The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures

Ulnar styloid fracture in distal radius fractures managed with volar locking plates: to fix or not?

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4 weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5 % excellent, 17.9 % good and 3.6 % fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2 weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9 % excellent, 15.8 % good and 5.3 % fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.

Defining residual radial translation of distal radius fractures: a potential cause of distal radioulnar joint instability

BACKGROUND

Instability of the distal radioulnar joint (DRUJ) is a complication that can occur following distal radius fracture or malunion. We have observed that residual radial translation of the distal radius, relative to the radial shaft, may be a causal factor of DRUJ instability, even once the traditional radiographic parameters (volar tilt, radial inclination, and ulnar variance) have been restored. Residual radial translation of the distal fragment may cause detensioning of the distal interosseous membrane (IOM) and pronator quadratus with poor apposition between the ulnar head and sigmoid notch. This may potentially lead to persistent instability of the ulnar head following internal fixation. Residual radial translation deformity is at risk of being overlooked by the wrist surgeon as there is no existing radiographic parameter that accurately measures this deformity.

PATIENTS AND METHODS

In this study, 100 normal wrist radiographs were reviewed by three fellowship-trained orthopedic surgeons to develop a simple and reproducible technique to measure radial translation.

RESULTS

Utilizing the method described, the point of intersection between the ulnar cortex of the shaft of the radius and the lunate left a mean average of 45.48% (range 25–73.68%) of the lunate remaining on the radial side. In the majority of cases more of the lunate resided ulnar to this line. High levels of agreement with inter-rater (intraclass coefficients = 0.967) and intra-rater (intraclass coefficients = 0.79) reliability was observed.

CONCLUSIONS

The results of this study can be used to define a normal standard against which residual radial translation can be measured to assess the reduction of distal radius fractures. This new parameter aids in the development of surgical techniques to correct residual radial translation deformity. In addition, awareness and correction of this potential malreduction at the time of surgery may decrease the need for other procedures on the ulnar side of the wrist to improve DRUJ stability, such as ulnar styloid fixation, TFCC repair, or ligamentous grafting [corrected].

The incidence of ulnocarpal complaints after distal radial fracture in relation to the fracture of the ulnar styloid

Two hundred distal radial fractures, with a mean follow up of 20 months (range 6-49), were divided into three groups according to the presence and healing status of an ulnar styloid fracture. The patients underwent both clinical and radiological examination and completed two different questionnaires. One hundred and one, of 200 distal radial fractures, were associated with an ulnar styloid fracture. Forty-six of these developed an ulnar styloid nonunion. The authors encountered significantly higher pain scores (ulnar sided pain p = 0.012), a higher rate of DRUJ instability (p = 0.032), a greater loss of motion and grip strength (p = 0.001), and a poorer clinical outcome in cases with an ulnar styloid fracture, but no differences were apparent when those with healed ulnar styloid fractures or ulnar styloid nonunions were compared (p > 0.05). The investigators propose that the incidence of ulnocarpal complaints following distal radial fracture depends on the presence but not the healing status of an ulnar styloid fracture.

Union of the ulnar styloid fracture as a function of fracture morphology on conventional radiographs

OBJECTIVE

In a retrospective radiological study, the authors aimed to detect the influence of fracture morphology on the union rate of ulnar styloid fractures associated with distal radial fractures.

MATERIALS AND METHODS

Eighty-two out of 101 ulnar styloid fractures were included in the final statistical analysis. Initially, they were grouped into six different morphological types based on a novel classification system. They were also classified as per the established Fernández and Frykman classification systems. Furthermore, the initial ulnar styloid displacement was measured in conventional anteroposterior radiographs. Union of the ulnar styloid fracture was evaluated after at least 6 months of follow-up.

RESULTS

The current investigators demonstrated that the various ulnar styloid fracture patterns have no significant predictive value for ulnar styloid union. In contrast, it could be attested, that an initial fragment dislocation of greater than 2.4 mm in the conventional AP radiographs has a significantly lower chance of successful union (p = 0.022).

CONCLUSION

Initial displacement of the ulnar styloid should be measured in each distal radial fracture with a concomitant ulnar styloid fracture. This could be useful to inform the decision regarding surgical fixation of the ulnar styloid fragment in patients with an unstable distal radioulnar joint (DRUJ) or persistent symptoms at the ulnar aspect of the wrist.

Will the untreated ulnar styloid fracture influence the outcome of unstable distal radial fracture treated with external fixation when the distal radioulnar joint is stable

BACKGROUND

The ulnar styloid is an important supportive structure for the triangular fibrocartilage complex. However, it remains inconclusive whether or not a fractured ulnar styloid should be fixed in an unstable distal radius fracture (DRF) with a stable distal radioulnar joint (DRUJ). The purpose of this study is to evaluate the effect of an untreated ulnar styloid fracture on the outcome of unstable DRF treated with transarticular external fixation when the DRUJ is stable.

METHODS

106 patients with an unstable DRF and a stable DRUJ were included in this study following external fixation. The patients were divided into the non-fracture, the tip-fracture and the base-fracture groups according to the location of the ulnar styloid fracture at the time of injury. Postoperative evaluation included the range of wrist motion, the radiological index, the grip strength, the PRWE-HK scores, the wrist pain scores, and the instability of DRUJ at the external fixator removal time, three months postoperatively and the final follow-up visit.

RESULTS

The patients were followed for 12 to 24 months (15 months in average). Sixty-two of 106 patients (58%) had ulnar styloid fracture and 16 patients (26%) showed radiographic evidence of union of ulnar styloid fractures at the final follow-up visit. No significant difference in the radiological findings, the range of wrist motion, the grip strength, the PRWE-HK scores, and the wrist pain scores among three patient groups was detected at the external fixator removal time, three months postoperatively, or the final follow-up visit. Six of the 106 patients (5.7%) complained of persistent ulnar-side wrist pain during daily activities. One patient (0.9%) showed a positive sign in a stress-test, three patients (2.8%) showed a positive sign in a provocative-test, and five patients (4.7%) showed a positive sign in a press-test. There was no significant difference in the percentages of patients who complained of persistent ulnar-side wrist pain or showed a positive sign in the physical examination of the distal radioulnar joint among the three groups at the final follow-up time points.

CONCLUSION

When the DRUJ is stable, an untreated ulnar styloid fracture does not affect the wrist outcome of the patient with an unstable DRF treated with external fixation.

Nonunion of the ulnar styloid associated with distal radius malunion

PURPOSE

Malunion is a complication of distal radius fractures and may be associated with a nonunion of the ulnar styloid. We tested the null hypothesis that there is no difference in outcome between patients without ulnar styloid fracture and those with the ulnar styloid nonunion after corrective radial osteotomy for distal radius malunion.

METHODS

A total of 19 patients with dorsally angulated distal radius malunion who had simultaneous radial closing-wedge and ulnar shortening osteotomies were included. There were 16 women and 3 men with a mean age of 63 years. All patients were followed up for a minimum of 1 year. During surgery, the accompanying ulnar styloid nonunion was not internally fixed in any patient. Eight patients had no ulnar styloid fracture, and 11 had a nonunion of the ulnar styloid. Each group of patients was evaluated on the basis of objective radiographic measurements and functional outcomes as determined on the basis of clinical examination, including wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder, and Hand score.

RESULTS

There were no differences in the demographic and preoperative radiographic measurements between the nonfracture and nonunion groups. Postoperative radiographic measurements and functional outcomes improved significantly compared with the preoperative status in both groups. There were no significant differences in postoperative radiographic measurements, motion, strength, pain scores, Mayo scores, or Disabilities of the Arm, Shoulder, and Hand scores between the 2 groups. Four of the 11 ulnar styloid nonunions were healed within 1 to 12 months after corrective radial osteotomy.

CONCLUSIONS

An accompanying ulnar styloid nonunion in patients with distal radius malunion has no apparent adverse effect on outcome or function after corrective radial osteotomy. An accompanying nonunion of the ulnar styloid can heal following corrective radial osteotomy.

Impact of ulnar styloid fractures in nonoperatively treated distal radius fractures

PURPOSE

The effect of an ulnar styloid fracture (USF) on the stability of nonoperatively treated distal radius fractures (DRF) is unknown. The aim of this study was to evaluate the influence of USFs on the dislocation of DRFs treated by closed reduction.

METHODS

Standardized radiographs of 100 nonoperatively treated DRFs were evaluated. DRFs with a USF were compared to DRFs without a USF with respect to dorsal tilt, radial inclination, and ulnar variance.

RESULTS

We evaluated the radiographs of 100 DRFs in 99 consecutive patients, of whom 84 were women. An accompanying USF was present in 58 wrists, of which 49 were displaced. On the trauma radiograph, the USF group showed significantly more overall dislocation. After closed reduction, fracture position improved, and no significant differences in dislocation were observed between groups. After a mean of 42 days, radial inclination significantly decreased if a USF was present. When USF displacement was taken into account, significantly more ulnar variance occurred in the displaced USF group on the trauma and follow-up radiograph compared to the nondisplaced USF group and no-USF group.

CONCLUSIONS

The results of this study show that presence of a dislocated USF in patients with a DRF is associated with a worse position directly after trauma, and with recurrence of radial shortening after adequate reduction. These results warrant early radiologic follow-up in patients with reduced combined DRFs and USFs in order to evaluate the redislocation of the distal radius. Early detection of redislocation in these combined fractures may induce early surgical intervention.

Treatment with or without internal fixation for ulnar styloid base fractures accompanied by distal radius fractures fixed with volar locking plate

The purpose of this study was to evaluate the treatment results, with and without internal fixation of ulnar styloid base fractures associated with acute distal radius fractures. A total of 48 patients were enrolled, including 20 patients treated by internal fixation (fixation group) and 28 treated without internal fixation (non-fixation group). The evaluated parameters were postoperative range of motion, grip strength, DASH score, and the presence or absence of ulnar wrist pain over time. The outcome was assessed as "excellent" in 15 patients of the fixation group and 21 patients of the non-fixation group, and "good" in five patients of the fixation group and seven patients of the non-fixation group. There were no significant differences in the clinical outcomes or any of the parameters at the final evaluation between the two groups. However, the grip strength was significantly better in the non-fixation group than in the fixation group until 12 weeks postoperatively. The overall clinical outcome was good in both groups, with no significant difference between the groups.

Clinical and radiographic factors associated with distal radioulnar joint instability in distal radius fractures

BACKGROUND

Distal radioulnar joint (DRUJ) instability is an important cause of ulnar-sided wrist pain in distal radius fractures. However, instability is frequently undiagnosed and the clinical and radiographic factors associated with instability are not well understood.

QUESTIONS/PURPOSES

We therefore identified clinical and radiographic factors associated with DRUJ instability in distal radius fractures.

PATIENTS AND METHODS

We retrospectively reviewed all 221 patients who underwent surgical treatment for unstable distal radius fractures from 2007 to 2010. Ten patients (five men and five women) had DRUJ instability by intraoperative manual testing (Group I); these patients had a median age of 52 years. The other 211 patients (81 men and 130 women) (Group II) had a median age of 55 years. Clinical and radiographic data were compared between the groups.

RESULTS

The incidence of open wounds at the wrist and the relative ulnar length measured on the prereduction radiograph were greater in Group I. An open wound at the wrist and positive ulnar variance of 6 mm or greater on the prereduction radiograph increased the risk of DRUJ instability (relative risks = 45 and 17, respectively) in distal radius fractures.

CONCLUSIONS

An open wound at the wrist or positive ulnar variance of 6 mm or greater observed on the prereduction radiograph in patients with distal radius fractures should alert the physician to the possibility of DRUJ instability.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Management of the distal radioulnar joint and ulnar styloid fracture

Fractures of the distal radius and ulnar styloid have the potential to disturb the normal function of the distal radioulnar joint (DRUJ), resulting in loss of motion, pain, arthritis, or instability. The DRUJ can be adversely affected by several mechanisms, including intra-articular injury with step-off, shortening, and angulation of an extra-articular fracture; injury to the radioulnar ligaments; ulnar styloid avulsion fracture; and injury of secondary soft tissue stabilizers. This article discusses the management of the DRUJ and ulnar styloid fracture in the presence of a distal radius fracture.

Treatment strategies of distal radius fractures

There has been a surge in the operative management of distal radius fractures. Closed reduction, external fixation, and open reduction with internal fixation each have advantages and disadvantages. The purpose of this review is not to provide the clinician with an algorithm for treatment of distal radius fractures. These fractures span an extensive spectrum of severity across age groups and demographics. Fortunately, the surgeon holds a vast array of options to provide care for patients with distal radius fractures. The choice of fixation or conservative care resides in the personality of the fracture and the needs of the patients.

Common myths and evidence in the management of distal radius fractures

Distal radius fractures (DRFs) are the most common fracture treated by physicians, but questions remain regarding optimal management. Fracture patterns, biomechanics, and treatment strategies have been debated for more than 200 years, and research shows many controversies regarding long-held beliefs. Although these common myths have been propagated and considered fact, they are not based on the best-available evidence. This article illustrates some of the major controversies regarding the management of DRFs. To provide optimal care in a world of evidence-based medicine, clinicians must shift their thinking and accept that some of the indoctrinated ideas may represent a flawed heuristic approach.

Incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures

PURPOSE

To investigate the incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures and to determine the risk factors for this combination.

METHODS

We retrospectively analyzed 161 consecutive patients with 170 distal radius fractures who were treated between 2007 and 2011. Posteroanterior, lateral, and oblique radiographs of the wrist were examined, as were computed tomography scans when available. We evaluated the incidence and characteristics of carpal fractures occurring concurrently with distal radius fractures and the patient factors of gender, age, AO/ASIF classification, and energy of the injury.

RESULTS

Of the 170 distal radius fractures, 11 (7%) also had 1 or 2 carpal fractures. Of the 15 carpal fractures, 8 were scaphoid, 2 triquetrum, 2 pisiform, 1 capitate, 1 trapezium, and 1 hamate. Eleven of the 15 carpal fractures were diagnosed by computed tomography alone. Male gender, patients of lower mean age, AO/ASIF type B, and high-energy trauma significantly raised the risk of simultaneous fractures of the distal radius and carpals.

CONCLUSIONS

The incidence of carpal fractures occurring concurrently with distal radius fractures was not negligible, and almost all carpal fractures had no or minimal displacement. Suspicion of carpal fractures occurring concurrently with distal radius fracture should be high, and computed tomography should be considered, in males, young patients, and those with AO/ASIF type B fractures and high energy trauma.

A functional outcomes survey of elderly patients who sustained distal radius fractures

PURPOSE

This study aims to examine the subjective functional outcomes of patients 70 years or older who sustained distal radius fractures through the use of the Disability of the Arm, Shoulder, and Hand (DASH) and Short Form-8 Health (SF-8) surveys.

METHODS

Patients at least 70 years old with a distal radius fracture between 2000 and 2004 were identified and their charts reviewed. They were contacted to answer the DASH and SF-8 surveys. The radiographic injury parameters examined were articular stepoff greater than 2 mm, dorsal tilt on the lateral radiograph, ulnar variance, and presence of an ulnar styloid fracture.

RESULTS

Fifty-eight patients answered the DASH and SF-8 surveys. The mean age at the time of injury in the survey group was 78 years old (range 70-94 years). Mean follow-up period was 33 months (range 13-65 months). Average DASH and SF-8 scores were 22.3 (SD 22.4) and 31.5 (SD 6.9), respectively. DASH scores were inversely correlated with SF-8 scores (R = -0.65, p < 0.01). Patients who sustained an associated ulnar styloid fracture demonstrated worse DASH scores than those without an ulnar styloid fracture (presence of ulnar styloid fracture: mean DASH 26.2, no ulnar styloid fracture: mean DASH 12.9, p = 0.04). There were no significant differences in functional outcome for any other radiographic parameters assessed. Males had statistically better DASH scores than the females (males: mean DASH 6.9, females: mean DASH 24.4, p = 0.003). No difference was found in functional outcome scores among different treatment groups.

CONCLUSION

In elderly patients with distal radius fractures, the only radiographic parameter we found that affects functional outcome is an associated ulnar styloid fracture. Additionally, females had worse functional outcomes than males.

Development of a brief, 12-item version of the Michigan Hand Questionnaire

BACKGROUND

The Michigan Hand Questionnaire is one of the most widely used hand-specific surveys that measure health status relevant to patients with acute and chronic hand disorders. However, item redundancy exists in the original version, and an abbreviated survey could minimize responder burden and offer broader applicability.

METHODS

Patients (n = 422) with four specific hand conditions--rheumatoid arthritis (n = 162), thumb carpometacarpal osteoarthritis (n = 31), carpal tunnel syndrome (n = 97), and distal radius fracture (n = 132)--completed the Michigan Hand Questionnaire at two time points. Correlation analysis identified two items from each of six domains (i.e., function, activities of daily living, work, pain, aesthetics, and satisfaction). The Brief Michigan Hand Questionnaire score was calculated as the sum of the responses to the 12 items. Psychometric analysis was performed to describe the reliability, validity, and responsiveness of the Brief Michigan Hand Questionnaire.

RESULTS

The Brief Michigan Hand Questionnaire includes 12 items that were highly correlated with the summary Michigan Hand Questionnaire score (r = 0.99, p < 0.001). The Brief Michigan Hand Questionnaire scores were highly correlated between the two time periods (r = 0.78, p < 0.001) and by disease type. Responsiveness of the Brief Michigan Hand Questionnaire was high for all diseases and similar to that of the original Michigan Hand Questionnaire.

CONCLUSIONS

The 12-item Brief Michigan Hand Questionnaire is an efficient and versatile outcomes instrument specific to hand disability that retains the psychometric properties of the original Michigan Hand Questionnaire. The Brief Michigan Hand Questionnaire is an important tool with which to measure patient outcomes and the quality of care in hand surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.(Figure is included in full-text article.).

Acute dislocations of the distal radioulnar joint and distal ulna fractures

This article reviews acute dislocations of the distal radioulnar joint (DRUJ) and distal ulna fractures. Acute dislocations can occur in isolation or in association with a fracture to the distal radius, radial metadiaphysis (Galeazzi fracture), or radial head (Essex-Lopresti injury). Distal ulna fractures may occur in isolation or in combination with a distal radius fracture. Both injury patterns are associated with high energy. Outcomes are predicated on anatomic reduction and restoration of the stability of the DRUJ.

A guide to organizing a multicenter clinical trial

Multicenter clinical trials are important research tools. Planning a multicenter clinical trial is a long and arduous task that requires substantial preparation time. In this guide, the authors discuss the steps used to plan a multicenter clinical trial. A preplanning phase, which involves formulating and refining a research question and conducting pilot studies, is detailed, and the planning phase, which involves the acquisition of funding to support the coordination and preparation of a multicenter clinical trial, culminating in the submission of an R01 grant, is described. An essential asset to planning a multicenter clinical trial is the fluidity with which all collaborators work together toward a common vision. The philosophy among collaborators should be consensus and commitment and is emphasized by the development of a consensus assisted study protocol. Most important are the recruitment of centers and co-investigators who are dedicated, collaborative, and selfless in the team effort to achieve goals that cannot be reached by a single-center effort.

Distal radius instability and stiffness: common complications of distal radius fractures

Emphasis in the literature over the past hundred years regarding distal radius fracture management has been on restoration of anatomic radio-carpal alignment. Until the two most recent decades, little emphasis has been placed on the great morbidity and compromise to upper limb function associated with distal radio-ulna joint (DRUJ) pathology occurring with fractures of the distal radius. This article emphasizes that attention to restoration of anatomy of the DRUJ should be considered at least as important as that given to the radio-carpal relationship. This article also points out how stiffness of forearm rotation can result from a well-treated distal radius fracture and how this complication can be treated to restore healthy upper limb function.