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Teunis T, Burnier M, Chin AYH, Ring D. Pain and instability ascribed to the distal radioulnar ligaments and central disc as part of the triangular fibrocartilage complex: a round table discussion. J Hand Surg Eur Vol 2024:17531934241254705. [PMID: 39275970 DOI: 10.1177/17531934241254705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2024]
Affiliation(s)
- Teun Teunis
- Department of Plastic Surgery, University Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marion Burnier
- Institut Chirurgical de la Main et du Membre Supérieur, Lyon, France
| | - Andrew Y H Chin
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | - David Ring
- Dell Medical School, the University of Texas at Austin, Austin, TX, USA
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Kolovich GP, Heifner JJ, Falgiano PA, Mahoney B. Distal Radioulnar Joint Instability. J Orthop Trauma 2024; 38:S4-S10. [PMID: 39150287 DOI: 10.1097/bot.0000000000002859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 08/17/2024]
Abstract
SUMMARY The distal radioulnar joint (DRUJ) is vital to the stability and function of the wrist and forearm. The osseous morphology is variable and provides little stability. A complex of confluent soft tissues is the primary stabilizer; however, the contribution of each component has yet to be elucidated. It has become increasingly clear that the anatomic fixation of distal radius fractures restores DRUJ stability, obviating the need for additional DRUJ stabilization. This review will describe the anatomy and biomechanics of the DRUJ and discuss injury patterns, treatments, and clinical results.
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Affiliation(s)
| | - John J Heifner
- Department of Orthopedic Surgery, Larkin Hospital, Miami, FL
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Wieschollek S, Megerle K. [Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:430-436. [PMID: 38592447 DOI: 10.1007/s00113-024-01424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.
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Affiliation(s)
- Stefanie Wieschollek
- Zentrum für Handchirurgie, Mikrochirurgie und plastische Chirurgie, Schön Klinik München Harlaching, Harlachinger Straße 51, 81547, München, Deutschland.
| | - Kai Megerle
- Zentrum für Handchirurgie, Mikrochirurgie und plastische Chirurgie, Schön Klinik München Harlaching, Harlachinger Straße 51, 81547, München, Deutschland
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El Barbari JS, Kohlhas L, Franke J, Grützner PA, Schnetzke M, Swartman BJ. Analyzing the reduction quality of the distal radioulnar joint after closed K-wire transfixation in a cadaver model: is supination or neutral position superior? Arch Orthop Trauma Surg 2024; 144:1603-1609. [PMID: 38441618 PMCID: PMC10965740 DOI: 10.1007/s00402-023-05181-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 12/11/2023] [Indexed: 03/27/2024]
Abstract
INTRODUCTION Distal radioulnar joint (DRUJ) instabilities are challenging and their optimal treatment is controversial. In special cases or when reconstruction of the stabilizing triangular fibrocartilage complex (TFCC) fails, K-wire transfixation can be performed. However, no consensus has been reached regarding the rotational position of the forearm in which this should be done. Therefore, it was investigated whether anatomical reduction would best be achieved by transfixation in neutral position or supination of the forearm. MATERIALS AND METHODS Twelve cadaveric upper limbs were examined before dissection of the DRUJ stabilizing ligaments and after closed transfixation in both positions by C-arm cone-beam CT. Whether this was first done in neutral position or in supination was randomized. The change in the radioulnar ratio (RR) in percentage points (%points) was analyzed using Student's t-test. RR was used since it is a common and sensitive method to evaluate DRUJ reduction, expressing the ulnar head's position in the sigmoid notch as a length ratio. RESULTS The analysis showed an increased change in RR in neutral position with 5.4 ± 9.7%points compared to fixation in supination with 0.2 ± 16.1%points, yet this was not statistically significant (p = 0.404). CONCLUSIONS Neither position leads to a superior reduction in general. However, the result was slightly closer to the anatomical position in supination. Thus, transfixation of the DRUJ should be performed in the position in which reduction could best be achieved and based on these data, that tends to be in supination. Further studies are necessary to validate these findings and to identify influential factors.
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Affiliation(s)
- Jan Siad El Barbari
- BG Klinik Ludwigshafen, Department for Orthopaedics and Trauma Surgery, Clinic at Heidelberg University, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Laura Kohlhas
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Jochen Franke
- BG Klinik Ludwigshafen, Department for Orthopaedics and Trauma Surgery, Clinic at Heidelberg University, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Paul Alfred Grützner
- BG Klinik Ludwigshafen, Department for Orthopaedics and Trauma Surgery, Clinic at Heidelberg University, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Marc Schnetzke
- German Joint Center Heidelberg, ATOS Clinic Heidelberg, Heidelberg, Germany
| | - Benedict James Swartman
- BG Klinik Ludwigshafen, Department for Orthopaedics and Trauma Surgery, Clinic at Heidelberg University, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
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Bakker D, Derksen BM, Kramer SB, Cleffken BI, Schep NWL. Concomitant ligament injuries can be left untreated during surgery of distal radial fractures. J Hand Surg Eur Vol 2023; 48:1068-1073. [PMID: 37226470 DOI: 10.1177/17531934231177424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Instability of the distal radioulnar joint and scapholunate dissociation may cause pain, functional impairment and subsequent arthrosis. There is no consensus about whether these injuries should be treated acutely in patients undergoing surgery for distal radial fractures. We conducted a prospective cohort study to determine whether concomitant distal radioulnar joint instability or scapholunate dissociation negatively influence patient-related outcomes in these patients. The primary outcome was the patient-reported wrist/hand evaluation at 6 and 12 months after surgery. Out of 62 patients, 58% and 27% had intraoperative distal radioulnar joint instability and scapholunate dissociation, respectively. No significant differences were found in patient-reported scores at follow-up between patients with stable and unstable distal radioulnar joints, nor between patients with and without scapholunate dissociation. Sixty-three per cent of patients with an unstable distal radioulnar joint during surgery were stable on retesting after 6 months. Our study suggests that a wait-and-see policy in these patients therefore seems reasonable.Level of evidence: III.
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Affiliation(s)
- Daniel Bakker
- Department of Hand and Wrist Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Bas M Derksen
- Department of Hand and Wrist Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Simon B Kramer
- Department of Hand and Wrist Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Berry I Cleffken
- Department of Hand and Wrist Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Niels W L Schep
- Department of Hand and Wrist Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Tawonsawatruk T, Phoophiboon P, Kanchanathepsak T, Tuntiyatorn P. Comparative Analysis of Treatment Outcomes: Modified Ulnar Gutter Slab vs. Sugar Tong Slab for Distal Radioulnar Joint Instability Following Triangular Fibrocartilage Complex Repair. J Clin Med 2023; 12:6574. [PMID: 37892712 PMCID: PMC10607602 DOI: 10.3390/jcm12206574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
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.
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Affiliation(s)
- Tulyapruek Tawonsawatruk
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Pheeraphat Phoophiboon
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Thepparat Kanchanathepsak
- Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Panithan Tuntiyatorn
- Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Samut Prakan 10540, Thailand
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Goorens CK, Eetvelde GV, Debaenst N, Royen KV. A Stepwise Intraoperative Protocol to Minimize Complications after Volar Plating. J Wrist Surg 2023; 12:384-389. [PMID: 37841359 PMCID: PMC10569858 DOI: 10.1055/s-0043-1760736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/28/2022] [Indexed: 02/11/2023]
Abstract
Background Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described. Purpose We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making. Conclusion Large prospective studies of the "WRIST" protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.
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Affiliation(s)
- Chul Ki Goorens
- Department of Orthopaedics and Traumatology, Regionaal Ziekenhuis Tienen, Kliniekstraat, Tienen, Belgium
| | - Gilles Van Eetvelde
- Department of Orthopaedics and Traumatology, Regionaal Ziekenhuis Tienen, Kliniekstraat, Tienen, Belgium
- Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium
| | - Niels Debaenst
- Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium
| | - Kjell Van Royen
- Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan, Brussels, Belgium
- Department of Orthopaedics and Traumatology, OLV Aalst, Moorselbaan, Aalst, Belgium
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Stabilization of the Distal Radioulnar Joint with or without Triangular Fibrocartilage Complex Tear by an External Wrist Band Brace: A Cadaveric Study. Healthcare (Basel) 2022; 10:healthcare10050828. [PMID: 35627965 PMCID: PMC9142000 DOI: 10.3390/healthcare10050828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to investigate whether a watch-shaped external wrist band brace improves distal radioulnar joint (DRUJ) stability. Seven fresh cadaveric arms were used. Using a customized testing system, volar and dorsal translation forces were applied to the radius externally while the ulna was fixed. The test was performed with the forearm in neutral, 60° pronated, and 60° supinated positions, once without the brace and once with the brace applied. In each condition, the amount of translation was measured. Then, the triangular fibrocartilage complex (TFCC) was detached from the ulnar styloid process and the fovea ulnaris, and the same tests were performed again. Detachment of the TFCC significantly increased volar and dorsal translations in all forearm rotations compared to the intact condition (p < 0.05), except for the pronated dorsal translation of the radius (p = 0.091). Brace application significantly reduced volar and dorsal translations in all forearm rotations both in intact specimens and in TFCC-detached specimens (p < 0.05), except for pronated volar and dorsal translations in TFCC-detached specimens (p = 0.101 and p = 0.131, respectively). With the brace applied, the TFCC-detached specimens showed no significant difference in volar or dorsal translation in all forearm rotations compared to the intact specimens (p > 0.05). The external wrist band brace improved DRUJ stability in both normal and TFCC-torn wrists and reduced the DRUJ instability caused by TFCC tear to a near-normal level.
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