Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability

[Traumatic TFCC lesions in childhood and adolescence-A previously neglected injury?]

Although injuries to the triangular fibrocartilage complex (TFCC) are less common in children and adolescents than in adults, can lead to chronic pain and instability in the distal radioulnar joint (DRUJ), ultimately predisposing individuals to long-term osteoarthritis. A dislocated distal radius fracture with avulsion of the styloid process of the ulna following high-energy trauma is a risk factor for a TFCC injury. The diagnostics include a thorough clinical examination and imaging procedures, such as X‑ray and magnetic resonance imaging (MRI). If there is no instability of the DRUJ, conservative treatment can be successful in most cases. However, if there is instability of the DRUJ or if there is no improvement after 3 months of conservative treatment, diagnostic arthroscopy of the wrist is indicated for further diagnostics and concurrent treatment. Depending on the age and extent of the injury, various surgical techniques can be used, such as transcapsular or transosseous refixation. Early diagnosis and treatment are essential to achieve freedom from pain, a stable DRUJ and enable a return to sports activities. In our own patient collective 12 children and adolescents showed very good results with no major complications.

Suture-Based Distal Radioulnar Joint Stabilization: A Biomechanical Evaluation in a Cadaveric Model

Purpose  Management of acute distal radioulnar joint (DRUJ) instability is complex and controversial. Common treatment options include prolonged immobilization, stabilization with wires, and acute triangular fibrocartilage complex repair. However, none of these permits an early range of motion. The purpose of this study is to investigate the feasibility of a suture-based stabilization (SBS) technique for acute DRUJ instability to permit early active motion. Materials and Methods  A biomechanical study utilizing eight cadaveric arms was performed. All specimens were tested in the intact state prior to the creation of bidirectional DRUJ instability. For the SBS group, 2-mm suture tapes with suture button fixation were utilized to recreate the respective contributions of distal oblique bundle and volar and dorsal radioulnar ligaments to DRUJ stability. All specimens were cyclically loaded with a simulated ballottement stress of 20N in forearm positions of neutral, 60 degrees of pronation and 60 degrees of supination. Range of motion and total translation were measured and then compared between the two groups. Results  The average range of motion in the intact and SBS specimens was 174 and 175 degrees, respectively. There were no significant differences in displacement between the intact and SBS group in neutral and in supination. However, the SBS group had less translation than the intact group in pronation. Conclusion  For acute DRUJ instability, the described SBS technique provides similar stability to the native intact DRUJ without compromising the range of motion in a cadaveric model. Future comparative studies are warranted prior to translation into the clinical arena. Clinical Relevance  This is a biomechanical study investigating a treatment technique for acute DRUJ instability that would allow an early range of motion.

Comparative Outcomes Between Three Different Techniques in the Fixation of Ulnar Styloid Fractures

PURPOSE

This study aims to compare the clinical and radiological outcomes of three different techniques used in the surgical treatment of ulnar styloid fractures.

MATERIAL AND METHOD

Ulnar styloid fractures treated surgically between 2012 and 2022 were evaluated retrospectively. There were three groups in the study: Group I (Kirschner wire, N= 19), Group II (tension band, N= 27) and Group III (headless compression screw, N= 25). The Gaulke classification was applied to categorise the fractures. After a follow-up period of at least one year, range of motion, Modified Mayo Wrist Score (MMWS), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH), Visual Analogue Scale (VAS) and grip strength were measured. In addition, radiological union, bone resorption and dorsal subluxation of the DRUJ were evaluated.

RESULTS

There was no difference between the three groups in terms of demographic data. Gaulke type 2 A was more frequently observed in all three groups (47.4%, 74.1%, 64%, respectively). Range of motion (flexion, extension, supination, pronation) was similar in all three groups (p>0.05). QDASH and MMWS were similar in all three groups. Grip strength was significantly lower in Group I than in Group II (p=0.039). Radiological outcomes (nonunion, dorsal subluxation, bone resorption) were similar in all three groups. Implant irritation was significantly higher in Group II (p=0.026).

CONCLUSION

K-wires, tension band wiring and headless compression screws yield similar clinical and radiological outcomes in the surgical treatment of unstable ulnar styloid fractures. However, the need for secondary surgery is more frequent when a tension band is used.

LEVEL OF EVIDENCE

Level IV.

Association of dorsal malunion in distal radius fractures with wrist osteoarthritis: Alterations of bone density and stress-distribution patterns in relation to deformation angles

OBJECTIVE

Distal radius fractures (DRFs) with dorsal malunion increase the risk of osteoarthritis (OA), although the cause of post-DRF OA is yet to be elucidated. To clarify the abnormal effects of a post-DRF dorsal radius deformity, we evaluated the bone density (BD) and stress-distribution patterns of the articular surface in dorsally malunited DRFs.

DESIGN

In 36 cases of dorsally malunited DRFs following extra-articular fractures, we generated three-dimensional computerized models of the malunited distal radius from computed tomography data and extracted the subchondral bones of the radiocarpal joint (RCJ) and distal radioulnar joint (DRUJ). Both BD and stress distribution in the subchondral bones were quantitatively evaluated by comparing the affected and normal sides. Correlations of alterations in high-BD distribution and deformation angles were analyzed.

RESULTS

The center of high-BD distribution from the center of the RCJ in the volar(-)-dorsal(+) direction was dorsal (0.56 ± 0.72 mm) on the affected side compared with the normal side (-0.15 ± 0.63 mm) [95% CI: 0.43, 1.00, P < 0.0001]. The maximum stress distribution was also dorsal on the affected side (2.34 ± 3.52 mm) compared with the normal side (-2.49 ± 1.62 mm) [95% CI: 0.89, 1.79, P < 0.0001]. The alterations in BD and stress distribution correlated with the dorsiflexion and radial deviation angles. In the DRUJ, there was no significant difference in BD between the affected and normal sides.

CONCLUSIONS

In dorsally malunited DRFs, the alignment change of the RCJ resulted in high BD-concentration areas and stress distribution on the dorsal side of the radius, which may constitute a precursor for OA.

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).

Surgical intervention for distal radial fractures with concurrent ulnar styloid fractures may be beneficial for the elderly patients: a retrospective study

BACKGROUND

Distal radius fractures are highly prevalent among older adults. Ulnar styloid fractures frequently accompany distal radius fractures, raising concerns about treatment outcomes due to the risk of distal radioulnar joint (DRUJ) instability. This study investigated the necessity of surgical intervention (open reduction internal fixation; ORIF) for distal radius fractures in very old patients with coexisting ulnar styloid fractures.

MATERIALS AND METHODS

A retrospective analysis of 96 patients aged ≥ 80 years with AO classification 23-A2 to 23-B3 distal radius fractures with concomitant ulnar styloid fracture between 2019 and 2022 was performed. Patients were excluded if they were aged < 80 years, had a preinjury Barthel index of < 90, or had high-energy multiple trauma. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score assessed at 3, 6, and 12 months. We compared the DASH score and their trajectories between the ORIF and conservative treatment groups.

RESULTS

ORIF group demonstrated significantly better DASH functional scores (25.31 ± 4.71) at the 12-month follow-up compared with the conservative group (34.42 ± 8.03; p < 0.001). Treatment choice was identified as a significant predictor of DASH scores at 12 months, with ORIF significantly improved patient's wrist function and demonstrated a β coefficient of - 9.11 (95% confidence interval: -11.95 to - 6.27, p < 0.001). The other factors investigated, namely age, lowest T-score, and medical history of diabetes mellitus, hypertension, coronary artery disease, cerebrovascular accidents, cancer, and dementia, did not exhibit a significant association with the 12-month DASH scores in the adjusted model (p > 0.05).

CONCLUSIONS

Our findings suggest that very old patients with distal radius fracture accompanied by ulnar styloid fractures may benefit from ORIF to achieve optimal long-term functional recovery.

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.

[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

Analyzing the reduction quality of the distal radioulnar joint after closed K-wire transfixation in a cadaver model: is supination or neutral position superior?

INTRODUCTION

Distal radioulnar joint (DRUJ) instabilities are challenging and their optimal treatment is controversial. In special cases or when reconstruction of the stabilizing triangular fibrocartilage complex (TFCC) fails, K-wire transfixation can be performed. However, no consensus has been reached regarding the rotational position of the forearm in which this should be done. Therefore, it was investigated whether anatomical reduction would best be achieved by transfixation in neutral position or supination of the forearm.

MATERIALS AND METHODS

Twelve cadaveric upper limbs were examined before dissection of the DRUJ stabilizing ligaments and after closed transfixation in both positions by C-arm cone-beam CT. Whether this was first done in neutral position or in supination was randomized. The change in the radioulnar ratio (RR) in percentage points (%points) was analyzed using Student's t-test. RR was used since it is a common and sensitive method to evaluate DRUJ reduction, expressing the ulnar head's position in the sigmoid notch as a length ratio.

RESULTS

The analysis showed an increased change in RR in neutral position with 5.4 ± 9.7%points compared to fixation in supination with 0.2 ± 16.1%points, yet this was not statistically significant (p = 0.404).

CONCLUSIONS

Neither position leads to a superior reduction in general. However, the result was slightly closer to the anatomical position in supination. Thus, transfixation of the DRUJ should be performed in the position in which reduction could best be achieved and based on these data, that tends to be in supination. Further studies are necessary to validate these findings and to identify influential factors.

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.

Comparative Analysis of Treatment Outcomes: Modified Ulnar Gutter Slab vs. Sugar Tong Slab for Distal Radioulnar Joint Instability Following Triangular Fibrocartilage Complex Repair

The standard treatment for distal radioulnar joint (DRUJ) instability involves repairing the triangular fibrocartilage complex (TFCC) and immobilizing the joint with a sugar tong slab, but this can cause elbow stiffness. To address this, a modified ulnar gutter slab was designed to enhance elbow mobility during immobilization. A prospective randomized controlled trial was conducted on 23 DRUJ instability patients who underwent arthroscopic TFCC repair. Two post-operative splinting techniques were compared: the modified ulnar gutter slab and the sugar tong slab. The assessment included the Disabilities of Arm, Shoulder, and Hand (DASH) score; elbow, forearm, and wrist range of motion (ROM); post-operative DRUJ stability; and complications. DASH scores at 4 and 6 weeks were not significantly different. However, the modified ulnar gutter slab improved elbow extension range of motion at 4 weeks (extension lag: 20.0 vs. 6.5 in the sugar tong group) (p = 0.011). Post-operative DRUJ stability was comparable between the two groups. Notably, one patient in the sugar tong slab group experienced complex regional pain syndrome (CRPS). The modified ulnar gutter slab offers a post-operative alternative after TFCC repair. It effectively immobilizes forearm and wrist motion while enhancing elbow mobility, potentially reducing post-operative elbow stiffness.

Current Concepts: Corrective Osteotomy for Extra-Articular Deformity Following a Distal Radius Fracture

Fracture malunion alters wrist and distal radioulnar joint (DRUJ) biomechanics, resulting in incongruence and instability of the DRUJ. Selected patients with painful functional limitation and significant deformity of the radius, but without advanced degenerative joint disease, may benefit from corrective distal radial osteotomy. Non-union and complications arising from metalwork are the most common reasons for reoperation. Surgeons should have a good understanding of risks and complications in order to fully inform their patients and manage expectations. This article reviews the biomechanical effects of radial malunion and the current concepts for treatment. Distal radial osteotomy is suitable for symptomatic patients with angular radial deformity and shortening. Evidence supports a volar approach without bone grafts for modest corrections. Bone grafts or synthetic bone substitutes are appropriate for larger corrections. Functional improvements are reported regardless of technique. Despite a high complication rate, patient satisfaction with the corrective radial osteotomy is high.

MDCT evaluation of distal radius fractures and their association with carpal and distal ulnar fractures

PURPOSE

The purpose of this study was to evaluate the characteristics of distal radius fractures (DRFs) in patients undergoing multi-detector computed tomography (MDCT) and their association with carpal and distal ulnar fractures.

METHODS

This retrospective study analyzed 120 patients, who underwent MDCT for evaluation of DRFs. Two radiologists independently evaluated the data for various fracture characteristics and for associated carpal and distal ulnar fractures.

RESULTS

Out of 120 DRFs, 74 were complete articular, 40 were partial articular and only 6 were extra-articular. Displacement was present in 99 fractures and intra-articular step off was present in 73 fractures. A total of 81 carpal bone fractures were identified in 46 (38.3%) patients, with more than one carpal bone fracture in 21 patients. Distal ulnar fractures were detected in 79 patients (65.8%), out of which 67 involved the ulnar styloid. DRFs with intra-articular step off were more frequently associated with carpal bone fracture (p value: 0.021), while displaced DRFs were more frequently associated with distal ulnar fracture (p value <0.001). Interobserver agreement for detection of carpal bone fractures (κ = 0.807) and distal ulnar fractures (κ = 0.923) was excellent.

CONCLUSION

Majority of DRFs in patients referred for MDCT were complete articular with high incidence of displacement and intra-articular step off. Associated carpal bone and distal ulna fractures were not uncommon.

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.

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.

Coronal translation of the forearm, proximal capitate, and ulnar styloid predict radial inclination in distal radius fractures in older female patients

Aims

The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

Methods

From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis.

Results

In the study (fracture) and control groups, respectively, the mean values were: RI, 17.2° (SD 7.2°; -7° to 35°) and 25.6° (SD 2.6°; 21° to 30°); DRS-U, 13.5 mm (SD 1.7; 4.9 to 20.8) and 15.3 mm (SD 0.72; 13.8 to 16.3); DUS-R, 13.4 mm (SD 2.1; 4.8 to 18.5) and 12.0 mm (SD 0.99; 9.7 to 13.9); DRS-PC (positive value radial to DRS, negative value ulnar), 0.14 mm (SD 5.4; -10.9 to 22.7) and -6.1 mm (SD 1.6; -10.6 to -2.3); and IAD, 25.3 mm (SD 2.5; 17.6 to 31.1) and 27.1 mm (SD 1.5; 24.5 to 31.0). All means were significantly different between the study and control groups. RI correlated strongly with DRS-PC. Ulnar styloid fracture intersection with the DUS axis, reflective of ulnar translation of both radial and ulnar shafts, was associated with significantly lower RI.

Conclusion

After DRF, the relationship of the proximal capitate to the DRS axis in the coronal plane correlates with the final radial inclination. Additionally, ulnar styloid intersection with the DUS axis is associated with even lower radial inclination. DRF reduction should seek to restore the normal coronal relationship of both radial and ulnar shafts to their distal counterparts.

Three Column Fixation Through a Single Incision in Distal Radius Fractures

Purpose  The purpose of this study was to evaluate the clinical and functional results of 67 patients with distal radius fracture (DRF), treated with a modified surgical technique that allows three-column fixation through the same palmar approach. Patients and Methods  Between 2014 and 2019, we treated 67 patients using a particular surgical technique. All patients suffered DRF, classified using the universal classification system. Two different intervals were developed palmary: the first ulnarly to the flexor carpi radialis tendon for direct visualization of the distal radius and the second one radially to the radial artery for direct visualization of the styloid process. An anatomic volar locking compression plate was applied to all patients. The radial styloid process was fixed and stabilized either with Kirschner-wires or an anatomic plate through the same incision. Functional results were evaluated based on the Disabilities of the Arm, Shoulder and Hand and Mayo wrist scores. Range of motion and grip strength of the injured wrist were statistically compared with the opposite side. Results  The mean follow-up was 47 months (13-84). All fractures were united, and all patients recovered to the preinjury level of activity. The mean flexion-extension range was 73.8° to 55.2° and the supination-pronation range 82.8° to 67°. No infection or nonunion occurred. No major complications were reported. Conclusion  Open reduction and internal fixation, under specific indications, is the best treatment option in DRF. The described technique provides excellent visualization to the distal radius surfaces and allows the internal fixation of the radial columns through the same skin incision. Therefore, it can constitute an efficient choice in the treatment armamentarium of DRF.

Distal radius fracture with concomitant ulnar styloid fracture: does distal radioulnar joint stability depend on the location of the ulnar styloid fracture?

INTRODUCTION

Studies are conflicting regarding the relationship between ulnar styloid fracture (USF) location and distal radioulnar joint (DRUJ) instability in patients with distal radius fracture (DRF) and concomitant USF. The objective of this study was to determine the association of USF location with TFCC foveal tear and factors associated with DRUJ instability in patients with both DRF and USF.

MATERIALS AND METHODS

Fifty-four patients with both DRF and USF who had wrist MRI examination before surgery were analyzed. USF location (tip or base) and TFCC foveal insertion status (intact, partial tear, or complete tear or avulsion with fractured fragment) were evaluated. DRUJ stability was assessed intra-operatively after fixation of the radius. Factors potentially associated with DRUJ instability, such as age, gender, USF location, USF fragment gap, radioulnar distance, radial shortening, and TFCC foveal tear, were analyzed.

RESULTS

Among 54 patients, 37 (69%) and 17 (31%) had USF at the base and the tip, respectively. In patients with base fractures, TFCC foveal insertion was found to be disrupted in 89% (33/37) patients (complete tear in 11 and partial tear in 22) but intact in 11% (4/37). On the contrary, in patients with tip fractures, the insertion was found to be disrupted in 88% (15/17) patients (complete tear in 2 and partial tear in 13) but intact in 12% (2/17). After fixation of the radius, total 52% (28/54) patients showed DRUJ instability. Especially, DRUJ instability was found in 57% (21/37) of ulna styloid process base fracture patients and 41% (7/17) of ulna styloid process tip fracture patients. In univariate analysis, complete tear of TFCC foveal insertion and wider USF fragment distance were associated with DRUJ instability.

CONCLUSIONS

Tears of TFCC foveal insertion are common in patients with DRF and concomitant ulnar styloid base fractures. Based on the findings of this study, tear of TFCC foveal insertion seems to be also common in patients with DRF and concomitant ulnar styloid tip fractures. And also, DRUJ instability seems to be associated with a TFCC foveal tear independent of USF location.

Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion

PURPOSE

To determine whether clinical outcomes of arthroscopic one-tunnel wrist triangular fibrocartilage complex (TFCC) transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion (USPFN).

METHODS

Patients who underwent arthroscopic 1-tunnel transosseous suture repair of Palmer 1B foveal TFCC tear (with/without superficial fiber tear; Atzei class 2 or 3 TFCC tear) from 2015 to 2020 were retrospectively reviewed. Group I was the TFCC foveal tear repair group with USPFN. Group II was the TFCC foveal tear repair group without USPFN. In group I, no additional treatment for USPFN was made. Functional preoperative and postoperative outcomes were compared by Modified Mayo Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; grip strength; pain visual analog scale (VAS); and distal radioulnar joint (DRUJ) stability. Wrist posteroanterior, lateral, and both oblique views of the wrist were used to assess the ulnar styloid process before and after operation.

RESULTS

This study consisted of 66 patients: group I (n = 22) and group II (n = 44). No differences were found between the 2 groups preoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .94, Quick-DASH: P = .23, grip strength: P = .69, VAS: P = .45). No differences were found between the 2 groups with respect to outcome measures postoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .59, Quick DASH: P = .82, grip strength: P = .15, VAS: P = .84). All of the enrolled patients achieved restored function with negative ballottement test and maintained DRUJ stability on follow-up. Of the 22 USPFN cases in group I, 11 (50%) showed spontaneous union after transosseous TFCC foveal repair without any additional USPFN treatment. The proportion of patients achieving a minimal clinically important difference for the Quick-DASH was similar between the 2 groups.

CONCLUSIONS

Although this current study has insufficient statistical power, the available data suggest that patients with TFCC foveal tear combined with USPFNs treated with arthroscopic transosseous repair surgery could experience similar functional improvement compared with those with TFCC foveal tear without USPFNs. The presence of USPFN accompanied by Palmer 1B type TFCC foveal tear may not affect the clinical results, including MMWS, Quick-DASH, grip strength, VAS, and DRUJ stability of patients who undergo arthroscopic 1-tunnel transosseous suture repair.

LEVEL OF EVIDENCE

Level III, retrospective comparative 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.

Residual stability of the distal radioulnar joint following ulnar styloid fracture: influence of the remnant distal radioulnar ligaments

Clinical studies suggest that even untreated basal ulnar styloid fractures may not affect patient outcomes. This may be due to the remaining parts of the distal radioulnar ligament still attached providing sufficient residual stability of the distal radioulnar joint. We tested this hypothesis in a biomechanical cadaveric model. Dorsopalmar translation of the distal radioulnar joint and forearm rotation were measured. Seventeen specimens were tested after a simulated ulnar styloid fracture including the fovea, followed by transection of the remaining palmar (n = 9) or dorsal (n = 8) portions of the distal radioulnar ligament and finally with all remnants transected. Rotation and translation both increased significantly after the final transection compared with the foveal fracture. The increase in translation was larger after transection of the dorsal remnants. We conclude that in an ulnar styloid fracture including the fovea, some ligament components are still attached to the ulnar head, giving residual stability to the distal radioulnar joint.

Clinical Features and Surgical Strategies of Distal Radius Posttraumatic Deformity

Objective

To investigate the clinical features and surgical strategies of distal radius posttraumatic deformity.

Methods

A retrospective analysis was performed on the data of 30 patients with distal radius posttraumatic deformity treated by osteotomy and orthopedic surgery in the department of orthopedics, the First Affiliated Hospital of Nanjing Medical University, from February 2016 to November 2018. All the patients underwent preoperative anterior and lateral X-ray plain scanning of bilateral wrist joints, showing different degrees of radius shortening, inferior ulnar and radial mismatch, palmar angle, and ulnar deviation angle, among which 11 patients had an uneven joint surface. After a full evaluation, osteotomy and orthopedic surgery were performed to restore the original anatomical structure, plaster fixation was performed for two weeks after surgery, and regular outpatient follow-up was conducted. The function of the wrist was evaluated by the MMWS (wrist joint improvement) scoring scale before and after surgery, and the changes in the wrist joint-related treatment parameters were evaluated according to X-ray.

Results

All 30 patients had no neurological symptoms after surgery, and all wounds healed within the first stage. All patients were followed up for 6–12 months, with an average healing time of 3.5 months. There was no reduction loss, internal fixation loosening, or fracture in the regular postoperative review. Postoperative MMWS (wrist joint improvement) score scale data were significantly higher than those before surgery, and there were differences between groups (P < 0.05). Postoperative treatment parameters of wrist joints such as palmar inclination angle, ulnar deviation angle, radius height, and lower ulnar and radial matching were significantly improved, and there were differences between groups (P < 0.05).

Conclusions

The patients with distal radius posttraumatic deformity have the clinical characteristics of shortening of radius, mismatch of lower ulnar and radius, an abnormal inclination of palm, and ulnar declination. For patients with distal radius posttraumatic deformity, osteotomy and orthopedic surgery can effectively improve wrist function and improve patients' quality of life, which is worthy of clinical reference.

Treatment of Distal Radius Fractures with Bridging External Fixator with Optional Percutaneous K-Wires: What Are the Right Indications for Patient Age, Gender, Dominant Limb and Injury Pattern?

The aim of this retrospective study was to evaluate the medium-term clinical and functional outcomes of patients with closed, displaced, and unstable, simple or complex, intra- and extra-articular distal radius fractures (DRFs) treated with a bridging external fixator (BEF) and optional K-wires (KWs). AO classification was used to differentiate the injuries radiographically. Clinical-functional outcomes were evaluated using the Patient-Rated Wrist and Hand Evaluation Score (PRWHE Score) and the Quick Disabilities of the Arm Shoulder and Hand Score (QuickDASH). A total of 269 dorsally displaced fractures of 202 female (75%) and 67 male subjects (25%) were included, with a mean follow-up of 58.0 months. Seventy-five patients (28%) were treated by additional KWs. No differences were found comparing the two groups of patients (BEF vs. BEF + KWs) regarding age, sex, and fracture side (dominant vs. non-dominant). PRWHE and QuickDASH scores were lower in the BEF + KWs group compared to the BEF group (p < 0.0001 and p = 0.0007, respectively). Thus, patients treated with KWs had a better clinical outcome. Beta multivariate regression analysis confirmed that patients of the BEF + KWs group exhibited a better PRWHE score but not a better QuickDASH score. Patients treated by the BEF + KWs with the fracture on the dominant site were characterised by better clinical outcomes. Older patients had a better PRWHE score independently from the treatment. Our findings suggest that the use of BEF for DRFs with optional KWs can be indicated in both young and elderly patients of any gender, independent of limb side and fracture pattern. As the best functional results were achieved in the elderly when KWs were added, the combination of BEF and KWs seems to be mainly indicated for the treatment of DRF, also complex, in the elderly population.

Intraoperative evaluation of DRUJ instability through dorsal stress radiography in distal radius fractures

INTRODUCTION

Certain type of injury of the triangular fibrocartilage complex associated with distal radius fracture can result in distal radioulnar joint instability (DRUJ). Untreated DRUJ instability may lead to poor result in the treatment of acute distal radius fractures. The aim of this study was to evaluate DRUJ instability in distal radius fractures through dorsal stress radiography comparing the affected and unaffected wrists intraoperatively.

MATERIALS AND METHODS

49 patients with a distal radius fracture who were operatively treated with a volar locking plate were included. Dorsal stress radiography was used to evaluate both affected and unaffected wrists peri-operatively to detect DRUJ instability. Under general anesthesia, a dorsal stress test was performed on the unaffected wrist. Additionally, after fixation of the affected wrist, a dorsal stress test was performed. The ulnar translation ratio (UTR) was measured through the dorsal stress radiograph. Arthroscopic examination was performed on all affected wrists according to Palmer's and Atzei classification.

RESULTS

The UTR of the affected wrist and the TFCC injury Palmer-type IB tendency were positively correlated (odds ratio: 1.18, p-value: 0.002). Additionally, as the UTR difference between the affected and unaffected wrists enlarged, it revealed a significant DRUJ instability tendency due to Palmer-type IB TFCC injury (p-value: 0.000006, Wilcoxon rank-sum test).

CONCLUSIONS

Dorsal stress radiography is a reliable, simple procedure to evaluate DRUJ instability intraoperatively. UTR value from dorsal stress radiography could be useful for evaluating DRUJ instability associated with distal radius fracture.

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.

Open Foveal Repair of the Triangular Fibrocartilage Complex Tears Associated with Symptomatic Ulnar Styloid Non-union

Background: Symptomatic ulnar styloid non-union can be treated by excision of the ulnar styloid fragment. For combined triangular fibrocartilage complex (TFCC) tears, several repair techniques such as arthroscopic repair, open repair to the fracture site or reconstruction using a tendon graft have been introduced. This study reports the technique and outcomes of open foveal repair of the TFCC with excision of the ulnar styloid fragment in patients with symptomatic ulnar styloid non-union and distal radioulnar joint (DRUJ) instability. Methods: Consecutive patients with symptomatic ulnar styloid non-union with TFCC tears and DRUJ instability who underwent excision of the ulnar styloid fragment and open foveal repair of the TFCC were retrospectively reviewed. After excising the ulnar styloid fragment, a capsular window was created between the triquetrum and TFCC, followed by attaching the TFCC to the fovea using three sutures through a bone tunnel from the ulnar cortex to the fovea. Additional ulnar shortening osteotomies were performed in patients with positive ulnar variance and ulnar impaction test. The outcomes were evaluated in terms of DRUJ stability and the Quick Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: In total, 21 patients with a mean age of 40 were enrolled in the study. All patients demonstrated DRUJ stability at a mean follow-up duration of 14 months. The mean Quick DASH score significantly improved from 18.9 ± 11.7 to 2.5 ± 4.1 (p < 0.05). Eleven patients underwent combined ulnar shortening osteotomies, and no difference in the Quick DASH score was found between patients who underwent ulnar shortening osteotomy and those who did not. Conclusions: This study demonstrates that open foveal repair of the TFCC with ulnar styloid fragment excision is an effective strategy to surgically treat patients with symptomatic ulnar styloid non-union with TFCC tear and DRUJ instability. Level of Evidence: Level III (Therapeutic).

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.

In vivo measurement of distal radioulnar translation following distal radius fracture

The incidence of distal radioulnar joint instability following a distal radius fracture is estimated around one in three based upon clinical examination. Using a validated rig, we objectively measured distal radioulnar joint translation in vivo following distal radius fracture. Dorsopalmar translation of the distal radioulnar joint was measured in 50 adults with previous distal radius fractures. Measurements were compared with the uninjured wrist and against a database of previous measurements within healthy and clinically lax populations. Translation at the distal radioulnar joint was greater in injured wrists at 12.2 mm (range 10-15, SD 1.2) than the uninjured wrists at 6.4 (range 4-9, SD 0.8) (p < 0.001) and was always outside the established normal range. There was no statistically significant link between translation and the severity of the injury. Instability appears almost inevitable following a distal radius (wrist) fracture, albeit subclinical in the vast majority.

Advanced Imaging of Ulnar Wrist Pain

Ulnar-sided wrist pain can be a diagnostic challenge for clinicians and radiologists. The ulnar wrist has complex morphology and is composed of many small bone and soft tissue structures. Within these structures, a wide variety of pathologic conditions can occur. To successfully diagnose and treat these pathologic conditions, clinicians and radiologists must have a strong understanding of the advanced imaging techniques available to them. In this review, the authors present a brief review of the normal ulnar wrist anatomy, discuss the differential diagnosis of ulnar-sided wrist pain, and examine the indications for different advanced imaging modalities.

Distal Radioulnar Joint Instability

Instability of the distal radioulnar joint is a source of ulnar-sided wrist pain and functional impairment. Symptomatic instability may present acutely, after a recent traumatic injury, or in a delayed fashion as chronic instability following a history of a traumatic event. A detailed understanding of the complex anatomy, biomechanics, and stabilizing structures of the distal radioulnar joint is important to evaluate and treat acute and chronic instability. This article describes the pathophysiology of distal radioulnar joint instability with attention to the anatomic structures involved and provides information about evaluation and treatment.

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.

Should We Repair the Pronator Quadratus in a Distal Radius Fracture with an Ulnar Styloid Base Fracture? A Biomechanical Study

Background  Merits of repairing the pronator quadratus (PQ) to restore distal radioulnar joint (DRUJ) stability after a volar approach remain controversial. Distal radius fractures are often associated with ulnar styloid fractures (USF). When involving the fovea, this USF can lead to a DRUJ instability. The PQ repair may be key in reducing this DRUJ instability. Methods  This study aims to assess the biomechanical role of PQ repair in a cadaveric model of USF. In 17 forearm specimens, a USF including the fovea was executed. Positional changes of the DRUJ in forearm rotation and dorso-palmar (DP) translation were measured with variable loads (0, 2.5, and 5N) applied to the PQ origin. Results  Forearm rotation and DP-translation decreased significantly with PQ loading of 5N, changing on average by 5 degrees and 0.6 mm, respectively. Conclusion  We found a significant decrease in forearm rotation and DP-translation comparing a fully loaded PQ to an unloaded PQ in our cadaveric model.

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.

Is there a correlation between functional results and radiographic findings in patients with distal radius fracture A0 type A3 treated with volar locking plate or external fixator?

The aim of this study was to test the hypothesis that precise restoration of distal radius fractures is correlated to better patient-reported outcome.

METHODS

The correlation between radiographic results and functional outcome was explored in 156 patients with extra-articular distal radius fractures included in a multicenter, randomized controlled trial comparing 2 surgical interventions, Volar Locking Plate or External Fixator. The primary functional outcome was the Patient Rated Wrist and Hand Evaluation score (PRWHE). Radiographically we assessed volar tilt, radial inclination, radial height, ulnar variance, and the presence of ulnar styloid fracture. The Pearson correlation analysis was used to estimate correlations between parameters.

RESULTS

At 1-year follow-up the mean difference in radiographic findings compared with the uninjured side (min, max) was: reduced volar tilt 5.3° (-15°, 25°), reduced radial inclination 2.3° (-6°, 12°), radial height 1.3 mm (-4 mm, 7 mm), and ulnar variance -0.5 mm (-6 mm, 3 mm). Overall, we found no correlation between radiographic parameters and the PRWHE at 1-year follow-up within the whole group, regardless of which treatment was chosen. At the time of injury 53% (N = 80) had sustained an additional ulnar styloid fracture. After 1 year this fracture was still radiographically present in 31% (N = 43) of the patients. No correlation between PRWHE score and the presence of an ulnar styloid fracture at 1-year follow-up was found.

CONCLUSIONS

We found no correlation between functional outcome (PRWHE) and radiographic findings after 1 year in patients operated on with a Volar Locking Plate or External Fixator. Patient-specific factors were more important than radiographic measurements in this study group.Level of evidence: Therapeutic Level 2Trial registration: Norway: National Committee for Medical and Health Research Ethics 213/555ClinicalTrials.gov ID: NCT01904084Randomization of first patient: 02.09.2013.

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.

Distal Radioulnar Joint Instability and Associated Injuries: A Literature Review

The distal radioulnar joint (DRUJ) allows supination and pronation of the distal forearm and wrist, an integral motion in everyday human activity. DRUJ injury and chronic instability can be a significant source of morbidity in patients' lives. Although often linked with distal radius fractures, DRUJ injury may occur in a variety of other upper extremity injuries, as well as an isolated pathology. Diagnosis of this injury requires the clinician to have a high index of suspicion and low threshold for clinical testing and further imaging of the DRUJ. The purpose of this article is to provide a review on DRUJ anatomy and biomechanics, to discuss common diagnostic and treatment modalities, and to identify common injuries associated with DRUJ instability.

Ulnar Styloid Fracture Accompanying Distal Radius Fracture Does Not Affect Hand Function, but What About Hand Dexterity?

Introduction  Hand dexterity is not addressed in patients with distal radius fracture (DRF) accompanied with ulnar styloid fracture (USF) in literature. This study aimed to determine whether an associated USF following a DRF has any effect on hand dexterity. Materials and Methods  Patients diagnosed with DRF were included in the study and were divided into two groups according to the USF presence (USF group and non-USF group). Pain, range of motion, Quick-DASH (Quick-Disabilities of the Arm, Shoulder, and Hand), handgrip and pinch strength, Purdue Pegboard test, and Jebsen Taylor Hand Function test were measured in the sixth month. Results  A total of 125 patients, 68 females (54.4%) and 57 males (45.6%) were included in the study. The mean age of the patients was 47.15 ± 13.41 (18-65) years. There were 60 patients (48%) in the USF group and 65 patients (52%) in the non-USF group. No significant difference was found in pain, range of motion, Quick-DASH and handgrip and pinch strength between the groups ( p > 0.05). The hand dexterity tests showed no statistically significant difference between the groups in the sixth month ( p > 0.05). Discussion  Hand function can be determined more accurately by assessing hand dexterity. In this study, it is emphasized that concomitant USF does not lead to poorer hand dexterity.

Isolated Volar Dislocation of the Distal Radioulnar Joint Treated With Successful Closed Reduction

We report the case of A 34-year-old right-hand-dominant male who presented with an isolated left volar dislocation of the distal radioulnar joint (DRUJ) without any associated fractures. The patient had sustained the injury in an altercation in the evening prior to the presentation and had woken up the next morning with left wrist pain and restricted wrist motion. Closed reduction was successful under conscious sedation and the patient was treated conservatively with splint immobilization without needing operative intervention.

This report highlights a rare injury pattern - an isolated volar DRUJ dislocation - that was successfully closed reduced, despite reports that this injury pattern frequently requires open reduction.

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.

Radiographic Healing and Functional Outcomes of Untreated Ulnar Styloid Fractures Following Volar Plate Fixation of Distal Radius Fractures: A Prospective Analysis

Background: Ulnar styloid fractures (USFs) are common concomitant injuries associated with distal radius fractures (DRFs). Recent studies have found conflicting evidence on whether these fractures treated or untreated effect pain and functional outcomes. The purpose of this study was to prospectively evaluate pain and function outcomes of consecutively untreated USFs in surgically repaired DRFs. The study hypothesis was that there would be no difference in outcomes whether an USF is present or not, with all cases left untreated. Methods: A prospective study at a single institution of consecutive DRF treated surgically with volar locked plating was undertaken. No patients underwent fixation of an USF if present. There were no treated USF that were excluded. Patients with associated ulnar neck and shaft fractures were excluded. Functional outcome measures were analyzed using the Quick Disabilities of the Arm, Shoulder, and Hand score (QDASH) and the Patient-Rated Wrist Evaluation (PRWE) scores. Outcome measures were collected at 3 months and 1 year postoperatively. Results: There was an incidence of 52.2% (n = 70/134) USF associated with surgically treated DRF. By location, there were 52.9% (n = 37/70) ulnar styloid tip fractures and 46.1% (33/70) ulnar styloid base. There were 75.7% of USF (53/70) still not healed by 1-year follow-up. When comparing patients with a DRF without an USF versus DRF with an associated USF at 12 months, there was no statistical difference in the QDASH score (6.7 vs 8.4, P = .47) or the PRWE total score (4.8 vs 7.5, P = .24). Similarly, subgroup analysis showed no statistical difference in QDASH or PRWE scores at final follow-up in united USF versus nonunited USF subjects (QDASH 14.2 vs 6.8, P = .112; PRWE 14.8 vs 5.4, P = .185). Conclusions: USFs are a common concomitant injury occurring in nearly half of DRFs treated surgically. Our prospective cohort analysis showed that neither the presence, type, nor bony union status of a concomitant USF has any significant effect on patient outcomes or reoperations at 1-year postoperatively. Our study confirms our hypothesis that USF of the tip and base should be left untreated.

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.

Tension Band Wiring in Upper Extremity Surgery

Tension band wiring is a simple, inexpensive, and effective technique to treat many upper extremity fractures. When tension forces result in a mechanical failure of bone, tension band wiring provides stability and promotes early mobilization by converting tensile forces across a fracture into compressive forces. The tension band principle has distinct advantages of reducing periosteal stripping, technical ease, and cost effectiveness when compared with other operative strategies. This technique can be implemented in a variety of fractures and avulsions about the upper extremity as well as small bone arthrodeses.

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.

Acute Distal Radioulnar Joint Instability: Evaluation and Treatment

This article reviews the anatomy and mechanics of pronation and supination (axial rotation) of the forearm through the distal radioulnar joint (DRUJ), and the proximal radioulnar joint (PRUJ). Injuries to the bones and/or ligaments of the forearm, wrist, or elbow can result in instability, pain, and limited rotation. Acute dislocations of the DRUJ commonly occur along with a fracture to the distal radius, radial metadiaphysis, or radial head. These injuries are all caused by high-energy trauma. Outcomes are predicated on anatomic reduction and restoration of stability to the DRUJ and PRUJ with or without ligamentous repair or reconstruction.

Ulnar footprints of the distal radioulnar ligaments: a detailed topographical study in 21 cadaveric wrists

Understanding of the exact topography of the distal radioulnar ligaments insertions remains limited. An anatomical study was performed in 21 fresh frozen cadaveric wrists, where the superficial and deep ligaments were sequentially transected sharply at their ulnar insertions. The relationships between the distal radioulnar ligament footprints relative to the bony landmarks of the ulnar styloid were digitized. Our study demonstrated that in the coronal plane, the superficial distal radioulnar ligaments inserted at an average of 87% of the styloid height proximally to the styloid tip distally. The deep distal radioulnar ligaments inserted at an average of 81% of the styloid height distally to the fovea proximally. The superficial footprint had an area of 10.6 mm² on the ulnar styloid. The deep distal radioulnar ligaments attachment was asymmetric and generally had two separate footprints. This study adds important topographical knowledge about the footprint of the distal radioulnar ligaments and may contribute to understanding the consequences of ulnar styloid fractures and distal radioulnar ligaments lesions.

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.

Ulnocarpal-Spanning Plate Fixation as a Novel Technique for Complex Distal Ulna Fracture: A Case Report

CASE

The patient was a 60-year-old woman with a comminuted, open distal radius and distal ulna metadiaphyseal fracture. After fixation of the distal radius, the distal ulna was unstable and crepitant with rotation and anteroposterior translation. Because of limited bone stock and poor soft tissue, we spanned the distal ulna using a wrist spanning plate. This was removed at 6 weeks postoperatively. She healed and was satisfied with her outcomes.

CONCLUSION

This case describes the original use of a wrist spanning plate for a complex distal ulna fracture. Ulnocarpal-spanning plate fixation provides an alternative to traditional methods of fixation.

[Effectiveness of volar oblique T-type locking plate and raft screws reduction and fixation in treatment of extreme distal radius fractures]

OBJECTIVE

To investigate the effectiveness of volar oblique T-type locking plate and raft screws reduction and fixation in the treatment of extreme distal radius fractures.

METHODS

Between July 2014 and July 2018, 15 patients with extreme distal radius fractures were treated with volar oblique T-type locking plate and raft screws reduction and fixation. There were 6 males and 9 females, aged from 30 to 66 years with an average age of 56.6 years. The cause of injury was falling from height in 2 cases and falling in 13 cases. All of them were fresh closed injuries. The fractures were rated as type 23C1 in 8 cases and as type 23C2 in 7 cases according to AO/Orthopaedic Trauma Association (AO/OTA) classification. There were 7 cases of ulnar styloid process fracture and 2 cases of distal radioulnar joint instability. The time from injury to operation was 6 to 9 days with an average of 7.3 days. The fracture healing and the radial height, palm inclination, and ulnar deviation were observed by X-ray reexamination. Cooney score was used to evaluate the effectiveness.

RESULTS

All incisions healed by first intention. All patients were followed up 12-24 months, with an average of 14.6 months. X-ray films showed that all fractures healed, and the healing time ranged from 5 to 10 months, with an average of 8.2 months. No internal fixation failure or secondary fracture displacement occurred. At last follow-up, the radial height, palm inclination, and ulnar deviation recovered well, and the differences between pre- and post-operation were significant ( P<0.05). The pain, function, activity, and grip strength scores and the total score of Cooney score were significantly higher than those before operation ( P<0.05). There were 11 cases of excellent, 3 cases of good, and 1 case of good, with an excellent and good rate of 93%.

CONCLUSION

For extreme distal radius fractures, the volar oblique T-type locking plate and raft screws reduction and fixation can restore the radialheight, palm inclination, and ulnar deviation, fix firmly, and recover the wrist joint function exercise early, and obtain satisfactory effectiveness.

[Effects of ulnar styloid and sigmoid notch fractures on postoperative wrist function of patients with distal radius fracture]

OBJECTIVE

To study the effects of ulnar styloid and sigmoid notch fractures on postoperative wrist function in patients with distal radius fracture.

METHODS

In total, 139 patients treated for distal radius fracture in the Department of Orthopedic Trauma at Peking University People's Hospital from Jan. 2006 to June 2016 were selected for outpatient follow-ups. Evaluation was based on Sartiento's modification of the Gartland and Werley scores. Efficacy was assessed with wrist pain as the focus.

RESULTS

The excellent and good efficacy rate was 97.1% (excellent: n=107, 77.0%; good: n=28, 19.4%; and fair: n=4, 2.9%). Gender, age, and whether the ulnar styloid fracture achieved union did not significantly impact the scores (P>0.05). The scores of the basal fracture group were significantly different (P=0.001). Internal fixation of ulnar styloid fracture was associated with a significant difference in scores (P=0.005). The effect of sigmoid notch fracture was also associated with a significant difference in scores (P=0.024). This study included 22 cases of ulnar wrist pain, and the overall incidence of ulnar wrist pain was 15.8%. Gender, age, whether the ulnar styloid fracture achieved union, and whether internal fixation was conducted for ulnar styloid fracture and sigmoid notch fracture had no significant effect on the occurrence of ulnar wrist pain (P>0.05). The incidence of ulnar wrist pain was higher in basal fractures than that in tip fractures. Among ulnar styloid fractures, the union rate of basal fracture was higher than that of tip fractures. The union rates of basal fracture and tip fracture were significantly different (P<0.001). Basal fractures were significant risk factors for ulnar wrist pain (P=0.028). Basal fracture of the ulnar styloid group and sigmoid notch fracture group had poor wrist function scores. Wrist function score improved significantly after internal fixation of ulnar styloid fracture. The incidence of ulnar wrist pain was higher in basal fracture group. The union rate in basal fracture group was higher than in tip fracture group.

CONCLUSION

The overall effect of surgical treatment of distal radius fracture is satisfactory. Ulnar styloid basal fracture and sigmoid notch fracture are risk factors for postoperative wrist dysfunction in patients with distal radius fracture, and the basal fracture is one of the risk factors of ulnar wrist pain. The union rate of ulnar styloid basal fractures is better than that of tip fractures. Internal fixation of ulnar styloid fracture can improve wrist function.