Athletes often complain of pain on the outside (ulnar) side of the wrist. There are many causes of ulnar wrist pain, but one of the more common problems is DRUJ (distal radioulnar) joint injury, such as DRUJ arthritis. How does DRUJ injury present, and what can we do to treat it?
What is the distal radioulnar joint?
The DRUJ (distal radioulnar joint) sits between the ends of the forearm bones, the radius and the ulna. It is connected by cartilage in the wrist, known as the TFCC. Generally, the joint is stabilised by the cartilage and the ligaments sitting at the front and the back of the wrist. The forces on the joint are determined by the relationship length of the ulna and radius: a longer ulna (positive ulnar variance) increases the forces on the ulnar head, while a shorter ulna (negative ulnar variance) puts more force on the radius.
DRUJ injuries
DRUJ injuries take the form of arthritis, instability and ulnar abutment syndrome.
First, DRUJ arthritis can develop after a wrist fracture. Fractures of the wrist that involve the distal radioulnar joint (DRUJ) can lead to an uneven joint surface and early degenerative changes. Additionally, inflammatory diseases such as rheumatoid arthritis can affect the DRUJ and often serve as the first signs of inflammatory arthritis.
Next, distal radioulnar instability means the joint fails to maintain proper alignment as the wrist rotates, leading to cracking, popping or sliding.
Finally, ulnar abutment syndrome results in excessive loads on the ulnar aspect of the wrist joint, typically due to a longer ulna.
Diagnosis
Generally, DRUJ injuries produce pain, swelling and movement restriction of the wrist, particularly in rotation.
When your doctor examines your wrist, she often finds tenderness at the ulnar styloid and restriction in wrist rotation. Moving the ulnar head against the radius produces pain and excessive movement – we call this test the ‘shucking test’. Your doctor will also assess other structures, such as the triangular fibrocartilage complex (TFCC) and the extensor carpi ulnaris (ECU) tendon.
Typically, we use wrist X-rays to assess the alignment of the bones and arthritic changes in the distal radioulnar joint (DRUJ). Additionally, an MRI scan helps determine the soft tissue structures of the wrist, including cartilage, joint surfaces, and tendons.
Treatment of DRUJ injuries
For DRUJ arthritis, it is recommended to try simple measures first, such as ibuprofen, intensive hand therapy, and a wrist splint. An injection directed into the distal radioulnar joint can be helpful.
DRUJ injection
In some cases, we inject cortisone for DRUJ arthritis. Cortisone is a potent anti-inflammatory that reduces swelling associated with arthritis. It is particularly effective for inflammatory arthritis.
Generally, for a small joint like the DRUJ, an ultrasound-guided injection is recommended. We know that ultrasound guidance enhances the accuracy and effectiveness of injections. Additionally, directing cortisone into the joint rather than the surrounding soft tissue reduces side effects, such as skin thinning or depigmentation.
Sometimes, when symptoms return after a cortisone injection, we consider other injectables. Hyaluronic acid is a natural substance that, when injected into joints, reduces inflammation gently and naturally. PRP is extracted from blood after it is spun in a centrifuge. We inject PRP for upper and lower limb joints, although the evidence is less robust for the DRUJ.
Surgery
There are various surgical procedures considered for DRUJ arthritis, such as bone excision, fusion, and joint replacement.
Final word from Sportdoctorlondon regarding DRUJ injury
DRUJ injury is a common cause of pain on the outside of the wrist. Diagnosis depends on the presentation of pain symptoms, physical examination, and various investigations, including X-rays and MRIS. See a doctor who has experience in managing ulnar wrist pain.
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