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Purpose: To describe a surgical approach for open repair of the triangular fibrocartilage complex foveal avulsion via ulnar styloid osteotomy, and to assess its clinical results., Methods: We reviewed 12 patients with distal radioulnar joint (DRUJ) instability due to isolated foveal avulsion of DRUJ ligaments. Wrist arthroscopy was conducted for all patients to exclude the presence of concomitant tear of the superficial part of the triangular fibrocartilage complex and to corroborate the diagnosis with a positive hook test. Through an ulnar approach between flexor and extensor carpi ulnaris, an ulnar styloid osteotomy was performed under image intensifier control just ulnar to the fovea of the head of the ulna. The avulsed foveal attachment was anchored through transosseous sutures passing from the fovea to the neck of the ulna. The ulnar styloid was fixed by means of screws or tension band wires. Outcome measures included clinical assessment of pain (visual analog scale), grip strength, DRUJ instability, range of motion of the wrist, and modified Mayo wrist score. Radiographic assessment was done to determine union of the ulnar styloid osteotomy, DRUJ subluxation, and any hardware-related problems., Results: Outcome measures were evaluated after a mean follow-up of 21 months. Healing of the osteotomy was obtained in all cases by 11 weeks. The DRUJ laxity, visual analog scale, and modified Mayo wrist score improved, while grip strength and range of motion remained unchanged. One patient had prominent hardware necessitating removal after union of the osteotomy. There were no reported cases of injury or neuropraxia of the dorsal cutaneous branch of the ulnar nerve., Conclusions: Open repair of an avulsed foveal attachment of the triangular fibrocartilage complex using an ulnar styloid osteotomy is an alternative to either open or arthroscopic repair approaches., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2024 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The aim was to assess the direction of distal radius fractures and their relationship to the ulnar head., Methods: We reviewed the 160 wrist radiographs. The fracture line was measured on the postero-anterior and lateral radiographs relative to the long axis of the forearm and the relationship to the ulnar head., Findings: PA radiographs: the fracture line ran distal ulnar to proximal radial (ulnar to radial) in 11%, transverse in 74% and distal radial to proximal ulnar (radial to ulnar) in 16%. Lateral radiographs: the fracture line ran distal volar to proximal dorsal in 88%, transverse in two 1% and dorsal to volar in 11%. Radial shift (7.5%) only occurred with ulnar to radial or transverse fractures. The ulnar to radial fracture line started at the proximal end of the ulnar head/distal radio-ulnar joint in 88%. The radial to ulnar fracture line started ended a mean of 2.5 mm proximal to the distal radio-ulnar joint (p < 0.01). The transverse fracture line started at the base of the distal radio-ulnar joint in 53% and proximally in 47%., Interpretation: There are two distinct coronal patterns: radial to ulnar ending c. 2 mm proximal to the distal radio-ulnar joint; ulnar to radial starting at the proximal distal radio-ulnar joint. There may be third pattern - transverse fractures; these may be variants of the above. Sagittally the main direction is volar to dorsal but 11% are obverse. This is the first description of distinct fracture patterns in extra-articular distal radius fractures. In addition the fracture patterns appear to correlate with different directions of force transmission which fit with our understanding of falling and the relatively uncontrolled impact of the wrist/hand with the ground. These patterns of fracture propagation help understand how the biomechanics of wrist fractures and may enable prediction of collapse., Competing Interests: Declaration of competing interest There are no interests to declare., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

The purpose of this study was to investigate the necessity for surgical fixation of basal fractures of the ulnar styloid without distal radioulnar joint (DRUJ) instability, after stabilization of associated distal radial fractures using an anterior plate. This single-centre, prospective, randomized controlled trial, conducted between 2015 to 2021, included 43 patients in each study arm who were randomized to either fixation (Group A) or non-operative treatment (Group B) of the ulnar styloid. The mean follow-up period was 24 months (SD 5.2) in Group A and 23.9 months (SD 5.5) in Group B. At the final follow-up, patients were evaluated by the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the Modified Mayo Wrist Score (MMWS), the visual analogue scale (VAS) for pain, the grip strength, wrist range of motion. The DASH score was 6 (SD 2.6) in Group A and 6 (SD 2.4) in Group B; the MMWS was 87 (SD 5.6) in Group A and 87 (SD 5.6) in Group B; and the grip strength was 88% (SD 9.4) in Group A and 87% (SD 7.7) in Group B. In conclusion, fixation of basal ulnar styloid fractures is not mandatory if the DRUJ is stable after rigid fixation of the associated fracture of the distal radius. Level of evidence: II.

Introduction: Current literature reports varied significance of ulnar styloid fractures (USF) associated with distal radius fractures. Our study assesses the role of ulnar styloid fractures and fragment size in surgically managed distal radius fractures., Materials and Methods: We reviewed patients who underwent surgical fixation of distal radius fractures between January 2004 to June 2006. Patients were divided into those with (Group 1) and without (Group 0) USFs. Post-operative radiographic parameters, clinical outcomes and overall wrist function were analysed. Outcomes included ulnar-sided wrist pain, extensor carpi ulnaris (ECU) tendinitis, triangular fibrocartilage complex (TFCC) grind test, distal radioulnar joint (DRUJ) instability and pain. Overall wrist function was assessed with range of motion and Disabilities of the Arm, Shoulder and Hand (DASH) score., Results: Our study cohort included 31 males and 23 females, and 38.9% of these patients had concomitant USFs. There was no difference in terms of demographic data and fracture configuration between groups. Radiographic parameters were similar, except for palmar tilt, which was significantly higher in Group 1 (4.6º vs 9.4º, p=0.047). At 24 months, there were no differences in clinical outcomes and overall wrist function. A sub-group analysis showed that mean USF fragment size was larger in patients with a positive TFCC grind test (3.9mm vs 7.3mm, p=0.033)., Conclusion: The presence of USFs in surgically managed distal radius fractures does not compromise clinical and functional outcome. Similarly, the size of USFs does not impact clinical and functional outcome but is associated with the presence of a positive TFCC grind test., Competing Interests: The authors declare no potential conflict of interest., (© 2023 Malaysian Orthopaedic Association (MOA). All Rights Reserved.)

Introduction: Nonunion of ulnar styloid fractures after radius stabilisation by volar locking plate (VLP) fixation without surgical fixation on ulnar styloid fractures is quite common. However, the factors affecting the nonunion of ulnar styloid fractures and their effect on functional outcomes in patients with distal radius fractures (DRFs) treated with VLP fixation are unclear., Hypothesis: The purpose of this study was to investigate the predictors affecting nonunion of unrepaired ulnar styloid fractures in patients with DRFs and the effect of nonunion and its predictors on functional outcomes., Materials and Methods: We retrospectively reviewed data from 84 patients with DRF who underwent VLP fixation. None of the accompanying ulnar styloid fractures were manipulated during the surgery. Postoperative evaluation included the measurement of the grip strength, wrist range of motion, and Disabilities of the Arm, Shoulder, and Hand score at a minimum of one year postoperatively. Patients were divided into the nonunion and union groups according to the presence of union of ulnar styloid fracture. Demographic and radiologic parameters, including age, sex, bone mineral density, location and displacement distance of ulnar styloid fracture, and fracture pattern of DRFs, were analysed to identify predictors of nonunion. Functional outcomes were compared between the two groups and were compared according to the presence of predictors of nonunion., Results: Univariate analysis revealed that the nonunion rate was higher in ulnar styloid non-base fractures, substantial displacement (≥1.9mm) of ulnar styloid fracture, and AO/OTA C-type DRF. However, multivariate logistic regression analysis showed that non-base fractures and substantial displacement were significant predictors. Accompanying ulnar styloid fracture nonunion and its predictors were found not to influence functional outcomes., Discussion: Substantial displacement and non-base fracture are predictive factors for nonunion of unrepaired ulnar styloid fractures after DRF treatment with VLP fixation. However, nonunion and its predictors do not influence the overall wrist function. These findings suggest that the ulnar styloid fracture accompanying DRF should not be considered a fracture affecting the wrist function when treating with VLP fixation., Level of Evidence: III, Retrospective, Case Control study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

In the real condition, the small sensor found it difficult to detect the position of the pressure sore because of casting displacement clinically. The large sensor will detect the incorrect pressure value due to wrinkles without close to arm. Hence, we developed a simulated arm with physiological sensors combined with an APP and a cloud storage system to detect skin pressure in real time when applying a short arm cast or splint. The participants can apply a short arm cast or splint on the simulative arm and the pressure in the cast or splint could be immediately displaced on the mobile application. The difference of pressure values from six pressure detection points of the simulated arm between the intern and the attending physician with 20-year working experience were 22.8%, -7.3%, 25.0%, 8.6%, 38.2%, 49.6%, respectively. It showed that the difference of pressure values in two farthest points, such as radius stab and ulnar styloid, was maximal. The pressures on the skin surface of the short arm cast were within acceptable range. Doctors would obtain reliable reference data and instantly understand the tightness of the swathed cast which would enable them to adjust it at any time to avoid complications.

Background: Ulnar styloid fractures (USFs) are common concomitant injuries associated with distal radius fractures (DRFs). Recent studies have found conflicting evidence on whether these fractures treated or untreated effect pain and functional outcomes. The purpose of this study was to prospectively evaluate pain and function outcomes of consecutively untreated USFs in surgically repaired DRFs. The study hypothesis was that there would be no difference in outcomes whether an USF is present or not, with all cases left untreated. Methods: A prospective study at a single institution of consecutive DRF treated surgically with volar locked plating was undertaken. No patients underwent fixation of an USF if present. There were no treated USF that were excluded. Patients with associated ulnar neck and shaft fractures were excluded. Functional outcome measures were analyzed using the Quick Disabilities of the Arm, Shoulder, and Hand score (QDASH) and the Patient-Rated Wrist Evaluation (PRWE) scores. Outcome measures were collected at 3 months and 1 year postoperatively. Results: There was an incidence of 52.2% (n = 70/134) USF associated with surgically treated DRF. By location, there were 52.9% (n = 37/70) ulnar styloid tip fractures and 46.1% (33/70) ulnar styloid base. There were 75.7% of USF (53/70) still not healed by 1-year follow-up. When comparing patients with a DRF without an USF versus DRF with an associated USF at 12 months, there was no statistical difference in the QDASH score (6.7 vs 8.4, P = .47) or the PRWE total score (4.8 vs 7.5, P = .24). Similarly, subgroup analysis showed no statistical difference in QDASH or PRWE scores at final follow-up in united USF versus nonunited USF subjects (QDASH 14.2 vs 6.8, P = .112; PRWE 14.8 vs 5.4, P = .185). Conclusions: USFs are a common concomitant injury occurring in nearly half of DRFs treated surgically. Our prospective cohort analysis showed that neither the presence, type, nor bony union status of a concomitant USF has any significant effect on patient outcomes or reoperations at 1-year postoperatively. Our study confirms our hypothesis that USF of the tip and base should be left untreated.

In this article, we discuss the incidence and types of injuries to the distal radioulnar joint (DRUJ) that occur in the setting of a distal radius fracture. We review the anatomy of the distal radioulnar joint, which is critical to understanding its biomechanics, and how injury could cause symptomatic incongruency and instability. We highlight how patients with an injury to the distal radioulnar joint might present both at the time of injury and after treatment of a distal radius fracture, the appropriate workup, the available treatment options, and the evidence-based literature., Competing Interests: Disclosure Dr C. Nypaver has nothing to disclose. Dr D.J. Bozentka has no funding source. Disclosures: Axogen principal investigator, speaker Medartis, Synthes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background  There has been clinical question in the treatment of ulnar styloid fracture with distal radius fracture, surgical fixation of the styloid fragment, or ignorance of the fragment. We examined relationship between size of the ulnar styloid fracture and distal radioulnar joint (DRUJ) stability biomechanically to answer the above clinical question. Methods  Changes in the dorsopalmar stiffness of the DRUJ after experimentally simulating in four types of ulnar styloid fractures were examined in cadavers. After tip, middle, base-horizontal, and base-oblique type of styloid fractures were made sequentially, changes in dorsopalmar DRUJ stiffness were measured using the MTS machine in the intact wrist, for each fracture, at 60 degrees pronation, neutral, and 60 degrees supination, respectively. Additional cutting of the radioulnar ligament (RUL) at the fovea was also simulated with the base-horizontal fracture. Results  The tip and middle type fractures did not demonstrate significant loss of stiffness compared with the intact. The base-horizontal fracture demonstrated only significant loss of stiffness in the dorsal direction (radius palmar; ulnar dorsal) with forearm in neutral rotation. The base-oblique fracture demonstrated significant loss of dorsopalmar stiffness of the DRUJ. Additional section of the RUL with the base-horizontal fracture induced significant loss of stiffness of the DRUJ compared with the intact. Conclusions  Because the RUL originates from the fovea as well as from the base of the ulnar styloid, these results suggest that DRUJ instability closely correlates with how much of the bony fragment includes the originating portions of the RUL. The findings further suggest that larger base-oblique and base-horizontal fragments with resultant DRUJ instability must be reattached, but that even base-horizontal fragment as well as tip and middle ulnar styloid fragment can be ignored when there is no instability., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

The purpose of this study was to systematically quantify distal radioulnar joint stability with a cadaveric model, using radiographic and joint contact force measurements. Six fresh-frozen cadavers underwent sequential ulnar styloid osteotomies. Posteroanterior and lateral stress radiographs were obtained and joint contact forces and areas were measured. Posteroanterior radiographs showed a significant increase in the distal radioulnar joint gap after osteotomy of the base of the ulnar styloid. Contact force and contact area measurements were not significantly different. We conclude that fractures that involve the ulnar styloid base should be considered for operative fixation when carrying out open reduction and internal fixation of fractures of the distal radius.

Background: Fractures of the radial shaft with disruption of the distal radial ulnar joint (DRUJ) or Galeazzi fractures are treated with reduction of the radius followed by stability assessment of the DRUJ. In rare instances, the reduction of the DRUJ is blocked by interposed structures requiring open reduction of this joint. The purpose of this study is to review all cases of irreducible Galeazzi fracture-dislocations reported in the literature to offer guidelines in the diagnosis and management of this rare injury., Methods: A search of the MEDLINE database, OVID database, and PubMed database was employed using the terms "Galeazzi" and "fracture." Of the 124 articles the search produced, a total of 12 articles and 17 cases of irreducible Galeazzi fracture-dislocations were found., Results: The age range was 16 to 64 years (mean = 25 years). A high-energy mechanism of injury was the root cause in all cases. More than half of the irreducible DRUJ dislocations were not identified intraoperatively. In a dorsally dislocated DRUJ, a block to reduction in most cases (92.3%) was secondary to entrapment of one or more extensor tendons including the extensor carpi ulnaris, extensor digiti minimi, and extensor digitorum communis, with the remaining cases blocked by fracture fragments. Irreducible volar dislocations due to entrapment of the ulnar head occurred in 17.6% of cases with no tendon entrapment noted., Conclusions: In the presence of a Galeazzi fracture, a reduced/stable DRUJ needs to be critically assessed as more than half of irreducible DRUJs in a Galeazzi fracture-dislocation were missed either pre- or intraoperatively.

Background: The role of surgical fixation of ulnar styloid fractures remains a subject of debate. The purpose of this study was to compare the surgical outcomes following early and late intervention., Methods: We retrospectively reviewed 28 patients who underwent surgical repair for unilateral ulnar styloid fractures with distal radioulnar instability between 2004 and 2014. Surgical fixation was performed within 3 months of injury in 13 patients (group A) and beyond 3 months in 15 patients (group B). Patient characteristics and functional outcomes were compared between the two groups. The outcome survey consisted of QuickDASH score, grip strength, range of motion, pain score based on the visual analog scale, and surgical complications. Descriptive statistics were calculated for key variables. A p value of < 0.01 was considered statistically significant., Results: Patient characteristics including age, sex, injured side, dominant side injury, and concomitant distal radius fracture showed no significant differences between the two groups. Time to surgery averaged 1.1 months in group A and 12.3 months in group B. Significantly better outcomes were found in group A than in group B, including QuickDASH scores (4.4 ± 5.9 vs. 12.9 ± 9.9) and grip strength (37.4 ± 5.1 vs. 29.1 ± 5.9 kg). Significantly better range of motion was found in group A than in group B with respect to supination (81.9° ± 4.3° vs. 75° ± 8.5°), extension (84.6 ± 4.3 vs. 76.7 ± 6.5), and flexion (80.4° ± 3.8° vs. 72° ± 4.1°). The difference was not significant in case of pronation (78.8° ± 3° vs. 74.3° ± 5.9°) and with respect to pain scores (0.6 ± 0.7 vs. 1.3 ± 1)., Conclusion: Both osseous and soft tissue lesions need to be fully addressed in ulnar styloid fractures. Early detection and surgical repair yielded better outcomes. Higher complication rates in late-treated fractures show that surgeons should select surgical candidates and modalities properly.

Purpose  In this literature review, functional outcomes such as Disability of Arm, Shoulder and Hand (DASH) score and the visual analog scale (VAS) of pain along with clinical outcomes such as range of movement and grip strength of treated distal radius fractures (DRF) accompanied with ulnar styloid fractures (USF) will be compared with those with isolated DRF. Materials and Methods  We analyzed articles from MEDLINE, Embase, and CINAHL that met our predetermined inclusion and exclusion criteria as per the Preferred Reporting Items for Systematic Reviews and Meta-analysis statements. This resulted in the identification of 464 articles with 18 potentially eligible studies of which 6 were included at the full-text screening stage. The primary outcomes were wrist pain, range of motion, functional outcome and satisfaction, such as VAS, and the DASH questionnaire along with radiological assessment and incidence of complications. Results  These studies involved 796 participants with DRF and 806 wrists with DRF; 444 (55%) of DRF had an associated USF. Three studies did not report any statistically significant difference in DASH scores between the DRF patients with or without USF. Two studies reported worse DASH scores in the group with associated USF. Wrist pain was reported to be statistically significantly worse in patients with associated USF in two studies. Grip strength did not exhibit a statistically significant difference in any groups in four studies. On assessing the range of motion of the wrist and forearm, only one study reported a statistically significant difference in flexion at 2 years follow-up, with less flexion in patients with USF. Conclusion  This review suggests that there is no significant correlation between a USF and the functional and clinical outcomes of DRF treatment, albeit wrist pain and less flexion were reported in some studies to be associated with USF. There is a need for more robust evidence from large randomized controlled trials to specifically look at the effects of fixation versus nonfixation of USF on DRF, or large prospective cohort studies assessing DRF with and without USF, with a minimum of 12 months follow-up. Level of Evidence  Level II-therapeutic.

Background: The deep portion of the distal radioulnar ligaments (DRUL) inserts on the ulnar fovea and is the most important stabilizer of the distal radioulnar joint (DRUJ). Ulnar styloid base fractures that include the ulnar fovea may cause DRUJ instability., Methods: DRUJ stability in pronosupination was evaluated in 12 fresh-frozen upper extremities (4 female) aged 52 to 68 years (mean: 58.8 years) using a custom fixture, which allowed free rotation of the radius around the fixed ulna. Optical motion capture was used to record rotation of the radius with respect to the ulna. Each specimen was subjected to 3 N m of torque in both supination and pronation under 4 conditions: intact, ulnar styloid osteotomy with disruption of the foveal insertion of the DRUL, ulnar styloid fixation, and DRUL transection. Group differences were compared using a 1-way repeated-measures analysis of variance and Tukey multiple comparison post hoc tests., Results: When compared with the intact condition, both ulnar styloid osteotomy and DRUL transection significantly increased mean pronation (by 9.40° and 15.21°, respectively) and supination (by 9.05° and 17.42°, respectively) of the forearm. Screw fixation only significantly reduced pronation compared with osteotomy (by 2.62°). Screw fixation did not significantly affect supination., Conclusions: Ulnar styloid fractures that disrupt the fovea cause instability of the DRUJ in pronation and supination under 3 N m of torque in a cadaveric model. Screw fixation of ulnar styloid base fractures achieves anatomic reduction; however, it only partially returns rotational stability acutely to the DRUJ and only during pronation.

Both ulnocarpal impaction syndrome and ulnar styloid impaction syndrome can produce ulnar wrist pain. The definition and clinical differentiation are explained. The relevant anatomy, biomechanics, causes, diagnosis, and arthroscopic treatments, as well as the surgical indications, techniques, and outcomes of these syndromes are discussed in detail., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Distal radioulnar dislocations typically occur in association with fractures of the distal radius and/or ulna. Rare isolated dislocations or subluxations are more difficult to diagnose and are initially missed in up to 50 % of cases. We present two cases of missed isolated volar rotatory dislocation of the distal radioulnar joint. Subtle, overlooked radiographic findings of abnormal radioulnar alignment and ulnar styloid projection are highlighted. The supplemental role of cross-sectional imaging is reviewed. Adequate clinical information, appropriate radiographic technique, and high index of suspicion are necessary for the accurate and timely diagnosis of this rare injury pattern.

Background: There are significant variations in the anatomy of the dorsal cutaneous branch of the ulnar nerve (DCBUN). The DCBUN is at risk for iatrogenic injury during surgeries around the ulnar side of the wrist. The purpose of this study was to demonstrate the relationship between the ulnar styloid process and the DCBUN and to confirm the DCBUN's change in location with different forearm positions., Methods: We examined 9 fresh frozen cadaveric limbs to establish the course of this nerve. The DCBUN was dissected and traced around the ulnar border of the wrist. The distance from the tip of the ulnar styloid process to the origin of the DCBUN was measured. The distances from the ulnar styloid process to the DCBUN were measured in supination, pronation, and in a neutral position of the forearm., Results: The DCBUN originated on average 4.92 cm proximal to the ulnar styloid process. In all cases, the DCBUN crossed the ulnar distal to ulnar styloid process and it moved more closely to the ulnar styloid process with a forearm position change from supination to pronation., Conclusions: We recommend making a skin incision on the ulnar side around the styloid process with the forearm in supination or neutral position was another method to avoid injury of DCBUN.

Distal ulna fractures, especially styloid injuries, classically have not been repaired, and only recently have these injuries been considered important. Certain fracture patterns of the distal ulna contribute to distal radioulnar joint (DRUJ) incongruity and potential instability. Appropriate fixation of the distal ulna is frequently difficult for several reasons: (1) high incidence of osteoporois in the affected patient population, (2) proximity of the injury to articular surfaces, and (3) lack of a proper implant to treat these injuries. The 2.0-mm locking compression distal ulna plate (LC-DUP) is an anatomically contoured implant with a low profile and fixed angle that provides proper stability to treat injuries of the distal ulna. The plate was designed for the treatment of distal ulna fractures, but its success has led to an extension of its indications to be used in treating symptomatic basistyloid ulnar nonunions and in ulnar shortening osteotomy for ulnocarpal abutment syndrome. The authors' description of the techniques used for each indication as well as their perspectives in the treatment of distal ulna injuries are described in detail in this report.