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

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.

Impact of Time to Fixation on Outcomes of Operative Treatment of Intra-articular Distal Radius Fractures

BACKGROUND

The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes.

METHODS

We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication.

RESULTS

Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%).

CONCLUSIONS

Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.

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

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

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

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

A Stepwise Intraoperative Protocol to Minimize Complications after Volar Plating

Background  Although outcome of volar plating is generally good, care should be taken to avoid specific iatrogenic and preventable complications, with an incidence reporting averaging 15%. Flexor tendon rupture due to a prominent plate, extensor tendon rupture due to a dorsal protruding screw tips, cartilage lesions due to intra-articular screw placement, loss of reduction due to insufficient stability, and persisting ulnar pain with distal radioulnar joint instability due to unstable triangular fibrocartilaginous complex lesions or unstable ulnar styloid base fractures all have been described. Purpose  We believe that a majority of these complications can be prevented by meticulous assessment of several intraoperative parameters during volar plating. Therefore, we introduce the WRIST protocol, a stepwise easy-to-remember manual that combines multiple fluoroscopic measurements to guide intraoperative decision making. Conclusion  Large prospective studies of the "WRIST" protocol are needed for validation. But we believe that it may help surgeons to optimize surgical technique, functional and radiographic outcome, and prevent complications when treating distal radial fractures.

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

PURPOSE

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

METHODS

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

RESULT

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

CONCLUSION

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

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

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

Relationship of ulna styloid fracture to the distal radio-ulnar joint stability. A clinical, functional, and radiographic outcome study

BACKGROUND

Ulna styloid fracture occurs approximately about 55% of all distal end of radius fractures. However, the clinical and functional outcome of these fractures remains indefinite.

RESULTS

Only 56 patients with distal radius fractures had concomitant ulna styloid fractures. The mean age was 32 years (range: 18-69; SD: ± 12.7). The majority were men. The mean time from injury was 18.7 months (range: 6-84; SD: ± 13.3). The most common was Frykman 2, followed by 6, type 8, and type 4. All were closed fractures; 60.7% were base, and 39.3% were tip fractures. 50% were treated with casting, 48.3% plating, and 1.8% external fixation. The mean period of casting was 7.67 weeks (range: 4-16; SD ± 3.1). The ulna styloid was united in 35.7%. There is no significant difference in the range of movement between those with ulna styloid union and non-union. The Ballottement test and Piano key sign was statistically insignificant between both groups. All the displacements were dorsal except in 1 case. The mean displacement of ulna styloid is 1.88mm (SD±1.08, Range: 0.20-4.60mm). The mean VAS score at rest and work is not statistically significant. The mean grip strength and functional score (DASH) are similar in both groups.

CONCLUSION

Ulna styloid fractures do not contribute to the DRUJ instability and the status of the union of the ulna styloid and the site of the ulna styloid fracture (tip or base) did not have a bearing on the range of movement and functional status of the affected wrist. Temporary DRUJ immobilization might allow TFCC recovery.

Treatment with Buttress Plate Technique for Symptomatic Ulnar Styloid Base Nonunion

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

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.

[Surgical treatment of the ulnar styloid process using an angle-stable hook plate in fractures and symptomatic nonunions]

OBJECTIVE

Anatomical reduction of dislocated fractures using an angle-stable hook plate. Surgical revision of symptomatic nonunions with the aim of bone regeneration.

INDICATIONS

Dislocated fractures of the ulnar styloid process with involvement of the ulnar fovea. Combined fractures with instability of the distal radioulnar joint and symptomatic nonunions.

CONTRAINDICATIONS

Undisplaced fractures of the ulnar styloid process and asymptomatic nonunions.

SURGICAL TECHNIQUE

Dorsoradial access to the distal ulna between the 6th extensor tendon compartment and the tendon of the flexor carpi ulnaris muscle. Exposition of the fracture/nonunion. In case of nonunions, excision and freshening of the fracture ends. Reduction is carried out using the hooks of the plate, if necessary additional attachment of autologous cancellous bone in case of nonunions. Fixation of the plate over the gliding hole and subsequent filling of the angular stable screw holes.

POSTOPERATIVE MANAGEMENT

Depending on the accompanying injury, immobilization in a forearm plaster splint for 1-2 weeks. Active movement exercises of the fingers from postoperative day 1, if necessary lymph drainage. After bone development, load build-up under ergotherapy guidance.

RESULTS

Bony healing was achieved in 100% of our cases. The surgical treatment of symptomatic nonunions as well as dislocated fractures of the ulnar styloid process using an angle-stable hook plate has proven to be successful.

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.

Instability in the Setting of Distal Radius Fractures: Diagnosis, Evaluation, and Treatment

Distal radius fractures with severe displacement or concomitant triangular fibrocartilage complex tears may be accompanied by distal radioulnar joint instability. Clinicians should examine the distal radioulnar joint closely when managing wrist fractures and treat coexisting instability appropriately. Chronic instability from distal radius malunion may require osteotomy or radioulnar ligament reconstruction. With proper management, most patients recover forearm stability and rotational motion after distal radius fracture.

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.

Surgical management of ulnar styloid fractures: comparison of fixation with anchor suture and tension band wire

BACKGROUND

Limited reference is available regarding surgical management in symptomatic ulnar styloid fractures with small bony avulsion. The study goal is to report the surgical outcomes using anchor suture fixation with comparison to traditional tension band wire fixation.

METHODS

We retrospectively reviewed the medical records in patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2017. A total of 31 patients were enrolled including two kinds of fixation methods. Anchor suture fixation plus distal radioulnar joint pinning was performed in ten patients with tiny avulsion bony fragments (group A); tension band wire fixation was performed in 21 patients with big styloid fracture fragments (group B). Patient characteristics and 2-year treatment outcomes were compared between two groups based on Mayo Modified Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); visual analog scale (VAS), and surgical complication. Descriptive statistics were used for calculation of key variables; a p value of < 0.05 was considered statistically significant.

RESULTS

Based on Gaulke classification, there were five subtypes in group A and three subtypes in group B. Incidence of concomitant distal radius fractures was significantly higher in group B; other patient characteristics including age, sex, injury side, and time to surgery showed no significant difference. Outcome assessment regarding MMWS, QuickDASH, and VAS was comparable between two groups. Bone-related complications including nonunion, DRUJ subluxation, and styloid resorption were analyzed; the difference was not significant. Incidence of implant-related complications including migration and secondary removal surgery was significantly higher in group B (p = 0.021).

CONCLUSION

Surgical fixation in symptomatic ulnar styloid fractures yields comparable treatment outcomes in both fracture patterns. Implant-related complication with secondary removal surgery is more common in tension band wire group. Anchor suture fixation is a feasible option for tiny styloid avulsion fragments with limited surgical complication.

Factors associated with the decision for operative versus conservative treatment of displaced distal radius fractures in the elderly

BACKGROUND

The treatment of senile distal radius fractures had not been clearly defined. The objective of this study was to identify the factors associated with the decision for operative treatment of displaced distal radius fractures in patients aged over 55 years.

METHODS

Data of 318 patients with displaced distal radius fractures were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for operation. Mean comparisons or chi-squared test were used for univariate analysis of the above-mentioned factors, and then multiple logistic regression was used to identify factors associated with the decision for operation.

RESULTS

Univariate analysis showed that age, osteoporosis, Charlson score, associated orthopaedic injuries requiring surgery, Orthopaedic Trauma Association (AO) and Fernandez classification, radial height, volar tilt, volar/dorsal comminution, ulnar variance, intra-articular displacement/step-off, associated distal radioulnar joint instability or radiocarpal joint dislocation and subspecialty of treating surgeons had statistically significant association with operative intervention. In the multivariate analysis, the predictors of operative intervention were younger patient age (P = 0.028), associated orthopaedic injuries requiring surgery (P = 0.020), higher AO classification (P = 0.037), higher Fernandez classification (P = 0.041), radial shortening >5 mm (P = 0.020), volar tilt > -10° (P = 0.020), volar/dorsal comminution (P = 0.020), ulnar variance >5 mm (P = 0.023), intra-articular displacement/step-off >2 mm (P = 0.004), associated distal radioulnar joint instability or radiocarpal joint dislocation (P = 0.047) and treatment by an upper extremity specialist (P = 0.038).

CONCLUSION

The decision for surgery was predominantly influenced by the characteristics and severity of the fracture. Patients' age and treatment by an upper extremity specialist were also significant factors associated with a higher likelihood of operative intervention.

Intramedullary nailing and plating osteosynthesis in the correction of post-traumatic deformity in late-diagnosed distal radius fractures: a retrospective comparison study

BACKGROUND

Various surgical modalities are available for correction of deformity in late-diagnosed distal radius fractures. This study compared surgical outcomes between intramedullary nailing and plating osteosynthesis in open-wedge osteotomy.

METHODS

We retrospectively reviewed 47 unilateral distal radius fractures that underwent open-wedge osteotomy at more than 4 weeks after injury between 2006 and 2011. A locally resected exuberant callus was used as the bone graft. Two types of fixation were used: intramedullary nail in 22 patients (group A) and locking plate in 25 patients (group B). Radiographic analysis including radial height, radial inclination, and volar tilt were performed preoperatively and 2-year postoperatively. The Modified Mayo Wrist Score (MMWS) was used for functional evaluation and a 10-point visual analog scale (VAS) for residual pain assessment. Patient satisfaction was self-reported as a 5-point scale. Radiographic data, functional outcomes, and surgical complications were compared between the two groups.

RESULTS

All fractures achieved bone union without major complications. The MMWS averaged 84.8 ± 9.7 in group A and 85.2 ± 8.4 in group B, without significant differences (p = 0.436). Instead, significant differences were found in mean wrist flexion (73.6 ± 7.9 vs. 69.6 ± 7.8 degrees; p = 0.042), patient satisfaction (3.6 ± 1.1 vs. 2.9 ± 1.2; p = 0.034), postoperative radial height (11.6 ± 2.6 vs. 10.2 ± 3 mm; p = 0.039) and inclination (20.8 ± 2.8 vs. 17.7 ± 4.1 degrees; p = 0.004), and implant-related complications (9% vs. 36%; p = 0.03). There were no significant differences in other assessment items including postoperative grip strength, pain scale, supination/pronation/extension, volar tilt, correction angles of all three parameters, and general complication rate. Four patients in group A (18%) and 2 in group B (8%) experienced postoperative paresthesia of the surgical hand; no significant difference was noted. All except one patient in group B had full recovery of neurological symptoms.

CONCLUSIONS

Open-wedge osteotomy with either an intramedullary nail or locking plate fixation yielded encouraging radiographic and functional outcomes. Intramedullary nail fixation may facilitate restoration of radial height and inclination with better wrist flexion, less implant-related complications, and greater patient satisfaction.