnar resection, and ulnar
shortening osteotomy

56. ULNAR SHORTENING OSTEOTOMY(CHUN AND PALMER))

58. LIMITED ULNAR HEAD EXCISION:
HEMIRESECTION INTERPOSITION
ARTHROPLASTY(Bower’s)

59. WAFER” DISTAL ULNAR RESECTION

60. Sauve Kapandji’s procedure
1. Resection of a portion of distal ulna shaft and
fusion of ulnar head to radius.
2. Maintains function of TFCC & maintains normal
anatomic configuration of wrist.
3. Should not be performed with ulnar variance
positive unless ulna shortened as part of procedure

61. DISTAL RADIOULNAR ARTHRODESIS WITH DISTAL ULNAR
PSEUDARTHROSIS (BALDWIN; SAUVÉ-KAPANDJI; LAUENSTEIN)

62. Distal Ulnar Resection
(Darrach Procedure)
 The general indication for a distal ulnar resection is
any condition that causes incongruity or arthritis of
the DRUJ, with resultant pain or stiffness.
 The procedure is particularly effective in a low-
demand patient with an incongruous or degenerative
sigmoid notch owing to the sequelae of an intra-
articular fracture.
 COMPLICATIONS:
 Increased ulno-carpal translocation
 Decreased grip strength
 Unstable rotation of radio carpal joint

64. THANK YOU
DR. BEN