MRI of fractures of the distal radius: comparison with conventional radiographs

Fracture Severity and Triangular Fibrocartilage Complex Injury in Distal Radius Fractures with or without Osteoporosis

The purpose of this study was to investigate the fracture morphology of distal radius fractures (DRFs) with the status of triangular fibrocartilage complex (TFCC) foveal insertion in patients with or without osteoporosis and to identify the relationship between osteoporosis and foveal tear. Seventy-five patients who underwent surgery for DRF from January 2021 to September 2023 were included. All patients were evaluated by standard radiography and dual-energy X-ray absorptiometry and underwent a 3.0 T magnetic-resonance imaging examination of the involved wrist to identify TFCC foveal tear. Patients were allocated into two groups according to the presence of osteoporosis: patients with osteoporosis (group I) and those without osteoporosis (group II). Group I showed a significantly larger displacement of fractures compared to group II (radial inclination; 13.7 ± 5.4 vs. 17.9 ± 4.2; p < 0.001, dorsal angulation; 22.2 ± 12.1 vs. 16.5 ± 9.4; p = 0.024, ulnar variance; 4.15 ± 2.1 vs. 2.2 ± 1.9; p < 0.001). Dorsal angulation and ulnar variance were found to be independent prognostic factors for TFCC foveal tear in logistic regression analysis. Displacement of fractures was related to osteoporosis, and dorsal angulation and ulnar variance were independent prognostic factors for TFCC foveal tear. However, osteoporosis was not identified as a factor associated with TFCC foveal tears.

Feasibility and clinical usefulness of deep learning-accelerated MRI for acute painful fracture patients wearing a splint: A prospective comparative study

OBJECTIVE

To evaluate the feasibility and clinical usefulness of deep learning (DL)-accelerated turbo spin echo (TSEDL) sequences relative to standard TSE sequences (TSES) for acute radius fracture patients wearing a splint.

METHODS

This prospective consecutive study investigated 50 patients' preoperative wrist MRI scans acquired between July 2021 and January 2022. Examinations were performed at 3 Tesla MRI with body array coils due to the wrist splint. Besides TSES obtained according to the routine protocol, TSEDL sequences for axial T2-, coronal T1-, and coronal PD-weighted TSE sequences were scanned for comparison. For quantitative assessment, the relative signal-to-noise ratio (rSNR), the relative contrast-to-noise ratio (rCNR), and the relative contrast ratio (rCR) were measured. For qualitative assessment, all images were assessed by two independent musculoskeletal radiologists in terms of perceived SNR, image contrast, image sharpness, artifacts disturbing evaluation, overall image quality and diagnostic confidence for injuries using a four- or five-point Likert scale.

RESULTS

The scan time was shortened approximately by a factor of two for TSEDL compared to TSES. TSEDL images showed significantly better rSNR, rCNR, and rCR values for all sequences, and scored significantly better in terms of both image quality and diagnostic confidence for both readers than TSES images (all p < .05). Interrater reliabilities were in almost perfect agreement.

CONCLUSION

The DL-accelerated technique proved to be very helpful not only to reduce scan time but also to improve image quality for acute painful fracture patients wearing a splint despite using body array coils instead of a wrist-specific coil. Based on our study, the DL-accelerated technique can be very useful for MRI of any part of the extremities in trauma settings just with body array coils.

Radiography of the Distal Radius

Imaging of the distal radius is of paramount importance in diagnosing injuries, indicating patients for operative or nonoperative treatment, and appropriately following patients for associated injuries and complications. Plain radiographs and fluoroscopy are the dominant imaging modalities in all settings because they are readily available and provide valuable information about the osseous structures and any instrumentation. Computed tomography can offer more information about implant placement and the level of comminution of the articular surfaces but is more expensive and exposes patients to higher doses of radiation. Magnetic resonance imaging is less commonly used but is useful for occult fractures and other associated injuries. Ultrasonography is gaining popularity in evaluating implant placement, especially regarding tendon impingement and subsequent tendon injury.

The role of concomitant ligament injury in the development of post-traumatic osteoarthritis after distal radius fractures: a protocol for a systematic review

INTRODUCTION

Treatment of distal radius fractures (DRFs) aims to restore anatomic position of the fracture fragments and congruity of the articular surface to optimise functional outcomes and prevent osteoarthritis in the long term. While ligament injury of the wrist is often associated with DRFs and sole ligament injuries of the wrist lead to osteoarthritis, it is plausible that concomitant ligament injury in DRFs may aggravate degenerative changes of the wrist. The relationship between concomitant ligament injury and post-traumatic osteoarthritis in patients with DRFs is unclear. This study aims to identify the types of associated ligament injury in patients with a DRF and to elucidate the association of ligament injury on the development of post-traumatic osteoarthritis.

METHODS AND ANALYSIS

This protocol is written in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. An electronic search in MEDLINE, Embase, Web of Science, Cochrane Central Register of Trials and Google Scholar has been created and performed by a Health Sciences librarian with expertise in systematic review searching. Original research articles in English literature, which report on concomitant ligament injury of the wrist in relation to post-traumatic osteoarthritis, patient-reported outcome measures or clinician-reported outcome measures in patients (aged ≥18 years) with DRFs will be included. Two reviewers will independently screen and appraise articles and perform data extraction. In case of any disagreements, a third reviewer will be consulted. A systematic qualitative synthesis will be performed using text and tables.

ETHICS AND DISSEMINATION

No ethical approval is required, since this is a protocol for a systematic review. The systematic review will be submitted for publication in a peer-reviewed scientific journal and for presentation at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42020165007.

Isolated Volar Dislocation of the Distal Radioulnar Joint: A Case Report

Introduction

Isolated dislocation of the distal radioulnar joint (DRUJ) is a rare phenomenon. Approximately 50% of isolated DRUJ dislocations are undiagnosed or diagnosed late with significant functional consequences. This clinical injury is rarely described in the literature and management is not well established. We reported a case of volar DRUJ dislocation early diagnosed.

Case Report

A 36-year-old man was diagnosed with an isolated volar dislocation of the DRUJ. The clinical examination, X-rays, and computed tomography scan allowed an early diagnosis. A reduction by external maneuvers was performed and the patient was immobilized in an above elbow plaster cast for 6 weeks. Magnetic resonance imaging did not reveal any capsuloligamentous lesions requiring surgery. Evolution was favorable.

Conclusion

Isolated volar dislocation of the DRUJ is an uncommon injury which can be easily missed. Missed or late diagnosis may lead to significant morbidity. Early diagnosis and treatment of such injuries usually results in excellent functional recovery.

Non-union of the ulnar styloid process in children is common but long-term morbidity is rare: a population-based study with mean 11 years (9-15) follow-up

Background and purpose - Fracture of the ulnar styloid process (USP) is common in children in connection with distal radius fracture. The long-term morbidity of USP non-union following a childhood distal radius fracture is unclear. We evaluated long-term clinical and radiographic findings of USP non-union. Patients and methods - All 208 children (< 16 years) who had suffered from distal radius fracture with or without a diagnosed concomitant ulnar fracture during 1992-1999 in the study institution were invited to follow-up at mean of 11 years (9-15) after the injury. Radiographs of both wrists of all 139 participants (67%) were taken; 22 patients showed USP non-union and they made up the study population. Distal radioulnar joint (DRUJ) instability, decreased range of motion (ROM), and weakened grip strength as compared with the uninjured side were the main functional outcomes. Elements of the "Disability of Arm, Shoulder and Hand" questionnaire were used for subjective symptoms. Results - The rate of USP non-union following childhood distal forearm fracture was 16% (22/139) and only 9 of the ulnar styloid fractures were visible in the radiographs primarily. At follow-up wrist flexion-extension ROM and ulnar and radial deviation ranges did not differ between the injured and uninjured sides. Grip strengths were similar. 6 patients reported pain during exercise. 7 had ulna minus (mean 2.3 mm) but none showed degenerative radiographic findings. Interpretation - The long-term clinical results of USP non-union following a childhood wrist fracture were good. However, one-third of the patients with USP non-union had ulnar shortening, which may predispose them to degenerative processes later in life.

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.

Predictive Power of Distal Radial Metaphyseal Tenderness for Diagnosing Occult Fracture

PURPOSE

To correlate the physical examination finding of distal radial metaphyseal tenderness with plain radiographic and magnetic resonance imaging after acute wrist injury to diagnose occult distal radius fractures. We hypothesized that persistent distal radial metaphyseal tenderness 2 weeks after acute injuries is predictive of an occult fracture.

METHODS

Twenty-nine adult patients presented, after acute trauma, with distal radial metaphyseal tenderness and initial plain radiographs and/or fluoroscopic images that did not show a distal radius fracture. Patients were reevaluated clinically and radiographically at approximately 2 weeks after initial presentation. Patients with persistent distal radial tenderness and negative radiographs underwent magnetic resonance imaging to definitively diagnose an occult distal radius fracture. We calculated the sensitivity and positive predictive value for persistent distal radial metaphyseal tenderness using a 95% confidence interval and standard formulas. Both radiographs and magnetic resonance imaging were used as our endpoint diagnosis for a distal radius fracture.

RESULTS

We diagnosed 28 occult distal radius fractures, 8 by follow-up radiograph and 20 by magnetic resonance imaging. The positive predictive value for patients who completed the protocol was 96%. One patient who did not have an occult distal radius fracture had a fracture of the ulnar styloid.

CONCLUSIONS

Tenderness of the distal radial metaphysis after wrist injury is strongly suggestive of a distal radius fracture despite both normal plain radiographs and fluoroscopic images.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

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.

The use of bone cement in difficult distal radius fractures

BACKGROUND

The lack of structural support remains a challenge in the treatment of comminuted distal radius fractures. Calcium phosphate and calcium sulfate bone cement has been used in other fracture locations in addition to fixation and has been shown to allow for retention of reduction in difficult cases.

METHODS

A case-control retrospective review of 34 consecutive distal radius fractures treated with surgery was performed with the patients classified by Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. Complications and postoperative radiographs were evaluated.

RESULTS

Cement was used in the most difficult cases. Radial height was retained in both groups. Volar tilt was significantly better in the cement group. There were no significant differences between the case and control groups for any complication. No complications related to the use of the cement were found.

CONCLUSIONS

The use of bone cement as an adjunct to fixation of distal radius fractures seems to include minimal risks and may afford a technical advantage in maintaining reduction during surgery for difficult fractures. Since there is an aspect of fracture difficulty that we cannot control for by using radiographic assessment alone, cement may provide an advantage over fixation without cement, despite similar outcomes. Bone cement can be part of the "tool box" for difficult distal radius fractures. Further study is necessary to define the technical advantages and limitations of each particular cement product.

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.

NMR findings in patients after wrist trauma with a negative plain radiographs

Background:

The purpose was to assess the prevalence and location of the injuries of the carpal bones and soft tissue of the wrist on NMR in patients with negative radiographs.

Material/Methods:

A total of 89 patients (9–81years) were consecutively examined after wrist trauma. Radiograms were performed in four projections: AP, PA, oblique and lateral. In 63 cases of negative radiographs and persistent clinical problem, simplified NMR (T1,T2, STIR; in coronal plane) was conducted with a 1.5 Tesla magnet. Results were evaluated by two independent observers. A positive X-ray result was stated when at least one observer suggested bone fracture. The MR images were viewed for detection of possible bone fracture, bone edema and soft tissue injuries. Cohen’s kappa coefficient was calculated to assess the quality of chosen criteria by means of agreement between both observers and both methods.

Results:

As many as 26 X-ray studies were classified as positive. Substantial agreement between independent observers was found (kappa=0.63). In 17 cases out of 63 with two negative wrist radiogram, the NMR result was positive (19%). The most frequently fractured or injured bone was scaphoid (10 cases) and distal radius (5 cases). Fair agreement was found between X-ray and NMR studies (kappa=0.37) due to different diagnostic information received in both methods.

Conclusions:

Simplified NMR imaging of the wrist proved to be strongly efficient in the detection of pathological changes in injured wrists.

[Unrepaired fracture of the styloid process of the ulna: not a bad treatment result at distal radius fracture]

BACKGROUND

There are well-defined criteria for the treatment of distal radius fractures but the impact of an unrepaired fracture of the styloid process of the ulnar on recovery after operative treatment is uncertain. This study evaluated radiological and functional results after different operative treatment procedures of distal radius fractures in patients with an untreated fracture of the styloid process of the ulna and those without such a fracture.

METHODS

Out of 480 patients with operatively treated distal radius fractures 238 were examined at least 1 year after injury. The fracture of the styloid process of the ulna was not repaired. Three groups (patients without a fracture of the styloid process of the ulna, patients with a tip fracture and those with a basal fracture) were evaluated by multivariate analysis (MANOVA) in order to detect influences of the fracture of the styloid process of the ulna on the radiological and functional results.

RESULTS

Neither the existence nor the location of the fracture of the styloid process of the ulna had a significant effect on the radiological and functional results (p(function)=0,849, p(radiology)=0,330, p(scores)=0,426, MANOVA).

CONCLUSIONS

The repair of a fracture of the styloid process of the ulna is not necessary if reduction and fixation of the distal radius fracture is anatomical and stable.

Multiple occult wrist bone injuries and joint effusions: prevalence and distribution on MRI

This study aims (1) to assess the prevalence and distribution of multiple occult injuries of the carpal bones and the distal forearm in patients with wrist pain and negative radiographs following trauma and (2) to evaluate the distribution and significance of joint effusions in the wrists with multiple osseous injuries. One hundred and thirty-one subjects, 74 men and 57 women, were consecutively examined in two institutions. All were acute trauma patients with negative X-rays whose clinical examination suggested possible fracture at the wrist or the distal forearm. Magnetic resonance (MR) wrist imaging was performed with and without fat saturation sequences. The MR images were analysed for detection of occult trabecular contusions and cortical discontinuity in the carpus, the distal forearm and the metacarpal bases. The prevalence and distribution of the injuries were assessed along with the distribution of joint effusions. Eight patients were excluded due to inadequate image quality. Two patients had bilateral injury. A total of 125 wrists were analysed. Seventy-eight (62.4%) wrists had occult bone injuries. Among these 78, 53 (68%) wrists had more than one injured bone. Twenty-five wrists (32%) had one injured bone. The highest number of injured bones per wrist was six. Injuries with a visible fracture line were seen in 29 (37.1%) wrists on MRI. The distal radius was the most frequent location for occult fracture line (11 cases). The injuries without a fracture line (contusion) were present in 49 (63%) wrists; they were detected more frequently in the scaphoid (35 cases). The lunate (29 cases) and the triquetrum (26 cases) were almost equally affected. The bone that was less frequently injured was the pisiform (four cases). Joint effusions were present in all 53 wrists with multiple bone lesions but more often situated in the ulnocarpal space [27 (50.3%) wrists]. There was no correlation between effusions in multiple locations (grades III and IV) and multiple bone injuries. This study revealed the presence of multifocal trabecular contusions without correlation with increased joint effusions in patients with negative radiographs and persistent pain. The clinical significance of these findings deserves further investigation.

Bone bruising of the distal forearm and wrist in children

Bone bruising represents a new category of bone injury that can only be demonstrated by magnetic resonance imaging (MRI) with fat suppression. This study proposed the nature of non-radiographically evident injuries of the distal radius and wrist in children whose symptoms did not resolve after 5 weeks. We aimed to describe and classify the lesions and delineate the importance and potential complications of the injuries. Bone bruising was diagnosed in 20 patients (mean age: 11.6 years; range: 9-13 years). Bone bruises were classified according to anatomical location and whether they were solitary lesions or were combined with other injuries. Injuries of the distal radius were classified according to location: type 1 was localised to the metaphysis, close to the physeal plate; type 2 involved both the metaphysis and diaphysis; and type 3 extended on both sides of the distal radial growth plate. The type 1 injuries were consistent with complete, un-displaced Salter-Harris type I fractures, whilst type 3 lesions were potentially Salter-Harris type V injuries. Our data indicate that an MRI should be considered for a child with an injury to the distal radius or wrist whose symptoms do not resolve after 5 weeks of immobilisation.

The effect of an associated ulnar styloid fracture on the outcome after fixation of a fracture of the distal radius

A total of 118 consecutive patients with a fracture of the distal radius were treated with a volar locking plate; 50 patients had no ulnar styloid fracture, 41 had a basal ulnar styloid fracture, and 27 had a fracture of the tip of the ulnar styloid. There were no significant differences in radiological and clinical results among the three groups. The outcome was good and was independent of the presence of a fracture of the ulnar styloid. A total of five patients (4.2%) had persistent ulnar-sided wrist pain at final follow-up. Nonunion of the ulnar styloid fracture did not necessarily lead to ulnar wrist pain. Patients with persistent ulnar pain had a higher mean initial ulnar variance and increased post-operative loss of ulnar variance.

The presence of an associated ulnar styloid fracture of the ulnar styloid does not adversely affect the outcome in patients with a fracture of the distal radius treated by volar plating.

The value of plain X-rays in predicting TFCC injury after distal radial fractures

In this prospective study, the plain X-rays and MRI scans of 60 patients with intraarticular distal radius fractures were examined in random order. MRI evaluation revealed that 27 of the 60 patients (45%) had triangular fibrocartilage lesions. No correlation was found between triangular fibrocartilage injury and the Melone classification system, the presence of an ulnar styloid fracture, comminution of the articular surface of the distal radius, >20 degrees dorsal angulation of the distal radius or subluxation/dislocation of the distal radioulnar joint on the plain X-rays. When Frykman Type VI and VIII fractures were compared with all the other Frykman subtypes, a significant difference in the incidence of triangular fibrocartilage complex tears was observed. We conclude that triangular fibrocartilage injury should be considered with all distal radial fractures, especially the Frykman Types VI and VIII.

Management of intra-articular metacarpal base fractures of the second through fifth metacarpals

Intra-articular fractures of the second through fifth metacarpal bases are uncommon injuries but can result in serious morbidity if improperly managed. These injuries usually occur because of forced flexion of the wrist with simultaneous extension of the arm, as occurs with a punch or a fall. As there are few large series of reports for these injuries, there is no consensus in the current literature on the most appropriate treatment for them. Whereas some authors have reported successful results after closed reduction, many recommend open reduction with internal fixation to ensure the integrity of the tendinous insertions of the extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris. This article reviews the case reports and case series extant in the literature concerning intra-articular fractures of the bases of the second through fifth metacarpals, and it provides important diagnostic and management considerations for these injuries.

High-resolution MRI of the triangular fibrocartilage complex (TFCC) at 3T: Comparison of surface coil and volume coil

PURPOSE

To evaluate high-resolution MRI of the triangular fibrocartilage complex (TFCC) at 3T using a surface coil (SC) or volume coil (VC).

MATERIALS AND METHODS

MRI was obtained from nine volunteers in the supine position with a 3-inch SC and in prone position with a transmit-receiver wrist VC at 3 T. Coronal two-dimensional-gradient echo (2D-GRE) images (TR/TE/FA = 500 msec/15 msec/40 degrees , 1 mm slice-thickness, 60 mm field of view [FOV], 192 x 256 matrix) and coronal 3D-GRE images (TR/TE/FA = 33 msec/15 msec/10 degrees , 0.8 mm slice-thickness, 80 mm FOV, 256 x 256 matrix) were used. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the TFCC and surrounding structures were measured. For qualitative measurement, visualization of TFCC and intercarpal ligaments was graded.

RESULTS

SNR of TFCC, cartilage, and bone marrow on 2D-GRE with SC/VC was as follows: 5.3/5.3 (TFCC), 16.5/14.4 (cartilage), and 3.61/3.96 (bone marrow). 3D-GRE showed similar SNR. Cartilage-TFCC/cartilage-bone marrow CNR were 11.1/12.8 (SC-2D-GRE), 8.8/10.5 (VC-2D-GRE), 14.1/15.5 (SC-3D-GRE), and 11.9/15.0 (VC-3D-GRE). Quantitative values were not significantly different between SC and VC. Visualization of TFCC and intercarpal ligament with SC was superior to that with VC. All structures show higher scores with 3D-GRE imaging compared to 2D-GRE imaging.

CONCLUSION

SC may provide superior qualitative and quantitative results and can be an alternative in case of difficulty in prone position at 3T.

Essential radiographic evaluation for distal radius fractures

Fractures of the distal radius can be complex injuries, often generating multiple fragments with distortion of the normal anatomy in all three dimensions. Superficial assessment of the injury on the standard PA and lateral radiographs often can result in incomplete recognition of the injury pattern and a misdirected approach to treatment. In addition, failure to recognize subtle radiographic findings may result in the acceptance of a reduction that has significant residual incongruency and articular surface disruption. Standard radiographs of the distal radius can provide a wealth of information about the topography of the bone if the surgeon knows what to look for. The ability to recognize detailed landmarks and parameters on the radiographic images and convert this information into a three-dimensional visual image is a skill that requires education and training. As more aggressive treatments have emerged for anatomic restoration of the bony and articular anatomy, accurate identification of the pattern of injury has become essential. Parameters such as the tear drop angle, AP distance, and articular separation have been recognized only recently. Because these parameters reflect the congruency of the articular surface,it would be natural to assume that postreduction films in which these parameters are abnormal would compromise clinical outcome. Because nearly all historical studies do not include routine evaluation of these parameters, knowledge of radiographic correlation with clinical outcome is still incomplete. At the same time, previous studies to assess outcome of distal radius fractures may be compromised by the failure to recognize residual deformity and articular incongruency that would have been evident with measurement of these parameters. With careful understanding of the radiographic landmarks, radiographic parameters, and patterns of injury, the surgeon can visualize a more accurate picture of the fracture itself and the reduction. As a result, treatment decisions for distal radius fractures can be based on a more thorough understanding of the anatomy of the injury, and future grading of radiographic results may reflect more accurately the precision of the articular restoration.

[Incorrect classification of extra-articular distal radius fractures by conventional X-rays. Comparison between biplanar radiologic diagnostics and CT assessment of fracture morphology]

Thirty-five displaced fractures of the distal radius, classified by standard radiographs as extra-articular type A2 and A3 fractures according to the AO classification, were investigated before operative treatment by computed tomography. The comparative analysis surprisingly revealed an involvement of the articular surface of the distal radius in 57%. The intra-articular fractures were classified after CT as C1 in 15%, C2 in 65%, and C3 in 20%. The distal radioulnar joint was involved in 80% of the type C injuries and showed a dorsal subluxation in 17% of all cases. Similar to the results of type A2 and A3 fractures, type B and C fractures of the distal radius also may be underestimated in standard radiographs. This concerns important components such as the involvement of the radiocarpal joint surface and concomitant injuries of the distal radioulnar joint. Since joint congruency is an important predictor of outcome, CT scanning should be used more generously for planning and controlling surgical therapy.

Malunion of the ulnar styloid as a cause of ulnar wrist pain

We present a case of ulnar wrist pain that had been wrongly attributed to non-union of the ulnar styloid. Surgical exploration revealed an ulnar styloid malunion that had caused pain by impinging on the triquetrum and a triangular fibrocartilage complex (TFC) lesion. There was no fracture of the distal radius and no associated carpal instability or disruption of the distal radio-ulnar joint. Treatment by resection of the ulnar styloid and re-attachment of the TFC provided a satisfactory outcome.

Assessment of articular displacement of distal radius fractures

Intraarticular step and gap displacements represent the most common indication for surgical treatment of distal radius fractures. Most often, treatment decision making relies only on good-quality plain radiographs taken before and after reduction with measurement accuracy maximized by using the longitudinal axis method. When plain radiographs alone prove insufficient, CT scans or tomograms will significantly improve interobserver and intraobserver reliability of measurements, especially when evaluated using the arc method. Tomography is an effective method for postoperative evaluation of fractures immobilized in splints or casts. The role of MRI in assessing intraarticular distal radius fractures is limited to confirming injuries to carpal ligaments or the triangular fibrocartilage complex. Intraoperatively, we use fluoroscopy to obtain 30 degrees cephalad posteroanterior views and as 22 degrees lateral views to best observe articular surface reduction. Our current operative indications include fractures with radiocarpal or distal radioulnar joint step or gap deformities greater than 1-2 mm, gross distal radioulnar joint instability, or those with extensive metaphyseal comminution rendering them particularly unstable after closed reduction. In general, we tend to lean toward operative fixation in younger, more active patients.

Static scapholunate dissociation diagnosed by scapholunate gap view in wrists with or without distal radius fractures

This prospective study investigated static scapholunate dissociation (SLD) in wrists associated with distal radius fractures. SLD was detected as a widening of the scapholunate (SL) joint interval by SL gap view. Ninety-six distal radius fractures and 154 normal wrists were investigated by SL gap view, which is better for detecting SLD than the standard posteroanterior (PA) view. Incidences of non-symptomatic SLD detected by SL gap view in normal wrists increased by age. In the young age bracket, incidences of SLD in distal radius fractures were significantly higher than in normal wrists. Our results indicated that in patients younger than 30 years old, SLD in distal radius fractures was a fracture-caused abnormality. In those over 30, ascribing SLD to the fracture was difficult. Close examinations, like arthroscopy and dynamic cineradiography, need to be made in patients with SLD associated with distal radius fractures, especially in those younger than 30.