Outcomes and complications of ulnar shortening osteotomy: an institutional review

Background

Ulnar impaction syndrome (UIS) is a common cause of ulnar wrist pain. Patients may be candidates for surgical intervention if nonoperative options are ineffective. At our institution, ulnar shortening osteotomy is the preferred procedure to manage this disorder. The purpose of this study was to present patient reported outcomes and complication rates of ulnar shortening osteotomy (USO) at mid-term follow-up.

Methods

A retrospective chart review of 72 patients (75 wrists) obtained from our institutional database was performed. At a mean 32 months postoperatively, telephone interviews (n = 53) were performed for all patients who were available for follow-up. The patient-rated wrist evaluation (PRWE), a validated outcome tool, was completed and complications were reviewed.

Results

Patient-rated outcomes were favorable; however, complications were frequent and included: delayed union (10/75, 13.3 %), nonunion (6/75, 8 %), and complex regional pain syndrome (5/75, 6.7 %). Ten patients (13.3 %) required revision surgery. Thirty-four patients (45.3 %) required hardware removal with 4/30 (11.4 %) of these patients experiencing refracture. Smokers (mean PRWE 67.1) and patients with workers’ compensation claims (mean PRWE 64.9) reported higher residual pain and disability than their counterparts (mean PRWE 28.0; 25.2).

Conclusions

General outcome measures were favorable. Smokers and patients with workers’ compensation claims experienced significantly poorer outcomes. However, the incidence of nonunion and delayed union was higher than most reports in the literature. Furthermore, we demonstrated a high refracture rate (11.4 %) following removal of hardware.     

Positive or Negative Ulnar Variance after Ulnar Shortening for Ulnar Impaction Syndrome: A Retrospective Study

Background

The goal of this study was to compare simple radiographic findings and clinical results according to residual ulnar variance following ulnar shortening for ulnar impaction syndrome.

Methods

Forty-five cases of ulnar impaction syndrome, which were treated with ulnar shortening from 2005 to 2008, were studied retrospectively. Group I included 13 cases with positive residual variance after ulnar shortening and group II included 32 cases with negative variance after shortening. The presence of a lunate cystic lesion both preoperatively and at final follow-up and assessments of wrist function based on the modified Mayo wrist score, the disabilities of the arm, shoulder, and hand (DASH) score, as well as the Chun and Palmer score were evaluated.

Results

A cystic lesion of the lunate was present in 4 cases preoperatively and the size decreased in 2 cases at final follow-up in group I, and in 10 and 5 cases, respectively, in group II. No statistical difference was observed between the groups. The modified Mayo wrist score, DASH score, as well as the Chun and Palmer score improved significantly in both groups. No significant differences were observed between the two groups in terms of the proportion of positive cystic lesions at final follow-up or the functional scores.

Conclusions

After ulnar shortening, the degree of radiological change in the cystic lunate lesions and clinical improvement did not differ significantly between the groups with unintended residual positive and negative variance after shortening.     

Outcome analysis of ulnar shortening osteotomy for ulnar impaction syndrome

BACKGROUND:

Ulnar-sided wrist pain is a common problem in the upper extremity. It affects a broad patient population and can be difficult to treat. Ulnar impaction syndrome (UIS) is major cause of ulnar-sided wrist pain and a number of different operations have been used to correct it, including ulnar shortening osteotomy (USO).

OBJECTIVE:

To retrospectively review functional outcomes and complication rates of USO for UIS at the Hand and Upper Limb Centre (London, Ontario) over a two-year period.

METHODS:

Twenty-eight patients who underwent USO between 2007 and 2009 participated in the present study. Ulnar variance pre- and post-surgery was assessed using standard radiographic examination. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disabilities of the Arm, Shoulder and Hand (DASH) survey for functional outcomes. Objective grip strength and range of motion were compared with the contralateral extremity.

RESULTS:

On average, USO achieved a 3.11 mm reduction in ulnar variance. Nonunion occurred in five patients and required a secondary bone grafting procedure. All USO eventually healed. Overall, pain improved by 47.2% and the mean DASH score after surgery was 37.21. Flexion, extension and supination range of motion decreased by 10° compared with the unaffected side. Eleven patients (39%) elected to undergo a second surgery for hardware removal. Patients receiving compensation from the Workplace Safety and Insurance Board experienced significantly higher residual pain (VSA 5.24 versus 1.97) and disability levels (DASH 60.23 versus 25.70). Smokers also experienced worse outcomes in terms of pain (VSA 4.43 versus 2.36) and disability (DASH 51.06 versus 29.67). In this cohort, smoking was not associated with a higher rate of nonunion.

CONCLUSION:

USO is effective in reducing pain in UIS and improves disability, at the price of a small decrease in range of motion. Smokers and people receiving compensation from the Workplace Safety and Insurance Board, however, have significantly worse subjective outcomes (VAS and DASH), but similar objective outcomes (range of motion).     

Long-term Outcomes of Ulnar Shortening Osteotomy for Idiopathic Ulnar Impaction Syndrome: At Least 5-Years Follow-up

Background

There have been few outcomes studies with follow-up after performing ulnar shortening osteotomy for ulnar impaction syndrome. We investigated the long-term clinical and radiological outcomes of ulnar shortening osteotomy for the treatment of idiopathic ulnar impaction syndrome.

Methods

We retrospectively reviewed 36 patients who had undergone ulnar shortening osteotomy for idiopathic ulnar impaction syndrome for a mean follow-up of 79.1 months (range, 62 to 132 months). The modified Gartland and Werley scores were measured pre- and postoperatively. The radiographic parameters for the assessment of the distal radioulnar joint (DRUJ) as well as the relationship between these radiographic parameters and the clinical and radiological outcomes were determined.

Results

The average modified Gartland and Werley wrist score improved from 65.5 ± 8.1 preoperatively to 93.4 ± 5.8 at the last follow-up visit. The average preoperative ulnar variance of 4.7 ± 2.0 mm was reduced to an average of -0.6 ± 1.4 mm postoperatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 ± 11.1 months follow-up in 6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider preoperative ulnar variance, a longer distal radioulnar distance and a greater length of ulnar shortening, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were comparable to those who did not have osteoarthritic changes in the DRUJ.

Conclusions

The clinical outcomes are satisfactory for even more than 5 years after ulnar shortening osteotomy for treating idiopathic ulnar impaction syndrome despite the osteoarthritic changes of the DRUJ. The patients who need a larger degree of ulnar shortening may develop DRUJ arthritis.     

Comparison of united and nonunited fractures of the ulnar styloid following volar-plate fixation of distal radius fractures

Introduction

The purpose of this study was to determine whether associated nonunion of ulnar styloid fracture following plate-and-screw fixation of a distal radius fracture (DRF) has any effect on wrist functional outcomes, ulnar-sided wrist pain or distal radioulnar joint (DRUJ) instability.

Materials and methods

A total of 91 consecutive patients with a DRF and an accompanying ulnar styloid fracture treated by open reduction and volar locking plate fixation were included in this study. In the first part of the analysis, the 91 study subjects were subdivided according to the presence or not of ulnar styloid union (20 and 71, respectively) by radiography at final follow-up (average 23 months). These two cohorts were compared with respect to wrist functions at 3 months postoperatively and the final follow-up visit, and ulnar-sided wrist pain and DRUJ instability at the final follow-up visit and ulnar styloid length as determined radiographically at final follow-up. In the second part of the analysis, 49 of the 91 study subjects with an ulnar styloid base fracture were subdivided according to the presence or not of ulnar styloid base fracture union (12 and 37, respectively) at final follow-up by radiography. These two groups were also compared with respect to the above-mentioned parameters.

Results

Ulnar styloid fractures united in 20 (22%) of the 91 patients at final follow-up visit (average 23 months). No significant differences were found at any time during follow-up between patients who achieved or did not achieve ulnar styloid fracture union or ulnar styloid base fracture union.

Conclusion

Ulnar styloid nonunion does not appear to affect wrist functional outcomes, ulnar-sided wrist pain or DRUJ stability, at least when a DRF is treated by open reduction and volar plate fixation.     

A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Background

This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO.

Methods

The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system.

Results

The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05).

Conclusions

Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable.     

Effect of preservation of corticoperiosteal attachment on bone healing at osteotomy sites after ulna-shortening osteotomy

Background

Although precise ulna-shortening osteotomy is popular, the procedure sometimes results in delayed union or nonunion. The periosteum including the inner cambium layer plays an important role in fracture healing. We tested the hypothesis that preservation of the corticoperiosteal attachment may accelerate healing at osteotomy sites after ulna-shortening osteotomy.

Methods

We performed a chart review of 32 patients who underwent ulna-shortening osteotomy for ulnar impaction syndrome or triangular fibrocartilage complex tears in a retrospective single-surgeon series. Of the 32 cases, the periosteum was preserved in 21 osteotomies performed from April 2009 onwards (periosteum-preserved group) and not preserved in 11 osteotomies performed before April 2009 (control group). Following sugar tong immobilization, patients in both groups used a short wrist supporter during the first two postoperative weeks (POW) and up to at least four POW. Union of the osteotomy site was assessed at 2-week intervals using radiographs taken at three different projections until 12 POW and at 4-week intervals thereafter until 24 POW. Ulna shortening was performed using a transverse osteotomy cut with the aid of a commercially available compression device.

Results

All osteotomies achieved complete union except in one case in the control group. The mean interval to complete cortical union was 7.7 weeks in the periosteum-preserved group and 9.5 weeks in the control group. The corresponding mean times for endosteal union were 15.6 and 21.8 weeks. The periosteum-preserved group had reduced times for both types of union but only the endosteal union time was significantly different from the control group.

Conclusions

Preservation of the corticoperiosteal attachment significantly shortened the endosteal union time. Our results indicate that preservation of the periosteum may accelerate bone healing after ulna-shortening osteotomy.     

Ulnar impaction syndrome: Managed by wrist arthroscopy

Background:

The development of handicraft industry and increase of various such works that need a large amount of repeated wrist ulnar deviation strength, the incidence of ulnar impaction syndrome (UIS) is increasing, but the traditional simple ulnar shortening osteotomy has more complications. This study aimed to explore the early diagnostic criteria of UIS and its wrist arthroscopic treatment experience.

Materials and Methods:

9 UIS patients were enrolled in this study. According to magnetic resonance imaging, X-ray and endoscopic features, the diagnostic criteria of UIS were summarized and the individualized treatment schedule was made. If the ulnar positive variance was less than 4 mm, the arthroscopic wafer resection was performed. If the ulnar positive variance was more than 4 mm, the arthroscopic resection of injury and degenerative triangular fibrocartilage complex and ulnar osteotomy were conducted.

Results:

In all patients, the wound healed without any complications. All patients returned to normal life and work, with no ulnar wrist pain again. One patient had wrist weakness. There was a significant difference of the wrist activity between the last followup and before operation (P < 0.05). According to the modified wrist function scoring system of Green and O’Brien, there were 6 cases of excellent, 2 cases of good and 1 case of appropriate and the overall excellent and good rate was 92.3%.

Conclusion:

In the treatment of UIS, the arthroscopy can improve the diagnosis rate, optimize the treatment plan, shorten the treatment cycle, with good treatment results.     

Mid-Term Results Following Ulna Shortening Osteotomy

Background

Successful short-term results of diaphyseal ulna shortening osteotomy are documented in both idiopathic and post-traumatic ulnar impaction.

Questions/Purposes

The purpose of this study was to evaluate the mid-term outcomes of ulnar shortening osteotomy with respect to radiographic assessment of corrected alignment and healing as well as patient satisfaction, pain, and function assessed using the Disability of the Arm, Shoulder, and Hand (DASH) score.

Patients and Methods

This retrospective case series included follow-up of 33 patients with ulnar impaction syndrome following ulna shortening osteotomy at a minimum of 5 years. Patient-rated outcomes included satisfaction, pain assessment, and DASH score. Pre- and postoperative radiographs were reviewed to quantify ulnar variance and osteotomy union rates. Subsequent operations were also recorded.

Results

Average follow-up was 10 years (range, 5–20 years). Eighty-eight percent of patients reported they were either satisfied or very satisfied with the procedure and 91% reported they would have the same procedure again. Average pain rating was 2 out of 10 at final follow-up. The mean DASH score was 11 (range, 0–39). Removal of hardware was performed in 10 patients (30%). The overall rate of reoperation was 45%.

Conclusions

Ulna shortening osteotomy yields reliable midterm satisfaction and pain relief in patients with idiopathic and post-traumatic ulnar impaction syndrome. Reoperation is frequent. Consistent with results of short-term follow-up, plate irritation requiring removal remains the most common cause for reoperation over time.     

Malunited extra-articular distal radius fractures: corrective osteotomies using volar locking plate

Background

Multiple techniques for corrective osteotomy have been developed in recent years with the same aims: to improve the radiographic parameters and improve motion, pain and grip strength. Volar fixed-angle plates have added a new concept to the treatment of distal radius fractures thanks to the low morbidity of the surgical approach and the strength of the final construct, allowing early mobilization and return to function.

Materials and methods

Between 2005 and 2012, 20 patients with symptomatic dorsally malunited extra-articular fractures of the distal radius underwent corrective osteotomy using a volar locking plate without additional bone graft. At a mean follow-up of 50 months, all the patients were clinically and functionally evaluated.

Results

All measurements of pain, final range of motion and grip strength significantly improved compared with preoperative measurements. The mean preoperative DASH score reduced from 54 points preoperatively to 25 postoperatively. Based on the modified Mayo wrist score, we obtained 14 excellent and six good results. Palmar tilt improved from an average of 23° to 11°. Radial inclination improved from an average of 29° to 22°, and ulnar variance decreased from an average of 3.6 mm to 0.9 mm. There were two cases of transient median neuroapraxia that resolved before the 6-week follow-up appointment. No other major complications, including non-union and infection, were observed.

Conclusion

The volar approach and locking plate, without necessarily the use of bone grafting, proved to be an effective approach for addressing symptomatic and even severe deformities of the distal radius.

Type of study/level of evidence

Therapeutic IV     

Plate removal after ulnar-shortening osteotomy

PURPOSE: Ulnar-shortening osteotomy using plate and screw fixation is a reliable method for treating various wrist disorders. In some patients the plate remains as a source of discomfort even after the osteotomy has healed and the preoperative complaints have resolved. There is not a large body of information to guide the surgeon in the timing of plate removal should it be needed to address persistent forearm complaints caused by prominent hardware. This study investigated the outcome of patients who had removal of the plate because of persistent symptoms after undergoing ulnar-shortening osteotomy once radiographic healing was apparent. METHODS: A consecutive series of 40 ulnar shaft-shortening osteotomies was performed in which 14 patients requested removal of the plate because of persistent tenderness despite nonsurgical management. There were 12 Rayhack (11 titanium, 1 stainless steel) and 2 Synthes 3.5-mm dynamic compression titanium plates used. Before removal radiographic union was documented by 2 sets of films taken in multiple planes at least 4 weeks apart. The average time to plate removal was 6.6 months. RESULTS: All patients had resolution of the ulnar forearm pain after hardware removal. There were no repeated surgeries and all patients returned to their prior levels of activity or employment. Patients were followed-up for an average of 17 months after plate removal. There was 1 refracture in an osteoporotic patient when she fell down a flight of stairs 7 months after plate removal. CONCLUSIONS: When used for fixation after ulnar shaft-shortening for ulnar-sided wrist pain of various causes 3.5-mm compression plates seem to be removable at 6 to 9 months in symptomatic patients with a low risk for refracture when sequential sets of x-rays confirm healing of the osteotomy site according to this small series of patients.     

Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome

A retrospective review was performed that compared the results of 2 different surgical treatments for ulnar impaction syndrome in 22 patients over a 6-year period. Ulnar shortening osteotomy and wafer distal ulna resection (wafer resection procedure) were each performed in 11 patients based on the preference of 3 individual hand surgeons. All patients presented with ulnar wrist pain and positive ulnar variance on either neutral rotation or pronated-grip x-rays and each failed conservative management. At a minimum follow-up time of 18 months, 9 patients had good to excellent results following ulnar shortening osteotomy compared with 8 following the wafer resection procedure. This difference was not statistically significant. All patients regained functional wrist motion and 21 of the 22 patients had satisfactory pain relief. There was 1 poor result in the wafer group that required revision to complete resection of the distal ulna. Five secondary procedures were required in the osteotomy group to remove painful hardware and union was delayed in 2 patients. Although ulnar shortening osteotomy provides effective treatment for ulnar impaction syndrome, the wafer resection procedure provides favorable pain relief and restoration of function but without the potential for nonunion or hardware removal. (J Hand Surg 2000; 25A:55-60.     

Kienbock��s disease in a varsity football player: a case report and review of the literature

Objective:

To present the diagnostic, clinical features, and management of Kienbock’s disease and create awareness of the differential diagnosis of this condition in patients presenting with insidious, progressive dorsal wrist pain.

Clinical Features:

A 23-year old male varsity football player presented with insidious progressive dorsal sided wrist pain with reduced wrist flexion and extension. A diagnosis of Kienbock’s disease was made based on radiographs and magnetic resonance imaging.

Intervention and Outcome:

A 3mm ulnar-minus variance was found and a joint leveling procedure to shorten the radius was performed. Conservative therapy was provided pre and post surgical management.

Summary:

This case report demonstrates the importance of findings on radiographs, MRI, and clinical examination in the accurate diagnosis and management of a patient with wrist pain.     

Ulnar shortening after failed arthroscopic treatment of triangular fibrocartilage complex tears.

Ulnar shortening osteotomy was performed in 11 wrists with ulnar abutment syndrome, after failed arthroscopic surgery on the TFCC (ten debridements, one repair). A delayed union was present in three, a non-union occurred in two, of whom one needed a revision and grafting procedure. According to the Mayo wrist score, only four had an acceptable outcome. Patient's satisfaction was higher: seven were satisfied, four were not. The postoperative wrist pain score was good in ten patients. Overall outcome was not very successful. Problems related to the procedure could be avoided by adapting the technique (oblique osteotomy, palmar placement of the plate, and compression devices). The key statement remains however to us; ulnar sided wrist pain thought to be caused by an ulnar abutment is not necessarily resolved by decompressing the ulnocarpal joint.     

Conservative management of De Quervain's stenosing tenosynovitis: a case report

Objective

To chronicle the conservative treatment and management of a 32-year old female patient presenting with radial wrist pain of 4 months duration, diagnosed as De Quervain’s stenosing tenosynovitis.

Clinical features

The primary clinical feature is wrist pain at the radial styloid with resultant impairment of wrist, hand, and thumb function.

Intervention and outcome

The conservative treatment approach consisted of activity modification, Graston Technique^®, and eccentric training. Outcome measures included verbal pain rating scale, QuickDASH Disability/Symptom Score, and a return to activities of daily living (ADLs). The patient attained symptom resolution and at 6 month follow-up reported no recurrence of wrist pain.

Conclusion

A combination of conservative rehabilitation strategies may be used by chiropractors to treat De Quervain’s stenosing tenosynovitis and allow for an individual to return to pain free ADLs in a timely manner.     

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

Introduction

The treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.

Materials and methods

For this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.

Results

Ulnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.

Conclusions

Radial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.     

Oblique ulnar shortening osteotomy with a new plate and compression system

Ulnocarpal abutment or the ulnocarpal impaction syndrome occurs when excessive loads exist between the distal ulna and ulnar carpus. This overloading occurs as a result of the distal ulnar articular surface being more distal than the ulnar articular surface of the distal radius. This situation has been termed positive ulnar variance, and it can quickly lead to ulnar-sided wrist degenerative changes and functional losses. Patients often have vague, ulnar-sided complaints of chronic pain and swelling with an insidious onset that does not correlate with any specific traumatic event. Many procedures have been developed to alleviate this condition, but the gold standard for correcting positive ulnar variance is the ulnar shortening osteotomy. The goals of the shortening procedure are to relieve pain and prevent arthritis by reestablishing a neutral or slightly negative ulnar variance. We describe a new plate and compression system in which an oblique ulnar diaphyseal osteotomy is both completed and stabilized through the same jig-based system.     

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Background and purpose

Mechanisms of injury to ulnar-sided ligaments (stabilizing the distal radioulnar joint and the ulna to the carpus) associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods

Fresh frozen human cadaver arms were used. A dorsal open-wedge osteotomy was performed in the distal radius. In 8 specimens, pressure was applied to the palm with the wrist in dorsiflexion and ulnar-sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 other specimens, the triangular fibrocartilage complex (TFCC) was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results

Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32^o (16–34). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6 of 8 specimens.

Interpretation

A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32^o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.A complex of ligaments on the ulnar side of the wrist supports the stability of the ulnocarpal and the distal radioulnar (DRU) joints. Included in this are the extensor carpi ulnaris (ECU) subsheath and the triangular fibrocartilage complex (TFCC), which is further subdivided into the radioulnar ligaments (RULs), the ulnotriquetral ligament (UT), and the ulnolunate (UL) ligament (Garcia-Elias 1998, Berger 2001). Injuries to the TFCC are common in dorsally angulated fractures of the distal radius fracture (Colle''s fracture) and may adversely affect functional outcome (Lindau et al. 2000). The pathomechanics of these injuries are poorly studied, however.During wrist arthroscopy, we have observed two lesions that are often present when treating TFCC lesions associated with distal radius fractures: (1) a separation of the floor of the ECU tendon sheath from the TFCC, and (2) an injury to the foveal insertion of the TFCC into the ulna. It seems probable that there must be a limit to how much the distal radius fragment can be displaced without rupture of the TFCC or fracture of the ulna.We investigated the characteristics of a TFCC injury in a cadaveric fracture model of dorsally displaced fractures. We hypothesized that (1) a TFCC lesion can be expected at a certain degree of displacement and that (2) a rupture of the foveal insertion would begin in the palmar capsule and progress dorsally, due to the dorsal displacement of the distal radius fragment.     

Ulnar shortening osteotomy with a premounted sliding-hole plate

BACKGROUND: Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. METHODS: We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. RESULTS: All 27 osteotomies healed uneventfully over an average of 9.2 +/- 2.1 weeks. The mean postoperative ulnar variance was -2.1 mm (range, -3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. CONCLUSION: Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.