Subluxation of the distal radioulnar joint

Introduction

Dislocation of the distal radioulnar joint (DRUJ) without concomitant fracture is an uncommon injury. DRUJ subluxation is very easy to miss in the first presentation. It would appear that a common cause of misdiagnosis is to dismiss the appearance as positional/projectional.

Clinical Presentation

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Anatomy

"Distal ulna has a convex articular surface; this articulates with the concave semicylindrical sigmoid notch of radius. The important stabilizers of the distal radio-ulnar joint include all of the separate structures composing the triangular fibrocartilage complex. Of great clinical importance is the fact that these structures blend at the fovea, thus creating the potential for instability of the distal radio-ulnar joint when the ulnar styloid process is fractured. The flat pronator quadratus muscle originates from a long, narrow strip of the volar aspect of the distal part of the ulna and has a broad insertion on the volar aspect of the radius. It acts as a secondary stabilizer of the DRUJ by providing compressive force across the joint during pronation and supination."
<a class="external" href="http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/wrist/distalradioulnajoint.htm" rel="nofollow" target="_blank">http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/wrist/distalradioulnajoint.htm</a>

A study of the role of the interosseous membrane on the stability of the DRUJ reported the following

Radiographic Features of DRUJ Subluxation

widening of RU joint on AP view;
fracture (or non union) at base of ulnar styloid;
significant shortening of the radius;
obvious dislocation on the lateral view;
it is essential that the lateral view be taken w/ proper technique so that the radial styloid process overlies the proximal pole of the scaphoid, lunate, and triquetrum;
when proper positioning is ensured, dorsal or volar subluxation is noted by the relative position of the ulna above or below the radius;
<a class="external" href="http://www.wheelessonline.com/ortho/radial_ulnar_joint_instability" rel="nofollow" target="_blank">http://www.wheelessonline.com/ortho/radial_ulnar_joint_instability</a>

What is a Lateral wrist?

adapted from <a class="external" href="http://www.radiologyassistant.nl/en/476a23436683b" rel="nofollow" target="_blank">http:/</a><a class="external" href="http://www.radiologyassistant.nl/en/476a23436683b" rel="nofollow" target="_blank">/www.radiologyassistant.nl/en/476a23436683b</a>

quoted from <a class="external" href="http://www.radiologyassistant.nl/en/476a23436683b" rel="nofollow" target="_blank">http://www.radiol</a><a class="external" href="http://www.radiologyassistant.nl/en/476a23436683b" rel="nofollow" target="_blank">ogyassistant.nl/en/476a23436683b</a>

drawing based on

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank">Charles A. Goldfarb, MD, Yuming Yin, MD, Louis A. Gilula, MD, Andrew J. Fisher, MD and Martin I. Boyer, MD
</a>
<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank">What the Clinician Wants to Know</a>

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank"> Wrist Fractures: What the Clinician Wants to Know1 </a>
<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank"> Radiology. 2001;219:11-28.</a>

adapted from

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank">Charles A. Goldfarb, MD, Yuming Yin, MD, Louis A. Gilula, MD, Andrew J. Fisher, MD and Martin I. Boyer, MD
</a>
<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank">What the Clinician Wants to Know</a>

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank"> Wrist Fractures: What the Clinician Wants to Know1 </a>
<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank"> Radiology. 2001;219:11-28.</a> These authors go one step further by establishing the bounds of acceptability of lateral wrist positioning.

Case 1

This 45 year old lady presented to the Emergency Department after falling onto her wrist.

There is overlap of the distal radio-ulnar joint. There is also a moderate degree of positive ulnar variance. The position of the ulna on this oblique wrist view is unusual. The ulna appears to be subluxed in a volar/palmar direction. The wrist is dorsally rotated off lateral as evident by the position of the pisiform (see above). Is this sufficient to account for the position of the ulna?... probably not.

Case 2

This 38 year old male presented to the Emergency Department with a right forearm injury after a steel pipe fell on his arm.

This is a mixed AP/lateral view of the forearm- the elbow is AP and the wrist is lateral. This is not ideal positioning for forearm imaging, but is considered acceptable when the patient is unable to adopt true AP/Lateral positioning. There is a fracture of the ulna and the distal ulna appears to be displaced dorsally raising the possibility of a DRUJ subluxation. Unfortunate side-marker placement. There is a butterfly fracture of the mid/distal third of the ulna. There is positive ulnar variance.

COMPARISON
The wrist appears to be in a true lateral position using the criteria described above. The ulna is subluxed dorsally. For this position of the ulna to be positional/projectional, you would expect the wrist to be in an oblique position. There is possibly obliteration of the pronator quadratus fat pad. This is a normal lateral wrist (different patient) for comparison.

COMPARISON
There is positive ulnar variance. There is a suggestion of a subtle fracture of the distal ulna (arrowed). Normal PA wrist for comparison (different patient). Note the normal ulnar variance.

Case 3

This 21 year old male presented to the Emergency Department following a sports injury. He reported falling onto an outstretched hand and another player falling on his right forearm. On examination, he had an obvious depression where you would expect to see his ulnar styloid process.

The patients injured wrist (right) and normal wrist (left) are shown to the left.

He was referred for forearm radiography.
The radiographer performed PA and lateral projections of the right wrist. The PA wrist image is unremarkable. The lateral wrist is in a true lateral position - the position of the pisiform in relation to the volar aspects of the scaphoid and capitate suggest the carpal bones are in a near perfectly lateral position. The position of the distal ulna with respect to the distal radius is inconsistent with the true lateral demonstration of the carpal bones. The abnormally volar psoiton of the distal radius indicates the patient has a subluxation of the distal radio-ulnar joint (DRUJ) with volar displacement of the distal ulna.
The patient was mildly sedated and the ulna was manipulated back into a normal anatomical position.

Comment
The patient's right wrist showed clear deformity on examination. Whilst not well demonstrated in the photographs, it was clinically very convincing that the patient had subluxed his distal ulna in a volar direction. The difficulty with this type of injury is that the failure of superimposition of the distal radius and ulna on the lateral wrist X-ray image can be dismissed as projectional. This case demonstrates the importance of consideration of the patients mechanism of injury, clinical signs and radiographic appearances.

Case 4

Normal Lateral Wrist for Comparison
This patient fell over and injured his right hand/wrist. This wrist position in not true lateral- the hand is supinated. This lateral wrist is also not true lateral- the hand is pronated. This position suggests DRUJ subluxation but this appearance was thought to be projectional. Using the lateral wrist criteria for assessing a true lateral position, the wrist could be argued to be in an acceptable position (note the position of the pisiform in relation to the volar aspects of the capitate and scaphoid. The carpal bones dot not, however, appear lateral, suggesting that the carpal bones are more oblique than the criteria for lateralness would suggest.

Discussion

Isolated subluxation/dislocation of the DRUJ is an easily missed diagnosis. The positive ulnar variance was a firm and consistent sign of wrist injury in the 2 cases. If the radiographer has identified the possibility of a DRUJ injury, appropriate supplementary views, including a PA and/or lateral view of the contra-lateral wrist may be useful.

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Subluxation of the distal radioulnar joint

Contents

Anatomy

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank">What the Clinician Wants to Know</a>

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank"> Wrist Fractures: What the Clinician Wants to Know1 </a>

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank">What the Clinician Wants to Know</a>

<a class="external" href="http://radiology.rsnajnls.org/cgi/content/full/219/1/11" rel="nofollow" target="_blank"> Wrist Fractures: What the Clinician Wants to Know1 </a>

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There is overlap of the distal radio-ulnar joint. There is also a moderate degree of positive ulnar variance.	The position of the ulna on this oblique wrist view is unusual.	The ulna appears to be subluxed in a volar/palmar direction. The wrist is dorsally rotated off lateral as evident by the position of the pisiform (see above). Is this sufficient to account for the position of the ulna?... probably not.


This is a mixed AP/lateral view of the forearm- the elbow is AP and the wrist is lateral. This is not ideal positioning for forearm imaging, but is considered acceptable when the patient is unable to adopt true AP/Lateral positioning. There is a fracture of the ulna and the distal ulna appears to be displaced dorsally raising the possibility of a DRUJ subluxation. Unfortunate side-marker placement.	There is a butterfly fracture of the mid/distal third of the ulna. There is positive ulnar variance.
	COMPARISON
The wrist appears to be in a true lateral position using the criteria described above. The ulna is subluxed dorsally. For this position of the ulna to be positional/projectional, you would expect the wrist to be in an oblique position. There is possibly obliteration of the pronator quadratus fat pad.	This is a normal lateral wrist (different patient) for comparison.
	COMPARISON
There is positive ulnar variance. There is a suggestion of a subtle fracture of the distal ulna (arrowed).	Normal PA wrist for comparison (different patient). Note the normal ulnar variance.

	This 21 year old male presented to the Emergency Department following a sports injury. He reported falling onto an outstretched hand and another player falling on his right forearm. On examination, he had an obvious depression where you would expect to see his ulnar styloid process. The patients injured wrist (right) and normal wrist (left) are shown to the left. He was referred for forearm radiography.
	The radiographer performed PA and lateral projections of the right wrist. The PA wrist image is unremarkable. The lateral wrist is in a true lateral position - the position of the pisiform in relation to the volar aspects of the scaphoid and capitate suggest the carpal bones are in a near perfectly lateral position. The position of the distal ulna with respect to the distal radius is inconsistent with the true lateral demonstration of the carpal bones. The abnormally volar psoiton of the distal radius indicates the patient has a subluxation of the distal radio-ulnar joint (DRUJ) with volar displacement of the distal ulna.
	The patient was mildly sedated and the ulna was manipulated back into a normal anatomical position. Comment The patient's right wrist showed clear deformity on examination. Whilst not well demonstrated in the photographs, it was clinically very convincing that the patient had subluxed his distal ulna in a volar direction. The difficulty with this type of injury is that the failure of superimposition of the distal radius and ulna on the lateral wrist X-ray image can be dismissed as projectional. This case demonstrates the importance of consideration of the patients mechanism of injury, clinical signs and radiographic appearances.

		Normal Lateral Wrist for Comparison
This patient fell over and injured his right hand/wrist. This wrist position in not true lateral- the hand is supinated.	This lateral wrist is also not true lateral- the hand is pronated. This position suggests DRUJ subluxation but this appearance was thought to be projectional. Using the lateral wrist criteria for assessing a true lateral position, the wrist could be argued to be in an acceptable position (note the position of the pisiform in relation to the volar aspects of the capitate and scaphoid. The carpal bones dot not, however, appear lateral, suggesting that the carpal bones are more oblique than the criteria for lateralness would suggest.