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Distal radioulnar joint reconstruction using palmaris longus graft
Indications
Indications for this procedure include:
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Chronic, symptomatic distal radioulnar joint (DRUJ) instability that is generally associated with irreparable triangular fibrocartilage complex (TFCC) injury/degeneration.
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No evidence of distal radioulnar joint arthritis.
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No evidence of a malunited distal radius fracture with resulting DRUJ dysfunction.
Contraindications
Although not a true contraindication, a relatively flat DRUJ may risk failure of the reconstruction because of inadequate added support and stability from DRUJ anatomy.
Clinical examination
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It is important to consider and properly diagnose other conditions that may result in ulnar-sided wrist pain before performing a DRUJ reconstruction. Ulnar-sided pain may be caused by extensor carpi ulnaris (ECU) or flexor carpi ulnaris (FCU) tendinitis, ECU subluxation, lunotriquetral instability, TFCC injury that does not create DRUJ instability (e.g., a central TFCC tear), or ulnar impaction syndrome.
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Several clinical examination maneuvers can be useful in confirming instability of the DRUJ: the piano key sign, the radioulnar ballottement test, the press test, the ulnar compression test, and the Schaeffer test.
The piano key sign
With the forearm pronated and resting on the table, the ulnar head tends to be prominent when the DRUJ is unstable. If the ulnar head can be depressed easily and springs back dorsally into the proud position, that is a positive piano key sign.
The radioulnar ballottement test
The examiner stabilizes the distal radius as the distal ulna is moved volar to dorsal with the other hand ( Fig. 30.1 ). Comparison to the contralateral, unaffected side may reveal excessive motion or pain. The wrist should be stressed in pronation, neutral, and supination. More laxity typically occurs in neutral because the radioulnar ligaments of the DRUJ are tightened in extremes of pronation and supination.
The press test
The patient is asked to rise from a chair by pushing off with his or her hands. If instability of the DRUJ is present, the affected ulna head will depress in relation to the radius and compared with the contralateral side. This will result in pain.
Ulnar compression test
With the elbow in 90 degrees of flexion and the forearm neutral, manually compress the radius and ulna at the DRUJ ( Fig. 30.2 ). Pain indicates likelihood of DRUJ arthritis or synovitis.
Schaeffer test
Use the Schaeffer test to evaluate for the presence or absence of a palmaris longus (PL) tendon: The patient is asked to oppose the thumb to the small finger and flex the wrist. If present, the PL tendon will be identifiable and prominent immediately ulnar to the flexor carpi radialis tendon.
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