Unstable DRUJ

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    Saturday, October 9, 2010General Scientific Session

    Room: Auditorium, Hynes CC2:45 - 3:30 PM

    65th Annual Meeting of the American Society for Surgery of the HandEmbracing Excellence: Making a Difference

    Symposium 12

    The Unstable DRUJ

    Co-Moderators:Richard A. Berger, MDScott W. Wolfe, MD

    Faculty:David S. Ruch, MD

    J effrey A. Greenberg, MDBrian D. Adams, MDDean G. Sotereanos, MD

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    Anatomy, Diagnosis andAnatomy, Diagnosis andPathomechanics of DRUJPathomechanics of DRUJ

    InstabilityInstability

    Richard A. Berger, MD, PhDRichard A. Berger, MD, PhD

    Symposium 12Symposium 12

    ASSH Boston 2010ASSH Boston 2010

    Why do we care about the DRUJ?Why do we care about the DRUJ?

    Serves as a connection between theServes as a connection between theforearm and the wristforearm and the wrist

    Why do we care about the DRUJ?Why do we care about the DRUJ?

    Torque TransmissionTorque Transmission

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    Why do we care about the DRUJ?Why do we care about the DRUJ?

    Positioning the handPositioning the hand

    Why do we care about the DRUJ?Why do we care about the DRUJ?

    Weight/load bearingWeight/load bearing

    Why do we care about the DRUJ?Why do we care about the DRUJ?

    Differentiates primatesDifferentiates primates

    Well, maybe!!!

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    AnatomyAnatomy

    Andreas Vesaliu s 1514-1564

    Distal Radioulnar JointDistal Radioulnar Joint

    sigmoid

    notch

    Distal Radioulnar JointDistal Radioulnar Joint

    sigmoid

    notch

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    Distal Radioulnar JointDistal Radioulnar Joint

    styloid

    Distal Radioulnar JointDistal Radioulnar Joint

    fovea

    Distal Radioulnar JointDistal Radioulnar Joint

    seat

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    Distal Radioulnar JointDistal Radioulnar Joint

    ECUgroove

    Distal Radioulnar JointDistal Radioulnar Joint

    AnatomyAnatomy

    Distal Radioulnar JointDistal Radioulnar Joint

    AnatomyAnatomy

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    Distal Radioulnar JointDistal Radioulnar Joint

    Radius of curvatureRadius of curvature

    ulnar head

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    TTriangularriangular FFibroibroCCartilageartilage CComplexomplex

    TTriangularriangular FFibroibroCCartilageartilage CComplexomplex

    radius

    lunate

    TFCC

    RadioUlnar LigamentsRadioUlnar Ligaments

    dorsal radioulnar ligament

    fovea

    styloid

    radius

    lunate

    palmar

    radioulnar

    ligament

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    Ulnar HeadUlnar Head

    styloid

    TFCC

    head

    fovea

    radius

    coronal section, fetal wrist

    ECU subsheathECU subsheath

    DRUJ capsuleDRUJ capsule

    radius

    ulna

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    Ulnocarpal LigamentsUlnocarpal Ligaments

    Ulnar styloid

    Ulnar headprocess

    radius

    Ulnocarpal LigamentsUlnocarpal Ligaments

    DRU

    PRU

    UC ligamentsUC ligaments

    ulnar head TFC

    ulnocarpal

    ligaments

    Ulnocarpal LigamentsUlnocarpal Ligaments

    Ulnolunate (UL)

    Ulnotri uetral UT

    Ulnocapitate (UC)

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    Functional AnatomyFunctional Anatomy

    forearm joint forearm joint

    bicondylar jointbicondylar joint

    PRUJ DRUJPRUJ DRUJ

    Carl J. Hagert

    forearm joint forearm joint

    annular ligamentannular ligament TFCCTFCC

    IOMIOM

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    KinematicsKinematics

    Axes of Rotat ionAxes of Rotat ion

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    Stabili ty AnalysesStabili ty Analyses

    Role of Ulnar headRole of Ulnar head

    Common FailureCommon Failure

    Loss of articular contact constraintLoss of articular contact constraint

    30% of join t const raintStuart et al. JHS 2000

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    Common FailureCommon Failure

    Loss of cam effectLoss of cam effect

    of ulnar headof ulnar head

    Common FailureCommon Failure

    Loss of cam effectLoss of cam effect

    of ulnar headof ulnar head

    Common FailureCommon Failure

    Loss of cam effectLoss of cam effect

    of ulnar headof ulnar head

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    ResultsResults

    Dynamic si mulator:

    - actively loads tendons

    - simultaneousl

    measures torque,

    displacement, tendon

    excursion and resultant

    tendon load

    Sauerbier et al., 2001

    Acta Ort hop, J HS(Am), JHS(Br-E)

    ResultsResults

    ResultsResults

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    intact

    resectionre lacement

    To

    r

    u

    e

    pro sup

    A Functional Algori thm forA Functional Algori thm forUlnarUlnar--sided Wrist Painsided Wrist Pain

    Disclaimer:Disclaimer:

    -- not intended as a research toolnot intended as a research tool

    -- used as a tool to guideused as a tool to guidediagnostic and therapeuticdiagnostic and therapeuticdecisionsdecisions

    DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury

    Injury to:Injury to:

    triangular disctriangular discdistal radioulnar l igamentsdistal radioulnar l igaments

    distal radioulnar joint capsuledistal radioulnar joint capsuleulnar extrinsic t endon mechanismsulnar extrinsic t endon mechanisms

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    DRUJ: Articular Surface InjuryDRUJ: Articular Surface Injury

    Injury to:Injury to:

    ulnar headulnar headsigmoid notchsigmoid notchpisiformpisiform

    DRUJ InjuryDRUJ Injury

    Etiology:Etiology:

    traumatrauma torsion and axial loadtorsion and axial load developmental variancedevelopmental variance inflammatory arthropathyinflammatory arthropathy

    DRUJ InjuryDRUJ Injury

    Spectrum o f InjurySpectrum o f Injury

    soft tissue disruption of TFCCsoft tissue disruption of TFCC

    fracture of radius, ulna, or carpalfracture of radius, ulna, or carpaloneoneextension of perilunate dislocationextension of perilunate dislocation

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    ClassificationClassification

    A

    B

    C

    D

    ClassificationClassification

    painpain

    ClassificationClassification

    painpain

    oror

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    ClassificationClassification

    painpainoror

    oror

    pain with arthrosispain with arthrosis

    DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury

    pain alone:pain alone:

    central TFC tearcentral TFC tear

    DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury

    pain alone:pain alone:

    central TFC tearcentral TFC tear

    split of UL/UT ligaments split of UL/UT ligaments

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    DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury

    pain alone:pain alone:

    central TFC tearcentral TFC tear split of UL/UT ligaments split of UL/UT ligaments

    capsular stretchcapsular stretch

    DRUJ: Soft Tissue InjuryDRUJ: Soft Tissue Injury

    pain alone:pain alone:

    central TFC tearcentral TFC tear

    split of UL/UT ligaments split of UL/UT ligaments

    capsular stretchcapsular stretch

    tear of LTI ligament tear of LTI ligament

    DRUJ InjuryDRUJ Injury

    pain alone:pain alone:

    central TFC tearcentral TFC tear

    split of UL/UT ligaments split of UL/UT ligamentscapsular stretchcapsular stretch

    tear of LTI ligament tear of LTI ligament

    synovitissynovitis

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    DRUJ InjuryDRUJ Injury

    pain with instabilitypain with instability

    tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)

    DRUJ InjuryDRUJ Injury

    pain with instabilitypain with instability

    tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)

    ransverse ear o gamen sransverse ear o gamen s

    DRUJ InjuryDRUJ Injury

    pain with instabilitypain with instability

    tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)

    ransverse ear o gamen sransverse ear o gamen s

    tear of joint capsuletear of joint capsule

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    DRUJ InjuryDRUJ Injury

    pain with instabilitypain with instability

    tear/avulsion of DRU/PRU ligamentstear/avulsion of DRU/PRU ligaments(ulnar or radial)(ulnar or radial)

    ransverse ear o gamen sransverse ear o gamen s

    tear of joint capsuletear of joint capsule

    ECU subsheath tearECU subsheath tear

    DRUJ InjuryDRUJ Injury

    pain with instabilitypain with instability

    LT dissociationLT dissociation

    DRUJ InjuryDRUJ Injury

    pain with arthrosispain with arthrosis

    ulnar impaction syndromeulnar impaction syndrome

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    DRUJ InjuryDRUJ Injury

    pain with arthrosispain with arthrosis

    ulnar impaction syndromeulnar impaction syndromepisotriquetral DJDpisotriquetral DJD

    DRUJ InjuryDRUJ Injury

    pain with arthrosispain with arthrosis

    ulnar impaction syndromeulnar impaction syndrome

    pisotriquetral DJDpisotriquetral DJD

    Ove