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Periulnar Injuries Associated with Distal Radius Fractures
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics and Sports Medicine. Linköping University, Faculty of Health Sciences.
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 [en]
Triangular fibrocartilage complex, Distal radius fractures, Wrist injuries, Distal radioulnar joint, Ulnocarpal stability
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-67998ISBN: 978-91-7393-201-1OAI: oai:DiVA.org:liu-67998DiVA: diva2:414864
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
List of papers
1. Tricalcium phosphate bone substitute in corrective osteotomy of the distal radius
Open this publication in new window or tab >>Tricalcium phosphate bone substitute in corrective osteotomy of the distal radius
2009 (English)In: INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED, ISSN 0020-1383, Vol. 40, no 3, 262-267 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To evaluate the outcome of using tricalcium phosphate (TCP) as void filler and structural support in corrective opening-wedge osteotomy of the distal radius.

Methods: A consecutive series of 17 patients with malunited dorsally angulated distal radius fracture postoperatively with DASH at 6 months with radiography at 8-12 weeks and 0.5-3.5 years.

Results: Mean DASH score improved from 52 (S.D. 22) preoperatively to 30 (S.D. 22) postoperatively. There was one non-union. There was also a mean loss of radial length of 1.1 mm (S.D. 1.0 mm) between the first postoperative radiograph and final follow-up. Radiolucent zones were observed around the TCP grafts after 6-8 weeks in 10/14 cases, but could not be statistically correlated with the slight loss of reduction.

Conclusions: TCP seems to be an alternative to iliac crest bone grafting in corrective osteotomies of the distal radius. The shortening observed over time may be attributable to inflammation induced by the TCP.

Keyword
Bone substitute, Calcium phosphate, Malunion, Osteotomy, Radius fracture
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18033 (URN)10.1016/j.injury.2008.08.013 (DOI)
Available from: 2009-05-04 Created: 2009-05-04 Last updated: 2011-05-10
2. Radioulnar ratio in detection of distal radioulnar joint instability associated with acute distal radius fractures
Open this publication in new window or tab >>Radioulnar ratio in detection of distal radioulnar joint instability associated with acute distal radius fractures
2010 (English)In: JOURNAL OF HAND SURGERY (EUROPEAN VOLUME), ISSN 1753-1934, Vol. 35E, no 9, 730-734 p.Article in journal (Refereed) Published
Abstract [en]

Lesions of the triangular fibrocartilage complex (TFCC) are commonly associated with distal radius fractures and may adversely affect the functional outcome. This prospective study evaluated computed tomography, using the radioulnar ratio (RUR), to detect laxity of the distal radioulnar joint in 48 consecutive patients with acute distal radius fractures and compared the results with a radioulnar stress test. We found the clinical stress test to be reliable in chronic cases, but the RUR method of questionable value in both acute and chronic cases.

Place, publisher, year, edition, pages
Elsevier Science B. V., Amsterdam, 2010
Keyword
distal radius fracture, triangular fibrocartilage complex, radioulnar stress test, DRUJ instability, radioulnar ratio
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-63150 (URN)10.1177/1753193410376289 (DOI)000284568500006 ()
Available from: 2010-12-13 Created: 2010-12-13 Last updated: 2011-05-10
3. Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model
Open this publication in new window or tab >>Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model
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
Keyword
Distal radius fracture, Triangular fibrocartilage complex, Pathomechanisms, Wrist injury
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67926 (URN)10.3109/17453674.2011.579517 (DOI)000291060000017 ()
Available from: 2011-05-09 Created: 2011-05-02 Last updated: 2011-06-14Bibliographically approved
4. Radioulnar laxity and clinical outcome after a distal radius fracture do not correlate after a distal radius fracture
Open this publication in new window or tab >>Radioulnar laxity and clinical outcome after a distal radius fracture do not correlate after a distal radius fracture
2011 (English)In: Journal of Hand Surgery - British and European Volume, ISSN 0266-7681, E-ISSN 1532-2211, Vol. 36, no 6, 503-508 p.Article in journal (Refereed) Published
Abstract [en]

Injury to the triangular fibrocartilage complex associated with distal radius fracture may cause symptoms of ulnar instability. Assessed by a radioulnar stress test, increased laxity of the distal radio-ulnar joint has in two previous studies been depicted to be associated with poorer outcome. This prospective study of 40 adults investigates the correlation of this test with functional outcome as measured by DASH. No clinically significant difference was found in relation to this test at two and five years after injury. Therefore using this test alone to decide whether or not to perform an acute repair of the TFCC cannot be recommended.

Place, publisher, year, edition, pages
SAGE Journals online, 2011
Keyword
Adult, Prospective trial, Distal radius fractures, Triangular fibrocartilage complex, Radioulnar stress test, DRU joint instability
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-67919 (URN)10.1177/1753193411403690 (DOI)
Note
On the day of the defence date the status of this article was "Epub ahead of print".Available from: 2011-05-04 Created: 2011-05-02 Last updated: 2011-08-22Bibliographically approved
5. Patterns of triangular fibrocartilage complex (TFCC) injury associated with severely dorsally displaced extra-articular distal radius fractures
Open this publication in new window or tab >>Patterns of triangular fibrocartilage complex (TFCC) injury associated with severely dorsally displaced extra-articular distal radius fractures
2012 (English)In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 43, no 6, 926-932 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: The aim of the study was to examine triangular fibrocartilage (TFCC) injury patterns associated with unstable, extra-articular dorsally displaced distal radius fractures.

Methods: Twenty adult patients with an Arbeitsgemeinschaft für Osteosynthesefragen (AO), type A2 or A3, distal radius fracture with an initial dorsal angulation greater than 20° were included. Nine had a tip fracture (distal to the base) of the ulnar styloid and 11 had no such fracture. They were all openly explored from an ulnopalmar approach and TFCC injuries were documented. Eleven patients also underwent arthroscopy and intra-articular pathology was recorded.

Results: All patients had TFCC lesions of varying severity, having an extensor carpi ulnaris subsheath avulsion in common. Eighteen out of 20 also displayed deep foveal radioulnar ligament lesions, with decreasingly dorsal fibres remaining. The extent of this foveal injury could not be appreciated by radiocarpal arthroscopy.

Conclusions: Severe displacement of an extra-articular radius fracture suggests an ulnar-sided ligament injury to the TFCC. The observed lesions concur with findings in a previous cadaver study. The lesions follow a distinct pattern affecting both radioulnar as well as ulnocarpal stabilisers.

Keyword
Distal radius fractures; Triangular fibrocartilage complex; Wrist injury; Pathomechanisms; Injury patterns
National Category
Surgery
Identifiers
urn:nbn:se:liu:diva-67921 (URN)10.1016/j.injury.2012.02.013 (DOI)000304045100045 ()
Note

On the day of the defence date the title of this article was TFCC-injuries associated with severely displaced Colles’ fractures: a clinical study.

funding agencies|local County Council||

Available from: 2011-05-04 Created: 2011-05-02 Last updated: 2012-06-08Bibliographically approved

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