American Association for Hand Surgery
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Distal Radioulnar Joint Instability: Assessment of Three Intraoperative Radiographic Stress Tests
Joseph A Gil, MD1; Lindsay R Kosinski, MD2; Kalpit N Shah, MD2; Julia A. Katarincic, MD3; Sanjeev Kakar, MD4
1Department of Orthopaedic Surgery, Alpert Medical School of Brown University, Providence, RI, 2Brown University, Providence, RI, 3Department of Orthopaedic Surgery, Brown University, Providence, RI, 4Department of Orthopedics, Mayo Clinic, Rochester, MN

Distal Radioulnar Joint Instability: Assessment of Three Intraoperative Radiographic Stress Tests
ABSTRACT
Purpose: To describe three radiographic stress tests that could be used to examine for distal radioulnar joint (DRUJ) instability intraoperatively, and to determine their ability to detect DRUJ instability after sequentially sectioning the DRUJ.
Materials & Methods: Eleven fresh frozen cadaveric upper extremities (mean age 52.6 ± 14.9 years) were obtained. We sequentially sectioned the DRUJ, in the following order: extensor carpi ulnaris (ECU) subsheath, deep head of pronator quadratus (PQ), dorsal and volar radioulnar (RU) ligaments, the foveal attachment of the triangular fibrocartilage complex (TFCC), and the distal oblique bundle (DOB). After each component of the DRUJ was sectioned, we performed three radiographic stress tests—squeeze test, ulnar pull in coronal plane, and simulated DRUJ ballotment test.
Results: The squeeze test was able to detect a significant increase in diastasis relative to the intact DRUJ after sectioning of the foveal insertion of the TFCC (1.1 mm, P=0.0294) and the DOB (1.2 mm, P=0.0093). The simulated DRUJ ballotment test was also able to detect a significant increase in dorsal translation of the ulna relative to the intact DRUJ with sectioning of the foveal insertion of the TFCC (2.4mm, P=0.0003) and the DOB (4.4mm, P=0.0004). The ulnar pull test in the coronal plane was able to detect a significant increase in diastasis relative to the intact DRUJ earlier in the sectioning sequence with a significant increase after the PQ was transected (0.4mm, P=0.0002).
Conclusion: Objective intraoperative assessment of DRUJ instability can be a vexing problem for surgeons. The squeeze test and simulated DRUJ ballotment test detect a significant increase in diastasis after the foveal attachment of the TFCC was sectioned. The ulnar pull test in the coronal plane was the most sensitive test for detecting a significant increase in diastasis relative to the intact DRUJ.


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