DRUJ Instability
Distal Radioulnar Joint
Jacksonville, FL
Pain and instability with forearm rotation — wrist that clunks, gives way, or feels unstable when turning a door handle or using a screwdriver. R. David Graham, MD at JOI always assesses pronation/supination stability as part of any wrist evaluation. DRUJ instability is repaired acutely, reconstructed for chronic cases, and salvaged with Sauve-Kapandji or Darrach when reconstruction is not viable.
- DRUJ = where the radius pivots around the ulnar head during forearm rotation
- Instability from DRUJ ligament (dorsal and volar radioulnar ligaments) disruption
- Always assess pronation/supination stability in wrist evaluation
- Acute: DRUJ ligament repair
- Chronic: reconstruction with tendon graft around the ulna
- Late salvage: Sauve-Kapandji or Darrach when reconstruction not viable
DRUJ instability is frequently missed or attributed to TFCC pathology alone. Specific assessment of the DRUJ — dorsal-volar translation of the ulnar head relative to the radius — is part of every wrist evaluation.
Understanding DRUJ Instability
The Joint That Makes
Forearm Rotation Possible
The distal radioulnar joint (DRUJ) is where the distal radius pivots around the fixed ulnar head during forearm pronation and supination. The primary stabilizers are the dorsal and volar radioulnar ligaments — deep fibers of the triangular fibrocartilage complex (TFCC) — which tighten alternately during rotation to maintain the radius-ulna relationship. When these ligaments are torn, the DRUJ becomes unstable: the ulnar head can translate dorsally or volarly relative to the radius, producing pain, clicking, and weakness with forearm rotation.
DRUJ instability occurs from wrist fractures (particularly distal radius fractures with significant displacement), forearm fractures (Essex-Lopresti), direct trauma, and isolated TFCC ligament disruption. It produces characteristic symptoms: pain and instability with forearm rotation, particularly in power grip with the wrist loaded, and a clunk or shift at the ulnar wrist with active pronation and supination.
Dr. Graham assesses DRUJ stability specifically during every wrist examination — dorsal-volar translation of the ulnar head relative to the radius compared to the contralateral side is the clinical test. The classification matters for treatment: acute injuries (within weeks) are repaired directly; chronic instability (months to years) requires reconstruction using a tendon graft around the ulna to recreate the radioulnar ligaments. Late salvage procedures — Sauve-Kapandji (pseudarthrosis of the ulnar neck with distal ulna fusion to the radius) or Darrach (distal ulna resection) — are considered when reconstruction is not viable due to bone quality, previous surgery, or salvage-level disease.
- ✓ Acute (< 6 weeks): direct DRUJ ligament repair — best tissue quality
- ✓ Chronic (> 3 months): tendon graft reconstruction around ulna — Adams procedure or variant
- ✓ Late salvage: Sauve-Kapandji (pseudarthrosis + fusion) or Darrach (ulna resection)
- ✓ Darrach: good for low-demand patients, RA; dynamic stabilization often added
- ✓ Sauve-Kapandji: preserves ulnar length, better for higher-demand patients
- ✓ TFCC repair often performed concurrently — TFCC and DRUJ ligaments are the same structure
Treatment by Stage
Repair → Reconstruction → Salvage
Scroll the table sideways to see all columns
| Stage | Procedure | Key Points |
|---|---|---|
| Acute DRUJ instability (<6 weeks from injury) | Direct DRUJ ligament repair | Open repair of dorsal and/or volar radioulnar ligaments. Suture anchor fixation. Immobilization in supination (dorsal instability) or pronation (volar instability) for 6 weeks. |
| Chronic DRUJ instability (>3 months) | Tendon graft reconstruction | Palmaris longus or other tendon graft routed through bone tunnels in the radius and ulna to recreate the radioulnar ligaments. Multiple reconstruction techniques — Adams procedure is a common reference. 6-week immobilization post-op. |
| Late salvage — higher demand | Sauve-Kapandji procedure | Pseudarthrosis created at the ulnar neck allows forearm rotation; distal ulna is fused to the radius for stability. Preserves ulnar length. Better for patients who require wrist loading. |
| Late salvage — lower demand / RA | Darrach procedure | Distal ulna resection eliminates the unstable joint. Effective pain relief. Dynamic stabilization of the ulnar stump may be added. Best for lower-demand patients and RA. |
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Wrist that clunks or gives way
with forearm rotation?
DRUJ instability is assessed at every wrist evaluation. Early identification allows repair — the longer it goes unaddressed, the more complex the reconstruction. Walk-ins welcome via JOI Now.
Jacksonville Beach, FL 32250
No imaging required.