Dorsal radioulnar ligament
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Description[edit | edit source]
The dorsal radioulnar ligament (DRUL) is comprised of parallel collagen bundles divides into deep and superficial limbs, which attach into the fovea and ulnar styloid respectively, spanning across the radius and ulna and forming ,among other structures, the triangular fibrocartilage complex (TFCC) located on the ulnar aspect of the wrist joint between the lunate, triquetrum, and ulnar head. [1][2]
Attachment[edit | edit source]
The DRUL is connecting the posterior margin of the ulnar notch at the distal radius to the posterior portion of the head of the ulna. The ligament innervated by the anterior and posterior interosseous nerve and the anterior interosseous artery supply her blood[3][4]
function[edit | edit source]
DRUL acts along with the palmar radioulnar ligament as primary stabilizers of the dorsal radioulnar joint (DRUJ) and act as a shock absorber across the ulna-carpal joint. [5][6]
clinical relevance[edit | edit source]
Traumatic or degenerative Injuries can occur with aging and due to the complexity of the anatomical structure and the way load transmission takes place around the ulnar aspect of the wrist joint. Injury often occurs under forced ulnar deviation.[5] Repetitive forearm rotation, in particular, can lead to overuse of DRUL and therefore to degenerative changes.[2] The injuries prevalence in patients age 70 or older is 49% and 27% in patients age 30 or younger. [5]The DRUL injuries are associated with damage involves the TFCC or other radioulnar ligaments resulting from distal radius fractures, fractures of the ulnar styloid, and eponymous Galeazzi or Essex Lopresti fractures. Injury to the interosseous membrane (IOM) can also put a lot of strain on the DRUL consequently can cause injury to the DRUL. [7][8]
Assessment[edit | edit source]
Diagnostic tool: as a preliminary diagnosis MRI imaging is useful ; however arthroscopy is the diagnostic gold standard.[5]
subjective[edit | edit source]
Patient may complain of dull ulnar-sided wrist pain often worsen with activity, particularly during forearm rotation. [2]However, difficulty carrying loads is the hallmark of injury to the DRUL.[9]
[5]Patient history may includes previous injuries or fractures (as mentioned above) [5] Patient may participate sports that include swinging a racket or a bat such as baseball player[5]
Physical examination[edit | edit source]
The pain is accompanied by clicking or tender points between the pisiform and the ulnar head. The physical examination reveals Muscle weakness in the grip, supination and pronation, which can then indicate on wrist instability. [5]
There is no specific test for the DRUL but several physical exams test the TFCC can possibly indicate injury to the DRUL .[5]
These include:
- TFCC compression test: Pain is reproduced with ulnar deviation when forearm in the neutral position.
- TFCC stress test: Pain is reproduced while the wrist in ulnar deviation apply a force across the ulnar.
- Press test: Pain is reproduced while the patient lifts themselves out of a chair using the wrists in an extended position.
- Supination test: Pain is reproduced while the patient grabs the underside of a table with the forearms supinated.
- Piano key test: The distal ulna is prominent on the affected side while the patient place both hands on the table and press his palms on the table. If the distal ulna is prominent on the affected side, this indicate DRUJ instability, which can be related to TFCC injury. If the palms are relaxed and the ulnar head goes back to normal position, this is a positive test.
Treatment[edit | edit source]
1. It is important to identify the daily activities aggravating the pain and modify them with the help of professionals such as physiotherapists.
2. Allow rest and completely avoid sports activities that consist of full weight bearing on the wrist while performing maneuver movements such as Yoga poses etc.[2]
2. Application of temporary splint or cast.
3. NSAIDs
4. Administration of corticosteroid injection in conjunction with physical therapy in extremely symptomatic patients.
5.Arthroscopy, a surgical procedure is performed only if the conservative treatment fails to alleviate symptoms, or in cases presenting initially with instability of the DRUJ or with unstable and displaced fractures. In most, if not all conditions involving TFCC, arthroscopic management can be conducted successfully. [2]
Resources[edit | edit source]
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References[edit | edit source]
- ↑ Pulos N, Bozentka DJ. Carpal ligament anatomy and biomechanics. Hand Clinics. 2015 Aug 1;31(3):381-7.
- ↑ 2.0 2.1 2.2 2.3 2.4 Jawed A, Ansari MT, Gupta V. TFCC injuries: How we treat?. Journal of Clinical Orthopaedics and Trauma. 2020 Jul 1;11(4):570-9.
- ↑ Moore KL, Dalley AF, Agur AMR. Clinically oriented anatomy. Lippincott Williams and Wilkins. ISBN:0781775256. Read it at Google Books - Find it at Amazon
- ↑ MIKIC Ž. The blood supply of the human distal radioulnar joint and the microvasculature of its articular disk. Clinical Orthopaedics and Related Research®. 1992 Feb 1;275:19-28.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Casadei K, Kiel J. Triangular Fibrocartilage Complex.
- ↑ Moritomo H. Advantages of open repair of a foveal tear of the triangular fibrocartilage complex via a palmar surgical approach. Tech Hand Upper Extrem Surg. 2009;13:176–81. doi: 10.1097/BTH.0b013e3181bd8319
- ↑ Werner FW, LeVasseur MR, Harley BJ, Anderson A. Role of the interosseous membrane in preventing distal radioulnar gapping. Journal of Wrist Surgery. 2017 May;6(02):097-101.
- ↑ Thomas BP, Sreekanth R. Distal radioulnar joint injuries. Indian journal of orthopaedics. 2012 Oct;46(5):493-504.
- ↑ Altman E. The ulnar side of the wrist: clinically relevant anatomy and biomechanics. Journal of Hand Therapy. 2016 Apr 1;29(2):111-22.
