Distal radioulnar joint injuries

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.

Ulnar Bowing and Distal Radioulnar Joint Anatomy: A Three-Dimensional, In Situ Clinical Assessment

Purpose

Distal radioulnar joint (DRUJ) injuries can be devastating and challenging to manage. The multiplanar curvature exhibited by the ulna impacts the morphology of the DRUJ, making it difficult to assess through two-dimensional radiographs alone. We used full-length, three-dimensional (3D) computed tomography angiography scans to assess the relationship between ulnar bowing, DRUJ ulnar variance (UV), and sigmoid notch angle. The goal of this study was to establish normal anatomic ranges for these landmarks to improve treatment for forearm traumas and DRUJ pathologies.

Methods

Eighty-two intact upper extremity computed tomography angiography scans were examined and reconstructed into 3D models. We characterized ulnar bowing and DRUJ metrics using computer-aided design software. Measures of central tendency and Pearson correlation coefficients were calculated for comparative analysis.

Results

The study yielded an average ulnar length of 272.3 mm. We identified the proximal ulnar bow at 36.7% of the bone's total length, possessing a depth of 10.3 mm, a proximal angle of 6.6°, and a distal angle of 3.9°. The distal ulnar bow appeared at 75.3% of the bone's length, characterized by a depth of 4.2 mm, a proximal angle of 2°, and a distal angle of 4.3°. In the coronal plane, the proximal angle of the proximal ulnar bow correlated positively with UV (r = 0.39, P < .001), whereas the distal angle of the distal ulnar bow correlated negatively (r = -0.48, P < .001). We also found significant correlations between the depths of both proximal and distal bows with UV (r = 0.38, P < .001; r = -0.34, P < .001, respectively). Moreover, UV within the DRUJ strongly correlated with the sigmoid notch angle (r = -0.77, P = .01). In contrast, the sagittal plane metrics did not show meaningful correlations with UV.

Conclusion

Sagittal alignment and translation at the DRUJ articulation are directly related to ulna bowing at the distal ulna. A nuanced understanding of these 3D relationships can enhance preoperative planning when correcting ulnar-side pathology.

Type of study/level of evidence

Therapeutic IV.

An alternative treatment for degenerative triangular fibrocartilage complex injuries with distal radioulnar joint instability: first experience with 48 patients

Treatment of ulnar impaction syndrome combined with distal radioulnar joint instability due to irreparable degenerative triangular fibrocartilage complex injuries can be complex. We describe the outcomes of a novel technique for restoring distal radioulnar stability due to ulnar impaction syndrome using a distally based extensor carpi ulnaris tendon strip combined with ulnar shortening osteotomy in 48 patients. Patients were assessed using standardized outcome measurements. The patient-rated wrist/hand evaluation total score improved from 66 (SD 15) at intake to 40 (SD 25) at 3 months, and 28 (SD 23) at 12 months postoperatively (p < 0.001). Wrist extension and flexion improved significantly at 12 months from 53° (SD 11) to 65° (SD 8) (p < 0.001) and from 45° (SD 10) to 56° (SD 12) (p = 0.01), respectively. Adding a distally based longitudinal extensor carpi ulnaris strip to ulnar shortening osteotomy for restoring distal radioulnar joint stability seems to be an effective treatment in patients with irreparable degenerative triangular fibrocartilage complex injuries due to ulnar impaction syndrome. Level of evidence: IV.

Acute isolated volar distal radioulnar joint dislocation: first surgery or conservative?

Isolated distal radioulnar joint (DRUJ) dislocations are referred to as dorsal or volar of neglected isolated volar DRUJ dislocation which was detected at the second dislocations concerning the position of the ulnar head in relationship to the radius. In contrast to large joint dislocations such as a shoulder dislocation, the clinical picture may mimic a simple soft tissue injury and the dislocation may be missed. In this article, we aimed to present a case presentation to the emergency department. Our patient who had no complaint other than wrist pain was diagnosed with volar dislocation on lateral radiography and closed reduction was performed in the emergency department with sedation. There was no recurrence in the follow-up and we achieved a satisfactory result with a painless and unrestricted wrist joint at six months. DRUJ and the ligaments stabilize the joint work in anatomical coordination and play an important role in forearm rotation movement. Traumatic injuries to these structures range from isolated tears to severe fractured dislocations. Isolated DRUJ dislocations are rare. Initial treatment of this injury is closed reduction, post-reduction stability is important and fixation is required in case of instability. Although surgical treatment is performed in cases that cannot be closed reduced and in the presence of instability after reduction, it is possible to obtain successful results in acute cases with closed reduction performed with sedation in emergency departments. For this reason, a conservative approach should be tried before making a surgical decision in these injuries that require special attention in diagnosis.

Lisfranc Sports Injuries: What Do We Know So Far?

Lisfranc sports injuries include tarsometatarsal joint injuries, which may be accompanied by fractures. They most commonly occur due to a blow or axial force. The aim of this review is to assess the current standards for surgical intervention in Lisfranc injuries resulting from sports-related accidents. This evaluation will cover the timing of treatment, the recovery process, and the appropriate timing for a return to normal sporting activities. This research was done via an analytical review of current literature. Methods included a structured search strategy on PubMed, Science Direct, and Google Scholar. The collated literature was processed using formal inclusion or exclusion, data extraction, and validity assessment. Joint involvement and severity were taken into account while classifying Lisfranc injuries. The primary fixation and fusion techniques for Lisfranc injuries were compared, and the surgical management of these injuries was examined in all of the literature. Treatment recovery times were examined, and the results were talked about. A variety of injuries, from minor sprains to serious fractures and rips, make up Lisfranc injuries. Although open reduction internal fixation (ORIF) in combination with primary arthrodesis (PA) is now thought to be the optimum course of treatment, its acceptance has increased. Patients with Lisfranc injuries can usually expect excellent outcomes and the return of joint function to its pre-injury form if the injury is appropriately assessed and treated. Lisfranc injuries are manageable and have a good recovery time if not neglected. The outcomes of management and surgical options are also quite satisfactory.

Isolated dorsal dislocation of the distal radioulnar joint: A case report

Isolated acute dislocation of the distal radioulnar joint is a rare lesion, and in 50 % of cases goes unrecognized; it may be palmar or dorsal. Its diagnosis is suspected when the wrist is traumatic, painful, with limited pronosupination and no fracture on radiological examination. Treatment is aimed at preventing the development of chronic instability and/or arthrosis, and consists of reduction followed by immobilization.

Both Bone Forearm Fracture with Complex DRUJ Dislocation: What Are the Odds?

Background  Distal radioulnar joint (DRUJ) dislocation can occur as an isolated injury or in association with fracture radius (Galeazzi fracture-dislocation), Essex-Lopresti lesion or, rarely, with fracture of both radius and ulna (termed "Galeazzi type fracture"). DRUJ dislocations can be simple or complex. While simple DRUJ dislocation can be reduced by closed methods once the associated fractures are fixed anatomically, complex dislocation does not reduce by closed means. A complex DRUJ dislocation occurring in a both bone forearm fracture is an extremely unusual pattern of injury. Case Description  We describe the clinical presentation, intraop findings, management, and follow-up of two such cases of both bone forearm fracture with complex DRUJ dislocation. In both the cases, the ulnar head was found to be buttonholed through extensor retinaculum between the extensor tendons. Open reduction had to be done via dorsal approach. Timely intervention allowed good results in both the patients. Literature Review  Several authors have reported simple DRUJ dislocations in both bone forearm fractures; however, we could come across only three cases of complex DRUJ dislocation in a both bone forearm fracture. A summary of various series and reports on these injuries is presented. Case Relevance  Through this case report, we want to highlight this unusual association and emphasize on sequence of fixation, so that this perilous injury pattern is not missed, and favorable outcomes could be obtained through appropriate and timely intervention.

Greenstick Fractures of the mid- Radial and Ulnar Diaphysis with Volar Angulation

The authors present the case of a patient who was brought to the emergency department (ED) with severe left forearm pain following a classroom fall. This incident exacerbated the fractures that the patient experienced three months earlier in an accident. He had partial fractures of the middle radial and ulnar diaphyses. A review of the various presentations of forearm fractures and the nonoperative and surgical treatment options are discussed.

Reconstructing a chronic, malunited Galeazzi fracture with distal radial ulnar joint instability: a simple, modified technique

A male in his 70s presented with a chronic malunited comminuted Galeazzi fracture dislocation, including angular malunion, radial shortening (1.3 cm ulnar-plus variance) and distal radioulnar joint (DRUJ) instability secondary to chronic dislocation with mechanical rotation block. A modified, single-stage radius corrective osteotomy with bone grafting technique to overcorrect radius length was employed, restoring normal DRUJ motion and stability by engaging the secondary DRUJ stabilisers without triangular fibrocartilage complex repair. DRUJ stability was restored via radius lengthening, engaging the DRUJ's secondary stabilisers, bypassing the need for complex ligamentous reconstruction. The patient returned to full activity. We recommend our simple yet effective approach to treat chronic, malunited Galeazzi fractures with DRUJ instability.

Finite element analysis of intraosseous distal radioulnar joint prosthesis

BACKGROUND

Joint replacement is one of the options to retrieve the interosseous distal radioulnar joint (DRUJ) function. DRUJ prosthesis has recently been introduced clinically to treat DRUJ instability. This article analyzes the biomechanical behavior of the prosthesis during different loadings by the finite element method.

METHODS

CT images of a healthy 33 years old man were used to construct the three-dimensional geometry of the forearm bone. Then two models, a healthy foreman (Model A) and a damaged model with an inserted interosseous prosthesis (Model B), were constructed to analyze and compare the foreman's biomechanical behavior under different loading conditions using the finite element method. Both models were examined during pronation and supination with 500, 1000, 2000, and 5000 N.mm values. Also, both models were subjected to volar and dorsal loads with values of 10, 30, and 50 N and traction force with 100, 150, and 200 N.

RESULTS

Maximum and minimum principal stresses were evaluated for bones in all conditions, and von Mises stress was considered for the prosthesis and fixing screws. In supination, the maximum stress in Model A is significantly higher than the Model B. However, the maximum principal stress of both models is similar during volar and dorsal loading. In Model A, the maximum principal stress in traction is much smaller than in Model B. The absolute value of minimum principal stress in pronation and supination in Model B is higher than in Model A. The prostheses and screws are subjected to higher stresses during pronation than supination. Also, the amount of stress created in prostheses and screws during volar and dorsal loading is almost equal. In traction loading, screws are subjected to significantly high stresses.

CONCLUSION

Our study indicates that the interosseous DRUJ prosthesis can perform the foreman's normal daily activities. This prosthesis provides the ability similar to a normal hand.

LEVEL OF EVIDENCE

IV.

3D analysis of the distal ulna with regard to the design of a new ulnar head prosthesis

STUDY DESIGN

A retrospective, single center, data analysis.

OBJECTIVE

Persistent pain and instability are common complications after distal ulnar head arthroplasty. One main reason may be the insufficient representation of the anatomical structures with the prosthesis. Some anatomical structures are neglected such as the ulnar head offset and the ulnar torsion which consequently influences the wrist biomechanics.

METHODS

CT scans of the ulnae of forty healthy and asymptomatic patients were analyzed in a three-dimensional surface calculation program. In the best fit principle, cylinders were fitted into the medullary canal of the distal ulna and the ulnar head to determine their size. The distance between the central axes of the two cylinders was measured, which corresponds to the ulnar offset, and also their rotational orientation was measured, which corresponds to the ulnar torsion.

RESULTS

The mean medullary canal diameter was 5.8 mm (±0.8), and the ulnar head diameter was 15.8 mm (±1.5). The distance between the two cylinder axes was 3.89 mm (±0.78). The orientation of this offset was at an average of 8.63° (±15.28) of supination, reaching from 23° pronation to 32° supination.

CONCLUSION

With these findings, a novel ulnar head prosthesis should have different available stem and head sizes but also have an existing but variable offset between these two elements. A preoperative three-dimensional analysis is due to the high variation of offset orientation highly recommended. These findings might help to better represent the patients natural wrist anatomy in the case of an ulnar head arthroplasty.

LEVEL OF EVIDENCE

III.

Creation of 3D anatomical models illustrating an intact and centrally torn triangular fibrocartilage complex for patient education prior treatment

BACKGROUND

The triangular fibrocartilage complex (TFCC) is a composite structure located in the human wrist and is made up from fibrocartilage and ligaments. It consists of eight distinct structures, with the ligamentous structures acting as the major stabilizer of the distal radioulnar joint and with the articular disc acting as a shock absorber at the ulnocarpal joint. The articular disc can be called the triangular fibrocartilage (TFC). Thus, traumatic injuries of the TFCC ligamentous structures cause instability of the joint and a centrally torn TFC disc causes ulnar sided wrist pain. TFCC pathologies can be difficult for patients to understand in clinic, due to their complex three-dimensional (3D) nature. The purpose of this study was to produce 3D anatomical models illustrating the normal anatomy of the wrist joint with the TFCC structure and a pathological model with a centrally torn TFC. These models would be used in a hand clinic to aid explanation of this complex three-dimensional anatomical structure and their injury to patients and trainee doctors.

MATERIALS

Three fresh frozen forearm and hand specimens were dissected, 3D scanned, 3D printed and painted. These models were introduced into a hand clinic to aid explanation of the complex anatomical structures, with the first 50 patients being asked, on a visual analog scale of 0-10, to state how much the models helped their understanding of the condition.

RESULTS

Three 3D printed anatomical models were produced to illustrate the (1) forearm muscles and wrist tendons, (2) an intact TFC and (3) a centrally torn TFC. 48 of 50 patients surveyed completed the scale, with an average rating of 8.7 increase in understanding with the models.

CONCLUSION

Patient education and understanding is crucial as it enhances decision making between surgeon and patient. These 3D anatomical models were shown to increase patient's understanding of the pathology. This should consequentially improve discussions on corresponding treatment options during consultation.

Monteggia Fracture-Dislocation with Associated TFCC Injury and DRUJ Subluxation - A Very Rare Case Report

Introduction

Monteggia fracture-dislocation is defined as a proximal third ulna fracture with radiocapitellar joint dislocation. The term "Monteggia equivalent or variant" describes various injuries with similar radiographic patterns and injury biomechanics. Several isolated cases of unusual injuries associated with Monteggia fractures have been reported. However, an associated TFCC injury has not been described in the literature before. We present a rare report of a 24-year-old female with a Monteggia fracture and associated TFCC injury - a crisscross type of injury.

Case Report

A 24-year-old female was involved in a road traffic accident and presented to our level I trauma center with pain and deformity in the left forearm. On evaluation, she was found to have type I Monteggia fracture-dislocation. Intraoperatively, once the proximal ulna was fixed, she had clicking in the wrist during rotations. Fluoroscopic images showed DRUJ subluxation, but it was stable in supination. Hence was splinted in a reduced position. The patient continued to have persistent symptoms in the wrist despite adequate conservative measures. Hence, she underwent arthroscopic TFCC repair and DRUJ pinning. At her last follow-up (3 months), the patient was clinically better with a good range of motion and no pain.

Conclusion

In treating Monteggia fracture-dislocations, high index of suspicion is needed to diagnose radioulnar joint instability. If they are missed, they can result in long-term disability, so appropriate evaluation to diagnose TFCC and DRUJ injuries is required. DRUJ stabilization and TFCC repair can produce consistent results when treated adequately.

Influence of volar margin of the lunate fossa fragment fixation on distal radius fracture outcomes: A retrospective series

BACKGROUND

Distal radius fractures accompanied by the volar margin of the lunate fossa (VMLF) lesions are often overlooked or inadequately reduced in clinical practice.

AIM

To investigate the impact of VMLF fragment in distal radius fractures on the stability and function of the wrist joint.

METHODS

This was a retrospective study of patients with distal radius fractures who underwent surgical treatment between January 2013 and December 2017. The patients were divided into two groups according to whether the VMLF fragments were fixed or not. X-rays and computed tomography were performed before surgery, immediately postoperatively, and at 1, 3, and 6 mo to measure the scapholunate angle, radiolunate angle, capitolunate angle, and effective radiolunate flexion (ERLF). The Mayo wrist score and disabilities of the arm, shoulder, and hand (DASH) score were determined at 1 year.

RESULTS

Thirty-five patients were included. There were 15 males and 20 females. Their mean age was 52.5 ± 14.3 (range: 19-70) years. There were 38 wrists (17 on the left side, 15 on the right, and three bilateral; 16 in the fixed group, and 22 in the unfixed group). The interval between trauma and surgery was from 1 h to 1 mo. The incidence of postoperative wrist instability in the unfixed group (86.4%) was higher than in the fixed group (25.0%) (P ≤ 0.001). Ten patients had ERLF > 25° in the unfixed group and none in the fixed group (P = 0.019). The Mayo wrist score was 94 ± 5.7 in the fixed group and 68 ± 15.1 in the unfixed group (P < 0.001). The DASH score was 4.6 ± 2.5 in the fixed group and 28.5 ± 19.5 in the unfixed group (P < 0.001).

CONCLUSION

Injuries of VMLF, even small fractures, might damage the radial-lunar ligament, leading to postoperative wrist instability, sagittal force line imbalance, and poor recovery of wrist joint function.

Distal Radioulnar Joint Instability and Associated Injuries: A Literature Review

The distal radioulnar joint (DRUJ) allows supination and pronation of the distal forearm and wrist, an integral motion in everyday human activity. DRUJ injury and chronic instability can be a significant source of morbidity in patients' lives. Although often linked with distal radius fractures, DRUJ injury may occur in a variety of other upper extremity injuries, as well as an isolated pathology. Diagnosis of this injury requires the clinician to have a high index of suspicion and low threshold for clinical testing and further imaging of the DRUJ. The purpose of this article is to provide a review on DRUJ anatomy and biomechanics, to discuss common diagnostic and treatment modalities, and to identify common injuries associated with DRUJ instability.

Isolated dorsal dislocation of the distal radioulnar joint: A case report

Isolated distal radioulnar joint (DRUJ) dislocation is a rare injury. Reports of isolated DRUJ luxations, volar or dorsal, are often case reports and rarely a series of cases. We present a case of an isolated acute dorsal dislocation of the distal radioulnar joint in a 25-year-old man. The patient underwent closed reduction and a transcutaneous radioulnar pinning was done followed by cast immobilization in neutral rotation during 6 weeks. After six months follow -up, the functional result was satisfactory, patient experienced no pain and had no restrictions in work or sports-related activities.

Evaluation and Management of Hand, Wrist and Elbow Injuries in Ice Hockey

Ice hockey continues to be a popular, fast-paced, contact sport enjoyed internationally. Due to the physicality of the game, players are at a higher risk of injury. In the 2010 Winter Olympics, men’s ice hockey had the highest injury rate compared to any other sport. In this review, we present a comprehensive analysis of evaluation and management strategies of common hand, wrist, and elbow injuries in ice hockey players. Future reseach focusing on the incidence and outcomes of these hand, wrist and elbow injuries in ice hockey players is warranted.

Comparison of a standard locking screw versus a double-threaded cortical compression screw for fixation of die-punch fragments in distal radius fractures with volar plating

The aim of this study was to use a compression screw in the epiphyseal medial orifice of a volar plate to reduce and stabilize the die-punch fragment in distal radius fractures (DRF) undergoing open reduction and internal fixation (ORIF). The main hypothesis was that the range of motion (ROM) in supination would be poorer when a standard screw was used. Our case series included 19 patients with an average age of 59 years (24-91) (SD -35.32) (10 male patients and 9 females) who underwent ORIF of DRFs with a volar plate. Group I included 10 patients in which the die-punch fragment was fixed with a standard locking screw and group II included the 9 patients in which the die-punch fragment was fixed with an angle stable compression screw through both cortices. At the 6-month follow-up visit, the average ROM in flexion was 83% in group I and 81% in group II (-2.327 [-13.657; 8.960]), the ROM in extension was 91% and 89% (-2.754 [-13.410; 7.602]), the ROM in pronation was 100% and 102% (+3.178 [-5.242; 11.457]), the ROM in supination 100% and 97% (-3.171 [-10.825; 4.537]), the pain level was 0.6/10 and 1/10 (+0.106 [-0.809; 0.977]), the QuickDASH score was 8.1/100 and 17.17/100 (+5.790 [-2.934; 15.012]), the PRWE was 6.2/100 and 22/100 (+13.109 [4.416; 22.779]) and the grip strength was 95% and 74% of the contralateral side (-12.478 [-24.832; 0.538]). No complications, nonunions or revision surgery were reported in the two groups. One case of secondary displacement of the die-punch fragment occurred in each group. The main hypothesis was not proven. In conclusion, despite what several biomechanical studies have suggested, the use of double-threaded compression screws for die-punch fragment fixation in DRFs does not improve the clinical outcomes compared to standard locking screws.

Technique of Tendon Interposition Arthroplasty for Chronic Volar Dislocation of the Distal Radioulnar Joint

Volar distal radioulnar joint (DRUJ) dislocations are uncommon wrist injuries. Failed diagnosis or treatment can result in irreversible damage to the articulating surfaces and ultimately lead to chronic degenerative arthritis. When the DRUJ is reducible, and the cartilage is preserved, ligament reconstruction and ulnar osteotomy are surgical options for residual wrist instability or pain. When destruction of the native DRUJ has already occurred, surgical treatment options are salvage procedures. Here we present treatment for a chronic volarly dislocated DRUJ with open reduction and internal fixation using an alternative joint-preserving surgical technique with tendon allograft interposition arthroplasty.

A very rare presentation of reoperation combined both old Monteggia fracture and secondary distal radioulnar joint dislocation in adult: A case report

RATIONALE

The old Monteggia fracture is an uncommon lesion pattern in adult, which may lead to the potential complications such as recurrent dislocation of the radial head, heterotopic ossification of the elbow, nerve palsy, malunion of the ulna, and residual forearm deformity. However, the secondary distal radioulnar joint (DRUJ) dislocation is rarely reported in the similar lesion. Here we present a unique reoperation of old Monteggia fracture combined with secondary DRUJ disruption after the initial operation failure.

PATIENT CONCERNS

A 38-year-old male presented to our hospital outpatient office complaining of left elbow stiffness and ongoing wrist dysfunction with a history of injury to the left forearm caused by a forklift accident that occurred 5 months previously.

DIAGNOSIS AND INTERVENTIONS

At the local hospital, the patient underwent successively fasciotomy and decompression, ulnar open reduction, and internal fixation due to osteofascial compartment syndrome and a misdiagnosed ulnar fracture. Upon examination, the secondary dorsal dislocation of the DRUJ was obvious both clinically and radiographically. We performed a revision surgery called ulnar osteotomy, radioulnar ligament repair, and temporary fixation of the DRUJ with a Kirschner wire.

OUTCOMES

The patient received a satisfactory result without observed redislocation and relapse according to the 1-year follow-up.

LESSONS

Considering the notoriously poor outcomes, the importance of early recognition and accurate treatment should be emphasized repeatedly in similar lesions. Paying close and continuous attention to the clinical and radiographic examinations of the elbow and wrist joint is necessary to avoid misdiagnosis and missed diagnosis.

Current perspectives in conventional and advanced imaging of the distal radioulnar joint dysfunction: review for the musculoskeletal radiologist

Distal radioulnar joint (DRUJ) dysfunction is a common cause of ulnar sided wrist pain. Physical examination yields only subtle clues towards the underlying etiology. Thus, imaging is commonly obtained towards an improved characterization of DRUJ pathology, especially multimodality imaging, which is frequently resorted to arrive at an accurate diagnosis. With increasing use of advanced MRI and CT techniques, DRUJ imaging has become an important part of a musculoskeletal radiologist's practice. This article discusses the normal anatomy and biomechanics of the DRUJ, illustrates common clinical abnormalities, and provides a comprehensive overview of the imaging evaluation with an insight into the role of advanced cross-sectional modalities in this domain.

A new classification and its value evaluation for intermediate column fractures of the distal radius

BACKGROUND

Intermediate column fractures of the distal radius (ICF) are fractures only or mainly limited to the lunate fossa of the distal radius. There are no classification systems and its value evaluation for ICF in the literature.

METHODS

According to the characteristics of ICF, ICF were divided into the volar, dorsal, split, collapse, and collapse with split types. Inter- and intra-observer agreements were analyzed with kappa statistics. Seventy-four patients with ICF were retrospectively studied from January 2008 to June 2016. Surgical approach and reduction-fixation method were taken under the guidelines of the classification in 54 patients with displaced fractures, while conservative treatment was taken in 16 patients with non-obvious displaced fractures and 4 patients with displaced fractures who declined surgery.

RESULTS

The inter- and intra-observer kappa coefficients were 0.875~0.925 and 0.900~0.950, respectively. All patients were followed up for 13~36 months (average, 18.4 months). At the last follow-up, according to Gartland and Werley score of the functional recovery of wrist, all except 3 patients had excellent or good results (the excellent and good rate was 95.95%).

CONCLUSION

The classification reflects the characteristics of ICF and may provide an important reference for choosing treatment and evaluating prognosis.

Functional Effects of the Adams Procedure: A Retrospective Intervention Study

Background  Injury to the distal radioulnar joint (DRUJ) causes swelling and ulnar-sided wrist pain. The Adams procedure stabilizes the DRUJ and shows promising short-term results. Purpose  We studied the long-term functional outcome in patients who underwent the Adams procedure. We also tested the null hypothesis that there would be no difference in range of motion (ROM) and grip strength between the operated wrist compared to the unaffected side. Patients and Methods  We identified 74 consecutive patients that were operated from March 2005 to February 2014. Twenty-three patients responded to our invitation and underwent clinical follow-up. Three patients had a re-do of the Adams procedure after presenting with postoperative DRUJ instability, one was excluded due to additional wrist surgery not related to the initial procedure. Wrist functionality in the remaining 22 patients was examined by measuring ROM in all planes and grip strength of the operated and non-operated hand. Functional outcome was measured by asking patients to complete the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome measure and the Patient-Rated Wrist and Hand Evaluation (PRWHE). Results  After a mean follow-up time of 5.0 years (standard deviation [SD] 2.0), we found that supination, pronation, and grip strength were significantly decreased in the operated wrist. Postoperative DASH and PRWHE-scores averaged 13.1 (SD 18.6) and 20.3 (SD 15.1), respectively. Conclusion  The Adams procedure affects, but largely restores pronation and supination, and clinical examination, DASH, and PRWHE scores indicate that the Adams procedure leaves patients with upper extremity functionality comparable to a healthy population. Level of Evidence  Level IV.

Treatment of distal radioulnar joint dislocation with spontaneous rupture of extensor tendon by Sauve-Kapandji osteotomy assisted by wrist arthroscopy: A case series and literature review

RATIONALE

Dislocation of the distal radioulnar joint and injury to distal forearm are commonly encountered. However, delayed diagnosis or misdiagnosis has been relatively rare due to improved diagnosis and treatment. Treatment of old dislocation of radioulnar joint is challenging due to development of secondary chronic instability and difficulties in restoration of joint function.

PATIENT CONCERNS

This report describes three cases of patients complained about inability to extend their little fingers.

DIAGNOSES

Local examination and X-ray revealed chronic ulnar joint dislocation.

INTERVENTION

Wrist arthroplasty was used to perform ulnar distal articular cleansing and repair of the triangular fibrocartilage complex (TFCC) articular cartilage. The Sauve-Kapandji osteotomy was performed to treat radial joint dislocation and stabilize ulnar joint. Repair of spontaneous fracture of the extensor tendon was also performed. Postoperative gypsum was used for immobilization for 4 weeks.

OUTCOMES

The follow-up results are reported. Based on Cooney wrist score, the preoperative scores were poor (55, 50, 60), while the post-operative scores were excellent (90, 85, 90) in all 3 cases.

LESSONS

Early and accurate diagnosis and treatment is important for the recovery of distal radius fracture for patients with dislocation of the ulnar joint. The correct treatment determines the degree of later functional recovery. Early surgical treatment is recommended for patients with unsatisfactory reset. Delayed diagnosis and treatment often lead to chronic and persistent lower ulnar joint subluxation or dislocation, or even osteoarthritis. All patients in this report showed great improvement in wrist function after surgery.

Volar Distal Radioulnar Joint Dislocation Associated with Acute Median Nerve Neuropathy and a Distal Radius Fracture

Volar distal radioulnar (DRUJ) dislocations are uncommon and can easily be missed. We present a rare case of an irreducible volar DRUJ dislocation associated with a distal radius fracture and acute median nerve neuropathy at the wrist. An attempt to reduce the DRUJ dislocation in the emergency department had failed. The patient was then taken to the operating room requiring a carpal tunnel release, as well as an open reduction and internal fixation of the distal radius fracture and repair of the volar distal radioulnar ligament. We also review some of the volar DRUJ case reports in the literature.

Image classification for Die-punch fracture of intermediate column of the distal radius

OBJECTIVE

The aim of the study was to analyze the imaging findings of Die-punch fracture of intermediate column of the distal radius, and to explore the clinical application value of image classification.

METHODS

The clinical data of 45 patients who were admitted to our hospital from May 2010 to October 2016 were analyzed retrospectively. All patients met the inclusion criteria for Die-punch fracture. X-ray and CT scan were performed to examine the fracture, and the results were assessed by two doctors in a double blind method. Finally, the image classification of Die-punch fracture was formulated.

RESULTS

According to the imaging features of Die-punch fracture, it was divided into four types: type I (dorsal type, 15 cases), type II (volar type, 8 cases), type III (splitting type, 10 cases), type IV (collapsed type, 12 cases). The accuracy rate of CT was 100% (45/45). The misclassification rate of X-ray was 15.6% (7/45) and the missed diagnosis rate was 11.1% (5/45).

CONCLUSIONS

CT examination could accurately diagnose Die-punch fracture and perform preoperative image classification.

Ultrasound-Guided Intra-articular Injection of the Radio-ulnar and Radio-humeral Joints and Ultrasound-Guided Dry Needling of the Affected Limb Muscles to Relieve Fixed Pronation Deformity and Myofascial Issues around the Shoulder, in a Case of Complex Regional Pain Syndrome Type 1

BACKGROUND

Complex regional pain syndrome (CRPS) occurs due to different pathophysiological mechanisms. Presently there is no description of definitive treatment that can resolve the especially recalcitrant motor issues of disability in CRPS type 1 (CRPS-1).

CASE REPORT

We have herein described the successful management of motor disability with a multimodal approach in a patient with CRPS-1 that occurred as a result of a fracture sustained in the lower end of the radius. Sensory/sudomotor/vasomotor symptoms were relieved completely by medications and stellate ganglion block in 2 weeks. Ultrasound-guided dry needling secured near-complete improvement of shoulder and hand movements in 45 days. Ultrasound guided intra-articular (radio-ulnar and radio-humeral joint) injections with steroid reduced residual pain and improved forearm movements by 50% initially. The patient continued to receive regular sessions of dry needling, physiotherapy, and cognitive behavioral therapy. By the end of 1 year, the functions of the limb improved remarkably, as did the functional outcome scores.

CONCLUSION

In this patient with CRPS-1, intra-articular injections with steroid reduced nociception in the affected local structures and sensitization in the nervous system; dry needling resolved the myofascial issues; sustained physiotherapy maintained the motor recovery; and behavioral therapy techniques addressed the cognitive and life stress issues. It was concluded that the presenting symptoms in this case were a consequence of interactions between humoral, nervous, and myofascial systems.

The ulnar side of the wrist: Clinically relevant anatomy and biomechanics

BACKGROUND

In the hectic environment of a hand therapy clinic, the opportunity to carefully consider the relationships among pathology, pathomechanics, surgical repair techniques, tissue healing, postoperative management, and rehabilitation program development and progression is limited. Clinicians often default to seeking a protocol, a recipe to follow.

OBJECTIVES

Using the ulnar side of the wrist as an example, relevant anatomy and biomechanics are directly related to several commonly seen pathologies, including fractures, ligament injuries, and instability.

CONCLUSION

Armed with knowledge of anatomy, biomechanics, and surgical procedures, the need for a protocol disappears. Each patient can be individually managed according to his or her unique set of variables and responses to injury, repair, healing, and recovery of function.

Minimally Displaced Distal Radius Fracture Treated with Closed Reduction and Percutaneous Fixation Resulting in an Iatrogenic Galeazzi Lesion

Galeazzi fracture in skeletally immature patients is a relatively uncommon injury. No previously published case has been associated with an iatrogenic mechanism. Here, we report a case of a 10-year-old boy with a minimally displaced distal radius fracture evolving into a Galeazzi lesion after unnecessary surgical treatment. Unnecessary surgical procedure associated with poor knowledge of bone growth and physiology contributed significantly to the reported condition.

Traumatic disorders of forearm rotation: anatomy, biomechanics and treatment

The forearm is a complex structure which produces a wide range of movement. Forearm injuries are very common, but many injuries are missed or poorly treated. This article examines the anatomy and biomechanics of the forearm, and describes the important injuries to be recognized.