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The American Academy of Orthopaedic Surgeons

Printed with permission of the
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as well as other lectures presented
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J. L AWRENCE M ARSH
EDITOR, VOL. 56

C OMMITTEE
J. L AWRENCE M ARSH
CHAIRMAN

FREDERICK M. A ZAR
PAUL J. D UWELIUS
TERR Y R. L IGHT
E X -O FFICIO
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DISTAL RADIOULNAR JOINT INSTABILIT Y

Distal Radioulnar
Joint Instability
BY ROBERT M. SZABO, MD, MPH
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The distal radioulnar joint is inherently

unstable. Pathologic instability can be
acute or chronic; it can be dorsal, palmar, or multidirectional; and it can result primarily from soft-tissue injury
or osseous malunion. Recognition of
the type and cause of instability is fundamental in order to provide effective
treatment.
Anatomy of the
Distal Radioulnar Joint
The distal radioulnar joint is a distal articulation in the biarticulate rotational
arrangement of the forearm. This articulation allows only one degree of motion:
pronation and supination. The sigmoid
notch of the radius is concave and is
shallow with a radius of curvature of
15 mm. The ulnar head is semicylindrical and has an articulate convexity
of 220 with a radius of curvature of
10 mm1. The ulnar head is surrounded
by an ulnar carpal ligament complex.
This consists of the ulnolunate and ulnotriquetral ligaments, which originate
from the palmar radioulnar ligament
near the ulnar styloid process. When
seen through an arthroscope, these ligaments appear to be continuous with the
triangular fibrocartilage.
The triangular fibrocartilage is a
fibrocartilaginous disk originating at
the junction of the lunate fossa and the
sigmoid notch and inserting at the base
of the ulnar styloid. Its central portion
is cartilaginous, and it is designed for

weight-bearing. It is also avascular. The

peripheral margins are composed of
thick lamellar cartilage designed for
tensile loading and are called the dorsal
and palmar radioulnar ligaments. The
peripheral margins of the triangular fibrocartilage are well vascularized from
the palmar and dorsal branches of the
anterior interosseous artery and from
the ulnar artery. The ulnar styloid is the
continuation of the subcutaneous ridge
of the ulnar shaft, and it stands as a
strut on the end of the ulna to stabilize
the ulnar soft tissues of the wrist. The
sheath of the extensor carpi ulnaris, the
ulnocarpal ligaments, and the triangular fibrocartilage help to maintain the
congruency of the distal radioulnar
joint with attachments at the base of the
ulnar styloid; together, they are known
as the triangular fibrocartilage complex2-6.
The radius of curvature of the ulna
does not equal that of the sigmoid notch.
Full congruity of two articulating surfaces is therefore not possible. The shallow sigmoid cavity and the difference
between the radii of curvature of the
sigmoid notch and the ulnar head cause
the ulna to translate volarly in supination and dorsally in pronation. In the
extremes of forearm rotation, <10% of
the ulnar head may be in contact with
the notch1. Translation is normal. In
pronation, the ulna translates 2.8 mm
dorsally from a neutral position; in supinaton, the ulna translates 5.4 mm
volarly from a neutral position7. The

stability of the distal radioulnar joint

is provided by the joint surface morphology, the joint capsule, the dorsal
and palmar radioulnar ligaments, the
interosseous membrane, and the musculotendinous units, primarily the extensor carpi ulnaris and the pronator
quadratus8,9. The pronator quadratus
and the extensor carpi ulnaris are dynamic stabilizers of the distal part of
the ulna. The pronator quadratus has
a superficial head that is a prime mover
in forearm pronation and a deep head
that helps to stabilize the distal radioulnar joint10. The pronator quadratus actively stabilizes the joint by coapting the
ulnar head in the sigmoid notch, particularly in pronation, and it passively
stabilizes the joint by viscoelastic forces
in supination11,12. The extensor carpi ulnaris is maintained in its position over
the dorsal aspect of the distal part of the
ulna by a separate fibro-osseous tunnel
deep to and separate from the extensor
retinaculum. This separate arrangement
allows unrestricted rotation of the radius and ulna. An intact extensor carpi
ulnaris and fibro-osseous tunnel partially stabilize the distal radioulnar joint
even after the triangular fibrocartilage
and other ligaments are sectioned13. The
important role of the distal radioulnar
joint capsule as a restraint and as a contributor to stability was demonstrated
by Ward et al.14, Watanabe et al.15, and
Marangoz and Leblebicioglu16. Its complementary role in posttraumatic limi-

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tations of forearm rotation was described by Kleinman and Graham17.

The triangular fibrocartilage, the
ulnar carpal ligaments, the infratendinous extensor retinaculum, the pronator quadratus, and the interosseous
membrane provide additional key softtissue constraints. The triangular fibrocartilage attaches to the fovea in the
ulna by way of the dorsal and palmar
radioulnar ligaments. The fibers that
insert into the fovea are separated from
those that insert into the styloid by an
areolar vascular tissue known as the
ligamentum subcruentum18. There is a
debate in the literature regarding the
radioulnar ligaments. According to
Schuind et al., in pronation the dorsal
radioulnar ligament tightens as the ulna
translates dorsally and in supination the
palmar radioulnar ligament tightens as
the ulna translates palmarly19 (Table I).
In contrast, Ekenstam showed that in
pronation the palmar radioulnar ligament becomes taut (although the
dorsal capsule tightens) as the ulna
translates dorsally, and in supination
the dorsal radioulnar ligament tightens
(although the palmar capsule becomes
tight) as the ulna translates volarly20.
Ekenstam believed that stability in
pronation depends on the tension in
the volar radioulnar ligament and compression between the contact areas of
the dorsal aspect of the sigmoid notch
and the ulna, whereas stability in supination depends on the tension in the
dorsal radioulnar ligament and the triangular fibrocartilage articular disk as
well as compression between the contact areas of the volar aspect of the sigmoid notch and the ulna.
Adams and Holley measured strain
on the surface of the triangular fibrocartilage articular disk and calculated the

DISTAL RADIOULNAR JOINT INSTABILIT Y

strain at the dorsal and palmar margins

of the disk21. In supination, strain increased dorsally; in pronation, strain
increased palmarly. In a biomechanical
study of eleven fresh cadavers, Ward et
al. measured tension in the dorsal and
palmar radioulnar ligaments, joint rotation, and radial translation after sequential excision of the disk, interosseous
membrane, joint capsule, and radioulnar
ligaments14. This experiment confirmed
that the dorsal ligament tightens during
pronation while the palmar ligament becomes progressively lax, whereas the
converse occurs during supination.
The preponderance of biomechanical evidence supports the findings
reported by Schuind et al.19, and the inconsistency between their observations
and those presented by Ekenstam20 can
be resolved because, in pronation, the
dorsal radioulnar ligament tightens and
tends to displace the ulna dorsally. Left
unconstrained, this dynamic tensioning
would lead to subluxation and dislocation of the joint. The palmar radioulnar
ligament checks that force and keeps the
joint reduced. If the interosseous membrane is disrupted and the palmar radioulnar ligament is sectioned, the distal
part of the ulna dislocates dorsally in pronation. If the interosseous membrane is
disrupted and the dorsal radioulnar ligament is sectioned, the distal part of the
ulna dislocates palmarly in supination.
Classification
Disorders of the distal radioulnar joint
can be classified into four categories: (1)
impaction, (2) incongruity, (3) inflammation, and (4) instability. All of these
disorders can produce pain around the
distal radioulnar joint and should be
considered when a patient reports symptoms at the distal radioulnar joint. Ulnar

impaction is due to a positive ulnar

variance that causes the distal part of
the ulna to abut against the lunate, often
leading to thinning of the triangular fibrocartilage and eventually to a central
tear. Some surgeons also refer to this as
ulnar abutment syndrome. Incongruity
refers to the lack of a smooth interface
between the ulnar head and the sigmoid
notch. Incongruity can be due to a posttraumatic condition such as a distal radial fracture into the sigmoid notch,
or it can be secondary to osteoarthritis
or rheumatoid arthritis. Inflammation
around the distal radioulnar joint is
usually due to extensor carpi ulnaris
tendinitis dorsally or flexor carpi ulnaris tendinitis palmarly, and sometimes these disorders can be of a
calcific variety.
Instability of the distal radioulnar joint may be acute or chronic and
may be related to osseous changes after
a fracture or to soft-tissue injury. Softtissue injury of the triangular fibrocartilage, dorsal radioulnar ligament, palmar
radioulnar ligament, interosseous membrane, joint capsule, or any combination of those structures is capable of
producing instability of the distal radioulnar joint. Fractures of the distal part
of the radius or distal part of the ulna
alter the biomechanics of the distal radioulnar joint22. It is important to keep
in mind that instability can occur alone
or in conjunction with impaction, incongruity, or inflammation. Treatment
must be directed at each component of
the disease complex.
Examination of the
Distal Radioulnar Joint
To examine the ulnar styloid, one
should follow the superficial border of
the ulnar shaft distally while the wrist is

TABLE I Effects of Pronation and Supination on the Dorsal and Palmar Radioulnar Ligaments and Joint Capsule
Pronation

Supination

Dorsal radioulnar ligament

Tight as ulna displaces dorsally. Dorsal capsule

imbrication stabilizes distal radioulnar joint, preventing volar translation of radius

Lax

Palmar radioulnar ligament

Lax

Tight as ulna displaces palmarly. Palmar capsule

imbrication stabilizes distal radioulnar joint,
preventing dorsal translation of radius

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Fig. 1

Posteroanterior radiograph showing a distal radioulnar joint with chronic palmar instability in a fifteen-year-old girl who had sustained a fracture of the distal part of the radius two years previously. Note the large ulnar styloid nonunion fragment and a fleck fracture representing the site
where the triangular fibrocartilage complex avulsed from the fovea.

in radial deviation. The ulnar styloid

can be found more volarly than anticipated. This maneuver should be done
with the wrist in a pronated position.
The distal radioulnar joint is the most
complex structure to evaluate. The
most common pathological finding is
radioulnar incongruity secondary to a
malunited distal radial fracture with
loss of the pronation-supination arc.
With loss of the volar tilt of the radius,
the distal part of the ulna appears to be
more prominent. With ulnar impaction, ulnar deviation and extension are
limited and can be painful. The areas
of pronation, supination, and flexionextension should be determined. To test
for instability of the distal radioulnar
joint, the examiner should supinate the
wrist while supporting the hand, perform a ballottement maneuver of the
distal part of the ulna, and compare the
affected side with the normal side. During this maneuver, he or she should feel
for crepitus and ask the patient if pain
occurs. To check for instability of the
extensor carpi ulnaris tendon, the patient should be asked to flex the elbow
and pronate and supinate the forearm
with the hand in slight ulnar deviation

while the examiner looks for abnormal

motion of the extensor carpi ulnaris
tendon. Peripheral tears of the triangular fibrocartilage complex can produce
instability of the distal radioulnar joint
with the wrist in supination. With the
patients forearm in supination, the examiner should hold the distal part of
the ulna between the thumb and index
finger and test for dorsal and volar displacement of the distal part of the ulna.
The so-called press-test is a simple assessment. The patient is asked to push
himself or herself up from a seated position with use of the affected wrist. This
test creates an axial ulnar load and has a
high sensitivity for detecting a tear of
the triangular fibrocartilage complex23.
Pain with this maneuver suggests that
there is a lesion in the triangular fibrocartilage complex.
Radiographic Tests
Standard radiographs of the distal part
of the ulna should be made with comparison views of the unaffected side. The
images should include a true lateral radiograph made with the forearm in neutral rotation. Any deviation of >10 from
a true lateral view will greatly reduce the

accuracy of the examination. Ulnar variance should be measured and compared

with that on the contralateral side on radiographs made with the forearm in neutral rotation and the shoulder and elbow
in 90 of flexion with the x-ray beam
directed from posterior to anterior24.
Ulnar variance changes by up to a millimeter as the forearm moves from full supination to full pronation; therefore, this
standard position should be used. Ulnar
variance is measured by drawing a transverse line at the level of the lunate fossa
and a second transverse line at the level
of the ulnar head, and determining the
distance between the two lines. On the
posteroanterior radiograph, one should
look for a fleck fracture demonstrating
an avulsion of the triangular fibrocartilage complex, an ulnar styloid nonunion,
and joint widening between the radius
and ulna (Fig. 1). Radiographic signs of
injury to the distal radioulnar joint include a fracture at the base of the ulnar
styloid, widening of the distal radioulnar joint space seen on the posteroanterior radiograph, >20 of dorsal radial
angulation, and >5 mm of proximal displacement of the distal part of the radius.
Computed tomography scanning
is the technique of choice for evaluating congruity of the distal radioulnar
joint, but the same information can be
obtained with magnetic resonance imaging (Figs. 2-A and 2-B). There are
several methods for evaluating subluxation of the distal radioulnar joint, including the method described by Mino
et al.25,26, the congruency method27, the
epicenter method27, and the RUR (radioulnar ratio) method28. Magnetic resonance imaging is useful for identifying
tears of the triangular fibrocartilage
(Fig. 3), but its specificity and sensitivity vary29. It is necessary to use highresolution magnetic resonance imaging
with a dedicated wrist coil to obtain accurate scans30-32. Arthrography is still a
valuable examination, and it is even
more useful when it is combined with
magnetic resonance imaging. Arthroscopy is a sensitive method for evaluating tears of the triangular fibrocartilage
complex and is considered the gold
standard with which to compare the
accuracy of other examinations.

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Fig. 2-A

DISTAL RADIOULNAR JOINT INSTABILIT Y

Fig. 2-B

T1-weighted magnetic resonance images of both wrists in pronation made to compare the normal wrist (Fig. 2-A) with the wrist that had a dorsal distal ulnar subluxation (Fig. 2-B).

Subluxation and Dislocation

By convention, the ulna is considered
to dislocate with respect to the radius,
but it is the radius that moves and
therefore is displaced. With dorsal subluxation, the head of the ulna becomes
prominent dorsally, particularly in pronation, and may snap during wrist rotation. This is usually associated with a
weak and painful wrist. With complete
dislocation, the ulnar head is locked in
position, most commonly dorsally but
on occasion palmarly. Supination is restricted with either type of dislocation
because the radius cannot slip dorsally
over the ulnar head.
The mechanism of action for a
dorsal subluxation or dislocation of the
ulna is extreme pronation and extension with the coiled and tightened extensor carpi ulnaris and ulnar carpal
ligaments acting as a sling to lift the
ulnar head through the dorsal capsule.
Weakening of the triangular fibrocartilage complex secondary to its avulsion
(or a fracture of the ulnar styloid) and
attenuation of the palmar radioulnar
ligament will allow the dislocation.
Sheer stress during this mechanism
may produce associated chondral defects. The clinical appearance of a dorsal dislocation of the ulna is a tender
prominent dorsally displaced ulna and
a forearm with limited supination or
locked in pronation. Direct pressure

may reduce the dislocation, but the ulnar head usually springs back into a
dorsal position if the forearm remains
pronated. There is increased anteroposterior translation of the distal radioulnar joint with passive motion. Routine

radiographs may be nondiagnostic. A

posteroanterior radiograph can show
the ulna overlapping the distal part of
the radius. The best study with which to
visualize a subluxation or dislocation is
a computed tomography examination

Fig. 3

T2-weighted magnetic resonance image showing a complex peripheral tear (double arrows) and
radial tear (single arrow) of the triangular fibrocartilage complex.

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Fig. 4-B

Standard posteroanterior (Fig. 4-A) and lateral (Fig. 4-B) radiographs of the wrist, demonstrating palmar dislocation of the ulna.
Fig. 4-A

of both wrists performed in both pronation and supination25,26,33-35.

Treatment of Acute Dislocations
Dorsal Subluxation and Dislocation

An acute dorsal dislocation can be reduced with digital pressure on the distal
part of the ulna and forceful supination.
The reduction should be maintained
for six weeks. Some authors36 have advocated full supination, whereas others37
have recommended the neutral position. Nonoperative methods of treatment should be used only when there
is congruity of the distal radioulnar
joint in two planes. Open reduction
with repair of the triangular fibrocartilage complex should be performed if
the joint is locked and cannot be reduced, or if it is incongruous following
reduction. Open repair of the triangular
fibrocartilage complex is done with a
dorsal incision through the fifth compartment with the extensor digiti minimi reflected radially and the extensor
carpi ulnaris reflected ulnarly, thereby
exposing the triangular fibrocartilage
complex and visualizing the dorsal radi-

oulnar ligament. Nonabsorbable sutures should be used to reattach the

triangular fibrocartilage complex to
the ulnar styloid38.
Ulnar styloid fractures have an
important effect on the stability of the
triangular fibrocartilage complex. These
fractures commonly occur together with
fractures of the distal part of the radius
and can be a sign of instability of the triangular fibrocartilage complex. Symptomatic nonunions of the styloid can
occur. Hauck et al. classified these nonunions as type 1 when the distal radioulnar joint is stable and as type 2 when
it is unstable2. Type-1 fractures occur
through the tip of the styloid, and when
they become symptomatic they are often treated successfully with excision.
Type-2 fractures occur through the base
of the styloid, creating a much larger
fragment, and usually open reduction
and internal fixation and restoration of
the integrity of the triangular fibrocartilage complex is recommended even if
there is a nonunion.
The distal part of the ulna can dislocate or subluxate palmarly as a result of

a fall on a supinated hand or from exertional lifting in supination, with failure

of the dorsal radioulnar ligament being
the critical event. Clinically, patients
present with the forearm held in a supinated position. Pronation is painful and
restricted39. The ulnar head is palpable
volarly, and ulnar dysesthesias may develop from pressure on the ulnar nerve.
Once again, a diagnosis can be made on
the basis of good standard radiographs
(Figs. 4-A and 4-B) and can be confirmed by comparing computed tomography scans of the affected and normal
wrists. A fracture or erosion of the palmar lip of the sigmoid notch may lead
to persistent instability. An acute palmar dislocation can be reduced with
digital pressure on the distal part of the
ulna in a dorsal direction combined with
forceful pronation. The treatment for
an acute palmar dislocation is closed
reduction with immobilization for six
weeks in an above-the-elbow cast in a
neutral or slightly pronated position.
Open treatment is reserved for patients
for whom closed reduction has failed.
The approach is volar with careful re-

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traction of the volar neurovascular bundle in an ulnar direction.

Tears of the Triangular
Fibrocartilage Complex
Triangular fibrocartilage tears can occur
without causing instability of the distal
radioulnar joint. The most common
tear occurs within the articular disk
of the triangular fibrocartilage, near its
attachment to the radius, and is not associated with instability of the distal
radioulnar joint40-44. The tears themselves, however, can be unstable and
symptomatic. Despite the recognition
of specific types of triangular fibrocartilage lesions45, the exact mechanisms
of injury remain uncertain. Adams et
al., using a laboratory model to simulate distraction of the radius and ulna
through the distal radioulnar joint, postulated that such a distraction force may
result from a violent axial load on the
forearm40. This model did not, however, produce the types of tears of the
triangular fibrocartilage complex that
are seen clinically. Probably, a combination of compression across the wrist
trapping the disk in the ulnocarpal joint
with distraction or twisting of the distal

Fig. 5-A

DISTAL RADIOULNAR JOINT INSTABILIT Y

radioulnar joint then creates enough

shear forces to tear the disk.
Symptomatic instability and tears
of the triangular fibrocartilage complex
require surgical treatment. The peripheral rim of the triangular fibrocartilage
is well vascularized and has good healing potential. Repair of these lesions
with a variety of techniques can lead to
healing. Historically, open repair was
advocated38, but currently most peripheral tears can be treated arthroscopically. This arthroscopic approach
repairs only the superficial fibers of
the triangular fibrocartilage complex
to the joint capsule and not the deep
portion that inserts onto the fovea.
There is much less chance that central
tears of the triangular fibrocartilage
complex will heal because they are in
areas of hypovascularity or avascularity. Arthroscopic dbridement of these
lesions is recommended46.
Chronic Distal Radioulnar
Joint Instability
Dorsal, Palmar, or
Bidirectional Instability
Chronic distal radioulnar joint instability is a painful and often disabling con-

dition. Functional bracing, which has

been tested in a cadaveric model47, can
be used for patients who do not wish to
have surgery, but most patients prefer
surgical treatment. It is necessary to
check the osseous anatomy in patients
with chronic palmar dislocation. Many
patients have had a fracture of the wrist
or forearm, sometimes many years before symptoms developed at the distal
radioulnar joint. Bilateral radiographs
of the entire wrist and forearm, made
in the same position, should be compared. Osseous malalignment should
be corrected. The status of the triangular fibrocartilage complex is evaluated
with either magnetic resonance imaging
or arthroscopy. If the triangular fibrocartilage complex is not repairable, a
tendon reconstruction is needed and
should be tightened in supination48,49.
Illustrative Case Report

An eighteen-year-old, right-handdominant man presented with pain

in the left wrist and forearm that had
been increasing during the previous
two years. He had sustained a fracture
of the distal third of the left radius at
the age of twelve years and had been

Fig. 5-B

Posteroanterior (Fig. 5-A) and lateral (Fig. 5-B) radiographs made three years after plate fixation of a fracture of the distal part of the left radius in a
twelve-year-old boy. Note the apex volar angulation of the radius. The normal right side is shown for comparison.

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Fig. 6-B

Figs. 6-A through 6-D A twenty-eight-year-old man was seen with a Galeazzi-type fracture
with an entrapped extensor carpi ulnaris tendon preventing reduction of the ulnar styloid
that is attached to the triangular fibrocartilage complex. Note the disrupted distal radioulnar joint in addition to the fractures of the radius and distal part of the ulna. Fig. 6-A Posteroanterior radiograph showing the injury. Fig. 6-B Lateral radiograph showing the injury.

Fig. 6-A

treated nonoperatively. One month

later, he fell and sustained a refracture
of the radius as well as an ulnar styloid
fracture. The fracture of the radius was
treated with open reduction and internal fixation through a volar approach.
It healed without complication, and the
patient returned to full participation in
volleyball, weight-lifting, soccer, and
snowboarding.
Three years later, he noticed swelling about the wrist and had pain at the
distal part of the left ulna in association
with many activities. Volar angulation
of the radius could be seen on radiographs (Figs. 5-A and 5-B). The triangular fibrocartilage complex appeared
normal on the magnetic resonance imaging scan. The symptoms were attributed to malunion of the fracture and
angular overgrowth of the radius resulting in palmar subluxation of the distal
part of the ulna and instability of the distal radioulnar joint. The hardware was
removed, and a dome osteotomy of the

left radius with iliac crest bone-grafting

was done. A closing-wedge osteotomy
of the radius was not performed because
of the potential that it could further destabilize the distal radioulnar joint50.
Eight months after the surgery, the osteotomy site had healed and the patient
had regained the preoperative range of
wrist motion. The distal radioulnar joint
was stable on examination. He resumed
all of his previous activities, including
volleyball and weight-lifting, without
any symptoms in the left upper extremity, and he was discharged from our
clinic. He subsequently joined the Marine Corps and wrote to say that he had
remained asymptomatic throughout all
physical endeavors involved in his strenuous active training51.
Dorsal Subluxation and
Dislocations with Fractures
Galeazzi Fractures
A Galeazzi fracture is a diaphyseal fracture of the radius associated with a dis-

location of the radioulnar joint52. A

Galeazzi fracture has also been called
the fracture of necessity because nonoperative treatment so often yields a
poor result. The radioulnar joint may
be dislocated or subluxated, and it is
always affected (Figs. 6-A through 6-D).
Detection of the disorder of the distal
radioulnar joint in a patient with a radial shaft fracture requires a high level
of suspicion. Radiographs of the contralateral side may be helpful. Rettig
and Raskin found that twelve of twentytwo fractures of the distal third of the
radius (within 7.5 cm of the midarticular surface of the distal part of the radius)
were associated with intraoperative instability of the distal radioulnar joint,
whereas only one of eighteen fractures
in the middle third of the radial shaft
(>7.5 cm from the midarticular surface
of the distal part of the radius) was associated with intraoperative instability
of the distal radioulnar joint53. Open
reduction with internal fixation of the

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the radial head, and the secondary stabilizers are the interosseous ligament
and the triangular fibrocartilage. Diagnosing the wrist injury in this complex
is important. Treatment consists of
open reduction and internal fixation of
the radial head if possible, with immobilization of the forearm in supination.
Pinning of the distal radioulnar joint is
an option, but if the pins break they can
be difficult to retrieve. Comminuted radial head fractures often are not repairable and require replacement, usually
with a metallic prosthesis. Silicone radial head replacements have not performed well in this situation because
they fracture, causing particulate synovitis, when they are placed under load.
The operation is best done early as delayed treatment can lead to poorer results. The options for delayed surgery
include radial head replacement with
a prosthesis or allograft56, or a SauvKapandji procedure.

Fig. 6-C

Fig. 6-D

Fig. 6-C Posteroanterior radiograph made after initial fixation of the radial and ulnar
fractures. Note the widening of the distal radioulnar joint. Fig. 6-D Lateral radiograph
made after initial fixation of the radial and ulnar fractures. Note the dorsal displacement of the ulna. This problem occurred because the initial surgeon did not recognize
the interposition of the extensor carpi ulnaris tendon, which prevented the reduction
of the ulnar styloid/triangular fibrocartilage complex. Reoperation was performed,
and anatomical reduction and fixation was possible after the extensor carpi ulnaris
tendon was repositioned dorsally.

radial fracture is the first stage of treatment of a Galeazzi fracture. If the distal
radioulnar joint is stable, early motion
can be initiated. If it is unstable and reducible, the wrist should be immobilized in slight supination for four to six
weeks. If a sizable ulnar styloid fracture
is present, fixation may allow early mobilization and should be considered. If
the distal radioulnar joint is irreducible,
open reduction of the joint is necessary;
this usually requires repair of the triangular fibrocartilage or fixation of the
ulnar styloid fragment. Six weeks of immobilization in slight supination is recommended if the distal radioulnar joint
requires surgical treatment. Rarely, the

extensor carpi ulnaris is interposed

and prevents reduction; if it is, it needs
to be removed from the joint (Figs. 6-C
and 6-D)54.
Essex-Lopresti Injuries
Essex-Lopresti injuries, which are severe and disrupt the entire forearm55,
consist of a radial head fracture with
proximal migration of the radius. The
migration indicates complete disruption of the interosseous ligament and
the triangular fibrocartilage complex.
These injuries are usually caused by a
fall on the outstretched hand with axial
loading. The primary stabilizer preventing proximal migration of the radius is

Multidirectional Instability
The axis of forearm motion passes
through the fovea of the distal part of
the ulna. The deep fibers of the distal
radioulnar ligaments, the palmar radioulnar ligament, the triangular fibrocartilage, the ulnolunate ligament, the
ulnotriquetral ligament, and the ulnocapitate ligament all insert onto the fovea57. These ligamentous attachments
are key to the stability of the distal radioulnar joint. The distal radioulnar
joint can be stabilized surgically in one
of three ways: (1) a repair of the triangular fibrocartilage complex and the
distal radioulnar ligaments, (2) an
extrinsic soft-tissue reconstruction either with a direct link (i.e., a radioulnar
tether) or an indirect link (i.e., an ulnar
carpal sling tenodesis), or (3) a distal
radioulnar ligament reconstruction.
Procedures for Stabilization
of the Distal Radioulnar Joint
The first option for stabilizing the distal radioulnar joint is to repair the triangular fibrocartilage complex to the
fovea, from which it is usually found to
be ruptured. When repair is not possible, reconstruction is indicated. There
are several procedures for stabilization

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DISTAL RADIOULNAR JOINT INSTABILIT Y

Fig. 7

Dorsal and palmar ligament reconstruction, as described by Adams and Divelbiss48, for treatment of a chronically unstable distal radioulnar joint. (Reprinted from: Adams BD, Divelbiss BJ.
Reconstruction of the posttraumatic unstable distal radioulnar joint. Orthop Clin North Am.
2001;32:353-63; with permission from Elsevier.)

Fig. 8

This patient underwent open reduction and internal fixation to treat a fracture of the distal
part of the radius, but the dorsal subluxation
of the ulna was never corrected. Arthritic
changes developed in the distal radioulnar
joint, with pain and limitation of pronationsupination. This problem was treated with a
Sauv-Kapandji procedure.

of the distal radioulnar joint, as described

by Hui and Linscheid58, Tsai and Stilwell59, Breen and Jupiter60, Fulkerson
and Watson61, and Ellison, Boyes, and
Bunnell1, just to mention a few. The
above are all indirect stabilization procedures through an ulnocarpal sling or
tenodesis, or a direct radioulnar tether
extrinsic to the joint (the technique
described by Fulkerson and Watson).
Johnson described a dynamic muscle
transfer involving use of the pronator
quadratus11. Other distal radioulnar stabilization procedures involving reconstruction of the radioulnar ligaments
were described by Scheker et al.62, Sanders and Hawkins63, and Bowers64. We are
not aware of any long-term follow-up
study of an adequate series of patients
treated with such procedures. In a biomechanical cadaver model, reconstructions of the radioulnar ligaments were
found to be superior to radioulnar tethering procedures although the results
of capsular repair alone most closely
matched the kinematics of an intact
distal radioulnar joint65.
I recommend the procedure described by Adams et al. to reconstruct
the ligamentous anatomy (Fig. 7)48,49.
Their indications and criteria for ligament
reconstruction include unidirectional or
bidirectional chronic instability of the
distal radioulnar joint, absence of substantial arthritis, and a competent sigmoid notch rim with no residual axial
instability of the forearm. Any malunion
should be mild or corrected concurrently. Adams and Divelbiss cautioned
that, if the volar or dorsal lip of the sigmoid notch is incompetent (shallow),
ligament reconstruction may not be
sufficient and an opening-wedge osteotomy of the distal part of the radius
may be required48. The procedure is
done with use of a dorsal approach
through the fifth extensor compartment, which provides direct access to
the distal radioulnar joint. Typical findings are a triangular fibrocartilage complex that is torn from the ulna, a torn
extensor carpi ulnaris sheath, concomitant carpal ligament injuries, and perhaps an ulnar styloid fracture. Adams
and Berger reported that, of twenty patients (twelve with bidirectional insta-

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bility and eight with unidirectional

instability) followed for a minimum
of one year after the procedure, eighteen recovered stability, with an 80%
recovery of supination, 84% recovery
of pronation, and 88% recovery of grip
strength49.
Salvage
If there is residual instability after a
distal ulnar resection, a flexor carpi ulnaris and extensor carpi ulnaris tenodesis, as described by Breen and Jupiter60,66,
can be considered. Wolfe et al. reported
that the distal part of the ulna will remain stable even after removal of more
than a third of it67. This may be true after a tumor resection, but it is not a
reliable assumption after traumatic
injuries. Wide resections of the distal
part of the ulna usually require some
additional form of stabilization, and
tenodesis of the flexor carpi ulnaris and
extensor carpi ulnaris tendons is recommended. Implantation of a metallic
prosthesis to replace the distal part of
the ulna can also be considered as a salvage procedure for treatment of this difficult problem68. The Sauv-Kapandji
procedure is a useful salvage technique
when there is instability of the distal
part of the ulna and arthritic changes

DISTAL RADIOULNAR JOINT INSTABILIT Y

(Fig. 8). The Sauv-Kapandji procedure

involves fusion of the distal radioulnar
joint and creation of a pseudarthrosis of
the ulna just proximal to the arthrodesis
to allow forearm rotation69. There can
be subluxation of the proximal ulnar
stump, which can be symptomatic, after
a Sauv-Kapandji procedure, and this
can be stabilized with either an extensor
carpi ulnaris tenodesis, as described by
Minami et al.70, or a flexor carpi ulnaris
tenodesis, as described by Lamey and
Fernandez71.
Overview
Acute dislocations of the distal radioulnar joint should be reduced promptly
and treated with cast immobilization.
If the dislocation is irreducible, open
reduction is warranted. The first attempts to treat chronic instability
should be directed at repairing the triangular fibrocartilage complex, but
only after careful assessment for any
osseous malunions along the forearm
axis, which must also be corrected. If it
is not possible to repair the triangular
fibrocartilage complex, the osseous architecture is normal, and no arthritis is
present, a ligament reconstruction can
be considered, but the competency of
the sigmoid notch must be evaluated

carefully. If there are arthritic changes

at the distal radioulnar joint, a SauvKapandji procedure should be performed,
with stabilization of the proximal stump
with a slip of either the flexor carpi ulnaris or the extensor carpi ulnaris.

Robert M. Szabo, MD, MPH

Department of Orthopaedic Surgery, University of California, Davis, School of Medicine,
4860 Y Street, Sacramento, CA 95817. E-mail
address: rmszabo@ucdavis.edu
The author did not receive grants or outside
funding in support of his research for or preparation of this manuscript. He did not receive
payments or other benefits or a commitment
or agreement to provide such benefits from a
commercial entity. No commercial entity paid
or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or
nonprofit organization with which the author
is affiliated or associated.
Printed with permission of the American
Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the
Academys Annual Meeting, will be available in
February 2007 in Instructional Course Lectures,
Volume 56. The complete volume can be ordered online at www.aaos.org, or by calling
800-626-6726 (8 A.M.-5 P.M., Central time).

References
1. Bowers WH. The distal radioulnar joint. In: Green
DP, editor. Operative hand surgery. Volume 1. 3rd ed.
New York: Churchill Livingstone; 1993. p 973-1019.
2. Hauck RM, Skahen J 3rd, Palmer AK. Classification and treatment of ulnar styloid nonunion. J Hand
Surg [Am]. 1996;21:418-22.
3. Heiple KG, Freehafer AA, Vant Hof A. Isolated
traumatic dislocation of the distal end of the ulna or
distal radio-ulnar joint. J Bone Joint Surg Am.
1962;44:1387-94.
4. Linscheid RL. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1992;275:46-55.
5. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wristanatomy and function.
J Hand Surg [Am]. 1981;6:153-62.
6. Palmer AK, Linscheid RL, Fisk GR, Taleisnik J.
Symposium: distal ulnar injuries. Contemp Orthop.
1983;7:81-118.
7. Pirela-Cruz MA, Goll SR, Klug M, Windler D.
Stress computed tomography analysis of the distal radioulnar joint: a diagnostic tool for determining translational motion. J Hand Surg [Am]. 1991;
16:75-82.
8. Gofton WT, Gordon KD, Dunning CE, Johnson JA,
King GJ. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. J Hand Surg
[Am]. 2004;29:423-31.

9. Kihara H, Short WH, Werner FW, Fortino MD,

Palmer AK. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg [Am]. 1995;20:930-6.

17. Kleinman WB, Graham TJ. The distal radioulnar

joint capsule: clinical anatomy and role in posttraumatic limitation of forearm rotation. J Hand Surg
[Am]. 1998;23:588-99.

10. Stuart PR. Pronator quadratus revisited. J Hand

Surg [Br]. 1996;21:714-22.

18. Kauer JM. The articular disc of the hand. Acta

Anat (Basel). 1975;93:590-605.

11. Johnson RK. Stabilization of the distal ulna by

transfer of the pronator quadratus origin. Clin Orthop Relat Res. 1992;275:130-2.

19. Schuind F, An KN, Berglund L, Rey R, Cooney WP

3rd, Linscheid RL, Chao EY. The distal radioulnar ligaments: a biomechanical study. J Hand Surg [Am].
1991;16:1106-14.

12. Johnson RK, Shrewsbury MM. The pronator

quadratus in motions and in stabilization of the radius and ulna at the distal radioulnar joint. J Hand
Surg [Am]. 1976;1:205-9.

20. Ekenstam F. Osseous anatomy and articular

relationships about the distal ulna. Hand Clin.
1998;14:161-4.

13. Spinner M, Kaplan EB. Extensor carpi ulnaris.

Its relationship to stability of the distal radio-ulnar
joint. Clin Orthop Relat Res. 1970;68:124-9.

21. Adams BD, Holley KA. Strains in the articular disk

of the triangular fibrocartilage complex: a biomechanical study. J Hand Surg [Am]. 1993;18:919-25.

14. Ward LD, Ambrose CG, Masson MV, Levaro F. The

role of the distal radioulnar ligaments, interosseous
membrane, and joint capsule in distal radioulnar joint
stability. J Hand Surg [Am]. 2000;25:341-51.

22. Kihara H, Palmer AK, Werner FW, Short WH, Fortino MD. The effect of dorsally angulated distal radius
fractures on distal radioulnar joint congruency and
forearm rotation. J Hand Surg [Am]. 1996;21:40-7.

15. Watanabe H, Berger RA, An KN, Berglund LJ, Zobitz ME. Stability of the distal radioulnar joint contributed by the joint capsule. J Hand Surg [Am].
2004;29:1114-20.

23. Lester B, Halbrecht J, Levy IM, Gaudinez R.

Press test for office diagnosis of triangular fibrocartilage complex tears of the wrist. Ann Plast Surg.
1995;35:41-5.

16. Marangoz S, Leblebicioglu G. Stability of the distal radioulnar joint contributed by the joint capsule. J
Hand Surg [Am]. 2005;30:868-9.

24. Epner RA, Bowers WH, Guilford WB. Ulna variancethe effect of wrist positioning and roentgen
filming technique. J Hand Surg [Am]. 1982;7:298-305.

894
THE JOUR NAL OF BONE & JOINT SURGER Y JBJS.ORG
VO L U M E 88-A N U M B E R 4 A P R I L 2006

25. Mino DE, Palmer AK, Levinsohn EM. The role of

radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal
radioulnar joint. J Hand Surg [Am]. 1983;8:23-31.
26. Mino DE, Palmer AK, Levinsohn EM. Radiography
and computerized tomography in the diagnosis of incongruity of the distal radio-ulnar joint. A prospective
study. J Bone Joint Surg Am. 1985;67:247-52.
27. Wechsler RJ, Wehbe MA, Rifkin MD, Edeiken J,
Branch HM. Computed tomography diagnosis of distal
radioulnar subluxation. Skeletal Radiol. 1987;16:1-5.
28. Lo IK, MacDermid JC, Bennett JD, Bogoch E,
King GJ. The radioulnar ratio: a new method of quantifying distal radioulnar joint subluxation. J Hand
Surg [Am]. 2001;26:236-43.
29. Steinbach LS, Smith DK. MRI of the wrist. Clin
Imaging. 2000;24:298-322.
30. Potter HG, Asnis-Ernberg L, Weiland AJ, Hotchkiss RN, Peterson MG, McCormack RR Jr. The utility
of high-resolution magnetic resonance imaging in the
evaluation of the triangular fibrocartilage complex of
the wrist. J Bone Joint Surg Am. 1997;79:1675-84.
31. Kocharian A, Adkins MC, Amrami KK, McGee KP,
Rouleau PA, Wenger DE, Ehman RL, Felmlee JP.
Wrist: improved MR imaging with optimized transmitreceive coil design. Radiology. 2002;223:870-6.
32. Yoshioka H, Ueno T, Tanaka T, Shindo M, Itai Y.
High-resolution MR imaging of triangular fibrocartilage complex (TFCC): comparison of microscopy
coils and a conventional small surface coil. Skeletal
Radiol. 2003;32:575-81.
33. Burk DL Jr, Karasick D, Wechsler RJ. Imaging of
the distal radioulnar joint. Hand Clin. 1991;7:263-75.
34. Cone RO, Szabo R, Resnick D, Gelberman R, Taleisnik J, Gilula LA. Computed tomography of the normal radioulnar joints. Invest Radiol. 1983;18:541-5.
35. King GJ, McMurtry RY, Rubenstein JD, Ogston
NG. Computerized tomography of the distal radioulnar joint: correlation with ligamentous pathology in a
cadaveric model. J Hand Surg [Am]. 1986;11:711-7.
36. Linscheid RL. Disorders of the distal radioulnar
joint. In: Cooney WP, Dobyns JH, Linscheid RL, editors. The wrist: diagnosis and operative treatment.
St. Louis: Mosby; 1998. p 829.
37. Garcia-Elias M, Dobyns JH. Dorsal and palmar
dislocations of the distal radioulnar joint. In: Cooney
WP, Dobyns JH, Linscheid RL, editors. The wrist: diagnosis and operative treatment. St. Louis: Mosby;
1998. p 768.
38. Hermansdorfer JD, Kleinman WB. Management
of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg [Am]. 1991;16:340-6.
39. Singletary EM. Volar dislocation of the distal radioulnar joint. Ann Emerg Med. 1994;23:881-3.
40. Adams BD, Samani JE, Holley KA. Triangular fibrocartilage injury: a laboratory model. J Hand Surg
[Am]. 1996;21:189-93.

DISTAL RADIOULNAR JOINT INSTABILIT Y

41. Adams BD. Partial excision of the triangular fibrocartilage complex articular disk: a biomechanical
study. J Hand Surg [Am]. 1993;18:334-40.
42. Chidgey LK, Dell PC, Bittar ES, Spanier SS.
Histologic anatomy of the triangular fibrocartilage.
J Hand Surg [Am]. 1991;16:1084-100.
43. Osterman AL. Arthroscopic debridement of triangular fibrocartilage complex tears. Arthroscopy.
1990;6:120-4.
44. Reinus WR, Hardy DC, Totty WG, Gilula LA.
Arthrographic evaluation of the carpal triangular
fibrocartilage complex. J Hand Surg [Am]. 1987;
12:495-503.
45. Palmer AK. Triangular fibrocartilage complex
lesions: a classification. J Hand Surg [Am]. 1989;
14:594-606.
46. Minami A, Ishikawa J, Suenaga N, Kasashima T.
Clinical results of treatment of triangular fibrocartilage complex tears by arthroscopic debridement. J
Hand Surg [Am]. 1996;21:406-11.
47. Millard GM, Budoff JE, Paravic V, Noble PC.
Functional bracing for distal radioulnar joint instability. J Hand Surg [Am]. 2002;27:972-7.
48. Adams BD, Divelbiss BJ. Reconstruction of the
posttraumatic unstable distal radioulnar joint. Orthop Clin North Am. 2001;32:353-63, x.
49. Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg
[Am]. 2002;27:243-51.
50. Nishiwaki M, Nakamura T, Nakao Y, Nagura T,
Toyama Y. Ulnar shortening effect on distal radioulnar joint stability: a biomechanical study. J Hand
Surg [Am]. 2005;30:719-26.
51. Williams AA, Szabo RM. Case report: radial
overgrowth and deformity after metaphyseal fracture fixation in a child. Clin Orthop Relat Res.
2005;435:258-62.
52. Galeazzi R. ber ein besonderes syndrom bei
verletzungen im bereich der unterarmknochen. Arch
Orthop Unfallchir. 1935;35:557-62.
53. Rettig ME, Raskin KB. Galeazzi fracturedislocation: a new treatment-oriented classification. J Hand Surg [Am]. 2001;26:228-35.
54. Alexander AH, Lichtman DM. Irreducible
distal radioulnar joint occurring in a Galeazzi
fracturecase report. J Hand Surg [Am]. 1981;
6:258-61.

57. Nakamura T, Takayama S, Horiuchi Y, Yabe Y.

Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg
[Br]. 2001;26:446-54.
58. Hui FC, Linscheid RL. Ulnotriquetral augmentation tenodesis: a reconstructive procedure for dorsal subluxation of the distal radioulnar joint. J Hand
Surg [Am]. 1982;7:230-6.
59. Tsai TM, Stilwell JH. Repair of chronic subluxation of the distal radioulnar joint (ulnar dorsal) using flexor carpi ulnaris tendon. J Hand Surg [Br].
1984;9:289-94.
60. Breen TF, Jupiter JB. Extensor carpi ulnaris and
flexor carpi ulnaris tenodesis of the unstable distal
ulna. J Hand Surg [Am]. 1989;14:612-7.
61. Fulkerson JP, Watson HK. Congenital anterior
subluxation of the distal ulna. A case report. Clin
Orthop Relat Res. 1978;131:179-82.
62. Scheker LR, Belliappa PP, Acosta R, German DS.
Reconstruction of the dorsal ligament of the triangular fibrocartilage complex. J Hand Surg [Br].
1994;19:310-8.
63. Sanders RA, Hawkins B. Reconstruction
of the distal radioulnar joint for chronic volar
dislocation. A case report. Orthopedics. 1989;
12:1473-6.
64. Bowers WH. Distal radioulnar joint arthroplasty.
Current concepts. Clin Orthop Relat Res. 1992;
275:104-9.
65. Gofton WT, Gordon KD, Dunning CE, Johnson
JA, King GJ. Comparison of distal radioulnar joint reconstructions using an active joint motion simulator.
J Hand Surg [Am]. 2005;30:733-42.
66. Breen TF, Jupiter J. Tenodesis of the chronically unstable distal ulna. Hand Clin. 1991;
7:355-63.
67. Wolfe SW, Mih AD, Hotchkiss RN, Culp RW,
Keifhaber TR, Nagle DJ. Wide excision of the distal
ulna: a multicenter case study. J Hand Surg [Am].
1998;23:222-8.
68. Masaoka S, Longsworth SH, Werner FW, Short
WH, Green JK. Biomechanical analysis of two ulnar head prostheses. J Hand Surg [Am]. 2002;
27:845-53.
69. Sauv L, Kapandji M. Nouvelle technique de
traitement chirurgical des luxations rcidivantes
isoles de lextrmit infrieure du cubitus. J Chir.
1936;47:589-94.

55. Essex-Lopresti P. Fractures of the radial head

with distal radio-ulnar dislocation; report of two
cases. J Bone Joint Surg Br. 1951;33:244-7.

70. Minami A, Suzuki K, Suenaga N, Ishikawa J.

The Sauv-Kapandji procedure for osteoarthritis
of the distal radioulnar joint. J Hand Surg [Am].
1995;20:602-8.

56. Szabo RM, Hotchkiss RN, Slater RR Jr. The use

of frozen-allograft radial head replacement for treatment of established symptomatic proximal translation of the radius: preliminary experience in five
cases. J Hand Surg [Am]. 1997;22:269-78. Erratum in: J Hand Surg [Am]. 1997;22:765.

71. Lamey DM, Fernandez DL. Results of the

modified Sauv-Kapandji procedure in the treatment of chronic posttraumatic derangement of
the distal radioulnar joint. J Bone Joint Surg Am.
1998;80:1758-69.