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

Round table discussion. Distal radioulnar joint instability after surgical treatment of distal radial fractures

Distal radioulnar joint instability is commonly seen after surgical fixation of a distal radial fracture, and surgeons' ability to reliably determine stability on examination is poor. Debate remains regarding whether to fix the ulnar styloid or reinsert the triangular fibrocartilaginous complex. Four surgeons with Level 5 expertise were asked to respond to questions surrounding this debate.

A proposed paradigm shift in the management of distal radius fractures

Background and objective

Distal radius fractures represent a remarkable orthopaedic entity. Most distal radius fractures can be treated conservatively with closed reduction and immobilisation with satisfactory results, while open reduction and internal fixation is reserved for displaced fractures. Our objective was to propose a paradigm shift in the management of distal radius fractures.

Methods

A literature search of management of distal radius fractures was conducted. PubMed and Cochrane databases were used for the search. English articles with open access or institutional subscription availability were included.

Key content and finding

Current literature supports operative management for younger active patients with defined radiographic inclusion parameters, but among the elderly there is little evidence of benefit. Most orthopaedic literature defines "elderly" as patients above 65 years of age. Non-surgical treatment for fractures of the distal radius tends to yield satisfactory functional results, and these favourable outcomes do not necessarily align with normal radiological parameters. For the minority of patients that have symptomatic malunion, corrective osteotomy is a good option to improve the function provided the symptoms can be clearly attributed to the malalignment.

Conclusion

The vast majority of distal radius fractures can be managed conservatively. Further studies are recommended to explore the feasibility of advocating for universal conservative treatment for patients with less functional demands while still having the option of staged surgery in the form of corrective osteotomy where there is symptomatic malunion amenable to anatomical correction. Future research should also aim to identify patients who would benefit most from surgical intervention by considering the type of functional recovery needed, rather than relying predominantly on the patient's chronological age as the determining factor in the decision-making process.

Ulnar-Sided Sclerosis of the Lunate Does Not Affect Outcomes in Patients Undergoing Volar Locking Plate Fixation for Distal Radius Fracture

BACKGROUND AND AIM

Radial shortening after distal radius fracture causes ulnar impaction, and a mild reduction loss of radial height occurs even after volar locking plate fixation. This study aimed to determine whether preoperative ulnar-sided sclerosis affects clinical outcomes after volar locking plate fixation for distal radius fracture (DRF).

METHOD

Among 369 patients who underwent volar locking plate fixation for DRF, 18 with preoperative ulnar-sided sclerosis of the lunate were included in Group A and compared to a 1:4 age-, sex- and fracture-pattern-matched cohort without sclerosis (72 patients, Group B). The visual analog scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and grip strength were assessed as clinical outcomes. Ulnar variance (UV), radial inclination, radial length, and volar tilt at two weeks after surgery and the final follow-up were measured as radiographic outcomes.

RESULTS

The mean VAS and DASH scores and grip strength did not differ between the two groups. The mean UV at two weeks after surgery and the last follow-up was significantly higher in Group A. The mean changes in UV were +0.62 mm in Group A and +0.48 mm in Group B. There were no significant intergroup differences. Neither UV nor its changes showed any association with DASH and VAS scores.

CONCLUSIONS

Preoperative ulnar-sided sclerosis of the lunate did not affect clinical outcomes after volar locking plate fixation, even if UV increased postoperatively.

The distal radioulnar joint after distal radial fractures: when and how do we need to treat pain, stiffness or instability?

The importance of distal radioulnar joint problems associated with distal radial fractures is recognized increasingly. But there remains considerable disagreement about how to treat these problems both acutely and chronically. This review outlines the knowledge about the natural history of ulnar-sided wrist problems with distal radials fractures. In particular, the recent increased understanding of the almost inevitable joint instability associated with distal radial fractures is highlighted, including the unreliability of clinical assessment and hence why there has been so much misunderstanding. Provided there is reasonable bony alignment, most ulnar-sided wrist problems can be treated non-operatively initially (typically for over a year) in anticipation of substantial improvement with time. The exception is early marked subluxation of the distal radioulnar joint (DRUJ) blocking forearm rotation, which needs urgent (typically closed) reduction.

Radial distraction may reduce the incidence of ulnar-sided wrist pain in ulna-plus morphology intraoperatively following distal radius fractures fixation

INTRODUCTION

Fixed-angle plate fixation can be an effective treatment for distal radius fractures (DRFs). However, patients with existing ulnar positive variance might be at risk of developing symptoms of ulnar-sided wrist pain (USWP). Ulnar shortening osteotomy (USO) is one of the main treatment options for USWP. We hypothesized that a limited radial distraction at the fracture site at the time of surgery for DRF would be functionally equivalent to an indirect USO and that if this were done in a patient with an ulnar plus morphology it could potentially decrease the risk of USWP.

METHODS

This retrospective study was conducted at a single institution and all the surgeries were performed by single surgeon. A total of 136 patients (92 women and 44 men) with a mean age of 55 years were enrolled with 57 patients in the distraction group (from 2014 to 2017) and 79 patients (from 2011 to 2013) in the non-distraction group. Patients were assessed USWP. Functional outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Visual Analogue Scale (VAS) for pain, grip strength, and range of motion for the wrist.

RESULTS

The mean follow-up was 37.9 months (range, 28-61 months). The radiographs at postoperative 2-year follow-ups showed the mean ulnar positive variance was 1.3 mm (range, 1-2 mm) in the distraction group and 3.5 mm (range, 2-5 mm) in the non-distraction group. The average of the distraction length was 2.32 mm (range, 2-3 mm). At the 2-year follow-ups, USWP presented in 7% (four patients) in the distraction group, which was significantly less than the incidence of 28% (22 patients) in the non-distraction group. The distraction group exhibited significantly better DASH scores and grip strength and less subsequent ulnar-shortening osteotomy for ulnar-sided wrist pain.

CONCLUSIONS

The radial distraction procedure performed during DRFs fixation could possibly reduce the occurrence of postoperative USWP and improve the functional outcomes.

LEVEL OF EVIDENCE

Level III, Therapeutic.

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion

INTRODUCTION

Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union.

MATERIALS AND METHODS

We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months.

RESULTS

The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up.

CONCLUSION

Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

Radiocarpal joint stiffness following surgical treatment for distal radius fractures: the incidence and associated factors

Background

Postoperative radiocarpal joint stiffness (RJS) is common in patients with distal radius fractures (DRFs). The purpose of this study was to record the incidence of RJS and to determine potential risk factors that may be associated with it.

Methods

We retrospectively included a series of patients who suffered from DRFs and underwent volar plate fixation. Patients’ basic data, radiographic data, and postoperative data were collected. The incidence of RJS during follow-up was recorded, and both univariate analyses and multivariate logistic regression were used to determine factors associated with it.

Results

A total of 119 patients were included in this study. After surgical procedures, there were 42 (35.3%) patients with RJS and 77 (64.7%) patients without. The incidence of RJS after surgical treatment is 35.3%. Multivariate analysis showed that intra-articular fracture (OR, 1.43; 95% CI, 1.13–1.81), pre-operative severe swelling (OR, 1.35; 95% CI, 1.05–1.74), post-operative unsatisfied volar tile (OR, 1.38; 95% CI, 1.01–1.89), and improper rehabilitation exercise (OR, 1.72; 95% CI, 1.18–2.51) were correlated with the incidence of RJS during follow-up.

Conclusions

Patients with intra-articular fracture, pre-operative severe swelling, post-operative unsatisfied volar tile, and improper rehabilitation exercise were factors associated with the incidence of wrist stiffness. Preoperative risk notification and postoperative precautions are necessary for relevant patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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