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Journal of Hand Surgery

(European Volume)
Ligaments and muscles stabilizing the 2022, Vol. 47(1) 65–72
! The Author(s) 2021
radio-ulno-carpal joint Article reuse guidelines:
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DOI: 10.1177/17531934211042316
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Marc Garcia-Elias1, Dirck Ananos2 , Mireia Esplugas1,
Elisabet Hagert3,4, Carlos Heras-Palou5 and Sanjeev Kakar6

Abstract
The technical simplicity of the Darrach procedure may explain why it has been so popular. Excising the distal
ulna, however, may have potentially undesired consequences to the biomechanics in two areas: the distal
radioulnar and the ulno-carpal joints. These conjointly define the radio-ulno-carpal joint (RUCJ). The RUCJ is
not a small and irrelevant articulation that can be removed without possibly paying a functional penalty. It is
an important link of the antebrachial frame that provides stability to the distal forearm and the carpus. This
article revisits the mechanisms by which some ligaments and muscles ensure that all forces about and within
the RUCJ are dealt with efficiently.

Keywords
Radio-ulno-carpal joint, wrist biomechanics, wrist stabilization, distal radioulnar joint, triangular fibrocarti-
lage complex

Date received: 29th April 2021; revised: 6th August 2021; accepted: 9th August 2021

Introduction that the so-called ‘Feldon operation’ (Feldon et al.,

Palmer and Werner (1981) described the triangular
fibrocartilage complex (TFCC), which has been a
target of many investigations. Much time and
energy has been spent to clarify its function, which
still remains controversial. Is the TFCC the only
distal radioulnar stabilizer, as so often assumed?
What are the mechanical consequences of a distal
ulna excision?
Similarly, the distal radioulnar joint (DRUJ) only
describes one portion of the complex ulnar wrist
articulation. The other portion, the ulno-carpal joint
is often ignored. It is well known that the distal radio-
ulnar and the ulno-carpal joints are not independent
from each other. If this is the case, why should we
talk about one and ignore the other one?
The DRUJ is a trochlear articulation in which the
radius rotates about the ulna. If we consider the
whole ulnar wrist articulation, the radio-ulno-carpal
joint (RUCJ) is a more inclusive composite that
includes the radioulnar trochlea and the distally
convex ulnar dome, which articulates with the ulnar
aspect of the carpus (Figure 1). Failure to recognize
the importance of this joint as a whole may lead into
believing that only the DRUJ is essential. A statement
of this magnitude can lead the surgeon into accepting
1992), in which a wafer of the dome is excised, is a
perfectly logical idea.
From a kinetic point of view, the RUCJ is said to be
stable when it is capable of resisting physiologic
loads throughout the entire range of forearm prono-
supination. No matter how flexed or extended the
elbow is, a stable RUCJ will not give way unless a
non-physiological stress is applied. When stressed, a
stable RUCJ will be compressed, adjusting its inter-
nal articular coherence to become a solid block
through which forces can be dissipated. Once the
stress is over, the joint returns to its original,
1
Hand and Upper Limb Surgery, Institut Kaplan, Barcelona, Spain
2
Royal Perth Hospital, Fremantle Hand Unit, Sir Charles Gairdner
Hospital, Perth, Western Australia, Australia
3
Department of Clinical Science and Education, Karolinska
Instituten, Stockholm, Sweden
4
Musculoskeletal & Sports Injury Epidemiology Center,
Sophiahemmet University, Stockholm, Sweden
5
Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK
6
Mayo Clinic, Rochester, MN, USA
Corresponding Author:
Marc Garcia-Elias, Hand and Upper Limb Surgery, Institut Kaplan,
Passeig de la Reina Elisenda 17, 08034 Barcelona, Spain.
Email: marc@garcia-elias.cat
66
Figure 1. The structures of the radio-ulno-carpal joint
(RUCJ).
relatively unconstrained alignment without having
suffered any noticeable damage.
The RUCJ may become unstable in many different
ways, and an isolated TFCC tear is hardly ever the
only cause of pain. Indeed, most stable tears of the
TFCC are the consequence of a more general prob-
lem rather than the actual cause of instability. If the
TFCC is not the sole stabilizer of the RUCJ, what
other elements could be considered as such?
For the RUCJ to be functional, both in kinematic
(mobility) and kinetic (loading) terms, a number of
conditions need to be present.
1. The articulating bones must have adequate
shapes and without fractures, nonunions or mal-
unions altering its external dimensions.
2. The articulating surfaces must be congruent, par-
allel and normally tilted.
3. The ligaments need to be intact or sufficiently
competent to provide stabilization.
4. The so-called ‘sensorimotor system’ needs to be
finely tuned and able to process all proprioceptive
information generated within and about the joint.
5. The muscles crossing the joint need to be capable
of reacting efficiently when a warning message is
received from the sensorimotor system.
6. All nerves connecting ligaments and muscles to
the sensorimotor system need to be fully
functional.
Failure of any one of these factors may affect, if
not completely alter, the grasping capabilities of the
Journal of Hand Surgery (Eur) 47(1)
hand. What follows is a review of the structures that
stabilize the RUCJ, how they work and how they
interact with each other.
Terminology
Before discussing RUCJ kinetics, it is important to
clarify the meaning of some frequently used, yet
poorly understood, terms. One of the most often mis-
used words is ‘instability’. Carelessly borrowed from
non-medical literature, it is sometimes used to qual-
ify something as ‘unstable’ when it is merely ‘mala-
ligned’. The two terms are not equivalent concepts
(Ananos and Garcia-Elias, 2019). A possible contribu-
tion to this confusion is our reliance on plain radio-
graphs and static investigations when trying to
understand a dynamic problem. A misalignment
may be permanent or occasional; it may appear spor-
adically, under certain loading conditions or be
always present. If the joint is permanently disso-
ciated, the term ‘instability’ is not adequate. In
those cases, we should use terms such as perman-
ent ‘subluxation’ (partial loss of joint contact) or
‘dislocation’ (complete loss of bone contact).
The term ‘dysfunction’ also needs a similar com-
mentary. Most instabilities are dysfunctions, but not
all dysfunctions are unstable. Truly, the term ‘dys-
function’ is to be used only when there is an alteration
of function. If two articulating bones dissociate from
each other only under high stress, but not under
physiologic loading conditions, that joint may be
called unstable, but not dysfunctional. If two articulat-
ing bones dissociate from each other under physio-
logical loading conditions, that joint may be called
unstable and dysfunctional. However, if the force
necessary to reduce a dissociated joint is high, and
yet, a residual subluxation persists, that joint is dys-
functional, but not unstable. In other words, the term
‘instability’ should not be used as a primary diagnosis,
but as an adjective that qualifies the risk that exists
either for a structure to collapse or for two bones to
dissociate from each other and become dysfunctional.
RUCJ biomechanics
Forearm pronosupination is not an axial rotation of
the radius about the ulna, but about a virtual axis that
connects the centre of the radial head with the centre
of the basistyloid fovea (Figure 2). The consequence
of this axis being oblique is that the radial head turns
about itself proximally, whereas distally, it rotates
about the ulna. The carpus rotates with the radius.
Consequently, during pronosupination, there is fric-
tion both between the distal radius and ulna and
between the ulnar head and the carpus. This
Garcia-Elias et al.
Figure 2. Pronosupination axis of the forearm.
mechanism allows for a maximum range of 90 of
supination and 51 of pronation (Kihara et al., 1995).
The central portion of the TFCC, the so-called
discus articularis, behaves not as a ligament, but as
a shock-absorbing fibrocartilage, interposed
between the ulna and the lunate. If longitudinal
forces within the distal radius and ulna were mea-
sured with the forearm in a vertical position, resting
on the elbow, assuming neutral variance, the ulnar
head would get no more than 10% of all compressive
forces crossing the wrist. Research on this topic was
pioneered by Palmer and Werner (1984) and subse-
quently studied in more detail by Markolf et al.
(1998). This seemingly low percentage would
inaccurately minimize the importance of the ulnar
head as a load-bearing structure.
Indeed, the ulnar head is rarely stressed longitu-
dinally (ulno-carpal component), but more commonly
it is loaded transversely (radioulnar component).
With the long axis of the forearm parallel to the
floor, the ulnar head becomes an essential pivot
point about which the radiocarpal unit rotates.
According to Hagert and Hagert (2010), when
the wrist is loaded, the stresses registered across
the sigmoid notch are similar to those crossing the
radiocarpal joint. In this situation, the proportion of
shear forces in relation to compression forces regis-
tered at the DRUJ is different, depending on the pos-
ition of forearm rotation. Shear forces are higher at
67
the extremes of rotation, while compression forces
predominate in neutral rotation.
The DRUJ has been defined as a small troclear-
throsis, in which the radius of curvature of the ulnar
head is smaller than that of the sigmoid notch of the
radius. As a result, there must be some joint gliding
instead of a pure rotation at the extremes of prona-
tion or supination. The centroid of pressure on the
sigmoid notch articular surface translates dorsally in
pronation, whereas it becomes palmar in supination.
The widest contact area within the radioulnar joint
interval is registered in neutral axial rotation (60%
of the sigmoid notch), while less than a 10% of con-
tact is found at the two extremes of pronosupination
(Figure 3). In addition, this difference in curvatures
allows for some proximal-distal movement of the
ulnar head relative to the sigmoid notch.
If the articulating bones are normally aligned and
are adequately shaped, without fractures, nonunions
or malunions, and the forearm is in neutral pronosu-
pination, RUCJ stability is likely due to the anatomical
shape of the articular surfaces. There is no need for
ligaments, muscles or capsules. Conversely, if the
forearm is fully pronated or supinated, a more com-
plex interaction of stabilizers, both passive and active,
is needed to maintain RUCJ stability. This explains
why most injuries occur in those extreme positions.
The structures that constrain, guide and stabilize
any excessive displacement of the RUCJ under
physiologic loads can be passive (capsule and liga-
ments) or active (muscles). When a stable joint is
loaded, the first line of defence consists of a number
of ligaments, which passively constrain any attempt of
the bones to dislocate. If only ligaments are con-
sidered, however, the joint would be easily dislocated.
None of the ligaments in the area are strong enough to
resist most stresses applied during daily activities.
Muscles provide active constraining forces when
the stress applied to the joint gets to a certain
point. As long as they all interact in a coordinated
manner, both active and passive stabilizers are
needed. None of them are more important than the
other in all forearm positions.
The sensorimotor system is also an important
agent in this regard. It determines (based on the pro-
prioceptive information that the receptors within the
passive stabilizers in the joint have provided) which
active stabilizers (muscles) need to be activated and
which need to be inhibited.
Passive RUCJ stabilizers
1. The horizontal portion of the TFCC is composed of
two elements: the articular disc and the distal
radioulnar ligaments (Figure 4).
68 Journal of Hand Surgery (Eur) 47(1)

Figure 3. Contact area of distal radioulnar joint surfaces.

Figure 4. TFCC components: (1) extensor carpi ulnaris subsheath, (2) articular disc, (3) volar radioulnar ligament,
(4) dorsal radioulnar ligament, (5) ulnolunate ligament, (6) ulnotriquetral ligament and (7) meniscus homologue.
Garcia-Elias et al.
a. The articular disc is a biconcave, fibrocartila-
ginous structure, poorly vascularized, whose
main function is to absorb axial stresses
across the ulno-carpal space. It has a poor
stabilizing action.
b. In contrast, the two radioulnar ligaments
have quite important stabilization roles.
They originate at the volar and dorsal corners
of the sigmoid notch of the radius and con-
verge on the fovea where the deepest fibres
insert. The superficial fibres continue medi-
ally and distally until inserting onto the top of
the ulnar styloid process. Some authors
defend the existence of two components
(superficial and deep) as if they had different
functions, but there is no real separation
between the two fascicles in its radial
origin. It is one ligament with two ulnar inser-
tions. In between these two insertions there
is a space filled with loose connective tissue
profusely innervated and vascularized. It is
the ‘space cruentum’ that separates superfi-
cial and deep insertions of the TFCC. Some
authors use the term ‘ligamentum subcruen-
tum’ to refer to the latter. The dorsal radio-
ulnar ligament restraints radial volar
translation when the hand is loaded while
the forearm is kept in a horizontal position
and in full pronation. The volar one does it
in full supination.
2. The membrane that keeps the extensor carpi
ulnaris (ECU) tendon in the ECU subsheath of
the sixth compartment, is gaining recognition as
an important secondary passive stabilizer. This
tendon is constrained in a dorsal vertical groove
of the ulnar head, and thus the tendon and bone
rotate together independent from the rest of the
extensor tendons, which remain associated to the
radius. At the level of the ulnar head, the sub-
sheath is strongly attached to the ulna, and yet it
is independent of the extensor retinaculum. At the
level of the ulnar styloid, it becomes thinner and
almost disappears. From that point on, the ECU
becomes protected by the extensor retinaculum,
which forces the tendon to move following the
radius. There is a zone where the tendon suddenly
changes in both direction and rotation during pro-
nosupination. It is crucial that this torsion occurs
distal to the ulnar styloid. If the torsion occurs
proximal to the styloid, the tendon will sublux
from its compartment. This produces well-
known consequences: the moment arm of the
69
tendon will increase and the wrist will become
stiff in flexion and ulnar deviation.
Forearm supination induces a 30 angulation in
the distal course of the ECU tendon. In this forearm
position, the ECU’s index of extension and its work
capacity are the highest, therefore, the muscle max-
imally stabilizes the distal ulna in forearm
supination.
3. The ulno-carpal ligaments are also important pas-
sive stabilizers controlling the sagittal stability of
the ulnar column of the wrist. They originate on
the anterior border of the triangular fibrocartilage
and consist of two diverging bundles: the ulnotri-
quetral and the ulnolunate ligaments. They are
both long, elastic and poorly resistant to tension
(Hagert and Hagert, 2010), which is maximal when
the hand is loaded in forearm supination. When
these ligaments are torn, the radial column of
the wrist moves palmarly in relation to the ulna,
creating the volar carpal rotational subluxation in
pronation so typical in rheumatoid patients.
4. The distal fibres of the radioulnar interosseous
membrane (of the so-called distal oblique
bundle (DOB)) are also considered secondary sta-
bilizers (Arimitsu et al., 2011). They are important
in cases where there is a complete avulsion of the
distal radioulnar ligaments associated with a
distal radius fracture. In those circumstances,
the instability cannot be denied. When the fracture
has been reduced, however, the wrist often
becomes stable again, even though the ligaments
are avulsed. This stability comes from the distal
fibres of the interosseous membrane.
Nevertheless, recent inmunoflourescence ana-
lyses have concluded that the DOB is richly inner-
vated and contains a high number of
mechanorreceptors (Rein et al., 2020). These find-
ings suggest that the DOB acts more sensitively
than mechanically in RUCJ stability.
Active RUCJ Stabilizers
The role of the different muscles involved actively in
the stabilization of the RUCJ is essentially based on a
direct coaptation of the two matching articular sur-
faces of the radioulnar joint. If the joint is congruent,
articular dynamic coaptation may effectively avoid
subluxation.
1. Brachialis muscle. This muscle is the first to react
to any external force transferred from the radius
70
Figure 5. Dynamic stabilizers: abductor pollicis longus,
extensor pollicis brevis.
into the ulna when the hand is loaded while the
forearm is kept in a horizontal position. Because
of its insertion onto the proximal ulna, the bra-
chialis muscle generates the reaction force
necessary to achieve a coaptation of the DRUJ
(Holmes and Keir, 2014). Its antagonist muscle,
as far as neutralizing excessive compression of
the joint, is the brachioradialis muscle, which
inserts onto the distal radius.
2. The abductor pollicis longus (APL) and extensor
pollicis brevis (EPB) muscles also contribute to
the distal radioulnar stability (Figure 5). Because
they originate in the ulna but have an oblique
course toward the first extensor compartment
(radius), their contraction increases joint stability
by compressing the DRUJ.
3. The tendon of the ECU is constrained in a fairly
narrow subcompartment at the dorsal aspect of
the ulnar head. During pronation, the tendon is
located directly opposite to the radial styloid
(Figure 8, detailed in the following section). As a
result, its contraction triggers a dynamic com-
pression of the ulnar head against the sigmoid
notch of the radius.
4. The deep head of pronator quadratus is also an
important stabilizer of this joint. In pronation the
muscle is distended, while in supination, it is in
tension by embracing the ulnar head around its
medial face. The action of this muscle is, there-
fore, more effective in supination because in this
position it produces joint coaptation that prevents
instability (Figure 6).
Interaction between passive and
active RUCJ stabilizers
When the forearm begins supinating, tension in both
of the radioulnar ligaments does not change much
until a certain degree of rotation is achieved. At this
point, the palmar ligament begins to support tension.
Journal of Hand Surgery (Eur) 47(1)
Figure 6. Dynamic stabilizers: PQ: Pronator Quadratus.
Tension increases until the ulna undergoes a palmar
translational movement that is counteracted by the
dorsal ligament, the pronator quadratus muscle and
the volar capsule (Figure 7).
A similar phenomenon occurs with pronation.
Initially, there are only small tensional changes up
to a certain degree of rotation. When the dorsal liga-
ment is tensioned, the ulna undergoes a dorsal
translational vector that is neutralized by the
palmar ligament, the dorsal capsule and the ECU
muscle (Figure 8).
Summary
Forearm rotation induces synchronous mobility in
two distal joint spaces: the distal radioulnar and the
ulno-carpal joints. They should, thus, be considered
together: the RUCJ.
The TFCC connects with both of them; its func-
tional competence in any forearm rotation will influ-
ence RUCJ stability whether the wrist is subjected to
movement or load. Nevertheless, attention is often
given to the TFCC as the primary stabilizer of the
proximal component of the RUCJ, the DRUJ.
Similarly, attention is often given to the DRUJ while
the ulno-carpal component of this complex joint is
ignored. We believe that RUCJ is a more appropriate
acronym, which encompasses both segments of the
joint.
Just like disorders of the RUCJ are often multifac-
torial (Kakar and Garcia-Elias, 2016), stability of this
region is also a complex multifactorial phenomenon
that rests on the proper function of eight different
anatomical structures, and that is modified by the
degree of forearm rotation. This may enhance under-
standing of how stability in this area is achieved and
hence balance attention focused on the TFCC.
Garcia-Elias et al. 71

Figure 7. Interaction between stabilizers in forearm supination.

Figure 8. Interaction between different stabilizers in forearm pronation.

72
Regardless, questions remain about the multiple
static and dynamic structures discussed in this art-
icle, which are mediated by a complex network of
neural connections still undergoing investigation.
Acknowledgement This work is dedicated to the
loving memory of Professor John Knowles Stanley who
passed away in February 2021. We all learned a lot from
his kindness, good humour and enthusiasm. He was a true
gentleman and academic scholar who will be missed
fondly.
Declaration of conflicting interests The authors
declare no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD Dirck Ananos https://orcid.org/0000-0002-
8601-3659
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