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Fracture of the distal ulna metaphysis in the setting of distal radius fractures.

Abstract

Background: Fracture of the metaphyseal region of the distal ulna is an uncommon injury that has been reported to occur concomitantly with distal radius fracture. We aimed to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare outcomes in operatively versus non-operatively treated patients.

Methods: Over a 5-year period a distal radius fracture registry was maintained at our institution. Eleven of 512 consecutive patients had metaphyseal distal ulna fractures in association with distal radius fractures and at least 1-year follow-up. Baseline radiographs and functional data were obtained, and patients were followed at 1-week, 2-week, 3-week, 6-week, 3-month, 6-month, 1-year, and 2-year intervals. Patients were split into two treatment groups: Group 1 consisted of five non-operatively treated patients, and Group 2 consisted of six operatively treated patients.

Results: Four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head, fracture of the neck region with concomitant fracture of the tip of the ulnar styloid, simple fracture of the ulnar head, and comminuted fracture of the ulnar head. There were no statistical differences between the two groups with regard to flexion, extension, supination, pronation, and functional outcomes.

Conclusions: Ulnar fracture patterns observed did not easily fall into previously described categories, and we have proposed anew classification system. Simple fractures of the ulnar neck or head often do not require operative fixation.

Fractures of the distal radius are common injuries and may be the result of either high- or low-energy trauma. Distal radius fractures are often associated with either ligamentous or bony injury of the distal radioulnar joint. The most common associated bony type of distal radioulnar injury is avulsion of the ulnar styloid. While good fixation techniques have evolved for distal radius fractures, the treatment of ulnar styloid fractures has remained challenging. (1) In general, small avulsions of the ulnar styloid do not require formal treatment, whereas displaced fractures of the base of the styloid involving the fovea may require operative repair, if there is clinical instability, to reestablish the attachment of the triangular fibrocartilage complex. The incidence of distal radius fractures with large ulnar styloid fractures requiring surgical fixation has ranged from 8% to 10% in various published reports. (2,3)

Fracture of the metaphyseal region of the distal ulna is a much less common bony type of DRUJ injury that has been reported to occur concomitantly with fracture of the distal radius. (4) Similar to ulnar styloid fractures, fractures of the distal ulnar metaphysis can complicate the treatment of distal radius fractures, with the potential to cause instability, loss of forearm rotation, and posttraumatic DRUJ arthrosis. In one series, these types of fractures had a reported incidence of 6%. (5)

The purpose of this study is to report the incidence and types of distal ulnar head and neck fractures associated with distal radius fractures and compare functional and range of motion outcomes in operatively versus non-operatively treated patients.

Materials and Methods

Over a 5-year period, a distal radius fracture registry was maintained at our institution. Five hundred twelve patients were enrolled into this database by three different surgeons. Inclusion criteria were those patients with distal radius fractures, age greater than 18 years, and the ability to cognitively participate in the study. Baseline radiographs and functional data were obtained, and patients were followed at 1 week, 2 weeks, 3 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years. At each visit, radiographs were obtained and reviewed, and the patient's functional status was evaluated.

All patients in this study underwent operative treatment of the distal radius fracture with either internal fixation with a volar locking plate, external fixation with percutaneous Kirschner wires, or combined internal and external fixation. The surgeries were performed by four different surgeons; three fellowship trained trauma surgeons and one fellowship trained hand surgeon. After fixation of the distal radius fracture, an intraoperative decision was made regarding treatment of the distal ulna fracture based upon residual displacement, amount of incongruence of the DRUJ, and degree of instability of the distal ulna.

A review of the database revealed 15 patients with the described fracture pattern. The incidence of metaphyseal distal ulna fracture in association with distal radius fractures was 15 of 512 or 2.9%. Of these 15 patients, 11 (73%) had a minimum follow-up of 1 year. The remaining 4 patients were excluded. There were 10 females and 1 male in the group. With regards to the distal ulna, four separate fracture patterns were observed: simple transverse or oblique fracture of the ulnar neck just proximal to the ulnar head (type A), fracture of the neck region with concomitant fracture of the tip of the ulnar styloid (type B), simple fracture of the ulnar head (type C), and comminuted fracture of the ulnar head (type D), (Figs. 1 and 2). Of the 11 fractures observed, 7 were classified as type A, 1 was classified as type B, none were classified as type C, and 3 were classified as type D. Four of the 11 (36%) fractures were Gustilo-Anderson grade I open fractures (1 type B, 3 type D).

Results

There were two treatment groups with regards to the associated distal ulna fractures. Group 1 consisted of five non-operatively treated patients (45%) who underwent closed management (all type A). Group 2 included six operatively treated patients (54%), five of whom underwent internal fixation of the distal ulna fracture with either Kirschner wires or a plate and screw construct (2 type A, 1 type B, 2 type D), and 1 patient who underwent acute Darrach-type resection of the distal ulna (type D). In the case of distal ulna resection, the distal ulna had completely protruded from the skin and was noted to be completely stripped of periosteum.

The latest average follow-up time for Group 1 was 2.1 years and for Group 2, 1.5 years (p = 0.4). Range of motion in extension and pronation and DASH favored the operative group (Table 1). However, there were no statistical differences between the two groups with regards to flexion (55[degrees] versus 49[degrees], p = 0.59), extension (50.5[degrees] versus 59.6[degrees], p = 0.35), supination (86[degrees] versus 54.5[degrees], p = 0.2), and pronation (57.5[degrees] versus 86.25[degrees], p = 0.95). There were also no statistical differences in the standardized DASH work (18.75 versus 13.54, p = 0.73), sports (6.3 versus 4.2, p = 0.91), and function (22.9 versus 16.8, p = 0.71) scores.

The average grip strength in Group 1 was 45, as measured in four patients. The average grip strength in Group 2 was 41.4, also measured in four patients.

There was one patient (type D, 0.09%) who required a secondary surgery. This patient initially underwent closed reduction and percutaneous pinning but ultimately underwent a distal ulna resection 6 weeks after. No other patients required secondary surgery or had evidence of infection, need for hardware removal, or other postoperative complication.

Discussion

Fractures of the distal ulna metaphysis that occur in conjunction with distal radius fractures are a rare subset of osseous injuries encountered about the wrist. These fractures can affect the function of both the radiocarpal and distal radioulnar joints. While the incidence of ulnar metaphyseal fractures has been previously reported to occur in 6% of distal radius fractures, (5) we found the incidence in our series to be lower (2.9%). Although this fracture pattern has been previously described and classified by Biyani and coworkers, (5) our experience was somewhat different. When analyzing our series, we found that the fracture patterns we observed did not easily fall into the categories they proposed. We have, therefore, proposed a new classification system that we found described the injury patterns we observed. We feel that this proposed classification system is potentially better able to address the management of metaphyseal fractures of the distal ulna.

Geissler and colleagues (6) reported on a case series of 15 patients where distal ulnar fractures associated with distal radius fractures were treated surgically. The series included a wide variety of injuries treated with many different types of fixation. The incidence of the distal ulnar injuries was not reported, and there was no comparison group. The investigators stated that extra-articular fractures can be treated without additional surgery, and that intra-articular fractures should be treated surgically to prevent posttraumatic arthritis.

In our series, the five extra-articular fractures of the ulna metaphysis did not receive additional fixation. Our results show that these patients had good functional outcomes and did not require further surgery during the follow-up period. The presence of the extra-articular fracture pattern does not seem to adversely affect the outcome of the distal radius fracture.

Several investigators have confirmed these findings. The true incidence of posttraumatic arthritis of displaced intraarticular fractures of the distal ulna (subtypes C and D) is not known. When the majority of distal radius fractures were treated non-operatively, there are many more malunions of distal radius fractures. (7) Treatment of distal radius malunions that have settled into a short and radially deviated position has often involved a distal ulna resection. However, current treatment trends have been toward operative fixation of distal radius fractures in the higher demand patients. In this setting of restoration of distal radius anatomy, extra-articular malunions of the distal ulna appear to be well tolerated, and even intra-articular displacement may be well tolerated. We had one patient in our study who needed a secondary surgical intervention for treatment of her distal ulna fracture and ultimately required a distal ulna resection. She had limited range of motion as recorded at her latest follow-up appointment 9 months from her second surgery.

There have been several papers looking at the incidence and treatment of ulnar styloid fractures in association with distal radius fractures. Our focus was not on this injury, we were interested in more proximal ulnar fractures involving the neck or head. With regards to ulnar styloid fractures associated with distal radius fractures, strict indications for surgical intervention currently do not exist. Most series have not demonstrated superior results with surgical interventions or even which patients should get surgery. Currently, surgeons assess the stability of the DRUJ manually after fixation of the distal radius to determine which ulnar styloid fractures are associated with instability and require additional intervention. (8) May and associates found that there was an association with fractures at the base of the ulnar styloid and DRUJ instability. (3) Buijze and Ring found no difference in functional outcomes in those patients who had a nonunion of an ulnar styloid fracture in the setting of fixation of the distal radius. (9)

Strict parameters for deciding when surgery is necessary for metaphyseal or intra-articular head fractures do not exist. Dennison (10) reported a case series of internal fixation of five distal ulna fractures associated with a distal radius fracture. The distal ulna fractures were all treated with locked plates. He reported acceptable functional results with this treatment. The range of motion described by Dennison is similar to the results that we achieved in our series (flexion 52[degrees], extension 59[degrees], pronation 67[degrees], and supination 72[degrees]). Some patients in our series were treated with plates, others with K-wires, and one with a distal ulna resection.

In terms of outcome, it is difficult to draw scientific conclusions from our data due to the lack of statistical significance. This lack of significance is possibly due to our low sample size. Patients treated operatively appear to have a better outcome. The decision to do an additional procedure to the distal ulna was at the discretion of the surgeon and was biased by the severity of the injury as perceived by the operating surgeon. The strengths of our study included the analysis of a patient population at a single institution and a sample size that was equivalent or larger compared to other studies in the literature. The weaknesses include the fact that four different surgeons were involved, inevitably leading to variation in surgical technique. Additionally, though our sample size was equivalent or larger to other similar studies, it is still a small sample.

In our experience, simple fractures of the ulnar neck or ulnar head (with or without a fracture of the tip of the styloid) have a lower tendency toward DRUJ incongruence and instability and are less likely to require operative fixation. On the other hand, higher energy injuries that result in angulation, open fractures or comminuted fractures of the ulnar head are more likely to require operative fixation. For select open fractures with severe periosteal stripping, distal ulna resection is a viable option. While these general guidelines can add to the treatment algorithm, long-term outcome data is necessary to further elucidate the role of operative versus nonoperative management for these types of fractures.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

References

(1.) Kim JK, Koh YD, Do NH. Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg Am. 2010 Jan;92(1):1-6.

(2.) Fernandez DL: Fractures of the distal radius: operative treatment. Instr Course Lect. 1993;42:73-88.

(3.) May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg Am. 2002 Nov;27(6):965-71.

(4.) RuchelsmanDE, Raskin KB, Rettig ME. 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). 2009 Dec;4(4):391-6.

(5.) Biyani A, Simison AJ, Klenerman L. Fractures of the distal radius and ulna. J Hand Surg Br. 1995 Jun;20(3):357-64.

(6.) Geissler WB, Fernandez DL, Lamey DM. Distal radioulnar joint injuries associated with fractures of the distal radius. Clin Orthop Relat Res. 1996 Jun;(327):135-46.

(7.) Laino DK, Tejwani N. Indications for operative fixation of distal radius fractures: a review of the evidence. Bull NYU Hosp Jt Dis. 2012;70(1):35-40.

(8.) Wysocki RW, Ruch DS. Ulnar styloid fracture with distal radius fracture. J Hand Surg Am. 2012 Mar;37(3):568-9.

(9.) Buijze GA, Ring D. Clinical impact of united versus nonunited fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. J Hand Surg Am. 2010 Feb;35(2):223-7.

(10.) Dennison DG: Open reduction and internal locked fixation of unstable distal ulna fractures with concomitant distal radius fracture. J Hand Surg Am. 2007 Jul-Aug;32(6):801-5.

Nader Paksima, D.O., M.P.H., Sonya Khurana, M.D., Michael G. Soojian, M.D., Vipul Patel, M.D., and Kenneth A. Egol, M.D.

Nader Paksima, D.O., M.P.H., Sonya Khurana, M.D., and Kenneth A. Egol, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Michael G. Soojian M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, and Coastal Orthopaedics, P.C., Norwalk, Connecticut. Vipul Patel, M.D., NYU Hospital for Joint Diseases, New York, New York, and Crystal Run Healthcare, Middletown, New York.

All work was performed at the NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Kenneth A. Egol, M.D., 301 East 17th Street, Suite 1402, New York, New York 10003; kenneth.egol@nyumc.org.

Caption: Figure 1 Proposed classification system for distal ulna fractures in the setting of distal radius fractures. A, Simple fracture of ulnar neck without ulnar styloid. B, Simple fracture of ulnar neck with ulnar styloid fracture. C, Simple fracture of ulnar head. D, Comminuted fracture of the head and neck.

Caption: Figure 2 Radiographic examples of proposed classification system demonstrating the classification for distal ulna fractures in the setting of distal radius fractures.
Table 1 Functional Outcome Data at Latest Follow-Up

Measure                      Operative  Non-Operative  P-Value

Flexion                      49         55             0.59
Extension                    50.5       59.6           0.35
Supination                   54.5       86             0.2
Pronation                    86.25      86             0.95
DASH-standardized, function  16.8       22.9           0.71
DASH--standardized, sports    4.2        6.3           0.91
DASH- standardized, work     13.5       20.3           0.73

For all measures, no statistical difference between operatively and
non-operatively treated patients.
p > 0.05.
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Article Details
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Author:Paksima, Nader; Khurana, Sonya; Soojian, Michael G.; Patel, Vipul; Egol, Kenneth A.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Apr 1, 2017
Words:2753
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