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The distal radioulnar joint (DRUJ) allows supination and pronation of the distal forearm and wrist, an integral motion in everyday human activity. DRUJ injury and chronic instability can be a significant source of morbidity in patients’ lives. Although often linked with distal radius fractures, DRUJ injury may occur in a variety of other upper extr...
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Objective:
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Background
Limitations in forearm rotation resulting from distal radius fracture are often neglected in clinical practice. We aimed to explore possible influencing factors of forearm rotation limitation following conservative treatment of these fractures.
Methods
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Citations
... Failure to recognize dynamic instability in conditions such as distal radius fractures or malunion, palmar or dorsal radioulnar ligament injury, triangular fibrocartilage complex (TFCC) injury, Essex-Lopresti injury, and Galeazzi fracture-dislocation can result in chronic instability and subsequent osteoarthritis; hence, accurate and timely diagnosis of DRUJ instability is essential. 3 The diagnosis of DRUJ pathology is however challenging, as diagnosis is largely based on examination, together with static imaging methods such as plain radiographs, computed tomography (CT), and MRI. 4-6 Dynamic assessment methods have been previously reported using plain radiographs, 7 ultrasound, 8 and dynamic CT. ...
Background The kinematics of the distal radioulnar joint (DRUJ) are complex and not fully understood. Much current knowledge is based on cadaveric and static imaging studies. Management of DRUJ pathology will remain a challenge until the anatomy and kinematics at the normal DRUJ are defined. The aim of this study was to report kinematic findings at the DRUJ and their relationships in normal wrists using static and dynamic computed tomography (CT).
Materials and Methods This was a retrospective cohort study of patients who underwent dynamic CT scanning of one or both wrists at Tauranga Hospital between March 2018 and July 2022, utilizing a previously described protocol. Sigmoid notch and ulnar head dimensions in the axial and coronal planes were measured on static imaging, with sigmoid notch morphologies described utilizing the Tolat classifications. The degree of translation of the ulnar head with the wrist in full pronation, neutral rotation, and full supination were measured relative to a perpendicular line drawn across the midpoint of the sigmoid notch. The ulnar variance and sigmoid notch gap on coronal views were measured with the wrist in radial and ulnar deviation and with a relaxed and clenched fist.
Results A total of 38 wrists were studied in 24 patients, consisting of 15 females and 9 males with a mean age of 38.0 years (range 15–61). There was no statistically significant difference between ulnar variance or translation of the ulna relative to the midpoint of the sigmoid notch in each position when compared for morphology types in coronal or axial planes. The mean radius of curvature of the ulnar head was 8.3 degrees, with the mean radius of the sigmoid notch measuring 17.1 degrees (p < 0.001), at a mean ratio of 0.51. The ulnar head was most dorsal to the midpoint of the sigmoid notch in full pronation (mean −2.8 mm dorsal), and translated volarly as the wrist moved toward neutral (mean −1.1 mm dorsal) and to full supination (mean −0.6 mm dorsal) (p < 0.001), but remained dorsal to the sigmoid notch midpoint in each position. The mean sigmoid notch gap was 1.3 mm relaxed, which increased to 2.0 mm in a clenched fist (p = 0.001). Mean ulnar variance measured −1.0 mm relaxed, and −0.5 mm in a clenched fist (p = 0.014). The mean sigmoid notch gap on radial deviation was 2.0 mm, and 1.4 mm on ulnar deviation (p = 0.012).
Conclusion The ulnar head remains dorsal relative to the midpoint of the sigmoid notch throughout the range of forearm rotation but becomes relatively more volar as the wrist rotates from full pronation to a position of full supination. The morphology of the notch was not associated with any parameter measured in our study. We have shown that ulnar variance is dynamic in response to deviation and loading. We have presented new data that loading and ulnar deviation increase the gap at the distal sigmoid notch between the radius and ulna. Our findings have implications in the surgical management of pathologies at the joint, particularly in reconstructive procedures for DRUJ instability. Further study is indicated to investigate the relationship between morphology and kinematics at the DRUJ.
... fibrocartilage complex (TFCC), are the main soft-tissue stabilizers. Because of the DRUJ's intricate mobility and function, injuries to this joint need specific attention [2]. Forearm fractures, including ulnar styloid fractures, Essex-Lopresti injuries, and distal radius fractures, are frequently associated with acute traumatic DRUJ injuries; reports of these occurrences range from 10 to 19%. ...
Introduction: The peripheral radioulnar articulation and the bony radioulnar articulation make up the distal radioulnar joint (DRUJ), a diarthrodial trochoid synovial joint stabilizers for soft tissues. Of the DRUJ’s stability, only around 20% may be attributed to the bony articulation. Treatment for DRUJ injuries resulting from a solely ligamentous rupture varies and is subject to debate. Usually, non-operative care is coupled with occupational therapy, activity modification, brace or splint immobilization, and pain management. Aim: The aim of this study was to analyze comprehensive management approaches for acute DRUJ instability post-distal radius fracture. The key takeaway from the article is that TFCC repair may not be essential, with K-wire stabilization providing better range of motion and cast immobilization offering stronger grip, but further large-scale controlled trials are required to fully assess these treatment options in terms of patient satisfaction and functional outcomes. Materials and Methods: After primary fixation of the respective fractures (distal end radius fracture or distal end ulna fracture or both) by ORIF with Plating or CRIF with K-wiring or by Traction for casting, the distal radio ulna joint instability is stabilized by casting, closed reduction internal fixation (CRIF) with K-wiring or open triangular fibrocartilage complex (TFCC) repair and the outcome is measured by grip strength, range of motion with DASH and MMWS scores by follow up and compared. Results: Between the groups, there was no discernible variation in grip strength (P > 0.05). A noteworthy variation in flexion was seen among the groups (P < 0.05). The groups’ differences in extension were statistically significant (P < 0.05). Pronation did not significantly differ across the groups (P > 0.05). Supination did not differ significantly between the groups (P > 0.05). The DASH scores of the groups did not differ significantly (P > 0.05). Between the groups, there was a significant difference in MMWS (P < 0.05). Conclusion: The major findings of analysis have suggested that the time, effort, and cost of TFCC repair do not appear to be necessary, however, there may be trade-offs between various treatments, with K-wire stabilization offering a better range of motion and cast immobilization a stronger grip. Keywords: DRUJ Instability, TFCC repair, K-wiring, Casting
... This is mainly attributed to a low index of suspicion, subtle clinical presentation, and failure to obtain proper Xrays [4]. Interestingly, only a small degree of forearm rotation in the lateral X-rays is just enough to mislead diagnosis [5,6]. If this injury is overlooked and left untreated, it can lead to devastating functional outcomes, including secondary DRUJ instability, loss of pronation-supination, painful wrist, and osteoarthritis [2,7,8]. 2 of 9 Understanding the complex anatomy of DRUJ is a prerequisite to accurate diagnosis and management. ...
... Volar dislocations typically result in an overlap of the distal radius and ulna due to the pull of the pronator quadratus, while dorsal dislocations lead to joint widening [27]. Surprisingly, only 10 degrees of pronosupination in the lateral view can result in misleading X-rays [5,6]. In a true lateral view, the volar cortex of the pisiform appears to sit within the interval between the volar cortices of the capitate and distal pole of the scaphoid, ideally within the central third of this interval [6]. ...
Background/Objectives: Acute isolated distal radioulnar joint (DRUJ) dislocations are rare and often misdiagnosed during initial evaluation due to subtle clinical presentation, low index of suspicion, and imaging barriers. Prompt diagnosis and treatment are critical to avoid chronic instability, limited wrist mobility, and osteoarthritis. This systematic review evaluates the functional outcomes of conservative and surgical treatment protocols for acute isolated DRUJ dislocations. Methods: A systematic search of PubMed, Scopus, and Mendeley databases (2000–2024) was conducted following PRISMA guidelines. Inclusion criteria involved adult patients with isolated DRUJ dislocations diagnosed and managed within one week of injury. Studies reporting on underage patients, associated fractures, delayed management, and open injuries were excluded. Data on demographics, injury mechanism, diagnostic methods, treatment protocols, and functional outcomes were extracted and analyzed. Results: In total, 22 cases across 20 studies were included. The majority (90.9%) were males, with a mean age of 37.9 years (range: 20–70 years). Falls and sports injuries were the major causes, with volar dislocations predominating (18/22). The misdiagnosis rate was equal to 18%. Most cases were treated conservatively with closed reduction and immobilization for an average of 4.9 weeks. Operative treatment was performed in 6 cases, mainly following failed closed reductions. Functional outcomes were generally favorable, although the same parameters were not consistently studied in all patients. Overall, 82% (14 of 17 patients) achieved a full range of motion; 88% (14 of 16 patients) reported no pain, and all assessed cases had stable DRUJs at follow-up. Conclusions: This review highlights the rarity and diagnostic challenges of this injury. The functional outcomes of both conservative and operative treatment are generally satisfactory. Conservative treatment should be the first-line approach, with surgery reserved for irreducible or unstable cases. Future research using standardized outcome measures is needed to provide guidance for clinicians.
... Comparing these findings to those on the contralateral side is important, and audible or palpable clinking may occur during active and passive pronation and supination. Obvious subluxation of the ulnar head indicates DRUJ instability [18,19]. ...
... Chronic cases benefit from specific diagnostic tests, such as the ulnar fovea sign, which elicits pain between the ulnar styloid and the flexor tendon of the carpi ulnaris, indicative of ligament involvement [3,19]. The dorso-palmar stress test assesses instability based on the degree of ulnar head translation during firm radius stabilization [23]. ...
... Isolated acute dislocation of the distal radioulnar joint (DRUJ) is rare but noteworthy, with cases reported in the medical literature [19]. Unlike dislocations with fractures of the radius or distal ulna, isolated DRUJ dislocations are less common [37]. ...
Distal radioulnar joint (DRUJ) instability is a complex condition that can severely affect forearm function, causing pain, limited range of motion, and reduced strength. This review aims to consolidate current knowledge on the diagnosis and management of DRUJ instability, emphasizing a new classification system that we propose. The review synthesizes anatomical and biomechanical factors essential for DRUJ stability, focusing on the interrelationship between the bones and surrounding soft tissues. Our methodology involved a thorough examination of recent studies, incorporating clinical assessments and advanced imaging techniques such as MRI, ultrasound, and dynamic CT. This approach allowed us to develop a classification system that categorizes DRUJ injuries into three distinct grades. This system is intended to be practical for both clinical and radiological evaluations, offering clear guidance for treatment based on injury severity. The review discusses a range of treatment options, from conservative measures like splinting and physiotherapy to surgical procedures, including arthroscopy and DRUJ arthroplasty. The proposed classification system enhances the accuracy of diagnosis and supports more effective decision making in clinical practice. In summary, our findings suggest that the integration of advanced imaging techniques with minimally invasive surgical interventions can lead to better outcomes for patients. This review serves as a valuable resource for clinicians, providing a structured approach to managing DRUJ instability and improving patient care through the implementation of our new classification system.
... After observing the PHUS fracture, it may be worth considering the evaluation of the wrist with a CT scan, even if the fracture appears well reduced in standard radiographs. Various radiologic methods were described for assessing DRUJ subluxation [29]. In a study on 12 cadaver wrists in which 3D imaging was performed after creating different instability patterns, Swartmann et al. showed that the RUR method is one of the most sensitive methods to evaluate DRUJ instability [29]. ...
... Various radiologic methods were described for assessing DRUJ subluxation [29]. In a study on 12 cadaver wrists in which 3D imaging was performed after creating different instability patterns, Swartmann et al. showed that the RUR method is one of the most sensitive methods to evaluate DRUJ instability [29]. Park et al. examined RUR values were examined in healthy patients [30]. ...
Background/aim
Distal radius fractures (DRFs) are frequently associated with distal radioulnar joint (DRUJ) instability. The purpose of this study is to evaluate the effect of the sigmoid notch and ulna styloid fracture types on DRUJ subluxation following closed reduction and casting of DRFs via calculating radioulnar ratio (RUR) on postreduction computed tomography (CT) images.
Materials and methods
In our study, postreduction CT images of 202 patients with distal radius fractures were evaluated retrospectively. CT images were evaluated for RUR, sigmoid notch fracture, and ulna styloid types. Sigmoid notch fractures were classified as nondisplaced in the sigmoid notch fractures (NDS) and displaced sigmoid notch (DS) fractures; ulna styloid fractures were grouped as the proximal half ulna styloid (PHUS) and distal half ulna styloid (DHUS) fractures.
Results
The mean age of Rozental type 3b (62.8 years) was significantly higher among others. The mean RUR value was significantly higher in Rozental type 3a in compared to type 1a and type 2 fractures. PHUS fractures were more common with DS fractures than DHUS fractures.
Conclusion
DS fractures and higher patient age are associated with DRUJ subluxation on postreduction CT images following DRFs. DS fractures are seen more commonly with PHUS fractures than DHUS. Patients with PHUS should be carefully assessed for sigmoid notch fractures and DRUJ congruency. These findings could be helpful for preoperative decision making in the treatment of DRFs.
... The distal radioulnar (DRU) joint's stability over the long term must be taken into account when addressing acute ulnar styloid fractures [14]. It is decided by the relationship between the ulnar styloid and the stabilizing ligaments if a particular type of injury has the potential to create instability in the DRU joint [15]. Primary reduction and immobilization need to be done to optimally prep the patient for surgical procedures since the majority of forearm fractures necessitate surgery [16]. ...
Distal ulna and radius fractures are the most frequent upper extremity fractures seen in emergency rooms. The axis of rotation for forearm pronation and supination runs through the radial head (proximal) and the ulnar fovea (distal). Throughout pronation and supination, the radius can rotate relative to the ulna, thanks to the way its head articulates with it. The ulna remains relatively stable during these movements. However, in cases of fractures of these bones, surgery to repair the radius is usually the best course of action for a distal ulna fracture. Most distal ulna fractures heal successfully with only conservative treatment once the radius is stabilized. To achieve the best results, medical personnel must take into account patient characteristics including age, level of activity, and aspirations. The majority of distal ulna injuries do not require surgery, but there are several circumstances where it is necessary. In therapeutic practice, muscle energy techniques (METs) are comparatively painless methods for restoring a restricted spectrum of motion. Malunion, reduced grasp, and other significant problems might result from a lack of understanding of this illness. The 48-year-old patient in the present study was reported to have sustained injuries to his left forearm in a road traffic accident (RTA) as he fell from his bike and slid during a traffic collision. X-ray imaging of the left forearm revealed an isolated ulnar shaft fracture. METs, isometric contractions, and active concentric and eccentric movements were all part of the physiotherapy intervention protocol to produce an active range of motion in the upper extremity. In this particular case, the specified physiotherapy management was found to be effective.
... Distal radioulnar joint (DRUJ) instability is a frequently encountered issue in wrist injuries. This condition results from damage to the stabilizing structure of the DRUJ, known as the triangular fibrocartilage complex (TFCC) [1]. It can manifest as an isolated injury [2] or occur in conjunction with forearm fractures, particularly involving the distal radius [3][4][5]. ...
... Currently, both conservative immobilization and surgical treatment can be chosen after joint reduction in isolated DRUJ instability and DRUJ instability with concomitant distal radius fractures [1,11]. Surgical treatment for DRUJ instability can be performed either via open or arthroscopic repair of the TFCC [11,12]. ...
The standard treatment for distal radioulnar joint (DRUJ) instability involves repairing the triangular fibrocartilage complex (TFCC) and immobilizing the joint with a sugar tong slab, but this can cause elbow stiffness. To address this, a modified ulnar gutter slab was designed to enhance elbow mobility during immobilization. A prospective randomized controlled trial was conducted on 23 DRUJ instability patients who underwent arthroscopic TFCC repair. Two post-operative splinting techniques were compared: the modified ulnar gutter slab and the sugar tong slab. The assessment included the Disabilities of Arm, Shoulder, and Hand (DASH) score; elbow, forearm, and wrist range of motion (ROM); post-operative DRUJ stability; and complications. DASH scores at 4 and 6 weeks were not significantly different. However, the modified ulnar gutter slab improved elbow extension range of motion at 4 weeks (extension lag: 20.0 vs. 6.5 in the sugar tong group) (p = 0.011). Post-operative DRUJ stability was comparable between the two groups. Notably, one patient in the sugar tong slab group experienced complex regional pain syndrome (CRPS). The modified ulnar gutter slab offers a post-operative alternative after TFCC repair. It effectively immobilizes forearm and wrist motion while enhancing elbow mobility, potentially reducing post-operative elbow stiffness.
... This would be the standard choice of most surgeons. 1 In severely comminuted fractures with dorsal fragments, especially in the intermediate column, a dual approach may be required with both volar and dorsal fixation. [2][3][4] These fracture patterns usually include a free dorsal lunate fossa fragment, and stabilizing this column is essential to the maintenance of radial length and congruency of the joint. ...
... Restoration of this joint relative to the ulna is important for functional recovery because it is essential for pronation and supination. 1,6 Currently, this is performed using locking plates. In these highly comminuted fracture patterns, when stabilization of the dorsal fragments cannot be achieved from the volar side or the fragments are too small and too distal to accept a screw, this technique may be very useful. ...
This article is a technical note to outline a novel technique of fixation in complex, comminuted distal radius fractures using a double-locked K-wire construct using a new implant called K-lock. In these (AO) C-type fractures, with significant dorsal comminution, it is often difficult to attain stable and secure fixation of the dorsal rim fragments, especially the dorsal lunate fossa fragment. This often results in patients being treated by temporary spanning devices or asking to have a restricted use of the hand during a given period to avoid loss of position. If dorsal plating is necessary, because of the severity of the comminution, a double-locked K-wire (locked in both the dorsal and volar plates) offers a fixation option and may create a significantly stronger construct and allow confident early mobilization. The K-lock was recently launched by Newclip Technics as an adjunct to the Xpert Wrist 2.4 set as a fragment-specific fixation option. The wire has less chance of displacing or fracturing the fragment and has a smooth surface compared with a screw; this wire would be safer close to the joint in severe distal intra-articular comminution. Of the 9 cases performed so far (as is our usual practice), despite the complexity of the fractures, none were immobilized postoperatively and all started hand therapy in the first week. Most were driving by 2 weeks and returned to light work at 4 weeks and heavy work or sports at 6 to 8 weeks. This principle of fixation may also be extended to other fractures where dual plating is used.
... Based on whether the patient's DRUJ is unstable in supination, pronation, or globally through a physical examination, the angle and placement of the Mini Tightrope will be determined to achieve maximum stability according to the patient's laxity and pattern of instability compared with the contralateral side. 26 This examination is compared with a preoperative assessment to confirm the mechanism of instability. Once correct positioning of maximum stability is achieved, an Arthrex 1.6 mm K-wire is driven obliquely, beginning at the ulnar incision site as noted. ...
... 46 This technique was utilized as an alternative fixation of the TFCC, similar to pinning the DRUJ. 26 While the literature does not detail examples of TFCC healing after repair of chronic DRUJ instability, there is data that discusses healing in acute injury as well as the analogous structures of the syndesmosis. 26,47 It can be conjectured that as the IOM was still intact in 3 patients and the hardware was in place for a time period suitable for TFCC scarring, this could have contributed to continued DRUJ stability after hardware removal. 1 On a similar note, as patient 3 presented with a ruptured IOM, this could have contributed to his poorer ROM after the removal of hardware. ...
... 26 While the literature does not detail examples of TFCC healing after repair of chronic DRUJ instability, there is data that discusses healing in acute injury as well as the analogous structures of the syndesmosis. 26,47 It can be conjectured that as the IOM was still intact in 3 patients and the hardware was in place for a time period suitable for TFCC scarring, this could have contributed to continued DRUJ stability after hardware removal. 1 On a similar note, as patient 3 presented with a ruptured IOM, this could have contributed to his poorer ROM after the removal of hardware. As documented by Werner et al, 48 reconstruction of the IOM and TFCC should be considered if these patients return to instability in the future. ...
Chronic distal radioulnar joint (DRUJ) instability is a complex clinical condition that is difficult to treat. Currently, there is no gold standard treatment. We present a novel technique using Arthrex Mini Tightrope for DRUJ stabilization. In this case series, a 1.6 mm K-wire was passed transversely through the distal ulna and radius. The Mini Tightrope was inserted into the end of the K-wire and pulled through the bone tunnels. Appropriate tension was achieved to stabilize the joint according to individual laxity comparable to the contralateral side. Five patients (3 males and 2 females) comprised this pilot series, with a mean age of 27.1 years. All sustained a traumatic injury at an average of 12.4 months before surgery (range: 5 to 32 mo). In addition, 3 patients had central triangular fibrocartilage complex tears treated with arthroscopy at the time of Mini Tightrope placement. While one patient was lost to follow-up after 7 weeks postoperative due to incarceration, 4 patients demonstrated coronal and sagittal stability in the context of DRUJ motion and a satisfactory range of motion. The mean time for the return to work for the two patients who were laborers or normal activity postoperatively was 5.2 weeks (range: 1 to 16.4 wk). Unrestricted activity was generally allowed 8 weeks postoperatively but varied by patient. The same 4 patients underwent hardware removal at an average of 31 weeks (range: 15 to 44 wk). Although this is only a pilot series, this suggests that temporary Mini Tightrope stabilization of the DRUJ may be a viable solution while upholding the benefits of minimally invasive surgery.
... Further imaging with CT scans can be done if there is suspicion of DRUJ injury and is beneficial in evaluating the joint congruity. MRI might be needed to assess for soft tissue injuries [6]. ...
Introduction
Isolated acute distal radioulnar joint (DRUJ) dislocation is a rare injury that should be early recognized and treated promptly to avoid the limitation and disability associated with delayed diagnosis and management.
Case presentation
We present a patient with a traumatic dorsal isolated DRUJ dislocation who was successfully treated with a closed reduction and k-wire pinning along with cast immobilization.
Discussion
Previous reports of distal radioulnar joint dislocation have described the mechanics of this injury as well as a guidance to diagnosis and treatment. Closed reduction, stabilization of wrist joint, and early mobilization of elbow joint can help in preserving the joint function and a faster recovery.
Conclusion
Closed reduction under general anesthesia, DRUJ stabilization by k-wire pinning, and above elbow casting can be successful in most cases. We recommend an early transition to below elbow cast to encourage early elbow range of motion and prevent joint stiffness.
