Treatment of DRUJ (Wrist) Arthritis

The wrist is a complex joint with many bones, ligaments, and tendons to support it through all of the motions needed for daily activities. Damage to the distal radioulnar joint (DRUJ) portion of the wrist can be a challenge to treat. In this article, hand surgeons from Mass General Hospital in Boston bring us up-to-date on this problem and offer their advice about treatment.

The distal radioulnar joint (DRUJ) is located between the two bones of the forearm. Since these two bones (the radius and the ulna) meet up at the elbow and down at the wrist, the word "distal" (meaning at the far end) tells us we are talking about the connection point at the wrist end of the bones.

The place where these two bones meet is designed to allow for rotation and gliding motions. These movements make it possible to shake a bell, wring out a wet rag, turn your palm up to receive change, take care of personal toileting needs, and many more activities of daily living. There is an S-shaped notch on the ulnar bone where the head of the radius sets. It's this special anatomy combined with the soft tissues that hold everything together that makes everything work together so well.

But sometimes, due to a traumatic injury, inflammation, aging (degeneration), or a congenital problem (present at birth), the DRUJ becomes painful and/or unstable. Wrist fracture is a common cause of post-traumatic arthritis at this joint. Improper healing and deformity at the DRUJ from any trauma can create this type of painful arthritis.

Pain, tenderness, and loss of wrist and forearm motion are the main symptoms. But crepitus (that crunching, crackling sound and feeling when moving the wrist) is reported by some patients. And "clunking" is possible when there is subluxation (partial dislocation) of the joint.

Any of these symptoms can be addressed with proper management and treatment. Conservative care is always advised first. A physical therapist guides the patient through ways to modify activities that aggravate the condition while addressing the pain and loss of motion.

Surgery may be needed for the patient who does not respond well to nonoperative care or when there is significant, disabling instability and/or arthrosis (degenerative disease of the DRUJ). There are many different ways to approach this problem surgically. That's one of the reasons the authors wrote this article. They present what they refer to as their preferred treatment algorithm.

An algorithm is a series of steps that help a surgeon make the final decision about what is best for each patient. With DRUJ problems, a careful history, examination, and imaging studies are necessary. The full extent of the injury and soft tissue involvement must be revealed before doing any surgery.

Once a decision has been made to operate, there are many choices. Resection arthroplasty is the first one discussed. This involves removing a portion of the bone to eliminate the painful anatomy.

The authors present three options for resection arthroplasty: the Darrach procedure, hemiresection procedures (there are several variations), and the Sauvé-Kapandji procedure. Indications for use, pros and cons, and outcomes for each approach are provided.

The second major category of surgical options for DRUJ problems is the implant arthroplasty. This is a type of joint replacement that includes partial ulnar head replacement, total ulnar head arthroplasty, or total DRUJ arthroplasty. Arthroplasty is another word for joint replacement.

The third and final surgical choice is listed as a salvage option. Salvage means "to save" as much of the joint and surrounding soft tissues as possible. This type of approach often means sacrificing forearm motion in order to preserve function and strength. Some examples of salvage procedures for DRUJ instability include creating a one-bone forearm (OBF). This is a fusion technique. Another salvage procedure is a wide excision of the distal ulna (removal of a large portion of the bottom of the ulnar bone).

In summary, the authors use descriptions, drawings, photos, MRI images, and X-rays to assist other surgeons in evaluating and managing painful, disabling arthritis of the distal radioulnar joint (DRUJ). This is an important joint needed for forearm rotation (turning hand up and down) and putting weight through the hand and wrist. It is a complex joint that presents many treatment challenges. The treatment algorithm offered comes from the many years of experience of these authors managing patients with this problem.

Reference: 

Ryan M. Zimmerman, MD, et al. Arthritis from the Distal Radioulnar Joint: From Darrach to Total Joint Arthroplasty. In Journal of the American Academy of Orthopaedic Surgeons. October 2012. Vol. 20. No. 10. Pp. 623-632.

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