The Distal Interosseous Membrane: Current Concepts in Wrist Anatomy and Biomechanics

doi:10.1016/j.jhsa.2012.04.037

The Journal of Hand Surgery

Volume 37, Issue 7, July 2012, Pages 1501-1507

https://doi.org/10.1016/j.jhsa.2012.04.037 Get rights and content

The distal interosseous membrane (DIOM) of the forearm acts as a secondary stabilizer of the distal radioulnar joint (DRUJ) when the dorsal and palmar radioulnar ligaments of the triangular fibrocartilage complex are cut. Recent anatomical studies revealed that thickness of the DIOM varies widely among specimens and the distal oblique bundle (DOB) exists within the DIOM in 40% of specimens. The DOB originates from the distal one-sixth of the ulnar shaft and runs distally to insert on the inferior rim of the sigmoid notch of the radius. The mean thickness of the DIOM without a DOB was 0.4 mm, which was significantly thinner than 1.2 mm with a DOB. Biomechanical studies have shown that the DOB is an isometric stabilizer of the forearm during pronosupination. The presence of a DOB was shown to have a significant impact on DRUJ stability. Innate DRUJ laxity in the neutral forearm position was greater in the group without a DOB than in the group with a DOB. Ulnar shortening with the osteotomy performed proximal to the attachment of the DIOM had a more favorable effect on stability of the DRUJ compared with the effect of distal osteotomy, especially in the presence of a DOB. The longitudinal resistance to ulnar shortening was significantly greater in proximal shortening than in distal shortening. It also suggested that the DIOM is of great importance in the management of concomitant ulnar-side injuries in distal radius fracture.

Section snippets

Anatomy of the DIOM

The DIOM is on the distal side of the middle ligamentous complex, spanning the radius and ulna under the region of the pronator quadratus muscle. A hole exists in that portion, through which the interosseous artery passes. Noda et al³ reported anatomical variation of the DIOM. The authors found that thickness of the DIOM varied widely among specimens, and identified the distal oblique bundle (DOB) in 12 of 30 specimens (40%) (FIGURE 1, FIGURE 2). The DOB is an obvious thick fiber running within

Length change during pronosupination

Moritomo et al⁶ investigated changes in the length of the IOM during forearm rotation in vivo. In that study, the author calculated the 3-dimensional lengths of the 5 ligaments in the IOM between attachments during forearm rotation using a markerless bone registration technique. They also examined relationships between the axis of forearm rotation and each ligament, and found that the distal 3 ligaments (central band, accessory band, and DOB) had little change in length during forearm rotation,

Discussion

The form of the ulnar side of the human wrist represents progressive evolutionary development. The embryological and clinical material suggests that there is a tremendous variation in the development of the ulnar side of the wrist. Recent studies have demonstrated anatomical variation of the DIOM, and the DOB was recognized as the exact fiber responsible for function of the DIOM. Biomechanical studies have shown that the DOB changed minimally in length during forearm rotation; therefore, it was

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Cited by (77)

Adjuvant Arthroscopy Does Not Improve the Functional Outcome of Volar Locking Plate for Distal Radius Fractures: A Randomized Clinical Trial
2024, Arthroscopy - Journal of Arthroscopic and Related Surgery
To evaluate the outcomes of adding arthroscopy to osteosynthesis of distal radius fractures (DRF) with volar locking plate (VLP), by Patient-Rated Wrist Evaluation (PRWE) 1 year after surgery.
In total, 186 functionally independent adult patients who met the inclusion criteria (DRF and a clinical decision for surgery with a VLP) were randomized to arthroscopic assistance or not. Primary outcome was PRWE questionnaire results 1 year after surgery. For the main variable, PRWE, we obtained the minimal clinically important difference based on a distribution-based method. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand and 12-Item Short Form Health Survey questionnaires, range of motion, strength, radiographic measures, and presence of joint step-offs by computed tomography. Data were collected preoperatively and at +1 and +4 weeks, +3 and +6 months, and +1 year after surgery. Complications were recorded throughout the study.
In total, 180 patients (mean age: 59.0 ± 14.9 years; 76% women) were analyzed by modified intention to treat. A total of 82% of the fractures were intra-articular (AO type C). No significant difference between arthroscopic (AG) and control (CG) groups in median PRWE was found at +1 year (median AG: 5.0, median CG: 7.5, difference in medians 2.5; 95% confidence interval [CI] –2.0, 7.0, P = .328). The proportion of patients who exceeded the minimal clinically important difference of 12.81 points in the AG and CG was 86.4% vs 85.1%, P = .819, respectively. Percentage of associated injuries and step-offs reduction maneuvers was greater with arthroscopy (mean differences: 17.1 95% CI –0.1, 26.1, P < .001) and 17.4 (95% CI 5.0, 29.7, P = .007). The difference in percentage of residual joint step-offs at the postsurgical computed tomography in radioulnar, radioscaphoid, and radiolunate joints was not significant (P = .990, P = .538, and P = .063). Complications were similar between groups (16.9% vs 20.9%, P = .842).
Adjuvant arthroscopy did not significantly improve PRWE score +1 year after surgery for DRF with VLP, although the statistical power of the study is below the initially estimated to detect the expected difference.
Level I, randomized controlled trial.
Anatomic and Biomechanical Study of the Forearm Interosseous Membrane, Distal Oblique Bundle, and Triangular Fibrocartilage Complex: Role in Galeazzi Fracture Dislocation
2023, Journal of Hand Surgery Global Online
The purpose of this study was to measure distal radioulnar joint (DRUJ) dislocation and radioulnar displacement associated with sequential sectioning of the different bands of the interosseous membrane and triangular fibrocartilage complex in the simulation of a Galeazzi fracture dislocation.
Twelve fresh-frozen cadaver forearms were dissected. We examined the anatomy and function of the forearm interosseous membrane. Each forearm was then mounted onto a biomechanical wrist and forearm device. In the control group, radial osteotomy was performed and the degree of DRUJ displacement with progressive loads was measured. In addition to radial osteotomy, in group 1, the central band (CB) was sectioned; in group 2, the CB, distal membranous portion of the interosseous membrane, and distal oblique bundle were sectioned; and in group 3, the CB, distal membranous portion of the interosseous membrane, distal oblique bundle, and triangular fibrocartilage complex were sectioned.
The radioulnar displacement (mm) at 25 N, 50 N, and 75 N was recorded. In group 1, applying progressive loads resulted in an average DRUJ displacement of 4.3, 5.9, and 7.9 mm, respectively. In group 2, the displacement was 5.2, 5.7, and 6.9 mm, respectively. In group 3, the displacement was 6.2, 8.1, and 9.9 mm, respectively. Our study showed a correlation between increase in the load applied to the same injury and the degree of displacement (P = .001). In group 3, the degree of DRUJ displacement was statistically increased compared to the other groups (P = .04).
Migration of the radius under loads implies disruption of both the CB and triangular fibrocartilage complex. The distal oblique bundle by itself does not seem to have a relevant role in radioulnar displacement at the DRUJ.
This study provides insights into the interosseous membrane and stability of the DRUJ, which can contribute to a better understanding of Galeazzi fracture-dislocations.
Does surgical reconstruction of the distal oblique bundle (DOB) provide similar stability as the intact bundle or Adams procedure? A systematic review
2023, Annals of Anatomy
The aim of this review was to summarize the available evidence for biomechanical stability following surgical DOB reconstruction, and to determine whether distal radioulnar joint (DRUJ) stability with a reconstructed DOB was similar to the native intact condition or that after the Adams procedure.
A systematic literature search according to the PRISMA guidelines was performed using the databases PubMed and Embase. The following search algorithm was used: (“DOB” OR “Distal Oblique Bundle”) AND “Reconstruction”. Biomechanical or human cadaveric studies that measured stability of the DRUJ after reconstruction of the DOB were included.
Four articles were included in the final analysis. DOB incidence was reported to be between 50% and 70%. Two studies observed no differences between the intact situation and the reconstructed DOB, respectively the Adams procedure. A further author group found no signs of major instability after the Adams reconstruction or after DOB reconstruction, except for decreased stability during supination in the DOB sample. In another study, similar results could be shown for the Adams and DOB reconstruction groups; however, the DOB sample showed decreased dorsal translation of the radius during forearm supination.
In conclusion, DOB reconstruction was proven to stabilize the DRUJ adequately. Moreover, the reconstructed DOB showed the same stability as the native DOB, except for one study, in which stability following reconstruction was reduced during supination. No significant difference between the DOB and the Adams reconstruction could be observed.
Do triangular fibrocartilage complex foveal injuries affect the clinical outcome of ulnar shortening osteotomy for ulnar impaction syndrome?
2023, Journal of Orthopaedic Science
Citation Excerpt :
Milch described ulnar shortening osteotomy (USO) in 1941 [7]. USO can reduce the load of the ulnar wrist column and improve DRUJ stability; it can also improve the stability of the ulnar wrist, as confirmed by biomechanical studies [8,9]. As a secondary effect, USO may create a favorable situation for the repair of a torn TFCC [10].
Ulnar shortening osteotomy (USO), as its name implies, is used to shorten the ulna. It subsequently tightens the triangular fibrocartilage complex (TFCC) and ulnar wrist. TFCC foveal insertion is a primary stabilizer of the distal radioulnar joint. It is unclear whether USO is effective in TFCC foveal injuries. The purpose of this study was to review the clinical outcomes of ulnar shortening osteotomies with and without TFCC foveal injuries.
We retrospectively reviewed patients with ulnar wrist pain treated with USO and wrist arthroscopy including the distal radioulnar joint (DRUJ). Sixty-five patients were included in this study. An algorithm was used to guide surgical decision-making. After arthroscopic confirmation of ulnar impaction syndrome, we performed USO with a locking compression plate (mean length of shortening, 2.7 mm; range, 1–7.5 mm). The flattened TFCC disc due to ulnar shortening was confirmed arthroscopically. If the DRUJ was unstable after USO, we repaired the TFCC foveal insertion.
There were 32 post-traumatic and 33 idiopathic cases. We detected TFCC disc injuries in 34 wrists and TFCC foveal injuries in 33 wrists; both types were found in 15 wrists. TFCC foveal injuries were not significantly correlated with patient age, history of trauma, or clinical outcome. Most patients showed good clinical outcomes; 31 of 65 patients had preoperative DRUJ instability, with a significant number having foveal but not disc injuries.
USO achieved reasonable outcomes, even in patients with TFCC foveal injuries. In cases demonstrating ulnar impaction, USO should be prioritized over TFCC repair.
Distal radioulnar joint instability: Diagnosis and treatment of acute and chronic lesions
2023, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
Preserving the TFCC provides sufficient stabilization when peripheral structures are damaged [5]. Thus the TFCC is not the only DRUJ stabilizer, but restoring it provides sufficient stability to ensure the kinematics are nearly normal [5,12,14,18,19]. The pronator quadratus (PQ) and the ECU tendon are two stabilizers that act as agonist/antagonist [17]:
Distal radioulnar joint instability is a common clinical condition that can be either acute or chronic. Its management requires extensive knowledge of all the anatomical structures around the wrist area. The clinical examination must identify all damaged structures in order to define a customized reconstruction strategy. The aim of treatment is to prevent the development of chronic instability and/or arthritic lesions, which can only be treated with palliative surgery. Distal radioulnar instability is complex. Its management shares similarities with that of knee instability, with a wide range of conditions ranging from a sprain with isolated ligament tear to complex dislocation in which multiple ligaments are torn. In particular, the triangular fibrocartilage complex, which is a pillar of distal radioulnar joint stability, is not the sole stabilizer of this joint. The treatment strategy is not as simple as just reattaching this ligament to treat all of the acute and chronic clinical signs. The goal of the present study is to describe the various structures and possible lesions in this joint and then how to repair them. The diagnostic and therapeutic difficulties justify treatment at a specialized center.
Intra-articular Pressure in the Distal Radioulnar Joint: A Biomechanical Study
2023, Journal of Hand Surgery
The aim of the study was to use cadaveric models to assess the effect of loading the forearm muscles in different forearm rotations, with or without disruption to the stabilizing components, on the intra-articular pressure of the distal radioulnar joint (DRUJ).
Ten forearms with no severe osteoarthritis or injury to the DRUJ stabilizers were used. They were placed in a vertical support, and pressure sensors measured pressure within the DRUJ in 5 forearm rotations (neutral, pronation, supination, extension, and flexion) under the following 6 conditions: 1) no loading; 2) loading (at 1/5 of the load per cross-sectional area) with no disruption; 3) loading with disruption of the triangular fibrocartilage complex (TFCC); 4) loading with disruption of the TFCC and ulnar ligaments (ULs); 5) loading with disruption of the TFCC, ULs and interosseous membrane (IM); and 6) loading with disruption of the TFCC, ULs, IM, and pronator quadratus (PQ).
Under the no disruption-no load, no disruption-loaded, and disrupted TFCC conditions, the highest intra-articular pressures were recorded in supination. Compared with the no-load condition, pressure was greater in the no disruption-loaded condition with a mean difference (MD) of 1.57 kg/cm² in a neutral position. In flexion, pressure was greater with a disrupted TFCC (MD, 4.3 kg/cm²). In supination, pressure was only greater with a disrupted TFCC (MD, 3.3 kg/cm²), and pressure decreased in the other disruption conditions. The pressures recorded did not differ from the no disruption-no load condition in pronation or extension.
Pressures within the DRUJ changed with forearm rotations. In the no disruption-no load, no disruption-loaded, and disrupted TFCC conditions, intra-articular pressure was highest in supination. In flexion and supination with load and disruption of stabilizers, intra-articular pressure only increased significantly in the disrupted TFCC condition compared with no load.
Based on our findings, exercises in supination should be avoided during the first phase of rehabilitation of TFCC injuries given the increased pressure on the DRUJ.

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Current conceptThe Distal Interosseous Membrane: Current Concepts in Wrist Anatomy and Biomechanics

Section snippets

Anatomy of the DIOM

Length change during pronosupination

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Current concept
The Distal Interosseous Membrane: Current Concepts in Wrist Anatomy and Biomechanics