The clinical presentation is consistent with DRUJ arthritis in a heavy laborer. Of the options listed, ulnar hemiresection arthroplasty with concurrent TFCC reconstruction would be the most appropriate treatment.
While there are multiple treatment options, the ulnar hemiresection arthroplasty with concurrent TFCC reconstruction is considered most appropriate in heavy laborers, as it would likely resolve the pain and enable them to return to work sooner. The TFCC should be intact when performing an ulnar hemiresection arthroplasty to prevent distal ulna instability with forearm rotation. One could also consider performing a Suave-Kapandji procedure laborers. This procedure creates a distal radioulnar fusion and an ulnar pseudarthrosis proximal to the fusion site through which rotation can occur. The advantage is that the ulnocarpal joint is not sacrificed, and a stable wrist is created.
Scheker et al reported on the outcome of ulnar shortening performed on 32 wrists with early osteoarthritis of the DRUJ. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32 fair, 5/32 poor, with plate irritation being the most frequent postoperative complication.
Figure A is a radiograph showing significant DRUJ arthritis. Illustration A shows ulnar hemiresection arthroplasty. Illustration B shows a Darrach procedure. Illustration C shows a Suave-Kapandji procedure. Illustration D is a treatment schematic of TFCC reconstruction.
Answer 1: There is no obvious ulnar styloid non-union.
Answer 2: As mentioned in Miller's review text, the Darrach procedure is typically reserved for low-demand, elderly patients and may lead to painful proximal ulna stump instability.
Answer 3: Complete ulnar head resection is not indicated.
Answer 5: TFCC reconstruction will not improve or treat the DRUJ arthritic changes.
Scheker LR, Severo A. Ulnar shortening for the treatment of early post-traumatic osteoarthritis at the distal radioulnar joint. J Hand Surg Br. 2001 Feb;26(1):41-4.
PMID:11162014 (Link to Abstract)