Neglected GaleazziM.Sada Baskara

90% patients have wrist & digital disease

Wrist ‘joint’ includes◦radiocarpal◦midcarpal◦carpometacarpal◦distal radioulnar◦(forearm)

Skeletal architecture allows both rotation and translation during normal forearm motion

The DRUJ and proximal radioulnar joint are interdependent in producing forearm motion. Disruptions of either joint, deformity of the radius or ulna, or injury to the interosseous membrane (IOM) alters the function of both joints.

This disccus about the relationships between anatomy, function, and acquired instability of the DRUJ are developed and treatment alternatives provided.

2 Articular surfaces with 10-80% surface contact depending on rotation

1. Sigmoid notch 2. Ulnar seat

The soft tissue structures that contribute to DRUJ stability are the pronator quadratus, extensor carpi ulnaris (ECU), IOM, DRUJ capsule, and components of the triangular fibrocartilage complex (TFCC)

The majority of isolated DRUJ dislocations are dorsal and caused by hyperpronation and wrist extension, usually in a fall on the outstretched hand.

volar dislocations occur in the supinated forearm or from a direct blow to the ulnar aspect of the forearm.

The most common cause for DRUJ instability is a distal radius fracture. Dorsal angulation of the radius induces palmar instability of the ulna. Angulation of more than 20 degrees to 30 degrees creates marked incongruity of the DRUJ, distorts the TFCC

The radioulnar ligaments can tolerate no more than 5 to 7 mm of radial shortening before one or both ligaments tear

In mild instability, pain and weakness often occur only with activities that require power rotation of the forearm, especially while gripping, such as using a screwdriver.

Pain or a mechanical block from dislocation causes loss of motion.

DRUJ instability in adults after a distal radius or forearm malunion usually presents with loss of forearm motion, prominence of the ulnar head, and ulnar-sided wrist pain.

Shortening from a distal radius malunion causes modest loss of both pronation and supination but infrequently produces dorsal or palmar DRUJ dislocation.

An acute dislocation usually produces a deformity, with the ulnar head locked over a rim of the sigmoid notch, producing tenderness, swelling, and limited motion.

A chronically dislocating DRUJ causes reproducible clunks that are visible and palpable as the ulnar head dislocates and reduces in the sigmoid notch during active or passive forearm rotation.

On passive manipulation of radius to the ulna, increased anteroposterior translation of the DRUJ , its called piano key sign.

The press test , diagnose TFCC tears, and evaluating suspected bidirectional or dorsal DRUJ instability, Instability is shown by greater “depression” of the ulnar head and pain

When a DRUJ dislocation is recognized acutely, close reduction can be perfome and fix it with Cast for 3-4 week

Conservative management of chronic DRUJ instability usually fails .

Restoration of stability and full painless arc of motion is the goal of surgical treatment for the posttraumatic unstable DRUJ.

Instability must be identified causes can be bony deformity, ligament injury, or a combination.

Pain with extreme pronation – supinationClicking during rotational activityLoss of pronation and supination

Adams

Darrach

Sauve-Kapandji

Bowers

1. Darrach procedure 1. resection of the distal end of the ulna 2. higher failure rate, with serious disability,

especially in younger patients 3. unstable forearm, ulnar translocation of

the carpus and 2. Sauve-Kapandji procedure

1. fusion ulna to the distal radius pseudarthrosis of ulna

2. supporting the ulnar carpus, preserving the TFCC, and the ECU tendon

3. Younger patient with higher function4. ulnar stump instability.

Distal radius fracturesChronic instability InfectionRheumatoid arthritis

a 35 yo female with history accident 2 years ago, diagnosis with a close Radius distal fracture and she went to bone setter, but she feld her wrist getting bow

Thats it...Thank You