Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1427-y
ORIGINAL ARTICLE
LCP distal ulna plate fixation of irreducible or unstable distal ulna fractures associated with distal radius fracture Soo Hong Han • In Tae Hong • Woo Hyun Kim
Received: 19 November 2013 / Accepted: 8 February 2014 Ó Springer-Verlag France 2014
Abstract Purpose The advent of locking compression plate (LCP) has provided convenient and secure fixation of distal ulna fractures. This study was performed to evaluate the functional and clinical outcomes following LCP distal ulna plate fixation of irreducible or unstable distal ulna fractures with concomitant distal radius fractures. Methods Retrospective review of 17 patients who had been treated with LCP distal ulna plates for distal ulna fractures was performed. The average age of the patients was 58.9 years (range 21–87 years), and the mean followup period was 15 months (range 12–20 months). This study consisted of eleven fractures involving metaphysis and six ulna styloid base fractures. Fracture union, radiologic parameters, stability of the distal radioulnar joint (DRUJ), and functional outcomes, including ROM, grip strength, and functional scores were evaluated. Results All patients showed bony union, the average radial height was 10.5 mm, and the ulnar variance was 0.8 mm on final radiographs. None of the patients had instability of the DRUJ compared with the opposite wrist, and the subluxation ratio was within normal range on the follow-up CT scan. There were 6 excellent and 11 good cases according to Sarmiento’s modified wrist score at the last follow-up. Conclusions Locking compression plate distal ulna plate fixation of irreducible or unstable distal ulna fractures after stabilization of concomitant distal radius fractures showed favorable results in union, alignment, and functional
S. H. Han (&) I. T. Hong W. H. Kim Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea e-mail: [email protected]
outcomes and therefore could be one of the recommendable implant options for distal ulna fractures. Keywords Unstable distal ulna fracture DRUJ instability Distal ulna locking compression plate
Introduction Fractures of the distal ulna occur often with distal radius fractures [1–3]. Compared with distal radius fractures, the significance of distal ulna fractures is much less appreciated and the treatment of these fractures still remains controversial. Many distal ulna fractures are considered stable after reduction and stabilization of distal radius fractures, and satisfactory outcomes can be achieved with conservative treatment [4–7]. In cases of displaced or unstable ulna fractures, however, some reports have shown poor outcomes after nonoperative treatment [8]. Displaced or mal-aligned fractures of the distal ulna can affect the distal radioulnar joint (DRUJ) function [1, 3, 9, 10]. Also, these fractures are often associated with distal radioulnar ligament injury and result in chronic ulna-sided pain and instability [8, 11, 12]. For these reasons, operative treatment is recommended in case of irreducible or unstable distal ulna fractures associated with distal radius fractures [1, 2, 4, 5]. Recently introduced locking compression plate (LCP) distal ulna plates have provided convenient and secure fixation with wider range of indications. These low profile, anatomically precontoured plates can be used to achieve stable fixation, regardless of ulna styloid fragment size or fracture extent and bone quality. The purpose of this study is to evaluate the functional and clinical outcomes following LCP distal ulna plate fixation of unstable distal ulna
123
Eur J Orthop Surg Traumatol
fractures after fixation of concomitant ipsilateral distal radius fractures.
Materials and methods Study design This study was approved by the Institutional Review Board at CHA Bundang Medical Center. A retrospective review was performed on patients who had been treated with LCP distal ulna plates (Synthes, Oberdorf, Switzerland) for distal ulna fractures, between August 2011 and June 2012. All patients had concomitant distal radius fractures that were fixed at the same time. Medical records and radiographs were reviewed to identify patient demographics, fracture type, union, alignment, motion, grip strength, and complications. Author’s surgical indications were unstable distal meta-diaphyseal ulnar fracture with mal-alignment (angulation[20°, ulna shortening[3 mm, translation[1/2 of the diaphysis) or an irreducible ulnar styloid base fracture with DRUJ instability (no end point on the stress test). Exclusion criteria were life-threatening comorbidity, previous fracture or surgery on the affected wrist, or insufficient follow-up of less than a year. All surgical procedures were performed by a single surgeon (S. H. Han). Patients The study includes 14 women and 3 men with an average age of 58.9 years (range 21–87 years), and the average follow-up duration was 15 months (range 12–20 months) (Table 1). All patients were right-handed, 12 patients had left-side injuries, and 5 had right-side injuries. In this study, 11 patients had injuries by falling from standing height, 2 patients fell from 2 m height, and 4 patients had either a bicycle or a motor vehicle accident. All of the associated distal radius fractures were treated with variable angle locking compression plates (VA-LCP) (Synthes, Oberdorf, Switzerland). Among the distal ulna fractures, 11 cases were fractures involving metaphysis or meta-diaphyseal junction and 6 cases were ulnar styloid base fractures. All patients had closed fractures and underwent surgery within 7 days after injury (average 2.9 days). Active wrist motion out of the short arm splint was started postoperative 4 weeks, and resistive exercises were implemented 10–12 weeks postoperatively. Surgical techniques After distal radius fracture was reduced and fixed with VA-LCP, distal ulna fracture was assessed by C-arm fluoroscope, and DRUJ stability was evaluated manually
123
Table 1 Preoperative patient demographics Variable
No.
Total
17
Sex (M:F)
3:14
Mean age, year (range)
58.9 (21–87)
Mean follow-up, month (range)
15 (12–20)
Fracture side (Rt:Lt)
5:12
Dominant side (Rt:Lt)
15:0
Mechanism of injury Simple fall
11
Fall down
2
MVA Concomitant injury Distal radius fracture type (AO)
4 4
A3
2
C1.2
1
C2.2
1
C2.3
7
C3
6
Distal ulna fracture type (Q modifier classification) Q1
6
Q2
2
Q3
1
Q1 ? Q2
5
Q1 ? Q3
2
Q1 ? Q4 Injury to Op, day (range)
1 2.9 (0.5–7)
(Fig. 1). If there was significant displacement, mal-alignment, or DRUJ instability, the decision was made to treat the distal ulna operatively. Before incision, the elbow was flexed to 90° and the wrist was pronated and radial-deviated to obtain a clear view of the bony contour of the distal ulna. A longitudinal incision was made on the slight dorsal side of the ulnar border to maximize the length of the skin bridge. The dorsal sensory branch of the ulnar nerve, which crosses the bone at this level to supply the dorsal skin of the hand, was avoided (Fig. 2). Once the distal shaft of the ulna is visible, subperiosteal dissection was done to visualize the fracture fragments (Fig. 3a) and the fragments were reduced. Then, the pointed hooks of the plate were placed around the tip of the ulnar styloid as a reference guide. Compression force was applied proximally to obtain adequate reduction and alignment (Fig. 3b). Then, two proximal locking screws were inserted into the metaphyseal/diaphyseal region of the distal ulna. The remaining locking screws were then inserted into the rest of the holes (Fig. 3c, d). The wound was closed layer by layer, and a short arm splint was applied.
Eur J Orthop Surg Traumatol
Fig. 1 After a distal radius fracture was reduced and fixed with a VA-LCP, DRUJ stability was checked manually. DRUJ instability was diagnosed when the distal ulna is subluxated more than 50 %. To
Fig. 2 The dorsal sensory branch of the ulnar nerve (arrow), which crosses the bone at the level of incision to innervate the dorsal skin of the hand, should be avoided
Assessment Radial inclination and volar tilt were checked on anteroposterior and lateral radiographs unilaterally during the follow-up. At final follow-up, bilateral forearm radiographs
check DRUJ instability, a the patient’s elbow was held in 90° flexion and the forearm in neutral position and b the surgeon translated the distal ulna in dorsal and volar directions with one hand
were checked to compare the ulnar variance. Union was determined by bony bridging formation or obliteration of the fracture lines of at least three cortexes on the anteroposterior and lateral radiographs. Arthritic change on the radiocarpal or DRUJ was also assessed. Functional outcomes included range of motion of the wrist, grip, and pinch strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Sarmiento et al. modification of the Gartland and Werley rating score. Wrist flexion and extension, and forearm pronation and supination were measured bilaterally with a goniometer. Grip strength was recorded bilaterally (in kilograms) and reported as an average of three attempts from the third position on a grip dynamometer (JAMAR, Therapeutic Equipment Corporation, Clayton, New Jersey). The distal radioulnar stability of a patient was assessed by both physical examination and postoperative CT scan. With the elbow in 90° flexion and the forearm in neutral rotation, the surgeon firmly grabbed the distal end of the radius with one hand and tried to passively translate the distal ulna in the dorsal and volar directions with the other hand. DRUJ instability was diagnosed when there was no firm end point. Subluxation ratio was measured on CT scans to assess the DRUJ congruency and stability (Fig. 4) [13]. Complications and any subsequent operations related to either the ulna or radius fractures were also investigated.
123
Eur J Orthop Surg Traumatol
Fig. 3 a Subperiosteal dissection was done to visualize fracture fragments. b Pointed hooks of the plate were placed around the tip of the ulnar styloid as a reference guide. Compression force was applied proximally to obtain adequate reduction and alignment. c Two
proximal screws were inserted into the metaphyseal/diaphyseal region of the distal ulna, and then, the remaining locking screws were then inserted into the rest of the holes. d, e, Adequate reduction and fixation were checked with fluoroscopy intraoperatively
Results
radial deviation 22°, ulnar deviation 36°, pronation 78°, and supination 85°. All patients were able to make a full composite grip and had full-finger range of motion. In patients with dominant wrist injury (5 patients), grip strength averaged 25 kg (range 22–27 kg) and was 105 % of the opposite side. In patients with nondominant wrist injury (12 patients), grip strength averaged 21 kg and was 88 % of the opposite side. In all cases, the DRUJ was stable in neutral, pronation, and supination and their average value calculated by subluxation ratio method was -0.12 (range -0.23 to 0.03) on the postoperative CT scan. None of the patient complained of ulnar wrist pain at the last follow-up, and the average DASH score was 11 points. Sarmiento et al. modification scores for the wrist showed 6 excellent and 11 good results, and there were no operation-
All distal radius and ulna fractures regained satisfactory radiological alignment without significant deterioration compared with the contralateral side. On the final radiograph, the average radial height was 10.5 mm (range 8.6–12.8 mm), ulnar variance was 0.8 mm (range -2.6 to 2.7 mm), volar tilt was 11.6° (range 3.2°–17.6°), and radial inclination was 22.5° (range 18.4°–27.6°) (Table 2). Radiocarpal joint congruency was restored, and articular step-off was \2 mm in all patients. All patients gained solid bony union, and the average union time of ulnar fractures was postoperative 11.7 weeks (range 9–15 weeks). No arthritic change was seen on final radiographs. On the clinical examination at the last follow-up (Table 3), the mean wrist flexion was 75°, extension 72°,
123
Eur J Orthop Surg Traumatol Table 3 Clinical outcomes Variable
Avg. (range)
ROM (°) Flexion
75 (65–85)
Extension
72 (65–85)
Radial deviation
22 (15–35)
Ulnar deviation
36 (20–45)
Supination
85 (65–90)
Pronation
78 (60–90)
Grip strength (kg) Dominant injury % To opposite side Nondominant injury % To opposite side Fig. 4 Among the several methods that measure the translation of the distal radioulnar joint on CT scans, the most reliable method (the subluxation ratio) was used
Table 2 Postoperative radiographic parameters Variable
Avg. (range)—final
Radial inclination (°)
22.5 (18.4–27.6)
Radial height (mm) Volar tilt (°)
10.5 (8.6–12.8) 11.6 (3.2–17.6)
Ulnar variance (mm)
0.8 (-2.6 to 2.7)
Time to union (weeks)
11.7 (9–15)
related complications such as infections, neurologic problems, or hardware failures.
Discussion There is still no clear consensus about the operative indication of a distal ulna fracture accompanying a distal radius fracture. Souer et al. [14] and Kim et al. [15] concluded in their study that ulnar styloid fractures have no adverse effect on wrist function or stability of the DRUJ, regardless of the amount of initial displacement and the level of fractures on the ulnar styloid. Ring et al. [5] also reported that most fractures of the distal ulnar metaphysis associated with fracture on the distal radius are well aligned and stable once the distal radius has been realigned and secured. However, mal-aligned or unstable distal ulnar fractures may affect distal radioulnar function and may also increase the risk of nonunion. Biyani et al. [1] reported that two comminuted distal ulna fractures resulted in nonunion, four of five simple neck fractures had marked restriction of rotation, and three cases had fracture callus encroachment of the DRUJ that limited forearm rotation from the 19 distal ulna fractures that were treated nonoperatively. Other
DASH score
25 (22–27) 105 % 21 (18–26) 88 % 11 (0–46)
Modified Sarmiento’s score Excellent
6
Good
11
Fair
0
Poor
0
reports [2, 3, 16] also emphasized the management of distal ulna fractures and clear setting of treatment indications. Authors also have a similar opinion that open reduction and internal fixation should be considered for an irreducible or unstable distal ulna fracture, which includes the styloid process, metaphysis, and meta-diaphysis. There have been several surgical options for ulnar fracture fixation: percutaneous Kirschner wire fixation, interosseous wiring, tension band wiring, and plate fixation. Each fixation method has its advantages and disadvantages and which method to use is determined depending on the patient and fracture characteristics. Percutaneous K-wire fixation has relatively weak stability, and interosseous wiring and tension band wiring pose the risk of complications related to pin site irritation and/or pin migration or loosening, which restrict application to complex fractures or osteoporotic bones. Furthermore, percutaneous K-wire fixation is limited to simple ulnar styloid base to distal metaphysis fractures. Fixation using a mini-condylar locking plate and a blade plate can be used to fix complex distal ulna fractures. However, direct reduction and fixation of an unstable comminute fracture are difficult with these plates and several reports have shown limitations in reducing such fragments [4, 5]. Locking compression plate distal ulna plates are low profile and anatomically precontoured, which can avoid implant-related skin irritation. The pointed hook on the distal tip of LCP distal ulna plate is the most distinct and important feature. The hook acts as a reference point when applying the plate and allows indirect reduction and
123
Eur J Orthop Surg Traumatol
Fig. 5 Indirect reduction using a LCP distal ulna plate makes reduction and fixation technically easy and can be applied with wider indications, regardless of bone quality or fracture characteristics. Preoperative AP (a) and lateral (b) radiograph of a 66-year-old female
who had a comminuted fracture of the distal radius and the distal ulna metaphysic area. The 12 months postoperative AP (c) and lateral (d) radiograph shows that the fracture fragments are well aligned and united
compression of fracture fragments and maintenance of reduction by grasping the ulnar styloid process fragment. These advantages reduce operation time and make application of the plate technically much easier, regardless of fracture characteristics. Moreover, the length of the plate is enough to cover fractures extending to the meta-diaphyseal junction (Fig. 5). Similar to our results, Lee et al. [17] also reported the favorable results after using LCP distal ulna plate for unstable distal ulna fracture associated with distal radius fracture. Our study has strength in that all surgery was done by a single surgeon (S. H. Han), and DRUJ stability was thoroughly evaluated by both physical examination and postoperative CT scans using subluxation ratio method. Evaluation of the DRUJ stability with CT scans after fixation of distal ulna fracture associated with distal radius fracture was not mentioned in the prior studies. Several techniques have been proposed to measure translation of the DRUJ on CT scans. Park et al. [13] reported that the subluxation ratio method is the most useful technique for measuring translation of the DRUJ as a result of its reliability and simplicity. This study analyzed 45 asymptomatic normal wrists and showed different normal values depending on the wrist position (supination, neutral, and pronation). In our study, postoperative CT scans were taken with the wrist in supination and all results were within the normal range according to the normal values suggested by Part et al. On the other hand, this study is limited by the small number of patients, a variety of fracture types, and lack of
comparative groups. However, all cases showed union of both fractures and excellent or good functional and clinical outcomes without complications.
123
Conclusions Locking compression plate distal ulna plate fixation for unstable distal ulna fractures after treating concomitant distal radius fractures showed favorable results in union, alignment, and functional outcome and is comparable to the results of other implants studied so far. Moreover, this plate fixation is relatively convenient in surgery with minimal complications and wider range of indication. Therefore, LCP distal ulna plate fixation could be one of the recommendable implant options for an irreducible or unstable distal ulna fracture associated with a distal radius fracture. Conflict of interest
None.
References 1. Biyani A, Simison AJ, Klenerman L (1995) Fractures of the distal radius and ulna. J Hand Surg 20(3):357–364 2. Fernandez DL, Ring D, Jupiter JB (2001) Surgical management of delayed union and nonunion of distal radius fractures. J Hand Surg 26(2):201–209. doi:10.1053/jhsu.2001.22917 3. McKee MD, Waddell JP, Yoo D, Richards RR (1997) Nonunion of distal radial fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma 11(1):49–53
Eur J Orthop Surg Traumatol 4. Dennison DG (2007) Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg 32(6):801–805. doi:10.1016/j.jhsa.2007.03. 010 5. Ring D, McCarty LP, Campbell D, Jupiter JB (2004) Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. J Hand Surg 29(1):103–109. doi:10.1016/j.jhsa.2003.10.019 6. De Smet L (2008) The DASH questionnaire and score in the evaluation of hand and wrist disorders. Acta Orthop Belg 74(5):575–581 7. May MM, Lawton JN, Blazar PE (2002) Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg 27(6):965–971. doi:10.1053/jhsu.2002.36525 8. Seitz WH Jr, Raikin SM (2007) Resection of comminuted ulna head fragments with soft tissue reconstruction when associated with distal radius fractures. Tech Hand Up Extrem Surg 11(4):224–230. doi:10.1097/BTH.0b013e31805752f8 9. Foster BJ, Bindra RR (2012) Intrafocal pin plate fixation of distal ulna fractures associated with distal radius fractures. J Hand Surg 37(2):356–359. doi:10.1016/j.jhsa.2011.11.013 10. Ruchelsman DE, Raskin KB, Rettig ME (2009) Outcome following acute primary distal ulna resection for comminuted distal ulna fractures at the time of operative fixation of unstable fractures of the distal radius. Hand (N Y) 4(4):391–396. doi:10.1007/ s11552-009-9175-x
11. Carlsen BT, Dennison DG, Moran SL (2010) Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin 26(4):503–516. doi:10.1016/j.hcl.2010.05.009 12. Solan MC, Rees R, Molloy S, Proctor MT (2003) Internal fixation after intra-articular fracture of the distal ulna. J Bone Joint Surg Br 85(2):279–280 13. Park MJ, Kim JP (2008) Reliability and normal values of various computed tomography methods for quantifying distal radioulnar joint translation. J Bone Joint Surg Am 90(1):145–153. doi:10. 2106/JBJS.F.01603 14. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M, Jupiter JB, Group APODRS (2009) Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-andscrew fixation of a distal radial fracture. J Bone Joint Surg Am 91(4):830–838. doi:10.2106/JBJS.H.00345 15. Kim JK, Koh YD, Do NH (2010) Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg Am 92(1):1–6. doi:10.2106/JBJS.H.01738 16. Ring D (2005) Nonunion of the distal radius. Hand Clin 21(3):443–447. doi:10.1016/j.hcl.2005.01.005 17. Lee SK, Kim KJ, Park JS, Choy WS (2012) Distal ulna hook plate fixation for unstable distal ulna fracture associated with distal radius fracture. Orthopedics 35(9):e1358–e1364. doi:10. 3928/01477447-20120822-22
123
ORIGINAL ARTICLE
LCP distal ulna plate fixation of irreducible or unstable distal ulna fractures associated with distal radius fracture Soo Hong Han • In Tae Hong • Woo Hyun Kim
Received: 19 November 2013 / Accepted: 8 February 2014 Ó Springer-Verlag France 2014
Abstract Purpose The advent of locking compression plate (LCP) has provided convenient and secure fixation of distal ulna fractures. This study was performed to evaluate the functional and clinical outcomes following LCP distal ulna plate fixation of irreducible or unstable distal ulna fractures with concomitant distal radius fractures. Methods Retrospective review of 17 patients who had been treated with LCP distal ulna plates for distal ulna fractures was performed. The average age of the patients was 58.9 years (range 21–87 years), and the mean followup period was 15 months (range 12–20 months). This study consisted of eleven fractures involving metaphysis and six ulna styloid base fractures. Fracture union, radiologic parameters, stability of the distal radioulnar joint (DRUJ), and functional outcomes, including ROM, grip strength, and functional scores were evaluated. Results All patients showed bony union, the average radial height was 10.5 mm, and the ulnar variance was 0.8 mm on final radiographs. None of the patients had instability of the DRUJ compared with the opposite wrist, and the subluxation ratio was within normal range on the follow-up CT scan. There were 6 excellent and 11 good cases according to Sarmiento’s modified wrist score at the last follow-up. Conclusions Locking compression plate distal ulna plate fixation of irreducible or unstable distal ulna fractures after stabilization of concomitant distal radius fractures showed favorable results in union, alignment, and functional
S. H. Han (&) I. T. Hong W. H. Kim Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, South Korea e-mail: [email protected]
outcomes and therefore could be one of the recommendable implant options for distal ulna fractures. Keywords Unstable distal ulna fracture DRUJ instability Distal ulna locking compression plate
Introduction Fractures of the distal ulna occur often with distal radius fractures [1–3]. Compared with distal radius fractures, the significance of distal ulna fractures is much less appreciated and the treatment of these fractures still remains controversial. Many distal ulna fractures are considered stable after reduction and stabilization of distal radius fractures, and satisfactory outcomes can be achieved with conservative treatment [4–7]. In cases of displaced or unstable ulna fractures, however, some reports have shown poor outcomes after nonoperative treatment [8]. Displaced or mal-aligned fractures of the distal ulna can affect the distal radioulnar joint (DRUJ) function [1, 3, 9, 10]. Also, these fractures are often associated with distal radioulnar ligament injury and result in chronic ulna-sided pain and instability [8, 11, 12]. For these reasons, operative treatment is recommended in case of irreducible or unstable distal ulna fractures associated with distal radius fractures [1, 2, 4, 5]. Recently introduced locking compression plate (LCP) distal ulna plates have provided convenient and secure fixation with wider range of indications. These low profile, anatomically precontoured plates can be used to achieve stable fixation, regardless of ulna styloid fragment size or fracture extent and bone quality. The purpose of this study is to evaluate the functional and clinical outcomes following LCP distal ulna plate fixation of unstable distal ulna
123
Eur J Orthop Surg Traumatol
fractures after fixation of concomitant ipsilateral distal radius fractures.
Materials and methods Study design This study was approved by the Institutional Review Board at CHA Bundang Medical Center. A retrospective review was performed on patients who had been treated with LCP distal ulna plates (Synthes, Oberdorf, Switzerland) for distal ulna fractures, between August 2011 and June 2012. All patients had concomitant distal radius fractures that were fixed at the same time. Medical records and radiographs were reviewed to identify patient demographics, fracture type, union, alignment, motion, grip strength, and complications. Author’s surgical indications were unstable distal meta-diaphyseal ulnar fracture with mal-alignment (angulation[20°, ulna shortening[3 mm, translation[1/2 of the diaphysis) or an irreducible ulnar styloid base fracture with DRUJ instability (no end point on the stress test). Exclusion criteria were life-threatening comorbidity, previous fracture or surgery on the affected wrist, or insufficient follow-up of less than a year. All surgical procedures were performed by a single surgeon (S. H. Han). Patients The study includes 14 women and 3 men with an average age of 58.9 years (range 21–87 years), and the average follow-up duration was 15 months (range 12–20 months) (Table 1). All patients were right-handed, 12 patients had left-side injuries, and 5 had right-side injuries. In this study, 11 patients had injuries by falling from standing height, 2 patients fell from 2 m height, and 4 patients had either a bicycle or a motor vehicle accident. All of the associated distal radius fractures were treated with variable angle locking compression plates (VA-LCP) (Synthes, Oberdorf, Switzerland). Among the distal ulna fractures, 11 cases were fractures involving metaphysis or meta-diaphyseal junction and 6 cases were ulnar styloid base fractures. All patients had closed fractures and underwent surgery within 7 days after injury (average 2.9 days). Active wrist motion out of the short arm splint was started postoperative 4 weeks, and resistive exercises were implemented 10–12 weeks postoperatively. Surgical techniques After distal radius fracture was reduced and fixed with VA-LCP, distal ulna fracture was assessed by C-arm fluoroscope, and DRUJ stability was evaluated manually
123
Table 1 Preoperative patient demographics Variable
No.
Total
17
Sex (M:F)
3:14
Mean age, year (range)
58.9 (21–87)
Mean follow-up, month (range)
15 (12–20)
Fracture side (Rt:Lt)
5:12
Dominant side (Rt:Lt)
15:0
Mechanism of injury Simple fall
11
Fall down
2
MVA Concomitant injury Distal radius fracture type (AO)
4 4
A3
2
C1.2
1
C2.2
1
C2.3
7
C3
6
Distal ulna fracture type (Q modifier classification) Q1
6
Q2
2
Q3
1
Q1 ? Q2
5
Q1 ? Q3
2
Q1 ? Q4 Injury to Op, day (range)
1 2.9 (0.5–7)
(Fig. 1). If there was significant displacement, mal-alignment, or DRUJ instability, the decision was made to treat the distal ulna operatively. Before incision, the elbow was flexed to 90° and the wrist was pronated and radial-deviated to obtain a clear view of the bony contour of the distal ulna. A longitudinal incision was made on the slight dorsal side of the ulnar border to maximize the length of the skin bridge. The dorsal sensory branch of the ulnar nerve, which crosses the bone at this level to supply the dorsal skin of the hand, was avoided (Fig. 2). Once the distal shaft of the ulna is visible, subperiosteal dissection was done to visualize the fracture fragments (Fig. 3a) and the fragments were reduced. Then, the pointed hooks of the plate were placed around the tip of the ulnar styloid as a reference guide. Compression force was applied proximally to obtain adequate reduction and alignment (Fig. 3b). Then, two proximal locking screws were inserted into the metaphyseal/diaphyseal region of the distal ulna. The remaining locking screws were then inserted into the rest of the holes (Fig. 3c, d). The wound was closed layer by layer, and a short arm splint was applied.
Eur J Orthop Surg Traumatol
Fig. 1 After a distal radius fracture was reduced and fixed with a VA-LCP, DRUJ stability was checked manually. DRUJ instability was diagnosed when the distal ulna is subluxated more than 50 %. To
Fig. 2 The dorsal sensory branch of the ulnar nerve (arrow), which crosses the bone at the level of incision to innervate the dorsal skin of the hand, should be avoided
Assessment Radial inclination and volar tilt were checked on anteroposterior and lateral radiographs unilaterally during the follow-up. At final follow-up, bilateral forearm radiographs
check DRUJ instability, a the patient’s elbow was held in 90° flexion and the forearm in neutral position and b the surgeon translated the distal ulna in dorsal and volar directions with one hand
were checked to compare the ulnar variance. Union was determined by bony bridging formation or obliteration of the fracture lines of at least three cortexes on the anteroposterior and lateral radiographs. Arthritic change on the radiocarpal or DRUJ was also assessed. Functional outcomes included range of motion of the wrist, grip, and pinch strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Sarmiento et al. modification of the Gartland and Werley rating score. Wrist flexion and extension, and forearm pronation and supination were measured bilaterally with a goniometer. Grip strength was recorded bilaterally (in kilograms) and reported as an average of three attempts from the third position on a grip dynamometer (JAMAR, Therapeutic Equipment Corporation, Clayton, New Jersey). The distal radioulnar stability of a patient was assessed by both physical examination and postoperative CT scan. With the elbow in 90° flexion and the forearm in neutral rotation, the surgeon firmly grabbed the distal end of the radius with one hand and tried to passively translate the distal ulna in the dorsal and volar directions with the other hand. DRUJ instability was diagnosed when there was no firm end point. Subluxation ratio was measured on CT scans to assess the DRUJ congruency and stability (Fig. 4) [13]. Complications and any subsequent operations related to either the ulna or radius fractures were also investigated.
123
Eur J Orthop Surg Traumatol
Fig. 3 a Subperiosteal dissection was done to visualize fracture fragments. b Pointed hooks of the plate were placed around the tip of the ulnar styloid as a reference guide. Compression force was applied proximally to obtain adequate reduction and alignment. c Two
proximal screws were inserted into the metaphyseal/diaphyseal region of the distal ulna, and then, the remaining locking screws were then inserted into the rest of the holes. d, e, Adequate reduction and fixation were checked with fluoroscopy intraoperatively
Results
radial deviation 22°, ulnar deviation 36°, pronation 78°, and supination 85°. All patients were able to make a full composite grip and had full-finger range of motion. In patients with dominant wrist injury (5 patients), grip strength averaged 25 kg (range 22–27 kg) and was 105 % of the opposite side. In patients with nondominant wrist injury (12 patients), grip strength averaged 21 kg and was 88 % of the opposite side. In all cases, the DRUJ was stable in neutral, pronation, and supination and their average value calculated by subluxation ratio method was -0.12 (range -0.23 to 0.03) on the postoperative CT scan. None of the patient complained of ulnar wrist pain at the last follow-up, and the average DASH score was 11 points. Sarmiento et al. modification scores for the wrist showed 6 excellent and 11 good results, and there were no operation-
All distal radius and ulna fractures regained satisfactory radiological alignment without significant deterioration compared with the contralateral side. On the final radiograph, the average radial height was 10.5 mm (range 8.6–12.8 mm), ulnar variance was 0.8 mm (range -2.6 to 2.7 mm), volar tilt was 11.6° (range 3.2°–17.6°), and radial inclination was 22.5° (range 18.4°–27.6°) (Table 2). Radiocarpal joint congruency was restored, and articular step-off was \2 mm in all patients. All patients gained solid bony union, and the average union time of ulnar fractures was postoperative 11.7 weeks (range 9–15 weeks). No arthritic change was seen on final radiographs. On the clinical examination at the last follow-up (Table 3), the mean wrist flexion was 75°, extension 72°,
123
Eur J Orthop Surg Traumatol Table 3 Clinical outcomes Variable
Avg. (range)
ROM (°) Flexion
75 (65–85)
Extension
72 (65–85)
Radial deviation
22 (15–35)
Ulnar deviation
36 (20–45)
Supination
85 (65–90)
Pronation
78 (60–90)
Grip strength (kg) Dominant injury % To opposite side Nondominant injury % To opposite side Fig. 4 Among the several methods that measure the translation of the distal radioulnar joint on CT scans, the most reliable method (the subluxation ratio) was used
Table 2 Postoperative radiographic parameters Variable
Avg. (range)—final
Radial inclination (°)
22.5 (18.4–27.6)
Radial height (mm) Volar tilt (°)
10.5 (8.6–12.8) 11.6 (3.2–17.6)
Ulnar variance (mm)
0.8 (-2.6 to 2.7)
Time to union (weeks)
11.7 (9–15)
related complications such as infections, neurologic problems, or hardware failures.
Discussion There is still no clear consensus about the operative indication of a distal ulna fracture accompanying a distal radius fracture. Souer et al. [14] and Kim et al. [15] concluded in their study that ulnar styloid fractures have no adverse effect on wrist function or stability of the DRUJ, regardless of the amount of initial displacement and the level of fractures on the ulnar styloid. Ring et al. [5] also reported that most fractures of the distal ulnar metaphysis associated with fracture on the distal radius are well aligned and stable once the distal radius has been realigned and secured. However, mal-aligned or unstable distal ulnar fractures may affect distal radioulnar function and may also increase the risk of nonunion. Biyani et al. [1] reported that two comminuted distal ulna fractures resulted in nonunion, four of five simple neck fractures had marked restriction of rotation, and three cases had fracture callus encroachment of the DRUJ that limited forearm rotation from the 19 distal ulna fractures that were treated nonoperatively. Other
DASH score
25 (22–27) 105 % 21 (18–26) 88 % 11 (0–46)
Modified Sarmiento’s score Excellent
6
Good
11
Fair
0
Poor
0
reports [2, 3, 16] also emphasized the management of distal ulna fractures and clear setting of treatment indications. Authors also have a similar opinion that open reduction and internal fixation should be considered for an irreducible or unstable distal ulna fracture, which includes the styloid process, metaphysis, and meta-diaphysis. There have been several surgical options for ulnar fracture fixation: percutaneous Kirschner wire fixation, interosseous wiring, tension band wiring, and plate fixation. Each fixation method has its advantages and disadvantages and which method to use is determined depending on the patient and fracture characteristics. Percutaneous K-wire fixation has relatively weak stability, and interosseous wiring and tension band wiring pose the risk of complications related to pin site irritation and/or pin migration or loosening, which restrict application to complex fractures or osteoporotic bones. Furthermore, percutaneous K-wire fixation is limited to simple ulnar styloid base to distal metaphysis fractures. Fixation using a mini-condylar locking plate and a blade plate can be used to fix complex distal ulna fractures. However, direct reduction and fixation of an unstable comminute fracture are difficult with these plates and several reports have shown limitations in reducing such fragments [4, 5]. Locking compression plate distal ulna plates are low profile and anatomically precontoured, which can avoid implant-related skin irritation. The pointed hook on the distal tip of LCP distal ulna plate is the most distinct and important feature. The hook acts as a reference point when applying the plate and allows indirect reduction and
123
Eur J Orthop Surg Traumatol
Fig. 5 Indirect reduction using a LCP distal ulna plate makes reduction and fixation technically easy and can be applied with wider indications, regardless of bone quality or fracture characteristics. Preoperative AP (a) and lateral (b) radiograph of a 66-year-old female
who had a comminuted fracture of the distal radius and the distal ulna metaphysic area. The 12 months postoperative AP (c) and lateral (d) radiograph shows that the fracture fragments are well aligned and united
compression of fracture fragments and maintenance of reduction by grasping the ulnar styloid process fragment. These advantages reduce operation time and make application of the plate technically much easier, regardless of fracture characteristics. Moreover, the length of the plate is enough to cover fractures extending to the meta-diaphyseal junction (Fig. 5). Similar to our results, Lee et al. [17] also reported the favorable results after using LCP distal ulna plate for unstable distal ulna fracture associated with distal radius fracture. Our study has strength in that all surgery was done by a single surgeon (S. H. Han), and DRUJ stability was thoroughly evaluated by both physical examination and postoperative CT scans using subluxation ratio method. Evaluation of the DRUJ stability with CT scans after fixation of distal ulna fracture associated with distal radius fracture was not mentioned in the prior studies. Several techniques have been proposed to measure translation of the DRUJ on CT scans. Park et al. [13] reported that the subluxation ratio method is the most useful technique for measuring translation of the DRUJ as a result of its reliability and simplicity. This study analyzed 45 asymptomatic normal wrists and showed different normal values depending on the wrist position (supination, neutral, and pronation). In our study, postoperative CT scans were taken with the wrist in supination and all results were within the normal range according to the normal values suggested by Part et al. On the other hand, this study is limited by the small number of patients, a variety of fracture types, and lack of
comparative groups. However, all cases showed union of both fractures and excellent or good functional and clinical outcomes without complications.
123
Conclusions Locking compression plate distal ulna plate fixation for unstable distal ulna fractures after treating concomitant distal radius fractures showed favorable results in union, alignment, and functional outcome and is comparable to the results of other implants studied so far. Moreover, this plate fixation is relatively convenient in surgery with minimal complications and wider range of indication. Therefore, LCP distal ulna plate fixation could be one of the recommendable implant options for an irreducible or unstable distal ulna fracture associated with a distal radius fracture. Conflict of interest
None.
References 1. Biyani A, Simison AJ, Klenerman L (1995) Fractures of the distal radius and ulna. J Hand Surg 20(3):357–364 2. Fernandez DL, Ring D, Jupiter JB (2001) Surgical management of delayed union and nonunion of distal radius fractures. J Hand Surg 26(2):201–209. doi:10.1053/jhsu.2001.22917 3. McKee MD, Waddell JP, Yoo D, Richards RR (1997) Nonunion of distal radial fractures associated with distal ulnar shaft fractures: a report of four cases. J Orthop Trauma 11(1):49–53
Eur J Orthop Surg Traumatol 4. Dennison DG (2007) Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg 32(6):801–805. doi:10.1016/j.jhsa.2007.03. 010 5. Ring D, McCarty LP, Campbell D, Jupiter JB (2004) Condylar blade plate fixation of unstable fractures of the distal ulna associated with fracture of the distal radius. J Hand Surg 29(1):103–109. doi:10.1016/j.jhsa.2003.10.019 6. De Smet L (2008) The DASH questionnaire and score in the evaluation of hand and wrist disorders. Acta Orthop Belg 74(5):575–581 7. May MM, Lawton JN, Blazar PE (2002) Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg 27(6):965–971. doi:10.1053/jhsu.2002.36525 8. Seitz WH Jr, Raikin SM (2007) Resection of comminuted ulna head fragments with soft tissue reconstruction when associated with distal radius fractures. Tech Hand Up Extrem Surg 11(4):224–230. doi:10.1097/BTH.0b013e31805752f8 9. Foster BJ, Bindra RR (2012) Intrafocal pin plate fixation of distal ulna fractures associated with distal radius fractures. J Hand Surg 37(2):356–359. doi:10.1016/j.jhsa.2011.11.013 10. Ruchelsman DE, Raskin KB, Rettig ME (2009) Outcome following acute primary distal ulna resection for comminuted distal ulna fractures at the time of operative fixation of unstable fractures of the distal radius. Hand (N Y) 4(4):391–396. doi:10.1007/ s11552-009-9175-x
11. Carlsen BT, Dennison DG, Moran SL (2010) Acute dislocations of the distal radioulnar joint and distal ulna fractures. Hand Clin 26(4):503–516. doi:10.1016/j.hcl.2010.05.009 12. Solan MC, Rees R, Molloy S, Proctor MT (2003) Internal fixation after intra-articular fracture of the distal ulna. J Bone Joint Surg Br 85(2):279–280 13. Park MJ, Kim JP (2008) Reliability and normal values of various computed tomography methods for quantifying distal radioulnar joint translation. J Bone Joint Surg Am 90(1):145–153. doi:10. 2106/JBJS.F.01603 14. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M, Jupiter JB, Group APODRS (2009) Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-andscrew fixation of a distal radial fracture. J Bone Joint Surg Am 91(4):830–838. doi:10.2106/JBJS.H.00345 15. Kim JK, Koh YD, Do NH (2010) Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg Am 92(1):1–6. doi:10.2106/JBJS.H.01738 16. Ring D (2005) Nonunion of the distal radius. Hand Clin 21(3):443–447. doi:10.1016/j.hcl.2005.01.005 17. Lee SK, Kim KJ, Park JS, Choy WS (2012) Distal ulna hook plate fixation for unstable distal ulna fracture associated with distal radius fracture. Orthopedics 35(9):e1358–e1364. doi:10. 3928/01477447-20120822-22
123
