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

Round table discussion. Distal radioulnar joint instability after surgical treatment of distal radial fractures

Distal radioulnar joint instability is commonly seen after surgical fixation of a distal radial fracture, and surgeons' ability to reliably determine stability on examination is poor. Debate remains regarding whether to fix the ulnar styloid or reinsert the triangular fibrocartilaginous complex. Four surgeons with Level 5 expertise were asked to respond to questions surrounding this debate.

Distal Radioulnar Joint Instability

SUMMARY

The distal radioulnar joint (DRUJ) is vital to the stability and function of the wrist and forearm. The osseous morphology is variable and provides little stability. A complex of confluent soft tissues is the primary stabilizer; however, the contribution of each component has yet to be elucidated. It has become increasingly clear that the anatomic fixation of distal radius fractures restores DRUJ stability, obviating the need for additional DRUJ stabilization. This review will describe the anatomy and biomechanics of the DRUJ and discuss injury patterns, treatments, and clinical results.

Pediatric distal both-bone forearm fractures treated with percutaneous pinning with or without ulna fixation: a retrospective cohort study from two centres

PURPOSE

This study investigated the clinical and functional outcomes of children with distal both-bone forearm fractures treated by fixation of the radius only compared to fixation of both the radius and ulna.

METHODS

A total of 71 patients from two centres with distal both-bone forearm fractures (30 in the ulna-yes group, 41 in the ulna-no group) who underwent closed reduction and percutaneous pinning treatment were retrospectively analysed. Operation duration, number of fluoroscopic exposures, loss of reduction rate and angulation based on radiographic assessment were compared between the two groups. Evaluation of wrist function including Gartland-Werley Score and Mayo Wrist Score were compared at the last follow-up.

RESULTS

Ulna angulation upon bone healing on the posteroanterior and the lateral plane of ulna-no group (6.11 ± 1.56°; 6.51 ± 1.69°) was significantly greater than that of ulna-yes group (4.49 ± 1.30°; 5.05 ± 2.18°) (p < 0.05). No significant difference was found in the loss of reduction rate between ulna-yes group (6.67%, 2/30) and the ulna-no group (4.88%, 2/41) (p > 0.05). At last follow-up, no significant difference was found between the Gartland-Werley Scores of the ulna-yes group (1.83 ± 3.25, range: 0-16) and ulna-no group (1.85 ± 2.72, range: 0-11.5) (p > 0.05). No significant difference was found between the Mayo Wrist Scores of the ulna-yes group (92.60 ± 6.20) and ulna-no group (92.15 ± 7.58) (p > 0.05).

CONCLUSIONS

For distal both-bone forearm fractures in children, fixation of only the radius appears to be a viable method with equivalent clinical outcomes compared to fixation of both the radius and ulna.

[Concomitant injuries of the wrist, distal ulna and distal radioulnar joint in distal radius fractures : Primary operative cotreatment vs. healing with no additional treatment]

Distal radius fractures are the most common fractures in adults and account for one quarter of all fractures, with increasing incidence. The number of patients and the requirement of an exact treatment are high. Continuous developments in diagnostic and operative possibilities enable in many cases a high-quality treatment with good clinical outcome; however, radius fractures rarely occur alone but in combination with additional fractures or ligamentous injuries. The frequency and extent of these injuries are not linked to the complexity of the primary injury. The aim is to recognize and correctly diagnose potential concomitant injuries. Many injuries do not need immediate treatment but heal without additional treatment after the radius has been treated. It is important to recognize those injuries which can cause severe complications if untreated; however, exactly this is often difficult. In many cases there is still no consensus if and how concomitant injuries should be treated. This article highlights the most frequent concomitant injuries in distal radius fractures with the possible advantages and disadvantages of cotreatment in order to facilitate decision making.

Electric Scooter-Related Upper Limb Fractures: Analysis of 458 Cases

PURPOSE

To perform an analysis of electric scooter (e-scooter)-related upper limb fractures (ULFs), which have increased dramatically in parallel with the rapid rise in the use of e-scooters and shared e-scooter services in recent years.

METHODS

We retrospectively reviewed the medical charts of e-scooter-related emergency department visits between January 2017 and January 2020 at a level I trauma center. All patients with ULFs were included in the study, and their data were analyzed for demographics, fracture diagnosis, associated injuries, and required surgical treatment.

RESULTS

This study included 356 patients (50% men) with 458 ULFs, of which 23 (5%) were open fractures. The mean age of the cohort was 32.9 years (standard deviation, 10.1 years). The most common mechanism of injury was rider fall (92.1%). The nondominant hand was injured in 53.1% of cases, and 32.1% of all fractures were treated with surgery. A total of 120 (33.7%) patients sustained more than 1 ipsilateral ULF, and 27 (7.6%) patients had a concomitant contralateral ULF. Radial head fracture was the most common fracture type (n = 123, 26.8%), of which 16 (13%) were bilateral. The fifth ray was injured most frequently among the metacarpal and phalangeal fractures (n = 33, 47.1%). Most of the nonextremity-associated injuries were those of the head and maxillofacial bones.

CONCLUSIONS

The most common ULF associated with e-scooters was the radial head fracture. Physicians should be alert to and seek associated fractures during initial assessments of e-scooter-related upper limb injuries. Further investigation may be warranted to evaluate the effectiveness of protective measures in reducing the number of injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Association between perceived and objective hand-wrist function in distal radius fracture

The relationship between patient-reported outcome measures and objective measures is important for understanding patient expectations. The aim of this study was to investigate the relationship of each section of the Michigan Hand Outcomes Questionnaire (MHQ) to objective measurements in patients with distal radius fracture (DRF). Eighty-four patients who were treated operatively or non-operatively for DRF were included. Injury severity was assessed by the Modified Hand Injury Severity Score. Joint motion was assessed at 6 and 12 weeks and grip strength at 12 weeks after non-operative treatment or surgery. The MHQ was used to assess hand functionality. The relationships between measurements were analyzed by Spearman correlation analysis. Statistical significance was set at p &lt; 0.05. Fifty-one patients (60.7%) were women and 33 (39.3%) men. Mean age was 48.17 ± 12.26 (range, 20-64) years. Fifty-two (61.9%) patients were treated surgically and 32 (38.1%) non-operatively. Forearm pronation-supination and wrist flexion and ulnar deviation at week 6 and forearm pronation-supination, wrist extension and radial deviation at week 12 correlated with MHQ scores, unlike wrist extension and radial deviation at week 6 and flexion and ulnar deviation at week 12. Gross and fine grip strength at week 12 correlated with MHQ, except for the overall hand function, work performance and pain subsections. The MHQ subsections correlated with joint motion and grip strength in the early period after DRF. These findings clarified patient expectations in the early period.

Radius distraction during volar plating of distal radius fractures may improve distal radioulnar joint stability at minimum 3-year follow-up: a retrospective case series study

BACKGROUND

The surgical technique of radius distraction for stabilization of distal radioulnar joint (DRUJ) if intraoperative DRUJ instability was found after the fixation of distal radius fracture has been previously described, but this surgical technique lacks clinical and radiographic effect in minimal 3 years follow-up. We therefore evaluated the clinical outcome and radiographic results of radius distraction in minimal 3 years follow-up as long-term evaluation.

METHODS

We reviewed the case series of distal radius fracture with concomitant DRUJ instability receiving radius distraction from the senior author over a 5-year period (January 1st, 2013, to June 30th, 2017) retrospectively. Radius distraction during volar plating was performed by moving the volar plate distally via compression screw loosening/fastening to achieve firm endpoint on the dorsopalmar stress test. The evaluations of radiographic, including bone union time and ulnar variance, and clinical outcomes, including grading of DRUJ instability, NRS of wrist pain, DASH score, MMWS score, and range of motion of operated wrist at final follow-up, were performed at clinic as minimum 3-year follow-up; a total 34 patients had been evaluated.

RESULTS

At minimal post-operative 36 months follow-up, all cases demonstrated acceptable wrist range of motion with stable DRUJs, low NRS of wrist pain (0.6, SD 0.7), and satisfactory DASH score (mean 9.1, SD 6.2) and MMWS score (mean 87, SD 10). There were no cases suffering from nonunion of distal radius. The mean ulnar variance of injured wrist and uninjured wrist were -1.2 mm and 0.2 mm, respectively (SD 1.0 and 0.6) with significant statistical difference.

CONCLUSIONS

Radius distraction during volar fixation of distal radius fracture should be considered if DRUJ instability was found by the dorsopalmar stress test intraoperatively, and the long-term DRUJ stability could be achieved by maintenance of normal-to-negative ulnar variance, with decreased wrist pain and satisfactory function outcome.

LEVEL OF EVIDENCE

Therapeutic Level IV.

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.

The Critical Size of Ulnar Styloid Fragment for the DRUJ Stability

Background  Ulnar styloid fractures can be associated with clinically significant instability of the distal radioulnar joint (DRUJ). However, the exact fragment size that results in DRUJ instability is unknown. Purpose  The objective of this study was to determine the critical size of an ulnar styloid fracture that would result in a significant increase in DRUJ translation and forearm rotation. Methods  Eight cadaveric specimens were used to investigate the effects of three different ulnar styloid fracture sizes on DRUJ instability: tip fracture, base fracture, and a fracture including the fovea. Forearm rotation and dorsopalmar DRUJ translation were measured after each sequential increase in fracture size. Results  Relative to the uninjured state, a significant increase in forearm rotation and dorsopalmar translation was found for all three fractures. However, the fovea fracture showed a statistically significant increase in forearm rotation compared with all other fracture types and a statistically significant increase in total dorsopalmar translation compared with the tip fracture. Conclusion  In this study, ulnar styloid fractures involving the fovea resulted in significantly greater DRUJ instability comparted to tip and base fractures alone. This study provides important biomechanical data regarding the critical size of ulnar styloid fractures that result in DRUJ instability and may aid in the surgical decision-making algorithm in these patients.

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.

Ulnar Styloid Fracture Accompanying Distal Radius Fracture Does Not Affect Hand Function, but What About Hand Dexterity?

Introduction  Hand dexterity is not addressed in patients with distal radius fracture (DRF) accompanied with ulnar styloid fracture (USF) in literature. This study aimed to determine whether an associated USF following a DRF has any effect on hand dexterity. Materials and Methods  Patients diagnosed with DRF were included in the study and were divided into two groups according to the USF presence (USF group and non-USF group). Pain, range of motion, Quick-DASH (Quick-Disabilities of the Arm, Shoulder, and Hand), handgrip and pinch strength, Purdue Pegboard test, and Jebsen Taylor Hand Function test were measured in the sixth month. Results  A total of 125 patients, 68 females (54.4%) and 57 males (45.6%) were included in the study. The mean age of the patients was 47.15 ± 13.41 (18-65) years. There were 60 patients (48%) in the USF group and 65 patients (52%) in the non-USF group. No significant difference was found in pain, range of motion, Quick-DASH and handgrip and pinch strength between the groups ( p > 0.05). The hand dexterity tests showed no statistically significant difference between the groups in the sixth month ( p > 0.05). Discussion  Hand function can be determined more accurately by assessing hand dexterity. In this study, it is emphasized that concomitant USF does not lead to poorer hand dexterity.

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

OBJECTIVE

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

INDICATIONS

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

CONTRAINDICATIONS

Undisplaced fractures of the ulnar styloid process and asymptomatic nonunions.

SURGICAL TECHNIQUE

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

POSTOPERATIVE MANAGEMENT

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

RESULTS

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

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.

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.

Ulnar footprints of the distal radioulnar ligaments: a detailed topographical study in 21 cadaveric wrists

Understanding of the exact topography of the distal radioulnar ligaments insertions remains limited. An anatomical study was performed in 21 fresh frozen cadaveric wrists, where the superficial and deep ligaments were sequentially transected sharply at their ulnar insertions. The relationships between the distal radioulnar ligament footprints relative to the bony landmarks of the ulnar styloid were digitized. Our study demonstrated that in the coronal plane, the superficial distal radioulnar ligaments inserted at an average of 87% of the styloid height proximally to the styloid tip distally. The deep distal radioulnar ligaments inserted at an average of 81% of the styloid height distally to the fovea proximally. The superficial footprint had an area of 10.6 mm² on the ulnar styloid. The deep distal radioulnar ligaments attachment was asymmetric and generally had two separate footprints. This study adds important topographical knowledge about the footprint of the distal radioulnar ligaments and may contribute to understanding the consequences of ulnar styloid fractures and distal radioulnar ligaments lesions.

Predictive Factors for Return to Driving following Volar Plate Fixation of Distal Radius Fracture

Background  A common query by patients undergoing distal radius fracture (DRF) repair is when (s)he can resume driving postoperatively. A prospective cohort analysis was performed to assess fracture and patient factors on a patient's self-reported ability to return to driving to better inform patients and surgeons. Methods  Consecutive patients undergoing DRF repair with locking volar plate were enrolled. Preoperative demographic and radiographic characteristics, and postoperative time to return to driving were collected. Data collected included age, sex, hand dominance, body mass index (BMI), level of education, concomitant ulnar fracture, fracture setting prior to surgery, and AO fracture classification. Results  A total of 131 patients were enrolled (108 women, 23 men) with 36 AO type A, 22 AO type B, and 73 AO type C DRFs, with an average age of 59.5 years. Fracture severity by classification did not significantly affect time to return to driving. However, BMI, sex, and age were found to significantly affect time to return to driving. Patients aged 19 to 59 years, 60 to 75 years, and over 75 years returned to driving 13.1, 15.4, and 30.1 days following surgery, respectively ( p  < 0.01). Classified by BMI, patients that were normal weight, overweight, and obese returned to driving 11.5, 13.1, and 21.0 days following surgery, respectively ( p  < 0.05). Men returned to driving 8.8 days and women 17.3 days postoperatively ( p  = 0.001). Conclusion  Patients severity of fracture as determined by AO fracture type did not affect time to driving, while increased BMI, female sex, and increased age were found to be significant factors in patients' return to driving time after distal radius fracture repair. Level of Evidence  This is a Level II, prospective cohort study.

Association between bone mineral density and ulnar styloid fracture in older Japanese adults with low-energy distal radius fracture

We investigated the association of the ulnar styloid fracture (USF) with the bone mineral status and fractured radial displacement in elderly patients. The presence of USF correlates with decreased BMD and severe displacement of the radius. These findings are helpful in treating osteoporosis to prevent subsequent fragility fracture.

PURPOSE

The pathogenesis of ulnar styloid fracture (USF), which often occurs with distal radius fracture (DRF), is unclear. This study aimed to investigate whether USF concomitant with low-energy DRF was associated with the bone mineral status and the degree of radiographically observed pretreatment radius displacement in Japanese adults above 50 years of age.

METHODS

The study subjects were 45 (44 female, 1 male) consecutive patients aged > 50 years with DRF caused by falls from June 2015 to May 2016. Fractures due to high-energy injuries were excluded. Patients were divided into two groups according to the presence or absence of USF. Radius displacement was assessed on anteroposterior and lateral radiographs by measuring ulnar variance, radial inclination, and volar tilt at initial examination before manual reduction of the bone. Bone mineral density (BMD) of the lumbar spine, femoral neck, and distal radius was also measured by dual-energy X-ray absorptiometry within 1 week of injury.

RESULTS

Significant differences in the BMD values of femoral neck, ulnar variance, radial inclination, and volar tilt were found between patients with USF and those without USF (all comparisons, p < 0.05). Logistic regression analysis of all subject data identified that volar tilt was significantly associated with the presence of USF (p = 0.048).

CONCLUSIONS

The presence of USF in low-energy DRF correlates with the decreased BMD of femoral neck and severe displacement of radius in elderly patients. These findings are helpful for the treatment of osteoporosis to prevent subsequent fragility fracture.

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.

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.

EVALUATION OF DISTAL FOREARM FRACTURES USING THE AO 2018 CLASSIFICATION

OBJECTIVE

Distal forearm fractures are among the most common upper limb fractures in all ages, and many classifications have been proposed to describe them. Recently, a new version of AO/OTA classification was proposed. The aim of this study is to use the AO/OTA 2018 classification to report the epidemiology of distal forearm fractures in adults treated at a single center.

METHODS

A retrospective analysis of the initial radiographs obtained from cases of distal forearm fractures in an orthopedic emergency room at a single tertiary hospital.

RESULTS

Three hundred twenty-two cases were studied, aged 50.35 ± 18.98 years, 55.3% were female and 44.7% were right-sided. Type 2R3A, 2R3B and 2R3C fractures corresponded to 32.3%, 18.0% and 48.4% of the cases, respectively. Distal ulnar fracture was present in 41.9%. There was a correlation between age and sex: 78.3% of the subjects aged under 30 years were male, and 80.6% of those aged over 60 years were female (p<0.001).

CONCLUSION

The most common type of radial fractures was 2R3C, and the most common type of ulna fracture was 2U3A1.1. There was a correlation between age and sex. Level of evidence IV, Case-series.

Distal radius nonunion after epiphyseal plate fracture in a 15 years old young rider

BACKGROUND AND AIM OF THE WORK

Radius and ulna fractures are the most common long bone fractures in children and adolescents. The majority of these injuries involve the distal metaphyseal portion of the radius associated or not to physeal plate injuries. Because of the high remodelling potential of the distal radius in growing children most injuries heal without complication after closed reduction and immobilization in a long arm cast. Nonunions of closed distal radius fracture are an extremely rare occurrence especially in paediatric population. Methods: In this report, we describe a rare case of distal radius fracture nonunion in a 15-years old male rider treated conservatively with cast immobilization. Eight months later he underwent surgical closed reduction and fixation with kirschner wire and cannulated screw. Results: Follow-up at 2 years showed satisfying radiological and functional outcomes. The patient ultimately returned to ride 3 months following surgery. Conclusions: Nonunion is rarely seen in distal radius fractures in healthy children and adolescents, and there are few studies in the literature. Treatment of the nonunion must be individualized and the results are not entirely predictable.

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

Background

The role of surgical fixation of ulnar styloid fractures remains a subject of debate. The purpose of this study was to compare the surgical outcomes following early and late intervention.

Methods

We retrospectively reviewed 28 patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2014. Surgical fixation was performed within 3 months of injury in 13 patients (group A) and beyond 3 months in 15 patients (group B). Patient characteristics and functional outcomes were compared between the two groups. The outcome survey consisted of QuickDASH score, grip strength, range of motion, pain score based on the visual analog scale, and surgical complications. Descriptive statistics were calculated for key variables. A p value of < 0.01 was considered statistically significant.

Results

Patient characteristics including age, sex, injured side, dominant side injury, and concomitant distal radius fracture showed no significant differences between the two groups. Time to surgery averaged 1.1 months in group A and 12.3 months in group B. Significantly better outcomes were found in group A than in group B, including QuickDASH scores (4.4 ± 5.9 vs. 12.9 ± 9.9) and grip strength (37.4 ± 5.1 vs. 29.1 ± 5.9 kg). Significantly better range of motion was found in group A than in group B with respect to supination (81.9° ± 4.3° vs. 75° ± 8.5°), extension (84.6 ± 4.3 vs. 76.7 ± 6.5), and flexion (80.4° ± 3.8° vs. 72° ± 4.1°). The difference was not significant in case of pronation (78.8° ± 3° vs. 74.3° ± 5.9°) and with respect to pain scores (0.6 ± 0.7 vs. 1.3 ± 1).

Conclusion

Both osseous and soft tissue lesions need to be fully addressed in ulnar styloid fractures. Early detection and surgical repair yielded better outcomes. Higher complication rates in late-treated fractures show that surgeons should select surgical candidates and modalities properly.