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Distal Radioulnar Joint Dislocation

From WikiSM

Other Names

  • DRUJ Injury
  • Distal Radioulnar Joint Disruption
  • Distal Radioulnar Joint Instability
  • Distal Radioulnar Joint Subluxation
  • DRUJ Disruption
  • DRUJ Instability
  • DRUJ Subluxation

Background

History

  • Attributed to a report by Desault in 1777 (need citation)
  • A Case report by Alexander AH in 1977 provides some historical context[1]

Epidemiology

  • Rare, representing less than 0.02% of all bony injuries[2]
  • There is a male predominence with a mean age of 37.9 years (range 20 to 70)[3]
  • Annual incidence and prevalence of DRUJ instability in Germany were reported as 23.55 and 30.55 per 100,000 inhabitants[4]
    • This included both acute and chronic instability, not just dislocation

Introduction

Normal DRUJ on a PA film[5]
Anatomy of the radius (R) and ulna (U) showing the DOB and illustrating of the three-locker system concept.[6]
Forearm fracture with radiographic evidence indicating distal radioulnar joint (DRUJ) injury[6]

General

  • Interruption of the Distal Radial Ulnar Joint is a complex condition that can cause significant morbidity
  • Commonly missed or overlooked diagnosis
  • Rare in isolation, more commonly associated with wrist and forearm fracture-dislocations

Mechanism of Injury

  • Fall from standing
  • Sports related trauma

Pathophysiology

  • Dorsal dislocation more common than volar?
  • Other literature suggests volar is more common[3]

Missed Diagnosis

  • Up to 36% of cases are diagnosed late[7]
  • 18% are missed at initial presentation
  • This is primarily due to subtle clinical findings, challenges in finding adequate views

Associated Injuries

Anatomy of the Distal Radioulnar Joint

Biomechanics of the DRUJ

  • Combines anterior-to-posterior translation with proximal-to-distal translation
  • Facilitates pronation/supination with approximately 150° of motion

Risk Factors

  • Unknown

Differential Diagnosis

Differential Diagnosis Wrist Pain

Differential Diagnosis Forearm Pain

Clinical Features

Example of DRUJ Compression test
Demonstration of the Piano Key Test[9]

History

  • The patient should be able to describe a mechanism of injury, even remotely
  • Ulnar sided wrist pain worse with pronation/supination
  • Clicking and clunking during wrist movement
  • Diminished grip strength
  • Feeling of giving way or instability
  • Acutely, swelling, tenderness and/or bruising

Physical Exam: Physical Exam Wrist

  • Acute
    • Patient has swelling, deformity
    • Inability to supinate/pronate the forearm
  • Subacute/ Chronic
    • Snapping, crepitus
    • Decreased grip strength
  • Ask the patients to make a fist
    • Protrusion of ulnar head suggests dorsal displacement
    • Dimple of the ulnar head suggests volar displacement

Special Tests

Evaluation

Isolated DRUJ dislocation without any bony lesions[10]
Posttraumatic contour deformity after DRUJ dislocation. FS T2-WI Axial. A bony contour deformity (large arrow) persists after reduction of an anterior dislocation of the ulna. The anterior part of the capsule is distended and filled with joint fluid (small arrow).[11]

Radiographs

  • Standard Radiographs Wrist
    • May or may not be sufficient to make diagnosis
    • Findings on radiographs can be subtle and are easily overlooked
  • Potential findings
    • AP view: widening of DRUJ
    • Lateral view: dorsal displacement (most commonly)
    • Description of ulnar in reference to the radius

CT

  • Can be performed dynamically for subtle DRUJ injuries

MRI

  • Considered gold standard for soft tissue lesions of the wrist, including TFCC
  • Valuable for evaluating the DRUJ stability and ligamentous lesions

Ultrasound

  • Useful to evaluate joint stability dynamically
  • Can evaluate for other soft tissue injuries such as interosseous membrane, tenosynovitis

Dynamic Imaging

  • Includes stress radiograph, 4D-CT
  • Can provide valuable insights during active range of motion exercises

Dual Fluoroscopic and Computed Tomography

  • Captures dynamic fluoroscopic images while acquiring high resolution CT scans

Arthroscopy

  • Remains "gold standard" for diagnosing TFCC injuries

Classification

Classification system proposed by Dmour et al[6]

Dmour Classification System[6]

  • Grade 1
    • X-ray/CT: normal joint congruency
    • US/MRI: ligamentous integrity may appear intact
    • Presentation: Occasional discomfort or mild limitation of wrist movement
    • Treatment: Activity modification, Immobilization, Physical therapy
  • Grade 2
    • X-ray/CT: joint subluxation or incongruity may be present in stress tests or 4D-CT scans
    • US/MRI: Partial ligamentous tears or attenuations (TFCC/DOB/volar and dorsal radioulnar ligaments)
    • Presentation: Persistent pain, occasional clicking or catching sensations, mild to moderate limitation of wrist movement
    • Treatment: Immobilization, Physical therapy, Possible surgical intervention
  • Grade 3
    • X-ray/CT: severe joint incongruity/dislocation
    • US/MRI: complete ligamentous tears (complex TFCC, DOB, and pronator quadratus tears) and joint dislocation
    • Presentation: Persistent pain, significant functional impairment, instability during daily activities, possible neurovascular compromise
    • Treatment: surgical intervention

Management

Short Arm Cast
Illustration of graft fixation of the DRUJ at the ulnar neck[12]

Nonoperative

  • Nonsurgical management indicated in some cases
  • Indications
    • Isolated ligamentous injury without fracture
    • TFCC Tear (acute)
  • Closed reduction
  • Cast: Short Arm Cast for 4-6 weeks

Operative

  • Indications
    • Ulnar styloid fracture displaced with instability
    • Essex-Lopresti Fracture
    • Galeazzi Fracture
  • Technique
    • Repair (open or arthroscopic) of the TFCC or DOB
    • Reconstruction of the TFCC or DOB
    • Ulnar shortening osteotomy
    • Arthrodesis
    • DRUJ Arthroplasty

Rehabilitation and Return to Play

Rehabilitation

  • Immobilization typically for at least 4-6 weeks
  • Following this, gradual, supervised initiation of range of motion exercises
  • Emphasis on:
    • Forearm rotation (pronation/supination)
    • Wrist mobility

Return to Play

  • Highly variable depending on injury pattern
  • In general, minimum 6 weeks and will require post-recovery rehab
    • 8-12 weeks is a better estimate[13]
  • General RTP guidelines
    • Full, pain-free range of motion,
    • Joint stability
    • Absence of complications

Prognosis and Complications

Posterior-anterior (PA) radiograph demonstrating osteoarthritis in the DRUJ (A). An increased distance in the DRUJ at 2.5 years follow-up (B), and similar findings 5 years postoperatively (C)[14]

Prognosis

  • General
    • Favorable when diagnosis is made and treatment is prompt[3]
    • Most patients recovery full, pain free range of motion and joint stability with conservative management[15]
  • Conservative Management
    • 82% regain full range of motion, 88% report no pain at follow up[3]
  • Delayed or missed diagnosis
    • Increases risk of complications such as chronic subluxation or dislocation, secondary degenerative changes, need for complex surgical management[16]

Complications

  • Chronic instability
  • Persistent pain
  • Limited wrist mobility
  • Post-traumatic osteoarthritis

See Also

Internal

External

References

  1. ↑ ALEXANDER, A. HERBERT. "Bilateral traumatic dislocation of the distal radioulnar joint, ulna dorsal: case report and review of the literature." Clinical Orthopaedics and Related Research (1976-2007) 129 (1977): 238-244.
  2. ↑ O’malley, O., et al. "Isolated volar dislocation of the distal radioulnar joint: a case series and systematic review." The Annals of The Royal College of Surgeons of England 105.3 (2023): 196-202.
  3. ↑ 3.0 3.1 3.2 3.3 Zampetakis, Konstantinos, et al. "Systematic Review of Acute Isolated Distal Radioulnar Joint Dislocation: Treatment Options." Journal of Clinical Medicine 13.24 (2024): 7817.
  4. ↑ Andersson, J. K., et al. "Distal radio-ulnar joint instability in children and adolescents after wrist trauma." Journal of Hand Surgery (European Volume) 39.6 (2014): 653-661.
  5. ↑ Image courtesy of musculoskeletalkey.com
  6. ↑ 6.0 6.1 6.2 6.3 Dmour, Awad, et al. "Advancements in Diagnosis and Management of Distal Radioulnar Joint Instability: A Comprehensive Review Including a New Classification for DRUJ Injuries." Journal of Personalized Medicine 14.9 (2024): 943.
  7. ↑ Duryea, Dennis M., Alexander H. Payatakes, and Timothy J. Mosher. "Subtle radiographic findings of acute, isolated distal radioulnar joint dislocation." Skeletal radiology 45.9 (2016): 1243-1247.
  8. ↑ Mirghasemi AR, Lee DJ, Rahimi N, Rashidinia S, Elfar JC. Distal Radioulnar Joint Instability. Geriatr Orthop Surg Rehabil. 2015 Sep;6(3):225-9.
  9. ↑ Qazi, Sohail, et al. "Distal radioulnar joint instability and associated injuries: a literature review." Journal of Hand and Microsurgery 13.03 (2021): 123-131.
  10. ↑ Image courtesy of litfl.com
  11. ↑ Image courtesy of jbsr.be/
  12. ↑ Vignesh, S., and Chandermohan Singh. "Management of chronic distal radio-ulnar joint (DRUJ) instability using Adams-Berger technique–A report of two cases in different scenarios." Journal of Orthopaedic Reports 1.3 (2022): 100058.
  13. ↑ Pajares, Samuel, Natalia Martínez-Catalán, and Ulrike Novo-Rivas. "Stabilization for acute distal radioulnar instability: a novel surgical technique." Injury 52 (2021): S137-S144.
  14. ↑ Muder, Daniel, and Torbjörn Vedung. "Reconstruction of the distal radioulnar joint with rib perichondrium–midterm follow-up." BMC Musculoskeletal Disorders 23.1 (2022): 388.
  15. ↑ O’malley, O., et al. "Isolated volar dislocation of the distal radioulnar joint: a case series and systematic review." The Annals of The Royal College of Surgeons of England 105.3 (2023): 196-202.
  16. ↑ Qian, Hui, Guozhao Chen, and Zongbao Liu. "Treatment of distal radioulnar joint dislocation with spontaneous rupture of extensor tendon by Sauve–Kapandji osteotomy assisted by wrist arthroscopy: A case series and literature review." Medicine 97.22 (2018): e10752.
Created by:
John Kiel on 18 June 2019 23:03:09
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Last edited:
1 October 2025 00:08:00
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