acute druj instability & tfcc tears keox 2014

Nickolaos A. Darlis, MD

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“Forearm Joint”“Forearm Joint”

One functional unit

“Forearm Joint”“Forearm Joint”

The forearm as a ring

Anatomy Distal RadiusAnatomy Distal Radius

DRUJ AnatomyDRUJ Anatomy

• Radii of curvature differ – 10mm vs 15mm– Full congruity impossible

DRUJ anatomyDRUJ anatomy

• Congruity of DRUJ– Neutral rotation: 60% of

sigmoid notch in contact– Extremes of rotation: 10%– Dorsal and palmar rims

important

• Little osseous stability

TFCC componentsTFCC components

VRULDRUL

ARTICULARDISC

UL, UTr ECU sub sheath

Volar & Dorsal RU lig.-Deep bundleVolar & Dorsal RU lig.-Deep bundle

Distal Radio-ulnar ligamentsDistal Radio-ulnar ligaments

Exact role disputed for years• Primary constraint to volar dislocation?• Primary constraint to dorsal dislocation?

However, most common explanation:However, most common explanation:

• Pronation– Ulnar head dorsal– DRUL taut– If PRUL ruptures,

dislocates dorsally• Supination– Ulnar head volar– PRUL taut– If DRUL ruptures,

dislocates volarly

Deep bundle, Foveal attachmentDeep bundle, Foveal attachment

The Iceberg Concept Atzei &Lucetti 2011The Iceberg Concept Atzei &Lucetti 2011

TFCC anatomyTFCC anatomy

• Vascular supply– Central portion• avascular

– Periphery (dorsal and palmar radio-ulnar ligaments)• vascularized

DRUJDRUJ

• Rotation• Load transmission• Stability

KinematicsKinematics

• Radius rotates about the distal ulna• “Ulnar head dislocation” by convention• Axis of rotation

Load transmission (RH intact )Load transmission (RH intact )

40% 60%

Halls 1964, Palmer 1984, Birkbeck 1997

Load TransmissionLoad TransmissionExplains common fracture patterns

Galeazzi

Forearm

Monteggia

Essex-Lopresti

Interosseous Membrane AnatomyInterosseous Membrane Anatomy

Two main bands:• Central Band (volar)• Proximal Interosseous

Band (dorsal)

• Accessory bands (1-5)• Membranous portion

Skahen 1997

IOM-Central BandIOM-Central Band

• 70% of forearm stability

• Injury of other elements of IOM (partial tears), increase CB strains

Hotchkiss,1989, Lafferty 1990, Rabinowitz, 1994, Skahen III 1997

Radius

IOM AnatomyIOM Anatomy

75%250120mm

outlineoutline

Acute DRUJ instabilityDistal radius-Galeazzi-Essex Lopresti

TFCC management

Common misconceptionsCommon misconceptions

• TFCC tear ≠ DRUJ instability– In fact: most tears don’t cause instability

• Ulnar styloid fracture ≠ DRUJ instability– Styloid fractures may co-excist with TFCC tears

Acute Ulnar head Dislocation

without fracture

without fracture• Dorsal: reduce in supination• Palmar: reduce in pronation• Global instability: usually requires

stabilization

• If stable: immobilize in stable position– Sugartongue splint for 6 weeks

• Failed closed reduction may result from trapped ECU, capsule, ulnar styloid, extensor tendon

• Open reduction dorsal - 5th compt.

• TFCC repair if avulsed

without fracture

DRUJ in Distal Radius FracturesDRUJ in Distal Radius Fractures

• 1777 Desault isolated DRUJ dislocation• 1814 Colles: DRUJ with distal radius– “at some remote period again enjoy perfect freedom”

• 1837- Diday– “the problem is really the overriding ulna”

• 1934 Galeazzi • 1951 Essex-Lopresti• 1967 Frykman– “Disturbances of the DRUJ make for worse results”

• “Most common source of pain following distal radius Fx”

Fernandez &Geissler JHS 1992

• Loss of supination most common functional complaint following distal radius Fx

Hanel AAOS ICL 2004

• Residual depression of the lunate facet ≥2mm results in articular incongruity and arthrosis

Jupiter JBJS 1986

DRUJ injury in distal radius FxDRUJ injury in distal radius Fx

Highly possible when:• shortening >5-7mm• displaced fx base of the

ulnar styloid, • angulation >25-300 any

plane• DRUJ diastasis in PA Rö

projection

• Accurate osseus reduction first– Ulnar column stabilization

Common pitfallsCommon pitfalls

• Radial translocation- sigmoid notch malreduction

Common pitfallsCommon pitfalls

• Excessive volar tilt/ translocation

• Geissler and Fernandez Instabilty classification AFTER radius reduction– Type I: Stable– Type II: Unstable– Type III: Potentially Unstable

Type I: StableType I: Stable

• minimally displaced avulsion tip of the ulnar styloid

• fracture of the neck of the ulna

(just fix)

Type III: Potentially UnstableType III: Potentially Unstable

• Fx through sigmoid notch (4-part fracture) or• Ulnar head fracture

(fix & test)

Type II: UnstableType II: Unstable

• avulsion Fx base of the ulnar styloid or• massive tear of the TFCC and/or secondary

stabilizers

Ulnar styloid FxUlnar styloid Fx

• Management controversial• May be fixed or tends to reduce in supination• Fix when DRUJ unstable, usually base.• Make sure TFCC attaches to fragment

• CRIF: easier said than done; supinate

• Re-check stability

• ORIF: ample skin incision– Kirschner wires,– tension band wire– screw– suture anchors

• ORIF– Dedicated plates

• However, if no clinical instability, value of fixation questionable

152 pts with displaced fx involving 75% of ulnar styloid

– 76 treated and 76 untreated

• The fracture itself trended to worse outcomes than if there was no fracture

• No differences noted between the treated group and the untreated group

The unsolved questionThe unsolved question• How do you define and test DRUJ stability in

the acute setting?

If DRUJ stable after osseus fixation (distal radius ± ulna):

• Immobilize in stable position for 4-6 weeks– Sugartongue splint– Avoid excessive pronation (DRUJ stable but

associated w loss of forearm motion)

Congruent reduction with an unstable joint, consider:

• Cross pinning– Pin breakage

• TFCC repair• External fixation

Galeazzi Fx DlGaleazzi Fx Dl

• Accurate ORIF first• Same principles for DRUJ as for distal radius Fx

Essex Lopresti injuryEssex Lopresti injury

Failure of the IOM• Acute• Secondary to overload following Radial Head Excision

Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis

• Distal Radioulnar Joint pain and dissociation

• Distraction-compression X-rays

• Intraoperative manual testing

Essex Lopresti injury- DiagnosisEssex Lopresti injury- Diagnosis

• MRI

• Ultrasound

• Radial Head Reconstruction- Replacement (Titanium-Vitallium-Allograft)

• DRUJ reduction- pinning in supination

• TFCC repair

Mayhall 1981, Morrey 1981, Gordon 1982

Acute Essex Lopresti injury-TreatmentAcute Essex Lopresti injury-Treatment

Essex Lopresti injury- complicationsEssex Lopresti injury- complications

• Proximal radial migration• Symptomatic DRUJ

subluxation

Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency

• Ulnar shortening • Radial Head Replacement

Results inconsistent

Bowers 1999

Essex Lopresti- Chronic insufficiencyEssex Lopresti- Chronic insufficiency

• Attempts at IOM reconstruction

75%250

TFCC management

The unsolved questionThe unsolved question• How do you define and test DRUJ stability in

the acute setting?

Wrist arthroscopy in distal radius FxWrist arthroscopy in distal radius FxConcomitant lesions increasingly recognized:• ΤFCC ≈60% (43-78%)

• SL lig.≈ 40% (32-75%)

• LT lig. ≈20% (15-61%)

• Chondral lesions ≈20% (19-32%)

Arthroscopically assisted reduction Arthroscopically assisted reduction

• Currently indicated in selected injuries– Radial styloid Fx– Die Punch Fx– Three & Four part Fx– DRUJ instability

Especially in young, high demand patients

1. Radial styloid

2. die punch2. die punch

3. Three & Four part fractures3. Three & Four part fractures

Palmer ClassificationPalmer Classification• Traumatic (Class 1)

• Degenerative (Class 2)- associated with ulnocarpal impaction syndrome

Central tear

Peripheral tear)

Radial tear

Tear locationTear location

Deep bundle of TFCC

Volar radioulnar lig.

radius

1. Central TFCC lesions1. Central TFCC lesions• Poorly vascularized- healing potential minimal• Arthroscopic debridement up to 2/3 of

articular disc

• Debridement ± pinning

1. Central TFCC lesions1. Central TFCC lesions

• Debridement ± pinning

Darlis & Sotereanos, JHS(A), 2006

1. Central TFCC lesions1. Central TFCC lesions

• Often degenerative and associated with ulnocarpal impaction syndrome

• Ulnar recession procedure to prevent symptom recurrence

Arthroscopic Wafer procedureArthroscopic Wafer procedure

• Preferred when modest shortening needed

2. Radial TFCC tears2. Radial TFCC tears• Repair or debridement?

2. Radial TFCC tears2. Radial TFCC tears• Repair if:

– VRUL or DRUL are involved– DRUJ instability

3. Peripheral (ulnar) TFCC tears3. Peripheral (ulnar) TFCC tears

• Well vascularized• Repairable

Usual location of peripheral tearsUsual location of peripheral tears

Dorsal

Usual location of peripheral tearsUsual location of peripheral tears

REPAIR TO CAPSULE REATTACH TO FOVEAOR

TFCC TFCC

REPAIR TO CAPSULE

REATTACH TO FOVEA

3. Peripheral (ulnar) TFCC tears

Hook test

REPAIR TO CAPSULE

TFCC managementTFCC management

REATTACH TO FOVEA

TFCC managementTFCC management

REATTACH TO FOVEA

Alternative: Mini open

Chou, Sarris, Sotereanos, JHS(B), 2003

EDM ECU

Incision

Chou, Sarris, Sotereanos JHS(B), 2003

Arthroscopically assisted reduction Arthroscopically assisted reduction

Need for routine TFCC repair unproven

But repair if:• DRUJ unstable• Young active patient

Take Home MessagesTake Home Messages

• Much known about biology and biomechanics of DRUJ

• Little known about treatment outcomes from DRUJ disruption

• Restore osseous anatomy first• Address residual instability with soft tissue

procedures• TFCC has capacity to heal- IOM does not

Take Home MessagesTake Home Messages

• In young active patients tend to:– Fix styloid base fx– Repair TFCC

Whatever you doWhatever you do• Remenber Vit C for disproportionate pain• Reassess ligaments and TFCC status after

fracture healing– Still window of opportunity

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 6 months 1 year

3mo 6mo

THANK YOUTHANK YOU

To access this presentation on the web:

acute druj instability & tfcc tears keox 2014

dorsal dislocation

volar dislocation

distal radius fxhanel

common explanation

common functional complaint

volarlydeep bundle

tfcc repair

forearm stabilityinjury

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