Treatment of Injuries to the Ulnar Side of the Wrist Occuring with Distal Radial Fractures

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1 Hand Clin 21 (2005) Treatment of Injuries to the Ulnar Side of the Wrist Occuring with Distal Radial Fractures Tommy Lindau, MD, PhD a,b, * a Department of Orthopedics, Hospital of A ngelholm, S A ngelholm, Sweden b The Pulvertaft Centre Derbyshire Royal Infirmary, London Road, Derby, DE1 2QY, UK Frykman first emphasized in 1967 [1] the importance of the disturbance of the distal radioulnar joint. This article is not remembered for its important emphasis on methods for the prevention of reflex sympathetic dystrophy, but rather for its classification, which implied an increased severity if the ulnar styloid was fractured. Frykman, as well as many other authors, recognized that the most frequent complaint after distal radial fractures was ulnar-sided wrist pain [1 5]. It is present in every fifth patient after distal radius fracture [1] and affects the end result adversely [1,6,7]. Ulnar-sided wrist pain has mainly been attributed to malunion of the distal radius [1,6,8 14], creating an imbalance distally, which might lead to ulno-carpal abutment [15], incongruency [16], and osteoarthrosis of the distal radio-ulnar joint (DRUJ) [17]. Wrist arthroscopy has revealed that the common distal radial fracture often is complicated by ligamentous injuries [18 20]. These injuries can lead to laxity of the DRUJ and subsequent worse outcome [21], so that if we want to better understand the fracture and its sequel, we must have a complete diagnosis that includes ligament injuries. This may partly explain way the Frykman classification does not correlate with the outcome [22] and why there is still insufficient knowledge regarding treatment of the fracture and its associated ligament injuries [23]. However, by analyzing recent literature [24], we can recognize the different problems and plan a strategy to address the acute fracture and ligament injuries and later secondary problems related to malunion, instability, and pain. * The Pulvertaft Centre Derbyshire Royal Infirmary, London Road, Derby, DE1 2QY, UK. address: tommy.lindau@telia.com Functional anatomydligaments are important stabilizers The radius rotates around the ulnar head during pronation and supination of the forearm through the DRUJ (Fig. 1) [25,26]. This joint is also connected to the carpus with a ligament apparatus (see Fig. 1) and thus transmits forces to and from the hand [26]. The stability of the DRUJ is achieved by bony congruity between the sigmoid notch of the radius and the ulnar head, which are held together by ligaments (see Fig. 1) [15,26,27]. The bony stability can easily deteriorate after trauma as only approximately 60% of the joint surfaces are in contact in neutral forearm position and 10% in full pronation and supination [27 30]. The major stabilizer of the DRUJ are the ulnoradial ligaments, which represent the transverse, peripheral part of the triangular fibro-cartilage complex (TFCC) [15,26,27,31 34]. The ligaments run from the fovea of the ulnar head and the base of the ulnar styloid to the dorsal and palmar edges of the distal radius [31 35]. The periphery is wellvascularized [35,36], which implies that peripheral tears might heal. The TFCC also includes a central articular disc and the ulno-carpal ligament (see Fig. 1). Secondary stability is achieved through different degrees of contribution from the extensor carpi ulnaris tendon [27], the pronator quadratus muscle [29], and the radio-ulnar interosseous membrane [37]. The fracture must be congruently fixed Ulnar fragments of the distal radius create a problem, because they represent a possible risk of a double joint incongruency [38]; ie, in both /05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi: /j.hcl hand.theclinics.com

2 418 LINDAU Fig. 1. Ligaments are important stabilizers. (A) Schematic drawing showing the triangular fibrocartilage complex (TFCC), which is the major stabilizer of the DRUJ. (B) The TFCC is cut open to show that the central disc is membranous and adds no stability between ulna and radius. A = the ulno-carpal ligament, which is the palmar, distal part of the TFCC arising from the fovea of the ulna and inserting at the palmar aspect of triquetrum. B = the central articular disc. C = the dorsal and palmar ulno-radial ligaments, which stabilize the DRUJ. the obvious radio-carpal and the DRUJ. There are several options, decisions, and questions that must be addressed in treating these fractures, and every surgeon has a preference of addressing such an incongruency by means of closed, minimally invasive, or open reduction techniques. It is comforting to know that only a few and provisional conclusions relating to clinical management can be drawn from the available randomized trials, which do not provide robust nor sufficient evidence for most of the decisions necessary in the management of these fractures [23]. Careful analysis has not demonstrated differences of outcome results from treatment of intra-articular incongruencies when comparing medullary pinning with external fixation [39] or percutaneous pinning with external fixation [40,41]. However, it has been shown that a 1 4 tubular plate may be somewhat better than a pi-plate [42] and that arthroscopy-assisted reduction with pinning supported by an external fixator is superior to open reduction and plate fixation [43]. These results agree with nonrandomized studies in which arthroscopy-assisted reduction has been found to realign pre-operative incongruity with good accuracy and give an excellent or good outcome in about 90% of patients [44 47]. Bearing this in mind, there is evidence that arthroscopy should be considered when addressing ulnar-sided injuries, because it combines the possibility of securing the bony congruity with complete diagnosis and treatment of ulnar-sided and intercarpal-associated injuries [38,48]. Arthroscopic reduction and percutaneous pinning Arthroscopy is performed under upright [38,48] or horizontal [49] traction, which can help reduce some fragments by way of ligamentotaxis. Most often, however, the fragments have to be mobilized before reduction, which is done either with a probe within the joint or with an elevator through a separate skin incision over the fracture. This is well described in the article by Geissler elsewhere in this issue. However, in the specific treatment of ulnarsided fragments, I prefer to start the realignment at the ulnar border of the radius, thereby reducing the double joint incongruency of both the radiocarpal joint and the DRUJ (Fig. 2), then add further fragments to the ulnar platform. Finally, the extra-articular fracture component, the cancellous defect, and associated injuries have to be evaluated, and additional procedures have to be considered. Ligamentous (triangular fibro-cartilage complex) injuries are underestimated The TFCC is the most involved associated injury with distal radial fractures (80%) [19].

3 INJURIES TO THE ULNAR SIDE OF THE WRIST 419 Fig. 2. Realignment of the incongruency from the ulnar side. Fragment reduction with arthroscopy-assisted technique should reconstruct the double incongruency of both the DRUJ and the radio-carpal joints, hereby minimizing the risk for instability as well as posttraumatic secondary osteoarthritis. The next step is to realign the other fragments (3) to the ulnar platform. This laxity was not correlated to malunion [21,51], but instead correlated to these peripheral tears of the TFCC. Only a few uncontrolled studies have reported results after acute management of DRUJ injuries; in these studies, reasonably good results have been reported with both open and arthroscopic treatment in selected patients [45,52]. On the other hand, the natural course of untreated peripheral TFCC tears has been found by some authors to end with fairly good results [21]. Hence, the recommendations given here are based upon the authors opinions from what is currently known about these conditions. Keep in mind, though, that there are still no randomized studies that merit surgical treatment regarding these associated injuries, and that surgery itself adds trauma and possible morbidity. Because the TFCC is a combination of structures that make up the ligamentous support of the DRUJ and the ulno-carpal joint, I prefer to describe these injuries not entirely according to Palmer s classification [34], but rather as either central perforation tears, tears of the ulno-radial ligament (ie, peripheral tears), or tears of the ulnocarpal ligament [50]. This facilitates the functional understanding and importance of the different tears, namely as representing possibly destabilizing tears of the DRUJ or not [50], as we have found that tears to the ulno-radial ligament caused laxity and a subsequent worse outcome [21]. Arthroscopic management Central perforation tears are located parallel to the sigmoid notch of the radius with a 2-mm rim of membranous substance left between the sigmoid notch and the perforation (Fig. 3A). These tears are stable and can be debrided with a suction punch (Fig. 3B). Care should be taken not to be too aggressive, thus jeopardizing the stability by debriding the important palmar and dorsal ulnoradial ligaments. The edges are then smoothened with a motorized shaver or vaporizer. Tears of the ulno-radial ligament can be either avulsion tears from the insertion of the dorsal and Fig. 3. Central perforations in the articular disc are stable. (A) Radio-carpal arthroscopy shows a stable central perforation tear in the central articular disc of the TFCC (dorsum of the wrist to the right). The lunate facet of the radius (R) is in the foreground with the probe (1 mm thick) lifting the torn ligament about 2 mm from its insertion in the sigmoid notch of the radius. (B) The tear without healing capacity is best treated with debridement (eg, with a suction punch).

4 420 LINDAU palmar edge of the sigmoid notch of the radius or ulnar avulsion tears (Fig. 4). They can sometimes be hidden behind a capsular blood clot. Hence, debride the area with the shaver to fully examine the ulno-radial ligament. As previously stated, these tears are associated with late clinical instability of the DRUJ [21] and worse outcome [21,51]. Consequently, they probably have to be repaired. Radial avulsion tears are often caused by dorso-ulnar fracture fragments, but may be true avulsions from the insertion site of the ulno-radial ligament. Fragments should be anatomically reduced to both give bony congruity of the sigmoid notch as well as fixate the ligament insertion. A true avulsion at the insertion probably has to be reinserted, either with drill holes through the radius [52,53] or with a suture anchor. An ulnar avulsion tear (Fig. 4A) is preferably repaired with two or three 2-0 absorbable (PDS) sutures through a drill hole of the fovea in the distal ulna (Fig. 4B D) rather than the previously recommended technique through the dorsoulnar capsule and extensor carpi ulnaris tendon sheath. The repair is protected from supination and pronation for 4 weeks, followed by 2 to 4 weeks in a short arm cast or splint. Tears of the ulno-carpal ligament are rare [19]. Treatment may be considered with a palmar open reinsertion technique. Degenerative tears with secondary cartilage changes on the ulnar head and the lunate may be found, en passent, together with the fracture. Sometimes there may be acute tears superimposed on the degenerative tears [19]. The degenerative changes are probably best left alone, as they most Fig. 4. Peripheral TFCC tears cause laxity of the DRUJ. (A) An arthroscopic view of a dorsal ulnar avulsion tear of the ulno-radial ligament of the TFCC (right wrist with dorsal to the right). The lunate is on top with a chondral flake hanging down. The dorso-ulnar peripheral tear (arrows) creates a rough longitudinal line from the lunate facet of the radius in the bottom going all the way toward the ulnar styloid, which is not visible arthroscopically. There is synovium with hematoma to the right and a cloud of blood over the central disc. (B) A drill hole is made to the fovea of the ulnar head. (C) The suture is retrieved after it has been inserted through the extensor carpi ulnaris subsheath with the instrument. (D) The suture is tied after the arm is taken from the traction and with the forearm in neutral.

5 INJURIES TO THE ULNAR SIDE OF THE WRIST 421 often have been asymptomatic before the fracture. However, an acute component may need treatment as recommended above. The ulnar styloid fracture is unimportant Ulnar styloid fractures have been associated with worse outcome [1,7,10,54], which was part of the reason for Frykman s classification [1]. This classification pointed out that each fracture type (extra-articular = I, radio-carpal = III, radioulnar = V, radio-carpal and radio-ulnar = VII) had a worse counterpart when the ulnar styloid was fractured (type II, IV, VI, and VIII) [1]. However, the usefulness of his classification has been questioned [55], because others have not found a correlation between this classification and outcome [22]. Furthermore, several studies have not found any correlation between ulnar styloid fractures and end result [14,21,51,56 58]. This controversy might be explained by the previously stated findings of acute TFCC tears without ulnar styloid fractures [38,48]. Furthermore, there has been no correlation between ulnar styloid fractures at the time of trauma and development of late DRUJ instability [21,51]. Consequently, the outcome is more correlated with the other ulnarsided injuries than the fracture of the ulnar styloid itself. This is probably the reason why no studies have shown any benefits with repair of ulnar styloid fractures [38,57]. Even if operative treatment cannot be advocated, I strongly recommend arthroscopic evaluation if a subluxation or dislocation is present on normal radiography. After complete diagnosis, I then recommend a combined repair of both the TFCC tear (as described above) and the styloid fracture, preferably with a tension band wiring technique. Late DRUJ-related problems are often misunderstood There are many possible causes of ulnar-sided wrist pain after distal radial fractures (Box 1) [24]. Patients who have symptomatic malunion of the distal radius mainly have symptoms secondary to the relatively longer ulna, causing an ulna abutment syndrome. By performing a radial osteotomy with bone graft [17,28,59], the distal radius can be realigned regarding both axial shortening as well as radial and dorsal angulation. The lengthening osteotomy rebalances the load distribution in the wrist, thereby decompressing the Box 1. Verified and suggested causes of distal radio-ulnar joint related symptoms after distal radial fractures Verified causes Ulno-carpal abutment DRUJ laxity Tears of the TFCC Radiographic osteoarthrosis of the DRUJ Incongruency of the sigmoid notch Nonunion of hypertrophic ulnar styloid Arthrofibrosis Suggested causes Tenosynovitis of the extensor carpi ulnaris Adapted from Lindau T, Aspenberg P. The radioulnar joint in distal radial fractures. A review. Acta Orthop Scand 2002;73:583. ulna abutment. The techniques of this are addressed in Stevanovic s article on extra-articular distal radial fracture malunion. The ulna abutment might also be decompressed with ulnar shortening osteotomies [15,60], with Sauve - Kapandji arthrodesis of the DRUJ [61 64], or with an ulnar head resection arthroplasty [65]. The arthroplasty might in turn be performed as an arthroscopic [60,66] or open [60] procedure. The radial osteotomy for malunion also alters the sigmoid notch, which might give both better range of pro-supination motion and create bony stability of the DRUJ [17,59]. However, this osteotomy alone does not yield stability in all cases. Some authors have considered additional ligament stabilizing procedures to be necessary in almost half the patients [17,67,68], while af Ekenstam and colleagues [28] did not find this advantageous. Because ulnar styloid fixation was seen as a ligament-stabilizing procedure, these contradictory results might be explained by the findings that the stabilizing ulno-radial ligaments might be torn without an ulnar styloid fracture [19]. Furthermore, ligament rupture alone can give laxity of the DRUJ even without malunion [21]. Consequently, we should not only reinsert the ulnar styloid when we attempt to stabilize the DRUJ in conjunction with a radial osteotomy, but also need to address the soft-tissue problem completely.

6 422 LINDAU Fig. 5. Ligament reconstruction is sometimes the final solution. (A) The most appealing reconstruction technique uses a tendon graft (most often palmaris longus), which is passed in a tunnel parallel to the sigmoid notch of the radius and reinserted in the fovea [1]. (B) After reconstruction, the graft is pulled firmly and tied with the forearm in neutral rotation. Thereafter, the capsule is closed. Authors preferred assessment of posttraumatic ulnar wrist pain Every patient with ulnar sided wrist pain after distal radial fractures should be examined with a stability test of the DRUJ [50], including ulnocarpal stress test, and assessment of radiographic signs of malunion. In cases with obviuos axial, radial and dorsal malunion, I do a straightforward lengthening osteotomy of the radius with bone graft. If congruity and stability of the DRUJ is not achieved, there is a clear indication to add arthroscopy to evaluate the status of the TFCC and continue with a reattachment of its ulnar insertion in the fovea of the ulnar head, sometimes combined with reinsertion of the ulnar styloid. In cases with only axial shortening malunion, I always start with an arthroscopic evaluation of the ulno-carpal complex and grade the findings according to Palmer [34] (as opposed to the acute tears were I follow my previous recommendations for classification). A shortening osteotomy of the ulna is done if there is an ulnar variance of 1 to 2 mm or more, while I do an arthroscopic partial ulnar head resection (wafer) if the ulnar variance is less than 1 to 2 mm, bearing in mind that the full circumference of the ulnar head must be resected. However, in cases with additional wear of the luno-triquetral ligament [34], I always do an ulnar shortening osteotomy to stabilize the entire ulno-carpal complex. In cases with laxity of the DRUJ without malunion of the radius, I perform an arthroscopy to see if there is an option to arthroscopically reinsert the ligament to the fovea, as previously described. However, in many cases it is necessary to do a reconstruction procedure, where a tendon graft I used to constrain the joint by passing the graft in a tunnel parallel to the sigmoid notch of the radius and reinserting both ends in the fovea through a tunnel of the ulnar head [69] (Fig. 5). This pulls the radius toward the ulna like the reigns of a horse. Summary We still do not know how to best treat the DRUJ condition that was recognized 200 years ago by Abraham Colles and later addressed in Frykman s classic thesis [18]. To improve the outcome, we must recognize the differences between osteoporotic and other fractures and understand the importance of ligament injuries, especially in patients under the osteoporotic age [39]. However, our current problem is that neither the initial ligament injury nor the posttraumatic laxity is detectable with radiographic methods, which creates future challenges regarding diagnosis and treatment. We therefore have to critically analyze each fracture in each patient and be aware of the complexity of the entire injury to the wrist. References [1] Frykman G. Fracture of the distal radius including sequele, shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. Acta Orthop Scand 1967;38(Suppl 108):83 8. [2] Altissimi M, Antenucci R, Fiacca C, et al. Longterm results of conservative treatment of fractures

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