The extremity was exsanguinated, and an upper arm tourniquet was inflated. The patient was placed on the table in supine position with the left upper extremity extended over a hand table. The decision was made to proceed with DRUJ arthroplasty under regional block and monitored anesthesia care. Like all arthroplasties, there is a risk for wear and/or fatigue failure, particularly in a younger man, as the longitudinal stress of the forearm will be seen at the ultra-high-molecular-weight polyethylene ball and radial plate cover. Option 3 addresses all the issues with which this patient presents, but not without potential complication. Additionally, radiocapitellar arthroplasty has been recalled and is not an option in this case. However, if we address the radiocapitellar joint with a radial head arthroplasty (option 2), there is no guarantee that the radiocapitellar joint will be stable or pain-free postoperatively because the capitellum is likely pathologic, as well. With option 1, the radiocapitellar joint is not addressed, which can result in continued longitudinal stress on the forearm, potentially causing stress on the IOM reconstruction and recurrent instability. Options 1 and 2 both address chronic longitudinal instability and ulnocarpal/DRUJ pathologies, but have their downsides. Possible options for treatment include 1) intraosseous membrane (IOM) reconstruction with an ulnar head resection (Darrach procedure) 2) radial head arthroplasty with a Darrach procedure or 3) DRUJ arthroplasty. The DRUJ, ulnocarpal joint and longitudinal stability all likely need to be addressed in the treatment of this patient’s problem. Was this a ramification of malreduced proximal ulnar fixation resulting in significant ulnar positivity causing ulnocarpal impaction and stress on the DRUJ or was this a result of chronic longitudinal instability from malreduction of the radiocapitellar joint? Likely, all of these factors played a role in the patient’s presentation. The treating surgeon should consider why this occurred. This is presumed to be the result of chronic stress and eventual attenuation of the DRUJ or a missed, concomitant DRUJ injury at the time of the trauma. The patient’s complaint is isolated wrist pain, deformity and decreased function. However, the patient has a relatively functional flexion-extension arc of the elbow and no elbow pain. Additionally, the chronic posterior subluxation and deformity of the radiocapitellar joint is a sequela from the Monteggia fracture-dislocation. The patient has a chronic proximal ulna malunion from a Monteggia fracture-dislocation. There are multiple pathologies present in this patient and numerous potential treatment options. Mild volar and dorsal muscle atrophy were present, which the patient stated were chronic at his baseline.Ĭhronic proximal ulna malunion with chronic posterior subluxation, deformity of radiocapitellar joint Radial, median and ulnar sensorimotor nerves were intact with normal ulnar and radial pulses at the wrist. Significant DRUJ instability was also appreciated. He had a 30° to 100° flexion-extension arc at the elbow. However, he had only a 10° flexion-extension arc of wrist ROM with mechanical block, as well as a mechanical block to pronosupination. There was a well-healed incision over the dorsal, proximal ulna. On exam, the patient had obvious deformity of the wrist with dorsal prominence of the ulnar head and associated tenderness at the ulnar wrist. AP (a), oblique (b) and lateral (c) left elbow X-rays demonstrating radiocapitellar subluxation with radial head deformity, proximal ulnar fracture malunion with intact hardware and mild ulno-trochlear post-traumatic arthritis are shown. Anteroposterior (AP) (a), oblique (b) and lateral (c) left wrist X-rays demonstrate dorsal DRUJ dislocation with significant ulnar impaction, and ulno- and radiocarpal arthritis are shown.Ģ. The patient currently denied elbow pain.ġ. There, radiographs of the left wrist and elbow were obtained demonstrating dorsal distal radioulnar joint (DRUJ) dislocation with significant ulnar impaction, ulnocarpal and radiocarpal arthritis, radiocapitellar subluxation with radial head deformity, and proximal ulnar fracture malunion with intact hardware (Figures 1 and 2). He had woken up from sleep with severe pain and was evaluated at an ED. The patient had 1 week of severe, atraumatic left wrist pain, dorsal deformity and decreased range of motion (ROM). If you continue to have this issue please contact to HealioĪ 39-year-old left-hand dominant man with a history of left Monteggia fracture-dislocation that was treated abroad about 10 years ago presented to clinic.
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