Treatment of DRUJ Ligament Injury
For acute DRUJ ligament injuries, initial treatment should be conservative with closed reduction and immobilization for 4-6 weeks, reserving surgery for cases that are irreducible, unstable after reduction, or fail conservative management.
Initial Assessment and Diagnosis
The diagnostic workup begins with standard radiographs in two orthogonal projections (PA and lateral views). However, DRUJ injuries are frequently misdiagnosed—the misdiagnosis rate reaches 18% 1. Clinical examination should focus on:
- Ballottement test for dorsopalmar instability
- Ulna-fovea sign for foveal disruption
- Dorsopalmar stress test for ligamentous integrity
- Press test for TFCC pathology
When radiographs are equivocal but clinical suspicion remains high, MRI without contrast is the preferred advanced imaging 2. MRI detects concomitant ligament injuries including TFCC tears, which CT cannot evaluate 2. MR arthrography demonstrates DRUJ lesions with 100% sensitivity and 80-100% specificity 3. Diagnostic arthroscopy remains the reference standard for visualizing TFCC lesions 3.
Treatment Algorithm
Conservative Management (First-Line)
82% of patients achieve full range of motion and 88% report no pain with conservative treatment 1. The approach includes:
- Closed reduction under appropriate anesthesia if needed
- Immobilization for 4-6 weeks in a position that maintains reduction (typically supination for volar dislocations, pronation for dorsal dislocations)
- Short arm cast or splint immobilization
This should be the initial approach for all reducible, stable DRUJ injuries 1, 4.
Surgical Indications
Surgery is indicated when:
- Irreducible dislocations (complex injuries with soft tissue interposition) 4
- Instability persists after closed reduction 5, 6
- Failed conservative management 1
Surgical Options
The choice depends on injury pattern and stability:
For unstable but reducible injuries:
- Percutaneous K-wire transfixation provides adequate stabilization and allows earlier mobilization (1 week vs 6-8 weeks) 5, 6, 7
- K-wire stabilization offers better range of motion compared to prolonged casting 7
- Pins typically remain for 4-6 weeks
For TFCC tears with foveal disruption:
- Arthroscopic or open TFCC repair with foveal refixation is indicated when foveal integrity is compromised, as this is the central criterion for DRUJ stability 8
- Direct repair of peripheral TFCC tears via capsular sutures 8
For complex dislocations:
- Open exploration to extract interposed tissue
- TFCC repair
- ORIF of displaced ulnar styloid fractures if present 4
Important Caveats
- Not all ulnar styloid fractures require fixation 3—only those contributing to instability
- TFCC repair may not always be necessary; one study found no significant difference in DASH scores between TFCC repair, K-wire stabilization, and casting alone 7
- Early recognition is critical—delayed diagnosis leads to chronic instability, limited mobility, and osteoarthritis 1, 4
- Dynamic stabilization techniques allow earlier mobilization (first postoperative week) without compromising TFCC healing 5
Outcomes
With appropriate treatment:
- All assessed cases achieved stable DRUJs at follow-up 1
- Functional outcomes are generally favorable for both conservative and operative approaches 1
- Negative Ballottement tests achieved in 95% of surgically treated patients by 3 months 5
The key is matching treatment intensity to injury severity: start conservatively, escalate to surgery only when instability persists or reduction cannot be maintained.