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صدق الله العظيم الآيه( 32 ) سوره البقره ﴿ قالوا سبحانك لا علم لنا الا ما علمتنا إنك انت العليم الحكيم ﴾

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Mangement of Distal Radioulnar Joint Instability Presented by Sameh Ali ElSanafawy Master Degree in Orthopedic Surgery   El Helal Hospital

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Introduction DRUJ: Trochoid , diarthrodial articulation Distal link between radius and ulna Pivot for pronation - supination . Instability: Abnormal path of articular contact occurring during or at the end of the range of motion. Due to either alteration in joint surface orientation or by deficiencies in the main restricting ligaments, or by both.

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Anatomy Bones: Distal radius: Sigmoid notch is shallow concave articular surface Distal ulna: covered with articular cartilage, the seat of the joint is the articular surface.

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Soft tissue and ligamentous support: 1) The DRUJ capsule: Originates from the sigmoid notch and inserts near the cartilage of the ulnar seat. 2) The triangular fibrocartilage complex (TFCC): A) The meniscus homologue: This is an unfortunate term, it originate from the sigmoid notch to be inserted in triquetrium . Anatomy

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B) TFC proper (articular disc): Is a triangular fibrocartilage structure with ulnar apex and radial base. It’s blood supply : Ulnar artery, palmar and dorsal branches of anterior interosseous artery. Radial border is avascular but volar , dorsal and medial margins are vascularized . Anatomy

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C) The ulnar collateral ligament: Run from volar radio- ulnar ligament to triquetrum , hamate and base of fifth metacarpal. D) The palmar and dorsal radioulnar ligament Palmar : Extend from anterior edge of ulnar notch of radius to ulnar border of the ulna. Dorsal: Extend from posterior edge of ulnar notch of radius to ulnar border of the ulna. E)Extensor carpi ulnaris (ECU) tendon sheath: it has its own fibro-osseous tunnel Anatomy

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Ulnar variance: It is the relative lengths of the ulna and radius. Ranges from + 6 mm to -8 mm with a mean of - 0.6 mm. Negative ulnar variance Positive ulnar variance Anatomy

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Biomechanics Relation between the DRUJ & the PRUJ: Both joints are coupled functionally. The tow are co axial just like the tow hinges of the door. Movement of the DRUJ: Not only a pure rotational movement but also includes a sliding movement. Functions of the DRUJ: I) Pronation-supination Movement: rotates through 180o.

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II) Load-bearing: about 30% of weight bearing during grasp activities. III) Suspension of the ulnar carpus : by attachment of its ligaments. Rotational axis of the DRUJ: A consequence of the variable axis. Biomechanics

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Biomechanics The Motors of the DRUJ: "extrinsic" : Biceps brachii , supinator and pronator teres . "intrinsic" : Supinator and pronator quadratus . They have greater supinatory torque. Forces acting on the DRUJ: The articular disc has a significant role in transmission of axial load which is converted to tensile loading within peripheral margins of the discs. Stability of the DRUJ: I) TFCC: In pronation, tension in volar part of TFC. In supination, tension in dorsal part of TFC .

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Biomechanics II) Palmar and dorsal distal radio-ulnar ligaments: (PRUL) become maximally tightened in forearm supination and vice versa. III) Depth of the sigmoid notch: Sigmoid notch has different: Types Angles

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Biomechanics IV) Pronator Quadratus: The deep head is transverse and form one of the stabilizing forces at the DRUJ. VI) ECU tendon: and its fibro-osseous tunnel. V) Interosseous membrane: IOM has three portions the central band and dorsal oblique bundle is the main stabilizers.

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Classification DRUJ instability can be classified as acute versus chronic. Acutely can be classified according to the position of the ulna: 1. Ulna-dorsal. 2. Ulna- palmar . 3. Multidirectional Chronic distal radioulnar joint instability classified according to: 1) Ligament injury including ulnar styloid fracture. 2) Intraarticular skeletal deformity. 3) Extraarticular skeletal deformity.

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Etiology DRUJ instability may be the consequence of a single (acute) or multiple (repetitive) traumas, or be the consequence of a local or systemic disease (inflammatory, congenital, developmental, neoplastic, infectious, or degenerative). It may be an isolated or may be the result of fractures. A) Isolated dislocation of the DRUJ: Occur from Forced hyperpronation or supination and also from one of the both bone being forced volar or dorsal while the other is fixed. Ulna volar Ulna dorsal

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Etiology B) DRUJ dislocation associated with radial fracture: 1) Galeazzi fracture dislocation: Fracture of the shaft of the radius with an associated dislocation of the DRUJ between the bicipital tuberosity and an area four to five centimeters from the distal articulating surface of the radius. The most probable mechanism is a fall on the outstretched hand with extreme pronation.

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Etiology 2) Essex-Lopresti fracture: Fractures of the radial head associated with acute dislocation of the DRUJ. The mechanism of injury is a longitudinal force on the outstretched hand. 3) Distal radius fractures

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I) Clinical Diagnosis of DRUJ Instability: A) Diagnosis of TFCC Injuries: 1) History : Traumatic Lesions - Class I Class IA: central tears present with dorsal pain at the distal aspect of the ulna and pain with rotation . Class IB: ulnar side tears present with pain around the ECU and may be reproduced with ulnar deviation. Class IC: volar side tears results in ulnocarpal instability. Class ID: radial side tears present with diffuse pain along the entire ulnar aspect. Degenerative lesions - Class II Present ulnar side wrist pain, aching discomfort with rotation, with decreased grip strength and a sensation of catching or snapping. Diagnosis

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Diagnosis 2) Physical examination: Palpation, Stress loading the DRUJ, Dorsal ballottement of the distal ulna (Piano key sign) is a second important stress test and direct compression over the head. B) Diagnosis of Galeazzi fracture-dislocation: C) Diagnosis of Essex- Lopresti fracture: Angular concave deformity on the DRUJ. (A-P) and lateral radiographs of both the forearm and the wrist is essential. D) Diagnosis of abutment syndrome: positive ulno-carpal impingement test. E) Diagnosis of Chronic Instability of DRUJ: weakness in grip strength and positive shearing test.

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Diagnosis II) Diagnostic tools: Plain X-ray: Posteroanterior (PA), lateral and scaphoid oblique projection. A true lateral radiograph the proximal pole of the scaphoid , the lunate , and the triquetrum will be superimposed and the radial styloid process will be centered over them. a. Dorsal dislocation. b. Dorsal subluxation. c. Palmar subluxation. d. Palmar dislocation.

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Diagnosis 2) CT scan: It may be normal in spite of disruption ligaments and the TFC. Methods for measuring distal radioulnar joint instability. Congruency. Radio-ulnar lines. Epicenter. Radioulnar ratio (RUR) and Standard deviation (SD). 3) Arthrography : Advantages: diagnostic modalities with high sensitivity to detect: (1)TFC injuries.(2) Defects of the articular disc (3) tears in the intrinsic ligaments of the wrist.

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Diagnosis Disadvantages: Less reliable in patients older than age 40. Certain contra indication as allergy. Inability to direct visualization of all component of TFCC ligaments. Site, size and extent of the lesion could not be determined. Degenerative tears and partial lesions could not be identified. Result depend on personal interpretations.

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Diagnosis 4) Diagnostic arthroscopy: Advantages: the same disadvantages of arthrography. Disadvantages: liability for iatrogenic injuries. 5) Magnetic resonance imaging (MRI): Alone or enhanced with gadolinium or saline Degenerative lesions appear as an area of higher signal intensity on both T1- and T2 the arrow points to the degenerative changes. Advantages: 100% sensitivity and 90%specificity. Disadvantages: less reliable for diagnosis of intercarpal ligament.

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Diagnosis 6) Magnetic resonance arthrography (MRA): Increase sensitivity specificity to carpal ligament tears. Both MRI and MRA main indication for surgery. T1-weighted MRI of both wrists in pronation made to compare the normal wrist with the wrist that had a dorsal distal ulnar sublaxation

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Patient-related considerations (age, profession, quality of bone stock, etc.) is a main issue when deciding treatment of DRUJ instability. The main prognostic factors are: presence or absence of any extra- or intra- articular radial or ulnar deformity preventing the joint from being reduced. Status of the cartilage of the joint. Feasibility of repairing TFCC. Presence or absence of tendinopathy of the ECU ( tenosynovitis or subluxation ). Treatment

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Conservative Treatment of DRUJ injuries: DRUJ reduction is uncomplicated unless there is interposed soft tissue. The position of maximum stability is opposite to the position of instability and the casting should be in this position with custom bi valve or Muenster orthosis. Treatment Bi valve orthosis. Muenster orthosis.

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Treatment Local Injection: Patient sits with hand palm down. Identify styloid process of ulna. Insert needle just distal to styloid aiming transversely towards radius, passing through the ulnar collateral ligament to penetrate capsule. Inject solution as a bolus. Conservative management of chronic DRUJ instability usually fails unless individual is willing to use the modified anti-pronation DRUJ instability splint on a regular basis . A 4-week trial of wrist splinting and anti inflammatory medications is indicated for mild instability. Steroid injection and splinting, may provide sufficient relief.

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II) Treatment of DRUJ injuries: 1) Treatment of DRUJ Acute Dislocation: In dorsal dislocations can usually be reduced with the forearm in supination and in volar dislocation in pronation . Open reduction of an irreducible (dorsal or volar ) dislocation. If the joint redislocates , a transfixing (1.6 mm) Kirschner wire. Primary repair of any ligamentous injury is recommended. 2) Treatment of Galeazzi fracture: Open reduction and internal fixation by plating of the radius. + Treatment of DRUJ acute dislocation. In children longitudinal traction, manipulation of the fracture and immobilization in long-arm cast. 3) Treatment of Essex- Lopresti injury: Reconstruct the proximal radius whenever possible. If it is not reconstructable , use a radial head implant. Treatment

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4) Treatment of TFCC Tears: A) Surgical Treatment: When TFCC detachment occurs reattachment should be combined with a shortening osteotomy of the ulna. Treatment Arthroscopic repair by suture for type 1(B). C) Arthroscopic TFCC surgery: Debridement either with shaver and saline irrigation or with holmium YAG laser for type1 (A,C,D) and also with Degenerative tears.

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Treatment 5) Treatment of DRUJ incongruity Arthritis: Type of Arthritis Treatment Options Early Osteoarthritis Ulnar shortening osteotomy Established Osteoarthritis Ablative procedures: Sauve-Kapandji , hemi- resection interposition arthroplasty , matched distal ulna resection, Darrach Implant procedures Hemi- arthroplasty . Total arthroplasty .

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Treatment III) Surgical procedures: A) Reconstructive soft tissue procedures: Radio-ulnar sling to hold the ulnar head in the ulnar notch of the radius using fascia lata , retinacular flap or rerouted ECU tendon. 3) Pronator Quadratus origin transfer. 2) Reconstruction of the DRUL. 4)Tenodesing procedures involving the ECU, the FCU, or a substitute tendon graft.

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Treatment B) Bony procedures: I) Excisional arthroplasty : ( Darrach procedure) Resection of the distal end of the ulna sub- periosteally leaving all ligaments in continuity with the periosteum . II) Hemi-resection arthroplasty : Matched ulnar resection: is resecting the painful articular surface. Hemiresection -interposition arthroplasty : The ulnar articular surface and its subchondral bone are removed and Inter-position of material in the cavity that is left after excision.

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Treatment III) Ulnar shortening: Feldon wafer procedure: A "wafer“ of the ulnar head is excised with 2 to 4 mm of thickness of cartilage and subchondral bone is removed. Distal ulna recession: resection of a variable amount of ulnar diaphysis and hold the osteotomy in position for healing. IV) Sauvé-Kapandji procedure: Included an arthrodesis across the DRUJ and created a pseudoarthrosis of the ulna proximal to the fusion.

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Rehabilitation Postoperative Rehabilitation 1) Tears of the TFCC surgically repaired: After 10 days to 2 weeks, the cast may be changed to a thermoplastic splint ( long arm splint). The digits and thumb are for full range of motion. Elbow range of motion may be permitted at 4 weeks. At 6 weeks, intermittent support and protection when outside. After 8-10 weeks, progressive strengthening may begin. If limitations persist in forearm rotation pt use Collelo splint.

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Rehabilitation 2) Ulnar Shortening: At 2 weeks long cast may be replaced with a long thermoplastic splint. At 4 weeks splint may be reduced to a short splint to free the elbow. At 6 weeks, full active range of motion generally begins. Once the osteotomy site is healed, the patient may progress to strengthening exercises. 3) Darrach Procedure: Darrach encouraged active motion within 24h. at 4-6 weeks Patients progress to strengthening exercises.

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Rehabilitation 4) Suave- Kapandje Procedure: At 1 week a short arm cast is changed to a removable thermoplastic splint. Once the fusion appears radiographically solid (by 8 weeks), strengthening can begin. 5) TFCC Debridement : Within 1 week of the active wrist motion is permitted. At 4-6 weeks following surgery, strengthening begins. A small cuff-style splint supporting the pseudoarthrosis.

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Conclusion Acute dislocation Reduction Stable → splinting Unstable → ORIF + TFCC repair Chronic dislocation Instability mild to moderate → splinting + ant inflammatory +/- steroid injection Severe → ORIF + Lig . reconstruction Treatment of DRUJ Instability is according to underlying causes . Galeazzi # Operative → Better results

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Essex- Lopresti Inj. R of radial head # → controversial. Excision → satisfactory results. Conclusion TFCC tears with tears in articular disc Partial resection of the TFCC Suture of the TFCC ? ulnar shortening Recently ,TFCC are best diagnosed and treated arthroscopically

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Arthroscopic treatment is the least invasive, most effective and safest mean of performing procedures such as debridement, TFCC reattachment, and ulna shortening. Conclusion DRUJ incongruity + arthritis Osteoarthritis Established : Interposition arthroplasty. Distal ulna resection Hemi or total arthroplasty Early → ulnar shortening

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