Intra-articular distal ulnar fractures associated with distal radial fractures in older adults: early experience in fixation of the radius and leaving the ulna unfixed

Internal Fixation for Unstable Distal Ulnar Fractures by 2.7 mm Semitubular Hook Plate

Objective: The purpose of this study is to investigate the outcomes of the use of a 2.7 mm semitubular hook plate for internal fixation of unstable metaphyseal ulnar fractures. Methods: Between January 2015 and July 2019, 30 consecutive patients with a recent unstable distal ulnar fracture were included in this prospective case series. All patients were subjected to follow-up with the time of union, range of motion, pain using a Visual Analog Scale (VAS), and radiological and functional outcome using the quick Disabilities of the Arm, Shoulder, and Hand (DASH) score and Mayo wrist score after 12 months. Results: The mean age of the patients was 45.3 ± 10 years. There were 18 males (60%) and 12 females (40%), and there were 16 patients associated with distal radius fractures (53.33%). According to the AO classification of distal ulnar fractures, 3 fractures were type A2.1 (10%), 9 were type A2.2 (30%), 8 fractures were type A2.3 (26.67%), and 10 fractures were type A3 (33.33%). All fractures have been united with a mean duration of 9 ± 1.4 weeks, the mean supination was 81.4° ± 3.5°, the mean pronation was 81.3° ± 4.5°, the mean flexion was = 71.7° ± 3.6°, and the mean extension was = 81.7° ± 3.4°. The mean VAS was 1.1 ± 1 points, the mean DASH score was 9.3 ± 5.6 points, and the mean Mayo wrist score was 88.5 ± 7.2 points; 17 patients were excellent (56.67%) and 10 patients were good (33.33%) while 3 patients had satisfactory outcome (10%). Conclusion: Using the 2.7 mm semitubular hook plate is a successful choice for internal fixation of unstable distal ulnar fractures isolated or associated with distal radius fractures with a favorable union time, functional outcome, and range of motion with minimal complications.

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.

Management of Very Distal Ulna Fractures: A Systematic Review

OBJECTIVES

To synthesize all-cause complications and reoperations data, and secondary clinical, functional, and radiographic outcomes after the management of very distal ulna fractures (VDUFs) either nonoperatively or operatively.

DATA SOURCES

MEDLINE, Embase, and Web of Science were searched for English-language articles from inception to February 17, 2022.

STUDY SELECTION

Studies reporting the nonoperative or operative management of VDUFs were eligible for inclusion. VDUFs were defined as either being Q2-Q5 distal ulna fractures using the OTA/AO Comprehensive Classification of Fractures for distal ulna fractures associated with distal radius fractures or being amenable to characterization by the classification system for ulnar head, neck and metaphyseal fractures by Biyani et al.

DATA EXTRACTION

Two reviewers independently extracted data from included studies. Study validity was assessed using the methodological index for nonrandomized studies.

DATA SYNTHESIS

Seventeen studies (512 VDUFs) were included for analysis. There were 209, 237, and 66 fractures in the nonoperative, open reduction internal fixation (ORIF), and distal ulna resection groups, respectively. Descriptive statistics including weighted mean values, standard deviations, and 95% confidence intervals were calculated.

CONCLUSIONS

The treatment of VDUFs with nonoperative management, ORIF, or distal ulna resection may all be acceptable treatment options in specific patient populations. Nonoperative management of VDUFs is a promising treatment strategy even for complex fracture patterns in patients 65 years of age or older. Despite higher reoperation rates, ORIF may be considered for the younger, high-demand patient. Distal ulna resection presents with very favorable functional outcomes in patients 65 years of age or older presenting with a complex VDUF with the lowest reoperation rate across all groups.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of surgical treatments for distal ulna fracture when combined with anterior locking plate fixation of distal radius in the over 70 age group

We conducted a retrospective multicentre study to compare the clinical and radiographic outcomes, and complications of three surgical treatments of distal ulna fracture (DUF) when combined with anterior locking plate fixation for distal radial fracture (DRF) in patients over 70 years of age. We identified 1521 patients over 70 years of age who were diagnosed as having DRF and who underwent anterior locking plate fixation between 2015 and 2020, among which 122 cases of DUF were analysed. Three surgical treatment options for DUF were identified in this cohort: K-wire fixation (Group K), locking plate fixation (Group L) and Darrach procedure (Group D). The results of the analysis showed the total immobilization period in Group D to be the shortest among the three treatments. Functional outcomes were superior, and the rate of complications were smaller in Group D than in Group L. In addition, rotational range of motion was larger in Group D and Group L compared with Group K. In patients who are 70 years of age or older with combined unstable DRF and highly comminuted or displaced DUF, the Darrach procedure for DUF seems to be the most useful and reasonable treatment option once the fracture of the distal radius has been rigidly fixed.Level of evidence: 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).

Treatment Modality of Distal Ulnar Head and Neck Fractures Associated With Operatively Treated Distal Radius Fractures Does Not Affect Outcomes

Background: This study compares the functional outcomes and complications between operatively and nonoperatively treated distal ulnar head and neck fractures associated with internal fixation of concomitant distal radius fractures. Methods: A 7-year retrospective chart review was performed to identify patients with operatively treated distal radius fractures associated with distal ulnar head and neck fractures. Ulnar styloid fractures were excluded. Fifty-eight patients who had a minimum of 6 months of follow-up were identified. Patients were divided into 3 treatment groups: nonoperative, open reduction internal fixation (ORIF), and distal ulna resection. Reviewed data included demographics, injury and treatment details, complications, and patient-reported outcome measures. Outcomes measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE) surveys. Due to inadequate power, 5 patients treated with distal ulna resection were excluded from statistical analysis. Results: The average patient age was 56 years, with an average follow-up of 27 months. All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF in 28 patients, and with distal ulna resection in 5 patients. There were no statistically significant differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores between ORIF and nonoperative treatment. Conclusion: No differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores were observed between ORIF and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures.

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.

Results of wrist hemiarthroplasty for comminuted distal radius fractures in independent elderly people: A retrospective study on eleven patients

The comminuted distal radius fractures among elderly people are usually linked to osteoporosis, and repairing them in this context is a therapeutical challenge. Several teams have reported good results of radius resurfacing. The goal of our study was to evaluate the usability of the wrist in a new series of patients after surgery. We performed a monocentric retrospective study on the data of the medical files. All the included patients were older than 65 years and received a wrist hemiarthroplasty according to the criteria that have been established by the in charge medical team. Eleven patients have been included, their average age was 80.4 years old, and the average follow-up was 18.3  months. The average QuickDASH Score was 59 (27-95). The Visual Analogue Scale for pain was in average 3.8/10 and the average mobility was: flexion 36° (12-50), extension 27° (12-50), radial deviation 15° (12-15), ulnar deviation 26° (12-40), pronation-supination range of motion 164° (150-170). The average measured strength was 44% (16-72%) of the strength of the unaffected hand. Our results are rather modest, probably because of insufficient follow-up and very severe fractures. Furthermore, the implant that has been used does not take into account the distal radioulnar joint. Another bound of this treatment is the complexity of surgical revision in case of bad result. So far, hemiarthroplasty cannot be considered as the standard treatment for complex fractures of the distal radius.

Conservative treatment of distal ulna metaphyseal fractures associated with distal radius fractures in elderly people

INTRODUCTION

Although volar locking plates (VLPs) have been exclusively used for unstable distal radius fractures (DRFs), the optimal management of distal ulna fractures (DUFs) remains controversial. Internal fixation using a plate for DUFs might be challenging because of the presence of osteoporotic bone and fragile bone fragments in elderly patients.

HYPOTHESIS

We hypothesized that a strategy including VLP fixation for DRFs and non-intervention for DUFs with early wrist mobilization would provide encouraging results in elderly patients.

MATERIALS AND METHODS

Eighteen patients (17 women and one man, mean age 74.7 years) were included in the study. According to the Biyani classification, there were seven patients with type-1, three with type-2, five with type-3, and three with type-4 DUFs. Radiological results were analyzed in 18 patients and the clinical results could be evaluated in 10 patients who attended the necessary follow-up meetings. Ulnar angular deformity (UAD) and ulnar shortening amount (USA) were measured using anteroposterior radiographs. USA was defined as the difference in ulnar variance between just after surgery and at the final visit. Clinical results were assessed using the modified Gartland and Werley score, disability arm shoulder hand (DASH) score, range of motion, grip strength, pain, and distal radioulnar joint (DRUJ) instability.

RESULTS

All ulna metaphyseal fractures united. The mean UAD just after surgery was 5.9° (range, 0-22). At the final visit, the mean UAD was 6.4° (range, 0-17). The mean USA was 0.35mm, and only one patient showed ulnar shortening of >2mm. The results were "excellent" in nine patients and "good" in one, according to the modified Gartland and Werley score. The mean DASH score was 4.2. Mean flexion and extension angles were 58° and 71°. One patient complained of ulnar-sided pain during exertion and no patients complained of DRUJ instability.

DISCUSSION

All DUFs achieved good radiological results, including comminuted fractures. Functional outcomes were promising, including wide wrist ROM and no DRUJ instability. An approach including VLP fixation for DRFs and non-intervention for DUFs is a good option for elderly patients.

LEVEL OF EVIDENCE

IV retrospective study.

Technique for Intramedullary Stabilization of Ulnar Neck Fractures

BACKGROUND

Distal ulna fractures at the ulnar neck can be seen in association with distal radius fractures, and multiple techniques have been described to address the ulnar neck component of these injuries. We have found that treatment of ulnar neck fractures can be challenging in terms of anatomy and fracture fixation. We present a new percutaneous fixation technique for ulnar neck fractures commonly seen with distal radius fractures.

TECHNIQUE

Fixation of the ulnar neck fracture is performed after fixation of the distal radius fracture. Our technique uses anterograde intramedullary fixation to stabilize the fracture with a 1.6-mm (0.062 inch) Kirschner wire or a commercially available metacarpal fixation intramedullary nail. The fixation is introduced into the intramedullary space of the ulnar shaft 4 to 6 cm proximal to the fracture at a separate surgical site along the subcutaneous border of the ulna. The fixation is also supported with a sugar-tong splint for the first few weeks after surgery and requires removal of the ulnar implant approximately 10 weeks after implantation.

CONCLUSION

Our technique utilizes a percutaneous approach with minimal fracture exposure. It provides a relatively simple and reproducible method to address ulnar neck fractures commonly seen in association with distal radial fractures.

Ulnar Neck Fractures Associated with Distal Radius Fractures

Background  There is little published data to guide management of ulnar neck fractures associated with fractures of the distal radius. Purpose  As unplanned surgery usually reflects adverse events and this injury combination is relatively uncommon, we used a large database to study the incidence of unplanned surgeries after surgical and nonsurgical treatment of distal metaphyseal ulna fractures associated with a distal radius fracture and identify factors associated with these unplanned surgeries. Patients and Methods  We identified 277 patients with an ulnar neck fracture associated with a distal radius fracture. Fifty-six (20%) ulnar neck fractures were initially treated operatively and six of them (11%) had a second, unplanned surgery. Of the 221 initially nonoperatively treated fractures, only one (0.45%) had a subsequent unplanned surgery that seemed unrelated to the fracture (ulnar nerve neurolysis). Results  Bivariate analysis showed that younger age, open fracture, multifragmentary fractures, and initial operative treatment of the ulnar neck fracture were significantly associated with unplanned surgery. A multivariable analysis was not feasible due to the small number of unplanned surgeries. Conclusion  Eighty percent of ulnar neck fractures associated with a fracture of the distal radius was treated nonoperatively in our region, and subsequent surgery for problems was very uncommon. Operative treatment and fracture complexity were associated with unplanned surgery, which reflected some measure of injury severity, technical inadequacy, and inherent problems associated with surgery. Level of Evidence  Level II, prognostic study.

Proposed Guidelines for Treatment of Concomitant Distal Radius and Distal Ulna Fractures

BACKGROUND

Concomitant distal radius and distal ulna metaphysis or head fractures (DRUF) are uncommon and acceptable results have been reported from cast immobilisation and internal fixation.

METHODS

We reviewed the charts of 1094 patients treated for distal radius fracture at our institution in a two year period from 2009 to 2010. 24 patients with concomitant DRUF with were treated by cast immobilisation (group 1, n = 11), internal fixation of both bones (group 2, n = 7), internal fixation of radius alone (group 3, n = 2), and internal fixation of radius with distal ulna resection (group 4, n = 4). Patients treated by surgery underwent intraoperative assessment of distal ulna stability to determine the indication for ulna fixation. Post surgical range of motion, clinical parameters, and functional outcome scores (Gartland-Werley and modified Mayo) were measured.

RESULTS

Wrist motion was comparable in each group. Radiographic parameters were better in surgical groups. 23 of 24 patients achieved excellent/good outcomes based on Gartland-Werley scores, while 12 of 24 achieved good modified Mayo wrist score. There was a case of distal ulna non-union in group 1, and another case of delayed distal radius union in group 2.

CONCLUSIONS

By evaluating patients' functional requirement, and dynamic fluoroscopy examination, satisfactory outcomes can be achieved for various presentations of DRUF.

Primary excision of the ulnar head for fractures of the distal ulna associated with fractures of the distal radius in severe osteoporotic patients

We performed primary excision of the ulnar head on 23 patients over 70 years of age with severe comminuted fractures of both the distal radius and ulna. The distal radius fracture was fixed rigidly with a volar locking plate, and the ulnar head was resected at the fracture site. All the distal radial fractures united without major complications. The mean wrist flexion/extension arc was 122°, the mean pronation/supination arc was 164°, and grip strength was 69% of that on the contralateral side. All patients returned to their daily activities within a short time without any additional surgical treatment. For elderly patients, primary excision of the ulnar head is an effective treatment for comminuted distal radius and ulna fractures.

Distal ulna fractures

In isolation, distal ulna fractures are rare. They are often found in conjunction with distal radius fractures, and the complexity of the interaction of the distal ulna with the radioulnar joint and triangular fibrocartilage complex makes understanding and treatment of distal ulna fractures challenging. Fixation of distal ulna fractures can be problematic owing to comminution making reduction challenging. A thin soft tissue can lead to hardware prominence and necessitate implant removal. In this Current Concepts article, we review the anatomy, pathology, and treatment of distal ulna fractures as well as potential complications and salvage procedures.

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.

[Anatomy and biomechanics of distal radius fractures: a literature review]

Distal radius fractures remain the most frequent fractures in the adult. Associated osteoporosis increases morbidity risk (secondary displacement is the most frequent) and mortality risk (in women older than 60). Severity of the fracture and functional results are related to the bone mineral density. Anatomy has been recently revisited with better description of palmar and dorsal aspects in order to avoid material-related complications. Standard postero-anterior, lateral and oblique radiographs of the wrist show the fracture and the displacement. CT scan is warranted if conventional X-rays are insufficient to show the articular surface. The involvement of the metaphysis (comminution), the epiphysis (articular fracture) and the ulna is different in each case and each fracture is an association of these three components. The MEU classification describes the fracture with sufficient inter-observer reliability and intra-observer reproducibility to be a useful tool for treatment and prognosis. The PAF system is used to propose the most appropriate treatment for each patient. Anatomical reduction and stable fixation are associated with good functional results but in high demanding patients.

Remodeling of distal ulna after excision arthroplasty for acute comminuted distal ulnar fracture: a case report

Bone adaptation after excision arthroplasty of distal radioulnar joint in an acute traumatic distal ulna fracture has never been reported. A case of irreparable and comminuted distal ulnar head fracture was managed by excising the ulna head and repairing the fovea (deep ligament) attachments of distal radioulnar ligaments, and then an unexpected remodeling of the distal ulna with the shape of pole and seat was noted. The anatomy of deep fibers of distal radioulnar ligament is important not only in biomechanics about the stability of distal radioulnar joint but it is also possible in the morphology about the shape of the distal radioulnar joint.