x
x

DISLOCATION, WRIST DISTAL RADIAL ULNAR JOINT (DRUJ)

Introduction

Isolated distal radioulnar joint (DRUJ) dislocations with only ligamentous involvement are uncommon injuries. In most cases, they are associated with a concomitant fracture, usually of the distal ulna or rarely of the distal radius.1,2 The mechanism of injury depends on the direction of displacement, as dorsal DRUJ dislocations typically result from a hyperpronation force—in most cases a fall on an outstretched hand (FOOSH)—and the less common volar dislocation from a hypersupination force.1,3 For acute DRUJ dislocations that are closed and reducible, conservative treatment that consists of closed reduction and immobilization is typically recommended. Surgery is indicated for open injuries, those that cannot be reduced closed, and when the dislocation has become chronic due missed diagnosis or patient neglect.1,4
 

Definitions

  • A DRUJ dislocation occurs when the articular surface of the distal ulna is displaced off the articular surface of the distal radius.

Hand Surgery Resource’s Dislocation Description and Characterization Acronym

D O C S

D – Direction of displacement

O – Open vs closed dislocation

C – Complex vs simple

S – Stability post reduction

D – Direction of displacement

  • The primary description and characterization of DRUJ dislocations are done by noting the direction of the displacement of the distal ulna relative to the distal radius. The three possible directions of displacement are dorsal, lateral, and volar.5 Dorsal dislocations are the most common, while volar dislocations are extremely rare.3,6
    • In dorsal dislocations, the mechanism of injury is believed to be a hyperpronation force, which usually results from a FOOSH. This fixes the hand to the ground and causes the ulna to rotate around it, which disrupts the volar radioulnar ligament and dorsal joint capsule. This causes extreme difficulty with wrist supination.1,3,6
    • In volar dislocations, the mechanism is typically a hypersupination force that disrupts the dorsal radioulnar ligament and volar joint capsule. This causes extreme difficulty with wrist pronation.1,3
  • The degree of displacement of the ulna further characterizes DRUJ dislocations. In a true complete dislocation, the articular surface of the ulna is no longer in contact with the articular cartilage of the radius. If there is contact of the cartilaginous surfaces that is >50%, then this is not a true dislocation but rather a joint subluxation.5

O – Open vs closed

  • The majority of DRUJ dislocations are closed; the skin is intact, and there is no route for bacteria to contaminate the joint space.
  • Open DRUJ joint dislocations are extremely rare, but when they do occur, require urgent irrigation, debridement, open reduction, and ligament repair if the dislocation is unstable after reduction.

C – Complex vs simple

  • Most DRUJ dislocations are simple, meaning that reduction is easily achieved under digital anesthetic block and is not blocked by soft tissue being interposed in the joint between the distal ulna and radial joint surfaces.
  • Complex (irreducible) DRUJ dislocations are very rare, but do occur on some occasions.
    • The extensor carpi ulnaris (ECU) tendon is the most commonly interposed soft-tissue structure that blocks reduction, but other structures that may be involved include the extensor digitorum communis, extensor digiti minimi, or flexor pollicis longus tendons, or the triangular fibrocartilage complex (TFCC) or median nerve.3
    • Complex DRUJ dislocations are high-energy injuries that nearly always occur in conjunction with a fracture, most commonly with the distal radius as part of a Galeazzi fracture.1
    • Irreducible simple dislocations without soft tissue interposition are also possible. In such cases, the ulna may be irreducible because of a bony mechanical blockage at the volar lip of the sigmoid notch of the radius.1

S – Stability

  • A stable DRUJ dislocation can be reduced and then put through an active range of motion (ROM) test under a local anesthetic block without redislocating.
  • Furthermore, a stable DRUJ dislocation is stable to stress testing after reduction. This maneuver should always be done after ORIF of a Galeazzi fracture to determine the DRUJ stability.

Related anatomy3,4,6

  • Extensor tendons
  • Flexor tendons
  • Radial collateral ligament
  • Radioulnar ligaments (dorsal and volar)
  • Intrinsic interosseous ligments
  • Extrinsic radiocarpal and ulnocarpal ligaments
  • Intracapsular ligaments
  • Infratendinous extensor retinaculum
  • Interosseous membrane
  • Pronator quadratus muscle
  • Sigmoid notch
  • Osteology of the distal ulna and distal radius
  • TFCC which is the most important stabilizer of the DRUJ

Overall incidence

  • DRUJ dislocations are uncommon injuries, but their exact incidence is not well documented. In one series of 1,236 forearm fractures, 6.8% were Galeazzi fractures, indicating that a DRUJ dislocation was also present.7

Related Injuries/Conditions

  • Distal ulna fractures
  • Distal radius fractures
  • Galeazzi fractures of the radius
  • Essex-Lopresti fractures
  • Intrinsic ligament injuries
  • Extrinsic ligament injuries
  • Extensor tendon ruptures
  • Flexor tendon ruptures
ICD-10 Codes

  • DISLOCATION, WRIST DISTAL RADIAL ULNAR JOINT (DRUJ)

    Diagnostic Guide Name

    DISLOCATION, WRIST DISTAL RADIAL ULNAR JOINT (DRUJ)

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

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    DISLOCATION WRIST: DISTAL RADIAL ULNAR JOINT (DRUJ) S63.015_S63.014_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S63, S64, S65 AND S69
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    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

Clinical Presentation Photos and Related Diagrams
DRUJ Dislocations
  • Classic deformity (arrow) associated with a volar DRUJ dislocation.
    Classic deformity (arrow) associated with a volar DRUJ dislocation.
Symptoms
History of trauma
Wrist pain, swelling and deformity localized at the DRUJ
Typical History

The typical patient is a 34-year-old right-handed female equestrian athlete. During a recent competition, her horse started acting erratically and moving in unpredictable directions. Eventually, this threw the rider off her horse in an awkward way, flipping her upside down and causing her to land on two outstretched hands to break the fall. This traumatic force hyperpronated her right wrist and led to a dorsal dislocation of the DRUJ, which was followed by severe pain, swelling, and tenderness in the area.  She could not move her wrist or forearm without severe pain.  The woman subsequently removed herself from the competition to seek out medical help.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
DRUJ Dislocation Imaging
  • Volar distal radial ulnar joint dislocation (D) and distal radius fracture (Fx). Note the overlap of the distal ulna on the distal radius in the AP view which is typical of a DRUJ volar dislocation.
    Volar distal radial ulnar joint dislocation (D) and distal radius fracture (Fx). Note the overlap of the distal ulna on the distal radius in the AP view which is typical of a DRUJ volar dislocation.
Treatment Options
Treatment Goals
  • Determine the direction of the dislocation
  • Reduce the dislocation
  • Analyze the DRUJ’s stability
  • Rehab the wrist to regain ROM and normal wrist and hand function
Conservative
  • Most acute, simple, and closed DRUJ dislocations without an associated fracture can be treated conservatively with closed reduction under local anesthesia, which should be a regional block or wrist block. Anesthesia allows a gentle reduction with minimal pain, and may be applied with or without sedation.1-3
    • In dorsal dislocations, reduction is accomplished with gentle traction, dorsal pressure over the ulnar head, and supination.
    • In volar dislocations, reduction can be more difficult because of the pull of the pronator quadratus muscle, and the clinician may have to distract the ulna from the radius—or vice versa—while applying volar pressure over the ulnar head and pronation.1
  • After reduction, the patient should be assessed for DRUJ stability and wrist ROM. If the joint is stable, the forearm should be immobilized with an above-elbow cast in either supination (dorsal dislocations) or pronation (volar dislocations) for 4-6 weeks. If instability persists or the dislocation proves to be irreducible even with conscious sedation or general anesthesia, surgery is typically needed.1,2
Operative
  • Surgery is indicated for DRUJ dislocations that are open, unstable, or complex—or otherwise irreducible—and those that present in a delayed fashion.1,4
  • Open reduction
    • In complex dislocations, this procedure also requires extraction and reduction of the interposed soft tissue, and open repair of the TFCC.1
    • DRUJ repair or reconstruction may also be needed when severe instability is present, which can be performed either intra-articularly or extra-articularly. It appears that the most effective reconstructive methods are DRUJ ligament reconstruction with external DRUJ fixation.4
    • For irreducible simple DRUJ dislocations due to bony mechanical blockage, direct repair of the TFCC to the foveal insertion is typically needed. This procedure is performed using suture anchors or heavy sutures through bone tunnels, and after repair, the forearm should be immobilized in a long-arm or Munster-type cast with or without transcutaneous radioulnar pinning.1
  • Treatment of chronic DRUJ dislocations is challenging because of severe instability, difficulties in functional restoration, and unsatisfactory outcomes of conservative treatment. Most of these injuries therefore require a salvage procedure.6,8
Hand Therapy
  • Patients with closed DRUJ dislocations that are reduced early may be able to exercise their wrist on their own.
  • However, patients with marked swelling and pain will need hand therapy to help reduce swelling and improve ROM and strength.
  • Surgically repaired complex DRUJ dislocations, repaired ligaments, and unstable DRUJ dislocations will definitely need hand therapy, custom splinting, and possibly dynamic extension splints.
Complications
  • Recurrent dislocations
  • Stiffness
  • Pain
  • Infection
  • Residual deformity
  • Weakened grip
  • Impaired ROM
  • Nerve injuries 
  • Vascular injuries
  • Posttraumatic osteoarthritis
  • Spontaneous extensor tendon rupture
Outcomes
  • Simple DRUJ dislocations that are recognized and treated early typically have a positive outcome.3,8,9
  • In one series of 11 patients with an isolated volar DRUJ dislocation, 9 were treated with closed reduction on the same day as presentation at the ED. All of these patients had a successful outcome, as well as the 1 patient who presented >3 weeks after the injury.8
  • Even after a late diagnosis, a good result can be obtained by open reduction and TFCC repair.9
  • All patients with DRUJ dislocations should be warned that the DRUJ on the injured side will likely remain slightly larger than the opposite side because the stretched ligaments are likely to heal with a little extra bulk (collagen) and some loss of supination and/or pronation is not unusual.
  • If not promptly recognized and treated, DRUJ dislocations can lead to significant functional disability.3
Key Educational Points
  • Open and complex DRUJ joint dislocations require urgent surgical treatment.
  • Up to 50% of all DRUJ dislocations are missed upon initial evaluation, especially if an associated fracture is not present or when there are no obvious signs of deformity in the ED. This highlights the need for elevated clinical suspicion and careful evaluation of radiographs after all high-energy wrist injuries.3
  • Due to improved diagnostic and therapeutic techniques, the incidence of delayed diagnosis and misdiagnosis of DRUJ dislocations appears to be decreasing.6  A true lateral x-ray view should be used to confirm this diagnosis.3  The anteroposterior (AP) x-ray view in dorsal dislocations typically shows a widened DRUJ with divergence of the radius and ulna, whereas volar dislocations demonstrate an overlap of the radius and ulna at the DRUJ.1,3  Any rotation of the forearm during radiographic examination will change the relative position of the ulna, which makes the diagnosis difficult.3
  • CT scan:  This is the preferred advanced imaging option if the diagnosis cannot be confirmed with plain radiographs.2
References

New and Cited Articles

  1. Carlsen, BT, Dennison, DG and Moran, SL. Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin 2010;26(4):503-16.PMID: 20951900
  2. Wassink, S, Lisowski, LA and Schutte, BG. Traumatic recurrent distal radioulnar joint dislocation: a case report. Strategies Trauma Limb Reconstr 2009;4(3):141-3.PMID: 19937146
  3. Bouri, F, Fuad, M and Elsayed Abdolenour, A. Locked volar distal radioulnar joint dislocation. Int J Surg Case Rep 2016;22:12-4. PMID: 27016647
  4. Sang, L, Liu, H, Liu, J, et al. A case report of distal radioulnar joint dislocation fixed by using mini-plate-button. Int J Surg Case Rep 2017;34:69-73. PMID: 28371634
  5. Merrell G, Slade JF. Dislocations and ligament injuries in the digits. In: Wolfe, SW, Hotchkiss RN, Pederson WC, Kozin SH (eds): Green’s Operative Hand Surgery.  Philadelphia 2011: Elsevier Churchill Livingstone, pp. 291-332.
  6. Qian, H, Chen, G and Liu, Z. Treatment of distal radioulnar joint dislocation with spontaneous rupture of extensor tendon by Sauve-Kapandji osteotomy assisted by wrist arthroscopy: A case series and literature review. Medicine (Baltimore) 2018;97(22):e10752.PMID: 29851780
  7. Moore, TM, Klein, JP, Patzakis, MJ, et al. Results of compression-plating of closed Galeazzi fractures. J Bone Joint Surg Am 1985;67(7):1015-21.PMID: 4030820
  8. Mulford, JS, Jansen, S and Axelrod, TS. Isolated volar distal radioulnar joint dislocation. J Trauma 2010;68(1):E23-5. PMID: 20065743
  9. Zannou, RS, Rezzouk, J and Ruijs, AC. Non-reducible palmar dislocation of the distal radioulnar joint. Case Reports Plast Surg Hand Surg 2015;2(2):43-45.PMID: 26158121

Review

  1. Carlsen, BT, Dennison, DG and Moran, SL. Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin 2010;26(4):503-16. PMID: 20951900

Classics

  1. Morrissy RT, Nalebuff EA. Dislocation of the distal radioulnar joint: anatomy and clues to prompt diagnosis. Clin Orthop Relat Res1979;(144):154-8. PMID: 535217
  2. Weseley MS, Barenfeld PA and Bruno J. Volar dislocation distal radioulnar joint. J Trauma1972;12(12):1083-8. PMID: 4651332
Subscribe to DISLOCATION, WRIST DISTAL RADIAL ULNAR JOINT (DRUJ)
⇡