Abstract
Background: This study compares the functional outcomes and complications between operatively and nonoperatively treated distal ulnar head and neck fractures associated with internal fixation of concomitant distal radius fractures. Methods: A 7-year retrospective chart review was performed to identify patients with operatively treated distal radius fractures associated with distal ulnar head and neck fractures. Ulnar styloid fractures were excluded. Fifty-eight patients who had a minimum of 6 months of follow-up were identified. Patients were divided into 3 treatment groups: nonoperative, open reduction internal fixation (ORIF), and distal ulna resection. Reviewed data included demographics, injury and treatment details, complications, and patient-reported outcome measures. Outcomes measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE) surveys. Due to inadequate power, 5 patients treated with distal ulna resection were excluded from statistical analysis. Results: The average patient age was 56 years, with an average follow-up of 27 months. All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF in 28 patients, and with distal ulna resection in 5 patients. There were no statistically significant differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores between ORIF and nonoperative treatment. Conclusion: No differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores were observed between ORIF and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures.
Keywords: distal radius fracture, distal ulna fracture, patient-reported outcomes
Introduction
Distal ulnar head and neck fractures usually occur in conjunction with distal radius fractures and rarely occur in isolation. 1 Studies have reported that 3% to 6% of distal radius fractures have an associated distal ulnar metaphyseal fracture.2,3 Proper management of distal ulna fractures is important as the ulnar head is a major component of the distal radioulnar joint, which is necessary for forearm rotation and wrist stability. Insufficient treatment can lead to restriction in forearm rotation, persistent wrist pain, and distal radioulnar joint instability, all of which can be functionally limiting. 4 Biyani et al, 3 in a retrospective review of 14 patients who underwent treatment for distal ulna and radius fractures, found that 53.3% of patients had some restriction of forearm rotation.
Choices for the treatment of distal ulna fractures include nonoperative management following closed reduction, open reduction internal fixation (ORIF), and distal ulna resection. Although some studies show favorable functional results following operative management5,6 and others show acceptable outcomes following nonoperative treatment, 7 relatively few studies have compared operative and nonoperative management. Paksima et al, 2 in a retrospective review of 11 patients, found that the 6 patients who were treated operatively had more favorable range of motion and Disabilities of the Arm, Shoulder, and Hand (DASH) scores than the patients treated nonoperatively, although the difference was not statistically significant.
Despite having a major influence on wrist stability, distal ulnar head and neck fractures associated with distal radius fractures have not been widely studied. Existing studies have largely been limited to small cohorts, and comparative studies between methods of treatment are lacking. The purpose of this study was to compare functional outcomes between treatment methods for distal ulnar head and neck fractures and to report any complications or secondary procedures following treatment.
Materials and Methods
Institutional review board approval was obtained prior to the initiation of this study. A retrospective chart review was performed to identify patients who underwent operative treatment of a distal radius fracture. The surgeries were performed at a single academic institution between May 2011 and June 2018 by 7 surgeons, all of whom were either hand-fellowship-trained or trauma-fellowship-trained. A total of 891 patients were identified using Current Procedural Terminology codes for operatively treated distal radius fractures (25607, 25608, and 25609). Injury radiographs were reviewed to determine the presence of an ipsilateral distal ulna fracture. Ulnar fractures that only involved the ulnar styloid were excluded. Ninety-nine patients had a concomitant distal ulnar head or neck fracture and were reviewed.
Initial data collection was performed through review of the electronic medical record. Data points included patient demographics (age, sex, body mass index [BMI], smoking status), injury and treatment details (side of injury, mechanism of injury, open or closed fracture, method of treatment), radiographic data, follow-up examinations (wrist and forearm range of motion, grip strength), reoperation, and complications. Fractures were classified using the AO-Müller/Orthopaedic Trauma Association (AO/OTA) system (Appendix A).
Patients were contacted by telephone or mail to complete 2 validated outcome surveys: the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE).8,9 The PROMIS uses computer adaptive testing to measure a patient’s pain and functioning. The survey is scored using a T-score metric in which a score of 50 corresponds to the mean of a reference population. Higher scores indicate less pain and better functioning. The PRWE also measures a patient’s wrist pain and function. The survey is scored on a scale of 0 to 100, where a score of 0 corresponds to extreme pain and poor functioning and a score of 100 corresponds to no pain and excellent functioning. Patients were directed to complete the surveys online using REDcap (Research Electronic Data Capture: a secure Web-based application for building and managing online surveys and databases). 10
Statistical Analysis
Patients were divided into 3 treatment groups based on the treatment method used for the distal ulna fracture: nonoperative, ORIF, and distal ulna resection. Due to inadequate power, the patients in the distal ulna resection group were excluded from statistical analysis. However, the data collected from these patients were still reported in the descriptive analysis. Statistical comparison was thus limited to the ORIF and nonoperative treatment groups. Continuous and categorical data were compared using 1-way analysis of variance and Fisher exact test, respectively. Statistical values were calculated using R version 3.4.0 (R Foundation for Statistical Computing, Vienna, Austria) 11 with R studio version 1.0.153 (R Studio Inc., Boston, Massachusetts). 12 Probability values less than .05 were considered significant.
Results
Patient Demographics and Injury Data
The incidence of distal ulna head and neck fractures (ulnar styloid fractures excluded) associated with distal radius fractures was 11% of all distal radius fractures. Fifty-eight patients with a minimum of 6 months of follow-up were identified (Table 1). The average patient age was 56 years (range, 21-89 years), with an average follow-up of 27 months (range, 6-92 months). All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF with plate and screws in 28 patients (Figures 1 and 2), and with distal ulna resection in 5 patients. Management of the ulnar head injury was surgeon-dependent. All patients who underwent distal ulna resection sustained an open fracture, whereas 6 patients treated with ORIF (21%) and 2 patients treated nonoperatively (8%) sustained an open fracture. Most patients treated nonoperatively (64%) and with ORIF (68%) sustained high-energy injuries. Patients frequently sustained additional injuries (67%), 49% of which included the ipsilateral upper extremity. The most common additional injury was a lower extremity fracture, and the most common ipsilateral upper extremity injury was a proximal humerus fracture (Table 2). Twenty-one of the ulna fractures involved both the ulnar head and the neck (Q5). Most of these fractures were treated with ORIF (n = 11). Thirty-one fractures involved the ulnar neck alone. Seventy-one percent of simple neck fractures (Q2) were treated nonoperatively (n = 10). Seventy-two percent of comminuted neck fractures (Q3) were treated with ORIF (n = 13). Six fractures involved the ulnar head alone (Q4). One-half of those fractures were treated nonoperatively (n = 3). There were no statistically significant differences in age, sex, BMI, or smoking status between the ORIF and nonoperative treatment groups (P > .05).
Table 1.
Patient Demographics and Injury Characteristics.
| Variable | Darrach a | Nonoperative | ORIF |
|---|---|---|---|
| Patients, n | 5 | 25 | 28 |
| Age, y, mean | 65 | 56 | 54 |
| Mechanism, No. (%) | |||
| High energy | 2 (40) | 16 (64) | 19 (68) |
| Low energy | 3 (60) | 9 (36) | 9 (32) |
| Open fractures, No. (%) | 5 (100) | 2 (8) | 6 (21) |
| Fracture classification, No. (%) | |||
| Q2 | 1 (20) | 10 (40) | 3 (11) |
| Q3 | 0 (0) | 5 (20) | 13 (46) |
| Q4 | 1 (20) | 3 (12) | 1 (4) |
| Q5 | 3 (60) | 7 (28) | 11 (40) |
| Ipsilateral upper extremity injury, No. (%) | 1 (20) | 8 (32) | 7 (25) |
| Other extremity injury, No. (%) b | 1 (20) | 9 (36) | 9 (29) |
Note. ORIF = open reduction internal fixation.
Distal ulna resection.
Other extremity injuries include contralateral upper extremity injury or lower extremity injury.
Figure 1.
A 61-year-old woman fell 3 ft and sustained distal radius and ulna fractures. The patient underwent open reduction internal fixation with plate and screws for both fractures. (a, b) Posteroanterior and lateral radiographs of the injured wrist. (c, d) Postoperative views of the wrist.
Note. L = lateral; M = medial.
Figure 2.
A 49-year-old man was involved in a motorcycle collision and sustained distal radius and distal ulna fractures. The patient underwent open reduction internal fixation of the distal radius fracture and nonoperative treatment of the distal ulna. The distal radius plate caused pain and was later removed. (a, b) Posteroanterior (PA) and lateral radiographs of the injured wrist. (c, d) Fluoroscopic postoperative views of the wrist. (e, f). PA and lateral radiographs of the wrist at 9-month follow-up. L = lateral; M = medial.
Note. L = lateral; M = medial.
Table 2.
Additional Injuries.
| Type of injury | No. of patients (%) |
|---|---|
| Neurological | 10 (17) |
| Pulmonary/Thoracic | 10 (17) |
| Abdominal | 5 (9) |
| Spine | 11 (19) |
| Lower extremity fracture | 14 (24) |
| Contralateral upper extremity fracture | 7 (12) |
| Ipsilateral upper extremity fractures | |
| Scapula | 1 (2) |
| Clavicle | 1 (2) |
| Humerus | 5 (9) |
| Proximal radius/Ulna | 4 (7) |
| Metacarpal | 2 (3) |
| Ipsilateral upper extremity dislocations | |
| Shoulder | 1 (2) |
| Elbow | 3 (5) |
| Proximal interphalangeal joint | 1 (2) |
Wrist and Forearm Range of Motion
Supination and pronation were superior in the distal ulna resection group (Table 3). Wrist flexion and extension were similar between treatment groups. Differences in range of motion were not statistically significant between the ORIF and nonoperative groups (P > .05).
Table 3.
Outcome Measures.
| Variable | Darrach a | Nonoperative | ORIF | P values (ORIF vs nonoperative) |
|---|---|---|---|---|
| Forearm and wrist range of motion, deg, mean | ||||
| Supination | 88 | 63 | 67 | .67 |
| Pronation | 87 | 69 | 81 | .1 |
| Extension | 50 | 48 | 46 | .65 |
| Flexion | 49 | 54 | 62 | .43 |
| Patient-reported outcomes, mean | ||||
| PRWE | 70 | 49 | 28 | .18 |
| PROMIS | 34 | 38 | 45 | .11 |
| Complication rate, No. (%) | 0 (0) | 1 (4) | 3 (11) | .61 |
| Secondary procedure rate, No. (%) | 0 (0) | 2 (8) | 4 (15) | .67 |
Note. ORIF = open reduction internal fixation; PRWE = Patient-Rated Wrist Evaluation; PROMIS = Patient-Reported Outcomes Measurement Information System.
Distal ulna resection.
Functional Outcomes
The average PRWE scores were 70 in the distal ulna resection group, 49 in the nonoperative group, and 28 in the ORIF group (Table 3). The average PROMIS scores were 34 in the distal ulna resection group, 38 in the nonoperative group, and 45 in the ORIF group. Differences in scores were not statistically significant between the ORIF and nonoperative groups.
Complications and Secondary Procedures
There were no complications in the distal ulna resection group (Table 3). There was 1 case of complex regional pain syndrome in the nonoperative group, which eventually resolved with physical therapy. In the ORIF group, there was 1 distal radius nonunion, 1 case of wrist osteomyelitis, and 1 development of radioulnar synostosis. No patients in the distal ulna resection group required a secondary procedure. One patient in the nonoperative group required a subsequent distal ulna resection. The resection was performed for rotational stiffness (5°-10° pronation and supination arc) at 5 months postoperatively. There were a total of 4 patients who underwent additional surgery following ORIF. One patient in the ORIF group required subsequent distal ulna resection, 1 required revision ORIF with bone grafting for nonunion, 1 required irrigation and debridement and removal of hardware for osteomyelitis, and 1 required excision of radioulnar synostosis. The distal ulna resection was performed for rotational stiffness (20° pronation and supination arc) and persistent pain at 8 months postoperatively. The rates of complications and secondary procedures were not statistically significant between the ORIF and nonoperative groups.
Discussion
Clear guidelines to direct the management of distal ulna fractures associated with operatively treated distal radius fractures have not been established. The anatomy of the distal ulna makes plate fixation difficult as the bone has a triangular cross-sectional shape and a thin soft tissue envelope. 4 In addition, the distal ulna is prone to prominent hardware, often requiring a secondary procedure for plate removal. Despite these difficulties, good outcomes have been reported with the use of condylar blade plate fixation for unstable fractures of the distal ulna. 5 Satisfactory radiographic and functional outcomes have also been reported for nonoperative treatment of the distal ulna in elderly patients.7,13 In this study, no statistically significant difference, for outcomes and complications, was found between plate fixation and nonoperative treatment of distal ulnar head and neck fractures.
Other studies comparing operative and nonoperative treatment of distal ulna fractures have similarly found no significant difference in outcomes. Radiographic healing, union, and wrist and forearm range of motion have been reported to be similar between treatments groups.2,14,15 In this study, no difference was found in wrist and forearm range of motion, PRWE scores, or PROMIS scores between groups. Wrist and forearm range of motion was similar to what has been reported in previous studies.2,5,7,13,14 The reason why no difference was found between treatment outcomes is unclear. Perhaps the differing distribution of fracture patterns or selection bias between the treatment groups led to a difficult comparison. Most ulnar head fractures treated with ORIF were either comminuted neck fractures or combined head and neck fractures, whereas many of the nonoperatively treated ulna fractures were simple neck fractures. Thus, the treatment methods chosen may have been best suited for those fracture patterns, leading to a selection bias.
Few studies have focused on patient-reported outcomes in distal ulna fractures. Paksima et al 2 found similar DASH scores between patients treated operatively and nonoperatively for distal ulna fractures. Although the DASH survey has frequently been used to evaluate patient outcomes following upper extremity surgery, many researchers are now shifting to the use of PROMIS. The PROMIS survey is preferred for its ease of use and quicker time to complete. The scores have been correlated to other frequently used surveys for the upper extremity.16-18 This study found that PROMIS scores did not differ significantly between patients treated nonoperatively and those treated with ORIF. However, the total average PROMIS score was 40, a full standard deviation below the mean of the reference population. This result indicates that patients remain functionally impaired at an average of 27 months after surgery.
The low functional scores may reflect the nature of the population studied. Previous studies investigating distal ulna fractures have largely focused on the elderly population, who are more likely to sustain wrist fractures by a low-energy mechanism. Several studies evaluating distal radius fractures in the elderly population have found that low-demand patients often have satisfactory functional outcomes despite imperfect radiographic results.19-21 In contrast, this study consists largely of patients who sustained high-energy injuries with a mean age of less than 60 years. As most patients were younger than retirement age, functional deficiencies may have had a greater impact on this working-age cohort. In addition, many patients had multiple injuries, which also may have affected their functional outcome. Nearly one-half (49%) of patients sustained an additional injury to the ipsilateral upper extremity. Additional involvement of the upper extremity likely contributed to an increased sense of functional impairment.
This study has limitations. Our study is retrospective, and only 59% of patients eligible for the study had adequate follow-up for inclusion. In addition, an inherent selection bias exists in determining which fractures should be treated operatively or nonoperatively. Certain fracture patterns were more likely to undergo operative treatment in this patient cohort, such as comminuted ulnar neck fractures, whereas other patterns, such as simple neck fractures, were more likely to undergo nonoperative management. The study included several surgeons who may have differing indications for operative treatment of distal ulna fractures. Another limitation was that it was underpowered to detect a statistically significant difference in PROMIS scores between patients treated nonoperatively or with ORIF. A power analysis determined that to detect a significant difference in PROMIS and PRWE scores between groups would require 40 patients in each group to achieve 80% power. This study had 60% power.
Conclusion
No differences in wrist and forearm range of motion, PRWE scores, PROMIS scores, complications, and secondary operations were observed between operative and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures. The PRWE and PROMIS scores suggested continued functional impairment at an average of 27 months of follow-up despite satisfactory wrist and forearm range of motion.
Appendix A
AO/OTA Classification of Distal Ulna Fractures
Q1. Ulnar styloid fracture
Q2. Ulnar neck fracture
Q3. Comminuted ulnar neck fracture
Q4. Ulnar head fracture
Q5. Ulnar head and neck fracture
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Statement of Informed Consent: Informed consent was obtained from all patients who participated in the prospectively collected patient-reported outcome measures. Retrospective data collected were exempt from informed consent by the institutional review board.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Georgina Glogovac 
https://orcid.org/0000-0001-9740-4308
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