HAND/PERIPHERAL NERVE Disorders of the Distal Radioulnar Joint Matthew T. Houdek, M.D. Eric R. Wagner, M.D. Steven L. Moran, M.D. Richard A. Berger, M.D., Ph.D. Rochester, Minn.

Summary: The distal radioulnar joint is responsible for stable forearm rotation. Injury to this joint can occur following a variety of mechanisms, including wrist fractures, ligamentous damage, or degenerative wear. Accurate diagnosis requires a clear understanding of the anatomy and mechanics of the ulnar aspect of the wrist. Injuries can be divided into three major categories for diagnostic purposes, and these include pain without joint instability, pain with joint instability, and joint arthritis. New advancements in imaging and surgical technique can allow for earlier detection of injuries, potentially preserving joint function. In this article, the authors review the pertinent anatomy, biomechanics, and major abnormality involving the distal radioulnar joint. (Plast. Reconstr. Surg. 135: 161, 2015.)

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he ulnar aspect of the wrist contains the ligamentous and bony structures that constitute the distal radioulnar joint; the distal radioulnar joint allows for stable forearm rotation but is susceptible to injury following trauma and degenerative wear. The anatomy and mechanics of the distal radioulnar joint have long been considered a “black box,” making diagnosis and treatment of injuries in this region complicated1; fortunately, over the past 25 years, advancements in our anatomical and biomechanical understanding of this joint have allowed surgeons to better diagnose and treat injuries in this area.1 This article reviews the pertinent anatomy, biomechanics, and major abnormality involving the distal radioulnar joint.

ANATOMY OF THE Distal Radioulnar Joint The distal radioulnar joint is one of three stabilizers of the forearm joint; the other two are the interosseous membrane and the proximal radioulnar joint (Fig. 1). The forearm joint is responsible for forearm rotation, allowing for pronation and supination of the hand and wrist. The axis of rotation for the forearm occurs along a line running from the radial head through the fovea, found on the ulnar portion of the ulnar head. The hand, carpus, and radius all rotate around From the Department of Orthopedic Surgery and the Division of Plastic and Reconstructive Surgery, Mayo Clinic. Received for publication May 1, 2014; accepted June 6, 2014. The first two authors contributed equally to the preparation of this article. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000838

the fixed ulna, with the majority of forearm rotation occurring at the distal radioulnar joint, as opposed to the proximal radioulnar joint.1,2 The distal radioulnar joint is a diarthrodial trochoid joint3; the concave distal ulnar head rests on the shallow convex surface of the distal radius, known as the sigmoid notch.4,5 The radius of curvature of the sigmoid notch is larger than that of the ulnar head and allows for dorsal to palmar translation of the ulnar head in relation to the radius during pronation and supination. In addition to this translational motion, the radius will move proximal to distal on the ulnar shaft as the arm moves from pronation to supination; this is seen as a change in ulnar height as read on a true posteroanterior radiograph. In full wrist pronation, the ulna may appear to be 2 to 3 mm more “ulnar positive” than on a neutral forearm view.4 Four anatomical variations of the sigmoid notch have been described.6 Tolat et al. described these as flat faced, C type, S type, and ski-slope configurations (Fig. 2).6 The incongruent shape of the sigmoid notch compared with the ulna head makes the distal radioulnar joint relatively unconstrained, with only 20 percent of the stability of the joint produced through bony contact.4,7 Patients who have a less concave sigmoid notch, such as those with flat-face geometry, may have even less stability provided by bony contact. Because so little joint stability is afforded by bony contact, the majority of the stability present in the distal radioulnar joint is based on the intrinsic (intracapsular) and extrinsic (extracapsular) soft-tissue and

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Fig. 1. Illustration of the major components of the distal radioulnar joint. The distal radioulnar joint is a diarthrodial joint that relies mainly on soft-tissue attachments for stabilization. The primary stabilizer of the distal radioulnar joint is the triangular fibrocartilage complex. Other important volar stabilizers include the ulnotriquetral and ulnolunate ligaments. (Copyright Mayo Foundation, 2009.)

ligamentous attachments about the distal radioulnar joint (Fig. 1).1,7,8 The extrinsic stabilizing structures include the sixth dorsal compartment and the extensor carpi ulnaris,9 the pronator quadratus,10 and the interosseous ligament.11,12 The intrinsic stabilizers include a group of ligaments collectively referred to as the triangular fibrocartilage complex.1,4 The triangular fibrocartilage complex is the major stabilizer of the distal radioulnar joint. The triangular fibrocartilage complex was first described in 1981 as a group of structures that are functionally related but anatomically distinct.13 These structures include the triangular fibrocartilage, the palmar and dorsal radioulnar ligaments, meniscal homologue, the ulnar collateral ligament, and the extensor carpi ulnaris tendon subsheath.3,13 In the center of the triangular

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fibrocartilage complex lies the avascular triangular fibrocartilage, also known as the central disk (Fig. 3). The central disk acts as a cushion between the distal ulna and the carpus, especially during ulnar deviation.13,14 Although the central disk provides no substantial stability to the distal radioulnar joint, it does serve to transmit load between the carpus and forearm. In an ulnar-neutral wrist (a wrist where the radius and ulna are the same height on a posteroanterior radiograph), approximately 20 percent of axial load is directed through the triangular fibrocartilage complex into the ulna, and the remaining 80 percent is directed through the radius. This value can rise with increasing ulnar height (as the ulna becomes longer in relation to the radius). Injury to the central disk may occur because of repetitive ulnar loading, attritional changes associated with advanced age,

Volume 135, Number 1 • Disorders of the Distal Radioulnar Joint

Fig. 2. Variations of the sigmoid notch as described by Tolat et al. The most common variant was a flat face, with the remainder described as C type, S type, and ski slope. (Copyright Mayo Foundation, 2009.)

and in patients with an ulnar-positive wrist. Central disk perforations do not produce instability but can lead to pain through mechanical irritation or through changes within load transmission to the forearm. At the dorsal and palmar edges of the central disk, one finds the dorsal and palmar radioulnar

Fig. 3. The triangular fibrocartilage complex originates from the dorsal and volar corners of the radius near the lunate facet and inserting onto the ulnar styloid. The avascular central disk (CD) is surrounded by the vascular dorsal (DRUL) and volar (VRUL) radioulnar ligaments. Also shown in the photograph is the scaphoid facet (S), lunate fact (L), ulnar styloid (asterisk), and Lister tubercle (LT). (From Hagert E, Chim H, Moran SL. Anatomy of the distal radioulnar joint. In: Greenberg JA, ed. Ulnar Sided Wrist Pain: A Master Skills Publication. Rosemont, Ill: American Society for Surgery of the Hand; 2013:11–22. All rights reserved.)

ligaments. These are the major stabilizers of the distal radioulnar joint, with a blood supply arising from the posterior and anterior interosseous arteries.8,15,16 As the ligamentous fibers of the palmar and dorsal radioulnar ligaments arise from the ulnar aspect of the radius and move toward the ulna, they branch into a superficial component and a deep component, with the superficial component attaching to the ulnar styloid, and the deep component, also known as the ligamentum subcruentum, attaching to the fovea (the fovea represents the depression just radial to the ulnar styloid).1,4,17,18 The ability of these fibers to guide the radius around the ulna is based on the angle at which these fibers attach to the ulna.1,4,17 The superficial fibers approach the ulnar styloid at an acute angle, giving them a poor mechanical advantage to control motion at the distal radioulnar joint.4,17 Unlike the superficial fibers, the deep fibers attach to the fovea at an obtuse angle, providing a mechanical advantage to stabilize the radius as it rotates around the ulna.4,17 During pronation, the dorsal superficial fibers and palmar deep fibers tighten; likewise, during supination, the dorsal deep fibers and the superficial palmar fibers tighten to constrain motion at the distal radioulnar joint.1,4,7,17,18

DIAGNOSIS Disorders of the distal radioulnar joint can be broken down into three major categories for diagnostic purposes: (1) pain without instability,

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Plastic and Reconstructive Surgery • January 2015 (2) pain with instability, and (3) pain caused by arthritis. The diagnosis is made by careful clinical examination and radiographic analysis. Physical examination of the distal radioulnar joint is best performed with the patient seated across from the examiner. The patient is first asked to move through supination and pronation with the elbows held close to the sides so that compensatory motion cannot be generated by the shoulders. Active and passive motions are compared. Then, the physician should evaluate the stability of the distal radioulnar joint. The radius is stabilized between the thumb and fingers; then, using the other hand, the examiner translates the ulna dorsal then palmar in full pronation, full supination, and neutral position. The uninjured side should be used as an internal control. Pain, clicking, clunking, increased mobility, and subluxations are all potential signs of instability. Direct compression of the distal radioulnar joint by medially loading the radius and ulna can result in pain because of distal radioulnar joint synovitis or arthritis. Pain caused by ulnar impaction is best solicited by bringing the patient’s wrist into full pronation and ulnar deviation. Following a careful physical examination, all patients should have posteroanterior and lateral radiographs of the wrist. Comparative forearm views should be added if there is a history of previous forearm fracture or limitations in forearm rotation. To obtain a true posteroanterior and a true lateral radiograph of the distal radioulnar joint, the upper arm must be placed in adduction (adjacent to the trunk); the elbow must be flexed 90 degrees with the forearm in a neutral position (0 degrees of pronation/supination); the fingers of the hand are then placed in a neutral position with the thumb

placed at the side of the second metacarpal to create a flattened hand with the ulnar side down and the thumb up. The x-ray beam is then projected perpendicular to the flexion-extension plane of the elbow to obtain a true posteroanterior or parallel to flexion-extension plane to obtain a true lateral view.19 Widening at the sigmoid notch, dorsal subluxation of the ulna head on true lateral radiographs, and proximal ulnar styloid nonunions can all be radiographic indications of instability (Fig. 4). Dynamic stress computed tomographic views have been described to evaluate subtle instability (Fig. 5). Magnetic resonance imaging is helpful for evaluation of tears of the triangular fibrocartilage complex, ulnocarpal ligament injury, and intracarpal abnormality. Evidence of joint arthritis may be present on both posteroanterior radiographs and computed tomographic imaging. Further descriptions of radiographic and magnetic resonance imaging findings in distal radioulnar joint injury are beyond the scope of this article, but the reader is referred to Amrami et al.19 When the diagnosis is still unclear, intraarticular injections with lidocaine or lidocaine and steroid can help differentiate intraarticular abnormality from more superficial problems such as tendonitis, tendon subluxation, or nerve irritation overlying the distal radioulnar joint. If all other modalities fail to provide a source for the patient’s pain, diagnostic arthroscopy can be considered and remains the criterion standard for identifying triangular fibrocartilage complex injuries.

PAIN WITHOUT INSTABILITY Pain without instability may be caused by injury to the extensor carpi ulnaris subsheath, the

Fig. 4. Signs of distal radioulnar joint instability can be seen on posteroanterior radiographs as loss of the space between the radius and the ulna (left), and displacement of the ulna from the sigmoid fossa as seen on an axial computed tomographic scan (right).

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Fig. 5. Dynamic computed tomographic image of the wrist showing subluxation of the ulna dorsal to the radius. This is a sign of instability.

volar ulnocarpal ligaments, impaction, or isolated injury to portions of the triangular fibrocartilage complex. Tears to the triangular fibrocartilage complex (Fig. 6) are the most common cause of ulnar-side wrist pain, frequently occurring following an axial load with ulnar deviation and forearm rotation.3 Tears to the triangular fibrocartilage complex can be readily diagnosed based on the patient’s history and physical examination.3 Pain over the ulna fovea was found to be 95.2 percent

Fig. 6. Mayo classification of triangular fibrocartilage tears including central (A), peripheral ulnar insertion (B), linear peripheral tear (C), and peripheral radial rim tears (D). (Copyright Mayo Foundation, 2009.) Triangular fibrocartilage complex injuries following trauma can occur within the articular disk (A), ulnar periphery (B), palmar periphery (C), and along the radial attachment (D). Lesions that may result in instability include B and C. Triangular fibrocartilage complex detachment from the radius (a type D lesion) could also theoretically result in distal radioulnar joint instability if the tear proceeds palmarly or dorsally through the palmar or dorsal radioulnar ligaments, respectively. Arthroscopic evaluation needs to be combined with physical examination to verify the diagnosis of a destabilizing triangular fibrocartilage complex injury. (Copyright Mayo Foundation, 2009.)

sensitive and 86.5 percent specific for a tear to the triangular fibrocartilage complex or ulnotriquetral ligament.20 Diagnosis through the use of magnetic resonance imaging has improved the detection of tears up to 97 percent.21 Although magnetic resonance imaging has become accurate at detecting tears, the modality is still dependent on the experience of the radiologist reading the images22; thus, wrist arthroscopy remains the criterion standard for diagnosing tears to the triangular fibrocartilage complex.3 Tears to the triangular fibrocartilage complex are classified based on the nature of injury, either traumatic (type I) or degenerative (type 2), and are further separated by their location (type 1 tears) and the extent of associated degeneration (type 2 tears).23 Tears to the triangular fibrocartilage complex can be treated either with arthroscopic débridement/repair or through an open incision (Fig. 7). Only one study has compared arthroscopic versus open repair of the triangular fibrocartilage complex, and no significant difference in clinical outcomes was noted between the two groups.24 Open repair of the triangular fibrocartilage complex has shown good results,25 and although arthroscopy can be time consuming, improved tear visualization and less damage to other ulnar-side wrist structures are frequently cited reasons to perform arthroscopic repair.26,27 Currently, the literature is lacking in prospective data comparing these two treatment modalities. Triangular fibrocartilage complex injuries can lead to distal radioulnar joint instability if the triangular fibrocartilage complex injury results in complete dissociation of the deep fibers from their attachment to the fovea or if there is a peripheral tear disrupting the superficial radioulnar fibers from their capsular attachments. In these cases, instability should be identified on physical examination. If injury is acute, it is our opinion that open repair should be considered to reestablish the appropriate attachment of the triangular fibrocartilage complex to the fovea. For chronic cases where an untreated triangular fibrocartilage complex injury has led to chronic instability, we opt for the Adams-Berger procedure, which is discussed below.

INSTABILITY OF THE DISTAL RADIOULNAR JOINT WITH PAIN Acute Distal Radioulnar Joint Dislocations Failure of the intrinsic or extrinsic stabilizers of the distal radioulnar joint can lead to acute dislocation, occurring in isolation or associated with

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Fig. 7. Arthroscopic repair of the triangular fibrocartilage complex (TFC) (above). Needles are used to pass sutures from above and below the tear in the triangular fibrocartilage complex (above and center). The sutures are passed multiple times to repair the tear (below). (Copyright Mayo Foundation, 2009.)

a fracture of the ulna or radius.2 Isolated dislocations of the distal radioulnar joint are relatively uncommon injuries, and can occur in either a volar or a dorsal direction.28,29 Dorsal dislocations are thought to occur following a hyperpronation injury, disrupting the volar radioulnar ligament.2,17,30–34 Likewise, volar dislocations occur with hypersupination injuries, following an injury to the dorsal radioulnar ligaments.2,30–34 Because of the vascular supply to the radioulnar ligaments, with prompt reduction there is potential for healing of the ligaments and restoration of a stable joint.15 Despite the fact that the radius rotates around a fixed ulna, historical convention has described distal radioulnar joint injuries in terms of the position of the ulnar head in relationship to the radius. Thus, a palmar dislocation refers to an ulnar head that lies palmar to the radius on lateral radiographs.

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Acute dislocations or subluxation of the distal radioulnar joint can also occur in association with a fracture of the radius.2 Injuries to the triangular fibrocartilage complex frequently occur following a distal radius fracture.35 Stability of the distal radioulnar joint is frequently difficult to assess following a distal radius fracture because of swelling and associated pain with examination of the joint. Examination of the distal radioulnar joint in these cases should occur under anesthesia following reduction of the bony fracture. Comparison with the contralateral side should be performed, and if any instability is found, it should be managed surgically.2 Galeazzi fractures, which are fractures at the junction of the middle and distal thirds of the radius, are highenergy injuries often associated with disruption of the distal radioulnar joint. These fractures are best managed by open reduction and internal

Volume 135, Number 1 • Disorders of the Distal Radioulnar Joint fixation to stabilize the radius and reestablish stability at the distal radioulnar joint,2,36,37 as closed management has been associated with poor outcomes (Fig. 8).38 The distal radioulnar joint should be evaluated in all cases of a diaphyseal radius fracture34; this is especially true in fractures that occur within 7.5 cm from the midarticular surface of the radius.37 Fractures of the radial head associated with distal radioulnar joint dislocation are termed Essex-Lopresti injuries.39 These fractures typically occur following an axial compression, leading to a fracture of the radial head, the primary constraint of proximal migration of the radius.2,40 With the proximal constraint removed, the distal radioulnar joint is free to migrate and will become unstable.2 These injuries require open reduction and internal fixation or replacement of the radial head within 1 week of injury to obtain acceptable outcomes.40,41 Chronic Distal Radioulnar Joint Instability Chronic injury to the distal radioulnar joint frequently occurs following an unrecognized acute injury, after an injury that was inadequately treated, or repetitive minor injuries leading to attritional disruption of the supporting ligaments.5 Rheumatoid arthritis may also lead to chronic distal radioulnar joint instability through attritional disruption of the supporting ligaments during repeated episodes of synovitis. Stretching of the ulnar capsule allows the radius to sublux volar to the ulnar head, leading to dorsal prominence of the ulnar head on physical examination. Tenosynovitis results in subluxation and dysfunction of the extensor carpi ulnaris tendon, contributing to radial deviation of the wrist. Longstanding dorsal prominence of the ulnar head can lead to caput ulnae syndrome and eventual rupture of the extensor tendons. Most patients with posttraumatic instability report a history of falling on their wrist and will present with a painful clunking of the wrist with forearm rotation, along with a prominent ulnar head at the extremes of pronation.5 On physical examination, patients typically have a positive foveal sign,20 piano-key sign (pain with volar depression and release of the ulnar head),42 and press test (pain over the ulnar head when the patient pushes himself or herself up from a chair).43 The clinical examination should also include standard wrist radiographs to assess for widening of the distal radioulnar joint, volar or ulnar displacement of the ulnar head, and evidence of arthritis or a malunited fracture.5

Fig. 8. Anteroposterior radiograph of a Galeazzi fracture.

Computed tomographic scans can also be used to assess for degeneration of the distal radioulnar joint.5 Treatment for chronic distal radioulnar joint instability is based on the severity of the patient’s symptoms. A trial of nonoperative treatment including wrist and forearm strengthening along with functional bracing should be attempted.5,44 Surgical reconstruction of the distal radioulnar joint is indicated in patients who fail nonoperative treatments and have pain, loss of motion caused by pain, or weakness and clicking.5 Soft-tissue reconstruction should be considered on patients with irreparable or chronic triangular fibrocartilage complex tears and no evidence of arthritis at the sigmoid notch5; in these cases, the goal of surgery is to link the ulna and radius and stabilize rotation, similar to an intact triangular fibrocartilage complex.37 Current options include creating a tether between the radius and ulna,28 using a retinacular flap to “reduce” the distal radioulnar joint to the ulna by tightening the capsule,45 or using a tenodesis procedure to provide stability to the distal radioulnar joint46,47; however, none of these options restores natural distal radioulnar joint stability and motion.48 To attempt to restore the motion of the joint, Adams and Berger (Fig. 9) used a tendon graft to reconstruct the origins of the radioulnar ligaments.49 This reconstruction has shown good results both clinically and functionally for the patient,49,50 and in our opinion offers the best treatment for chronic painful instability without arthritis.

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Plastic and Reconstructive Surgery • January 2015 DARRACH PROCEDURE AND THE HEMIRESECTION INTERPOSITION TECHNIQUE MODIFICATION

Fig. 9. Schematic drawing of the Adams-Berger procedure to reconstruct the stability of the distal radioulnar joint. In this procedure, a tendon graft is passed through a bone tunnel just radial to the sigmoid notch and then obliquely through the fovea and out the ulnar shaft. The procedure attempt to reproduce the shape and path of the dorsal and volar radioulnar ligaments in an effort to stabilize the joint. (Copyright 2009 Mayo Foundation.)

DISTAL RADIOULNAR JOINT ARTHRITIS Chronic distal radioulnar joint instability and pain over time will lead to joint degeneration. Once the patient presents with distal radioulnar joint instability combined with arthritis of the sigmoid notch, they are no longer an appropriate candidate to undergo distal radioulnar joint reconstruction.5 Additional contraindications to distal radioulnar joint reconstruction include ulnar impaction leading to distal radioulnar joint arthritis, length discrepancies between the radius and ulna, and inflammatory arthritis in some cases.42 Options for patients with instability and arthritis are primarily salvage procedures and include the Darrach procedure, the hemiresection interposition procedure, the Sauve-Kapanji procedure, or a constrained ulnar head arthroplasty.51,52 Options for patients with arthritis without instability would include all previously mentioned options but also the possibility of ulnar head replacement arthroplasty.

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In the early twentieth century, Darrach popularized the treatment of radioulnar joint abnormality through resection of the distal ulna. Its indications and technique have changed through the years; however, the Darrach procedure remains a very good option for those patients with low physical demands who suffer from distal radioulnar joint arthrosis.51,52 The operation involves resecting a limited amount of the distal ulna subperiosteally just proximal to the sigmoid notch. It is critical to leave as many soft-tissue structures intact as possible to maximize stability, including the extensor carpi ulnaris tendon sheath and portions of the triangular fibrocartilage complex. If needed, the dorsal retinaculum can be sutured to create a sling for additional support for the extensor carpi ulnaris sheath.53 Recent techniques have attempted to resect as little bone and soft tissue as possible, increasing the postoperative stability of the residual ulnar stump. In fact, if the triangular fibrocartilage complex is intact, hemiresection of only the articular surface of the distal ulna remains a possibility54 (Fig. 10). The Darrach procedure has been demonstrated to improve the patient’s pain, grip strength, and forearm motion in the setting of distal radioulnar joint arthrosis53,55–58; however, recent publications have noted many long-term complications of the procedure. These complications include anteroposterior instability of the residual ulnar stump, ulnar translocation of the carpus, radioulnar convergence, and pain.59–61 The radioulnar convergence, first described by Bell et al. as “ulnar impingement syndrome,” is difficult to treat.59 Patients feel a painful clicking during forearm pronation and supination. Radiographs may show “scalloping” on the radius at the site of impingement. The mechanism underlying impingement is still not entirely clear but may be associated with the unopposed contraction of the pronator quadratus once the distal radioulnar joint articulation is removed. The incidence of this complication is unknown, and although some reports have indicated it is prevalent radiographically in up to 56 percent of patients, most of the cases are asymptomatic.59,61 As it is felt that the incidence of this complication is correlated with the amount of distal ulna resected, many recent techniques attempt to minimize the amount of bone resected. A modification of the Darrach procedure, in an attempt to prevent impingement, involves

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Fig. 10. Posteroanterior radiograph showing an example of a Darrach procedure following a failed distal radioulnar joint softtissue reconstruction.

Fig. 11. Posteroanterior radiograph showing an example of a Sauve-Kapandji procedure that has been performed in conjunction with a radioscapholunate fusion.

hemiresection of the ulnar head with interposition of soft tissues between the remaining ulnar stump and radius. This modification is known as the hemiresection interposition technique. The soft-tissue interposition attempts to prophylactically prevent radioulnar convergence through soft-tissue interposition.62 Furthermore, although this modification does not address the abnormal distal radioulnar joint motion created by the ulnar resection, one report noted that only 20 percent of patients reported distal ulnar instability, compared with 60 percent of those who underwent the Darrach procedure.63 Overall, pain relief and functional improvements are comparable to the results of the Darrach procedure.63,64 Of note, one recent study by Ahmed et al. demonstrated very good long-term results when the hemiresection interposition technique procedure was used to treat patients with rheumatoid arthritis and distal radioulnar joint arthritis.65

the ulnar head into the sigmoid notch can be performed with either Kirschner wire fixation or cancellous screws. Modifications include interposing pronator quadratus fascia into the osteotomy site to prevent future ossification, and flexor carpi ulnaris tenodesis through the ulnar stump for further stability of the ulnar shaft.58,66 Biomechanical advantages include the maintenance of the ulnar column length to preserve the ulnocarpal articulation and prevent ulnar migration of the carpus.52 Historically, this procedure has been recommended for young, active, high-demand patients; however, few studies have demonstrated any significant difference between the Darrach procedure and the Sauve-Kapandji procedure.5,67 Furthermore, in a manner similar to that of the Darrach procedure, radioulnar convergence is thought to be present radiographically in up to 74 percent of patients.68 Most patients experience significant pain relief, with some degree of subjective instability.64,67,68

SAUVE-KAPANDJI PROCEDURE In an attempt to create a more stable postoperative construct, the Sauve-Kapandji procedure fuses the ulnar head to the radius at the sigmoid notch and creates an osteotomy at the level of the ulnar neck (Fig. 11). As with the Darrach procedure, maintaining the soft-tissues surrounding the distal radioulnar joint is critical for postoperative forearm stability, and the ulnar neck resection should be less than 1 to 2 cm in length.52 Arthrodesis of

ULNAR HEAD ARTHROPLASTY Unlike the Darrach or Sauve-Kapandji procedure, ulnar head arthroplasty attempts to restore more normal distal radioulnar joint kinematics by replacing the ulnar head that has been affected by arthritis.51 There are two major types of ulnar head arthroplasties: constrained implant arthroplasties (which are used in cases of arthritis with instability)

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Plastic and Reconstructive Surgery • January 2015 and unconstrained arthroplasties (which can be used in cases of arthritis with minimal instability).51,69 The surgical procedure involves resection of the distal ulnar head and neck, followed by implantation of a stemmed implant down the ulnar shaft. The surrounding soft tissue of the triangular fibrocartilage complex and capsule is preserved and repaired to restore stability. In the setting of substantial instability or bone loss from prior trauma or procedures, a total distal radioulnar joint arthroplasty, such as the Aptis prosthesis (Aptis Medical, Glenview, Ky.), combines the ulnar head replacement with a plate and screws into the ulnar aspect of the distal radius.70 Total ulnar head arthroplasty is indicated as a primary treatment for arthritis alone, for arthrosis combined with instability, or as a salvage option in the setting of a failed Darrach procedure.51,71 This procedure restores more normal forearm rotation, providing stability to tensile and compressive forces across the distal radioulnar joint.72–75 Furthermore, the ulnar head arthroplasty avoids the risk of impingement of the ulnar stump after the Darrach procedure. A review of 47 total ulnar head arthroplasties demonstrated a significant improvement in pain scores and Mayo wrist scores, with an 83 percent implant survival at 6 years (Fig. 12).71

OTHER SALVAGE OPTIONS In the setting of failed distal ulnar resections or failed ulnar arthroplasty, patients have a few

remaining options. Greenberg and Sotereanos have described the use of interpositional Achilles tendon allograft to prevent intractable radioulnar impingement following failed Darrach procedures.76 They reported improvements in grip strength and pain in 17 patients at an average of 34 months’ follow-up. If all other procedures fail, the ultimate salvage procedure for intractable distal radioulnar joint instability and pain remains the creation of a one-bone forearm, or radioulnar synostosis. This obviously leaves the patient with no pronation or supination but possibly pain relief.

AUTHORS’ TREATMENT ALGORITHM Patients are all treated initially with nonoperative management, which includes physical therapy, antiinflammatory drugs, and immobilization. Surgical management is then considered on an individual basis depending on the patient’s physical findings, the chronicity of the injury, and the results of imaging studies. For cases of pain without instability, ligament repair is attempted arthroscopically. For treatment of distal radioulnar joint instability and pain, triangular fibrocartilage complex repair can be performed arthroscopically if the patient is diagnosed within 6 to 8 weeks of the injury. Open repair can be attempted if the injury extends beyond this window or if the instability is caused by a foveal disruption of the triangular fibrocartilage complex. Chronic instability without arthritis is best treated with ligament

Fig. 12. A 64-year-old man with a history of chronic ulnar-side wrist pain without instability. (Left) Anteroposterior radiograph of the wrist showing primary distal radioulnar joint arthritis. Treatment was performed with an ulnar head arthroplasty. Anteroposterior (center) and lateral radiographs (right) showing result at 2 years. The patient has pain-free pronation and supination.

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Volume 135, Number 1 • Disorders of the Distal Radioulnar Joint reconstruction as described by Adams and Berger. Patients with arthritis and instability are best managed with a constrained arthroplasty or a Darrach procedure if they are older and have low demands for their extremity. Unconstrained ulnar head arthroplasty is a consideration in patients with arthritis without major instability. Advances in our understanding of the anatomy and mechanics of the distal radioulnar joint have improved our ability to treat ulnar-side wrist pain. The major stabilizing structures of the distal radioulnar joint are the dorsal and palmar radioulnar ligaments. Diagnosis of distal radioulnar joint injury is based on careful physical examination in conjunction with radiographs and magnetic resonance imaging. Future advances in arthroscopic technique and arthroplasty will allow for improved outcomes in this patient population. Steven L. Moran, M.D. Division of Plastic and Reconstructive Surgery Mayo Clinic 200 First Street SW Rochester, Minn. 55905 [email protected]

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