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.     

The Influence of Non-union of the Ulnar Styloid on Pain, Wrist Function and Instability after Distal Radius Fracture

The influence of non-union on the outcome of distal radius fractures is debated. We tested the null hypothesis that there is no difference in pain, wrist function, or instability between patients with union or non-union of an ulnar styloid base fracture after operative treatment of a fracture of the distal radius. Eighteen adults with an ulnar styloid base non-union were compared to 16 patients with union of an ulnar styloid base fracture with a mean post-operative follow-up of 30 months. None of the patients had distal radioulnar joint instability, there were no significant differences in pain, complications, or function, and patients with nonunion had significantly greater grip strength. Ulnar styloid nonunion is not associated with pain, instability, or diminished function after fracture of the distal radius.     

桡骨远端骨折对下尺桡关节稳定性的影响

目的:分析桡骨远端骨折后腕部功能与下尺桡关节稳定性之间的关系,探讨桡骨远端骨折影响下尺桡关节稳定性的原因。方法:85例桡骨远端骨折患者,男27例,女58例;年龄17~74岁,平均42.3岁。采用手法复位石膏外固定治疗,伤后6~9个月(平均6.7个月)摄腕关节正侧位X线CR片,检查下尺桡关节稳定性,采用Sarmiento改良的Gartland-Werley评分系统(GW评分)对腕部进行功能评估。结果:85例获得6~9个月随访,平均6.7个月。19例有下尺桡关节不稳定。下尺桡关节不稳与放射学检查下尺桡关节情况之间无明显的联系。下尺桡关节不稳的患者GW评分平均为12.37±5.899,稳定的患者GW评分平均为6.85±4.222,差异有统计学意义。尺骨茎突是否骨折其GW评分差异无统计学意义。是否有尺骨茎突骨折其下尺桡关节不稳发生率比较差异无统计学意义。结论:明显成角或短缩畸形的桡骨远端骨折损伤三角纤维软骨复合体可能是造成下尺桡关节不稳、影响腕部功能的主要原因。伴随桡骨远端骨折的尺骨茎突骨折对下尺桡关节稳定性无明显影响。     

桡骨远端骨折类型和腕不稳定关系

目的 研究桡骨远端骨折类型对腕不稳定发生的作用。方法 在160例正常腕关节测量并确定腕不稳定标准基础上,比较236例桡骨远端骨折中桡骨远端关节面不平整(52例)、桡骨明显缩短(50例)、桡骨远端关节面背倾(43例)和伴尺骨茎突骨折(65例)与无以上因素的一般骨折(63例)不稳定发生率及类型,分析以上骨折相关因素的严重程度和不稳定发生的关系。结果 伴有尺骨茎突骨折例腕不稳定发生率为47.7％,腕关节背倾例中发生率为30.2％,桡骨明显缩短例中发生率为22％,关节面不平整例中发生率为17.3％,一般骨折例中发生率为7.8％。腕不稳定例的桡骨缩短、关节面背倾和尺骨茎突骨折移位程度与无不稳定的比较有显著差异。结论 桡骨远端骨折的关节面不完整、桡骨明显缩短、关节面背倾和伴尺骨茎突骨折对腕不稳定例发生及程度有显著影响。     

两种内固定治疗桡骨远端骨折伴尺骨茎突基底部骨折的疗效比较

目的比较采用桡骨远端掌侧锁定钢板+尺骨茎突单皮质骨螺钉固定和单纯桡骨远端掌侧锁定钢板治疗桡骨远端骨折伴尺骨茎突基底部骨折的疗效。方法将73例桡骨远端骨折伴尺骨茎突基底部骨折患者按治疗方法的不同分为观察组(采用桡骨远端掌侧锁定钢板+尺骨茎突单皮质骨螺钉固定治疗,38例)和对照组(采用单纯桡骨远端掌侧锁定钢板治疗,35例)。测量桡骨远端掌倾角、尺偏角、桡骨高度。术后4个月采用Dienst功能评分标准评价临床疗效。末次随访时采用腕关节活动度评价腕关节功能恢复情况。结果患者均获得随访,时间9~16个月。术后掌倾角、尺偏角、桡骨高度两组比较差异均无统计学意义(P>0.05)。术后4个月采用Dienst功能评分标准评价临床疗效的优良率,观察组明显高于对照组(P<0.05)。末次随访时两组腕关节功能均已恢复。结论与采用单纯桡骨远端掌侧锁定钢板治疗相比,桡骨远端掌侧锁定钢板+尺骨茎突单皮质骨螺钉固定治疗桡骨远端骨折伴尺骨茎突基底部骨折更利于改善患者临床症状,更利于恢复腕关节的稳定性。     

Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: A meta-analysis of comparative clinical trials

PurposeThere is no consensus on the relation between ulnar styloid process nonunion and outcome in patients with distal radius fractures. The aim of this study was to analyze whether patient-reported outcome is influenced by the nonunion of the accompanying ulnar styloid fracture in distal radius fracture patients.MethodsA meta-analysis of published studies comparing outcomes after distal radius fractures with a united versus a non-united ulnar styloid process was performed. In addition, if provided by the authors, the raw data of these studies were pooled and analysed as one study. The outcome measures of the analyses included patient-reported outcome, functional outcome, grip-strength, pain, and distal radioulnar joint (DRUJ) instability.ResultsData from six comparative studies were included, concerning 365 patients with a distal radius fracture. One hundred and thirty-five patients with an ulnar styloid union were compared with 230 patients with a nonunion of the ulnar styloid. No significant differences were found between groups regarding any outcome measure.ConclusionBased on this meta-analysis, there is no relation between the nonunion of the ulnar styloid process and function in patients with a distal radius fracture.     

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.     

Isolated radial shaft fractures are more common than Galeazzi fractures

PURPOSE: In contrast to isolated diaphyseal fractures of the ulna (so-called night-stick fractures), isolated fractures of the radial diaphysis generally are expected to have associated injury of the distal radioulnar joint (DRUJ), the so-called Galeazzi fracture. This study retrospectively reviewed isolated fractures of the radial diaphysis in a large cohort of patients to determine how often such fractures occur without DRUJ injury METHODS: Thirty-six patients with fracture of the radius without fracture of the ulna were followed up for at least 6 months after injury. Injury of the DRUJ was defined as more than 5 mm of ulnar-positive variance on radiographs taken before any manipulative or surgical reduction. All of the fractures were treated with plate and screw fixation (8 with autogenous bone grafting) and all healed. Patients with DRUJ injury had either temporary pinning or immobilization of the DRUJ or surgical fixation of a large ulnar styloid fracture. Patients without DRUJ injury were mobilized within 2 weeks. RESULTS: Nine patients had dislocation of the DRUJ, 4 with large ulnar styloid fractures. Among the remaining 27 patients 1 had displacement of the proximal radioulnar joint noted after surgery, leading to a secondary procedure for radial head resection. The functional results were satisfactory or excellent in all but 2 patients with functional limitations related to central nervous system injury. No patient had DRUJ dysfunction at the final follow-up evaluation. CONCLUSIONS: Isolated fractures of the radial diaphysis are more common than true Galeazzi fractures. Surgeons should take great care not to overlook injury to the distal or proximal radioulnar joint in association with isolated diaphyseal fractures of the radius; however, fractures without identifiable radioulnar disruption can be treated without specific treatment of the DRUJ and with immediate mobilization. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Management of the distal radioulnar joint and ulnar styloid fracture

Fractures of the distal radius and ulnar styloid have the potential to disturb the normal function of the distal radioulnar joint (DRUJ), resulting in loss of motion, pain, arthritis, or instability. The DRUJ can be adversely affected by several mechanisms, including intra-articular injury with step-off, shortening, and angulation of an extra-articular fracture; injury to the radioulnar ligaments; ulnar styloid avulsion fracture; and injury of secondary soft tissue stabilizers. This article discusses the management of the DRUJ and ulnar styloid fracture in the presence of a distal radius fracture.     

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。     

尺骨茎突骨折对桡骨远端骨折手术疗效及腕关节功能的影响

目的观察尺骨茎突骨折对桡骨远端骨折手术疗效及腕关节功能的影响。方法对64例不稳定桡骨远端骨折进行回顾性分析,选择AO分型为A型和B型的不稳定桡骨远端骨折患者,均行切开复位T型桡骨远端锁定钢板内固定治疗,尺骨茎突骨折未作特殊处理,将所有资料按照未合并尺骨茎突骨折组、尺骨茎突骨折(体部骨折)Ⅰ型组及尺骨茎突骨折(基底部骨折)Ⅱ型组分组进行整理分析,记录病例AO分型及术前、术后6个月和术后1年的X线片测量结果 ,按照Bunger提出的解剖学评分(掌倾角、尺偏角、桡骨茎突高度)进行解剖学评估,同时进行GartlandWerly评分。结果随访时间为7~12个月,平均11个月,64例桡骨远端骨折均愈合。未合并尺骨茎突骨折组、尺骨茎突骨折Ⅰ型组及Ⅱ型组术前、术后6个月及术后1年解剖学评分差异无统计学意义,未合并尺骨茎突骨折组与尺骨茎突骨折Ⅰ型组Gartlant-Werley评分、优良率差异无统计学意义。但未合并尺骨茎突骨折组与尺骨茎突骨折Ⅱ型Gartlant-Werley评分、优良率差异有统计学意义,尺骨茎突骨折Ⅰ型组与Ⅱ型组相比,Gartlant-Werley评分、优良率差异有统计学意义。结论尺骨茎突骨折与否及分型对桡骨远端骨折术后解剖学评分无影响,尺骨茎突体部骨折对腕关节功能无影响,但尺骨茎突基底部骨折对腕关节功能有一定影响,值得进一步研究。     

尺骨茎突骨折对外固定架治疗桡骨远端骨折的影响

目的探讨尺骨茎突骨折对外固定支架治疗不稳定性桡骨远端骨折疗效的影响。方法回顾性分析118例不稳定性桡骨远端骨折患者的随访资料。根据尺骨茎突骨折情况分为:A组(尺骨茎突基底部骨折)、B组(尺骨茎突尖部骨折)、C组(无尺骨茎突骨折)。所有患者均采用外固定支架治疗,尺骨茎突骨折不做任何治疗,术后6~8周拆除外固定支架,平均随访15.3个月,终末随访时行影像学参数(掌倾角、尺偏角、桡骨高度)、腕关节活动度(掌屈、背伸、尺偏、桡偏、旋前、旋后)及Gartland-Werley评分测定。结果终末随访时三组病例之间在影像学参数、腕关节活动度及Gartland-Werley评分方面均未发现统计学差异。结论采用外固定支架治疗不稳定性桡骨远端骨折时,若下尺桡关节稳定,对伴有的尺骨茎突骨折可不做任何治疗。     

累及桡尺远侧关节不稳定的尺骨茎突骨折手术治疗

目的 介绍累及桡尺远侧关节不稳定的桡骨远端合并尺骨茎突骨折的手术指征和治疗方法.方法 2005年1月至2009年6月,对12例桡骨远端骨折合并尺骨茎突骨折的患者,采用克氏针结合张力带钢丝固定尺骨茎突,同时采用骨锚修复下尺桡韧带深层结构在尺骨隐窝的止点,从而稳定桡尺远侧关节.结果 术后12例桡骨远端骨折及尺骨茎突骨折均愈合,术后随访时间为6～18个月.按改良的Mayo腕关节评分标准评定:优4例,良5例,中2例,差1例.结论 尺骨茎突在桡尺远侧关节稳定中起着重要作用,对累及下尺桡韧带结构损伤的尺骨茎突骨折进行固定并重建韧带对稳定桡尺远侧关节有较为重要的作用.     

Distal radioulnar joint injuries

Distal radioulnar joint is a trochoid joint relatively new in evolution. Along with proximal radioulnar joint, forearm bones and interosseous membrane, it allows pronosupination and load transmission across the wrist. Injuries around distal radioulnar joint are not uncommon, and are usually associated with distal radius fractures,fractures of the ulnar styloid and with the eponymous Galeazzi or Essex_Lopresti fractures. The injury can be purely involving the soft tissue especially the triangular fibrocartilage or the radioulnar ligaments. The patients usually present with ulnar sided wrist pain, features of instability, or restriction of rotation. Difficulty in carrying loads in the hand is a major constraint for these patients. Thorough clinical examination to localize point of tenderness and appropriate provocative tests help in diagnosis. Radiology and MRI are extremely useful, while arthroscopy is the gold standard for evaluation. The treatment protocols are continuously evolving and range from conservative, arthroscopic to open surgical methods. Isolated dislocation are uncommon. Basal fractures of the ulnar styloid tend to make the joint unstable and may require operative intervention. Chronic instability requires reconstruction of the stabilizing ligaments to avoid onset of arthritis. Prosthetic replacement in arthritis is gaining acceptance in the management of arthritis.     

Ulnar wrist pain after Colles' fracture: 109 fractures followed for 4 years

109 patients with unilateral Colles' fracture, treated with closed reduction and cast immobilization, were re-examined after 4 (1-9) years. At follow-up, 40 patients had persistent ulnar wrist pain. The most important factor for predicting ulnar pain was final dorsal angulation of the radius. Initial and final radial shortening, fracture of the distal radioulnar joint, ulnar styloid fracture, or instability of the distal ulna were not correlated to ulnar wrist pain. We suggest that ulnar wrist pain following Colles' fracture is caused by incongruity of the distal radioulnar joint.     

青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗

目的 探讨青年桡骨远端陈旧性骨折继发下尺桡关节重度脱位的手术治疗方法.方法 采用短缩尺骨、重建下尺桡关节法,对7例桡骨陈旧性骨折、短缩,下尺桡关节重度脱位患者进行治疗.术后对患者腕关节外形、功能进行随访.结果 所有患者外形恢复良好,功能评价优6例,良1例.结论 短缩尺骨、重建下尺桡关节法是治疗桡骨陈旧性骨折、短缩,下尺桡重度脱位的有效方法.     

Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture

PURPOSE: To evaluate the results following locking plate fixation of unstable distal ulna fractures with concomitant distal radius fracture. METHODS: A retrospective review was conducted to identify patients who had been treated with a locking plate for unstable displaced fractures of the distal ulna in which a concomitant ipsilateral distal radius fracture was also treated operatively. Medical records and radiographs were reviewed, and 5 patients were identified with an average age of 52 years (range, 47-61 years) and with follow-up averaging 11.6 months (range, 6-17 months). There were 2 open and 3 closed fractures. Included was 1 simple neck, 1 comminuted neck, 1 head, and 2 head and neck fractures of the distal ulna. All distal radius fracture implants were locked volar plates. RESULTS: All distal ulna and distal radius fractures united, and the average motion was: flexion 59 degrees ; extension 59 degrees ; pronation 67 degrees ; and supination 72 degrees . Average grip strength was 97% of the opposite extremity. Final ulnar variance averaged -0.4 mm (ulnar negative), radial inclination was 20 degrees , and volar tilt was 8 degrees . All distal radioulnar joints were stable. Two patients had mild, transient paresthesias of the dorsal sensory branch of the ulnar nerve, and both patients recovered completely within 3 months. There were no subsequent surgeries or hardware failures. There were no infections and no wound problems. Based upon the Sarmiento modification of the Gartland and Werley rating score, there were 4 excellent results and 1 good result. CONCLUSIONS: Locked plating of unstable distal ulna fractures, in the setting of an associated distal radius fracture, resulted in union, good to excellent alignment and motion, nearly symmetric grip strength, and minimal transient morbidity.     

Should ulnar styloid be fixed following fixation of a distal radius fracture?,

IntroductionFracture of the base of the ulnar styloid has shown to have higher incidence of TFCC tears and DRUJ instability leading to nonunion and impaired function. Poorer functional outcomes of the distal radius fracture have been attributed to the untreated associated ulnar styloid fractures while some studies have shown no difference. Thus, the treatment remains controversial. However, it has been shown that fractures at the base of the ulnar styloid have a higher incidence of tears in the triangular fibrocartilage complex (TFCC) and instability in the distal radioulnar joint (DRUJ), which can lead to nonunion and impaired function. Despite this, there are currently no studies comparing the outcomes of surgically and conservatively treated patients.MethodsA retrospective study was conducted to analyze the outcomes of intra-articular distal radius fractures associated with base of ulnar fracture treated with distal radius LCP fixation. The study included 14 patients who were treated surgically and 49 patients who were treated conservatively, with a minimum follow-up of 2 years. Radiological parameters such as union and amount of displacement, VAS score for ulnar-sided wrist pain, functional assessment using the modified Mayo score and the quick DASH questionnaire and complications were analyzed.ResultsAt the final follow-up, the mean scores for pain (VAS), functional outcomes (modified Mayo score), disability (QuickDASH score), range of motion, and non-union rate were found to be statistically insignificant (p > 0.05) between the surgically treated and conservatively treated groups. However, patients with non-union had statistically significant higher scores for pain (VAS), greater post-operative displacement of the styloid, poorer functional outcomes, and higher disability (p < 0.05).ConclusionWhile there was no significant difference in ulnar-sided wrist pain and functional outcomes between the surgically treated and conservatively treated groups, the conservatively treated cases had a higher risk of non-union, which can negatively impact functional outcomes. The amount of pre-operative displacement was found to be a key factor in predicting non-union and can be used as a guide for determining the management of this type of fracture.     

Intrafocal pin plate fixation of distal ulna fractures associated with distal radius fractures

Subcapital ulnar fractures in association with distal radius fractures in elderly patients increase instability and pose a treatment challenge. Fixation of the ulnar fracture with traditional implants is difficult due to the subcutaneous location, comminution, and osteoporosis. We describe an intrafocal pin plate that provides fixation by a locking plate on the distal ulna and intramedullary fixation within the shaft. The low profile and percutaneous technique make this device a useful alternative for treatment of subcapital ulna fractures in the elderly.     

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.