Sporting people often complain of pain on the little finger (ulnar) side of the wrist. There are many causes of ulnar wrist pain, but one of the more common problems is an injury to the DRUJ — the distal radioulnar joint — including DRUJ arthritis. So how does a DRUJ injury present, and what can we do to treat it?
What is the distal radioulnar joint?
The DRUJ sits between the ends of the two forearm bones — the radius and the ulna. It’s connected by a cartilage structure in the wrist called the TFCC (triangular fibrocartilage complex). The joint is stabilised by this cartilage and by the ligaments at the front and back of the wrist.
The forces through the joint depend on the relative lengths of the ulna and radius. A longer ulna (positive ulnar variance) increases the load on the ulnar head, while a shorter ulna (negative ulnar variance) puts more force through the radius.
Types of DRUJ injury
DRUJ injuries take three main forms: arthritis, instability, and ulnar abutment syndrome.
DRUJ arthritis
DRUJ arthritis can develop after a wrist fracture. Fractures involving the joint can leave an uneven joint surface, leading to early degenerative change. Inflammatory conditions such as rheumatoid arthritis also affect the DRUJ — and wrist symptoms are often among the first signs of an inflammatory arthritis.
DRUJ instability
Distal radioulnar instability means the joint fails to hold its alignment as the wrist rotates, causing cracking, popping, or a sliding sensation.
Ulnar abutment syndrome
Ulnar abutment (also called ulnar impaction) produces excessive load on the ulnar side of the wrist joint, usually because the ulna is relatively long.
Diagnosis of a DRUJ injury
DRUJ injuries produce pain, swelling, and restricted wrist movement — particularly rotation (turning the palm up and down).
On examination, your doctor often finds tenderness at the ulnar styloid and restricted wrist rotation. Moving the ulnar head against the radius reproduces the pain and may show excessive movement — the “shucking” test. Your doctor will also assess the other structures on this side of the wrist, including the TFCC and the ECU tendon, as these commonly cause similar symptoms.
Wrist X-rays assess the alignment of the bones, the ulnar variance, and any arthritic change in the DRUJ. An MRI scan is helpful for the soft-tissue structures — the cartilage, joint surface, and tendons.
Treatment of DRUJ injuries
For DRUJ arthritis, always try simple measures first: ibuprofen, intensive hand therapy, and a wrist splint. An injection directed into the distal radioulnar joint can also help.
The DRUJ injection
In some cases, we inject cortisone for DRUJ arthritis. Cortisone is a potent anti-inflammatory that reduces the swelling associated with arthritis, and it’s particularly effective in inflammatory arthritis.
For a small joint like the DRUJ, you should have an ultrasound-guided injection. Ultrasound guidance improves the accuracy and effectiveness of the injection. Directing the cortisone into the joint rather than the surrounding soft tissue also reduces side effects such as skin thinning and depigmentation.
When symptoms return after a cortisone injection, we consider other injectables. Hyaluronic acid is a natural substance that, injected into the joint, reduces inflammation gently. PRP is prepared from your own blood after spinning it in a centrifuge. We use PRP in upper and lower limb joints, although the evidence in the DRUJ specifically is limited.
Surgery
Several surgical procedures are considered for DRUJ arthritis, including bone excision, joint fusion, and joint replacement. Surgery is reserved for cases that fail simple treatment and injections.
How much does a DRUJ injection cost?
Dr Masci offers a one-stop appointment — consultation, diagnostic ultrasound, and the injection in a single visit. At the Chelsea clinic (the most cost-effective location), a consultation with an ultrasound-guided cortisone injection is £400; other clinic locations cost more. See the full one-stop injection fees here and our clinic locations.
Frequently asked questions about DRUJ injury.
What are the symptoms of a DRUJ injury?
Pain on the little finger side of the wrist, swelling, and restricted movement — especially rotating the forearm to turn the palm up and down. Instability can also cause clicking, popping, or a sliding sensation, and the wrist is often tender over the ulnar styloid.
What’s the difference between a DRUJ injury and a TFCC tear?
They’re closely related and often occur together, since the TFCC is the cartilage that stabilises the DRUJ. A TFCC tear specifically involves that cartilage, while DRUJ problems include arthritis, instability, and ulnar abutment. Both cause ulnar-sided wrist pain and pain on rotation, so an examination and MRI are used to tell them apart — and treatment differs.
What is ulnar variance, and why does it matter?
Ulnar variance describes the relative lengths of the ulna and radius at the wrist. A longer ulna (positive variance) loads the ulnar side more heavily and predisposes to ulnar abutment syndrome and TFCC problems. It’s measured on a wrist X-ray and helps explain why some people develop ulnar-sided wrist pain.
Does a DRUJ injection work for wrist arthritis?
An ultrasound-guided cortisone injection into the DRUJ reduces inflammation and pain, and is particularly effective in inflammatory arthritis. It works best combined with hand therapy and a splint. Where symptoms return, hyaluronic acid or PRP may be considered.
Does a DRUJ injury need surgery?
Usually not. Most people improve with anti-inflammatory medication, hand therapy, splinting, and a guided injection. Surgery — bone excision, fusion, or joint replacement — is reserved for persistent cases that fail these measures.
Final word from Sport Doctor London about DRUJ injury
DRUJ injury is a common cause of pain on the ulnar side of the wrist. The diagnosis depends on the pattern of symptoms, a careful examination, and investigations such as X-rays and MRI. See a doctor experienced in managing ulnar wrist pain, as several conditions in this area produce very similar symptoms.
To discuss wrist pain or a DRUJ injection with Dr Masci in London, contact the team here or call +44 (0) 203 488 0350.
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