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Journal Club

April 2010

Should an Ulnar Styloid Fracture Be Fixed Following Volar Plate Fixation of a Distal Radial Fracture?

• Authors: Jae Kwang Kim, Young-Do Koh, Nam-Hoon Do
• Institution: Department of Orthopedic Surgery, Ewha Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, South Korea
  
• Journal: J Bone Joint Surg Am. 2010;92:1-6

Abstract link

No outside funding

Introduction

• Null Hypothesis
  
  • An un-repaired ulnar styloid fracture, regardless of fracture level or displacement, does not affect wrist function or distal radio-ulnar joint stability.

Methodology

• Prospective cohort study
  • 2005 – 2007
    
  • 149 consecutive patients with an unstable fracture distal radius
    
  • 9 patients excluded
  • 2 surgeons
• Operative
  • ORIF Synthes volar locking plate in all
  • No fixation of any accompanying ulnar styloid fracture
  • Intraoperative assessment of DRUJ stability
    • Unstable DRUJ
      
      • Sugar tong splint in 30 degrees supination 4/52
    • Stable DRUJ (???)
      
      • Short arm splint 4/52
• Postop
  • Wrist ROM allowed at 4/52 with intermittent use of short arm brace for further 2/52
• Followup
  • Mean follow up 19 months (12-36)
• Radiological Assessment of Ulnar styloid fracture
  
  • Location
    • Not fractured
    • base
    • non-base
      
  • Displacement
    • Non-displaced/minimally <2mm
    • considerably >2mm
• Outcome Measures
  
  • Radiographic
    
    • Post-op vs final follow up
      
      • Radial inclination,
      • radial height,
      • volar tilt,
      • ulnar variance,
      • joint congruity,
      • healing status of ulnar styloid
  • Ulnar styloid displacement
    • Pre-op vs post op
      
  • Subluxation of DRUJ
    • Intra-op
  • Clinical
    
    • Minimum follow up 1 year
      
      • Wrist ROM
        
      • Modified Mayo wrist score
        
      • DASH
        
      • DRUJ stability

Results

• Ulnar styloid fracture
  
  • 76/138 (55%)
    
    • Location
      • 47 base, 29 non base
        
        • No impact on clinical outcome
    • Amount of displacment
      • 34 Mild /42 Considerable
        
        • No impact on clinical outcome
• DRUJ stability
  
  • 32 pts with intra-operative laxity
    
    • Location
      • 13 non #, 10 non base, 9 base
        
        • No correlation
    • Displacement
      • 13 non #, 7 Minimal Displacement, 12 Considerable Displacement
        
        • No correlation
  • 2 pts with chronic instability
    
    • Both had intra-op laxity
      
    • Asymptomatic
      
    • No further intervention
• Radiological
  
  • Ulna styloid displacement post ORIF radius
    
  • Significant reduction in Considerable Displacment group (not Minimal Displacement group)
• Ulnar styloid union
  
  • 31/76 at final follow up
    
  • Not dependent upon displacement or fracture level

Discussion

• Controversy surrounding
  
  • Function
    
  • DRUJ stability
• Studies demonstrating worse outcomes have mostly treated the distal radial fracture conservatively
• Cause of instability (and worse functional outcome) more likely the radial fracture itself and anatomical reduction and internal fixation solve this problem
• Intra-op DRUJ laxity did not correlate with ulnar styloid fracture
  
• Styloid fracture probably not an indicator of DRUJ stability
  
• TFCC reduces when radial fracture reduces and heals without operative intervention

Pros of Study

• Controlled against non-fracture
  
• Blinded assessment
  
• Both radiological and functional outcome measures
  
• Prospective
  

Cons of Study

• Follow up
  
• Subjective assessment of DRUJ stability
  
• Not enough power to assess chronic DRUJ instability