Validating Clinical Distal Radioulnar Joint Examination With Radiographic Parameters

BACKGROUND

The purpose of this study was to quantify the in vivo displacement of bilateral distal radioulnar joints (DRUJs) in resisted pronosupination. We hypothesize that this will demonstrate no appreciable difference between the left and right DRUJ, thus validating the concept of using the uninjured wrist as a control for physical examination as well as dynamic imaging studies.

METHODS

Thirty-two participants without a history of wrist pathology underwent a dynamic computed tomography (CT) protocol evaluating bilateral forearm rotation in neutral forearm rotation, 60° pronation, and 60° supination, including maximal isometric muscle loading. The DRUJ alignment, specifically the absolute degree and direction of subluxation of the ulna relative to the sigmoid notch, was then assessed using a modification of the radioulnar line method.

RESULTS

There was no significant difference in the mean displacement when comparing the right and left sides in neutral, pronation, or supination. The mean displacement was also compared between male and female patients, and there was no statistically significant difference in absolute displacement in neutral (male 0.99 mm vs female 1.38 mm) or supination (male -0.57 mm vs female -0.23 mm). However, the difference in pronation was statistically significant (male 2.69 mm vs female 3.26 mm). Of the 192 sequences, the measurements of displacement of the authors were within 1 mm 86% of the time (166 of 192).

CONCLUSIONS

Dynamic CT of bilateral DRUJs in resisted pronation, supination, and neutral demonstrated symmetry between the right and left DRUJ, supporting the concept of using the contralateral side as a control to identify instability in an injured wrist.

Comparing the Outcomes of Suture Anchor Repair and Rein-Type Capsular Suture for Triangular Fibrocartilage Complex Foveal Tears With a Minimum 2-Year Follow-Up

PURPOSE

Recent biomechanical studies have highlighted the importance of foveal reinsertion when repairing triangular fibrocartilage complex (TFCC) injury with foveal tears. However, clinical studies comparing different repair techniques are scarce. We compared the clinical outcomes of suture anchor repair and rein-type capsular suture in patients with TFCC palmer 1B foveal tears with a minimum of 2-year follow-up.

METHODS

This was a single-surgeon, single-center, retrospective, comparative study. We included patients who underwent TFCC repair surgery due to a foveal tear from December 2013 to October 2018 with a minimum follow-up of 24 months. Postoperative Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, Modified Mayo Wrist Score, visual analogue scale for pain, wrist range of motion, and grip strength were compared. We also measured the maximal ulnar head displacement with dynamic ultrasound to quantify distal radioulnar joint stability.

RESULTS

In total, 103 patients were in the suture anchor group (group A) and 84 patients in the rein-type capsular suture group (group B). The mean follow-up time exceeded three years for both groups. There was a minimal difference regarding QuickDASH score, visual analogue scale for pain, and grip strength ratio between the two groups. The rein-type group had significantly better Modified Mayo Wrist Score. The suture anchor group showed better distal radioulnar joint stability with dynamic ultrasound, but was more limited in ulnar deviation. However, these differences are most likely clinically insignificant.

CONCLUSIONS

Both suture anchor repair and rein-type capsular suture yielded satisfactory results for TFCC 1B foveal tear in a minimum of 2-year follow-up. The functional scores were similar, and no major complications or recurrent instability were noted in either group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Retrospective Therapeutic Comparative Investigation IV.

Adolescent Distal Ulna Physeal Fracture with Extensor Retinaculum Interposition

Background  Isolated distal ulna fractures are rare injuries and are commonly associated with distal radius fractures. Though most of them can be managed conservatively, few of them require open reduction due to the interposition of various structures. Case Description  In this case report, we report two cases of irreducible isolated distal ulna fractures in adolescents due to the interposition of the extensor retinaculum with its underlying tendons requiring open reduction to achieve bony union and distal radioulnar joint stability. These distal ulna fractures can be best reduced by open reduction with hypersupination and maintaining the distal ulna shaft gothic arch with pins. Literature Review  There are very few case reports reported on isolated distal ulna fractures commonly seen in paediatric and adolescent patients leading to growth arrest. The interposition of various structures is a cause of irreducibility requiring open reduction. These fractures are equivalent to TFCC injuries in adults. Clinical Relevance   Whenever there is a gross displacement or difficult reduction interposition is to be considered. Open reduction of the fracture and maintenance of DRUJ congruity is sufficient without being critical on articular reduction.

Effects of Ulnar Styloid Fractures on Unstable Distal Radius Fracture Outcomes: A Systematic Review of Comparative Studies

Purpose  In this literature review, functional outcomes such as Disability of Arm, Shoulder and Hand (DASH) score and the visual analog scale (VAS) of pain along with clinical outcomes such as range of movement and grip strength of treated distal radius fractures (DRF) accompanied with ulnar styloid fractures (USF) will be compared with those with isolated DRF. Materials and Methods  We analyzed articles from MEDLINE, Embase, and CINAHL that met our predetermined inclusion and exclusion criteria as per the Preferred Reporting Items for Systematic Reviews and Meta-analysis statements. This resulted in the identification of 464 articles with 18 potentially eligible studies of which 6 were included at the full-text screening stage. The primary outcomes were wrist pain, range of motion, functional outcome and satisfaction, such as VAS, and the DASH questionnaire along with radiological assessment and incidence of complications. Results  These studies involved 796 participants with DRF and 806 wrists with DRF; 444 (55%) of DRF had an associated USF. Three studies did not report any statistically significant difference in DASH scores between the DRF patients with or without USF. Two studies reported worse DASH scores in the group with associated USF. Wrist pain was reported to be statistically significantly worse in patients with associated USF in two studies. Grip strength did not exhibit a statistically significant difference in any groups in four studies. On assessing the range of motion of the wrist and forearm, only one study reported a statistically significant difference in flexion at 2 years follow-up, with less flexion in patients with USF. Conclusion  This review suggests that there is no significant correlation between a USF and the functional and clinical outcomes of DRF treatment, albeit wrist pain and less flexion were reported in some studies to be associated with USF. There is a need for more robust evidence from large randomized controlled trials to specifically look at the effects of fixation versus nonfixation of USF on DRF, or large prospective cohort studies assessing DRF with and without USF, with a minimum of 12 months follow-up. Level of Evidence  Level II-therapeutic.