Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845

https://doi.org/10.1007/s00402-021-04199-y

ORTHOPAEDIC SURGERY

Distal radius fracture with concomitant ulnar styloid fracture: does

distal radioulnar joint stability depend on the location of the ulnar
styloid fracture?
Kyung Wook Kim1 · Che Ho Lee2 · Jae Heouk Choi2 · Joong Mo Ahn3 · Hyun Sik Gong2,4

Received: 24 March 2021 / Accepted: 28 September 2021 / Published online: 7 October 2021
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Introduction  Studies are conflicting regarding the relationship between ulnar styloid fracture (USF) location and distal
radioulnar joint (DRUJ) instability in patients with distal radius fracture (DRF) and concomitant USF. The objective of this
study was to determine the association of USF location with TFCC foveal tear and factors associated with DRUJ instability
in patients with both DRF and USF.
Materials and methods  Fifty-four patients with both DRF and USF who had wrist MRI examination before surgery were
analyzed. USF location (tip or base) and TFCC foveal insertion status (intact, partial tear, or complete tear or avulsion with
fractured fragment) were evaluated. DRUJ stability was assessed intra-operatively after fixation of the radius. Factors poten-
tially associated with DRUJ instability, such as age, gender, USF location, USF fragment gap, radioulnar distance, radial
shortening, and TFCC foveal tear, were analyzed.
Results  Among 54 patients, 37 (69%) and 17 (31%) had USF at the base and the tip, respectively. In patients with base
fractures, TFCC foveal insertion was found to be disrupted in 89% (33/37) patients (complete tear in 11 and partial tear in
22) but intact in 11% (4/37). On the contrary, in patients with tip fractures, the insertion was found to be disrupted in 88%
(15/17) patients (complete tear in 2 and partial tear in 13) but intact in 12% (2/17). After fixation of the radius, total 52%
(28/54) patients showed DRUJ instability. Especially, DRUJ instability was found in 57% (21/37) of ulna styloid process
base fracture patients and 41% (7/17) of ulna styloid process tip fracture patients. In univariate analysis, complete tear of
TFCC foveal insertion and wider USF fragment distance were associated with DRUJ instability.
Conclusions  Tears of TFCC foveal insertion are common in patients with DRF and concomitant ulnar styloid base fractures.
Based on the findings of this study, tear of TFCC foveal insertion seems to be also common in patients with DRF and con-
comitant ulnar styloid tip fractures. And also, DRUJ instability seems to be associated with a TFCC foveal tear independent
of USF location.

Keywords  Distal radius fracture · Ulnar styloid fracture · Distal radioulnar joint · Triangular fibrocartilage complex ·
Foveal tear · Magnetic resonance imaging

* Hyun Sik Gong Introduction

hsgong@snu.ac.kr
1
Distal radius fracture (DRF) is one of the most common
Department of Orthopaedic Surgery, Dankook University fractures in the upper extremity [1]. Previous studies have
Hospital, Cheonan, South Korea
2
reported that concomitant ulnar styloid fracture (USF) and
Department of Orthopaedic Surgery, Seoul National combined triangular fibrocartilage complex (TFCC) injury
University Bundang Hospital, Seongnam, South Korea
3
are present in 50–65% and 35–55% of patients with DRF,
Department of Radiology, Seoul National University respectively [2–4].
Bundang Hospital, Seongnam, South Korea
4
Because of its close association with TFCC, USF usu-
Department of Orthopedic Surgery, Seoul National ally indicates the possibility of a TFCC tear [5], which can
University Bundang Hospital, Seoul National University
College of Medicine, 300 Gumi‑dong, Bundang‑gu, cause DRUJ instability in DRF and result in residual wrist
Seongnam‑si 463‑707, Gyeonggi‑do, Korea pain, decreased range of motion, and decreased grip strength

13
Vol.:(0123456789)

840
[6–8]. Moreover, Palmer et al. [9] have reported that USF
at the tip is stable as the TFCC foveal attachment is intact,
while USF at the base is unstable as TFCC foveal detach-
ment can occur. However, studies are conflicting regarding
the relationship between USF location and DRUJ instability.
Some recent studies have reported that DRUJ instability is
not associated with the presence of USF or the location of
it in DRF patients [10–12]. Instead, other study revealed
that DRUJ instability closely correlated with the TFCC tear
rather than USF [13]. Furthermore, another study noted the
association between DRUJ instability and TFCC foveal tear
through the anatomical reconstruction of the deep fibers of
the radioulnar ligaments using tendon grafts [14].
The purpose of this study was to determine the associ-
ation of TFCC foveal tear with USF location and factors
associated with DRUJ instability in patients with DRF and
concomitant USF.
Materials and methods
Patients
This study was approved by our institutional review board.
Using an electronic medical data record program, consecu-
tive 207 patients with DRF were retrospectively reviewed
between December 2016 and September 2019, and 141 of
them had both DRF and USF. Seventy-four of the 141 had
MRI examination for further evaluation of the TFCC and the
others did not due to reasons, such as difficulty of timing the
examination before surgery, claustrophobia, or limitation of
insurance coverage. Those who have a history of surgery
or have inflammatory disease on their wrist were excluded.
Finally, 54 patients with DRF and concomitant USF who
had MRI examination were analyzed. The average age of
these patients was 56 years (range 25–80 years). There were
14 men and 40 women.
Radiographic evaluation of USF and TFCC
USFs were classified based on fracture line morphology.
In this study, the base of ulnar styloid process was defined
as the conjoined line perpendicular to the ulnar axis and
through the ulnar styloid fovea, and the reference line was
defined as the halfway between the base and the distal tip of
the ulnar styloid process. According to the location of the
fracture line relative to the reference line, USF was divided
into the ulnar styloid base or tip fractures. Tip fracture was
defined as a fracture of the distal parts of ulnar styloid pro-
cess (Fig. 1). USF fragment displacement, radial shortening,
and coronal shift were also assessed (Fig. 2).
All MR examinations were performed on a 3.0 T unit
(Achieva & Ingenia; Philips Healthcare, Netherlands)
13
Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845
Fig. 1  Using plain radiograph, the base and tip fracture of the ulnar
styloid process was defined. The base fracture was defined as the
below of the reference line which is defined as the halfway between
the base and the distal tip of the ulnar styloid process. The tip fracture
was defined as the above of the reference line (dotted line: reference
line)
according to the standard MR protocol for wrist imaging
in our hospital. Musculoskeletal section radiologists’ MRI
readings were reviewed for TFCC lesions. Diagnostic cri-
teria for TFCC tears were established in discussion with
radiologists. A complete foveal TFCC tear included loss of
continuity of the foveal fiber or complete bony avulsion with
the foveal insertion attached to the fracture fragment. Par-
tial TFCC tear was diagnosed when abnormal intermediate
signal intensity was detected on T1 SPIR images with high
signal intensity on T2 FFE reaching one of articular surfaces
of TFCC. Two orthopedic surgeons who were blinded to
operative findings classified tears according to the diagnostic
criteria.
Assessment of DRUJ stability
During surgery, the radius fracture was exposed with a
palmar approach and fixed with locking plate and screws.
After fixation, one surgeon performed stress test to check
for residual DRUJ instability and end-point sensation. The
radius was grasped with the forearm in a neutral position
by the surgeon. The distal ulna, which was fixed between
the surgeon's thumb and index finger, was moved in dor-
sal and palmar directions with respect to the radius. The
test was positive if the ulna was conspicuously displaced
relative to the contralateral side [15]. When DRUJ insta-
bility was found after fixation of distal radius, an ulnar
styloid process fixation, TFCC repair or immobilization
in a longarm splint for 4–6 weeks were performed. Basilar
styloid fragments were fixed with tension band wiring and
Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845 841
Fig. 2  a Measurement of ulnar styloid fracture fragment displace-
ment. Lines are drawn each along the long axis of the ulnar styloid
proximal and distal fracture fragment. Displacement degree is meas-
ured as the connecting line between the proximal end of the distal
fragment and the distal end of the proximal fragment; b Measurement
TFCC tears were repaired with two PDS sutures through
a bone tunnel. DRUJ stability was restored after repairing
the USF or TFCC (Fig. 3).
Statistical analysis
The integrity of TFCC foveal insertion and clinical fea-
tures according to the USF type (tip or base) were com-
pared. Categorical variables were compared with Chi-
square test or Fisher's exact test. Continuous variables
were compared with Wilcoxon signed rank test. Poten-
tially associated factors with DRUJ instability, such as
USF location, TFCC foveal tears, USF fragment gap,
radial shortening, and radioulnar distance were analyzed.
Univariate and multivariate analyses were performed using
logistic regression to find factors associated DRUJ insta-
bility. Factors with p < 0.05 in univariate analyses were
entered into multivariate analysis. Statistical power was
calculated using statistical software R (version 4.0.1).
Results
TFCC foveal tear according to the type of USF
Among 54 patients, 37 (69%) had an ulnar styloid base
fracture and 17 (31%) had a tip fracture. In patients with
a base fracture, TFCC foveal insertion was found to be
disrupted in 33 (89%) patients (complete tear in 11, partial
tear in 22) but intact in four (11%). In patients with tip
fracture, TFCC foveal insertion was found to be disrupted
in 15 (88%) (complete tear in 2 and partial tear in 13) but
intact in two (12%) (Table 1).
of radial shortening. Distance is measured from the volar or dorsal
margin of the sigmoid notch of distal radius to the base line of the
ulnar head. The base line is determined as the adjusted location com-
pared to the contralateral plain radiograph; c Measurement of radioul-
nar gap distance. The average of the shortest volar and dorsal distance
Factors associated with DRUJ instability
Out of 54 patients, 28 (52%) showed DRUJ instability
after radius fixation. Compared to those with stable DRUJ,
patients with unstable DRUJ were significantly more likely
to have a TFCC foveal tear, and a wider USF fragment dis-
tance (Table 1). In addition, patients with unstable DRUJ
tended to be younger, an USF at the base, wider radioulnar
distance and wider radial shortening than patients with sta-
ble DRUJ. Especially, DRUJ instability was found in 57%
(21/37) of ulna styloid process base fracture and 41% (7/17)
of ulna styloid process tip fracture. However, such differ-
ences did not reach statistical significance.
In univariate analysis, complete tear of TFCC foveal
insertion and wider USF fragment distance were associated
with DRUJ instability. Factors with p < 0.05 in univariate
analyses were entered into multivariate analysis. Results of
multivariate analysis indicated that DRUJ instability was
only associated with complete tear of TFCC foveal inser-
tion (odds ratio: 14.7; 95% confidence interval 2.4–91.0;
p = 0.016) (Table 2). Intraclass correlation coefficient (ICC)
for TFCC tear was 0.78 for intra-observer reliability and
0.62 for inter-observer reliability.
Discussion
Studies are conflicting regarding the relationship between
USF location and DRUJ instability in patients presenting
both DRF and concomitant USF. Nakamura et al. [16] noted
that the USF location is closely correlated with DRUJ insta-
bility, but they focused mostly on the location of USF rather
than the effect of TFCC tear. On the contrary, Kim et al.
[10] and Mulders et al. [11] mentioned that fracture level
of USF does not affect the stability of DRUJ, but in those
13

842
Fig. 3  a, b Pre-operative plain radiographs of a 33-year-old man
with distal radius fracture and concomitant ulna styloid tip fracture.
c Pre-operative MRI showed a TFCC foveal tear (asterisk). d, e Intra-
operative DRUJ instability was detected and stabilization of DRF
by palmar locking plate and open TFCC foveal repair were done. f,
g Pre-operative plain radiographs of a 25-year-old woman with dis-
studies, the location of USF was arbitrarily determined.
Hence, compared to most of previous studies [10–12, 16,
17], this study has significant advantages in that it identified
the relationship between USF as well as TFCC foveal tear
and DRUJ instability through imaging modality. Results of
this study demonstrate that although tear of the TFCC foveal
insertion is more common and severe in patients with ulnar
styloid base fracture, the tear is also common in patients
with an ulnar styloid tip fracture. Moreover, it demonstrates
that DRUJ instability is associated with TFCC foveal tear
independent of USF location.
In the current study, TFCC foveal insertion was disrupted
in 89% (33/37) of patients with ulnar styloid base fractures.
Such result is expected in accordance with the anatomy of
TFCC foveal insertion [18]. However, TFCC foveal inser-
tion was also disrupted in 88% (15/17) of patients with ulnar
styloid tip fractures and 41% (7/17) of them had DRUJ
instability (Table 1). It is considered that the injury force
13
Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845
tal radius fracture and concomitant ulna styloid base fracture. h Pre-
operative MRI showed that foveal fiber of the TFCC was attached to
the styloid fracture fragment. i, j Intra-operative DRUJ instability was
detected. Stabilization of DRF by palmar locking plate and USF by
tension band wiring was done, and stability of the DRUJ was restored
can transmit through the broad TFCC foveal insertion and
then through the ulnar styloid tip or can transmit from the
ulnar styloid tip to the TFCC foveal insertion. In addition, it
was found that DRUJ instability was associated with tear of
TFCC foveal insertion independent of USF location. There-
fore, the presence of an ulnar styloid tip fracture should not
be regarded as a stable DRUJ in patients with DRF.
Omokawa et al. [19] have reported that more than 5 mm
widening of DRUJ gap distance is the most important pre-
dictor for DRUJ instability accompanying an unstable distal
radius fracture. In addition, Kwon et al. [20] have reported
that initial distal radial shortening for more than 6.0 mm is
one of risk factors of DRUJ instability. In this study, patients
with unstable DRUJ tended to have wider radioulnar dis-
tance and wider radial shortening, although such difference
was not statistically significant. It is assumed that even
though the interosseous membrane which is another soft tis-
sue stabilizer of the DRUJ can be injured or thin in patients
Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845 843

Table 1  Patient characteristics Overall Stable DRUJ Unstable DRUJ P value

and DRUJ stability
N 54 26 28
Ageª 58 [52–63] 60 [54–65] 58 [46–61] 0.068
Gender
 Men 14 5 9 0.279
 Women 40 21 19
Type of ulna styloid process fracture
 Tip 17 10 7 0.287
 Base 37 16 21
TFCC foveal tear
 No tear 6 6 0  < 0.001
 Partial tear 35 19 16
 Complete tear 13 1 12
Ulnar styloid process fracture fragment 2 [2–3] 2 [1–3] 2 [2–3] 0.048
distance (mm)ª
Radial shortening (mm)ª 4 [2–6] 4 [2–6] 4 [3–6] 0.465
Radioulnar distance (mm)ª 3 [3–5] 3 [2–4] 3 [3–5] 0.082

DRUJ distal radioulnar joint, TFCC triangular fibrocartilage complex;

ªmedian [IQR]

Table 2  Univariate and multivariate regression analyses for factors associated with DRUJ instability
Variable (event) Univariate analysis Multivariate analysis
OR 95% CI P value OR 95% CI P value

Age (year) 1.0 0.6–1.4 0.072

Gender (women) 0.5 0.2–1.4 0.283
Type of ulna styloid process fracture (base) 1.9 0.7–5.0 0.290
Presence of TFCC (complete foveal tear) 18.7 3.1–112.4 0.007 14.7 2.4–91.0 0.016
Ulnar styloid process fracture fragment distance (mm) 1.9 1.1–3.2 0.043 1.4 0.8–2.6 0.335
Radial shortening (mm) 1.1 0.9–1.3 0.387
Radioulnar distance (mm) 1.4 1.0–2.0 0.129

Boldface letters indicate significant value

OR odds ratio, CI confidence interval

with DRF and concomitant USF, it may prevent excessive
widening of radioulnar distance or radial shortening.
This study has several limitations. DRUJ instability
assessment was performed only by physical examination,
which could be subjective. However, clinical examination
has been used in previous studies [15]. It showed better
correlation than imaging method and high interobserver
reliability in the assessment of DRUJ instability [20].
Besides, other soft tissue stabilizers for DRUJ were not
considered. Recent cadaveric and biomechanical studies
have reported that the distal oblique bundle or distal inter-
osseous membrane can act as a secondary stabilizer of
the DRUJ [21–23]. Although there was an effort to assess
its thickness in this study, it was not reliably identifiable
due to wave and destructive changes after fracture. Futher-
more, in this study, Among DRF and concomitant USF
patients, only who had MRI were included. Therefore, the
selection bias caused by excluding patients without MRI
could affect the incidence of the location of USF or the
degree of the TFCC tear in the patient group. Moreover,
as only 54 (26%) of 207 patients had been finally enrolled,
it could significantly affect the validity of this study. And
more, the intra-operative stress test was conducted only in
neutral position. Performing stress test in neutral position
as well as in full pronation or supination position could
have been more accurate in identifying DRUJ instabil-
ity. Finally, because of the lack of a unified perspective,
the reference line of ulnar styloid fracture was arbitrarily
determined. Hence, if other classification method had been
used, there was a possibility that the type of fracture could
have been changed.

13

844
Conclusion
Tears of TFCC foveal insertion are common in patients with
DRF and concomitant ulnar styloid base fractures. Based
on the findings of this study, tear of TFCC foveal inser-
tion seems to be also common in patients with DRF and
concomitant ulnar styloid tip fractures. It can be assumed
that DRUJ instability due to a TFCC foveal tear is independ-
ent of the USF location. Therefore, careful examination of
DRUJ stability is recommended in patients with DRF and
concomitant USF regardless of its location.
Acknowledgements  We received statistical support from professor
Seung Hyun Won of Medical Research Collaborating Center (MRCC)
at Seoul National University Bundang Hospital. This study was sup-
ported by the National Research Foundation of Korea (NRF) grant
funded by the Korea government (Ministry of Science and ICT).
Author contributions  All authors contributed to the study conception
and design. Material preparation, data collection and analysis were
performed by Kyung Wook Kim, Che Ho Lee, Jae Heouk Choi, Joong
Mo Ahn and Hyun Sik Gong. The first draft of the manuscript was
written by Kyung Wook Kim and Hyun Sik Gong. All authors read
and approved the final manuscript.
Funding  This study was supported by the National Research Founda-
tion of Korea (NRF) grant funded by the Korea government (Ministry
of Science and ICT) (Grant No. 2020R1A2C1005778).
Availability of data and materials  The data sets used and analysed dur-
ing the current study are available from the corresponding author on
reasonable request.
Code availability  Not applicable.
Declarations  32(3):262–270. https://​doi.​org/​10.​1007/​s00064-​019-​00638-7
Conflict of interest  On behalf of all authors, the corresponding author
states that there is no conflict of interest.
Ethical approval  This study obtained institutional review board
approval from Seoul National University Bundang Hospital (SNUBH
IRB-B-2009/637-104).
Consent to participate  Not applicable.
Consent to publish  Not applicable.
References
1. Chung KC, Spilson SV (2001) The frequency and epidemiology
of hand and forearm fractures in the United States. J Hand Surg
Am 26(5):908–915. https://​doi.​org/​10.​1053/​jhsu.​2001.​26322
2. Fujitani R, Omokawa S, Akahane M, Iida A, Ono H, Tanaka Y
(2011) Predictors of distal radioulnar joint instability in distal
radius fractures. J Hand Surg Am 36(12):1919–1925. https://​doi.​
org/​10.​1016/j.​jhsa.​2011.​09.​004
3. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspen-
berg P (2000) Distal radioulnar instability is an independent
13
Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845
worsening factor in distal radial fractures. Clin Orthop Relat
Res 376(376):229–235
4. Richards RS, Bennett JD, Roth JH, Milne K Jr (1997) Arthro-
scopic diagnosis of intra-articular soft tissue injuries associated
with distal radial fractures. J Hand Surg Am 22(5):772–776
5. Lindau T, Arner M, Hagberg L (1997) Intraarticular lesions
in distal fractures of the radius in young adults. A descriptive
arthroscopic study in 50 patients. J Hand Surg Br 22(5):638–
643. https://​doi.​org/​10.​1016/​s0266-​7681(97)​80364-6
6. Geissler WB, Fernandez DL, Lamey DM (1996) Distal radioul-
nar joint injuries associated with fractures of the distal radius.
Clin Orthop Relat Res 327(327):135–146. https://​doi.​org/​10.​
1097/​00003​086-​19960​6000-​00018
7. May MM, Lawton JN, Blazar PE (2002) Ulnar styloid fractures
associated with distal radius fractures: incidence and implica-
tions for distal radioulnar joint instability. J Hand Surg Am
27(6):965–971. https://​doi.​org/​10.​1053/​jhsu.​2002.​36525
8. Palmer AK, Werner FW (1981) The triangular fibrocartilage
complex of the wrist—anatomy and function. J Hand Surg Am
6(2):153–162. https://​doi.​org/​10.​1016/​s0363-​5023(81)​80170-0
9. Palmer AK (1990) Triangular fibrocartilage disorders: injury
patterns and treatment. Arthroscopy 6(2):125–132
10. Kim JK, Koh Y-D, Do N-H (2010) Should an ulnar styloid frac-
ture be fixed following volar plate fixation of a distal radial
fracture? J Bone Jt Surg Am 92(1):1–6
11. Mulders MAM, Snethlage LJF, Keizer RJOM, Goslings JC,
Schep NWL (2018) Functional outcomes of distal radius frac-
tures with and without ulnar styloid fractures: a meta-analysis.
J Hand Surg Eur 43(2):150–157
12. Quadlbauer S, Pezzei C, Jurkowitsch J et al (2020) Functional
and radiological outcome of distal radius fractures stabilized by
volar-locking plate with a minimum follow-up of 1 year. Arch
Orthop Trauma Surg 140(6):843–852
13. Lindau T, Adlercreutz C, Aspenberg P (2000) Peripheral tears
of the triangular fibrocartilage complex cause distal radioulnar
joint instability after distal radial fractures. J Hand Surg Am
25(3):464–468
14. Spies CK, Langer MF, Müller LP, Unglaub F (2020) Reconstruc-
tion of the deep fibers of the distal radioulnar ligaments facili-
tating a tendon graft-Adams’ procedure. Oper Orthop Traumatol
15. Kim JP, Park MJ (2008) Assessment of distal radioulnar joint
instability after distal radius fracture: comparison of computed
tomography and clinical examination results. J Hand Surg Am
33(9):1486–1492. https://​doi.​org/​10.​1016/j.​jhsa.​2008.​05.​017
16. Nakamura T, Moy OJ, Peimer CA (2021) Relationship between
fracture of the Ulnar styloid process and DRUJ instability: a
biomechanical study. J Wrist Surg 10(02):111–115
17. Quadlbauer S, Pezzei C, Jurkowitsch J et al (2018) Early com-
plications and radiological outcome after distal radius fractures
stabilized by volar angular stable locking plate. Arch Orthop
Trauma Surg 138(12):1773–1782
18. Kirchberger MC, Unglaub F, Muhldorfer-Fodor M et al (2015)
Update TFCC: histology and pathology, classification, examina-
tion and diagnostics. Arch Orthop Trauma Surg 135(3):427–437
19. Omokawa S, Iida A, Fujitani R, Onishi T, Tanaka Y (2014)
Radiographic predictors of DRUJ instability with distal radius
fractures. J Wrist Surg 3(1):2–6. https://​doi.​org/​10.​1055/s-​0034-​
13658​25
20. Kwon BC, Seo BK, Im HJ, Baek GH (2012) Clinical and radio-
graphic factors associated with distal radioulnar joint instability in
distal radius fractures. Clin Orthop Relat Res 470(11):3171–3179.
https://​doi.​org/​10.​1007/​s11999-​012-​2406-4
21. Arimitsu S, Moritomo H, Kitamura T, Berglund LJ, Zhao KD,
An K-N, Rizzo M (2011) The stabilizing effect of the distal
interosseous membrane on the distal radioulnar joint in an ulnar
Archives of Orthopaedic and Trauma Surgery (2023) 143:839–845 845

shortening procedure: a biomechanical study. J Bone Jt Surg Am Publisher's Note Springer Nature remains neutral with regard to
93(21):2022–2030 jurisdictional claims in published maps and institutional affiliations.
22. Kim YH, Gong HS, Park JW, Yang HK, Kim K, Baek GH (2017)
Magnetic resonance imaging evaluation of the distal oblique bun-
dle in the distal interosseous membrane of the forearm. BMC
Musculoskelet Disord 18(1):1–5
2 3. Watanabe H, Berger RA, Berglund LJ, Zobitz ME, An K-N (2005)
Contribution of the interosseous membrane to distal radioulnar
joint constraint. J Hand Surg Am 30(6):1164–1171

13