A c u t e Di s t a l R a d i o u l n a r

Joint Instability
Evaluation and Treatment
Louis H. Poppler, MD, MSCIa, Steven L. Moran, MDb,c,*

KEYWORDS
 Distal radioulnar joint  DRUJ  DRUJ dislocation  Wrist fracture  TFCC

KEY POINTS
 Pronation and supination (axial rotation) occur through both the proximal radioulnar joint and distal
radioulnar joint (DRUJ), which function as 1 unit.
 Injury to the triangular fibrocartilage complex (TFCC) is common and associated with fractures of
the distal radius and ulna.
 Injuries to the radial head, the interosseous membrane (IOM), and the TFCC result in dissociation of
the radius and ulna, instability, proximal migration of the radius relative to the ulna, and impinge-
ment of the distal ulna on the carpus (Essex-Lopresti injury). For this reason, it is important to always
examine the elbow along with the wrist.
 Anatomic reduction and fixation of fractures of the radius and ulna is imperative to restoring axial
stability to the forearm.
 Understanding the complex anatomy of the TFCC, DRUJ, and IOM allows anatomic reconstruction
of these structures at the initial surgery, restoring stability and proper rotation, and avoiding the
need for secondary procedures or salvage procedures in future.

INTRODUCTION stabilizers of the DRUJ and PRUJ so that acute in-

juries to these stabilizers are recognized and
Pronation and supination of the forearm occur treated before the need for later salvage proced-
through the proximal radioulnar joint (PRUJ) and ures arises.
distal radioulnar joint (DRUJ), which function as 1
unit. A combination of bony support and ligamen-
tous constraints are essential for stability and mo- Anatomy
tion. Failure to recognize, anatomically reduce,
The ulna is the fixed unit of the forearm, although
and stabilize injuries to these joints leads to insta-
by convention the nomenclature implies that the
bility, stiffness, and/or painful arthritis. This article
ulna moves. Nevertheless, pronation and supina-
focuses on acute DRUJ instability in the context
tion of the radius occur around the ulna through
of triangular fibrocartilage complex (TFCC) in-
the DRUJ and PRUJ. Although motion through
juries, distal radius fractures (DRFs), distal ulnar
these joints is primarily rotational, both axial (prox-
fractures, Galeazzi fractures, Essex-Lopresti in-
imal-distal) and translational (volar-dorsal) motion
juries, and DRUJ dislocation. The emphasis is on
occur at the DRUJ with load and rotation.1,2 In pro-
understanding the primary and secondary
nation, ulnar length at the wrist relative to radial
hand.theclinics.com

a
Department of Plastic & Reconstructive Surgery, St. Luke’s Health System, Boise, ID, USA; b Department of
Plastic & Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA; c Department of Orthopedic Surgery,
Mayo Clinic, Rochester, MN, USA
* Corresponding author. Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
E-mail address: [email protected]

Hand Clin 36 (2020) 429–441

https://doi.org/10.1016/j.hcl.2020.07.005
0749-0712/20/Ó 2020 Elsevier Inc. All rights reserved.
430 Poppler & Moran

length (ulnar positivity or negativity) may be 2 mm radioulnar ligaments insert at the base of the sty-
greater than in supination.3–6 loid, whereas the deep radioulnar ligaments insert
Stability of the DRUJ arises from a combination at the fovea. Along with normal bony anatomy, the
of bony architecture and ligamentous constraints. deep dorsal and palmar radioulnar ligaments are
The bony anatomy of the sigmoid notch is variable thought to be the most important contributors to
but accounts for only 20-30% of the joints stabil- DRUJ volar-dorsal stability.7,12–14 The superficial
ity7,8 (Fig. 1A). Deepening of the sigmoid notch palmar and dorsal radioulnar fibers act to restrain
has been suggested to improve stability.9 supination and pronation, respectively, and are
The primary stabilizer of the DRUJ is the less important to DRUJ stability. The remainder
TFCC.10,11 The TFCC is composed of several of the TFCC serves as secondary stabilizers
structures that are not readily distinguishable on (ECU subsheath, ulnar collateral ligament) or to
histologic dissection but are subdivided based cushion the distal ulna from the carpus (TFC, ulno-
on injury patterns and clinical experience. These carpal meniscus).
structures include the dorsal and palmar radioul- Extensive research has been performed in an
nar ligaments, the subsheath of the extensor carpi attempt to determine whether the palmar or dor-
ulnaris (ECU) tendon, triangular fibrocartilage sal radioulnar ligament complex is more impor-
(TFC), the ulnocarpal meniscus, and the ulnar tant to DRUJ stability, and the answer is that the
collateral ligament (Fig. 1B, C). The dorsal and two work together to achieve stability, with
palmar radioulnar ligaments are subdivided into neither being more important.12,15–17 The superfi-
deep and superficial ligaments.12 Both the superfi- cial palmar and deep dorsal radioulnar ligaments
cial and deep radioulnar ligaments originate from tighten in supination, working together to
the ulnar side of the radius. The superficial constrain motion. In contrast, the superficial

Fig. 1. (A) Bony anatomy of the DRUJ. The sigmoid notch has been shown to have 4 anatomic variations as
described by Tolat and colleagues.8 Flat or shallow joints are hypothesized to be more prone to dislocation.
(B) The primary stabilizer of the DRUJ is the TFCC. The TFCC is composed of the triangular fibrocartilage articular
disc, the ulnocarpal meniscus (meniscus homologue), the ulnar collateral ligament, the dorsal radioulnar liga-
ment, the palmar radioulnar ligament, and the subsheath of the extensor carpi ulnaris (ECU). (C) Cadaveric dissec-
tion of the TFCC showing a distal view of the DRUJ, with the fibrocartilaginous portion of the central disc (CD)
shown in light gray. The dorsal radioulnar (DRUL) and volar radioulnar ligaments (VRUL) are seen emanating
from the dorsal and volar ulnar corners of the distal radius, inserting onto the distal ulna. Also seen is the lunate
facet (L); the scaphoid facet (S); Lister tubercle (LT), and the ulnar styloid (asterisk). (From [A] Kakar S, Carlsen BT,
Moran SL, Berger RA, Hand Clin. 2010, 26: 518; with permission; and [C] From Hagert E, Chim H, Moran SL. Anat-
omy of the distal radioulnar joint. In: JA G, editor. Ulnar sided wrist pain: A master skills publication. Rosemont:
American Society for Surgery of the Hand; 2013. p. 11-22; with permission.)
 Acute Distal Radioulnar Joint Instability 431

dorsal and deep palmar radioulnar ligaments examination, with inspection revealing a promi-
tighten in pronation. Dorsal displacement of the nent ulnar head suggesting dorsal translation of
distal ulna relative to the radius is caused by fail- the ulnar head relative to the radius, or a dimple
ure of the palmar radioulnar ligaments, whereas suggesting volar translation. Clinical diagnosis of
volar displacement is caused by failure of the dor- DRUJ instability is the gold standard and consists
sal radioulnar ligaments.7,18–20 of stabilizing the radius and carpus with 1 hand
Other secondary stabilizers of the DRUJ while “shucking” the ulna volar and dorsal.31,32
include the interosseous membrane (IOM), the This test can only be done following fixation of
pronator quadratus (PQ), and the DRUJ joint any associated fractures. A stable DRUJ should
capsule. The PQ has 2 heads: superficial and have a firm end point, especially in pronation or su-
deep.21 The deep head passes between the pination. Comparison with the contralateral side is
radius and ulna, inserting on the dorsal ulna. essential. Ruch and colleagues33 suggest greater
This head may resist dorsal displacement of the than 1 cm of dorsal-volar translation is abnormal
ulna relative to the ulna.22 Of particular impor- and instability should be assumed.
tance in fractures of the radius and ulna is the There are several radiographic indications of
distal oblique bundle (DOB) of the IOM.17,23–25 DRUJ instability that should be noted. Radial
This structure is present, or thick, in 29% to diaphyseal fractures within 7.5 cm of articular sur-
36% of patients.26–28 This distal thickening of face (Fig. 3A), fractures through the base of the ul-
the IOM runs obliquely from the ulna proximally nar styloid or with a second foveal fragment
at the proximal end of the PQ to insert on the (Fig. 3B), DRUJ widening or overlap of the radius
radius at the capsule of the DRUJ (Fig. 2). The and ulna on anteroposterior (AP) radiographs,
DOB is responsible for seating the head of the volar or dorsal dislocation of the ulna relative to
ulna in the sigmoid notch and is slackened the radius on a true lateral view, or greater than
when the radius is shortened because of fracture. 5-mm to 7-mm (Fig. 4)34 radial shortening suggest
Similarly, the IOM is slackened when radial trans- DRUJ injury.35,36 AP radiographs of the contralat-
lation of a DRF is not corrected.29 Tightening of eral wrist are helpful in determining changes in
the DOB in addition to the radioulnar ligaments radial or ulnar length, and ulnar positivity. If there
has been shown to improve DRUJ stability is significant shortening of the radius without
following ulnar shortening osteotomy.30 DRF, obtaining forearm and elbow radiographs
may help diagnosis an Essex-Lopresti injury.
Diagnosis of Distal Radioulnar Joint Instability Large ulnar styloid fragments, ulnar styloid frag-
Diagnosis of DRUJ instability relies on the exam- ments displaced more than 2 mm, or displacement
iner having a high index of suspicion. DRUJ insta- of the styloid volar to the axis of the ulnar shaft also
bility occurs most commonly following high- suggest DRUJ instability.33,37–39
energy injuries of radius or ulna. DRUJ dislocation Computed tomography (CT) protocols for diag-
or instability may be apparent on physical nosing instability of the DRUJ have been

Fig. 2. (A) The neuromuscular stabil-

ity of the DRUJ is primarily deter-
mined by (A) the PQ, in particular
the deep head, which wraps around
the volar forearm just proximal to
the DRUJ. (B) The ECU with its sub-
sheath (SS) similarly plays a role in
the dynamic stability of both the
DRUJ and the carpus as a whole. The
asterisk indicates the ulnar head.
(From Hagert E, Chim H, Moran SL.
Anatomy of the distal radioulnar
joint. In: JA G, editor. Ulnar sided
wrist pain: A master skills publication.
Rosemont: American Society for Sur-
gery of the Hand; 2013. p. 11-22;
with permission.)
432 Poppler & Moran

Fig. 3. (A–C) There are several radiographic indicators of potential DRUJ instability. (A) A fracture within 7.5 cm of
the radius articular surface can be an indication of a Galeazzi fracture. (B) A proximal ulnar styloid fracture, which
may indicate a disruption of the foveal insertion of the deep fibers of the dorsal and volar radioulnar ligaments.
(C) Axial CT of a close reduced distal radius fracture with concomitant dorsal dislocation of the ulnar. Arrow
points to an avulsion fracture fragment attached to volar radioulnar ligament.

described and have some utility for assessing radiograph. Significant instability is suggested
static and dynamic instability.40–42 However, MRI with displacement of more than 9 mm. However,
has largely supplanted CT because of its ability this test requires comparison with the normal
to detect the specific soft tissue lesions causing side and has not been validated in a clinical se-
DRUJ instability.43 CT is the study of choice for ries.45 Until dynamic intraoperative radiographic
intra-articular DRFs to assess the congruency of evaluation improves, wrist arthroscopy will remain
the sigmoid facet and to facilitate operative plan- the gold standard for assessment of TFCC injury.
ning (Fig. 3).42,44 CT should also be used if mal- With the use of DRUJ portals, surgeons may also
union or osseous anatomy is thought to evaluate the foveal insertion, signs of impaction,
contribute to DRUJ instability. and associated ligamentous injury.46–48
Intraoperative assessment of the DRUJ has pri-
marily relied on arthroscopic evaluation. Radio- Acute Distal Radioulnar Joint Dislocation
graphic dynamic parameters of instability have
been described. Specifically, the DRUJ ballotte- Isolated acute dislocation of the DRUJ is uncom-
ment test has been described to evaluate DRUJ mon.37,44 DRUJ dislocation is, by convention,
instability intraoperatively. To perform the test, described in terms of the position of the ulnar
force is applied to the palmar surface of the ulna head relative to the sigmoid notch, even though
and dorsal displacement is assessed on a lateral the ulna is the fixed unit of the forearm. Therefore,
in a dorsal dislocation of the DRUJ, the ulnar head

Fig. 4. Isolated palmar dislocation of

the ulna in relation to the radius. AP
radiograph (A) shows overlap of the
ulna and radius at the sigmoid notch,
whereas lateral radiograph (B) show
anterior displacement of ulna in rela-
tion to the radius. Such an injury in-
volves an injury to the dorsal
radioulnar ligaments, in addition to
the palmar radioulnar ligament and
IOM.
 Acute Distal Radioulnar Joint Instability 433

is prominent dorsally (see Fig. 3C). Although the head is dislocated and protrudes through the skin,
TFCC can be completely disrupted in DRUJ dislo- the diagnosis of associated TFCC injury/avulsion
cation, case reports have noted restoration of sta- is easy. The authors recommend placing a suture
bility with simple reduction of the dislocation.49,50 anchor in the fovea before reduction to facilitate
In volar dislocation, the dorsal radioulnar liga- TFCC repair. Following repair, the arm is still
ments and volar capsule are often disrupted, immobilized in a Munster-style splint or cast for 4
whereas in dorsal dislocations the palmar radioul- to 6 weeks. The authors prefer immobilization in
nar ligaments and dorsal capsule are often disrup- neutral rotation as opposed to full supination or
ted (see Fig. 4).51–53 Closed reduction of the DRUJ full pronation. Stiffness in full supination or prona-
is performed under local anesthesia with or tion can cause more morbidity than stiffness in a
without sedation. Gentle traction and pressure on neutral position. In addition, studies have failed
the ulnar head are often enough to reduce the joint. to show superiority of splinting in the extremes of
Reduction of volar dislocations can be more diffi- pronation or supination compared with neutral
cult because of the pull of the deep head of the forearm positioning.59
PQ. In these cases, distraction of the radius from
the ulna coupled with pronation and volar pressure
Triangular Fibrocartilage Complex Injuries
assists reduction.
DRUJ dislocations have been classified as sim- TFCC injuries are the most common cause of
ple or complex. In complex dislocations the DRUJ ulnar-sided wrist pain and can be a cause of acute
cannot be reduced following reduction and stabili- or chronic DRUJ instability. Traumatic tears of the
zation of the radius. In simple dislocations, the TFCC occur with axial load on an extended and
DRUJ can be reduced.49,54–57 Clinicians should ulnar-deviated wrist or with an axial load and ex-
be cognizant of complex dislocation that cannot tremes of pronation or supination.60 Palmer61 clas-
be closed reduced because of interposition of ten- sified TFCC tears as traumatic or degenerative,
dons, most commonly the ECU tendon.44,49,58 central or peripheral (Fig. 5, Table 1). A complete
When closed reduction is difficult or incomplete, review of sources of ulnar-sided wrist pain is
it is best to proceed with an open, or beyond the scope of this article; however, DRUJ
arthroscopic-assisted, reduction to allow extrac- instability with TFCC tears or degeneration are a
tion of interposed structures. common cause of ulnar-sided wrist pain. Insta-
If DRUJ stability is restored following closed bility of the DRUJ requires either disruption or
reduction, management in a Munster-style splint laxity of the radioulnar ligaments, often with
or cast with the forearm in the position of stability disruption or disorder of the secondary stabilizers
(supination for dorsal dislocations; pronation for (DOB, ECU subsheath, ulnotriquetral ligament,
volar dislocations) is recommended. However, if DRUJ capsule).
open reduction is required, direct repair of the Treatment of DRUJ instability caused by TFCC
TFCC to its foveal insertion is recommended using injury focuses on diagnosis, tightening, and repair
a suture anchor or bone tunnels. When the ulnar or reconstruction of the radioulnar ligaments and/

Fig. 5. TFCC injuries following trauma

can occur within the articular disc (A),
ulnar periphery (B), palmar periphery
(C), and along the radial attachment
(D). TFCC tears which result in insta-
bility occur in areas B and C. TFCC
detachment from the radius (a type
D Palmar lesion) could also theoreti-
cally result in DRUJ instability if the
tear proceeds palmarly or dorsally
through the palmar or dorsal radioul-
nar ligaments respectively. Arthro-
scopic evaluation needs to be
combined with physical exam to
verify the diagnosis of a destabilizing
TFCC injury. (Used with permission of
Mayo Foundation for Medical Educa-
tion and Research, all rights reserved.)
434 Poppler & Moran

Table 1
Distal Radius Fractures and Distal Radioulnar
Palmer classification of triangular Joint Instability
fibrocartilage complex injuries Patients presenting with a DRF also have a TFCC
or DRUJ injury in 43% to 84% of cases.75,76 There-
Traumatic Lesions:
fore, it is essential to examine for DRUJ instability
Class 1A Central rupture in all patients with DRF. However, because the
Class 1B Disruption of insertion of volar and dorsal radioulnar ligaments originate
radioulnar ligaments at from the distal radius, this will necessarily be un-
ulnar fovea and/or styloid
stable until the fracture has been fixated. DRFs
(with or without ulnar
styloid fracture)
affect the DRUJ anatomy and stability in 3 major
ways: (1) dorsal tilt of the distal radius alters the
Class 1C Avulsion/tear of the
orientation of the sigmoid notch, causing incon-
ulnocarpal ligaments
gruity with the ulnar head; (2) shortening of the
Class 1D Disruption of radial origins of
distal radius slackens the radioulnar ligaments
radioulnar ligaments (with
or without sigmoid notch
and the DOB; and (3) failure to secure the volar
fracture) or dorsal ulnar fragments of an intra-articular frag-
ment results in uncoupling of the radius and ulna at
Degenerative Lesions:
the DRUJ through the radioulnar ligaments.34,77
Class 2A TFCC wear
For this reason, proper identification, restoration
Class 2B TFCC wear with lunate and/or of alignment, and fixation of both the volar and
ulnar chondromalacia dorsal ulnar-sided fragments of a DRF is impera-
Class 2C TFCC perforation with lunate tive, especially if early motion or short arm immo-
and/or ulnar bilization is planned.78
chondromalacia
However, following fixation of a DRF, if instability
Class 2D Class 2C plus lunotriquetral of the DRUJ remains, there is no accepted algo-
ligament perforation rithm for management.79 Lindau and col-
Class 2E Class 2D plus ulnocarpal leagues80,81 showed worse outcomes 12 months
arthritis or more after DRF fixation in patients with DRUJ
instability or partial or complete TFCC tears diag-
nosed arthroscopically but treated with immobili-
or secondary stabilizers. Before repairing, recon-
zation rather than fixation. Therefore, our practice
structing, or tightening these structures, surgeons
is to address DRUJ instability at the time of DRF
should ensure that bony alignment is correct and
fixation. We do this by first checking our reduction
there is no arthritis of the DRUJ to avoid causing
to ensure that we have adequately restored radial
pain in the process of improving stability. If arthritis
length and corrected radial translation of the distal
does already exist, it must be addressed with
fragment. To do so, it is essential to check for
denervation, interposition arthroplasty, hemiar-
DRUJ stability after securing a volar locking plate
throplasty, or whole-joint arthroplasty.62–66 Resec-
proximally with the oblong hole but before drilling
tion arthroplasty (Darrach or Sauve-Kapandji
the other holes of the proximal plate. If this is
procedure) may resolve the arthritis and pain but
done and DRUJ instability remains, the surgeon
does not address instability.67
may loosen the proximal fixation, apply traction
The fovea and peripheral TFCC are well vascu-
and radially directed force to the proximal radial
larized and have good healing potential. Immobili-
diaphysis, and resecure the fixation. Some investi-
zation in neutral pronation-supination is often
gators even report that overdistracting of the
adequate to treat DRUJ instability caused by
radius relative to the ulna improved DRUJ stabil-
TFCC injury and can be trialed if the patient is
ity.82 If this does not restore DRUJ stability, then
reluctant to undergo surgery.59,68 Repair of the
special attention should be paid to the dorsal ulnar
radioulnar ligaments can be done arthroscopically
corner fragment of the DRF to ensure that it is
or as an open procedure.69–71 Reattachment of the
reduced and fixated. Fragment-specific fixation
TFCC to the fovea is achieved with the aid of a su-
of this fragment may be necessary using pins, a
ture anchor, or through bone tunnels drilled in the
screw, or a plate.77
ulna using arthroscopic imaging of foveal detach-
If instability remains following these maneuvers, it
ment, hook test, trampoline test, and arthroscopic
may be necessary to address an associated ulnar
repair. In the setting of chronic instability without
styloid fracture. Most ulnar styloid fractures do not
DRUJ arthritis, the radioulnar ligaments can be
require fixation, and association of ulnar styloid
reconstructed with tendon graft with good suc-
fractures and TFCC injury has not been
cess72–74 (Fig. 6).
 Acute Distal Radioulnar Joint Instability 435

Fig. 6. (A–F) A 17-year-old girl who presents with 3-month history of wrist pain and inability to rotate the fore-
arm. (A) AP radiograph shows overlapping of the radius and ulna. (B) The original lateral radiograph is of poor
quality and may have resulted in delay in diagnosis by primary physician; however, (C) MRI showed palmar dislo-
cation of the ulna in relation to the radius. (D) The Adams-Berger procedure was used for reconstruction of the
DRUJ in the setting of chronic dislocation (Used with permission of Mayo Foundation for Medical Education and
Research, all rights reserved). (E, F) ten-year results with preservation of reduction and excellent motion and pain
relief.

established.80,83 However, nonunion and malunion is most easily achieved through a 2-cm to 3-cm
of the ulnar styloid have been associated with incision made directly over the ulnar styloid. The
poor outcomes.84,85 Several investigators have TFCC is secured to the fovea using a suture anchor
shown that large fragments, especially those dis- through this incision and the styloid fragment can
placed 2 mm or more, are associated with disrup- be repaired with a Kirschner wire (K-wire) and ten-
tion of the foveal insertion of the radioulnar sion band9,86 (Fig. 7). If there is not an ulnar styloid
ligaments.37–39 Therefore, the authors acutely fragment requiring fixation, the authors prefer to
repair all large ulnar styloid fragments, especially perform an arthroscopy of the radiocarpal joint,
those associated with DRUJ instability. This repair assess for TFCC injury, and repair that as indicated.
436 Poppler & Moran

Fig. 7. (A–E) Proximal ulnar styloid fractures (A) with concomitant DRUJ injury may be managed through a small
incision over the ulnar styloid in line with the ECU tendon. (B) The dorsal ulnar sensory nerve is identified and
marked with a vessel loop and then dissection is carried just palmar to the ECU down to the bone and the fracture
can be exposed. (C) Suture placement, which is used to secure TFCC before tension band fixation of styloid frac-
ture. The authors prefer tension band fixation for isolated styloid fractures (D) and plate fixation in conjunction
with tension band (E) for ulnar head or metaphyseal fractures with concomitant ulnar styloid fractures.

Distal Ulnar Fractures and Distal Radioulnar fractures likely benefit from surgical treatment.
Joint Instability Operative fixation can be achieved with percuta-
neous K-wire fixation in young, nonosteoporotic
Isolated fractures of the distal ulna are rare but can
patients without comminution. Open reduction
be a cause of DRUJ instability.87–89 Fractures of
and internal fixation (ORIF) provides more secure
the ulnar head and neck associated with DRFs
fixation and the option for earlier motion but is
have been shown to have increased complications
often challenging because fragments of the distal
relative to fractures isolated to the radius and ulnar
ulna are often small and osteoporotic (see
styloid.90–92 Following stable locked fixation of
Fig. 7). Plates need to be low profile and carefully
DRFs, many ulnar head and neck fractures are sta-
positioned to avoid irritating the dorsal cutaneous
ble and can be managed with immobilization in a
branch of the ulnar nerve and mechanically inter-
Munster-type splint or cast.88,93 However, stability
fering with DRUJ rotation, respectively. ORIF is
should be checked with fluoroscopy following DRF
achieved with a condylar plate or locking 2.0-mm
fixation. Unstable, comminuted, or displaced
plate, and good results have been reported with
 Acute Distal Radioulnar Joint Instability 437

both.93,94 Associated styloid fractures or foveal associated coronoid fracture or a medial collateral
avulsions should be repaired at the same time. ligament injury.
The most important step for obtaining a reduced The Essex-Lopresti injury is described in detail
ulna is properly reducing an associated DRF. elsewhere in this issue, and includes disruption
of the DRUJ, the IOM, and the PRUJ because of
Galeazzi Fractures and Distal Radioulnar Joint axial compression that causes longitudinal radio-
Instability ulnar disruption. Radial head excision in the case
of Essex-Lopresti injury results in proximal migra-
A Galeazzi fracture is a diaphyseal fracture of the
tion of the radius, ulnar impingement of the carpus,
radius, occurring at least 4 to 5 cm proximal to
and radial impingement of the capitellum.107–109
the radiocarpal joint with an associated DRUJ
The radius pull test is a useful maneuver to assess
dislocation95 (see Fig. 3A). These fractures are
for Essex-Lopresti injury, in which the radius is
described in detail Rohit Garg and Chaitanya Mud-
pulled proximally while imaging the DRUJ with
gal’s article, “Galeazzi Injuries,” elsewhere in this
fluoroscopy. Proximal migration of the radius sug-
issue. Briefly, this is a high-energy trauma that is
gests Essex-Lopresti injury.110 Timely diagnosis of
thought to occur with hyperextension and prona-
this injury is important because delayed manage-
tion.36,96 Galeazzi fractures typically present with
ment is associated with worse outcomes.111,112
angular deformity of the radius and prominence
Following stabilization of the forearm, the DRUJ
of the ulnar head. The ulnar head sometimes pro-
should be assessed for stability. If the DRUJ re-
trudes through the skin as an open fracture-
mains unstable, the surgeon should then repair
dislocation. Radial fractures within 7.5 cm of the
the TFCC arthroscopically, or open, in addition to
midarticular surface are more likely to involve
addressing the other sites of instability.113–120
injury to the DRUJ.96 Clues to DRUJ instability
mirror those of DRF: ulnar styloid base fracture,
SUMMARY
DRUJ widening on true AP radiographs, disloca-
tion of the ulna on true lateral radiographs, and Pronation and supination (axial rotation) occur
greater than 5 mm of radial shortening. through both the PRUJ and DRUJ, which function
This fracture requires ORIF because it is unsta- as 1 unit. Instability of the DRUJ acutely may occur
ble and immobilization alone has been associated in the setting of injury to the TFCC and may be
with poor outcomes.97–100 Galeazzi fractures, like associated with fractures of the distal radius and
DRFs, are often fixed with a volar plate through a ulna. Furthermore, clinicians should be cognizant
modified Henry incision in the forearm. As with of the possibility of concomitant injury to the fore-
DRFs, reduction of the DRUJ and its stability arm axis, including the elbow. Thus it is important
should be checked following reduction and stable to examine not only the wrist but also the forearm
fixation of the radius. If the DRUJ is unstable, the and elbow when presented with patients with
surgeon should repair an ulnar styloid fragment, acute distal radioulnar instability.
the TFCC, or both.
Like acute DRUJ dislocation, Galeazzi fractures DISCLOSURE
have been classified as simple or complex49,54–57
because of interposition of soft tissues, most The authors have nothing to disclose.
commonly the ECU tendon.101–103 If unable to
reduce the DRUJ following radial fracture fixation REFERENCES
and a mushy feeling is encountered, proceed to
1. Ray RD, Johnson RJ, Jameson RM. Rotation of the
an open, or arthroscopically assisted, reduction
forearm; an experimental study of pronation and
of the DRUJ.104
supination. J Bone Joint Surg Am 1951;33-A(4):
993–6.
Essex-Lopresti Fractures and Distal Radioulnar
2. Linscheid RL. Biomechanics of the distal radioulnar
Joint Instability
joint. Clin Orthop Relat Res 1992;(275):46–55.
As mentioned earlier, but frequently forgotten, pro- 3. Houdek MT, Wagner ER, Moran SL, et al. Disorders
nation and supination of the forearm occur through of the distal radioulnar joint. Plast Reconstr Surg
2 joints that function as 1, the DRUJ and PRUJ.105 2015;135(1):161–72.
Essex-Lopresti106 described 2 cases of radial 4. Epner RA, Bowers WH, Guilford WB. Ulnar vari-
head fracture in combination with DRUJ disloca- ance–the effect of wrist positioning and roentgen
tion in 1951. This injury pattern is the reason why filming technique. J Hand Surg 1982;7(3):298–305.
the elbow should always be examined along with 5. Palmer AK, Werner FW. Biomechanics of the distal
the wrist when assessing wrist injuries. Clinicians radioulnar joint. Clin Orthop Relat Res 1984;187:
should specifically assess for elbow stability and 26–35.
438 Poppler & Moran

6. Drobner WS, Hausman MR. The distal radioulnar 23. Moritomo H, Noda K, Goto A, et al. Interosseous
joint. Hand Clin 1992;8(4):631–44. membrane of the forearm: length change of liga-
7. Stuart PR, Berger RA, Linscheid RL, et al. The dor- ments during forearm rotation. J Hand Surg 2009;
sopalmar stability of the distal radioulnar joint. 34(4):685–91.
J Hand Surg Am 2000;25(4):689–99. 24. Noda K, Goto A, Murase T, et al. Interosseous
8. Tolat AR, Stanley JK, Trail IA. A cadaveric study of membrane of the forearm: an anatomical study of
the anatomy and stability of the distal radioulnar ligament attachment locations. J Hand Surg 2009;
joint in the coronal and transverse planes. J Hand 34(3):415–22.
Surg Br 1996;21(5):587–94. 25. Watanabe H, Berger RA, Berglund LJ, et al. Contri-
9. Tham SK, Bain GI. Sigmoid notch osseous recon- bution of the interosseous membrane to distal ra-
struction. Tech Hand Up Extrem Surg 2007;11(1): dioulnar joint constraint. J Hand Surg Am 2005;
93–7. 30(6):1164–71.
10. Palmer AK, Werner FW. The triangular fibrocarti- 26. Hohenberger GM, Schwarz AM, Weiglein AH, et al.
lage complex of the wrist–anatomy and function. Prevalence of the distal oblique bundle of the inter-
J Hand Surg Am 1981;6(2):153–62. osseous membrane of the forearm: an anatomical
11. Hagert E, Chim H, Moran SL. Anatomy of the distal study. J Hand Surg Eur Vol 2018;43(4):426–30.
radioulnar joint. In: JA G, editor. Ulnar sided wrist 27. Trehan SK, Gould HP, Meyers KN, et al. The effect
pain: a master skills publication. Rosemont (IL): of distal radius fracture location on distal radioulnar
American Society for Surgery of the Hand; 2013. joint stability: a cadaveric study. J Hand Surg 2019;
p. 11–22. 44(6):473–9.
12. Hagert CG. Distal radius fracture and the distal ra- 28. Kim YH, Gong HS, Park JW, et al. Magnetic reso-
dioulnar joint–anatomical considerations. Handchir nance imaging evaluation of the distal oblique
Mikrochir Plast Chir 1994;26(1):22–6. bundle in the distal interosseous membrane of
13. Kleinman WB. Stability of the distal radioulna joint: the forearm. BMC Musculoskelet Disord 2017;
biomechanics, pathophysiology, physical diag- 18(1):47.
nosis, and restoration of function what we have 29. Dy CJ, Jang E, Taylor SA, et al. The impact of cor-
learned in 25 years. J Hand Surg Am 2007;32(7): onal alignment on distal radioulnar joint stability
1086–106. following distal radius fracture. J Hand Surg
14. Xu J, Tang JB. In vivo changes in lengths of the lig- 2014;39(7):1264–72.
aments stabilizing the distal radioulnar joint. 30. Arimitsu S, Moritomo H, Kitamura T, et al. The sta-
J Hand Surg Am 2009;34(1):40–5. bilizing effect of the distal interosseous membrane
15. af Ekenstam F. Anatomy of the distal radioulnar on the distal radioulnar joint in an ulnar shortening
joint. Clin Orthop Relat Res 1992;(275):14–8. procedure: a biomechanical study. J Bone Joint
16. Schuind F, An KN, Berglund L, et al. The distal ra- Surg Am 2011;93(21):2022–30.
dioulnar ligaments: a biomechanical study. J Hand 31. Rampazzo A, Gharb BB, Brock G, et al. Functional
Surg Am 1991;16(6):1106–14. outcomes of the aptis-scheker distal radioulnar
17. Kihara H, Short WH, Werner FW, et al. The stabiliz- joint replacement in patients under 40 years old.
ing mechanism of the distal radioulnar joint during J Hand Surg 2015;40(7):1397–403.e3.
pronation and supination. J Hand Surg Am 1995; 32. Bellevue KD, Thayer MK, Pouliot M, et al. Com-
20(6):930–6. plications of semiconstrained distal radioulnar
18. Rose-Innes AP. Anterior dislocation of the ulna at joint arthroplasty. J Hand Surg 2018;43(6):566.
the inferior radio-ulnar joint. Case report, with a dis- e1-e9.
cussion of the anatomy of rotation of the forearm. 33. Ruch DS, Weiland AJ, Wolfe SW, et al. Current con-
J Bone Joint Surg Br 1960;42-B:515–21. cepts in the treatment of distal radial fractures. Instr
19. Hui FC, Linscheid RL. Ulnotriquetral augmentation Course Lect 2004;53:389–401.
tenodesis: a reconstructive procedure for dorsal 34. Adams BD. Effects of radial deformity on distal ra-
subluxation of the distal radioulnar joint. J Hand dioulnar joint mechanics. J Hand Surg Am 1993;18:
Surg 1982;7(3):230–6. 492–8.
20. Buterbaugh GA, Palmer AK. Fractures and disloca- 35. Moore TM, Klein JP, Patzakis MJ, et al. Results of
tions of the distal radioulnar joint. Hand Clin 1988; compression-plating of closed Galeazzi fractures.
4(3):361–75. J Bone Joint Surg Am 1985;67(7):1015–21.
21. Johnson RK, Shrewsbury MM. The pronator quad- 36. Giannoulis FS, Sotereanos DG. Galeazzi fractures
ratus in motions and in stabilization of the radius and dislocations. Hand Clin 2007;23(2):153–63, v.
and ulna at the distal radioulnar joint. J Hand 37. Mikic ZD. Treatment of acute injuries of the trian-
Surg 1976;1(3):205–9. gular fibrocartilage complex associated with distal
22. Stuart PR. Pronator quadratus revisited. J Hand radioulnar joint instability. J Hand Surg Am 1995;
Surg Br 1996;21(6):714–22. 20(2):319–23.
 Acute Distal Radioulnar Joint Instability 439

38. Nakamura R, Horii E, Imaeda T, et al. Ulnar styloid 54. Cetti NE. An unusual cause of blocked reduction of
malunion with dislocation of the distal radioulnar the Galeazzi injury. Injury 1977;9(1):59–61.
joint. J Hand Surg Br 1998;23(2):173–5. 55. Alexander A, Lichtman DM. Treatment of acute in-
39. May MM, Lawton JN, Blazar PE. Ulnar styloid juries of the distal radioulnar joint. In: Lichtman D,
fractures associated with distal radius fractures: Alexander AH, editors. The wrist and its disorders.
incidence and implications for distal radioulnar Philadelphia: WB Saunders; 1997.
joint instability. J Hand Surg Am 2002;27(6): 56. Jenkins NH, Mintowt-Czyz WJ, Fairclough JA. Irre-
965–71. ducible dislocation of the distal radioulnar joint.
40. Park MJ, Kim JP. Reliability and normal values of Injury 1987;18(1):40–3.
various computed tomography methods for quanti- 57. Hanel DP, Scheid DK. Irreducible fracture-
fying distal radioulnar joint translation. J Bone Joint dislocation of the distal radioulnar joint secondary
Surg Am 2008;90(1):145–53. to entrapment of the extensor carpi ulnaris tendon.
41. Mino DE, Palmer AK, Levinsohn EM. The role of Clin Orthop Relat Res 1988;(234):56–60.
radiography and computerized tomography in the 58. Garrigues GE, Aldridge JM 3rd. Acute irreducible
diagnosis of subluxation and dislocation of the distal radioulnar joint dislocation. A case report.
distal radioulnar joint. J Hand Surg 1983;8(1): J Bone Joint Surg Am 2007;89(7):1594–7.
23–31. 59. Park MJ, Pappas N, Steinberg DR, et al. Immobili-
42. Amrami KK, Moran SL, Berger RA, et al. Imaging zation in supination versus neutral following surgi-
the distal radioulnar joint. Hand Clin 2010;26(4): cal treatment of Galeazzi fracture-dislocations in
467–75. adults: case series. J Hand Surg 2012;37(3):
43. Coggins CA. Imaging of ulnar-sided wrist pain. Clin 528–31.
Sports Med 2006;25(3):505–26. 60. Henry MH. Management of acute triangular fibro-
44. Carlsen BT, Dennison DG, Moran SL. Acute dislo- cartilage complex injury of the wrist. J Am Acad Or-
cations of the distal radioulnar joint and distal thop Surg 2008;16(6):320–9.
ulna fractures. Hand Clin 2010;26(4):503–16. 61. Palmer AK. Triangular fibrocartilage complex le-
45. Gil JA, Kosinski LR, Shah KN, et al. Distal radioul- sions: A classification. J Hand Surg Am 1989;
nar joint instability: assessment of three intraopera- 14A:594–606.
tive radiographic stress tests. Hand (N Y) 2019. 62. Hohenberger GM, Maier MJ, Dolcet C, et al. Sen-
https://doi.org/10.1177/1558944719875487. sory nerve supply of the distal radio-ulnar joint
1558944719875487. with regard to wrist denervation. J Hand Surg Eur
46. Park A, Lutsky K, Matzon J, et al. An evaluation of volume 2017;42(6):586–91.
the reliability of wrist arthroscopy in the assessment 63. Kakar S, Noureldin M, Elhassan B. Ulnar head
of tears of the triangular fibrocartilage complex. replacement and sigmoid notch resurfacing arthro-
J Hand Surg 2018;43(6):545–9. plasty with a lateral meniscal allograft: ’calamari
47. Brogan DM, Berger RA, Kakar S. Ulnar-sided procedure. J Hand Surg Eur volume 2017;42(6):
wrist pain: a critical analysis review. JBJS Rev 567–72.
2019;7(5):e1. 64. Clark NJ, Munaretto N, Elhassan BT, et al. Ulnar
48. Ochman S, Wieskotter B, Langer M, et al. High-res- head replacement and sigmoid notch resurfacing
olution MRI (3T-MRI) in diagnosis of wrist pain: is arthroplasty with minimum 12-month follow-up.
diagnostic arthroscopy still necessary? Arch Or- J Hand Surg Eur volume 2019;44(9):957–62.
thop Trauma Surg 2017;137(10):1443–50. 65. Savvidou C, Murphy E, Mailhot E, et al. Semicon-
49. Bruckner JD, Lichtman DM, Alexander AH. Com- strained distal radioulnar joint prosthesis. J Wrist
plex dislocations of the distal radioulnar joint. Surg 2013;2(1):41–8.
Recognition and management. Clin Orthop Relat 66. Kachooei AR, Chase SM, Jupiter JB. Outcome
Res 1992;(275):90–103. assessment after aptis distal radioulnar joint
50. Heiple KG, Freehafer AA, Van’T Hof A. Isolated (DRUJ) implant arthroplasty. Arch Bone Jt Surg
traumatic dislocation of the distal end of the ulna 2014;2(3):180–4.
or distal radio-ulnar joint. J Bone Joint Surg Am 67. Jochen-Frederick H, Pouyan Y, Khosrow BA, et al.
1962;44-A:1387–94. Long-term functional outcome and patient satisfac-
51. Hagert CG. The distal radioulnar joint. Hand Clin tion after ulnar head resection. J Plast Reconstr
1987;3(1):41–50. Aesthet Surg 2016;69(10):1417–23.
52. Hagert CG. The distal radioulnar joint in relation to 68. Faucher GK, Zimmerman RM, Zimmerman NB.
the whole forearm. Clin Orthop Relat Res Instability and arthritis of the distal radioulnar joint:
1992;(275):56–64. a critical analysis review. JBJS Rev 2016;4(12).
53. Bruckner JD, Alexander AH, Lichtman DM. Acute 01874474.
dislocations of the distal radioulnar joint. Instr 69. Argintar E, Mantovani G, Pavan A. TFCC reattach-
Course Lect 1996;45:27–36. ment after traumatic DRUJ instability: a simple
440 Poppler & Moran

alternative to arthroscopic management. Tech in a prospective randomized study. Acta Orthop

Hand Up Extrem Surg 2010;14(4):226–9. Scand 1989;60(4):393–6.
70. Atzei A, Luchetti R, Braidotti F. Arthroscopic foveal 86. Chen AC, Chiu CH, Weng CJ, et al. Early and late
repair of the triangular fibrocartilage complex. fixation of ulnar styloid base fractures yields different
J Wrist Surg 2015;4(1):22–30. outcomes. J Orthop Surg Res 2018;13(1):193.
71. Anderson ML, Larson AN, Moran SL, et al. Clinical 87. Richards TA, Deal DN. Distal ulna fractures. J Hand
comparison of arthroscopic versus open repair of Surg 2014;39(2):385–91.
triangular fibrocartilage complex tears. J Hand 88. Moloney M, Farnebo S, Adolfsson L. Incidence of
Surg Am 2008;33(5):675–82. distal ulna fractures in a Swedish county: 74/
72. Kakar S, Carlsen BT, Moran SL, et al. The manage- 100,000 person-years, most of them treated non-
ment of chronic distal radioulnar instability. Hand operatively. Acta Orthop 2020;91(1):104–8.
Clin 2010;26(4):517–28. 89. Ciminero M, Yohe N, Garofolo-Gonzalez G, et al. Iso-
73. Gillis JA, Soreide E, Khouri JS, et al. Outcomes of lated distal ulna fracture with distal radioulnar joint
the Adams-Berger ligament reconstruction for the dislocation: a novel fracture pattern. Hand (N Y)
distal radioulnar joint instability in 95 consecutive 2019. https://doi.org/10.1177/1558944719856116.
cases. J Wrist Surg 2019;8(4):268–75. 1558944719856116.
74. Adams BD, Berger RA. An anatomic reconstruction 90. Lafontaine M, Hardy D, Delince P. Stability assessment
of the distal radioulnar ligaments for posttraumatic of distal radius fractures. Injury 1989;20(4):208–10.
distal radioulnar joint instability. J Hand Surg 2002; 91. Biyani A, Simison AJ, Klenerman L. Fractures of the
27(2):243–51. distal radius and ulna. J Hand Surg Br 1995;20(3):
75. Geissler WB, Fernandez DL, Lamey DM. Distal ra- 357–64.
dioulnar joint injuries associated with fractures of 92. McKee MD, Waddell JP, Yoo D, et al. Nonunion of
the distal radius. Clin Orthop Relat Res distal radial fractures associated with distal ulnar
1996;(327):135–46. shaft fractures: a report of four cases. J Orthop
76. Lindau T, Arner M, Hagberg L. Intraarticular lesions Trauma 1997;11(1):49–53.
in distal fractures of the radius in young adults. A 93. Dennison DG. Open reduction and internal locked
descriptive arthroscopic study in 50 patients. fixation of unstable distal ulna fractures with
J Hand Surg Br 1997;22(5):638–43. concomitant distal radius fracture. J Hand Surg
77. Rhee PC, Medoff RJ, Shin AY. Complex distal radius 2007;32(6):801–5.
fractures: an anatomic algorithm for surgical manage- 94. Ring D, McCarty LP, Campbell D, et al. Condylar
ment. J Am Acad Orthop Surg 2017;25(2):77–88. blade plate fixation of unstable fractures of the
78. Medoff RJ. Essential radiographic evaluation for distal ulna associated with fracture of the distal
distal radius fractures. Hand Clin 2005;21(3): radius. J Hand Surg 2004;29(1):103–9.
279–88. 95. Faierman E, Jupiter JB. The management of acute
79. Carlsen B, Rizzo M, Moran S. Soft-tissue injuries fractures involving the distal radio-ulnar joint and
associated with distal radius fractures. Oper Tech distal ulna. Hand Clin 1998;(14):213–29.
Orthop 2009;19(2):107–18. 96. Rettig ME, Raskin KB. Galeazzi fracture-
80. Lindau T, Adlercreutz C, Aspenberg P. Peripheral dislocation: a new treatment-oriented classifica-
tears of the triangular fibrocartilage complex cause tion. J Hand Surg Am 2001;26(2):228–35.
distal radioulnar joint instability after distal radial 97. Anderson LD, Meyer FN. Fractures of the shafts of
fractures. J Hand Surg Am 2000;25(3):464–8. the radius and ulna. In: Rockwood CA, Green DP,
81. Lindau T, Hagberg L, Adlercreutz C, et al. Distal ra- editors. Fractures in adults. 3rd edition. Philadel-
dioulnar instability is an independent worsening phia: JB Lippincott Co; 1991. p. 728.
factor in distal radial fractures. Clin Orthop Relat 98. Hughston JC. Fracture of the distal radial shaft.
Res 2000;376:229–35. Mistakes in management. J Bone Joint Surg Am
82. Wang JP, Huang HK, Fufa D. Radial distraction to 1957;39:249–64.
stabilize distal radioulnar joint in distal radius fixa- 99. Mikic ZDJ. Galeazzi fracture-dislocations. J Bone
tion. J Hand Surg 2018;43(5):493.e1-4. Joint Surg 1975;57A:1071–80.
83. Richards RS, Bennett JD, Roth JH, et al. Arthro- 100. Reckling FW. Unstable fracture-dislocations of the
scopic diagnosis of intra-articular soft tissue in- forearm (Montaggia and Galeazzi lesions).
juries associated with distal radial fractures. J Bone Joint Surg Am 1982;64:857–63.
J Hand Surg Am 1997;22(5):772–6. 101. Paley D, Rubenstein J, McMurtry RY. Irreducible
84. Knirk JL, Jupiter JB. Intra-articular fractures of the dislocation of distal radial ulnar joint. Orthop Rev
distal end of the radius in young adults. J Bone 1986;15(4):228–31.
Joint Surg Am 1986;68(5):647–59. 102. Itoh Y, Horiuchi Y, Takahashi M, et al. Extensor
85. af Ekenstam F, Jakobsson OP, Wadin K. Repair of tendon involvement in Smith’s and Galeazzi’s frac-
the triangular ligament in Colles’ fracture. No effect tures. J Hand Surg 1987;12(4):535–40.
 Acute Distal Radioulnar Joint Instability 441

103. Yohe NJ, De Tolla J, Kaye MB, et al. Irreducible Ga- 113. Moro JK, Werier J, MacDermid JC, et al. Arthro-
leazzi Fracture-Dislocations. Hand (N Y) 2019; plasty with a metal radial head for unreconstructible
14(2):249–52. fractures of the radial head. J Bone Joint Surg Am
104. Iwamae M, Yano K, Kaneshiro Y, et al. Arthroscopic 2001;83-A(8):1201–11.
reduction of an irreducible distal radioulnar joint in 114. Edwards GS Jr, Jupiter JB. Radial head fractures
Galeazzi fracture-dislocation due to a fragment of with acute distal radioulnar dislocation. Essex-
the ulnar styloid: a case report. BMC Musculoske- Lopresti revisited. Clin Orthop Relat Res 1988;
let Disord 2019;20(1):354. 234:61–9.
105. Elzinga K, Chung K. Evolution of the ring concept 115. Gaspar MP, Adams JE, Zohn RC, et al. Late recon-
for the forearm and its implication on treatment: struction of the interosseous membrane with bone-
from galeazzi, monteggia, essex-lopresti, and dar- patellar tendon-bone graft for chronic essex-
rach to the current era. J Hand Surg Asian Pac Vol lopresti injuries: outcomes with a mean follow-up
2019;24(3):251–7. of over 10 years. J Bone Joint Surg Am 2018;
106. Essex-Lopresti P. Fractures of the radial head with 100(5):416–27.
distal radio-ulnar dislocation; report of two cases. J
116. Masouros PT, Apergis EP, Babis GC, et al. Essex-
Bone Joint Surg Br 1951;33B(2):244–7.
Lopresti injuries: an update. EFORT Open Rev
107. Shepard MF, Markolf KL, Dunbar AM. Effects of
2019;4(4):143–50.
radial head excision and distal radial shortening
117. Kam CC, Jones CM, Fennema JL, et al. Suture-but-
on load-sharing in cadaver forearms. J Bone Joint
ton construct for interosseous ligament reconstruc-
Surg Am 2001;83(1):92–100.
tion in longitudinal radioulnar dissociations: a
108. Shepard MF, Markolf KL, Dunbar AM. The effects of
biomechanical study. J Hand Surg 2010;35(10):
partial and total interosseous membrane transec-
1626–32.
tion on load sharing in the cadaver forearm.
J Orthop Res 2001;19(4):587–92. 118. Gaspar MP, Kearns KA, Culp RW, et al. Single-
109. Taylor TK, O’Connor BT. The Effect Upon the Infe- versus double-bundle suture button reconstruction
rior Radio-Ulnar Joint of Excision of the Head of of the forearm interosseous membrane for the
the Radius in Adults. J Bone Joint Surg Br 1964; chronic Essex-Lopresti lesion. Eur J Orthop Surg
46:83–8. Traumatol 2018;28(3):409–13.
110. Smith AM, Urbanosky LR, Castle JA, et al. Radius 119. Hackl M, Andermahr J, Staat M, et al. Suture button
pull test: predictor of longitudinal forearm insta- reconstruction of the central band of the inteross-
bility. J Bone Joint Surg Am 2002;84-A(11):1970–6. eous membrane in Essex-Lopresti lesions: a
111. Trousdale RT, Amadio PC, Cooney WP, et al. Radio- comparative biomechanical investigation. J Hand
ulnar dissociation. A review of twenty cases. Surg Eur volume 2017;42(4):370–6.
J Bone Joint Surg Am 1992;74(10):1486–97. 120. de Vries EN, Walenkamp MM, Mulders MA, et al.
112. Schnetzke M, Porschke F, Hoppe K, et al. Outcome Minimally invasive stabilization of the distal radioul-
of early and late diagnosed essex-lopresti injury. nar joint: a cadaveric study. J Hand Surg Eur vol-
J Bone Joint Surg Am 2017;99(12):1043–50. ume 2017;42(4):363–9.