n Feature Article

Distal Hook Plate Fixation for Unstable Distal Ulna Fracture Associated With Distal Fracture

Sang Ki Lee, MD; Kap Jung Kim, MD; Ju Sang Park, MD; Won Sik Choy, MD

abstract Full article available online at Healio.com/Orthopedics. Search: 20120822-22

The significance of distal ulna fractures is often undermined, which can result in inad- equate treatment compared with fractures of the radius, the ulna’s larger counterpart. However, little guidance exists in the current literature on how to manage distal ulna head or neck fractures and intra-articular ulna head fractures. Therefore, the purpose of this retrospective study was to evaluate the outcomes of distal ulna hook plate fixa- tion for the treatment of an unstable distal ulna fracture associated with a . A B C D Twenty-five patients with unstable distal ulna fractures who underwent stable fixation Figure: Anteroposterior (A) and lateral (B) photo- for an associated distal radius fracture were included in the study. All patients achieved graphs of the distal ulna hook plate showing that it is precontoured anatomically to facilitate easy fixation to satisfactory reduction and bony union. Average final motion was as follows: wrist flex- the distal ulna. The plate has a pointed hook that grips ion, 72° (range, 60°-85°); extension, 69° (range, 65°-80°); pronation, 77° (range, 55°- to the ulna styloid. Posteroanterior (C) and lateral 95°); supination, 82° (range, 65°-90°); ulnar deviation, 35° (range, 15°-50°); and radial (D) photographs of the plate with the screw inserted deviation, 24° (range, 10°-40°). Average postoperative grip strength was 28 kg (range, showing that 2 distal holes are used to intercross the screws. 22-30 kg) and was 91% (range, 71%-100%) in the cases in which the dominant was injured and 80% (range, 65%-100%) in the cases in which the nondominant hand was injured. Average postoperative modified Mayo wrist score and Disabilities of the , Shoulder and Hand score was 87 points (range, 65-100 points) and 14 points (range, 0-54 points), respectively. Chronic instability of the distal radioulnar joint was not encountered in any patient. Thus, the study demonstrated that distal ulna hook plate fixation for the treatment of unstable distal ulna fractures can achieve healing with good alignment, satisfactory function, and minimal transient morbidity.

Drs Lee, Kim, Park, and Choy are from the Department of Orthopedic Surgery, Eulji University College of Medicine, Daejeon, Korea. Drs Lee, Kim, Park, and Choy have no relevant financial relationships to disclose. Correspondence should be addressed to: Sang Ki Lee, MD, Department of Orthopedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon 302-799, Korea (sklee@ eulji.ac.kr). doi: 10.3928/01477447-20120822-22

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etaphyseal fractures of the dis- ulna fixation is an attractive method to pro- that displaced more than 50% of the ulnar tal ulna often occur with distal vide low-profile, stable fixation that allows metaphyseal diameter in any plane18-20; Mradius fractures.1-3 Unlike dis- early range of motion (ROM) and rehabili- skeletal maturity; and minimum follow- tal radius fractures, few reports exist in the tation of the hand, wrist, and .16,17 up of at least 1 year. The exclusion criteria medical literature of distal ulna neck or Thus, Dennison4 and Ring et al5 intro- included stable distal ulna fracture after head fractures, and controversy remains duced the locked plate fixation technique distal radius fixation, pathological frac- over the treatment of such fractures. for the treatment of distal ulna fractures ture, and previous surgery on the affected Several studies have suggested that distal and achieved relatively good outcomes. wrist. All procedures were performed by ulna fractures associated with distal radius However, this technique has some limita- 1 surgeon (S.K.L.). The study protocol fractures realign and are considered stable tions: if the fracture extends to the intra- and consent forms were approved by the once the radius is reduced and can achieve articular neck or head portion, fixation and institutional review board of the authors’ satisfactory outcomes with conservative restoration of these plates can be difficult institution. treatment.4-7 because the articular surface of the fixation Many reports recommended nonop- area is not large enough. Patients erative treatment for Recently, the locking compression A total of 20 women and 5 men (mean fractures not associated with posttrau- plate distal ulna hook plate was introduced age, 62.3 years [range, 47-85 years]) were matic distal radioulnar joint arthrosis.8-10 for the treatment of distal ulna fractures. included in this study. Fourteen injuries These reports validate conservative treat- This plate is precontoured anatomically were to the left wrist and 11 were to the ment for distal ulna fractures. and has a slim design, rounded edges, and right wrist. Mean follow-up was 15.2 However, some studies have reported a polished surface, which limits the irrita- months (range, 12-21 months). poor outcomes in unstable distal ulna tion of overlying soft tissues. In addition, Distal ulna fractures and distal ra- fractures treated nonoperatively.11 Several it can be used to achieve angular stable dius fractures were classified according reported that unstable or malaligned frac- fixation of the fragments regardless of the to the Q modifier of the Comprehensive tures of the ulnar head or neck can affect quality, and a lower risk of primary Classification of Fractures (Table 1).21 distal radioulnar joint function and dimin- and secondary loss of reduction exists. Three patients had open fractures: 2 were ish distal forearm stability, which can con- The purpose of this retrospective study grade I and 1 was grade IIIC, accord- tribute to the risk of distal radius nonunion was to investigate the clinical and radio- ing to the criteria defined by Gustilo and and callus encroachment of the distal ra- graphic outcomes of open reduction and Anderson.22 The grade I open fractures dioulnar joint, leading to chronic pain locked internal fixation of unstable distal were treated with debridement and irri- and instability.1,3,12,13 Furthermore, intra- ulna (metaphyseal or articular) fractures gation, and plate fixation was performed articular distal ulna head or neck fractures using a distal ulna hook plate when an as- on the date of admission. The grade IIIC have been associated with disruption of sociated ipsilateral distal radius fracture is fracture was treated initially with irrigation the distal radioulnar ligament, result- also treated operatively. and debridement, arteriorrhaphy for radial ing in a loss of structural support for the artery injury, and a temporary external fix- triangular fibrocartilage complex.11,14,15 Materials and Methods ator. Two weeks later, when the soft tissue For these reasons, several studies have Study Design and vascular conditions had improved, the recommended operative treatment when Between January 2009 and March external fixator was replaced with a distal displaced or unstable intra-articular distal 2011, twenty-five consecutive patients ulna hook plate. Twenty-four of the 25 pa- ulna fractures remain after reduction and with distal ulna fractures were treat- tients had concomitant distal radius frac- firm fixation of the concomitant distal -ra ed surgically with a distal ulna hook tures, that were treated with open reduction dius fracture.1,2,4,5 plate (Synthes, Oberdorf, Switzerland). and internal fixation with a volar locked Open reduction with internal fixation Medical records and radiographs were plate. One patient had a radial styloid frac- of the distal ulna fracture can allow secure reviewed to identify patient demograph- ture, that was treated with percutaneous fixation and early motion. However, small ics, fracture type, union, alignment, Kirschner wire fixation. All patients under- and often osteoporotic fracture fragments ROM, grip strength, and complications. went surgery within 5 days of injury and typically exist, and the short nonarticular Inclusion criteria included unstable dis- received a distal ulna hook plate. arc of the ulnar head limits hardware place- tal ulna neck or head fracture that was ment, which can interfere with the distal defined as angulation of more than 108, Implant Design radioulnar joint or the articular surface of or instability of the distal ulna fracture The plates are precontoured anatomi- the ulnar head.4 Nevertheless, locked distal after stabilization of the radius fracture cally and fit the distal ulna metaphysis

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properly. The shaft of the plate has point- postoperatively. Patients were ed hooks that grip the ulnar styloid pro- immobilized in a sugar-tong Table 1 cess and act as reference points for plate splint for 7 to 10 days post- Preoperative Demographic Data application. Intercrossing locking screws operatively. Then, the splint securely hold the distal ulna metaphysis. was changed to a removable Variable No. (%) The plate has oblong holes that accept sugar-tong splint, and initi- Fracture side 2.0-mm cortex screws for ulna length ad- ated wrist flexion and exten- Left 14 (66) justment, which potentially can offer good sion exercises were performed Right 11 (44) stability and allow early mobilization. as tolerated. Between 4 to 5 Dominant side Unlike the conventional form of a plate, weeks postoperatively, active the distal ulna hook plate merges locking wrist supination and pronation Yes 11 (66) screw technology with conventional plat- was initiated depending on the No 14 (44) ing techniques, providing angular stability surgeon’s assessment of the No. of F/M 20 (75)/5 (25) and compression of the fracture regardless overall stability of the fixa- Mean age (range), y 62.3 (47-85) of bone quality and the presence of mul- tion. Resistive exercises were Mean follow-up (range), mo 15.2 (12-21) tiple fragments. Moreover, the relatively delayed until advanced heal- Q modifier classification system small-sized pointed hook of the distal ulna ing was present, usually 10 to Q2 7 (28) hook plate can act as a buttress, and has a 12 weeks postoperatively. Q3 4 (16) grasping effect on small and comminuted Q4 6 (24) fragments, such as the ulnar styloid pro- Patient Assessment Q5 8 (32) cess, and can achieve additional success- Postoperative radiographs ful fixation of the far distal intra-articular were scheduled for 2, 4, and Q1 with Q3 10 (40) extended fracture of the ulna metaphysis 6 weeks postoperatively and Q1 with Q4 3 (12) (Figure 1). at monthly intervals thereafter Q1 with Q5 2 (8) as needed until final follow- Gustilo and Anderson open fractures Surgical Technique up. Alignment was assessed I 2 (8) The distal radius fracture was reduced by measurement of the angu- IIIC 1 (4) and securely fixated with a volar locked lation of the ulna metaphysis plate. Then, the elbow was flexed to 90° on anteroposterior radio- and an incision was made at the ulnar bor- graphs with anatomical posi- der of the wrist. The fracture was exposed, tion (coronal plane) and lateral and the reduction was held temporarily radiographs with 90° prona- with a temporary K-wire. The plate was tion (sagittal plane),19 as well applied on trial, and the hook was cov- as evaluation of ulnar vari- ered over the ulnar styloid and metaphy- ance, radial inclination, and sis. Compression force then was applied volar tilt of the distal radius.2 proximally to the fracture fragments and In addition, distal radioulnar ulnar metaphysic until they were reduced joint arthrosis was assessed by to their desired alignment. Once adequate follow-up radiographs.23 reduction was achieved, locking screws Wrist function was evalu- were placed into the metaphysis and di- ated with wrist ROM, modi- aphysis of the distal ulna to secure the fied Mayo wrist score,24 plate to the bone. If the fracture was com- Disabilities of the Arm, minuted or the bone was osteoporotic, the Shoulder and Hand (DASH) bone defect was filled with autologous score,25 and grip strength. 1A 1B 1C 1D iliac crest bone or allogeneic bone graft Range of motion of the wrist Figure 1: Anteroposterior (A) and lateral (B) photographs of the substitute. The wound was closed layer and forearm (extension, flex- distal ulna hook plate showing that it is precontoured anatomi- by layer. ion, supination, and pronation) cally to facilitate easy fixation to the distal ulna. The plate has a pointed hook that grips to the ulna styloid. Posteroanterior (C) For postoperative rehabilitation, ac- was measured using a goniom- and lateral (D) photographs of the plate with the screw inserted tive finger motion was encouraged 1 day eter. Grip strength was mea- showing that 2 distal holes are used to intercross the screws.

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ration of anatomic alignment, including ulnar variance, radial inclination, and volar tilt. A congruous radiocarpal joint (a step-off of less than 2 mm) and carpal alignment were restored in all patients. Twenty-three of 25 ulna fractures were reduced anatomically or with the ulnar shaft angulated less than 5° (range, 0.5°- 4.5°; combined angulation on biplanar radiographs).19 Two patients had ulna an- gulation in the coronal plane of 8.5° and 9.5°. However, some differences between radiographs taken immediately postop- eratively and those taken at last follow-up 2A 2B 2C were not statistically significant (Table 2). Figure 2: Preoperative radiograph of a 74-year-old woman with a distal ulna fracture (Q5) and an associ- Clinical examination showed an accept- ated ulnar styloid fracture (Q1) showing intra-articular involvement and basal oblique fracture of the ulnar able wrist ROM in all patients (Table 3). styloid (A). Postoperative radiograph showing satisfactory fracture reduction and internal fixation of the All patients were able to make a full com- ulnar styloid and ulna neck fracture (B). Radiograph at 15 months postoperatively showing complete bony union and congruent joint surface (C). posite grip and had full finger ROM. Average modified Mayo wrist score was 87 points (range, 65-100 points), and average DASH score was 14 points sured using a JAMAR hand dynamom- Corporation, Armonk, New York). An (range, 0-54 points). One patient with a eter (Therapeutic Equipment Corporation, independent-sample Student’s t test was type IIIC experienced com- Clayton, New Jersey). In accordance with used to compare the pre- and postoperative plications of skin defects and vascular the guidelines for the use of the JAMAR radiographic assessments. Significance problems, which led to muscle weakness, dynamometer, issued by the American was set at a P value less than .05. slightly limited activities of daily living, Society for Surgery of the Hand, the sec- and a subsequently high DASH score. ond grip handle was used for all patients.26 Results Four plates were removed at the patients’ Chronic instability of the distal radioul- Satisfactory reduction (defined as request at an average of 13.2 months nar joint was assessed by physical exami- within 208 of normal volar tilt, less than (range, 11-15 months). nation.27 The radius was grasped by 1 hand 2 mm of radial shortening, and less than 1 No cases of infection, tendon rupture, of the examiner with the forearm in a neu- mm of articular incongruity) was achieved loss of reduction, complex regional pain tral rotation position while the distal end of in all distal radius fractures. All distal ulna syndrome, malunion, or nonunion oc- the ulna, which was fixed by the contralat- fractures also healed. All fractures united curred. Four of 25 patients underwent eral hand of the examiner, was translated in at an average of 12.5 weeks (range, 9-18 bone grafting: 2 in Q3 fractures and 2 dorsal and palmar directions with respect weeks), as determined by clinical exami- in Q5 fractures. One of these 4 patients to the radius. Distal radioulnar joint insta- nation and follow-up radiographs (Figure received the autologous bone from the bility was confirmed by a finding of more 2). One patient had delayed union. This iliac crest, whereas the other 3 received than 8 mm of palmar–dorsal translation of patient was an older woman with severe allograft materials such as demineralized the ulna relative to the radius.28 However, who did not achieve union bone matrix. These 4 patients were wom- distal radioulnar joint instability was not until 12 weeks with callus formation. en aged older than 65 years. One patient determined if the distal radioulnar joint of She was treated conservatively with an had paresthesia in the median nerve distri- the contralateral uninjured side was more additional period of wearing a short-arm bution without motor deficit, and another noticeably translated without pain than the removable splint. As a result, her fracture experienced mild paresthesia in the ulnar injured wrist. united at 6 weeks after the diagnosis of nerve dorsal sensory branch distribution. delayed union, with acceptable clinical These 2 patients improved after 3 months Statistical Analysis outcome. without specific treatment. Statistical analysis was performed According to the mean radiographic Chronic instability of the distal radio- with SPSS version 20 software (IBM data, all patients had a significant resto- ulnar joint was not encountered in any pa-

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tient. However, 2 patients had radiograph- ic signs of distal radioulnar joint arthrosis Table 2 and mild distal radioulnar joint pain dur- Radiographic Outcomes ing wrist pronation or supination without distal radioulnar joint instability. These 2 Mean (Range) patients had postoperative increased ulnar Immediately angulation. Although both patients had Variable Postoperatively Final Follow-up P pain in the distal radioulnar joint, neither Time to union, wk 12.5 (9 to 18) – – had restriction in activities of daily living Ulnar variance, mm 0.9 (21.9 to 2.5) 0.4 (22.2 to 1.2) .16 because their symptoms were not viewed Radial inclination, deg 23.9 (16.3 to 28.1) 22.7 (15.5 to 26.1) .73 as troublesome. Volar tilt, deg 11.3 (7.2 to 16.5) 10.5 (5.2 to 15.4) .36 Ulnar metaphyseal angulation, deg Discussion This study demonstrates that good out- Coronal plane 1.8 (0.2 to 3.4) 4.7 (0.5 to 9.5) .08 comes are achievable in unstable distal Sagittal plane .8 (0.3 to 2.8) 2.4 (0.7 to 4.5) .23 ulna fractures treated with a distal ulna Abbreviation: deg, degrees. hook plate. Fracture of the distal ulna oc- curs most commonly through the tip or base of the ulnar styloid process; how- fractures after fixa- ever, some fractures occur through the ul- tion of the associated Table 3 nar head or neck.1,24 Most fractures of the distal radius fracture. Clinical Results at Last Follow-up distal ulnar metaphysis associated with However, when a frac- the distal radius fracture are well aligned ture of the ulnar neck Contralateral and stable once the distal radius has been exists, the distal fracture Variable Mean (Range) Side, % realigned and secured and do not benefit fragment is small, me- Range of motion, deg from internal fixation.5 Thus, several stud- taphyseal, and covered Flexion 72 (60-85) 82 ies report the outcomes of nonoperative with articular surface Extension 69 (65-80) 89 1 treatment of these fractures. Biyani et al over a 270° arc, making Pronation 77 (55-95) 93 reported that the combination of distal internal fixation chal- Supination 82 (65-90) 94 ulna fracture with distal radius fracture lenging.5 Therefore, in Ulnar deviation 35 (15-50) 84 was 6% (19/320) and that certain types of the past, because few Radial deviation 24 (10-40) 89 fractures were more problematic. Of the proper operative proce- 19 ulna fractures treated nonoperatively, 2 dures existed, the distal Grip strength, kg comminuted distal ulna fractures had non- ulna fracture was likely Dominant 28 (22-30) 91 unions, 4 of 5 simple neck fractures had to have poor outcomes, Nondominant 24 (22-26) 80 marked restriction of rotation, and 3 had such as distal radioul- Modified Mayo wrist score 87 (65-100) fracture callus encroachment of the distal nar joint arthrosis or in- DASH score 14 (0-54) radioulnar joint that limited forearm rota- stability and nonunion. Abbreviation, DASH, Disabilities of the Arm, Shoulder and tion. Moreover, McKee et al3 reported an Thus, until recently, Hand; deg, degrees. association of distal radius fracture non- some reports suggest- union with ulna fracture in elderly wom- ed distal ulna salvage en. Fernandez et al2 and Ring29 also added methods, such as the Darrach procedure30 However, the limitation of this procedure to the understanding of potential pitfalls, or primary resection arthroplasty at the was difficulty in reconstructing the original especially nonunion of the radius, with time of injury.11,13 These procedures have biomechanics of the distal radioulnar joint combined distal radius and distal ulna the advantage of diminished pain in the by providing the radius with its distal sup- fractures. injured wrist and the disadvantages of de- port during forearm rotation and allowing a Because the aforementioned compli- creased wrist and forearm ROM and grip normal pressure distribution from the hand cations occurred after nonoperative treat- strength weakness.11 Therefore, Berger and wrist on both forearm .32 ment, several studies have emphasized and Cooney31 introduced primary ulnar Fixation of distal ulna fractures remains surgical treatment of unstable distal ulna head prosthesis replacement arthroplasty. technically challenging.16,17 Surgical man-

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agement has been described using several radioulnar joint stability. In the current articular ulna neck or head fractures, as methods, including percutaneous K-wires,1 study, basal oblique ulnar styloid fractures well as basal oblique ulnar styloid frac- condylar blade plating,5 intrafocal pin can achieve satisfactory outcomes postop- tures. plating,12 and locked plating.4 However, eratively using a distal ulna hook plate as each fixation method has complications. a buttress. To the authors’ knowledge, no References Percutaneous K-wire techniques provide reports exist on the optimal management 1. Biyani A, Simison AJ, Klenerman L. Frac- support but have limited indications in of concomitant ulnar styloid and distal tures of the distal radius and ulna. J Hand Surg Br. 1995; 20(3):357-364. comminuted or osteoporotic bone, require ulna fractures. Ring et al5 used a com- 2. Fernandez DL, Ring D, Jupiter JB. Surgical postoperative immobilization, and have as- bined method with a condylar blade plate management of delayed union and nonunion sociated morbidity related to pin-site irrita- and tension band wiring for fixation of the of distal radius fractures. J Hand Surg Am. tion, infection, and migration or loosening. concomitant distal ulna and ulnar styloid 2001; 26(2):201-209. When reduction is attempted using a fractures. The current authors were able to 3. McKee MD, Waddell JP, Yoo D, Richards RR. Nonunion of distal radial fractures as- mini-condylar locked plate or blade con- achieve secure fixation using only a distal sociated with distal ulnar shaft fractures: a dylar plate, the thin cortical bone of the ulna hook plate. report of four cases. J Orthop Trauma. 1997; articular ulnar head often fragments under The number of patients in the current 11(1):49-53. load, leading to further comminution and study (N 25) is larger than that in any 4. Dennison DG. Open reduction and internal 5 locked fixation of unstable distal ulna frac- possible failure. In this respect, the indirect other report; in this respect, the outcomes tures with concomitant distal radius fracture. reduction method using a small angularly have significant meaning. Alignment of J Hand Surg Am. 2007; 32(6):801-805. stable implant, such as the distal ulna hook the ulnar shaft was anatomic or angulated 5. Ring D, McCarty LP, Campbell D, Jupiter JB. Condylar blade plate fixation of unstable plate, can be used to perform stable fixation to less than a combined angulation (on bi- fractures of the distal ulna associated with of relatively small fragments. The distal planar radiographs) of 58 in most patients. fracture of the distal radius. J Hand Surg Am. ulna hook plate is best placed on the medial Two patients had more than 5° of angula- 2004; 29(1):103-109. border of the ulna, directly in line with the tion, but this was accepted at the time of 6. De Smet L. The DASH questionnaire and score in the evaluation of hand and wrist ulnar styloid, and acts as a buttress for the fixation because good rotation and distal disorders. Acta Orthopaedica Belgica. 2008; fracture fragment of the ulnar styloid. radioulnar joint stability existed, and sin- 74(5):575-581. Information is contradictory regarding gle plane deformity was less than 10°. 7. May MM, Lawton JN, Blazar PE. Ulnar sty- the significance of ulnar styloid fractures. This study had some limitations. First, loid fractures associated with distal radius fractures: incidence and implications for dis- Some reports claim that distal radius frac- the study lacked any comparative groups; tal radioulnar joint instability. J Hand Surg tures with an associated ulnar styloid frac- a study comparing various fixation tech- Am. 2002; 27(6):965-971. ture have an increased incidence of distal niques would have been beneficial. 8. Reichl M, Piatek S, Adolf D, Winckler S, Westphal T. Unrepaired fracture of the sty- radioulnar joint instability than do distal Second, severely comminuted cases were loid process of the ulna: not a bad treatment radius fractures without a concomitant ul- excluded. In these cases, rigid plate fixa- result at distal radius fracture. Unfallchirurg. nar styloid fracture.7 Current reports have tion is difficult and may be unachievable in 2011; 114(12):1099-1104. concluded that no difference exists in over- comminuted distal ulna fractures. Third, 9. Kim JK, Koh YD, Do NH. Should an ulnar styloid fracture be fixed following volar plate all functional results when comparing dis- mean follow-up was approximately 15.2 fixation of a distal radial fracture? J Bone tal ulna fractures with or without an ulnar months, and some degree of radiographic Joint Surg Am. 2010; 92(1):1-6. styloid fracture, regardless of displacement change in distal ulna angulation existed at 10. Souer JS, Ring D, Matschke S, et al. Effect amount.9,33 Concerns about instability of last follow-up. Therefore, developmental of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixa- the distal radioulnar joint in patients with angulation changes may become more tion of a distal radial fracture. J Bone Joint an ulnar styloid fracture originate from apparent with a longer follow-up period Surg Am. 2009; 91(4):830-838. the anatomic feature that the radioulnar because some degree of collapse of the 11. Seitz WH Jr, Raikin SM. Resection of com- ligaments, a primary stabilizer of the distal metaphysis existed. minuted ulna head fragments with soft tissue reconstruction when associated with distal radioulnar joint, attach to the base of the radius fractures. Tech Hand Up Extrem Surg. ulnar styloid.34 Conclusion 2007; 11(4):224-230. Moreover, the potential factor of The distal ulna hook plate is an ana- 12. Foster BJ, Bindra RR. Intrafocal pin plate fixation of distal ulna fractures associated chronic distal radioulnar joint instability tomic plate contoured to fit to the distal with distal radius fractures. J Hand Surg Am. can depend on the site of the ulnar styloid ulna metaphysis. The good outcomes 2012; 37(2):356-359. fracture. Nakamura et al35 reported that, if achieved in this study suggest that use of 13. Ruchelsman DE, Raskin KB, Rettig ME. Out- the ulnar styloid fracture is basal oblique, the distal ulna hook plate could be an al- come following acute primary distal ulna re- section for comminuted distal ulna fractures it can produce up to 70% loss in distal ternative treatment method for intra-

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at the time of operative fixation of unstable Arch Orthop Trauma Surg. 1998; 118(1- 28. Haugstvedt JR, Berger RA, Berglund LJ, fractures of the distal radius. Hand (N Y). 2):53-56. Neale PG, Sabick MB. An analysis of the 2009; 4(4):391-396. constraint properties of the distal radioulnar 21. Muller ME, Nazarian S, Koch P, Schatz- ligament attachments to the ulna. J Hand 14. Carlsen BT, Dennison DG, Moran SL. Acute ker J. The Comprehensive Classification of Surg Am. 2002; 27(1):61-67. dislocations of the distal radioulnar joint Fractures of Long Bones. Berlin, Germany: and distal ulna fractures. Hand Clin. 2010; Springer-Verlag; 1990. 29. Ring D. Nonunion of the distal radius. Hand 26(4):503-516. Clin. 2005; 21(3):443-447. 22. Gustilo RB, Anderson JT. Prevention of in- 15. Solan MC, Rees R, Molloy S, Proctor MT. fection in the treatment of one thousand and 30. Mansat P, Ayel JE, Bonnevialle N, et al. Internal fixation after intra-articular fracture twenty-five open fractures of long bones: ret- Long-term outcome of distal ulna resection– of the distal ulna. J Bone Joint Surg Br. 2003; rospective and prospective analyses. J Bone stabilisation procedures in post-traumatic ra- 85(2):279-280. Joint Surg Am. 1976; 58(4):453-458. dio-ulnar joint disorders. Orthop Traumatol Surg Res. 2010; 96(3):216-221. 16. Orbay JL, Fernandez DL. Volar fixation for 23. Geissler WB, Fernandez DL, Lamey DM. dorsally displaced fractures of the distal ra- Distal radioulnar joint injuries associated 31. Berger RA, Cooney WP III. Use of an ulnar dius: a preliminary report. J Hand Surg Am. with fractures of the distal radius. Clin Or- head endoprosthesis for treatment of an un- 2002; 27(2):205-215. thop Relat Res. 1996; (327):135-146. stable distal ulnar resection: review of me- chanics, indications, and surgical technique. 17. Orbay JL, Fernandez DL. Volar fixed-angle 24. Amadio PC, Berquist TH, Smith DK, et al. Hand Clin. 2005; 21(4):603-620. plate fixation for unstable distal radius frac- Scaphoid malunion. J Hand Surg Am. 1989; tures in the elderly patient. J Hand Surg Am. 14(4):679-687. 32. van Schoonhoven J. The ulnar head prosthe- 2004; 29(1):96-102. sis: indications and limitations. International 25. Hudak PL, Amadio PC, Bombardier C. De- Congress Series. 2006; 1295:69-72. 18. Tarr RR, Garfinkel AI, Sarmiento A. The ef- velopment of an upper extremity outcome fects of angular and rotational deformities of measure: the DASH (disabilities of the arm, 33. Kim JK, Yun YH, Kim DJ, Yun GU. Com- both bones of the forearm. An in vitro study. shoulder and hand) [corrected]. The Upper parison of united and nonunited fractures of J Bone Joint Surg Am. 1984; 66(1):65-70. Extremity Collaborative Group (UECG). Am the ulnar styloid following volar-plate fixa- Injury. 19. Yasutomi T, Nakatsuchi Y, Koike H, Uchiya- J Ind Med. 1996; 29(6):602-608. tion of distal radius fractures. 2011; 42(4):371-375. ma S. Mechanism of limitation of pronation/ 26. Bechtol CO. Grip test; the use of a dyna- supination of the forearm in geometric mod- mometer with adjustable handle spacings. J 34. Lindau T. Treatment of injuries to the ulnar els of deformities of the forearm bones. Clin Bone Joint Surg Am. 1954; 36(4):820-824. side of the wrist occurring with distal radial Biomech (Bristol, Avon). 2002; 17(6):456- fractures. Hand Clin. 2005; 21(3):417-425. 27. Lindau T, Arner M, Hagberg L. Intraarticu- 463. lar lesions in distal fractures of the radius 35. Nakamura T, Moy OJ, Peimer CA. Relation- 20. Muellner T, Fuchs M, Kwasny O. Rotational in young adults. A descriptive arthroscopic ship between the ulnar styloid fracture and instability and integrity of the interosseous study in 50 patients. J Hand Surg Br. 1997; DRUJ instability. J Hand Surg Br. 2003; membrane in cadaveric ulnar shaft fractures. 22(5):638-643. 28(suppl 1):48.

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