PMC9481415_01
(A) Bony prominence on the ulnar side of the left wrist. (B) Normal gap on the PA view wrist radiograph. (C) A radioulnar distance greater than 6 mm.
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On the physical examination, there was a bony prominence over the ulnar styloid and tenderness over the distal ulnar region and ulnar side of the wrist (Figure 1A). The plain radiograph suggested DRUJ subluxation (Figure 1B and C) and the MRI revealed an absence of volar radio-ulnar ligament (Figure 2).
Magnetic Resonance Imaging. (A) Axial T1-weighted image revealed a lack of volar RUL, redundant extensor retinaculum, and flipped ECU sub-sheath that trapped between the ECU and the bony surface. (B) The axial T2 weighted image showed hyperintensity suggesting ECU tendinitis. (C) Coronal T2 images suggested an ulnar avulsion of the TFCC palmer 1B (dotted red circle). (Pink asterisk: dorsal RUL; yellow asterisk: ECU tendon; blue arrow: extensor retinaculum; red arrow: flipped ECU sub-sheath; green arrow: tendinitis).
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The plain radiograph suggested DRUJ subluxation (Figure 1B and C) and the MRI revealed an absence of volar radio-ulnar ligament (Figure 2). There was also evidence of ECU sub-sheath injury (Figure 2).
(A) PL variation with a bitendinous portion at the distal attachment. The lateral division (LD) lies superficial to the flexor retinaculum (red dots) and the medial division (MD) lies under the flexor retinaculum. (B) The harvested 13-cm-long tendon.
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The total length obtained from the harvesting was only 13 cm (Figure 3).
(A) Dorsally, the whole fourth extensor compartment was retracted radially and subperiosteally. The radial tunnel is made by drilling the ulnar column of distal radius 5 mm radial to the DRUJ and 5 mm proximal to the radiocarpal joint. (B) At the palmar side, a longitudinal incision proximal to the wrist crease is made to harvest the tendon and pass the graft. (C) The volar limb of the graft is passed dorsally to be secured at the fovea interosseous tunnel.
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A 3.5 mm drill hole was made in the lunate fossa approximately 5 mm radial to the radial edge of DRUJ and 5 mm to the radio-carpal joint to avoid breaching the sigmoid notch (Figure 4A). After the graft preparation, the PL graft was passed through this radial tunnel with a suture retriever from dorsal to volar (Figure 4B). The volar limb of the graft was passed back dorsally through the soft tissue tunnel from volar to dorsal DRUJ capsule (Figure 4C).
(A) A longitudinal skin incision was made over the DRUJ. The EDM in the 5th compartment was retracted, then, an ulnarly-based flap of dorsal retinaculum is raised over the distal ulna, exposing the DRUJ capsule. In a hyperflexed wrist, a 3.5-mm bony tunnel was made from the fovea to the ulnar neck. (Black dot: Second ulnar tunnel) (B). The second ulnar interosseous tunnel (2.5 mm) is made proximally to pass one of the limbs. (Blue line: the first ulnar tunnel). (C and D) Both limbs are tied with the Pulvertaft weave technique.
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Both limbs were fixed with Pulvertaft's weave technique after appropriate graft tensioning in the neutral wrist and compressed DRUJ (Figure 5).
An illustration of the intra articular RUL reconstruction technique using a PL graft. Both graft limbs are shown in different colors. (A) Dorsal view. (B) Radio-carpal view.
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The summary of the technique is illustrated in Figure 6.