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Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Surgery, Orthopaedics and Cancer Treatment, Department of Orthopaedics in Linköping.
2011 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 82, no 3, 360-364 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Mechanisms of injury to ulnar sided ligaments, stabilizing the distal radioulnar joint and the ulna to the carpus, associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods: Fresh frozen human cadaver arms were used. A dorsal open wedge osteotomy was made in the distal radius. In 8 specimens pressure was applied to the palm with the wrist in dorsiflexion and ulnar sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 more specimens the triangular fibrocartilage complex was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results: Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32o (16-34o). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6/8 specimens.

Interpretation: A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32o. The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.

Place, publisher, year, edition, pages
Informa Healthcare , 2011. Vol. 82, no 3, 360-364 p.
Keyword [en]
Distal radius fracture, Triangular fibrocartilage complex, Pathomechanisms, Wrist injury
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-67926DOI: 10.3109/17453674.2011.579517ISI: 000291060000017OAI: oai:DiVA.org:liu-67926DiVA: diva2:414250
Available from: 2011-05-09 Created: 2011-05-02 Last updated: 2011-06-14Bibliographically approved
In thesis
1. Periulnar Injuries Associated with Distal Radius Fractures
Open this publication in new window or tab >>Periulnar Injuries Associated with Distal Radius Fractures
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Residual dysfunction after a fracture of the distal radius is most often mild but may give rise to significant impairment especially in the younger active population. The symptoms often manifest around the distal ulna when loading the hand or rotating the forearm. In this region are found articular and soft tissue connections running from the distal ulna to the distal radius as well as to the ulnar side of the carpus. The aims of this thesis were to investigate the effects of distal radius fractures on the structures about the distal ulna and to what extent malunion and ulnar soft tissue lesions affect function. Both patients and cadaver specimens were used in the five different studies.

In a retrospective study of 17 malunited distal radius fractures supination impairment improved significantly by correction of the skeletal malunion. This highlights the importance of distal radioulnar joint congruity for forearm rotation in a subset of cases.

The pathomechanisms of injury to the triangular fibrocartilage complex (TFCC) were studied. In a cadaveric distal radius fracture model different restraining properties and injury patterns were investigated. Similar patterns of injury were then observed in 20 patients with a displaced distal radius fracture. It was found that a TFCC injury can be expected with dorsal displacement of the distal radius fragment of 32o or more from the anatomically correct position. The distribution of a TFCC injury apparently differs depending on the size of an associated ulnar styloid fracture. In cases of an intact ulnar styloid or a concomitant tip fracture (Type 1) the first stage of injury seems to be extensor carpi ulnaris subsheath separation from the distal ulna and the dorsal radioulnar ligament. Thereafter follows a disruption of the deep insertions into the fovea of the ulna starting from the palmar and extending dorsally and radially. An extensive injury can be detected with a novel non-invasive test called the ‘bald ulnar head test’, which is performed under anaesthesia.

Diagnosis of an acute TFCC injury is difficult using non-invasive methods. In a prospective study of 48 patients, CT scanning to detect pathologic subluxation was found to be of little use in both acute and chronic cases, and is therefore not endorsed on this indication. A radioulnar stress test, which in previous studies has correlated well to a deep TFCC injury, was found to be highly reliable but not to correspond with significant disability in self-administered questionnaires of functional outcome two years or more after injury. This indicates that the subset of patients possibly benefiting from acute repair must be identified by other means.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 66 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1236
Keyword
Triangular fibrocartilage complex, Distal radius fractures, Wrist injuries, Distal radioulnar joint, Ulnocarpal stability
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67998 (URN)978-91-7393-201-1 (ISBN)
Public defence
2011-06-03, Berzeliussalen, Hälsouniversitete, Campus US, Linköpings universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-05-10 Created: 2011-05-04 Last updated: 2012-05-29Bibliographically approved

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Scheer, JohanAdolfsson, Lars
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Orthopaedics and Sports MedicineFaculty of Health SciencesDepartment of Orthopaedics in Linköping
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