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Scientific Articles   |    
Effect of an Unrepaired Fracture of the Ulnar Styloid Base on Outcome After Plate-and-Screw Fixation of a Distal Radial Fracture
J. Sebastiaan Souer, MD1; David Ring, MD, PhD1; Stefan Matschke, MD2; Laurent Audige, PhD3; Marta Marent-Huber3; Jesse B. Jupiter, MD1
1 Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114. E-mail address for D. Ring: dring@partners.org
2 BG Unfallklinik, Ludwig-Guttmann-Strasse 13, D-67071 Ludwigshafen, Germany
3 AO Clinical Investigation and Documentation, Stettbachstrasse 10, CH-8600 Zurich/Dübendorf, Switzerland
View Disclosures and Other Information
The AOCID (AO Clinical Investigation and Documentation) Prospective ORIF Distal Radius Study Group includes Dr. Beate Hanson, MD, AOCID, Dübendorf, Switzerland; Dr. D. Rikli, Kantonspital Luzern, Switzerland; Prof. H.R. Siebert, Dakonie-Krankenhaus, Schwäbisch Hall, Germany; Dr. D.A. Campbell, St. James' University Hospital, Leeds, Great Britain; Dr. Teoh Lam-Chuan, Singapore General Hospital, Singapore; Dr. F. Torretta, Istituto Ortopedico Gaetano Pini, Milano, Italy; Dr. G. Lauri, Centro Traumatologico Ortopedico, Firenze, Italy; Dr. W. Hintriger, Krankenanstaltverbund Korneuburg-Stockerau, Austria; Dr. H. Drobetz, Unfallabteilung Krankenhaus Neunkirchen, Austria; Dr. M. Plecko, Abteilung Unfallchirurgie, UKH, Graz, Austria; Prof. A. Wentzensen, BG Unfallklinik, Ludwigshaven, Germany; Prof. D. Höntzsch, BG Unfallklinik, Tübingen, Germany; Prof. R.H. Neugebauer, Krankenhaus der Barmherzigen Brüder, Regensburg, Germany; Prof. N.P. Haas, Charité, Berlin, Germany; Prof. K.E. Rehm, Chirurgische Universitätsklinik, Köln, Germany; Prof. K.H. Winker, HELIOS Klinikum Unfallchirugie, Erfurt, Germany; Prof. W. Ertel, Universitätsklinik Benjamin Franklin, Berlin, Germany; Dr. Chr. Sommer, Rätisches Kantons- und Regionalspital, Chur, Switzerland; Prof. M. Wagner, Wilhelminenspital, Wien, Austria; and Prof. S.P. Chow, Queen Mary Hospital, Hong Kong.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from Stichting Michael van Vloten Fonds and Stichting Anna Fonds as well as outside funding or grants of more than $10,000 from Small Bone Innovations, Smith and Nephew, Wright Medical, and the AO Clinical Investigation and Documentation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Apr 01;91(4):830-838. doi: 10.2106/JBJS.H.00345
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Abstract

Background: The impact of an unrepaired fracture of the ulnar styloid base on recovery after internal fixation of a fracture of the distal part of the radius is uncertain. We evaluated a series of patients with an internally fixed fracture of the distal part of the radius to test the hypothesis that there is no difference in wrist motion or function scores between those with an untreated fracture of the ulnar styloid base and those with no ulnar fracture.

Methods: Two cohorts of seventy-six matched patients, one with a fracture of the ulnar styloid base and the other with no ulnar fracture, were retrospectively analyzed by examining data gathered in a prospective study of plate-and-screw fixation of distal radial fractures. Patients were matched for age, sex, AO fracture type, and injury mechanism. The two cohorts were analyzed for differences in motion, grip strength, pain, the Gartland and Werley score, the DASH (Disabilities of the Arm, Shoulder and Hand) score, and the SF-36 (Short Form-36) score at six, twelve, and twenty-four months postoperatively. In a second analysis, sixty-four patients with <2 mm of displacement of a fracture of the ulnar styloid base were compared with forty-nine patients with greater displacement. Differences between cohorts and within cohorts over time were determined with use of regression analysis and the likelihood ratio test.

Results: No significant differences were found between patients with an unrepaired fracture of the ulnar styloid base and those with no ulnar fracture at any of the follow-up intervals. However, a trend was observed toward less grip strength at six months (71% [of that on the contralateral side] compared with 79%; mean difference, -8% [95% confidence interval = -15.3% to -0.6%]; p = 0.03) and less flexion (54° compared with 59°; mean difference, -5° [95% confidence interval = -11.7° to -0.8°]; p = 0.02) and ulnar deviation (32° compared with 36°; mean difference, -4° [95% confidence interval = -7° to -0.1°]; p = 0.05) at twenty-four months after surgery in patients with an untreated fracture of the ulnar styloid base. There were no significant differences with regard to any tested outcome measure between the patients with =2 mm of displacement of an unrepaired fracture of the ulnar styloid base and those with less displacement.

Conclusions: An unrepaired fracture of the base of the ulnar styloid does not appear to influence function or outcome after treatment of a distal radial fracture with plate-and-screw fixation, even when the ulnar fracture was initially displaced =2 mm.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David Ring, MD, PhD
    Posted on September 06, 2009
    Dr. Ring and colleagues respond to Mr. Al-Fakayh
    Massachusetts General Hospital

    Mr. Al-Fakayh clearly restates part of the rationale that has led many of us to think of base of ulnar styloid fractures as a marker for poor outcome, which our data clearly show is not the case. Mr. Al-Fakayh also correctly restates the shortcoming of our study — that there was no specific evaluation of DRUJ instability; however, the 2-year follow-up and few symptoms and no procedures related to the DRUJ is fairly convincing. At a minimum, our data confirm that the concern regarding base of ulnar styloid fractures is overstated. In terms of pure science, we agree with Mr. Al-Fakayh’s proposed study design; however, does data such as ours make randomization to operative treatment of an ulnar styloid base fracture in 50% of patients unethical?

    We think the next study might be a prospective cohort study with specific evaluation of the DRUJ, or perhaps a clinical trial comparing two nonoperative treatments (for instance free forearm motion immediately versus immobilization in mid-supination for several weeks). For this to be meaningful, we will need to develop a clear definition and an objective and quantifiable measure of DRUJ instability. In any case, we are all in agreement that science will be the ultimate arbiter of this debate.

    Omar Al-Fakayh
    Posted on August 21, 2009
    Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures
    Aberdeen Royal Infirmary, Aberdeen, United Kingdom

    To the Editor:

    I read with great interest the study by Souer et al. (1) and I have a few comments. It is well known that distal radius fracture is associated with ulnar styloid fracture in more than 40% of cases (2). It has been suggested that injuries to the ulnar styloid will lead to instability of the distal radio-ulnar joint (DRUJ) (3,4). The authors suggested that there is no difference between the groups regarding DRUJ stability, although it was not assessed clinically or radiographically. As previous research has identified, distal radioulnar joint instability may lead to long-term problems with wrist pain (5) and May et al. found that all distal radial fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture (3).

    I agree with the authors that comparing outcomes between patients with ulnar styloid fractures and those without will provide some information about the impact of the unrepaired ulnar styloid fracture on the outcome of distal radius fracture fixation. However, the best way to answer this question is to select a group of distal radius fracture patients with associated ulnar styloid fractures only and then to randomize them to have the ulnar styloid fixed or not and compare the outcomes of these two cohorts of patients.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M, Jupiter JB, AOCID Prospective ORIF Distal Radius Study Group. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixation of a distal radial fracture. J Bone Joint Surg Am. 2009;91:830-8.

    2. Logan AJ, Lindau TR. The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment. Strategies Trauma Limb Reconstr. 2008;3:49–56.

    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. 2008;27:965–71.

    4. Stoffelen D, De Smet L, Broos P. The importance of the distal radioulnar joint in distal radial fractures. J Hand Surg Br. 1998;23:507-11.

    5. Cheng HS, Hung LK, Ho PC, Wong J. An analysis of causes and treatment outcome of chronic wrist pain after distal radial fractures. Hand Surg. 2008;13:1-10.

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