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Introduction
  • Definition
    • distal 1/3 radius shaft fx AND
    • associated distal radioulnar joint (DRUJ) injury
  • Incidence of DRUJ instability
    • if radial fracture is <7.5 cm from articular surface
      • unstable in 55% 
    • if radial fracture is >7.5 cm from articular surface
      • unstable in 6% 
  • Mechanism
    • direct wrist trauma
      • typically dorsolateral aspect
    • fall onto outstretched hand with forearm in pronation
Anatomy
  •  DRUJ
    • sigmoid notch
      • found along ulnar border of distal radius
      • is a shallow concavity for the articulating ulnar head
    • volar and dorsal radioulnar ligaments 
      • function as the primary stabilizers of the DRUJ
    • most stable in supination
Classification
  • OTA classification of radius/ulna
    • included under subgroups and qualifications 
OTA classification of radius/ulna
22-A2.3 Radius/ulna, diaphyseal, simple fracture of radius with dislocation of DRUJ
22-A3.3 Radius/ulna, diaphyseal, simple fracture of both bones (distal zone radius) with dislocation of DRUJ

22-B2.3 radius/ulna, diaphyseal, wedge fracture of radius with dislocation of DRUJ
22-B3.3 radius/ulna, diaphyseal, wedge of both bones with dislocation of DRUJ
 
Presentation
  • Symptoms
    • pain, swelling, deformity
  • Physical exam
    • point tenderness over fracture site
    • ROM
      • test forearm supination and pronation for instability
    • DRUJ stress
      • causes wrist or midline forearm pain
Imaging
  • Radiographs
    • recommended views
      • AP and lateral views of forearm, elbow, and wrist
    • findings
      • signs of DRUJ injury
        • ulnar styloid fx
        • widening of joint on AP view
        • dorsal or volar displacement on lateral view
        • radial shortening (≥5mm)
Treatment
  • Operative
    • ORIF of radius with reduction and stabilization of DRUJ
      • indications
        • all cases, as anatomic reduction of DRUJ is required
        • acute operative treatment far superior to late reconstruction
Surgical Techniques
  • ORIF of radius
    • approach
      • volar (Henry) approach to radius  
    • plate fixation
      • perform anatomic plate fixation of radial shaft
      • radial bow must be restored/maintained
  • Reduction & stabilization of DRUJ   
    • approach
      • dorsal capsulotomy
    • reduction technique
      • immobilization in supination (6 weeks)
        • indicated if DRUJ stable following ORIF of radius
      • percutaneous pin fixation 
        • indicated if DRUJ reducible but unstable following ORIF of radius
        • cross-pin ulna to radius
          • leave pins in place for 4-6 weeks
      • open surgical reduction
        • indicated if reduction is blocked
          • suspect interposition of ECU tendon
      • open reduction internal fixation
        • indicated if a large ulnar styloid fragment exists
        • fix styloid and immobilize in supination
Complications
  • Compartment syndrome
    • increased risk with
      • high energy crush injury
      • open fractures
      • vascular injuries or coagulopathies
    • diagnosis
      • pain with passive stretch is most sensitive
  • Neurovascular injury
    • uncommon except type III open fractures
  • Refracture
    • usually occurs following plate removal
    • increased risk with
      • removing plate too early
      • large plates (4.5mm)
      • comminuted fractures
      • persistent radiographic lucency
    • prevention
      • do not remove plates before 18 months after insertion
        • amount of time needed for complete primary bone healing
  • Nonunion
  • Malunion
  • DRUJ subluxation
    • displaced by gravity, pronator quadratus, or brachioradialis
 

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Questions (4)
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(OBQ10.117) A 42-year-old female sustains the injury shown in Figure A. What other anatomic structure is most commonly injured with this fracture? Review Topic

QID: 3211
FIGURES:
1

Volar long radiolunate ligament

2%

(100/4053)

2

Radioscaphocapitate ligament

3%

(108/4053)

3

Dorsal radioulnar ligaments

91%

(3676/4053)

4

Ligament of Testut and Kuentz

1%

(59/4053)

5

Scapholunate ligament

2%

(92/4053)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ12.147) A 33-year-old man sustains blunt trauma to his forearm and presents with the injury seen in Fig A and B. Definitive management of this injury involves the following: Review Topic

QID: 4507
FIGURES:
1

Perform closed reduction of the radius, then immobilize the forearm in a long arm cast in supination.

1%

(48/5080)

2

Perform open reduction and internal fixation of the radius, then assess the proximal radioulnar joint for instability, and percutaneously fix the proximal radioulnar joint if instability persists.

4%

(211/5080)

3

Perform open reduction and internal fixation of the radius, then assess the distal radioulnar joint for instability, and reconstruct the distal radioulnar joint with a looped palmaris longus autograft if instability persists.

3%

(174/5080)

4

Perform closed reduction of the radius, then assess the distal radioulnar joint for instability, and perform internal fixation of the radius if instability persists.

3%

(173/5080)

5

Perform open reduction and internal fixation of the radius, then assess the distal radioulnar joint for instability, and percutaneously fix the distal radioulnar joint if instability persists.

87%

(4436/5080)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ07.47) A 30-year-old female presents with the injury shown in Figure A after falling on her outstretched arm. During operative treatment of the fracture, anatomic reduction of the radius is achieved. However, the surgeon is unable to reduce the distal radioulnar joint. What structure is most likely impeding the reduction? Review Topic

QID: 708
FIGURES:
1

Median nerve

1%

(7/655)

2

Flexor carpi radialis

6%

(40/655)

3

Pronator quadratus

42%

(274/655)

4

Extensor carpi ulnaris

43%

(282/655)

5

Flexor carpi ulnaris

7%

(48/655)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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