Review Question - QID 212051

This patient sustained a distal radius and ulna fracture. The presence of intraoperative distal radial ulnar joint (DRUJ) instability may necessitate distal ulna fixation.

DRUJ injuries are often under appreciated and are associated with ulnar styloid and distal ulna fractures, TFCC tears, ulnar impaction syndrome, Essex-Lopresti injuries, and Galeazzi fractures. The primary stabilizers of the DRUJ include volar and dorsal radioulnar ligaments and the TFCC. The primary method to prevent disability related to DRUJ injuries is anatomic reduction of the distal radius which often results in an anatomically-reduced DRUJ. A distal ulna fracture with an associated DRUJ injury may require distal ulna fixation or fragment excision. Indications for either operative fixation or fragment excision include displaced fractures through the base with associated instability, sigmoid notch fractures, Galeazzi fracture patterns, and TFCC avulsions in the face of an unstable DRUJ.

May et al. retrospectively reviewed distal radius fractures with concomitant ulnar-sided injuries. They found that all distal radius fractures complicated by DRUJ instability were accompanied by an ulnar styloid fracture. They concluded that a fracture at the ulnar styloid's base and significant displacement of an ulnar styloid fracture were found to increase the risk of DRUJ instability.

Sammer et al. evaluated the outcome of ulnar styloid fractures without DRUJ instability on patient-rated outcomes after distal radius fracture ORIF. They reported that in 88 patients with ulnar styloid fractures, DRUJ instability was found intraoperatively in 3 patients. They concluded that in patients with a stable DRUJ after distal radius fracture open reduction internal fixation (ORIF), ulnar styloid fractures did not affect subjective outcomes.

Wysocki et al. reported on an active, 54-year-old woman who sustained an extra-articular distal radius fracture with a concomitant ulnar styloid base fracture. They reported that they are more likely to consider volar plate fixation of the radius in the presence of an ulnar styloid base fracture. They concluded that if the DRUJ is stable after fixation of the radius, then neither repair nor immobilization of the ulnar styloid fracture is needed, regardless of size or displacement; if there is DRUJ instability after volar plate fixation, then ORIF of an ulnar styloid base fracture is recommended.

Figures A and B are the radiographs of the wrist demonstrating a distal radius and ulna fracture

Incorrect Answers:
Answer 1-4: These factors may be associated with DRUJ instability, but do not alone provide indication for distal ulna fixation. However, the intraoperative presence of DRUJ instability may merit the need for distal ulna fixation.