Ulnocarpal impaction syndrome restricts even midcarpal range of motion.

Ulnocarpal impaction syndrome is believed to be caused by abutment between the ulna and the ulnar carpus. We measured radiocarpal and midcarpal ranges of motion in 40 patients with ulnocarpal impaction syndrome by radiographic motion studies. The results showed that the radiocarpal and midcarpal ranges of motion were equally restricted in the affected wrist compared with the unaffected wrist. Therefore, motion of the radiocarpal joint and midcarpal joint contributed equally to total wrist motion bilaterally. No correlation between ulnar variance and the contribution of radiocarpal motion to overall wrist motion was found. Restriction of wrist motion in ulnocarpal impaction syndrome is not caused directly by abutment between the ulna and ulnar carpus, but a satisfactory explanation for restricted motion is still lacking.     

Intercondylar fractures of the distal humerus in adults: a critical analysis of 55 cases

Intercondylar fractures of the distal humerus in adults are difficult management problems on account of the complex anatomy of the elbow, small sized fracture fragments and the limited amount of sub-chondral bone, which is often osteopenic. The results of managing these fractures non-operatively are compromised by the failure to get anatomical reduction and early mobilization. This often results in a painful stiff elbow and/or pseudarthrosis, thereby making an operative approach for these fractures, desirable. Fifty-five such fractures, operated on by the author during the last 9 years, were reviewed. All the fractures were managed by open reduction and internal fixation followed by early mobilization. The outcome in 51 of these cases was graded as excellent or good using the evaluation criteria of Aitken and Rorabeck. Thirty-three of these cases achieved a range of flexion of more than 130 degrees. There was minimal incidence of complications like ulnar nerve neuropraxia or heterotopic bone formation. Anterior transposition of the ulnar nerve was performed in only one of the patients. Dorsal application of both the plates instead of the commonly advocated supracondylar crest placement resulted in a stable configuration requiring less extensive dissection and retraction of the ulnar nerve and resulting in a low incidence of complications.     

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.     

Bicortical K-wires for distal radius fracture fixation: how many?

The aim of this study was to find out whether number and position of K-wires influence the stability of distal radius fractures treated by percutaneous wire fixation. Patients who underwent K-wire fixation for unstable fractures of the distal radius over a period of three years were included in this retrospective study. Radiographs taken immediately after the procedure and radiographs taken after removal of K-wires were analysed to study three radiological parameters: palmar or dorsal tilt, radial inclination and ulnar variance. Loss of these angles was analysed statistically against the number of wires (2 or 3) and position of wires (from radial styloid or a combination of styloid and dorsal wires). Ninety-five fractures were analysed with a mean age of 52.8 years and male to female ratio of 1:2. Average loss of radial inclination was 5.2 degrees, loss of palmar tilt was 8.3 degrees and loss of ulnar variance was 3.4 mm. Using 3 wires or using a dorsal wire in addition to the styloid wires both improved the final radial length by 1.2 mm and 2 mm respectively, but the effects were statistically not significant. We found that the number or position of wires did not influence radiological outcome. Based on our findings we recommend the use of two K-wires: one from the radial styloid and one from the dorsal side for these fractures.     

Ulnar shortening for tears of the triangular fibrocartilaginous complex

Ten consecutive patients had their ulnas shortened for treatment of ulnar wrist pain associated with triangular fibrocartilaginous complex tears. Each injury was traced to a previous fall or an overuse syndrome. Conservative treatment failed. In all patients, x-ray films showed ulnar positive or neutral variance. The ulna was shortened an average of 2 mm. Frank ulnolunate abutment and/or cartilage degeneration was found in six cases. Follow-up averaged 23 months, and except for one patient in whom radiocarpal arthritis developed, the remaining patients were satisfied and returned to their work or previous level of activity. Relief of pain, grip strength, and range of motion were excellent, except for an average decrease in flexion of 25.8 degrees (p = 0.01). Hardware irritation was noted in six patients. These findings substantiate the use of ulnar shortening to relieve ulnolunate impingement in patients with ulnar positive or neutral wrists in whom ulnar wrist pain develops and who demonstrate triangular fibrocartilaginous complex tears after acute trauma and/or overuse syndromes.     

Surgical treatment of unstable distal radius fractures with volar locking plates

BACKGROUND: Surgical treatment of unstable distal radius fractures does not always yield a satisfactory outcome. The several surgical strategies available have problems associated with them. This study was undertaken to determine if volar locking plate fixation could be useful for treating unstable distal radius fractures. METHODS: This retrospective follow-up study assessed 24 fractures in 24 patients with unstable distal radius fractures surgically treated with one of three volar locking plate systems. According to the AO classification system, 7 patients had type A3 fractures, 5 patients had type C2 fractures, and the remaining 12 patients had type C3 fractures. Radiographic measurements included volar tilt, radial inclination, and ulnar variance. Clinical outcomes were evaluated by active range of motion of the wrist and forearm, grip strength, Saito's wrist score, and the Japanese Society for Surgery of the Hand version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (JSSH version of the DASH). RESULTS: At the time of final follow-up (5 months minimum) the mean volar tilt was 8.1 degrees , radial inclination was 20 degrees, and ulnar variance was 0.4 mm. Mean wrist extension measured 61 degrees, wrist flexion 55 degrees, radial deviation 23 degrees, ulnar deviation 35 degrees, pronation 87 degrees, and supination 87 degrees. Grip strength recovered to a mean of 84% of the grip strength in the contralateral limb for patients who had injured their dominant hand and to a mean of 73% for patients who had injured their nondominant hand. Saito's wrist score calculations revealed 20 excellent and 4 good results. The mean DASH disability/symptom score was 9.9 points, and the mean DASH work module score was 8.2 points. CONCLUSIONS: The present study demonstrated that unstable distal radius fractures could be successfully treated with volar locking plate systems.     

Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion

PURPOSE: Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia; however, they require an ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. The literature contains little information on concomitant ulnar shortening osteotomy despite a physiologic solution. We report the functional and radiographic outcomes of 5 patients treated for symptomatic distal radius malunion with simultaneous radial closing wedge and ulnar shortening osteotomies. METHODS: All 5 patients were women aged 52 to 69 years (average, 61 years). Four patients had extra-articular radius fractures with dorsal angulation (20-22 degrees ) and shortening (3-7/mm); the other had the fracture with volar angulation (24 degrees ) and shortening (11 mm). Through a volar approach an appropriate amount of bone wedge was removed from the distal radius. A small volar T-plate was used to secure the osteotomized bone fragment. Six to 11 mm of ulnar shortening osteotomy was performed by using transverse osteotomy and compression plating technique with an AO compression device. RESULTS: In all 5 wrists healing of radial and ulnar osteotomies occurred less than 3 months after surgery. There were no postsurgical complications. Postsurgical radiographs showed that the volar tilt angle of the radius was reduced to normal range (range, 8-15 degrees ) in all wrists. The ulnar variance was 0 mm in 4 wrists and 2 mm in 1 wrist. There were significant improvements in pain, function, and range of motion at an average follow-up evaluation of 17 months. The average grip strength as a percentage of the opposite side improved from 30% before to 73% after surgery. CONCLUSIONS: This study showed that closing wedge osteotomy of the radius concomitant with ulnar shortening osteotomy is technically and functionally adequate. Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate.     

Ulnar shortening or arthroscopic wafer resection for ulnar impaction syndrome

The outcome of ulnar shortenings was compared to the outcome after arthroscopic wafer resections for ulnar impaction (or abutment) syndrome in patients with a positive ulnar variance. Both surgical techniques are described. The outcome was measured by the DASH score, the visual analogue score for pain and the working incapacity. The mean DASH score in the ulnar shortening group was 26, in the wafer group it was 36. The VAS were respectively 4.4 and 4.6. The working incapacity was 7 months in the ulnar shortening group and 6.1 months in the wafer group. The differences between the two groups were not statistically significant.     

Intramedullary fixation for pediatric unstable forearm fractures

Forty-nine children with diaphyseal both-bone forearm fractures were treated with either both-bone intramedullary wire fixation (24), single ulnar intramedullary wire fixation (22), or single radial intramedullary wire fixation (3). Six fractures were open and 43 were closed. A limited open approach to one or both bones was necessary for insertion of the intramedullary wire in 10 of 43 closed fractures. All both-bone and single radial intramedullary wire fixations healed with less than 5 degrees angulation. Progressive reangulation of the nonfixed radial fracture after an initial satisfactory reduction was seen in seven of the 22 fractures treated with single ulnar intramedullary wire fixation. In four patients, the reangulation was controlled by a change of cast and molding of the fracture and was between 8 degrees and 12 degrees at union. In two other patients a second operative procedure was required to reduce and internally fix the radius. One fracture healed with a radial angulation of 25 degrees. Three fractures in older patients showed late reangulation after early removal of intramedullary wires at 5 weeks. The results of the current study suggest that the radius and ulna should be stabilized with intramedullary wires and that the wires should be buried to reduce the need for early removal.     

Treatment of isolated ulnar shaft fractures with prefabricated functional fracture braces

In a prospective study, from September 1980 to December 1984, 146 isolated ulnar shaft fractures were treated with prefabricated fracture braces. Clinical and roentgenographic follow-up data were available for 73 fractures. Functional results were rated excellent in 64 fractures (88%), good in seven (9%), and poor in two (3%). All fractures healed in an average time of 57 days. The mean angulation measured 6 degrees in the mediolateral plane and 4 degrees in the anteroposterior plane. The complication rate was 18%, relating mostly to residual angulation. Most isolated fractures of the distal one-half of the ulnar shaft can be treated successfully with prefabricated fracture braces.     

Ultrasound-guided surgical treatment for ulnar nerve entrapment: A cadaver study

Several open and endoscopic techniques for the surgical treatment of ulnar nerve entrapment at the elbow (cubital tunnel syndrome) have been described that provide decompression with or without anterior transposition. Based on our experience with US-guided decompression for carpal tunnel syndrome in our department, we developed a similar surgical technique for the decompression of the ulnar nerve at the elbow. Using sixteen cadaver upper limbs, we performed decompression of all the structures possibly responsible for ulnar nerve compression at the elbow. The structures involved were Struthers’ arcade, the cubital tunnel retinaculum, Osborne's fascia and Amadio-Beckenbaugh's arcade. The procedure was followed by anatomical dissection to confirm complete sectioning of the compressive structures, absence of iatrogenic vascular or nervous injuries and absence of nerve dislocation or instability. There were no remaining compressive structures after the release procedure. There was no iatrogenic damage to the nerves and no nerve dislocation was observed during elbow flexion or extension. In 3.4% cases, a thin superficial layer of one or more of the identified structures remained but these did not appear to compress the nerve based on US imaging. Using ultrasonographic visualization of the nerve and compressive structures is easy. Each procedure can be tailored according to the nerve compression sites. Our cadaveric study shows the feasibility of an US-guided percutaneous surgical release for ulnar nerve entrapment.     

Medial approach for fixation of displaced supracondylar fractures of the humerus in children

This study aimed at evaluating our protocol for displaced Gartland Type 3 supracondylar fractures of the humerus in children. Forty-eight children had 49 fractures during the study period, from 1997 to 2002; they were included in the study. Their mean age was 7.02 years. They all were treated with crossed K-wires. The medial wire was always put under direct vision through a medial approach. All fractures were manipulated maximum twice. Ten patients (23.25%) required open reduction which was done through the same medial approach which we use for medial pin placement. No patient had iatrogenic ulnar nerve neuropathy. At final review radiographs were taken of the normal and operated sides and films were compared with immediate post-op films. The postoperative mean value of Bauman's angle in the affected elbow was 76.7 degrees with a range of +/- 1.0 degrees and 74.8 degrees with a range of +/- 0.6 degrees on the unaffected elbow. Carrying angle and movements of operated and normal sides were measured at review. According to Flynn's criteria, all patients showed satisfactory results. We conclude that cross K-wiring gives excellent results; the medial approach provides an excellent view of the supracondylar area, leaves a cosmetically acceptable scar and enables to avoid iatrogenic injury to the ulnar nerve.     

The treatment of ulnar impaction syndrome: a systematic review of the literature

Ulnar impaction syndrome is a common cause of ulnar-sided wrist pain that is thought to be a result of abutment between the ulna and the ulnar carpus. A systematic review of the literature was conducted to determine the effectiveness of different treatment options in managing ulnar impaction syndrome. PubMed, the Cochrane database, and secondary references were reviewed to identify all English-language articles with reported results on the treatment of ulnar impaction syndrome. A total of 16 articles met the criteria for review. Three procedures were identified as the most commonly used in treating this syndrome: ulnar shortening osteotomy, the wafer procedure, and the arthroscopic wafer procedure. Mean time to union and percentage nonunion for the osteotomy group was 10.3 weeks and 1.7%, respectively. The overall complication rate for patients in the ulnar shortening osteotomy group, the wafer procedure group, and the arthroscopic wafer group was 30%, 8.8%, and 21%, respectively. The authors were unable to determine a single best treatment option based on the available studies, mainly due to the variability in the reporting of subjective outcome measures. Ulnar shortening osteotomy was associated with a higher complication rate than other procedures.     

儿童肱骨髁上骨折移位程度与Baumann角关系的分析研究

目的:应用Excel软件对小儿肱骨髁上骨折的桡尺侧移位值和Baumann角进行数值拟合分析,得出相关数据曲线,以期用于指导临床小儿肱骨髁上骨折治疗。方法:收集2010年7月至2011年7月间就诊的小儿肱骨髁上骨折病例56例(年龄3～14岁;男34例,女22例;桡偏型15例,尺偏型41例)。采用数据测量工具MB-Ruler,测量各病例X线片骨折的移位值及Baumann角,将数值录入于Excel,分别对56组骨折的移位值和Baumann角,以及15组桡偏型、41组尺偏型数值行拟合分析,并对所得数据曲线进行分析。结果:用2种方式进行拟合所得出结果相近,即尺偏切线斜率>桡偏切线斜率;当桡偏系数<-0.18,尺偏系数>0.50时,Baumann角有反向改变的趋势,即Baumann角变化范围在65.70°～96.77°;当尺偏系数≥0.15时,Baumann角≥82°。结论:小儿肱骨髁上骨折尺偏移位对Baumann角的影响大于桡偏移位,当尺偏系数≥0.15时应注重纠正,预防肘内翻发生。     

Dorsal plating for comminuted intra-articular fractures of the distal end of the radius.

Forty-one dorsally displaced intra-articular fractures of the distal radius were treated by open reduction and internal fixation with the dorsal Symmetry plates. The average age at the time of the injury was 49 years. An average follow-up period was 15 months. The final radial length averaged 11 mm, radial inclination 23 degrees, volar tilt 7 degrees, ulnar variance 1.5 mm, and articular incongruity 0.3 mm. According to the Gartland and Werly scales, 36 fractures were excellent and five were good. However, ulnar variance increased more than 3 mm during follow-up in eight patients, and volar tilt increased more than 5 degrees during follow-up in ten patients. Use of dorsal Symmetry plate is effective for unstable comminuted intra-articular distal radius fractures, but severely comminuted fractures may possibly undergo re-displacement post-operatively.     

超声技术引导闭合穿针保护尺神经治疗儿童肱骨髁上骨折

目的 探讨在治疗肱骨髁上骨折时利用超声技术探查尺神经的位置,以提高内侧穿针时尺神经安全性的效果观察.方法 对我科于2012年2月至2014年5月收治的53例移位的肱骨髁上骨折患儿进行了肱骨内侧穿针的前瞻性研究.其中,男33例,女20例;年龄为1~13岁,平均为(5.3±0.4)岁.GartlandⅡ型18例,GartlandⅢ型35例.患儿均无尺神经损伤,开放复位4例,闭合复位49例.对患儿骨折复位后进行了交叉穿针技术固定,术中使用超声引导内侧穿针,以避免尺神经损伤.记录术中神经血管的状态和并发症情况,观察患儿愈合情况和愈合时间.超声观察术中、术后情况:术中尺神经和固定针的位置关系,术后有无尺神经损伤的临床症状和表现.结果 术中使用超声检查,能够清楚地观察到肘管解剖形态,尺神经能得到清楚的显示.屈肘10°时,患儿使尺神经在肘管内松弛,在超声引导下顺利完成骨折内侧穿针.术中没有病例发生尺神经损伤.患儿术后均获得随访,随访时间为6~24个月,平均为(16.2±9)个月.患儿骨折全部愈合,愈合时间为2.7~3.1个月,平均为(2.9±0.2)个月.结论 目前在操作技术上有较高的要求,但其可以准确地显示尺神经位置、引导穿针,可以有效地提高尺神经安全性,故我们认为超声技术是引导肱骨髁上骨折治疗时内侧穿针的有效工具.     

Open reduction and palmar plate-osteosynthesis in combination with a nanocrystalline hydroxyapatite spacer in the treatment of comminuted fractures of the distal radius

In a prospective study, we used the nanocrystalline hydroxyapatite paste Ostim (Osartis, Obernburg, Germany) in combination with a palmar plate to treat comminuted radius fractures with a metaphyseal and articular component in order to examine the clinical use of Ostim as a bone substitute. Twenty-one patients with 22 radius fractures of AO types C2 and C3 were included in the study. The measurements, taken 10.2+/-1.3 months after the initial treatment, revealed a dorsopalmar tilt of 8.8+/-3.7 degrees , a radioulnar inclination of 18.8+/-2.8 degrees and an ulnar variance of 0.8+/-1.8mm. According to the Gartland and Werley evaluation, eight of the treated fractures attained an excellent, 11 a good and the remaining three a fair result. The study demonstrates that Ostim, in combination with angularly stable osteosynthesis, can be used as an acceptable bone substitute for the treatment of type C2 and C3 radial fractures.     

Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius

PURPOSE: To review the results of condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. METHODS: Twenty-four patients in whom a minicondylar blade plate was used to repair an unstable fracture of the distal ulna associated with a fracture of the distal radius were reviewed retrospectively an average of 26 months (range, 12-50 months) after injury. According to the Q modifier of the Comprehensive Classification of Fractures, there were 1 simple fracture of the ulnar neck (Q2), 20 comminuted fractures of the ulnar neck (Q3), and 3 fractures of the head and neck (Q5). Subsequent surgeries included repeat fixation and autogenous cancellous bone grafting in 2 patients with nonunion of the distal radius and 1 with nonunion of the distal ulna. Seven patients had a second operation to remove the ulnar plate secondary to discomfort from plate prominence. RESULTS: The final average motion was as follows: degrees of flexion (range, 30 degrees-80 degrees), 52 degrees of extension (range, 40 degrees-90 degrees), 76 degrees of pronation (range, 45 degrees-90 degrees), and 70 degrees of supination (range, 45 degrees-90 degrees). Grip strength averaged 64% of the contralateral, uninjured extremity (range, 35%-100%). Final radiographic measurements included an average palmar tilt of the distal articular surface of the radius of 8 degrees (range, 0 degrees-20 degrees of palmar tilt), ulnar inclination of 21 degrees (range, 15 degrees-25 degrees), and ulnar positive variance of 1 mm (range, 0-4 mm). There were no problems related to the distal radioulnar joint. According to the system of Gartland and Werley as modified by Sarmiento, there were 6 excellent, 15 good, and 4 fair results at final evaluation. CONCLUSION: For unstable fractures of the distal ulna associated with fracture of the distal radius, condylar blade plate fixation can achieve healing with good alignment, satisfactory function, and an acceptable rate of secondary surgery.     

Percutaneous pinning for fractures of the distal radius

The results of treatment of wrist fractures with percutaneous pin fixation in 106 patients are reported. Functional and radiological evaluation was made for all patients. All fractures healed; loss of reduction occurred in only two cases. The best results were obtained in metaphyseal fractures of the radius, while good results were obtained in intra-articular fractures; the worst results were noted in cases with an associated fracture of the ulnar styloid, in elderly patients, or in cases with associated fractures in other parts of the skeleton. When the volar tilt has been restored to more than 10 degrees higher than normal, loss of wrist motion may occur. No vascular, nervous or tendinous lesion was noted. A nerve entrapment syndrome at the wrist occurred in a fairly high percentage of cases (14.1%).     

Ulnar styloid fracture in children: a retrospective study of 46 cases

Ulnar styloid fractures are frequently ignored in the treatment of wrist fractures in children. Forty-six untreated ulnar styloid fractures (40 tip and six base fractures) associated with radial injuries (45 patients) were retrospectively analysed. At the removal of the cast, we recorded that 80% had a nonunion of the styloid fracture. Thirty-five patients were reviewed at an average of 19 months after treatment. Thirty tip fractures and five base avulsions were found. We recorded 28 patients with a good clinical result despite 21 cases of nonunion, whereas seven patients (all nonunions) had a fair result. All the fair results suffered from intermittent pain during sports and movement, radioulnar joint instability and tears of the triangular fibrocartilage complex. It can be concluded that both distal radius and ulnar styloid fractures should be taken into account in the initial treatment and pain associated with a nonunion of the ulnar styloid in a child may be due to a tear of the triangular fibrocartilage complex.