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Triangular fibrocartilage complex (TFCC) injuries are a common cause of ulnar-side wrist pain and may progress to persistent pain, instability of the distal radioulnar joint, and arthritis if left untreated. Diagnosis and management of these injuries requires a nuanced understanding of features pertinent to the clinical presentation, imaging, and arthroscopic findings for accurate management. Arthroscopic-assisted repair techniques have revolutionized surgical management, providing detailed visualization and facilitating the repair of TFCC injuries and associated pathologies with minimally invasive techniques. In this review, we discuss the anatomy of the TFCC, history and examination of ulnar-sided pathology, imaging findings, and classification schemes and review surgical techniques for the treatment of TFCC injuries. We also touch on pearls and pitfalls of the techniques, complications, and results of treatment.

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PURPOSE: This study compared the biomechanical stability of transosseous repair and transosseous combined with capsular repair techniques to reattach the triangular fibrocartilage complex (TFCC) for distal radioulnar joint instability. METHODS: Eight adult cadaveric upper-extremity specimens were studied. Each underwent peripheral ulnar-sided detachment of the deep and superficial TFCC fibers and repair. Four groups were prepared sequentially: intact TFCC, disrupted TFCC, transosseous repair, and combined transosseous with capsular repair. Forearm rotational torque was measured in three wrist positions: 60° flexion, neutral position, and 60° extension. Maximum dorsal and palmar ulnar translations in response to a 20-N traction load were measured at nine wrist positions after stabilizing the humerus and radius. Measurements were taken before and after TFCC disruption and following repair. RESULTS: Clear instability of the radius relative to the ulna was observed after sectioning the deep and superficial fibers of the TFCC, and stability was markedly improved after reconstruction in all positions. Compared with the normal group, rotational torque was similar between the two repair methods. In the pronation palmar flexion and supination dorsal extension positions, dorsal-palmar translation was smaller in the combined transosseous with capsular repair group than in the transosseous repair-alone group. CONCLUSIONS: Triangular fibrocartilage complex deep fibers are the primary stabilizing structure of the distal radioulnar joint. In this cadaveric study, the combined transosseous with capsular repair technique demonstrated less dorsal-palmar translation compared with the transosseous-alone repair technique. CLINICAL RELEVANCE: Combined transosseous with capsular repair is expected to provide improved postoperative stability for patients with peripheral TFCC tears and distal radioulnar joint instability.

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BACKGROUND: The Sauvé-Kapandji (S-K) method is a surgical procedure performed for chronic deformities of the distal radial ulnar joint (DRUJ). Changes to the joint contact surface from pre- to postoperatively under physiological in vivo conditions have not yet been determined for this useful treatment. The aim of the present study was therefore to compare the articular contact area of the wrist joint between before and after the S-K method for DRUJ disorders. METHODS: The SK method was performed for 15 patients with DRUJ osteoarthritis and ulnar impaction syndrome. We calculated the Mayo Wrist Score as the patient's clinical findings and created 3-dimensional bone models of cases in which the S-K method was performed and calculated the contact area and shift in the center of the contact area using customized software. RESULTS: The Mean modified Mayo Wrist Score improved significantly from 60.3 preoperatively to 80.3 postoperatively (P < 0.01). Scaphoid contact area to the radius increased significantly from 112.6 ± 37.0 mm2 preoperatively to 127.5 ± 27.8 mm2 postoperatively (P = 0.03). Lunate contact area to radius-ulna was 121.3 ± 43.3 mm2 preoperatively and 112.5 ± 37.6 mm2 postoperatively, but this decrease was not significant (P = 0.38). Contact area ratio of scaphoid to lunate increased significantly from 1.01 ± 0.4 preoperatively to 1.20 ± 0.3 postoperatively (P = 0.02). Postoperative translations of the center of the scaphoid and lunate contact areas were decomposed into ulnar and proximal directions. Ulnar and proximal translation distances of the scaphoid contact area were 0.8 ± 1.7 mm and 0.4 ± 0.6 mm, respectively, and those of the lunate contact area were 1.1 ± 1.7 mm and 0.4 ± 1.1 mm, respectively. This study revealed changes in wrist contact area and center of the contact area before and after the S-K method. CONCLUSION: These results may accurately indicate changes in wrist joint contact area from pre- to postoperatively using the S-K method for patients with DRUJ disorder. Evaluation of changes in contact area due to bone surface modeling of the wrist joint using 3DCT images may be useful in considering surgical methods.

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INTRODUCTION: Isolated volar dislocations of the distal radioulnar joint are reported as rare. We observed three such cases over a 12-month period. Literature to date consists of multiple case reports and case series with no structured reviews. There is debate as to incidence, mechanism, investigation, treatment and prognosis. METHODS: A case series and formal systematic review was performed. This included an analysis of the demographics, mechanism, presentation, investigation, treatment and outcome of the cases identified from the wider published series. FINDINGS: In total 99 cases of this injury were identified from 59 papers, with a further 9 cases having an associated ulna styloid fracture. CONCLUSIONS: This is a rare injury, representing up to 0.02% of all bony injuries, which is diagnosed late in 36% of cases. Inability to obtain a true lateral radiograph may contribute to the diagnosis being missed. Computed tomography scans are useful in suspected cases without radiographic confirmation. Acute cases are successfully treated with closed reduction in 78% of cases; however associated soft tissue injuries may need to be surgically addressed. Delayed presentation is more likely to require open surgery and preoperative MRI scans are indicated to aid surgical planning. Chronic instability rarely occurs and may need treatment with reconstruction or salvage. A good, subjective, result is reported in the majority of patients.

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Introduction: There is a lack of methods to objectively evaluate improvement in distal radioulnar joint (DRUJ) instability through treatment. We used ultrasonography to assess DRUJ instability and calculated the minimal detectable change (MDC) in healthy individuals. MDC was used to evaluate post-treatment changes in a patient with triangular fibrocartilage complex (TFCC) injury. Methods: DRUJ instability was evaluated using force-monitor ultrasonography in eight healthy male participants to determine MDC and in a man in his 60s who underwent surgery and rehabilitation for TFCC injury (Palmer classification: type 2C). In the patient, DRUJ instability was measured pre-operatively, 3 months postoperatively, and 1 year post-operatively. Self-reported hand and upper limb functional ability were also recorded. The transducer of the force-monitor ultrasonographic system was used to apply cyclic compressions to the wrists automatically and measure DRUJ displacements. The amount of displacement was calculated using the distance between the radius and ulna before and during cyclic compression to the wrists. The applied pressure was measured as the force to the wrist, and the displacement-to-force ratio was calculated. Results: The 95% confidence MDC95 for radioulnar displacement, displacement force, and displacement-to-force ratio were 0.27-0.31 mm, 0.30-0.59 N, and 0.12-0.15 mm/N, respectively. The patient's post-operative decrease in displacement exceeded the MDC95. DRUJ stability, pain, and use of the affected hand in daily life improved. Discussion: Force-monitor ultrasonography can quantitatively evaluate post-treatment improvement in DRUJ stability over time. MDC for DRUJ instability can assess recovery after treatment or rehabilitation and determine changes resulting from interventions.

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Objective The objective of this article is to evaluate the outcomes and complication rate for Adams-Berger anatomic reconstruction of the distal radioulnar joint (DRUJ), in addition, to determine the role of sigmoid notch anatomy on failure. Methods We conducted a retrospective chart review to evaluate adult patients that had undergone reconstruction of the DRUJ for instability with the Adams-Berger procedure between 1998 and 2015 within our institution with > 24 months follow-up. Charts were reviewed for patient demographics, mechanism of injury, outcome, and complications. Results Ninety-five wrists in 93 patients were included. Mean age at surgery was 37.3 years with 65.2 months follow-up. At the last follow-up, 90.8% had a stable DRUJ, 5.3% did not, and 3.4% had some laxity. Postoperatively, 75.9% described either no pain or mild pain. Grip strength increased while pronosupination decreased. Procedure success was 86.3%, as 12 patients underwent revision at 13.3 months postoperatively. Reconstructive failure was more common in females when an interference screw was utilized for tendon fixation. Age, timing of surgery, type of graft, sigmoid notch anatomy, and previous surgery did not affect revision or failure rate. Conclusion Our findings demonstrate that Adams-Berger reconstruction of the DRUJ provides reliable long-term results with an overall success of 86% at > 5 years follow-up. Level of evidence/Type of study This is a Level IV, therapeutic study.

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BACKGROUND: The interosseous membrane (IOM) and distal radioulnar joint (DRUJ) provide axial stability to the forearm. Our hypothesis was that injury to these structures alters force transmission through the elbow. METHODS: A custom-designed apparatus that applies axial loads from the wrist to the elbow was used to test 10 cadaveric upper limbs under the following simulated conditions (1) intact, (2) DRUJ injury, (3) IOM injury, or (4) IOM + DRUJ injury. IOM injury was simulated by osteotomies of the IOM attachment to the radius, and DRUJ injury was simulated by distal ulnar oblique osteotomy. We applied 160 N of axial force during cyclic and functional range of forearm rotation (40o pronation/40o supination), and force, contact pressure, and contact area through the elbow joint were measured simultaneously. RESULTS: The force across the radiocapitellar joint was significantly higher in the IOM + DRUJ injury and the IOM injury groups than in the intact and DRUJ injury groups. The mean force across the radiocapitellar joint was not significantly different between the intact and DRUJ injury groups or between the IOM + DRUJ injury and the IOM injury groups. Forces across the ulnohumeral joint showed an inverse pattern to those in the radiocapitellar joint. CONCLUSIONS: These findings suggest that injury to the IOM contributes more to the disruption of the normal distribution of axial loads across the elbow than injury to the DRUJ.

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BACKGROUND: Injuries of the interosseous membrane (IOM) of the forearm are frequently unrecognized, difficult to treat, and can result in a devastating sequelae for the wrist and elbow. PURPOSE: The purpose of this review article is to evaluate the dignosis, biomechanics, clinical results, and propose a treatment approach to this rare complex entity. METHODS: The biomechanical and clinical literature is reviewed. A treatment approach is described based on the known biomechanics and clinical experience of the senior author (T. W. W.). RESULTS: Multiple different reconstructive methods have been proposed for the treatment of both acute and chronic IOM injuries. The results of the published series are reviewed. IOM injuries can have reasonable outcomes particularly if diagnosed and treated early. CONCLUSION: There are multiple methods for treating patients with IOM injuries. Physicians should be highly suspicious about this injury when a patient presents with a highly displaced radial head fracture associated with wrist pain. Treatment with reconstruction of the cerebral band of the IOM with radial head replacement (do not overstuff) and temporary uploading the construct with K-wires from the ulna to the radius will give the most predictable results.

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Background Studies have established an increased risk of radiocarpal joint posttraumatic arthritis in patients with displaced intra-articular fractures of the distal radius, although this phenomenon has yet to be evaluated in the distal radioulnar joint (DRUJ). Purpose We hypothesized that patients with displaced intra-articular fractures of the sigmoid notch would have a higher prevalence of DRUJ arthritis and greater upper extremity dysfunction after operative treatment of distal radius fractures compared with fractures without sigmoid notch involvement. We also hypothesized that the degree of sigmoid notch incongruity would be correlated with the grade of DRUJ arthritis and the severity of upper extremity dysfunction. Patients and Methods A retrospective review was conducted on surgically treated patients with distal radius fractures with pre- and/or postoperative computed tomography (CT) scans. Patients were divided into groups based on presence or absence of fracture extension into the sigmoid notch. Within the sigmoid notch group, postoperative CT scans were used to measure sigmoid notch fracture step-off and diastasis (mm), as well as volar or dorsal DRUJ subluxation (%). Patients were administered Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires and radiographs were obtained to grade DRUJ arthritis using the Kellgren-Lawrence (KL) radiographic criteria. Results Thirty-three patients were included (19 with sigmoid notch involvement and 14 without) with an average radiographic follow-up of 6.3 years (range: 3.5-10.1 years). DASH scores were available for all patients, and radiographic follow-up was available in 24 patients (73%). A trend toward higher grade of DRUJ arthritis and poorer average DASH was found in those with sigmoid notch involvement, but was not statistically different. In the sigmoid notch group there were poorer DASH scores in patients with coronal step-off > 1.0-mm (p < 0.05). There were no significant correlations between sigmoid notch step-off, diastasis or DRUJ subluxation and either KL grade of arthritis or DASH scores. Conclusion Fractures involving the sigmoid notch did not appear to have a greater prevalence of DRUJ posttraumatic arthritis in operatively treated patients at greater than 6 years of follow-up. Postoperative sigmoid notch step-off, diastasis or DRUJ subluxation had a minimal effect on upper extremity function, but fractures with a coronal step-off of > 1.0-mm exhibited higher levels of upper extremity dysfunction. Level of Evidence Prognostic, Level III-Case control.

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The purpose of this study was to measure the position of the radius relative to the ulna through a complete range of elbow flexion and forearm rotation. Twenty cadaveric upper extremities were mounted on a testing jig that allowed simultaneous control of elbow flexion and forearm rotation. The longitudinal position of the radius relative to the ulna was measured using a three-dimensional digitizer at full pronation, mid-pronation (45°), neutral (0°), mid-supination (45°) and full supination at 10°, 30°, 60°, 90° and 120° of elbow flexion. Our results showed that the radius is located distally when in supination and is located more proximally as it is rotated into pronation. The longitudinal position of the radius changes over 9 mm when moving through a complete arc of forearm rotation. The angle of elbow flexion had a secondary effect on the longitudinal position of the radius, causing changes of less than 0.8 mm.

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