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DRUJ Procedures — Darrach, Sauvé-Kapandji & Ulnar Shortening

Comprehensive surgical technique guide for distal radioulnar joint procedures including Darrach resection arthroplasty, Sauvé-Kapandji arthrodesis with pseudarthrosis, ulnar shortening osteotomy for ulnar impaction syndrome, and TFCC anatomy

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High-yield overview

DRUJ dysfunction: match procedure to patient. Darrach (elderly/low demand) vs Sauvé-Kapandji (young/active) vs USO (ulnar impaction). Know TFCC anatomy and ulnar variance measurement. | advanced

Surgical Imaging

DRUJ and triangular fibrocartilage complex anatomy
DRUJ and TFCC anatomy: sigmoid notch, ulnar head and fovea, dorsal and volar radioulnar ligaments, articular disc and ECU subsheath. The TFCC is the primary stabiliser of the DRUJ.Credit: AI-generated medical image · OrthoVellum
Darrach, Sauve-Kapandji and ulnar shortening osteotomy compared
Salvage options compared: Darrach distal ulna resection, Sauvé–Kapandji (DRUJ fusion + proximal pseudarthrosis retaining the ulnar head), and ulnar shortening osteotomy with a compression plate.Credit: AI-generated medical image · OrthoVellum
DRUJ instability clinical and radiographic assessment
Assessing DRUJ instability: the piano-key sign (dorsally prominent ulnar head springs back when depressed) and dorsal–volar ballottement against the sigmoid notch, always compared to the contralateral side. CT in pronation/neutral/supination is the gold standard.Credit: AI-generated medical image · OrthoVellum

Critical Exam Concepts — DRUJ Procedures

Darrach vs Sauvé-Kapandji

Patient selection is THE exam question

Darrach: elderly, low demand, RA, poor bone quality — resect 1.5-2cm distal ulna

Sauvé-Kapandji: young active, RA (preserve carpal support), failed Darrach — DRUJ arthrodesis + pseudarthrosis 1cm proximal

Never offer Darrach to a young active patient — convergence syndrome and instability significantly impact function

Ulnar Translation (Post-Darrach)

Most important Darrach complication

After distal ulna resection, the ulnar buttress for the carpus is lost

Carpus (and hand) translates ulnarly over time on the distal radius

Progressive deformity, weakness, pain

Sauvé-Kapandji preserves ulnar stump as carpal support, preventing this complication

Risk higher in RA and ligamentous laxity

Convergence Syndrome

Post-Darrach painful instability

Definition: painful approximation of the ulnar stump toward the radius under axial load or pronation/supination

Presentation: painful click, clunk, or catching during forearm rotation; weak grip

Incidence: 20-30% after Darrach in active patients

Management: stabilisation procedure (ECU tenodesis, FCU sling), Bowers hemiresection, DRUJ prosthesis (Aptis, UHMWPE)

Ulnar Variance Measurement

Technique critical for exam

Standard PA radiograph: shoulder abducted 90°, elbow flexed 90°, forearm neutral rotation, beam perpendicular to wrist

Zero variance: radius and ulna same length at articular surface

Positive variance: ulna longer than radius (associated with ulnar impaction)

Negative variance: radius longer than ulna (associated with Kienbock's disease)

Dynamic positive variance: with grip/pronation; static measurements may underestimate

TFCC Anatomy (5 Components)

Comprehensive anatomy — exam favourite

  1. Central articular disc: horizontal fibrocartilage, weight-bearing surface

  2. Dorsal radioulnar ligament: stabilises DRUJ in pronation

  3. Volar radioulnar ligament: stabilises DRUJ in supination

  4. Meniscus homologue: ulnar border, provides cushion

  5. ECU subsheath: floor of 6th extensor compartment, DRUJ stabiliser

Foveal attachment: deep fibres of radioulnar ligaments insert at ulnar fovea (base of ulnar styloid) — critical for DRUJ stability

Piano Key Sign

Clinical test for DRUJ instability

Positive test: ulnar head depressed dorsally by examiner's thumb and springs back up like a piano key when released — indicates DRUJ instability

Normal: firm endpoint on dorsal ulnar head compression

Clinical significance: DRUJ instability (TFCC tear, post-trauma, RA) — may require stabilisation

Compare bilaterally — some laxity is physiological

Mnemonic

DRUJDRUJ — Anatomy and Components

Hook:In the exam, when asked about TFCC anatomy name all 5 components: central disc, dorsal radioulnar ligament, volar radioulnar ligament, meniscus homologue, and ECU subsheath. State the foveal attachment is critical for DRUJ stability.

Mnemonic

DARRACH-vs-SKDARRACH-vs-SK — Procedure Selection Guide

Hook:The single most important exam question about DRUJ procedures is patient selection. Young active patient = Sauvé-Kapandji. Elderly low demand = Darrach acceptable. Never say Darrach first without qualifying patient age/activity level.

Darrach Procedure — Indications

Appropriate Indications

  • Elderly, low-demand patient with symptomatic DRUJ arthritis
  • Rheumatoid arthritis with DRUJ involvement (caution: risk of ulnar carpal translation)
  • Post-traumatic DRUJ arthritis (low-demand patient)
  • Failed prior DRUJ procedures in elderly patient
  • Malunited distal radius with DRUJ incongruence (elderly)
  • Salvage of failed total wrist arthroplasty with DRUJ involvement

Contraindications

  • Young active patients — convergence syndrome risk is unacceptably high
  • Patients requiring strong grip force (manual workers, athletes)
  • Ligamentous laxity (higher ulnar carpal translation risk)
  • Isolated TFCC tear without bony pathology — too destructive
  • Ulnar variance abnormality without DRUJ arthritis — USO preferable

Sauvé-Kapandji — Indications

Preferred Over Darrach In:

  • Young active patients with DRUJ arthritis/instability
  • RA patients where ulnar carpal support must be preserved
  • Ulnar impaction syndrome with DRUJ arthritis (combined pathology)
  • Failed Darrach with convergence syndrome in active patient
  • Post-traumatic DRUJ arthritis in working-age patient

Relative Contraindications

  • Severe osteoporosis (pseudarthrosis fixation unreliable)
  • Active infection
  • Very elderly with very low demands (Darrach simpler)

Ulnar Shortening Osteotomy — Indications

Ulnar Impaction Syndrome (Ulnocarpal Abutment)

Primary indication:

  • Positive ulnar variance (typically greater than +2mm)
  • TFCC degenerative central disc tear (Palmer class II)
  • Ulnocarpal abutment — ulnar head impacting triquetrum and/or lunate
  • Lunotriquetral ligament tears secondary to impaction
  • Symptoms: ulnar-sided wrist pain, worse with grip, pronation

Shortening amount: 2-4mm typically, aiming for zero or slightly negative variance

Alternative/Supplementary Procedures

  • Wafer procedure (arthroscopic): 2-3mm distal ulna resection through central TFCC defect — less invasive, avoids osteotomy hardware but limited shortening
  • Darrach (elderly only): if concurrent DRUJ arthritis and low demand

Evidence Base

  • Darrach W 1913: original case series describing distal ulna excision for deformity after distal radius fracture
  • Sauvé & Kapandji 1936: original description of combined DRUJ arthrodesis + proximal pseudarthrosis
  • Palmer AK 1989 (PMID 2666492): definitive classification of TFCC lesions — traumatic (class I) vs degenerative (class II); used universally
  • Feldon, Terrono & Belsky 1992 (PMID 1629557): original wafer resection series — distal 2-4mm of ulnar head resected; contraindicated if positive ulnar variance greater than 4mm
  • Minami et al 2005 (PMID 16568521): direct comparison of Darrach, Sauvé-Kapandji and hemiresection-interposition in 61 wrists at mean 10-year follow-up — grip strength and return-to-work after SK and HIT were statistically superior to Darrach, which had the most complications
  • Owens et al 2018 (PMID 30342784): systematic review of 37 studies / 1,423 patients reporting an overall ulnar-shortening-osteotomy non-union rate of 4.0%, with no significant difference between transverse and oblique cuts

Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures

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Minami A, Iwasaki N, Ishikawa J, Suenaga N, Yasuda K, Kato H • Hand Surgery (2005)
Clinical Implication: In working-age patients, Sauvé-Kapandji (or hemiresection where the TFCC is intact/reconstructable) gives better grip and return-to-work than Darrach; reserve Darrach for elderly, low-demand patients with advanced DRUJ arthritis.
Verify on PubMed (PMID 16568521)

Nonunion rates among ulnar-shortening osteotomy for ulnar impaction syndrome: a systematic review

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Owens J, Compton J, Day M, Glass N, Lawler E • Journal of Hand Surgery (American) (2018)
Clinical Implication: Ulnar-shortening osteotomy is reliable with a low (~4%) non-union rate; the choice between transverse and oblique osteotomy should be based on factors other than union risk (oblique allows lag-screw compression and rotational stability).
Verify on PubMed (PMID 30342784)

Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome

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Feldon P, Terrono AL, Belsky MR • Journal of Hand Surgery (American) (1992)
Clinical Implication: The wafer procedure is a limited, less invasive option for mild ulnar impaction (positive variance up to roughly 2-4mm) with an intact DRUJ; for larger positive variance or DRUJ pathology, formal ulnar-shortening osteotomy is preferred.
Verify on PubMed (PMID 1629557)

Triangular fibrocartilage complex lesions: a classification

Guideline
Palmer AK • Journal of Hand Surgery (American) (1989)
Clinical Implication: Use the Palmer system to direct treatment: peripheral class IB tears are vascular and repairable, central class IA tears are debrided not repaired, and class II degenerative tears reflect ulnar impaction best treated by unloading the ulnocarpal joint.
Verify on PubMed (PMID 2666492)

Distal ulnar prosthetic replacement

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Scheker LR, Babb BA, Killion PE • Orthopedic Clinics of North America (2001)
Clinical Implication: A constrained DRUJ prosthesis (e.g. the Aptis/Scheker design) is a recognised salvage for painful instability after a failed Darrach resection, restoring the ulnar buttress that simple resection removes.
Verify on PubMed (PMID 11331548)

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"A 35-year-old primary school teacher presents with 18 months of right wrist pain, worst on the ulnar side. X-ray shows positive ulnar variance of 3mm. MRI confirms a central TFCC disc tear. She has no arthritis. She has failed 6 months of conservative management including splinting and physiotherapy. What procedure do you recommend and describe the key steps?"

PRACTICAL APPROACH
This young, active patient with positive ulnar variance of 3mm, a Palmer class II degenerative central TFCC tear, and no arthritis is the ideal candidate for ulnar shortening osteotomy. She is young, high demand, and has mechanical ulnar impaction syndrome — the underlying cause is positive ulnar variance compressing the ulna against the TFCC and proximal carpal row. The Darrach procedure would be inappropriate here as she is young and active, risking convergence syndrome and functional compromise. The Sauvé-Kapandji is designed for DRUJ arthritis, which she does not have. USO addresses the root cause by unloading the ulnocarpal joint. Key steps: medial forearm approach over distal ulnar shaft, subperiosteal exposure, oblique osteotomy 4-6cm proximal to DRUJ, resect a measured 3-4mm segment aiming for zero or slightly negative variance, fix with a dedicated ulnar shortening plate with 3 screws each side. Confirm variance on intra-operative fluoroscopy. Below-elbow cast 6 weeks, then rehabilitation. I would counsel her that 30% require hardware removal due to plate prominence at 12+ months.
CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"A 55-year-old retired man presents 2 years after a Darrach procedure performed elsewhere. He complains of a painful click and giving way in his right wrist during forearm rotation, and his grip is very weak. On examination you note medial forearm pain and a palpable clunk when loading the wrist in pronation. What complication has occurred and how do you manage it?"

PRACTICAL APPROACH
This clinical picture is consistent with convergence syndrome — the most important complication of Darrach procedure. After distal ulna resection, the ulnar stump lacks the sigmoid notch constraint and approximates the radius under axial load and forearm rotation, causing painful catching and impingement. Incidence is 20-30% in active patients, which is why Darrach should not be performed in younger or active individuals. Management depends on severity. Initial conservative measures — splinting, physiotherapy, activity modification — rarely solve the problem once established. Surgical options include soft tissue stabilisation procedures such as ECU tenodesis (rerouting ECU volar to the ulnar stump to act as a dynamic restraint) or an FCU sling around the stump. If these fail, Bowers hemiresection-interposition arthroplasty or a formal DRUJ prosthesis (such as the Aptis device, an ulnar head implant) provides reliable salvage. I would discuss with the patient that this is a recognised complication of the initial surgery and that outcomes of revision surgery are acceptable but not guaranteed to fully restore function.
CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"A 42-year-old nurse with rheumatoid arthritis has progressive DRUJ instability and pain. She has Larsen grade 3 RA changes at the wrist. Her piano key sign is markedly positive. She is still working full time and requires good hand function. What DRUJ procedure do you recommend and why?"

PRACTICAL APPROACH
For this young, working, active patient with RA and DRUJ involvement, I would recommend the Sauvé-Kapandji procedure rather than a Darrach. The key reason is carpal support preservation: RA patients are already at significant risk of ulnar carpal translation due to ligamentous laxity and synovitis. Darrach removes the ulnar buttress and would accelerate this deformity. The Sauvé-Kapandji fuses the ulnar head in its anatomical position at the DRUJ — preserving the ulnar carpal support — while creating a proximal pseudarthrosis 1-1.5cm proximal to the fusion to maintain forearm rotation. Surgical technique: dorsal approach between 5th and 6th compartments, strip DRUJ articular surfaces, fix with 2 cannulated screws in neutral rotation, resect 1-1.5cm segment proximal to fusion, interpose soft tissue in pseudarthrosis gap. I would address the positive piano key sign (DRUJ instability) by confirming TFCC status at surgery. RA-specific considerations: tissue quality is poor, use screws rather than K-wires for fusion, add ECU subsheath repair, and plan post-operative above-elbow cast for 6 weeks given unreliable healing. I would also assess the remainder of the wrist and MCP joints to plan any concurrent procedures.

DRUJ Procedures — Exam Day Essentials

Clinical summary

References

  1. Darrach W. Partial excision of the lower shaft of the ulna for deformity following Colles' fracture. Ann Surg 1913;57(5):764-5. [Original description of distal ulna resection for DRUJ dysfunction]

  2. Sauvé L, Kapandji M. Nouvelle technique de traitement chirurgical des luxations récidivantes isolées de l'extrémité inférieure du cubitus. J Chir (Paris) 1936;47:589-94. [Original description of DRUJ arthrodesis with proximal pseudarthrosis creation]

  3. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989;14(4):594-606. PMID: 2666492. doi:10.1016/0363-5023(89)90174-3. [Definitive classification of TFCC injuries — Palmer class I (traumatic) and class II (degenerative), used universally]

  4. Feldon P, Terrono AL, Belsky MR. Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg Am 1992;17(4):731-7. PMID: 1629557. doi:10.1016/0363-5023(92)90325-j. [Original wafer procedure series; distal 2-4mm resection, contraindicated if positive variance greater than 4mm]

  5. Minami A, Iwasaki N, Ishikawa J, Suenaga N, Yasuda K, Kato H. Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures. Hand Surg 2005;10(2-3):243-8. PMID: 16568521. doi:10.1142/S0218810405002942. [Darrach vs Sauvé-Kapandji vs hemiresection, 61 wrists, mean 10-year follow-up; SK/HIT superior grip and return-to-work vs Darrach, which had the most complications]

  6. Minami A, Iwasaki N, Ishikawa J, Suenaga N, Kato H. Stabilization of the proximal ulnar stump in the Sauvé-Kapandji procedure by using the extensor carpi ulnaris tendon: long-term follow-up studies. J Hand Surg Am 2006;31(3):440-4. PMID: 16516739. doi:10.1016/j.jhsa.2005.11.012. [ECU half-slip stabilisation of the proximal stump to address post-SK radioulnar convergence]

  7. Owens J, Compton J, Day M, Glass N, Lawler E. Nonunion rates among ulnar-shortening osteotomy for ulnar impaction syndrome: a systematic review. J Hand Surg Am 2018;44(7):612.e1-612.e12. PMID: 30342784. doi:10.1016/j.jhsa.2018.08.018. [37 studies / 1,423 patients; overall USO non-union 4.0%, no difference transverse vs oblique]

  8. Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am 2002;27(2):243-51. PMID: 11901383. doi:10.1053/jhsu.2002.31731. [Anatomical reconstruction of the radioulnar ligaments restored stability in 12 of 14 patients with an irreparable TFCC and intact articular surfaces]

  9. Scheker LR, Babb BA, Killion PE. Distal ulnar prosthetic replacement. Orthop Clin North Am 2001;32(2):365-76. PMID: 11331548. doi:10.1016/s0030-5898(05)70256-x. [DRUJ/distal ulna prostheses as salvage for failed resection and convergence syndrome]