Effective Reduction Techniques for Irreducible Distal Radioulnar Joint Dislocations: A Case Report

ABSTRACT

Irreducible distal radioulnar joint (DRUJ) dislocations are often caused by bony impingement rather than soft tissue entrapment alone. Careful analysis of CT scans can identify the specific locking mechanism, allowing for successful closed reduction through a targeted “unlocking” maneuver, thereby avoiding open surgery.

1. Introduction

Dislocation of the radioulnar joint, though relatively rare, represents a significant injury. The challenges associated with diagnosis and treatment are particularly pronounced in cases of isolated dislocation. The functional integrity of the DRUJ is essential for effective forearm rotation and maintaining wrist stability. A failure to achieve prompt and effective reduction of the dislocation may lead to persistent functional impairment and chronic pain [1]. Isolated distal radioulnar joint dislocation, especially those presenting with reduction difficulties, frequently necessitates precise realignment to restore normal joint function. Closed reduction techniques not only mitigate surgery‐associated complications but may also, in certain cases, yield outcomes comparable to those achieved through open surgical procedures [2]. In this report, we describe a successful closed reduction technique developed through the management of a recent case involving isolated distal radioulnar joint dislocation. Following multiple unsuccessful reduction attempts, the dislocation was ultimately successfully reduced through a modified closed reduction technique. This technique is particularly well‐suited for challenging cases of isolated dislocations, as it minimizes patient trauma and expedites the recovery process.

2. Case History/Examination

The patient, a 34‐year‐old male physical education teacher, with his left hand as the dominant hand, sustained an injury while forcefully attempting to close a door from the side using his left hand. At the time of impact, his wrist was slightly pronated, and his palm made direct contact with the door, leading to ulnar‐sided wrist pain and subsequent loss of mobility. He presented to our emergency department 20 min post‐injury.

Physical examination revealed the patient's wrist to be in a slightly pronated position with restricted mobility. Mild swelling was observed on the ulnar side, along with a distinct depression on the dorsal ulnar aspect of the wrist (Figure 1). Wrist flexion and extension were preserved, with no abnormalities detected in the elbow joint. Neurovascular assessment of the hand was within normal limits. Radiographs revealed an overlap of the distal ulna and radius, and subsequent CT imaging confirmed a distal radioulnar joint dislocation, with the ulna embedded in the volar aspect of the radius, resembling a Hill‐Sachs lesion (Figures 2 and 3).

FIGURE 1.

The wrist is maintained in a slightly pronated position, and a pronounced depression is observed on the dorsal ulnar side, suggesting volar dislocation of the distal radioulnar joint (DRUJ).

FIGURE 2.

DR imaging reveals overlapping of the ulna and radius, indicative of a distal radioulnar joint dislocation.

FIGURE 3.

CT 3D reconstruction demonstrates volar dislocation of the distal radioulnar joint, with impaction on the volar aspect of the radius, resembling a Hill‐Sachs lesion of the shoulder joint.

3. Differential Diagnosis, Investigations, and Treatment

The patient was evaluated by an orthopedic specialist. In the examination room, we initially attempted a manual reduction, but the attempt was unsuccessful. Subsequently, we administered 5 mL of local lidocaine anesthesia to the wrist joint and the distal radioulnar joint and attempted the manual reduction again, without success. Consequently, we opted to proceed with manual reduction under intravenous anesthesia in the operating room. Initially, two physicians attempted reduction by applying traction and pronation to the wrist; however, due to the patient's robust physique, the dislocation could not be reduced. As a result, we increased the team to three physicians for the reduction procedure. One physician applied proximal traction to the forearm, a second pressed the distal ulna from the volar to the dorsal side, and a third applied distal traction to the wrist while fully pronating it (Figure 4).

FIGURE 4.

The reduction technique for distal radioulnar joint dislocation involves axial traction, vertical pressure, and extreme pronation.

4. Conclusion and Results

Immediately following the maneuver, the mechanical block disappeared. Anatomical reduction was confirmed intraoperatively using C‐arm fluoroscopy, which demonstrated restored congruency of the DRUJ. The wrist also showed full, unobstructed passive pronation and supination. Unfortunately, fluoroscopic images were not saved at that time. Post‐reduction examination indicated a positive Ballottement test (Figure 5). We immobilized the wrist in a neutral position with a plaster cast and flexed the elbow joint to 90 degrees. The patient was advised to commence rehabilitation exercises from 4 to 6 weeks post‐immobilization. At the 6‐week follow‐up, the patient reported mild discomfort during wrist movement; however, pronation, supination, and flexion‐extension functions had returned to normal, and the Ballottement test was negative (Figure 6). Although regular radiographic follow‐up was strictly recommended, the patient did not return to the outpatient clinic due to his busy work schedule and immediate functional recovery. A recent telephone interview confirmed that he remains asymptomatic with a full range of motion and has returned to his original occupation without limitations.

FIGURE 5.

After reduction of the distal radioulnar joint dislocation, a ballottement test was performed, yielding a positive result.

FIGURE 6.

At the 6‐week follow‐up after reduction, the patient exhibited normal wrist pronation and supination functions upon clinical re‐evaluation.

5. Discussion

Isolated DRUJ dislocations often present acutely or chronically, yet this injury is frequently overlooked by clinicians, particularly in emergency settings. Notably, up to 50% of cases are misdiagnosed during the initial evaluation [3]. Traditional treatment modalities predominantly consist of closed reduction and casting, which are the preferred approaches for acute dislocations. Both Sreenivasan and Haouzi have reported successful management of isolated dorsal dislocations using closed reduction and casting, with patients demonstrating favorable functional outcomes upon follow‐up [4, 5]. However, in more complex scenarios, particularly those complicated by fractures or extensive ligamentous injury, closed reduction frequently proves inadequate, thereby necessitating open surgical intervention. Ellanti documented a case of volar DRUJ dislocation, analogous to our case, where the ulna became lodged within the volar aspect of the radius, mimicking a Hill‐Sachs lesion of the shoulder, thus exacerbating the reduction difficulty. In that case, surgical intervention was ultimately required to restore both the joint's alignment and stability [6]. Typically, irreducible dislocations require open reduction. However, strict analysis of the CT images in this case revealed the specific unlocking mechanism. We decided to attempt one precise, modified manipulation based on this understanding before committing to open surgery, in order to minimize patient morbidity.

In contrast to cases requiring open surgery, our report highlights that successful closed reduction is achievable even in “locked” dislocations if the mechanism is properly understood. Three key features from our case warrant emphasis. Firstly, the clinical presentation is diagnostic: the wrist was slightly pronated with a noticeable depression on the dorsal ulnar side. Since volar dislocations may be less conspicuous on standard imaging compared to dorsal dislocations, this characteristic physical sign is pivotal for early diagnosis.

Secondly, the specific mechanics of our reduction technique were critical. Following the initial unsuccessful manual reduction, we employed a novel combination of axial traction, vertical pressure, and extreme pronation (Figure 4). We hypothesize that the ulnar head was engaged on the volar rim of the radius—similar to a Hill‐Sachs lesion—which prevented standard reduction. The management of this “Hill‐Sachs‐like” impression fracture depends on joint stability. If the joint remains stable after reduction, as in our case, conservative management with immobilization is generally sufficient. However, potential complications such as recurrent instability or post‐traumatic arthritis may occur, necessitating close long‐term monitoring. The addition of extreme pronation was the key maneuver to disengage this locking mechanism, aligning with the inherent stability of volar dislocations in a pronated position. This technique offers a viable alternative for managing similarly complex cases where conventional methods fail.

Regarding imaging modalities, while CT is superior for evaluating bony locking mechanisms, Magnetic Resonance Imaging (MRI) plays a crucial role in assessing soft tissue injuries, particularly the TFCC. As noted in a recent systematic review by Zampetakis et al. [7], MRI is recommended to evaluate persistent instability or irreducible cases where soft tissue interposition is suspected. In this case, CT provided sufficient detail for the bony blockade, so an acute MRI was not performed.

Although surgery remains the ultimate recourse for irreducible cases, it carries inherent risks. Zannou et al. have highlighted that recovery following open reduction surgery is often protracted, with some patients experiencing postoperative joint stiffness or limited range of motion [8]. Furthermore, conventional surgical techniques, such as the use of Kirschner wires for fixation, may be associated with risks of wire displacement or infection [5]. Therefore, our non‐invasive technique, which resulted in normalized pronation, supination, and flexion‐extension functions with a negative Ballottement test, demonstrates the value of exhausting conservative measures before proceeding to surgery.

This study has certain limitations. First, it is a report of a single case, and the efficacy of this specific reduction maneuver needs to be validated in a larger cohort of patients with volar DRUJ dislocations. Second, while the short‐term functional recovery was excellent, longer‐term follow‐up (e.g., > 2 years) would be beneficial to rule out late complications such as post‐traumatic arthritis or chronic instability.

In summary, the success of closed reduction for volar DRUJ dislocations hinges on early diagnosis, precise reduction mechanics, and effective immobilization. Our case demonstrates that even when the joint appears “locked” due to a Hill‐Sachs‐like mechanism, a modified maneuver involving traction, vertical pressure, and extreme pronation can achieve reduction without the need for open surgery. If joint stability is maintained post‐reduction, further surgical intervention is typically unnecessary, resulting in favorable outcomes [9]. This modified manipulation technique proved to be a viable and effective option for this specific patient with an irreducible DRUJ dislocation. It may serve as an alternative to open surgery in similar cases where the locking mechanism is identified as a bony impression on the ulnar head.

Author Contributions

Jianlan Wang: conceptualization, resources, writing – original draft. Jiang Mu: conceptualization, investigation, methodology, project administration. Wen Liu: investigation, methodology. Limin Wei: data curation, investigation, software. Yuxuan Wu: conceptualization, investigation, project administration, supervision, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

This case report was conducted in accordance with the ethical standards of the institutional research committee. Written informed consent for participation and publication of this case report was obtained from the patient. The patient was fully informed about the purpose of the study, the procedures involved, and their right to withdraw at any time without consequence.

Consent

The patient provided written informed consent for the publication of this case report, including any associated images and clinical details. The patient's identity has been kept confidential in accordance with institutional guidelines and ethical standards.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.