DISTAL RADIO-ULNA JOINT (DRUJ) - Mr David Murray Orthopaedic Surgeon (2023)

What is distal radio-ulna joint?

The distal radio-ulna joint (DRUJ) is the distal (far) joint between the radius and ulna bones. The forearm is made of 2 bones: the radius; and the ulna. They are linked just below the elbow and just above the wrist. In between they do not meet but are linked by a long stout ligament. The joints at the elbow (proximal radio-ulna joint) and at the wrist (DRUJ) allow the radius to rotate around the ulna thus allowing forearm movement: pronation – turning the hand down to the floor; and supination – turning the hand up to the ceiling. The distal ulna bone also gives support to the wrist bones. At the far end of the ulna is a ligament complex called the triangular fibrocartilaginous complex (TFCC). This stabilises the radius to the ulna and helps support the wrist.
The problems at the DRUJ are most commonly instability following an injury and occasionally DRUJ arthritis. (Ulno-carpal impaction/abutment/impingement occurs when the ulna bone bumps against the wrist bones. This could be considered a DRUJ problem but is better considered under wrist ligament injuries – see information sheet).
DRUJ instability:Wrist fractures are often associated with tears of the TFCC or fracture (break) of the ulna styloid to which the TFCC is attached. In most cases this heals back well with either no instability or mild instability but with minimal or no symptoms. Some patients have aching over the ulnar (little finger) side of the wrist, some stiffness particularly into supination (turning the palm up) and reduced grip strength. Wrist fractures and soft tissue injuries occur a all ages so these problems can present at any age.
DRUJ arthritis:aWear and tear (osteoarthritis) is uncommon. It may follow a fracture although very few fractures give rise to DRUJ arthritis. Mostly it occurs for no obvious reason. The patients are typically late middle age or older (60+). The have a combination of pain over the DRUJ and stiffness in forearm rotation both pronation and supination. One or the other may predominate.

Making the diagnosis

The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at the elbows, wrists and hands. Stressing i.e. pushing on the affected area is usually uncomfortable. It is usually necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful.

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Treatment:
What are the non-operative treatments?

Treatment should start with non-operative options. The first step is activity modification which the patient may well already have tried. Pain killers (analgesics) particularly anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be very helpful for the pain in arthritis. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion. A splint for certain activities can also be of value particularly for instability. Some patients find splints very helpful, other not at all. If these measures are insufficient then a steroid injection may be recommended particularly for arthritis. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb. The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site. Success cannot be guaranteed but in 70-80% of patients there is some significant benefit. How long this lasts is unpredictable. Some people only have a few weeks or months of benefit. Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms. If one injection provides only short term benefit then it may well be repeated for arthritis but probably not for instability. Patients often ask how many injections can be given. There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable). By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely the any further injections will be successful and most surgeons would recommend an alternative approach. If, however, injections are only required infrequently, perhaps once every 2-3 years, then having a fourth or fifth injection would, in themselves, be a lot safer than having an operation, and if they give benefit this is reasonable. There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic. In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years. The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked. This is not common with this injection but is common with some other injections. If it does occur then that is a relative contra-indication to further injections, i.e. the patient’s surgeon would probably decide not to go ahead with further injections because of the risks of further local damage.

What does the operation involve?

For instability of the DRUJ there are a number of possible operations highlighting the complexity of this problem. The 2 main operations are either: ligament reconstruction; or ulna shortening.
Ligament reconstruction: This is the preferred option as in theory it directly addresses the problem. It is, however, difficult to reconstruct full ligament function and as yet there is no fully proven technique although there are a number of preferred and increasingly accepted techniques. The operation is performed under regional block/general anaesthetic. i.e. the patient’s arm is numbed or they are asleep. The surgeon makes a cut over both the back and the front of the wrist. A “spare” tendon or part of a tendon is used to reconstruct the ligament complex. The deep tissues are closed and the skin is then stitched up usually with absorbable stitches. A supportive plaster of Paris is applied and the patient’s arm(s) elevated.
The total time in hospital is usually 4-6 hours, although occasionally an overnight stay is required.

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Ulna shortening: In this operation the ulna bone is cut near the wrist, shortened by typically 1-3 mm and held with a plate and screws. This acts to tighten the remaining ligaments linking the radius and ulna bones and can be very effective in resolving instability. Each operation has strengths and weaknesses. The Hand specialist should help the patient to decide on the correct way forward. The operation is almost always performed under regional block/general anaesthetic. i.e. the patient’s arm is numbed or they are asleep. The surgeon makes a 6-8cm cut over the ulnar border of the distal forearm. The ulna bone is cut by a predetermined amount and held in its new shortened position with a plate and screws. The deep tissues are closed and the skin is then stitched up with absorbable stitches. A supportive plaster of Paris is applied and the patient’s arm(s) elevated.

The total time in hospital is usually 6-8 hours.
For arthritis of the DRUJ there are a number of possible operations again highlighting the complexity of this problem. The 2 main operations are either: excision of the distal ulna; or distal ulna replacement (hemi-arthroplasty):
Excision of the distal ulna:This is a well established called a Darrach’s procedure. It removes the site of the arthritis and resolves pain. In low demand patients such as the elderly (70+) or those with rheumatoid arthritis is works very well. Higher demand patients particularly younger males tend to have problems with pain and instability. In response to this a hemi-joint replacement has been developed replacing the end of the ulna (see below).
The operation is performed under regional block/general anaesthetic. i.e. the patient’s arm is numbed or they are asleep. The surgeon makes a cut over both the back and the front of the wrist. The end of the ulna bone is removed. In time the space will form with scar tissue forming a pseudo joint. The deep tissues are closed and the skin is then stitched up usually with absorbable stitches. A supportive plaster of Paris is applied and the patient’s arm(s) elevated.
The total time in hospital is usually 4-6 hours.
Distal ulna replacement (hemi-arthroplasty): This is a recently developed operation that appears to give good early and mid-term results but the long term results are not known.

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The operation is performed under regional block/general anaesthetic. i.e. the patient’s arm is numbed or they are asleep. The surgeon makes a cut over both the back of the wrist. The end of the ulna bone is removed and replaced with a piece of metal shaped like a new end of ulna. The deep tissues are closed and the skin is then stitched up usually with absorbable stitches. A supportive plaster of Paris is applied and the patient’s arm(s) elevated.
The total time in hospital is usually 6-8 hours.

What happens in the next few weeks?

The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.
The patient is reviewed in clinic within 2 weeks of the operation. Typically dissolvable stitches are used so they should not require to be removed. For ligament reconstruction progress tends to be a little slower than for ulna shortening, distal ulna removal or ulna replacement.

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Most of the movement gained following surgery occurs in the first 6 weeks although some further late movement often occurs. Thus the early post-operative period must be used productively to ensure a good result. The key is regular long gentle stretches both into supination and pronation. The Hand surgeon should be guide their patient carefully. Ideally the stretches should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day. Elevation and icing the elbow also help reduce swelling and thus pain and improve movement.
The hand can be used for gentle activity after the first few days. Most patients can drive after 6 weeks or so. Most patients return to work in 4-6 weeks, but this varies with occupation; heavy manual work usually takes a good 3 months. The wound should be massaged by the patient 3 times a day with a bland soft cream for 3 months once the wound is well healed (typically after 2 weeks). This reduces the scar sensitivity which can be a nuisance. Patients should avoid heavy use of the wrist or hand for at least 6 weeks and often longer following the operation.

Are there any risks?

All interventions in medicine have risks. In general the larger the operation the greater the risks. For distal ulna surgery the risks include:

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  • The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
  • Aching at the site may last for several months
  • Grip strength can also take some months to return to normal.
  • Stiffness may occur in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below)
  • Numbness can occur around the scar but this rarely causes any functional problems.
  • Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
  • For joint replacement there is a risk of long-term joint replacement failure requiring reoperation.
  • For joint fusion there is a risk of failure to achieve bone to bone union of to gain union with some malalignment. Either may (but not of necessity) require reoperation.
  • Chronic Regional Pain Syndrome “CRPS”. This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand “over-react”, causing swelling, pain, discolouration and stiffness, which improve very slowly.
  • Any operation can have unforeseen consequences and leave a patient worse than before surgery.

FAQs

What is distal radio ulnar joint? ›

The distal radioulnar joint (DRUJ) is part of the complex forearm articulation that includes proximal radioulnar joint (PRUJ), forearm bones, and interosseous membrane (IOM) allowing pronosupination. It is functionally and anatomically integrated with the ulnocarpal articulation of wrist.

How long is recovery for DRUJ surgery? ›

What Precautions should be Taken as You Recover from DRUJ Arthroscopy? You may be asked to keep the operated area (wrist) immobilized in a semi-circular ulnar-sided cast for 1 week and avoid heavy lifting for 4 weeks.

How is DRUJ instability treated? ›

Surgery should be considered for DRUJ instability to recover bone and ligament injuries if nonsurgical treatment fails to restore forearm stability and function. To recover bone deformities, osteotomies of the radius,14,15 ulna,16 or, in some cases, sigmoid notch osteoplasty17 are used.

What is DRUJ disease? ›

Distal radioulnar joint (DRUJ) arthritis is an inflammatory condition characterized by gradual wearing away of the cartilaginous surface of the radioulnar joint resulting in significant pain, swelling, stiffness, and interference in the functioning of the wrist and/or arm.

What causes distal radioulnar joint instability? ›

Distal Radioulnar Joint Instability occurs when articular contact between the two forearm bones at the wrist follows an abnormal path in rotation. Though this is an exceptionally stable and mobile joint, it is prone to injury when someone falls on an outstretched hand (FOOSH) with the wrist pronated.

Where is DRUJ in wrist? ›

The region towards the wrist is called the distal end. Distal radioulnar joint (DRUJ) is a pivot type synovial joint located between the radius and the ulna just proximal to the wrist joint and assists in pronation and supination of the forearm.

What can you not do after wrist surgery? ›

Do not do any weight-lifting or strengthening exercises without talking with your surgeon or occupational therapist. Most patients will be able to perform most activities of daily living at about 6 weeks but with residual stiffness, with recovery of about 50% of their normal wrist motion.

How long after wrist surgery can I drive? ›

Conclusions: Most patients could safely return to driving within 3 weeks of surgery. Pain was the primary limiting factor affecting driving ability. Safe return to driving may be warranted within 3 weeks of distal radius volar plate fixation in some patients.

How long does it take to feel better after wrist surgery? ›

Depending on the type of wrist surgery you get done, your recovery can be anywhere from 4 – 12 weeks. Most patients are able to heal in about a month and can begin rehabilitation soon after. During the healing period, you should wear appropriate casts or braces as directed by your surgeon.

How do I check my DRUJ instability? ›

DRUJ stress test or ballottement test: The radiocarpal joint is stabilized with one hand while the ulna is shucked with another hand against the radius. The test is positive if it is aching and severely unstable in symptomatic individuals. The test has a specificity of 96% but solely a sensitivity of 59% (31).

Where is DRUJ? ›

The distal radio-ulnar joint (DRUJ) is the joint between the lower end of the radius and the ulna. It is part of the forearm, whose motion allows the hand to be placed palm down, palm up and everything in between. At the distal radio-ulna joint, the radius is gently concave and the ulna head gently convex (see figure).

Where is distal radius? ›

The radius is one of two forearm bones and is located on the thumb side. The part of the radius connected to the wrist joint is called the distal radius. When the radius breaks near the wrist, it is called a distal radius fracture. The break usually happens due to falling on an outstretched or flexed hand.

What position is DRUJ most stable? ›

Generally speaking, a dorsal dislocation is most stable in supination while a volar dislocation is more stable in pronation. If the DRUJ is unstable after reduction, the radioulnar joint may be pinned in the position of greatest stability.

How do you prevent a DRUJ dislocation? ›

In most cases of isolated volar ulna dislocation, the injury is reduced under general anaesthetic by forceful manipulation of the joint, using manual pressure on the ulna in a medial and dorsal direction, and hyperpronation of the forearm.

What is DRUJ arthroplasty? ›

DRUJ prostheses have been developed to replace the mechanical function of the ulnar head in patients with pain related to distal ulnar resection (1, 3) and post-traumatic arthritis (2).

Where is the distal radioulnar located? ›

The distal radioulnar articulation, also known as the distal radioulnar joint (DRUJ), is a synovial pivot-type joint between the two bones in the forearm; the radius and ulna. It is one of two joints between the radius and ulna, the other being the proximal radioulnar articulation.

What causes ulnar impaction syndrome? ›

Ulnar impaction syndrome is a progressive degenerative condition, most commonly resulting from repetitive abutment of a lengthened ulna, with the TFCC, lunate, triquetrum, and lunotriquetral ligament.

Where is the ulna styloid? ›

The ulnar styloid is located at nearly the ulnar-most (the opposite side of the humerus with the elbow flexed) and slightly dorsal aspects of the ulnar head on the axial plane. It should appear almost midway (55% dorsally) from the ulnar head on the standard lateral view of the wrist in neutral forearm rotation.

Can you drive after TFCC surgery? ›

Your doctor may prescribe medication to relieve pain and discomfort. You can apply ice to reduce the swelling. You will be taught strengthening and stretching exercises to regain range-of-motion of the wrist. It is recommended that you avoid driving for at least 2 months after the surgery.

What is distal radius joint? ›

The distal radioulnar joint is a synovial joint between the distal ends of the radius and ulna. This is a uniaxial pivot joint that allows the movements in one degree of freedom; pronation-supination.

What is wrist joint called? ›

The wrist joint also referred to as the radiocarpal joint is a condyloid synovial joint of the distal upper limb that connects and serves as a transition point between the forearm and hand. A condyloid joint is a modified ball and socket joint that allows for flexion, extension, abduction, and adduction movements.

How long do you stay in hospital after wrist surgery? ›

The type of surgery you have had will affect your length of stay, but it would be expected that you will be able to go home within 24 – 48 hours of your operation unless further treatment is required.

How long do I need to wear a sling after wrist surgery? ›

Your doctor may instruct you on the proper care and cleaning of the surgical site. You might also have a splint or cast to keep your wrist immobilized, which you may need to wear for 4-6 weeks. A doctor may prescribe pain medication for the first few days after surgery to help alleviate any discomfort you might have.

Can I use my hand after wrist surgery? ›

After the operation

Repaired tendons need at least six weeks to heal. During this time you won't be able to use your hand at all and must only do the exercises shown to you by your hand therapist. You'll have to wear a splint on your hand day and night to protect the healing tendons.

How painful is wrist surgery? ›

It is not uncommon for patients to get concerned about how long the pain will last after wrist surgery. As a general rule, most patients have dull pain for about two months post-surgery with minor occurrences of severe pain happening with an accidental movement or overextension.

How long after wrist surgery can I bend my wrist? ›

The wrist should remain immobile for 1 week until the sutures are removed, but after that patients can begin mobility exercises. A course of physical therapy will be prescribed to help patients restore range of motion, decrease swelling, and rebuild strength.

Are you put to sleep for wrist surgery? ›

In most hospitals, surgery on the hand and wrist is usually performed using regional anesthesia and intravenous sedation, or general anesthesia. Patients must undergo preoperative tests, fast starting the night before, and spend an hour or more in a recovery room.

How should you sleep after wrist surgery? ›

Elevate your arm above your heart. The best way to do this comfortably is to lie flat on your back with your hand resting on a few pillows. Elevate your hand for at least three days after surgery.

What do you wear for wrist surgery? ›

Please wear loose, comfortable clothing such as t-shirts, button down shirts, sweat pants/warm ups or baggy shorts that will fit over bandages or dressing following surgery. Please do not bring valuables or wear jewelry the day of surgery.

How long does it take for nerves to heal after wrist surgery? ›

It usually takes 3 to 4 months to recover and up to 1 year before hand strength returns.

What causes ulnar dislocation? ›

By isolated injuries, ulna dorsal dislocations occur as a result of hyperpronation, while ulna palmar dislocations occur as a result to hypersupination. There are simple and complex types of distal radioulnar joint dislocation. Simple dislocations are reduced spontaneously or by closed means and minimal effort.

How do you test the distal radioulnar joint? ›

Distal Radioulnar Joint Test / DRUJ Test - YouTube

How do you treat a TFCC injury? ›

Initial treatment of all types of TFCC injury includes rest, activity modification, splint, physical therapy, and corticosteroid injections. In case of failure of conservative treatment to give relief or in tears with joint instability early surgical intervention is recommended.

What is radio ulnar? ›

The radioulnar joints are two joints between the two bones of the forearm: the ulna, on the medial side, and the radius, on the lateral side. There's one superior, or proximal radioulnar joint, and one inferior, or distal radioulnar joint, and together they allow for the movements of pronation and supination.

What joint is the radius and ulna? ›

Elbow. The radius articulates with the ulna in a synovial pivot joint.

Is the distal radioulnar joint part of the wrist? ›

Abstract. The distal radioulnar joint plays an intricate part in the function of the wrist and thus in the function of the entire upper extremity. The radius and hand move in relation to and function about the distal ulna.

How long does pain last after distal radius? ›

Conclusions. This study demonstrated that the normal course of recovery following a distal radius fracture is one where severe symptoms subside within the first two-months and the majority of patients can be expected to have minimal pain and disability by six-months following fracture.

Does a distal radius require surgery? ›

Distal radius fractures do not always require surgery. Many heal just fine without an operation. Minor fractures with minimal displacement do very well with nonsurgical treatment. Other displaced fractures can be “reduced” and casted.

Do you get a cast after wrist surgery? ›

Following wrist fracture surgery, you will likely have some sort of wrist support, be it a plaster cast, a brace, or a splint. These should be used according to your doctor's instructions. Icing your wrist will help reduce swelling and pain.

What is radio ulnar? ›

The radioulnar joints are two joints between the two bones of the forearm: the ulna, on the medial side, and the radius, on the lateral side. There's one superior, or proximal radioulnar joint, and one inferior, or distal radioulnar joint, and together they allow for the movements of pronation and supination.

Where is the distal radioulnar joint? ›

The distal radioulnar articulation, also known as the distal radioulnar joint (DRUJ), is a synovial pivot-type joint between the two bones in the forearm; the radius and ulna. It is one of two joints between the radius and ulna, the other being the proximal radioulnar articulation.

What type of joint is the radio ulnar joint? ›

The proximal radioulnar joint is a synovial joint that connects the proximal ends of the radius and ulna. In this joint, the circumferent head of radius is placed within the ring formed by the radial notch of ulna and the annular ligament. This configuration makes this joint a pivot joint.

Is the distal radioulnar joint part of the wrist? ›

Abstract. The distal radioulnar joint plays an intricate part in the function of the wrist and thus in the function of the entire upper extremity. The radius and hand move in relation to and function about the distal ulna.

Is radioulnar synostosis a disability? ›

Superior radioulnar synostosis is a rare abnormality which frequently gives rise to functional disability.

How many people have radioulnar synostosis? ›

Congenital radioulnar synostosis is rare, with only about 350 cases identified worldwide. The average age at diagnosis is about 6 years, which is typically the age when children start attending school and having more physical activity demands.

What holds the radius and ulna together? ›

The distal radioulnar articulation is composed of the palmar radioulnar ligament (volar radioulnar ligament) that attaches the anterior radius to the anterior ulna, the dorsal radioulnar ligament (posterior radioulnar ligament) which attaches the posterior radius to the posterior ulna, and the articular disc which lies ...

What are the primary movements that occur at the distal radio ulnar joint? ›

The primary movement of the distal radioulnar joint is to allow pronation and supination of the forearm.

What movements occur at the distal radioulnar joint? ›

—The movements in the distal radioulnar articulation consist of rotation of the lower end of the radius around an axis which passes through the center of the head of the ulna. When the radius rotates forward, pronation of the forearm and hand is the result; and when backward, supination.

What makes up the DRUJ? ›

It consists of the articular disc of the distal radioulnar joint, ulnar collateral ligament, dorsal and palmar radioulnar ligaments, the base of the extensor carpi ulnaris sheath, and the ulnolunate and ulnotriquetral ligaments.

What is DRUJ instability? ›

What is Distal Radioulnar Joint (DRUJ) Instability? Distal radioulnar joint instability is the abnormal orientation or movement of the radius and ulna bones at the wrist in relation to one another. Injury to the tendons, ligaments and/or muscles stabilizing the joint may cause partial or complete dislocation.

What is the wrist joint called? ›

The wrist joint also referred to as the radiocarpal joint is a condyloid synovial joint of the distal upper limb that connects and serves as a transition point between the forearm and hand. A condyloid joint is a modified ball and socket joint that allows for flexion, extension, abduction, and adduction movements.

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