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Acute Distal Radioulnar Joint Instability


Key Points

  • All fractures of the distal radius should be evaluated with a physical exam to test for concurrent instability at the distal radioulnar joint.

  • Radiographs that show excessive radial shortening, widening at the distal radioulnar joint, or a large ulnar styloid fracture should raise suspicion for instability.

  • Most cases of instability can be managed with immobilization of the forearm in the position of stability.

  • Cases in which stability cannot be maintained with immobilization are indicated for pinning of the forearm or repair of the ulnar structures.

Panel 1: Case Scenario

A 28-year-old man fell from a ladder at 14 ft and presented with a dorsally displaced and shortened distal radius fracture. The fracture was repaired with a volar plate and immobilized in a short arm splint. At the first follow up visit, the patient complains of a clunking sensation with rotation of the forearm. How can one diagnose acute instability of the forearm preoperatively or intraoperatively? How is acute distal radioulnar joint instability treated?

Importance of the Problem

Stability at the distal radioulnar joint (DRUJ) is imparted by the bony congruity of the sigmoid notch and the ulna and by the integrity of the soft tissue constraints of the triangular fibrocartilage complex (TFCC), radioulnar ligaments, and interosseous membrane (IOM). Dynamic stabilizers such as the pronator quadratus and extensor carpi ulnaris play a minor role. Instability at the DRUJ may result from several causes:

  • (1)

    Simple dislocation from hyperpronation or hypersupination

  • (2)

    Essex-Lopresti dislocation from longitudinal rupture of the IOM

  • (3)

    Galeazzi fracture-dislocation from diaphyseal radial fracture

  • (4)

    Distal radius fracture and rupture of the soft tissue stabilizers

The aim of the following chapter will focus on those associated with distal radius fractures—a common fracture representing 16% of skeletal failures. Fractures of the distal radius are often associated with an additional soft tissue injury. Studies reporting on wrist arthroscopy in distal radius fractures have estimated that concomitant TFCC injuries occur in 43%–84% of cases. Those with a complete TFCC rupture were more likely to develop instability at the DRUJ and experienced an inferior outcome. Significant morbidities associated with residual instability of the DRUJ include poor strength, reduction in range of motion, pain, and premature arthrosis.

Main Question

What is the most effective diagnostic approach and treatment for acute DRUJ instability associated with DRF (including TFCC lesions)?

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