Chronic DRUJ Instability After Distal Radius Fractures

Importance of the Problem

Peripheral tears of the triangular fibrocartilage complex (TFCC) can cause pain and distal radioulnar joint (DRUJ) instability. There are several techniques for the repair or reconstruction of these lesions, which vary depending on the location, healing capacity, and tissue viability.

TFCC injuries are frequently associated (in up to 78% of cases) with distal radius fractures. The volar and dorsal radioulnar ligaments form the proximal component of the TFCC. Lesions of this component can cause pain and DRUJ instability, with functional and mobility limitations.

In chronic nonrepairable TFCC tears with clinical DRUJ instability in which the articular cartilage is in good condition, ligament reconstruction with tendon graft is the treatment of choice, either by open or arthroscopy-assisted surgery. It is also the preferred treatment in cases of previous failed repair surgeries in patients with clinical DRUJ instability.

Atzei and Luchetti published a new classification of Palmer class 1-B injuries, in which they differentiated these types of nonrepairable tears of the proximal component with DRUJ instability, designating them as class 4 ( Table 1 ).

Table 1

Atzei and Luchetti Classification.

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Comprehensive classification of TFCC peripheral tears and associated ulnar styloid fracture. Class 4, nonrepairable TFCC tears. Suggested treatment: tendon graft ligamentoplasty.

Numerous procedures have been described to restore the stability of the DRUJ through nonanatomic reconstructions, and include extra-articular ulnocarpal plasty, direct radioulnar fixation plasty to the joint and dynamic muscle transfers using the pronator quadratus muscle. The role of the distal oblique bundle in DRUJ stability has also been studied recently, but is present in only 40% of cases. These techniques are less effective compared to anatomic reconstruction of the DRUJ ligaments using a tendon graft.

The growth and refinement of arthroscopy has led to a considerable qualitative leap in the diagnosis and treatment of wrist injuries, and many classic surgical techniques have been converted to arthroscopic procedures, including those aimed at restoring stability in the DRUJ. The main advantages of arthroscopy over open procedures are better intraarticular visualization and reduced morbidity.

In order to correctly indicate TFCC reconstruction with tendon graft, it is important to be able to diagnose a nonrepairable injury to the proximal component of the TFCC, ensure that the articular surfaces are in good condition, and confirm the correct functioning of the interosseous membrane (to rule out Essex-Lopresti injury). Wrist arthroscopy is the gold standard for accurate diagnosis and guidance, and very often for the application of the appropriate treatment in a given case.

Main Question

“What is the most effective ligament reconstruction for management of chronic DRUJ instability associated with a (healed) distal radius fracture?”

Current Opinion

Anatomic DRUJ ligament reconstruction using a tendon graft is an effective method for restoring DRUJ stability. The ideal candidate is a patient with clinically significant chronic DRUJ instability, nonrepairable TFCC and healthy articular cartilage. Evidence will need to establish whether there is an advantageous role for arthroscopic and minimally invasive techniques to potentially reduce soft tissue morbidity including periarticular scarring and fibrosis.

Finding the Evidence

A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. On March 2, 2020, a search was conducted on the PubMed and Cochrane databases with the terms “DRUJ instability” or “chronic distal radioulnar joint instability” ( Fig. 3 ). Abstracts and subsequently full-text articles were analyzed by two senior orthopedic surgery and traumatology specialists. Relevant articles from the bibliography of the selected articles were included. Articles that were not available in English or Spanish were excluded.