Validation of the extensor carpi ulnaris groove as a predictor for the recognition of standard posteroanterior radiographs of the wrist

This study was designed to establish the extensor carpi ulnaris groove (ECUG) as a reliable radiographic criterion for recognition of true neutral posteroanterior (PA) radiographs and to verify precise measurements of ulnar variance in a large cohort of patients. In 197 patients 197 wrists were evaluated with a series of radiographic views obtained during routine wrist arthrography. Posteroanterior views were taken in all patients at 90 degrees, 45 degrees, and 0 degrees arm abduction and in 171 patients at 90 degrees elbow flexion and 90 degrees arm abduction with full elbow extension. The ECUG position was classified according to its profile with the ulnar styloid as excellent, acceptable, or unacceptable. Ulnar variance was measured on all x-ray films. Statistical analysis included interobserver reliability with 100 x-ray films measured by 2 evaluators. The ECUG was excellent or acceptable in 100% of the x-rays on standard PA views (arm abducted 90 degrees ), 87% excellent or acceptable and 13% unacceptable on 45 degrees arm abduction views, and 23% excellent or acceptable and 77% unacceptable on 0 degrees arm abduction (adducted) views (all with the elbow flexed at 90 degrees ). With the arm at 90 degrees abduction and full elbow extension the ECUG was excellent or acceptable in 91% of cases. These results show that the ECUG is a reliable criterion to verify arm position during PA wrist radiography and therefore provides a standard for making treatment decisions. The need for repeat radiographs should be reduced.     

Carpal impaction with the ulnar styloid process: treatment with partial styloid resection

Carpal impaction with the ulnar styloid process (stylocarpal impaction) occurs less frequently than with the ulnar head (ulnocarpal impaction), and more commonly develops in wrists with negative ulnar variance. Physical examination, radiographic evaluation, and wrist arthroscopy are all helpful in excluding alternative causes of ulnar wrist pain. When an ulnocarpal stress test elicits pain, and radiographs suggest that this is due to carpal impaction with the ulnar styloid, partial resection of the styloid process provides successful treatment, so long as the insertion of the triangular fibrocartilage at the base of the styloid is not disrupted.     

Ulnar styloid triquetral impaction.

BACKGROUND: Ulnar styloid triquetral impaction (USTI), one of many causes of ulnar sided wrist pain, is a pathological entity with clear clinical and radiographic features, distinct and different from the impaction of the ulnar head against the lunate or ulno-carpal impaction (UCI). Pain is ulnar and point-tenderness is present precisely over the ulnar styloid as opposed to the proximal lunate in UCI. The provocative maneouvre of dorsiflexion in pronation followed by supination is markedly different from the ulnar deviation grind test maneouvres used to diagnose UCI. Multiple anatomical and pathological features interplay to produce a situation in which the distance between the tip of the ulnar styloid and the triquetrum is reduced resulting in USTI. The concept of ulnar styloid variance is introduced and anatomical variations of ulnar styloid length are demonstrated. METHODS: The clinical and radiographic features of 56 patients diagnosed with USTI were analysed. One thousand standardised film-file wrist radiographs were measured to determine the average length of the ulnar styloid in the population as well as the average projection of the styloid above the radius (ulnar styloid variance). RESULTS: An aetiological classification system for USTI was developed based on the clinical and radiographic features of the aforementioned patients and radiographs. CONCLUSIONS: The causes of this syndrome are often complex and classification of the aetiological features is clinically useful. It is important for physicians and surgeons to recognise the clinical and radiographic features of this syndrome in order to properly manage the symptoms and prevent an iatrogenic production of USTI.     

Evaluation of ulnar styloid length

PURPOSE: General awareness of the ulnar styloid impaction syndrome is low and often is neglected. Radiographic evaluation of the ulnar styloid length generally includes an x-ray of the posteroanterior view. This study analyzed the effect of different radiographic views to assess the length of the ulnar styloid. The ulnar styloid-capitate ratio (SCR) expresses the relative length of the ulnar styloid, and we compare this ratio with the ulnar styloid process index (USPI). METHODS: To evaluate the ulnar styloid and to analyze the effect of different radiographic views on measurement outcome, measurements were performed in 7 different radiographic positions of both wrists of 69 patients. To assess the relative size of the ulnar styloid and its impaction potential the USPI was calculated, re-evaluated, and compared with the SCR, in which the length of the ulnar styloid is divided by the length of the capitate bone. RESULTS: The mean ulnar styloid length in all standard posteroanterior radiographs is 4.4 +/- 1.2 mm. In our population the average USPI was 0.21 +/- 0.11 and the average SCR was 0.18 +/- 0.05. The SCR has a stronger correlation with the length of the ulnar styloid than the USPI. Furthermore this new ratio eliminates differences related to gender, whereas the USPI does not. CONCLUSIONS: To identify ulnar impaction potential we recommend using the USPI, but to compare ulnar styloid between patients we recommend using the SCR obtained from neutral posteroanterior radiographs. For white patients we suggest defining a long ulnar styloid as having an SCR greater than 0.18 +/- 0.05 and/or an overall styloid length greater than 6 mm.     

Effects of forearm rotation on the clinical evaluation of ulnar variance

Neutral rotation radiographs of the wrist are recommended to standardize the measurement of ulnar variance because it is known that changes in forearm rotation result in changes of this measurement. The purpose of this study was to examine whether there are clinically measurable differences in ulnar variance between radiographs in various degrees of forearm rotation in human subjects. Forty-five wrist radiographs of 15 normal adults were obtained in 3 positions: maximum forearm pronation, neutral rotation, and maximum supination. The ulnar variance on each view was measured by 3 independent observers using a standard millimeter ruler. The average absolute difference in ulnar variance was 0.4 mm between pronation, 0.6 mm between pronation and supination, and 0.2 mm between neutral and supination. Although we found a statistically significant difference in ulnar variance between the pronated and neutral positions, this difference may not be clinically significant and may not justify concerns of forearm position during the radiographic evaluation of ulnar variance.     

一种新的腕关节正侧位平片投照法及其摄影装置

目的　介绍一种新的腕关节正、侧位平片投照方法及其摄影装置。方法　设计并制作一种用于腕关节正、侧位平片投照的摄影架 ,以其为外参照物 ,限定上肢各个部位的活动角度 ,行腕关节前后正、侧位平片摄影。选取 2 0名志愿者的 2 0个腕关节 ,先用摄影架作侧位摄影 ,后做 Epner- Palmar腕关节标准位摄影 ,以桡舟角和桡月角为观测对象 ;比较两种投照方法角度的差值及可重复性。结果　摄影架摄影的重复性优于 E- P腕关节标准摄影 (P<0 .0 1)。该摄影架的操作较 E- P方法及国外的现有摄影架简便 ,受检者的体位更舒适。结论　用该摄影架作腕关节正、侧位平片摄影检查 ,其投影变异小 ,重复性强 ,可常规用于对腕关节细小变异的观测     

尺骨茎突骨折愈合对桡骨远端骨折术后关节功能影响

目的观察尺骨茎突骨折愈合情况短期内对桡骨远端骨折内固定术后腕关节功能的影响。 方法回顾性分析2012年6月至2013年6月于聊城市中医医院收治的136例单侧不稳定的桡骨远端骨折伴尺骨茎突骨折患者的临床资料,所有患者均采用锁定钢板固定桡骨骨折,根据尺骨茎突骨折愈合情况将患者分为尺骨茎突骨折愈合组(愈合组,n＝43)和尺骨茎突骨折未愈合组(未愈合组,n＝93)。根据术后X线正侧位片测量并记录患者桡骨高度(桡骨茎突与尺骨茎突之差)、掌倾角、尺偏角,评价桡骨骨折复位、愈合情况和尺骨茎突愈合情况,记录腕关节尺侧旋转疼痛的患者数量。末次随访时采用Gartlant-Werley评分和臂肩手功能障碍评分(DASH)评分评估腕关节功能,测定并记录腕关节的活动范围及握力。性别、骨折类型等计数资料比较采用卡方检验,时间、DASH评分等计量资料比较采用t检验。 结果两组患者在年龄、性别、受伤至手术时间、骨折内固定研究学会(AO)骨折分型、受伤侧别和致伤原因方面比较差异无统计学意义(P>0.05)。尺骨茎突骨折愈合组尺侧旋转疼痛有18例(41.9%),而未愈合组有40例(43.0%),差异无统计学意义(χ²＝1.021,P>0.05)。两组患者的住院时间、桡骨骨折愈合时间、掌倾角、尺偏角和桡骨高度方面比较,差异无统计学意义(P>0.05),具有可比性。两组患者背伸、掌曲、桡偏、尺偏、握力和DASH评分、Gartlant-Werley评分和优良率方面比较差异无统计学意义(P>0.05)。 结论尺骨茎突骨折愈合情况在短期内对桡骨远端骨折内固定术后腕关节功能的康复无明显影响。     

Radiologic evaluation of the ulnar styloid.

The ulnar styloid (US) architecture was examined radiologically and directly by dissection in 13 cadaver wrists to examine a potential relationship between US shape and US abutment syndrome and to determine an optimal radiographic view that could be used to detect US fractures. A higher incidence of US abutment syndrome in the radially deviated US type was observed by dissection. Radiographs taken at varying shoulder abduction angles suggested that the base of the US and ulnar head are not round. To best evaluate the fovea and the US for possible US fractures, radiographs should be taken with the glenohumeral joint abducted 45 degrees, the elbow flexed 90 degrees, the forearm in neutral rotation, and the x-ray beam directed through the wrist perpendicular to the floor.     

How many clinic visits does it take to treat distal radial fractures?

The purpose of this study was to evaluate the changes in alignment during the course of treatment for extra-articular distal radius fracture and the relationship of initial and intermediate radiographs, with the final radiograph taken at fracture union. A cohort of 96 consecutive patients who were conservatively managed for extra-articular distal radius fracture in an 18-month period was undertaken. The radiographs analysed were taken at prereduction, postreduction, a week later and at fracture union. The radiological parameters analysed were radial tilt, radial length, radial inclination, dorsal comminution and ulnar styloid fracture. There was a significant change in radiographic alignment between initial and immediate postreduction radiographs, and between postreduction 1 week later radiographs (p < 0.05), but the number of patients in the 1 week later and fracture union groups remained similar (p > 0.05). All patients with poor radiological outcome had ulnar styloid fractures. This was also associated with dorsal comminution in 86% of patients. Patients with satisfactory radiological outcome had ulnar styloid fracture and comminution in 34% and 43% of patients respectively. The final radiological outcome was not found to be influenced by initial unsatisfactory alignment of radial tilt, radial length and radial inclination individually or in combination. We suggest that two clinic visits after initial reduction of the fracture should be sufficient to manage such injuries; the first visit 1 week after manipulation to detect unacceptable displacement and if found satisfactory, the last visit at fracture union for final review, advice and referral to physiotherapy.     

Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability

Ulnar-sided injuries of the wrist have received more attention recently for their potential negative impact on the outcome of distal radius fractures. Radiographs and medical records were retrospectively reviewed for 166 distal radius fractures treated during a 1-year interval. Distal radius fractures were classified according to the AO system, and accompanying ulnar styloid fractures were evaluated for both size and displacement. Each distal radius fracture was also evaluated for radiographic and clinical evidence of distal radioulnar joint instability. The distribution of ulnar styloid fractures was not random; greater than one third involved the base. All distal radius fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture. A fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of distal radioulnar joint instability.     

Non-union of the ulnar styloid process in children is common but long-term morbidity is rare: a population-based study with mean 11 years (9–15) follow-up

Background and purpose — Fracture of the ulnar styloid process (USP) is common in children in connection with distal radius fracture. The long-term morbidity of USP non-union following a childhood distal radius fracture is unclear. We evaluated long-term clinical and radiographic findings of USP non-union.

Patients and methods — All 208 children (< 16 years) who had suffered from distal radius fracture with or without a diagnosed concomitant ulnar fracture during 1992–1999 in the study institution were invited to follow-up at mean of 11 years (9–15) after the injury. Radiographs of both wrists of all 139 participants (67%) were taken; 22 patients showed USP non-union and they made up the study population. Distal radioulnar joint (DRUJ) instability, decreased range of motion (ROM), and weakened grip strength as compared with the uninjured side were the main functional outcomes. Elements of the “Disability of Arm, Shoulder and Hand” questionnaire were used for subjective symptoms.

Results — The rate of USP non-union following childhood distal forearm fracture was 16% (22/139) and only 9 of the ulnar styloid fractures were visible in the radiographs primarily. At follow-up wrist flexion–extension ROM and ulnar and radial deviation ranges did not differ between the injured and uninjured sides. Grip strengths were similar. 6 patients reported pain during exercise. 7 had ulna minus (mean 2.3?mm) but none showed degenerative radiographic findings.

Interpretation — The long-term clinical results of USP non-union following a childhood wrist fracture were good. However, one-third of the patients with USP non-union had ulnar shortening, which may predispose them to degenerative processes later in life.     

Editorial Commentary: In Cases of Concurrent Triangular Fibrocartilage Complex Tears and Ulnar Styloid Process Fracture Nonunions,We May Neither Need to Excise nor Repair the Ulnar Styloid Fracture Nonunion Fragment

The ulnar-sided wrist contains multiple potential pain generators that may present in isolation. Occasionally, however, wrist trauma results in multiple concurrent and overlapping injuries that make diagnosis and treatment of these conditions challenging. Deep/foveal tears of the triangular fibrocartilage complex (TFCC) may occur in the setting of nonunited ulnar styloid process fractures. Treatment of these injuries has historically included open TFCC repair with fixation or excision of the ulnar styloid fracture nonunion fragment; however, recent literature suggests that addressing the ulnar styloid nonunion fragment may not be as important as we think. Recent research shows that we may not need to excise or repair the ulnar styloid fracture nonunion fragment, which in turn may help preserve the complex ligamentous architecture that stabilizes the ulnar-sided wrist. One thing we know for sure is that foveal tears of the deep fibers of the TFCC, with or without ulnar styloid fracture (Palmer 1B, Atzei class 2 or 3), can produce distal radioulnar joint (DRUJ) instability and wrist dysfunction and should be addressed sooner rather than later to prevent long-term consequences, including DRUJ osteoarthritis. Whether you choose to approach the problem arthroscopically or open, the foveal TFCC tear should be repaired to prevent long-term sequalae.     

Effects of a scaphoid waist osteotomy on carpal kinematics

The effects of a scaphoid osteotomy on the kinematics of the carpal bones were determined in five cadaveric wrist specimens. Minute radiographic markers were inserted into the distal radius and selected carpal bones through limited arthrotomies between the intercarpal ligaments. Simultaneous biplanar radiographs were obtained in neutral and the extreme wrist positions of extension, flexion, radial deviation, and ulnar deviation, both before and after a scaphoid waist osteotomy. The positions of each of the carpal markers and their corresponding carpal bones were digitized for each wrist position , and a computer-assisted motion analysis was performed for each specimen before and after transverse scaphoid waist osteotomy. Following the osteotomy, there was a tendency for the scaphoid osteotomy to collapse into a dorsally angulated or "humpback collapse" deformity during each extreme wrist position. There was also multiplanar osteotomy site motion as well as complex collapse deformities of the midcarpal joint associated with loss of the mechanical tie-rod function of the scaphoid. These findings reveal the importance of the scaphoid in maintaining normal kinematics and the inherent instability of these fractures with loss of scaphoid integrity.     

Chip fractures of the os triquetrum: the mechanism of injury.

Studies derived from analyses of radiographs and dissections of cadaveric wrists have been directed at testing and disproving the commonly held theories that link chip fractures of the os triquetrum with avulsion. The authors found that the mechanism of such injuries involved a chisel action of the ulnar styloid upon the dorsum of the os triquetrum; furthermore, the impact of a fall on the outstretched arm with the hand rigidly held in strong dorsiflexion and ulnar deviation could be forceful enough to fracture the body of the os triquetrum as well. In all cases a striking prolongation of the ulnar styloid, beyond the surface of the ulnar head, was consistently noted.     

Symptoms and radiographic findings in the proximal and distal ulnar stumps after the Sauvé-Kapandji procedure for treatment of chronic derangement of the distal radioulnar joint

PURPOSE: We analyzed correlations between symptoms and radiographic findings with respect to the proximal and distal ulnar stumps after the Sauvé-Kapandji procedure for treating chronic derangement of the distal radioulnar joint. METHODS: A total of 26 patients were studied (13 men, 13 women) with a mean age of 46 years at examination. Clinical assessment included elicitation of postoperative symptoms related to the proximal and distal ulnar stumps. In the radiographic study the radioulnar distance in the neutral wrist position and the presence or absence of scalloping at the radius were determined from posteroanterior (PA) views. The total mobility distance of the proximal ulnar stump was measured on the PA and lateral views while the wrist moved from radial to ulnar deviation or from extension to flexion. RESULTS: Eleven patients complained of tenderness over the distal ulnar stump and 5 patients felt discomfort around the proximal ulnar stump during forearm rotation. The postoperative radioulnar distance in patients with tenderness was significantly smaller than in the group without tenderness. Scalloping at the radius was shown in 9 patients but it was not related to the radioulnar distance. The total mobility distance of the proximal ulnar stump on the PA view was significantly greater in patients with tenderness than in those without, and it also was significantly greater in patients with scalloping than in those without. The total mobility distance on the lateral view was significantly greater in the group with discomfort than in the group without discomfort. CONCLUSIONS: The radioulnar distance was related to tenderness over the distal ulnar stump but not to the scalloping. Tenderness and scalloping each were related to radioulnar instability of the proximal ulnar stump. Discomfort around the proximal ulnar stump was related to dorsovolar instability of the stump. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level IV.     

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.     

Repair of the triangular ligament in Colles' fracture. No effect in a prospective randomized study

We present a prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. The study comprised 41 patients with 2 years' follow-up; 22 patients were treated with closed manipulation and an above-the-elbow plaster cast, whereas in 19 patients the avulsed ulnar styloid was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. In all the operated on patients, a complete rupture of the triangular ligament was found. Good reduction of all the fractures was achieved primarily according to the radiographic examination. At follow-up the alignment had deteriorated, with no difference between the two treatment groups. Neither did the findings in the wrist arthrograms differ between the two groups nor did the subjective complaints of the patients. We conclude that repair of the ruptured triangular ligament in extraarticular fractures of the distal radius is not better than conventional treatment.     

Repair of the triangular ligament in Colles' fracture: No effect in a prospective randomized study

We present a prospective and randomized study of two different treatments of extraarticular Colles' fracture with a fractured ulnar styloid. The study comprised 41 patients with 2 years' follow-up; 22 patients were treated with closed manipulation and an above-the-elbow plaster cast, whereas in 19 patients the avulsed ulnar styloid was transfixed and/or the triangular ligament was repaired after closed reduction of the fractured radius. In all the operated on patients, a complete rupture of the triangular ligament was found. Good reduction of all the fractures was achieved primarily according to the radiographic examination. At follow-up the alignment had deteriorated, with no difference between the two treatment groups. Neither did the findings in the wrist arthrograms differ between the two groups, nor did the subjective complaints of the patients. We conclude that repair of the ruptured triangular ligament in extraarticular fractures of the distal radius is not better than conventional treatment.     

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.     

Motion of the distal radioulnar joint in extension and flexion of the wrist using axial CT imaging of healthy volunteers

BackgroundThe midcarpal joint and the radiocarpal joint contribute to the extension and flexion of the wrist. Little is known about the contribution of the distal radioulnar joint (DRUJ) to the extension and flexion of the wrist. This study evaluated the ulnar motion in extension and flexion of the wrist using computed tomography (CT) imaging.MethodsA total of 30 wrists of healthy volunteers were enrolled. CT images of the axial sections of the DRUJ were obtained with 3 different positions of the wrist: 0° of extension (straight position), maximum active extension, and maximum active flexion. Each wrist motion was performed with 3 different forearm positions: neutral, pronation, and supination. Ulnar position at the DRUJ level was measured and ulnar position with the wrist in straight position was defined as baseline. The ulnar position was recorded as positive value when the position of the ulnar head was volar side and negative value when the position of the ulnar head was dorsal side. The difference from baseline in a position of maximum extension and flexion was evaluated.ResultsIn forearm neutral position and pronation, a value of ulnar position in maximum wrist flexion is significantly negative compared to that in the wrist straight position: the ulnar head moved dorsally from the wrist straight position to wrist flexion. In forearm supination, a value of ulnar position in maximum wrist extension is significantly positive compared to that in the wrist straight position: the ulnar head moved to the volar side from the wrist straight position to wrist extension.ConclusionsThe ulnar head moves during extension and flexion of the wrist. The direction of the ulnar motion was different according to the wrist and forearm position.