Persistent Ulnar-Sided Wrist Pain After Distal Radius Fracture





Key Points





  • The development of palmar locking plate fixation for surgical treatment for distal radius fracture (DRF) provides successful outcome. However, persistent ulnar-sided wrist pain (USWP) after healed DRF is often encountered.



  • USWP is common after DRF and can improve for a year or more, so patience is warranted.



  • The main causes of persistent USWP after healed DRF are malunion of the distal radius, triangular fibrocartilage complex (TFCC) injury, and nonunion of ulnar styloid.



  • TFCC injury is frequently associated to DRF and has a good healing potential. The type of TFCC tear that is most troublesome would be a foveal tear causing distal radioulnar joint instability.



  • When conservative treatment fails, correction osteotomy for malunion, arthroscopic management for TFCC injury, and fixation or resection for nonunion of ulnar styloid seem to be the best solutions.





Panel 1: Case Scenarios


Case 1: Palmarly Angulated Malunion


A 76-year-old, right-handed female suffered a left DRF. She underwent cast immobilization for 4 weeks. She visited our clinic with a swollen and deformed left wrist 3 months after removing the cast. She complained of persistent USWP. Range of motion (ROM) was restricted: extension (ex) 50 degrees (deg), flexion (flex) 60 deg, pronation (pro) 80 deg, supination (sup) 65 deg, grip strength was 60% of the contralateral side. Radiographs showed radial shortening with an ulnar variance (UV) which was + 3.5 mm, radial inclination (RI) was 5 deg, and palmar tilt (PT) was 35 deg ( Fig. 1 ). What is the most effective approach for management of USWP for this patient?




Fig. 1


Preoperative radiographs showed malunion with radial shortening and palmar angulation.


Case 2: Dorsally Angulated Malunion


A 56-year-old, right-handed male injured his wrist by falling, was diagnosed with a DRF and treated with cast immobilization. He visited our clinic 3 months after injury with USWP. His radiographs showed a dorsally angulated malunion of the distal radius (RI: 23.5 deg, UV: 5.5 mm, PT: − 27 deg) and an ulnar styloid nonunion ( Fig. 2 ). This nonunion was already diagnosed before the DRF and seemed an old injury. He often felt mild USWP before his DRF. How do you consider the best plan to resolve his USWP?




Fig. 2


Preoperative radiographs and CT showed a shortened and dorsally angulated malunion of the distal radius, and an ulnar styloid nonunion.


Case 3: TFCC Disc Tear


A 56-year-old, right-handed female sustained a right DRF, treated with cast fixation for 4 weeks. The DRF healed within normal range alignment (RI: 27 deg, PT: 10 deg, UV: + 1.5 mm) ( Fig. 3 ), however she complained of USWP for 10 months and therefore visited our clinic. Grip strength was 62% of the contralateral side. A TFCC slit tear was suspected on MRI. How would this be best managed?




Fig. 3


Alignment of the distal radius was almost normal. On MRI, a TFCC slit tear was suspected (red arrow) .


Case 4: TFCC Foveal Tear


A 54-year-old, right-handed female suffered left DRF, classified as A3 in the AO classification. She underwent palmar plate fixation ( Fig. 4 A and B ) with arthroscopic radiocarpal inspection, showing a normal appearing TFCC. The postoperative course was uneventful, plate removal was performed 6 months after surgery ( Fig. 4 C). Around 9 months after surgery, she gradually complained of USWP with instability of the ulnar head and grip weakness of 75% of the contralateral side. Radiographs showed widening of the DRUJ ( Fig. 4 D). How could this finding best be explained and managed?




Fig. 4


Extraarticular DRF was fixed with a volar plate (A and B). At 6 months after surgery, the plate was removed (C). At 9 months after surgery, the DRUJ was distended (D).


Case 5: Ulnar Styloid Nonunion


A 28-year-old, right-handed male visited our clinic for USWP that appeared after slightly twisting the wrist several days earlier. His medical history revealed a left DRF that uneventfully healed with cast immobilization for 4 weeks at the age of 13 years. He complained not only of USWP but also of a slack sensation of the ulnar head during forearm rotation. Radiographs and MRI showed an ulnar styloid nonunion probably due to the old injury ( Fig. 5 ). It is unclear if the foveal origin of the TFCC was still attached to the fragment or not. A removable wrist splint was applied for 4 months, but failed, USWP continued. How would this best be managed?




Fig. 5


Ulnar styloid nonunion was recognized on radiograph and MRI.



Importance of the Problem


USWP is a common complaint that contains a diagnostic challenge for hand surgeons because of the small and complex anatomic structures involved. The history and physical examination findings for a wide range of pathologies often overlap. Pain may derive from injured forearm and carpal bones, TFCC, ligament tears, tendinitis, vascular pathology, osteoarthritis and systemic arthritis, and ulnar nerve compression. DRF is the most common fracture in the upper extremity, and is frequently associated with injury of the ulnar wrist structures such as the ulnar styloid, TFCC, lunotriquetral (LT) ligament, etc. The development of palmar locking plate fixation for surgical treatment for DRF provides rigid fixation, maintains accurate reduction acquired when the surgery was carried out, results successful outcome. However, USWP after DRF healed is often encountered, though only some of these patients have persistent moderate to severe pain that persists even a few years after, limiting proper function of the hand. The causes of pain are often difficult to diagnose and resolve. A comprehensive examination of the wrist such as inspection, palpation, provocative maneuvers, radiography, computed tomography (CT), magnetic resonance imaging (MRI), and wrist arthroscopy are required. Wrist arthroscopy plays an increasingly important role in the diagnosis and management of persistent USWP. It is considered the benchmark for the diagnosis and management of TFCC injuries and other pathologies including carpal ligament injuries.


Main Question


What are the main causes of persistent USWP after healed DRF and how is it best managed?


Current Opinion


USWP is common after DRF and can improve for a year or more, so patience and exhausting conservative trial outs are generally warranted. Acute injury of the TFCC and ulnar styloid fractures are common, and treatment remains controversial as routine repair is not indicated. As the natural course is mostly benign and self-limiting, persistent USWP is much less common and necessities a careful diagnostic work-up before surgical treatment.


What Are the Elements of USWP After DRF?


USWP after DRF has mainly been attributed to malunion, creating an imbalance distally, which might lead to ulno-carpal abutment, incongruency, and osteoarthrosis of the distal radioulnar joint (DRUJ). Although malunion is a three-dimensional deformity, extraarticular malunited DRF are often categorized on radiographs as palmarly angulated, dorsally angulated, loss of radial inclination, and/or radial shortening.


TFCC injuries are the most common associated intraarticular injuries with DRF, and may cause USWP. TFCC injury can be divided into disc tear and peripheral tear. “Disc” refers to the articular disc that acts as a shock absorber, while “peripheral” indicates the attachment of the disc to the surrounding tissue and the surrounding tissue itself. The surrounding tissue include both palmar and dorsal radioulnar ligaments, the ulnocarpal ligament, the sigmoid notch of the radius, the ulnar styloid and fovea. A disc tear may be treated by resection, on the other hand, peripheral tear should be repaired as it could lead to DRUJ or carpal instability. Wrist arthroscopy is the best procedure to clearly recognize the associated TFCC tear.


Ulnar styloid fracture is often accompanied with DRF, and nonunion of this fracture is also common. However, the relationship between ulnar styloid nonunion and persistent USWP remains unclear. It is considered that whether nonunion of ulnar styloid is symptomatic or not depends on the stability of DRUJ.


LT ligament tear could become the source of USWP after a healed DRF. However, the detail is still unclear.


Finding the Evidence





  • Cochrane search: Distal Radius Fracture, Ulnar-Sided Wrist Pain



  • PubMed (Medline): Distal Radius Fracture, Ulnar-Sided Wrist Pain, Distal Radius Fracture AND Ulnar-Sided Wrist Pain, Distal Radius Fracture AND Distal Radius Malunion, Distal Radius Fracture AND Triangular Fibrocartilage Complex injury, Distal Radius Fracture AND Ulnar Styloid Nonunion



  • Bibliography of eligible articles



  • Articles that were not in English were excluded



Quality of the Evidence


Level II: Prospective case series: 2


Level III: Retrospective comparative studies: 6


Level IV: Case series: 2


Findings


Although there were many high-level studies on DRF, there were no randomized controlled trials, systematic reviews, or metaanalyses about USWP after healed DRF. We only found 10 relevant articles with evidence levels II to IV ( Table 1 ).



Table 1

FINDINGS




















































































Author LoE Study Design Objective Number of Patients Content Comments
Kim IIIB Retrospective Longitudinal observation of the incidence of USWP after DRF treated by plate fixation 140 Number of cases of USWP. PO 3M: 22, PO 6M: 11, PO12M: 3 The incidence of USWP decreased significantly with time after surgery.
Cheng IIIB Retrospective Analysis of 22 cases who complained of chronic wrist pain after DRF 22 Four patterns identified: (1) ulnar impaction due to malunion, (2) ulnar styloid nonunion, (3) TFCC injury with/without DRUJ instability, (4) intercarpal ligament and chondral lesion Reconstruction for each abnormality gave satisfactory outcome
Prommersberger IIIB Retrospective The outcome of corrective osteotomy for malunited DRF Dorsally tilted: 29 Palmarly angulated: 20 Changes of XP index Dorsally tilted RI: 14 to 24, PT: − 22 to 0, UV: 4 to 0 Palmarly angulated RI: 18 to 30, PT: 32 to 13, UV: 8 to 0 Postoperative XP index significantly improved and radiological results correlated with the functional outcome.
Wada IIIB Retrospective Compared the clinical and radiographic results of opening and closing wedge osteotomy Radial opening: 22 Radial closing and ulnar shortening: 20 Restoration of UV was significantly better in closing. exflex arc, Mayo wrist score: significantly better in closing Closing osteotomy was significantly better than opening in terms of UV, exflex arc, and Mayo wrist score
Deniz IIC Prospective Investigated the effect of untreated TFCC tear on the outcome of conservatively treated DRF Total 47 Detect TFCC tear using MRI: 24 Undetected: 23 In the mean follow-up period of about 39 months, TFCC tears did not affect the functional results Further diagnostic tests and treatment of TFCC tears in patients with stable DRF may be unnecessary
Mrkonjic IIC Prospective 13–15 years, longitudinal outcome study of the natural course of TFCC tears associated with DRF 38 Only 1 patient needed a stabilizing procedure because of painful instability of the DRUJ. The results did not provide evidence that a TFCC injury would influence the long-term outcome Larger and preferably randomized studies needed
Abe IV Retrospective The incidence of traumatic TFCC tear associated with DRF 456 intra- and extraarticular DRF 48.6%
Wijffels IIIB Retrospective The influence of nonunion of the ulnar styloid base fracture on the outcome of DRF is debated Nonunion: 18 Union: 16 In the mean follow-up period of about 30 months, There were no significant differences in both groups Ulnar styloid nonunion is not associated with pain, instability or diminished function after DRF
Hauck IIIB Retrospective Investigation for 20 cases of USWP associated with nonunion of the ulnar styloid Type 1: with a stable DRUJ: 11 Type II: with subluxation of DRUJ: 9 Type 1: all excision and pain relief Type 2: ORIF 3 complete relief, excision 6 excellent 4, good 1, fair 1 DRUJ was stable or its stability was restored, long-term pain relief was achieved by treatment of the nonunion

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Mar 15, 2021 | Posted by in RHEUMATOLOGY | Comments Off on Persistent Ulnar-Sided Wrist Pain After Distal Radius Fracture
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