Distal Radioulnar Joint Instability: Diagnosis and Treatment

Document Type : CURRENT CONCEPTS REVIEW

Authors

1 Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain. 2 Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain

2 Orthopedic Research Center, Department of Orthopedic, Hand, and Microsurgery, St. Marien Stift Medical Campus, Friesoythe, Germany

3 Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, USA. - Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran. Iran

Abstract

Distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) tears are more usual than estimated and are frequently overlooked. Diagnosis is often clinical, which can be confirmed using computed tomography (CT) scan and magnetic resonance imaging (MRI). In doubtful cases, bilateral computed tomography in neutral forearm rotation, supination, and pronation should also be performed. Wrist arthroscopy can be diagnostic and therapeutic for ulnar-sided wrist pain. Two systematic reviews showed equivalent outcomes between open and arthroscopic repair of the TFCC. There is scant proof to advise one technique over the other in clinical practice. TFCC repair and reconstruction are contraindicated when there is a bony deformation of the radius or ulna or osteoarthritis of the DRUJ. With the advancement of implant arthroplasty, salvage procedures are less desirable. Constrained distal radioulnar arthroplasty is stable, and the longevity is encouraging. Level of evidence: III

Keywords


  1. Carr LW, Adams B. Chronic distal radioulnar joint instability. Hand Clin. 2020;36(4):443-453.
    2. Poppler LH, Moran SL. Acute distal radioulnar joint instability: Evaluation and treatment. Hand Clin. 2020;36(4):429-441.
    3. Rodriguez Merchan EC, De la Corte H. Injuries of the distal radioulnar joint. Contemp Orthop 1994;29(3):193-200.
    4. Ekenstam FA, Hagert CG. Anatomical studies on the geometry and stability of the distal radio ulnar joint. Scand J Plast Reconstr Surg 1985;19(1):17-25.
    5. af Ekenstam FW, Palmer AK, Glisson RR. The load on the radius and ulna in different positions of the wrist and forearm. A cadaver study. Acta Orthop Scand 1984;55(3):363-365.
    6. Tolat AR, Stanley JK, Trail IA. A cadaveric study of the anatomy and stability of the distal radioulnar jointin the coronal and transverse planes. J Hand Surg Br 1996;21(5):587-594.
    7. Haugstvedt J-R, Berger RA, Nakamura T, Neale P, Berglund L, An K-N. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg Am 2006;31(3):445-451.
    8. Stuart PR, Berger RA, Linscheid RL, An KN. The dorsopalmar stability of the distal radioulnar joint. J Hand Surg Am 2000;25(4):689-699.
    9. Faucher GK, Zimmerman RM, Zimmerman NB. Instability and arthritis of the distal radioulnar joint: a critical analysis review. JBJS reviews. 2016;4(12).
    10. Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: its clinical significance. J Hand Surg Am 1991;16(6):1101-1105.
    11. Hotchkiss RN, An KN, Sowa DT, Basta S, Weiland AJ. An anatomic and mechanical study of the interosseous membrane of the forearm: Pathomechanics of proximal migration of the radius. J Hand Surg Am 1989;14(2 Pt 1):256-261.
    12. Moritomo H. The function of the distal interosseous membrane and its relevance to the stability of the distal radioulnar joint: An anatomical and biomechanical review. Handchir Mikrochir Plast Chir 2015;47(5):277-280.
    13. Arimitsu S, Moritomo H, Kitamura T, Berglund LJ, Zhao KD, An K-N, et al. The stabilizing effect of the distal interosseous membrane on the distal radioulnar joint in an ulnar shortening procedure: a biomechanical study. J Bone Joint Surg Am 2011;93(21):2022-2030.
    14. Gofton WT, Gordon KD, Dunning CE, Johnson JA, King GJW. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg Am 2004;29(3):423-431.
    15. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am 2007;32(7):1086-1106.
    16. Omokawa S, Iida A, Kawamura K, Nakanishi Y, Shimizu T, Kira T, et al. A biomechanical perspective on distal radioulnar joint instability. J Wrist Surg 2017;6(2):88-96.
    17. Kakar S, Carlsen BT, Moran SL, Berger RA. The management of chronic distal radioulnar instability. Hand Clin 2010;26(4):517-528.

18. Moradi A. Mousavi SM, Hassankhani GG, Chaharjouy NT, Rasouli A, Ebrahimzadeh MH. Fixing ulnar styloid fracture with stable distal radioulnar joint: A randomized clinical trial. Arch Bone Jt Surg 2021;9:189-194.
19. Cole DW, Elsaidi GA, Kuzma KR, Kuzma GR, Smith BP, Ruch DS. Distal radioulnar joint instability in distal radius fractures: the role of sigmoid notch and triangular fibrocartilage complex revisited. Injury 2006;37(3):252-258.
20. Kleinman WB. Distal radius instability and stiffness: common complications of distal radius fractures. Hand Clin 2010;26(2):245-264.
21. Lans J, Alvarez J, Kachooei AR, Ozcan S, Jupiter JB. Dorsal lunate facet fracture reduction using a bone reduction forceps. J Wrist Surg 2019; 8(2):118-123.
22. Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg Am 1993;18(3):492-498.
23. Kihara H, Palmer AK, Werner FW, Short WH, Fortino MD. The effect of dorsally angulated distal radius fractures on distal radioulnar joint congruency and forearm rotation. J Hand Surg Am 1996;21(1):40-47.
24. Nishiwaki M, Welsh MF, Gammon B, Ferreira LM, Johnson JA, King GJW. Effect of volarly angulated distal radius fractures on forearm rotation and distal radioulnar joint kinematics. J Hand Surg Am 2015;40(11):2236-2242.
25. Dy CJ, Jang E, Taylor SA, Meyers KN, Wolfe SW. The impact of coronal alignment on distal radioulnar joint stability following distal radius fracture. J Hand Surg Am 2014;39(7):1264-1272.
26. Fujitani R, Omokawa S, Akahane M, Iida A, Ono H, Tanaka Y. Predictors of distal radioulnar joint instability in distal radius fractures. J Hand Surg Am 2011;36(12):1919-1925.
27. Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Beris AE, Soucacos PN. Distal radioulnar joint instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern. J Hand Surg Am. 2011;36(5):847-852.
28. Glowacki KA, Shin LA. Stabilization of the unstable distal ulna: the Linscheid-Hui procedure. Tech Hand Up Extrem Surg 1999;3(4):229-236.
29. Wijffels M, Brink P, Schipper I. Clinical and nonclinical aspects of distal radioulnar joint instability. Open Orthop J 2012;6:204-210.
30. Tay SC, Tomita K, Berger RA. The "ulnar fovea sign" for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg Am 2007;32(4):438-444.
31. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fractures. J Hand Surg Am 2000;25(3):464-468.
32. Scheker LR, Belliappa PP, Acosta R, German DS. Reconstruction of the dorsal ligament of the triangular fibrocartilage complex. J Hand Surg Br 1994;19(3):310-318.
33. Lester B, Halbrecht J, Levy IM, Gaudinez R. Press test" for office diagnosis of triangular fibrocartilage complex tears of the wrist. Ann Plast Surg 1995;35(1):41-45.
34. Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumaticdistal radioulnar joint instability. J Hand Surg Am
2002;27(2):243-251.
35. Adams BD. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. Tech Hand Up Extrem Surg 2000;4(3):154-160.
36. Nilsson K, Hallberg P, Tesselaar E, Farnebo S. A novel technique to assess distal radioulnar joint stability using increasing torque. J Wrist Surg. 2019;8(4):327-334.
37. Nakamura R, Horii E, Imaeda T, Tsunoda K, Nakao E. Distal radioulnar joint subluxation and dislocation diagnosed by standard roentgenography. Skeletal Radiol 1995; 24(2):91-94.
38. El Naga AN, Jordan ME, Netscher DT, Adams BD, Mitchell SA. Reliability of the dorsal tangential view in assessment of distal radioulnar joint reduction in the neutral, pronated, and supinated positions in a cadaver model. J Hand Surg Am 2020;45(4):359.e1-359.e8.
39. Mino DE, Palmer AK, Levinsohn EM. The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radioulnar joint. J Hand Surg Am 1983;8(1):23-31.
40. Squires JH, England E, Mehta K, Wissman RD. The role of imaging in diagnosing diseases of the distal radioulnar joint, triangular fibrocartilage complex, and distal ulna. AJR Am J Roentgenol 2014;203(1):146-153.
41. Mino DE, Palmer AK, Levinsohn EM. Radiography and computed tomography in the diagnosis of incongruity of the distal radio-ulnar joint. J Bone Joint Surg Am 1985;67(2):247-252.
42. Wechsler RJ, Wehbe MA, Rifkin MD, Edeiken J, Branch HM. Computed tomography diagnosis of distal radioulnar subluxation. Skeletal Radiol 1987;16(1):1-5.
43. Lo IK, MacDermid JC, Bennett JD, Bogoch E, King GJ. The radioulnar ratio: a new method of quantifying distal radioulnar joint subluxation. J Hand Surg Am 2001;26(2):236-243.
44. Chiang CC, Chang MC, Lin CF, Liu Y, Lo WH. Computerized tomography in the diagnosis of subluxation of the distal radioulnar joint. Zhonghua Yi Xue Za Zhi (Taipei) 1998;61(12):708-715.
45. Nakamura R, Horii E, Imaeda T, Nakao E. Criteria for diagnosing distal radioulnar joint subluxation by computed tomography. Skeletal Radiol 1996;25(7): 649-653.
46. Wijffels M, Stomp W, Krijnen P, Reijnierse M, Schipper I. Computed tomography for the detection of distal radioulnar joint instability: normal variation and reliability of four CT scoring systems in 46 patients. Skeletal Radiol 2016;45(11):1487-1493.
47. Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am 2008;33(5):675-682.
48. Hess F, Farshad M, Sutter R, Nagy L, Schweizer A. A novel technique for detecting instability of the distal radioulnar joint in complete triangular fibrocartilage complex lesions. J Wrist Surg 2012;1(2):153-158.
49. Dao KD, Solomon DJ, Shin AY, Puckett ML. The efficacy of ultrasound in the evaluation of dynamic scapholunate ligamentous instability. JBJS. 2004;86(7):1473-8. 50. Yoshii Y, Yuine H, Tung WL, Ishii T. Quantitative assessment of distal radioulnar joint stability with pressure-monitor ultrasonography. Journal of orthopaedic surgery and research. 2019;14(1):1-7.
51. Axelsson P, Fredrikson P, Nilsson A, Andersson JK, Kärrholm J. Forearm torque and lifting strength: normative data. The Journal of hand surgery. 2018;43(7):677-e1.

52. Andersson JK, Hagert EM, Fridén J. Patients with triangular fibrocartilage complex injuries and distal radioulnar joint instability gain improved forearm peak pronation and supination torque after reinsertion. Hand. 2020;15(2):281-6.
53. Wijffels M, Stomp W , Krijnen P, Reijnierse M, Schipper I. Computed tomography for the detection of distal radioulnar joint instability: normal variation and reliability of four CT scoring systems in 46 patients. Skeletal Radiol 2016;45(11):1487-1493.
54. Arimitsu S, Masatomi T, Shigi A, Yukioka C, Moritomo H. Proximal horizontal flap tears of TFCC diagnosed by computed tomography arthrography: six case series. J Wrist Surg 2021;10(1):36-41.
55. Lee SK, Kim KJ, Cha YH, Choy WS. Conservative treatment is sufficient for acute distal radioulnar joint instability with distal radius fracture. Ann Plast Surg 2016;77(3):297-304.
56. Mesplié G, Grelet V, Léger O, Lemoine S, Ricarrère D, Geoffroy C. Rehabilitation of distal radioulnar joint instability. Hand Surg Rehabil 2017;36(5):314-321.
57. Millard GM, Budoff JE, Paravic V, Noble PC. Functional bracing for distal radioulnar joint instability. J Hand Surg Am 2002;27(6):972-977.
58. Hermann K, Rene S, Wolters R. Corrective osteotomy after malunited distal radius fractures. Archives of orthopaedic and trauma surgery. 2020;140(5):675-80.
59. Lee SK, Chun YS, Bae JH, Yu YT, Choy WS. Arthroscopic suture repair with additional pronator quadratus advancement for the treatment of acute triangular fibrocartilage complex tear with distal radioulnar joint instability. Ann Plast Surg 2019; 83(4):411-418.
60. Gordon KD, Dunnin CE, Johnson JA, King GJW. Influence of the pronator quadratus and supinator muscle load on DRUJ stability. J Hand Surg Am 2003;28(6):943-950.
61. Kim BS, Song HS, Jung KH, Kim HT. Distal radioulnar joint volar instability after ligament reconstruction failure treated with sigmoid notch osteotomy. Orthopedics 2012;35(6):e984-e987.
62. Moritomo H. The distal interosseous membrane: current concepts in wrist anatomy and biomechanics. J Hand Surg Am 2012;37(7):1501-1507.
63. Nishiwaki M, Nakamura T, Nakao Y, Nagura T, Toyama Y. Ulnar shortening effect on distal radioulnar joint stability: a biomechanical study. J Hand Surg Am 2005; 30(4):719-726.
64. Wagner ER, Elhassan BT, Rizzo M. Diagnosis and treatment of chronic lunotriquetral ligament injuries. Hand Clin. 2015;31(3):477-486.
65. Atzei A, Luchetti R, Garagnani L. Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears. J Hand Surg Eur Vol 2017;42(4):405-414.
66. Andersson JK, Ahlén M, Andernord D. Open versus arthroscopic repair of the triangular fibrocartilage complex: a systematic review. J Exp Orthop 2018;5(1):6.
67. Robba V, Fowler A, Karantana A, Grindlay D, Lindau T. Open versus arthroscopic repair of 1B ulnar-sided triangular fibrocartilage complex tears: a systematic review. Hand (N Y) 2020;15(4):456-464.
68. Fulkerson JP, Watson HK. Congenital anterior subluxation of the distal ulna. A case report. Clin Orthop Relat Res 1978;131:179-182.
69. Purisa H, Sezer I, Kabakas‚ F, Tuncer S, Ertürer E, Yazar M. Ligament reconstruction using the Fulkerson-Watson method to treat chronic isolated distal radioulnar joint instability: short-term results. Acta Orthop Traumatol Turc 2011;45(3):168-174.
70. Burke CS, Zoeller KA, Waddell SW, Nyland JA, Voor MJ, Gupta A. Assessment of distal radioulnar joint stability after reconstruction with the brachioradialis wrap. Hand (N Y) 2018;13(4):455-460.
71. Lee SK, Lee JW, Choy WS. Volar stabilization of the distal radioulnar joint for chronic instability using the pronator quadratus. Ann Plast Surg 2016;76(4):394-398.
72. Riggenbach MD, Wright TW, Dell PC. Reconstruction of the distal oblique bundle of the interosseous membrane: a technique to restore distal radioulnar joint stability. J Hand Surg Am 2015;40(11):2279-2282.
73. Brink PR, Hannemann PF. Distal oblique bundle reinforcement for treatment of DRUJ instability. J Wrist Surg 2015;4(3):221-228.
74. Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand Surg Am 1982;7(3):230-236.
75. Dy CJ, Ouellette EA, Makowski AL. Extensor retinaculum capsulorrhaphy for ulnocarpal and distal radioulnar instability: the Herbert sling. Tech Hand Up Extrem Surg 2009;13(1):19-22.
76. Seo KN, Park MJ, Kang HJ. Anatomic reconstruction of the distal radioulnar ligament for posttraumaticdistal radioulnar joint instability. Clin Orthop Surg 2009;1(3):138-145.
77. Kootstra TJM, van Doesburg MH, Schuurman AH. Functional effects of the Adams procedure: a retrospective intervention study. J Wrist Surg 2018;7(4):331-335.
78. Meyer D, Schweizer A, Nagy L. Anatomic reconstruction of distal radioulnar ligaments with tendon graft for treating distal radioulnar joint instability: surgical technique and outcome. Tech Hand Up Extrem Surg 2017;21(3):107-113.
79. Gillis JA, Soreide E, Khouri JS, Kadar A, Berger RA, Moran SL. Outcomes of the Adams-Berger ligament reconstruction for the distal radioulnar joint instability in 95 consecutive cases. J Wrist Surg 2019;8(4):268-275.
80. Tse WL, Lau SW, Wong WY, Cheng H-S, Chow C-S, Ho P-C, et al. Arthroscopic reconstruction of triangular fibrocartilage complex (TFCC) with tendon graft for chronic DRUJ instability. Injury 2013;44(3):386-390.
81. Luchetti R, Atzei A. Arthroscopic assisted tendon reconstruction for triangular fibrocartilage complex irreparable tears. J Hand Surg Eur Vol 2017;42(4):346-351.
82. Frantz ML, Helsper EA. Morris HA, Hearon BF. Outcomes after anatomic reconstruction of the radioulnar ligaments for distal radioulnar joint instability. J Hand Surg Eur Vol 2020;45(9):909-915.
83. Adams BD. Anatomic reconstruction of the distal radioulnar ligaments for DRUJ instability. Tech Hand Up Extrem Surg 2000;4(3):154-160.
84. Neto BC, Neto JHS. Chronic posttraumatic instability of the distal radioulnar joint: Foveal reattachment of the triangular fibrocartilage complex with dorsal capsuloplasty and extensor retinaculum imbrications. Hand (N Y) 2020 Apr 17;1558944720912566.
85. Unglaub JM, Heyse T, Bruckner T, Langer MF, Spies CK. Long-term functional outcome after dorsal capsular imbrication for post-traumatic dorsal instability of the distal radioulnar joint. Int Orthop. 2020;44(12):2683-2690.
86. Helsper EA, Frantz LM, Adams JM, Morris HA, Hearon BF. Arthroscopic thermal stabilization for distal radioulnar joint instability: 3 to 19 years follow-up. J Hand Surg Eur Vol 2020;45(9):916-922.
87. Breyer JM, Vergara P. Solutions for the unstable and arthritic distal radioulnar joint. Hand Clin 2020;36(4):523-530.
88. Giberson-Chen CC, Leland HA, Benavent KA, Harper CL, Earp BE, Rozental TD. Functional outcomes after Sauve-Kapandji arthrodesis. J Hand Surg Am 2020;45(5):408-416.
89. Barret H, Lazerges C, Chammas PE, Degeorge B, Coulet B, Chammas M. Modification of matched distal ulnar resection for distal radio-ulnar joint arthropathy: Analysis of distal instability and radio-ulnar convergence. Orthop Traumatol Surg Res 2020;106(8):1597-1603.
90. Zimmermann R, Gschwentner M, Arora R, Harpf C, Gabl M, Pechlaner S. Treatment of distal radioulnar joint disorders with a modified Sauve-Kapandji procedure: long-term outcome with special attention to the DASH Questionnaire. Arch Orthop Trauma Surg. 2003;123(6):293-298.
91. Reissner L, Schweizer A, Unterfrauner I, Estermann L, Nagy L. Long-term results of Sauvé–Kapandji procedure. Journal of Hand Surgery (European Volume). 2021:17531934211004459.
92. Verhiel SH, Özkan S, Ritt MJ, Chen NC, Eberlin KR. A comparative study between Darrach and Sauvé-Kapandji procedures for post-traumatic distal radioulnar joint dysfunction. Hand. 2021;16(3):375-84.
93. Auzias P, Delarue R, Camus EJ, Van Overstraeten L. Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome. Hand Surg Rehabil. 2021;40(2):156-161.
94. Sauerbier M, Hahn ME, Fujita M, Neale PG, Berglund LJ, Berger RA. Analysis of dynamic distal radioulnar convergence after ulnar head resection and endoprosthesis implantation. J Hand Surg 2002;27(3):425-434.
95. van Schoonhoven Jr, Fernandez DL, Bowers WH, Herbert TJ. Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis. J Hand Surg 2000;25(3):438-446.
96. Gordon KD, Dunning CE, Johnson JA, King GJ. Kinematics of ulnar head arthroplasty. Journal of hand surgery. 2003;28(6):551-8.
97. Kopylov P, Tägil M. Distal radioulnar joint replacement. Tech Hand Up Extrem Surg. 2007;11(1):109-114.
98. Schuurman AH, Teunis T. A new total distal radioulnar joint prosthesis: functional outcome. J Hand Surg 2010;35(10):1614-1619.
99. Moradi A, Binava R, Hasanabadi SE, Vahedi E, Ebrahimzadeh MH. Introduction and early outcomes of intraosseus distal radioulnar joint prosthesis: A pilot study and a technique of a new design of the Sauvé-Kapandji procedure. Arch Bone Jt Surg 2020;8(6):703-709.
100. Moradi A, Binava R, Vahedi E, Ebrahimzadeh MH, Jupiter J. Distal radioulnar joint prosthesis. Arch Bone Jt Surg 2021;9(1):22-32.
101. Willis AA, Berger RA, Cooney III WP. Arthroplasty of the distal radioulnar joint using a new ulnar head endoprosthesis: Preliminary report. J Hand Surg 2007;32A:177-189.
102. Kachooei AR, Chase SM, Jupiter JB. Outcome assessment after Aptis distal radioulnar joint (DRUJ) implant arthroplasty. Arch Bone Jt Surg 2014;2:180-184