Treatment of symptomatic non-unions of the base of the ulnar styloid with plate osteosynthesis

Headless screw fixation of unstable ulnar styloid base fractures after distal radial fractures fixation

Ulnar styloid fractures occur frequently concomitant with distal radial fractures. Although unstable distal radial fractures are mostly surgically treated, ulnar styloid fractures are often ignored. Unstable fractures at the base of the ulnar styloid may lead to persistent ulnar pain, due to distal radioulnar joint instability or ulnar styloid non-union. We retrospectively analyzed a single-surgeon cohort series of surgically treated distal radial fractures on how these concomitant ulnar styloid fractures were regarded: indications for surgery and surgical technique with headless screw fixation. 119 surgically treated distal radial fractures were assessed. 51 (42.8%) of the surgically treated distal radial fractures had a distal ulnar fracture, and more specifically 23 (19.3%) had a base fracture of the ulnar styloid. 9 (7.6%) of the wrists had a base fracture of the ulnar styloid which was considered after distal radial fracture fixation as persistently unstable, during distal radioulnar joint ballottement translation test. This fracture subtype was immediately treated with headless screw fixation, resulting in all cases in bony union, with a mean active pronation of 85°, a mean active supination of 80° and a clinical stable distal radioulnar joint, with minimal ulnar pain after 6 weeks (mean Visual Analogue Scale 1). After at least 12 months, persistent pain did not occur and mean QuickDASH was 2.5. According to this single-surgeon cohort series, headless screw fixation provides a reliable treatment for unstable base fractures of the ulnar styloid after distal radial fixation.

Management of Ulnar Styloid Nonunions

Ulnar styloid fractures commonly occur in the setting of distal radius fractures and often progress to asymptomatic nonunion. Displaced basilar ulnar styloid fractures involving the deep radioulnar ligament attachments may cause distal radioulnar joint (DRUJ) instability. A careful clinical history, physical examination, review of imaging studies, and selected diagnostic interventions are important for confirming the relationship of the ulnar styloid nonunion with ulnar-sided wrist symptoms and/or DRUJ instability. Improved functional and symptomatic outcomes can be achieved with nonunion repair or fragment excision with or without triangular fibrocartilage complex repair, depending on the location and size of the ulnar styloid fracture.

Treatment of type II symptomatic ulnar styloid nonunions with reinsertion of the triangular fibrocartilage complex

PURPOSE

The purpose of this retrospective study was to introduce an alternative technique for the treatment of type II symptomatic ulnar styloid nonunion by the reinsertion of the triangular fibrocartilage complex and the ulnar collateral ligament.

METHODS

Between March 2009 and May 2017, 45 patients (34 males and 11 females) suffering from the nonunion of type II ulnar styloid fractures all underwent the subperiosteal resection of the avulsed fragments and the reinsertion of the TFCC and ulnar collateral ligament. Outcome assessments included the ranges of motion of the wrist, grip strength, pain, and Mayo wrist score. The preoperative and postoperative parameters were compared. A P-value less than 0.05 was considered to be statistically significant.

RESULT

The mean follow-up period was 21.66 ± 7.93 months (range, 12 to 26 months). At the final follow-up, the mean preoperative flexion and extension were 79.32 ± 4.52° and 74.40 ± 4.36° respectively. The mean preoperative pain score, grip strength, and Mayo wrist score were 32.48 ± 4.00; 23.88 ± 8.38 kg, and 77.72 ± 8.31 respectively. The mean postoperative flexion and extension of the wrist were 80.56 ± 6.32° and 75.43 ± 3.12° respectively. The mean postoperative pain score, grip strength, and Mayo wrist score were 12.41 ± 3.27, 26.31 ± 8.30 kg, and 90.71 ± 7.97 respectively. There were significant differences in pain, grip strength, and Mayo wrist score (P < 0.05), but no significant differences concerning the range of motion of the wrist.

CONCLUSION

In the treatment of the nonunion of type II ulnar styloid fractures, the resection of the avulsed fragments followed by the reinsertion of the TFCC and the ulnar collateral ligament with an anchor was a reliable alternative technique, bringing the satisfactory function of the wrist.

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]

INTRODUCTION

Fracture of the base of the ulnar styloid has shown to have higher incidence of TFCC tears and DRUJ instability leading to nonunion and impaired function. Poorer functional outcomes of the distal radius fracture have been attributed to the untreated associated ulnar styloid fractures while some studies have shown no difference. Thus, the treatment remains controversial. However, it has been shown that fractures at the base of the ulnar styloid have a higher incidence of tears in the triangular fibrocartilage complex (TFCC) and instability in the distal radioulnar joint (DRUJ), which can lead to nonunion and impaired function. Despite this, there are currently no studies comparing the outcomes of surgically and conservatively treated patients.

METHODS

A retrospective study was conducted to analyze the outcomes of intra-articular distal radius fractures associated with base of ulnar fracture treated with distal radius LCP fixation. The study included 14 patients who were treated surgically and 49 patients who were treated conservatively, with a minimum follow-up of 2 years. Radiological parameters such as union and amount of displacement, VAS score for ulnar-sided wrist pain, functional assessment using the modified Mayo score and the quick DASH questionnaire and complications were analyzed.

RESULTS

At the final follow-up, the mean scores for pain (VAS), functional outcomes (modified Mayo score), disability (QuickDASH score), range of motion, and non-union rate were found to be statistically insignificant (p > 0.05) between the surgically treated and conservatively treated groups. However, patients with non-union had statistically significant higher scores for pain (VAS), greater post-operative displacement of the styloid, poorer functional outcomes, and higher disability (p < 0.05).

CONCLUSION

While there was no significant difference in ulnar-sided wrist pain and functional outcomes between the surgically treated and conservatively treated groups, the conservatively treated cases had a higher risk of non-union, which can negatively impact functional outcomes. The amount of pre-operative displacement was found to be a key factor in predicting non-union and can be used as a guide for determining the management of this type of fracture.

Clinical Outcomes of Arthroscopic One-Tunnel Triangular Fibrocartilage Complex Transosseous Suture Repair Are Not Diminished in Cases of Ulnar Styloid Process Fracture Nonunion

PURPOSE

To determine whether clinical outcomes of arthroscopic one-tunnel wrist triangular fibrocartilage complex (TFCC) transosseous suture repair are not diminished in cases of ulnar styloid process fracture nonunion (USPFN).

METHODS

Patients who underwent arthroscopic 1-tunnel transosseous suture repair of Palmer 1B foveal TFCC tear (with/without superficial fiber tear; Atzei class 2 or 3 TFCC tear) from 2015 to 2020 were retrospectively reviewed. Group I was the TFCC foveal tear repair group with USPFN. Group II was the TFCC foveal tear repair group without USPFN. In group I, no additional treatment for USPFN was made. Functional preoperative and postoperative outcomes were compared by Modified Mayo Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; grip strength; pain visual analog scale (VAS); and distal radioulnar joint (DRUJ) stability. Wrist posteroanterior, lateral, and both oblique views of the wrist were used to assess the ulnar styloid process before and after operation.

RESULTS

This study consisted of 66 patients: group I (n = 22) and group II (n = 44). No differences were found between the 2 groups preoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .94, Quick-DASH: P = .23, grip strength: P = .69, VAS: P = .45). No differences were found between the 2 groups with respect to outcome measures postoperatively in MMWS, Quick-DASH, grip strength, and VAS (MMWS: P = .59, Quick DASH: P = .82, grip strength: P = .15, VAS: P = .84). All of the enrolled patients achieved restored function with negative ballottement test and maintained DRUJ stability on follow-up. Of the 22 USPFN cases in group I, 11 (50%) showed spontaneous union after transosseous TFCC foveal repair without any additional USPFN treatment. The proportion of patients achieving a minimal clinically important difference for the Quick-DASH was similar between the 2 groups.

CONCLUSIONS

Although this current study has insufficient statistical power, the available data suggest that patients with TFCC foveal tear combined with USPFNs treated with arthroscopic transosseous repair surgery could experience similar functional improvement compared with those with TFCC foveal tear without USPFNs. The presence of USPFN accompanied by Palmer 1B type TFCC foveal tear may not affect the clinical results, including MMWS, Quick-DASH, grip strength, VAS, and DRUJ stability of patients who undergo arthroscopic 1-tunnel transosseous suture repair.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Treatment with Buttress Plate Technique for Symptomatic Ulnar Styloid Base Nonunion

Background  Surgical treatment options for symptomatic ulnar styloid base nonunion can be divided into two groups: styloid excision and styloid fixation methods. Styloid fixation is commonly performed using tension band wiring or distal ulna hook plate. However, these methods are more suitable for large styloids than small ones. For this reason, fixation of small styloids still remains a problem. Purpose  To present the surgical details and results of patients operated using the buttress plate technique, due to the symptomatic ulnar styloid base nonunion. Patients and Methods  In this study, 11 patients who underwent surgery for symptomatic ulnar styloid base nonunion using buttress plate technique were evaluated retrospectively. The patients were evaluated with the help of forearm and wrist range of motion, grip strength, disabilities of the arm, shoulder, and hand (DASH) score and visual analogue pain score. Results  The mean follow-up period was 15 months (range: 13-21 months). Union was achieved in 10 patients. At the final follow-up, the forearm supination and pronation active range of motions were significantly higher than those in the preoperative period, the visual analogue pain score mean value was 0.7 (range: 0-5), and the DASH score mean value was 7 (range: 1-32). Conclusion  We conclude that good results can be achieved with the buttress plate technique in patients with both large and small fragmented ulnar styloid base nonunions and no distal radioulnar joint instability. Level of Evidence  This is a Level IV, therapeutic study.

[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.

Factors predictive for union of basal fracture of the ulnar styloid process after distal radial fracture fixation using a volar locking plate

BACKGROUND

Some basal ulnar styloid fractures (USFs) achieve union without surgical fixation when accompanying distal radius fractures (DRFs) are treated via placement of volar locking plates (VLPs). The purpose of this study was to seek factors predictive of such healing through the retrospective case-control study.

METHODS

We evaluated 203 patients who received VLPs to treat DRFs in our institute from March 2010 to February 2018; Group 1 contained "union" patients and Group 2 contained "nonunion" patients. Basic demographic, radiological, and operative variables were compared. At the final follow-up (at least 2 years postoperatively), pain was scored using a visual analog scale (VAS). Scores on the Disabilities of the Arm, Shoulder, and Hand (DASH) instrument; grip strengths; and demerit points of the Gartland and Werley system were compared between groups.

RESULTS

Group 1 consisted of 58 patients and Group 2 consisted of 147 patients. Univariate analysis showed that age, bone mineral density (BMD), and Gaulke USF classification significantly differed between groups (all p < 0.05). Multivariate analysis showed that BMD (p < 0.001, odds ratio [OR] = 0.214, 95% confidence interval [95% CI] = 0.126-0.363) and Gaulke classification (p < .001, OR = 0.092, 95% CI = 0.034-0.250) were significantly associated with USF union, which was significantly higher in patients with mean BMD ≥ -0.12 (the cutoff value) and type IIC USFs. However, postoperative clinical outcomes at the final follow-up did not differ significantly between groups (all p > 0.05).

CONCLUSIONS

Approximately 30% (58/205) of basal USFs associated with DRFs united after VLPs alone were placed to treat the DRFs. BMD ≥ -0.12 independently predicted union. Type IIC USFs exhibited more union than other fracture types. Additional surgical fixation of a basal USF accompanied by a DRF treated via VLP placement may be unnecessary, especially if BMD is good and fracture type is IIC.

LEVEL OF EVIDENCE

Level III, Case-control study.

Surgical management of ulnar styloid fractures: comparison of fixation with anchor suture and tension band wire

BACKGROUND

Limited reference is available regarding surgical management in symptomatic ulnar styloid fractures with small bony avulsion. The study goal is to report the surgical outcomes using anchor suture fixation with comparison to traditional tension band wire fixation.

METHODS

We retrospectively reviewed the medical records in patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2017. A total of 31 patients were enrolled including two kinds of fixation methods. Anchor suture fixation plus distal radioulnar joint pinning was performed in ten patients with tiny avulsion bony fragments (group A); tension band wire fixation was performed in 21 patients with big styloid fracture fragments (group B). Patient characteristics and 2-year treatment outcomes were compared between two groups based on Mayo Modified Wrist Score (MMWS); Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH); visual analog scale (VAS), and surgical complication. Descriptive statistics were used for calculation of key variables; a p value of < 0.05 was considered statistically significant.

RESULTS

Based on Gaulke classification, there were five subtypes in group A and three subtypes in group B. Incidence of concomitant distal radius fractures was significantly higher in group B; other patient characteristics including age, sex, injury side, and time to surgery showed no significant difference. Outcome assessment regarding MMWS, QuickDASH, and VAS was comparable between two groups. Bone-related complications including nonunion, DRUJ subluxation, and styloid resorption were analyzed; the difference was not significant. Incidence of implant-related complications including migration and secondary removal surgery was significantly higher in group B (p = 0.021).

CONCLUSION

Surgical fixation in symptomatic ulnar styloid fractures yields comparable treatment outcomes in both fracture patterns. Implant-related complication with secondary removal surgery is more common in tension band wire group. Anchor suture fixation is a feasible option for tiny styloid avulsion fragments with limited surgical complication.

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.