The reliability of clinical assessment of distal radioulnar joint instability

Abstract

Accurate assessment of distal radioulnar joint (DRUJ) stability is increasingly recognized as an important part of clinical examination of the wrist. The ability of 30 specialist UK hand surgeons to clinically determine the stability of four volunteers’ wrists was assessed. Volunteers’ wrist stability had previously been confirmed with a validated measurement rig. Use of the wrist ballottement test as the primary examination technique yielded a positive predictive value of 81%, a negative predictive value of 55%, a specificity of 94% and a sensitivity of only 24%, for the detection of DRUJ instability. No correlation between background speciality (orthopaedic versus plastic surgery), nor years of clinical experience was found. Clinical assessment of DRUJ instability among experienced clinicians appears unreliable and instability is typically under recognized. Previous research to date using this clinical assessment method as a parameter of success is therefore brought into question. Level of evidence: IV

Concomitant ligament injuries can be left untreated during surgery of distal radial fractures

“…Previous studies on upper extremity conditions, such as SLD or proximal humeral fractures, have already noted limited reliability and reproducibility of diagnostic tests (Bakker et al., 2022; Papakonstantinou et al., 2016). A recent study on the reliability of the ballottement test reported a low sensitivity of 24% and concluded the test could be unreliable (Pickering et al., 2022). In our study, the ballottement test was carried out during surgery.…”

The distal radioulnar joint after distal radial fractures: when and how do we need to treat pain, stiffness or instability?

“…There are case series recommending acute TFCC repair, but we do not see many patients with long-term symptomatic DRUJ instability requiring treatment after distal radial fractures despite these fractures being very common. It should be noted that Pickering et al. (2022) have shown that clinical assessment of DRUJ instability is unreliable, so any published studies on DRUJ instability based purely on clinical testing pre- or post-intervention remain open to question.…”

“…Various published studies have reviewed DRUJ instability and reported ulnar-sided surgery at the same time as stabilization of the distal radial fracture to address DRUJ instability (Kasapinova and Kamiloski, 2019). As it has been shown that clinical assessment of DRUJ instability is unreliable (Pickering et al., 2022) and we know all patients with distal radial fractures have DRUJ instability (Giddins and Pickering, 2021), the published studies advocating ulnar-sided treatment have to be viewed sceptically. Currently there is no evidence that additional ulnar-sided wrist surgery at the same time as stabilization of the distal radial fracture improves patient outcomes.…”

“…Various techniques have been reported to improve stability (Adams and Berger, 2002; Filius et al., 2017). As these are all based upon clinical assessment and this has been shown to be unreliable (Pickering et al., 2022), it brings into question how effective they are. Nonetheless patients report improvement in their symptoms.…”

Structurally intact and functionally incompetent foveal triangular fibrocartilage complex injuries

“…11 Clinical detection of subtle DRUJ laxity may be difficult and not reliably detected clinically. 12 Ulnar wrist pain may be the only symptom in these patients, making the diagnosis of a foveal injury less straightforward. Furthermore, foveal tears may occur with injury to another component of the TFCC.…”