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Trauma: Y. Zenke, A. Sakai, T. Oshige, S. Moritani, and T. Nakamura The effect of an associated ulnar styloid fracture on the outcome after fixation of a fracture of the distal radius J Bone Joint Surg Br 2009; 91-B: 102-107 [Abstract] [Full text] [PDF]

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Author's reply

A Sakai   (27 February 2009)

Associated ulnar styloid fracture

Rohit Rambani, Rohit Rambani, Hannah Phillips, and Balachandran Venkateswaran   (27 February 2009)

Outcome following fixation of distal radial fractures

Saeed Al-Naser, Aberdeen, UK   (20 February 2009)

Author's reply 27 February 2009
A Sakai, Associate Professor University of Occupational and Environmental Health Send letter to journal: Re: Author's reply a-sakai{at}med.uoeh-u.ac.jp A Sakai	Sir, I would like to thank Doctor Al-Naser for his interest in our paper. I agree with his comment that further studies should be undertaken to look at distal radial fracture patients with associated ulnar styloid fractures only, and then to randomise them to have the ulnar styloid fixed or not to detect reliable results. On the other hand, I have no satisfactory technique for fixing the ulnar styloid at present. I have used tension band wiring in the past but patients frequently complained of ulnar wrist pain and/or discomfort due to skin irritation from the wire. Ruch et al1 reported that 16 patients in whom the ulnar styloid base fracture was treated with tension band wiring had a total of 14 complications referable to the distal radioulnar joint (DRUJ). If I had an adequate way of fixing the ulnar styloid, a randomised comparative study would be undertaken. I also agree that injuries to the ulnar styloid may lead to instability of the DRUJ. Although I had no cases of dislocation of DRUJ in this study, I consider that the relationship between ulnar styloid injuries, DRUJ instability, and ulnar wrist pain is a very important issue. A method of evaluating DRUJ instability quantitatively is needed. Ulnar wrist pain occurred in none of the patients with united styloid fractures (0 of 22) and 4.3% of those with nonunion of styloid fractures (two of 46). Statistical analysis revealed that there was no significant difference (p =0.23 by chi-square test) between ulnar wrist pain and ulnar styloid union. I am currently investigating soft-tissue injuries, including that of the triangular fibrocartilage associated with distal radial fractures. I would like to clarify the relationship between these injuries and ulnar wrist pain. A. Sakai, MD, PhD, Associate Professor, University of Occupational and Environmental Health, Kitakyushu, Japan. 1. Ruch DS, Lumsden BC, Papadonikolakis A. Distal radius fractures: a comparison of tension band wiring versus ulnar outrigger external fixation for the management of distal radioulnar instability. J Hand Surg [Am] 2005;30-A:969-77.
Associated ulnar styloid fracture 27 February 2009
Rohit Rambani, Specialist Registrar Trauma and orthopaedics Dewsbury district general hospital dewsbury UK, Rohit Rambani, Hannah Phillips, and Balachandran Venkateswaran Send letter to journal: Re: Associated ulnar styloid fracture rohitrambani{at}gmail.com Rohit Rambani, et al.	Sir, I read with interest this paper regarding the effect of an associated ulnar styloid fracture on the outcome after fixation of a fracture of the distal radius. I compliment the authors on adding another facet of information to the natural history of these complex injuries. This paper does raise some queries. The study does not identify the effects of these fractures on distal radioulnar joint (DRUJ) instability. As previous research has identified, distal radioulnar joint instability may lead to long-term problems with wrist pain.1 May et al reviewed 166 distal radial fractures and found that all distal radial fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture.2 The ulnar styloid remains an important stabiliser of the distal radioulnar joint, and ulnar styloid fractures associated with distal radial fractures have a higher incidence of ulnar wrist pain and loss of grip strength.3,4 The authors have not specifically measured these parameters in their study. We think further randomised controlled trials are needed to evaluate the effect of ulnar styloid fractures on distal radioulnar joint instability and chronic wrist pain, and the conclusion that an associated ulnar styloid fracture of the ulnar styloid does not adversely affect the outcome in patients with a fracture of the distal radius cannot be made based on this paper until the issue of DRUJ instability is addressed. R. Rambani, Specialist Registrar Trauma and Orthopaedics, H. Phillips, B. Venkateswaran, Dewsbury District General Hospital, Dewsbury, UK. 1. Cheng HS, Hung LK, Ho PC, Wong J. An analysis of causes and treatment outcome of chronic wrist pain after distal radial fractures. Hand Surg 2008;13:1-10. 2. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg [Am] 2002;27:965-71. 3. Shaw JA, Bruno A, Paul EM. Ulnar styloid fixation in the treatment of posttraumatic instability of the radioulnar joint: a biomechanical study with clinical correlation. J Hand Surg [Am] 1990;15:712-20. 4. Rappold G, Poigenfürst J. [Should an osseous rupture of the ulnar styloid in radius fractures be repaired?]. Handchir Mikrochir Plast Chir 1997;29:234-7.
Outcome following fixation of distal radial fractures 20 February 2009
Saeed Al-Naser, Specialist Registrar Woodend Hospital, Aberdeen, UK Send letter to journal: Re: Outcome following fixation of distal radial fractures alnasersaeed{at}yahoo.co.uk Saeed Al-Naser, et al.	Sir, I read with great interest the study by Zenke et al in the January 2009 edition and I have a few comments. I would like firstly to thank the authors for this well-conducted study on a very controversial topic in trauma surgery. It is well known that distal radial fracture is associated with ligamentous and soft-tissue injuries; the triangular fibrocartilage (TFC) is damaged in about 10% of cases.1 It has been suggested that injuries to the ulnar styloid (where the TFC is inserted) will lead to instability of the distal radio-ulnar joint (DRUJ). I would agree with the authors that comparing outcome between patients with ulnar styloid fractures and those without will give some conclusions about the best treatment method. However, the best way of determining that is to study distal radial fracture patients with associated ulnar styloid fractures only, and then to randomise them to have the ulnar styloid fixed or not to detect reliable results. It was also mentioned that there was no relationship between post-operative ulnar side pain and ulnar styloid union. However, none of the patients with united styloid fractures in this study had any ulnar pain post-operatively. This is a little unclear and I would appreciate the authors' clarification. S. Al-Naser, Specialist Registrar, Woodend Hospital Aberdeen, UK. 1. Spence LD, Savenor A, Nwachuku I, Tilsley J, Eustace S. MRI of fractures of the distal radius: comparison with conventional radiographs. Skeletal Radiol 1998;27:244-9.