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Effect of Ulnar Styloid Fracture on Outcomes After Conservative Treatment of Distal Radius Fracture

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Effect of Ulnar Styloid Fracture on Outcomes After Conservative Treatment of Distal Radius Fracture Eklem Hastalıkları ve Eklem Hastalık Cerrahisi Cerrahisi 2016;27(2):87-93 Joint Diseases and Related Surgery Original Article / Özgün Makale doi: 10.5606/ehc.2016.19 Effect of ulnar styloid fracture on outcomes after conservative treatment of distal radius fracture Radius distal uç kırığının konservatif tedavisi sonrasında ulnar stiloid kırığının sonuçlar üzerine etkisi Sualp Turan, MD.,1 Deniz Çankaya, MD.,1 Serdar Yılmaz, MD.,1 Dilek Karakuş, MD.,2 Abdurrahim Dündar, MD.,1 Güzelali Özdemir, MD.1 1Department of Orthopedics and Traumatology, Ankara Numune Training and Research Hospital, Ankara, Turkey 2Department of Physical Therapy and Rehabilitation, Ankara Physical Therapy and Rehabilitation Training and Research Hospital, Ankara, Turkey ABSTRACT ÖZ Objectives: This study aims to investigate the effect of Amaç: Bu çalışmada ayrılmış radius distal uç kırığı (RDUK) accompanying ulnar styloid fracture (USF) on clinical outcomes sonrası konservatif tedavi edilen aktif hastalarda eşlik eden and hand-wrist muscle strength in conservatively treated active ulnar stiloid kırığının (USF) klinik sonuçlar ve el-bilek kas patients after displaced distal radius fracture (DRF). gücü üzerindeki etkisi araştırıldı. Patients and methods: The retrospective study, which was Hastalar ve yöntemler: Ekim 2012 - Eylül 2014 tarihleri conducted November 2012 and September 2016, included 56 arasında yapılan bu retrospektif çalışmaya kapalı redüksiyon patients (34 males, 22 females; mean age 28.8 years; range 20 ve alçı ile tedavi edilen ayrılmış RDUK’li 56 hasta (34 erkek, to 40 years) with displaced DRF treated with closed reduction 22 kadın; ort. yaş 28.8 yıl; dağılım 20-40 yıl) dahil edildi. and casting. Patients were divided into three groups according Hastalar ulnar stiloidin durumuna göre; grup A (sağlam ulnar to ulnar styloid status as group A (intact ulnar styloid), group stiloid), grup B (kaynamayan USF) ve grup C (iyileşmiş B (USF non-union), and group C (healed USF). Grip strength, USF) olmak üzere üç gruba ayrıldı. Kavrama gücü, hızlı-kol, quick-disabilities of the arm, shoulder and hand (DASH) omuz ve el için engellilik (DASH) skoru ve eklem hareket score, and joint range of motions were evaluated; the results açıklıkları değerlendirildi; sonuçlar el-bilek bölgesi izokinetik were combined with measurements of isokinetic muscle kas kuvvetlerinin ölçümleriyle birleştirildi. Distal radyoulnar strengths of hand-wrist region. Magnetic resonance imaging eklem yaralanmasının ve triangular fibrokıkırdak kompleks was performed to evaluate the accompaniment of distal (TFCC) lezyonunun eşlik edip etmediğini değerlendirmek radioulnar joint injury and triangular fibrocartilage complex amacıyla RDUK’ye manyetik rezonans görüntüleme (TFCC) lesion. uygulandı. Results: There were no significant differences between Bulgular: Gruplar arasında eklem hareket açıklığı, the groups regarding joint range of motion, grip strength, kavrama gücü ve hızlı-DASH skorları yönünden anlamlı and quick-DASH scores. However, the peak torque and total bir farklılık yoktu. Ancak, supinasyonun pik tork ve work of supination was better in group A compared to group toplam iş değerleri grup A’da grup B’ye kıyasla daha B (p=0.008 and p=0.006, respectively). According to the iyiydi (sırasıyla, p=0.008 ve p=0.006). Manyetik rezonans magnetic resonance imaging findings, of the 10 patients with görüntüleme bulgularına göre, TFCC lezyonu tespit detected TFCC lesion, four were in group C, five in group B, edilen on hastanın dördü grup C’de, beşi grup B’de ve biri and one was in group A. grup A’da idi. Conclusion: Results of this study suggest that USF should Sonuç: Bu çalışmanın bulguları RDUK’nin ilk tedavisinde not be the focus of attention during initial treatment of DRF USF’ye odaklanılmaması gerektiğini ve eşlik eden TFCC and surgical intervention might be considered in case of an lezyonu olması halinde cerrahi girişimin düşünülebileceğini accompanying TFCC lesion. önermektedir. Keywords: Cast; closed reduction; distal radius fracture; isokinetic Anahtar sözcükler: Alçı; kapalı redüksiyon; radius distal uç kırığı; evaluation; ulnar styloid. izokinetik değerlendirme; ulnar stiloid. • Received: February 17, 2016 Accepted: May 05, 2016 • Correspondence: Sualp Turan, MD. Ankara Numune Eğitim ve Araştırma Hastanesi Ortopedi ve Travmatoloji Anabilim Dalı, 06100 Altındag, Ankara, Turkey. Tel: +90 505 - 765 72 56 Fax: +90 312 - 311 43 40 e-mail: [email protected] 88 Eklem Hastalık Cerrahisi Distal radial fractures (DRF) are among the most patients with DRF were included in the study with common orthopedic injuries, accounting for one-sixth their MRI examinations and prospectively collected of all fractures and often result from a fall onto an data of wrist motion, grip strength, quick-DASH outstretched hand.[1,2] Ulnar styloid fractures (USF) are (Disabilities of the Arm, Shoulder and Hand) scores injuries commonly associated with patients who have and isokinetic performances. The MRI results were DRF.[2-4] Studies on the clinical relevance of USF have examined specifically with the intention to evaluate produced conflicting results, and comparative studies DRUJ injury and its impact over functional scores were generally about surgically treated patients.[2,3] and isokinetic testing results. All of the patients It is still not clear whether USF accompanied with evaluated in this study had displaced extra- DRF affect the clinical outcome and whether surgical articular DRF, namely, type A fractures according to treatment is necessary for USF.[5] The data from the Association for Osteosynthesis/Association for the literature is contradictory as to whether USF results Study of Internal Fixation (AO/ASIF) classification. in instability, disability and pain in the wrist[6,7] or has Intra-articular fractures were excluded from the no adverse effect.[2,3,8,9] study so as not to conflict with the functional results. Exclusion criteria were previous injuries or The triangular fibrocartilage complex (TFCC) surgeries on either side; bilateral fractures; intra- consists of ligament, structures that contribute to articular fractures; non-displaced fractures; Smith’s distal radioulnar joint (DRUJ) stability as well as fracture; fractures treated with surgical treatment; ulnocarpal stability.[1,4,10] and the secondary attachment malunited fracture; a pre-existing severe illness; of these structures is the ulnar styloid. The function multiple trauma; systemic disease; pathological of the wrist can be objectively evaluated with muscle fractures; open fractures; patients presenting more strength measurements in a dynamic fashion. The than a week after injury; uncooperative patients TFCC lesions are commonly seen in wrist injuries and during isokinetic testing; and bone and joint magnetic resonance imaging (MRI) has been shown diseases, which could interfere with rehabilitation. to be a reliable diagnostic tool for TFCC and other ligamentous injuries.[11] We evaluated patients with regular follow-ups of between 12-24 months because a similar follow-up We aimed to investigate the effect of USF on period is required for evaluation during isokinetic the wrist in active patients after displaced DRF in testing as an improvement might be expected in conservatively treated patients. We asked whether that amount of time. We selected patients between (i) there is any functional difference and muscle 20-40 years of age so who could reliably cooperate strength alteration between intact ulnar styloid and and complete the isokinetic testing. The patients the healed and non-union of USF and (ii) whether the were subdivided into three groups according to ulnar accompanying TFCC injuries diagnosed in MRI have styloid status in this retrospective study: group A: any impact on functional scores and isokinetic testing intact ulnar styloid, group B: ulnar styloid non-union results? and group C: healed ulnar styloid fracture. Stability of PATIENTS AND METHODS the DRUJ was assessed by identifying any dislocation with either anteroposterior stress of the distal ulna This retrospective study using prospectively (the piano key sign) or forearm rotation. All of the collected data revealed the effect of USF on wrist patients were also evaluated with MRI for TFCC function in patients treated with closed reduction injury. None of the patients had instability as it was and casting after DRF. The study was approved by previously defined. the ethics committee of Ankara Numune Training and Research Hospital and informed consent was Patients were treated with closed reduction in obtained from all study participants. The study the emergency room under local anesthesia and was conducted in accordance with the principles under sedation. After the reduction, a circular well- of the Declaration of Helsinki. Some data on this molded short arm cast was applied to the wrist up to cohort of patients has previously been published 30º flexion and 15º-20º ulnar deviations with a plaster as a short report letter[12] and data of new patients of paris cast. Follow-up radiographies were obtained who completed a one-year follow-up has been weekly thereafter. The patients were encouraged included in the present study. In the previous to begin elbow and metacarpophalangeal joint short-letter, there were 68 patients and we could motion and the cast was removed six weeks post- only find MRI results for 38 of them. These MRI fracture according to fracture healing. The outcome results were reevaluated regarding the presence assessments were performed between
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