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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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Tan J, Zhang F, Liu Q, Fang X, Jiang H, Qian J, Mi J, Zhao G. Effect of different ulnar osteotomies on loading of the distal radioulnar joint: a finite element analysis. BMC Musculoskelet Disord 2024; 25:454. [PMID: 38851696 PMCID: PMC11162099 DOI: 10.1186/s12891-024-07562-3] [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: 08/12/2023] [Accepted: 05/31/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Ulnar impingement syndrome is a prevalent source of ulnar carpal pain; however, there is ongoing debate regarding the specific location of shortening, the method of osteotomy, the extent of shortening, and the resulting biomechanical alterations. METHOD To investigate the biomechanical changes in the distal radioulnar joint (DRUJ) resulting from different osteotomy methods, a cadaveric specimen was dissected, and the presence of a stable DRUJ structure was confirmed. Subsequently, three-dimensional data of the specimen were obtained using a CT scan, and finite element analysis was conducted after additional processing. RESULTS The DRUJ stress did not change significantly at the metaphyseal osteotomy of 2-3 mm but increased significantly when the osteotomy length reached 5 mm. When the osteotomy was performed at the diaphysis, the DRUJ stress increased with the osteotomy length, and the increase was greater than that of metaphyseal osteotomy. Stress on the DRUJ significantly increases when the position is changed to pronation dorsi-extension. Similarly, the increase in stress in diaphyseal osteotomy was greater than that in metaphyseal osteotomy. When the model was subjected to a longitudinal load of 100 N, neither osteotomy showed a significant change in DRUJ stress at the neutral position. However, the 100 N load significantly increased stress on the DRUJ when the position was changed to pronation dorsi-extension, and the diaphyseal osteotomy significantly increased stress on the DRUJ. CONCLUSIONS For patients with distal oblique bundle, metaphyseal osteotomy result in a lower increase in intra-articular pressure in the DRUJ compared to diaphyseal osteotomy. However, it is crucial to note that regardless of the specific type of osteotomy employed, it is advisable to avoid a shortening length exceeding 5 mm.
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Affiliation(s)
- Jiyang Tan
- Medical College, Soochow University, Suzhou, China
- Department of Sports Medicine, Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road No. 999, Wuxi, Jiangsu, China
| | - Fei Zhang
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road No. 999, Wuxi, Jiangsu, China
| | - Qianyuan Liu
- Medical College, Soochow University, Suzhou, China
| | - Xiaodong Fang
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road No. 999, Wuxi, Jiangsu, China
| | - Hong Jiang
- Medical College, Soochow University, Suzhou, China
| | - Jun Qian
- Department of Sports Medicine, Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road No. 999, Wuxi, Jiangsu, China
| | - Jingyi Mi
- Department of Sports Medicine, Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road No. 999, Wuxi, Jiangsu, China.
| | - Gang Zhao
- Department of Hand Surgery, Wuxi 9th People's Hospital Affiliated to Soochow University, Liangxi Road No. 999, Wuxi, Jiangsu, China.
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Hohenberger G, Pirrung F, Hammer N, Niestrawska JA. Distal oblique bundle influence on distal radioulnar joint stability: a biomechanical study. Sci Rep 2023; 13:21718. [PMID: 38066077 PMCID: PMC10709441 DOI: 10.1038/s41598-023-48875-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
Chronic instability of the distal radioulnar joint (DRUJ) presents a highly disabling condition. Several surgical techniques have been reported for its treatment. These involve reconstruction of the distal oblique bundle (DOB) of the interosseous membrane (IOM) of the forearm. The aim of this study was to examine whether surgical reconstruction of the DOB is necessary to restore DRUJ stability following trauma with DOB disruption and to compare two restoration techniques utilizing a tendon or suture-button graft. Stability in supination and pronation was assessed by means of maximum torque and force in twenty forearms. Test cycles were performed with the DOB/IOM in an intact condition, with the DOB or distal IOM transected, and following surgical reconstruction of the DOB with either tendon graft or suture-button system. In pronation, the relative change in maximum axial force was significantly lower in samples with a transected DOB in comparison to samples without a preexisting DOB. No statistically significant differences were observed between forearms including DOB reconstruction and specimens in the intact and transected state. Neither were there statistically significant differences concerning the two surgical techniques. From a biomechanical perspective, surgical DOB reconstruction is hence not indicated in cases of isolated DOB rupture.
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Affiliation(s)
- G Hohenberger
- Department of Trauma Surgery, State Hospital Feldbach-Fürstenfeld, Feldbach, Austria
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - F Pirrung
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - N Hammer
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
- Department of Orthopedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Biomechatronics, Fraunhofer Institute for Machine Tools and Forming Technology, Dresden, Germany
| | - J A Niestrawska
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria.
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Angelis S, Apergis E, Kanellos P, Apostolopoulos A, Vlasis K, Piagkou M, Filippou D. The Distal Oblique Bundle in the Distal Forearm: From Anatomical Features to Clinical Implementation. Cureus 2023; 15:e50252. [PMID: 38196414 PMCID: PMC10774832 DOI: 10.7759/cureus.50252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/11/2024] Open
Abstract
Background and objective The distal oblique bundle (DOB) is nowadays recognized as the thickest component of the distal interosseous membrane (DIOM). It is neither thought to be a clear-cut ligament, and nor does it follow the typical configuration of the rest of the DIOM. It is not always present and some studies have raised disputes about its prevalence and a few anatomical features. In this study, we aimed to provide data on the prevalence and anatomical features of the DOB, which are of great importance at this early stage of research into the topic. Our findings have been correlated with current knowledge and are expected to contribute to clinical implementation. Materials and methods Twenty-eight fresh-frozen forearms were utilized for measurements. Specifically, mean length, width, distance from the middle of the bundle's insertion to the ulna to the tip of the styloid process of the ulna, as well as the distance from the midpoint of its insertion to the radius to the tip of the radiuses' styloid process were calculated. The prevalence was described with a cutoff thickness point of 0.5 mm. Early results based on three cases of DOB reconstruction with the "Riggenbach" technique due to distal radioulnar joint (DRUJ) instability were documented. Results Eleven DOBs were reported out of the 28 specimens, suggesting a prevalence of 39.3%. The mean thickness was 0.88 mm (range: 0.6-1.3 mm), the mean width was 5.22 mm (range: 2.2-8.4 mm), and the mean length was 25.68 mm (range: 22.7-29.2 mm). Proximally, the mean distance from the bundle's ulnar insertion to the tip of the styloid process of the ulna was 51.02 mm (range: 45.5-55.6 mm) while distally, the mean distance from the bundle's insertion to the radius to the tip of the styloid process of the radius was 34.5 mm (range: 31.3-37.7 mm). After a follow-up of at least six months, improvement was evident in all measured areas in the three patients who underwent surgery. Additionally, they reported satisfaction and accomplishment of their preoperative goals. Conclusions Discrepancies in measurements in some anatomic features between studies are probably due to variations in specimen types, measurement methods, and sites. Efforts must continue to be made on a more extensive scale and in a more standardized manner for more factual results and conclusions. "Reconstruction-recreation" or "original construction-creation" procedures yield promising results in a fast, simple, and less invasive manner than traditional methods of DRUJ stabilization.
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Affiliation(s)
- Stavros Angelis
- Anatomy, National and Kapodistrian University of Athens, Athens, GRC
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
| | - Emmanouil Apergis
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
| | | | | | | | - Maria Piagkou
- Anatomy, National and Kapodistrian University of Athens, Athens, GRC
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Jawahier PA, Rahimtoola ZO, Schep NWL. Stabilization of the Distal Radioulnar Joint Using the TightRope Implant: A Distal Oblique Bundle Augmentation. J Wrist Surg 2023; 12:453-459. [PMID: 37841350 PMCID: PMC10569831 DOI: 10.1055/s-0043-1764346] [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: 01/18/2022] [Accepted: 02/03/2023] [Indexed: 10/17/2023]
Abstract
Background Triangular fibrocartilage complex (TFCC) injury often results in distal radioulnar joint (DRUJ) instability. However, not all patients with a ruptured TFCC have an unstable DRUJ as in these patients a distal oblique bundle (DOB) may be present. We assumed that augmentation of the DOB leads to a more stable situation following reinsertion of the TFCC. We present the clinical results of a new surgical technique using the TightRope system as a DOB augmentation. Description of Technique All cases were treated under regional anesthesia with the TightRope implant for which a tunnel was drilled from the distal ulna through the radius along the path of the DOB. The TightRope was passed through the tunnel and secured with buttons on either side. X-rays were made during surgery to confirm correct positioning. Methods A retrospective study was performed analyzing 21 cases treated with a TightRope augmentation of the DOB. The primary outcome was measured using the patient-rated wrist evaluation (PRWE) score at least 12 months after surgery. Results Postoperatively, the DRUJ was stable in all patients. The median PRWE score was 16 for the injured side compared to zero for the uninjured side ( p -value: < 0.001). The median pronation and supination were not statistically significant when we compared the injured side to the uninjured side. The median grip strength was 31 kg for the injured side compared to 38 kg for the uninjured side ( p -value: 0.015). There were two minor postoperative complications (10%). Conclusion This technique is capable of restoring DRUJ stability with a short immobilization period resulting in good patient-related outcomes and a low complication rate.
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Affiliation(s)
| | - Zulfi O. Rahimtoola
- Department of Orthopaedic Surgery, The Royal Berkshire Hospital, Berkshire, United Kingdom
| | - N. W. L. Schep
- Department of Hand and Wrist Surgery, Maasstad Hospital, Rotterdam, the Netherlands
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Wittig US, Prager W, Sarahrudi K, Gkourlias G, Thomas N, Hammer N, Hohenberger GM. Does surgical reconstruction of the distal oblique bundle (DOB) provide similar stability as the intact bundle or Adams procedure? A systematic review. Ann Anat 2023; 250:152130. [PMID: 37467811 DOI: 10.1016/j.aanat.2023.152130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/21/2023] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION The aim of this review was to summarize the available evidence for biomechanical stability following surgical DOB reconstruction, and to determine whether distal radioulnar joint (DRUJ) stability with a reconstructed DOB was similar to the native intact condition or that after the Adams procedure. MATERIAL AND METHODS A systematic literature search according to the PRISMA guidelines was performed using the databases PubMed and Embase. The following search algorithm was used: ("DOB" OR "Distal Oblique Bundle") AND "Reconstruction". Biomechanical or human cadaveric studies that measured stability of the DRUJ after reconstruction of the DOB were included. RESULTS Four articles were included in the final analysis. DOB incidence was reported to be between 50% and 70%. Two studies observed no differences between the intact situation and the reconstructed DOB, respectively the Adams procedure. A further author group found no signs of major instability after the Adams reconstruction or after DOB reconstruction, except for decreased stability during supination in the DOB sample. In another study, similar results could be shown for the Adams and DOB reconstruction groups; however, the DOB sample showed decreased dorsal translation of the radius during forearm supination. CONCLUSION In conclusion, DOB reconstruction was proven to stabilize the DRUJ adequately. Moreover, the reconstructed DOB showed the same stability as the native DOB, except for one study, in which stability following reconstruction was reduced during supination. No significant difference between the DOB and the Adams reconstruction could be observed.
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Affiliation(s)
- Ulrike Susanne Wittig
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria; Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria.
| | - Walter Prager
- Department of Trauma, LKH Feldbach-Fürstenfeld, Feldbach, Austria
| | - Kambiz Sarahrudi
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Georgios Gkourlias
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Norbert Thomas
- Department of Trauma Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria; Department of Trauma, Orthopedic and Plastic Surgery, University Hospital of Leipzig, Leipzig, Germany; Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Division of Medical Technology, Dresden, Germany
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Thomsen NO, Björkman A. Reconstruction of the Distal Oblique Bundle for DRUJ Instability. J Wrist Surg 2023; 12:261-264. [PMID: 37223386 PMCID: PMC10202563 DOI: 10.1055/s-0041-1740488] [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: 02/18/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
Background Treatment algorithm for disruption of the triangular fibrocartilage complex (TFCC) from the ulnar fovea includes direct TFCC repair, tendon reconstruction of the radioulnar ligaments, or a salvage procedure in cases with painful distal radioulnar joint (DRUJ) degeneration. Case Description We describe our surgical technique for reconstruction of the distal oblique bundle (DOB), to attain DRUJ stability in a young man, after failed attempts of direct TFCC reinsertion and radioulnar ligament reconstruction with the Adams procedure. Literature Review Reconstruction of the central band of the interosseous membrane is well recognized for Essex-Lopresti injuries that demonstrate longitudinal forearm instability. The role for reconstruction/reinforcement of the DOB to restore DRUJ stability after TFCC injury has not gained the same recognition and needs further clarification. Clinical Relevance DOB reconstruction technique described is extra-articular and technically straightforward. We believe that the procedure could be considered for patients with an irreparable TFCC injury as a part of the treatment algorithm for younger patients, who otherwise would face a more extensive salvage procedure.
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Affiliation(s)
- Niels O.B. Thomsen
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden
| | - Anders Björkman
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden
- Department of Hand Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Marès O, Bosch C. Distal radioulnar joint instability: Diagnosis and treatment of acute and chronic lesions. Orthop Traumatol Surg Res 2023; 109:103465. [PMID: 36942792 DOI: 10.1016/j.otsr.2022.103465] [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: 01/24/2022] [Accepted: 07/01/2022] [Indexed: 11/07/2022]
Abstract
Distal radioulnar joint instability is a common clinical condition that can be either acute or chronic. Its management requires extensive knowledge of all the anatomical structures around the wrist area. The clinical examination must identify all damaged structures in order to define a customized reconstruction strategy. The aim of treatment is to prevent the development of chronic instability and/or arthritic lesions, which can only be treated with palliative surgery. Distal radioulnar instability is complex. Its management shares similarities with that of knee instability, with a wide range of conditions ranging from a sprain with isolated ligament tear to complex dislocation in which multiple ligaments are torn. In particular, the triangular fibrocartilage complex, which is a pillar of distal radioulnar joint stability, is not the sole stabilizer of this joint. The treatment strategy is not as simple as just reattaching this ligament to treat all of the acute and chronic clinical signs. The goal of the present study is to describe the various structures and possible lesions in this joint and then how to repair them. The diagnostic and therapeutic difficulties justify treatment at a specialized center.
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Affiliation(s)
- Olivier Marès
- CHU de Nîmes, avenue du Professor Debré, 30000 Nîmes, France.
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Verbeek DO, Wilssens NOJ, Ten Bosch JA, Hannemann PFW. Long-term results of distal oblique bundle reinforcement for treatment of chronic bidirectional instability of the distal radioulnar joint. J Hand Surg Eur Vol 2022; 47:1128-1133. [PMID: 36071642 DOI: 10.1177/17531934221121925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Distal oblique bundle (DOB) reinforcement for treatment of post-traumatic bidirectional instability of the distal radioulnar joint (DRUJ) has previously been reported. The objective of the current study was to assess the incidence of symptomatic graft failure and the need for secondary wrist procedures at a longer follow-up in an updated patient cohort of 27 patients with 28 DOB reinforcement procedures. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and patient-rated wrist/hand evaluation (PRWHE) outcome measures were also evaluated. At median 82 months follow-up, pre- to postoperative QuickDASH score improved from a mean of 62 (SD 14) to 31 (SD 22) (p < 0.01) and PRWHE score from a mean of 67 (SD 17) to 34 (SD 23) (p < 0.01). Symptomatic graft failure with resultant painful DRUJ instability occurred in four out of 28 procedures, which was better than the published results of alternative surgical options for DRUJ instability. DOB reinforcement presents a relatively safe, effective and durable method for treatment of post-traumatic DRUJ instability.Level of evidence: III.
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Affiliation(s)
- Diederik O Verbeek
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nicholas O J Wilssens
- Department of Plastic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan A Ten Bosch
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pascal F W Hannemann
- Department of Surgery, Division of Trauma Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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Mau M, Livingstone J, Lee G, Murray P. Optimizing the Orientation of a Suture Button to Stabilize the Distal Radioulnar Joint in a Sawbones Model. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:355-359. [PMID: 36425361 PMCID: PMC9678699 DOI: 10.1016/j.jhsg.2022.06.007] [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: 05/02/2022] [Accepted: 06/27/2022] [Indexed: 10/15/2022] Open
Abstract
Purpose When left untreated, distal radioulnar joint (DRUJ) instability leads to prolonged wrist pain and weakness during pronosupination. Current treatment options are technically demanding and result in mixed outcomes. This study used a synthetic bone model to evaluate the potential of using a suture button to stabilize the DRUJ and find its optimal configuration. Methods A suture button was placed between the radius and ulna of a synthetic bone model with DRUJ instability. The suture button was placed straight across or in an oblique orientation while the forearm was in 60° of pronation, neutral, or 60° of supination for 6 configurations. The range of motion, dislocation events, dorsal translation, volar translation, and gaps between the radius and ulna were measured and compared among these 6 configurations. Results Full range of motion (ROM) was achieved in all configurations except for suture buttons placed while the forearm was in 60 ° pronation. Obliquely placed suture buttons led to more dislocations than straight across suture buttons. The 2 configurations that offered full ROM with the greatest stability were straight across 60° supination and straight across neutral configuration, with the supinated configuration slightly improving stability. Conclusions In this model, suture buttons restored DRUJ stability while maintaining full ROM, indicating that suture buttons have the potential to be used as a treatment option for stabilization of DRUJ. The optimal configuration of a suture button is likely in the straight across 60° supinated configuration, as it provides the greatest stability without sacrificing ROM compared with the other suture button configurations. Clinical relevance Additional treatment options for the stabilization of DRUJ are needed. Suture buttons may be of use.
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Affiliation(s)
- Makoa Mau
- John A Burns School of Medicine, University of Hawai'i, Honolulu, HI
| | - John Livingstone
- Department of Orthopedic Surgery, University of Hawai'i, Honolulu, HI
| | - Gordon Lee
- Department of Orthopedic Surgery, University of Hawai'i, Honolulu, HI
| | - Patrick Murray
- Department of Orthopedic Surgery, University of Hawai'i, Honolulu, HI
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Rodríguez-Merchán EC, Shojaie B, Kachooei AR. Distal Radioulnar Joint Instability: Diagnosis and Treatment. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:3-16. [PMID: 35291239 PMCID: PMC8889419 DOI: 10.22038/abjs.2021.57194.2833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/30/2021] [Indexed: 01/24/2023]
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.
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Affiliation(s)
- E. Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain. ,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
| | - Babak Shojaie
- Department of Hand, Plastic and reconstructive Surgery,Göttingen University of medical Sciences,Klinikum Bremen Mitte,Bremen,Germany,Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir R. Kachooei
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, USA. ,Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Pajares S, Martínez-Catalán N, Novo-Rivas U. Stabilization for acute distal radioulnar instability: A novel surgical technique. Injury 2021; 52 Suppl 4:S137-S144. [PMID: 33663804 DOI: 10.1016/j.injury.2021.02.043] [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: 11/28/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Instability of the distal radioulnar joint (DRUJ) commonly results from traumatic disruption of the distal radioulnar ligaments of the triangular fibrocartilage complex (TFCC). Treatment of this rupture typically requires immobilization of the wrist and elbow for a period of 6 to 8 weeks. This study evaluated the hypothesis that treatment of DRUJ instability with dynamic stabilization would allow early mobilization of both the radiocarpal and distal radioulnar joints by the first postoperative week without compromising restoration of TFCC integrity. MATERIALS AND METHODS Between September 2017 and January 2019, a retrospective study was conducted on 22 patients presenting with DRUJ instability confirmed by intraoperative Ballottement testing. Once instability was confirmed, dynamic surgical stabilization was performed, followed by one week of short cast immobilization. Arthrographic computed tomography (CT) of each patients' affected wrist was performed 4 months later to evaluate TFCC integrity. The recovery of patients was monitored at 1, 3, 6, and 12 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Ballottement test, and evaluation of radioulnar join range of motion (ROM), pain, and complications. RESULTS All patients were followed postoperatively for a mean of 13.5 months. After 1 month, all patients exhibited satisfactory range of motion and DRUJ stability. By 3 months, Ballottement tests were negative in 21 of 22 patients, with instability persisting in only 1 patient. At 4 months, CT arthrography contrast leakage (indicative of a TFCC tear) was observed in 5 of 20 patients. Upon reexamination a mean of 10.5 months later, the TFCC tears of these patients had healed in 2 cases (with foveal tears), while no difference in contrast leakage was observed for the other 3 cases (with horizontal or central tears). Revision surgery for implant related complications was performed in 2 cases. CONCLUSION Acute DRUJ instability treated with dynamic stabilization led to satisfactory clinical outcomes in terms of range of motion, pain relief and joint stability, allowing DRUJ movement from the first postoperative week. This technique represents a simple, reproducible and minimally invasive procedure with a low rate of implant related complications.
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Affiliation(s)
- Samuel Pajares
- Department of Orthopaedic Surgery and Traumatology, Clínica Universidad de Navarra, Calle Marquesado de Santa Marta 1, 28027 Madrid, Spain.
| | - Natalia Martínez-Catalán
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario Fundación Jiménez Diáz, Universidad Autónoma, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Ulrike Novo-Rivas
- Department of Radiology, Hospital Universitario Fundación Jiménez Diáz, Universidad Autónoma, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
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Delbast L, Pic JB, Marty-Diloy T, Dimet J, Lepetit C. Stabilization of the distal radioulnar joint by reconstructing the interosseous membrane's distal oblique bundle: Cadaver study. Orthop Traumatol Surg Res 2020; 106:1581-1587. [PMID: 33082121 DOI: 10.1016/j.otsr.2020.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 02/27/2020] [Accepted: 03/27/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The distal radioulnar (DRU) ligaments play a key role in stabilizing the DRU joint. Ligament reconstruction in this area is an accepted treatment. However, another structure may also be a significant DRUJ stabilizer-the distal oblique bundle (DOB) of the interosseous membrane (IOM). Recent studies have described DOB reconstruction methods, which should be compared to DRU ligament reconstruction. METHODS Twelve upper limbs were used. First, a descriptive anatomy study was done to determine the prevalence and features of the DOB (insertions, thickness, and relationship with DRU ligaments). Second, biomechanical testing was done with the wrist in neutral position, supination, and pronation. Distal radius translation was evaluated first on an intact wrist then evaluated again after creating bidirectional instability. Lastly, the same tests were repeated after DRU reconstruction using the Adams-Berger technique and DOB reconstruction using the Riggenbach technique. RESULTS The DOB was present in 50% of specimens and was bilateral. Reconstructing the DOB stabilized the wrist to the same degree as the Adams-Berger technique in neutral and pronation (8% residual major instability). Stability was harder to achieve in supination (25% major instability). It was better at controlling posterior radial translation than anterior translation (3% versus 14% major instability). CONCLUSION DOB reconstruction appears to be a reliable and less invasive treatment option for DRUJ instability since it is extra-articular. However, the wrist's position and the direction of radial translation seem to alter the stabilization's effectiveness. LEVEL OF EVIDENCE IV; Cadaver study.
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Affiliation(s)
- Laurent Delbast
- Service de chirurgie orthopédique du centre hospitalier de Mont-de-Marsan, 417, avenue Pierre-de-Coubertin, BP 417, 40024 Mont-de-Marsan cedex, France.
| | - Jean-Baptiste Pic
- Service de chirurgie orthopédique du centre hospitalier de Niort, 40, avenue Charles-de-Gaulle, BP 70600, 79021 Niort cedex, France
| | - Thibault Marty-Diloy
- Service de chirurgie orthopédique du centre hospitalier universitaire de Poitiers, 2, rue de la-Milétrie, 86021 Poitiers, France
| | - Jérôme Dimet
- Centre de recherche clinique GHT des Landes, centre hospitalier de Mont-de-Marsan, 417, avenue Pierre-de-Coubertin, BP 417, 40024 Mont-de-Marsan cedex, France
| | - Cédric Lepetit
- Capio clinique Aguiléra, 21, rue de l'Estagnas, CS 60179, 64201 Biarritz, France
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Martínez-Martínez F, Giménez-Ros A, León-Muñoz VJ, Santonja-Medina F. Reconstruction of the Distal Oblique Bundle of the Interosseous Membrane with Extensor Carpi Radialis Hemitendon: A New Minimally-Invasive Technique. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2020. [DOI: 10.1055/s-0040-1719013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractThe main stabilizing element of the distal radioulnar joint (DRUJ) is the triangular fibrocartilage complex (TFCC). Secondary stabilizers include the distal oblique band (DOB), which is inconsistently found. When TFCC repair has failed or cannot be performed, DOB reconstruction is a therapeutic option. Even though distal radioulnar ligamentoplasty remains the technique of choice, recent papers show similar outcomes from both methods. We present two cases of successful DOB repair with the extensor carpi radialis longus (ECRL) hemitendon.
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Affiliation(s)
| | - Alberto Giménez-Ros
- Department of Orthopedic Surgery, Hospital Universitario Virgen del Castillo de Yecla, Murcia, Spain
| | - Vicente J. León-Muñoz
- Department of Orthopedic Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Fernando Santonja-Medina
- Department of Orthopedic Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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Iqbal MS, Mishra AK, Kaul R. Fixação suspensiva percutânea de luxação crônica da articulação radioulnar distal (ARUD) usando um dispositivo de endobutton de laço ajustável: Relato de caso. Rev Bras Ortop 2020; 58:351-355. [DOI: 10.1055/s-0040-1715515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022] Open
Abstract
ResumoLuxação crônica da articulação radioulnar distal (ARUD) foi tratada historicamente com osteotomias complexas e procedimentos reconstrutivos, geralmente resultando em rigidez intratável e perda de função. É desejável usar uma técnica de fixação que não apenas restaure a biomecânica do punho, mas também seja esteticamente atraente para o indivíduo. Apresentamos uma nova técnica de redução e fixação de uma ARUD deslocada cronicamente em um homem de 26 anos, usando uma abordagem minimamente invasiva, com restauração bem-sucedida da função da ARUD e sem complicações pós-operatórias.
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Affiliation(s)
| | | | - Rajiv Kaul
- Departamento de Ortopedia, Armed Forces Medical College, Pune, Índia
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Bahm J, Bouslama S, Hagert EM, Andersson JK. Ulnar Wrist Deviation in Children With Obstetric Brachial Plexus Palsy: A Descriptive Study of Clinical and Radiological Findings of Impaired Ulnar Growth and Associated Incongruence of the Distal Radioulnar Joint. Hand (N Y) 2020; 15:615-619. [PMID: 30819026 PMCID: PMC7543203 DOI: 10.1177/1558944719831243] [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] [Indexed: 11/17/2022]
Abstract
Backround: Some children with obstetric brachial plexus palsy (OBPP) present later on with an ulnarly deviated wrist. The aim of this study was to present a retrospective analysis of a subgroup of OBPP children with ulnarly deviated wrists and to describe their morphologic wrist deformity in terms of clinical and radiological appearance. Methods: We present a retrospective analysis of the records of 27 children with an ulnarly deviated wrist as a consequence of OBPP. Radiographs of the affected wrist were performed when the ulnar deformity became clinically manifest and merited investigation, at a mean age of 15 (range: 6.5-27) years. Available clinical and radiological data were analyzed and categorized. Results: The ulnar-deviated position was associated with impaired active and passive pronosupination in all patients. Fifteen fixed supination deformities and 3 anterior radial head dislocations were noted clinically. Plain radiographs were completed in 24 patients and could be analyzed in 18, showing variations in ulnar variance (7 neutral, 7 ulna minus, and 4 ulna plus) along with 6 subluxations of the distal radioulnar joint (DRUJ). Of the patients treated surgically (n = 7), only the 2 patients treated with wrist fusion had an actual improvement in ulnar wrist deformity. Conclusion: Radiologically visible ulnar head hypoplasia, overgrowth of the distal ulna, or a shortened ulnar diaphysis and an incongruent DRUJ were present in all examined OBPP patients with a clinically evident ulnarly deviated wrists. The radiological findings highlight the morphologic adaptation behind this clinical condition and could allow further investigation into suitable treatment strategies.
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Affiliation(s)
| | | | - Elisabet M. Hagert
- Karolinska Institute, Stockholm, Sweden,ARCADEMY Stockholm, Sophiahemmet Hospital, Stockholm, Sweden
| | - Jonny K. Andersson
- SportsMed, Carlanderska Hospital, Göteborg, Sweden,Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Sweden,Jonny K. Andersson, SportsMed, Carlanderska Hospital, Göteborg SE-405 45, Sweden.
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Angelis S, Apergis E, Vynichakis G, Triantafyllou S, Skandalakis P, Filippou D. Anatomic Characteristics of the Distal Oblique Bundle of the Interosseous Membrane of the Forearm. Cureus 2019; 11:e3964. [PMID: 30956916 PMCID: PMC6436668 DOI: 10.7759/cureus.3964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The distal oblique bundle of the forearm is a structure that has been under vigorous investigation for the past decade. It is part of the distal interosseous membrane (DIOM) and seems to have an important stabilizing effect in the distal radioulnar joint. In this essay, we have tried to summarize the anatomical characteristics of the structure. We have also compared and contrasted this to our own experience with eight freshly frozen forearms. It is our strong belief that the distal oblique bundle (DOB) may play a keystone role in future stabilization techniques of the distal radioulnar joint, and its anatomy characteristics need to be fully investigated.
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Affiliation(s)
- Stavros Angelis
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
| | - Emmanouil Apergis
- Orthopaedics, General Hospital Hellenic Red Cross Korgialenio - Benakio, Athens, GRC
| | | | | | | | - Dimitrios Filippou
- Surgery, Medical School of National and Kapodistrian University of Athens, Athens, GRC
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Kootstra TJM, van Doesburg MH, Schuurman AH. Functional Effects of the Adams Procedure: A Retrospective Intervention Study. J Wrist Surg 2018; 7:331-335. [PMID: 30174991 PMCID: PMC6117174 DOI: 10.1055/s-0038-1660812] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 05/10/2018] [Indexed: 10/14/2022]
Abstract
Background Injury to the distal radioulnar joint (DRUJ) causes swelling and ulnar-sided wrist pain. The Adams procedure stabilizes the DRUJ and shows promising short-term results. Purpose We studied the long-term functional outcome in patients who underwent the Adams procedure. We also tested the null hypothesis that there would be no difference in range of motion (ROM) and grip strength between the operated wrist compared to the unaffected side. Patients and Methods We identified 74 consecutive patients that were operated from March 2005 to February 2014. Twenty-three patients responded to our invitation and underwent clinical follow-up. Three patients had a re-do of the Adams procedure after presenting with postoperative DRUJ instability, one was excluded due to additional wrist surgery not related to the initial procedure. Wrist functionality in the remaining 22 patients was examined by measuring ROM in all planes and grip strength of the operated and non-operated hand. Functional outcome was measured by asking patients to complete the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure and the Patient-Rated Wrist and Hand Evaluation (PRWHE). Results After a mean follow-up time of 5.0 years (standard deviation [SD] 2.0), we found that supination, pronation, and grip strength were significantly decreased in the operated wrist. Postoperative DASH and PRWHE-scores averaged 13.1 (SD 18.6) and 20.3 (SD 15.1), respectively. Conclusion The Adams procedure affects, but largely restores pronation and supination, and clinical examination, DASH, and PRWHE scores indicate that the Adams procedure leaves patients with upper extremity functionality comparable to a healthy population. Level of Evidence Level IV.
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Affiliation(s)
- Thomas J. M. Kootstra
- Department of Plastic Surgery, Universitair Medisch Centrum Utrecht, Universiteit Utrecht, Utrecht, The Netherlands
| | - Margriet H. van Doesburg
- Department of Plastic Surgery, Universitair Medisch Centrum Utrecht, Universiteit Utrecht, Utrecht, The Netherlands
| | - Arnold H. Schuurman
- Department of Plastic Surgery, Universitair Medisch Centrum Utrecht, Universiteit Utrecht, Utrecht, The Netherlands
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Distal radioulnar joint instability. HAND SURGERY & REHABILITATION 2017; 36:305-313. [DOI: 10.1016/j.hansur.2017.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 07/06/2017] [Accepted: 08/01/2017] [Indexed: 11/22/2022]
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de Vries EN, Walenkamp MMJ, Mulders MAM, Dijkman CD, Strackee SD, Schep NWL. Minimally invasive stabilization of the distal radioulnar joint: a cadaveric study. J Hand Surg Eur Vol 2017; 42:363-369. [PMID: 27402281 DOI: 10.1177/1753193416656773] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study describes a minimally invasive procedure for stabilization of the distal radioulnar joint, using a suture-button construct placed percutaneously in the direction of the distal oblique bundle in the distal interosseous membrane. In five cadaveric specimens, placement of the suture-button suspension system reduced dorsal displacement of the radius in an unstable distal radioulnar joint to baseline values, both in neutral position and in pronation and supination. These results indicate the possibility of minimally invasive treatment for distal radioulnar joint instability.
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Affiliation(s)
- E N de Vries
- 1 Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M M J Walenkamp
- 1 Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A M Mulders
- 1 Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - C D Dijkman
- 2 Department of Medical Innovation and Development, Academic Medical Centre, Amsterdam, The Netherlands
| | - S D Strackee
- 3 Department of Plastic Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - N W L Schep
- 1 Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.,4 Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
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Abstract
BACKGROUND Injuries of the interosseous membrane (IOM) of the forearm are frequently unrecognized, difficult to treat, and can result in a devastating sequelae for the wrist and elbow. PURPOSE The purpose of this review article is to evaluate the dignosis, biomechanics, clinical results, and propose a treatment approach to this rare complex entity. METHODS The biomechanical and clinical literature is reviewed. A treatment approach is described based on the known biomechanics and clinical experience of the senior author (T. W. W.). RESULTS Multiple different reconstructive methods have been proposed for the treatment of both acute and chronic IOM injuries. The results of the published series are reviewed. IOM injuries can have reasonable outcomes particularly if diagnosed and treated early. CONCLUSION There are multiple methods for treating patients with IOM injuries. Physicians should be highly suspicious about this injury when a patient presents with a highly displaced radial head fracture associated with wrist pain. Treatment with reconstruction of the cerebral band of the IOM with radial head replacement (do not overstuff) and temporary uploading the construct with K-wires from the ulna to the radius will give the most predictable results.
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Affiliation(s)
- Robert Matthias
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida
| | - Thomas W. Wright
- Orthopaedics and Sports Medicine Institute, University of Florida, Gainesville, Florida
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