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A Black Box
Anatomy and Dysfunction of the DRUJ and TFCC
Input Output

Diane Coker, PT, DPT, CHT South County Hand Center Laguna Woods, CA dacoker@cox.net

Outline
Osteology Soft Tissue Stability Joint biomechanics Articulations Arthrokinematics Extrinsic support Pathology Intrinsic support Traumatic Degenerative

Bony Architecture

TFCC Anatomy

Diagnostic imaging

DRUJ

The Distal Pole of the Ulna

Radius

The Sigmoid Notch

Ulna Seat Hyaline cartilage

TFCC

FOVEA

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The Sigmoid Notch

An Inherently Unstable Joint

Articular Contact

42%

14%

30%

14% Tolat 1996

At extremes of pronation & supination, there may be as little as 2mm, or < 10%, articular contact between radius & ulna

Soft Tissue Stabilizers

Extrinsic Stabilizers of the DRUJ

1: Tendon of ECU
2: Sixth dorsal

compartment subsheath
3: Pronator quadratus 4: Interosseous ligament

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ECU only motor unit w/ a

Contributions of the ECU

Pronator Quadratus
Some texts describe a 2-

relationship to the TFCC

Tendon sheath blends with TFCC

headed composition
Medial & anterior surface

ECU held close to center of

of ulna
Lateral & anterior surface

rotation of wrist by the TFCC

TFCC is an important pulley for

of radius
Only muscle that attaches

the ECU
Disruption of the ECU may

contribute to abnormal loading & force transmission through TFCC

to radius at one end & ulna at the other Activation of PQ may contribute to ulnar impingement syndrome
Gordon 2003

The Interosseous Membrane

Combination of ligaments and

The Dorsal Oblique Bundle

Distal 3 ligaments in

membranes
3 portions: proximal, middle,

distal
Distal 3 ligaments in constant

constant tension during f/a rotation Dorsal oblique bundle (DOB) has continuity with fibers of TFCC
DOB present in 40%

tension during f/a rotation

Central band (CB) widest,

population
Possible secondary

stoutest

stabilizer of the DRUJ

Intrinsic Stabilizers of the DRUJ

Joint capsule Ligamentous attachments include
Volar ulnolunate Ulnotriquetral DOB

Triangular Fibrocartilage Complex

Palmar and Werner

introduced term TFCC 1981

Structures include
Articular disc Meniscus homologue Prestyloid recess Dorsal & volar radioulnar

ligaments

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Cross Section View

Coronal View

Vascularity
Anterior interosseous &

Intrinsic Stabilizers of the DRUJ

ulnar arteries
Central disc relatively

avascular
Peripheral 15-20% well

vascularized, will heal

Innervation
Volar, ulnar portions: ulnar N
Dorsal portion: PIN, dorsal

Attachments
Originates from medial

border of distal radius

Inserts into base of ulnar

sensory branch Central disc relatively aneural

styloid (fovea)

Axis of Rotation of the Forearm Joint Biomechanics

Radial head Fovea

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Ulnar Variance Affected by Forearm Rotation

Ulnar Variance

Functions of the TFCC

Provides a continuous gliding surface across the entire distal

A Controversy
Ekenstam/Hagert,1985: dorsal radioulnar fibers tighten in

face of the 2 forearm bones for flexion-extension and translational movements Provides a flexible mechanism for stable rotational movements of the radiocarpal unit around the ulnar axis Suspends the ulnar carpus from the dorsal ulnar face of the radius Cushions the forces transmitted through the ulnocarpal axis Solidly connects the ulnar axis to the volar carpus

supination, palmar fibers tighten in pronation

Schuind,1991: dorsal fibers tighten in pronation, palmar

fibers tighten in supination

Hagert 1994: both theories are correct

pronation

neutral

supination

Superficial and Deep Fibers

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Deep Fibers Have the Mechanical Advantage

A Buckboard analogy

Ulnar Head Translation

Pronation
Sigmoid notch migrates

Supination
Sigmoid notch migrates

The Controversy continues.

Xu et al, (2009)
Validates conclusions of other

volarly to <10% articular contact Superficial dorsal fibers ineffective in pronation Deep palmar ligamentum subcruentum tightens

dorsally to <10% articular contact Superficial palmar fibers ineffective in supination Deep dorsal ligamentum subcruentum tightens

The deep RUL are considered more important to the stability of the DRUJ than the superficial ligaments

studies that dorsal superficial and palmar deep ligaments tighten during pronation, and vice versa However, all 4 ligaments are important stabilizers, playing different roles during the arc of forearm rotation To maintain an entirely stable DRUJ, integrity of all 4 ligaments likely required

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Pathology Affecting the DRUJ & TFCC Pathology

Anatomical variations Congenital ulnar + Acute trauma
Fractures
Distal radius Ulnar styloid Radial shaft Radial metaphysis

Chronic overuse
ECU tendonitis FCU tendonitis

Ligament

Degeneration Arthritis Malunion of radius Madelungs deformity Growth disturbance

disruptions/dislocations
Lunatotriquetral DRUJ

Ulnar Variance

Dynamic Ulnar Variance

26%

51%

23%

Abnormal Ulnar Variance = Abnormal WB Distribution

Ulnar Impaction Syndrome

80%

20%

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Ulnar Styloid Length

Trauma: Colles Fracture

Abraham Colles, MD, 1814 Nonarticular metaphyseal

Galeazzi Fracture

fracture with dorsal tilt

LOOSH (land on an

outstretched hand)

Fracture of radial shaft, dislocation of distal ulna

Monteggia Fracture
Ulnar shaft fracture, dislocation of proximal radius

Essex Lopresti Fracture

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Palmer Classification of TFCC Abnormalities

Class 1A

Traumatic Lesions

Most common traumatic

tear
Dorsal palmar tear 1-2mm

to radial origin of TFCC

Minimal healing potential

2 poor vascularity

Palmar 1989

Traumatic Lesions
Class 1B
Traumatic avulsion of the

Traumatic Lesions
Class 1C
TFCC avulsed distally from its

TFCC from its insertion into the distal ulna. May or may not be associated with an ulnar styloid fracture Includes peripheral tears in the vascular zone

bony insertion to lunate by the ulnohamate ligament &/or triquetrum by the ulnotriquetral ligament
Rare, high energy injury

Results in ulnocarpal instability &

palmar translocation of ulnar carpus Well-vascularized, better healing potential

Traumatic Lesions
Class 1D
Avulsion of TFCC from its

Degenerative Lesions
Nontraumatic lesions have been

noted in fetuses
Seldom in 1st 2 decades No normal appearance of TFCC

radial origin Seen with or without sigmoid notch fracture

by 6th decade Mikic 1978

Degeneration linked to + ulnar

variance
Degeneration s w/ rotational

and loading activities

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Degenerative Lesions
Class 2A
Both proximal and distal

Degenerative Lesions
Class 2B
Both proximal & distal

aspect show degenerative changes

aspects show degenerative changes Cartilage erosion of ulnar head beneath TFCC or medial border of lunate distal to TFCC

Degenerative Lesions
Class 2C
Large central perforation

Degenerative Lesions
Class 2D
Through and through

of the TFCC
Underlying cartilage

abnormality of the ulnar head, medial aspect of lunate

perforation of horizontal portion of TFCC Cartilage abnormalities of ulnar head, medial border of lunate Disruption of lunatotriquetral ligament

Diagnostic Imaging
Plain films
Abnormal ulnar variance Loss of radial tilt Joint widening Sclerosis

MRI Arthrography
A specialized technique Contrast dye leaking into

Dynamic stress or grip

DRUJ (white arrow), indicating a tear of the TFCC

view

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Diagnostic Arthroscopy Medical Management

Sensitive for identifying acute

tears or degeneration in the central portion of the disc, chondromalacia, and ulnocarpal ligament injuries. More sensitive and accurate than non-invasive imaging modalities

Linda de Haas PT, MPT, OCS, CHT Whittier, CA lldehaas@msn.com

Diagnostic Arthroscopy
Standard portals are mostly

Trampoline Test
Loss of the TFC

dorsal. Relative lack of neurovascular structures on the dorsum of the wrist Dorsal portals are named in relation to the extensor compartments

trampoline effect during arthroscopic ballotment with a probe strongly suggests a destabilizing injury to the periphery of the TFCC.

Arthroscopic Procedures
TFCC repairs Ganglionectomy Synovectomy Chondroplasty and loose Arthroscopic assisted internal

Surgical Procedures for Ulnar Impaction and DRUJ Instability

fixation: scaphoid
Arthroscopic assisted fixation:

distal radius
Radial styloidectomy
Proximal pole of hamate

bodies Avascular necrosis Dorsal radiocarpal ligament repair Arthroscopic release of wrist contracture

resection
Ulnocarpal impaction Capsular shrinkage

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Darrach Procedure
Excision of the distal ulna through its

Wafer Osteotomy
The distal 2-4 mm of the

neck

Ulnar styloid and soft tissue

attachments retained to preserve some TFCC function stabilization with FCU and/or ECU

Often combined with a soft tissue

distal ulna is resected while preserving the distal radioulnar joint and the styloid process of the ulna and the ligaments attached to it

Hemiresection With Tendon Interposition

Resects DRUJ at sigmoid

Ligament Reconstruction

notch
Portion of ulna retained

to maintain TFCC
Portion of tissue

interposed to prevent impingement between radius and ulna.

Tendon graft passed through the bone tunnel parallel to the

sigmoid notch and reinserted into the fovea. The capsule is then closed.

Suave-Kapandji Procedure
Retains the distal ulna

Ulna Styloid Fixation

Fuses the ulnar head to the

sigmoid notch

Creates a pseudoarthrosis

at the ulnar neck.

Preserves TFCC and ECU

tendon

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Ulnar Hemiarthroplasty

Physical Therapy Management

Evaluation
Inspection
Patients posture and carriage of affected UE Swelling, erythema, scars, nodules, masses

Range of Motion
Active and Passive ROM

Palpation
Bones and soft tissues

Provocative Tests

General Inspection
Inspect for swelling about the DRUJ, ECU sheath and carpus

TFCC Diagnosis:
Classic symptoms are ulnar sided wrist pain that is associated with

popping or clicking
ECU subluxation is most apparent with the forearm and wrist in

supination and ulnar deviation. The tendon subluxates ulnarly.

Palpable tenderness over the TFCC Combined ulnar deviation and pronation/supination will produce

Pain and crepitus with compression of the pisiform against the

triquetrum suggest pisotriquetral arthritis.

popping or clicking and reproduce the patients pain

Press Test in which the patient is asked to lift himself out of a chair

Reduced grip strength strongly suggests intraarticular pathology.

bearing weight on extended wrists has been shown to have 100% sensitivity for detecting tears

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Provocative Maneuvers

Distal Radio-Ulnar Joint

Ulnar Fovea Sign

The fovea lies between

The Ulnar Fovea Sign

The elbow is in 90 to 110 of flexion, forearm in neutral rotation and wrist in neutral position.

The ulnar styloid (US) process Flexor carpi ulnaris (FCU) tendon

The examiners thumb tip is then pressed distally and deep into the interval soft spot

Distally it is bounded by the Pisiform (P) bone Proximally by the volar surface of the ulnar head.

The ulnar fovea sign is positive when there is exquisite tenderness compared with the contralateral side.

95.2% sensitive 86.5% specific

Dorsal Ulnar Zone

L-T Instabilities

L-T Instability Tests

TFCC Load Test
Ulnar deviation Axial Load Rotation

TFCC Stress Test Ballottement Test Lunotriquetral shear test Shuck Triquetrum squeeze test

ECU subluxation ECU Synergy Test Piano KeyTest

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L-T Instability Tests

Ballottement Test
Stabilize Lunate bone between

L-T Instability Tests

Lunotriquetral Shear test
Grasp the Pisiform and Triquetrum The contralateral thumb and index finger

thumb and index finger of one hand The other hand moves pisotriquetral complex in a volar and dorsal direction.
Sensitivity .69 Specificity .44

hold the Lunate and radial carpus.

Move the Triquetrum while the lunate and

radial wrist remain stationary.

The force is transmitted across the

lunotriquetral joint.
Sensitivity .66 Specificity .44

Reagan Shuck Test

Grasp the whole piso-triquetral unit. The contralateral thumb and index finger

L-T Instability Tests

Linscheid Compression Test
Squeeze Test

hold the lunate. Apply a dorsally directed force with one hand and volarly directed force with the other hand. This force is switched in the opposite directions in both hands. This creates a shear stress at the lunotriquetral joint, and if painful, the result is positive.

Ulnar border of the Triquetrum Push in radial direction Compression force across the

lunotriquetral joint.

ECU Subluxation
Supination Ulnar deviation Wrist flexion

The ECU Synergy Test

ECU Tendinitis This test is performed by having the

patient radially deviate the thumb against resistance. Note that the ECU tendon bowstrings against the skin (large arrow).
Robert T. Ruland, MD, Christopher J. Hogan, JHS Vol 33A, December 2008

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Piano Key Test

Patients hand pronated on

Ulnar Compression Test

Compress the ulnar head

the table. Ballottement of the ulna is performed by the examiner applying a dorsal-to-volar load with his or her hand 4 cm proximal to the distal radioulnar joint.
Sensitivity .59 Specificity .96

against the sigmoid notch.

A positive result is

exacerbation of pain, which suggests arthritis or instability. In addition, with ulnar compression, dorsal or volar subluxation may be noted.

Volar Ulnar Zone

Flexor carpi ulnaris (FCU)

Pisiform Shear Test

Pisotriquetral arthritis Pisiform instability

tendinitis Pisiform Hook of Hamate Guyons canal

Hook of Hamate

Guyons Canal

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GRIT Test Gripping Rotatory Impaction Test

Quantifiable measurement Expressed as a ratio:

Therapeutic Management
Wound care Edema reduction Protective splinting

Supination strength Pronation strength

1.0 is normal, > 1.0

predicts ulnar impaction problems

Around hardware Immobilize joints To increase joint mobility

Therapeutic Management
Maintain/improve ROM finger motion Uninvolved Joints Composite flexor or extensor

During rehab, isolate the actions of wrist extensors from finger

extensors
Limits cheating with finger extensors

tightness

Joint mobilization? Grades I & II for pain Grades III & IV to increase ROM Goal = maximum pain-free wrist &

forearm AROM

Consider supinated position to start grip strengthening exercises in those with ulnar impaction syndrome.

Nonoperative Versus Operative Management

Initial treatment begins with activity modifications, splinting,

and anti-inflammatory medications.

Failure to respond to non-operative treatment is an

indication for surgery.

Goals for surgery is to decrease the loading across the ulnar

side of the wrist.

Rehab of the Hand pg. 1162

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Corrective Splinting Prefabricated - TFCC

Universal Wristlet Wrist Widget

Corrective Splinting Custom - TFCC

Corrective Splinting Custom - TFCC

Pre-Cut Long Arm Splints

Custom bivalve Thermoplastic Orthosis

Custom Muenster Thermoplastic Orthosis

Corrective Splinting Custom Pronation/Supination

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Corrective Splinting Prefabricated Pronation/Supination Splints

Research on Dynamic Splinting

Average forearm rotation in all 15 patients was 83before and 126 after DFRS, an increase of 52%. Dynamic forearm rotational splinting produced significant increases in both pronation (p.05) and supination (p.05). The Journal of Hand Surgery, 27A(3).

Corrective Splinting
Splints to Increase Flexion/Extension
JAS Custom

Rehabilitation Guidelines
Note: The following guidelines arise from the Indiana Hand Therapy

Protocol. Please refer to this publication for additional information.

Dynasplint

Conservative Management of TFCC Injuries

0-6 weeks

Phase I for Central Debridement:

Days 3-5
Goals: Control edema and pain Protect repair Minimize deconditioning Intervention:
Bulky compressive dressing is removed Edema control begun with light compressive dressing to hand and

Splinting in a long arm cast or splint with the elbow in 90 flexion and the forearm neutral for 0-6 weeks to reduce the symptoms 6 weeks Active and active-assistive ROM exercises are initiated to the wrist and forearm 6 times a day for 10 minute sessions. A wrist immobilization splint is fabricated for comfort and protection. 8 weeks If patient is asymptomatic, progressive strengthening to the hand and wrist, avoiding a torsion load at the wrist.
If the patients symptoms are not alleviated in 4-6 weeks surgical

forearm

Active ROM exercises for wrist and forearm are begun 6-8 times a day

for 10 minute sessions. comfort

A wrist splint is fabricated to wear between exercises and at night for

repair or debridement is suggested.

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Phase II for Central Debridement:

Days 10-14
Goals: Control edema and pain Continue to protect repair Continue to minimize deconditioning Begin scar management Intervention:
Scar management begun within 48 hours of suture removal Initiation of active-assistive ROM for wrist and forearm

Phase III for Central Debridement:

Weeks 3-4
Goals: Control edema and pain Improve ROM Intervention:
Passive ROM of wrist and forearm may be initiated Dynamic wrist splinting may be initiated to improve ROM Weighted wrist stretches may be initiated to increase ROM

Phase IV for Central Debridement:

Week 6
Goals: Continue with ROM gains Begin strengthening Intervention:
Progressive strengthening may be initiated if patient is pain free. This may

Considerations
It is important to keep in mind that the goal of therapy is to

eliminate pain.
Aggressive PROM which increases pain is not appropriate. In patients with positive ulnar variance additional surgical

include using putty or a hand exerciser and progressing to hand weights.

The wrist immobilization splint may be discontinued if the patient is

procedures may be required and this will change the post op therapy. These may include a wafer resection or ulnar shortening to decrease the variance

asymptomatic.

Phase II for Peripheral Repair: Phase I for Peripheral Repair:

Week 1
Goals: Edema control Protect repair Intervention:
Patient remains in bulky post-op dressing Instructions in edema control

Week 2
Goals: Edema and pain control Continue to protect repair Limit deconditioning Intervention: Removal of bulky dressing Edema control with retrograde massage, Isotoner glove, and/or Coban wrapping Daily pin care as needed Long arm cast with 90 elbow flexion and wrist in neutral or wrist cock-up splint fabricated Active and passive ROM for wrist and digits, include tendon glides (lumbrical grip, hook fist, full fist) Isometric exercises for forearm/hand: 10 repetitions 4 times/day Low-grade isotonic exercises can be initiated (i.e., lightest putty) Light ADLs with 5 pound limit

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Phase III for Peripheral Repair:

Weeks 3-6
Goals: Edema and pain control Increase ROM Scar management Improve strength Intervention:
Scar management with scar massage, scar pad Discontinue splint (unless patient is still symptomatic) Increase isotonic exercises up to 10 pounds maximum for upper arm, forearm Wrist mobility/weighted stretches with less than 5 pounds 3-4 times/day for

Phase IV for Peripheral Repair:

Weeks 8 - Discharge
Goals: Continue to improve ROM Continue to increase strength Simulate work requirements
Intervention: Dynamic splinting as necessary to increase ROM Progress strengthening with putty, hand exerciser, free weights Simulate work tasks as able

20 minutes
ADLs with less than 10 pounds

References
Greens

References
Operative Orthopedics, on line edition: www.greenshandsurgery,com, 2009, Retrieved 12-28-2009. Gordon, Karen, Dunning, Cynthia, Johnson, James, King, Graham, 2003. Influence of the Pronator Quadratus and Supinator Muscle Load on DRUJ Stability Journal of Hand Surgery28A:6, 943-950 Ishii S, Palmer A, Werner F, Short W Fortino M. 1998. An Anatomic , study of the Triangular Fibrocartilage Complex Journal of Hand Surgery 23A:6, 977-985. Jaffe R, Chidley L, LaStayo P, 1996: The Distal Radioulnar Joint: Anatomy and Management of Disorders Journal of Hand Therapy, AprilJune:129-138. Kleinman W 2007: Stability of the Distal Radioulnar Joint: . Biomechanics, Pathophysiology, Physical Diagnosis, and Restoration of Function. What We Have Learned in 25 Years. The Journal of Hand Surgery, 32A:7.1086-1106.

Adams BD, Berger RA: An Anatomic Reconstruction of the Distal

Radioulnar Ligaments for Posttraumatic Distal Radioulnar Joint Instability. The Journal of Hand Surgery, 27A:2,243-251. Cannon NM (ed.): Diagnosis and Treatment Manual for Physicians and Therapists: upper extremity rehabilitation 4th ed. The Hand Rehabilitation Center of Indiana. Indianapolis. 2001:163-165. Chidgey, J 1995. The Distal Radioulnar Joint: Problems and Solutions J Am Acad Orthop Surgery 3:2, 95-109. Dodds, S,Yeh, P, Slade, J 2008. Essex-Lopresti Injuries Hand Clinics 24: 125-137 Garcia-Elias M 1998. Soft Tissue Anatomy and Relationships about the Distal Ulna. Journal of Hand Surgery 14:2, 165-176.

References
LaStayo P, Weiss, S. 2001: The GRIT: A Quantitative Measure of Ulnar Impaction Syndrome. Journal of Hand Therapy, 14:173-179. Mackin E, Callahan A, Hunter J. Rehabilitation of the hand and upper extremity. St Louis, Mosby, 2002 Monasterio M, Brou K.E. Modified Anti-Pronation DRUJ Instability Splint. Journal of Hand Therapy Oct-Dec 2007. Moritomo H, Noda K, Goto A, Murase T, Yoshikawa H, Sugamoto K 2009. Interosseous Membrane of the Forearm: Length Change of Ligaments During Forearm Rotation. Journal of Hand Surgery,34A; 685-691. Palmer, A 1989. Triangular Fibrocartilage Complex Lesions: A Classification Journal of Hand Surgery, 14A:4, 594-606.

References
Ruland RT, Hogan, CJ (2008): The ECU Synergy Test: An aid

to diagnose ECU Tendinitis. The Journal Of Hand Surgery, 33:10.

Shah MA, Lopez JK: Escalante A, Green DP: Dynamic Splinting of

Forearm Rotational Contracture After Distal Radius Fracture The Journal of Hand Surgery, 27A(3). Sachar, K.(2008): Ulnar sided wrist pain. Evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears of the wrist. The Journal of Hand Surgery, 33A:9, 1669-1679. Shin AY, Deitch MA, Sachar K, Boyer MI (2004): Ulnar sided wrist pain: Diagnosis and treatment. Journal of Bone and Joint Surgery, 86-A:7, 1560-1574. Slutsky DJ, Nagle DJ: Wrist Arthroscopy: Current Concepts. Journal of Hand Surgery, 33A, 1228-1243.

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References
Tang, Jin Bo, Ryu, Jai Young, Kish, Vincent 1998. The Triangular

Fibrocartilage Complex: An Important Component of the Pulley for the Ulnar Wrist Extensor Journal of Hand Surgery, 23A:6. 986-991. Tay SC, Tomita K, Berger RA (2007): The Ulnar fovea sign for defining ulnar wrist pain: An analysis of sensitivity and specificity. The Journal of Hand Surgery, 32:4, 438-444. Trumble TE, Budoff JE, Cornwall R. 2006: Hand, Elbow & Shoulder Core Knowledge in Orthopedics. Mosby Elsevier Philadelphia, PA. Xu J, Tang J 2009. In Vivo Changes in Lengths of the Ligaments Stabilizing the Distal Radioulnar Joint. Journal of Hand Surgery, 34A, 40-45. Yu, Chase, Strauch 2004. Atlas of Hand Anatomy and Clinical Implications. Mosby, St. Louis.

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