Nickolaos A. Darlis, MD

Acute DRUJ Instability

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DRUJ Instability is a clinical diagnosis

Radioulnar ballottement test (Neutral- pronation- supination) DRUJ compression test

Piano- Key sign

ECU subluxiation in supination- ulnar deviation

The unsolved question• How do you define and test DRUJ stability in

the acute setting?

The unsolved question• How do you define and test DRUJ stability in

the acute setting?

“Forearm Joint”

One functional unit

“Forearm Joint”

The forearm as a ring

Anatomy Distal Radius

DRUJ Anatomy

• Radii of curvature differ – 10mm vs 15mm– Full congruity impossible

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

The Iceberg Concept Atzei &Lucetti 2011

radius

ulna

N.D

radius

ulna

N.D

radius

ulna

N.D

Volar & Dorsal Radioulnar Lig

Foveal attachment

TFC MENISCUS

radiusulna

N.D

radiusulna

N.D

TFC CRUCIATE Lig

Volar & Dorsal RU lig.-Foveal Attachment

TFCC anatomy

• Vascular supply– Central portion

• avascular

– Periphery (dorsal and palmar radio-ulnar ligaments)

• vascularized

DRUJ

• Rotation• Load transmission• Stability

Kinematics

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

Load transmission (RH intact )

80%

20%

40% 60%

U

U

R

R

Load TransmissionExplains common fracture patterns

Galeazzi

Forearm

Monteggia

Essex-Lopresti

Interosseous Membrane Anatomy

Two main bands:• Central Band (volar)• Proximal Interosseous

Band (dorsal)

• Accessory bands (1-5)• Membranous portion CB

PIOB

IOM-Central Band

• 70% of forearm stability

• Injury of other elements of IOM (partial tears), increase CB strains

Radius

Ulna

CB

IOM Anatomy

60%

40%

35%

75%250120mm

Essex –Lopresti injury

Acute TFCC tear management

Galeazzi Fracture /Dislocation

Distal Radius Fractures

Isolated Ulnar head dislocation

Acute DRUJ Instability:

Isolated 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

• 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 Dislocation

DRUJ 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”

DRUJ 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

Highly possible when:• shortening >5-7mm

Highly possible when:• shortening >5-7mm• radialy displaced fx base

of the ulnar styloid

Highly possible when:• shortening >5-7mm• radialy displaced fx base

of the ulnar styloid, • angulation >25-300 any

plane

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

DRUJ in Distal Radius Fractures

• Accurate osseus reduction first– Ulnar column stabilization

Common pitfalls

• Radial translocation- sigmoid notch malreduction

Common pitfalls

• Excessive volar tilt/ translocation

DRUJ in Distal Radius Fractures

• Geissler and Fernandez Instabilty classification AFTER radius reduction– Type I: Stable– Type II: Unstable– Type III: Potentially Unstable

Type I: Stable

• minimally displaced avulsion tip of the ulnar styloid

• fracture of the neck of the ulna (just fix)

Type III: Potentially Unstable

• Fx through sigmoid notch (4-part fracture) or• Ulnar head fracture

(fix & test)

Type II: Unstable

• avulsion Fx base of the ulnar styloid or• massive tear of the TFCC and/or secondary

stabilizers

Ulnar 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

Ulnar styloid Fx

• CRIF: easier said than done; supinate

• Re-check stability

Ulnar styloid Fx

• ORIF: ample skin incision– Kirschner wires,– tension band wire– screw– suture anchors

• Re-check stability

Ulnar styloid Fx

• ORIF– Dedicated plates

• Re-check stability

Ulnar 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

Ulnar styloid non-unions

• Type I- tip - stable → excision• Type II- base – unstable →ORIF ± TFCC repair

DRUJ 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)

DRUJ in Distal Radius Fractures

Congruent reduction with an unstable joint, consider:

• Cross pinning– Pin breakage

• TFCC repair• External fixation

Galeazzi fracture/dislocation

• Accurate ORIF first• Same principles for DRUJ as for distal radius Fx

Essex Lopresti injury

Failure of the IOM• Acute• Secondary to overload following Radial Head Excision

Essex Lopresti injury- Diagnosis• Distal Radioulnar Joint pain

and dissociation

• Distraction-compression X-rays

• Intraoperative manual testing

Essex Lopresti injury- Diagnosis

• MRI

• Ultrasound

• Radial Head Reconstruction- Replacement

• DRUJ reduction- pinning• TFCC repair?

Acute Essex Lopresti injury-Treatment

Essex Lopresti injury- complications

• Proximal radial migration• Symptomatic DRUJ

subluxation

Essex Lopresti- Chronic insufficiency• Ulnar shortening • Radial Head ReplacementResults inconsistent

Essex Lopresti- Chronic insufficiency• Attempts at IOM reconstruction

60%

40%

35%

75%250

120mm

BPTB

IOM

FCR

Acute TFCC tears

ISOLATED WITH DISTAL RADIUS Fx

Wrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)

• SL lig.≈ 40% (32-75%)

• LT lig. ≈20% (15-61%)

• Chondral lesions ≈20% (19-32%)

Common 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

Acute TFCC treatment

“Initial conservative treatment for 8 -12 weeks”

Literature, Conservative treatment

Literature, TFCC with Distal Radius Fx

• Contradicting …

Treatment 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

Timing of operative repair

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 6 months 1 year

3mo 6mo

Conservative treatment

• Sugartongue or Long Arm splint 3-4 weeks• Short Arm Splint 1-2 weeks

Palmer ClassificationClass 1: Traumatic Injuries

A Central perforation of the disk properB Peripheral avulsion from the ulna

Without styloid fractureWith styloid fracture

C Distal avulsion from the carpusD Radial avulsion

Without sigmoid notch fractureWith sigmoid notch fracture

D TFCC perforation + lunate and/or head chondromalacia + lunotriquetral ligament perforation

E TFCC perforation + ulnocarpal arthritis

Class 2: Degenerative InjuriesA TFCC wearB TFCC wear + lunate and/or head chondromalaciaC TFCC perforation + lunate and/or head chondromalacia

Central tear

Peripheral tear)

Radial tear

Tear location

Deep bundle of TFCC

Volar radioulnar lig.

radiusulna

N.D

Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of

articular disc

Shaver debridement

Central TFCC lesions

Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005

Central TFCC lesions

1. Central TFCC lesions

• Often degenerative and associated with ulnocarpal impaction syndrome

• Ulnar recession procedure to prevent symptom recurrence

Ulnocarpal Impaction SyndromeClinical 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 variance

Arthroscopic Wafer procedure

Arthroscopic Wafer procedure

Open Ulna Recession Procedures• Several options…

Open Ulna Recession Procedures

Another approach: Keep it simple…• Step-Cut Ulnar Shortening Osteotomy

Darlis & Sotereanos JHS(A), 2005

Peripheral (ulnar) TFCC tears

• Well vascularized• Repairable

Usual location of peripheral tears

Dorsal

Usual location of peripheral tears

REPAIR TO CAPSULE REATTACH TO FOVEAOR

TFCC TFCC

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

REATTACH TO FOVEA

3. Peripheral (ulnar) TFCC tears

• Clinical DRUJ instability• Fracture through the fovea• MRI findings• Arthroscopic findings

– Positive Hook Test– Direct Foveal Portal Arthroscopy

Foveal attachment involvement

Hook test

REPAIR TO CAPSULE

REPAIR TO CAPSULE

1. Mini open: Sotereanos

Chou, Sarris, Sotereanos, JHS(B), 2003

U

EDM ECU

Incision

Chou, Sarris, Sotereanos JHS(B), 2003

REATTACH TO FOVEA

2. All Arthroscopic, Knotless: Geissler

REATTACH TO FOVEA

TFCC6R

ACC 6R

TFCC6R

ACC 6R

TFCC6R

ACC 6R

TFCC6R

ACC 6R

TFCC6R

ACC 6R

Take Home Messages

Take Home Messages

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