Hand Surgery Source

Volar DRUJ Stability

Test, Exam and Signs

Historical Overview

  • By 1913, William Darrach started performing an operation to help resolve distal radioulnar joint (DRUJ) dysfunction. In 1941, this surgery earned the eponym of the Darrach procedure.1

Description

  • The causes of ulnar-sided wrist pain include acute traumatic injuries, chronic overuse injuries and chronic degenerative conditions.2 When examining patients with ulnar-sided wrist pain, it is vital to identify a potential triangular fibrocartilage complex (TFCC) injury with DRUJ pathology.3
  • There is no objective measurement of DRUJ instability. It is vital to assess the patient’s uninjured wrist.3

Pathophysiology

  • Volar DRUJ stability can be affected by a distal radius fracture or a DRUJ dislocation. 
  • Volar DRUJ instability may also be due to osteoarthritis, Madelung’s deformity, Essex-Lopresti lesions or inflammatory arthropathies.3

Instructions

  1. Record the patient’s history, including any sports-related injuries. Ask the patient to rate how much pain s/he usually experiences in the affected wrist on a scale from 1 to 10.
  2. Palpate the volar DRUJ with a single fingertip to isolate areas of potential pathology.3
  3. Check for instability, tenderness, crepitus, swelling and pain in the volar DRUJ.
  4. Examine the contralateral wrist for comparison.

Variations

  • A DRUJ injury may be indicated by a dorsally protruding ulnar head that is more noticeable on the affected than the contralateral side.3 

Related Signs and Tests

  • Piano key test
  • TFCC tenderness

Diagnostic Performance Characteristics

  • Computed tomography (CT) scan
  • Magnetic resonance imaging (MRI)
  • Arthroscopy4
  • In assessing DRUJ instability, CT scans may improve reliability. These scans aid in visualization of degenerative changes in the ulnar head or sigmoid notch.2
  • Do not use other patients’ reactions as a comparison, because other patients may have different perceptions of similar tenderness and/or pain.
Definition of Positive Result
  • A positive result occurs when pressure applied to the volar DRUJ causes increased tenderness. 
Definition of Negative Result
  • A negative result occurs when pressure does not cause increased tenderness in the volar DRUJ. 
Comments and Pearls
  • In TFCC tears, the primary therapeutic goal should be to stabilize the DRUJ by reattachment of the torn ligaments in ulnar-sided ruptures to the deep fibers in the fovea.4
  • Operative treatments for DRUJ arthritis include the Darrach procedure or the Sauve-Kapandji procedure. More recently, physicians may consider a prosthetic replacement for either the ulnar head or the entire DRUJ.5
Diagnoses Associated with Tests, Exams and Signs
References
  1. Lau FH, Chung KC. William Darrach, MD: his life and his contribution to hand surgery. J Hand Surg Am 2006;31A:1056e1-e7. PMID: 16945703
  2. Sachar K. Ulnar-sided wrist pain evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears. J Hand Surg Am 2008;33(9):1669-79. PMID: 18984356
  3. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012
  4. Mannil L, Martin W, Dahmen J, et al. Arthrocsopic treatment for ulnar-sided TFCC-tears. Eur J Trauma Emerg Surg 2016;42(1):29-35. PMID: 26566794
  5. Nacke E, Paksima N. The Evaluation and treatment of the Arthritic Distal Radioulnar Joint. Bull Hosp Jt Dis 2015;73(2):141-7. PMID: 26517168