Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture?

Is surgery superior for distal ulna fractures? a comprehensive systematic review and meta-analysis

BACKGROUND

The management of distal ulna fractures remains a subject of considerable debate within orthopedic practice. This systematic review and meta-analysis aims to evaluate the efficacy of surgical versus non-surgical management strategies for distal ulna fractures and their impact on functional outcomes.

METHODS

This study followed PRISMA guidelines and involved a systematic search of databases like PubMed, Scopus, and Web of Science for relevant studies published in English up to December 2023. The search included keywords such as "ulnar styloid fracture", "non-surgical management", "surgical management", and "treatment outcomes". Studies were selected based on predefined inclusion and exclusion criteria, and data were extracted on patient demographics, fracture characteristics, treatment details, functional outcomes, patient-reported outcomes, complications, and follow-up duration. The methodological quality of included studies was assessed using the GRADE system. The meta-analysis used standardized mean differences for continuous outcomes and log odds ratios for dichotomous outcomes.

RESULTS

The initial search yielded 1253 studies, which were narrowed down to 12 studies suitable for review after removing duplicates and irrelevant articles. These studies included a total of 709 patients, with 422 receiving non-surgical management and 287 undergoing surgical treatment. The results showed no significant differences in grip strength, DASH score, or VAS score between surgical and non-surgical management. However, a higher union rate was observed with surgical management.

LIMITATIONS

The moderate quality of the included studies and the moderate to high heterogeneity among them are noted as limitations, indicating a need for more standardized research methodologies in this area.

CONCLUSIONS

While surgical management may offer a higher union rate, the choice of treatment should be individualized, balancing the potential benefits against the risks of surgery, as ORIF implants are typically associated with higher ulnar-sided pain rates and limited ulnar deviation due to implant prominence. Future research should focus on standardizing study designs to improve the quality of evidence in the management of distal ulna fractures.

LEVEL OF EVIDENCE I

Evidence from a meta-analysis and systematic review from all relevant studies.

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.

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.

Treatment of the Distal Forearm Fracture by Volar Dual Window Approach

BACKGROUND

Distal forearm fractures were defined as distal radius fractures with concomitant distal ulna fractures, except ulna styloid fractures. Distal forearm fractures are common among geriatric populations, particularly those with osteoporosis. Conventionally, distal forearm fractures are reduced by a double incision approach; however, malreduction and instability of the distal radioulnar joint were not uncommon. We introduced a modified volar dual window approach to treat the distal forearm fracture and evaluate the functional outcomes and complications.

METHODS

From January 2020 to June 2023, 13 patients with distal forearm fractures underwent open reduction by the modified dual window approach with locking plate fixation. After surgery, splints were applied for two weeks, and the patients underwent postoperative hand therapy for three months. The mean Quick Disabilities of the Arm, Shoulder, and Hand scores, range of motions, grip strength, postoperative radiographic parameters, and complications data were collected.

RESULTS

The mean follow-up period was 12.1 months, and the mean age was 52.3 years. Average wrist flexion was 67°, extension 69°, pronation 81°, and supination 79°. Grip strength was 28.3 ± 11.5 kg, which was 88% of the uninjured opposite side. The Visual Analog Scale score during activities was recorded as 0.5 ± 0.9. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14 ± 11.5. The postoperative radiographic parameters were as follows: radial height: 10.8 ± 1.7 mm, radial inclination: 22.6 ± 3.7°, volar tilting: 4.0 ± 3.9°, and ulnar variance: -0.4 ± 1.4 mm. All the patients achieved bone union at the final follow-up. Two patients underwent ulnar implant removal due to irritation symptoms. Neither infection, nor neurovascular injury, nor malreduction developed in these patients.

CONCLUSIONS

The modified volar dual window approach can achieve good wrist function and distal forearm fracture reduction without increasing neurovascular or wound healing complications. This method is an alternative approach for distal forearm fracture, especially in comminuted distal ulna fracture or distal radioulnar joint incongruity.

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.

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.

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.

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.

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.

Predictors for nonunion of unrepaired ulnar styloid fracture associated with distal radius fractures in patients treated with volar locking plate fixation and their effect on functional outcomes

INTRODUCTION

Nonunion of ulnar styloid fractures after radius stabilisation by volar locking plate (VLP) fixation without surgical fixation on ulnar styloid fractures is quite common. However, the factors affecting the nonunion of ulnar styloid fractures and their effect on functional outcomes in patients with distal radius fractures (DRFs) treated with VLP fixation are unclear.

HYPOTHESIS

The purpose of this study was to investigate the predictors affecting nonunion of unrepaired ulnar styloid fractures in patients with DRFs and the effect of nonunion and its predictors on functional outcomes.

MATERIALS AND METHODS

We retrospectively reviewed data from 84 patients with DRF who underwent VLP fixation. None of the accompanying ulnar styloid fractures were manipulated during the surgery. Postoperative evaluation included the measurement of the grip strength, wrist range of motion, and Disabilities of the Arm, Shoulder, and Hand score at a minimum of one year postoperatively. Patients were divided into the nonunion and union groups according to the presence of union of ulnar styloid fracture. Demographic and radiologic parameters, including age, sex, bone mineral density, location and displacement distance of ulnar styloid fracture, and fracture pattern of DRFs, were analysed to identify predictors of nonunion. Functional outcomes were compared between the two groups and were compared according to the presence of predictors of nonunion.

RESULTS

Univariate analysis revealed that the nonunion rate was higher in ulnar styloid non-base fractures, substantial displacement (≥1.9mm) of ulnar styloid fracture, and AO/OTA C-type DRF. However, multivariate logistic regression analysis showed that non-base fractures and substantial displacement were significant predictors. Accompanying ulnar styloid fracture nonunion and its predictors were found not to influence functional outcomes.

DISCUSSION

Substantial displacement and non-base fracture are predictive factors for nonunion of unrepaired ulnar styloid fractures after DRF treatment with VLP fixation. However, nonunion and its predictors do not influence the overall wrist function. These findings suggest that the ulnar styloid fracture accompanying DRF should not be considered a fracture affecting the wrist function when treating with VLP fixation.

LEVEL OF EVIDENCE

III, Retrospective, Case Control study.

Arthroscopic Foveal Repair of the Triangular Fibrocartilage Complex Improved the Clinical Outcomes in Patients With Persistent Symptomatic Distal Radio-Ulnar Joint Instability After Plate Fixation of Distal Radius Fractures: Minimum 2-Year Follow-Up

PURPOSE

To investigate the longitudinal trend of symptomatic distal radioulnar joint (DRUJ) instability after plate fixation for distal radius fractures (DRFs), determine which factors are associated with persistent symptomatic DRUJ instability, and evaluate the postoperative outcomes of arthroscopic foveal repair of the triangular fibrocartilage complex (TFCC) in patients with persistent symptomatic DRUJ instability after plate fixation for DRF.

METHODS

All consecutive patients who underwent plate fixation for DRF between January 2014 and December 2017 and were followed up for a minimum of 1 year were included in this retrospective study. DRUJ instability was evaluated by subjective ulnar wrist pain and physical examination that included foveal sign and ballottement testing every 2 months after surgery. In patients with persistent symptomatic DRUJ instability lasting >6 months, arthroscopic transosseous foveal repair was performed with consent. Clinical outcomes were evaluated at a minimum of 2 years after surgery. The Generalized Estimating Equation model was used to analyze the incidence rate trend of symptomatic DRUJ instability.

RESULTS

Overall, 204 patients were included. The incidence of symptomatic DRUJ instability decreased gradually with time after fixation for DRF until 6 months and was maintained thereafter. Thirty-four of 204 patients (16.6%) had persistent symptomatic DRUJ instability. In multivariable analysis, only high-energy injury was an independent risk factor for persistent symptomatic DRUJ instability (P = .003; odds ratio = 3.599). Seventeen patients underwent arthroscopic foveal repair. The mean follow-up period thereafter was 28.6 months. All clinical outcomes improved significantly compared with preoperative values, and no patient had residual DRUJ instability.

CONCLUSION

In patients who had persistent symptomatic DRUJ instability for >6 months after plate fixation for DRFs, arthroscopic foveal repair of the TFCC is considered as a treatment option. Arthroscopic foveal repair of the TFCC to stabilize the DRUJ provided satisfactory clinical and functional outcomes and decreased ulnar-side pain.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Effect of Ulnar Styloid Fractures on Patient-Reported Outcomes After Surgically Treated Distal Radial Fractures

Ulnar styloid fractures (USFs) are often associated with distal radial fractures (DRFs). When unstable DRFs are treated surgically, any associated USF is most commonly left untreated. The purpose of this study was to evaluate the effect of a concomitant USF on outcome after surgical stabilization of a DRF.

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.

Stabilization for acute distal radioulnar instability: A novel surgical technique

INTRODUCTION

Instability of the distal radioulnar joint (DRUJ) commonly results from traumatic disruption of the distal radioulnar ligaments of the triangular fibrocartilage complex (TFCC). Treatment of this rupture typically requires immobilization of the wrist and elbow for a period of 6 to 8 weeks. This study evaluated the hypothesis that treatment of DRUJ instability with dynamic stabilization would allow early mobilization of both the radiocarpal and distal radioulnar joints by the first postoperative week without compromising restoration of TFCC integrity.

MATERIALS AND METHODS

Between September 2017 and January 2019, a retrospective study was conducted on 22 patients presenting with DRUJ instability confirmed by intraoperative Ballottement testing. Once instability was confirmed, dynamic surgical stabilization was performed, followed by one week of short cast immobilization. Arthrographic computed tomography (CT) of each patients' affected wrist was performed 4 months later to evaluate TFCC integrity. The recovery of patients was monitored at 1, 3, 6, and 12 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, Ballottement test, and evaluation of radioulnar join range of motion (ROM), pain, and complications.

RESULTS

All patients were followed postoperatively for a mean of 13.5 months. After 1 month, all patients exhibited satisfactory range of motion and DRUJ stability. By 3 months, Ballottement tests were negative in 21 of 22 patients, with instability persisting in only 1 patient. At 4 months, CT arthrography contrast leakage (indicative of a TFCC tear) was observed in 5 of 20 patients. Upon reexamination a mean of 10.5 months later, the TFCC tears of these patients had healed in 2 cases (with foveal tears), while no difference in contrast leakage was observed for the other 3 cases (with horizontal or central tears). Revision surgery for implant related complications was performed in 2 cases.

CONCLUSION

Acute DRUJ instability treated with dynamic stabilization led to satisfactory clinical outcomes in terms of range of motion, pain relief and joint stability, allowing DRUJ movement from the first postoperative week. This technique represents a simple, reproducible and minimally invasive procedure with a low rate of implant related complications.

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.

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.

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.

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.

[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.

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

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Prevalence of triangular fibrocartilage complex injuries in patients with distal radius fractures: a 3.0T magnetic resonance imaging study

Objective

This study was performed to determine the prevalence of triangular fibrocartilage complex (TFCC) injuries as shown by 3.0T magnetic resonance imaging (MRI) in patients with distal radius fractures.

Methods

In total, 57 patients with distal radius fractures underwent 3.0T MRI examinations to observe the incidence of TFCC injuries after manual reduction and cast fixation. The fracture type was categorized by the AO classification, and the TFCC injury pattern was evaluated using the Palmer classification. The correlation between the location of the TFCC injury and the distal radius fracture pattern, distal radioulnar joint instability, or ulnar styloid fracture was analyzed.

Results

Fifty-five TFCC injuries were diagnosed. There was no significant relationship between the TFCC injury pattern and the type of distal radius fracture, distal radioulnar joint instability, or ulnar styloid fracture.

Conclusions

This study revealed a high prevalence of TFCC injuries in patients with distal radius fractures. The 3.0T MRI examination helps to assess TFCC injuries in patients with distal radius fractures.

Clinical Trial Registration

ChiCTR1800017101.

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

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

The current evidence-based management of distal radial fractures: UK perspectives

Distal radial fractures are extremely common injuries, yet many basic questions remain unanswered about their optimum management. Recently in the United Kingdom several guideline development groups have produced national standards and best-practice guidelines based on review of the best available evidence and expert knowledge. All guideline groups agree that when surgery is needed for dorsally displaced distal radial fractures, that can be reduced closed, K-wire fixation and cast immobilization, should be offered. Further research questions have been identified. The important findings and recommendations are summarized in this article.

Influence of distal radius fractures involving the intermediate column on forearm rotation

BACKGROUND

The objective of the study was to compare the radiologic and clinical outcome of patients with distal radius fractures involving the intermediate column and distal radial metaphyseal fractures treated conservatively.

METHODS

Two cohorts of 52 matched patients with distal radius fractures treated conservatively, one with a fracture involving the intermediate column and the other with no intermediate column fracture, were retrospectively analyzed by examining the data. Patients were matched for age, sex, fracture side, and AO fracture type. The two groups were analyzed for differences in wrist motion; grip strength; Gartland and Werley score; Disabilities of the Arm, Shoulder and Hand (DASH) score; and visual analogue scale (VAS) score at 12 months. The differences in continuous variables were compared using the paired t test. Linear regression analyses or Pearson correlation analyses were used to evaluate the associations of radiological parameters with clinical outcomes.

RESULTS

The analysis showed significant differences in the range of motion (ROM) for pronation (p = 0.000) and supination (p = 0.008) in the paired groups. There was a significant difference in DASH scores (p = 0.024) in the paired groups. Using Pearson correlation analysis, negative correlations (r = - 0.360, p = 0.000) were observed between articular step-off and ROM for pronation. Linear regression analyses also indicated that ROM for pronation had negative relationships (β = - 6.327, p = 0.001) with articular step-off.

CONCLUSIONS

Distal radius fractures involving the intermediate column had an adverse effect on forearm rotation after distal radius fractures treated conservatively.

Current perspectives in conventional and advanced imaging of the distal radioulnar joint dysfunction: review for the musculoskeletal radiologist

Distal radioulnar joint (DRUJ) dysfunction is a common cause of ulnar sided wrist pain. Physical examination yields only subtle clues towards the underlying etiology. Thus, imaging is commonly obtained towards an improved characterization of DRUJ pathology, especially multimodality imaging, which is frequently resorted to arrive at an accurate diagnosis. With increasing use of advanced MRI and CT techniques, DRUJ imaging has become an important part of a musculoskeletal radiologist's practice. This article discusses the normal anatomy and biomechanics of the DRUJ, illustrates common clinical abnormalities, and provides a comprehensive overview of the imaging evaluation with an insight into the role of advanced cross-sectional modalities in this domain.

Technique for Intramedullary Stabilization of Ulnar Neck Fractures

BACKGROUND

Distal ulna fractures at the ulnar neck can be seen in association with distal radius fractures, and multiple techniques have been described to address the ulnar neck component of these injuries. We have found that treatment of ulnar neck fractures can be challenging in terms of anatomy and fracture fixation. We present a new percutaneous fixation technique for ulnar neck fractures commonly seen with distal radius fractures.

TECHNIQUE

Fixation of the ulnar neck fracture is performed after fixation of the distal radius fracture. Our technique uses anterograde intramedullary fixation to stabilize the fracture with a 1.6-mm (0.062 inch) Kirschner wire or a commercially available metacarpal fixation intramedullary nail. The fixation is introduced into the intramedullary space of the ulnar shaft 4 to 6 cm proximal to the fracture at a separate surgical site along the subcutaneous border of the ulna. The fixation is also supported with a sugar-tong splint for the first few weeks after surgery and requires removal of the ulnar implant approximately 10 weeks after implantation.

CONCLUSION

Our technique utilizes a percutaneous approach with minimal fracture exposure. It provides a relatively simple and reproducible method to address ulnar neck fractures commonly seen in association with distal radial fractures.

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

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

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

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

LEVEL OF EVIDENCE

I.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Topographical Anatomy of the Distal Ulna Attachment of the Radioulnar Ligament

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Complex Distal Radius Fractures: An Anatomic Algorithm for Surgical Management

Most distal radius fractures result from low-energy mechanisms and can be successfully treated nonsurgically or with a variety of surgical techniques if indicated. High-energy distal radius fractures can involve extensive comminution or bone loss with concomitant ligament, soft-tissue, and neurovascular injuries. In patients with complex distal radius fractures, reconstruction of the distal radius, ulna, and triangular fibrocartilage complex can be challenging. Effective restoration of the bony architecture requires intimate knowledge of the anatomy of the distal radius, a thorough understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

Unstable Distal Radius Fractures Treated by Volar Locking Anatomical Plates

INTRODUCTION

Fracture of the distal end of radius represents the most common fracture of the upper extremity accounting for 16-20% of all fractures. Plating is now emerging as the gold standard for management of distal radius fractures due to increased rate of complications such as malunion, subluxation/dislocation of distal radio-ulnar joint or late collapse of fracture. Procedures such as closed reduction and cast immobilization, ligamentotaxis with external fixator and percutaneous pin fixation are no longer acceptable.

AIM

The purpose of the study was to evaluate the functional and radiological outcome of unstable distal radius fractures treated with the volar locking plate.

MATERIALS AND METHODS

We reviewed 53 patients from January 2011 to December 2015, treated for unstable distal radius fractures using a volar locking compression plate. Standard radiographic and clinical assessment after 12 months (range 12-16 months) were measured and final functional and radiological outcome were assessed using the Modified Mayo wrist scoring system and Sarmiento's modification of Lindstorm criteria respectively.

RESULTS

There were 42 males and 11 females with an average age of 39.12±31.78 years (18-71 years). At the end of 12 months, 36 patients had an excellent radiological outcome and 10 patients had good radiological outcome as per Sarmiento's modification of Lindstorm criteria. Eleven patients had an excellent functional outcome and 26 patients had a good functional outcome as per modified Mayo wrist scoring system. There was one case of superficial wound infection which subsided with intravenous antibiotics.

CONCLUSION

The volar locking plate fixation helps in early mobilization of the wrist, restores anatomy, allows early return to function, prevents secondary loss of reduction and hence is an effective treatment for unstable fractures of the distal radius.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reasons for Implant Removal after Distal Radius Fractures

Background: With new low profile locked volar plate designs for distal radius fractures, soft tissue complications are uncommon. However, there are still patients who request to have their implants removed. In this study, we retrospectively reviewed the reasons for this.

Methods: We reviewed the hospital operative records of patients who had operative fixation of wrist fractures between November 2008 and May 2009. We examined the clinical records of these patients in order to ascertain if there was a difference in patient demographics between those who eventually had their implants removed and those who had their implants retained. We also noted down the reasons for removal of implants.

Results: In the period of study, 165 patients had operative fixation of their distal radius fractures, of which 44 (26.7%) had had their implants eventually removed. These patients tended to be younger (mean age of 37.1 years compared to 45.5 years in those who retained their implants). We also found a correlation between removal of implants and the presence of ulnar implants, as well as hand dominance. Reasons for implant removal were symptomatic irritation/implant prominence (15), joint stiffness requiring arthrolysis (6), infection (2), malunion (2), and patients who did not have a clinical reason (19).

Conclusions: Our results suggest the involvement of other psychosocial factors, such as cultural attitudes towards the presence of implants within the body. In light of our results, we also suggest that ulnar styloid fractures be treated non-operatively.

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

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

LEVEL OF EVIDENCE

Prognosis, Level IV.