Untreated Ulnar Styloid Fracture and Unstable DRF Outcome
Untreated Ulnar Styloid Fracture and Unstable DRF Outcome
Between January 2009 and March 2011, 106 patients with unstable DRF and stable DRUJ were involved in this study (Table 1). DRF was considered unstable according to the radiographic criteria described in literature: (1) the initial dorsal angulation >20°, (2) with dorsal or volar comminution of the metaphysis, (3) shortening of radius >5 mm, or (4) with an associated ulnar fracture. Additionally, fractures were also considered unstable if radiographic displacements occurred after primary closed reduction and splinting: shortening of radius >2 mm, joint fragment displacement >2 mm, or dorsal angulation >10°. The stability of DRUJ was checked during the surgical management.
The patients were assigned into three groups according to the fracture characteristics of the ulnar styloid measured on anterior-posterior digital radiographs: 44 patients had no fracture of ulnar styloid (non-fracture group), 20 patients had a fracture of the tip of ulnar styloid (tip-fracture group), and 42 patients had a fracture of the base of ulnar styloid (base-fracture group). The protocols and the procedure were approved by the Committee on Medical Ethics of Nanjing Drum Tower Hospital. Written informed consents were obtained from all of the participants in this study.
With general or brachial plexus anesthesia, distal radius fractures were reduced and fixed with external fixator and K-wires according to the standard technique described in literature. In brief, threaded half-pins (2.5 mm in diameter) were inserted in the dorsoradial aspect of the metacarpal shaft of the index finger as well as the radial shaft 5 to 10 cm proximal to the fracture site through small incisions. Under fluoroscopic guidance, the DRF was reduced closely and fixed with percutaneous K-wires (1.2 or 1.5 mm in diameter). Then the bridging external fixator was applied to stabilize the fracture (Figure 1). If a satisfactory reduction of the DRF or a smooth interface between the ulnar head and the sigmoid notch could not be obtained via close reduction, limited open reduction was performed. In this series, totally 29 patients underwent limited open reduction.
(Enlarge Image)
Figure 1.
The 65-year-old male patient with unstable distal radius fracture. (a, b) The initial anterior-posterior and lateral radiographs of the distal radius showed an unstable fracture accompanied with the ulnar styloid base fracture: dorsal angulation at 30°; shortening of radius 7 mm. (c, d) The radiographs at the external fixator removal time: the fracture was treated with external fixation augmented with percutaneous Kirschner wires. (e, f) The radiographs at three months postoperatively: the distal radius fracture had united but the ulnar styloid base fracture had not. (g, h) The radiographs at the final follow-up visit: the ulnas styloid base fracture still had not united. Written informed consent was obtained from the patient to show the information here.
After fixation of the DRF, the stability of the distal radioulnar joint (DRUJ) was checked. Only the patients with a stable DRUJ were included in this study, and the distal ulnar styloid fracture was left untreated despite of the size or displacement of the fragment. The patients with DRUJ instability who required ulnar styloid fracture fixation were excluded from this study. After surgery, all patients underwent hand therapy including edema control, active and passive finger motion and forearm rotation. The K-wires and external fixator were removed 6–8 weeks after surgery.
Radiological and clinical assessments were performed at three time point: the external fixator removal, three months postoperatively and the final follow-up visit. Standard anterior-posterior and lateral radiographs were obtained at each time point to evaluate fracture healing and the alignment of the distal part of the radius. Radial inclination, volar tilt, and radial height were measured with the techniques described by Kereder et al.. Wrist motion ranges, in terms of the extension, flexion, radial deviation, ulnar deviation, forearm pronation and forearm supination, were measured. The patients were also asked to complete the Patient-rated Wrist Evaluation Form (Hong Kong Version: PRWE-HK), and rate their wrist pain both at rest and in motion on a 10-point visual analogue scale at each follow-up time point. The grip strength was evaluated by JAMAR hand dynamometer (Homecraft Ltd.)
The presence of ulnar-sided wrist pain during daily activities was recorded. Provocative-test, stress-test and press-test were performed on both the injured and the uninjured sides at the final follow-up time point to evaluate the characteristics of the DRUJ. The provocative-test was performed to detect ulnar styloid impaction syndrome: the examiner positioned the forearm in neutral rotation, and then maximally extended the wrist and rolled the forearm into maximum supination; if this maneuver produces localized pain at the ulnar styloid, findings are considered positive. The stress-test was used to detect the DRUJ stability: the distal radius was stabilized by the examiner, and then the distal ulna was translated dorsally and volarly with the forearm in neutral position, pronation, and supination; if the greater laxity and pain of the DRUJ was present, findings were considered positive. The press-test creates an axial ulnar load and has high sensitivity for detecting a tear of the triangular fibrocartilage complex: the patient was asked to grip both sides of a chair and pushed himself or herself up from a seated position; a positive press-test causes focal ulnar-sided wrist pain.
The statistical differences of the age, radiological finding, range of motion and functional outcomes were detected by means of one-way ANOVA (S-N-K) if the variances were homogeneous; but if not, Kruskal-Wallis test was used. Chi-square test was used to evaluate the differences of the gender and the union rate of the fracture of ulnar styloid. Fisher's exact test was used to detect the differences of the positive rate of the wrist physical examination. The SPSS version 15.0 software (SPSS Inc, Chicago, IL, USA) was used and statistical significance was accepted at P < 0.05.
Methods
Patient Inclusion Criteria
Between January 2009 and March 2011, 106 patients with unstable DRF and stable DRUJ were involved in this study (Table 1). DRF was considered unstable according to the radiographic criteria described in literature: (1) the initial dorsal angulation >20°, (2) with dorsal or volar comminution of the metaphysis, (3) shortening of radius >5 mm, or (4) with an associated ulnar fracture. Additionally, fractures were also considered unstable if radiographic displacements occurred after primary closed reduction and splinting: shortening of radius >2 mm, joint fragment displacement >2 mm, or dorsal angulation >10°. The stability of DRUJ was checked during the surgical management.
The patients were assigned into three groups according to the fracture characteristics of the ulnar styloid measured on anterior-posterior digital radiographs: 44 patients had no fracture of ulnar styloid (non-fracture group), 20 patients had a fracture of the tip of ulnar styloid (tip-fracture group), and 42 patients had a fracture of the base of ulnar styloid (base-fracture group). The protocols and the procedure were approved by the Committee on Medical Ethics of Nanjing Drum Tower Hospital. Written informed consents were obtained from all of the participants in this study.
Surgical Technique
With general or brachial plexus anesthesia, distal radius fractures were reduced and fixed with external fixator and K-wires according to the standard technique described in literature. In brief, threaded half-pins (2.5 mm in diameter) were inserted in the dorsoradial aspect of the metacarpal shaft of the index finger as well as the radial shaft 5 to 10 cm proximal to the fracture site through small incisions. Under fluoroscopic guidance, the DRF was reduced closely and fixed with percutaneous K-wires (1.2 or 1.5 mm in diameter). Then the bridging external fixator was applied to stabilize the fracture (Figure 1). If a satisfactory reduction of the DRF or a smooth interface between the ulnar head and the sigmoid notch could not be obtained via close reduction, limited open reduction was performed. In this series, totally 29 patients underwent limited open reduction.
(Enlarge Image)
Figure 1.
The 65-year-old male patient with unstable distal radius fracture. (a, b) The initial anterior-posterior and lateral radiographs of the distal radius showed an unstable fracture accompanied with the ulnar styloid base fracture: dorsal angulation at 30°; shortening of radius 7 mm. (c, d) The radiographs at the external fixator removal time: the fracture was treated with external fixation augmented with percutaneous Kirschner wires. (e, f) The radiographs at three months postoperatively: the distal radius fracture had united but the ulnar styloid base fracture had not. (g, h) The radiographs at the final follow-up visit: the ulnas styloid base fracture still had not united. Written informed consent was obtained from the patient to show the information here.
After fixation of the DRF, the stability of the distal radioulnar joint (DRUJ) was checked. Only the patients with a stable DRUJ were included in this study, and the distal ulnar styloid fracture was left untreated despite of the size or displacement of the fragment. The patients with DRUJ instability who required ulnar styloid fracture fixation were excluded from this study. After surgery, all patients underwent hand therapy including edema control, active and passive finger motion and forearm rotation. The K-wires and external fixator were removed 6–8 weeks after surgery.
Clinical Evaluation
Radiological and clinical assessments were performed at three time point: the external fixator removal, three months postoperatively and the final follow-up visit. Standard anterior-posterior and lateral radiographs were obtained at each time point to evaluate fracture healing and the alignment of the distal part of the radius. Radial inclination, volar tilt, and radial height were measured with the techniques described by Kereder et al.. Wrist motion ranges, in terms of the extension, flexion, radial deviation, ulnar deviation, forearm pronation and forearm supination, were measured. The patients were also asked to complete the Patient-rated Wrist Evaluation Form (Hong Kong Version: PRWE-HK), and rate their wrist pain both at rest and in motion on a 10-point visual analogue scale at each follow-up time point. The grip strength was evaluated by JAMAR hand dynamometer (Homecraft Ltd.)
The presence of ulnar-sided wrist pain during daily activities was recorded. Provocative-test, stress-test and press-test were performed on both the injured and the uninjured sides at the final follow-up time point to evaluate the characteristics of the DRUJ. The provocative-test was performed to detect ulnar styloid impaction syndrome: the examiner positioned the forearm in neutral rotation, and then maximally extended the wrist and rolled the forearm into maximum supination; if this maneuver produces localized pain at the ulnar styloid, findings are considered positive. The stress-test was used to detect the DRUJ stability: the distal radius was stabilized by the examiner, and then the distal ulna was translated dorsally and volarly with the forearm in neutral position, pronation, and supination; if the greater laxity and pain of the DRUJ was present, findings were considered positive. The press-test creates an axial ulnar load and has high sensitivity for detecting a tear of the triangular fibrocartilage complex: the patient was asked to grip both sides of a chair and pushed himself or herself up from a seated position; a positive press-test causes focal ulnar-sided wrist pain.
Statistical Analysis
The statistical differences of the age, radiological finding, range of motion and functional outcomes were detected by means of one-way ANOVA (S-N-K) if the variances were homogeneous; but if not, Kruskal-Wallis test was used. Chi-square test was used to evaluate the differences of the gender and the union rate of the fracture of ulnar styloid. Fisher's exact test was used to detect the differences of the positive rate of the wrist physical examination. The SPSS version 15.0 software (SPSS Inc, Chicago, IL, USA) was used and statistical significance was accepted at P < 0.05.
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