Hand Surgery, Vol. 4, No.

2 (December 1999) 109–115

© World Scientific Publishing Company

ORIGINAL ARTICLES
ANATOMICAL STUDY OF THE DISTAL RADIOULNAR
JOINT: DEGENERATIVE CHANGES AND
MORPHOLOGICAL MEASUREMENT

Ryo Yoshida, Moroe Beppu, Syoji Ishii and *Kazuaki Hirata

Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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*Department of Anatomy, St. Marianna University School of Medicine, Kawasaki, Japan

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Received 20 September 1999; Accepted 18 November 1999

ABSTRACT
A study of the degenerative changes in the distal radioulnar joint compared with morphological measurement of that joint using
91 joints of the hand from 51 systemic anatomy cadavers was conducted. X-ray images of the joints of the hand were taken
followed by measurement of radial inclination, ulnar variance, volar tilt, sigmoid notch inclination and ulnar seat inclination.
Macroscopic observations of the ulnar notch of the radius and surface of the distal radioulnar joint of the ulnar head were
made by dividing them into six and nine areas, respectively,. These were then used to classify the degree of cartilage
degeneration. In addition, the status of the triangular fibrocartilage complex (TFCC) was also observed.
Arthropathic changes of the distal radioulnar joint were associated with factors including TFC degeneration and UV(+),
SNI(−) and USI(+).

INTRODUCTION School of Medicine of St. Marianna University) was conducted.

Although there have previously been scattered reports describing
morphological measurement of the ulnar notch in anatomical
studies of the distal radioulnar joint, there are no reports
correlating this with degenerative changes in surface of articular
cartilage, including the distal radioulnar joint surface of the
ulnar head. In this study, detailed radiological measurements
and anatomical examinations of the morphology of joint surfaces,
localisation of arthropathic changes and related factors were
conducted, and these measurements were combined with an
examination of those findings.
SUBJECTS AND METHODS
The study on 91 distal radioulnar joints from 51 cadavers (used
for systemic anatomy in the Department of Anatomy at the
Fifty-six of the joints were from 30 male cadavers, while 35 joints
were from 21 female cadavers. The ages of the cadavers ranged
from 53 to 96 years, and the mean age was 78 years (males:
78 years, females: 79 years). Eighty of the joints from 40 cadavers
allowed comparative observation of the left and right sides.
Those joints exhibiting chronic rheumatoid arthritis-like changes
and those recognised to have a history of fracture were omitted
from the study.
Radiological Measurements
The arms were severed from the trunk with the scapula attached.
X-ray images of the postero-anterior and lateral views of the wrist
joint were taken at a distance of 60 cm between the tubular film
plates using a simple X-ray imaging system at 90° abduction of

Correspondence to: Department of Orthopaedic Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.

109
 110 R. Yoshida et al.
the shoulder joint, 90° of flexion of the elbow joint, the neutral
position of forearm supination and pronation, and the neutral
position of the wrist joint. These images were then used to
measure radial inclination (RI), ulnar variance (UV), volar tilt
(VT), sigmoid notch inclination (SNI) and ulnar seat inclination
(USI) (Fig. 1). An error occurred upon measuring RI due to
individual differences in flexion when the shaft of the radius was
attempted to be visualised from the postero-anterior view. To
eliminate this error, parallel lines were drawn to two locations
at proximal 3 and 6 cm from the distal end of the ulnar head
having a low degree of curvature, a line passing through their
respective centres was determined, and that line was used as the
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centre of the shaft of the ulna. RI was then taken to be the angle
formed by a line connecting the styloid process of the radius and
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the distal end of the sigmoid notch, and a line perpendicular to
the shaft of the ulna. UV was expressed in mm units as plus or
minus the distance from the distal end of the ulnar head to
palmar margin of the distal end of the sigmoid notch as
determined from the postero-anterior view. VT was determined
by drawing parallel lines at two locations — proximal 3 and
6 cm from the distal end of the radius as determined from the
side image, determining the line that passes through their
respective centres, and taking that line to be the lateral shaft of
the radius. VT was then taken to be the angle formed by a line
perpendicular to that shaft and a line connecting the dorsal edge
(a)
Fig. 1 Radiological measurement. (a) Postero-anterior view: radial inclination, ulnar variance, sigmoid notch inclination and ulnar seat inclination.
(b) Lateral view: volar tilt.
and volar edge of the lunate fossa on the distal end of the radius.
SNI was determined by drawing a vertical line from the long axis
of the ulna and determining the ulnar angle formed by that line
and the tangent of the sigmoid notch. USI was taken to be the
radial angle formed by the vertical line of the long axis of the
ulna and the tangent of the joint surface of the ulnar head.
Macroscopic Observations of Distal
Radioulnar Articular Cartilage Surface
The ulnar notch of the radius and the articular cartilage surface
of the ulnar head were divided into six and nine areas,
respectively (Fig. 2). The degree of degeneration of each area
was graded macroscopically using a scoring system in which
normal findings were given a grade of 0, erosion and fibrillation
following loss of luster a grade of 1, ulceration without exposure
of subchondral bone a grade of 2, and exposure of subchondral
bone a grade of 3. The degree of degeneration of each subarea
was taken to be the degree of degeneration of the site within that
area demonstrating the most prominent cartilage degeneration.
The degree of degeneration of the distal radioulnar joint was
assessed according to the total degree of degeneration of the 15
areas (Fig. 2).
In addition, the size of the articular cartilage surface in the
sigmoid notch (measured at each of the centres in the volar
(b)

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(a)
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Fig. 2(a) Demarcation of articular face. (b) Sigmoid notch and ulnar head.
dorsal direction and axial direction) and the position of the
sigmoid notch (subjects in which the volar edge of the sigmoid
notch was farther dorsal than a position one-fourth the total
length of the ulnar edge of the lunate fossa on the volar side
were designated as the dorsal shift type, while those in which it
was farther volar were designated as the central type) were also
observed. In addition, the status of the triangular fibrocartilage
complex (TFCC) was evaluated according to three levels based
on absence of slits (-), perforation (P) and slits (S).
Fig. 3 Position of sigmoid notch. Subjects in which the volar edge of the
sigmoid notch was farther dorsal than a position one-fourth the total length
of the ulnar edge of the lunate fossa on the volar side were designated as
the dorsal shift type, while those in which it was farther volar were
designated as the central type.
Anatomical Study of the Distal Radioulnar Joint 111
(b)
Correlations between cartilage degeneration of each area as
determined by macroscopic observations, morphologically
measured values as determined by X-ray imaging, and the
presence or absence of TFC slits were compared by regression
analysis and one-way layout analysis of variance.
RESULTS
Radiological Measurements
RI ranged from 20° to 37° and yielded a mean value of 27.9°.
VT ranged from 2° to 20° and yielded a mean value of 11.9°.
UV ranged from −2 to 3.4 mm and yielded a mean value of
0.57 mm. No significant changes were observed in RI, VT or UV
caused by aging in regression analysis. In addition, SNI ranged
from 74° to 111° and yielded a mean value of 92.9°. USI ranged
from 50° to 86° and yielded a mean value of 67.6°. There were
no significant changes observed in SNI or USI related to aging.
SNI decreased significantly accompanying increased UV
( p < 0.01) (Fig. 4). In addition, there was a negative correlation
between SNI and USI ( p < 0.01) (Fig. 5).
Anatomical Findings
When considering degeneration of the distal radioulnar joint as
the sum of the degree of degeneration of the 15 areas (although
regression analysis indicated that cartilage degeneration on the
surface of the distal radioulnar joint tends to increase with age),
there were no statistically significant differences observed. In a
 112 R. Yoshida et al.
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Fig. 4 Relationship between SNI and UV. SNI decreased accompanying
increased UV ( p < 0.01) (regression analysis).
comparison of the degeneration of the sigmoid notch and surface
of the ulnar joint, the mean degeneration of each joint surface
was found to be 1.4 and 1.6, respectively. In looking at these
findings in terms of individual areas, the mean degeneration of
91 joints was most prominent at the dorsal proximal of the
ulnar surface (Area 9), demonstrating a value of 2.09. This was
followed by the volar proximal of the ulnar surface (Area 7) —
2.01, and central proximal of the ulnar surface (Area 8) —
1.96. In the case of the sigmoid notch, degeneration of the
dorsal proximal was most prominent (Area 6) — 1.88, followed
Fig. 6 Average cartilaginous changes in demarcation.
Fig. 5 Relationship between SNI and USI. There was a negative correlation
between SNI and USI (p < 0.01) (regression analysis).
by that of the central proximal (Area 5) — 1.70 (Fig. 6). The
sigmoid notch, surface of the radioulnar joint, the respective
dorsal proximal, and the volar proximal of the ulnar surface
significantly demonstrated more prominent degeneration
( p < 0.01) than other areas as determined by the t-test.
In the relationship between UV and cartilage degeneration of
the entire distal radioulnar joint, larger values of UV resulted in
significantly more prominent degeneration ( p < 0.01) (Fig. 7).
Fig. 7 Relationship between UV and degeneration sites of DRUJ. Larger
values of UV were associated with more prominent cartilage degeneration
of DRUJ ( p < 0.01) (regression analysis).

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Fig. 8 Relationship between UV and TFCC. Degeneration of TFCC was
more prominent in cases of large values of UV ( p < 0.01) (one-way layout
analysis of variance).
With respect to the status of TFCC, there were 34 cases of no
slits (37.4%), 19 cases of perforation (20.9%) and 38 cases in
which slits were present (41.7%). Larger values for UV resulted
in prominent TFCC degeneration (p < 0.01) (Fig. 8). In the
relationship between TFCC status and cartilage degeneration,
cases exhibiting prominent TFCC degeneration were demonstrated
Fig. 9 Relationship between SNI and degeneration sites of sigmoid notch.
Degeneration of the sigmoid notch regressed as SNI increased ( p < 0.01)
(regression analysis).
Relationship between USI and degeneration sites of DRUJ and sigmoid
notch. Degeneration of the sigmoid notch and overall degeneration of DRUJ
became more prominent as USI increased ( p < 0.01) (regression analysis).
Anatomical Study of the Distal Radioulnar Joint 113
to also exhibit prominent cartilage degeneration ( p < 0.01).
With respect to the relationship with SNI, degeneration of the
sigmoid notch decreases as SNI increased ( p < 0.01), while the
sum of sigmoid notch degeneration and cartilage degeneration
increases as USI increased ( p < 0.01) (Fig. 9). The length of
the sigmoid notch in the volar dorsal direction ranged from 7.4
to 14.2 mm with a mean value of 11.9 mm, and from 3.6 to
9.2 mm with a mean value of 5.6 mm in the axial direction. The
position of the sigmoid notch was of the dorsal shift type in 74
cases (81.3%) and of the central type in 17 cases (18.7%).
Statistical analysis of the relationship between position of the
sigmoid notch and cartilage degeneration by one-way layout of
variance revealed the central type to exhibit significantly more
prominent degeneration as compared with the dorsal shift type
( p < 0.01) (Fig. 10).
Fig. 10 Relationship between sigmoid notch type and degeneration sites
of DRUJ. Subjects of the central type exhibited more prominent degeneration
of DRUJ than subjects of the dorsal shift type ( p < 0.01) (one-way layout
analysis of variance).
DISCUSSION
Simple X-Ray Findings
RI and VT continue to be widely used as indicators of morphology
of joints of the hand.4 Although RI is typically measured using
the long axis of the radius for the axis, the RI in this study was
measured using the long axis of the ulna for the axis because
of its low degree of curvature following the method of Ishii,9
thereby obtaining results that resembled the report of Gartland
et al. Although Sadahiro et al.16 postulated that RI decreases
 114 R. Yoshida et al.
with aging, it was reported that this was unable to be proven
statistically. Although in this case, the value of RI also tended to
decrease with aging, it was impossible to prove this statistically.
Although the measured values obtained in this study for VT also
resembled the report of Gartland et al., the increase caused by
aging as postulated by Sadahiro et al. was unable to be verified.
UV has also been reported to increase accompanying
aging.5,10,12,14 Although this trend was also observed in the
measurements made in this study, it was unable to be proven
statistically. The values of SNI obtained were extremely close to
the range of 69° to 115° and mean value of 91.7° as described
by Hatano et al.8 Although Hatano et al. reported a negative
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correlation between SNI and UV, and the results obtained in this
study also showed SNI to decrease significantly accompanying
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increased UV. This finding suggested that UV is an important
factor for determining SNI.
If the values described in the report of Sagerman et al.17 are
converted to the measurement method used in this study, the
values of USI range from 49.5° to 103.8°, with a mean value of
69°, and closely approximate the measured values obtained in
this study. Although the measurements made in this study proved
that USI increases with decreased SNI, this is similar to the result
obtained by Sagerman et al. There was no clear correlation
observed between USI and UV in the measurements made in this
study.
Cartilage Degeneration
Although Tsuda,18 Kimura10 and Ishii et al.9 of this department
reported on the lenticular triangular joint, carpal bones and
ulnar head, radiocarpal joint and so forth in morphological
measurements and observation of the degree of degeneration on
the surface of articular cartilage, there have as yet been no
reports relating to the distal radioulnar joint, and specifically, the
ulnar head joint surface. This study examined degenerative
changes on the articular cartilage surface through in-depth
observation of this site.
The distal radioulnar joint is a trochoid joint composed of the
sigmoid notch forming an indentation and the ulnar head forming
a protrusion. Since the radius of curvature of the sigmoid notch
is greater than that of the ulnar head, simultaneous to rotating
about the ulna as its axis, the ulnar head also moves in the volar
dorsal direction during supination and pronation of the forearm.
In addition, during supination of the forearm, the ulnar head is
positioned on the volar side relative to the radius, resulting in
negative variance of the ulna, while the opposite motion occurs
during pronation.3,15 Although degeneration of the cartilage
surface on the volar dorsal proximal of the ulnar head was
significantly more prominent in the observations made in this
study (when considered from the perspective of the difference
in inclination with SNI being about 93° and USI being about
68°), it is believed that when the variance of the ulna changes
due to supination and pronation of the forearm, the side of the
centre closest to the joint surface is more susceptible to making
contact, thereby resulting in more prominent degeneration of the
ulnar joint surface that serves as the axis.
The occurrence of incompatibility of the distal radioulnar joint
along with the formation of bone spurs on the side of the ulnar
head proximal are frequently observed in cases of malunion of
distal radius fractures. In addition, if joint incompatibility is left
uncorrected for an extended period of time following ulnar
retrenchment performed for treatment of ulnar protrusion
syndrome or distal radioulnar joint instability, there are numerous
occurrences of hypoformation of the sigmoid notch.11 It is
therefore necessary to consider SNI and USI in order to prevent
arthropathic changes of the distal radioulnar joint occurring due
to post-surgical incompatibility. Since the joints of the hand
normally move in the pronated position during the course of
daily life, contact with the dorsal side of the sigmoid notch
becomes prominent on the cartilage surface of the distal
radioulnar joint,1,2 and this is suspected of contributing to
increased cartilage degeneration. According to the measurements
made in this study, cartilage degeneration of the distal radioulnar
joint increased significantly with increase in USI. This suggests
the possibility that USI can be an indicator in the same manner
as UV, etc. when regressive changes are suspected based on
X-ray images.
In addition, statistical results were obtained which indicated
that degeneration of the cartilage surface of the distal radioulnar
joint becomes prominent accompanying the presence of slits in
the TFCC. Owing to its complex structure, the TFCC provides
support on the ulnar side of the joints of the hand, namely
between the distal radius and ulna and between the ulna and
carpal bones.13 When this is considered, it suggests a correlation
between joint instability and degeneration of cartilage surface of
the distal radioulnar joint, although there is still the need to
conduct in-depth studies focussing on the correlation with the
structure and functions of the TFCC itself, interosseous
membranes and muscles, joint capsule and other tissues, along
with an examination of the proximal radioulnar joint.

According to the literature with respect to the size of the
sigmoid notch,6 the length in the volar dorsal direction in
Americans and Europeans is indicated as being about 15 mm,
while the width is about 10 mm. Although the measured values
obtained in this study were about 20% smaller with respect to
length in the volar dorsal direction and about 42% smaller with
respect to width, they resemble the values reported by Hatano
et al.7 This can be said to support the theory proposed by
Hatano et al. describing individual differences in the case of
comparing Japanese with Americans and Europeans.
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CONCLUSIONS
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1. In measurements made from X-ray images, SNI decreased
significantly with increased UV. In addition, a negative
correlation was observed between SNI and USI.
2. Articular cartilage degeneration became increasingly
prominent with increased UV and increased USI. SNI and USI
were suggested to be factors involved in arthropathic changes
of the distal radioulnar joint.
3. Changes in articular cartilage were the most prominent in the
dorsal proximal of the ulnar surface, and were also prominent
in the volar proximal of the ulnar surface and central proximal
of the ulnar surface in that order. In addition, degeneration
was significantly more prominent in the dorsal proximal on
the joint surface of the radius and the volar dorsal proximal
on the joint surface of the ulna in comparison with other
areas.
4. Cartilage degeneration was more prominent in the presence
of TFCC slits than in the absence of TFCC slits.
5. Although regressive changes of articular cartilage tended to
become more prominent with age, this was unable to be
proven statistically.
ACKNOWLEDGEMENTS
I would like to express my appreciation to Dr. Haruhito Aoki,
Chief Professor of the Department of Orthopaedic Surgery at the
School of Medicine of St. Marianna University for his guidance
Anatomical Study of the Distal Radioulnar Joint 115
and editing of this paper. (The abstract of this paper was
presented at the 42nd Meeting of the Japan Hand Surgery Society.)
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