The DRUJ is the distal pivot of forearm rotation where the sigmoid notch of the radius rotates around the ulnar head. The TFCC fills the gap distal to the ulnar head, transmitting 20% of axial wrist load. DRUJ instability from distal radius malunion, TFCC tears, or Essex-Lopresti injury produces painful forearm rotation. Ulnar positive variance (ulnar head protruding beyond the radial articular surface) increases TFCC compressive loading and produces ulnar abutment syndrome.
Ulnar positive variance greater than 2 mm produces TFCC central perforation, lunate chondromalacia, and lunotriquetral ligament tears from repetitive impaction (ulnar abutment syndrome). Ulnar shortening osteotomy (removing 2-4 mm of ulnar length) reliably reduces impaction load and resolves symptoms in 85-90% of cases.
Positive ulnar variance producing TFCC and lunate chondral injury managed with ulnar shortening osteotomy.
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