Clinical assessment for distal radioulnar joint instability in patients with distal end radius fracture

Vinay Kakkar; Mukesh Sancheti

doi:10.4103/ijors.ijors_14_20

ORIGINAL ARTICLES

Year : 2021 | Volume : 29 | Issue : 2 | Page : 53-57

Clinical assessment for distal radioulnar joint instability in patients with distal end radius fracture

Vinay Kakkar, Mukesh Sancheti
Department of Orthopaedics, Government Medical College and Hospital, Nagpur, Maharashtra, India

Date of Submission	30-Nov-2020
Date of Acceptance	11-Jul-2021
Date of Web Publication	20-Dec-2021

Correspondence Address:
Vinay Kakkar
Department of Orthopaedics, Government Medical College and Hospital, Nagpur 440003, Maharashtra.
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijors.ijors_14_20

Abstract

Background: Distal radioulnar joint (DRUJ) instability is an important cause of ulnar-sided wrist pain in distal radius fractures. By this study, it was tried to identify clinical factors associated with DRUJ instability in distal radius fractures. Materials and Methods: We prospectively reviewed all 87 patients who underwent surgery for unstable, unilateral distal radius fractures in a tertiary trauma center. Assessment of DRUJ instability was examined preoperatively, during surgery, and immediate postoperatively. Patients with clinical DRUJ instability were followed up at 6 weeks, 3 months, and 6 months, with clinical assessment of the DRUJ instability whether symptomatic or not. Results: Preoperative DRUJ instability was found in 23 patients as checked by the distal ulna ballottement test. Of these 23 patients, postoperative DRUJ instability was found in 9 patients and persisted as symptomatic DRUJ instability with ulnar-sided wrist pain till the last follow-up. Conclusion: Every distal radius fracture should be seen with the suspicion of associated DRUJ instability and the stability of DRUJ be thoroughly checked intraoperatively and postoperatively for better wrist function and better outcome after the union of distal radius fracture.

Keywords: Distal radioulnar joint (DRUJ), distal radius fractures, distal ulna ballottement test, instability, ulnar-sided wrist pain

How to cite this article:
Kakkar V, Sancheti M. Clinical assessment for distal radioulnar joint instability in patients with distal end radius fracture. Int J Orthop Surg 2021;29:53-7

How to cite this URL:
Kakkar V, Sancheti M. Clinical assessment for distal radioulnar joint instability in patients with distal end radius fracture. Int J Orthop Surg [serial online] 2021 [cited 2023 Mar 25];29:53-7. Available from: https://www.ijos.in/text.asp?2021/29/2/53/332929

Introduction

Injuries of the distal radioulnar joint (DRUJ) may occur in isolation, or along with fractures of the distal radius. The necessities of anatomic reduction of these fractures and its relation to functional outcomes have been shown by many authors.^[1] DRUJ instability is an important cause of ulnar-sided wrist pain after bony healing of distal radius fractures.^[1],[2] Approximately 2%–37% of patients with distal radius fractures reportedly have DRUJ instability after bony union, and approximately two-thirds of these patients were symptomatic.^[2],[3] A substantial proportion of DRUJ instability cases seem to be caused by injuries to soft-tissue stabilizers of the DRUJ such as the triangular fibrocartilage complex (TFCC).^[3] Identifying factors related to DRUJ instability would be helpful in diagnosing DRUJ instability; various studies^[4],[5],[6] reported that the ulnar styloid fracture is one of the risk factors for DRUJ instability in distal radius fractures because of its proximity to the deep TFCC. In addition, factors other than ulnar styloid fractures have been investigated only rarely in distal radius fractures for DRUJ instability.

In our everyday practice, DRUJ instability is most frequently encountered as an injury that accompanies fractures of the distal radius. Therefore, the aim of this work was to present information on its anatomy, pathology, its diagnosis, and clinical assessment in light of available literature and our own experience.

Materials and Methods

We prospectively reviewed the data for 87 patients who underwent surgery for unstable, unilateral distal radius fractures in a tertiary trauma center for a period of 18 months. Patients who present to the institution with injury/trauma to wrist were evaluated in detail clinically and X-ray evaluation of wrist with forearm anteroposterior view and lateral views [Figure 1]. Those with distal end radius fractures were classified according to AO/OTA classification^[7] by at least two qualified senior lecturers and patients with a fracture that needs surgical correction were included in the study. Before starting the surgery, written informed consent was obtained from each patient. Our indication for surgery was a distal radius fracture that met more than three of the following criteria before reduction: (1) dorsal angulation greater than 20°, (2) radial shortening greater than 5 mm, (3) metaphyseal comminution greater than 2.3 mm, and (4) an articular gap or step off greater than 2 mm. Patients with a previous history of distal end radius fracture, bilateral distal radius fractures, and pathological fractures, patients having age less than 18 years, and psychiatric patients were excluded from the study.

Figure 1: Radiograph of three patients/cases: Case 1 (A) showing anteroposterior (AP) and lateral views of preoperative X-rays of a case of distal radius fracture (A and B) who underwent volar plate fixation as shown in postoperative X-rays of lateral and AP view (C and D). Case 2 (B) showing AP view of preoperative X-rays of another case of distal radius fracture (E) who underwent K-wire fixation and external fixation with distractor as shown in postoperative X-rays of AP and lateral views (F and G). Case 3 (C) showing AP view of preoperative X-rays of another case of distal radius fracture (H) who underwent multiple K-wire fixation as shown in postoperative X-rays of AP and lateral views (H and I)

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Assessment of DRUJ instability was examined during surgery using a distal ulna ballottement test.^[8] The stability of the DRUJ in the injured wrist was assessed by comparison with the normal wrist because the amount of joint relaxation varies among individuals,^[9] and was categorized as no instability, moderate instability (increased translation of the DRUJ with firm end), or severe instability (increased translation without firm end). The DRUJ instability was checked again after the stable fixation in the operating room.

After surgery, a long-arm splint was applied with the forearm in neutral or 30° supination for 6 weeks for all patients with DRUJ instability. Physiotherapy for finger movements and edema control was started on the day of surgery. All the patients with DRUJ instability were followed up for 6 months for checking whether the instability is symptomatic or nonsymptomatic. At each follow-up visit, patients were asked about ulnar wrist symptoms such as a painful click or a subjective sense of instability. Also, intraoperative findings such as type of anesthesia and type of fixation were noted. Radiologically patients were evaluated for alignment and displacement. Patients with clinical DRUJ instability were followed up at 6 weeks, 3 months, and 6 months, with clinical assessment of the DRUJ instability whether symptomatic or not.

Results

A total of 87 patients were studied preoperatively, immediate postoperatively, and followed up at 6 weeks, 3 months, and 6 months after the surgery. The mean age of the cases was 41.43, ranging from 18 to 68 years. It was noted that most patients fell within the range of 61 and above. There were 72% (63) men and 28% (24) were women. The other demographic profiles and their distribution among the patients based on various parameters were also noted [Table 1].

Table 1: Distribution of cases among the patients based on various parameters

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Preoperative DRUJ instability was found in 23 (26.44%) patients as checked by the distal ulna ballottement test, whereas the remaining 64 (73.56%) patients had stable DRUJ [Figure 2A]. Percutaneous k-wiring was the most common surgical modality used in 54 (62%) patients, whereas 22 (25%) and 11 (11%) patients were operated on with plating and external fixation, respectively. Of the total 22 patients of associated ulnar styloid fracture, only 3 (12%) patients were given the fixation of the ulnar styloid fracture, whereas 19 (88%) patients were left without fixing fracture of ulnar styloid.

Figure 2: Percentage of patients with preoperative DRUJ instability (A). Percentage of postoperative DRUJ instability tested by the distal ulnar ballottement test in patients with preoperative DRUJ instability (B)

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After the fixation, postoperative DRUJ instability was found in 9 patients of the total 23 patients who had preoperative DRUJ instability. The remaining 14 (61%) patients showed no DRUJ instability and probably the initial preoperative instability improved by proper fixation of the distal end radius fracture [Figure 2B].

Distribution of patients with DRUJ instability, following the acute distal end radius fracture, was noted based on age [Figure 3A], based on mode of injury [Figure 3B], and based on fracture type [Figure 3C].

Figure 3: Age-wise distribution of patients with DRUJ instability (A). DRUJ instability based on the mode of injury (B). DRUJ instability based on the type of fracture (C)

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Of the total 23 patients who had preoperative DRUJ instability, only 5 had an initial associated ulnar styloid fracture; whereas of the total 9 patients who had the residual postoperative DRUJ instability, 2 had initial ulnar styloid fracture. Those two patients, who had initial ulnar styloid fracture which subsequently resulted in DRUJ instability postoperatively, were instead given fixation for their ulnar styloid fracture.

Of the total three patients who were given additional fixation to the ulnar styloid fracture, two patients had preoperative DRUJ instability which was not corrected post-fixation, whereas one patient who was given fixation did not have preoperative DRUJ instability. On regular follow-up, all the nine patients who had postoperative DRUJ instability had symptomatic DRUJ instability with ulnar-sided pain, the most common symptom.

Discussion

Distal end radius fracture is the most common fracture associated with DRUJ instability.^[1],[2],[10] The factors associated with this injury, however, rarely have been studied. Because of its anatomic proximity to the TFCC, fracture of the ulnar styloid at its base has been postulated to cause DRUJ instability.^{[11],[12],[13],[14]} Hence, early detection of the DRUJ instability will cause better outcomes of the surgically treated distal radius fractures. By early detection of the DRUJ instability clinically, the wrists involved can be subject to advanced investigations such as arthroscopy and CT for the further repair of the damaged TFCC and ligamentous supports of DRUJ. However, well-designed studies consistently denied the association between symptomatic DRUJ instability and the ulnar styloid fracture in distal radius fractures.^{[4],[5],[6],[15]} Recently widening of the DRUJ gap was identified as an independent risk factor for DRUJ instability in distal radius fractures.^[16] By this study, we tried to identify the clinical factors associated with DRUJ instability in distal radius fractures.

In our study, 23 patients had preoperative DRUJ instability (26% of the total patients). Eighteen patients had moderate instability, whereas five patients had severe instability. DRUJ instability preoperatively was found to be more in men (nearly 31% of total men) as compared with women (16% of the total females). In our study, DRUJ instability preoperatively was found commonly in both the younger and the older patients, whereas various previous studies^{[2],[17],[18]} accepted that the fractures of the distal radius in patients below the usual age for osteoporosis are associated with tears of the TFCC and subsequent DRUJ instability.

As far as type and mode of injury are concerned, DRUJ instability was seen more commonly in the open wounds and where there was high energy of trauma involved. This was in accordance with the study of Omokawa et al.^[19] from JAPAN in 2014 who suggested that an open wound at the wrist increased the risk of DRUJ instability.

Methods of fixation was also a concern for DRUJ instability, Of the total 23 patients with preoperative DRUJ instability, 9 patients still had postoperative DRUJ instability. Six patients had moderate instability, whereas three patients had severe instability. Remaining 60% of the patients (i.e., 14 patients) with preoperative DRUJ instability showed stable DRUJ postoperatively probably owing to good fixation of the distal radius fracture. This result was consistent with that obtained by the study of Andrzej Żyluk, Bernard Piotuch of POLAND^[20] who emphasized that acute instability accompanying fractures of the distal radius usually does not require separate management, if the fracture itself is firmly fixed. Our study matched with a study by Gholam Hossein Kazemian et al.^[21] who all showed that untreated stable or minimally displaced ulnar styloid fracture accompanied by distal radius fracture has no adverse effect on DRUJ stability following ORIF of the radius. Moreover, Kwon et al.^[22] studied the clinical and radiographic factors associated with DRUJ instability in distal radial fractures and found that the fracture of ulnar styloid at its base has a doubtful association with symptomatic DRUJ instability.

On regular follow-up of the patients, it was found that none of the patients with stable DRUJ postoperatively developed DRUJ instability and had good modified Mayo wrist scores on each follow-up. However, those nine patients who had the DRUJ instability postoperatively followed up with symptomatic DRUJ instability, with the most common symptom of ulnar-sided pain followed by difficult weight bearing at the wrist. All patients on follow-up had poor modified Mayo wrist scores and low-to-moderate VAS scores.

There are several limitations to this study. First is the subjectivity in the evaluation of DRUJ instability because only clinical assessment was performed. However, no gold standard for diagnosing DRUJ instability has been established. The clinical assessment method used in this study was also used in other studies.^{[3],[9],[16],[23]} Furthermore, physical evaluation methods correlate with intraoperative findings better than CT and show higher interobserver reliability in the assessment of DRUJ instability.^{[3],[9],[16],[23]}

Conclusion

This study concluded that the proper fixation of distal radius fracture markedly decreased in the DRUJ instability when compared preoperatively and postoperatively (from 23 to 9 patients), that is, nearly 61%. Hence, every distal radius fracture should be seen with the suspicion of associated DRUJ instability and the stability of DRUJ be thoroughly checked intraoperatively and postoperatively for better wrist function and better outcome after the union of distal radius fracture.

Acknowledgement

The authors would like to thank the Department of Orthopaedics, surgery, other staff of operation theatre, and administration of Government Medical College and Hospital, Nagpur, Maharashtra, for permission to study and providing facility to carry out the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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