Updated: 5/24/2021

Distal Radial Ulnar Joint (DRUJ) Injuries

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Images
https://upload.orthobullets.com/topic/1028/images/Xray - AP - Positive Ulnar variance_moved.jpg
https://upload.orthobullets.com/topic/1028/images/druj instability.jpg
https://upload.orthobullets.com/topic/1028/images/tfcc mri.jpg
https://upload.orthobullets.com/topic/1028/images/darrach procedure.jpg
https://upload.orthobullets.com/topic/1028/images/sauve-kapandji pa and lateral.jpg
  • Introduction
    • Frequently occur with distal radius fractures but must be considered independently
      • common cause of pain and limited ROM after distal radius fractures
      • often underappreciated and ignored
  • Etiology
    • Associated conditions
      • ulnar styloid and distal ulna fractures
      • TFCC tears
      • ulnar impaction syndrome
      • Essex-Lopresti injuries
      • Galeazzi fractures
  • Anatomy
    • DRUJ
      • arthrology
        • articulation occurs between the ulnar head and sigmoid notch (a shallow concavity found along ulnar border of distal radius)
        • most stable in supination
      • primary stabilizers
        • volar and dorsal radioulnar ligaments
        • TFCC
          • TFCC attaches to the fovea at the base of the ulnar styloid
          • components include
            • central articular disc
            • meniscal homologue
            • volar and dorsal radioulnar ligaments
            • ulnolunate and ulnotriquetral ligament origins
            • floor of the ECU tendon sheath
      • biomechanics
        • joint motion includes both rotation and translation
  • Presentation
    • Symptoms
      • pain and instability with acute DRUJ dislocation
        • associated with open distal radius fractures
      • dorsal wrist pain and limited pronosupination with post-traumatic arthritis
    • Physical exam
      • post-traumatic arthritis
        • snapping and crepitus
        • proximal rotation of the forearm with compression of the ulna against the radius elicits pain
        • decreased grip strength
  • Imaging
    • Radiographs
      • AP shows widening of the DRUJ
      • lateral shows dorsal displacement
        • instability of the DRUJ is present when the ulnar head is subluxed from the sigmoid notch by its full width with the arm in neutral rotation
    • Dynamic CT
      • useful in the diagnosis of subtle chronic DRUJ instability
      • sequential CT scans are performed with the forearm in neutral and full supination and pronation
      • >50% translation compared to the contralateral side is abnormal
    • MRI
      • useful in the identification of TFCC injuries
  • Treatment
    • Nonoperative
      • closed reduction, immobilization
        • indications
          • DRUJ instability resulting from purely ligamentous injury
        • techniques
          • closed reduction and immobilization in a position of stability for 4 weeks
            • dorsal instability is stable with the forearm in supination
            • volar instability is stable in pronation
        • outcomes
          • interposition of ECU may impede closed reduction
    • Operative
      • DRUJ pinning, radioulnar ligament repair
        • indications
          • highly unstable DRUJ
        • techniques
          • pinning across joint with 0.062-inch K-wires
  • Ulnar Styloid Fractures
    • Reflects high degree of initial fracture displacement
    • Fractures through base often associated with TFCC rupture and instability
    • In the absence of instability, ulnar styloid nonunions are not associated with worse outcomes
    • Treatment
      • nonoperative
        • cast immobilization
          • indications
            • nondisplaced fractures proximal to the ulnar styloid
      • operative
        • ORIF, symptomatic fragment excision
          • indications
            • displaced fractures through the base with associated instability
            • sigmoid notch fractures
            • Galeazzi fracture patterns
            • TFCC avulsions in the face of an unstable DRUJ
          • techniques
            • preserve ulnar attachments of TFCC with fragment excision
  • TFCC Tears
    • Etiology
      • Mechanism of injury
        • wrist extension, forearm pronation
          • in pronation, volar ligaments prevent dorsal subluxation
          • in supination, dorsal ligaments prevent volar subluxation
    • Classification
      • type I - traumatic
      • type II - degenerative (ulnocarpal impaction)
        • IIA - TFCC thinning
        • IIB - IIA + lunate and/or ulnar chondromalacia
        • IIC - IIB + TFCC perforation
        • IID - IIC + LT ligament disruption
        • IIE - IID + ulnocarpal and DRUJ arthritis
    • Treatment
      • nonoperative
        • immobilization, NSAIDS
          • indications
            • all acute traumatic TFCC tears
      • operative
        • arthroscopic vs. open debridement and/or repair
          • indications
            • failure of nonoperative management
            • persistent symptoms
          • techniques
            • type I injuries
              • arthroscopic vs. open debridement and/or repair
            • type II injuries
              • TFCC pathology treated with arthroscopic or open debridement
              • ulnocarpal impaction treated with ulnar shortening osteotomy (in the absence of DRUJ arthrosis) or wafer resection of the ulnar head
  • Ulnar Impaction Syndrome
    • Radial shortening leads to positive ulnar variance and altered mechanics
    • Sequelae includes
      • lunate chondromalacia
      • degenerative TFCC tears
    • Operative treatment
      • TFCC debridement
      • radial osteotomy
      • ulnar shortening
      • distal ulnar resection (Wafer procedure)
        • preserve ulnar attachment of TFCC
  • Essex-Lopresti Injuries
    • Radial head fracture with an interosseous membrane injury extending to DRUJ
      • unstable relationship between ulna and radius
      • leads to proximal migration of the radius
      • results in secondary DRUJ pathology and ulnocarpal abutment
    • Treatment
      • treat bony pathology (radial head or shaft)
      • pin DRUJ for 6 weeks in neutral to facilitate ligamentous healing
      • if pinning fails (or the initial injury is missed) radial head replacement may be required
  • Galeazzi Fractures
    • Distal one-third fracture of the radius and a DRUJ injury
    • ECU entrapment may cause DRUJ to be irreducible
    • Treatment
      • nonoperative
        • splint in supination
          • indications
            • rarely indicated for stable injuries
      • operative
        • radial ORIF and DRUJ pinning
          • indications
            • often required to achieve a stable reduction
  • Complications
    • DRUJ arthrosis
      • treatment
        • resection arthroplasty (resect distal ulna)
          • matched resection vs. Darrach
            • Darrach procedure
              • reserved for low-demand, elderly patients
              • an unstable, painful proximal ulna stump may result
        • hemiresection or interposition arthroplasty
          • ulnar insertion of TFCC is preserved
          • radioulnar impingement is prevented by soft tissue interposition
        • Sauve-Kapandji procedure
          • DRUJ fusion with creation of a proximal ulnar neck pseudoarthrosis
        • ulnar head prosthetic replacement
        • creation of a one-bone forearm
          • ultimate salvage procedure that eliminates forearm rotation
  • Prognosis
    • Primary method to prevent disability related to DRUJ injuries is anatomic reduction of the distal radius which often results in an anatomically-reduced DRUJ
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(SBQ17SE.86) Figures A and B are the radiographs of a 58-year-old female who sustained a ground-level fall. The decision is made to proceed with operative stabilization of the distal radius. Which of the following findings would indicate the need for distal ulna fixation?

QID: 212051
FIGURES:

Degree of angulation of the distal ulna fracture

1%

(8/854)

Degree of comminution of the distal ulna fracture

1%

(7/854)

Location of the distal ulna fracture

6%

(50/854)

Size of the distal ulna fracture

4%

(33/854)

Intraoperative distal radial ulnar joint instability

88%

(753/854)

L 1 A

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(SBQ06TR.1) A 36-year-old rancher is involved in a tractor roll-over accident and sustains the injury shown in Figure A to his dominant right arm. After undergoing rigid anatomic fixation of the fracture, the distal radio-ulnar joint (DRUJ) remains incongruent. What is the next step in management?

QID: 2613
FIGURES:

Revision plating of the fracture

15%

(271/1776)

Revision reduction and intramedullary fixation

2%

(30/1776)

Reduction of interposed extensor carpi ulnaris tendon

52%

(931/1776)

Reduction of interposed pronator quadratus tendon

16%

(288/1776)

Reduction of interposed flexor carpi ulnaris tendon

13%

(238/1776)

L 1 D

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