Subluxation of the distal radio-ulnar joint by hyperpronation

An All-Arthroscopic Technique of Repairing Foveal Tears of the Triangular Fibrocartilage Complex Using a Bone Anchor-Repair Made Simple

Traumatic foveal tears of the triangular fibrocartilage complex lead to ulnar-sided wrist pain and instability, resulting in painful motion and loss of grip strength with a severe impact on the overall function of the upper limb. Surgical repair is nothing new and has traversed through the realm of open repair to arthroscopic assisted to all arthroscopic repair techniques over the many decades, with arthroscopic repairs showing better visualization, lesser trauma, and equally favorable patient outcomes. Techniques had varied from using trans osseous tunnels to bone anchors, with or without the usage of special jigs. Here, we describe a simple and fast 3 portal arthroscopic technique of repairing the torn foveal insertion of the triangular fibrocartilage complex using a bone anchor inserted under arthroscopic and fluoroscopic guidance into the fovea. Both the dorsal and volar limbs of the triangular fibrocartilage complex are repaired arthroscopically, resulting in a strong anatomic repair resulting in a stable and pain-free wrist.

An All-arthroscopic Technique of Repair of Substance Tears of the Triangular Fibrocartilage Complex in Symptomatic Patients

Substance tears of the triangular fibrocartilage complex (TFCC) can occur secondary to trauma of the wrist. On the dorsal periphery, they are considered Palmer 1B tears or Atzei class 1 tears. If along the radial side, they can manifest as a tear of the central disc, classified as a Palmar class 1A tear. If it involves the ligaments, it is stated as a pre-1D tear as per the new classification system by Luchetti and colleagues. Multiple excellent repair techniques exist in the current literature for dorsal peripheral tears and even for those in the substance of the TFCC, whereas there are successful evolving techniques of repair of avulsed tears and those involving the substance of the ligaments on the radial side adjacent to the sigmoid notch. Here, we describe our technique of repairing substance tears of the TFCC arthroscopically without the need for any specialized equipment apart from the basic arthroscopy set. The technique was conducted in a patient with a transverse substance tear on the radial side of the triangular fibrocartilage involving the central disc with complete resolution of symptoms. It is a simple technique, which can be used to repair class 1B peripheral tears and pre-1D tears in the substance of the TFCC.

Stabilization for acute distal radioulnar instability: A novel surgical technique

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.

Minimally invasive stabilization of the distal radioulnar joint: a cadaveric study

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.

Anatomic reconstruction of the distal radioulnar ligaments: long-term results

Chronic post-traumatic dynamic distal radioulnar joint instability following rupture of the distal radioulnar ligaments may cause disabling and progressive ulnar-sided wrist symptoms. We use a free tendon graft to anatomically reconstruct both dorsal and palmar distal radioulnar ligaments simultaneously. Nine patients who underwent this procedure between 1990 and 1997 were assessed using a modified Mayo Wrist Score. Following surgery, average wrist scores improved from 66 (95% CI, +/-3.0) to 92 (95% CI, 92+/-6.9) and were maintained in the long term (average score, 87 at 9 years). Joint stability was restored and maintained in seven of the nine patients, but two developed recurrent instability. Pain, grip strength and function were better following surgery in the short and long term. Range of supination and pronation decreased slightly from an average of 169 degrees pre-operatively to 155 degrees (90% of normal) in the long term. Long-term radiographs show no distal radioulnar or ulnocarpal joint osteoarthritis.

Missed isolated volar dislocation of distal radio-ulnar joint: a case report

We report a case of isolated volar dislocation of the distal radio-ulnar joint in a young man who injured his left wrist while playing rugby. Initially, this injury was missed in the emergency department; however, a true lateral view radiograph later revealed volar dislocation of the distal radio-ulnar joint. The dislocation was subsequently reduced under general anesthesia with a good end result. The importance of thorough clinical examination and a true lateral view radiograph of the wrist is stressed.

Dislocation of the distal radioulnar joint associated with an intraarticular fracture of the ulnar head: report of two cases

This article presents two cases in which an intraarticular fracture of the ulnar head occurred in association with a dorsal dislocation of the distal radioulnar joint. After open reduction and internal fixation of the osteochondral fragment, final outcomes were excellent.

Treatment of chronic post-traumatic dorsal subluxation of the distal ulna by hemiresection-interposition arthroplasty

Twenty-four patients were evaluated for complaints of pain in the area of the distal radioulnar joint, decreased forearm rotation, and weakness of grip. All patients had a history of trauma to the involved wrist an average of 40 months prior to presentation. Six patients had undergone previous surgery that was unsuccessful. Twenty-three patients were available for follow-up evaluation at an average of 36 months following hemiresection-interposition arthroplasty. At that time, results were excellent in 13 patients, good in 4 patients, fair in 3, and poor in 3. Two patients developed symptoms of styloidcarpal abutment (poor results), one of whom was upgraded to an excellent result after undergoing a shortening osteotomy of the ulna.

Stress computed tomography analysis of the distal radioulnar joint: a diagnostic tool for determining translational motion

Sixteen distal radioulnar joints in eight normal volunteers (five females, three males) were evaluated by use of a special stress computed tomography technique. The mean palmar and dorsal translational motion was 2.2 millimeters +/- 1.6 and 1.0 millimeters +/- 0.9, respectively, for the combined group. The mean stress range was 3.3 millimeters +/- 1.4 for the entire group. There was no statistical difference for the amount of motion noted on palmar stress, dorsal stress, and the stress-range between males and females. There was also no statistical difference between contralateral sides and hand dominance. The average contralateral difference was 0.1 millimeters, 0.1 millimeters, and 0.3 millimeters for palmar, no stress, dorsal studies, respectively. We conclude the limits of maximal translational motion of the distal radioulnar joints can be determined by computed tomography stress analysis. Unilateral analysis allows the determination of frank instability. However, bilateral analysis allows the determination of frank instability, subluxation, and dynamic instability. This technique is useful in evaluating distal radioulnar joint stability.

Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna

A procedure for stabilizing the distal ulna using the extensor carpi ulnaris and flexor carpi ulnaris is described. Seven patients who had sustained posttraumatic distal ulnar dorsal instability and articular degeneration and one patient with instability caused by rheumatoid arthritis were operated on. All eight obtained stable ulnae with mean motion of 62 degrees of supination and 86 degrees of pronation (mean increase of 32 degrees of supination and 43 degrees of pronation). Follow-up averaged 28 months (range, 18 to 63 months). The tenodesis, using a weave of a distally-based slip of flexor carpi ulnaris and a proximally-based slip of extensor carpi ulnaris combined with a Darrach procedure, is a reliable, reproducible salvage procedure for stabilizing the degenerated distal radioulnar joint and for salvaging the symptomatic unstable ulna after excessive distal ulna resection.

Posteroanterior wrist radiography: importance of arm positioning

Proper interpretation of wrist radiography requires a standardized radiographic technique. We obtained posteroanterior (PA) radiographs of the wrist in nine patients in three different arm positions to study the effect of arm position on ulnar styloid process orientation. An appearance simulating a normal anteroposterior (AP) wrist radiograph was present in six of nine PA radiographs when the arm was positioned next to the trunk, and the elbow was flexed to a 90% angle. The orientation of the ulnar styloid was not helpful in differentiating either pronated from supinated wrist positions or AP from PA projections. We concluded that radiographic screening of the carpus should be performed with standardized wrist positioning and nomenclature as described in modern radiographic technological texts. Supplemental projections should be exposed and interpreted with an understanding of the position of the arm and the direction of the incident radiographic beam at the time of examination.

Computed tomography diagnosis of distal radioulnar subluxation

Eight patients with suspected diagnosis of distal radioulnar joint (DRUJ) subluxation underwent computed tomographic (CT) scans of the wrist. Five underwent surgery and had DRUJ subluxation or dislocation; CT scans revealed subluxation in four. Three CT criteria for the evaluation of DRUJ subluxation are discussed and compared in this manuscript.

Distal radioulnar involvement in trauma of the wrist

The distal radioulnar joint is the weakest point of the rotational column of the wrist. This joint is a functional part of the radiocarpal joint, united to it by an elastic tightening system, and perfectly controlled by the ulnaris (especially the extensor carpi) tendons. Our anatomic study allowed to define the mechanisms of the lesions and the methods for their correction. The key to success seems to be a functionally dynamic extensor carpi ulnaris and its dorsal position in supination. Our clinical study shows that all injuries to the distal radioulnar joint associated with trauma of the wrist or of the forearm are a factor of severity and they may be responsible for the high rate of complications. Therefore, in Galeazzi's fracture-dislocation, a specific method of stabilization may need to be associated with the radius osteosynthesis. In the absence of degenerative changes, chronic instability of the distal radioulnar joint can benefit from ligament stabilization. Results so far have been very encouraging, as far as young patients are concerned. Complex injuries remain a major obstacle, in which ligamentous and bone lesions must be distinguished by confronting clinical observation with paraclinical investigations. Computerized tomography seems to be of limited value, although this method of investigation is still in its prospective stages. Concerning management, shortening of the ulna with dorsal repositioning of the extensor carpi ulnaris allows to decompress the carpo-ulnar compartment, to stretch the tendinous and ligamentous structures, and, if need, to restore radioulnar congruity. Better knowledge of this pathology will allow to categorize radioulnar tears associated with wrist injuries. Under emergency conditions, surgical or non operative management must be adapted, allowing healing to occur with perfect restoration of the distal epiphysis of the radius. By doing so good functional results may be guaranteed.

The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radioulnar joint

The diagnosis of an isolated subluxation or dislocation of the distal radioulnar joint (DRUJ) may be extremely difficult to make from the standard radiographic examination. Radiographs and computerized tomographic (CT) scans of cadaver wrists were used to evaluate subluxation and dislocation of the DRUJ. Both subluxation and and dislocation could be accurately diagnosed from a true lateral radiographic projection of the wrist with the forearm in neutral rotation. Minimal supination or pronation of the forearm led to inaccurate diagnosis. A single CT scan through the DRUJ was diagnostic for subluxation and dislocation in all positions of forearm rotation. Wrist pain, plaster immobilization, or suboptimal wrist positioning may make it impossible to obtain a perfect lateral view of the wrist, thereby precluding the radiographic diagnosis of DRUJ subluxation and dislocation. In this instance, a single CT scan through the DRUJ is recommended.

Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint

Isolated posttraumatic dorsal subluxation of the distal ulna was surgically treated in eight patients by reduction of the subluxation and by a tenodesing procedure that used a tendon slip of flexor carpi ulnaris. The repair also imbricated the dorsal radioulnar ligament upon itself, and the forearm was secured in supination by a Kirschner wire. All patients had improved stability of the distal radioulnar joint: five had complete and three had satisfactory relief of pain. Slight residual joint laxity was noted in three patients and mild residual limitation of pronation in all, although the patients did not consider the limitations to be functionally important. All patients returned to improved functional activity.

An unusual cause of blocked reduction of the Galeazzi injury

Two cases of the Galeazzi lesion are described, in which a mechanical block to closed reduction of the dislocated inferior radio-ulnar joint was encountered. This does not seem to have been described before.