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Patients › Wrist

Distal Radioulnar Joint Surgery

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Updated Aug 20264 citations

Why this operation has been suggested

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment establishes the diagnosis. For long-standing problems we usually try non-operative care first and consider surgery when that has not given enough improvement. For structural issues, surgery may be recommended straight away.

We suggest this operation to restore stability and congruency to your wrist joint. This allows for painless, full motion when the joint is damaged or unstable. The procedure aims to relieve pain and improve function by correcting the alignment of your bones and ligaments.

Before the operation

Please fast for seven hours before your surgery. This allows your surgeon to bring you forward if the list runs early. You do not need routine blood tests or an anaesthetist review unless you have other medical conditions. Please arrange a lift home and bring a list of your current medications. Wear comfortable clothing. Your surgeon will use X-rays to plan the operation. If the X-rays are unclear, a high-resolution MRI may be needed to check the ligaments and bones in your wrist. This detailed imaging helps ensure the best possible outcome for your distal radioulnar joint.

On the day

You will present to the hospital’s surgical admissions unit. Here, you are checked in and prepared for theatre. You meet the anaesthetist to discuss your care. This operation is done under general anaesthetic. A regional nerve block is sometimes added for post-operative pain relief — the anaesthetist will discuss this with you on the day.

You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable, you either go to the ward or go home, depending on the procedure and your recovery.

What the operation involves

Your surgeon will begin by assessing whether your joint can be stabilised using soft-tissue repairs or if a more structural change is needed. In many cases, the goal is to prevent future instability or restore painless movement. If your ligaments are torn but can be repaired, your surgeon may tighten the tissue around the joint to restore stability. This often involves stitching the torn structures back together to secure the bones in their correct position.

If the joint surfaces are severely damaged or previous repairs have failed, your surgeon may discuss replacement options. This involves removing the worn-out or damaged parts of the joint and replacing them with artificial components. These replacements are designed to mimic the natural movement of your wrist, helping to reduce pain and improve grip strength. In some instances, a small portion of the ulna bone may be shortened or adjusted to relieve pressure on the joint, ensuring the bones align correctly without the need for prolonged immobilisation.

The procedure is tailored to your specific anatomy and the cause of your instability. Your surgeon will choose the technique that best addresses your condition, whether that is repairing existing tissues, adjusting bone alignment, or replacing joint surfaces. The aim is to create a stable, congruent joint that allows for full, pain-free motion. After the procedure, your wrist will be dressed and supported while you begin your recovery.

After the operation

You will wake up in our recovery ward. We manage your pain using standard methods to keep you comfortable. Your arm will be in a soft dressing and a sling to protect the joint. We do not use rigid braces for this procedure. Please arrange for someone to stay with you for the first 24 hours to help you. Your team will tell you whether you go home the same day or stay one night in hospital. Rest your arm and keep the dressing clean and dry. You can move your fingers and wrist gently as tolerated. Avoid lifting anything heavy until we review your progress at your follow-up appointment.

Recovery

In the early days after your surgery, some swelling and discomfort is normal. We manage this with rest, elevation, and prescribed medication. Keeping your hand raised above heart level helps reduce the swelling. This is a key part of your healing process.

You will wear a protective dressing or cast to keep the joint stable. We do not use hinged braces or abduction pillows for this procedure. Your hand therapist, Ruby Doolan at Extend Rehabilitation, will guide your care. She directs your exercises and makes any splint you need. You will not see a physiotherapist for your rehabilitation.

As the swelling settles, we focus on gentle movement. You will perform specific hand therapy exercises to restore motion. These activities are designed to be safe for your healing tissues. You can return to light daily tasks as comfort allows. Avoid heavy lifting or forceful gripping until your surgeon clears you.

Pain should gradually ease as your tissues heal. If you experience sharp pain or increased swelling, contact us. Your recovery is unique. Your timeline may differ from others; your surgeon and hand therapist will guide you based on your progress. We aim for painless, full motion in the long term.

If you plan to drive, remember the universal rules: no driving while in a sling or cast, and only when you can react quickly in an emergency. For full details on when you can return to driving, please visit our guide on Driving after upper-limb surgery.

What can go wrong

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

If you have had surgery for instability in the wrist, you might notice that pain or swelling does not settle down as expected. Sometimes the joint feels loose or unstable again. This can feel like the wrist is giving way or clicking when you turn your hand. If this happens, call the clinic. We can check if your healing is on track or if further treatment is needed.

In some cases, the bones may not heal in the perfect position. You might feel a sharp pain or notice that your wrist does not move as freely as it should. This can happen if the bone ends do not knit together properly. If you experience persistent pain or a loss of movement, bring it up at your next review. We can assess whether additional support or therapy is required to help the joint function better.

If you have had a replacement of the ulnar head (the small bone at the end of your forearm), you might feel discomfort or stiffness in the wrist. This can make everyday tasks like turning a doorknob difficult. If the pain becomes severe or the joint feels unstable, contact us. We can evaluate if the replacement is working as intended or if adjustments are needed to improve your comfort and function.

The complications table on this page lists typical rates if you want the specifics.

When to call us

Call us if you have fever, increasing wound redness or discharge, or sudden severe pain. Go to emergency if you have calf swelling, shortness of breath, loss of sensation, or cannot move your limb. We want to check these signs quickly. Early action helps protect your recovery and keeps you safe while your wrist heals.

Advanced reading: the deeper science (optional)

This section goes further than you need for your own treatment decisions. The distal radioulnar joint is worth the extra reading because it is the joint in the wrist we are worst at measuring, the one most often blamed prematurely, and the one where waiting is most often the right answer.

We cannot reliably measure the problem

Instability of this joint is diagnosed largely by feel — the examiner shifts the ulna against the radius and forms an impression. A 2025 review of assessment strategies concluded plainly that reliable, quantifiable methods for analysing distal radioulnar joint instability remain an unmet need, and that developing them is essential to improving management [1].

That has a direct consequence for you. When the diagnosis rests on a subjective test, the threshold for calling a joint unstable varies between examiners, and so does the threshold for operating on it. A second opinion here is not distrust; it is a reasonable response to a test with known limits.

Most ulnar-sided pain after a wrist fracture settles

This is the single most useful finding for anyone with a painful wrist after a distal radius fracture. A comprehensive review concluded that most ulnar-sided wrist problems following distal radial fractures can be treated non-operatively initially — typically for over a year — in anticipation of substantial improvement with time [2].

A year is longer than most people expect to be told to wait, and the temptation to intervene earlier is strong on both sides of the consultation. The exception named in the same review is important and specific: early marked subluxation of the joint that physically blocks forearm rotation does need addressing rather than observing [2].

So the default is patience, with a defined reason to abandon it.

When salvage is needed, the choice is finer than it looks

If the joint is destroyed and non-operative management has genuinely failed, the classic options are the Darrach procedure — removing the end of the ulna — and the Sauvé-Kapandji, which fuses the joint and creates a gap more proximally to allow rotation.

A systematic review comparing them found comparable satisfaction regardless of the underlying pathology, with similar improvement in range of motion, strength and overall function. The difference was in the reoperation rate, which was higher with the Sauvé-Kapandji [3].

That is a clean discriminator. Where two operations produce the same result, the one requiring fewer further operations has the advantage — though the Sauvé-Kapandji retains a role where preserving the ulnar support of the carpus matters, which is precisely why it was devised.

Ulnar impaction is a different problem with its own answer

Ulnar-sided pain from the ulna being relatively too long — ulnar impaction syndrome — is treated by shortening the load path, either by cutting and shortening the ulnar shaft or by arthroscopically removing the dome of the ulnar head. A meta-analysis of 311 patients found both effective, with the arthroscopic wafer procedure showing fewer complications and a lower reoperation rate [4].

The shaft osteotomy involves a plate, a healing bone and the possibility of the osteotomy failing to unite; the arthroscopic procedure avoids all three. Where the anatomy suits it, that is a meaningful difference.

Reviewed by Dr Kieran Hirpara · 13 August 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

References for the advanced reading
  1. Christy M, Wright DJ, Goldfarb CA. Assessment strategies for distal radioulnar joint instability: current state and a need for improved tools. J Hand Surg Am. 2025;50(12):1505-14.
  2. Giddins G. The distal radioulnar joint after distal radial fractures: when and how do we need to treat pain, stiffness or instability? J Hand Surg Eur Vol. 2023;48(3):230-45.
  3. Lamont S, Debkowska M, Johnsen P, Froehle A, Cotterell IH, Isaacs J. Outcomes of Darrach and Sauvé-Kapandji procedures: a systematic review. Hand (N Y). 2022;19(1):68-73.
  4. Shi H, Huang Y, Shen Y, Wu K, Zhang Z, Li Q. Arthroscopic wafer procedure versus ulnar shortening osteotomy for ulnar impaction syndrome: a systematic review and meta-analysis. J Orthop Surg Res. 2024;19(1).
Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

  • Salvage of failed distal radioulnar joint reconstruction requires a thorough understanding of normal anatomy, biomechanics, and the modes of failure of the primary procedure to develop effective strategies [1].
  • Most ulnar-sided wrist problems associated with distal radial fractures can be treated non-operatively initially, typically for over a year, in anticipation of substantial improvement with time [2].
  • Distal radioulnar joint instability is often an underestimated lesion requiring systematic clinical examination and imaging for detection [4].
  • Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios in a survey of treatment variation after plate fixation of distal radial fractures [5].
  • The most common recommended treatment for distal radioulnar joint issues after plate fixation of distal radial fractures was cast immobilization, cited in 41% (247 of 607) of scenarios [5].
  • Distal radioulnar joint instability management covers anatomic and biomechanical advances, categorization of instability, and treatment strategies including percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques [6].
  • Ulnar shortening osteotomy is a good option to treat patients with ulnar impaction syndrome regardless of the distal radioulnar joint angle [7].
  • Distal radioulnar joint ligament reconstruction is indicated when native ligaments are not reparable, provided there is no radius or ulna bony deformity or arthritis of the distal radioulnar joint [8].
  • Severely damaged and painful distal radioulnar joints can be reconstructed by resection arthroplasty or by hemi- or total arthroplasty [9].
  • There is presently no evidence that ulnar head and total radio-ulnar joint prostheses produce long-lasting results [10].
  • When appropriate patient selection criteria are met, partial and total ulnar head replacement typically produce reliable results [20].

Anatomy & Pathophysiology

  • Stability of the distal radioulnar joint is maintained by two factors: compression between the articulating surfaces and tension in the ligament in the direction of its fibers [33].
  • The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint [15].
  • Anatomical variations in the sigmoid notch and ulnar head significantly influence joint mechanics and treatment outcomes [34].
  • The interaction between ligaments, muscles, and bones is essential for distal radioulnar joint stability [16].
  • Closed treatment is frequently successful for isolated acute distal radioulnar joint dislocations due to the healing potential of the peripheral triangular fibrocartilage complex [18].
  • Radial lengthening did not demonstrate a benefit in improving distal radioulnar joint stability in a triangular fibrocartilage complex injury model [36].
  • Pressures within the distal radioulnar joint change with forearm rotations, with the highest intra-articular pressure recorded in supination under no disruption-no load, no disruption-loaded, and disrupted triangular fibrocartilage complex conditions [37].
  • The Aptis distal radioulnar joint arthroplasty considerably alters forearm kinematics, which can have clinical implications [29].
  • Distal radioulnar joint kinematics during handstanding vary with school age in female gymnasts, with high school students showing a significantly larger increase in distal radioulnar joint separation compared to elementary school students [30].

Classification

  • Salvage of failed distal radioulnar joint reconstruction requires understanding normal anatomy, biomechanics, and modes of failure of the primary procedure [1].
  • Thorough knowledge of the anatomy and kinematics of the distal radioulnar joint is necessary to manage pathologic conditions [3].
  • Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of scenarios, most commonly cast immobilization in 41% (247 of 607) [5].
  • The functional anatomy and pathomechanics of the distal radioulnar joint emphasize the interaction between ligaments, muscles, and bones for stability [16].
  • Advances in minimally invasive surgical techniques have transformed the management of distal radioulnar joint instability [24].
  • Coronal shift should be added to classic measures of distal radius fracture reduction because of its fundamental role in distal radioulnar joint stability [27].

Clinical Presentation

  • Salvage of failed distal radioulnar joint reconstruction requires a thorough understanding of normal anatomy, biomechanics, and the modes of failure of the primary procedure [1].
  • A thorough knowledge of the anatomy and kinematics of the distal radioulnar joint is necessary to manage pathologic conditions [3].
  • Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of scenarios involving plate fixation of distal radial fractures, most commonly cast immobilization in 41% (247 of 607) [5].
  • Distal radioulnar joint instability and its management involve anatomic and biomechanical advances, categorization of instability, and treatment strategies including percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques [6].
  • DRUJ ligament reconstruction is indicated when native ligaments are not reparable, provided there is no radius or ulna bony deformity or arthritis of the DRUJ [8].
  • Chronic distal radioulnar joint instability results from various traumatic injuries and can lead to chronic functional impairment, pain, and arthritis if left untreated [11].
  • Stabilization of the ulnar stump seems to alleviate pain and improve forearm rotation and functional outcomes, although no direct correlation exists between radioulnar convergence and patient outcomes [12].
  • Standard and alternative exposures of the wrist joint and DRUJ are discussed, with case examples illustrating their use [13].
  • The occurrence of osteoarthritis of the scaphotrapeziotrapezoid and distal radioulnar joints was affected by the presence of osteoarthritis of the adjacent joint [14].
  • There is substantial surgeon-to-surgeon variation in interpreting MRI signal changes and arthroscopic findings in the distal radioulnar ligaments and central disc, raising concerns about overdiagnosis and overtreatment versus underdiagnosis [17].
  • Treatment goals in the acute setting for distal radius fracture should be to prevent future instability or incongruency of the distal radioulnar joint, while goals in the chronic setting should be to restore stability and congruency to allow for painless, full motion [19].
  • Surgical outcomes for the management of the distal radioulnar joint in rheumatoid arthritis are best when performed before the patient displays severe joint destruction, fixed contractures, subluxation, or dislocation [21].
  • The etiology, clinical presentation, and treatment strategies for unique problems affecting the pediatric and adolescent distal radioulnar joint include Madelung deformity, physeal arrest, and osteochondromatosis [35].

Investigations

  • Coronal shift should be added to the classic measures of distal radius fracture reduction because of its fundamental role in distal radioulnar joint stability [27].
  • Conventional radiography should be the first imaging modality to exclude or diagnose wrist pathology [32].
  • When conventional radiography is inconclusive, high resolution 3 Tesla MRI is advised [32].
  • A nuanced understanding of 3D relationships can enhance preoperative planning when correcting ulnar-side pathology [39].
  • Imaging the DRUJ requires knowledge of the complex bony, muscular, and ligamentous anatomy [40].
  • Standard well-positioned radiography is the appropriate first step for imaging the DRUJ [40].
  • High-resolution MRI helps delineate ligamentous structures in the DRUJ [40].
  • Dynamic CT is indicated for clinical instability of the DRUJ [40].

Treatment

  • Treatment strategies for distal radioulnar joint instability include percutaneous, arthroscopic, soft-tissue, osteotomy, and arthroplasty techniques [6].
  • Treatment goals in the acute setting should be to prevent future instability or incongruency of the distal radioulnar joint [19].
  • Treatment goals in the chronic setting should be to restore stability and congruency to allow for painless, full motion [19].
  • Indirect ulnar shortening by distraction through the distal radius fracture site provides a simple and novel strategy for the management of persistent distal radioulnar joint instability during volar plating, obviating the need for prolonged immobilization or to alter standard postoperative protocols [23].
  • The Aptis total distal radioulnar joint prosthesis is a good rescue option for patients with previous failed surgical procedures, providing significant improvements in range of motion, grip strength, and pain scores with a mean follow-up of 9.7 years [25].
  • Combined extensor retinaculum capsulorrhaphy and suture repair effectively restores stability to both the distal radioulnar joint and ulnocarpal joint in patients with triangular fibrocartilage complex-related ulnocarpal instability, considerably reducing pain and preserving range of motion [38].

Complications

  • Most ulnar-sided wrist problems associated with distal radial fractures can be treated non-operatively initially for over a year in anticipation of substantial improvement with time [2].
  • Anatomic distal radioulnar joint reconstruction represents an important evolutionary step in the history of surgical treatment for distal radioulnar joint instability [22].
  • Indirect ulnar shortening by distraction through the distal radius fracture site provides a simple and novel strategy for managing persistent distal radioulnar joint instability during volar plating, obviating the need for prolonged immobilization or altering standard postoperative protocols [23].
  • Both APTIS distal radioulnar joint arthroplasty and ulnar head replacement yield substantial functional improvements and good long-term survivorship [26].
  • Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome [28].

Recovery

  • The original anatomic distal radioulnar joint reconstruction technique described by Sanders and its procedure modifications represent an important evolutionary step in the history of surgical treatment for distal radioulnar joint instability [22].
  • Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome [28].

Key Evidence

  • [L5] Salvage of failed distal radioulnar joint reconstruction requires a thorough understanding of normal anatomy, biomechanics, and the modes of failure of the primary procedure to develop effective strategies. [1] (10.1016/j.hcl.2010.05.004)
  • [L5] Most ulnar-sided wrist problems associated with distal radial fractures can be treated non-operatively initially, typically for over a year, in anticipation of substantial improvement with time. [2] (10.1177/17531934221140238)
  • [L5] A thorough knowledge of the anatomy and kinematics of the distal radioulnar joint is necessary to manage pathologic conditions. [3] (10.1016/j.hcl.2005.08.002)
  • [L5] Distal radioulnar joint instability is often an underestimated lesion requiring systematic clinical examination and imaging for detection. [4] (10.1007/s00402-020-03371-0)
  • [L4] Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios, most commonly cast immobilization in 41% (247 of 607). [5] (10.1177/17531934261449057)
  • [L5] The purpose of this article is to review distal radioulnar joint instability and its management, covering anatomic and biomechanical advances, categorization of instability, and treatment strategies including percutaneous, arthroscopic, soft-tissue, osteotomy and arthroplasty techniques. [6] (10.1177/1753193414527052)
  • [L4] Ulnar shortening osteotomy is a good option to treat patients with ulnar impaction syndrome regardless of the distal radioulnar joint angle. [7] (10.1177/17531934241262931)
  • [L5] DRUJ ligament reconstruction is indicated when native ligaments are not reparable, provided there is no radius or ulna bony deformity or arthritis of the DRUJ. [8] (10.1016/j.hcl.2020.07.004)
  • [L5] Severely damaged and painful distal radioulnar joints can be reconstructed by resection arthroplasty or by hemi- or total arthroplasty. [9] (10.1016/j.hcl.2020.07.008)
  • [L5] The introduction of ulnar head and total radio-ulnar joint prostheses has provided a new method, but there is presently no evidence that these implants produce long-lasting results. [10] (10.1054/jhsb.2002.0815)
  • [L5] Chronic distal radioulnar joint instability results from various traumatic injuries and can lead to chronic functional impairment, pain, and arthritis if left untreated. [11] (10.1016/j.hcl.2010.05.010)
  • [L5] Stabilization of the ulnar stump seems to alleviate pain and improve forearm rotation and functional outcomes, although no direct correlation exists between radioulnar convergence and patient outcomes. [12] (10.1016/j.hcl.2014.12.003)
  • [L5] Standard and alternative exposures of the wrist joint and DRUJ are discussed, with case examples illustrating their use. [13] (10.1016/j.hcl.2014.07.003)
  • [L4] The occurrence of osteoarthritis of the scaphotrapeziotrapezoid and distal radioulnar joints was affected by the presence of osteoarthritis of the adjacent joint. [14] (10.1016/j.jhsa.2023.05.009)
  • [L4] The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint. [15] (10.1177/17531934231168299)
  • [L5] The purpose of this review article is to present and illustrate the current understanding of the functional anatomy and pathomechanics of the distal radioulnar joint, emphasizing the interaction between ligaments, muscles, and bones for stability. [16] (10.1177/1753193417693170)
  • [L5] There is substantial surgeon-to-surgeon variation in interpreting MRI signal changes and arthroscopic findings in the distal radioulnar ligaments and central disc, raising concerns about overdiagnosis and overtreatment versus underdiagnosis. [17] (10.1177/17531934241254705)
  • [L5] This article reviews the anatomy, biomechanics, and treatment of acute dislocations of the distal radioulnar joint and distal ulna fractures, emphasizing that closed treatment is frequently successful for isolated dislocations due to the healing potential of the peripheral TFCC. [18] (10.1016/j.hcl.2010.05.009)
  • [L5] Treatment goals in the acute setting should be to prevent future instability or incongruency of the distal radioulnar joint, while goals in the chronic setting should be to restore stability and congruency to allow for painless, full motion. [19] (10.1016/j.hcl.2021.02.011)
  • [L4] When appropriate patient selection criteria are met, partial and total ulnar head replacement typically produce reliable results. [20] (10.1177/1753193417693177)
  • [L5] Surgical outcomes are best when performed before the patient displays severe joint destruction, fixed contractures, subluxation, or dislocation. [21] (10.1016/j.hcl.2005.08.009)
  • [L4] This report documents the original anatomic DRUJ reconstruction technique described by Sanders and our procedure modifications, representing an important evolutionary step in the history of surgical treatment for DRUJ instability. [22] (10.1016/j.jhsa.2020.08.001)
  • [L4] Indirect ulnar shortening by distraction through the distal radius fracture site provides a simple and novel strategy for the management of persistent DRUJ instability during volar plating, obviating the need for prolonged immobilization or to alter standard postoperative protocols. [23] (10.1016/j.jhsa.2018.02.030)
  • [L5] Advances in minimally invasive surgical techniques have transformed the management of DRUJ instability. [24] (10.1177/17531934261417561)
  • [L4] The Aptis total distal radioulnar joint prosthesis is a good rescue option for patients with previous failed surgical procedures, providing significant improvements in range of motion, grip strength, and pain scores with a mean follow-up of 9.7 years. [25] (10.1177/17531934231192375)
  • [L2] Both APTIS DRUJ arthroplasty and ulnar head replacement yield substantial functional improvements and good long-term survivorship. [26] (10.1177/17531934261415827)
  • [L5] Coronal shift should be added to the classic measures of distal radius fracture reduction because of its fundamental role in distal radioulnar joint stability. [27] (10.1016/j.jhsa.2014.08.022)
  • [L4] Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome. [28] (10.1177/17531934231197942)
  • [L4] The Aptis distal radioulnar joint arthroplasty considerably alters forearm kinematics, which can have clinical implications. [29] (10.1177/17531934241274142)
  • [L4] The DRUJ kinematics during handstanding vary with school age in female gymnasts, with high school students showing a significantly larger increase in DRUJ separation compared to elementary school students. [30] (10.1177/23259671251368997)
  • [L2] Conventional radiography should be the first imaging modality to exclude or diagnose wrist pathology; when inconclusive, high resolution 3 Tesla MRI is advised. [32] (10.1177/1753193416683876)
  • [L5] Stability of the distal radioulnar joint is maintained by two factors: compression between the articulating surfaces and tension in the ligament in the direction of its fibers. [33] (10.1016/j.hcl.2010.05.002)
  • [L5] Anatomical variations in the sigmoid notch and ulnar head significantly influence joint mechanics and treatment outcomes. [34] (10.1016/j.hcl.2012.03.002)
  • [L5] The purpose of this article is to review the etiology, clinical presentation, and treatment strategies for the management of unique problems affecting the pediatric and adolescent distal radioulnar joint, including Madelung deformity, physeal arrest, and osteochondromatosis. [35] (10.1016/j.hcl.2010.06.001)
  • [L5] Radial lengthening did not demonstrate a benefit in improving DRUJ stability in a triangular fibrocartilage complex injury model. [36] (10.1016/j.jhsa.2025.06.013)
  • [L5] Pressures within the DRUJ changed with forearm rotations, with the highest intra-articular pressure recorded in supination under no disruption-no load, no disruption-loaded, and disrupted TFCC conditions. [37] (10.1016/j.jhsa.2023.11.015)
  • [L4] The combined HS and suture repair effectively restores stability to both the DRUJ and UCJ in patients with TFCC-related ulnocarpal instability, considerably reducing pain and preserving range of motion. [38] (10.1016/j.jhsg.2025.100806)
  • [L4] A nuanced understanding of these 3D relationships can enhance preoperative planning when correcting ulnar-side pathology. [39] (10.1016/j.jhsg.2023.12.006)
  • [L5] Imaging the DRUJ requires knowledge of the complex bony, muscular, and ligamentous anatomy; standard well-positioned radiography is the appropriate first step, while high-resolution MRI helps delineate ligamentous structures and dynamic CT is indicated for clinical instability. [40] (10.1016/j.hcl.2010.07.001)

References

[1] Salvage of Failed Distal Radioulnar Joint Reconstruction. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.004

[2] The distal radioulnar joint after distal radial fractures: when and how do we need to treat pain, stiffness or instability?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221140238

[3] Hemiresection Arthroplasty of the Distal Radioulnar Joint. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2005.08.002

[4] Distal radioulnar joint instability: current concepts of treatment. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03371-0

[5] Factors associated with variation in treatment of the distal radioulnar joint after plate fixation of distal radial fractures. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261449057

[6] Instability of the distal radioulnar joint. Journal of Hand Surgery (European Volume). 2014. DOI: 10.1177/1753193414527052

[7] Does the distal radioulnar joint orientation influence the outcome of ulnar shortening osteotomy: a retrospective study. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241262931

[8] Chronic Distal Radioulnar Joint Instability. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.004

[9] Solutions for the Unstable and Arthritic Distal Radioulnar Joint. Hand Clinics. 2020. DOI: 10.1016/j.hcl.2020.07.008

[10] Failed Ulnar Head Resection: Prevention and Treatment. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0815

[11] The Management of Chronic Distal Radioulnar Instability. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.010

[12] Management of Complications of Distal Radioulnar Joint. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2014.12.003

[13] Exposures of the Wrist and Distal Radioulnar Joint. Hand Clinics. 2014. DOI: 10.1016/j.hcl.2014.07.003

[14] Prevalence and Associated Factors for Primary Osteoarthritis of the Scaphotrapeziotrapezoid, Radiocarpal, and Distal Radioulnar Joints in the Japanese General Elderly Population. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.05.009

[15] Stability of the distal radioulnar joint with and without activation of forearm muscles. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231168299

[16] Distal radioulnar joint: functional anatomy, including pathomechanics. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417693170

[17] Pain and instability ascribed to the distal radioulnar ligaments and central disc as part of the triangular fibrocartilage complex: a round table discussion. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241254705

[18] Acute Dislocations of the Distal Radioulnar Joint and Distal Ulna Fractures. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.05.009

[19] Distal Radius Fracture and the Distal Radioulnar Joint. Hand Clinics. 2021. DOI: 10.1016/j.hcl.2021.02.011

[20] Non-constrained implant arthroplasty for the distal radioulnar joint. Journal of Hand Surgery (European Volume). 2017. DOI: 10.1177/1753193417693177

[21] Management of the Distal Radioulnar Joint in Rheumatoid Arthritis. Hand Clinics. 2005. DOI: 10.1016/j.hcl.2005.08.009

[22] The Original Anatomic Reconstruction of Palmar and Dorsal Radioulnar Ligaments for Distal Radioulnar Joint Instability. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.08.001

[23] Radial Distraction to Stabilize Distal Radioulnar Joint in Distal Radius Fixation. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.02.030

[24] Restoring balance in the distal radioulnar joint: advancements in minimally invasive surgical approaches. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261417561

[25] Long-term results of the AptisTM total distal radioulnar joint prosthesis after previous failed surgical procedures. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231192375

[26] Efficacy and safety of prosthetic arthroplasty of the distal radioulnar joint: a systematic review. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261415827

[27] Coronal Shift of Distal Radius Fractures: Influence of the Distal Interosseous Membrane on Distal Radioulnar Joint Instability. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2014.08.022

[28] An alternative treatment for degenerative triangular fibrocartilage complex injuries with distal radioulnar joint instability: first experience with 48 patients. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231197942

[29] Performance of the Aptis distal radioulnar joint implant: kinematic and geometric analysis. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241274142

[30] Distal Radioulnar Joint Kinematics Evaluated Using Ultrasonography During Handstanding in Female Gymnasts. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251368997

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[35] The Management of Congenital and Acquired Problems of the Distal Radioulnar Joint in Children. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2010.06.001

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[37] Intra-Articular Pressure in the Distal Radioulnar Joint: A Biomechanical Study. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2023.11.015

[38] Extensor Retinaculum Capsulorrhaphy and Suture Repair for Ulnocarpal and Distal Radioulnar Joint Instability: One-Year Results. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2025.100806

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