The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures

Headless screw fixation of unstable ulnar styloid base fractures after distal radial fractures fixation

Ulnar styloid fractures occur frequently concomitant with distal radial fractures. Although unstable distal radial fractures are mostly surgically treated, ulnar styloid fractures are often ignored. Unstable fractures at the base of the ulnar styloid may lead to persistent ulnar pain, due to distal radioulnar joint instability or ulnar styloid non-union. We retrospectively analyzed a single-surgeon cohort series of surgically treated distal radial fractures on how these concomitant ulnar styloid fractures were regarded: indications for surgery and surgical technique with headless screw fixation. 119 surgically treated distal radial fractures were assessed. 51 (42.8%) of the surgically treated distal radial fractures had a distal ulnar fracture, and more specifically 23 (19.3%) had a base fracture of the ulnar styloid. 9 (7.6%) of the wrists had a base fracture of the ulnar styloid which was considered after distal radial fracture fixation as persistently unstable, during distal radioulnar joint ballottement translation test. This fracture subtype was immediately treated with headless screw fixation, resulting in all cases in bony union, with a mean active pronation of 85°, a mean active supination of 80° and a clinical stable distal radioulnar joint, with minimal ulnar pain after 6 weeks (mean Visual Analogue Scale 1). After at least 12 months, persistent pain did not occur and mean QuickDASH was 2.5. According to this single-surgeon cohort series, headless screw fixation provides a reliable treatment for unstable base fractures of the ulnar styloid after distal radial fixation.

Operative versus non-operative treatment of ulnar styloid process base fractures: a systematic review and meta-analysis

PURPOSE

Ulnar styloid process (USP) fractures are present in 40-65% of all distal radius fractures (DRFs). USP base fractures can be associated with distal radioulnar joint (DRUJ) instability and ulnar sided wrist pain and are treated by conservative management and surgical fixation, without consensus. This systematic review and meta-analysis compares operative to non-operative treatment of concomitant ulnar styloid base fractures in patients with distal radius fractures.

METHODS

PubMed/Medline/Embase/CENTRAL databases were searched identifying RCTs and comparative observational studies. Effect estimates were extracted and pooled using random effect models to account for heterogeneity across studies. Results were presented as (standardized) mean differences (SMD or MD) or odds ratios (OR) and corresponding 95% confidence intervals (95%CI).

RESULTS

Two RCTs (161 patients) and three observational studies (175 patients) were included. Tension band wiring was used for surgically treated USP fractures. Results were comparable across the different study designs and hence pooled across studies. Non-surgically treated patients had better wrist function at 6 months (SMD 0.57, 95%CI 0.30; 0.90, I2 = 0%). After 12 months there was no observed difference (MD 2.31, 95%CI -2.57; 7.19, I2 = 91%). Fewer patients had USP non-unions in the operative group (OR 0.08, 95%CI 0.04; 0.18, I2 = 0%). More patients suffered complications in the operative group (OR 14.3; 95%CI 1.08; 188, I2 = 89%).

CONCLUSION

Routinely fixating USP base fractures as standard of care is not indicated. Surgery may be considered in selective cases (e.g. persistent DRUJ instability during ballottement test after fixation of the radius).

Ipsilateral fractures of the ulnar styloid with distal radius fractures; to fix or not? A systematic review and meta-analysis

Background

The most common upper limb fracture encountered in clinical practice is distal radius fracture (DRF). They frequently occur due to falls onto an outstretched hand or other traumatic incidents, resulting in a break in the radius near the wrist joint. DRFs often present a spectrum of injuries and are a common reason for emergency department visits, affecting approximately one out of every six patients seeking medical attention in this setting.

Methods

This systematic review was performed according to the guidelines of PRISMA, using the electronic database search of PubMed, Embase, Scopus, and Cochrane Library, and the protocol for the review was registered to PROSPERO. All comparative study designs (prospective or retrospective) that compared fixation of ulnar styloid and no fixation in a case of ipsilateral distal end radius fracture were included.

Results

The current review analyzed 336 patients from five studies, two randomized controlled trials (RCTs), two prospective, and one retrospective comparative study. The meta-analysis revealed a significantly higher rate of union in fixation group than the no-fixation group, with an odds ratio of 10.29 (95%CI 4.74, 22.32; p < 0.00001). However, no significant differences were found in other radiological parameters such as radial inclination, volar angle, and ulnar variance. Regarding functional outcomes, the result was equivocal for the two groups regarding DASH/quick DASH score, Modified Mayo Wrist score MD of 0.22 [95 % CI -1.84, 2.28, p = 0.83; I2 = 0 %], grip strength, range of motion, and overall complications OR of 0.53 (95 % CI 0.08, 3.47; p = 0.51; I2 = 86 %), but higher occurrence of ulnar-sided pain, hardware prominence, and paraesthesias.

Conclusion

Fixation of ulnar styloid in conjunction with DRF does not significantly benefit patients. Despite better styloid union rates, it increases implant-related complications without improving final function, range of motion, stability, or grip strength. Patients may experience increased ulnar-sided pain due to implant prominence. Therefore, non-fixation of the ulnar styloid process is recommended as it offers no significant advantages.

Management of Ulnar Styloid Nonunions

Ulnar styloid fractures commonly occur in the setting of distal radius fractures and often progress to asymptomatic nonunion. Displaced basilar ulnar styloid fractures involving the deep radioulnar ligament attachments may cause distal radioulnar joint (DRUJ) instability. A careful clinical history, physical examination, review of imaging studies, and selected diagnostic interventions are important for confirming the relationship of the ulnar styloid nonunion with ulnar-sided wrist symptoms and/or DRUJ instability. Improved functional and symptomatic outcomes can be achieved with nonunion repair or fragment excision with or without triangular fibrocartilage complex repair, depending on the location and size of the ulnar styloid fracture.

Volar Barton Fracture and Ulnar Styloid Fracture With Distal Radial Ulnar Joint Disruption of the Right Wrist Without Neurovascular Deficit

Volar Barton fracture is a common condition in dislocation of the distal radius of the volar or dorsal aspect. It occurs due to violent injury or road traffic accidents. Radius is one of the most common parts to get affected. Various treatment plan is needed for this fracture like physical therapy and medication. Surgical intervention is necessary to treat the patient for a volar Barton fracture. Recovery takes time for this condition. For treatment, patient education is also important. The patient should be goal-oriented, cooperative, and motivated for the rehabilitation program. Isometric strengthening exercises for the shoulder and elbow were performed to regain the muscle's strength. The main aim is to make the patient independent of functional activities. Quality of life improved, and a rehabilitation program benefited the patient.

Validity of distal radius fracture diagnoses in the Swedish National Patient Register

Distal radius fractures are one of the most common fractures in adults. More research is needed to establish evidence-based clinical practice guidelines to generate cost-effective and fair fracture treatment. The Swedish National Patient Register is a principal source for population-based epidemiologic studies in Sweden. The validity of some-but not all-diagnoses in the register is high. Little is known regarding the validity of registration of distal radius fractures.A dataset of cases registered with diagnosis of distal radius fracture (S52.5) or distal radius and ulna fracture (S52.6) were collected from the Swedish National Inpatient and Outpatient Registers. Six cohorts, each containing 240 simple random samples, were constructed. Radiographic reports and medical records were reviewed to confirm or reject the diagnosis as well as, in relevant cases, the surgical intervention. Positive predictive values (PPV) were calculated.The PPV for distal radius fracture in the register ranges between 92 and 100%, lower if coded as S52.6 and higher if there was an adherent code of surgical intervention. Codes for surgical intervention reached a PPV of 95-100%.In conclusion, the validity of the codes for diagnosis and the surgical treatment of distal radius fracture is high in the Swedish National Patient Register. According to our results, the register may be used as a reliable data source for population-based research of distal radius fractures.

Treatment of type II symptomatic ulnar styloid nonunions with reinsertion of the triangular fibrocartilage complex

PURPOSE

The purpose of this retrospective study was to introduce an alternative technique for the treatment of type II symptomatic ulnar styloid nonunion by the reinsertion of the triangular fibrocartilage complex and the ulnar collateral ligament.

METHODS

Between March 2009 and May 2017, 45 patients (34 males and 11 females) suffering from the nonunion of type II ulnar styloid fractures all underwent the subperiosteal resection of the avulsed fragments and the reinsertion of the TFCC and ulnar collateral ligament. Outcome assessments included the ranges of motion of the wrist, grip strength, pain, and Mayo wrist score. The preoperative and postoperative parameters were compared. A P-value less than 0.05 was considered to be statistically significant.

RESULT

The mean follow-up period was 21.66 ± 7.93 months (range, 12 to 26 months). At the final follow-up, the mean preoperative flexion and extension were 79.32 ± 4.52° and 74.40 ± 4.36° respectively. The mean preoperative pain score, grip strength, and Mayo wrist score were 32.48 ± 4.00; 23.88 ± 8.38 kg, and 77.72 ± 8.31 respectively. The mean postoperative flexion and extension of the wrist were 80.56 ± 6.32° and 75.43 ± 3.12° respectively. The mean postoperative pain score, grip strength, and Mayo wrist score were 12.41 ± 3.27, 26.31 ± 8.30 kg, and 90.71 ± 7.97 respectively. There were significant differences in pain, grip strength, and Mayo wrist score (P < 0.05), but no significant differences concerning the range of motion of the wrist.

CONCLUSION

In the treatment of the nonunion of type II ulnar styloid fractures, the resection of the avulsed fragments followed by the reinsertion of the TFCC and the ulnar collateral ligament with an anchor was a reliable alternative technique, bringing the satisfactory function of the wrist.

Fixed Subluxation of the Distal Radioulnar Joint following Malunion of the Ulnar Styloid Process

Purpose  Recent literature on significance and treatment of ulnar styloid fractures suggest that the ulnar styloid is not the central problem but the radioulnar ligaments and their impact on joint stability. However, specifically displaced ulnar styloid process fractures that secondarily heal in an ectopic position remain a rare situation for which diagnostics and treatment options remain a topic of discussion. Methods  This case series presents four patients with limited supination due to a fixed dorsal subluxation of the distal radioulnar joint (DRUJ). The reason here fore was a significant malunion of ulnar styloid fracture that was addressed by corrective ulnar styloid osteotomy. Three of these osteotomies used three-dimensional (3D) preoperative planning and patient specific guides. Results  All patients presented with a significant displacement of the malunited ulnar styloid fracture (average 32-degree rotation and 5-mm translation). In all four patients, the fixed subluxation of the ulnar head was resolved clinically and radiographically, and the forearm rotation restored after corrective osteotomy of the ulnar styloid and fixation in an anatomical position. Conclusion  This case series presents a very specific subset of patients with nonanatomically healed ulnar styloid fractures responsible for a chronic DRUJ dislocation and limited prosupination and its treatment. Level of evidence  This is a Level IV, therapeutic study.

Is it necessary to fix basal fractures of the ulnar styloid after anterior plate fixation of distal radius fractures? A randomized controlled trial

The purpose of this study was to investigate the necessity for surgical fixation of basal fractures of the ulnar styloid without distal radioulnar joint (DRUJ) instability, after stabilization of associated distal radial fractures using an anterior plate. This single-centre, prospective, randomized controlled trial, conducted between 2015 to 2021, included 43 patients in each study arm who were randomized to either fixation (Group A) or non-operative treatment (Group B) of the ulnar styloid. The mean follow-up period was 24 months (SD 5.2) in Group A and 23.9 months (SD 5.5) in Group B. At the final follow-up, patients were evaluated by the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the Modified Mayo Wrist Score (MMWS), the visual analogue scale (VAS) for pain, the grip strength, wrist range of motion. The DASH score was 6 (SD 2.6) in Group A and 6 (SD 2.4) in Group B; the MMWS was 87 (SD 5.6) in Group A and 87 (SD 5.6) in Group B; and the grip strength was 88% (SD 9.4) in Group A and 87% (SD 7.7) in Group B. In conclusion, fixation of basal ulnar styloid fractures is not mandatory if the DRUJ is stable after rigid fixation of the associated fracture of the distal radius.Level of evidence: II.

Operative Stabilization of Distal Radius Fractures Presenting With Ulnar Head Subluxation/Dislocation Addresses Distal Radioulnar Joint Instability Without Further Stabilization Procedures

OBJECTIVES

To determine the prevalence of ulnar head subluxation/dislocation in distal radius fracture and to discuss management, surgical outcomes, and relevant anatomy.

SETTING

Urban tertiary care hospital.

PATIENTS/PARTICIPANTS

Two hundred seventy-one patients with displaced distal radius fractures undergoing surgical management were reviewed to determine the incidence of ulnar head subluxation or dislocation using the Mino criteria defined by Mino et al.

MAIN OUTCOMES

Postoperative computed tomography and radiographs were assessed for sigmoid notch and distal radioulnar joint (DRUJ) reduction and fracture healing. Range of motion, functional limitation, and pain were documented at final outcome.

RESULTS

Of the 271 cases, there were 8 cases of prereduction DRUJ subluxation/dislocation, including 2 frank dislocations and 6 subluxations (2.95%). All were treated with open reduction and internal fixation (ORIF) of the distal radius with a volar locked plate. In addition, 1 patient underwent ORIF of an associated distal ulnar shaft fracture and another, who had a grade 1 open fracture over the distal ulna, underwent open TFCC repair. The remaining 6 patients had closed reduction of the DRUJ without further stabilizing procedures. All had stable DRUJ joints following ORIF, both intra-operatively and at final follow-up. All ulnar heads were located within the DRUJ on post-op computed tomography; using the more sensitive radioulnar ratio there was residual ulnar head subluxation in 5/8 patients. Range of motion and functional outcome were excellent at an average of 133 weeks postoperatively. The DRUJ was stable at long-term follow-up in all patients.

CONCLUSIONS

Ulnar head subluxation/dislocation is an uncommon injury in the setting of distal radius fracture. When present, it can usually be treated effectively with operative stabilization of the distal radius fracture without further stabilizing procedures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radius distraction during volar plating of distal radius fractures may improve distal radioulnar joint stability at minimum 3-year follow-up: a retrospective case series study

BACKGROUND

The surgical technique of radius distraction for stabilization of distal radioulnar joint (DRUJ) if intraoperative DRUJ instability was found after the fixation of distal radius fracture has been previously described, but this surgical technique lacks clinical and radiographic effect in minimal 3 years follow-up. We therefore evaluated the clinical outcome and radiographic results of radius distraction in minimal 3 years follow-up as long-term evaluation.

METHODS

We reviewed the case series of distal radius fracture with concomitant DRUJ instability receiving radius distraction from the senior author over a 5-year period (January 1st, 2013, to June 30th, 2017) retrospectively. Radius distraction during volar plating was performed by moving the volar plate distally via compression screw loosening/fastening to achieve firm endpoint on the dorsopalmar stress test. The evaluations of radiographic, including bone union time and ulnar variance, and clinical outcomes, including grading of DRUJ instability, NRS of wrist pain, DASH score, MMWS score, and range of motion of operated wrist at final follow-up, were performed at clinic as minimum 3-year follow-up; a total 34 patients had been evaluated.

RESULTS

At minimal post-operative 36 months follow-up, all cases demonstrated acceptable wrist range of motion with stable DRUJs, low NRS of wrist pain (0.6, SD 0.7), and satisfactory DASH score (mean 9.1, SD 6.2) and MMWS score (mean 87, SD 10). There were no cases suffering from nonunion of distal radius. The mean ulnar variance of injured wrist and uninjured wrist were -1.2 mm and 0.2 mm, respectively (SD 1.0 and 0.6) with significant statistical difference.

CONCLUSIONS

Radius distraction during volar fixation of distal radius fracture should be considered if DRUJ instability was found by the dorsopalmar stress test intraoperatively, and the long-term DRUJ stability could be achieved by maintenance of normal-to-negative ulnar variance, with decreased wrist pain and satisfactory function outcome.

LEVEL OF EVIDENCE

Therapeutic Level IV.

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.

The Critical Size of Ulnar Styloid Fragment for the DRUJ Stability

Background  Ulnar styloid fractures can be associated with clinically significant instability of the distal radioulnar joint (DRUJ). However, the exact fragment size that results in DRUJ instability is unknown. Purpose  The objective of this study was to determine the critical size of an ulnar styloid fracture that would result in a significant increase in DRUJ translation and forearm rotation. Methods  Eight cadaveric specimens were used to investigate the effects of three different ulnar styloid fracture sizes on DRUJ instability: tip fracture, base fracture, and a fracture including the fovea. Forearm rotation and dorsopalmar DRUJ translation were measured after each sequential increase in fracture size. Results  Relative to the uninjured state, a significant increase in forearm rotation and dorsopalmar translation was found for all three fractures. However, the fovea fracture showed a statistically significant increase in forearm rotation compared with all other fracture types and a statistically significant increase in total dorsopalmar translation compared with the tip fracture. Conclusion  In this study, ulnar styloid fractures involving the fovea resulted in significantly greater DRUJ instability comparted to tip and base fractures alone. This study provides important biomechanical data regarding the critical size of ulnar styloid fractures that result in DRUJ instability and may aid in the surgical decision-making algorithm in these patients.

What's the best surgical repair technique of an ulnar styloid fracture? A biomechanical comparison of different techniques

INTRODUCTION

8-10% of all Ulnar styloid fractures (USF) accompanying distal radius fractures are addressed surgically. The surgical fixation has to counteract forces of translation and rotation acting on the distal radioulnar joint (DRUJ). The different technics used were never compared biomechanically. Our study aims to compare the effects of different techniques of USF fixation on the forearm rotation and the dorsal-palmar (DP)-translation of the DRUJ.

MATERIAL AND METHODS

9 forearm specimens were mounted on a custom testing system. Load was applied for Pronosupination and DP-translation with the forearm placed in neutral position, pronation and supination. The positional change of the DRUJ was measured using a MicroScribe. Six different, sequential conditions were tested in the same specimen: intact, USF and 4 repair techniques (2 K-wire, tension band wiring (TBW), headless compression screw, suture anchor).

RESULTS

The USF significantly increased DP-translation and pronosupination compared to the intact condition. The DP-translation in neutral was reduced significantly with all four techniques compared to the USF condition. TBW and suture anchor also showed a significant difference to the K-wire fixation. In supination only the TBW and suture anchor significantly decreased DP-Translation. The rotational stability of the DRUJ was only restored by the K-wire fixation and the TBW.

CONCLUSIONS

All four USF repair techniques partially restored translational stability; however, only K-wire fixation and TBW techniques restored rotational stability. TBW was biomechanically superior to the other techniques as it restored translational stability and rotational stability.

Conservative treatment of ulnar styloid fractures following volar-plate fixation of distal radius fractures: incidence of nonunion evaluated by computed tomography

PURPOSE

The first aim of this study was to investigate the incidence of ulnar styloid fractures (USFs) accompanied by distal radius fractures (DRFs), treated with volar locking plates. The fracture type of DRFs was evaluated by the classifications, based on computed tomography (CT) scan findings. The second aim was to investigate the bone union rate of USFs, depending on the fracture type of DRFs, by comparing union and nonunion groups in the USFs groups.

METHODS

Between May 2012 and December 2019, 239 consecutive patients with DRFs were treated. Of these patients, 177 DRFs met inclusion criteria. The fracture patterns of the DRFs, based on the classification, using CT scans, which included the AO classification, sagittal angulation, and axial fracture patterns of the articular surface of the distal radius in two-part intra-articular fractures were evaluated. The size of USFs, classified as a tip or base fracture was also investigated.

RESULTS

The incidence of USFs was significantly higher for AO types A and C than for type B. Analysis of the sagittal angulation of DRFs showed that the incidence of USFs was higher for the extension type than for the flexion type. Axial CT classification of two-part fractures revealed that DRFs with a dorsal fracture line was more frequent than the volar type of DRFs. These results suggested that dorsal displacement of DRFs was associated with a higher incidence of USFs. Finally, the analysis of the bone union rate of USFs revealed that AO classification and sagittal angulation were not correlated with bone union in USFs. However, it was found that a fracture line on the radial side of the radius had a significantly low rate of bone union, compared to a fracture line on the dorsal side. The size of USFs was also not correlated with the bone union rate.

CONCLUSIONS

The incidence and the bone union rate of USFs have different patterns. The incidence of USFs was higher in the dorsal displacement type of DRFs. However, the bone union rate of USFs was lower for a fracture line on the radial side. Therefore, USFs with DRFs that have a fracture line on the radial side is a candidate for fixation to prevent nonunion.

Common Complications of Distal Radial Fractures

Distal radial fractures are associated with good outcomes; however, although they occur at low rates, complications can significantly impair treatment success. Therefore, the treating surgeon should be aware of potential complications associated with each treatment type and how to best prevent them. Although certain patient-specific and fracture-specific factors may increase the risk of adverse outcomes, most are nonmodifiable risk factors at the time of presentation, so it is imperative that every effort is made to mitigate these risk factors to prevent long-term morbidity. Patients should be well-informed about these complications and potential symptoms so that they can be addressed expeditiously.

Distal Radius Fracture and the Distal Radioulnar Joint

In this article, we discuss the incidence and types of injuries to the distal radioulnar joint (DRUJ) that occur in the setting of a distal radius fracture. We review the anatomy of the distal radioulnar joint, which is critical to understanding its biomechanics, and how injury could cause symptomatic incongruency and instability. We highlight how patients with an injury to the distal radioulnar joint might present both at the time of injury and after treatment of a distal radius fracture, the appropriate workup, the available treatment options, and the evidence-based literature.

A Critical Assessment of the Most Cited Papers on Distal Radius Fractures

This article reviews the impact of the most cited works on distal radius fractures. Judged by the most cited works in this field, distal radius fracture research has followed other paradigm shifts in the history of science. Landmark papers showed that restoring premorbid anatomy led to better outcomes, and a plurality of fixation strategies emerged. A breakthrough in technology came with volar plating, and the new paradigm emerged: precise anatomic reduction is achieved typically with volar plates, unless fragment-specific approaches are needed. This paradigm is being challenged as the association among malunion, arthritis, and function continues to be understood. The best treatment of distal radius fractures in the elderly has also evolved through time.

Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis

Purpose

We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients.

Methods

A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS).

Results

Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3–16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups.

Conclusions

This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures.

Type of study/level of evidence: Therapeutic II.

Relationship between Fracture of the Ulnar Styloid Process and DRUJ Instability: A Biomechanical Study

Background  There has been clinical question in the treatment of ulnar styloid fracture with distal radius fracture, surgical fixation of the styloid fragment, or ignorance of the fragment. We examined relationship between size of the ulnar styloid fracture and distal radioulnar joint (DRUJ) stability biomechanically to answer the above clinical question. Methods  Changes in the dorsopalmar stiffness of the DRUJ after experimentally simulating in four types of ulnar styloid fractures were examined in cadavers. After tip, middle, base-horizontal, and base-oblique type of styloid fractures were made sequentially, changes in dorsopalmar DRUJ stiffness were measured using the MTS machine in the intact wrist, for each fracture, at 60 degrees pronation, neutral, and 60 degrees supination, respectively. Additional cutting of the radioulnar ligament (RUL) at the fovea was also simulated with the base-horizontal fracture. Results  The tip and middle type fractures did not demonstrate significant loss of stiffness compared with the intact. The base-horizontal fracture demonstrated only significant loss of stiffness in the dorsal direction (radius palmar; ulnar dorsal) with forearm in neutral rotation. The base-oblique fracture demonstrated significant loss of dorsopalmar stiffness of the DRUJ. Additional section of the RUL with the base-horizontal fracture induced significant loss of stiffness of the DRUJ compared with the intact. Conclusions  Because the RUL originates from the fovea as well as from the base of the ulnar styloid, these results suggest that DRUJ instability closely correlates with how much of the bony fragment includes the originating portions of the RUL. The findings further suggest that larger base-oblique and base-horizontal fragments with resultant DRUJ instability must be reattached, but that even base-horizontal fragment as well as tip and middle ulnar styloid fragment can be ignored when there is no instability.

Factors predictive for union of basal fracture of the ulnar styloid process after distal radial fracture fixation using a volar locking plate

BACKGROUND

Some basal ulnar styloid fractures (USFs) achieve union without surgical fixation when accompanying distal radius fractures (DRFs) are treated via placement of volar locking plates (VLPs). The purpose of this study was to seek factors predictive of such healing through the retrospective case-control study.

METHODS

We evaluated 203 patients who received VLPs to treat DRFs in our institute from March 2010 to February 2018; Group 1 contained "union" patients and Group 2 contained "nonunion" patients. Basic demographic, radiological, and operative variables were compared. At the final follow-up (at least 2 years postoperatively), pain was scored using a visual analog scale (VAS). Scores on the Disabilities of the Arm, Shoulder, and Hand (DASH) instrument; grip strengths; and demerit points of the Gartland and Werley system were compared between groups.

RESULTS

Group 1 consisted of 58 patients and Group 2 consisted of 147 patients. Univariate analysis showed that age, bone mineral density (BMD), and Gaulke USF classification significantly differed between groups (all p < 0.05). Multivariate analysis showed that BMD (p < 0.001, odds ratio [OR] = 0.214, 95% confidence interval [95% CI] = 0.126-0.363) and Gaulke classification (p < .001, OR = 0.092, 95% CI = 0.034-0.250) were significantly associated with USF union, which was significantly higher in patients with mean BMD ≥ -0.12 (the cutoff value) and type IIC USFs. However, postoperative clinical outcomes at the final follow-up did not differ significantly between groups (all p > 0.05).

CONCLUSIONS

Approximately 30% (58/205) of basal USFs associated with DRFs united after VLPs alone were placed to treat the DRFs. BMD ≥ -0.12 independently predicted union. Type IIC USFs exhibited more union than other fracture types. Additional surgical fixation of a basal USF accompanied by a DRF treated via VLP placement may be unnecessary, especially if BMD is good and fracture type is IIC.

LEVEL OF EVIDENCE

Level III, Case-control study.

A Comparative Study between Conservative and Surgical Treatments of Triangular Fibrocartilage Complex Injury of the Wrist with Distal Radius Fractures

Background

Triangular fibrocartilage complex (TFCC) injury is common in distal radius fractures. The purpose of this study was to compare the conservative and surgical treatments of TFCC injury of the wrist associated with distal radius fractures.

Methods

A retrospective study was conducted on 39 patients who received treatment for TFCC injury with distal radius fractures. All patients were treated using a volar locking plate for distal radius fractures. Twenty-six patients who received conservative treatment for TFCC through long arm splinting were classified into group 1, and 13 patients who received surgical treatment for TFCC were classified into group 2. The splint was maintained for 6 weeks in both groups. For clinical evaluation, the range of motion (ROM) of the wrist joint, patient-rated wrist evaluation (PRWE) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and grip strength were measured. Distal radioulnar joint (DRUJ) stability was evaluated through a stress load test and graded between grade 0 and 3 intraoperatively after fixation and at the final follow-up.

Results

In group 1, the average DASH score was 11.1 ± 4.4, the average PRWE score was 10.2 ± 4.6, the grip strength was 89.4% relative to the unaffected side, the average ROM of the wrist joint was 65° ± 7.0° for extension, 51.5° ± 8.1° for flexion, 86° ± 5.1° for supination, and 85° ± 5.2° for pronation, and DRUJ stability at the final follow-up was grade 0 in 58.62%, grade 1 in 31.03%, grade 2 in 10.34%, and grade 3 in 0%. In group 2, the average DASH score was 13 ± 5.0, the average PRWE score was 12.4 ± 3.7, the grip strength was 87.3% relative to the unaffected side, and the average ROM of the wrist joint was 60° ± 9.8° for extension, 53.1° ± 7.0° for flexion, 85° ± 5.3° for supination, and 86.8° ± 4.5° for pronation. At the final follow-up, DRUJ stability was grade 0 in 66.67%, grade 1 in 25%, grade 2 in 8.3%, and grade 3 in 0%. The 2 groups showed no statistically significant differences in DASH score, PREW score, grip strength, ROM, and final follow-up DRUJ stability.

Conclusions

There were no statistically significant differences in the clinical outcomes between the surgical and conservative treatment groups. Therefore, when normal radiological indices are achieved after treatment of distal radius fractures, DRUJ stability can be obtained by conservative treatment.

Patient-reported outcomes after corrective osteotomy for a symptomatic malunion of the distal radius

AIMS

The primary aim of this study was to describe patient satisfaction and health-related quality of life (HRQoL) following corrective osteotomy for a symptomatic malunion of the distal radius.

METHODS

We retrospectively identified 122 adult patients from a single centre over an eight-year period who had undergone corrective osteotomy for a symptomatic malunion of the distal radius. The primary long-term outcome was the Patient-Rated Wrist Evaluation (PRWE) score. Secondary outcomes included the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, the EQ-5D-5L score, complications, and the Net Promoter Score (NPS). Multivariate regression analysis was used to determine factors associated with the PRWE score.

RESULTS

Long-term outcomes were available for 89 patients (72%). The mean age was 57 years (SD 15) and 68 were female (76%). The median time from injury to corrective osteotomy was nine months (interquartile range (IQR) 6 to 13). At a mean follow-up of six years (1 to 11) the median PRWE score was 22 (IQR 7 to 40), the median QuickDASH score was 11.4 (IQR 2.3 to 31.8), and the median EQ-5D-5L score was 0.84 (IQR 0.69 to 1). The NPS was 69. Multivariate regression analysis showed that the presence of an associated ulnar styloid fracture was the only significant independent factor associated with a worse PRWE score when adjusting for confounding variables (p = 0.004).

CONCLUSION

We found that corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. However, the presence of an ulnar styloid fracture may adversely affect function. Level of Evidence: III (cohort study). Cite this article: Bone Joint J 2020;102-B(11):1542-1548.

The Presence and the Location of an Ulnar Styloid Fracture Associated With Distal Radius Fracture Predict the Presence of Triangular Fibrocartilage Complex 1B Injury

PURPOSE

To investigate the correlation between ulnar styloid fracture (USF) associated with distal radius fracture (DRF) and triangular fibrocartilage complex (TFCC) injuries and to elucidate whether the presence or location of an USF in a patient with DRF predicts the presence of traumatic TFCC injuries.

METHODS

From 2005 to 2018, an arthroscopic evaluation was performed to detect TFCC injuries associated with DRF. The presence and location of USFs were evaluated using computed tomography. TFCC injuries were classified in accordance with Palmer's classification. All wrists were divided into group A (DRF without USF) and group B (DRF with USF). The incidence of TFCC injuries in the 2 groups was compared. group B was then divided into 2 subgroups in accordance with the USF location: the tip or middle fracture subgroup and the base fracture subgroup. Data were analyzed with significance set at P < .05.

RESULTS

One hundred thirty-eight patients were enrolled in this study. Group A included 42 wrists in 42 patients, whereas group B included 96 wrists in 96 patients. There were significant differences between the 2 groups regarding the incidence of traumatic TFCC injuries (P = .036) and TFCC 1B injury (P = .002), although there were no differences between the 2 groups regarding age, sex, injured side, direction of displacement, and type of DRF. Within group B, the tip and middle fracture subgroup included 37 wrists in 37 patients, whereas the base fracture group included 59 wrists in 59 patients; a significant difference was observed between the two subgroups regarding the incidences of TFCC 1B injuries (P = .044).

CONCLUSIONS

The presence of USF associated with DRF predicted the presence of frequently occurring traumatic TFCC injury and TFCC 1B injury. Moreover, the location of USFs was a predictive factor for TFCC 1B injury in adults with DRF. On the other hand, traumatic TFCC injury had occurred in adults with DRF, regardless of the presence of USF.

LEVEL OF EVIDENCE

Level IV, Case series.

Outcomes of Distal Ulna Fractures Associated With Operatively Treated Distal Radius Fractures

Background: The purpose of this study was to report outcomes in patients with nonstyloid distal ulna fractures treated in conjunction with open reduction internal fixation (ORIF) of distal radius fractures. Methods: A retrospective review of all patients who had undergone ORIF of a distal radius fracture over a 5-year period at a single institution was performed. Radiographic review was performed to identify patients with a concomitant fracture of the distal ulna. Radiographs were examined to determine whether and how the distal ulna fracture was stabilized and to assess healing of the distal ulna. Range of motion (ROM) was determined by review of the patients' charts. All skeletally mature patients with distal ulna fractures (not including isolated styloid fractures) undergoing surgical fixation of the distal radius fracture were included. Patients were excluded if follow-up was inadequate. There were 172 fractures of the distal ulna meeting the inclusion criteria. Seven patients were excluded. There were 91 patients treated without ulna fixation (ulna-no) and 74 patients treated with ulna fixation (ulna-yes). Results: Seventy-two (97%) of the ulna-yes patients healed. All patients in the ulna-no group healed. The only significant difference in ROM was in pronation, although the magnitude of this difference was relatively small. Conclusions: Fractures of the distal ulna have high rates of healing and result in equivalent motion regardless of whether the distal ulna is treated operatively. Routine surgical fixation of concomitant distal ulna fractures during distal radius ORIF does not appear to be necessary.

Impact of Ulnar Styloid Fractures on the Treatment Effect of Distal Radius Fractures with Volar Plate Fixation: A Case Control Study

BACKGROUND

There is a controversy regarding whether ulnar styloid fractures affect the efficacy of treatment of distal radial fractures. The purpose of this study was to investigate whether ulnar styloid fractures impact wrist joint function in patients without distal radioulnar joint instability, after distal radial fracture fixation using a volar plate.

MATERIALS AND METHODS

Seventy-five patients with a distal radial fracture were treated using a volar plate between February 2010 and February 2016 (33 men and 42 women; mean age 40.9 ± 9.4 years). Forty-four patients had ulnar styloid fractures (Group A) and 31 patients did not (Group B). There were no differences between the two groups with regard to sex, age, course of the disease and fracture type (P > 0.05).

RESULTS

The mean follow-up time was 21 months. There were no differences between the groups in palmar tilt, radial inclination and radial length when the distal radial fractures had healed (P > 0.05). At the final follow-up visit, the two groups were similar in terms of wrist motion range, and grip and pinch strength (P > 0.05). The Gartland-Werley scores were 13 for excellent, 26 for good, 3 for fair and 2 for poor (excellence rate 89%) for Group A, and 10 for excellent, 17 for good, 2 for fair and 2 for poor (excellence rate 87%) for Group B. The difference between the two groups was not significant (Z = - 0.097, P = 0.922).

CONCLUSION

After open reduction and plate fixation of distal radial fractures, if stability of the distal radioulnar joint is achieved, untreated ulnar styloid fractures have no impact on wrist joint function.

The effects of incremental ulnar styloid osteotomies on distal radioulnar joint stability: a biomechanical cadaveric study

The purpose of this study was to systematically quantify distal radioulnar joint stability with a cadaveric model, using radiographic and joint contact force measurements. Six fresh-frozen cadavers underwent sequential ulnar styloid osteotomies. Posteroanterior and lateral stress radiographs were obtained and joint contact forces and areas were measured. Posteroanterior radiographs showed a significant increase in the distal radioulnar joint gap after osteotomy of the base of the ulnar styloid. Contact force and contact area measurements were not significantly different. We conclude that fractures that involve the ulnar styloid base should be considered for operative fixation when carrying out open reduction and internal fixation of fractures of the distal radius.

Radial shaft fracture obliquity as a predictor of distal radioulnar joint instability

We assessed whether radial shaft fracture obliquity measurements on radiographs could predict intra-operative distal radioulnar joint instability. We also clinically validated previously described predictors of distal radioulnar joint instability, which included a fracture line within 7.5 cm of the lunate fossa, radial shortening >5 mm, and ulna styloid fracture. We retrospectively analysed the radiographs of all surgically managed patients in our unit with radial shaft fractures from 2006 through 2016. The degree of obliquity was analysed on the basis of the maximum fracture-line angle in either the coronal or the sagittal plane. A radial shaft fracture obliquity >30° is predictive of distal radioulnar joint instability ( P = 0.001). Radial fracture shaft obliquity >30° was the most sensitive radiological parameter (76%) for predicting distal radioulnar joint instability. Oblique radial shaft fractures appear to be associated with increased incidence of distal radioulnar joint instability. This radiologic parameter may be used together with established parameters in predicting distal radioulnar joint instability for surgical treatment.

LEVEL OF EVIDENCE

III.

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.

Radial Distraction to Stabilize Distal Radioulnar Joint in Distal Radius Fixation

Persistent distal radioulnar joint (DRUJ) instability after internal fixation of distal radius fractures can be managed with soft tissue or bony stabilization and prolonged immobilization. However, these strategies limit postoperative motion. To address this limitation, we report our technique of indirect ulna shortening by radial distraction followed by early mobilization and provide a case example. We use this technique in cases of persistent DRUJ instability during standard volar plating of distal radius fractures. Radial lengthening is achieved by distraction through the fracture site using the oblong hole of the plate until DRUJ stability is obtained. No immobilization of forearm rotation and a standard, early mobilization rehabilitation program are used. Indirect ulnar shortening by distraction through the distal radius fracture site provides a simple and novel strategy for the management of persistent DRUJ instability during volar plating, obviating the need for prolonged immobilization or to alter standard postoperative protocols.

Effects of Ulnar Styloid Fractures on Unstable Distal Radius Fracture Outcomes: A Systematic Review of Comparative Studies

Purpose  In this literature review, functional outcomes such as Disability of Arm, Shoulder and Hand (DASH) score and the visual analog scale (VAS) of pain along with clinical outcomes such as range of movement and grip strength of treated distal radius fractures (DRF) accompanied with ulnar styloid fractures (USF) will be compared with those with isolated DRF. Materials and Methods  We analyzed articles from MEDLINE, Embase, and CINAHL that met our predetermined inclusion and exclusion criteria as per the Preferred Reporting Items for Systematic Reviews and Meta-analysis statements. This resulted in the identification of 464 articles with 18 potentially eligible studies of which 6 were included at the full-text screening stage. The primary outcomes were wrist pain, range of motion, functional outcome and satisfaction, such as VAS, and the DASH questionnaire along with radiological assessment and incidence of complications. Results  These studies involved 796 participants with DRF and 806 wrists with DRF; 444 (55%) of DRF had an associated USF. Three studies did not report any statistically significant difference in DASH scores between the DRF patients with or without USF. Two studies reported worse DASH scores in the group with associated USF. Wrist pain was reported to be statistically significantly worse in patients with associated USF in two studies. Grip strength did not exhibit a statistically significant difference in any groups in four studies. On assessing the range of motion of the wrist and forearm, only one study reported a statistically significant difference in flexion at 2 years follow-up, with less flexion in patients with USF. Conclusion  This review suggests that there is no significant correlation between a USF and the functional and clinical outcomes of DRF treatment, albeit wrist pain and less flexion were reported in some studies to be associated with USF. There is a need for more robust evidence from large randomized controlled trials to specifically look at the effects of fixation versus nonfixation of USF on DRF, or large prospective cohort studies assessing DRF with and without USF, with a minimum of 12 months follow-up. Level of Evidence  Level II-therapeutic.

Functional outcomes of distal radius fractures with and without ulnar styloid fractures: a meta-analysis

The aim of this meta-analysis was to compare the functional outcomes of patients with a distal radius fracture with and without a concomitant fracture of the ulnar styloid process. A systematic literature search was performed to identify all studies comparing patients with a distal radius fracture with and without an ulnar styloid process fracture. The initial search revealed 511 articles, of which 12 articles with a total of 2243 patients were included; 1196 patients with and 1047 patients without an ulnar styloid process fracture. A statistically significant mean difference of 3.40 points (95% CI 1.33-5.48) in the Disability of the Arm, Shoulder, and Hand score was found in favour of patients without an ulnar styloid process fracture. This difference is less than 10 and therefore not clinically important. No significant difference was found in Patient-Rated Wrist Evaluation scores, range of motion, grip strength, visual analogue scale pain scores, ulnar-sided wrist pain and distal radio-ulnar joint instability between patients with and without an ulnar styloid process fracture after 1 year of follow-up. Moreover, no significant differences were found between ulnar styloid base and nonbase fractures.

LEVEL OF EVIDENCE

I.

Ulnar Styloid Base Fractures Cause Distal Radioulnar Joint Instability in a Cadaveric Model

BACKGROUND

The deep portion of the distal radioulnar ligaments (DRUL) inserts on the ulnar fovea and is the most important stabilizer of the distal radioulnar joint (DRUJ). Ulnar styloid base fractures that include the ulnar fovea may cause DRUJ instability.

METHODS

DRUJ stability in pronosupination was evaluated in 12 fresh-frozen upper extremities (4 female) aged 52 to 68 years (mean: 58.8 years) using a custom fixture, which allowed free rotation of the radius around the fixed ulna. Optical motion capture was used to record rotation of the radius with respect to the ulna. Each specimen was subjected to 3 N m of torque in both supination and pronation under 4 conditions: intact, ulnar styloid osteotomy with disruption of the foveal insertion of the DRUL, ulnar styloid fixation, and DRUL transection. Group differences were compared using a 1-way repeated-measures analysis of variance and Tukey multiple comparison post hoc tests.

RESULTS

When compared with the intact condition, both ulnar styloid osteotomy and DRUL transection significantly increased mean pronation (by 9.40° and 15.21°, respectively) and supination (by 9.05° and 17.42°, respectively) of the forearm. Screw fixation only significantly reduced pronation compared with osteotomy (by 2.62°). Screw fixation did not significantly affect supination.

CONCLUSIONS

Ulnar styloid fractures that disrupt the fovea cause instability of the DRUJ in pronation and supination under 3 N m of torque in a cadaveric model. Screw fixation of ulnar styloid base fractures achieves anatomic reduction; however, it only partially returns rotational stability acutely to the DRUJ and only during pronation.

Does concomitant ulnar styloid fracture and distal radius fracture portend poorer outcomes? A meta-analysis of comparative studies

PURPOSE

An ulnar styloid fracture often occur in association with a distal radial fracture. Whether an ulnar styloid fracture interfere with the results of a distal radial fracture still remains controversial. The aim of this study was to analyse the effects of an accompanying ulnar styloid fracture on clinical outcomes in patients with distal radial fractures.

METHODS

A meta-analysis of published studies comparing outcomes of distal radial fractures with an ulnar styloid fracture versus isolated distal radial fractures was performed. Outcomes of function results, radiological evaluation, and patient reported scores were analyzed.

RESULTS

Ten studies including 1403 distal radius fractures were identified fitting inclusion criteria. There was no significant difference in wrist motion, grip strength, radial height, volar angle, ulnar variance, pain score, PRWE score, or SF-36 score for distal radial fractures associated with an ulnar styloid fracture versus isolated distal radial fractures. In final follow up, patients with associated an ulnar styloid fracture had lower radial inclination and higher DASH scores. But there was no significant clinical difference. In addition, we found there was no significant difference of outcomes between union and non-union ulnar styloid fractures.

CONCLUSIONS

Based on this meta-analysis, we suggest that an associated ulnar styloid fracture does not affect the outcomes of a distal radial fracture and clinicians should be caution in electing operative treatment for patients with an ulnar styloid fracture.

Topographical Anatomy of the Distal Ulna Attachment of the Radioulnar Ligament

PURPOSE

The deep component of the distal radioulnar ligament provides translational stability and rotational guidance to the forearm. However, controversy exists regarding the importance of this structure as well as the nature of its attachment to the distal ulna. We aimed to evaluate the topographic anatomy of the distal ulna attachment of both the superficial and the deep components of the radioulnar ligament and to assess the relationship between its internal and its external morphometry.

METHODS

Thirteen human distal ulnae attached by ulnar part of the distal radioulnar ligament were scanned using micro-computed tomography and reconstructed in 3 dimensions. In addition, the distal radioulnar ligaments were examined under polarized light microscopy to determine the histological characteristics of collagen contained within the ligaments.

RESULTS

The deep limbs have broad marginal insertions at the fovea, whereas the superficial limbs have a circular and condensed insertion to the ulnar styloid. The center of the deep limb was separated from the base of the ulnar styloid by a mean of 2.0 ± 0.76 mm, and this distance was positively correlated with the width of the ulnar styloid. The mean distance between the center of the ulnar head and the center of the fovea was 2.4 ± 0.58 mm. The proportion of collagen type I was lower in the deep limb than in the superficial limb.

CONCLUSIONS

This new observation of the footprint of the radioulnar ligament in the distal ulna indicates that the deep limb may serve as an internal capsular ligament of the distal radioulnar joint, whereas the superficial limb as the external ligament.

CLINICAL RELEVANCE

Knowledge of the topographic anatomy of the radioulnar ligament's attachment to the distal ulna may provide a better understanding of distal radioulnar ligament-related pathologies.

Clinical effects of internal fixation for ulnar styloid fractures associated with distal radius fractures: A matched case-control study

BACKGROUND

Ulnar styloid fractures are often associated with distal radius fractures. However, controversy exists regarding whether to treat ulnar styloid fractures. This study aimed to evaluate clinical effects of internal fixation for ulnar styloid fractures after distal radius fractures were treated with the volar locking plate system.

METHODS

We used prospectively collected data of distal radius fractures. 111 patients were enrolled in this study. A matched case-control study design was used. We selected patients who underwent fixation for ulnar styloid fractures (case group). Three control patients for each patient of the case group were matched on the basis of age, sex, and fracture type of distal radius fractures from among patients who did not undergo fixation for ulnar styloid fractures (control group). The case group included 16 patients (7 men, 9 women; mean age: 52.6 years; classification of ulnar styloid fractures: center, 3; base, 11; and proximal, 2). The control group included 48 patients (15 men, 33 women; mean age: 61.1 years; classification of ulnar styloid fractures: center, 10; base, 31; and proximal, 7). For radiographic examination, the volar tilt angle, radial inclination angle, and ulnar variance length were measured, and the union of ulnar styloid fractures was judged. For clinical examination, the range of motions, grip strength, Hand20 score, and Numeric Rating Scale score were evaluated.

RESULTS

There was little correction loss for each radiological parameter of fracture reduction, and these parameters were not significantly different between the groups. The bone-healing rate of ulnar styloid fractures was significantly higher in the case group than in the control group, but the clinical results were not significantly different.

CONCLUSIONS

We revealed that there was no need to fix ulnar styloid fractures when distal radius fractures were treated via open reduction and internal fixation with a volar locking plate system.

Natural history and factors associated with ulnar-sided wrist pain in distal radial fractures treated by plate fixation

We documented longitudinal changes in the incidence of ulnar-sided wrist pain after distal radial fractures treated by plate fixation and identified factors associated with ulnar-sided wrist pain. A total of 140 patients were enrolled in this study. Radiographs were taken 3 months after operation, and were used to measure radial inclination, anterior angulation and ulnar variance, and to identify the presence of an ulnar styloid fracture. Clinical assessments at the same time included grip strengths, ranges of wrist motion and the patient-rated wrist evaluation questionnaire. The presence of ulnar-sided wrist pain was noted at each follow-up visit. The incidence of ulnar-sided wrist pain decreased significantly with time after surgery (22 patients at 3 months, 11 patients at 6 months and three patients at 12 months). The mean age, sex, the presence of an ulnar styloid fracture and the classification of the distal radial fracture were not factors that were associated with a higher incidence of ulnar-sided wrist pain, but there was an association between higher patient-rated wrist evaluation scores and the presence of ulnar-sided wrist pain.

LEVEL OF EVIDENCE

Prognosis, Level IV.

Clinical DRUJ instability does not influence the long-term functional outcome of conservatively treated distal radius fractures

OBJECTIVE

The presence of distal radioulnar joint (DRUJ) instability remains often unnoticed initially, but may worsen functional outcome of distal radius fractures (DRF). The aim of this study was to evaluate the influence of concurring clinical DRUJ instability on the outcome of conservatively treated DRF.

METHODS

In a retrospective cohort study, all unilateral, conservatively treated DRF patients were invited for physical examination, CT scan of both wrists and filling out questionnaires. Static and dynamic DRUJ instability were clinically tested.

RESULTS

Forty-nine DRF patients with a mean follow-up of 4.2 years (SD 0.5) were assessed. Seventeen patients tested positive for DRUJ instability. No differences were found in baseline characteristics between the DRUJ stable and unstable group. Apart from wrist flexion, no statistical significant differences in outcome was found between patients with and without DRUJ instability.

CONCLUSION

The presence of clinical DRUJ instability does not seem to affect functional outcome of conservatively treated distal radius fractures at long-term follow-up.

Computed tomography for the detection of distal radioulnar joint instability: normal variation and reliability of four CT scoring systems in 46 patients

OBJECTIVES

The diagnosis of distal radioulnar joint (DRUJ) instability is clinically challenging. Computed tomography (CT) may aid in the diagnosis, but the reliability and normal variation for DRUJ translation on CT have not been established in detail. The aim of this study was to evaluate inter- and intraobserver agreement and normal ranges of CT scoring methods for determination of DRUJ translation in both posttraumatic and uninjured wrists.

MATERIALS AND METHODS

Patients with a conservatively treated, unilateral distal radius fracture were included. CT scans of both wrists were evaluated independently, by two readers using the radioulnar line method, subluxation ratio method, epicenter method and radioulnar ratio method. The inter- and intraobserver agreement was assessed and normal values were determined based on the uninjured wrists.

RESULTS

Ninety-two wrist CTs (mean age: 56.5 years, SD: 17.0, mean follow-up 4.2 years, SD: 0.5) were evaluated. Interobserver agreement was best for the epicenter method [ICC = 0.73, 95 % confidence interval (CI) 0.65-0.79]. Intraobserver agreement was almost perfect for the radioulnar line method (ICC = 0.82, 95 % CI 0.77-0.87). Each method showed a wide normal range for normal DRUJ translation. Normal range for the epicenter method is -0.35 to -0.06 in pronation and -0.11 to 0.19 in supination.

CONCLUSION

DRUJ translation on CT in pro- and supination can be reliably evaluated in both normal and posttraumatic wrists, however with large normal variation. The epicenter method seems the most reliable. Scanning of both wrists might be helpful to prevent the radiological overdiagnosis of instability.

Surgical treatment of acute distal radioulnar joint instability associated with distal radius fractures

This study investigates the question of whether open repair of acute distal radioulnar joint instability at the time of volar plating of distal radius fractures would enable early mobilization of the wrist without the risk of distal radioulnar joint instability. We evaluated 29 patients of mean age 53 years with a distal radius fracture and acute distal radioulnar joint instability who underwent volar plating of the radius combined with surgical repair of the triangular fibrocartilage complex or an ulnar styloid base fracture, followed by active motion exercise of the wrist at 1 week after surgery. At 1 year after treatment, all patients had a stable distal radioulnar joint and grip strength averaged 90% of the normal side. This study demonstrates that surgical repair of the triangular fibrocartilage complex or ulnar styloid fracture followed by early mobilization did not result in distal radioulnar joint instability, and suggests that the surgical treatment of distal radioulnar joint instability may permit early mobilization of the wrist in patients who are considered suitable for rapid rehabilitation after surgery. Type of study: Therapeutic Level IV.

Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: a meta-analysis of comparative clinical trials

PURPOSE

There is no consensus on the relation between ulnar styloid process nonunion and outcome in patients with distal radius fractures. The aim of this study was to analyze whether patient-reported outcome is influenced by the nonunion of the accompanying ulnar styloid fracture in distal radius fracture patients.

METHODS

A meta-analysis of published studies comparing outcomes after distal radius fractures with a united versus a non-united ulnar styloid process was performed. In addition, if provided by the authors, the raw data of these studies were pooled and analysed as one study. The outcome measures of the analyses included patient-reported outcome, functional outcome, grip-strength, pain, and distal radioulnar joint (DRUJ) instability.

RESULTS

Data from six comparative studies were included, concerning 365 patients with a distal radius fracture. One hundred and thirty-five patients with an ulnar styloid union were compared with 230 patients with a nonunion of the ulnar styloid. No significant differences were found between groups regarding any outcome measure.

CONCLUSION

Based on this meta-analysis, there is no relation between the nonunion of the ulnar styloid process and function in patients with a distal radius fracture.

The effects of ulnar styloid fractures on patients sustaining distal radius fractures

PURPOSE

To determine if ulnar styloid fractures (USF) affect clinical outcome following distal radius fracture (DRF) in adults under 65 years of age.

METHODS

This study involved 312 patients (aged 18-64) with surgically and nonsurgically treated DRFs. Patients were followed prospectively at baseline and 3, 6, and 12 months. The primary outcome was the Patient-Rated Wrist Evaluation (PRWE), and secondary outcomes were range of motion and grip strength. The USFs were classified by location (tip, middle, and base) and union status.

RESULTS

There were 170 patients with isolated DRFs and 142 with associated USF (64 tip, 32 middle, and 46 base fractures). The mean age of the entire cohort was 48 years with 218 (70%) women. All USFs were treated nonoperatively. There was a trend of higher PRWE scores in DRFs associated with USFs compared to isolated DRFs throughout the study. Associated ulnar styloid base fractures had higher but clinically insignificant PRWE scores than isolated DRFs at 6 and 12 months. Patients with an associated USF had a slower recovery of wrist flexion and grip strength compared to isolated DRF, but values were comparable at 12 months. United USFs and nonunited USFs had similar PRWE scores at all time points.

CONCLUSIONS

Adults under 65 years old with DRFs and associated USFs initially have greater pain and disability than those with isolated DRFs; however, this difference dissipated over time and was not significant at one year. No long-term differences in measured impairments were observed, but the presence of an associated USF resulted in a slower recovery of grip strength and wrist flexion. Presence of a USF nonunion did not significantly affect outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Should distal radioulnar joint be fixed following volar plate fixation of distal radius fracture with unstable distal radioulnar joint?

BACKGROUND

Distal radioulnar joint (DRUJ) instability often accompanies distal radial fractures. The goal of this study was to investigate whether DRUJ should be fixed to prevent recurrent DRUJ instability in distal radius fracture patients with unstable DRUJ following open reduction and volar plate fixation of the radius.

METHODS

A retrospective chart review was performed on forty-nine consecutive patients presenting distal radius fracture who were diagnosed with distal radioulnar instability after radius fixation with volar plate. Group one consisted of 24 patients whose DRUJs were fixed in neutral for 6 weeks with 1∼2 Kirschner wires (8 cases combined with casting), whereas group two consisted of 25 patients without DRUJ fixation. All patients had radiographic evaluation of their wrist and DRUJ for stabilities and underwent functional evaluation using modified Gartland and Werley demerit scoring system (GW score).

RESULTS

All patients were followed-up for an average of 15 months (12-24 months) after surgery. No significant difference was noted between the two groups with respect to gender, age, fracture types and damage types (no noteworthy medical comorbidities in either group). At the latest follow-up, patients in both groups had comparable grip strength, wrist motion, and visual analogue scale (VAS) and GW scores. Only one patient (2.4%) demonstrated DRUJ chronic instability, but did not require any additional surgery.

CONCLUSION

The results suggest that in patients with distal radius fractures, fixation of unstable DRUJs in neutral for 6 weeks does not have an advantage over non-fixation.

LEVEL OF EVIDENCE

III.

Complications following volar locking plate fixation for distal radial fractures: a systematic review

The purpose of this systematic review is to assess the prevalence of complications following volar locking plate fixation of distal radial fractures. A computer-based search was carried out using EMBASE and PUBMED/MEDLINE. Only prospective comparative and prospective cohort studies that presented data concerning complications after treatment of distal radial fractures with a volar locking plate in human adults with a minimal follow-up of 6 months were included. Two quality assessment tools were used to assess the methodological quality of the studies (level of evidence rating according to the Oxford Centre of Evidence Based Medicine and the modified version of the Cochrane Bone, Joint and Muscle Trauma Group's former quality assessment tool). Thirty three studies were eligible for final assessment. Most complications were problems with nerve and tendon function as well as complex regional pain syndrome. With an overall complication rate of 16.5%, most of which were 'minor' complications and low rates of nonunion and malunion, volar locking plate fixation can be considered a reasonably safe treatment option for patients with distal radial fractures.

Controversies in the management of distal radius fractures

Controversies span the entire spectrum of management of distal radius fractures-fracture assessment, diagnosis, treatment, and evaluation of outcomes. The utility of multiple radiographic views described in the literature has not been validated. Likewise, the several classification systems that exist have yet to demonstrate substantial interobserver and intraobserver reliability. Nonsurgical controversies involve fracture reduction, use of anesthesia, type of fracture immobilization, and forearm position during healing. Surgical controversies include surgical indications, need for release of carpal tunnel, fracture fixation method, and the need for augmentation (ie, bone graft). Postoperatively, rehabilitation, medication, and physical therapy also remain highly controversial. The best outcome measure has yet to be established. A strong need remains for high-level, prospective studies to determine the most effective way to assess, diagnose, treat, and measure outcomes in patients with distal radius fractures.

Ulnar styloid fracture in distal radius fractures managed with volar locking plates: to fix or not?

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4 weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5 % excellent, 17.9 % good and 3.6 % fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2 weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9 % excellent, 15.8 % good and 5.3 % fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.