Should ulnar styloid be fixed following fixation of a distal radius fracture?. Injury 2023;54:110768. [PMID: 37210301 DOI: 10.1016/j.injury.2023.04.055]

Surgical intervention for distal radial fractures with concurrent ulnar styloid fractures may be beneficial for the elderly patients: a retrospective study

BACKGROUND

Distal radius fractures are highly prevalent among older adults. Ulnar styloid fractures frequently accompany distal radius fractures, raising concerns about treatment outcomes due to the risk of distal radioulnar joint (DRUJ) instability. This study investigated the necessity of surgical intervention (open reduction internal fixation; ORIF) for distal radius fractures in very old patients with coexisting ulnar styloid fractures.

MATERIALS AND METHODS

A retrospective analysis of 96 patients aged ≥ 80 years with AO classification 23-A2 to 23-B3 distal radius fractures with concomitant ulnar styloid fracture between 2019 and 2022 was performed. Patients were excluded if they were aged < 80 years, had a preinjury Barthel index of < 90, or had high-energy multiple trauma. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score assessed at 3, 6, and 12 months. We compared the DASH score and their trajectories between the ORIF and conservative treatment groups.

RESULTS

ORIF group demonstrated significantly better DASH functional scores (25.31 ± 4.71) at the 12-month follow-up compared with the conservative group (34.42 ± 8.03; p < 0.001). Treatment choice was identified as a significant predictor of DASH scores at 12 months, with ORIF significantly improved patient's wrist function and demonstrated a β coefficient of - 9.11 (95% confidence interval: -11.95 to - 6.27, p < 0.001). The other factors investigated, namely age, lowest T-score, and medical history of diabetes mellitus, hypertension, coronary artery disease, cerebrovascular accidents, cancer, and dementia, did not exhibit a significant association with the 12-month DASH scores in the adjusted model (p > 0.05).

CONCLUSIONS

Our findings suggest that very old patients with distal radius fracture accompanied by ulnar styloid fractures may benefit from ORIF to achieve optimal long-term functional recovery.

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).

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.

Ipsilateral fractures of the ulnar styloid with distal radius fractures; to fix or not? A systematic review and meta-analysis

Background

The most common upper limb fracture encountered in clinical practice is distal radius fracture (DRF). They frequently occur due to falls onto an outstretched hand or other traumatic incidents, resulting in a break in the radius near the wrist joint. DRFs often present a spectrum of injuries and are a common reason for emergency department visits, affecting approximately one out of every six patients seeking medical attention in this setting.

Methods

This systematic review was performed according to the guidelines of PRISMA, using the electronic database search of PubMed, Embase, Scopus, and Cochrane Library, and the protocol for the review was registered to PROSPERO. All comparative study designs (prospective or retrospective) that compared fixation of ulnar styloid and no fixation in a case of ipsilateral distal end radius fracture were included.

Results

The current review analyzed 336 patients from five studies, two randomized controlled trials (RCTs), two prospective, and one retrospective comparative study. The meta-analysis revealed a significantly higher rate of union in fixation group than the no-fixation group, with an odds ratio of 10.29 (95%CI 4.74, 22.32; p < 0.00001). However, no significant differences were found in other radiological parameters such as radial inclination, volar angle, and ulnar variance. Regarding functional outcomes, the result was equivocal for the two groups regarding DASH/quick DASH score, Modified Mayo Wrist score MD of 0.22 [95 % CI -1.84, 2.28, p = 0.83; I2 = 0 %], grip strength, range of motion, and overall complications OR of 0.53 (95 % CI 0.08, 3.47; p = 0.51; I2 = 86 %), but higher occurrence of ulnar-sided pain, hardware prominence, and paraesthesias.

Conclusion

Fixation of ulnar styloid in conjunction with DRF does not significantly benefit patients. Despite better styloid union rates, it increases implant-related complications without improving final function, range of motion, stability, or grip strength. Patients may experience increased ulnar-sided pain due to implant prominence. Therefore, non-fixation of the ulnar styloid process is recommended as it offers no significant advantages.

Predictive factors of distal radioulnar joint instability after surgical treatment of distal radius fractures

Distal radioulnar joint (DRUJ) instability is a common postoperative complication of distal radius fractures, seriously impacting patients' quality of life. This study investigated its possible influencing factors to determine prognosis and to guide treatment better. We retrospectively included a series of patients with distal radius fractures that underwent volar locking plate fixation. Basic patient information and imaging parameters were collected. The incidence of DRUJ instability during follow-up was recorded, and factors associated with DRUJ instability were determined using univariate analysis and multifactorial logistic regression analysis. A total of 159 patients were enrolled in this study. At 6 months of follow-up, 54 patients (34.0%) had DRUJ instability, and multivariate analysis showed coronal plane displacement (OR, 1.665; 95% CI, 1.091-2.541), fracture classification (OR, 0.679; 95% CI, 0.468-0.984) and DRUJ interval (OR, 1.960; 95% CI, 1.276-3.010) were associated with DRUJ instability after volar locking plate. DRUJ interval, coronal plane displacement, and fracture classification are associated with DRUJ instability during follow-up. Therefore, preoperative risk communication and intraoperative attention to recovering relevant imaging parameters are necessary for these patients.