30.3.1 Radiography

Radiographic images of the injury are fundamental to define original fracture line and its possible orientation toward the DRUJ and its consequent involvement. Radiographic comparison with the healthy wrist should be performed in order to consider the following parameters: (1) shape and inclination of the DRUJ; (2) ulna variation; (3) posttraumatic changes of both the ulna head and the sigmoid notch; (4) position of the ulna relative to the radius in the lateral view.

30.3.2 CT Scan

The computed tomography (CT) scan allows to obtain further details on the anatomical profile of the radius and the ulna and on their relationships. Seldom, it must be performed bilaterally, for comparison. CT scan may also be performed in neutral position, maximum supination and pronation, in order to confirm the degree of pronosupination loss and mostly to reveal any bone conflicts, subluxations or dislocations of DRUJ.

30.3.3 Magnetic Resonance Imaging

MRI is useful for the evaluation of the ligament lesions and degree of bone and cartilage involvement. It is particularly indicated in case of persistent posttraumatic pain: as it may show areas of bone marrow edema or osteochondral damage of the ulna head, the ulnar styloid and/or the carpal bones, or residual signs of both the distal radius and ulnar head fractures. However, MRI accuracy in the assessment of chondral lesion is rather low. Also, it does not show any capsular contractures or if there are articular adhesions that may cause DRUJ stiffness.

30.3.4 Arthrography, ArthroCT, and ArthroMRI

Arthrography ¹⁰ is an examination that is no longer performed except in association with CT scan and MRI. The value of this test in wrist stiffness is to confirm the adhesive capsulitis and arthrofibrosis, as only a little amount of contrast medium can be introduced into the joint. In normal subjects, the wrist may be injected with 2 to 3 cc of liquid. When the joint is affected by arthrofibrosis or adhesive capsulitis, injection is rather difficult and the volume of liquid is drastically reduced to less than 1 cc, which is also frequently dispersed into the surrounding soft tissues. Noticeably, arthroCT and arthroMRI have less significance and clarity to show associated osteoarticular disorders as compared to patients without arthrofibrosis or adhesive capsulitis.

30.4.1 Open Arthrolysis

Appropriate forearm positioning is the key. Vertical position is recommended in order to allow unrestricted control of forearm rotation. Use of a simple traction tower, as from wrist or shoulder arthroscopy, may be beneficial. ⁷

The DRUJ is approached through a dorsal access (▶Fig. 30.3). The dorsal capsule is reached through the fifth dorsal compartment. Incision of the capsule starts at the level of the ulnar neck up to just proximal to the dorsal DRUJ ligament, taking care to preserve it. A freer periosteal elevator is introduced through this approach and the adherences at the level of the neck are released. The maneuver is continued just proximal to the ulnar head, permitting the resection of fibrotic bands between the ulna head and the TFCC (▶Fig. 30.4). The release is continued dorsally up to the extensor carpi ulnaris (ECU) tendon sheath to separate the capsule from the ulna head (▶Fig. 30.4). Gentle forearm rotation is performed to stretch remaining adherences and evaluate the amount of motion obtained.

Sharp resection may be repeated as necessary, until complete pronation is reached. If supination is still limited, a second step of surgery is performed. From the same dorsal access, the periosteal elevator is driven under the ulnar neck more palmarly (▶Fig. 30.4) to detach the anterior capsule from the ulnar head. Some lateral sliding maneuvers around the shape of the ulnar head will improve supination (▶Fig. 30.5a–d).

Actually, this is a blind maneuver performed with the tip of the elevator. It frequently detaches part of the capsule from the radius, producing the same effect as the actual release of the capsular adherences.

The detachment of the palmar capsule produces an improvement in supination, and the detachment of the posterior capsule improves the pronation.

When the supination loss persists after capsular release, the attention should be addressed to an ischemic retraction of the pronator quadratus muscle. ¹² Then, a 3-cm ulnar skin incision is made at the level of the ulnar neck (▶Fig. 30.6), the pronator quadratus muscle insertion is identified and the muscle fibers are detached from the ulna (preserving the deep insertion on the radial border of the ulna). Thus, a further improvement of the supination should be obtained without provoking DRUJ instability.

30.4.2 Arthroscopic Arthrolysis

Standard vertical position with elbow counter-traction of about 3 kg is used for proper joint distraction. Finger traps are applied to the index and middle finger to permit a more physiologic joint alignment. Arthroscopy is performed dry in all cases, ^{16 , 17} flushing the joint with saline to remove debris, if necessary. ^{16 , 17 , 18 , 19}

Arthroscopy always starts from the radiocarpal joint through the 3–4 and 6R portals. ⁷ Often, the radiocarpal space shows some capsular contracture, therefore radiocarpal arthrolysis is performed as needed.

Depending on the integrity of the TFCC, arthroscopic treatment may be performed in three different modalities which are as follows:

1. 
   

   When the central disc of the TFCC is intact, DRUJ arthrolysis is required by DRUJ arthroscopy (▶Fig. 30.7). Arthroscopy of the fibrotic DRUJ is even more difficult than in standard cases, as the joint space is almost completely occupied by adherences and synovial tissue, and joint visualization is very poor. Therefore, after the DRUJ portal is placed and proper intra-articular location is confirmed with scope, a periosteal elevator is introduced into the DRUJ portal to create some working space by resecting the adherences between the TFCC and the ulna head with a gentle blind maneuver. ⁷ Then the scope is introduced again in the DRUJ portal and both the ulna head and the proximal part of the TFCC are explored (▶Fig. 30.8a, b). In addition, a proximal DRUJ portal may be created at the level of the ulnar neck to introduce a periosteal elevator and resect any adherences within the sigmoid notch (▶Fig. 30.9b). A volar DRUJ portal may be created using an in-out technique, a periosteal elevator is introduced to release the anterior capsule (▶Fig. 30.9a). Then the scope may be shifted to detach the lateral capsule from the ulna head up to the ECU tendon sheath and complete the arthrolysis. Often, the scope can only see the tip of the periosteal elevator as some other blind maneuvers are required (▶Fig. 30.9). Particularly when the periosteal elevator is driven proximally to achieve a complete release, attention must be given to protect the ulnar neurovascular structures palmarly (▶Fig. 30.9c) and the ECU tendon dorsally. The patient undergoes immediate and prolonged rehabilitation.

   
   
2. 
   

   As an alternative option, still in case of intact TFCC, DRUJ arthrolysis may be performed with the scope in the radiocarpal joint. ²⁰ The freer elevator, positioned in the 6U or 4–5 portal, is introduced into the DRUJ through a small opening in the central disc close to the volar and the dorsal branches of the DRU ligament. Moving the periosteal elevator around the ulnar head, although in a blind fashion, allows detachment or stretching of the volar and the dorsal capsule thus restoring motion of the DRUJ (▶Fig. 30.10a–f). Sometimes, the central disc can be resected intentionally to facilitate the procedure.

   
   
3. 
   

   When the central disc of the TFCC is lacerated, the arthroscopic approach becomes much easier. Sometimes, the central disc can be resected intentionally to facilitate the procedure. Although a dorsal DRUJ portal may be useful to work under the TFCC and in the volar and dorsal capsular recesses, the whole procedure can be completed with the scope in the 3–4 portal (or rarely in the 6U portal). The adherences between the volar and the dorsal capsule and the ulna head are resected with the periosteal elevator introduced into the 6U and/or 6R portal (▶Fig. 30.11).

Management of associated joint damages is more complex. Decision-making depends on the location and extension of the chondropathy. In case of minimal joint damage limited to the periphery of the ulnar head or the edge of the sigmoid notch, DRUJ arthrolysis is still indicated. On the other hand, gross chondral damage should be treated with secondary reconstruction or salvage procedures, and it requires explicit and informed consent by the patient (see Chapter 30.8).