Hand Surgery Source

OSTEOARTHRITIS, DISTAL RADIOULNAR JOINT (DRUJ)

Introduction

In osteoarthritis (OA), cartilage wears away and cannot regenerate, making joints vulnerable to increased mechanical wear. Traditionally, OA is classified as primary, developing in previously healthy joints with no apparent cause, or secondary, resulting from known conditions such as trauma, septic arthritis, or joint instability. OA is increasingly prevalent in older age. It is more common and often more severe in females. OA of the distal radial ulnar joint (DRUJ) is a common cause of wrist pain in OA and in rheumatoid arthritis (RA). Primary OA of the DRUJ can be associated with positive ulnar variance. Causes of secondary OA of the DRUJ are numerous but generally are the result of pathologic incongruence or DRUJ instability, and follow trauma to distal radioulnar area.

Pathophysiology

  • Instability results from alteration in joint-surface congruence and deficiencies in the distal radioulnar ligaments; these deficiencies permit excessive movement and shear force across the joint.
  • Incongruence alters contact between joint surfaces and produces abnormal joint loading and accelerated wear.

Related Anatomy

  • The distal radius contains the sigmoid notch which supports the joint surface that articulates with the cartilage on the ulnar head.
  • The ulnar condyle articulates with the radius at the sigmoid notch.
  • The DRUJ forms the distal half of the bicondylar articulation between the forearm bones.
  • The bicondylar articulation provides ≤150° of pronation and supination of the forearm, which is critical for hand functional and performing activities of daily living.

Incidence and Related Conditions

  • Hand OA is much more common in Caucasian populations than in people of Asian descent.
  • In 2013, 28.8 million people in the United States had clinically apparent OA in ≥1 joint.

Differential Diagnosis

  • Arthrosis due to infection
  • Distal radial malunion
  • Galeazzi fracture dislocations
  • Essex Lopresti injury (instability after radial head excision)
  • Kienböck's disease
  • Madelung’s deformity
  • Post-traumatic arthritis
  • Rheumatoid arthritis 
  • Vaughan-Jackson syndrome
ICD-10 Codes

OSTEOARTHRITIS, DISTAL RADIOULNAR JOINT, (DRUJ)

Diagnostic Guide Name

OSTEOARTHRITIS, DISTAL RADIOULNAR JOINT, (DRUJ)

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
OSTEOARTHRITIS, DISTAL RADIOULNAR JOINT, WRIST (DRUJ) (PRIMARY)   M19.032 M19.031  

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Pain and DRUJ stiffness
Decreased strength and limited range of motion (ROM)
Loss of forearm function with or without swelling around the DRUJ
Typical History

The typical patient is female and the primary complaint is ulnar wrist pain. Stiffness and limited range of motion are additional common complaints. The patient is frequently older and may have a history of earlier distal radius fracture.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
DRUJ X-rays
  • Right DRUJ after a Darrach procedure
    Right DRUJ after a Darrach procedure
Treatment Options
Treatment Goals
  • Control symptoms
  • Improve hand and wrist function
Conservative
  • Activity modification
  • Physical therapy
  • Patient education
  • Pain control with acetaminophen and NSAIDS in mild-to-moderate OA
  • Splinting
  • Intra-articular or oral steroid therapy 
Operative

Surgical options are numerous and depend on the nature of the DRUJ disorder.

  • Congruence surgery and correction of malunion
    • Osteotomy of the sigmoid notch 
    • Ulnar shortening osteotomy if impaction is the chief source of pain and not DRUJ arthritis
  • Distal ulna resection (Darrach procedure)
  • Hemiresection of the distal ulna
  • Sauve-Kapandji procedue or Lauenstein Procedure where the head of the distal ulna is fused to the radius in a neutral or slightly negative variance position and segment of the ulnar neck is removed to create a nonunion which allows for forearm rotation.
  • Ulnar head replacement
  • DRUJ replacement arthroplasty partial or complete
  • Fusion of the distal ulna to the radius to create a one bone forearm.  This is a salvage procedure after a failed Darrach procedure that is associated with a painful dorsally subluxating remaining distal ulna that is not amenable to a soft tissue stabilization.
Treatment Photos and Diagrams
Treatment Options for DRUJ Osteoarthritis
  • Ulnar head after osteotomy through the neck of the ulna. Note proximal intact ulna still has attachments of the pronator quadrates attached to it.
    Ulnar head after osteotomy through the neck of the ulna. Note proximal intact ulna still has attachments of the pronator quadrates attached to it.
  • Ulnar head arthroplasty for DRUJ OA. Note retracted extensor tendons (1) and capsule edge (2) with insert showing capsular closer.
    Ulnar head arthroplasty for DRUJ OA. Note retracted extensor tendons (1) and capsule edge (2) with insert showing capsular closer.
CPT Codes for Treatment Options

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Common Procedure Name
Excision distal ulna or Darrach, wafer procedure
CPT Description
Excision distal ulna (Darrach proc)
CPT Code Number
25240
Common Procedure Name
Ulnar or radial shortening osteoplasty
CPT Description
Osteoplasty radius or ulna shortening
CPT Code Number
25390
Common Procedure Name
Excision distal ulna or Darrach, wafer procedure
CPT Description
Excision distal ulna (Darrach proc)
CPT Code Number
25240
Common Procedure Name
Extensor tendon transfer
CPT Description
Tendon transfer or transplant, CM area or dorsum of hand single w/o free graft
CPT Code Number
26480
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Outcomes
  • DRUJ replacement arthroplasty: limited positive results
    • DRUJ pathologies are not isolated, but are accompanied by other ulnar-wrist problems
  • Until now, outcomes have been suboptimal due to a broad spectrum of procedures attempting to manage a poorly understood joint.
  • Outcomes have improved with understanding of the DRUJ’s biomechanical principles. 
Key Educational Points
  • A global approach to ulnar wrist pathology is advisable, with detailed assessment of both the DRUJ and the ulnocarpal complex.
  • When evaluating the success of a DRUJ reconstructive procedure, assess the lifting capacity of the forearm.
  • The “scallop sign” in the sigmoid notch of the radius may be seen on X-ray in advanced OA of the DRUJ.
  • In one study, 59% were prepared to sacrifice joint mobility to achieve pain relief; after surgery, persistent pain was the main source of dissatisfaction. 
References

New Articles

  1. de Runz A, Pauchard N, Sorin T, et al. Ulna-shortening osteotomy: Outcome and repercussion of the distal radioulnar joint osteoarthritis. Plast Reconstr Surg 2016;137(1):175-84. PMID: 26710021
  2. Strigel RM, Richardson ML. Distal radioulnar joint arthroplasty with a Scheker prosthesis. Radiol Case Rep 2015;1(2):66-8. PMID: 27298685

Reviews

  1. Laulan J, Marteau E, Bacle G. Wrist osteoarthritis. Orthop Traumatol Surg Res 2015;101(1 Suppl):S1-9. PMID: 25596986
  2. Rosenfeld JF, Nicholson JJ. History and design considerations for arthroplasty around the wrist. Hand Clin 2013;29(1):1-13. PMID: 23168024

Classics

  1. Minami A, Suzuki K, Suenaga N, Ishikawa J. The Sauvé-Kapandji procedure for osteoarthritis of the distal radioulnar joint. J Hand Surg Am 1995;20(4):602-8. PMID: 7594287
  2. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg Am 1985;10(2):169-78. PMID: 3980927