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1

Distal Radioulnar Joint: Normal Anatomy, Imaging

of Common Disorders, and Injury Classification
Dyan V. Flores, MD • Darwin Fernández Umpire, MD • Kawan S. Rakhra, MD • Zaid Jibri, MD • Gonzalo A. Serrano Belmar, MD
Author affiliations, funding, and conflicts of interest are listed at the end of this article.

The distal radioulnar joint (DRUJ) is the distal articulation between the radius and ulna,
acting as a major weight-bearing joint at the wrist and distributing forces across the fore-
arm bones. The articulating surfaces are the radial sigmoid notch and ulnar head, while the
ulnar fovea serves as a critical attachment site for multiple capsuloligamentous structures.
The DRUJ is an inherently unstable joint, relying heavily on intrinsic and extrinsic soft-tissue
stabilizers. The triangular fibrocartilage complex (TFCC) is the chief stabilizer, composed of the
central disk, distal radioulnar ligaments, ulnocarpal ligaments, extensor carpi ulnaris tendon sub-
sheath, and ulnomeniscal homologue. TFCC lesions are traditionally classified into traumatic or
degenerative on the basis of the Palmer classification. The novel Atzei classification is promising,
correlating clinical, radiologic, and arthroscopic findings while providing a therapeutic algorithm.
The interosseous membrane and pronator quadratus are extrinsic stabilizers that offer a minor
contribution to the joint’s stability in conjunction with the joints of the wrist and elbow. Traumatic
and overuse or degenerative disorders are the most common causes of DRUJ dysfunction, al-
though inflammatory and developmental abnormalities also occur. Radiography and CT are used
to evaluate the integrity of the osseous constituents and joint alignment. US is a useful screening
tool for synovitis in the setting of TFCC tears and offers dynamic capabilities for detecting tendon
instability. MRI allows simultaneous osseous and soft-tissue evaluation and is not operator depen-
dent. Arthrographic CT or MRI provides a more detailed assessment of the TFCC, which aids in
treatment and surgical decision making. The authors review the pertinent anatomy and imaging
considerations and illustrate common disorders affecting the DRUJ.
©
RSNA, 2022 • radiographics.rsna.org

Introduction
Imaging of the distal radioulnar joint (DRUJ) represents a unique challenge for radiologists
and hand surgeons alike. The complex anatomy of the region—combined with the small
size of structures, subtle imaging findings, and variable terminology—compounds the
problem. Disorders of one or a combination of stabilizers lead to a multitude of imaging
findings. In this article, we review the relevant anatomy, pathologic conditions, classifi-
cation, and imaging of common disorders, emphasizing features that influence clinical
and preoperative decision making to aid in radiologic interpretation and reporting.

MUSCULOSKELETAL IMAGING
January 2023 Flores et al 2

RadioGraphics 2023; 43(1):e220109

Supplemental https://doi.org/10.1148/rg.220109
Material Content Code: MK
Abbreviations: DRUJ = distal radioulnar joint,
DRUL = distal radioulnar ligament, ECU = exten-
sor carpi ulnaris, TFC = triangular fibrocartilage,
TFCC = TFC complex

TEACHING POINTS
„ The diameter of the sigmoid notch is 1.5 to 1.6 times larger than that of the
ulnar seat, allowing dorsal-volar translation in addition to pronation-supination,
leading to a highly variable osseous contact area in different wrist positions,
thereby imparting intrinsic instability to the joint.
„ In contrast to the central disk, the DRULs are the chief stabilizers of the DRUJ,
acting in concert to stabilize the joint, depending on the wrist position. They
are peripheral extensions of the disk, commonly referred to as proximal/fove-
al and distal/styloid “laminae,” although surgical and histologic studies have
recognized their more complex organization. Each ligament is composed of
superficial and deep layers that subdivide into dorsal and volar fibers halfway
between the radius and ulna, producing a four-armed arrangement.
„ The deep layer along with the ulnocarpal ligaments and ECU subsheath con-
verge onto the fovea, making this roughened concave bony surface a critical
stabilizer of the DRUJ.
„ The ulnar side of the TFCC can be divided into the proximal ligament (the
DRULs, specifically the foveal fibers) and a distal hammock structure that sus-
pends the carpus. As with an iceberg, only the distal hammock or shock-ab-
sorbing part (ie, the emerging tip) is seen during radiocarpal arthroscopy. This
is significantly smaller and less functionally important than the proximal liga- Figure 1. Osseous constituents of the DRUJ. Three-dimen-
ment or the main stabilizers at the fovea (ie, the “submerged” part), which are
sional reconstructed CT image of the wrist shows the bony
components of the DRUJ: the radial sigmoid notch (red); the
visualized only at DRUJ arthroscopy.
ulnar head, consisting of the hub (blue) and seat (yellow);
„ Congenital Madelung deformity is distinguished from Madelung-type deformi- and the rest of the distal ulna, including the fovea (pink) and
ties by the presence of an anomalous radiolunate ligament (Vickers ligament) styloid (green). The radial sigmoid notch faces the hub of the
and a radial notch at the ligament attachment. The TFCC may become thick- ulna, and the proximal surface of the triangular fibrocartilage
ened and obliquely oriented secondary to the radial deformity. complex (TFCC) faces the ulnar seat. The fovea and base of
the ulnar styloid process are important attachments of the
peripheral TFCC.

Anatomy and Biomechanics

The DRUJ is a pivot joint between the distal radius and ulna
that allows forearm rotation in conjunction with grasping
function of the hand. Its osseous components are the radial
sigmoid notch; the ulnar head, consisting of the hub and seat;
the fovea; and the styloid (Fig 1) (1). The morphology of the
articulating surfaces affects the joint’s stability. The diame-
ter of the sigmoid notch is 1.5 to 1.6 times larger than that of
the ulnar seat, allowing dorsal-volar translation in addition
to pronation-supination, leading to a highly variable osseous
contact area in different wrist positions, thereby imparting in-
trinsic instability to the joint (1–3).
The shape of the sigmoid notch varies among individuals.
Four types are recognized on axial sections: flat face, ski slope,
C type, and S type (4). A flat or shallow face predisposes to
DRUJ dislocation and is associated with suboptimal outcome
after soft-tissue reconstruction for DRUJ instability (4). In the
coronal plane, the angle of the sigmoid notch can also be vari-
able, appearing vertical (neutral), ulnarly tilted (negative), or
radially tilted (positive) (5). The joint’s principal movements
are pronation and supination, integrated with motion at the
radiocapitellar and proximal radioulnar joints (6).
Owing to its intrinsic instability, the joint relies heavily
on soft-tissue stabilizers, of which there are two types. In-
trinsic stabilizers are intracapsular structures of greater
biomechanical significance and include the triangular fibro-
cartilage complex (TFCC) and its components. Extrinsic sta-
bilizers offer a minor contribution to the rotational stability
of the DRUJ and consist of the pronator quadratus muscle
and interosseous membrane.
Intrinsic Stabilizers
Triangular Fibrocartilage Complex.—The TFCC is the primary
stabilizer of the DRUJ, acting by restricting volar translation
of the radius on the ulnar head. It is composed of the central
articular disk or triangular fibrocartilage (TFC), distal radio­
ulnar ligaments (DRULs), ulnocarpal ligaments, extensor
carpi ulnaris (ECU) tendon subsheath, and ulnomeniscal ho-
mologue or meniscoid (Fig 2). Although the border between
the central and peripheral TFCC has not been formally de-
fined (7), the TFC is widely accepted as the central portion or
articular disk, whereas the term TFCC refers to the disk along
with the rest of the peripheral capsuloligamentous complex.
Central Articular Disk.—The central disk is a flat structure
that attaches squarely onto the ulnar-most margin of the dis-
tal articular surface of the radius. It is composed of densely
packed collagen, with sparse vascularity at its ulnar border and

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January 2023 Flores et al 3

Figure 2. Drawing shows the components of the TFCC: the central disk
or TFC (*), dorsal and volar DRULs, ulnolunate (UL) and ulnotriquetral (UT)
ligaments, ECU subsheath (ECU-ss), and ulnomeniscal homologue (UMH).

Figure 3. Normal appearance of the peripheral TFCC. Co­

ronal gradient-echo MR image shows the proximal or foveal
completely avascular central and radial areas (8). Its primary (arrowhead) and distal or styloid (straight arrow) laminae of
function is to dissipate forces across the ulnar side of the wrist, the peripheral TFCC. The disk and DRULs have low signal
thereby acting as a shock absorber, but it does not contribute intensity with all sequences and can be differentiated on
much to DRUJ stability (3,6,9). coronal images on the basis of their radial attachment. While
the DRULS attach directly to bone, the disk is separated from
bone by the intervening intermediate signal intensity of hya-
Distal Radioulnar Ligaments.—In contrast to the central disk, line cartilage (curved arrow). The proximal and distal laminae
the DRULs are the chief stabilizers of the DRUJ, acting in normally demonstrate internal increased signal intensity with a
concert to stabilize the joint, depending on the wrist position striated pattern, which should not be confused with a tear.
(8). They are peripheral extensions of the disk, commonly re-
ferred to as proximal/foveal and distal/styloid “laminae,” al-
though surgical and histologic studies have recognized their
more complex organization (10) (Fig 3). Each ligament is
composed of superficial and deep layers that subdivide into
dorsal and volar fibers halfway between the radius and ulna,
producing a four-armed arrangement (11) (Fig 4).
The superficial layer arises from the ulnar border of the
radius and courses along the volar part of the lunate fossa
before inserting onto the ulnar styloid (12). The deep layer or
ligamentum subcruentum originates from the same site and
inserts into the richly vascularized fovea (12). Historically
described as a vascular fissure between the styloid and foveal
fibers of the TFCC, the term ligamentum subcruentum has
been used more recently to represent the deep or foveal layer
of the DRULs (6,13).
The superficial layers form an acute angle as they converge
from the radius onto the ulnar styloid, while the deep layers
form an obtuse angle as they insert into the fovea (6). This ar-
rangement gives the deep layer a greater biomechanical effect
on forearm rotation, which some authors have compared to a
buckboard, thereby preventing dorsal migration of the radius
onto the ulnar head (6,12). The four arms act in synchrony to Figure 4. Drawing shows the organization of the DRULs. The four arms of
stabilize the DRUJ in various forearm positions (12) (Fig 5). the DRULs—the superficial dorsal (S-D), superficial volar (S-V), deep dorsal
(D-D), and deep volar (D-V)—interdigitate at their distal insertions to form
The deep layer along with the ulnocarpal ligaments and ECU conjoined ligaments, giving rise to the macroscopic appearance of two
subsheath converge onto the fovea, making this roughened laminae.
concave bony surface a critical stabilizer of the DRUJ (14).

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Ulnocarpal Ligaments.—The ulnocarpal ligamentous complex

is anatomically divided into the ulnocapitate, ulno­lunate, and
ulnotriquetral ligaments; macroscopically, these ligaments
are confluent and indistinguishable from each other in the
absence of joint fluid or arthrographic contrast material (15).
The volar fibers of the ulnolunate and ulnotriquetral liga-
ments contribute to DRUJ stability and arise together from
the volar radioulnar ligament at the fovea and base of the ul-
nar styloid, extending distally to insert at the volar lunate and
triquetrum, respectively (12,15,16) (Fig 6). The ulnolunate
and ulnotriquetral ligaments form part of the deep extrinsic
ligaments of the wrist, thereby contributing not only to DRUJ
stability but also to ulnocarpal stability (9).

ECU Tendon and Subsheath.—The ECU is a fusiform muscle

in the posterior aspect of the forearm that spans the lateral
epicondyle of the distal humerus and fifth metacarpal base
(17). In the wrist, the ECU tendon runs through an osseous
tunnel formed by the distal ulna and a fibrous connective tis-
sue referred to as the ECU subsheath; the entire fibro-osseous
tunnel lies deep to the extensor retinaculum (Fig 7). The ten-
don is constrained by the subsheath but not by the retinac-
ulum, allowing smooth rotation of the radius over the ulna
while restraining the ECU tendon within the ulnar groove
(8,18). As part of the TFCC, the floor of the ECU subsheath
blends with the dorsal DRUL; on its own, it augments the dor-
sal capsule to provide minor stability to the DRUJ (9).
Ulnomeniscal Homologue.—The ulnomeniscal homologue or
meniscoid is a multifascicular structure that buffers the TFCC
from the triquetrum. It is made of synovial tissue, which is
easily elongated and folded, acting as a shock absorber rather
than as a direct stabilizer (8,19). It consists of four compo-
nents: styloid, collateral, distal, and radioulnar; the main com-
ponent is the styloid, whereas the other three components are
its extensions (19).
At MRI, it may be challenging to view all components in
a single plane, as visibility may be affected by the imaging
parameters and the position of the wrist at the time of the
examination (19). Along with the ECU subsheath and ulnar
collateral ligament, the homologue reinforces the ulnar-sided
joint capsule and is therefore considered the “functional ulnar
collateral ligament” of the wrist (20,21) (Fig 8). Homologue
tears are usually associated with tears elsewhere in the TFCC,
although the clinical significance remains controversial (13).
Extrinsic Stabilizers
Pronator Quadratus.—The pronator quadratus muscle is a
fleshy trapezoidal mass that spans the distal volar surfaces
of the radius and ulna. It serves as the main pronator of the
forearm and consists of superficial and deep heads (Fig E1). It
is the deep head that stabilizes the DRUJ in concert with the
TFCC, ECU, and interosseous membrane (22).
Distally and dorsally, the deep head extends deep to the in-
terosseous membrane, filling the space or “axilla” formed by
the DRUJ (23). It is intimate with the ulnar and volar aspect of
the DRUJ capsule, tensing the capsule to prevent the redun-
Figure 5. Biomechanics of the DRULs in various forearm positions. The
superficial dorsal (white arrow) and deep volar (white arrowhead) fibers
are taut on pronation, whereas the superficial volar (black arrow) and deep
dorsal (black arrowhead) fibers tighten on supination.
dant pouch from being interposed within the joint on rotation
of the forearm (23,24). It also restricts dorsal translation of the
radius relative to the ulna, preventing radioulnar locking or
convergence (23,24).
Interosseous Membrane.—The interosseous membrane is
a broad and sheetlike connective tissue that runs obliquely
from the radius proximally, extending distally and oblique
to insert at the distal 25% of the ulna (25). It maintains lon-
gitudinal stability by transmitting load between the forearm
bones (25). Contrary to the TFCC, which stabilizes the DRUJ
by preventing volar translation of the radius, the interosseous
membrane prevents proximal migration and dorsal transla-
tion of the radius (25,26). It consists of membranous portions
and areas of bandlike thickening; accessory bands have also
been reported (25,26) (Fig 9).
Within the distal interosseous membrane is a thickening
termed the distal oblique bundle (DOB). Each component
contributes to forearm stability, but it is the DOB that acts
as a secondary stabilizer of the DRUJ (27). It originates
from the distal ulna a few centimeters proximal to the ul-
nar head before running distally to insert on the dorsal in-
ferior rim of the sigmoid notch of the radius (27). This bun-
dle is of greater biomechanical importance after a TFCC
injury, resection of the ulnar head, or an ulna-shortening
osteotomy (26,27).

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Figure 6. Normal appearance of the ulnolunate

and ulnotriquetral ligaments. Sagittal fat-sup-
pressed T2-weighted images show the normal
ulnolunate (arrow in A) and ulnotriquetral (arrow-
head in B) ligaments.

Figure 7. Normal ECU subsheath and retinaculum. Drawing (A) and axial proton-density–weighted MR image (B) of the sixth extensor compart-
ment show the ECU tendon enclosed by the subsheath (arrowheads), which lies deep to the retinaculum (arrows). The subsheath is anchored to
the distal ulna, while the retinaculum—which covers the other five extensor compartments—has no direct attachment to the ulna and functions to
prevent bowstringing of the tendon during muscle contraction.

Imaging Techniques
Radiography is the preferred initial imaging tool for assessing
the DRUJ. The posteroanterior projection enables evaluation
of ulnar variance and degenerative changes of the DRUJ or
intercarpal joints. Lateral radiography performed with ap-
propriate joint and patient positioning is useful in detecting
DRUJ or carpal malalignment.
On a true lateral view, the volar cortex of the pisiform
should lie between the volar cortices of the capitate and the
distal pole of the scaphoid, ideally within the central third
of this interval (28). The ulna normally projects 2 mm dorsal
to the radius; a distance of 6 mm or more between the distal
radius and ulna is diagnostic of instability (29). On the an-
teroposterior projection, there is an increased gap between
the distal radius and ulna with dorsal dislocation and super-
imposition of the radius and ulna with volar dislocation (30)
(Fig 10). A clenched-fist posteroanterior view in forearm pro-
nation to assess the DRUJ gap and a weighted lateral stress
view in pronation have shown promise for detecting DRUJ
instability (31).
US is a useful screening tool for soft-tissue changes second-
ary to DRUJ instability, including ECU tendinosis, tears, or te-
nosynovitis. Synovitis in the ulnocarpal recess of the wrist is
detected with color Doppler imaging, but it is nonspecific and
can be present in TFCC tears and inflammatory or infectious
disorders (Fig 11). US enables comparative assessment of the
opposite limb and dynamic evaluation between pronation and
supination but is unreliable in detailed evaluation of the TFCC.
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January 2023 Flores et al 6

Figure 8. Normal appearance of the ulnomeniscal homo-

logue. Coronal proton-density–weighted MR image of the
wrist shows the ulnomeniscal homologue as a pyramidal struc-
ture composed of redundant fibrous tissue (*) and vascular
tissue (straight arrow) directly above fluid within the prestyloid
recess (arrowheads). Some fibers of the ECU tendon are also
partially visualized (curved arrows).

CT allows evaluation of bony anatomy at high resolution

without use of contrast material or extended imaging times.
Simultaneous CT of both wrists is the preferred imaging tech-
nique for detecting DRUJ instability, as it provides functional
information along with detailed assessment of the fracture
pattern and displaced fragments.
MRI remains the most sensitive modality for assessing
soft-tissue structures, particularly the TFCC. Imaging with
a dedicated wrist coil, thin-section sequences, and a small
field of view enables adequate evaluation of the DRUJ at
routine imaging of the wrist (32,33). Three-tesla MRI is pre-
ferred, with diagnostic accuracy nearly equivalent to that
achieved with direct MR arthrography, but 1.5-T MRI may
be adequate with optimized techniques (33,34). Some insti-
tutions include a three-dimensional imaging sequence with
thin sections and multiplanar capability (33,35). Application
of traction has also been proposed, further improving depic-
tion of the TFCC, intrinsic ligament tears, and articular car-
tilage surfaces (36).
Pathologic Conditions
Trauma
TFCC Tears.—TFCC lesions are traditionally organized ac-
cording to the Palmer classification system. The main division
is between traumatic (type 1) and degenerative (type 2) tears.
Figure 9. Drawing shows the inter­osseous
membrane of the forearm. The interosseous
membrane consists of predominantly mem-
branous portions interspersed with areas of
discrete thickening: the distal oblique bundle
(DOB), central band or interosseous ligament
(IOL), and proximal oblique cord (POC).
Traumatic injuries are subdivided into four types on the basis
of the site of injury (Fig 12, Table 1).
Type 1A lesions are frank perforations of the central disk
(Fig 13). They are classically described as central tears, al-
though most injuries in this category are slightly off center and
nearer to the radial articular surface, thereby mimicking type
1D lesions when large. Because the articular disk is avascular,
these tears are generally not amenable to direct repair (8,20).
Type 1C lesions are carpal-sided avulsions of an ulnocar-
pal ligament (Fig 14). They may involve the lunotriquetral
ligament and manifest as ulnocarpal subluxation rather than
DRUJ instability (20).
Compared with type 1A and 1C lesions, type 1B and 1D lesions
are prone to DRUJ instability (14,20). Type 1B lesions involve the
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January 2023 Flores et al 7

Figure 10. Volar (top) and dorsal (bottom) DRUJ dislocation.

(A, B) Anteroposterior (A) and lateral (B) radiographs in a
67-year-old man after a motor vehicle accident show approx-
imation of the distal radius and ulna on the anteroposterior
view (A) and mild volar translation of the distal ulna (yellow
line in B) with respect to the distal radius on the lateral view,
consistent with volar DRUJ subluxation. A minimally displaced
fracture (arrowhead in A) of the ulnar styloid process is also
present. (C, D) Anteroposterior (C) and lateral (D) radiographs
in a 22-year-old male skier with recurrent wrist pain show
widening of the distal radioulnar joint on the anteroposterior
view (C) and dorsal translation of the distal ulna (yellow line
in D) with respect to the distal radius on the lateral view,
consistent with dorsal DRUJ dislocation.

Figure 11. ECU tenosynovitis in an 89-year-old patient with sudden marked

swelling of the ulnar side of the wrist. Transverse color Doppler image of the
ECU tendon (*) at the level of the ulnar groove shows florid synovial thickening
and hyperemia, consistent with tenosynovitis. The patient had no history of
recent trauma or rheumatoid arthritis. Cultures were negative, although the pa-
tient’s symptoms resolved after a course of intravenous antibiotics.

foveal or styloid attachment or both (Fig 15). Isolated tears of the
styloid insertion are repaired with a simple arthroscopic suture,
while avulsion of the foveal attachment requires reattachment of
the entire TFCC using a bone anchor or drill holes (20,37). Bone
avulsion of the ulnar styloid can manifest as subtle cortical irreg-
ularity or a separate fracture fragment (Fig E2) (38).
Type 1D lesions are radial-sided avulsions of the TFCC
from the weak cartilage-bone interface at the radius and are
further subdivided into central, dorsal, and volar rim tears
(20). The central tear limited to the fibrocartilage area is the
most common subtype and is managed with arthroscopic par-
tial resection (20) (Fig 16).
Palmer type 2 lesions are degenerative tears of the TFCC
related to ulnar impaction that are subclassified according to
progressive involvement of structures on the ulnar side of the
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January 2023 Flores et al 8

Figure 12. Drawings show the four types of Palmer 1 or traumatic lesions of the TFCC (see Table 1).

Table 1: Palmer Classification of TFCC Lesions

Class Description
Type 1: traumatic
1A Central slit tear or perforation of the disk proper
1B Ulnar avulsion with or without distal ulnar fracture
1C Distal avulsion of TFCC involving ulnotriquetral or
ulnolunate ligament
1D Radial avulsion of the disk proper with or without
sigmoid notch fracture
Type 2: degenerative
2A TFCC wear with thinning or fraying without perfora-
tion
2B TFCC wear as in 2A with lunate, triquetral, or ulnar
chondrosis
2C TFCC perforation with or without 2B chondrosis
2D Lunotriquetral ligament perforation with features of
2A, 2B, or 2C
2E Any or all of the above with ulnocarpal arthritis
Figure 13. Palmer type 1A lesion in a 39-year-old man with ul-
nar-sided pain after spraining his wrist. Coronal fat-suppressed
T2-weighted image shows frank perforation of the TFC (arrow-
head). The peripheral TFCC is intact.
wrist (Fig 17, Table 1). Type 2A lesions manifest as thinning
and fraying of the TFCC without frank perforation (Fig 18).
In type 2B to 2E lesions, lunate, triquetral, or ulnar chon- lunotriquetral ligament tear, and ulnocarpal arthritis in type
drosis may be present (Fig 19). There is TFCC perforation, a 2C, 2D (Fig 20), and 2E lesions, respectively.

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January 2023 Flores et al 9
Figure 14. Palmer type 1C lesion in a 20-year-old man with wrist pain after falling on an outstretched hand. Coronal (A) and sagittal (B) fat-suppressed pro-
ton-density–weighted MR images and lateral radiograph (C) show an avulsion fracture (arrowhead) involving the ulnolunate ligament (arrows).
Figure 15. Palmer type 1B lesion involving both the foveal
and styloid attachments in a 34-year-old man with a wrist
sprain. Coronal fat-suppressed proton-density–weighted MR
image shows complete disruption (arrowheads) of the foveal
and styloid laminae of the TFCC. There is also edema (arrows)
in the soft tissues alongside the distal ulna.
TFCC tears are the most widely known cause of DRUJ in-
stability and dysfunction. Arthroscopy is the standard of ref-
erence for diagnosing central disk tears but may be limited
in detecting deeper peripheral lesions (37). The challenge
of diagnosing deeper ulnar-sided tears is highlighted by the
layered arrangement of the TFCC, later updated to the “ice-
berg” concept (10,12).
The ulnar side of the TFCC can be divided into the proxi-
mal ligament (the DRULs, specifically the foveal fibers) and
a distal hammock structure that suspends the carpus (10).
As with an iceberg, only the distal hammock or shock-ab-
sorbing part (ie, the emerging tip) is seen during radiocarpal
arthroscopy (37). This is significantly smaller and less func-
tionally important than the proximal ligament or the main
stabilizers at the fovea (ie, the “submerged” part), which are
visualized only at DRUJ arthroscopy (37).
Direct CT arthrography and MR arthrography are argu-
ably the preferred imaging tools for detecting TFCC tears
(39) (Fig 21). They have sensitivity, specificity, and accuracy
close to 100% in diagnosing TFCC tears, compared with
70%–90% for conventional MRI (35,40). When a TFCC tear is
suspected, most institutions start with an injection into the
radiocarpal joint; communication with the DRUJ is positive
for a TFCC tear (32,41).
In the absence of communication between the two joints,
a few authors recommend an additional injection into the
DRUJ to rule out noncommunicating TFCC tears (41,42).
Contrast material injection into the midcarpal joint is added
if concomitant injury to the scapholunate or lunotriquetral
ligament is suspected (43). Dynamic maneuvers after fluo-
roscopy-guided contrast material injection—such as neutral
or grip view and radial or ulnar deviation—can aid in diag-
nosis of concurrent carpal instability, although their value in
diagnosing DRUJ instability is not established.
Although exhibiting excellent contrast resolution and the
ability to demonstrate central and radial-sided tears, conven-
tional MRI and MR arthrography have not shown similar
accuracy in diagnosing peripheral tears (37,44). Direct CT ar-
thrography has recently received attention for its speed and
excellent spatial resolution, allowing evaluation of concur-
rent bone injuries and loose bodies, both calcified and non-
calcified (35,40) (Fig 22). Radial sequences improve diagnos-
tic accuracy for peripheral lesions, making it almost equal to
that for central lesions (7). Personally, we prefer CT arthrog-
raphy for detecting peripheral TFCC tears, particularly the
critical deep or foveal lesions. Further studies are needed to
assess the accuracy of CT arthrography in diagnosing periph-
eral TFCC tears compared with that of MR arthrography.
Limitations of Palmer Classification.—There are several limita-
tions of the Palmer classification. Type 1B tears are not further
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January 2023 Flores et al 10

Figure 16. Palmer type 1D lesion in a 45-year-old female cyclist with 5 days of ulnar-sided wrist pain after a cycling injury.
Coronal (A) and axial (B) fat-suppressed T1-weighted images after administration of intra-articular contrast material show a contrast
material–filled defect (arrowheads) in the radial side of the TFCC near the articular cartilage, consistent with a Palmer type 1D tear.

Figure 17. Drawings show the five types of Palmer 2 or degenerative lesions of the TFCC (see Table 1).

subclassified as tears of the foveal attachment, homologue, ul-
nar collateral ligament, or ECU subsheath (45). Apart from the
rare Palmer type 1C tear, peripheral lesions at the ulna are con-
sidered Palmer type 1B despite requiring different therapeutic
approaches (37). Combined central and peripheral injuries are
not classified, although they are not uncommon (45) (Fig E3).
Tears of the superficial or deep layers of the peripheral TFCC
are not differentiated, although a different arthroscopic or sur-
gical approach may be required (37).
There are many lesions not described by the classification
(Fig E4). Dorsal capsular detachments are largely unrecog-
nized despite their diagnostic and surgical implications (39).
The Nishikawa lesion is a dorsal capsular avulsion from the
ulnar aspect of the triquetrum and may involve the meniscal

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January 2023 Flores et al 11

Figure 18. Palmer type 2A lesion in an adult man

with chronic ulnar-sided wrist pain. Coronal fat-sup-
pressed proton-density–weighted MR image shows
mild thinning (arrowhead) of the TFC with mild
chondrosis and subchondral edema in the overlying
lunate. Contrary to type 1A lesions, a type 2A lesion
is characterized by attrition or irregularity of the disk
without extension to the articular surface, similar to
degeneration of the menisci of the knee.
Figure 19. Palmer type 2C lesion in a 56-year-old man with
chronic wrist discomfort. Coronal fat-suppressed proton-den-
sity–weighted MR image shows perforation (arrowhead) of the
TFC, with chondrosis and subchondral cysts in the ulna. The
lunotriquetral ligament is intact (arrow). Scattered intraosseous
cysts are also seen in the triquetrum, hamate, and capitate.

homologue (46) (Fig 23). Dorsal capsular detachments at the

level of the TFC are usually located in the ulnar aspect and may
be concealed by abundant synovitis at arthroscopy (37,45).
The dorsal tear is a lesion that occurs between the TFC and
dorsal DRUL (47,48). It can produce abundant synovitis and
ulnar head entrapment, limiting forearm pronation and supi-
nation (45). Lastly, tears between the floor of the dorsal DRUL
and the ECU subsheath can occur alone or in combination
with distal radial fractures. In high-grade injuries, the defect
can extend to the sheath, allowing passage of fluid or arthro-
graphic contrast material and demarcating the tendon (Fig 24).
Atzei and Luchetti (37) devised a novel classification sys-
tem for peripheral TFCC tears that accounts for clinical, ar-
throscopic, and radiographic findings (Table 2). The system
takes into consideration the ballottement test, TFCC tension
at arthroscopy using the hook test, and the status of the DRUJ
cartilage (37). The ballottement test is positive when the ul-
nar head demonstrates abnormal translation on the radius
with passive volar and dorsal translation (37). The hook test Figure 20. Palmer type 2D lesion in a 72-year-old man with
is a specific assessment of the foveal insertion of the proximal wrist pain. Coronal fat-suppressed proton-density–weighted
TFCC (37). It consists of applying traction to the ulnar-most MR image shows perforation (arrowhead) of the TFC, with
border of the TFCC using the probe and is considered positive small subchondral cysts in the lunate. There is also a small
tear (arrow) of the lunotriquetral ligament and some intermedi-
when the TFCC can be displaced toward the center of the ra- ate signal intensity in the peripheral TFCC, also due to degen-
diocarpal joint (37). eration. The overall findings are consistent with a Palmer type
The classification also provides guidelines for specific 2D lesion.
treatment modalities: suture repair, foveal refixation, recon-
struction with a tendon graft, or salvage procedures (arthro-
plasty or joint replacement) (37). The system has not been head with respect to the sigmoid notch (49). Therefore, dorsal
widely adopted but may play an important complementary DRUJ dislocation refers to dorsal position or “movement” of
role to the Palmer classification in guiding treatment and sur- the distal ulna with respect to the distal radius, whereas volar
gical decision making. DRUJ dislocation corresponds to volar position of the distal
ulna with respect to the distal radius. Dorsal DRUJ dislocation
DRUJ Instability.—Despite the fact that the radius is the mobile is the more common form of instability (50).
component of the forearm, DRUJ instability or dislocation Diagnosis of DRUJ instability is difficult clinically and ra-
is customarily defined in terms of the position of the ulnar diologically. As little as 10° of pronation or supination on a

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January 2023 Flores et al 12

Figure 21. Peripheral
TFCC perforation. Coronal
conventional (A) and MR (B)
arthrograms after radiocarpal
injection show complete
tears (arrowheads in B) of
the foveal and styloid at-
tachments of the peripheral
TFCC, with extravasation of
contrast material (arrows)
into the soft tissues at the
ulnar aspect of the TFCC
beyond the borders of the
prestyloid recess, suspicious
for a concomitant ulnar cap-
sule injury. The patient did
not undergo arthroscopy or
surgery and was managed
conservatively.

lateral image can make DRUJ alignment inaccurate (29). A

few institutions use a wrist support to achieve satisfactory
positioning in the lateral projection or compare affected and
unaffected sides to improve sensitivity and reliability (29).
CT is the standard of reference for assessing DRUJ insta-
bility. Static scans provide excellent anatomic detail, while
dynamic imaging of both wrists allows real-time assessment
of stress-related changes to the joint (Figs 25, E5). Current
approaches focus on imaging in the neutral position, supi-
nation, and pronation during various degrees of loading and
resistance using dead-weight application (ie, sandbags) or a
special apparatus that provides torque (51).
There are various methods of evaluating the displacement
on these axial images: the radioulnar line (or Mino’s) method,
radioulnar ratio method, subluxation ratio method, epicen-
ter method, and congruency method (52,53) (Table 3). Mino’s
method is the quickest and easiest but is limited by high rates of
false-positive results (53–55). The epicenter method is unaffected
by rotational position but exhibits poor interrater agreement (54).
The subluxation ratio method is straight­forward and reliable but
may exhibit significant variation in normal values (53,54).
There is no consensus on the most optimal method. Per- Figure 22. TFC tear with an interposed flap within the
DRUJ in a 21-year-old man with marked wrist pain after
sonally, we prefer the subluxation ratio for its reproducibility a fall. Coronal CT arthrogram of the wrist after radiocar-
and reliability independent of the injury state of the wrist. We pal injection shows intra-articular contrast material (*)
agree with previous authors (53,54) that the main challenge in filling the region of the TFC, consistent with full-thick-
evaluating DRUJ instability with CT criteria is the large nor- ness perforation. There is also contrast material outlin-
ing a nonmineralized intra-articular body (arrowheads)
mal variation in translation of the joint. Therefore, we recom- within the DRUJ, consistent with a displaced flap from
mend reporting these measurements only in dynamic CT ex- the torn TFC.
aminations of both wrists performed for clinically suspected
or established DRUJ instability.

Intra- and Extra-articular Fractures.—The stabilizing effect of
the TFCC is irrelevant if the bony architecture of the DRUJ is
damaged. Fracture of the distal radius is the most common
cause of DRUJ instability (9). An associated TFCC tear is pres-
ent in more than 75% of patients with an intra-articular distal
radius fracture (56).
Fractures of the distal radius are also commonly associated
with an ulnar styloid fracture involving the tip or base (2).
Fractures at the base of the ulnar styloid are more clinically
significant, resulting in disruption of the TFCC attachment
and DRUJ instability (37). A nonunited styloid fracture may
become painful when it impinges on the ulnar carpus or irri-
tates the adjacent ECU tendon sheath (57).
An Essex-Lopresti fracture is characterized by a longitudinal
force that disrupts the proximal radial head or neck in conjunc-
tion with a DRUJ dislocation (2). The injury is complicated by

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January 2023 Flores et al 13

Figure 23. Carpal-sided avulsion of the dorsal capsule (Nishikawa lesion) in a 46-year-old rugby player. Diagram (A) and sagit-
tal fat-suppressed proton-density–weighted MR image (B) show avulsion of the dorsal capsule, characterized at MRI by capsular
stripping and marrow edema (arrowheads in B) in the triquetrum (T in B). The TFC is intact. 1A in A = Palmer type 1A lesion, 1C in A =
Palmer type 1C lesion.

Figure 24. ECU subsheath injury in a 57-year-old

man with recent ulnar-sided pain after a water-ski-
ing injury. Coronal (A) and axial (B) CT arthro-
grams of the wrist show intra-articular contrast
material (arrowheads) outlining the ECU tendon,
consistent with a subsheath injury.

interosseous membrane rupture with tearing of the interos-
seous ligament, which leads to radioulnar dissociation and
proximal migration of the radius in relation to the ulna (25).
The diagnosis can be made radiographically, although MRI
may provide a detailed evaluation of all the components of
the interosseous membrane, ligaments, and other soft tissues
(Fig 26) (58).
A Galeazzi fracture-dislocation is a fracture of the distal
one-third of the radius along with DRUJ instability (2). The
fracture is located at the proximal border of the pronator
quadratus muscle, and the DRUJ dislocation is commonly
dorsal (2). DRUJ instability is more common in fractures lo-
cated closer than 7.5 cm to the radiocarpal joint (59). The in-
jury often occurs in combination with ulnar styloid fractures
and TFC tears (2). As with an Essex-Lopresti fracture, MRI is
useful for evaluating surrounding soft-tissue structures and
preoperative planning (2).
Traumatic Tears of ECU Tendon.—Pathologic conditions of the
ECU tendon are most common in tennis and golf and in cer-
tain high-impact contact sports, such as rugby (17). Dis­orders
include tenosynovitis, tendinosis, traumatic or degenerative
tearing, and tendon instability. The contents of the entire
sixth extensor compartment are best depicted on axial MR im-
ages. The ECU, its subsheath, and the extensor retinaculum
are highlighted on fluid-sensitive or fat-suppressed images in
the presence of a small amount of tendon sheath fluid.
Partial tears manifest as intratendinous clefts, tendon at-
tenuation, or tendon thickening (Fig 27) (17). An accessory
ECU tendon is present in less than 40% of cases and may be
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January 2023 Flores et al 14

Table 2: Atzei Classification of TFCC Lesions

Arthroscopic Findings

Clinical Tension of Proxi-

Findings: DRUJ Appearance of mal TFCC (Hook Cartilage Status of Suggested
Class Ballottement Test Distal TFCC Test) DRUJ Radiographic Findings Treatment
0 Negative Normal Taut (negative Well-preserved Isolated ulnar styloid fracture Splinting
hook test) cartilage
1 Slight laxity Peripheral tear Taut (negative Well-preserved Isolated tear of distal TFCC TFCC suture
hook test) cartilage with or without ulnar styloid
fracture
2 Mild to severe No tear Loose (positive Well-preserved Tear of both distal and proximal TFCC foveal
laxity hook test) cartilage components refixation or
styloid fixation
3 Mild to severe No tear Loose (positive Well-preserved Isolated tear of proximal com- TFCC foveal
laxity hook test) cartilage ponent refixation or
styloid fixation
4 Mild to severe 4a: Massive tear with Loose (positive Well-preserved 4a: Irreparable TFCC tear due to Tendon graft re-
laxity degenerated edges hook test) cartilage a sizable defect construction
4b: Frayed edges 4b: Irreparable TFCC tear due to
with failed suture poor healing potential

5 Variable Variable Loose (positive Degenerative or DRUJ osteoarthritis after a Arthroplasty

hook test) traumatic carti- TFCC tear
lage defect

confused with a partial split tear (60). Complete traumatic
rupture of a nondegenerated tendon is unusual and is seen
only in high-force lacerating or penetrating injury (17).
At US and MRI, a fluid-filled defect is evident with vary-
ing degrees of retraction of the tendon ends and associated
soft-tissue hematoma. Similar to their appearance in ten-
dons elsewhere in the body, chronic ruptures manifest as
tendon nonvisualization with proximal muscle atrophy and
absence of other soft-tissue abnormalities (17).
ECU Subsheath Injury and Tendon Instability.—Athletic inju-
ries of the ECU subsheath are rarely seen in clinical practice.
Tearing or attenuation of the ECU subsheath allows sublux-
ation or dislocation of the ECU tendon despite an intact su-
perficial extensor retinaculum (Fig 28).
The injury is characterized by a painful snap over the
dorsal and ulnar aspect of the wrist, exacerbated by forearm
rotation. Most patients recall a specific traumatic event or
sporting activity (ie, tennis or golf), typically occurring during
forearm supination, ulnar deviation, and wrist flexion (61).
An untreated acute ECU subluxation or dislocation results in
chronic ECU instability, manifesting as repetitive irritation,
reactive tenosynovitis, and—in severe cases—osseous erosion
of the distal ulna (62). True ECU tendon dislocation at the
ulnar groove is exceptionally rare.
The position of the wrist at the time of imaging must be ac-
counted for when diagnosing ECU instability. At US and MRI,
it is common for the tendon to appear to be in an eccentric
position or even completely outside the ulnar groove (18,63).
It can displace by up to 5 mm and 40%–50% volar to the ulnar
border of the groove, maximal during supination, flexion, and
ulnar deviation (18,63). There is also greater ulnar translation
with shallower or more convex grooves (18,61).
Degenerative Conditions
ECU Tenosynovitis and Tendinosis.—Overuse or degenerative
abnormalities involving the tendons of the wrist are more
common than traumatic ruptures and typically take the form
of tenosynovitis, tendinosis, or degenerative tears. Repetitive
friction against the distal ulna in sporting activities often leads
to tenosynovitis. The ECU tendon sheath can be irritated by
repetitive flexion and extension as it exits the fibro-osseous
tunnel. Inflammatory arthropathies like rheumatoid arthritis
are an important consideration in patients with ECU teno­
synovitis but no history of recent trauma, repetitive stress, or
sporting activity (17).
Tendinosis of the ECU is the second most common tendi-
nosis in athletes and is frequently seen in rowing, golf, and
racquet sports (61,64). It is usually seen in the setting of TFCC
tears, lunotriquetral ligament tears, anomalous tendon slips,
nonunited ulnar styloid fractures, or a flat ECU tendon groove
(64). It appears as diffuse intratendinous high signal intensity
with increased tendon girth with or without tenosynovitis. On
axial images, central increased T1 or T2 signal intensity alone
without alteration in tendon caliber indicates mucoid degen-
eration and is not necessarily pathologic, the so-called ECU
pseudolesion (65) (Fig E6). Progressive tendinosis and degen-
eration predispose to partial tears and even complete failure,
which can occur after a minor traumatic event or insidiously.

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January 2023 Flores et al 15
Ulnar Variance.—Ulnar variance is implicated in ulnar-sided
impaction syndromes. It is measured as the distance be-
tween the distal edges of the ulnar head (not ulnar styloid)
and radius; a positive variance is greater than 2.5 mm, and a
negative variance is less than or equal to 2.5 mm. This value
changes with wrist position, increasing with maximum fore-
arm pronation, firm grip, and ulnar deviation and decreas-
ing with maximum forearm supination (2,66). It also varies
among individuals and over an individual’s lifetime (2). Pos-
itive or negative ulnar variance may represent a normal con-
genital variant or occur secondary to a malunited fracture or
previous surgery (2).
Ulnar Impaction.—Ulnar impaction, ulnar loading, or ulnar
abutment is the most common of the ulnar-sided wrist impac-
tion syndromes. It is an overuse or degenerative disorder char-
Figure 25. Dorsal DRUJ dislocation in a 26-year-old man with
suspected left DRUJ instability after internal fixation for a distal
radial fracture. Axial dynamic CT images of both wrists show
progressive dorsal translation and subsequent engagement (ar-
rowhead) of the left distal ulna with respect to the distal radius
from supination to the neutral position to pronation. The right
DRUJ also shows mild dorsal translation of the distal ulna with
respect to the distal radius (yellow line) on pronation but was
normal at clinical assessment. By convention, dorsal DRUJ dis-
location refers to dorsal position of the distal ulna with respect
to the distal radius, even though the radius is the mobile unit of
the forearm.
acterized by chronic impaction between the ulnar head, TFCC,
and ulnar carpus, resulting in a continuum of pathologic
changes. It is often associated with positive ulnar variance,
which increases loading across the ulnocarpal joint, but may
also be seen in neutral or negative variance in the context of
dynamic impingement (52). Other predisposing factors include
malunion of the distal radius, premature physeal closure of the
distal radius, and previous radial head resection (57).
In contrast to ulnar impaction, ulnar impingement is
caused by negative ulnar variance or a shortened distal ulna
that impinges on the distal radius proximal to the sigmoid
notch. A shortened distal ulna is typically a consequence of
any of the surgical procedures that involve resection of the
distal ulna secondary to rheumatoid arthritis, correction of
Madelung deformity, or premature fusion of the distal ulna
due to remote trauma (57) (Fig 29). Imaging findings include
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Table 3: Methods of Quantifying DRUJ Displacement on Axial CT Images

Method Construction
Radioulnar line or Two lines are drawn through the dorsal and volar borders of the
Mino’s method radius and extended toward the ulna. Instability is present when
(cd/ab) there is greater than 25% displacement of the ulna beyond these
borders (dotted outline of the ulna). This parameter can also be
quantitatively evaluated by obtaining the ratio cd/ab.

Radioulnar ratio The first line is drawn joining the dorsal and volar edges of the
 (ad/ab) sigmoid notch (total length of the sigmoid notch or ab), while
a second line is drawn perpendicular to the first that passes
through the center of the ulnar head. The radioulnar ratio is the
ratio between the line joining the point of intersection of the two
lines with the volar edge of the sigmoid notch (ad) and the total
length of the sigmoid notch (ab).

Subluxation ratio The total length of the sigmoid notch (ab) is obtained. Two lines
 (cd/ab) are drawn perpendicular to this length, one through the dorsal
edge of the sigmoid notch and one through the volar edge. The
maximum dimension of the ulna beyond either of these lines (cd)
is measured, and the ratio against the total length of the sigmoid
notch is calculated.

Epicenter method Two circles are drawn in the center of the ulnar head and the
 (cd/ab) styloid process. The center of rotation of the DRUJ lies at a point
halfway between the center of the ulnar styloid and the center of
the ulnar head. This line is joined perpendicular (d) to the line
depicting the length of the sigmoid notch (ab). The ratio of the
distance between the perpendicular line and the midpoint of the
sigmoid notch (cd) and the length of the sigmoid notch (ab) is
calculated.

Congruency method Subjective parameter based on the arcs of the ulnar head and sig-
moid notch.

Note.—Normal values for these parameters and other criteria for evaluation are available in references 53–55.

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January 2023 Flores et al 17
scalloping of the distal radius proximal to the sigmoid notch
and approximation of the lower ends of the radius and ulna or
radioulnar convergence (57). Other causes of ulnar impaction
are less common and include malunited styloid fractures and
a long ulnar styloid (57).
DRUJ Arthritis.—In comparison with that in other joints, pri-
mary degenerative arthritis of the DRUJ is rare. It usually
occurs secondary to long-standing nondegenerative arthrop-
athy or cartilage destruction after wrist trauma (67). The
typical clinical manifestation is ulnar-sided wrist pain exac-
erbated by load bearing and forearm supination as a conse-
quence of the ulnar head moving volar to and impinging on
the sigmoid notch. Joint space narrowing, osteophytes, and
subchondral bone cysts are the typical radiographic find-
ings but are usually present in advanced disease (67). MRI is
helpful in detecting early cartilage and subchondral abnor-
malities and synovitis.
Traditionally, DRUJ arthritis is initially managed conserva-
tively, followed by distal ulnar resection in recalcitrant cases.
Outcomes are usually favorable, but a residual distal ulnar
stump producing symptoms of instability is a significant com-
plication. Soft-tissue stabilization procedures and DRUJ im-
Figure 26. Essex-Lopresti frac-
ture-dislocation in a 46-year-old man
who fell on his outstretched hand
during a bicycle ride. (A) Anteroposte-
rior radiograph of the forearm shows
dislocation of the DRUJ (arrows) and
a displaced fracture-dislocation of the
radiocapitellar joint (arrowheads). (B,
C) Coronal (B) and axial (C) fat-sup-
pressed proton-density–weighted
MR images show severe disruption of
the peripheral TFCC (arrowheads in
B), dislocation of the ECU tendon (ar-
row in C), and diastasis of the DRUJ
(double-headed arrow in C), indica-
tive of disruption of the interosseous
membrane.
plant arthroplasty are novel methods that have been used to
address residual ulnar instability (68) (Fig 30).
Inflammatory Conditions
Rheumatoid arthritis involves the wrist in up to 80% of
cases. It can affect the DRUJ, radiocarpal joint, and midcar-
pal joint. Of these, the DRUJ is the earliest and most com-
monly involved compartment (69). Because early findings
are nonosseous, US and MRI are superior to radiography
and CT in terms of disease detection. US and MRI clearly
show features of tendon involvement, such as tenosynovi-
tis, partial tendon tear, and complete rupture (70) (Fig E7).
Some authors hypothesize that ECU tenosynovitis rep-
resents an imaging biomarker and predictor of erosive joint
damage in early rheumatoid arthritis (71). Advanced disease
is well characterized at radiography and manifests as joint
instability, severe osteopenia, destruction of the DRUJ, and
articular dissociation. The DRUJ demonstrates a typical pat-
tern of bone destruction that include erosions of the inferior
portion of the DRUJ and the prestyloid recess (72). Erosion
of the sigmoid notch (the scallop sign) correlates with rup-
ture of extensor tendons (Fig 31) (73). Caput ulnae syn-
drome describes the sequence of structural changes in the
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January 2023 Flores et al 18
Figure 27. ECU split tear in a 44-year-old man with wrist pain
after a fall on his outstretched forearm. The wrist pain was
suspected to be due to a TFCC tear. Axial (A) and coronal (B)
fat-suppressed proton-density–weighted MR images show flu-
id-filled clefts within the ECU tendon with surrounding tendon
sheath fluid (arrowheads), consistent with a high-grade partial
intrasubstance tear of the tendon.
DRUJ, which include volar subluxation and supination of
the carpus, dorsal prominence of the ulnar head with pain-
ful crepitus on reduction (the piano key sign), and carpal
trans­location (72,73).
Crystalline disorders such as gout and calcium pyro-
phosphate dihydrate crystal deposition disease (CPPD) (ie,
pseudo­gout) appear as chondrocalcinosis of hyaline carti-
lage or fibrocartilage, such as in the TFC disk (2,67). Pro-
gressive disease eventually leads to structural damage to
the joint with imaging findings typical of these arthropa-
thies. Calcific deposits, joint space narrowing, subchondral
Figure 28. Chronic ECU subsheath injury and ECU dis-
location in a 47-year-old male cyclist with long-standing
ulnar-sided wrist pain. Axial fat-suppressed proton-density–
weighted MR image shows ulnar and volar dislocation of the
ECU tendon (black arrowhead). The ECU subsheath is no
longer visualized, consistent with complete disruption. There
is also mild edema and thickening of the ulnar aspect of the
extensor retinaculum (white arrowheads), although most of it
remains intact (arrows).
sclerosis, cyst formation, and large geodes are evident at
conventional radiography (2). As with the menisci of the
knee, diffuse degeneration or signal intensity alteration
from chondrocalcinosis may mimic Palmer type 2 tears,
and correlation with radiography or CT is necessary for dif-
ferentiation (44,74).
Developmental Conditions
Madelung deformity is a painful condition of the wrist af-
ter premature closure of the ulnar volar aspect of the distal
radial physis. It has a 4:1 female predisposition and usually
occurs in adolescents between the ages of 8 and 14 years
(75). It is particularly common in Leri-Weill dyschondros-
teosis but may also occur in isolation (75). It is initially as-
ymptomatic before pain, loss of grip strength, and reduced
mobility develop.
Both true Madelung deformity and Madelung-type de-
formities result in progressive curvature of the radius, in-
creased volar tilt and inclination of the radial articular sur-
face, triangulation of the carpus with proximal migration
of the lunate, and dorsal displacement of the distal ulna or
“bayonet” deformity (75). Congenital Madelung deformity is
distinguished from Madelung-type deformities by the pres-
ence of an anomalous radiolunate ligament (Vickers liga-
ment) and a radial notch at the ligament attachment (75)
(Fig 32). The TFCC may become thickened and obliquely
oriented secondary to the radial deformity (75).
Madelung-type deformities can be posttraumatic owing
to a malunited distal radial fracture or can be neoplastic.
Multiple osteochondral tumors or hereditary exostoses are
common neoplasms implicated in Madelung-type deformi-
ties (Fig 33). In skeletally immature patients, the physeal
plate may be injured or tethered by a spanning or adjoining
tumor mass. In contrast to true Madelung deformity, there
is no radial notch and no Vickers ligament (75).
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January 2023 Flores et al 19

Figure 29. Ulnar impingement in a 13-year-old boy

with persistent ulnar-sided wrist pain after injury 1 year
earlier. (A) Anteroposterior radiograph shows a distal
radial diaphysis fracture and a metaphyseal corner
fracture (Salter-Harris II) (arrowhead) of the distal ulna,
transfixed with pins. (B) Coronal fat-suppressed pro-
ton-density–weighted MR image 1 year later shows a
markedly shortened distal ulna with mild scalloping
(arrows) of the adjacent radial sigmoid notch.

Figure 30. Surgical management of DRUJ arthritis in a 57-year-old woman who underwent distal ulnar resection for per-
sistent ulnar-sided pain and symptoms of DRUJ instability. (A) Coronal CT image of the left wrist shows cortical irregularity
and proliferative changes (arrowheads) in the distal ulnar stump. The distal radius and carpus also show smaller erosions.
(B) Anteroposterior radiograph shows DRUJ arthroplasty, which was performed 1 year later.

Conclusion
The DRUJ is an essential component of forearm motion that
enables smooth pronation and supination in coordination
with the wrist and elbow. This articulation is stabilized by
osseous and soft-tissue structures, which can be affected by
a spectrum of pathologic entities. An understanding of the
anatomy, classification, and imaging features of common dis-
orders that affect the joint enables accurate diagnosis.
Author affiliations.—From the Department of Medical Imaging, Ottawa
Hospital, 501 Smyth Rd, Ottawa, ON, Canada K1H 8L6 (D.V.F., K.S.R., Z.J.);
Department of Radiology, Clínica Internacional, Lima, Peru (D.F.U.); and
Department of Radiology, Clínica Alemana de Santiago, Vitacura, Chile
(G.A.S.B.). Presented as an education exhibit at the 2021 RSNA Annual Meet-
ing. Received May 1, 2022; revision requested June 29 and received July 1;
accepted July 6. For this journal-based SA-CME activity, the authors, editor,
and reviewers have disclosed no relevant relationships. Address correspon-
dence to D.V.F. (email: dflores@toh.ca).

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January 2023 Flores et al 20

Figure 31. Advanced rheumatoid arthritis in a 56-year-old

woman with long-standing rheumatoid arthritis and sudden
severe wrist pain. Coronal CT image shows a large erosion
(arrowhead) involving the distal ulna, primarily the ulnar head.
There is also erosion of the radial sigmoid notch (the scallop
sign) (arrow). Additional smaller erosions in the radial styloid,
triquetrum, lunate, and scaphoid are also present.

Figure 32. Congenital Madelung

deformity with a Vickers ligament.
(A) Anteroposterior radiograph
shows exaggerated radial inclina-
tion (arrow) with a V-shaped prox-
imal carpal row wedged between
the radius and ulna. (B) Coronal
fat-suppressed proton-density–
weighted MR image shows an
anomalous radiolunate or Vickers
ligament (arrowheads).

Figure 33. Madelung-type deformity in a 27-year-old woman

with multiple osteochondromas throughout both upper and lower
extremities. Anteroposterior radiographs of both hands show py-
ramidalization (white lines) of the proximal carpal rows with radial
inclination in both wrists. There are bone expansion and scattered
chondroid lesions in both hands and wrists, consistent with multiple
osteochondral and chondral tumors.

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January 2023 Flores et al 21
Acknowledgments.—The illustrations were prepared by G.A.S.B. and by Il-
ija Visnjic.
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