LCP distal ulna plate fixation of irreducible or unstable distal ulna fractures associated with distal radius fracture

Surgical fixation of distal ulna neck and head fractures

OBJECTIVES

Distal ulna plate fixation for ulnar neck and head fractures (excluding ulnar styloid fractures) aims to anatomically reduce the distal ulna fracture (DUF) by open reduction and internal fixation, while obtaining a stable construct allowing functional rehabilitation without need for cast immobilization.

INDICATIONS

Severe displacement, angulation or translation, as well as unstable or intra-articular fractures. Furthermore, multiple trauma or young patients in need of quick functional rehabilitation.

CONTRAINDICATIONS

Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation. Stable, nondisplaced fractures. Need for bridging plate or external fixator of distal radiocarpal joint.

SURGICAL TECHNIQUE

An ulnar approach, with a straight incision between the extensor and flexor carpi ulnaris. Preservation of the dorsal branch of the ulnar nerve. Reduction and plate fixation with avoidance of plate impingement in the articular zone.

POSTOPERATIVE MANAGEMENT

Postoperatively, an elastic bandage is applied for the first 24-48 h. In isolated DUF with stable fixation, a postoperative splint is often unnecessary and should be avoided. For the first four weeks, only light weightbearing of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be increased as tolerated.

RESULTS

The best available evidence likely shows that for younger patients with a DUF, with or without concomitant distal radius fractures, open reduction and internal fixation can be safely achieved with good functional outcome and acceptable union and complication rates as long as proper technique is ensured.

Distal Ulna Fracture Fixation with the Specialized Threaded Pin

Purpose

Distal ulna fractures can often be treated nonsurgically; however, many surgeons consider significant displacement or instability, especially following fixation of an associated distal radius fracture, an indication for surgical fixation because of potential problems associated with malunion of these fractures. Traditionally, these fractures have been addressed with plate fixation but hardware in this location is often prominent and associated with a high rate of symptomatic hardware and subsequent hardware removal. We proposed a method of intramedullary fixation using a specialized threaded pin. As this fixation is intramedullary, it avoids many of the problems associated with traditional surgical treatment methods for this fracture. We present a series of nine patients treated in this manner, all of whom had associated distal radius fractures.

Methods

Preoperative and postoperative radiographs were reviewed, after which patients were contacted via phone. Patient-reported outcome measures, including QuickDASH and visual analog scale scores, were assessed.

Results

The average QuickDASH score was 13.6 (range, 0-100), with a median of 9.1. Three patients reported occasional ulnar-sided wrist pain, with an average visual analog scale score of 1.3 (range, 0-10) and a median of 0.5. All patients returned to all activities except one patient who could not resume playing musical instruments because of stiffness. No patient required removal of the threaded pin, but one patient underwent removal of the radial volar plate. No other patients underwent secondary procedures.

Conclusions

Threaded pin fixation is a viable alternative to existing options for distal ulnar neck fractures and may have an advantage over plate fixation because of a lack of hardware prominence.

Type of study/level of evidence

Therapeutic IV.

Outcomes of distal ulna locking plate in management of unstable distal ulna fractures: a prospective case series

INTRODUCTION

Given the absence of a satisfying plate system to deal with multifragmentary or subcapital distal ulnar fractures, the Distal Ulna Locking Plate (DUL, I.T.S. GmbH, Graz, Austria) could become a useful treatment option. This study aimed to evaluate the results of this anatomically pre-contoured plate regarding patients with unstable or displaced distal ulnar fractures.

METHODS

In a prospective clinical trial, 20 patients (18 female, two male; mean age 70 years (24-91 years)) with unstable or displaced distal ulna fractures between December 2010 and August 2015 were analyzed. All patients were treated with open reduction and internal fixation using the DUL. They were evaluated at three follow-up appointments at 3, 6 and 12 months postoperatively regarding their bone healing, ulnar variance (UV), range of motion (ROM) and grip strength. Patient related outcomes were measured using the Disability of the Arm, Shoulder and Hand (DASH), the Patient Rated Wrist Evaluation (PRWE) questionnaires, and the Visual Analogue Scale (VAS). The results after one year were compared to the outcome of the healthy contralateral side.

RESULTS

All fractures treated with open reduction and internal fixation using the Distal Ulna Locking Plate healed within 6 months and showed stable ulnar variances after surgery. ROM (rotational plane 81.1 ± 9.0°, sagittal plane 55.1 ± 14.6°, frontal plane 33.0 ± 9.4°) and grip strength (18.7 ± 7.1 N) at the follow-up after 12 month had similar values compared with the uninjured side. The mean DASH score (36.4 ± 29.0), the PRWE-score (14.5 ± 27.0), and the VAS (at rest 0.5 ± 1.1, during activity 1.2 ± 2.4) after one year had no significant difference to the uninjured side. The surgeon's overall satisfaction rate regarding plate handling reached 81.8%.

CONCLUSION

Stabilization of unstable distal ulna fractures using the DUL restores nearly normal anatomy and function. Its pre-countered design, volar placement, and enhanced stability present a satisfying plate system.

TRIAL REGISTRATION

 The trial was retrospectively Registered at www.

CLINICALTRIALS

gov on 16 December 2021 (Trial Registration Number: NCT05329012).

Does Simultaneous Fixation of Both Distal Radius and Distal Ulnar Fractures Improve Outcomes? A Retrospective Cohort Study

Introduction: Distal metaphyseal ulnar fractures are often found in conjunction with distal radius fractures. However, there is no consensus on optimal management. The purpose of this study was to determine whether simultaneous fixation of both distal radius and distal ulnar fractures would improve outcomes. Materials and Methods: Patients treated for distal radial fractures over a 4-year period at our trauma center were identified, and their medical records were analyzed. Twenty-three patients met the inclusion criteria for this study. All radius fractures were fixed using a volar locking plate. Fourteen ulnar fractures were treated with surgical fixation, and nine were treated conservatively. Data were collected on patient demographics, mechanism of injury, whether it was a closed or open fracture, Gustilo classification, AO/OTA classification, immobilization period, follow-up period, and type of treatment. Physical findings comprising the active range of motion and grip strength and radiological findings, including the ulnar variance compared to the healthy side and bone union, were evaluated. Clinical outcomes were assessed using the quick Disabilities of the Arm, Shoulder, and Hand scores. Results: There was no significant difference between the groups in the quick Disabilities of the Arm, Shoulder, and Hand scores, but the arc of dorsi-palmar flexion was more restricted in the operative group than in the conservative group. Other results were not significantly different between the two groups. Discussion: Fixation of distal metaphyseal ulnar fractures can be challenging, and several studies have shown the validity of conservative treatments. This supports the view that if the distal radius fracture is anatomically and rigidly fixed, distal metaphyseal ulnar fractures can be successfully managed conservatively. Conclusion: Our results did not show any merit in the simultaneous fixation of both distal radius and distal ulnar fractures. Thus, needless surgery should be avoided.

Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis

Purpose

We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients.

Methods

A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS).

Results

Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3–16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups.

Conclusions

This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures.

Type of study/level of evidence: Therapeutic II.

Intramedullary Stabilization Technique Using Headless Compression Screws for Distal Ulnar Fractures

Distal ulnar fractures are commonly accompanied by distal radial fractures, and several treatment options such as plate osteosynthesis and pinning with Kirschner's wires are used. In this study, we present a technique using headless compression screws to achieve bony union of distal ulnar fractures. From November 2016 to November 2018, we treated 11 patients with distal ulnar fractures combined with distal radial fractures with headless compression screws (DePuy Synthes). Patients were instructed to maintain a short-arm splint for less than two weeks after the treatment. The mean time to bony union was 6.5 weeks, mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14.6 points, and mean visual analog scale score was 1.09 points. Full range of motion was possible in all directions after surgery and no specific complications were observed. The suggested technique allows minimal incision and minimally invasive intramedullary fixation and can promote bony union in a simple way without specific complications.

Screw Fixation and Autogenous Bone Graft for an Irreducible Distal Ulna Fracture Associated with Distal Radius Fracture

Distal ulna fractures often occur with distal radius fractures, and their treatment method is still controversial. We considered reduction of the distal radio-ulnar joint (DRUJ) surface the most important factor when treating distal ulna fractures accompanied by residual dislocation. We herein presented a patient with a distal ulna fracture accompanied by dislocation of the DRUJ surface in whom an autogenous bone fragment collected from the radius was grafted onto the ulnar bone defect after open reduction and Herbert screw fixation. In this technique, the bone fragment was supported through the medullary cavity by inserting a Herbert screw, which was less likely to cause irritation between the screw and surrounding tissue, because the screw was almost entirely present in the bone. In addition, an autogenous bone graft from the same surgical field may be less invasive than that from another region.