Traumatic injuries of the distal radioulnar joint

Isolated volar dislocation of the distal radioulnar joint: a case series and systematic review

INTRODUCTION

Isolated volar dislocations of the distal radioulnar joint are reported as rare. We observed three such cases over a 12-month period. Literature to date consists of multiple case reports and case series with no structured reviews. There is debate as to incidence, mechanism, investigation, treatment and prognosis.

METHODS

A case series and formal systematic review was performed. This included an analysis of the demographics, mechanism, presentation, investigation, treatment and outcome of the cases identified from the wider published series.

FINDINGS

In total 99 cases of this injury were identified from 59 papers, with a further 9 cases having an associated ulna styloid fracture.

CONCLUSIONS

This is a rare injury, representing up to 0.02% of all bony injuries, which is diagnosed late in 36% of cases. Inability to obtain a true lateral radiograph may contribute to the diagnosis being missed. Computed tomography scans are useful in suspected cases without radiographic confirmation. Acute cases are successfully treated with closed reduction in 78% of cases; however associated soft tissue injuries may need to be surgically addressed. Delayed presentation is more likely to require open surgery and preoperative MRI scans are indicated to aid surgical planning. Chronic instability rarely occurs and may need treatment with reconstruction or salvage. A good, subjective, result is reported in the majority of patients.

Irreducible Chronic Volar Dislocation of the Distal Radioulnar Joint After Surgery for Distal Radius Fracture: A Case Report

CASE

We report a case of irreducible chronic volar dislocation of the distal radioulnar joint (DRUJ) after surgery for distal radius fracture. The patient underwent volar locking plate fixation for distal radius fracture. Despite the satisfactory alignment of the distal radius, irreducible volar dislocation of the DRUJ was discovered at 5 weeks after the initial surgery. DRUJ reconstruction at 9 weeks after injury using the Adams-Berger procedure resulted in a stable and functional DRUJ and wrist.

CONCLUSION

To prevent postoperative DRUJ instability or dislocation, the DRUJ should be evaluated for stability immediately after fracture fixation.

Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis

Purpose

We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients.

Methods

A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS).

Results

Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3–16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups.

Conclusions

This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures.

Type of study/level of evidence: Therapeutic II.

Habitual volar dislocation of the ulnar head with a locked distal radioulnar joint after distal radius fracture: A case report

RATIONALE

Habitual volar dislocation of the ulnar head with a locked distal radioulnar joint (DRUJ) is a rare complication after distal radius fracture. We present a case of habitual volar dislocation of the ulnar head in a woman with a dorsally displaced malunited distal radius fracture.

PATIENT CONCERNS

A 72-year-old woman presented with occasional painful locking of the forearm in full supination. She had fractured the left distal radius in a fall 6 months previously. The fracture had been treated non-surgically with wrist immobilization in a long and short arm cast for 6 weeks. Physical examination showed no swelling of the left hand. The wrist locked when the forearm was fully supinated, and the patient was not able to pronate her forearm without reducing the ulna by pressing the left ulna down toward the DRUJ. She experienced sharp pain during the reduction procedure and pronation of the left forearm. The affected wrist had 91% motion compared with the contralateral wrist.

DIAGNOSIS

Radiography and computed tomography showed 28° dorsally angulated malunion of the distal radius and ulnar head subluxation with respect to the radius. Magnetic resonance imaging revealed disruption of the ulnar-side triangular fibrocartilage complex (TFCC) from the ulna fovea.

INTERVENTIONS

The patient desired surgery to address the painful click during full supination of her left wrist and the limitations in her activities of daily living. Corrective osteotomy of the distal radius and arthroscopic repair of the ulnar-side tear of the TFCC were performed. The TFCC was arthroscopically repaired to the ulnar fovea to stabilize the DRUJ.

OUTCOMES

At 1 year postoperatively, radiography showed complete union of the radius. The affected side had 97% wrist motion compared with the contralateral wrist and a full range of forearm rotation without pain or clicking. The grasp strength was 100% compared with the normal wrist.

LESSONS

Malunited distal radius fracture with concomitant TFCC injury can result in habitual volar dislocation of the ulnar head due to severely dorsally angulated malunion of the radius and avulsion of the ulnar-side TFCC from the ulna fovea. This condition required corrective osteotomy plus TFCC repair.

Reliability of the Dorsal Tangential View in Assessment of Distal Radioulnar Joint Reduction in the Neutral, Pronated, and Supinated Positions in a Cadaver Model

PURPOSE

Intraoperative assessment of distal radioulnar joint (DRUJ) alignment is often based on lateral radiographs whose interpretation is dependent upon positioning the forearm in neutral rotation. The dorsal tangential view (DTV) is a near-axial view of the dorsal wrist used in assessing dorsal screw penetration during radius fixation. The purpose of this study was to determine whether the DTV can also reliably assess DRUJ alignment in multiple forearm positions.

METHODS

Four transhumeral cadaveric specimens were used to simulate an unstable DRUJ. The stabilizing soft tissue structures of the DRUJ were sectioned. Fluoroscopic DTV images were obtained with the DRUJ of each specimen held in 5 positions: dorsally dislocated, dorsally subluxated, reduced, volarly subluxated, and volarly dislocated. In each position, images were taken with the forearm in neutral rotation, full pronation, and full supination. Three observers independently assessed DRUJ position on DTV images. Intra- and interobserver reliability were assessed in each forearm position.

RESULTS

Observers correctly identified DRUJ position as reduced, volarly malreduced, or dorsally malreduced on 94% of the DTV images (97%, 95%, and 92% in the neutral, supinated, and pronated forearm positions, respectively). Weighted kappa values for intraobserver reliability were 0.965, 0.964, and 0.965 for the 3 observers. The mean kappas for intraobserver reliability were 1.000, 0.967, and 0.930 with the forearm in neutral, supinated, and pronated positions, respectively. Weighted kappa values for interobserver reliability between paired observers were 0.948, 0.912, and 0.929. The mean kappa for interobserver reliability was 0.926, 0.931, and 0.930 for the forearm in neutral, supinated, and pronated positions, respectively.

CONCLUSIONS

The DTV reliably demonstrated the position of the DRUJ independent of forearm rotation in a cadaveric model.

CLINICAL RELEVANCE

Surgeons may consider the DTV as another tool for fluoroscopic verification of the DRUJ reduction in the operating room or clinic.

Closed Reduction of an Acute Volar Dislocation of the Distal Radio-Ulnar Joint by a Modified Technique

There is scarce literature describing treatment of volar dislocation of the distal radio-ulnar joint (DRUJ). Irreducible dislocation is usually treated surgically. We present the case of a 37-year-old male with acute right wrist pain and loss of pronation. A diagnosis of volar DRUJ dislocation was made. Reduction using conventional technique was unsuccessful. A second attempt was successful by applying pressure over the interosseous membrane of the forearm and manipulating the ulnar head. At three weeks, the patient had minimal pain, a stable DRUJ, and near complete range of motion. This modified technique for reduction of a locked anterior DRUJ dislocation can be used to avoid an unnecessary surgical intervention.

The "second ulnar groove", a MRI sign suggesting a previous palmar luxation of the ulna at the distal radioulnar joint

INTRODUCTION

A cortical lined impaction on the radiodorsal side of the ulnar head may be at the origin of a "second ulnar groove" (SUG). The goal of this article is to illustrate this MRI sign, prompting for further investigation of the distal radioulnar joint (DRUJ). Hence associated soft tissue pathology may be detected, which may lead to instability.

MATERIAL AND METHODS

Following an anterior luxation of the ulna at the DRUJ a second cortical lined groove in a previously normal distal ulna was discovered. A data base review from January 2008 to August 2016 of the axial FS PD-TSE WI 1.5T MRI views of 1.716 patients was accomplished in search of similar bone defects.

RESULTS

Eight patients with previous severe wrist trauma presented with a similar posttraumatic ulnar bone defect. The preceding anterior luxation at the DRUJ was only clearly demonstrated in five patients. However, two more patients had a residual anterior subluxation. Different imaging techniques are discussed and the differential diagnosis is well illustrated.

CONCLUSIONS

The type of trauma, the specific location and the morphology of a second ulnar groove, all compatible with a sequel of an anterior luxation of the ulna at the DRUJ, should lead to a further specific clinical and MRI revaluation of the DRUJ.

Upper extremity quad splint: indications and technique

Patients experiencing high-energy trauma evaluated at level I trauma centers often present with multiple injuries and varying levels of hemodynamic instability. The polytrauma patient requires immediate assessment and stabilization of their orthopedic injuries once the primary trauma survey is complete, and oftentimes, operative fixation of injuries is delayed while patients are resuscitated by general trauma services. The authors describe the application of the upper extremity "quad" splint which includes components of a sugar tong, intrinsic plus, thumb spica, and dorsal extension blocking splint and its indication for patients with multiple upper extremity fractures distal to the humerus. This splint is efficiently applied using minimal material while simultaneously allowing for the stabilizing aspects of 4 splints commonly applied in the emergency setting.

Supination and Pronation Strength Deficits Persist at 2-4 Years after Treatment of Distal Radius Fractures

Forearm rotation is a key function in the upper extremity. Following distal radius fracture, residual disability may occur in tasks requiring forearm rotation. The objectives of this study are to define pronation and supination strength profiles tested through the range of forearm rotation in normal individuals, and to evaluate the rotational strength profiles and rotational strength deficits across the testing range in a cohort of patients treated for distal radius fracture associated with an ulnar styloid base fracture. In a normative cohort of 29 subjects the supination strength profile showed an increasing linear relationship from supination to pronation. Twelve subjects were evaluated 2-4 years after anatomical open reduction and volar plate fixation of a distal radius fracture. The injured wrist was consistently weaker (corrected for hand dominance) in both supination and pronation strength in all testing positions, with the greatest loss in 60 degrees supination. Mean supination strength loss across all testing positions was significantly correlated with worse PRWE scores, highlighting the importance of supination in wrist function.

Should distal radioulnar joint be fixed following volar plate fixation of distal radius fracture with unstable distal radioulnar joint?

BACKGROUND

Distal radioulnar joint (DRUJ) instability often accompanies distal radial fractures. The goal of this study was to investigate whether DRUJ should be fixed to prevent recurrent DRUJ instability in distal radius fracture patients with unstable DRUJ following open reduction and volar plate fixation of the radius.

METHODS

A retrospective chart review was performed on forty-nine consecutive patients presenting distal radius fracture who were diagnosed with distal radioulnar instability after radius fixation with volar plate. Group one consisted of 24 patients whose DRUJs were fixed in neutral for 6 weeks with 1∼2 Kirschner wires (8 cases combined with casting), whereas group two consisted of 25 patients without DRUJ fixation. All patients had radiographic evaluation of their wrist and DRUJ for stabilities and underwent functional evaluation using modified Gartland and Werley demerit scoring system (GW score).

RESULTS

All patients were followed-up for an average of 15 months (12-24 months) after surgery. No significant difference was noted between the two groups with respect to gender, age, fracture types and damage types (no noteworthy medical comorbidities in either group). At the latest follow-up, patients in both groups had comparable grip strength, wrist motion, and visual analogue scale (VAS) and GW scores. Only one patient (2.4%) demonstrated DRUJ chronic instability, but did not require any additional surgery.

CONCLUSION

The results suggest that in patients with distal radius fractures, fixation of unstable DRUJs in neutral for 6 weeks does not have an advantage over non-fixation.

LEVEL OF EVIDENCE

III.

The role of imaging in diagnosing diseases of the distal radioulnar joint, triangular fibrocartilage complex, and distal ulna

OBJECTIVE

The purpose of this article is to review the anatomy, biomechanics, and multimodality imaging findings of common and uncommon distal radioulnar joint (DRUJ), triangular fibrocartilage complex, and distal ulna abnormalities.

CONCLUSION

The DRUJ is a common site for acute and chronic injuries and is frequently imaged to evaluate chronic wrist pain, forearm dysfunction, and traumatic forearm injury. Given the complex anatomy of the wrist, the radiologist plays a vital role in the diagnosis of wrist pain and dysfunction.

The emergent evaluation and treatment of hand and wrist injuries

The anatomy of the hand is complex, which allows for the dexterity, strength, and adaptability of the most functional aspect of the musculoskeletal system. The evaluation and management of injuries to this area can be time consuming and pose a significant medicolegal risk to the emergency physician. Improperly diagnosed and managed injuries can lead to chronic pain, inability to perform activities of daily living, and even seemingly minor injuries can lead to missed work causing a significant cost to the individual and society. The purpose of this article is to review injuries to the hand and wrist and discuss diagnostic studies and treatment plans that the emergency physician can use to treat patients effectively and minimize their exposure to risk.

Wrist injuries in young adults: the diagnostic impact of CT and MRI

PURPOSE

To evaluate the diagnostic impact of MRI or/and multidetector CT in young patients with wrist injury and inconclusive or negative clinical examination and X-rays and to analyze variations in imaging strategies between a district general hospital (GH) and a university hospital (UH).

MATERIALS AND METHODS

A retrospective analysis of 34 young patients (mean age 23 years) with wrist trauma who underwent CT or/and MRI was performed. The injury was acute in 24, and chronic in 10 patients. Twenty-two patients were from a GH and 12 from a UH. Two experienced musculoskeletal radiologists blindly reviewed the imaging studies. The effect of cross-sectional imaging on patient care and treatment plan was evaluated.

RESULTS

In 9 of 34 patients one or more fractures were diagnosed on cross-sectional imaging. The scaphoid was fractured in four patients, the lunate and/or the trapezium in three patients, the scaphoid together with the lunate in one patient, and finally the distal radius in one patient. Ligamentous trauma was identified solely on MRI in 11 patients (involving the TFCC in eight cases). In four patients with both imaging methods, CT revealed one fracture of the trapezium not seen on MRI, and one scapholunate fracture with MRI findings of distal radial fracture only. In two patients with normal CT, MRI revealed bone marrow oedema of the scaphoid in one and of the distal radius, lunate and triquetrum in the other.

CONCLUSION

Both CT and MRI might be considered in patients with acute or chronic wrist injury, clinical dilemma and normal initial radiographs, depending on the availability and the individual institution policies.