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Distal radioulnar joint hemiresection

97 citationsUpdated Sep 2026
Illustration: Distal radioulnar joint hemiresection

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Distal radioulnar joint hemiresection serves as a reconstructive option for severely damaged and painful distal radioulnar joints, where resection arthroplasty or hemi- and total arthroplasty are viable alternatives [2]. The procedure is best suited for post-traumatic patients in whom distal radioulnar joint arthrosis is the primary cause of pain [12]. In cases of traumatic osteonecrosis of the distal ulna, treatment with diagnostic wrist arthroscopy and Bowers hemiresection resulted in an excellent outcome at 12 months after surgery [1]. For elderly patients with distal ulna fractures associated with distal radius fractures, primary excision of the ulnar head is a reliable and safe procedure that permits early mobilization and minimizes complications at the distal radio-ulnar joint [39].

Biomechanical considerations are critical to maintaining stability; resection just distal to the triangular fibrocartilage complex insertion avoids detachment and potential distal radioulnar joint instability [73]. Compared with Darrach resection, which created extreme forearm instability with ulnar movement of the radius, the hemiresection interposition arthroplasty demonstrated significantly less instability [191]. While a period of conservative treatment for distal radioulnar joint instability will not hinder future outcomes if surgical intervention is pursued later, the decision for reconstruction of chronic instability at both proximal and distal radioulnar joints may be difficult due to unpredictable outcomes [10, 6].

Prosthetic replacement of the distal ulna restores stability in patients with partial or complete excision of the ulnar head or distal radioulnar joint arthrosis and corrects radioulnar impingement [26]. When appropriate patient selection criteria are met, partial and total ulnar head replacement typically produce reliable results [80]. Although the introduction of ulnar head and total radio-ulnar joint prostheses has provided a new method, there is presently no evidence that these implants produce long-lasting results [43]. 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 [14].

Anatomy & Pathophysiology

Bony Anatomy and Kinematics

The conventional concept of the forearm as part of either the elbow or wrist is outdated; a more relevant concept describes the forearm as a triarticular complex where the proximal, middle, and distal radioulnar joints work together to provide stability, mobility, and load transfer [56]. The ulnar styloid extends 2 to 6 mm distal to the ulnar head [46]. During forearm rotation, the ulnar head at its articulation with the sigmoid notch moves from dorsal and distal in full pronation to proximal and palmar in full supination [46]. The distal radioulnar joint allows dorsopalmar translation of about 1 cm with the forearm in neutral position [46]. Articular surface contact in the shallow sigmoid notch accounts for about 20% of distal radioulnar joint stability [46]. The contact area of the distal radioulnar joint increases during wrist flexion and decreases during wrist extension and ulnar deviation [103]. Dynamic CT imaging shows promise for evaluating the distal radioulnar joint during wrist motion [55].

Ligaments and Soft Tissue Stabilizers

The triangular fibrocartilage complex includes the dorsal and volar radioulnar ligaments, ulnar collateral ligament, meniscal homologue, articular disc, ulnolunate ligaments, ulnotriquetral ligaments, and extensor carpi ulnaris sheath [46]. The deep fibers of the triangular fibrocartilage complex attach ulnarly at the head of the ulna called the “fovea” [46]. The superficial fibers of the triangular fibrocartilage complex attach to the ulnar styloid tip where it joins with the ulnar collateral ligaments [46]. Most of the distal radioulnar ligaments and the ulnocapitate ligament attach to the fovea at the base of the ulnar styloid [46]. The articular disc passes from the distal margin of the sigmoid notch to the fovea at the base of the ulnar styloid [46]. The thickness of the articular disc has an inverse relationship to the amount of ulnar variance [46]. The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint [100].

Radio-ulno-carpal joint stability rests on the proper function of eight different anatomical structures and is modified by the degree of forearm rotation, rather than relying solely on the triangular fibrocartilage complex [54]. Each ligament stabilizing the distal radioulnar joint contributes to joint stability depending on the direction (palmar or dorsal) and different positions of the wrist and forearm [111]. In the event the radial head is resected, the central band of the interosseous membrane provides 71% of the stiffness to the forearm [3], while the triangular fibrocartilage complex contributes 8% of the stiffness [3].

Biomechanics and Load Distribution

Loads applied to the distal radiocarpal and ulnocarpal joints are distributed about 80% to the distal radius and 20% to the ulna [46]. All wrists have similar loading across the distal ulna regardless of ulnar variance, while pronation relatively increases loading across the distal ulna [99]. Axial loading of the wrist increases ulnar variance [93]. Increasing ulnar variance by 2.5 mm dramatically increases the load borne by the distal ulna [59]. Radial lengthening beyond the native length was not detrimental to radial loading and further reduced distal ulnar loading [110]. Achieving at least native ulnar variance seems to be appropriate to restore normal biomechanical loading based on in vitro study findings [110].

Pathomechanics and Injury Mechanisms

Longitudinal dissociation of the radius and ulna requires an axial loading force that disrupts the radial head, interosseous ligament complex, and distal radioulnar joint [3]. In longitudinal radioulnar dissociation, the radius can migrate proximally, which may lead to dysfunction of the distal radioulnar joint with positive ulnar variance or impingement of the remaining proximal radius [3]. The mechanism responsible for ulnar styloid fractures and triangular fibrocartilage complex tears with distal radius fractures is believed to be an avulsion through ligamentous attachments between the distal radius and the ulna [69]. Either bending or axial compression forces combined with a torsional force may increase the stresses across the distal radioulnar joint, leading to an avulsion of the ulna or radial styloid [69].

A fracture of the distal radius interferes with the biomechanical integrity of the wrist, limiting range of motion and affecting hand muscle strength [85]. Rotational malalignment of the wrist has significant effects on carpal, distal radial and distal radioulnar joint measurements [86]. The distal radioulnar joint has been described as 'inherently unstable' [66]. Pathologic instability of the distal radioulnar joint can be primary, post-traumatic or post-surgical and occur in a variety of directions [66]. Reconstructed animation from four-phase grip MRI demonstrated impairment of the articular disc and longitudinal instability of the distal radioulnar joint simultaneously [15]. The wrist's position and the direction of radial translation seem to alter the effectiveness of stabilization by reconstructing the interosseous membrane's distal oblique bundle [87].

Classification

DRUJ Injury and Instability

Fernandez: This classification defines combinations of distal radioulnar joint injuries in distal radius fractures to guide treatment [33]. Type I injuries are stable, featuring articular congruity and intact or minimally disrupted radioulnar ligaments, and are treated conservatively [33]. Type II injuries remain unstable despite adequate distal radius reduction, often involving large triangular fibrocartilage complex tears or basistyloid ulnar fractures, and require surgical intervention [33]. Type III injuries involve disruption of the joint surface at the sigmoid notch or ulnar head, necessitating reduction and stabilization [33]. Joint stability depends on the integrity of the sigmoid notch and the dorsal and volar radioulnar ligaments of the triangular fibrocartilage complex, including their insertion on the fovea [33].

Other Considerations: Acute dislocations and subluxations are categorized into simple and complex types based on associated injury patterns [29]. Distal radioulnar joint instability is an underestimated lesion requiring systematic clinical examination and imaging for detection [31]. Clinical assessment alone following a distal radius fracture is not reliable for detecting instability [18]. Pathologic instability can be primary, post-traumatic, or post-surgical and may occur in various directions [66].

TFCC Classification

Palmer: This system classifies triangular fibrocartilage complex tears into Class 1 (traumatic) and Class 2 (degenerative) [158]. Class 1A tears are central perforations with a low risk of distal radioulnar joint instability [158]. Class 1B tears are ulnar avulsions, with or without distal ulnar fracture, and carry a high risk of instability [158]. Class 1C tears are distal avulsions with a high risk of instability [158]. Class 1D tears are radial avulsions, with or without sigmoid notch fracture, and carry a high risk of instability [158]. The proximal component consists of the distal radioulnar ligaments and the strong foveal attachment of the ligamentum subcruentum [158]. Tearing of this proximal component renders the distal radioulnar joint unstable [158].

Associated Fracture Classifications

Bado: This system distinguishes four types of Monteggia lesions based on mechanism, treatment, and results [61]. Type I involves an ulnar diaphysis fracture at any level with anterior angulation and anterior radial head dislocation [61]. Type II involves an ulnar diaphysis fracture with posterior angulation and posterolateral radial head dislocation [61]. Type III involves an ulnar metaphysis fracture with lateral or anterolateral radial head dislocation [61]. Type IV involves fractures of the proximal third of the radius and ulna at the same level with anterior radial head dislocation [61].

Frykman: This classification identifies individual involvement of the radiocarpal and radioulnar joints and the presence or absence of an ulnar styloid process fracture [58]. Early classifications of distal radial fractures were based on fracture line, direction and degree of displacement, extent of articular involvement, and distal radioulnar joint involvement [58].

Other Considerations: A new intra-articular distal radius fracture classification was proposed based on the affection condition of the volar or dorsal side using a machine learning clustering method [162].

Clinical Presentation

Symptoms and Functional Deficits

Disorders of the distal radioulnar joint (DRUJ) are a common source of ulnar-sided wrist pain [17]. Untreated injuries can give rise to long-lasting complaints [11], while chronic instability leads to chronic functional impairment, pain, and arthritis if left untreated [149]. Dysfunction is also a frequent source of persistent complaints after distal radial malunions [59]. Characteristic symptoms include pain, decreased forearm rotation, decreased grip strength, and instability [59]. In symptomatic failed distal ulna resections, patients present with incapacitating pain over the distal stump of the ulna, aggravated by forearm rotation and grip [57]. These patients also report a sensation of instability and grip weakness [57]. Painful grinding and mechanical limitations to forearm rotation lead to painful disuse of the upper extremity in these cases [57].

Forearm rotation in both pronation and supination is reduced as soon as 10 to 20 degrees of distal radial deformity occurs in the palmar or dorsal direction [34]. Combined deformities of the distal radius are more likely to result in a clinically important loss of forearm rotation [62].

Physical Examination and Diagnostic Challenges

Diagnosis of DRUJ instability is made clinically and corroborated by imaging studies, with a thorough history and physical examination serving as the foundation [70]. Determining the etiology of ulnar-sided wrist pain is often challenging due to overlapping history and physical examination findings [156]. A detailed history, systematic physical examination with provocative maneuvers, and appropriate diagnostic imaging are essential for diagnosis [156]. There is substantial surgeon-to-surgeon variation in interpreting MRI signal changes and arthroscopic findings in the distal radioulnar ligaments and central disc [67]. This variation raises concerns about overdiagnosis and overtreatment versus underdiagnosis [67]. Post-traumatic abnormality of the DRUJ presents a therapeutic challenge, primarily due to failure to diagnose injuries early, resulting in chronic disorders [32].

Imaging and Diagnostic Modalities

Standard well-positioned radiography is always the appropriate first step in any imaging evaluation of the wrist [131]. Computed tomography with multiplanar reformatting is the most helpful test for assessing congruity of the DRUJ after trauma [131]. Imaging the DRUJ requires knowledge of the complex bony, muscular, and ligamentous anatomy that contribute to this unique joint [131]. Four-phase grip MRI should be of value in investigating dynamic pathophysiology causing ulnar wrist pain [15]. MRI-detectable carpal lesions at the time of a radial fracture are common, but only a few of them seem to decompensate later, give symptoms, and become of therapeutic relevance [64].

The Bald ulnar head test is performed under general anaesthesia before stabilising the distal radius fracture [130]. In this test, the hand is forced into dorsiflexion to reproduce maximum fracture displacement [130]. Fluoroscopy using a lateral projection assesses whether any carpal bones project over the dome of the ulnar head in a sector created between the extensions of the cortices of the distal ulna [130].

Injury Patterns and Mechanisms

Acute dislocations and subluxations of the DRUJ may be isolated phenomena or occur in association with fractures of the radial head, fractures of the distal part of the radius, fractures of both bones of the forearm, or dislocations of the elbow [29]. The reported long-term outcome of acute DRUJ dislocations and subluxations has not always been ideal [29]. The frequency of persistent pain, limitation of motion, and recurrent instability in DRUJ injuries has prompted a closer examination of the patterns of injury that occur at this joint [29].

Longitudinal dissociation of the radius and ulna requires an axial loading force that disrupts the three main stabilizers of the forearm: the radial head, interosseous ligament complex, and DRUJ [3]. This pattern of longitudinal dissociation injury is often referred to as the "terrible triad" [3]. In longitudinal radioulnar dissociation, soft tissue structures are injured in addition to the radial head, leaving no structures competent to provide forearm stability [3]. The central band of the interosseous membrane provides a significant amount (71%) of the stiffness to the forearm in the event the radial head is resected [3]. The triangular fibrocartilage complex contributes 8% of the stiffness to the forearm [3].

DRUJ injuries are classified by stability: * Type I: Stable, meaning there is articular congruity and the radioulnar ligaments are intact or minimally disrupted [33]. * Type II: Unstable despite an adequate reduction of the distal radius and require surgical intervention [33]. * Type III: Have the potential to be unstable and include disruption of the joint surface at the sigmoid notch or the ulnar head [33].

Stability of the DRUJ depends on the integrity of the sigmoid notch and the dorsal and volar radioulnar ligaments of the triangular fibrocartilage complex, and their insertion site on the fovea [33].

Positive ulnar variance or protrusion of the ulna distal to its normal articulation with the ulnar notch of the radius can be caused by malunited Colles fracture, malunion or nonunion of the radius, and cessation or abnormality of growth of the distal radius [59]. Radioulnar arthrosis has been found to be more common than radiocarpal arthrosis [59]. Approximately 70% of the patients who developed radioulnar arthrosis require surgical intervention [59]. Only 6 mm of radial shortening has been shown to cause DRUJ dysfunction [59]. The exception to conservative management is early marked subluxation of the DRUJ blocking forearm rotation, which requires urgent reduction [9].

Investigations

Clinical Assessment and Diagnostic Principles

Diagnosis of distal radioulnar joint (DRUJ) instability is established clinically and corroborated by imaging, with a thorough history and physical examination serving as the foundation [70]. Because DRUJ instability is often an underestimated lesion, systematic clinical examination and imaging are required for detection [31]. Surgeon-to-surgeon variation in interpreting MRI signal changes and arthroscopic findings of the distal radioulnar ligaments and central disc is substantial, raising concerns regarding overdiagnosis and overtreatment versus underdiagnosis [67].

Plain Radiography

Conventional radiography is the first imaging modality to exclude or diagnose wrist pathology; when inconclusive, high-resolution 3 Tesla MRI is advised [141]. Tangential views of the articular surface of the distal radius in the antero-posterior and medio-lateral directions have been described to aid in open reduction and internal fixation of fractures [37]. However, previously reported radiographic guidelines are only moderately accurate for predicting DRUJ instability in Galeazzi fractures [171], and the use of radiological parameters to determine management or act as surrogates for successful treatment in distal radius fractures remains a concern [185].

CT

CT may clarify fractures of the sigmoid notch and is helpful in assessing DRUJ instability [46]. Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction can be obtained by gradual lengthening of the radius, as assessed by computed tomography [7].

MRI

Improvements in imaging techniques have increased the usefulness of MRI in evaluating the DRUJ, especially tears of the triangular fibrocartilage complex (TFCC) [46]. Reconstructed animation from four-phase grip MRI demonstrates impairment of the articular disc and longitudinal instability of the distal radioulnar joint simultaneously, providing value in investigating dynamic pathophysiology causing ulnar wrist pain [15]. In young subjects, MRI remains valuable for diagnosing ulnar detachment, although the ability to distinguish between proximal and distal laminae remains questionable [159]. MRI should be used to validate radiographs that appear reverse oblique, as the true inclination might differ, thereby removing one possible contraindication to ulnar shortening [161]. In a case of volar dislocation of the ulna head, MRI demonstrated a tear in the triangular fibrocartilage with disruption of its radial attachment and fluid within the distal radio-ulnar joint [173].

While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy [170]. MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few decompensate later to become symptomatic and of therapeutic relevance [64]. Consequently, MRI imaging should not be treated in isolation without correlating with the patient’s symptoms, and patients should be prepared for a high likelihood of asymptomatic TFCC changes on routine wrist MRI [177]. Future in-vivo studies of the distal oblique bundle using MRI in patients with distal radioulnar joint pathologies may reveal its role in distal radioulnar joint stability [163].

Arthroscopy

Arthroscopy is the gold standard for detection of TFCC tears [48]. It allows accurate diagnosis of readily seen lesions, such as those in the central portion of the fibrocartilaginous disc and carpal bone osteocartilaginous lesions [46]. However, some peripheral ligament and cartilage damage may be more difficult to show with arthroscopy [46]. Specific arthroscopic tests include the trampoline test, which assesses TFCC resiliency by balloting the central portion with a small probe [48]; the hook test, which demonstrates peripheral detachment of the TFCC [48]; and the suction test, which shows laxity of the TFCC when peripherally scarred in or foveal detachment when the DRUJ is clinically unstable [48].

Treatment

Non-Operative

Conservative management is indicated for Type I distal radioulnar joint injuries, which present with articular congruity and intact or minimally disrupted radioulnar ligaments [33]. In broader clinical scenarios, surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of cases, with cast immobilization being the most common intervention at 41% (247 of 607) [21]. A period of conservative treatment for distal radioulnar joint instability does not hinder future outcomes if surgical intervention is pursued later after symptomatic improvement is not achieved with conservative means [10].

Operative

Indications: Surgical intervention is required for Type II injuries, which remain unstable despite adequate reduction of the distal radius, and Type III injuries, which involve disruption of the joint surface at the sigmoid notch or ulnar head [33]. Early marked subluxation of the distal radioulnar joint that blocks forearm rotation necessitates urgent reduction [9]. Distal ulnar resection is best suited for post-traumatic patients in whom distal radioulnar joint arthrosis is the primary cause of pain [12]. If no arthrosis is present, surgical reconstruction can restore stability in more active patients or when conservative management fails [116].

Surgical Approach / Technique: For Type III injuries, reduction and stabilization are required [33]. Indirect ulnar shortening by distraction through the distal radius fracture site provides a strategy for managing persistent distal radioulnar joint instability during volar plating, obviating the need for prolonged immobilization or altered postoperative protocols [180]. Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction can be obtained by gradual lengthening of the radius [7]. Primary excision of the ulnar head for distal ulna fracture associated with distal radius fracture is a reliable and safe procedure for elderly patients, permitting early mobilization and minimizing complications at the distal radioulnar joint [39]. Double bone forearm osteotomy in adolescence brought long-lasting functional improvement and provided long-term correction of distal radioulnar and radiocarpal subluxations [4]. Surgical reconstruction options for chronic instability include the creation of a radioulnar tether extrinsic to the joint, extensor retinaculum capsulorrhaphy, the creation of an indirect connection between the radius and ulna via an ulnocarpal sling or tenodesis procedure, and reconstruction of the volar and dorsal ligaments with tendon graft [116]. In rheumatoid arthritis cases, meticulous soft tissue reconstruction and extensor carpi ulnaris rebalancing is paramount to the success of any operation involving the distal radioulnar joint [90]. The ulnar limb of the extensor retinaculum is used for dorsal capsular reconstruction and is sutured over the distal ulna palmar to the reduced extensor carpi ulnaris tendon [90]. Extensor carpi radialis longus to extensor carpi ulnaris transfer is indicated in patients with metacarpophalangeal ulnar drift, a passively correctable wrist radial deviation deformity, and a spared radiocarpal joint [90]. This transfer is also useful in patients who lack the ability or can only weakly actively ulnar deviate the wrist [90].

Implant Selection: Distal radioulnar joint arthroplasty improved functional outcomes in both implant groups, but reoperations were frequent [5]. Distal ulna implant arthroplasty reduces pain and improves function in patients with distal radioulnar joint instability, arthrosis, or both [78]. Prosthetic replacement of the distal ulna restored stability to the distal radioulnar joint in patients with partial or complete excision of the ulnar head or distal radioulnar joint arthrosis and corrected radioulnar impingement [26]. Over short-term follow-up, ulnar head replacement and sigmoid notch resurfacing arthroplasty provides a feasible option for distal radioulnar joint arthritis, resulting in substantial improvements in pain and function [19]. Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm in the scarred wrist [79]. The Herbert ulnar head prosthesis was a safe method of treatment and provided satisfactory midterm results for selected cases of distal radioulnar joint disorders [165]. There is presently no evidence that ulnar head and total radio-ulnar joint prostheses produce long-lasting results [43].

Other Considerations: The Bowers hemiresection procedure resulted in an excellent outcome at 12 months after surgery for traumatic osteonecrosis of the distal ulna [1]. Distal ulnar resection results in a significant reduction in wrist pain but a reduction of wrist flexion [16]. The Darrach procedure provides reliably good long-term subjective and objective results for the treatment of a symptomatic distal radioulnar joint after a distal radius fracture [77]. Ligament reconstruction is contraindicated in the presence of distal radioulnar joint arthrosis, length discrepancies between the distal ulna and radius, ulnocarpal impaction, or malunion [116]. 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 [175]. The diagnosis of symptoms as secondary to a failed distal ulna resection and subsequent radio-ulnar impingement or instability is clinical, supported by history, physical exam, and plain radiographs [57]. A symptomatic failed distal ulna resection typically presents with incapacitating pain over the distal stump of the ulna aggravated by forearm rotation and grip, a sensation of instability, and complaints of grip weakness [57]. If decreased forearm rotation persists after a distal radioulnar joint procedure, the problem may lie in the proximal radioulnar joint of the elbow, which may require debridement or radial head resection [90].

Complications

Instability and Impingement: Serious potential postoperative complications following excision of the distal ulna include instability and potentially painful impingement of the residual distal ulnar stump [178]. The Sauvé-Kapandji procedure is not free of possible complications, such as nonunion or delayed union of the arthrodesis, fibrous or osseous union at the pseudoarthrosis, and painful instability at the proximal ulna stump [146].

Functional Deficits and Range of Motion: There is a significant reduction in wrist pain but a reduction of wrist flexion following extensor synovectomy and excision of the distal ulna in rheumatoid arthritis [16]. Injury to the distal radioulnar joint may result in a functional loss of forearm rotation [69]. Isolated limitation of forearm rotation is well compensated for by shoulder motion, so the functional deficit may not appear substantial [69].

Assessment and Diagnostic Challenges: Subacute distal radioulnar joint subluxation after a distal radius fracture may occur early, typically under 2 weeks after the original injury and is easily overlooked [179]. The presence of untreated triangular fibrocartilage complex tears has been found to correlate with objective and subjective distal radioulnar joint instability at 1 year [151]. In a prospective longitudinal study, 45% of patients with distal radius fractures and untreated complete triangular fibrocartilage complex injuries had laxity of the distal radioulnar joint at 13–15 years [151]. Patients with distal radius fractures and untreated complete triangular fibrocartilage complex injuries had worse grip strength, and trends of worse Gartland and Werley and QuickDASH scores compared to patients with stable distal radioulnar joints, though this difference did not reach statistical significance [151].

Natural History and Long-term Outcomes: The natural history of untreated Madelung deformity remains poorly understood in the absence of long-term prospective cohort studies [132]. Progressive arthrosis and instability of the distal radioulnar joint, radiocarpal arthrosis, or ulnocarpal abutment may eventually occur as Madelung deformity progresses [132]. Attritional rupture of finger extensor tendons has been reported as a rare complication of nonsurgical management of severe and symptomatic Madelung deformity [132]. In cases of severe and symptomatic Madelung deformity, attritional rupture of finger extensor tendons is caused by repeated mechanical irritation of the digital extensor tendons over the dorsal prominence of the subluxated ulnar head [132]. The ulnar-sided digital extensor tendons are most commonly involved in attritional rupture associated with Madelung deformity [132]. Less than 4% of patients treated for distal radius fractures had further surgery for persistent symptomatic distal radioulnar joint instability [151]. The natural history of patients with distal radius fractures and distal radioulnar joint instability seems fairly benign, with the majority improving with time and having good function without requiring further procedures [151]. There is evidence that support gradual improvement of ulnar-sided wrist symptoms up to 1 year in patients with operatively managed distal radius fractures [151]. Combined radioulnar osteotomy for Madelung deformity provided satisfactory and encouraging results without compromising the surgical future of the wrist, though longer follow-up is required to assess recurrence or long-term degenerative consequences [22].

Other Considerations: Adverse outcomes such as radial overgrowth should be discussed when considering surgical options for Kienböck disease in the skeletally immature patient [188]. Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening [190].

Recovery

Light activity (weeks): Wrist function recovers after an initial decrease from week 8 onward in patients undergoing ulnar shortening with the UOL [53].

Full activity (months): No specific month range for full activity return is provided in the evidence.

Complete recovery / outcome plateau (months): No specific month range for complete recovery or outcome plateau is provided in the evidence.

Rehabilitation protocol: No specific rehabilitation protocol details, such as PT phasing, immobilisation duration, or weight-bearing progression, are provided in the evidence.

Functional milestones: An improvement in range of motion, grip strength, and VAS with restoration of the radioulnar length relationship was observed in both cohorts of ulnar shortening versus distal radius corrective osteotomy [169]. At three years' follow-up, a patient with centralization of ulna for infected nonunion of radius had an infection-free forearm with a stable wrist joint and good hand grip, lacking the last 10 degrees of palmar and dorsiflexion [193].

Other Considerations: Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck’s disease [192]. Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis following corrective osteotomy for distal radius malunion [28].

Key Evidence

  • [L4] Treatment with diagnostic wrist arthroscopy and Bowers hemiresection resulted in an excellent outcome at 12 months after surgery. [1] (10.1016/j.jhsa.2021.05.019)
  • [L5] Severely damaged and painful distal radioulnar joints can be reconstructed by resection arthroplasty or by hemi- or total arthroplasty. [2] (10.1016/j.hcl.2020.07.008)
  • [L5] [3] (10.1016/j.hcl.2007.01.005)
  • [L4] Double bone forearm osteotomy in adolescence brought long-lasting functional improvement and provided long-term correction of distal radioulnar and radiocarpal subluxations. [4] (10.1054/jhsb.1999.0304)
  • [L4] Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. [5] (10.1016/j.jhsa.2022.02.014)
  • [Case_report] The decision for reconstruction of chronic instability at both proximal and distal radioulnar joints may be difficult due to unpredictable outcomes. [6] (10.1007/s00402-007-0456-y)
  • [L4] Given a relatively intact bony contour of the distal radioulnar joint, congruent reduction of the distal radioulnar joint can be obtained by gradual lengthening of the radius. [7] (10.1177/1753193408100955)
  • [L5] The exception is early marked subluxation of the distal radioulnar joint blocking forearm rotation, which requires urgent reduction. [9] (10.1177/17531934221140238)
  • [L5] A period of conservative treatment for distal radioulnar joint instability will not hinder future outcomes if symptomatic improvement is not achieved with conservative means and surgical intervention is then pursued at a later date. [10] (10.1016/j.arthro.2022.01.018)
  • [L5] Untreated distal radioulnar joint (DRUJ) injuries can give rise to long lasting complaints. [11] (10.2174/1874325001206010204)
  • [L4] The procedure is best suited for post-traumatic patients in whom distal radioulnar joint arthrosis is the primary cause of pain. [12] (10.1054/jhsb.1999.0288)
  • [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. [14] (10.1016/j.hcl.2010.05.004)
  • [L4] Reconstructed animation from four-phase grip MRI demonstrated impairment of the articular disc and longitudinal instability of the distal radioulnar joint simultaneously and should be of value in investigating dynamic pathophysiology causing ulnar wrist pain. [15] (10.1177/1753193413476979)
  • [L4] There is a significant reduction in wrist pain but a reduction of wrist flexion. [16] (10.1016/j.jhsa.2010.04.034)
  • [L5] Disorders of the distal radioulnar joint are a common source of ulnar-sided wrist pain, but increased understanding of anatomy and pathology has facilitated accurate diagnosis and successful treatment in most cases. [17] (10.5435/00124635-199503000-00005)
  • [L3] Clinical assessment alone of distal radioulnar joint instability following a distal radius fracture appears not to be reliable. [18] (10.1177/17531934211016668)
  • [L4] Over short-term follow-up, the procedure provides a feasible option for distal radial ulnar joint arthritis, resulting in substantial improvements in pain and function. [19] (10.1177/1753193419850116)
  • [L4] This report describes the first prosthetic hemiarthroplasty and full arthroplasty for the distal radioulnar joint, presenting two case reports with 24-year follow-up to describe experience and design problems in the hope that future developments may avoid past failures. [20] (10.1016/j.hcl.2012.08.024)
  • [L4] Surgeons recommended distal radioulnar joint treatment in 67% (404 of 607) of the scenarios, most commonly cast immobilization in 41% (247 of 607). [21] (10.1177/17531934261449057)
  • [L4] Combined radioulnar osteotomy restored anatomy to as near normal as possible and provided satisfactory and encouraging results without compromising the surgical future of the wrist, though longer follow-up is required to assess recurrence or long-term degenerative consequences. [22] (10.1007/s00264-008-0711-z)
  • [L1] A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis, and the expected benefit of preserving the midcarpal joint was not observed. [23] (10.1177/1753193418778471)
  • [L4] Good clinical results observed in patients 10 years after radial shortening osteotomy are likely to remain stable at 20 years after surgery. [24] (10.1016/j.jhsa.2025.04.018)
  • [L4] This distal radio-ulnar arthroplasty is less invasive and preserves the bone and ligaments. [25] (10.1016/j.otsr.2016.01.012)
  • [L4] Prosthetic replacement of the distal ulna restored stability to the DRUJ in patients with partial or complete excision of the ulnar head or DRUJ arthrosis and corrected radioulnar impingement. [26] (10.1016/j.jhsa.2006.12.004)
  • [L4] Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis. [28] (10.1177/1753193409357373)
  • [L5] [29] (10.2106/00004623-199506000-00017)
  • [L5] Distal radioulnar joint instability is often an underestimated lesion requiring systematic clinical examination and imaging for detection. [31] (10.1007/s00402-020-03371-0)
  • [L5] Post-traumatic abnormality of the distal radioulnar joint (DRUJ) presents a therapeutic challenge, primarily due to failure to diagnose injuries early resulting in chronic disorders. [32] (10.1016/s0020-1383(02)00286-3)
  • [L5] [33] (10.1016/j.hcl.2021.02.011)
  • [L5] Forearm rotation in both pronation and supination is reduced as soon as 10 to 20 degrees of distal radial deformity occurs in the palmar or dorsal direction. [34] (10.1177/17531934221117448)
  • [L4] The authors describe two new radiographic views of the wrist joint which show the tangential views of the articular surface of the distal radius in the antero-posterior and the medio-lateral directions. [37] (10.1016/s0020-1383(01)00155-3)
  • [L4] Primary excision of the ulnar head for distal ulna fracture associated with distal radius fracture is a reliable and safe procedure for elderly patients, which permits early mobilization and minimizes complications at the distal radio-ulnar joint. [39] (10.1177/1753193413504160)
  • [L3] Objective and subjective outcomes are noninferior to those of a dorsal or volar approach. [42] (10.1177/1558944718787290)
  • [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. [43] (10.1054/jhsb.2002.0815)
  • [L4] In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. [53] (10.1177/1558944717702465)
  • [L5] The radio-ulno-carpal joint (RUCJ) is a complex multifactorial phenomenon where stability rests on the proper function of eight different anatomical structures and is modified by the degree of forearm rotation, rather than relying solely on the TFCC. [54] (10.1177/17531934211042316)
  • [L4] Dynamic CT imaging shows promise for evaluating the distal radioulnar joint during wrist motion. [55] (10.1177/17531934251397297)
  • [L5] The conventional concept of the forearm as part of either the elbow or wrist is outdated; a more relevant concept describes the forearm as a triarticular complex where the proximal, middle, and distal radioulnar joints work together to provide stability, mobility, and load transfer. [56] (10.1177/1753193410396976)
  • [L4] [57] (10.1055/s-0032-1333062)
  • [L5] [58] (10.1016/0020-1383(95)90125-6)
  • [L5] [61] (10.1016/j.hcl.2007.01.008)
  • [L5] Combined deformities are more likely to result in a clinically important loss of forearm rotation, and this should be considered when choosing the optimal management of patients with displaced distal radial fractures. [62] (10.1016/j.jhsa.2009.02.011)
  • [L3] MRI-detectable carpal lesions at the time of the radial fracture are common, but only a few of them seem to decompensate later, give symptoms and became of therapeutic relevance. [64] (10.1007/s00402-015-2357-9)
  • [L5] [66] (10.1177/1753193414527052)
  • [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. [67] (10.1177/17531934241254705)
  • [L5] [69] (10.1016/s0749-0712(21)00159-1)
  • [L5] Diagnosis of DRUJ instability is made clinically and corroborated by imaging studies, with a thorough history and physical examination serving as the foundation. [70] (10.1016/j.hcl.2020.07.004)
  • [L4] Resection just distal to the TFCC insertion avoids TFCC detachment and potential distal radioulnar joint instability. [73] (10.1054/jhsb.2001.0591)
  • [L1] Adult patients with an acceptably reduced intra-articular distal radial fracture have better functional outcomes for 12 months when treated operatively instead of nonoperatively. [75] (10.2106/jbjs.20.01344)
  • [L4] The Darrach procedure provides reliably good long-term subjective and objective results for the treatment of a symptomatic DRUJ after a distal radius fracture. [77] (10.1016/j.jhsa.2012.08.044)
  • [L4] Distal ulna implant arthroplasty reduces pain and improves function in patients with distal radioulnar joint instability, arthrosis, or both. [78] (10.1016/j.jhsa.2012.03.026)
  • [L4] Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm. [79] (10.1055/s-0038-1670681)
  • [L4] When appropriate patient selection criteria are met, partial and total ulnar head replacement typically produce reliable results. [80] (10.1177/1753193417693177)
  • [L4] The article recommends simplifying decision-making between treatment options based on author experience and literature evidence, noting that wrist denervation is a first choice for patients with good range of motion, while total wrist arthrodesis remains the gold standard for salvage despite high complication rates. [82] (10.1016/j.hcl.2005.03.005)
  • [L3] These results supported the initial hypothesis that a fracture of the distal radius interferes with the biomechanical integrity of the wrist, limiting range of motion and affecting hand muscle strength. [85] (10.1177/1758998315574352)
  • [L4] Rotational malalignment of the wrist has significant effects on carpal, distal radial and distal radioulnar joint measurements. [86] (10.1177/1753193408090393)
  • [L5] However, the wrist's position and the direction of radial translation seem to alter the stabilization's effectiveness. [87] (10.1016/j.otsr.2020.03.041)
  • [L5] [90] (10.1016/j.hcl.2005.08.009)
  • [L2] Axial loading of the wrist increases ulnar variance. [93] (10.1055/s-0038-1627458)
  • [L5] The results show that all wrists have similar loading across the distal ulna regardless of ulnar variance, while pronation relatively increases loading across the distal ulna. [99] (10.1016/j.jhsa.2014.10.001)
  • [L4] The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint. [100] (10.1177/17531934231168299)
  • [L4] The contact area of the DRUJ increases during wrist flexion and decreases during wrist extension and ulnar deviation. [103] (10.1016/j.jhsa.2015.07.027)
  • [L5] Radial lengthening beyond the native length was not detrimental to radial loading and further reduced distal ulnar loading; achieving at least native ulnar variance seems to be appropriate to restore normal biomechanical loading based on this in vitro study. [110] (10.1016/j.jhsa.2019.03.017)
  • [L5] Each ligament stabilizing the DRUJ contributed to joint stability depending on the direction (palmar or dorsal) and different positions of the wrist and forearm. [111] (10.1055/s-0037-1601367)
  • [L5] [116] (10.1016/j.jht.2016.03.012)
  • [L4] [130] (10.1016/j.injury.2012.02.013)
  • [L5] [131] (10.1016/j.hcl.2010.07.001)
  • [L5] [132] (10.5435/00124635-201306000-00007)
  • [L2] Conventional radiography should be the first imaging modality to exclude or diagnose wrist pathology; when inconclusive, high resolution 3 Tesla MRI is advised. [141] (10.1177/1753193416683876)
  • [L4] [146] (10.1055/s-0032-1333465)
  • [L5] Chronic distal radioulnar joint instability results from various traumatic injuries and can lead to chronic functional impairment, pain, and arthritis if left untreated. [149] (10.1016/j.hcl.2010.05.010)
  • [L5] [151] (10.1177/17531934241268980)
  • [L5] Determining the etiology of ulnar-sided wrist pain is often challenging due to overlapping history and physical examination findings; a detailed history, systematic physical examination with provocative maneuvers, and appropriate diagnostic imaging are essential for diagnosis. [156] (10.5435/jaaos-d-16-00407)
  • [L5] [158] (10.2106/jbjs.rvw.n.00053)
  • [L3] For young subjects, MRI is still valuable, especially in diagnosing ulnar detachment, although the ability to distinguish between proximal and distal laminae remains questionable. [159] (10.1177/17531934221141986)
  • [L4] MRI should be used to validate radiographs in those that appear to be reverse oblique, as the true inclination might be different, thereby removing one possible contraindication to ulnar shortening. [161] (10.1302/0301-620x.99b3.38051)
  • [L3] A new intra-articular distal radius fractures classification was proposed based on the affection condition of volar or dorsal side. [162] (10.1186/s12891-024-08215-1)
  • [L4] Future in-vivo studies of the DOB using MRI in patients with distal radioulnar joint pathologies may reveal its role in the distal radioulnar joint stability. [163] (10.1186/s12891-017-1419-2)
  • [L4] The Herbert ulnar head prosthesis was a safe method of treatment and provided satisfactory midterm results for selected cases of distal radioulnar joint disorders. [165] (10.1016/j.jhsa.2015.06.100)
  • [L3] An improvement in range of motion, grip strength, and VAS with restoration of the radioulnar length relationship was observed in both cohorts. [169] (10.1177/1558944716685831)
  • [L2] While MRI is a useful adjunct for determining the cause of ulnar wrist pathologies, findings are often discordant when compared with diagnostic arthroscopy. [170] (10.1016/j.jhsa.2024.04.015)
  • [L3] Previously reported radiographic guidelines are only moderately accurate for predicting DRUJ instability. [171] (10.1016/j.injury.2016.04.003)
  • [L5] MRI demonstrated a tear in the triangular fibrocartilage with disruption of its radial attachment and fluid within the distal radio-ulnar joint. [173] (10.1016/0020-1383(94)90075-2)
  • [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. [175] (10.1016/j.hcl.2014.12.003)
  • [L4] This highlights the importance of not treating MRI imaging in isolation without correlating with the patient’s symptoms while also preparing patients for a high likelihood of asymptomatic TFCC changes on routine wrist MRI. [177] (10.1177/15589447241277846)
  • [L5] Although outcomes are typically favorable following excision of the distal ulna, serious potential postoperative complications include instability and potentially painful impingement of the residual distal ulnar stump. [178] (10.5435/00124635-201210000-00002)
  • [L4] Subacute DRUJ subluxation after a distal radius fracture may occur early, typically under 2 weeks after the original injury and is easily overlooked. [179] (10.1177/17531934241308137)
  • [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. [180] (10.1016/j.jhsa.2018.02.030)
  • [L2] This study raises concerns about the use of radiological parameters to determine management and to act as surrogates for successful treatment in patients with a fracture of the distal radius. [185] (10.1302/0301-620x.99b3.35819)
  • [L4] Adverse outcomes such as radial overgrowth should be discussed when considering surgical options. [188] (10.1016/j.jhsa.2018.02.029)
  • [L3] Longer-term studies will be required to ascertain whether the apparent benefits of radial head arthroplasty are offset by late complications of arthroplasty, such as loosening. [190] (10.1007/s11999-013-3331-x)
  • [L5] The Darrach resection created extreme instability of the forearm with ulnar movement of the radius, whereas the hemiresection interposition arthroplasty demonstrated significantly less instability compared with the Darrach results. [191] (10.1054/jhsb.2002.0763)
  • [L4] Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck’s disease. [192] (10.1177/1753193413512222)
  • [L5] At three years' follow-up, the boy had an infection-free forearm with a stable wrist joint and good hand grip, lacking the last 10 degrees of palmar and dorsiflexion. [193] (10.1016/s0020-1383(99)00307-1)

See Also

References

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Section 6 -- Term and Termination.

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For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

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