Distal Radioulnar Joint Surgery Info In-depth Evidence Consent

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Salvage of failed distal radioulnar joint reconstruction requires a thorough understanding of normal anatomy, biomechanics, and the modes of failure of the primary procedure to develop effective strategies [1].
• Most ulnar-sided wrist problems associated with distal radial fractures can be treated non-operatively initially, typically for over a year, in anticipation of substantial improvement with time [2].
• Distal radioulnar joint instability is often an underestimated lesion requiring systematic clinical examination and imaging for detection [4].
• Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios, most commonly cast immobilization in 41% (247 of 607) [5].
• The management of distal radioulnar joint instability includes treatment strategies such as percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques [6].
• Ulnar shortening osteotomy is a good option to treat patients with ulnar impaction syndrome regardless of the distal radioulnar joint angle [7].
• Severely damaged and painful distal radioulnar joints can be reconstructed by resection arthroplasty or by hemi- or total arthroplasty [8].
• DRUJ ligament reconstruction is indicated when native ligaments are not reparable, provided there is no radius or ulna bony deformity or arthritis of the DRUJ [9].
• The introduction of ulnar head and total radio-ulnar joint prostheses has provided a new method, but there is presently no evidence that these implants produce long-lasting results [10].
• When appropriate patient selection criteria are met, partial and total ulnar head replacement typically produce reliable results [39].

Anatomy & Pathophysiology

Bony Anatomy and Kinematics

• The distal radioulnar joint (DRUJ) is a complex anatomic unit providing an articular link between the distal radius and ulna [11].
• The DRUJ is composed of both bony and soft tissue structures that, along with the proximal radioulnar joint, allow for rotation (pronation/supination) of the forearm [11].
• Articular surface contact in the shallow sigmoid notch accounts for about 20% of DRUJ stability [46].
• The sigmoid notch allows dorsopalmar translation of about 1 cm with the forearm in neutral position [46].
• During forearm rotation, the ulnar head at its articulation with the sigmoid notch moves from dorsal and distal in full pronation to proximal and palmar in full supination [46].
• The ulnar styloid extends 2 to 6 mm distal to the ulnar head [46].
• Anatomical variations in the sigmoid notch and ulnar head significantly influence joint mechanics and treatment outcomes [56].
• The DRUJ kinematics during handstanding vary with school age in female gymnasts, with high school students showing a significantly larger increase in DRUJ separation compared to elementary school students [51].
• The Aptis distal radioulnar joint arthroplasty considerably alters forearm kinematics [45].

Soft Tissue Anatomy and Stability

• The triangular fibrocartilage complex (TFCC) includes the dorsal and volar radioulnar ligaments, ulnar collateral ligament, meniscal homologue, articular disc, ulnolunate ligaments, ulnotriquetral ligaments, and extensor carpi ulnaris sheath [46].
• The deep fibers of the TFCC attach ulnarly at the head of the ulna called the “fovea,” and the superficial fibers attach to the ulnar styloid tip where it joins with the ulnar collateral ligaments [46].
• Most of the distal radioulnar ligaments and the ulnocapitate ligament attach to the fovea at the base of the ulnar styloid [46].
• The articular disc has attachments to the distal radioulnar ligaments and passes from the distal margin of the sigmoid notch to the fovea at the base of the ulnar styloid [46].
• The thickness of the articular disc has an inverse relationship to the amount of ulnar variance [46].
• The DRUJ functions as a structure of tensegrity where ligament bundles shift tension based on forearm rotation [54].
• The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint [29].
• The interaction between ligaments, muscles, and bones is emphasized for DRUJ stability [31].

Biomechanics and Load Distribution

• Loads applied to the distal radiocarpal and ulnocarpal joints are distributed about 80% to the distal radius and 20% to the ulna [46].
• The distal ulna transmits significant loads to the forearm through the triangular fibrocartilage complex [17].
• A biomechanical analysis showed that increasing ulnar variance by 2.5 mm dramatically increases the load borne by the distal ulna [32].
• Pressures within the DRUJ change with forearm rotations, with the highest intra-articular pressure recorded in supination under no disruption-no load, no disruption-loaded, and disrupted TFCC conditions [60].
• Radial lengthening did not demonstrate a benefit in improving DRUJ stability in a triangular fibrocartilage complex injury model [59].

Pathophysiology and Injury Mechanisms

• Even minor disruptions of the precise anatomic relationships between the distal radius and ulna and ulnar carpus result in pain syndromes [17].
• The DRUJ can be dislocated by a variety of mechanisms, including low- and high-energy trauma [17].
• Dislocations are associated with disruption of the ulnar soft-tissue triangular fibrocartilage complex, including the articular disk and associated ligaments [17].
• A displaced fracture at the ulnar styloid base indicates a high risk of distal radioulnar instability [17].
• Injuries to the distal radioulnar joint are common in distal radius fractures [11].
• Failure to recognize and appropriately treat concomitant DRUJ injuries in distal radius fractures can lead to residual wrist disability and has been associated with worse functional outcomes [11].
• Alterations in DRUJ biomechanics due to injury can lead to instability and incongruency, which can cause ulnar-sided wrist pain, limitations in range of motion, and the development of further pathology [11].
• Rupture of the distal radioulnar ligaments usually causes diastasis of the distal radioulnar joint, which can be seen on radiographs and is a pathognomonic sign that the ligaments have been ruptured [18].
• In most patients with irreducible dislocations of the distal radioulnar joint, the extensor carpi ulnaris was entrapped in the joint and prevented closed reduction [18].
• Positive ulnar variance or protrusion of the ulna distal to its normal articulation with the ulnar notch of the radius and consequent impingement on the carpus can be caused by malunited Colles fracture, malunion or nonunion of the radius, and cessation or abnormality of growth of the distal radius [32].
• Significant extraarticular deformities of the distal radius adversely affect distal radioulnar joint function [32].
• Only 6 mm of radial shortening has been shown to cause distal radioulnar joint dysfunction [32].
• Decreased radial inclination and dorsal tilt led to moderate changes in joint kinematics, while dorsal displacement caused minimal changes [32].
• Radioulnar arthrosis has been found to be more common than radiocarpal arthrosis [32].
• Approximately 70% of the patients who developed radioulnar arthrosis require surgical intervention [32].
• Deterioration of the distal radioulnar joint is believed to be caused by shortening and angular deformities of the distal radius [32].

Classification

TFCC Tear Classification (Palmer)

• The Palmer classification categorizes triangular fibrocartilage complex (TFCC) tears into traumatic (Class 1) and degenerative (Class 2) types [27, 28].
• TFCC tear subtypes are defined based on the specific location within the TFCC [27, 28].
• The class and location of a TFCC tear have important implications for treatment [27, 28].
• Class 1 (Traumatic) TFCC injuries are subdivided into four types according to the tear's location [58].
• Type 1-B injuries are peripheral tears located at the ulnar end of the TFCC [58].
• Class 1A TFCC injuries are characterized by central perforation or tear [27, 28].
• Class 1B TFCC injuries are characterized by ulnar avulsion with or without ulnar styloid fracture [27, 28].
• Class 1C TFCC injuries are characterized by distal avulsion involving the origins of the ulnolunate and ulnotriquetral ligaments [27, 28].
• Class 1D TFCC injuries are characterized by radial avulsion involving the dorsal and/or volar radioulnar ligaments [27, 28].
• Class 2 (Degenerative) TFCC tears are associated with ulnocarpal impaction syndrome [27, 28].
• Class 2A TFCC tears are characterized by TFCC wear or thinning [27, 28].
• Class 2B TFCC tears are characterized by TFCC wear plus lunate and/or ulnar chondromalacia [27, 28].
• Class 2C TFCC tears are characterized by TFCC perforation plus lunate and/or ulnar chondromalacia [27, 28].
• Class 2D TFCC tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, and lunotriquetral ligament disruption [27, 28].
• Class 2E TFCC tears are characterized by TFCC perforation, lunate and/or ulnar chondromalacia, lunotriquetral ligament disruption, and ulnocarpal and DRUJ arthritis [27, 28].

Arthroscopic Treatment-Oriented Classification

• Advances in diagnostic arthroscopy permit a treatment-oriented classification of TFCC peripheral tears into five categories: repairable distal tears, repairable complete tears, repairable proximal tears, non-repairable tears, and tears associated with DRUJ arthritis [58].
• In the arthroscopic treatment-oriented classification, Class 1 tears should be sutured [58].
• In the arthroscopic treatment-oriented classification, Class 2 and 3 tears are associated with DRUJ instability and require TFCC reattachment to the fovea [58].
• In the arthroscopic treatment-oriented classification, Class 4 tears need reconstruction using a tendon graft [58].
• In the arthroscopic treatment-oriented classification, Class 5 tears require an arthroplasty [58].

DRUJ Instability and Pathology

• The management of distal radioulnar joint instability includes categorization of instability and treatment strategies such as percutaneous, arthroscopic, soft-tissue, osteotomy, and arthroplasty techniques [6].
• Arthrosis of the distal radioulnar joint can result from inflammatory arthropathy, traumatic disruption of articular surfaces, traumatic disruption of soft tissue constraints leading to instability, infection, or developmental malformation [36].

Clinical Presentation

General Presentation and Diagnosis

• Failure to recognize and appropriately treat concomitant distal radioulnar joint injuries in the setting of distal radius fractures can lead to residual wrist disability and is associated with worse functional outcomes [11].
• Chronic distal radioulnar joint instability results from various traumatic injuries and can lead to chronic functional impairment, pain, and arthritis if left untreated [12].
• There should be a high index of suspicion to diagnose distal radioulnar joint dislocation because radiographs not taken in the perfect lateral orientation tend to look relatively normal [17].
• In the presence of forearm and elbow fracture-dislocations, further evaluation of the radioulnar joint is mandatory [17].
• Dysfunction of the distal radioulnar joint is a frequent source of persistent complaints after distal radial malunions [32].
• Characteristic symptoms of distal radioulnar joint dysfunction after distal radial malunions include pain, decreased forearm rotation, decreased grip strength, and instability [32].
• Approximately 70% of patients who developed radioulnar arthrosis require surgical intervention [32].
• The occurrence of osteoarthritis of the distal radioulnar joint was affected by the presence of osteoarthritis of the adjacent joint [24].

Physical Examination

• The clinical examination is key, with identification of the distal radioulnar joint surface anatomy and clinical evaluation of the joint [17].
• The amount of stability should be carefully assessed and compared with that of the opposite wrist [17].
• The patient should position the wrist to reproduce the pain [17].
• With the hand pronated, the examiner tries to displace the ulnar head by applying a dorsal to volar load 4 cm proximal to the distal radioulnar joint, known as the "piano key test" [17].
• Little resistance to ballottement and volar movement of the ulna head corresponds to a positive piano key test [17].
• Subluxation is much more common than anterior or posterior dislocation [17].
• Limitation of pronation and supination, or pain associated with such motion, would be expected in the situation of subluxation [17].
• Palpation of the sixth extensor compartment during resisted pronation is useful to identify any subluxation [17].
• The reliability of clinical assessment of distal radioulnar joint instability has been questioned [50].
• A recent publication has shown distal radioulnar joint instability to be more common than previously appreciated [50].
• After a distal radial fracture, a degree of distal radioulnar joint instability is universally present when measured quantitatively [50].
• The figure for quantitative instability after distal radial fracture is far greater than the range of 0–35% previously reported in the literature when clinical assessment is the sole determinant of stability [50].
• Surgeons working in the United Kingdom were unreliable in assessing distal radioulnar joint instability [50].
• The sensitivity of clinical assessment of distal radioulnar joint instability in wrists previously measured on a validated jig was 24% [50].
• The specificity of clinical assessment of distal radioulnar joint instability in wrists previously measured on a validated jig was 94% [50].

Imaging and Diagnostic Modalities

• Distal radioulnar joint instability requires systematic clinical examination and imaging for detection [4].
• There is substantial surgeon-to-surgeon variation in interpreting MRI signal changes and arthroscopic findings in the distal radioulnar ligaments and central disc [35].
• Variation in interpreting MRI signal changes and arthroscopic findings raises concerns about overdiagnosis and overtreatment versus underdiagnosis [35].

Investigations

Clinical Examination

• Distal radioulnar joint instability is often an underestimated lesion requiring systematic clinical examination for detection [4].
• A thorough knowledge of the anatomy and kinematics of the distal radioulnar joint is necessary to manage pathologic conditions [3].

Imaging

• Standard well-positioned radiography is the appropriate first step for imaging the distal radioulnar joint [63].
• High-resolution MRI helps delineate ligamentous structures of the distal radioulnar joint [63].
• Dynamic CT is indicated for clinical instability of the distal radioulnar joint [63].
• Imaging the distal radioulnar joint requires knowledge of the complex bony, muscular, and ligamentous anatomy [63].
• MRI is controversial but newer innovations suggest value in detection and localization of triangular fibrocartilage complex pathology [27].
• Arthroscopy is the gold standard for detection of triangular fibrocartilage complex tears [27].
• The arthroscopic trampoline test is performed to assess triangular fibrocartilage complex resiliency by balloting the central portion with a small probe [27].
• The arthroscopic hook test can be used to demonstrate peripheral detachment of the triangular fibrocartilage complex [27].
• The arthroscopic suction test can show laxity of the triangular fibrocartilage complex when peripherally scarred in or foveal detachment when the distal radioulnar joint is clinically unstable [27].
• A nuanced understanding of three-dimensional relationships between ulnar bowing and distal radioulnar joint anatomy can enhance preoperative planning when correcting ulnar-side pathology [62].

Diagnostic Considerations

Treatment

Non-Operative

• Dorsal dislocation or subluxation of the distal radioulnar joint should be treated by reduction of the ulnar head into the sigmoid fossa and placement of the forearm in full supination [17].
• The arm should be immobilized in supination, which requires a long arm cast or splint [17].
• Volar dislocation is relatively rare and is usually stable after reduction [17].
• If dorsal or volar dislocation or subluxation of the distal ulna cannot be reduced with manipulation in the outpatient setting, closed treatment can be attempted under anesthesia [17].
• An excellent result can usually be expected if a distal radioulnar joint dislocation is reduced early and immobilized for 1 month in plaster [18].

Operative

• If closed reduction of a distal radioulnar joint dislocation fails, open reduction and soft-tissue reconstruction may be necessary [17].
• A retinacular flap may be used to transpose the extensor carpi ulnaris to a more dorsal position to stabilize the distal ulna [17].
• If a distal radioulnar joint dislocation is less than 2 months old and cannot be reduced closed, open reduction with exposure and repair of the triangular fibrocartilage is advised [18].
• If a distal radioulnar joint dislocation is reduced surgically after more than 2 months, consideration should be given to excision of the distal ulna and distal ligament reconstruction [18].
• Rupture of the distal radioulnar ligaments usually causes diastasis of the distal radioulnar joint, which is a pathognomonic sign that the ligaments have been ruptured and should be repaired [18].
• A dorsal approach was used to free the extensor carpi ulnaris, and repair of the triangular fibrocartilage or transosseous pinning was used to stabilize the joint in irreducible dislocations [18].
• Operations to reconstruct permanently damaged ligaments of the distal radioulnar joint cannot be successful unless the component bones are undeformed [18].
• Indirect ulnar shortening by distraction through the distal radius fracture site provides a simple and novel strategy for the management of persistent DRUJ instability during volar plating, obviating the need for prolonged immobilization or to alter standard postoperative protocols [40].
• Advances in minimally invasive surgical techniques have transformed the management of DRUJ instability [41].
• The combined HS and suture repair effectively restores stability to both the DRUJ and UCJ in patients with TFCC-related ulnocarpal instability, considerably reducing pain and preserving range of motion [61].
• The Aptis total distal radioulnar joint prosthesis is a good rescue option for patients with previous failed surgical procedures, providing significant improvements in range of motion, grip strength, and pain scores with a mean follow-up of 9.7 years [42].
• Surgical outcomes are best when performed before the patient displays severe joint destruction, fixed contractures, subluxation, or dislocation [19].
• Stabilization of the ulnar stump seems to alleviate pain and improve forearm rotation and functional outcomes, although no direct correlation exists between radioulnar convergence and patient outcomes [21].
• Approximately 2 cm of bone is resected during distal ulna excision [34].
• If excessive bone is removed during distal ulna excision, distal ulna stability may pose a problem [34].
• The dorsal edge of the proximal ulna should be made bevel and smooth to minimize the risk of postoperative attrition ruptures of the extensor tendons [34].
• Reconstruction of the soft tissue support for both the DRUJ and radiocarpal joint is important to correct carpal supination and stabilize the distal ulna after distal ulna excision [34].
• If the TFCC and radioulnar ligamentous complex are present, they are sutured tightly to the dorsal and ulnar aspect of the radius during distal ulna excision [34].
• A distally based strip of the ECU tendon can be detached, woven through the ulnar collateral ligament and any remnants of the triangular fibrocartilage, and sutured to the radius to stabilize the distal ulna [34].
• A distally based slip of the ECU tendon can be passed through the distal end of the ulna through a hole made in the dorsal cortex of the ulna and then sutured back onto itself to stabilize the distal ulna [34].
• The ulna can be compressed volarward using a Freer elevator and either the capsular tissue or ECU tendon sutured tightly to seat the ulna stump in this volar position to stabilize the ulna stump [34].
• Treatment goals in the acute setting should be to prevent future instability or incongruency of the distal radioulnar joint [11].
• Treatment goals in the chronic setting should be to restore stability and congruency of the distal radioulnar joint to allow for painless, full (or improved) motion of the wrist and forearm [11].
• Treatment in the chronic setting can be challenging [11].
• Hand therapy is essential after arthroplasty around the wrist [55].
• Pain-free functional motion with adequate strength is the main goal of all joint reconstructions [55].
• Loosening of the prosthesis is a leading cause of poor outcome in arthroplasty [55].
• To protect the prosthesis, patients are discouraged from lifting more than 2 lb regularly and no more than 10 lb [55].

Complications

Post-traumatic Instability and Natural History

• The presence of untreated triangular fibrocartilage complex (TFCC) tears has been found to correlate with objective and subjective distal radioulnar joint instability at 1 year [57].
• A prospective longitudinal study found that 45% of patients with distal radial fractures and untreated complete TFCC injuries had laxity of the distal radioulnar joint at 13–15 years [57].
• Patients with distal radioulnar joint laxity after distal radial fractures had worse grip strength and trends of worse Gartland and Werley and QuickDASH scores compared to patients with stable distal radioulnar joints, although this difference did not reach statistical significance [57].
• There is evidence that all patients with distal radial fractures have measurable distal radioulnar joint instability [57].
• There is evidence supporting gradual improvement of ulnar-sided wrist symptoms up to 1 year after distal radial fracture treatment [57].
• Persistent significant instability of the distal radioulnar joint in patients with distal radial fractures is not seen in large numbers at follow-up [57].
• A minority of patients presenting with primary TFCC rupture after distal radial fracture treatment experience long-term invalidating complaints due to instability of the distal radioulnar joint [57].
• Less than 4% of patients treated for distal radial fractures had further surgery for persistent symptomatic distal radioulnar joint instability in one institution's experience [57].
• The natural history of patients with distal radioulnar joint instability after distal radial fracture treatment seems fairly benign, although this is not supported by robust evidence in the literature [57].
• The majority of patients with distal radioulnar joint instability after distal radial fracture treatment improve with time, have good function, and do not require further procedures [57].

Complications of Immobilization and Surgical Technique

• Prolonged immobilization in supination leads to stiffness [57].
• Indirect ulnar shortening by distraction through the distal radius fracture site provides a strategy for the management of persistent distal radioulnar joint instability during volar plating, obviating the need for prolonged immobilization or to alter standard postoperative protocols [40].

Complications of Salvage and Arthroplasty Procedures

• The introduction of ulnar head and total radio-ulnar joint prostheses has provided a new method for failed ulnar head resection, but there is presently no evidence that these implants produce long-lasting results [10].
• Both APTIS distal radioulnar joint arthroplasty and ulnar head replacement yield substantial functional improvements and good long-term survivorship [43].
• Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome [44].

Degenerative and Associated Conditions

Recovery

• Chronic distal radioulnar joint instability can lead to chronic functional impairment, pain, and arthritis if left untreated [12].
• Stabilization of the ulnar stump seems to alleviate pain and improve forearm rotation and functional outcomes [21].
• No direct correlation exists between radioulnar convergence and patient outcomes [21].

Key Evidence

• [L5] Salvage of failed distal radioulnar joint reconstruction requires a thorough understanding of normal anatomy, biomechanics, and the modes of failure of the primary procedure to develop effective strategies. [1] (10.1016/j.hcl.2010.05.004)
• [L5] Most ulnar-sided wrist problems associated with distal radial fractures can be treated non-operatively initially, typically for over a year, in anticipation of substantial improvement with time. [2] (10.1177/17531934221140238)
• [L5] A thorough knowledge of the anatomy and kinematics of the distal radioulnar joint is necessary to manage pathologic conditions. [3] (10.1016/j.hcl.2005.08.002)
• [L5] Distal radioulnar joint instability is often an underestimated lesion requiring systematic clinical examination and imaging for detection. [4] (10.1007/s00402-020-03371-0)
• [L4] Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios, most commonly cast immobilization in 41% (247 of 607). [5] (10.1177/17531934261449057)
• [L5] The purpose of this article is to review distal radioulnar joint instability and its management, covering anatomic and biomechanical advances, categorization of instability, and treatment strategies including percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques. [6] (10.1177/1753193414527052)
• [L4] Ulnar shortening osteotomy is a good option to treat patients with ulnar impaction syndrome regardless of the distal radioulnar joint angle. [7] (10.1177/17531934241262931)
• [L5] Severely damaged and painful distal radioulnar joints can be reconstructed by resection arthroplasty or by hemi- or total arthroplasty. [8] (10.1016/j.hcl.2020.07.008)
• [L5] DRUJ ligament reconstruction is indicated when native ligaments are not reparable, provided there is no radius or ulna bony deformity or arthritis of the DRUJ. [9] (10.1016/j.hcl.2020.07.004)
• [L5] The introduction of ulnar head and total radio-ulnar joint prostheses has provided a new method, but there is presently no evidence that these implants produce long-lasting results. [10] (10.1054/jhsb.2002.0815)
• [L5] [11] (10.1016/j.hcl.2021.02.011)
• [L5] Chronic distal radioulnar joint instability results from various traumatic injuries and can lead to chronic functional impairment, pain, and arthritis if left untreated. [12] (10.1016/j.hcl.2010.05.010)
• [L5] Surgical outcomes are best when performed before the patient displays severe joint destruction, fixed contractures, subluxation, or dislocation. [19] (10.1016/j.hcl.2005.08.009)
• [L5] Stabilization of the ulnar stump seems to alleviate pain and improve forearm rotation and functional outcomes, although no direct correlation exists between radioulnar convergence and patient outcomes. [21] (10.1016/j.hcl.2014.12.003)
• [L4] The occurrence of osteoarthritis of the scaphotrapeziotrapezoid and distal radioulnar joints was affected by the presence of osteoarthritis of the adjacent joint. [24] (10.1016/j.jhsa.2023.05.009)
• [L4] The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint. [29] (10.1177/17531934231168299)
• [L5] The purpose of this review article is to present and illustrate the current understanding of the functional anatomy and pathomechanics of the distal radioulnar joint, emphasizing the interaction between ligaments, muscles, and bones for stability. [31] (10.1177/1753193417693170)
• [L5] There is substantial surgeon-to-surgeon variation in interpreting MRI signal changes and arthroscopic findings in the distal radioulnar ligaments and central disc, raising concerns about overdiagnosis and overtreatment versus underdiagnosis. [35] (10.1177/17531934241254705)
• [Paper] [36] (10.1016/j.hcl.2005.08.015)
• [L4] When appropriate patient selection criteria are met, partial and total ulnar head replacement typically produce reliable results. [39] (10.1177/1753193417693177)
• [L4] Indirect ulnar shortening by distraction through the distal radius fracture site provides a simple and novel strategy for the management of persistent DRUJ instability during volar plating, obviating the need for prolonged immobilization or to alter standard postoperative protocols. [40] (10.1016/j.jhsa.2018.02.030)
• [L5] Advances in minimally invasive surgical techniques have transformed the management of DRUJ instability. [41] (10.1177/17531934261417561)
• [L4] The Aptis total distal radioulnar joint prosthesis is a good rescue option for patients with previous failed surgical procedures, providing significant improvements in range of motion, grip strength, and pain scores with a mean follow-up of 9.7 years. [42] (10.1177/17531934231192375)
• [L2] Both APTIS DRUJ arthroplasty and ulnar head replacement yield substantial functional improvements and good long-term survivorship. [43] (10.1177/17531934261415827)
• [L4] Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome. [44] (10.1177/17531934231197942)
• [L4] The Aptis distal radioulnar joint arthroplasty considerably alters forearm kinematics, which can have clinical implications. [45] (10.1177/17531934241274142)
• [L5] [50] (10.1177/17531934241275456)
• [L4] The DRUJ kinematics during handstanding vary with school age in female gymnasts, with high school students showing a significantly larger increase in DRUJ separation compared to elementary school students. [51] (10.1177/23259671251368997)
• [L5] The joint functions as a structure of tensegrity where ligament bundles shift tension based on forearm rotation. [54] (10.1016/j.hcl.2010.05.002)
• [L5] [55] (10.1016/j.hcl.2012.08.025)
• [L5] Anatomical variations in the sigmoid notch and ulnar head significantly influence joint mechanics and treatment outcomes. [56] (10.1016/j.hcl.2012.03.002)
• [L5] [57] (10.1177/17531934241268980)
• [L5] [58] (10.1177/1753193409100120)
• [L5] Radial lengthening did not demonstrate a benefit in improving DRUJ stability in a triangular fibrocartilage complex injury model. [59] (10.1016/j.jhsa.2025.06.013)
• [L5] Pressures within the DRUJ changed with forearm rotations, with the highest intra-articular pressure recorded in supination under no disruption-no load, no disruption-loaded, and disrupted TFCC conditions. [60] (10.1016/j.jhsa.2023.11.015)
• [L4] The combined HS and suture repair effectively restores stability to both the DRUJ and UCJ in patients with TFCC-related ulnocarpal instability, considerably reducing pain and preserving range of motion. [61] (10.1016/j.jhsg.2025.100806)
• [L4] A nuanced understanding of these 3D relationships can enhance preoperative planning when correcting ulnar-side pathology. [62] (10.1016/j.jhsg.2023.12.006)
• [L5] Imaging the DRUJ requires knowledge of the complex bony, muscular, and ligamentous anatomy; standard well-positioned radiography is the appropriate first step, while high-resolution MRI helps delineate ligamentous structures and dynamic CT is indicated for clinical instability. [63] (10.1016/j.hcl.2010.07.001)

References

[1] Salvage of Failed Distal Radioulnar Joint Reconstruction. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.004

[2] The distal radioulnar joint after distal radial fractures: when and how do we need to treat pain, stiffness or instability?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221140238

[3] Hemiresection Arthroplasty of the Distal Radioulnar Joint. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2005.08.002

[4] Distal radioulnar joint instability: current concepts of treatment. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03371-0

[5] Factors associated with variation in treatment of the distal radioulnar joint after plate fixation of distal radial fractures. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261449057

[6] Instability of the distal radioulnar joint. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414527052

[7] Does the distal radioulnar joint orientation influence the outcome of ulnar shortening osteotomy: a retrospective study. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241262931

[8] Solutions for the Unstable and Arthritic Distal Radioulnar Joint. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.008

[9] Chronic Distal Radioulnar Joint Instability. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.004

[10] Failed Ulnar Head Resection: Prevention and Treatment. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0815

[11] Distal Radius Fracture and the Distal Radioulnar Joint. Hand Clinics. 2021. DOI: 10.1016/j.hcl.2021.02.011

[12] The Management of Chronic Distal Radioulnar Instability. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.010

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