The Distal Radioulnar Joint: Problems and Solutions

Larry K. Chidgey, MD

Abstract

Disorders of the distal radioulnar joint are a major source of ulnar-sided wrist Examination of the histology of pain. Fortunately, our understanding of the anatomy, joint mechanics, and patho- the TFCC helps in understanding physiology of this area has increased greatly in recent years, making resolution of its anatomy.2 Because collagen many of these problems feasible. In most cases, an accurate diagnosis can be made, fibers are oriented along lines of and successful treatment can then be prescribed. This review covers various prob- stress, microscopic observation of lems affecting the distal radioulnar joint, including fractures and dislocations, tri- the fiber arrangement provides angular fibrocartilage pathology, arthritis, and other disorders. insight into the stresses within the J Am Acad Orthop Surg 1995;3:95-109 TFCC. The dorsal and palmar radioulnar ligaments are com- posed of longitudinally oriented Disorders of the distal radioulnar degrees. The radius of curvature of bundles of collagen fibers that joint (DRUJ) are a common source of the sigmoid notch is 15 mm, com- originate and insert directly into ulnar-sided wrist pain. The ulnar pared with 10 mm for the ulna, bone, as they do in ligaments else- side of the wrist has often been resulting in both rotational and slid- where in the body. likened to the lower back because of ing motions in the normal joint. The central articular disk is com- the difficulties involved in establish- The DRUJ is one part of the fore- posed of fibrocartilage that origi- ing a specific diagnosis for pain at arm joint. During forearm motion, nates from the hyaline cartilage of both sites and therefore in prescrib- the entire length of the radius and the distal radiolunate fossa. The ing an effective treatment plan. For- ulna, the interosseous membrane, hyaline cartilage of the lunate fossa tunately, increased research interest and the proximal radioulnar articu- continues around the edge of the dis- during the past two decades has lation interplay with the DRUJ. In tal radius and is continuous with the improved our understanding of certain pathologic conditions, this hyaline cartilage of the sigmoid both the anatomy and the pathology critical interplay is compromised. notch. The continuous layer of hya- of this area of the wrist. As a result, The DRUJ is normally separated line cartilage has a different signal accurate diagnosis has been facili- from the radiocarpal joint by the tri- intensity on magnetic resonance tated, making possible the appropri- angular fibrocartilage complex (MR) imaging than the adjacent ate treatment that will yield a (TFCC). The term “TFCC” was articular disk fibrocartilage. This satisfactory outcome in most cases. coined by Palmer and Werner1 in difference in signal intensity should 1981. The complex includes the articular disk, or triangular fibrocartilage Anatomy proper; the dorsal and palmar Dr. Chidgey is Associate Professor, Department radioulnar ligaments; the meniscus of Orthopaedics, University of Florida College of The articulation of the distal radius homologue; and the extensor carpi Medicine, Gainesville. and ulna is through the sigmoid ulnaris sheath (the floor of which is notch of the radius and the ulnar often called the ulnar collateral liga- Reprint requests: Dr. Chidgey, Department of head (Fig. 1). The arc of curvature of ment) (Fig. 2). Although neither Orthopaedics, University of Florida PO Box 100246, Gainesville, FL 32610. the sigmoid notch ranges from 47 to included in the TFCC nor a part of the 80 degrees. Articular cartilage cov- DRUJ, the ulnotriquetral and ulnolu- Copyright 1995 by the American Academy of ers a much greater arc of the ulnar nate ligaments play an important Orthopaedic Surgeons. head, ranging from 90 to 135 functional role in this area of the wrist.

Vol 3, No 2, Mar/Apr 1995 95 Distal Radioulnar Joint

ments are well vascularized, as is the peripheral 15% to 20% of the articular disk. The central 80% to 85% is avascular, with no vessels entering Fig. 1 Articulation between the articular disk from the radius. Radius the sigmoid notch of the Therefore, traumatic peripheral tears radius and the ulnar head, viewed both end-on (left) and avulsions from the ulna have the and dorsally (right). The arc vascular potential to heal, while trau- 47°-80° covered with articular carti- matic tears located centrally and lage is greater for the ulnar head than for the sigmoid along the origin from the radius do notch, while the radius of not. Interestingly, however, a recent °-13 90 5°°° curvature is greater for the study in dogs has shown some heal- sigmoid notch. This results Ulna 15 mm in both rotational and slid- ing capability of traumatic articular- ing motions during supina- disk tears in the avascular region.4 In 10 mm tion and pronation. contrast, there is no evidence that central degenerative perforations are capable of healing.

Joint Mechanics not be misinterpreted as a tear in the The extrinsic vascularity of the articular disk. DRUJ is supplied from the dorsal Compressive loads across the wrist The site of origin of the articular and palmar branches of the anterior not only are borne by the distal disk fibrocartilage from the hyaline interosseous artery and the dorsal radius but also are transmitted through cartilage is reinforced by thick col- and palmar radiocarpal branches of the TFCC to the ulnar head. In a lagen bundles projecting 1 to 2 mm the ulnar artery. Interosseous vessels human cadaver study, Palmer and from the radius into the articular from the ulnar head also enter the Werner5 found that 82% of the com- disk. A common tear of the articu- TFCC through the foveal area. The pressive load across the wrist is lar disk is oriented in the sagittal dorsal and palmar radioulnar liga- transmitted through the radiocarpal plane at the junction of these thick bundles with the remainder of the Table 1 disk (a subtype of class 1A in Palmer’s Classiﬁcation of TFCC Injuries3* Palmer’s classification of TFCC injuries3 [Table 1]). Class 1: Traumatic In the central portion of the disk, Type A: Central perforation the collagen fibers are oriented at Type B: Medial avulsion (ulnar attachment) oblique angles to each other, form- With distal ulnar fracture ing a wave pattern. The interweav- Without distal ulnar fracture Type C: Distal avulsion (carpal attachment) ing of these waves produces a Type D: Lateral avulsion (radial attachment) basket-weave configuration well With sigmoid-notch fracture suited for both compressive and ten- Without sigmoid-notch fracture sile stresses. On the ulnar side, the Class 2: Degenerative (ulnocarpal impaction syndrome) collagen fibers coalesce into two Stage A: TFCC wear main bundles, one inserting into the Stage B: TFCC wear with lunate and/or ulnar chondromalacia styloid and one into the foveal area. Stage C: TFCC perforation with lunate and/or ulnar chondromalacia These two fiber bundles are sepa- Stage D: TFCC perforation with lunate and/or ulnar chondromalacia and rated by loose vascular connective lunotriquetral-ligament perforation tissue, which occupies the floor of Stage E: TFCC perforation with lunate and/or ulnar chondromalacia, the prestyloid recess and is fre- lunotriquetral-ligament perforation, and ulnocarpal arthritis quently involved in early rheuma- *Adapted with permission from Palmer AK: Triangular fibrocartilage complex lesions: toid arthritis of the wrist, producing A classification. J Hand Surg [Am] 1989;14:594-606. a lytic lesion on radiographs of this area.

96 Journal of the American Academy of Orthopaedic Surgeons Larry K. Chidgey, MD

load to 4.3%. Ulnar variance is not static; changes in forearm position and power grip continually alter it. ECU Full forearm pronation increases sheath ulnar variance, while full forearm Meniscus supination decreases it. Ulnar vari- homologue ance also becomes more positive with power grip. Variance changes PR related to forearm rotation and grip may be as much as 2 to 3 mm. Changes of this magnitude demonstrate the large load alterations across the ulnocarpal articulation during daily activities involving rotation of the forearm and grip. The structures contributing to sta- A B bility of the DRUJ include the TFCC, the extensor carpi ulnaris and its Triquetrum sheath, the interosseous membrane, the pronator quadratus, the forearm muscles that cross the supination- Lunate pronation axis, and the osseous UT ligament architecture of the joint. The exact PRUL UL ligament

Ulna AD DRUL

Radius

C D

Fig. 2 Dorsal views of the TFCC, looking from radial to ulnar. A, All components are shown in an intact TFCC. The sheath of the extensor carpi ulnaris (ECU) extends farther than drawn, reaching the fifth metacarpal with connections to the triquetrum and hamate. B, The sheath has been removed along with its thickened floor, called by some the “ulnar collateral ligament.” The meniscus homologue (MH) originates from the dorsal margin of the radius and sweeps palmarly and ulnarly to insert into the palmar/ulnar aspect of the triquetrum. Along its course, fibers insert into the ulnar styloid. As the MH sweeps past the palmar radioulnar ligament, it forms the dorsal roof of the prestyloid recess (PR), a synovium-lined recess that variably connects to the palmar aspect of the ulnar styloid. C, The MH has been removed to show the articular disk (AD), palmar radioulnar ligament (PRUL), and dorsal radioulnar ligament (DRUL). D, The TFCC has been removed. The ulnolunate (UL) and ulnotriquetral (UT) ligaments extend from the palmar aspect of the respective carpal bones and lunotriquetral ligament to the ulna, inserting into the foveal area and the base of the ulnar styloid.

Fig. 3 Ulnar variance is measured on a standardized PA radiograph. A line perpen- articulation, and 18% is transmitted technique of measuring ulnar vari- dicular to the longitudinal axis of the radius through the ulnocarpal articulation ance.) A 2.5-mm increase in variance is drawn at the level of the subchondral bone with a neutral ulnar variance. Small raises the ulnocarpal articular load of the palmar lip of the lunate fossa. The dis- tance the ulnar head extends above or below changes in ulnar variance can alter to 42%. A 2.5-mm decline in ulnar this line is the ulnar variance. In this case this force distribution markedly. variance from the neutral position there is 1 mm of positive ulnar variance. (Figure 3 illustrates the radiographic lowers the ulnocarpal compressive

Vol 3, No 2, Mar/Apr 1995 97 Distal Radioulnar Joint contribution of each to DRUJ stabil- caused DRUJ instability with symptoms, vary widely. By develop- ity has yet to be fully defined, but supination, but the joint was stable ing an orderly approach to the history clearly primary and secondary stabi- with pronation. In full pronation, and physical examination based on lizers are involved. the ulnar head slid dorsally, and the full knowledge of the possible injuries Palmer and Werner1 concluded intact palmar radioulnar ligament to and disorders of the DRUJ, the clin- from their study of cadavers that the became tight. The interaction ician can avoid oversights in diagnosis TFCC is the major stabilizer of the between the tight palmar ligament (Table 2). Important aspects of the his- DRUJ. As the authors sequentially and the dorsal lip of the sigmoid tory and physical examination will be sectioned the pronator quadratus, the notch provided stability. reviewed below as specific problems capsule of the DRUJ, and the TFCC, The studies by Schuind et al6 and of the DRUJ are discussed. As with the distal ulna was loaded dorsally, Ekenstam and Hagert7 suggest con- many musculoskeletal conditions, the palmarly, or laterally at various fore- tradictory conclusions regarding choice of treatment will be influenced arm positions. The pronator quadra- tension in the dorsal and palmar by the age of the patient, hand domi- tus and the capsule of the DRUJ radioulnar ligaments during supina- nance, and vocational and recreational contributed minimally to stability, tion and pronation. However, demands. Thus, this is important while sectioning of the TFCC resulted Schuind et albelieve that the two dif- information to obtain from all patients. in complete dislocation of the DRUJ ferent observations may actually be During the physical examination, except in full pronation. In this posi- compatible; that is, the tension pat- it is essential to compare the upper tion, the ulna displaced dorsally after tern may change in the ligaments, extremities, particularly because the TFCC sectioning, with incomplete progressing from normal motion to normal range of motion and laxity of palmar displacement. Complete pal- the extreme positions where disloca- the DRUJ vary considerably among mar displacement was prevented by tion takes place (Fig. 4). individuals. Range of motion can the interosseous membrane and the vary anywhere from 75 to over 100 osseous architecture. degrees of supination and pronation. The role played by individual com- Diagnostic Evaluation ponents of the TFCC in maintaining Imaging Studies stability remains controversial. The History and Physical central two thirds of the articular disk Examination Standard Radiography can be resected without affecting The histories of patients with DRUJ Standard radiographs should joint stability. Using a stereopho- problems, including the onset of include a posteroanterior (PA) and a togrammetric method in cadavers, Schuind et al6 demonstrated that the palmar radioulnar ligament is taut during normal supination, while the dorsal radioulnar ligament is taut during pronation. In another study of cadavers, Ekenstam and Hagert7 assessed DRUJ stability after sectioning either the dorsal or the palmar radioulnar ligament. After division of the palmar ligament alone, the DRUJ was stable during supination, but during pronation the ulnar head would dis- locate dorsally in relation to the radius. In full supination, the ulnar head slid palmarly and the still- intact dorsal radioulnar ligament Fig. 4 Tension patterns in the dorsal radioulnar ligament (DRUL) and the palmar radioul- became tight. Stability was pro- nar ligament (PRUL). Top, Studies have shown that during normal motion the DRUL is tight 6 vided by the interaction between the in pronation and the PRUL is tight in supination. Bottom, In apparent contradiction to the findings in normal motion studies, Ekenstam and Hagert7 have shown that in pronation the tight dorsal radioulnar ligament and PRUL is the important ligament in preventing dorsal dislocation and that in supination the the palmar lip of the sigmoid notch. DRUL prevents palmar dislocation. Division of only the dorsal ligament

98 Journal of the American Academy of Orthopaedic Surgeons Larry K. Chidgey, MD

tion/pronation. On a true lateral Table 2 view, the pisiform should overlie the Injuries and Disorders of the DRUJ distal third to fourth of the distal Intra-articular fractures without instability pole of the scaphoid. The variable Sigmoid notch (intra-articular distal radial fractures) shape of the distal ulna makes align- Ulnar head (including chondral fractures) ment of the dorsal cortex of the Ulnar styloid radius and ulna an unreliable deter- TFCC injuries without instability minant of a true lateral view. Com- Traumatic (some of Palmer’s class 1 injuries will be associated with parison lateral views taken with dislocation/instability) identical rotation of both forearms Degenerative (ulnocarpal impaction syndrome [Palmer’s class 2 injuries]) may show DRUJ subluxation or dis- Idiopathic positive ulnar variance location. However, one must be cau- Acquired positive ulnar variance tious about overinterpreting a single Dislocations and instability Acute lateral view, as this can be a pitfall in Dorsal with or without fracture diagnosing DRUJ subluxation. A Palmar with or without fracture few degrees of rotation can make the Multidirectional with or without fracture normal ulnar head appear dorsally Proximal-distal instability (Essex-Lopresti) or palmarly subluxated. Chronic (with or without arthritic changes) Oblique views in the semi- Dorsal with or without malunion or nonunion pronated and semisupinated posi- Palmar with or without malunion or nonunion tions may be used to profile the Multidirectional with or without malunion or nonunion dorsal and palmar ulnar aspects of Proximal/distal instability the wrist, respectively. The semi- Chronic instability after DRUJ resectional arthroplasty supinated view is especially helpful Arthritis (e.g., osteo-, posttraumatic, or rheumatoid arthritis, gout, pseudogout) when visualizing the pisotriquetral Other disorders joint and the hook of the hamate. A Congenital (Madelung’s deformity) metal marker over the specific site of Unstable extensor carpi ulnaris tendon tenderness may be helpful in identi- Fixed forearm rotational contracture fying the source of pain. Tumor (hereditary multiple exostosis involvement of DRUJ) Stress views with a subluxating force applied to the ulna may reveal patterns of instability. When evaluating pain due to suspected ulnocarpal impaction syndrome, it is lateral view. Hardy et al8 have ing the standard ulnar variance PA helpful to obtain a PA view with the pointed out several advantages of view with the wrist in full ulnar devi- forearm fully pronated while the obtaining the PA view in the “stan- ation. The scaphoid is rotated into a patient makes a tight fist. In patients dard ulnar variance position” (Fig. more horizontal position, which with ulnocarpal impaction syn- 4), in which the forearm is posi- facilitates the search for a possible drome, symptoms are usually most tioned in neutral pronation/supina- scaphoid fracture. The movement of pronounced in this position. Both tion, the shoulder is abducted 90 the lunate can also be assessed with grip and pronation of the forearm degrees from the side, the elbow is ulnar deviation. In the neutral posi- increase (i.e., make more positive) flexed 90 degrees, and the wrist is tion, the lunate is half on and half off ulnar variance. maintained in neutral flexion/exten- the ulnar border of the radius. Nor- sion. In this position, the ulnar sty- mally, the lunate moves entirely over Computed Tomography loid process projects along the ulnar the radius with ulnar deviation. The Computed tomography (CT) is the edge of the ulna, and the fovea at the lack of lunate movement radially study of choice for evaluating base of the ulnar styloid is clearly with ulnar deviation has been associ- patients with clinically suspected profiled. This standard PA view ated with radiocarpal arthritis. DRUJ subluxation and dislocation. enables one to measure the ulnar The lateral view is obtained with The modality is also helpful in evalu- variance consistently over time. the patient’s shoulder adducted to ating the congruity of the DRUJ artic- Epner et al9 feel that additional the side, the elbow flexed 90 degrees, ular surface in fractures. The patient information may be obtained by tak- and the forearm in neutral supina- is positioned prone with both arms

Vol 3, No 2, Mar/Apr 1995 99 Distal Radioulnar Joint extended overhead. The forearms MR Imaging are maintained parallel to each other, Magnetic resonance imaging is and imaging sections are obtained rapidly approaching arthrography through the area of Lister’s tubercle. in its ability to demonstrate TFCC When the two sides are compared, tears. A wrist coil is required. frank dislocation is obvious. Traumatic tears are best diagnosed For more subtle subluxation, sev- A on T2-weighted images in the coro- eral CT scan measurement methods nal plane. Areas of degenerative have been described (Fig. 5). In an change and traumatic tears both evaluation of three of these methods, display intermediate signal inten- Wechsler et al10 deemed it essential sity on T1-weighted images, mak- to obtain scans in the neutral, fully ing differentiation between the pronated, and fully supinated posi- conditions difficult. Also, the normal tions. The distal-radioulnar-line continuation of the articular carti- method was found to be less reliable lage of the distal radius with the than either the epicenter method or articular cartilage of the sigmoid the congruity method. Pirela-Cruz B notch may be misinterpreted as a et al11 have suggested a stress CT tear on a T1-weighted image. On method for visualization of even T2-weighted images, synovial fluid more subtle signs of subluxation. has a high signal intensity; there- With forced attempts at subluxating fore, it can act as an endogenous the DRUJ, they observed a transla- contrast agent when it fills a tear. tional difference of no more than 3 Several studies have compared mm between the upper extremities the sensitivity and specificity of of normal subjects. C arthrography with those of MR imaging.16-19 Both imaging tech- Arthrography Fig. 5 Methods for using CT scan measure- niques have a sensitivity of approx- Triple-injection arthrography of ments to assess DRUJ subluxation. A, Epi- imately 80% and a specificity center method. A perpendicular line is the wrist is currently the diagnos- drawn from the halfway point of a line approaching 100%. Perforations of tic study of choice in patients with drawn between the center of the ulnar head the articular disk seen on these suspected TFCC tears. Three hours and the center of the ulnar styloid. The joint studies must be correlated with the is not subluxated if this perpendicular line after the initial injection of con- points to the middle of the sigmoid notch. B, clinical history and symptoms. trast material into the radiocarpal Congruity method. The joint is normal if the Degenerative tears are a normal part joint, the patient returns for injec- arc of the ulnar head is congruent with the of aging20-22; in fact, by 50 to 60 years arc of the sigmoid notch. C, Radioulnar-line tions into the DRUJ and the mid- method. The joint is normal if the head falls of age, more than half of asympto- carpal row. Several studies have between the two lines. This method is the matic persons have perforations of shown the importance of triple- least reliable. the articular disk. injection arthrography compared with single-injection arthrography Arthroscopy of the radiocarpal joint or DRUJ.12-14 Arthroscopy is an excellent diag- When only a radiocarpal injec- 14% of TFCC tears become evident nostic tool in evaluating the TFCC tion is performed, approximately only when the wrist is stressed.14 from the radiocarpal side. However, one fourth of tears may be over- Herbert et al15 have questioned the arthroscopy of the DRUJ itself is dif- looked. usefulness of unilateral arthrograms in ficult and has limited usefulness. Digital subtraction arthrography diagnosing wrist pathology. They has been proposed as a method to used arthrography to examine 60 better visualize the area of a tear,13 patients with traumatic wrist pain, Intra-articular Fractures but the arm must be kept absolutely 70% of whom were less than 40 years Without Instability still throughout this procedure. old. In each case, both the painful wrist Stressing the wrist during an arthro- and the asymptomatic opposite wrist The most common intra-articular graphic study by moving the hand were examined. In 74% of patients, fractures of the DRUJ are distal around and having the patient clench communications were found in the radial fractures that extend into the the fist is important since as many as contralateral asymptomatic wrist. sigmoid notch. These fractures may

100 Journal of the American Academy of Orthopaedic Surgeons Larry K. Chidgey, MD also be associated with fractures of cast for 6 weeks, with the forearm in thirds of the articular disk can be the ulnar styloid or the ulnar head. neutral rotation and the wrist in excised without affecting the stabil- Isolated ulnar styloid fractures are slight ulnar deviation, is usually suf- ity of the DRUJ as long as the dorsal less common, and isolated fractures ficient. and palmar radioulnar ligaments involving the ulnar head are rare. are preserved. Osterman25 reported Perhaps because of their fre- that 73% of 52 patients had complete quency, distal radial fractures are TFCC Injuries Without resolution of their ulnar wrist pain often treated with less respect than Instability after arthroscopic debridement of they deserve. Attention is often an articular disk tear. Stokes et al26 directed primarily at the radiocarpal The TFCC is a major stabilizer of the reported that of 23 patients who joint, and the clinician may fail to DRUJ, and injury to this structure underwent arthroscopic debride- address the importance of fracture may lead to DRUJ instability. How- ment of articular disk tears, 77% displacement extending into the sig- ever, many injuries to the TFCC that remained asymptomatic an average moid notch. Also, the index of sus- produce no instability can still cause of 21 months after surgery. In my picion is often low for associated the patient pain. In the classification unpublished experience with DRUJ instability or dislocation. scheme for TFCC injuries developed arthroscopic debridement of articu- Findings on standard radiographs by Palmer3 (Table 1, Fig. 6), injuries lar disk tears, the results have been that should alert the clinician to pos- that do or do not result in instability generally satisfactory in patients sible instability are displaced sig- are not categorized separately; with no or negative ulnar variance. moid-notch fractures involving the rather, injuries are separated into However, in patients with positive dorsal or palmar rim and displaced two broad categories, traumatic and ulnar variance, debridement alone ulnar-styloid fractures. degenerative. has yielded poor results, and an The clinician should also pay par- ulnar head recession has also been ticular attention to restoring radial Traumatic Injuries required to avoid persistent postop- length and achieving adequate Traumatic tears of the articular erative symptoms of impaction. reduction of the sigmoid-notch artic- disk usually occur along the avascu- Peripheral rim tears of the articu- ular surface. A high proportion of lar origin from the radius. They are lar disk are less common than cen- unsatisfactory treatment outcomes class 1A injuries, according to tral and radial tears and lend following malunion of the distal Palmer’s classification, not to be themselves to surgical repair radius result from shortening of the confused with the less common because they occur in the vascular radius, with an associated acquired radial avulsion of the entire TFCC portion of the articular disk. positive ulnar variance. Ulnocarpal from the radius (class 1D). The most Cooney et al27 achieved good to impaction syndrome may result. common subtype of class 1A excellent results in 26 of 33 patients Knirk and Jupiter23 have docu- injuries is a tear in the sagittal plane treated with an open repair tech- mented poor results in distal radial approximately 1 to 2 mm from the nique. Arthroscopic suturing tech- fractures when displacement of the articular surface of the radius. This niques have also been used in the radiocarpal articular surface is site occurs at the junction of the TFCC.28 greater than 1 mm. No data are yet thick collagen bundles protruding Avulsions of the TFCC ulnar available that indicate whether the from the radial articular surface and attachment are more common than DRUJ articular surface is any more the fibrocartilage of the central artic- distal or radial TFCC avulsions. tolerant of articular surface displace- ular disk. Bowers24 has suggested These injuries are often associated ment. Computed tomography may that the palmar-radial corner of the with DRUJ instability and frank be needed to fully assess the sig- articular disk is especially vulnera- dislocation and will be discussed in moid-notch articular surface and ble to injury in full pronation. The the section on dislocations and DRUJ subluxation or dislocation in ulna slides dorsally in the sigmoid instability. cases in which plain radiographs are notch with full pronation, and the suggestive but not diagnostic. palmar-radial aspect of the articular Degenerative Problems Adequate reduction of the distal disk is unsupported by the ulnar Degenerative changes of the radius and DRUJ may require exter- head. TFCC (Palmer’s class 2 injuries, or nal fixation and/or internal fixation. Arthroscopic debridement of ulnocarpal impaction syndrome) For less complex ulnar-styloid frac- these articular disk lesions has progress through five stages. The tures that are isolated and nondis- become the treatment of choice for first stage involves wear of the cen- placed, application of a Muenster many clinicians. The central two tral articular disk region, which may

Vol 3, No 2, Mar/Apr 1995 101 Distal Radioulnar Joint

A B C

Fig. 6 Diagrammatic representation of the different classes of TFCC injuries, as described by Palmer.3 A, Class 1A central traumatic tear, usually in the sagittal plane 1 to 2 mm from the articular surface of the radius. B, Class 1B medial avulsion may or may not be associated with an ulnar styloid fracture. C, Class 1C distal avulsions involve disruption of the ulnocarpal ligaments. D, Class 1D lateral avulsions involve disruption of the radioulnar-ligament and articular-disk attachments to the radius. This injury may or may not be associated with a sigmoid-notch fracture. E, Class 2 degenerative perforations occur centrally.

D E

later be associated with lunate and Ulnocarpal impaction syndrome ance.29 Therefore, individuals born ulnar head chondromalacia. Ulti- is associated with positive ulnar with a long ulna have a thinner cen- mately, degeneration leads to perfo- variance. In persons born with pos- tral articular disk. Positive ulnar ration of the disk and then itive ulnar variance, impaction may variance may also be acquired, as, perforation of the lunotriquetral lig- occur with repetitive overload. The for example, when a distal radial ament. The last stage is associated thickness of the central portion of the fracture heals in a shortened posi- with ulnocarpal arthritic changes articular disk has been found to be tion or physeal growth arrest occurs, (Fig. 7). inversely related to the ulnar vari- involving the distal radius with con-

102 Journal of the American Academy of Orthopaedic Surgeons Larry K. Chidgey, MD

the lunotriquetral joint. Having the TFCC articular disk perforation patient pronate and supinate the should also be debrided is unclear. forearm with simultaneous clench- Ulnar shortening may be accom- ing of the fist and ulnar deviation of plished by a formal diaphyseal the wrist should exacerbate symp- osteotomy and plate fixation, which toms. Pain and crepitus produced is a modification of an osteotomy by compressing the radius and ulna originally described by Milch.30 together as the patient supinates Alternatively, a wafer procedure and pronates the hand can be useful (either open or arthroscopic), as in helping the clinician distinguish originally described by Feldon et DRUJ articular surface changes. al,31 may be performed. With the This information is important arthroscopic technique, debride- because if ulnocarpal impaction ment of a TFCC central perforation syndrome is associated with DRUJ is followed by burring of the ulnar surface changes, treatment must head through the perforation. The address both problems. wafer procedure, whether open or Radiographs are essential to char- arthroscopic, involves resecting only acterize ulnar variance and to iden- 2 to 3 mm of the distal ulnar head, tify any associated distal radial leaving the styloid process intact. It deformity. Cystic changes in the is recommended in patients with a ulnar head and lunate are evident in positive ulnar variance of only 2 to 4 later stages. An arthrogram may mm. Feldon et al31 reported good to show perforation of the articular excellent outcomes in a review of the Fig. 7 A PA radiograph of a patient with disk and lunotriquetral ligament. In results in 12 patients. ulnocarpal impaction syndrome. In this late stage, arthritic changes are present at both the radiographic examination, as in Some clinicians believe that a for- the ulnar head and the lunate (arrowheads). the physical examination, attention mal ulna-shortening osteotomy is should be directed to the appearance advantageous because patients with of the DRUJ articular surfaces. The ulnocarpal impaction have a loose finding of surface incongruities will ulnar ligamentous complex, and tinued growth of the ulna. Longitu- influence treatment options. Diag- ulnar shortening tightens those liga- dinal instability between the radius nostic arthroscopy has been espe- ments.32 No experimental or clinical and ulna after a radial head resection cially helpful, not only in examining data have been published to confirm or radial head fracture (especially the articular disk of the TFCC and this opinion, however. related to an Essex-Lopresti injury) the lunotriquetral ligament, but also When planning a shortening can also lead to ulnocarpal in detecting chondromalacic changes osteotomy, one should pay particu- impaction syndrome. in the lunate and ulnar head. lar attention to the slope of the The onset of symptoms in If conservative measures, such as DRUJ articular surface. In physeal patients with ulnocarpal impaction activity modification and the use of growth arrest of the distal radius, syndrome may be insidious or anti-inflammatory drugs and splints, accommodation to these injuries abrupt (i.e., due directly to a trau- fail to resolve the problem and no evi- may be made over time. The DRUJ matic event). If, for example, posi- dence can be found of DRUJ surface may be abnormally shaped, but the tive ulnar variance was acquired incongruity, surgical treatment articular surfaces may be congru- secondary to distal radial mal- should be directed at correcting the ent. Shortening of the ulna may union, the patient may have had disparity between the radial and ulnar result in incongruity of the surfaces persistent symptoms following the lengths. If ulnocarpal impaction is and persistent postoperative pain. initial fracture. Other patients, such secondary to a radial malunion, cor- Also, the sigmoid notch may have a as those born with positive ulnar rective osteotomy of the radius may be reverse slope in some individuals. variance, may report a gradual sufficient to correct the radioulnar Substantial shortening may cause onset of ulnar wrist pain exacer- length discrepancy (Fig. 8). the articular surface of the ulnar bated by activities, especially repet- For other causes of ulnocarpal head to ride up on the proximal rim itive forearm rotation and gripping. impaction, correction of length dis- of the sigmoid notch, resulting in Physical examination may reveal crepancy is by means of ulnar short- persistent pain and progression of tenderness over the TFCC area and ening. Whether an accompanying arthritic changes. Ulnocarpal

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tion is. Each of the forearm bones must be stabilized in the examiner’s hands. The two bones are then “shucked” past each other to deter- mine the amount of dorsal/palmar laxity. There is normally more laxity in neutral forearm rotation than in either supination or pronation. The joint should “tighten up” in full supination and full pronation. Com- parison with the opposite side is essential. Dorsal dislocations are reduced in supination, while palmar dislocations are reduced in pronation. If a congruent reduction can be achieved, immobilization for 6 weeks in a long-arm cast is sufficient for healing. If a congruent reduction cannot be achieved, open reduction A B is required. Interposed structures, such as the tendon and sheath of the Fig. 8 A, Preoperative PA (left) and lateral (right) radiographs of a patient with a distal extensor carpi ulnaris, may prevent radial malunion. The patient reported pain primarily on the ulnar side of the wrist secondary to ulnocarpal impaction. B, Posteroanterior (left) and lateral (right) radiographs reduction. Such interposition should obtained after the patient underwent an opening-wedge osteotomy of the distal radius and be suspected when reduction cannot an ulna-shortening osteotomy. be accomplished. Acute DRUJ instability associated with a forearm fracture is more fre- impaction syndrome associated long established in the literature and quent than previously assumed. In a with incongruity of the DRUJ artic- will probably remain in use. review of forearm injuries, Goldberg ular surface will be dealt with in the et al33 reported that two or more sites section on arthritis. Acute Dislocations and of injury are routine and that the Instability DRUJ is affected in 60% of patients. While dislocation of the DRUJ Complex distal radial fractures may Dislocations and Instability may occur as an isolated injury, be associated directly with TFCC more often it is associated with a injury or may render the DRUJ Dislocations, subluxations, and concomitant forearm fracture. The unstable because of an associated instabilities of the DRUJ have classi- more common dorsal dislocation fracture of the sigmoid notch, as cally been defined on the basis of the occurs with forced hyperpronation. described by Bowers.24 Galeazzi direction the ulnar head moves in Physical examination reveals limi- fracture-dislocations and their vari- relation to the radius. By this defin- tation of supination with a dorsal ants may be associated with either ition, if the ulnar head is dorsal to the prominence of the ulnar head. Pal- palmar or dorsal dislocation. Longi- radius, the condition is described as mar dislocation of the ulnar head tudinal instability may accompany a dorsal DRUJ dislocation, implying occurs with forced hypersupina- radial-head fractures and disruption that the radius is the stable unit, tion, and pronation is markedly of the central portion of the while the ulna moves in a dorsal or limited, with a dimple in the skin interosseous membrane (Essex- palmar direction. In reality, the ulna seen dorsally. Because of the over- Lopresti injuries). is the stationary bone of the forearm, lying soft tissues, the ulnar head Anatomic reduction of distal radial and the radius, wrist, and hand may not form an obvious promi- fractures and Galeazzi fracture-dislo- rotate around it. However, the con- nence palmarly. cations may by itself render the DRUJ vention of describing dislocations Subluxation and instability are stable. A review of DRUJ function and instabilities on the basis of the more difficult to diagnose on physi- after Galeazzi fracture-dislocations direction of the ulnar head has been cal examination than frank disloca- treated by open reduction and inter-

104 Journal of the American Academy of Orthopaedic Surgeons Larry K. Chidgey, MD nal fixation showed that with has pointed out the prerequisites reestablished stability better than anatomic reduction of the radius, and components of the stabilizing those that created a tether between DRUJ function usually returned to structures involved in successful the distal ulna and the ulnar carpus. normal without the need for direct soft-tissue reconstructive efforts. Chronic DRUJ instability may be open repair of the TFCC.34 However, These procedures are contraindi- associated with angulatory or rota- this result cannot be assumed; after cated if arthritic changes, bone malu- tional malunion of the forearm anatomic reduction and fixation of nion, or bone-length discrepancies bones. Angular deformities are usu- the fracture, DRUJ stability needs to are present. To fully deal with the ally obvious on standard radi- be assessed intraoperatively. This problem of instability, the following ographs, but axial CT scans of both should ideally be done with the arm components should be present: (1) upper extremities may be required in the neutral position and in supina- smooth articular surfaces, (2) a flexi- to help define rotational deformities. tion and pronation. The forearm can ble rotational tether between the Attempts at soft-tissue reconstruc- then be positioned postoperatively in radius and the ulna, (3) suspension tion alone in the face of an instability its most stable position (usually of the ulnar carpus to the radius, (4) that has resulted from a malunion somewhere between neutral and full an ulnocarpal cushion, and (5) an will be doomed to failure. Indeed, a supination), so that adequate soft-tis- ulnar shaft–ulnar carpus connection. congruent reduction may not even sue healing can occur. If the DRUJ is No technique that meets all these be possible unless a corrective unstable in all forearm positions requirements has yet been osteotomy is performed. (after adequate reduction of the described. In patients with only radius has been confirmed), reduc- minor degrees of subluxation, Her- Chronic Instability After tion can be maintained with a mansdorfer and Kleinman39 have Resectional Arthroplasty Kirschner wire inserted from the ulna reported success with reattachment Chronic instability of the distal to the radius just proximal to the of the TFCC to the fovea, even in ulnar shaft after DRUJ resectional joint. chronic cases. With associated ulnar arthroplasty is among the most diffi- In cases of radial head fracture, styloid nonunion, reduction and fix- cult DRUJ problems to solve. Insta- especially those associated with pain ation of large styloid fragments can bility of the distal ulnar shaft has over the DRUJ, every effort should be be successful. Smaller styloid frag- most commonly been associated made to retain the radial head. Geel ments can be excised, and the TFCC with the Darrach procedure, but it and Palmer35 reported good results in can then be reattached into the can- has also occurred after hemiresec- 18 of 19 patients treated with open cellous bone defect. tional arthroplasty and the Sauvé- reduction and internal fixation, With gross instability, further Kapandji procedure (Fig. 9). Breen avoiding radial head excision and the soft-tissue augmentation is war- and Jupiter43 have reported some possibility of DRUJ dysfunction. ranted. Bach40 recently described a success in resolving the instability by technique in which reattachment of creating a tenodesis with a distally Chronic Joint Instability the TFCC is augmented with a dis- based slip of the extensor carpi Chronic instability may develop tally based strip of the extensor carpi ulnaris and flexor carpi ulnaris as a residuum of an injury to DRUJ- ulnaris tendon woven through drill woven through the distal ulnar shaft. stabilizing structures or in associa- holes in the distal ulna and radius. In our institution, we have had tion with malunion or nonunion of a All 24 patients in his series had limited success with a modification forearm fracture. In either case, ini- objective improvement of their of the pronator quadratus advance- tial assessment should focus on the instability, and 23 had subjective ment described by Johnson44 and joint surface of the DRUJ. Incon- improvement. Scheker et al41 re- reported by Ruby et al.45 The prona- gruity of the joint surface or arthritic ported improvement in 9 of 14 tor quadratus is pulled up into the changes will influence the treatment patients who underwent reconstruc- defect left by the ulnar head and plan. Instability associated with tion of the dorsal radioulnar liga- sutured through a drill hole to the arthritic changes or incongruity of ment with use of a tendon graft distal ulnar shaft. Kapandji46 has the joint will be discussed in the sec- woven through drill holes in the reported using this technique as a tion on arthritis. radius and ulna. Petersen and supplement to the Sauvé-Kapandji Chronic instability without associ- Adams42 studied the biomechanics procedure. Pulling the pronator ated forearm bone malunion may be of numerous reconstructive proce- quadratus into the gap of the treated by soft-tissue reconstruction. dures in a cadaver model and found resected ulnar shaft may prevent Many techniques have been used, that procedures that created a tether bone bridging across the pseud- with mixed results.36,37 Bowers38 between the radius and the ulna arthrosis.

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amount of bone resected. According to his review, better results were achieved when very little bone was removed or when substantial bone regenerated between the ulnar shaft and the styloid. In a recent study of 33 patients who underwent the Dar- rach procedure, Tulipan et al48 reported good or excellent results at an average follow-up of 4 years in the 30 patients (91%) in whom the procedure had been modified to A B C involve minimal bone resection and associated soft-tissue reconstruc- Fig. 9 Techniques for treatment of the arthritic DRUJ. The cross-hatched area represents tion. the bone resected in each procedure. A, Darrach excisional arthroplasty. B, Hemiresection- 49 interposition technique. C, Sauvé-Kapandji procedure. In 1985, Bowers reported the use of a hemiresection-interposition technique (Fig. 9, B) on 38 patients, 27 of whom had rheumatoid arthritis. In No way of resolving the problem of associated instability of the DRUJ 1986, Watson et al50 described a simi- of chronic proximal/distal instabil- is important during the examination. lar “matched resection” of the distal ity secondary to an Essex-Lopresti Treatment options are altered by ulna in 44 patients, 34 of whom had injury is currently known. Patients associated instability. Destruction of rheumatoid disease. When the cases with this condition often undergo the joint surfaces is usually evident of other authors are added, the total multiple procedures without resolu- on standard radiographs. number of reported cases comes to tion of the persistent instability 152. In these cases, 42% of the patients between the radius and the ulna. Resectional Arthroplasty had rheumatoid arthritis; 29%, joint The creation of a one-bone forearm Techniques instability; 21%, ulnocarpal impinge- is a viable salvage procedure. Union Several techniques for resectional ment; 5%, osteoarthritis; and 3%, var- between the radius and the ulna may arthroplasty of the arthritic DRUJ ious other traumatic problems. After be difficult to achieve; experience at have been described. In the Darrach hemiresectional arthroplasty, 76% our institution has shown that a for- procedure (Fig. 9, A), the ulnar head were pain-free. The remaining 24% mal transposition of the radius to the is totally excised, although the ulnar reported mild pain but described it as ulna with plate fixation is an effec- styloid may be left intact. Stability of less severe than the pain they had tive solution to the problem. the distal ulnar shaft has been unpre- experienced preoperatively. No dictable following this procedure, patient had a poor postoperative especially in younger patients with result. Of the patients who had mild Arthritis posttraumatic arthritis or osteo- postoperative pain after a hemiresec- arthritis of the DRUJ. Modifications tional arthroplasty, 2% had pain that Patients with rheumatoid arthritis of the Darrach procedure have was secondary to persistent stylo- frequently have DRUJ involvement included variations in the amount of carpal impingement, which was cor- early in the course of the disease. bone resected, the addition of soft- rected by a secondary shortening Osteoarthritis and posttraumatic tissue reconstruction to enhance sta- osteotomy. Of the patients who did arthritis may also involve the DRUJ. bility, and the use of silicone capping not have preoperative instability, Less commonly, gout and pseudo- of the remaining ulnar stump. Sili- none had postoperative distal ulnar gout involve the joint. cone capping has been largely aban- instability. In the patients who did One hallmark of articular surface doned due to concerns about have preoperative instability, hemire- involvement of the DRUJ is pain silicone-induced synovitis, persis- sectional arthroplasty resulted in less associated with forearm rotation. tent instability, and cap fracture. painful instability. The pain becomes more severe if the In a review of factors influencing In patients with rheumatoid arthri- examiner exerts a compressive force the results of the Darrach procedure, tis, hemiresectional arthroplasty has across the DRUJ by squeezing the Dingman47 found that the most value in the early stages of the disease, radius and ulna together. Evaluation important prognostic factor was the when the TFCC is still reconstructible.

106 Journal of the American Academy of Orthopaedic Surgeons Larry K. Chidgey, MD

Patients with late disease usually them corrective osteotomy of the radioulnar ligaments must be pre- have radiocarpal translocation in distal radius combined with ulnar served. addition to DRUJ involvement; they shortening and/or angular Hereditary multiple exostosis are better treated with a radiolunate osteotomy, epiphysiodesis of the can involve the DRUJ. In a review arthrodesis combined with either a distal ulna, the Darrach procedure, of 50 patients with hereditary mul- Darrach procedure or a Sauvé- and the Sauvé-Kapandji procedure. tiple exostosis, Wood et al56 found Kapandji procedure (described No comparative studies have been that 30 had significant involvement below). A contraindication to the published to show whether one of the upper extremity; the degree hemiresection-interposition tech- procedure is superior to another, of involvement depended on the nique is the presence of an incompe- however. Results have, in general, location of the osteochondromas. tent or nonreconstructible TFCC. The been satisfactory. Osteochondromas on the radius stability of the ulnocarpal axis is Acute disruption of the tendon caused minimal deformity, while dependent on this complex. Most of sheath of the extensor carpi ulnaris those on the distal end of the ulna the cases in which the TFCC is not occurs when the forearm is usually caused physeal growth reconstructible occur in patients with supinated while the wrist is held arrest. In this situation, the TFCC late rheumatoid arthritis. forcibly in ulnar deviation. An acted as a tether as the radius con- external force pushes the wrist tinued to grow, resulting in defor- Sauvé-Kapandji Procedure radially, with resultant tearing of mity of the radius and/or An alternative to resectional the sheath. The tendon typically dislocation of the radial head at the arthroplasty for patients with an reduces back into the groove, and elbow. In 10 patients in the series of arthritic DRUJ is the Sauvé-Kapandji manipulation is required to sublux- Wood et al,56 corrective surgery procedure (Fig. 9, C). In this opera- ate the tendon and confirm the had good results. The procedure tion, the DRUJ is fused, and a diagnosis. Inspection will reveal consisted of sectioning of the TFCC pseudarthrosis is created just proxi- that during supination and ulnar tether, lengthening of the ulna, a mal to the DRUJ by resecting part of deviation against resistance, the corrective osteotomy and epiphys- the ulnar shaft. Sanders et al51 unstable extensor carpi ulnaris iodesis of the radius, and removal reported that all 10 of their patients pops out of its tunnel. Acute dis- of the offending osteochondroma. who underwent the procedure had ruption of the tendon sheath can be excellent or good postoperative out- treated by casting the forearm in comes. Nine of the patients had a full pronation with the wrist Summary diagnosis of posttraumatic arthritis. slightly extended and radially Vincent et al52 achieved good results deviated. Six weeks of immobiliza- Problems with the DRUJ are a major in 21 wrists in 17 patients with tion is required for healing. Suc- source of ulnar-sided wrist pain. As rheumatoid arthritis. They sug- cessful treatment of chronic our understanding of the anatomy gested that the surgery may prevent instability can be achieved by sur- and kinematics of this joint has pro- ulnar and palmar translocation of gical reconstruction of the sheath.55 gressed, so has our ability to diag- the carpus by providing a stable Contractures of the DRUJ with- nose specific problems and ulnar-sided support. out associated bone deformities or prescribe successful treatment. arthritic changes may follow direct Expanding the differential diagno- trauma to the joint, often with an sis to include pathologic conditions Other Disorders associated distal radial fracture. in the entire forearm gives one a They may also result from pro- more extensive understanding of Involvement of the DRUJ is always longed immobilization for other the processes involved. A system- found in Madelung’s deformity, problems. More common are atic approach to the history and which is characterized by palmar pronation contractures in which physical examination is strength- subluxation of the hand, a long dis- supination is limited or nonexis- ened by mentally working through tal ulna, and ulnar/palmar angula- tent. Dynamic splinting and serial a complete differential diagnosis. If tion of the distal radius. The casting are often successful in cor- conservative measures fail in condition can usually be treated recting the condition. Surgical patients whose conditions have conservatively, without operative release of the joint for pronation been correctly diagnosed, a number intervention. When surgery is contractures may be done through of operative techniques are avail- required, one can choose from a a palmar approach in which the able that can lead to a successful number of procedures,53,54 among capsule is resected.38 The distal outcome.

Vol 3, No 2, Mar/Apr 1995 107 Distal Radioulnar Joint

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