Palmaris longus tendon for distal radio-ulnar ligament reconstruction – A novel technique

Amitabh Mohan; R Nagamahendran; Sanjay Singh; R Shankaran

doi:10.4103/jbjd.jbjd_6_21

CASE REPORTS

Year : 2022 | Volume : 37 | Issue : 1 | Page : 13-14

Palmaris longus tendon for distal radio-ulnar ligament reconstruction – A novel technique

Amitabh Mohan¹, R Nagamahendran², Sanjay Singh³, R Shankaran⁴
¹ Department of Reconstructive Surgery, INHS Asvini, Colaba, Mumbai, Maharashtra, India
² Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India
³ Department of General Surgery, INHS Asvini, Colaba, Mumbai, Maharashtra, India
⁴ Institute of Naval Medicine, Colaba, Mumbai, Maharashtra, India

Date of Submission	24-Jun-2021
Date of Decision	20-Dec-2021
Date of Acceptance	15-Mar-2022
Date of Web Publication	13-May-2022

Correspondence Address:
R Nagamahendran
Dept of General Surgery, Institute of Naval Medicine, INHS Asvini, Near RC Church, Colaba, Mumbai 400 005, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_6_21

Abstract

Isolated Distal Radioulnar Joint (DRUJ) Instability is a rare phenomenon. It is usually associated with fractures of either the radius or ulna, and the treatment is not uniform. We present the case of a traumatic DRUJ instability presented to our centre with complaints of abnormal clicking sound in wrist during rotatory movements. During surgery, the stabilization of DRUJ was done using distal radioulnar ligament. Postoperative radiography showed proper alignment, with good stability of DRUJ.Correction of DRUJ instability is facilitated by distal radioulnar ligament reconstruction. The treatment is found to be effective with good outcome as compared to the conservative management and other surgical modalities widely practiced.

Keywords: Distal radio ulnar joint (DRUJ), Palmaris longus tendon, radio ulnar ligament reconstruction

How to cite this article:
Mohan A, Nagamahendran R, Singh S, Shankaran R. Palmaris longus tendon for distal radio-ulnar ligament reconstruction – A novel technique. J Bone Joint Dis 2022;37:13-4

How to cite this URL:
Mohan A, Nagamahendran R, Singh S, Shankaran R. Palmaris longus tendon for distal radio-ulnar ligament reconstruction – A novel technique. J Bone Joint Dis [serial online] 2022 [cited 2022 May 25];37:13-4. Available from: http://www.jbjd.in/text.asp?2022/37/1/13/345167

Introduction

DRUJ is a diarthrodial trochoid synovial joint,^[1] consisting of two parts—the bony radio ulnar articulation and soft tissue stabilizers. The radio ulnar articulation is formed by the lower end of ulna (seat) and the sigmoid notch (medial articular facet) of the distal radius. The sigmoid notch of the radius is concave with a radius of curvature of approximately 15 mm⁴. The ulnar head is semi cylindrical, convex, with a radius of curvature of 10 mm.^[2] The differential arc of curvature of ulna and sigmoid notch suggests that prono supination involves rotation as well as dorso palmar translation at the DRUJ.^[3]

Patients most commonly complain of ulnar-sided wrist pain (USWP), Clicking sounds, obvious instability, and weakness on lifting objects.

Case Report

A 19 year old female with normal built presented to our centre with complaints of abnormal clicking sound in left wrist during pronation and supination movements of wrist joint for past one year following direct trauma. On evaluation patient was found to have Left Radio-ulnar joint instability. On examination there was clicking sound while pronating and supinating wrist without any restriction of movements. Piano key sign was positive. The Radio-ulnar ballottement test showed excessive depression of ulnar head. Press test showed depression of ulnar head when patient rises from chair. On investigation with plain x ray- of bilateral forearm with left wrist joint widening was noticed in comparison to right. Further evaluation with MRI Left wrist joint showed rupture of dorsal radio-ulnar ligament.

Patient was taken up for definitive management in the form of Radio-ulnar ligament reconstruction using Palmaris longus tendon of the other forearm. The procedure was performed under regional anaesthesia with tourniquet control. A Y-shaped incision centered over the ulnar head was made on the ulnar border of the distal forearm [Figure 1]. The vertical limb was extended 5 cm proximal to the ulnar head along the ulnar border of the forearm. The volar limb extended to the pisiform and the dorsal limb was extended to the Lister’s tubercle. Three skin flaps (distal, volar, and dorsal) were raised in a plane superficial to the tendons and extensor retinaculum.

Figure 1: Marking of Y shaped incision over ulnar head

Click here to view

Dissection was continued in the following fashion.

Development of Volar plane

Development of Dorsal plane

Harvest of Palmaris longus tendon graft- from opposite upper limb

Creation of bone tunnel in radius and ulna

Passage of tendon graft via tunnel using polypropylene 1/0 suture.

Reduction of DRU joint

Suture fixation of reconstructed ligament using suture anchor

Closure and wrist joint immobilization with above elbow splint.

Patient was reviewed after 02 weeks and sutures were removed. Splint was removed after 08 weeks with advice of active physiotherapy. Complete correction of DRU instability with full range of pronation and supination movement was achieved. MWMS (Mayo modified wrist score) of the patient was 90 (25–100).

Discussion

Distal radioulnar (DRU) joint reconstruction is indicated for symptomatic chronic DRU joint instability, typically caused by distal radius fracture malunion, basilar ulnar styloid fracture nonunion, isolated DRU joint dislocation or subluxation and tear in supporting ligament. Apart our technique of Palmaris longus tendon graft technique, brachio radialis (BR) wrap technique is an option to restore the stability of the distal radioulnar joint (DRUJ).^[4] Radial-based extensor retinaculum strip and a capsular plication is also described.^[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Hagert E, Hagert CG. Understanding stability of the distal radioulnar joint through an understanding of its anatomy. Hand Clin 2010;26:459-66.
2.	Wu WT, Chang KV, Mezian K, Naňka O, Yang YC, Hsu YC, et al. Ulnar wrist pain revisited: Ultrasound diagnosis and guided injection for triangular fibrocartilage complex injuries. J Clin Med2019;8:1540.
3.	Mirghasemi AR, Lee DJ, Rahimi N, Rashidinia S, Elfar JC. Distal radioulnar joint instability. Geriatr Orthop Surg Rehabil 2015;6:225-9.
4.	Burke CS, Zoeller KA, Waddell SW, Nyland JA, Voor MJ, Gupta A. Assessment of distal radioulnar joint stability after reconstruction with the brachioradialis wrap. Hand (N Y) 2018;13:455-60.
5.	Filius A, Zuidam JM, Jaquet JB, Slijper HP, Coert JH. Modification of the use of the extensor retinaculum for reducible distal radioulnar joint instability: Technique and results. J Hand Surg Eur Vol 2017;42:839-45.