Post on 01-Jun-2015
Dnyanesh Lad
DRUJ + PRUJ = Longitudinal rotations = Special type
Bicondylar joint
Structural & Functional separation btw DRUJ and carpal bones = pronation-supination without affecting grasping
ANATOMY Triangular Fibro cartilage of Palmar and
Werner Ulna to radius and ulnar side of carpus TFCC includes1. Dorsal & Volar Radio-ulnar ligs( Primary
Restraint)2. Volar Ulno-lunar lig.3. Ulno-triquetral lig.4. Ulnar collateral lig.5. Articular disc6. Extensor Carpi Ulnaris Sheath
TFCC AnatomyOrigin: Ulnar side of lunate fossa of radius
(base-5mm thick)Insertion: Head of ulna & base of ulnar styloid
(apex-1mm thick)Joined by ulnar collateral ligDorsal Insertions:1. Triquetral2. Hamate3. Base of 5th metacarpal
FUNCTIONS OF TFCC1. Gliding surface at distal face of forearm
bones
2. Provides flexible mechanism for stable rotational movements of the radiocarpal unit around ulnar axis
3. Suspends the ulnar carpus from the dorsal ulnar face of the radius
4. Cushions forces transmitted through ulnocarpal axis
5. Connects ulnar axis to volar carpus
ADDITIONAL STABILITY TO DRUJ1. Contour of sigmoid notch
2. Interosseous membrane
3. Extensor Retinaculum
4. Dynamic forces of ECU and pronator quadratus
In Ulna neutral Position of Wrist20% applied load – Ulna80% applied load – Radius
Imp: Ulnar variance affects load distribution
TFCC thinner in wrists with +ve ulna variance
TFCC thicker in wrists with –ve ulna variance
a. Full Supination – Full pronation 1mm apparent increase in length of ulna
b. Head of ulna also dorsally displaced relative to lunate and triuetrum in full pronation
a. +b. = Minimal affect on axial force transmission
IN PRONATION: DORSAL RUL under tension
IN SUPINATION: VOLAR RUL under tension
“PIANO KEY SIGN”Avulsion of RUL from radial or ulnar
attachments
Increased mobility of ulnar head on radius
Appreciated by ballottement test
DRUJ DISORDERS
ACUTE # Ulnar head/styloid # Radius/carpal
bones Dislocation/
subluxation DRUJ carpal bones
TFCC & ECU subluxation
Symptomatic TFCC tears & perforations
CHRONIC Non unions/malunions
/incongruity of wrist jt. Including subluxation/dislocation of DRUJ, ulnocarpal region, carpal bones, TFCC
Arthritis of pisotriquetral, lunotriquetral jts
DRUJ arthritisSYMPTOMS: Pain-
weakness-instability-loss of motion
INVESTIGATIONS RADIOGRAPHSa. AP or PA wrist- semipronated (45*)USE: for dorso ulnar structures
b. Semisupinated/ Reverse Oblique/Ball catcher view
(30-45* supination)USE: Volar ulnar quadrant of the wrist
especially pisotriquetral jt and hook of hamate
c. Dynamic/Provocative/ Loaded viewsPt. made to make a fist/ squeeze an
objectCompare with opposite sideUSE: To recognize instability
d. Loaded PA radial and ulnar deviation views
USE: Movt. Of proximal row in relation with distal radius and TFC.
TOMOGRAPHYUSE: accurate for DRUJ
subluxation/dislocationADVANTAGES:1. Does not require precise positioning2. Can be done through a plaster cast3. Sigmoid notch abnormalities assessed
best
MRIUSE: location of ECU tendon, joint capsule, TFCC tears.
ARTHROSCOPYUSE: Small joint arthroscope- -TFCC tears-Synovitis-Erosion areas- Rim avulsion of radial head of TFCC
TREATMENT
For acceptable redn-intra articular # must be anatomically aligned and jt. congruity restored
Ulnar articular surface must not be translated in any direction
COMMINUTED STABLE #: Closed reduction and External fixation SEVERELY COMMINUTED+ UNSTABLE ORIF and Bone graft
Ulnar articular #: Open fix with k-wire or screw
Comminuted # ulna head: 1* resection of the head preserving shaft axis
Minimal displacement Rx with BE cast immobilization with interosseous moulding and avoiding more than mid pronation. Wrist neutral and slight ulnar deviation.
ESSEX- LOPRESTI INJURY DRUJ disruption + displaced radial head +
Proximal migration of radius ~ 5-10mmDISRUPTION OF:1. DRUJ ligament2. Interosseeos membrane3. Radiocapitular articular surfaceRADIOGRAPH: X ray Elbow+forearm+wristCT: Comparison of DRUJMRI: Interosseous haematoma
Rx: Fixation of large radial head fragment+ Reducn repair fixn of DRUJ
Radial head comminuted-Excise itUlnocarpal impaction: hemiresection and
arthroplasty
Isolated TFCC disruption=Periulnar dislocation of radiocarpal mass/Dislocation of lower end of ulna -ulna in N position at elbow
Volar Ulnar dislocation-reduced by pronation
Dorsal Ulnar dislocation-reduced by supination
AE cast x 6 weeksGreen recommends neutral rotation +
ulnar deviation for both
Direct TFCC Repair-intraosseous wire technique 24 gauge wire
Isolated TFCC damage without Instability
OPTION A: complete excision
OPTION B: Repair of tear if it is in Peripheral vascular zone; debridement if in central avascular zone.
BUNNEL-BOYES RECONSTRUCTION OF DRUJ
For dorsal dislocationDistally based FCU harvested proximally,
stripped distally to pisiform attachmentNew ligament woven through the volar capsuleStress on pisotriquetral jt relievedNew lig. Passed through drill hole in styloid to
exit in axilla of ulnar styloid processImbrication with dorsal capsuleC/I: VOLAR DISLOCATION
Moving pronator quadratus to a more lateral and dorsal insertion for stability-Johnson
Fascia lata used to stabilise DRUJ Fernandez Osteotomy: Osteotomy of distal radius re-establishes length, volar tilt and
ulnar inclination of radius
IMPINGEMENT ULNOCARPAL IMPACTION SYNDROMEUlnar head impinges against carpusLimitation of Rotation-ligaments relax
around wristSymptoms: 1. Ulnar wrist pain2. Rotation/Ulnar deviation3. Clicks/crepitus in TFCC region4. Long ulna relative to radius
X RAYS: Sclerotic/cystic changes in ulnar head & lunate
PREDISPOSING CONDITIONS1. Premature closure radial epiphysis 2* to
trauma (Acquired Madelung’s deformity)2. Premature wrist fusion3. Excision of radial head or shaft4. Fracture malunions with shortening of radius5. Normal variant long ulna
TFCC examined with MRI & Arthroscopy
Ulnar unloading-Feldon, Belsky and Torrono “Wafer” Osteotomy-2-4mm wafer of cartilage & bone from ulnar articular dome under TFC.
FOR DRUJ INCONGRUITY1. Darrach and modifications-Ulna head
excision
2. Sauve-kapandji Procedure: Ulnar recession & fusion ulnar head with radius
+ proximal pseudo arthrosis for restoration of forearm motion
3. Bowers resection-hemiresection
arthroplasty with shortening
4. Swanson resection and replacement arthroplasty
INDICATION-HEMIRESECTION ARTHROPLASTY
1. RA a. Early: Bower’s arthroplasty b. Late: Modified Darrach’s procedure
2. OA of DRUJ along with osteophyte resection
3. Ulnocarpal impaction Syndrome
4. Painful Instability of DRUJ
5. Rotational Contractures with radio ulnar disease
DISADVANTAGES OF BOWER’S ARTHROPLASTY1. Fails if TFCC is not functioning (trauma/severe RA)
2. Cannot restore stability in an unstable painful DRUJ
3. Unsuccessful if stylocarpal impingement is not anticipated.
4. In long standing contractures may not restore rotation
C/I TO BOWER’S OSTEOTOMY1. Unreconstructable TFCC
2. Advanced RA
3. Ulnocarpal translation (post traumatic/arthritic)
DARRACH’S PROCEDUREIncision proximal from ulnar styloidSeparate ECU and FCUBEWARE: Dorsal cutaneous br. Ulnar nerveOsteotomy 2.5cm proximal to styloidMobilization encouraged within 24 hrs.
DISADVANTAGES:1. Increased Ulnocarpal
translocation/instability2. Decreased Grip Strength
MODIFIED DARRACH’S PROCEDURES1. Blatt and Ashworth: flap of volar capsule
to dorsal ulnar stump2. O’Donovan and Ruby: tethering distal
ulnar stump with distally based strip of ECU3. Kessler and Hecht: dynamic stabilisation
looping tendon around distal ulnar stump and the ECU
4. Goldner and Hayes: ECU through drill hole in ulnar stump –forearm in supination
5. Tsai and Stilwel: FCU to stabilise ulnar stump and ECU
6. Johnson: Pronator advancement
SAUVE KAPANDJI POCEDURE
Radio ulnar jt. Fusion Creation of pseudoarthrosis proximal to fusion INDICATIONS:1. OA/Chondromalacia of DRUJ2. Post traumatic ulno carpal impingement a/w
DRUJ arthrosis3. Yong RA pt. with ulnar translocation + DRUJ
disease4. RA pt. who may need a stable radioulnar
surface for support of an arthroplasty or implant