Optimal management of fractures, post-traumatic arthritis and instability of the distal radioulnar joint (DRUJ) requires an understanding of the forces existing across this joint as a function of the activities of daily living. However, such knowledge is currently incomplete. The goal of this research was to quantify the loads that occur at the DRUJ during forearm rotation and to determine the effect that individual muscles have on those loads. Human and cadaver studies were used to analyze the shear (A-P), transverse (M-L) and resultant forces at the DRUJ and to determine the role that 15 individual muscles had on those forces. Data for scaling the muscles forces came from EMG analysis measuring muscle activity at nine positions of forearm rotation in volunteers during isometric pronation and supination. Muscle orientations were determined from the marked muscle origin and insertion locations of nine cadaveric arms at various stages of forearm rotation. The roles that individual muscles played in DRUJ loading were analyzed by removing the muscle of interest from the analysis and comparing the results. The EMG portion of this study found that the pronator quadratus, pronator teres, brachioradialis, flexor carpi radialis and palmaris longus contribute significantly to forearm pronation. The supinator, biceps brachii, and abductor pollicis longus were found to contribute significantly to supination. The results of the DRUJ analysis affirm that large transverse forces pass from the radius to the ulnar head at all positions of forearm rotation during pronation and supination (57.5N-181.4N). Shear forces exist at the DRUJ that act to pull the radius away from the ulna in the AP direction and are large enough to merit consideration when examining potential treatment options (7.9N-99.5N). Individual muscle analysis found that the extensor carpi radialis brevis, extensor pollicis longus, extensor carpi ulnaris, extensor indicis and palmaris longus had minimal effect on DRUJ loading. Other than the primary forearm rotators (pronator quadratus, pronator teres, supinator, biceps brachii), the muscles that exhibited the largest influence on DRUJ loading were the abductor pollicis longus, brachialis, brachioradialis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris.

Introduction: The forearm is a complex biological unit, which has allowed man's evolution. This PhD commenced with an analysis of the normal biomechanical functioning of the key components of the forearm: notably the distal radioulnar joint (DRUJ), interosseous ligament (IOL) and proximal radioulnar joint (PRUJ). Understanding normal forearm physiology, a clinical study followed to delineate the pathophysiology of a new clinical entity, related to DRUJ dysfunction. Methods: Biomechanical Study: A biomechanical testing jig was developed to facilitate collection of data about normal functioning of the DRUJ, IOL and PRUJ in both unloaded and loaded states. This permitted testing throughout the range of forearm pronosupination. Thawed fresh frozen cadaveric upperlimbs were mounted into the jig. Using Microstrain® strain gauges and Tekscan™ pressure sensors, the functional anatomy of the key components of the forearm was delineated, both with the forearm flexed at 90° and maximally extended at the elbow. Clinical Study: A series of 3-Tesla MRI scans was undertaken on patients symptomatic of an intermittent ulnar neuropathy. The causative pathophysiology was determined using 3D qualitative and quantitative analyses. Results: Biomechanical Study: Reproducible patterns of force transmitted and joint contact area have been determined for the DRUJ, and for the first time, the PRUJ. With the exception of PMax and P60 for the PRUJ, application of load increases contact areas and transmitted forces across the joints (P<0.05). The converse is true for PMax and P60 in the PRUJ. The IOL is lax during pronation, strain gradually increasing as the arm moves to neutral. In neutral the middle-portion of the IOL (m-IOL) demonstrates most strain, this decreasing again in supination, whilst the distal and proximal portions (d- & p-IOL) exhibit more strain (P<0.05). Axial loading consistently increases strain in all ligaments (P<0.05). Observed behaviour patterns across the joints and in the ligaments alter with elbow extension (P<0.05). Clinical Study: Salient symptoms of the new syndrome were described. Displacement of the ulnar nerve from its normal course was seen with compression/distraction in the distal forearm and Guyon’s canal. This was considered causative of the syndrome. As a by-product of the research, a new clinical device was also developed, which improves the patient pathway when investigating DRUJ dysfunction. Conclusions and Outcomes: This research has analysed normal forearm biomechanics determining that the PRUJ is a load-bearing joint, interrelated with the DRUJ and IOL. Elbow extension has been shown to alter the normal biomechanics of the forearm. A clinical entity of a dysfunctional forearm has been defined, called subluxation-related ulnar neuropathy or SUN syndrome. Finally, a new clinical device has been developed, which it is anticipated will translate into visible improvements in patient care.