The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment. Strategies Trauma Limb Reconstr. 2008;3:49-56. [PMID: 18766429 PMCID: PMC2553431 DOI: 10.1007/s11751-008-0040-1]

Distal ulnar neck fracture displacement with forearm rotation: A biomechanical cadaveric study

Management of distal ulnar fractures remains controversial, partly due to its low incidence and operative challenges encountered during surgical fixation. This cadaveric study examined fracture displacement in isolated distal ulnar fractures, specifically AO Muller Q2 and Biyani Type I fracture pattern, during forearm pronosupination.6 fresh frozen cadaveric upper limbs amputated at mid-humerus were used. Soft tissues including proximal and distal radioulnar joints were carefully preserved. Specimens were inspected grossly and radiographically for absence of pathologies. Radiocarpal and midcarpal pinning was performed to facilitate quantification of forearm rotation. 2 markers were each placed proximal and distal to fracture site to quantify fracture displacement. 3-dimensional positional data was recorded using an optoelectronic system (Vicon MX motion capture system).Distance between the 2 markers increased in the proximodistal and radioulnar axis, and decreased in the dorsovolar axis when the forearm was rotated from neutral to 100° pronation. The inverse was observed during supination. Mean aggregate fracture site displacement increased to 9.17 ± 2.78 mm at 100° pronation. Statistically significant increase in aggregate fracture site displacement was observed from 60° pronation onwards. At 100° supination, the aggregate fracture site displacement was 4.58 ± 8.62 mm. When supinating from neutral to 100°, fracture displacement did not increase significantly.

Results

from this study suggest that distal ulnar fractures are potentially stable, particularly in supination. However, unrestricted forearm pronation with inadequate immobilisation might still cause further fracture displacement. Further studies are required to assess distal ulnar fracture stability in vivo before treatment guidelines can be established.

Elastic stable intramedullary nails compared to locking compression plates for treating unstable distal ulnar fractures in adults: a prospective comparative study

BACKGROUND AND PURPOSE

Distal ulna fractures often occur in conjunction with distal radius fractures and other associated injuries. Currently, there are no satisfactory internal fixation systems available for addressing unstable distal ulna fractures, and a definitive consensus on the most effective treatment approach is still lacking. The objective of this research was to evaluate the clinical outcomes of using elastic stable intramedullary nails (ESIN) compared to locking compression plates (LCP) for treating unstable distal ulnar fractures in adults.

METHODS

In a prospective clinical study, a total of 54 patients (21 females and 33 males; average age 49.3 years, ranging from 30 to 63 years) suffering from unstable or displaced fractures of the distal ulna were randomly allocated to one of two treatment groups between January 2021 and August 2024. Specifically, 26 patients underwent treatment utilizing elastic stable intramedullary nails, whereas 28 patients were managed using locking compression plates. The two groups were evaluated prospectively for perioperative data and functional results.

RESULTS

The ESIN group comprised 26 patients, exhibiting a mean age of 48.27 years (with a range of 30 to 62 years), while the LCP group included 28 patients, whose mean age was 50.33 years (ranging from 32 to 63 years). Both groups were comparable regarding gender distribution, side of injury, mechanisms of injury, and classifications of fractures. However, there were significant differences noted in incision length of the ulna, surgical duration, frequency of fluoroscopy, and the rates of excellent and good functional outcomes as measured by the Gartland-Werley scores between the two groups (P < 0.05). Conversely, no significant differences were found concerning the time to union and the duration of immobilization between the two groups (P > 0.05).

CONCLUSION

ESIN offers several advantages, including reduced incision length, lower frequency of fluoroscopy, shorter duration of the surgical procedure, decreased complication rates, and improved Gartland-Werly scores. Therefore, fixation using ESIN serves as an effective alternative for the treatment of distal ulnar fractures in adults. The minimally invasive nature and lower complication rates are defining characteristics of ESIN fixation.

Routine 6-weeks outpatient visit in patients treated surgically for upper extremity fractures: is it truly necessary?

BACKGROUND

Due to the increasing burden on the heatlhcare system the usefulness of the routinely planned 6-week outpatient visit and radiograph in patients treated surgically for the most common upper extremity fractures, including clavicle, proximal humerus, humeral shaft, olecranon, radial shaft, and distal radius, should be investigated.

METHOD

This was a retrospective cohort study of all patients treated surgically for the most common upper extremity fractures between 2019 and 2022 in a level 1 trauma center. The first outcome of interest was the incidence of abnormalities found on the radiograph taken at the 6-week outpatient visit. Abnormalities were defined as all differences between the intraoperative (or direct postoperative) and 6-week radiograph. In case an abnormality was detected, the hospital records were screened to determine its clinical consequence. The clinical consequences were categorized into requiring either additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing, or allowed range of motion (ROM). The second outcome of interest was the incidence of deviations from the local standard postoperative treatment and follow-up protocol based on the 6-week outpatient visit as a whole. Deviations were also categorized into either requiring additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing, or allowed ROM.

RESULTS

A total of 267 patients were included. Abnormalities on radiograph at 6 weeks postoperatively were found in only 10 (3.7%) patients, of which only 4 (1.5%) had clinical implications (in 3 patients extra imaging was required and in 1 patient it was necessary to deviate from standard weightbearing/ROM limitation regimen). The clinical/radiologic findings during the 6-week outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symptoms suggestive of complications.

CONCLUSION

The routine 6-week outpatient visit and radiograph, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered.

Internal Fixation for Unstable Distal Ulnar Fractures by 2.7 mm Semitubular Hook Plate

Objective: The purpose of this study is to investigate the outcomes of the use of a 2.7 mm semitubular hook plate for internal fixation of unstable metaphyseal ulnar fractures. Methods: Between January 2015 and July 2019, 30 consecutive patients with a recent unstable distal ulnar fracture were included in this prospective case series. All patients were subjected to follow-up with the time of union, range of motion, pain using a Visual Analog Scale (VAS), and radiological and functional outcome using the quick Disabilities of the Arm, Shoulder, and Hand (DASH) score and Mayo wrist score after 12 months. Results: The mean age of the patients was 45.3 ± 10 years. There were 18 males (60%) and 12 females (40%), and there were 16 patients associated with distal radius fractures (53.33%). According to the AO classification of distal ulnar fractures, 3 fractures were type A2.1 (10%), 9 were type A2.2 (30%), 8 fractures were type A2.3 (26.67%), and 10 fractures were type A3 (33.33%). All fractures have been united with a mean duration of 9 ± 1.4 weeks, the mean supination was 81.4° ± 3.5°, the mean pronation was 81.3° ± 4.5°, the mean flexion was = 71.7° ± 3.6°, and the mean extension was = 81.7° ± 3.4°. The mean VAS was 1.1 ± 1 points, the mean DASH score was 9.3 ± 5.6 points, and the mean Mayo wrist score was 88.5 ± 7.2 points; 17 patients were excellent (56.67%) and 10 patients were good (33.33%) while 3 patients had satisfactory outcome (10%). Conclusion: Using the 2.7 mm semitubular hook plate is a successful choice for internal fixation of unstable distal ulnar fractures isolated or associated with distal radius fractures with a favorable union time, functional outcome, and range of motion with minimal complications.

Predictors of Functional Outcomes of Nonoperatively Treated Extra-articular Distal End Radius Fractures in Older Individuals: A Prospective Clinical Study

BACKGROUND

Distal radius fractures (DRFs) are some of the most common injuries suffered by the elderly; however, there are varied opinions on management. As there is limited research on patient factors affecting functional outcomes in conservatively managed patients with DRFs, this study aimed to find predictive factors for functional outcomes in such patients.

METHODS

Patients with DRFs satisfying the inclusion criteria were managed with closed reduction and slab followed by cast application. Radiological parameters (radioulnar angulation, dorsal tilt, radial height, and ulnar variance) and functional scores (patient-rated wrist evaluation [PRWE] score, Short Form 8 questionnaire [SF-8], and QuickDASH [Disabilities of the Arm, Shoulder, and Hand]-9) were recorded prereduction, postreduction, at the time of cast removal, and in follow-up visits. Patient factors such as underlying diseases were also recorded, and correlations were analyzed using appropriate software.

RESULTS

Patients with diabetes (43.33% of patients) and those with loss in radial height through the course of treatment were found to have poorer functional outcomes (P-values less than .05 for all functional scores-PRWE, QuickDASH-9, SF-8-except SF-8 at 12 weeks). Patients younger than 60 years were also found to have better functional outcomes at 24 weeks (for PRWE: P-value = .048, for QuickDASH-9: P-value = .032, and for SF-8: P-value = .026).

CONCLUSION

Conservative management plays a major role in the treatment of DRFs, despite the increasing trend of operative management. Diabetes was found to be a predictor of poorer functional outcomes; however, further research is needed to determine the role of these and other factors in detail.

Intramedullary nailing for concomitant extra-articular ulnar head fractures in distal radial fractures

Four adult female patients were treated with an intramedullary Steinmann pin for an unstable extra-articular distal ulnar fracture associated with a distal radial fracture treated with plate osteosynthesis. All showed good radiographic and functional outcomes. One patient required removal of the Steinmann pin.

Advancements in Diagnosis and Management of Distal Radioulnar Joint Instability: A Comprehensive Review Including a New Classification for DRUJ Injuries

Distal radioulnar joint (DRUJ) instability is a complex condition that can severely affect forearm function, causing pain, limited range of motion, and reduced strength. This review aims to consolidate current knowledge on the diagnosis and management of DRUJ instability, emphasizing a new classification system that we propose. The review synthesizes anatomical and biomechanical factors essential for DRUJ stability, focusing on the interrelationship between the bones and surrounding soft tissues. Our methodology involved a thorough examination of recent studies, incorporating clinical assessments and advanced imaging techniques such as MRI, ultrasound, and dynamic CT. This approach allowed us to develop a classification system that categorizes DRUJ injuries into three distinct grades. This system is intended to be practical for both clinical and radiological evaluations, offering clear guidance for treatment based on injury severity. The review discusses a range of treatment options, from conservative measures like splinting and physiotherapy to surgical procedures, including arthroscopy and DRUJ arthroplasty. The proposed classification system enhances the accuracy of diagnosis and supports more effective decision making in clinical practice. In summary, our findings suggest that the integration of advanced imaging techniques with minimally invasive surgical interventions can lead to better outcomes for patients. This review serves as a valuable resource for clinicians, providing a structured approach to managing DRUJ instability and improving patient care through the implementation of our new classification system.

Treatment of the Distal Forearm Fracture by Volar Dual Window Approach

BACKGROUND

Distal forearm fractures were defined as distal radius fractures with concomitant distal ulna fractures, except ulna styloid fractures. Distal forearm fractures are common among geriatric populations, particularly those with osteoporosis. Conventionally, distal forearm fractures are reduced by a double incision approach; however, malreduction and instability of the distal radioulnar joint were not uncommon. We introduced a modified volar dual window approach to treat the distal forearm fracture and evaluate the functional outcomes and complications.

METHODS

From January 2020 to June 2023, 13 patients with distal forearm fractures underwent open reduction by the modified dual window approach with locking plate fixation. After surgery, splints were applied for two weeks, and the patients underwent postoperative hand therapy for three months. The mean Quick Disabilities of the Arm, Shoulder, and Hand scores, range of motions, grip strength, postoperative radiographic parameters, and complications data were collected.

RESULTS

The mean follow-up period was 12.1 months, and the mean age was 52.3 years. Average wrist flexion was 67°, extension 69°, pronation 81°, and supination 79°. Grip strength was 28.3 ± 11.5 kg, which was 88% of the uninjured opposite side. The Visual Analog Scale score during activities was recorded as 0.5 ± 0.9. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14 ± 11.5. The postoperative radiographic parameters were as follows: radial height: 10.8 ± 1.7 mm, radial inclination: 22.6 ± 3.7°, volar tilting: 4.0 ± 3.9°, and ulnar variance: -0.4 ± 1.4 mm. All the patients achieved bone union at the final follow-up. Two patients underwent ulnar implant removal due to irritation symptoms. Neither infection, nor neurovascular injury, nor malreduction developed in these patients.

CONCLUSIONS

The modified volar dual window approach can achieve good wrist function and distal forearm fracture reduction without increasing neurovascular or wound healing complications. This method is an alternative approach for distal forearm fracture, especially in comminuted distal ulna fracture or distal radioulnar joint incongruity.

Intramedullary Threaded Nail Fixation of Distal Ulnar Fractures: The Surgical Technique and Case Series

BACKGROUND

 To describe the surgical technique of non-compressive intramedullary threaded nail (IMTN) fixation of distal ulnar neck fractures and present the clinical and radiographic outcomes of four patients treated with this novel technique.

METHODS

At a single Level 1 Trauma Center, a retrospective review was conducted for patients with distal ulnar neck fractures treated with retrograde IMTN between 2022 and 2024. Exclusion criteria included inadequate follow-up. A single surgeon performed all procedures using percutaneous retrograde IMTN fixation through the central disc of the triangular fibrocartilage complex (TFCC). Patients initiated a range of motion (ROM) protocol two weeks post-operatively. Post-operative radiographic images were used to calculate the ratio of IMTN diameter to the distal ulnar medullary isthmus diameter proximal to the fracture site. Radiographic changes in displacement, angulation, and ulnar variance were calculated between the first and last follow-up radiographs. Functional outcomes including grip strength and ROM were collected.

RESULTS

Four patients with distal ulnar neck fractures were treated with retrograde IMTN between 2022 and 2024. They were followed for a minimum of three months post-operatively. All were female with an average age of 65 years. All distal ulna fractures were associated with operatively treated intraarticular distal radius fractures. All patients were treated with 75 mm length and 4.5 mm diameter IMTNs. IMTN-to-Isthmus ratio was greater than 60% in all cases. Average radiographic displacement and angulation were unchanged at the final follow-up. The average ulnar variance increased by 1.2 mm. At the final follow-up, there were no post-operative complications. No cases demonstrated ulnar-sided wrist pain, nonunion, or required revision surgery.

CONCLUSIONS

Retrograde IMTN fixation is a novel surgical technique for the treatment of distal ulnar neck fractures. We found limited but promising post-operative radiographic and functional outcomes in our patients without reported ulnar-sided wrist pain, nonunion, or need for hardware removal.

Surgical fixation of distal ulna neck and head fractures

OBJECTIVES

Distal ulna plate fixation for ulnar neck and head fractures (excluding ulnar styloid fractures) aims to anatomically reduce the distal ulna fracture (DUF) by open reduction and internal fixation, while obtaining a stable construct allowing functional rehabilitation without need for cast immobilization.

INDICATIONS

Severe displacement, angulation or translation, as well as unstable or intra-articular fractures. Furthermore, multiple trauma or young patients in need of quick functional rehabilitation.

CONTRAINDICATIONS

Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation. Stable, nondisplaced fractures. Need for bridging plate or external fixator of distal radiocarpal joint.

SURGICAL TECHNIQUE

An ulnar approach, with a straight incision between the extensor and flexor carpi ulnaris. Preservation of the dorsal branch of the ulnar nerve. Reduction and plate fixation with avoidance of plate impingement in the articular zone.

POSTOPERATIVE MANAGEMENT

Postoperatively, an elastic bandage is applied for the first 24-48 h. In isolated DUF with stable fixation, a postoperative splint is often unnecessary and should be avoided. For the first four weeks, only light weightbearing of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be increased as tolerated.

RESULTS

The best available evidence likely shows that for younger patients with a DUF, with or without concomitant distal radius fractures, open reduction and internal fixation can be safely achieved with good functional outcome and acceptable union and complication rates as long as proper technique is ensured.

Should ulnar styloid be fixed following fixation of a distal radius fracture?. Injury 2023;54:110768. [PMID: 37210301 DOI: 10.1016/j.injury.2023.04.055]

INTRODUCTION

Fracture of the base of the ulnar styloid has shown to have higher incidence of TFCC tears and DRUJ instability leading to nonunion and impaired function. Poorer functional outcomes of the distal radius fracture have been attributed to the untreated associated ulnar styloid fractures while some studies have shown no difference. Thus, the treatment remains controversial. However, it has been shown that fractures at the base of the ulnar styloid have a higher incidence of tears in the triangular fibrocartilage complex (TFCC) and instability in the distal radioulnar joint (DRUJ), which can lead to nonunion and impaired function. Despite this, there are currently no studies comparing the outcomes of surgically and conservatively treated patients.

METHODS

A retrospective study was conducted to analyze the outcomes of intra-articular distal radius fractures associated with base of ulnar fracture treated with distal radius LCP fixation. The study included 14 patients who were treated surgically and 49 patients who were treated conservatively, with a minimum follow-up of 2 years. Radiological parameters such as union and amount of displacement, VAS score for ulnar-sided wrist pain, functional assessment using the modified Mayo score and the quick DASH questionnaire and complications were analyzed.

RESULTS

At the final follow-up, the mean scores for pain (VAS), functional outcomes (modified Mayo score), disability (QuickDASH score), range of motion, and non-union rate were found to be statistically insignificant (p > 0.05) between the surgically treated and conservatively treated groups. However, patients with non-union had statistically significant higher scores for pain (VAS), greater post-operative displacement of the styloid, poorer functional outcomes, and higher disability (p < 0.05).

CONCLUSION

While there was no significant difference in ulnar-sided wrist pain and functional outcomes between the surgically treated and conservatively treated groups, the conservatively treated cases had a higher risk of non-union, which can negatively impact functional outcomes. The amount of pre-operative displacement was found to be a key factor in predicting non-union and can be used as a guide for determining the management of this type of fracture.

Comparison of surgical treatments for distal ulna fracture when combined with anterior locking plate fixation of distal radius in the over 70 age group

We conducted a retrospective multicentre study to compare the clinical and radiographic outcomes, and complications of three surgical treatments of distal ulna fracture (DUF) when combined with anterior locking plate fixation for distal radial fracture (DRF) in patients over 70 years of age. We identified 1521 patients over 70 years of age who were diagnosed as having DRF and who underwent anterior locking plate fixation between 2015 and 2020, among which 122 cases of DUF were analysed. Three surgical treatment options for DUF were identified in this cohort: K-wire fixation (Group K), locking plate fixation (Group L) and Darrach procedure (Group D). The results of the analysis showed the total immobilization period in Group D to be the shortest among the three treatments. Functional outcomes were superior, and the rate of complications were smaller in Group D than in Group L. In addition, rotational range of motion was larger in Group D and Group L compared with Group K. In patients who are 70 years of age or older with combined unstable DRF and highly comminuted or displaced DUF, the Darrach procedure for DUF seems to be the most useful and reasonable treatment option once the fracture of the distal radius has been rigidly fixed.Level of evidence: IV.

Distal ulna fractures in adults-subcapitular, transverse fractures did not benefit from surgical treatment

INTRODUCTION

Fractures of the distal ulna, excluding the styloid, are rare. The cause of injury is often a fall on an outstretched hand with an extended wrist, and in most cases there is a concomitant distal radius fracture. The aims of this retrospective study were to investigate the results of the current treatment of distal ulna fractures in adults, with or without a concomitant distal radius fracture, and if a recently presented fracture classification could predict outcome.

MATERIALS AND METHODS

Patients, 18 years or older, treated for a fracture of the distal third of ulna in our county, were included. Fractures of the styloid tip were excluded. The radiographs of the fractures were independently classified by two specialists in radiology according to the 2018 AO/OTA classification. Follow-up was performed 5-7 years after the injury, through the questionnaire Patient-Rated Wrist Evaluation (PRWE) and new radiographs of both wrists.

RESULTS

Ninety-six patients with 97 fractures were included and filled out the PRWE. 65 patients also had new radiographs taken. 79 patients were women and the mean age at the time of injury was 63 years (SD 14.5). The most common fracture class was the extra-articular transverse fracture, 2U3A2.3 (42%). We found that 40% of the fractures had been treated by internal fixation and only 2 fractures had not healed, one conservatively treated and one operated. The median PRWE was 15 (IQR 33.5). The PRWE score was significantly worse in the operated ulna fractures (p = 0.01) and this was also true for extra-articular transverse fractures 2U3A2.3 (p = 0.001). Initial displacement was more common in operated transverse fractures, but it could not be proven that this was the reason for the inferior result.

CONCLUSIONS

Distal ulna fractures almost always unite and the result is comparable to that of isolated distal radius fractures when measured by PRWE. Based on the opinions of the radiologists and how often a consensus discussion was needed for classification, we found the updated AO classification system difficult to use, if dependent only on standard radiographic views. In the present study, transverse extra-articular ulna fractures did not benefit from internal fixation regardless if associated with a distal radius fracture or isolated.

Treatment with Buttress Plate Technique for Symptomatic Ulnar Styloid Base Nonunion

Background  Surgical treatment options for symptomatic ulnar styloid base nonunion can be divided into two groups: styloid excision and styloid fixation methods. Styloid fixation is commonly performed using tension band wiring or distal ulna hook plate. However, these methods are more suitable for large styloids than small ones. For this reason, fixation of small styloids still remains a problem. Purpose  To present the surgical details and results of patients operated using the buttress plate technique, due to the symptomatic ulnar styloid base nonunion. Patients and Methods  In this study, 11 patients who underwent surgery for symptomatic ulnar styloid base nonunion using buttress plate technique were evaluated retrospectively. The patients were evaluated with the help of forearm and wrist range of motion, grip strength, disabilities of the arm, shoulder, and hand (DASH) score and visual analogue pain score. Results  The mean follow-up period was 15 months (range: 13-21 months). Union was achieved in 10 patients. At the final follow-up, the forearm supination and pronation active range of motions were significantly higher than those in the preoperative period, the visual analogue pain score mean value was 0.7 (range: 0-5), and the DASH score mean value was 7 (range: 1-32). Conclusion  We conclude that good results can be achieved with the buttress plate technique in patients with both large and small fragmented ulnar styloid base nonunions and no distal radioulnar joint instability. Level of Evidence  This is a Level IV, therapeutic study.

Do "Anatomic" Distal Ulna Plating Systems Fit the Distal Ulna Without Causing Soft Tissue Impingement?

Background: Distal ulna fracture fixation plates commonly cause irritation, necessitating removal, due to the narrow area between the ulna articular cartilage and the extensor carpi ulnaris. This study defines the safe zone for plate application and determines whether wrist position affects risk of impingement. Methods: Four different distal ulna anatomic plates (Acumed, Medartis, Skeletal Dynamics, and Synthes) were applied to 12 cadaveric specimens. Safe zone size was measured in circumferential distance and angular arc. Impingement was examined in flexion and extension in neutral, pronation, and supination. Results: The distal ulna safe zone has dimensions of a 92° arc and perimeter circumference of 15 mm. Cumulative extensor carpi ulnaris (ECU) impingement occurred in 0% of the 6 simulated wrist/forearm positions for the Acumed plate, 22% for the Synthes plate, 31% for the Skeletal Dynamics plate, and 68% for the Medartis plate. Impingement was most common in supination. Likelihood of ECU impingement significantly decreased in the following order; Medartis > Skeletal Dynamics > Synthes > Acumed. Conclusion: The ECU tendon's mobility can cause impingement on ulnarly placed distal ulna plates. Intra-operative testing should be performed in supination. Take home points regarding each plate from the 4 different manufacturers: contouring of Medartis plates, when placed ulnarly, is mandatory. The Acumed plate impinged the least but is not designed for far-distal fractures. The Synthes plate is least bulky but not suitable for proximal fractures. The Skeletal Dynamics plate appeared the most versatile with a reduced incidence of impingement compared to other ulnarly based plates.

The Effect of Ulnar Styloid Fractures on Patient-Reported Outcomes After Surgically Treated Distal Radial Fractures

Ulnar styloid fractures (USFs) are often associated with distal radial fractures (DRFs). When unstable DRFs are treated surgically, any associated USF is most commonly left untreated. The purpose of this study was to evaluate the effect of a concomitant USF on outcome after surgical stabilization of a DRF.

Using autograft in the surgical treatment of isolated distal ulna fractures with open reduction internal fixation improves short-term clinical outcomes: 11 years of experience

BACKGROUND

Most of the studies on ulna fractures assess the treatment of fractures accompanied by other tissue injuries; thus, the number of studies focused directly on isolated distal ulna fractures are very few. In this study, it was aimed to evaluate the short-term results of open reduction internal fixation (ORIF) and autograft+ORIF approaches in the treatment of isolated distal ulna fractures.

HYPOTHESIS

Using autograft in the surgical treatment of isolated distal ulna fractures with open reduction internal fixation improves short-term clinical outcomes.

PATIENTS AND METHODS

The records of isolated distal ulna fractures (distal one-third) operated at the Maltepe University Hospital Orthopedics and Traumatology Clinic between January 2009 and December 2019 were retrospectively reviewed. The cases were divided into two groups according to surgical approach, ORIF (n=40) or autograft+ORIF (n=34).

RESULTS

The mean age was 41.55±12.42 years. 52.7% of the cases were female, 67.6% of the fractures were right-sided, and 37.8% of the traumas causing the fracture were high-energy trauma. There was no significant difference between the ORIF and autograft+ORIF groups in terms of age, gender, side and severity of trauma (p>0.05). It was found that pseudoarthrosis development was significantly more prevalent in the ORIF group (25%) compared to the autograft+ORIF group (5.9%) (p=0.026). The median (1st quartile-3rd quartile) time to union was 16 (14-17) weeks in the ORIF group, and 9.5 (8.5-12) weeks in the autograft+ORIF group. Compared to ORIF, the time to union was significantly shorter with the autograft+ORIF procedure (p<0.001). At both the 3rd and 12th month follow-up examinations, the autograft+ORIF group was found to have significantly higher MAYO score and grip strength, and lower DASH score, compared to the ORIF group.

DISCUSSION

When an autograft is used in addition to ORIF in the surgical treatment of isolated distal ulna fractures, the bone heals faster, pseudoarthrosis develops less frequently, and short-term (3rd and 12th months) functional results are better.

LEVEL OF EVIDENCE

III; therapeutic study.

Wrist and Hand Trauma Imaging

Injuries to the wrist and hands occur frequently in athletes from the high forces applied during sporting events. The examples presented illustrate the important role imaging has in the diagnosis of wrist and hand injuries. In addition, different imaging modalities are complementary and various examinations may be needed to help guide the management of wrist and hand traumatic pathology.

Influence of volar margin of the lunate fossa fragment fixation on distal radius fracture outcomes: A retrospective series

BACKGROUND

Distal radius fractures accompanied by the volar margin of the lunate fossa (VMLF) lesions are often overlooked or inadequately reduced in clinical practice.

AIM

To investigate the impact of VMLF fragment in distal radius fractures on the stability and function of the wrist joint.

METHODS

This was a retrospective study of patients with distal radius fractures who underwent surgical treatment between January 2013 and December 2017. The patients were divided into two groups according to whether the VMLF fragments were fixed or not. X-rays and computed tomography were performed before surgery, immediately postoperatively, and at 1, 3, and 6 mo to measure the scapholunate angle, radiolunate angle, capitolunate angle, and effective radiolunate flexion (ERLF). The Mayo wrist score and disabilities of the arm, shoulder, and hand (DASH) score were determined at 1 year.

RESULTS

Thirty-five patients were included. There were 15 males and 20 females. Their mean age was 52.5 ± 14.3 (range: 19-70) years. There were 38 wrists (17 on the left side, 15 on the right, and three bilateral; 16 in the fixed group, and 22 in the unfixed group). The interval between trauma and surgery was from 1 h to 1 mo. The incidence of postoperative wrist instability in the unfixed group (86.4%) was higher than in the fixed group (25.0%) (P ≤ 0.001). Ten patients had ERLF > 25° in the unfixed group and none in the fixed group (P = 0.019). The Mayo wrist score was 94 ± 5.7 in the fixed group and 68 ± 15.1 in the unfixed group (P < 0.001). The DASH score was 4.6 ± 2.5 in the fixed group and 28.5 ± 19.5 in the unfixed group (P < 0.001).

CONCLUSION

Injuries of VMLF, even small fractures, might damage the radial-lunar ligament, leading to postoperative wrist instability, sagittal force line imbalance, and poor recovery of wrist joint function.

Finite element analysis of different locking plate fixation methods for the treatment of ulnar head fracture

Background

Ulnar head fractures are increasingly higher with the growing proportion of the elderly people. Failure to achieve a stable anatomic reduction of ulna head fracture may lead to a distal radioulnar joint (DRUJ) dysfunction and nonunion of the distal radius. Due to the lack of the postoperative reporting outcomes and the biomechanical studies, it has not been well established about the optimal management of the comminuted distal ulna head fracture. Hence, the purpose of this study is to use finite element analysis to explain the advantages and disadvantages of ulnar-side locking plate fixation compared with dorsal-side locking plate fixation and its screw arrangement in the treatment of ulnar head fractures.

Methods

FE models of the ulnar head fracture and the models of ulnar-side locking plate and dorsal-side plate with two or three distal screws was constructed. In order to simulate forces acting on the ulnar and the osteosynthesis material during daily-life activity in subjects who underwent reconstructive surgery, we applied three loading conditions to each model, viz. 20 N axial compression, 50 N axial compression, 1 N∙m torsion moment, 1 N∙m lateral bending moments, and 1 N∙m extension bending moments. Under these conditions, values of the von Mises stress (VMS) distribution of the implant, peak VMS, the relative displacement of the head and shaft fragments between the fracture ends and the displacement and its direction of the models were investigated.

Results

The stress values of ulnar-side plates were lower than those of dorsal-side plates. And the ulnar-plate fixation system also has smaller maximum displacement and relative displacement. When adding a screw in the middle hole of the ulnar head, the values of model displacement and the peak stress in fixation system are lower, but it may evidently concentrate the stress on the middle screw.

Conclusions

In conclusion, our study indicated that ulnar-side locking plates resulted in a lower stress distribution in the plate and better stability than dorsal-side locking plates for ulnar head fracture fixation. Adding an additional screw to the ulnar head could increase the stability of the fixation system and provide an anti-torsion function. This study requires clinical confirmation of its practicality in the treatment of ulnar head fractures. This study requires clinical confirmation as to its practicality in the treatment of ulnar head fracture.

Osteosynthesis of Phalangeal Fractures: Biomechanical Comparison of Kirschner Wires, Plates, and Compression Screws

PURPOSE

The aim of this study was to compare several osteosynthesis techniques (intramedullary headless compression screws, T-plates, and Kirschner wires) for distal epiphyseal fractures of proximal phalanges in a human cadaveric model.

METHODS

A total of 90 proximal phalanges from 30 specimens (index, ring, and middle fingers) were used for this study. After stripping off all soft tissue, a transverse distal epiphyseal fracture was simulated at the proximal phalanx. The 30 specimens were randomly assigned to 1 fixation technique (30 per technique), either a 3.0-mm intramedullary headless compression screw, locking plate fixation with a 2.0-mm T-plate, or 2 oblique 1.0-mm Kirschner wires. Displacement analysis (bending, distraction, and torsion) was performed using optical tracking of an applied random speckle pattern after osteosynthesis. Biomechanical testing was performed with increasing cyclic loading and with cyclic load to failure using a biaxial torsion-tension testing machine.

RESULTS

Cannulated intramedullary compression screws showed significantly less displacement at the fracture site in torsional testing. Furthermore, screws were significantly more stable in bending testing. Kirschner wires were significantly less stable than plating or screw fixation in any cyclic load to failure test setup.

CONCLUSIONS

Intramedullary compression screws are a highly stable alternative in the treatment of transverse distal epiphyseal phalangeal fractures. Kirschner wires seem to be inferior regarding displacement properties and primary stability.

CLINICAL RELEVANCE

Fracture fixation of phalangeal fractures using plate osteosynthesis may have the advantage of a very rigid reduction, but disadvantages such as stiffness owing to the more invasive surgical approach and soft tissue irritation should be taken into account. Headless compression screws represent a minimally invasive choice for fixation with good biomechanical properties.

Nascent Malunion of an Isolated Intraarticular Fracture of the Ulnar Head

Background  Isolated fractures of the ulnar head are rare. Only few cases have been reported in literature. Case Description  We report a case of a 16-year-old student who was treated for an ulnar styloid fracture conservatively. An associated displaced intraarticular fracture of the ulnar head has been overlooked. He presented late in our clinic with a symptomatic nascent malunion of the ulnar head fracture. A corrective osteotomy by a palmar approach was performed. Fixation by screws was used with an excellent result at 7-year follow-up. Literature Review  The rare cases of isolated ulnar head fractures reported in literature were treated by open reduction and internal fixation only in case of fracture dislocation. Clinical Relevance  The authors highlight the fact that even a nascent malunion of an isolated intraarticular fracture of the ulnar head may be treated successfully by open reduction and internal fixation.

Reduction of an Unusual Salter-Harris Type IV Fracture of the Ulna

We report the case of a 14-year-old boy with an isolated Salter-Harris type IV physeal fracture of the distal ulna. Following failed closed reduction, transition to open reduction and pin fixation was required. Six-month follow-up showed a favourable clinical evolution. Evidence suggests that long-term follow-up is needed because of the increased risk of premature physeal closure and subsequent growth disturbances associated with this type of injury.

Incidence of distal ulna fractures in a Swedish county: 74/100,000 person-years, most of them treated non-operatively

Background and purpose - Fractures of the distal ulna can occur in isolation or in conjunction with a distal radius fracture. They may result in incongruence and instability of the distal radioulnar joint. We investigated the incidence of distal ulna fractures, whether any fracture types were more common, and the methods of treatment used.Patients and methods - Data were collected from patients 18 years or older, treated for a fracture of the distal ulna in Östergötland, Sweden, during 2010-2012. Patients were identified in the patient registry. The fractures were classified according to the AO comprehensive classification of fractures.Results - The incidence of distal ulna fractures was 74/100,000 person-years. The most common fracture type was that of the ulnar styloid Q1 (79%), followed by the ulnar neck Q2 (11%). Rarest was ulna head fracture, type Q4 (1%). Incidental findings were a mean age of 63 years (SD 18), a concomitant distal radius fracture in 92% of the patients and that 79% were caused by falling from standing height. Internal fixation was performed in 30% of the Q2-Q6 fractures. This indicates that most were considered stable without internal fixation or stable after fixation of a concomitant radius fracture.Interpretation - Our results show that fractures of the distal ulna are not very common, and some fracture types are even rare. There seem to be no consensus on treatment.

Non-union of the ulnar styloid process in children is common but long-term morbidity is rare: a population-based study with mean 11 years (9-15) follow-up

Background and purpose - Fracture of the ulnar styloid process (USP) is common in children in connection with distal radius fracture. The long-term morbidity of USP non-union following a childhood distal radius fracture is unclear. We evaluated long-term clinical and radiographic findings of USP non-union. Patients and methods - All 208 children (< 16 years) who had suffered from distal radius fracture with or without a diagnosed concomitant ulnar fracture during 1992-1999 in the study institution were invited to follow-up at mean of 11 years (9-15) after the injury. Radiographs of both wrists of all 139 participants (67%) were taken; 22 patients showed USP non-union and they made up the study population. Distal radioulnar joint (DRUJ) instability, decreased range of motion (ROM), and weakened grip strength as compared with the uninjured side were the main functional outcomes. Elements of the "Disability of Arm, Shoulder and Hand" questionnaire were used for subjective symptoms. Results - The rate of USP non-union following childhood distal forearm fracture was 16% (22/139) and only 9 of the ulnar styloid fractures were visible in the radiographs primarily. At follow-up wrist flexion-extension ROM and ulnar and radial deviation ranges did not differ between the injured and uninjured sides. Grip strengths were similar. 6 patients reported pain during exercise. 7 had ulna minus (mean 2.3 mm) but none showed degenerative radiographic findings. Interpretation - The long-term clinical results of USP non-union following a childhood wrist fracture were good. However, one-third of the patients with USP non-union had ulnar shortening, which may predispose them to degenerative processes later in life.

If there is smoke, there must be fire - Isolated distal, non-displaced, intraarticular ulna fracture: A case report

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Isolated distal ulna styloid fractures are a rarity.

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Timely diagnosis and appropriate therapy reduce posttraumatic morbidity.

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High level of suspicion should be maintained in the presence of nonspecific pain, even if the initial X-ray is inconspicuous.

Introduction

Falling on the outstretched arm is a frequent trauma. The consequences can be isolated fractures of the distal radius, combined fractures of the distal radius and distal ulna - whereas the isolated fracture of the distal ulna is an uncommon trauma.

Presentation of case

We report on a 20- year- old male who presented at the emergency department after a motorcycle accident, suffering pain at his left forearm and left wrist. After an unremarkable x-ray in two planes, a CT- scan of the left wrist was performed and detected an isolated distal ulna fracture. The patient was treated with a forearm cast which led to a satisfying long term outcome.

Discussion

Based on the presented case the anatomical peculiarities of the distal radioulnar joint and the different trauma mechanisms as well as the resulting lesions, the diagnostic modalities and the treatment options are discussed.

Conclusion

We recommend performing an additional CT scan of the wrist in case of credible complaints after trauma to avoid baulking this very rare type of fracture.

Headless Screw Fixation of Metacarpal Neck Fractures: A Mechanical Comparative Analysis

BACKGROUND

The purpose of this study was to compare the mechanical properties of metacarpal neck fracture fixation by headless compression screw (HCS) with that of Kirschner wire (KW) cross-pinning and locking plate (LP) fixation.

METHODS

A metacarpal neck fracture was created in 30 fourth-generation composite Sawbones metacarpal models. A volar-based wedge was removed using a custom jig to simulate a typical apex dorsal fracture, unstable in flexion. The models were divided into 3 equal groups based on the method of fixation: retrograde cross-pinning with two 1.2-mm KWs, 2.0-mm dorsal T-plate with six 2.0-mm locking screws (LP), and a 3.0-mm retrograde HCS. Models were fixed at the proximal end, mounted in a material testing machine, and loaded through a cable tensioned over the metacarpal head, simulating grip loading. Cyclic loading from 0 to 40 N was performed, followed by loading to failure. Load, displacement, and failure mode were recorded.

RESULTS

Stiffness of the HCS (7.3 ± 0.7 N/m) was significantly greater than the KW (5.8 ± 0.5 N/m) but significantly less than the LP (9.5 ± 1.9 N/m). With cyclic loading to 40 N, the LP exhibited significantly less displacement (0.2 ± 1.3 mm) compared with the HCS (2.5 ± 2.3 mm) and KW (2.8 ± 1.0 mm). Load to failure for the HCS (215.5 ±3 9.0 N) was lower than that of the KW (279.7 ± 100.3 N) and of the LP (267.9 ± 44.1 N), but these differences were not statistically significant.

CONCLUSIONS

The HCS provided mechanical fracture fixation properties comparable with KW fixation. The LP construct allowed significantly less displacement and had the highest strength of the 3 fixation methods.

Early and late fixation of ulnar styloid base fractures yields different outcomes

BACKGROUND

The role of surgical fixation of ulnar styloid fractures remains a subject of debate. The purpose of this study was to compare the surgical outcomes following early and late intervention.

METHODS

We retrospectively reviewed 28 patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2014. Surgical fixation was performed within 3 months of injury in 13 patients (group A) and beyond 3 months in 15 patients (group B). Patient characteristics and functional outcomes were compared between the two groups. The outcome survey consisted of QuickDASH score, grip strength, range of motion, pain score based on the visual analog scale, and surgical complications. Descriptive statistics were calculated for key variables. A p value of < 0.01 was considered statistically significant.

RESULTS

Patient characteristics including age, sex, injured side, dominant side injury, and concomitant distal radius fracture showed no significant differences between the two groups. Time to surgery averaged 1.1 months in group A and 12.3 months in group B. Significantly better outcomes were found in group A than in group B, including QuickDASH scores (4.4 ± 5.9 vs. 12.9 ± 9.9) and grip strength (37.4 ± 5.1 vs. 29.1 ± 5.9 kg). Significantly better range of motion was found in group A than in group B with respect to supination (81.9° ± 4.3° vs. 75° ± 8.5°), extension (84.6 ± 4.3 vs. 76.7 ± 6.5), and flexion (80.4° ± 3.8° vs. 72° ± 4.1°). The difference was not significant in case of pronation (78.8° ± 3° vs. 74.3° ± 5.9°) and with respect to pain scores (0.6 ± 0.7 vs. 1.3 ± 1).

CONCLUSION

Both osseous and soft tissue lesions need to be fully addressed in ulnar styloid fractures. Early detection and surgical repair yielded better outcomes. Higher complication rates in late-treated fractures show that surgeons should select surgical candidates and modalities properly.

Distal ulnar fracture nonunion management: An uncommon case report

Introduction:

Isolated distal ulnar fracture is an uncommon injury. Only a few case series that look into the management of ulnar fracture nonunion have been reported in the literature.

Case presentation:

A middle-aged manual worker presented to us for isolated fracture of his left distal ulna. He received open reduction and fixation of the distal ulnar fracture using distal ulna locking plate. It was complicated with nonunion and he complained of persistent wrist pain. This distal ulnar fracture nonunion was finally treated by Sauve-Kapandji procedure with good functional outcome.

Discussion:

Displaced distal ulnar fracture should be reduced anatomically with rigid fixation to prevent disruption of the distal radioulnar joint. Fracture nonunion was traditionally managed with revision osteosynthesis and bone grafting. It is, however, technically difficult at the distal ulnar region because of the poor bone stock and lack of soft tissue coverage.

Conclusion:

We have demonstrated that the Sauvé-Kapandji procedure is a good treatment alternative for distal ulnar fracture nonunion.

Ulnar Neck Fractures Associated with Distal Radius Fractures

Background  There is little published data to guide management of ulnar neck fractures associated with fractures of the distal radius. Purpose  As unplanned surgery usually reflects adverse events and this injury combination is relatively uncommon, we used a large database to study the incidence of unplanned surgeries after surgical and nonsurgical treatment of distal metaphyseal ulna fractures associated with a distal radius fracture and identify factors associated with these unplanned surgeries. Patients and Methods  We identified 277 patients with an ulnar neck fracture associated with a distal radius fracture. Fifty-six (20%) ulnar neck fractures were initially treated operatively and six of them (11%) had a second, unplanned surgery. Of the 221 initially nonoperatively treated fractures, only one (0.45%) had a subsequent unplanned surgery that seemed unrelated to the fracture (ulnar nerve neurolysis). Results  Bivariate analysis showed that younger age, open fracture, multifragmentary fractures, and initial operative treatment of the ulnar neck fracture were significantly associated with unplanned surgery. A multivariable analysis was not feasible due to the small number of unplanned surgeries. Conclusion  Eighty percent of ulnar neck fractures associated with a fracture of the distal radius was treated nonoperatively in our region, and subsequent surgery for problems was very uncommon. Operative treatment and fracture complexity were associated with unplanned surgery, which reflected some measure of injury severity, technical inadequacy, and inherent problems associated with surgery. Level of Evidence  Level II, prognostic study.

Fixation of distal ulna fractures associated with distal radius fractures using intrafocal pin plate

Background Unstable distal ulna fractures in the setting of distal radius fractures can present a challenging problem, especially in the elderly population. Operative fixation of the subcapital distal ulna fracture may help to provide a stable ulnar buttress for attempting to reduce the distal radius fracture. Traditional fixation techniques of the distal ulna may prove unsatisfactory in the setting of osteoporosis and comminution. Description The intrafocal pin plate is placed through a small incision distally and uses the curve of the plate to obtain multiple points of fixation within the intramedullary canal. The overhang of the distal aspect of the plate helps to reduce the fracture. The plate is secured using unicortical locking screws in the ulnar head. Patients and Methods The most ideal fracture pattern for this fixation technique is a subcapital distal ulna fracture that is unstable and associated with a distal radius fracture. This technique is contraindicated in ulnar head fractures, segmental fractures with proximal extension, and open fractures with gross contamination as well as in the setting of active infection. Results This technique has provided a stable ulnar buttress and aided in the reduction of grossly unstable distal radius fractures. All of these patients have gone on to union, and we have not experienced a need for plate removal due to pain or soft tissue irritation. Conclusions We have found the intrafocal pin plate to provide both a stable ulnar buttress as well as intramedullary fixation to aid in the fixation of distal radius fractures associated with unstable distal ulna subcapital fractures.

Sexual dimorphism in ulna: an osteometric study from India

Determination of sex constitutes the most important element during the identification process of human skeletal remains. Several sex-specific features of human skeleton have been exploited for sex determination with varying reliability. This study aims to obtain sexual dimorphic standards for ulnae of the north Indian population. Eight measurements were obtained on a sample of 106 ulnae (males--80, females--26) in the age range of 25-65 years. The sexual dimorphism index and demarking points were calculated for all the variables. The data were then subjected to stepwise and direct discriminant function analysis. The best discriminator of sex was the maximum length (84.9%) followed by radial notch width (84%). In stepwise analysis, these two variables were selected and provided an accuracy of 88.7% (M-87.5%, F-92.3%). The proximal end provided a classification rate of 81.1% (M-80%, F-84.6%) with selection of the notch length and olecranon width.

Treatment of unstable distal ulna fractures associated with distal radius fractures in patients 65 years and older

PURPOSE

To prospectively compare the clinical and radiological outcomes of 2 treatment methods for unstable distal ulna fractures associated with distal radius fractures in patients 65 years of age and older.

METHODS

From February 2008 to March 2010, the first 29 ulnas were treated surgically (group 1) and the next 32 ulnas were treated nonoperatively (group 2). The mean final follow-up period was 34 months (range, 24-56 mo). All radiuses were fixed internally, in both groups. Clinical outcomes were compared between groups using a visual analog scale for postoperative pain; Disabilities of the Arm, Shoulder, and Hand scores; active range of motion; grip strength; and the modified system of Gartland and Werley. Radiological outcomes, including ulnar variance, were evaluated. Arthrosis was evaluated at the radiocarpal joint or distal radioulnar joint (DRUJ) according to the system of Knirk and Jupiter.

RESULTS

There were no significant differences between the groups in any of the clinical outcomes. No significant differences were observed for radiological outcomes including ulnar variance, distal radius, and union rate. There were no patients in either group with symptomatic arthritic changes in the radiocarpal joint or DRUJ at the final follow-up. In group 2, 1 patient had malunion (angulated, 14°) on the anteroposterior view without evidence of arthrosis in the DRUJ, and functional outcomes were good.

CONCLUSIONS

In this population distal ulna fractures can be successfully managed nonoperatively when they occur in combination with distal radius fractures.

Remodeling of distal ulna after excision arthroplasty for acute comminuted distal ulnar fracture: a case report

Bone adaptation after excision arthroplasty of distal radioulnar joint in an acute traumatic distal ulna fracture has never been reported. A case of irreparable and comminuted distal ulnar head fracture was managed by excising the ulna head and repairing the fovea (deep ligament) attachments of distal radioulnar ligaments, and then an unexpected remodeling of the distal ulna with the shape of pole and seat was noted. The anatomy of deep fibers of distal radioulnar ligament is important not only in biomechanics about the stability of distal radioulnar joint but it is also possible in the morphology about the shape of the distal radioulnar joint.

Intra-articular distal ulnar fractures associated with distal radial fractures in older adults: early experience in fixation of the radius and leaving the ulna unfixed

There is no clear consensus about the best management of intra-articular distal ulnar fractures associated with distal radial fractures in older adults. We describe a treatment wherein the distal radial fractures were securely fixed with a palmar plate, leaving the associated ulnar fractures unfixed. The wrists of 14 patients with a mean age of 74 years were reviewed at an average of 18 months after surgery. The results were excellent in 11 cases and good in three, according to the modified Gartland and Werley score. All fracture sites displayed union, and there was no instability of the distal radioulnar joint. A widening of the distal radioulnar joint space was present in one wrist. Angular deformity of the distal ulnar metaphysis was seen in five wrists. This treatment could be an alternative to open reduction with internal fixation for intra-articular distal ulnar fractures in older adults.