CURRENT CONCEPTS

The Distal Interosseous Membrane: Current Concepts

in Wrist Anatomy and Biomechanics
Hisao Moritomo, MD, PhD

The distal interosseous membrane (DIOM) of the forearm acts as a secondary stabilizer of
the distal radioulnar joint (DRUJ) when the dorsal and palmar radioulnar ligaments of the
triangular fibrocartilage complex are cut. Recent anatomical studies revealed that thickness
of the DIOM varies widely among specimens and the distal oblique bundle (DOB) exists
within the DIOM in 40% of specimens. The DOB originates from the distal one-sixth of the
ulnar shaft and runs distally to insert on the inferior rim of the sigmoid notch of the radius.
The mean thickness of the DIOM without a DOB was 0.4 mm, which was significantly
thinner than 1.2 mm with a DOB. Biomechanical studies have shown that the DOB is an
isometric stabilizer of the forearm during pronosupination. The presence of a DOB was
shown to have a significant impact on DRUJ stability. Innate DRUJ laxity in the neutral
forearm position was greater in the group without a DOB than in the group with a DOB.
Ulnar shortening with the osteotomy performed proximal to the attachment of the DIOM
had a more favorable effect on stability of the DRUJ compared with the effect of distal
osteotomy, especially in the presence of a DOB. The longitudinal resistance to ulnar
shortening was significantly greater in proximal shortening than in distal shortening. It also
suggested that the DIOM is of great importance in the management of concomitant ulnar-side
injuries in distal radius fracture. (J Hand Surg 2012;37A:15011507. Copyright 2012 by
the American Society for Surgery of the Hand. All rights reserved.)
Key words Interosseous membrane, distal radioulnar joint, anatomy, biomechanics,
instability.

(IOM) of the fore- DRUJ, and indicated that the distal membranous por-

T
HE INTEROSSEOUS MEMBRANE
arm is a stout ligamentous complex linking the tion of the IOM acted as a secondary stabilizer of the
radius to the ulna. The IOM reportedly consists DRUJ when the dorsal and palmar radioulnar ligaments
of distal membranous, middle ligamentous, and proxi- of the triangular fibrocartilage complex (TFCC) were
mal membranous portions. Each portion includes sev- cut. Recently, anatomical variation of the distal IOM
eral ligamentous components. Some investigators have (DIOM) and the exact fiber responsible for its function
reported that the distal membranous portion stabilizes have been described.
the distal radioulnar joint (DRUJ). Watanabe et al1 and
Kihara et al2 performed a biomechanical cadaver study ANATOMY OF THE DIOM
to determine the role of the stabilizing structures of the
The DIOM is on the distal side of the middle ligamen-
From the Department of Physical Therapy, Osaka Yukioka College of Health Science, Osaka, Japan. tous complex, spanning the radius and ulna under the
Received for publication February 15, 2012; accepted in revised form April 27, 2012.
region of the pronator quadratus muscle. A hole exists
Current Concepts

in that portion, through which the interosseous artery

No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article. passes. Noda et al3 reported anatomical variation of the
Corresponding author: Hisao Moritomo, MD, PhD, Department of Physical Therapy, Osaka
DIOM. The authors found that thickness of the DIOM
Yukioka College of Health Science, Sojiji 1-1-41, Ibaragi-shi, Osaka 567-0801 Japan; e-mail: varied widely among specimens, and identified the dis-
hisao-moritomo@yukioka-u.ac.jp. tal oblique bundle (DOB) in 12 of 30 specimens (40%)
0363-5023/12/37A07-0036$36.00/0 (Figs. 1, 2). The DOB is an obvious thick fiber running
http://dx.doi.org/10.1016/j.jhsa.2012.04.037
within the DIOM that originates from the distal one-

ASSH Published by Elsevier, Inc. All rights reserved. 1501

 1502 DISTAL INTEROSSEOUS MEMBRANE
FIGURE 1: An obvious thick fiber bundle of the DOB from
the DIOM (white arrows). R, radius; U, ulna. (From Kitamura
T, Moritomo H, Arimitsu S, Berglund LJ, Zhao KD, An KN,
et al. The biomechanical effect of the distal interosseous
membrane on distal radioulnar joint stability. J Hand Surg
2011;36A:1626 1630. Reprinted with permission of Elsevier.)
sixth of the ulnar shaft and runs distally to insert on the
inferior rim of the sigmoid notch of the radius. The
mean width is 4.4 mm (range, 2 6 mm) and mean
thickness is 1.5 mm (range, 0.52.6 mm). The fibers
blend into the capsular tissue of the DRUJ. Further-
more, some fibers extend more distally along the ante-
rior and posterior ridges of the sigmoid notch, so the
DOB shows continuity with the dorsal and palmar
radioulnar ligaments of the TFCC. Kitamura et al4
reported that the dimensions of the DIOM varied
widely among 10 fresh specimens. In 4 specimens, an
obvious thick fiber bundle that was the DOB existed
Current Concepts
within the DIOM, whereas in 6 specimens an obvious
thick fiber was not evident within the DIOM. They
reported that the DOB originated from the distal ulna 54
mm (on average; range, 50 57 mm) proximal to the
ulnar head, which was 21% of the total ulnar length
from the ulnar styloid. The DOB inserted on the dorsal
inferior rim of the sigmoid notch of the radius, approx-
imately 35 mm from the radial styloid, which was 15%
of the total radial length from the radial styloid. They
JHS Vol A, July
FIGURE 2: Thin DIOM (arrow). Obvious DOB does not exist.
R, radius; U, ulna.
reported that the DOB showed variations (Fig. 3). In 2
of the 4 specimens in which a DOB was present, the
DOB was linear and clearly separate from the mem-
brane portion of the DIOM. In another specimen with a
DOB, a thick fiber bundle was visible only in the
proximal portion of the DIOM and spread in a fan shape
distally. In another specimen, the DOB was wide and
occupied almost the whole DIOM. The mean thickness
of the DIOM among the 10 specimens was 0.7 mm
(range, 0.51.3 mm). The mean thickness of the 6
specimens without a DOB was 0.4 mm (range, 0.3 0.5
mm), whereas the mean thickness of the 4 specimens
with a DOB was 1.2 mm (range, 1.0 1.3 mm). There
was a statistically significant difference in the thickness
of the DIOM between the groups with and without a
DOB.
Another variation in the anatomy of the DIOM is the
distal radioulnar tract, described by Gabl et al5 (Fig. 4).
The distal radioulnar tract extends from the radial shaft
proximally to the dorsal capsule of the distal radioulnar
joint distally. The distal radioulnar tract is located dorsal
to the DOB, which extends from the ulnar shaft prox-
imally to the distal radius distally; therefore, these 2
fibers run opposite each other. The tract originates from
the radius 22 mm proximal to the distal dorsal corner of
 DISTAL INTEROSSEOUS MEMBRANE 1503

FIGURE 3: Anatomical variation of the DIOM. A The DOB does not exist. B The DOB is linear and clearly separate from the
membrane portion of the DIOM. C A thick fiber bundle is visible only in the proximal portion of the DIOM and is spread in a fan
shape distally. D The DOB is wide and occupies almost the whole DIOM.

the sigmoid notch. Distally, it inserts at the capsule
of the DRUJ. There is considerable variation in shape.
The tract is 8 mm wide (range, 4 12 mm), 31 mm long
(range, 2550 mm), and 1.0 mm thick (range 0.6 1.3
mm). The distal radioulnar tract is taut in pronation and
loose in supination, which means that this fiber is not
isometric. It was suggested that during pronation, the
tract protects the ulnar head in a sling.
BIOMECHANICS OF THE DIOM
band, and DOB) had little change in length during
forearm rotation, with their ulnar attachments lo-
cated almost on the axis of forearm rotation (Fig.
5). The 2 proximal ligaments (proximal oblique
cord and dorsal oblique accessory cord) changed
substantially in length, with their attachments out
of the course of the axis. The authors suggested
that the distal 3 ligaments of the IOM are essen-
tially isometric stabilizers of the forearm.
Current Concepts

Length change during pronosupination
Moritomo et al6 investigated changes in the length of
the IOM during forearm rotation in vivo. In that study,
the author calculated the 3-dimensional lengths of the 5
ligaments in the IOM between attachments during fore-
arm rotation using a markerless bone registration tech-
nique. They also examined relationships between the
axis of forearm rotation and each ligament, and found
that the distal 3 ligaments (central band, accessory
Relationship between anatomical variation of the DIOM and
DRUJ laxity
It is well known that individual variation exists in
normal DRUJ laxity. Kitamura et al4 investigated
whether innate DRUJ laxity is influenced by the ana-
tomical variation of the DIOM. The researchers used 10
fresh-frozen cadaver upper extremities in the study.
They performed testing by translating the radius in
volar and dorsal directions relative to the ulna in neutral

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 1504 DISTAL INTEROSSEOUS MEMBRANE
FIGURE 4: The distal radioulnar tract (arrow) extends from
the radial shaft proximally to the dorsal capsule of the distal
radioulnar joint distally. The distal radioulnar tract and DOB
run opposite each other. R, radius; U, ulna.
forearm alignment, 60 pronation, and 60 supination.
Total translation of the radius was measured as DRUJ
laxity. After the experiment, they investigated the ana-
tomical variation of the DIOM, especially regarding the
existence of the DOB. They compared DRUJ laxity
between groups with and without the DOB, and found
that the degree of displacement of the radius relative to
the ulna in the neutral forearm position was smaller
in the group with a DOB than in the group without a
DOB. This suggests that DRUJ laxity was greater in the
group without a DOB than in the group with a DOB.
That study hypothesized that DRUJ laxity depends at
least in part on the presence and configuration of the
DIOM.
Stabilizing effect of the DIOM on ulnar shortening
Current Concepts
The ulnar shortening osteotomy is an effective treat-
ment for ulnar impaction syndrome. Although clinically
it is well known that ulnar shortening improves DRUJ
stability, the mechanism of that effect was unclear.
Nishiwaki et al7 used cadavers to examine the stabiliz-
ing effect of the TFCC on ulnar shortening and found
that 3 mm shortening or greater was required to obtain
a significant difference in distal radioulnar joint laxity
(P .01). They removed 10 mm of bone in their testing
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FIGURE 5: Relationship between the DOB and TFCC. The
DOB appears to form an isometric collateral ligament with the
TFCC to stabilize the forearm during forearm rotation because
the ulnar insertions of the DOB, central band (CB), and
accessory band (AB) almost coincide with the course of the
axis of forearm rotation. (From Moritomo H, Noda K, Goto A,
Murase T, Yoshikawa H, Sugamoto K. Interosseous membrane
of the forearm: length change of ligaments during forearm
rotation. J Hand Surg 2009;34A:685 691. Reprinted with
permission of Elsevier.)
at the distal 25% portion of the ulna for that shortening,
so it is reasonable to infer that the DIOM was sectioned.
Arimitsu et al8 evaluated DRUJ laxity after ulnar short-
ening osteotomy to quantify longitudinal resistance to
ulnar shortening when the osteotomy was proximal or
distal to the ulnar attachment of the DIOM. The authors
performed transverse osteotomy and ulnar shortening
proximal (proximal shortening) and distal (distal short-
ening) to the ulnar attachment of the DIOM (Fig. 6).
They found that the longitudinal resistance to ulnar
shortening was significantly greater in proximal short-
ening than in distal shortening (P .01). They also
found that in proximal shortening, significantly greater
stability of the DRUJ was obtained with even 1 mm of
shortening compared with that of the control, whereas
distal shortening demonstrated significant improvement
in stability of the DRUJ only after shortening of 4 mm
 DISTAL INTEROSSEOUS MEMBRANE
FIGURE 6: The longitudinal resistance to ulnar shortening and stability of the DRUJ were significantly greater for proximal
shortening than for distal shortening (P .01).
or more. Significantly greater stability of the DRUJ was
achieved with proximal shortening than with distal
shortening, and in specimens with a DOB rather than in
those without a DOB. They concluded that ulnar short-
ening with the osteotomy performed proximal to the
attachment of the DIOM had a more favorable effect on
stability of the DRUJ compared with the effect of distal
osteotomy, especially in the presence of a DOB.
DISCUSSION
The form of the ulnar side of the human wrist represents
progressive evolutionary development. The embryolog-
ical and clinical material suggests that there is a tremen-
dous variation in the development of the ulnar side of
the wrist. Recent studies have demonstrated anatomical
variation of the DIOM, and the DOB was recognized as
the exact fiber responsible for function of the DIOM.
Biomechanical studies have shown that the DOB
changed minimally in length during forearm rotation;
therefore, it was suggested to be an isometric stabilizer
of the forearm. The presence of a DOB was also shown
to have a significant impact on DRUJ stability (P
.05). The TFCC is the primary soft tissue DRUJ stabi-
lizer, and in normal situations, the influence of the
DIOM on DRUJ stability is relatively inconsequential.
However, after TFCC injury, ulnar head resection, or
JHS Vol A, July
1505
Sauv-Kapandji procedure, it is likely that the DIOM
has a more important role in the stability of the ulnar
head or ulnar stump (Fig. 7). The DIOM may explain
why some patients do not experience signs or symp-
toms of DRUJ instability, pain, or dysfunction after
TFCC disruption, or experience instability of the ulnar
stump after ulnar head resection.
Another biomechanical study demonstrated the sta-
bilizing effect of the DIOM on the DRUJ in ulnar
shortening, especially in patients with a DOB. It seems
plausible that increased DIOM tension accompanying
ulnar shortening after an osteotomy performed proxi-
mal to the attachment of the DIOM may improve the
stability of the DRUJ. Clinically, often there are diffi-
culties in achieving the desired amount of ulnar short-
ening because of increased tension when approximating
Current Concepts
the ulnar bone ends after osteotomy. However, little
attention has been given to the effect of the DIOM on
potential nonunion of the osteotomy. Recent data have
shown significant differences in longitudinal closure
difficulty for proximal compared with distal osteotomy
sites, depending on the DIOM thickness.8 These results
suggest that a proximal osteotomy and a thicker DIOM
could be risk factors for nonunion. For patients without
instability of the DRUJ, therefore, it may be advanta-
 1506 DISTAL INTEROSSEOUS MEMBRANE

FIGURE 7: A A thick DIOM (arrow) in a case with DRUJ arthrosis. B After the Sauv-Kapandji procedure, it is likely that the
DIOM has an important role in stabilizing the ulnar stump. R, radius; U, ulna.

FIGURE 8: In Galeazzi fracture dislocation, the fracture line passes proximal to the insertion of the DOB along the radius.
Instability can be managed only by anatomical reduction of the radius fracture by plate fixation, because tension of the DOB can
Current Concepts

be regained by the reduction.

geous to perform a distal osteotomy or to release the
DIOM for better healing of the ulna.
The DIOM is also of great importance in the man-
agement of concomitant ulnar-side injuries in distal
radius fracture. Orbay9 showed that in the stage of the
concomitant avulsion fracture of the ulnar styloid re-
sulting from the tension applied by the extensor carpi
ulnaris tendon sheath and TFCC, the only surviving
stabilizer of the DRUJ is the DIOM. The intact DIOM
may provide enough stability in most distal radius frac-
tures to allow stable forearm rotation. Orbay described
a fiber within the DIOM called the distal interosseous

JHS Vol A, July

 DISTAL INTEROSSEOUS MEMBRANE
ligament that behaves in an isometric manner during
forearm rotation. This fiber apparently coincides with
the DOB in Noda et als report.3 This fiber inserts on
the radius proximal to the sigmoid notch and proximal
to the fracture line in the most distal radius fracture. It
also originates from the ulna at a substantially more
proximal level, precisely where the axis of forearm
rotation intersects the surface of the ulna. Jupiter10
noted that despite the presence of disruption of the
TFCC or the presence of a large ulnar styloid fracture
with its attached soft tissue constraints, stability will
occur because of the presence of the DOB and contact
pressure of the ulnar head into a stable sigmoid notch
after plate fixation. Other, less common variation of
distal radius fracture can result in rupture or loosening
of the DOB in addition to TFCC disruption. This path-
ological condition may occur in either distal radius
fracture in which the DIOM is thin or in Galeazzi
fracture dislocation in which the fracture line passes
proximal to the insertion of the DOB on the radius (Fig.
8). In these types of distal radius fracture, all ligamen-
tous support for the DRUJ is lost, which results in
severe DRUJ instability. In some cases with loosening
(not rupture) of the DOB, instability can be managed
only by anatomical reduction of the radius fracture by
plate fixation because tension of the DOB can be re-
gained by the reduction. However, even after anatom-
ical reduction of the skeletal structures, when either
DRUJ subluxation persists or clinical testing shows
DRUJ instability because of insufficient DIOM func-
tionality resulting from disruption of the DOB or ana-
JHS Vol A, July
1507
tomical variation, it is necessary to address the persist-
ing DRUJ instability by specific means, such as TFCC
repair.
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Current Concepts