Influence of ulnar translation of the radial shaft in distal radius fracture on distal radioulnar joint instability

Surgical treatment of distal radius fractures: impact on forearm rotation in non-elderly patients

Forearm rotation restriction (FRR) is common after surgery for distal radius fractures (DRFs). The aim of the current study was to investigate the effect of DRFs on forearm rotation. This retrospective study reviewed patients with DRFs who underwent surgical treatment from January 2019 to December 2021. The patients' basic data and radiographic parameters were analyzed. Forearm rotation, including pronation and supination, was assessed using a standard goniometer. The Patient-Rated Wrist Evaluation (PRWE) score was evaluated, and the incidence of FRR at the 6-month follow-up was recorded. Univariate and multivariate logistic regression analyses were performed to identify risk factors correlated with FRR. A total of 127 patients with DRFs were included in this study. After surgery, 46 cases were considered to have FRR, with a rate of 36.2%, while the remaining 81 cases (63.8%) did not have FRR. The PRWE scores were 22.8 ± 5.2 and 17.9 ± 4.2 in the FRR group and non-FRR group, respectively, and the difference was statistically significant (P < 0.05). Multivariate analysis showed that the involvement of the sigmoid notch (OR, 2.88; 95% CI 1.49-5.56), post-operative volar tilt < 0° (OR, 2.16; 95% CI 1.34-3.50), and post-operative ulnar variance > 0 mm (OR, 1.37; 95% CI 1.06-1.78) were independently associated with the incidence of FRR. The FRR is associated with an increased PRWE score and may have had some impact on the patient's daily life. Fractures involving the sigmoid notch, dorsal angulation, and radial shortening deformity were found to be correlated with the incidence of FRR. Preoperative risk notification and intraoperative preventive measures are necessary for these patients.

Predictive factors of distal radioulnar joint instability after surgical treatment of distal radius fractures

Distal radioulnar joint (DRUJ) instability is a common postoperative complication of distal radius fractures, seriously impacting patients' quality of life. This study investigated its possible influencing factors to determine prognosis and to guide treatment better. We retrospectively included a series of patients with distal radius fractures that underwent volar locking plate fixation. Basic patient information and imaging parameters were collected. The incidence of DRUJ instability during follow-up was recorded, and factors associated with DRUJ instability were determined using univariate analysis and multifactorial logistic regression analysis. A total of 159 patients were enrolled in this study. At 6 months of follow-up, 54 patients (34.0%) had DRUJ instability, and multivariate analysis showed coronal plane displacement (OR, 1.665; 95% CI, 1.091-2.541), fracture classification (OR, 0.679; 95% CI, 0.468-0.984) and DRUJ interval (OR, 1.960; 95% CI, 1.276-3.010) were associated with DRUJ instability after volar locking plate. DRUJ interval, coronal plane displacement, and fracture classification are associated with DRUJ instability during follow-up. Therefore, preoperative risk communication and intraoperative attention to recovering relevant imaging parameters are necessary for these patients.

The Distal Oblique Bundle in the Distal Forearm: From Anatomical Features to Clinical Implementation

Background and objective The distal oblique bundle (DOB) is nowadays recognized as the thickest component of the distal interosseous membrane (DIOM). It is neither thought to be a clear-cut ligament, and nor does it follow the typical configuration of the rest of the DIOM. It is not always present and some studies have raised disputes about its prevalence and a few anatomical features. In this study, we aimed to provide data on the prevalence and anatomical features of the DOB, which are of great importance at this early stage of research into the topic. Our findings have been correlated with current knowledge and are expected to contribute to clinical implementation. Materials and methods Twenty-eight fresh-frozen forearms were utilized for measurements. Specifically, mean length, width, distance from the middle of the bundle's insertion to the ulna to the tip of the styloid process of the ulna, as well as the distance from the midpoint of its insertion to the radius to the tip of the radiuses' styloid process were calculated. The prevalence was described with a cutoff thickness point of 0.5 mm. Early results based on three cases of DOB reconstruction with the "Riggenbach" technique due to distal radioulnar joint (DRUJ) instability were documented. Results Eleven DOBs were reported out of the 28 specimens, suggesting a prevalence of 39.3%. The mean thickness was 0.88 mm (range: 0.6-1.3 mm), the mean width was 5.22 mm (range: 2.2-8.4 mm), and the mean length was 25.68 mm (range: 22.7-29.2 mm). Proximally, the mean distance from the bundle's ulnar insertion to the tip of the styloid process of the ulna was 51.02 mm (range: 45.5-55.6 mm) while distally, the mean distance from the bundle's insertion to the radius to the tip of the styloid process of the radius was 34.5 mm (range: 31.3-37.7 mm). After a follow-up of at least six months, improvement was evident in all measured areas in the three patients who underwent surgery. Additionally, they reported satisfaction and accomplishment of their preoperative goals. Conclusions Discrepancies in measurements in some anatomic features between studies are probably due to variations in specimen types, measurement methods, and sites. Efforts must continue to be made on a more extensive scale and in a more standardized manner for more factual results and conclusions. "Reconstruction-recreation" or "original construction-creation" procedures yield promising results in a fast, simple, and less invasive manner than traditional methods of DRUJ stabilization.

Does surgical reconstruction of the distal oblique bundle (DOB) provide similar stability as the intact bundle or Adams procedure? A systematic review

INTRODUCTION

The aim of this review was to summarize the available evidence for biomechanical stability following surgical DOB reconstruction, and to determine whether distal radioulnar joint (DRUJ) stability with a reconstructed DOB was similar to the native intact condition or that after the Adams procedure.

MATERIAL AND METHODS

A systematic literature search according to the PRISMA guidelines was performed using the databases PubMed and Embase. The following search algorithm was used: ("DOB" OR "Distal Oblique Bundle") AND "Reconstruction". Biomechanical or human cadaveric studies that measured stability of the DRUJ after reconstruction of the DOB were included.

RESULTS

Four articles were included in the final analysis. DOB incidence was reported to be between 50% and 70%. Two studies observed no differences between the intact situation and the reconstructed DOB, respectively the Adams procedure. A further author group found no signs of major instability after the Adams reconstruction or after DOB reconstruction, except for decreased stability during supination in the DOB sample. In another study, similar results could be shown for the Adams and DOB reconstruction groups; however, the DOB sample showed decreased dorsal translation of the radius during forearm supination.

CONCLUSION

In conclusion, DOB reconstruction was proven to stabilize the DRUJ adequately. Moreover, the reconstructed DOB showed the same stability as the native DOB, except for one study, in which stability following reconstruction was reduced during supination. No significant difference between the DOB and the Adams reconstruction could be observed.

Higher-Than-Expected Rates of Distal Radioulnar Joint Fixation in Radial Shaft Fractures: Location of Fracture Matters

BACKGROUND

The purpose of this study was to evaluate rates of distal radioulnar joint (DRUJ) fixation based on location of the radial shaft fracture and risk factors associated with postoperative complications following radial shaft open reduction internal fixation (ORIF).

METHODS

Adult patients who underwent isolated radial shaft ORIF from 2014 to 2018 were identified from American College of Surgeons National Surgical Quality Improvement Program database and stratified by fracture location and by the presence or absence of DRUJ fixation. Preoperative patient characteristics and postoperative complications were compared to determine risk factors associated with DRUJ fixation.

RESULTS

We identified 1517 patients who underwent isolated radial shaft ORIF, of which 396 (26.1%) underwent DRUJ fixation. Preoperative patient characteristics and postoperative complications were similar between cohorts. Distal radioulnar joint fixation was performed in 50 (30.7%) of 163 distal radial shaft fractures, 191 (21.8%) of 875 midshaft fractures, and 3 (13.0%) of 23 proximal shaft fractures (P = .025). Risk factors for patients readmitted include male sex (odds ratio [OR] = 12.76, P = .009) and older age (OR = 4.99, P = .035). Risk factors for patients with any postoperative complication include dependent functional status (OR = 6.78, P = .02), older age (50-69 vs <50) (OR = 2.73, P = .05), and American Society of Anesthesiologists (ASA) ≥3 (OR = 2.45, P = .047).

CONCLUSIONS

The rate of DRUJ fixation in radial shaft ORIF exceeded previously reported rates of concomitant DRUJ injury, especially among distal radial shaft fractures. More distally located radial shaft fractures are significantly associated with higher rates of DRUJ fixation. Male sex is a risk factor for readmission, whereas dependent functional status, older age, and ASA ≥3 are risk factors for postoperative complications.

Distal radioulnar joint instability: Diagnosis and treatment of acute and chronic lesions

Distal radioulnar joint instability is a common clinical condition that can be either acute or chronic. Its management requires extensive knowledge of all the anatomical structures around the wrist area. The clinical examination must identify all damaged structures in order to define a customized reconstruction strategy. The aim of treatment is to prevent the development of chronic instability and/or arthritic lesions, which can only be treated with palliative surgery. Distal radioulnar instability is complex. Its management shares similarities with that of knee instability, with a wide range of conditions ranging from a sprain with isolated ligament tear to complex dislocation in which multiple ligaments are torn. In particular, the triangular fibrocartilage complex, which is a pillar of distal radioulnar joint stability, is not the sole stabilizer of this joint. The treatment strategy is not as simple as just reattaching this ligament to treat all of the acute and chronic clinical signs. The goal of the present study is to describe the various structures and possible lesions in this joint and then how to repair them. The diagnostic and therapeutic difficulties justify treatment at a specialized center.

Clinical relationship between distal interosseous membrane thickness measured through magnetic resonance imaging and distal radioulnar joint stability: A retrospective study

BACKGROUND

Cadaveric studies suggest that a thick part of the distal interosseous membrane (DIOM), known as the distal oblique bundle (DOB), contributes to the distal radioulnar joint (DRUJ)'s stability. We hypothesized that the DIOM thickness, measured through magnetic resonance imaging (MRI), has a clinically significant association with DRUJ stability.

METHODS

We retrospectively reviewed patients, from February 2018 to April 2019, who underwent wrist MRI examination with physical examination for DRUJ stability. We evaluated the correlation between their MRI findings (i.e., triangular fibrocartilage complex [TFCC] tears and presence of the DOB) and DRUJ instability.

RESULTS

Out of 85 patients with an average age of 42 years, 45 (53%) had foveal TFCC tears, 29 (34%) had a DOB, and 38 patients (45%) had clinical DRUJ instability. Patients with DRUJ instability had a significantly higher incidence of foveal TFCC tears (30/38, vs 15/47, p < 0.001), while DOB was absent (36/38 vs. 20/47, p < 0.001). Among 45 patients with foveal TFCC tears, only 1 out of 13 patients with a DOB had DRUJ instability, whereas 29 out of 32 patients without a DOB had DRUJ instability (p < 0.001). The odds ratio for DRUJ instability was 11.7 (95% CI 2.9-47.5, p = 0.001) for foveal TFCC tear and 54.2 (95% CI 8.2-358.2, p < 0.001) for the absent DOB.

CONCLUSIONS

Clinical DRUJ instability was less common when the DOB is present in patients with foveal TFCC tears, which supports DOB's role as a secondary DRUJ stabilizer.

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

Background

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

Methods

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

Results

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

Conclusions

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

Stabilization of the distal radioulnar joint by reconstructing the interosseous membrane's distal oblique bundle: Cadaver study

INTRODUCTION

The distal radioulnar (DRU) ligaments play a key role in stabilizing the DRU joint. Ligament reconstruction in this area is an accepted treatment. However, another structure may also be a significant DRUJ stabilizer-the distal oblique bundle (DOB) of the interosseous membrane (IOM). Recent studies have described DOB reconstruction methods, which should be compared to DRU ligament reconstruction.

METHODS

Twelve upper limbs were used. First, a descriptive anatomy study was done to determine the prevalence and features of the DOB (insertions, thickness, and relationship with DRU ligaments). Second, biomechanical testing was done with the wrist in neutral position, supination, and pronation. Distal radius translation was evaluated first on an intact wrist then evaluated again after creating bidirectional instability. Lastly, the same tests were repeated after DRU reconstruction using the Adams-Berger technique and DOB reconstruction using the Riggenbach technique.

RESULTS

The DOB was present in 50% of specimens and was bilateral. Reconstructing the DOB stabilized the wrist to the same degree as the Adams-Berger technique in neutral and pronation (8% residual major instability). Stability was harder to achieve in supination (25% major instability). It was better at controlling posterior radial translation than anterior translation (3% versus 14% major instability).

CONCLUSION

DOB reconstruction appears to be a reliable and less invasive treatment option for DRUJ instability since it is extra-articular. However, the wrist's position and the direction of radial translation seem to alter the stabilization's effectiveness.

LEVEL OF EVIDENCE

IV; Cadaver study.

Distal radioulnar joint instability: current concepts of treatment

Distal radioulnar joint (DRUJ) instability is often an underestimated or missed lesion which may entail fatal consequences. The triangular fibrocartilage complex is a biomechanically very important stabilizer of the DRUJ and guarantees unrestricted range of motion of the forearm. To detect DRUJ instability a systematic examination is of uppermost importance. The contralateral healthy arm will be used for comparison during clinical examination. X-rays are required to exclude osseous lesions or deformities. Computed tomography of both wrists in neutral forearm rotation, supination, and pronation may be necessary to verify DRUJ instability in ambiguous situations. Following a systematic clinical examination wrist and DRUJ arthroscopy detects lesions definitely. Tears of the distal radioulnar ligaments which entail DRUJ instability should be repaired preferably anatomically. Ulnar-sided ligament ruptures which cause instability are detected more often than radial-sided ones. Osseous ligament avulsions are mostly refixated osteosynthetically. Ligamentous tears of the distal radioulnar ligaments may be reconstructed using anchor suture or transosseous refixation. Secondary procedures such as tendon transplants are necessary for anatomical reconstruction in cases of unrepairable ligament tears.

[Treatment of the ulnar impingement syndrome in the distal radioulnar joint]

Ligamentous stability and joint congruity are prerequisites for a physiological function of the distal radioulnar joint (DRUJ). Impingement of the ulnar head may be caused by a congenital ulna-minus variance or by an iatrogenically excessive ulna shortening osteotomy. This impingement is detected by a positive compression test at the DRUJ. Radius correction osteotomy with shortening and correction of the radial inclination to restore the sigmoid notch may solve the problem by reducing the pressure between both joint partners and by promoting the remodelling of the DRUJ. This technique may restore the distal radioulnar joint and thus prevent the necessity of salvage procedures.

Anatomic Characteristics of the Distal Oblique Bundle of the Interosseous Membrane of the Forearm

The distal oblique bundle of the forearm is a structure that has been under vigorous investigation for the past decade. It is part of the distal interosseous membrane (DIOM) and seems to have an important stabilizing effect in the distal radioulnar joint. In this essay, we have tried to summarize the anatomical characteristics of the structure. We have also compared and contrasted this to our own experience with eight freshly frozen forearms. It is our strong belief that the distal oblique bundle (DOB) may play a keystone role in future stabilization techniques of the distal radioulnar joint, and its anatomy characteristics need to be fully investigated.

Volar dislocation of the ulnar head after distal radial fracture: Case report and review of the pertinent literature

Introduction

We report the case of volar dislocation of the ulnar head occurred after osteosynthesis for the treatment of distal radius fracture.

Presentation of case

The patient, 68-year-old female, had the dorsal displaced left distal radius fracture and volar dislocation of the ulnar head. Osteosynthesis was performed using a volar locking plate without postoperative immobilization. Two weeks after surgery, volar dislocation of the ulnar head in distal radioulnar joint (DRUJ) was noted on CT. Re-operation, triangular fibrocartilage complex (TFCC) was sutured to the ulnar fovea using a suture anchor, was performed in order to stabilize DRUJ. At 24 months after surgery, left wrist joint pain and the range of motion have improved, and the Mayo wrist score was excellent.

Discussion

Based on the fact that the radius was fractured and the ulna was dislocated in DRUJ at the time of injury, the present case may have been a Galeazzi fracture.

Conclusion

When distal radius fracture is complicated by ulnar instability of DRUJ, active repair of the TFCC function may be necessary to prevent residual postoperative instability.

A Novel Technique for Correcting Radial Length and Translation in Distal Radius Fractures

We describe a novel technique in correcting distal radius fractures deformed with significant shortening or coronal plane translation in both the acute or chronic setting. The technique involves using a modified push-pull device to assist the surgeon in correcting length and/or translation of the articular block without the use additional hardware outside of the volar plate.

Prevalence of the distal oblique bundle of the interosseous membrane of the forearm: an anatomical study

A study was undertaken to examine the presence of the distal oblique bundle of the forearm in a large sample in order to describe its true prevalence. The study sample consisted of 200 cadaveric forearms. Fifteen were excluded due to defects in the distal interosseous membrane. In the remaining 185 specimens, the distal interosseous membrane was examined following removal of soft tissue, to determine whether a distal oblique bundle was present and whether there were connecting fibres to the distal radio-ulnar joint. The distal oblique bundle was observed in 53 specimens (29%). In 45 of these forearms (85%), one or more connecting fibres to the distal radio-ulnar joint were identified. The presence of a distal oblique bundle in 29% is less frequent than that reported in previous literature. The presence of the distal oblique bundle should be noted and may be of importance in the management of disorders of the distal radio-ulnar joint.

Radial Shaft Convergence in Distal Radius Fractures: Diagnosis and Treatment

Radial shaft convergence in distal radius fractures is often misdiagnosed. This common deformation is often associated with a radial translation of the distal fragment. This parameter has to be corrected because of the increased risk of distal radioulnar joint instability due to detensioning of the distal interosseous membrane if there is an associated triangular fibrocartilage complex lesion. A new radiologic sign for diagnosis of proximal radius convergence during distal radius fracture is presented as well as technical tips for correction of this deformity.

The distal radial decompression osteotomy for ulnar impingement syndrome

INTRODUCTION

The decompression of the distal radioulnar joint (DRUJ) is performed by ulnar translation of the radial shaft proximal to the sigmoid notch, i.e. detensioning of the distal part of the interosseous membrane (DIOM) while containment of the DRUJ is achieved by closed wedge osteotomy of the radius. The osteotomy shortens the radius which entails detensioning of the triangular fibrocartilage complex (TFCC).

SURGICAL TECHNIQUE

Facilitating the modified Henry approach to the distal palmar radius a radial based wedge osteotomy is applied. The proximal osteotomy is proximal to the ulnar head and distal osteotomy is proximal to the sigmoid notch to prevent iatrogenic impingement. Ulnar translation of the radial shaft is performed to loosen the DIOM. The closed wedge osteotomy reduces radial inclination which will foster containment of the DRUJ.

CONCLUSION

Distal radial decompression osteotomy of the DRUJ preserves DRUJ function while relieving painful impingement. Further surgical interventions are not compromised in case of failure.

Palmar reconstruction of the triangular fibrocartilage complex for static instability of the distal radioulnar joint

This study describes a new technique that can be used for reconstructing the triangular fibrocartilage complex to correct the static palmar radius instability of the distal radioulnar joint. In the abovementioned condition, the radius is extremely unstable with respect to the ulna and dislocates palmarly in the resting position. Using a palmar approach, a palmaris longus tendon graft was sutured to the remnant of the disrupted palmar radioulnar and ulnocarpal ligaments and then anchored to the bone tunnel that was created at the ulnar fovea. This technique predominantly reinforces the palmar structure of triangular fibrocartilage complex because the palmar radioulnar ligament is the most critical stabilizer of palmar radius instability.