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Erschienen in: Operative Orthopädie und Traumatologie 6/2023

Open Access 09.11.2023 | Surgical Techniques

Surgical fixation of distal ulna neck and head fractures

verfasst von: LX van Rossenberg, BJM van de Wall, N Diwersi, L Scheuble, FJP Beeres, M van Heijl, S. Ferree

Erschienen in: Operative Orthopädie und Traumatologie | Ausgabe 6/2023

Abstract

Objectives

Distal ulna plate fixation for ulnar neck and head fractures (excluding ulnar styloid fractures) aims to anatomically reduce the distal ulna fracture (DUF) by open reduction and internal fixation, while obtaining a stable construct allowing functional rehabilitation without need for cast immobilization.

Indications

Severe displacement, angulation or translation, as well as unstable or intra-articular fractures. Furthermore, multiple trauma or young patients in need of quick functional rehabilitation.

Contraindications

Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation. Stable, nondisplaced fractures. Need for bridging plate or external fixator of distal radiocarpal joint.

Surgical technique

An ulnar approach, with a straight incision between the extensor and flexor carpi ulnaris. Preservation of the dorsal branch of the ulnar nerve. Reduction and plate fixation with avoidance of plate impingement in the articular zone.

Postoperative management

Postoperatively, an elastic bandage is applied for the first 24–48 h. In isolated DUF with stable fixation, a postoperative splint is often unnecessary and should be avoided. For the first four weeks, only light weightbearing of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be increased as tolerated.

Results

The best available evidence likely shows that for younger patients with a DUF, with or without concomitant distal radius fractures, open reduction and internal fixation can be safely achieved with good functional outcome and acceptable union and complication rates as long as proper technique is ensured.
Hinweise

Editor

Thomas Pillukat, Bad Neustadt an der Saale

Illustrator

Harald Konopatzki, Heidelberg
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Introductory remarks

Distal ulna fractures (DUF) are a frequent concomitant injury in distal radius fractures (DRF) and to a lesser extent observed as isolated injury. The mechanism of injury is most often a fall on an outstretched hand. The distal ulna comprises the ulnar styloid, ulnar head, and distal ulnar metaphysis (neck). However, a distinction is often made between ulnar styloid process (USP) fractures and ulnar head and neck fractures. Logan et al. describes ulnar head fractures as either solitary or combined with an extra-articular component of the distal ulna (e.g., ulnar styloid). Ulnar neck fractures are considered so if they are within 5 cm of the distal dome of the ulnar head [16]. Ulnar styloid process fractures seldomly occur as a solitary fracture, but are most regularly observed as concomitant injury in distal radius fractures (± 60% of cases) [19]. Most USP fractures can be managed nonsurgically without compromising functional outcome [20]. However, in case of distal radioulnar joint (DRUJ) instability, triangular fibrocartilage complex pathology, or USP non-union, surgical fixation may be required [3]. Szalay et al. demonstrated that fixation of the USP with an angle stable hook plate is a viable and successful option when surgery is indicated [12]. Therefore, this article will focus on surgical treatment of distal ulna fractures excluding fractures of the ulnar styloid process.
For the treatment of distal ulnar fractures, excluding USP, evidence is sparse and limited to case series, retrospective studies, and only a few prospectively designed studies [6, 7, 10, 18, 19]. Distal ulna fractures are observed as a concomitant injury in distal radius fractures in approximately 5% of cases [3]. Isolated ulnar head and neck fractures comprise less than 20% of all (non USP) DUF fractures [19]. The “Arbeitsgemeinschaft für Osteosynthesefragen” (AO) has established a comprehensive, simple, and frequently used classification, although it does not predict outcome or dictate treatment decisions (Fig. 1; [1]).
For DUF, necessity of fixation can be debated and is not commonly performed. For example, in elderly patients with DUF and concomitant DRF, conservative management of the DUF with cast immobilization has proven successful after rigid fixation of the DRF [5, 15, 21]. However, fixation of DUF restores anatomical alignment and congruency of the DRUJ and allows for early mobilization. This is important as over time articular incongruity of the joints in the wrist (DRUJ, radiocarpal and midcarpal) leads to osteoarthritis in over 90% of patients [13]. Furthermore, fixation restores tension on the distal oblique bundle which in turn also adds to DRUJ alignment [2]. This also could be advantageous to prevent DRUJ instability and subsequently osteoarthritis [2, 27]. Fixation of DUF also prevents secondary problems related to ulnar and DRUJ instability after mal- or non-union of the distal ulna.
In concomitant DRF, fixation of the radius may restore DRUJ congruency and stability by tension on the distal oblique bundle. However, this is dependent on fracture morphology related to the distal oblique bundle anatomy [15]. Therefore, several previous reports have suggested to assess DRUJ stability after DRF fixation and perform DUF fixation in cases of instability [5, 10, 15]. Furthermore, DUF fixation could be advantageous to aid in stability of the radius open reduction and internal fixation (ORIF) and allows early active motion. Other indications for DUF fixation mentioned in literature are fracture angulation of ≥ 10°, ≥ 3 mm of ulnar shortening, or translation ≥ 1/3 of the diaphysis, instability of the distal ulna head/neck or fracture fragment motion with passive forearm motion and lastly articular displacement [6, 23, 26, 28]. However, it should be noted that these suggested indications are based on expert opinion rather than scientific evidence.
The purpose of this paper is the description of the surgical technique for this delicate procedure.

Surgical principle and objective

Plate osteosynthesis of the distal ulna to anatomically reduce the distal ulna fracture by open reduction and internal fixation to obtain a stable construct allowing functional rehabilitation without need for cast immobilization.

Advantages

  • Increased stability compared to conservative treatment in concomitant distal radius fracture
  • More precise alignment of the displaced fracture
  • No need for cast treatment, thus, allowing early active range of motion

Disadvantages

  • Increased risk of fracture related infection
  • Risk of damage to dorsal cutaneous branch of the ulnar nerve (DBUN)
  • Risk impingement during forearm rotation
  • Risk of extensor carpi ulnaris (ECU) irritation due to osteosynthesis
  • Risk of chronic luxation of ECU tendon by extensor retinaculum damage
  • Risk of secondary removal of osteosyntheses and adjoining complication risks
  • Risk of damage to the ulnar vessels and ulnar nerve while drilling at palmar side

Indications

The decision to perform ORIF in DUF should be based on more than fracture pattern alone and should account for specific demands of the patient. The following indications provide a guideline:
  • Displaced and/or unstable fractures (instability of ulnar head/neck or motion of fracture fragments during passive motion) with or without concomitant distal radius fracture which requires ORIF
  • Incongruency in DRUJ (both with or without concomitant distal radius fracture)
  • Open fractures (excluding acceptable reduced stable fractures after wound debridement)
  • Patient with bilateral extremity fracture and need for early active rehabilitation (multiple trauma)
  • High demands of the patients with regard to the level of activity

Contraindications

  • Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation
  • Stable, nondisplaced fractures
  • Severe osteoporosis of the ulnar head in which screws cannot hold
  • Need for bridging plate or external fixator of distal radiocarpal joint

Patient information

  • General patient information
  • Need for future plate removal due to irritation
  • Risk of damage to DBUN

Preoperative workup

  • Preoperative radiologic evaluation (including standard X‑rays of the injured and unaffected side as well as computed tomography scan) to determine fracture pattern, stability and DRUJ involvement, ulnar variance and DRUJ congruency
  • Preoperative admission of 2 g cefazoline intravenously within 60 min prior to incision

Instruments and implants

  • Standard surgical instruments for soft tissue procedures and osteosynthesis
  • Small drill with 1.8 mm drill head and 2.4 mm cortical and variable angle locking screws
  • K‑wires of different sizes for temporary fixation if necessary
  • Variable angle locking plate size 1.5 to 2.0 mm depending on patient size

Anesthesia and positioning

  • General anesthesia or axillary plexus block
  • Supine position of the patient, arm table and upper arm tourniquet
  • Arm abducted, wrist pronated and supported by elevating structure (± 20°; Fig. 2a)

Surgical technique

(Figs. 3, 4, 5, 6, 7, 8, 9 and 10)
Before wound closure, DRUJ stability is assessed using the manual shuck examination maneuver [11]. Comparison with the uninjured side can be helpful to adequately assess instability. Any residual DRUJ instability can now be addressed depending on the injury pattern. Many specific techniques to achieve this are available; however, USP fracture fixation when present or fixation of the distal ulna to the distal radius in stable rotational position with a K-wire are most frequently used. In this case, DRUJ was stable. The wound is sutured intracutaneously.

Special surgical considerations

  • X‑rays preoperative, during surgery and postoperative
  • Excessive soft tissue retraction in distal part of incision should be avoided to prevent damage to DBUN
  • It should be confirmed that plate placement does not cause impingement or ECU tendon irritation
  • The ulnar variance should be assessed comminuted fractures by comparing to uninjured side
  • DRUJ stability and congruency should be controlled by manual shuck examination maneuver pronated, neutral and supinated, neutral and supination

Postoperative management

Postoperatively, an elastic bandage is applied for the first 24–48 h. In isolated DUF with stable fixation, a postoperative splint is often not necessary and should be avoided. The goal is to ascertain active range of motion early after surgery, thus, fixation should strive to provide enough stability to allow this.
Alternatively, the wrist is placed in a short lower arm splint for pain control and soft tissue healing for 2–4 weeks. This could be indicated in cases with concomitant distal radius fracture ORIF, osteoporotic bone and/or uncertainty of fracture stabilization.
A special indication for postoperative casting could be persistent DRUJ instability after DUF fixation. In this situation the primary choice of treatment is upper arm casting in a stable position for 4–6 weeks, to maximize limitation of pro- and supination.
For the first 4 weeks, only light weightbearing (weight < 2 kg) of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be gradually increased as tolerated.
Postoperative outpatient clinic evaluation is performed with standard anteroposterior (AP) and lateral radiographs. As a general guideline this could be done at: 2 weeks to assess early surgical failure and any revision at this stage is possible; 6 weeks to assess early signs of consolidation and osteosynthesis integrity (i.e., early signs of bone healing issues like delayed union/non-union could be visible at this point as osteolysis around screws or hardware loosening); 3 months to assess full consolidation of the fracture. At this stage, range of motion can also be assessed and especially forearm rotation should be determined.
Plate removal is indicated in patients with complaints at 6 months or later.

Errors, hazards, complications

  • DBUN damage resulting in neuroma or hypesthesia in the ulnar side of the hand
  • Protrusion of screws into the DRUJ
  • Nonanatomic reduction leading to DRUJ incongruency and limitations to forearm rotation
  • Over or under reducing ulnar height leading to ulnar carpal abutment or DRUJ-related issues
  • Relative positive ulnar variance (with ulnar carpal abutment with result) can occur with anatomical reduction and fixation of DUF in concomitant DRF with loss of radial height
  • Plate position outside safe zone, causing impingement or ECU irritation
  • ECU subsheet damage resulting in instability or luxation of ECU tendon during wrist rotation
  • Persistent DRUJ instability after DUF fixation
  • Secondary dislocation due to hardware failure

Results

Case report

An 81-year-old woman was admitted to the emergency room (ER) after a fall on her outstretched right hand. During physical examination swelling, functional limitation, dislocation and pain were observed. X‑ray imaging showed a volar angulated distal radius and subcapital ulna fracture (Fig. 11a). After unsuccessful reposition and secondary dislocation the patient was advised to undergo surgery for both distal radius and distal ulna fractures via open reduction internal fixation. Intraoperative fluoroscopy images showed anatomic reduction of the distal radius and ulna fractures (Fig. 11b). Follow-up X‑rays showed adequate fracture healing with maintained radial height, angulation and DRUJ congruency (Fig. 11c).

Outcome literature

Several studies have analyzed outcome of operative techniques on the distal ulna. Ring et al. retrospectively analyzed the outcome of unstable DUF with concomitant DRF after minicondylar blade plate [23]. Twenty-four patients with 24 months follow-up were assessed for functional outcome and union rate. They found healing with good radiographical alignment, function (Gartland and Werley system 4 points) and 1 secondary surgery due to non-union after a grade 3 open fracture. A removal rate of 29% was found.
Han et al. reviewed results of their locked compression plating in unstable DUF with concomitant DRF. Seventeen patients with a follow-up of 15 months were included in this retrospective review. All patients went on to union and had good to excellent Sarmiento’s modified wrist scores [8].
Dennison retrospectively reviewed 5 patients with unstable DUF in concomitant DRF, who underwent ORIF [6]. All patients went on to union, had good to excellent alignment and motion, and nearly symmetric grip strength.
Ozkan et al. retrospectively identified 277 patients with an ulnar neck fracture associated with a DRF [22]. The purpose of their study was to identify factors associated with unplanned secondary surgery. Fifty-six (20%) patients received operative intervention for the DUF of which 6 (11%) needed secondary surgery versus only 1 (0.5%) in the non-operative group. Factors associated with unplanned surgery were the following: younger age, open and multifragment fractures, and initial surgical treatment of the ulnar neck fracture.
Sato et al. retrospectively reviewed all patients aged over 60 years who received conservative treatment for DUF with concomitant DRF [25]. All fractures united and functional outcome by modified Gartland and Werley scores were excellent in all but one patient. The disability of arm shoulder and hand (DASH) score was 4.2 which is considered normal.
Ruchelsman et al. performed Darrach resection of the distal ulna in fractures deemed unreconstructable [24]. They hypothesized that when anatomic restoration and stable fixation was not possible that resection would yield satisfactory results. Eleven patients with concomitant DUF underwent a Darrach procedure. At a mean of 42 months follow-up, the modified Gartland and Werley scores were 7 excellent and 4 good. No patients had distal ulna instability and none required secondary surgery.
Five studies compared outcome of fixation of DUF as a concomitant injury of a DRF versus non-operative treatment for the ulna [5, 7, 14, 17, 18]. Four studies were retrospective in design and only one had a prospective design [5]. The average age in all studies was above 50 years old, with the highest average age of 82 years old in the study by Lutsky et al. Kurozumi et al. and Cha et al. analyzed functional outcome with the DASH scores and found no difference between surgically and non-operatively treated patients [5, 14]. The patient-rated wrist evaluation (PRWE) was used by Moloney et al. and Glogovac et al, whereby Glogovac et al. did not find a statistically difference between the two treatment modalities [7]. Glogovac et al. also analyzed the outcome of Darrach resection. They found no statistical difference between this procedure and operative and non-operative treatment. However, the Darrach group (n = 5) had a PRWE score of 70, indicating severe functional disability. This was compared with a PRWE of 49 for non-operatively and 28 for operatively treated patients [7].
Moloney et al., who also performed a subanalysis of isolated DUF, found worse PRWE scores for operated DUF patients [18]. Patient rated wrist evaluation scores of 27.5 (standard deviation [SD] 36) were found for operated DUF patients compared with 7.75 (SD 22) for the non-operative group (p = 0.01) The isolated DUF group had a PRWE score of 7 (SD 19) versus 18 (SD 41) for the DUF with concomitant DRF. For both the isolated and concomitant DRF group, the PRWE was worse in the operated group. This study also examined the association of osteoarthritis, found radiographic signs in 22 DRUJ (33%) and this was associated with worse PRWE scores.
Range of motion was examined in four studies. Kurozumi et al. found a 30° decreased arc of dorsipalmar flexion in operated DUF patients compared with non-operative group (129 vs 158, p = 0.01) [14]. The other studies found no difference in range of motion.
With regard to bony union, no statistically differences were found in any of the studies. However, sample size and low prevalence of non-union may have led to a type II error. Therefore, no reliable conclusion can be drawn for these data. When all studies are combined, a non-union rate of 3.3% for operated DUF and 0.5% for non-operative patients is calculated.
Outcomes reported in the literature should be considered with care. In current practice, decision of best approach, positioning of the plate (dorsal, dorsoulnar, ulnar or palmar), and indications for surgery often differ and still pose a challenge in the treatment of distal ulnar fractures.

Declarations

Conflict of interest

L.X. van Rossenberg, B.J.M. van der Wall, N. Diwersi, L. Scheuble, F.J.P. Beeres, M. van Heijl and S. Ferree declare that they have no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.

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Metadaten
Titel
Surgical fixation of distal ulna neck and head fractures
verfasst von
LX van Rossenberg
BJM van de Wall
N Diwersi
L Scheuble
FJP Beeres
M van Heijl
S. Ferree
Publikationsdatum
09.11.2023
Verlag
Springer Medizin
Erschienen in
Operative Orthopädie und Traumatologie / Ausgabe 6/2023
Print ISSN: 0934-6694
Elektronische ISSN: 1439-0981
DOI
https://doi.org/10.1007/s00064-023-00835-5

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