Radioulnargelenkverletzungen

The proximal and distal radioulnar joints are both responsible for free rotation of the forearm and thus functionally interconnected. The Monteggia injury (ulna fracture + radial head luxation) and the Galeazzi injury (diaphyseal radial fracture + dislocation of the radioulnar joint) have a better prognosis than radioulnar joint injuries in conjunction with distal radius fractures. The latter lead to injury of the ulnocarpal complex and more frequently to malalignment of the distal radioulnar joint, which in turn leads to arthrosis. This is characterized by early occurrence of pain, loss of strength in the hand, and limited rotation of the forearm. Thus, surgical management should be especially directed at restoration of the articular surface, correct length adjustment, and reconstruction of the anatomic angle. The choice of surgical procedure depends on the extent of destruction of the distal radial articular surface, the degree of dislocation, and the presence of soft tissue damage.     

Influence of distal radioulnar joint subluxation on restricted forearm rotation after distal radius fracture

PURPOSE: To analyze the influence of subluxation of the distal radioulnar joint (DRUJ) on restricted forearm rotation after distal radius fracture. METHODS: Twenty-two cases of healed unilateral distal radial fracture with restricted forearm rotation were included in the study. The subluxation of the DRUJ was evaluated using helical computed tomography scan at neutral, maximum pronation, and maximum supination and presented as the percent displacement of the ulnar head in both the injured and uninjured sides. The radiographic parameters of palmar tilt, radial inclination, dorsal shift, radial shift, and ulnar variance were measured on plain x-ray films and the rotational deformity of the distal radius was evaluated from the computed tomography scan. The differences of each radiographic parameter from the uninjured side were calculated. The relationships between the restricted forearm rotation and the percent displacement of the ulnar head and each of the radiographic parameters were analyzed statistically. RESULTS: When forearm pronation was restricted the ulnar head was located palmarly at neutral, maximum supination, and maximum pronation with severe dorsal tilt of the distal radius. When supination was restricted the ulnar head was located dorsally at maximum supination with severe ulnar-positive variance. CONCLUSIONS: The subluxation of the DRUJ was related to restricted forearm rotation. The radiographic parameters of palmar tilt and ulnar variance showed an adverse influence on the position of the ulnar head at the DRUJ, which might lead to restricted forearm rotation after distal radial fracture.     

Derotational osteotomy of the proximal radius and the distal ulna for congenital radioulnar synostosis

Objective  To evaluate the clinical and functional results of a technical procedure in the surgical treatment of congenital radioulnar synostosis in children. Materials and methods  A prospective study had been undertaken from January 1992 to December 2004. Thirty-four patients with congenital radioulnar synostosis that are fixed in pronation were recruited. Congenital radioulnar synostosis was classified for two types according to Tachdjian’s criteria. All patients were treated by resection of the proximal radius and the distal ulna to remove a segmental bone of both parts of the forearm. After K-wires are inserted intramedullarly into both bones, the forearm is derotated manually, followed by cast immobilization. Results  There were 34 patients (52 forearms) with congenital radioulnar synostosis, whom the average age at surgery was 6 years and 3 months. There were two types of congenital radioulnar synostosis: Type 1 in six forearms (11.6%) and Type 2 in 46 forearms (88.4%). The preoperative forearm rotation ranged from 65° to 85° pronation. The postoperative forearm rotation angle was corrected from 0° to 30°; the best end position appears to be 70–100% of pronation. Of the patients, 78.8% had good or excellent results. All patients were operated on without complications; five patients had loss of correction during cast immobilization. Overall, the patient’s ability to perform daily activities showed a marked improvement after surgery. Conclusion  This method is a simple and safe technique to derotate the forearms of patients with congenital radioulnar synostosis that are fixed in pronation.     

The distal radioulnar joint in relation to the whole forearm.

The functional anatomy of the distal radioulnar joint was studied in relation to the whole forearm, using three fresh-frozen, above-elbow amputation specimens. The specimens demonstrate how the proximal and distal radioulnar joints together form a bicondylar joint of special character. The proximal "condyle," the radial head, rotates axially, whereas the distal "condyle," the ulnar head, is fixed with respect to rotation. The ordinary articulation of a bicondylar joint (pure axial rotation) is thereby changed into pronation-supination. Axial rotation is preserved proximally, while distally the radius swings around the ulnar head. The mobile radius is distally attached to the stable ulnar head by the dorsal and volar radioulnar ligaments, the dorsal ligament being tight for stabilization in supination and the volar ligament being tight in pronation. The ulnar head also serves as a keystone, carrying the load of the radius. Removal of the ulnar head allows the radius to "fall in" towards the ulna, with narrowing of the interosseous space.     

Biomechanical analysis of two ulnar head prostheses

The biomechanical effectiveness of 2 ulnar head prostheses was evaluated in 5 fresh-frozen cadaver arms. By using electromagnetic sensors, the amount of forearm rotation, diastasis, and dorsal/palmar subluxation of the radius at the level of the sigmoid notch was measured with the forearm in neutral rotation, pronation, and supination with and without dorsal/palmar loading. Testing was done in the intact specimens and after insertion of 2 types of ulnar head prostheses. Dynamic forearm rotation was also achieved by applying loads in the line of action of the appropriate pronator or supinator muscles to obtain a centroidal path of the radius relative to the ulna. Overall after ulnar head replacement forearm rotation lessened in pronation, diastasis decreased in most forearm positions, and subluxation increased in supination compared with the intact specimen. Despite these changes, both prostheses maintained near-normal biomechanics of the distal radioulnar joint when compared with the irregular behavior occurring after distal ulna resection. Therefore these prostheses are suggested for restoration of distal radioulnar joint function.     

手法间接复位掌侧锁定板固定治疗桡骨远端C3型骨折

目的 ：探讨手法间接复位后AO 2.4 mm桡骨远端锁定板联合经皮穿针固定治疗C3型（AO/OTA分型）桡骨远端骨折的临床疗效及操作技巧。方法：自2009年5月至2012年3月采用手法间接复位AO 2.4 mm桡骨远端掌侧锁定板联合经皮穿针固定治疗桡骨远端骨折AO/OTA分型C3型患者19例21腕（双侧2例）。年龄31~66岁,平均（45.3±17.4）岁;并发尺骨茎突骨折14腕,下尺桡关节不稳6腕;均为闭合性骨折;发病时间4.5~9 d,平均（6.7±3.5）d。采用Henry切口显露骨折部位,保留关节囊、韧带连续性,手法间接复位,C形臂X线透视关节面复位情况,仍存在塌陷者予以撬拨复位后桡骨远端掌侧锁定板固定。下尺桡关节发现不稳定和并发尺骨茎突骨折者均予前臂旋后位石膏托固定6周。结果：19例（21腕）获得随访,时间7~17个月,平均10.5个月。X线示患者桡骨远端骨折均达到骨性愈合,尺骨茎突骨折未愈合3例,下尺桡关节不稳0例,1例出现背侧伸肌腱激惹,内固定取出后激惹消除。术后随访观测患者掌倾角、尺偏角、桡骨茎突高度、关节面和下尺桡关节情况,按照Batra和Gupta评分标准行影像学评定：70分以下3腕,70~79分5腕,80分以上13腕。同时对患者进行主观和客观疗效评定,观测残留畸形和腕关节活动度、并发症情况等,根据Sarmiento改良的Gartland-Werley评分系统评定术后疗效：优17腕,良3腕,可1腕。结论：AO/OTA分型C3型桡骨远端骨折手法间接复位可获得良好复位效果,应用锁定板联合穿针可为其提供内固定架支撑式固定以满足早期功能锻炼要求,患腕功能预后良好。     

Isolated Diaphyseal Fractures of the Radius in Skeletally Immature Patients

Diaphyseal radius fractures without associated ulna fracture or radioulnar dislocation (isolated fracture of the radius) are recognized in adults but are rarely described in skeletally immature patients. A search of our database (1974–2002) identified 17 pediatric patients that had an isolated fracture of the radius. Among the 13 patients with at least 1 year follow-up, ten were treated with manipulative reduction and immobilization in an above elbow cast and three had initial operative treatment with plate and screw fixation. These 13 patients were evaluated for an average of 18 months (range, 12 to 45 months) after injury using the system of Price and colleagues. The incidence of isolated diaphyseal radius fractures in skeletally immature patients was 0.56 per year in our database and represented 27% of the 63 patients with a diaphyseal forearm fracture. All 13 patients, with at least 1 year follow-up, regained full elbow flexion and extension and full forearm rotation. According to the classification system of Price, all 13 patients (100%) had an excellent result. As in adults, isolated radius fractures seem to occur in children more frequently than previously appreciated. Treatment of isolated radius fractures in skeletally immature patients has a low complication rate, and excellent functional outcomes are the rule.     

Effects of distal radius malunion on distal radioulnar joint mechanics--an in vivo study.

Patients with a malunited distal radius often have painful and limited forearm rotation, and may progress to arthritis of the distal radioulnar joint (DRUJ). The purpose of this study was to determine if DRUJ congruency and mechanics were altered in patients with malunited distal radius fractures. In nine subjects with unilateral malunions, interbone distances and dorsal and palmar radioulnar ligament lengths were computed from tomographic images of both forearms in multiple forearm positions using markerless bone registration (MBR) techniques. The significance of the changes were assessed using a generalized linear model, which controlled for forearm rotation angle (-60 degrees to 60 degrees ). In the malunited forearm, compared to the contralateral uninjured arm, we found that ulnar joint space area significantly decreased by approximately 25%, the centroid of this area moved an average of 1.3 mm proximally, and the dorsal radioulnar ligament elongated. Despite our previous findings of insignificant changes in the pattern of radioulnar kinematics in patients with malunited fractures, we found significant changes in DRUJ joint area and ligament lengthening. These findings suggest that alterations in joint mechanics and soft tissues may play an important role in the dysfunction associated with these injuries.     

Management of posttraumatic radioulnar synostosis

Posttraumatic radioulnar synostosis is a rare complication following fracture of the forearm and elbow. Risk factors for synostosis are related to the initial injury and surgical management of the fracture. Typically, patients present with complete loss of active and passive forearm pronation and supination. Evidence of bridging heterotopic bone between the radius and ulna can be seen on plain radiographs. Although nonsurgical management is sufficient in some cases, surgical excision is typically required. The timing of surgical intervention remains controversial. However, early resection between 6 and 12 months after the initial injury can be performed safely in patients with radiographic evidence of bony maturation. Surgical management consists of complete resection of the synostosis with optional interposition of biologic or synthetic materials to restore forearm rotation. A low recurrence rate can be achieved following primary radioulnar synostosis excision without the need for routine adjuvant prophylaxis.     

The dorsopalmar stability of the distal radioulnar joint

Sixteen fresh-frozen adult human cadaveric upper extremities were used in a biomechanical analysis of distal radioulnar joint (DRUJ) stability. The relative contribution to stability of the DRUJ by the surrounding anatomic structures presumed to stabilize the joint was analyzed with respect to forearm rotation and wrist flexion and extension using a purpose-built 4-axis materials testing machine. The dominant structures stabilizing the DRUJ were the ligamentous components of the triangular fibrocartilage complex proper. The major constraint to dorsal translation of the distal ulna relative to the radius is the palmar radioulnar ligament. Palmar translation of the distal ulna relative to the radius is constrained primarily by the dorsal radioulnar ligament, with secondary constraint provided by the palmar radioulnar ligament and interosseous membrane. The ulnocarpal ligaments and extensor carpi ulnaris subsheath did not contribute significantly to DRUJ stability; however, approximately 20% of DRUJ constraint is provided by the articular contact of the radius and ulna. These relationships were consistent regardless of wrist position or degree of forearm rotation.     

Changes in length of the radioulnar ligament and distal oblique bundle after Colles' fracture

Abstract

The purpose of this study was to investigate changes in length of the radioulnar ligament and distal oblique bundle (DOB) within the distal interosseous membrane after Colles' fracture and correlate the magnitude of the changes in length with clinical features. This study investigated 10 patients with malunion of a Colles' fracture. In three-dimensional computed tomography, the paths of the four limbs of the radioulnar ligament (superficial and deep, dorsal, and palmar limbs) and DOB were modelled and each path length was computed. Differences in length between the affected and contralateral unaffected side were calculated and correlated with the radiographic parameters of deformity on plain X-ray, subluxation of the DRUJ on CT, and limited range of forearm rotation in the clinical examination. In the malunited radius, the superficial and deep dorsal limbs of the radioulnar ligament were significantly elongated and DOB was significantly shortened compared with the contralateral side. These length changes correlated with radiographic radial shortening, subluxation of the DRUJ, and inversely correlated with limited range of forearm pronation. This study suggests that the dorsal radioulnar ligament would be overstretched and disrupted in Colles' fracture with severely increased radial shortening, producing laxity of the distal radioulnar joint that could negate limitation of pronation.     

Three‐Dimensional In Vivo Analysis of Malunited Distal Radius Fractures With Restricted Forearm Rotation

Malunited distal radius fractures (DRFs) occasionally restrict forearm rotation, but the underlying pathology remains unclear. We aimed to elucidate the mechanism of rotational restriction by retrospective analysis of 23 patients with unilateral malunited DRFs who presented restricted forearm rotation. We conducted computed tomography during forearm rotation on both sides. Three‐dimensional (3D) bone surface models of the forearm were created, and 3D deformity of the distal radius, translation of the distal radius relative to the ulna, distal radioulnar joint (DRUJ) contact area, and estimated path length (EPL) of distal radioulnar ligaments (DRUL) during forearm rotation were evaluated. In total, 18 patients had dorsal angular deformities (DA group) and five had volar angular deformities (VA group). In the DA group, the closest point between the distal radius and ulna on DRUJ was displaced to the volar side during supination and pronation (p < 0.001); DRUJ contact area was not significantly different between the DA and normal groups. In bone–ligament model simulation, the EPL of dorsal DRUL was longer in the DA group than in the normal group (p < 0.001); opposite phenomena were observed in the VA group. In the DA group, translation of the distal radius in a volar direction relative to the ulna during pronation was impaired presumably due to dorsal DRUL tightness. Anatomical normal reduction of the distal radius by corrective osteotomy may improve forearm rotation by improving triangular fibrocartilage complex tightness and normalizing translation of the distal radius relative to the ulna. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1881–1891, 2019     

Distal radius fractures: a comparison of tension band wiring versus ulnar outrigger external fixation for the management of distal radioulnar instability

PURPOSE: To retrospectively compare the results of immobilization of the forearm in supination with the results of tension band fixation of the ulnar styloid in 35 patients with distal radius fractures, fracture of the base of the ulnar styloid, and distal radioulnar joint instability treated with external fixation. METHODS: Thirty-five patients with fractures of the distal radius, fracture of the base of the ulnar styloid, and unstable distal radioulnar joint had external fixation with adjunctive percutaneous pins and allograft bone to reduce and stabilize the distal radius fracture anatomically. Only those patients with an associated ulnar styloid base fracture displaced over 2 mm with gross distal radioulnar joint instability relative to the contralateral wrist were included in this study. Group 1 consisted of patients in whom the ulnar styloid base fracture was treated with conventional tension band wiring techniques. Group 2 patients were treated with a supplemental outrigger from the external fixator to the ulna and locked in 60 degrees of forearm supination. Groups 1 and 2 had an average follow-up period of 40 and 36 months, respectively. RESULTS: Group 2 had significantly better supination than group 1. In terms of functional outcome it was found that there was no significant difference for the Disabilities of the Arm, Shoulder, and Hand and the Gartland and Werley scores between the 2 treatment groups. There was a lower rate of complications and fewer secondary procedures were required in group 2. The incidence of distal ulna resection was 4 of the 35 patients (2 patients in each group). CONCLUSIONS: Our results indicate that patients in whom the ulnar styloid can be reduced and maintained in supination can be treated effectively with fixed supination outrigger external fixation. This method resulted in a statistically significant improvement in supination and a lower rate of distal radioulnar joint complications, and it required fewer secondary procedures.     

Contribution of the interosseous membrane to distal radioulnar joint constraint

PURPOSE: Although forearm injuries are accompanied frequently by rupture to the interosseous membrane (IOM) diagnosis of the extent of IOM injury is difficult. In this study we evaluated distal radioulnar joint (DRUJ) laxity caused by both partial and complete IOM disruption and compared these quantitative measurements with the common clinical manual evaluation of DRUJ laxity and dislocatability. METHODS: Human cadaveric forearms (n = 8) were used in this study. Skin, muscles, and tendons were removed. The specimens were mounted on an experimental apparatus that allowed the radius to move freely about the fixed ulna. Tests were performed in neutral rotation, 60 degrees pronation, and 60 degrees supination. Under various conditions of IOM sectioning testing was performed by volary and dorsally translating the radius relative to the ulna in the coronal plane of the radius. Testing was performed both qualitatively as would be performed in the clinic and quantitatively with an instrumented probe. RESULTS: Our results show that dorsal dislocation of the radius relative to the ulna strongly suggests distal IOM rupture. Disengagement of the radius from the DRUJ indicated injury to the distal and middle IOM. The distal IOM constrained volar and dorsal laxity of the radius at the DRUJ in all forearm rotation positions. The midportion of the IOM constrained laxity except in the volar direction of the pronated forearm. The proximal IOM did not constrain the proximal radius except dorsally for the pronated forearm position. CONCLUSIONS: The IOM, in particular the distal IOM, plays an important role in constraining dorsal dislocation of the radius at the DRUJ.     

上尺桡关节松解改善肘部创伤后前臂旋转受限

目的 探讨上尺桡关节松解改善肘部创伤后前臂旋转受限的效果.方法 2007年1月至12月共收治12例肘部创伤后前臂旋转受限患者,男9例,女3例;左侧3例,右侧9例.患者初次治疗时平均年龄为37.7岁(27～48岁).原始损伤包括:"恐怖三联征"3例,尺骨近端骨折4例,桡骨头骨折4例,冠状突骨折1例.11例患者松解术前有手术史.受伤至松解手术时间平均9个月(6～27个月).松解术前患者前臂旋前平均17.5°(0～80°),旋后平均39.1°(0～90°),前臂旋转活动度平均56.7°(0～130°).7例采用后侧入路,3例采用内、外侧联合入路,2例采用单纯外侧入路.术中去除上尺桡关节周围增生瘢痕及骨赘,如上尺桡关节已融合,则切除中间骨桥,注意保护肱二头肌腱止点,尽量保留桡骨头,术中尽量达到旋前80°,旋后90°.术后第1天开始主动及被动功能锻炼,并常规口服吲哚美辛预防异位骨化.结果 12例患者术后获平均18.3个月(14～25个月)随访.松解术后患者旋前平均70.8°(60°～80°),旋后平均86.7°(70°～90°),前臂旋转活动度平均为157.5°(130°～170°).术后前臂旋转功能按Failla标准 [2]评定:12例患者皆为优.6例合并异位骨化患者松解术后1例复发异位骨化,7例采用后侧入路患者2例出现皮下血肿,均未做特殊处理.12例患者均未出现感染、肘关节不稳定及上尺桡关节脱位等情况.结论 对于肘部创伤后前臂旋转受限患者,术前审慎评估肘关节功能情况,术中仔细松解上尺桡关节,尽量保留桡骨头,术后早期主动及被动功能锻炼,可以取得良好的临床疗效.     

Ulnar bursa distention following volar subluxation of the distal radioulnar joint after distal radial fracture: a rare cause of carpal tunnel syndrome

This report describes an eighty-four-year-old woman with persistent carpal tunnel syndrome attributable to an ulnar bursa distention associated with the subluxation of the distal radioulnar joint after distal radial fracture. During surgery, when the forearm was placed in supination, the ulna head with a sharp osteophyte was found to be displaced into the carpal tunnel through a defect of the ruptured capsule of the wrist joint. This volar subluxation of the ulnar head had caused distention of the ulnar bursa, causing compression of the median nerve, which resulted in carpal tunnel syndrome. In addition to reduce displaced fractured segment to obtain anatomic articular surface, original radial length and tilt, the anatomic restoration of the distal radioulnar joint is essential to maintain better long-term function after fracture of the distal radius.     

The stabilizing effect of soft-tissue constraints in artificial Galeazzi fractures

Shortening of the radius is observed in Galeazzi (Piedmont) fractures and results from muscle pull after distal radioulnar joint disruption. A cadaver study was designed to examine the normal laxity at the distal radioulnar joint and contributions of the fibrocartilaginous complex (triangular ligament) and the interosseous membrane in prevention of proximal displacement of the distal radius fragment. It was found that up to 5 mm of radial shortening occurred after osteotomy alone. Shortening of over 10 mm did not occur unless both the interosseous ligament and the triangular ligament were sectioned. Some Galeazzi-type fractures may occur in the absence of distal radioulnar joint disruption, and others may result in disruption of the interosseous membrane of the forearm in addition to disruption of the triangular ligament at the wrist. Diaphyseal fractures of the distal radius may occur in several stages of severity. Attempts to produce a Galeazzi lesion by axial loading and pronation of the forearm above the dorsiflexed wrist caused a variety of injuries but did not result in an isolated fracture of the distal radius or disruption of the distal radioulnar joint.     

Complex volar distal radioulnar joint dislocation occurring in a Galeazzi fracture

The Galeazzi fracture-dislocation of the forearm consists of a transverse or short oblique fracture of the radius at the junction of the middle and distal thirds with an associated subluxation or dislocation of the distal radioulnar joint. Anatomic reduction with rigid internal fixation of the radius typically produces anatomic reduction of the distal radioulnar joint and is the favored treatment. At least three cases of a mechanically blocked distal radioulnar joint requiring open reduction through a separate exposure have been reported. In all three cases there was dorsal displacement of the ulna. We report a case of an irreducible volar dislocation of the distal radioulnar joint following open anatomic reduction of the radius.     

The crisscross injury mechanism in forearm injuries

Introduction A new mechanism of injury of the forearm bones, crisscross injury, is described. It is more common than the Essex-Lopresti fracture dislocation. The old concept of isolated injury of one side of the radioulnar joint may be challenged. It often occurs in Mason type II fracture dislocation of the radial head or dislocation of radioulnar joints.Materials and methods The first part was a cadaveric study of the crisscross injury of forearms. The second part was a clinical study of the crisscross injury in some cases of Mason type II fracture radial head and double dislocation of the radioulnar joint.Results The cadaveric study confirmed a stable crisscross fracture dislocation injury with intact interosseous membrane. The clinical study echoed the presence of this injury by imaging techniques.Conclusion The crisscross injury mechanism explains the mirror pathogenesis of the traumatic fracture dislocation of the distal and proximal radioulnar joints with intact shaft of the radius and ulna. Co-existing subluxation or dislocation of the other radioulnar articulation must not be overlooked in cases of fracture dislocation of one radioulnar joint. Two types of crisscross injury of forearm bones are proposed.     

Ipsilateral radial shaft, head, and medial epicondyle fractures

A patient with a unique combination of ipsilateral midradial shaft (AO/OTA 22-A2), radial head (21-A2), and medial epicondyle (13-A1) fractures, without a recorded elbow dislocation or distal radioulnar joint disruption, is presented. The injury was treated surgically with a dorsal approach to the forearm and a lateral approach to the elbow through a single dorsolateral skin incision. The radial shaft fracture was stabilized using a 3.5-mm limited contact, dynamic compression plate; the radial head, using a 1.2-mm Luhr plate; and the medial epicondyle, using a partially threaded cancellous screw through a limited medial approach. The shaft fracture consolidated by 10 weeks, whereas radiographic consolidation of the radial head fracture was seen at 7 months. At the 15-month follow-up, the patient had achieved an excellent functional result. Awareness of the possibility of double injuries even in yet-unrecognized patterns is warranted when evaluating forearm and elbow trauma.