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J Hand Surg Am. 2016 Apr;41(4):551-64. doi: 10.1016/j.jhsa.2016.01.005. Epub 2016 Mar 2.

The "Four-Leaf Clover" Treatment Algorithm: A Practical Approach to Manage Disorders of the Distal Radioulnar Joint.

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Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN. Electronic address:
Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN; Kaplan Institute, Barcelona, Spain.


Most symptomatic distal radioulnar joint (DRUJ) conditions result from derangements to several structures that may include the length, shape, and/or orientation of the articulating surfaces; the cartilage of the DRUJ and/or ulnocarpal joint; the DRUJ and/or ulnocarpal joint ligaments; and the extensor carpi ulnaris and/or pronator quadratus muscle. Once a complete diagnosis is made, often only one of these components is addressed, which results in suboptimal clinical outcomes. In this article, we present a treatment algorithm (the Four-Leaf Clover algorithm) to guide treatment of DRUJ pathology. The Four-Leaf Clover principle is a guiding algorithm, not a document forcing the surgeon to adopt one particular treatment. Its purpose is to provide treating physicians with a checklist that helps ensure that they do not miss any of the different components that need to be addressed for a complete treatment. Using the treatment algorithm, we should achieve satisfactory resolution of patients' symptoms after addressing the particular components in a stepwise approach.


Distal radioulnar joint; distal radioulnar joint pathology; treatment

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