May 30, 2024

DRUJ involves numerous structures where the stability of 20% is given by distal radius and 80% by soft tissue

Anatomy of DRUJ
Anatomy of DRUJ

Anatomy

Diarthrodial trochoid Synovial Joint

Bony radio-ulnar articulation: Sigmoid notch (concave)

The shape of the sigmoid notch is

  • Flat face ( most suseptical to injury)
  • Ski shape
  • C shape
  • S shape

The lower end of ulna (semi-cylindrical convex)

Soft tissue stabilizers

  • Ulnoligamentous complex (Triangular fibrocartilagenous complex TFCC: transmit 20 % of axial load)
  • Triangular fibrocartilage (articular disc)
  • Meniscal homologue
  • Ulnocarpal (Ulnolunate, lunotriquetral ligaments)
  • Dorsal/ Volar radioulnar ligament (Primary stabilizers)
  • Ulnar collateral ligaments

Extensor carpi ulnaris subsheath reinforced medially by linea jugata

TFCC structures
TFCC Anatomy

Clinical Features

Ulnar side wrist pain

Tenderness over ulnar aspect of wrist

Clicking sound, obvious instability and weakness on lifting weakness

The periphery of TFCC is well vascularized whereas the radial central portion is avascular

TFCC is composed of superficial and deep limbs

Clinical Tests

Focal tenderness just distal to ulnar styloid

The impingement sign

Supinating/ Pronating ulnar deviated wrist with elbow resting at 90 degrees on the table will have pain is a positive test

Ulna fovea sign

Detecting foveal disruption and UT ligament injuries

Pressing area between FCU tendon and Ulnar styloid between pisiform and volar margin of ulna

Piano Key test

Ulnar head is depressed volarly with examiner’s thumb and release: Suggest instability

Table-top test

Asking the patient to press both hands on a flat table with the forearm in pronation

The affected ulna is more prominent

Grind test

Compressing distal ulna and radius with examiner hand and pronating a grinding motion: Elicit pain

See also: Hand and Wrist examination

Investigation of DRUJ/TFCC

Xray shows ulnar variance comparable to the normal side

Arthroscopy

Arthroscopy is gold standard for evaluation of TFCC injuries

Arthroscopic trampoline test

Performed to assess TFCC resiliency by balloting a small portion with probe

Arthroscopic Hook test

Can be used to demonstrate peripheral detachment of TFCC

Arthroscopic suction test

Laxity of the TFCC when periphery scarred in or foveal attachment when the DRUJ is peripherally detachable

Classification

Injuries of DRUJ and TFCC: A Working classification

A. Acute TFCC Injuries

  • Acute dislocation of DRUJ
  • DRUJ associated with fractures, fracture-dislocation

B. Chronic DRUJ Injuries

  • Chronic TFCC injures
  • Ulnar impaction syndrome

C. DRUJ Arthritis

TFCC Injuries: Palmar classification

TFCC Injuries: Palmar classification
Palmer classification

Melone described TFCC Injury

StagesFeatures
Stage 1Detachment of TFC from ulnar styloid
Stage 2ECU sub-sheath injury
Stage 3Ulno-carpal ligament disruption
Stage 4Lunotriquetral ligament injury
Stage 5Mid-carpal ligament injury
Melone staging as per the severity

Treatment

Non-operative

Splinting or Above elbow cast

Modification of activities

Occupational therapy

NSAIDS

Steroid Injection may be tried, which fails to improve with conservative care requires surgical treatment

Surgical Treatment

Management of TFCC as per Palmer classification

Type 1A: Arthroscopic debridement ( avascular: not able to heal)

Type 1B: Peripheral ( Increase healing potential so arthroscopic/open repair)

Type 1C/ 1D: Repair

Type 2:

Goal of surgery is the reduction of radio-carpal loading by the following methods:

  1. Ulnar Shortening Osteotomy
  2. Darrach procedure (resection of the distal ulna)
  3. Sauve-Kapanji procedure (DRUJ arthrodesis and surgical pseudoarthrosis of distal ulna)
  4. Hemiresection and interposition arthroplasty
  5. DRUJ Implant arthroplasty