The triangular fibrocartilage complex (TFCC) is a known stabiliser of the distal radioulnar joint (DRUJ). An injury to these structures can result in significant disability including pain, weakness and joint stiffness. The contribution each of its components makes to the stability of the TFCC is not well understood. This study was undertaken to investigate the role of the individual ligaments of the TFCC and their contribution to joint stability. The study was undertaken in two parts. 30 cadaveric forearms were studied in each group. The ligaments of the TFCC were progressively sectioned and the resulting effect on the stability of the DRUJ was measured. A custom jig was created to apply a 20N force through the distal radius, with the ulna fixed. Experiment one measured the effect on DRUJ translation after TFCC sectioning. Experiment two added the measurement of rotational instability. Part one of the study showed that complete sectioning of the TFCC caused a mean increase in translation of 6.09(±3) mm. Sectioning the palmar radioulnar ligament of the TFCC caused the most translation. Part two demonstrated a change in rotation with a mean of 18 (± 6) degrees following sectioning of the TFCC. There was a progressive increase in rotational instability until the palmar radioulnar ligament was also sectioned. Linear translation consistently increased after sectioning all of the TFCC ligaments, confirming its importance for DRUJ stability. Sectioning of the palmar radioulnar ligament most commonly caused the greatest degree of translation. This suggests injury to this ligament would more likely result in a greater degree of translational instability. The increase in rotation also suggests that this type of instability would be symptomatic in a TFCC injury

Purpose: Injury to the distal radioulnar joint can result in ulna sided wrist pain and instability. Stabilisation of the distal radioulnar ligaments described by Adams and Berger uses a tendon graft run along the anatomical course of the distal radioulnar ligaments from the lip of the radial sigmoid notch to the fovea of the ulna. The graft wraps around the ulna head and is fixed with a simple suture; this can be challenging for the surgeon and requires a considerable length of tendon. The length of graft required could be reduced by fixing the graft directly to the ulna. Alternative fixation methods when the graft is short would include bone anchors and interference screws. We therefore compared the fixation strength achieved with simple suture, by bone anchor and by interference screw (Mini Bio-suture Tack and 3mm Biotenodesis interference screw, Arthrex, UK). Methods: Four ulna bones were harvested along with four corresponding tendons. Tendons were divided into 2mm wide strips and run through a 3.5mm hole in the ulna. Maximum load was measured after fixing the tendon with 1) simple suture, 2) a bone anchor, and 3) an interference screw. Paired data was tested with the paired T-test and Wilcoxon test. Results: Maximum load recorded was highest for the Mini Bio-Suture Tack bone anchor (99.28 ± 47.39) followed by the simple suture method (96.23 ± 24.14 N), and the Biotenodesis interference screw (46.90 ± 11.29). Differences approached significance when comparing simple suture fixation with interference screws (p=0.02/0.068). Conclusions: No study has investigated the use of interference screws to secure two tendons in one graft tunnel. Previous work using a single graft and a single tendon has consistently shown that interference screws are superior to other methods of fixation. However, when performing Adam’s procedure for stabilisation of the distal radioulnar joint suturing the tendon together or using a bone anchor provide the greatest fixation strength. This might be due to loss of the interference effect when placing two grafts in the tunnel

This study quantified the joint reaction forces in the distal radioulnar joint using an instrumented ulnar head replacement implant. Muscle activity was simulated in-vitro to determine the effects on joint reaction force. Forces were found to linearly increase with simulated muscle load in all forearm positions for the biceps and pronator teres muscles. However, this did not occur for simulations of the supinator and pronator quadratus muscles, likely due to their broader insertion, smaller size and non-linear lines-of-action. This work has important implications in forearm biomechanical modelling, implant design, fixation and rehabilitation protocols following arthroplasty. To determine the relationship between forearm muscle activity and joint reaction force (JRF) in the distal radioulnar joint (DRUJ). The DRUJ reaction force is linearly related to the muscle activity of the PT and biceps, but not necessarily to the activity of the supinator and PQ. This work has implications for biomechanical modelling, implant design, fixation and rehabilitation protocols following DRUJ arthroplasty. JRFs were found to increase linearly with muscle load for all muscles simulated (biceps, pronator teres (PT), pronator quadratus (PQ), supinator) in all forearm positions tested (supination, neutral and pronation) (correlation coefficient r> 0.85, p< 0.01) with two exceptions; simulation of the PQ in the neutral position (r=−0.65, p=0.2), and the supinator in the pronated position (r=0.72, p=0.2). Biceps simulation generated larger JRF magnitudes in all positions compared to other muscles (p< 0.001), and the PQ generated larger JRF magnitudes compared to the supinator (p=0.05). Ulnar head arthroplasty was performed with a replacement ulnar head implant instrumented with strain gauges to allow measurement of the DRUJ reaction force. An upper extremity joint simulator applied muscle loads in seven fresh frozen cadaveric upper extremities through computer-controlled pneumatic actuators. Load was varied in 10N increments from 10-80N (biceps and PT) and from 10-50N (PQ and supinator). A hand clamp was used to restrain the forearm in varying positions. The results illustrate that broad insertion and non-linear muscles may not be linearly correlated to joint reaction force in the DRUJ. Please contact author for diagrams and graphs

Introduction: Injury to the wrist may result in derangement of the distal radioulnar joint (DRUJ) and lead to deformity and degenerative changes. This often gives pain on ulnar side of the wrist and limits forearm rotation. We share our experience with the Sauve-Kapandji procedure for chronic posttraumatic derangement of the DRUJ. Methods: Sixteen patients (seventeen wrists) with chronic posttraumatic derangement of the DRUJ were assessed before and after SauvŽ-Kapandji procedure using Cooneyñs score. There were six men and ten women and average follow up was 64 months. Results: Mean supination improved from 43.9û to 78.5û and the mean pronation improved from 44.4û to 80.6û at the time of latest follow-up. Pain relief was satisfactory, and the mean grip strength improved from 30.6% of that on the unaffected side preoperatively to 72.1% at the time of follow-up. The ulnar stump was stable in þf-teen patients. Thirteen of the sixteen patients were able to return to work full-time without restrictions. At a mean of 64 months four patients had an excellent result; six a good result; þve a fair result; and one patient a poor result. Conclusion: On the basis of our þndings, we believe that the index operation is a good salvage procedure for the treatment of chronic posttraumatic derangement of DRUJ, especially when non-operative treatment has been unsuccessful and rotation of the forearm is severely limited

Aims

The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome.

Material & Methods: Twenty three patients (15 male; 8 female) with an average 30 years old (16–63) presented with a posttraumatic multidirectional instability of the distal RU joint. In two occasions instability was associated to a malunited distal radial fracture which was corrected with a osteotomy. Through a dorsoulnar approach, the RU joint in all cases was inspected and found with no cartilage defects that could preclude this intervention. Also in all occasions there was an unrepairable peripheral TFCC detachment. In 11 cases the palmaris longus tendon was utilized, while in one the flexor superficialis of the ring finger was used. The graft was passed through an anteroposterior tunnel in the distal-medial edge of the radius and attached into another tunnel in the basistyloid fovea. The forearm was then immobilized in neutral pronosupination for 4–6 weeks, followed by appropriate physiotherapy.

Results: At an average 18 months follow-up (6–36) 21 patients regained radioulnar stability (symmetrical passive displacement of the joint relative to the contralateral side). In two there was a limitation of more than 25° pronosupination. All 15 patients with a follow-up longer than one year had returned to their previous activities with a less than 20% loss of grip strength.

Conclussion: Tendon reconstruction as suggested by Adams& Berger is anatomically sound, and it has shown promising short term results, certainly superior to the results obtained with other soft-tissue reconstructions.

Altered distal radioulnar joint contact (DRUJ) mechanics are thought to cause degenerative changes in the joint following injury. Much of the current research examining DRUJ arthrokinematics focuses on the effect of joint malalignment and resultant degenerative changes. Little is known regarding native cartilage contact mechanics in the distal radioulnar joint. Moreover, current techniques used to measure joint contact rely on invasive procedures and are limited to statically loaded positions. The purpose of this study was to examine native distal radioulnar joint contact mechanics during simulated active and passive forearm rotation using a non-invasive imaging approach. Testing was performed using 8 fresh frozen cadaveric specimens (6 men: 2 women, mean age 62 years) with no CT evidence of osteoarthritis. The specimens were thawed and surgically prepared for biomechanical testing by isolating the tendons of relevant muscles involved in forearm rotation. The humerus was then rigidly secured to a wrist simulator allowing for simulated active and passive forearm rotation. Three-dimensional (3D) cartilage surface reconstructions of the distal radius and ulna were created using volumetric data acquired from computed tomography after joint disarticulation. Using optically tracked motion data and 3D surface reconstructions, the relative position of the cartilage models was rendered and used to measure DRUJ cartilage contact mechanics. The results of this study indicate that contact area was maximal in the DRUJ at 10 degrees of supination (p=0.002). There was more contact area in supination than pronation for both active (p=0.005) and passive (p=0.027) forearm rotation. There was no statistically significant difference in the size of the DRUJ contact patch when comparing analogous rotation angles for simulated active and passive forearm motion (p=0.55). The contact centroid moved 10.5±2.6 mm volar along the volar-dorsal axis during simulated active supination. Along the proximal-distal axis, the contact centroid moved 5.7±2.4 mm proximal during simulated active supination. Using the technique employed in this study, it was possible to non-invasively examine joint cartilage contact mechanics of the distal radioulnar joint while undergoing simulated, continuous active and passive forearm rotation. Overall, there were higher contact area values in supination compared with pronation, with a peak at 10 degrees of supination. The contact centroid moved volarly and proximally with supination. There was no difference in the measured cartilage contact area when comparing active and passive forearm rotation. This study gives new insight into the changes in contact patterns at the native distal radioulnar joint during simulated forearm rotation, and has implications for increasing our understanding of altered joint contact mechanics in the setting of deformity

Introduction and Aims: Rotational malalignment following fracture of the distal radius results in subluxation of the distal radioulnar joint, alteration of the normal contact area of the ulnar head in the sigmoid notch of the radius, arthrosis, pain, limited pronation and supination and dysfunction. This paper describes the technique for restoration of appropriate rotation, as well as length and angulation following malunion. Method: Eleven cases of derotational osteotomy of the distal radius with low-profile plate fixation have been performed for correction of rotational malalignment with restoration of appropriate articular tilt, length and alignment. In eight cases, the articular surface of the distal ulna was found to be too degenerated to salvage the distal radioulnar joint and resection of the distal ulna with soft tissue reconstruction was performed. Results: Healing of the osteotomy of the distal radius was achieved in all 11 patients. None of the patients undergoing distal resection demonstrated instability of the distal radioulnar joint but one demonstrated distal radioulnar impingement. One patient with a preserved ulnar head demonstrated ulnocarpal abutment and required late secondary ulna head resection. Pre-operative pronation/supination arc was 40 degrees and postoperative arc was 130 degrees. In eight of the 11, pain was rated as zero on a 10-point scale, while the other three ranged between two and five on the same scale. At a two-year follow-up, grip strength measured 80% of the contralateral side while total range of motion measured 76% of the contralateral side. All 11 patients were functional at daily household activities, five out of seven previously working patients were back to work, and all patients felt that their post-operative status was a significant improvement over their pre-operative status. Conclusion: Rotatory malpositioning following distal radius fracture provides significant disability. Derotational osteotomy can be effective in restoring pronation and supination, diminishing pain and increasing function. Late treatment may also require resection of the distal ulnar articular surface due to post-traumatic arthrosis. Soft tissue stabilisation at the time of osteotomy provides stability of the distal radioulnar joint in the majority of cases

The Adams-Berger reconstruction is an effective technique for treating distal radioulnar joint (DRUJ) instability. Graft preparation techniques vary amongst surgeons with insufficient evidence to support one technique over another. Our study evaluated the biomechanical properties of four graft preparation techniques. Extensor tendons were harvested from fresh frozen porcine trotters obtained from a local butcher shop and prepared in one of three configurations (n=5 per group): tendon only; tendon prepared with non-locking, running suture (2-0 FiberLoop, Arthrex, Naples, FL) spaced at 6 mm intervals; and tendon prepared with suture spaced at 12 mm intervals. A fourth configuration of suture alone was also tested. Tendons were allocated in a manner to ensure comparable average diameters amongst groups. Biomechanical testing occurred using custom jigs simulating radial and ulnar tunnels attached to a Bose Electroforce 3510 mechanical testing machine (TA Instruments). After being woven through the jigs, all tendons were sutured end-to-end with 2-0 PROLENE suture (Ethicon). Tendons then underwent a staircase cyclic loading protocol (5-25 Newtons [N] at 1 hertz [Hz] for 1000 cycles, then 5-50 N at 1 Hz for 1000 cycles, then 5-75 N at 1 Hz for 1000 cycles) until graft failure; if samples did not fail during the protocol, they were then loaded to failure. Samples were visually inspected for mode of failure after the protocol. A one-way analysis of variance was used to compare average tendon diameter; post-hac Tuhey tests were used to compare elongation and elongation rate. Survival to cyclic loading was analyzed using Kaplan-Meier survival curves with log rank. Statistical significance was set at a = 0.05. The average tendon diameter of each group was not statistically different [4.17 mm (tendon only), 4.33 mm (FiberLoop spaced 6 mm), and 4.30 mm (FiberLoop spaced 12 mm)]. The average survival of tendon augmented with FiberLoop was significantly higher than tendon only, and all groups had significantly improved survival compared to suture only. There was no difference in survival between FiberLoop spaced 6 mm and 12 mm. Elongation was significantly lower with suture compared to tendon augmented with FiberLoop spaced 6 mm. Elongation rate was significantly lower with suture compared to all groups. Modes of failure included rupture of the tendon, suture, or both at the simulated bone and suture and/or tendon interface, and elongation of the entire construct without rupture. In this biomechanical study, augmentation of porcine tendons with FiberLoop suture spaced at either 6 or 12 mm for DRUJ reconstruction significantly increased survival to a staircase cyclic loading protocol, as suture material was significantly stiffer than any of the tendon graft configurations

Purpose: The Sauvé-Kapandji procedure is often performed for the treatment of posttraumatic degeneration of the distal radioulnar joint. Few studies have been devoted specifically to the proximal stump of the ulnar after this procedure. The aim of our study was to conduct a radioclinical evaluation of the dynamics of the proximal ulnar stump. Material and methods: This retrospective analysis involved fourteen patients (four women and ten men), mean age 48 years who underwent the procedure between January 1991 and March 2002. All presented posttraumatic degradation of the distal radioulnar joint. The operation took place twelve months after trauma on average. Mean ulnar resection was 11 mm, performed as distally as possible. The pronator quadratus was not advanced into the false joint. Pronation-supination rehabilitation exercises were instituted shortly after surgery. A static and dynamic x-rays protocol was designed for analysis. Results: Patients were reviewed at five years two months on average. There were two complications: fusion of the intentional ulnar pseudarthrosis and one pseudarthrosis of the distal radioulnar joint. Time to resumption of former activity was nine months on average. Two patients could not resume their former activity. Seven patients complained of mechanical pain at the ulnar resection. Three patients reported cracking sounds along the ulnar border of the wrist and two patients presented an objective snap during pronosupination. Clinically, the ulnar stump was unstable in the sagittal plan in all cases. Radiographs confirmed this instability. Clinically, there was also an instability in the frontal plane in three patients. The dynamic films did not confirm frontal instability. Discussion: Although less so than after the Darrach procedure, the proximal ulnar stump is the principle complication of the Savué-Kapandji procedure. Preservation of the structures stabilising the distal ulnar stump is crucial: periosteum, interosseous membrane, ulnar extensor of the carpus, pronator quadratus. Our use of a shorter resection made as distally as possible was only able to avoid a certain degree of instability which was nevertheless well tolerated. Conclusion: The Sauvé-Kapandji procedure provides very satisfactory results for pain and motion. All patients appeared to have some degree of distal ulnar stump instability which was as a rule well tolerated. Nevertheless, one patient required a revision for stabilisation. This instability remains an unsolved problem which apparently cannot be prevented even with a very rigorous technique

Aims: In the present study we reviewed 105 patients who had had Galeazzi fractures with particular emphasis on classiþcation (þve types according to the fracture patterns), treatment, and þnal results. Methods: One hundred and þve cases (75 males and 30 females) were included in this study. Most of the fractures (70 cases) occurred in the distal third of radial shaft (Type I). Seventeen fractures were in the middle third (Type II), and 11 fractures were in the proximal third of the shaft of the radius (Type III). In four cases disruption of the distal radio-ulnar joint associated with fractures of both bones (Type IV). Finally three cases considered as Galeazzi-equivalent lesions (Type V). Results: The mean follow-up time was 7 years. The overall results were good in 81% of the patients, fair in 14% and poor in the 5% of the patients. Union achieved in 102 cases and non union in three cases (two had had primary conservative treatment and one case was treated surgically). Supination ranged from 40 to 90 degrees (average 77.5 degrees), and pronation from 50 to 90 degrees (average 81.6 degrees). Conclusions: The Galeazzi fracture is uncommon injury with an incidence varying from 3% to 6% of all forearm fractures. The key to satisfactory results in the treatment of the Galeazzi lesion is anatomic restoration of the length of the radius, with application of rigid internal þxation to maintain the reduction. Although most of the reports do not recommend exposing the distal radioulnar joint, we suggest that once the anatomic reduction is secured, anteroposterior and true lateral x-rays planes to control the distal radioulnar joint

The clinical diagnosis of distal radioulnar joint (DRUJ) instability remains challenging. The current diagnostic gold standard is a dynamic computerized topography (CT) scan. This investigation compares the affected and normal wrists in multiple static positions of forearm rotation.. However, its accuracy has been questioned, as the wrist is unloaded and not placed under stress. This may fail to capture DRUJ instability that does not result in static malalignment between the ulnar head and sigmoid notch. The purpose of this biomechanical study was to evaluate the effectiveness of both dynamic and stress CT scans in detecting DRUJ instability. A customized DRUJ arthrometer was designed that allows for both static positioning, as well as dorsal and volar loading at the DRUJ in various degrees of forearm rotation. Ten fresh frozen cadavers were prepared and mounted in the apparatus. CT scans were performed both in the unloaded condition (dynamic CT) and with each arm subjected to a standardized 50N volar and dorsal force (stress CT) in neutral and maximum pronation/ supination. The TFCC (triangular fibrocartilage complex)was then sectioned peripherally to simulate DRUJ instability and the methodology was repeated. CT scans were then evaluated for displacement using the radioulnar ratio method. When calculating the radioulnar ratio for intact wrists using the dynamic CT technique, values were 0.50, 0.64, 0.34 for neutral, pronation and supination, respectively. When the TFCC was sectioned and protocol repeated, the values for the simulated unstable wrist for dynamic CT were 0.54, 0.62, 0.34 for neutral, pronation and supination, respectively. There was no statistically significant difference between the intact and sectioned states for any position of forearm rotation using dynamic CT. Usingstress CT, mean radioulnar ratios for the intact specimens were calculated to be 0.44, 0.36 and 0.31 for neutral, pronation and supination, respectively. After sectioning the TFCC, the radioulnar ratios increased to 0.61, 0.39 and 0.46 for neutral, pronation and supination. There was a statistically significant difference between intact and simulated-unstable wrists in supination (p = 0.002) and in neutral (p=0.003). The radioulnar ratio values used to measure DRUJ translation for dynamic CT scans were unable to detect a statistically significant difference between stable and simulated unstable wrists. This was true for all positions of forearm rotation. However, when a standard load was placed across the DRUJ, statically significant changes in the radioulnar ratio were seen in neutral and supination between stable and simulated unstable wrists. This discrepancy challenges the current gold standard of dynamic CT in its ability to accurately diagnosis DRUJ instability. It also introduces stress CT as a possible solution for diagnosing DRUJ instability from peripheral TFCC lesions

Advancements in treating complications of operatively treated distal radius fractures. We will review tips and tricks to avoid complications associated with operative fixation of these complicated injuries. We will cover treatment of the distal radioulnar joint, associated distal ulna fracture, complications of malreduction and implant prominence. During this session, we will review the latest techniques for treating these complex distal radius fractures and how to avoid associated complications

Quantitative measurements of load transfer through the distal radioulnar joint (DRUJ) are limited. An instrumented ulnar head prosthesis was developed to measure bending and torsion moments about the three anatomic axes of the ulna. This device has shown repeatable loading data following insertion in a cadaveric specimen during active forearm rotation trials conducted in an in-vitro upper extremity joint simulator. The data acquired from this device will have important implications for upper extremity modeling, implant fixation and design, and optimizing surgical procedures related to DRUJ arthroplasty. To develop a system to quantify in-vitro load transfer through the distal radioulnar joint (DRUJ) following ulnar head arthroplasty during simulated active forearm rotation. Also, the effect of an eccentric ulnar head implant design was investigated. A load-measuring system was developed that was easily surgically inserted, and produced repeatable loading data. The instrumented implant developed in this study will contribute to the optimization of surgical procedures and implant design parameters related to distal ulnar arthroplasty. Four pairs of strain gauges were applied to the stem of an ulnar head prosthesis to measure bending and torsion moments about the three anatomic axes of the ulna. Three ulnar heads were machined with varying eccentricities (axisymmetric, 1.5 mm offset and 3.0 mm offset). The implant was inserted in one unpreserved cadaveric upper extremity and active forearm rotation induced using a computer controlled joint simulator. Repeatability (assessed using the maximum standard deviation over 5 trials of pronation and supination) was less than 9% of the output range for all loads. Bending and torsion moments between −0.4 and 0.5 Nm, correlating to joint loads between 0 and 50 N, were measured. The measured loads followed a consistent pattern with forearm position. Higher loads were noted for the eccentric implant heads compared to the axisymmetric head, especially at the extreme ranges of rotation. Clinical interpretation of these findings is difficult since the optimal loading scenario for distal ulnar implant longevity remains unknown. Please contact author for diagrams and graphs

The influence of the supinator and pronator quadratus (PQ) muscles on distal radioulnar joint stability were evaluated using a joint simulator capable of producing forearm rotation, before and after ulnar head excision. Multiple pronation trials were conducted with incremental loading of the PQ relative to the pronator teres; supination trials were similarly conducted with the supinator and biceps. Incremental supinator muscle loading did not alter forearm kinematics. Increased PQ loading did not affect intact kinematics, but did alter joint motion following ulnar head excision. PQ activation will likely aggravate forearm instability following ulnar head excision; suggesting rehabilitation should incorporate immobilization in supination. The purpose of this study was to study the effect of pronator quadratus (PQ) and supinator loads on forearm kinematics in both an intact distal radioulnar joint (DRUJ) and following ulnar head excision. The PQ muscle appears to aggravate instability of the DRUJ following ulnar head excision, while incremental loading of the supinator muscle had no effect. Patients with DRUJ instability and/or who have undergone surgical removal of the ulnar head should be rehabilitated in supination to limit the influence of the PQ muscle. Eight cadaveric upper extremities were tested in a custom joint simulator employing motion and load-controlled tendon loading to produce forearm rotation. Pronation was achieved via loading of the pronator teres and PQ muscles. Repeated trials were conducted in which the ratio of the PQ load was increased incrementally relative to the pronator teres load. Supination trials were similarly conducted using the biceps and supinator muscles. Testing was conducted in the intact forearm and following ulnar head excision. An electromagnetic tracking device was used to record motion of the radius and ulna. Kinematic data was analyzed with a planar analysis that measured dorsal palmar displacements and diastasis of the DRUJ. Greater diastasis and dorsal translation of the radius relative to the ulna were noted under increased PQ loading following ulnar head excision (p< 0.05). Increased supinator load had no effect on kinematics before or after ulnar head excision. This effect is likely due to the location of the two muscles. The effect of PQ muscle loading was only noted in neutral to full pronation. These results suggest that rehabilitation of the forearm following ulnar head excision should be conducted with the forearm in supination to minimize joint instability. Funding: Natural Sciences and Engineering Research Council of Canada, The Arthritis Society (Canada)

Complications of distal radius fractures range from 20 to 30% and are consequence of injury or of treatment. Management of these complications must be individualised and the multitude of proposal treatments prove that this problem is controversial. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex symphatetic distrophy) or bone and joint (malunion, nonunion, osteoarthritis). Tendon complications following distal radius fractures, range from minor adhesions to complete rupture. Peritendinous adhesions will become apparent after cast removal. Diagnosis is based on the limitation of the range of movement for individual fingers.This complication can be avoided with a proper cast technique allowing full range of motion to the digits. Treatment consists of rehabilitation techniques and only rarely, in severe cases, operative tenolysis may be a treatment of choice. Tendons may be entrapped either in the fracture site or in the distal radioulnar joint. Most common tendon entrapment are for extensor carpi ulnaris and extensor digiti minimi. If early recognition is made, open reduction with freeing the tendon must be the choice. Late diagnosis will require more complex tenolysis procedures. Tendon rupture may occur at the time of injury due to sharp fracture fragments. Diagnosis is based on identification of functional loss and, whenever possible, primary tendon suture is recommended. If the diagnosis is late the treatment is free tendon graft or tendon transfer. The late rupture of extensor pollicis longus is the most common possibility. Since it is not related with comminution or displacement of fracture it is possible that an ischemic mechanism is involved. Solutions are free tendon graft or the transfer of extensor indicis proprius. Direct tendon repair is not recommended after few weeks. Nerve complications. Careful neurological investigations demonstrated that nerve injuries associated with distal radius fractures are more common than it is believed. Median nerve is most frequently involved. Primary mechanisms of injury are: direct lesions due to fracture fragments, lesions related to forced manipulation and nonanatomical position of immobilization. Late injuries, occurring a long time after the fracture are more frequent and are related to carpal tunnel syndrome or paraneural adhesions. Carpal tunnel pressure could be measured and ethiologic factors must be identificated in order to establish the proper treatment, usually based on relise of carpal tunnel. Ulnar and radial neuropathy are less common and treatment may vary from cast removal to relise of Guyon’s canal. Vascular complications are uncommon, arise usually in relation with high energy trauma and the treatment is complex, involving different speciality surgeons. Some authors presented rare cases of entrapment of vasculare structures or radial artery pseudoaneurism after the use a volar plate. Compartment syndrome after distal radius fracture is rare and is likely to occur in young adults suffering a high energy trauma. Clinical diagnosis is based on the classical 5 “P’s” (pain, pallor, paresthesias, paralysis, and pulselessness) but treatment must start before all symptoms are present. Anytime when compartment syndrome is suspected, intracompartimental pressure must be measured. The treatment must start immediately and consist in removal of constrictive devices (bandage, cast) and fasciotomy. Indications for fasciotomy are intracompartmental pressure of 15–25mmHg in presence of clinical signs or over 25mmHg in absence of clinical signs. If there is doubt, it is better to perform an unnecessary fasciotomy than to wait until lesions becomes irreversible. Reflex sympathetic distrophy is described with many terms such as algodistrophy, cauzalgia, Sûdeck’s atrophy, shoulder-hand syndrome. Recently, the term complex regional pain syndrome was proposed to replace all the exiting synonyms. Despite many theories, the pathogeny of this disease is uncertain. The diagnosis is mainly clinical, based on presence of pain, trophic changes (atrophy, stiffness, edema) and functional impairment but plain x-ray demonstrating osteopenia and bone scintigraphy showing abnormal bone turnover may be helpful. Since the patogeny is unclear, the treatment is targeting the symptoms rather then the disease. Treatment must be individualized and may consist of: physical therapy of the hand, pain control with general or local drugs, corticosteroids, and symphatectomy. Prevention of reflex symphatetic dystrophy in the first days of a distal radial fracture is very important and include: prevention of the edema (elevation of the hand, early mobilization of fingers), decrease of pain, cast removal to relive pression, non-traumatic surgery. Malunion is the most common complication of distal radius fracture and it usually occurs after close treatment. The malalignament may be extraarticular or it may involve the joint (radiocarpal or distal radioulnar joint). Axial shortening and dorsal or radial malalignament are the most common. Clinical signs are wrist pain, loss of grip strength, limitation of wrist mobility. Osteoarthritis is likely to develop in both types of malunions. For extraarticular nonunions osteotomy is usually the treatment of choice. Many types of osteotomies have been proposed but the most commonly used are opening wedge osteotomy and Watson osteotomy. Intraarticular malunion is more difficult to treat and many surgical solutions have been proposed: intraarticular osteotomy, bone resections (styloid, anterior or posterior rim, radiolunate or radioscapholunate limited arthrodesis, proximal row carpectomy, wrist denervation, wrist arthroplasty, total wrist arthrodesis). Salvage procedures on the distal radioulnar joint may be resection of distal cubitus (Darrach) or Sauve-Kapandji technique. Nonunion is an extremely rare complication and is likely to occur in patients with multiple comorbid conditions such as diabetes, peripheral vascular disease or alcoholism. In most cases the initial treatment was close reduction and cast immobilization or external fixation. Diagnosis is based on the absence of radiographic signs of union at 6 months. Treatment must be individualized but basic options are reconstructive procedures or wrist arthrodesis. Reconstructive procedures consist of debridement of nonunion site, realignment with distractor, plate and screw fixation and iliac crest bone grafting. Since the bone is of poor-quality, new implants providing fixation in orthogonal planes may be useful. Usually, malalignement is present, so some authors recommend to take in to consideration the possibility to associate reconstructive procedures with additional techniques such as: dividing brachioradialis tendon, incision of the dorsal or volar joint capsule or Darrach operation in presence of severe shortening of the radius. Wrist arthrodesis should be chosen when the distal fragment has less then 5 millimeters of subchondral bone supporting the articular surface

Various radiological classification systems exist for rheumatoid wrist progression but few have been evaluated for reliability and clinical application. In order to research these three sets of wrist radiographs of 35 rheumatoid patients, with an average duration of disease of 11 years, were classified according to four different classification systems (Larsen, Simmen, Wrightington and Modified Wrightington). The inter- and intraobserver reliability of each was calculated. The reliability of the Larsen and both Wrightington systems were good but the Simmen system had poor interobserver and intraobserver reproducibility. None of the classification systems satisfactorily assessed the distal radioulnar joint (DRUJ) and the Modified Wrightington system could not classify DRUJ disease in 6 of the 35 wrists

Introduction: The purpose of this paper is to describe our management of complex fractures of the distal radius and ulna using a combined type of stabilization, external with a Pennig fixator, internal with radial augmentation with plate. The patient have sustained a several general trauma or an high energy scheletral trauma upper limbs. Treatment: In a period from 24 July 2002 to today 8 October 2004 (26 months) we have treated surgically 93 wrists with distal radial fractures in 85 patient. The main problem, in the follow up results is a lack of pronosupination that stresses the importance of a perfect reduction of distal radioulnar joint to begin early a phisiotherapy. Clinical results: In conclusion our experience in timing of treatment indicate that is important fixate the lesions earlier, whenever the priority of treatment on severely injured patients are respected. We believe that a combination of the two fixation system allow an optimal external stabilization in the first week (So the therapist can move the patients in intensive care room). Secondary the internal fixator allows an anatomical reduction with a stable fixation in the secondary kinesiterapeutic time

The recognition of the role of TFCC as a major distal radioulnar joint stabilizer and a buffer to compressive forces indicates the importance of preserving as much of this structure as possible. We developed arthroscopic technique for repair of Palmer I B tears of TFCC using a hypodermic needle which obviates the need of any additional skin incision. With wrist under traction important landmarks like radial styloid process, ulnar styloid process, Lister's tubercle and extensor tendons are marked using skin marker. For placement of the arthroscope, 3–4 portal is used and for instruments 6 R and 6 U portals are used. An outside-in technique is used. A 19 G needle is inserted upward from 5mm proximal to the level of the 6 R portal through skin, subcutaneous tissue, capsular tissue and then through the 2mm inner side of detached area of TFCC, while stabilizing it with probe. A 2–0 polydioxanone-PDS suture is passed through needle and caught by grasper placed in the 6 R portal. Now needle is withdrawn and then suture is retrieved out of the joint through the 6 R portal. The procedure is repeated for required number of sutures for dorsal part of peripheral tear. Thus we have stitches with one limb exiting the joint through portal and the other limb entering the joint percutaneously. A small mosquito forceps is passed through the 6 R portal undermining subcutaneous area and these percutaneously passing limbs of sutures are withdrawn through the portal. Now we have sutures entering and exiting through the 6 R portal. Similar procedure is done for ulnar part of peripheral tear through the 6 U portal. Knots are tied and slid beneath the subcutaneous tissue. It offers advantages of a lower risk of neurovascular damage, reduced postoperative pain, faster rehabilitation and better cosmesis

Summary. When a TFCC tear is diagnosed, practitioners should maintain a high level of suspicion for the presence of a concomitant SL or LT ligament tear. Introduction. Disruption of the scapholunate (SL) or lunotriquetral (LT) ligament leads to dorsal and volar intercalated segment instability, respectively, while triangular fibrocartilage complex (TFCC) tears result in distal radioulnar joint (DRUJ) instability. Viegas et al. (1993) demonstrated that 56% of grossly visualised cadaveric wrists had one or more tears of a ligament or of the TFCC. The purpose of this investigation is to quantify the incidence, distribution, and correlation of SL, LT, and TFCC tears in a large group of cadaver wrists using magnetic resonance imaging (MRI). Additionally, statistical analysis was performed to predict. Methods. Spin density weighted, fat suppressed, and STIR MRI scans of the wrist were obtained in 48 fresh frozen cadaver arms using a 3 Tesla MRI scanner. The scans were scrutinised by one of us (PC) – a board certified musculoskeletal radiologist. The dorsal, volar, and membranous portions of the SL and LT ligaments were examined sequentially for the presence of a tear. Similarly, the central disk and radioulnar attachments of the TFCC were inspected for tears. Results. A ligament or the TFCC was labeled as torn if there was a complete tear, partial tear, or perforation of one or more of its components, but not if sole degenerative changes, thinning, or fraying of the fibers was observed. Four of the 48 images could not be interpreted due to unsatisfactory scans. The most prevalent injury was a TFCC tear, which was present in 28 (64%) of the 44 wrists examined. SL ligament tears were discovered in 20 (45%) of the wrists, and LT tears were present in 14 (32%) of the wrists. Moreover, 45% of the wrists examined had a TFCC tear and either a SL or LT ligament tear. Specifically, 50% of the 28 wrists with a TFCC tear had a concomitant LT tear, and 46% had a concomitant SL tear. Discussion. SL, LT, and TFCC tears were found in a substantial portion of the wrists examined. Moreover, the majority of wrists with a TFCC tear also had a SL or LT ligament tear. Viegas et al. found that 70% of wrists with a TFCC perforation also had a LT ligament tear. In our series, 71% had a TFCC tear, and 50% of those had a concomitant LT tear