Quantitative assessment of the course of distal radioulnar joint instability

Abstract

Introduction

There is a lack of methods to objectively evaluate improvement in distal radioulnar joint (DRUJ) instability through treatment. We used ultrasonography to assess DRUJ instability and calculated the minimal detectable change (MDC) in healthy individuals. MDC was used to evaluate post-treatment changes in a patient with triangular fibrocartilage complex (TFCC) injury.

Methods

DRUJ instability was evaluated using force-monitor ultrasonography in eight healthy male participants to determine MDC and in a man in his 60s who underwent surgery and rehabilitation for TFCC injury (Palmer classification: type 2C). In the patient, DRUJ instability was measured pre-operatively, 3 months postoperatively, and 1 year post-operatively. Self-reported hand and upper limb functional ability were also recorded. The transducer of the force-monitor ultrasonographic system was used to apply cyclic compressions to the wrists automatically and measure DRUJ displacements. The amount of displacement was calculated using the distance between the radius and ulna before and during cyclic compression to the wrists. The applied pressure was measured as the force to the wrist, and the displacement-to-force ratio was calculated.

Results

The 95% confidence MDC₉₅ for radioulnar displacement, displacement force, and displacement-to-force ratio were 0.27–0.31 mm, 0.30–0.59 N, and 0.12–0.15 mm/N, respectively. The patient’s post-operative decrease in displacement exceeded the MDC₉₅. DRUJ stability, pain, and use of the affected hand in daily life improved.

Discussion

Force-monitor ultrasonography can quantitatively evaluate post-treatment improvement in DRUJ stability over time. MDC for DRUJ instability can assess recovery after treatment or rehabilitation and determine changes resulting from interventions.

Keywords

Instability distal radial ulnar joint triangular fibrocartilage complex injury minimal detectable change

Introduction

Distal radioulnar joint (DRUJ) instability is a condition in which the ulna is unstable in the volar-dorsal plane relative to the radius. DRUJ instability due to triangular fibrocartilage complex (TFCC) injury is associated with pain on the ulnar side of the wrist joint and weakness of the forearm pronator and supinator muscles.¹ Manual tests, such as the ballottement test² and piano key test,³ are used to clinically assess DRUJ instability. However, these evaluations are not quantitative as the results are binary (positive or negative), making it difficult to measure any post-treatment improvement.

Recently, a diagnostic method using ultrasonography was developed to quantitatively assess DRUJ instability, allowing for the measurement of the amount of displacement and the compression force due to an external force using a strain gauge sensor.^4,5 This evaluation method has high inter-examiner reliability.⁶ Moreover, its diagnostic accuracy was confirmed by comparing healthy individuals and patients with TFCC injury and DRUJ instability.⁷ The cutoff value⁷ for distinguishing instability has been calculated; however, to our knowledge, no previous study has examined the implications of the amount of change within a single individual, that is, changes over time or improvement or deterioration after injury.

For case reports without a control group, change is interpreted using the minimal clinically important difference (MCID) to assess treatment efficacy.⁸ The minimal detectable change (MDC), a type of MCID, refers to the smallest numerical value of change that exceeds the measurement error. Post-treatment changes below the MDC are considered measurement errors; conversely, changes above the MDC indicate a true change above the measurement error due to intervention.⁹ MDC is an important index for verifying the amount of change before and after an intervention in clinical settings. Therefore, it would be useful to refer to MDC in the evaluation of DRUJ instability when interpreting clinical changes.

We hypothesized that calculating MDC may allow clinicians and researchers to estimate whether changes in DRUJ instability are greater than the measurement error. Accordingly, this study aimed to calculate the MDC of the assessment of DRUJ instability using ultrasonography and assess whether changes exceeding the measurement error are detectable in an individual after surgical intervention and rehabilitation for a TFCC injury.

Methods

The study protocol was registered at ClinicalTrials.gov (NCT03658096) and was approved by the appropriate ethics committees of the Tokyo Medical University Ibaraki Medical Center (approval number: 17–26) and the Ibaraki Prefectural University of Health Sciences (approval number: 788). Participants were recruited through a poster displayed in the hospital or direct contact. Written explanations were provided to all study participants, and informed consent was obtained.

Evaluation of distal radioulnar joint instability using ultrasonography

To assess instability, force-monitor ultrasonography⁴ was used to record the dynamic behaviour of DRUJ when subjected to external forces (Figure 1).

Figure 1.

Measurement conditions of DRUJ stability using ultrasonography. DRUJ, distal radial ulnar joint.

The probe (linear array transducer) of an ultrasound device (Hi Vision Avius; Hitachi, Tokyo, Japan) was attached to a cyclic compression apparatus to automatically compress the ulna head in the palmar direction and release. The device was also equipped with a dynamic force processor (F381A, Unipulse, Tokyo, Japan) integrated with a strain gauge sensor to measure the amount of force applied to the wrist joint.

All measurements were performed in a comfortable sitting posture with an abducted shoulder joint, flexed elbow joint, and pronated forearm. A previous study reported that the ulnar head was positioned more dorsally in the forearm pronated position than in the forearm supination position.¹⁰ The entire forearm was positioned horizontally on the support table. To stabilize the pisiform and radius, a support was placed against the distal surface of the forearm, which was also stabilized at the required position. Cyclic compression apparatus settings (vertical movement width, 3.0 mm; and compression cycle, 1.5 Hz) were based on the highest interrater reliability stated in a previous report.⁶ To ensure that the participant’s posture was similar in all measurements, cross-sectional images of DRUJ were depicted on the screen of the ultrasonographic device to ensure that the limb was immobilized at a position where the ulna head was at its widest diameter. Furthermore, the center of the distal end of the ulna was positioned at the middle of the screen. An ultrasonic gel was applied to the dorsal side, and the ultrasound probe was positioned in contact with the skin. Using the probe, automatic compression was applied repetitively from the dorsal aspect of the ulnar head to the palmar direction.

Cross-sectional images taken before and during compression were imported into the Image J Software (version 1.53e, National Institutes of Health, USA). The amount of DRUJ displacement (displacement X) was calculated as shown in Figure 2.

Figure 2.

Technique for measuring distal radioulnar joint instability. DR, distal radius; UH, ulnar head; X, amount of displacement; A, distance to the dorsal side of the radius; and B, distance to the dorsal side of the ulna. The distance from the surface of the probe was measured for each landmark. Formula: Amount of displacement X = distance between the radius and the ulna before compression X₁ (distance to the dorsal surface of the radius A₁-distance to the dorsal surface of the ulna B₁)-the distance between the radius and the ulna at volar compression position X₂ (distance to the dorsal surface of the radius A₂-distance to the dorsal surface of the ulna B₂).

Images were recorded while pressure was being directly applied using the ultrasound probe, allowing for the measurement of the relative displacement of the ulna with respect to the radius. The amount of displacement X was an index of instability, and it was higher on the affected side with DRUJ instability than on the unaffected side in patients with TFCC injury.⁷ Additionally, the periodic force applied to the wrist joint before and during compression was measured by a compression force sensor as waveform data at a rate of 4000 times per second. At the beginning of measurements, this sensor was zero-set using a digital zero button.

Automatic compression was applied multiple times at a constant cycle; displacement X (mm) and applied force (N) data were obtained independently. The mean values of the amount of displacement X and applied force across the first five compression cycles from the recorded interval data were calculated and used for data analysis. Furthermore, the displacement-to-force ratio (mm/N; that is, the amount of displacement normalized to the applied force) was calculated and used as an index of DRUJ stability.

Calculation of minimal detectable change in healthy volunteers

To calculate MDC, wrist joints from healthy volunteers with no history of upper limb disorders were evaluated twice, with a 1-week interval between measurements. All measurements were performed by the same examiner (an occupational therapist with 7 years of clinical research experience).

IBM SPSS Statistics version 27.0 (IBM, New York, USA) was used for all statistical analyses. The MDCs of displacement, applied force, and displacement-to-force ratio, were calculated. MDC₉₅ (95% confidence MDC) was calculated within the margin of measurement error, with a 95% confidence interval, using the following equation⁸:

MD C_{95} = Standard error of measurement (SEM) \times \sqrt{2} \times 1.96

(1)

SEM was first calculated using the standard deviation (SD) of the difference between the measured and re-measured values (s diff) (equation (2)).¹¹ SEM was also calculated using the mean of the SDs of the measurements/re-measurements and the intra-class correlation coefficient for intra-rater reliability (equation (3)).⁸

^{1} S E M = \frac{^{s} d i f f}{\sqrt{2}}

(2)

^{2} S E M = S D \times \sqrt{1 - I C C}

(3)

Evaluation of distal radioulnar joint instability using ultrasonography in the patient with triangular fibrocartilage complex injury

The patient with TFCC injury required surgery and postoperative rehabilitation and was recruited by a poster in the hospital or direct contact as a trial of the assessment on a single individual. The inclusion criteria were (i) positive ballottement test, (ii) TFCC tear confirmed by MRI findings, and (iii) clinical symptoms. Exclusion criteria were patients with fractures or bilateral injuries and minors. Assessments of DRUJ instability in the patient with TFCC injury were performed preoperatively, at 3 months after stabilization of the repaired ligament, and follow up evaluation at 1 year after surgery. The ratio of the affected to unaffected side was calculated from measurements of the affected side at each postoperative time point relative to the preoperative measurement of the unaffected side.

Clinical assessments in the patient with triangular fibrocartilage complex injury

For the patient with TFCC injury, a numeric rating scale (NRS) was used to assess pain, with 0 indicating no pain at all and 10 indicating the worst imaginable pain.¹² The active joint range of motion (ROM) of the affected side was measured in flexion, extension, radial deviation, ulnar deviation, and forearm rotation. The grip strength of the affected and unaffected hands was measured using a grip dynamometer (T.K.K.5101, Takei Scientific Instruments Co., Ltd. Tokyo, Japan). Pain and the self-reported performance of activities of daily living were assessed using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire.¹³ NRS, ROM, and grip strength were evaluated at 3 months and 1 year postoperatively. The Quick-DASH questionnaire was distributed and evaluated at 1 month, 3 months, and 1 year postoperatively.

Results

Calculation of minimal detectable change for distal radioulnar joint instability

The demographics of healthy volunteers are presented in Table 1. Table 2 presents values from the first and second measurements in healthy individuals and the MDCs using equations (2) and (3) to calculate SEM.

Table 1.

Demographics of participants when calculating MDC and a patient with TFCC injury.

Variable	Healthy volunteers (n = 8)	Patient with TFCC injury (n = 1)
Sex (n)	Men (8)/Women (0)	Man (1)
Age (years) mean ± SD	31.8 ± 2.3	60s
Age range (years)	29–35	—
Dominant side (n)	Right (7)/Left (1)	Right
Occupation	Educational instruction, teacher (2)	Maintenance and repair workers
	Office clerks (2)
	Medical scientist (1)
	Healthcare practitioners, therapist (3)

Table 2.

MDCs in healthy volunteers.

Variable	Mean ± SD (min–max)		s diff ICC (95% CI)	¹SEM	¹MDC₉₅
Variable	1^st measurement	2^nd measurement	s diff ICC (95% CI)	²SEM	²MDC₉₅
Displacement (mm)	0.69 ± 0.23	0.62 ± 0.22	0.16	0.11	0.31
Displacement (mm)	(0.33 – 1.03)	(0.22 – 0.91)	0.81 (0.55 – 0.93)	0.10	0.27
Applied force (N)	2.70 ± 0.31	2.67 ± 0.17	0.15	0.11	0.30
Applied force (N)	(2.39 – 3.58)	(2.45 – 3.12)	0.20 (−0.30 – 0.62)	0.21	0.59
Displacement-to-force ratio (mm/N)	0.26 ± 0.10	0.23 ± 0.09	0.07	0.05	0.15
Displacement-to-force ratio (mm/N)	(0.09 – 0.41)	(0.08 – 0.36)	0.79 (0.50 – 0.92)	0.04	0.12

Displacement, radioulnar displacement; applied force, force applied to the wrist; displacement-to-force ratio, displacement/applied force ratio; SD, standard deviation; ICC, intra-class correlation coefficient; 95% CI, 95% confidence interval; SEM, standard error of the measurement; MDC₉₅, minimal detectable change; s diff, standard deviation of the difference; ¹equation (1) was used to calculate ¹SEM; ²equation (2) was used to calculate ²SEM.

Description of the patient with triangular fibrocartilage complex injury

A right-handed man in his 60s sustained injuries while handling heavy objects at work (Table 1). He was suffering from ulnar-side wrist pain daily. The ulnocarpal stress test¹⁴ induced ulnar-side wrist pain, and the DRUJ ballottement test^2,15 showed DRUJ instability. Magnetic resonance imaging revealed a degenerative tear in the TFCC on the right side. The patient was classified as having a type 2C injury according to the Palmer¹⁶ classification. For surgical repair, arthroscopic synovectomy and TFCC suturing were performed.

Orthotic and occupational therapies were initiated for the patient after 4 weeks of splint fixation with slight wrist extension. Custom-made orthosis reduced the load on the wrist joint with slight wrist extension and in the neutral position of the radial ulnar deviation when using the affected hand daily. In occupational therapy, the joint ROM exercises were conducted with a low load from an early stage to prevent secondary impairments, such as a limited ROM and muscle weakness. At the beginning, the ROM exercises for the finger and wrist joints mainly on active exercise and mobilization were conducted once or twice a week for approximately 40 min per session, except for forearm pronation and supination (Supplementary table). Joint ROM exercises for forearm pronation and supination were conducted at 6 weeks postoperatively to improve joint ROM. Muscle strength training focused on the wrist extensor muscles and forearm pronator muscles, and the intensity of training was gradually increased. Wrist weight‐bearing exercises were gradually added, starting at 5 months postoperatively. Strengthening of the extensor carpi ulnaris muscle with electrical muscle stimulation was started at 6 months postoperatively, and the load amount was adjusted from isometric contractions to dynamic exercises in a stepwise manner. The stepwise progression of each program was adjusted for ulnar pain, a feeling of instability, and fatigue during exercise. The patient was allowed to perform without any restriction regarding work and activities of daily living, such as the handling of heavy objects, at 10 months postoperatively. Based on the patient’s pain report and DRUJ instability when using the affected hand in daily life, we instructed the patient on how to perform each movement and suggested alternative methods to avoid overloading the affected hand. For example, when carrying a heavy object at work, a feeling of instability occurred in the forearm supination position. Therefore, by performing a simulated movement and grasping in the forearm pronation position, the feeling of instability was reduced, and movement was sustained.

Evaluation of distal radioulnar joint instability using ultrasonography

The progression of DRUJ stability was demonstrated on the force-monitor ultrasonography of the patient (Table 3). DRUJ instability showed improvement 3 months postoperatively compared with the preoperative condition of the patient; this improvement was maintained at 1 year postoperatively.

Table 3.

Progression of DRUJ stability postoperatively.

		Preoperatively	3 months postoperatively	1 year postoperatively
Displacement	Affected side (mm)	0.64	0.35	0.30
	Unaffected side (mm)	0.20	—	—
	Affected/unaffected ratio	3.22	1.74	1.48
Applied force	Affected side (N)	3.75	2.26	2.42
	Unaffected side (N)	3.12	—	—
	Affected/unaffected ratio	0.83	0.60	0.65
Displacement-to-force ratio	Affected side (mm/N)	0.21	0.15	0.12
	Unaffected side (mm/N)	0.05	—	—
	Affected/unaffected ratio	3.87	2.89	2.29

DRUJ, distal radial ulnar joint; displacement, radioulnar displacement; applied force, force applied to the wrist; and displacement-to-force ratio, displacement/applied force ratio.

The clinical course of the patient with triangular fibrocartilage complex injury

The clinical assessment of the patient over time is presented in Table 4. Upper limb function and performance of activities of daily living improved. Additionally, the patient returned to work 1 month postoperatively but did not handle heavy objects; he gradually adjusted to the workload with rehabilitation. At 10 months postoperatively, the patient was able to fully return to work, meaning that he resumed all of his duties normally with the same frequency and continued handling heavy objects.

Table 4.

The clinical course of the patient with TFCC injury.

		1 month postoperatively	3 months postoperatively	1 year postoperatively
NRS		—	3.0	0–1^a
ROM	Flexion (°)	30	45	60
	Extension (°)	30	55	60
	Radial deviation (°)	—	—	20
	Ulnar deviation (°)	—	—	55
	Forearm pronation (°)	—	70	80
	Forearm supination (°)	—	50	90
Grip strength	Affected side (N)	—	235.3	379.5
Grip strength	Unaffected side (N)	—	353.0	297.1
Quick DASH	Disability/symptom score	61	30	16
Quick DASH	Work score	69	19	13

NRS, numeric rating scale; ROM, range of motion; and DASH, Disabilities of the Arm, Shoulder, and Hand.

^a0 at rest and 1 at weight-bearing or maximum ulnar deviation.

Discussion

To aid in the interpretation of changes in DRUJ instability in patients with a TFCC injury, repeated measurements in healthy volunteers were analyzed, and measurement errors were calculated using two different equations. The MDC₉₅ was between 0.27 and 0.31 mm for the amount of displacement, between 0.30 and 0.59 N for applied force, and between 0.12 and 0.15 mm/N for the displacement-to-force ratio. In the patient, assessment using force-monitor ultrasonography showed reduced DRUJ instability and improved wrist pain and use of the affected hand in daily life, suggesting a relationship between this quantitative assessment and important clinical parameters.

As statistically significant differences do not necessarily imply clinical significance, MCID has been increasingly used as an indicator of clinical relevance.⁸ The methods for determining MCID can be classified into distribution-based and anchor-based methods. Using the former method, MDC was calculated by conducting measurements and re-measurements to determine when changes are within or exceed the measurement error. Based on the results, changes in the same hand exceeding 0.27–0.31 mm in the amount of displacement, 0.30–0.59 N in applied force, and 0.12–0.15 mm/N in the displacement-to-force ratio, were considered greater than the measurement error. Thus, in this patient, radioulnar displacement changed more than the measurement error at 1 year postoperatively. The applied force to the wrist was lower postoperatively than preoperatively. However, the applied force to the wrist depends on the degree of compression at the initial position of the forearm and probe and varies with each measurement setup; this force alone cannot be an indicator of instability. Therefore, the change in the patient was verified using the normalized value of the displacement-to-force ratio as an indicator. In this patient, the displacement-to-force ratio changed less than the measurement error 1 year postoperatively.

Evaluations using ultrasonography have advantages over other imaging modalities, such as a lower risk of radiation exposure and suitability for dynamic assessment than computed tomography or dynamic X-ray. A method of assessment of radioulnar displacement during hand loading using ultrasonography was reported by Hess et al.¹⁷ It has been reported that the cutoff value for distinguishing pathological instability in patients with TFCC injury had good discrimination ability (88% sensitivity and 81% specificity). Another option is the method used in the current study, which allows for measuring the relationship between the applied force and the amount of displacement. As such, the dynamic reaction may be evaluated as DRUJ instability with even a small amount of automatic external force. Similarly, the method used in this study has a reported sensitivity of 82% and specificity of 86% (cutoff value of the affected/unaffected ratio = 1.71) for radioulnar displacement and a sensitivity of 73% and specificity of 82% (cutoff value of the affected/unaffected ratio = 1.68) for the displacement-to-force ratio.⁷ In the patient with TFCC injury, the displacement-to-force ratio was not below the cutoff value of the affected/unaffected ratio, but the radioulnar displacement improved to below the cutoff value of the affected/unaffected ratio 1 year postoperatively. Previous studies have verified the reliability and validity of assessing DRUJ instability,^6,18 but none have assessed MDC. Accordingly, no previous case report has quantitatively evaluated DRUJ instability by examining the clinical course of improvements before and after treatment or rehabilitation.

Previous studies have reported the MCID and MDC of the Quick DASH, a questionnaire-based evaluation used in orthopedic disorders of the upper extremities. Quick DASH has been utilized in various disorders; its MCID ranges between 3.5 and 25.8 points, and its MDC ranges between 10.8 and 27.6 points.^19–23 The improvement in the patient exceeded 27.6 points at 1 year postoperatively, suggesting a true improvement that exceeded the measurement error. Self-administered evaluations using the Quick DASH have also been on patients with DRUJ instability.^24,25 Therefore, combining the self-administered Quick DASH with a quantitative indicator from the present study may help verify the effects of interventions.

In addition to surgical treatment, improving the patient’s amount of displacement of DRUJ could be due to joint protection with postoperative orthotic therapy and graded muscle strength training. Strength training focused on wrist extension and forearm pronation, targeting the extensor carpi ulnaris²⁶ and the pronator quadratus,^27,28 which are supporting tissues contributing to the stability of DRUJ. However, considering both the previously reported cutoff value of the displacement-to-force ratio and MDC calculated in the present study, DRUJ instability in the patient with TFCC injury may not have sufficiently improved. One year postoperatively, the patient still had slight pain under weight-bearing conditions or maximum ulnar deviation. Reduced weight-bearing capacity is typical after TFCC lesions.²⁹

This study has several limitations. First, DRUJ instability measurement using the assessment method in this study may be affected by hypermobility. Additionally, the demographics of healthy volunteers and patients with TFCC injury were not equivalent. However, in a previous study, in healthy participants, there were no significant differences in radioulnar displacement and the displacement-to-force ratio between the 30-year-olds and other age groups.⁵ Moreover, there were also no significant differences in radioulnar displacement or the displacement-to-force ratio between the male and female groups. Therefore, it seems possible to refer to MDC values calculated in this study for patients of other ages and sex. Second, preoperative hand function and functional ability were not evaluated in detail. It was also necessary to follow up on changes over time by performing preoperative and postoperative evaluations as much as possible. Third, because our study largely included assessments conducted on healthy individuals, MCID was difficult to calculate. Thus, when this concept is applied to patients with a TFCC injury, MDC and cutoff values distinguishing pathological instability should be carefully considered. Fourth, stepwise rehabilitation was conducted according to the postoperative condition of the patient; however, treatment procedures were not performed with reference to the DRUJ instability indicator. For future clinical practice, it is necessary to consider rehabilitation methods based on indicators of DRUJ instability. Finally, based on our clinical experience, DRUJ instability may not always be consistent with the recovery of clinical symptoms. As such, there is a need to investigate the relationship between quantitative indicators of DRUJ instability and clinical symptoms in more cases. It is also necessary to measure not only changes in test-retest values in the affected hand, but also the ratio of the affected hand to the unaffected hand. In addition to the quantitative assessment of DRUJ instability, a wide range of assessments, including self-reported questionnaires and hand functions, should be considered comprehensively.

In conclusion, the MDC for DRUJ instability on force-monitor ultrasonography as defined in the present study can be useful to assess recovery status after treatment or rehabilitation and determine changes resulting from interventions.

Supplemental Material

Supplemental Material - Quantitative assessment of the course of distal radioulnar joint instability

Supplemental Material for Quantitative assessment of the course of distal radioulnar joint instability by Hiroshi Yuine, Yuichi Yoshii, Kazuhiro Miyata and Hideki Shiraishi in Hand Therapy

Supplemental Material

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the internal funds of the Ibaraki Prefectural University of Health Sciences and Tokyo Medical University, Ibaraki Medical Center, and a Japanese Society for the Promotion of Science KAKENHI grant (Grant Number JP20K19314).

Ethical approval

The study protocol was approved by the appropriate ethics committees of the Tokyo Medical University Ibaraki Medical Center (Approval Number 17–26) and the Ibaraki Prefectural University of Health Sciences (Approval Number 788).

Informed consent

Written explanations were provided to all study participants and informed consent was obtained.

Guarantor

Author contributions

HY contributed to the study design, data acquisition and analysis, and manuscript writing. YY contributed to the study concept, design, data acquisition and analysis, and manuscript revision. KM contributed to the data interpretation and analysis, and manuscript revision. HS contributed to the data analysis and interpretation and manuscript revision. All authors have read and approved the final submitted manuscript.

Trial registration

The study protocol was registered at (NCT03658096).

ORCID iD

Hiroshi Yuine

Supplemental Material

Supplemental material for this article is available online.

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