Decompression corrective osteotomy of the distal radius for treatment of the DRUJ-incongruency and impingement syndrome with focus on posttraumatic cases.

INTRODUCTION: Posttraumatic or congenital ulna-minus variance with altered shape of the sigmoid notch and increased tension of the distal oblique band of the interosseous membrane (DIOM) can lead to painful impingement in the distal radioulnar joint (DRUJ) during rotation and loading of the forearm. As an operative treatment concept, a new method was described in 2016. Its goal is to restore the osseous congruency, which is required for normal painless function. The hypothesis is based on remodelling of the joint surface and the decompression of the DRUJ by releasing the DIOM. The purpose of this study is to analyze the results of performed operations with detailed focus on posttraumatic cases. MATERIALS AND METHODS: The indication for the operation is the impingement and incongruency in the DRUJ with ulna-minus variance. The surgical procedure is based on shortening and closed-wedge osteotomy of the distal radius with an ulnar translation of the radial shaft. Fifty-nine operations were performed between 2011 - 2022 on 52 patients (13 men, 39 women). Twenty-four patients were operated on the right side, 21 on the left side and 7 bilaterally. In 45 cases the operation was indicated because of congenital, in 12 cases due to posttraumatic incongruency and in 2 cases because of iatrogenic impingement after previously performed excessive ulnar shortening osteotomy. Modified Mayo-Wrist-Score, patient questioning, VAS and ROM were used to evaluate the results. RESULTS: Significant reduction of pain on VAS from 7.22 to 1.98 (p < .001) was achieved. The pre- and postoperative range of motion did not show any significant changes (mean total arc of motion 301,94° vs. 295,20°, p = .300). Specific complications we observed included a too distally performed osteotomy, DRUJ instability, de Quervain´s tenosynovitis, persistent pain and conversion into an ulna-plus variance. CONCLUSION: Under consideration of the indication criteria and correct execution of the osteotomy, in about 90 % of the cases this operation leads to good-to-excellent results with pain reduction and improvement of weight-bearing and power. The preoperative examination, verification of the DRUJ stability and the radiological diagnostics are crucial for a good outcome.

Distal partial ulnectomy with ulnar styloid process excision for management of an aneurysmal bone cyst in a cat.

Case summary: An 8-year-old male neutered domestic shorthair cat was presented with an acute onset of left thoracic limb lameness and a firm swelling on the lateral aspect of the left distal antebrachium. A CT scan of the left thoracic limb revealed an expansile osteolytic cystic bone lesion centred at the distal left ulnar metaphysis. Cytology from fine-needle aspiration was not consistent with neoplasia. The CT features and the cytology results were suggestive of a bone cyst. A distal partial ulnectomy with ulnar styloid process excision was performed as the biopsy method and as the treatment approach. Histopathology results were consistent with an aneurysmal bone cyst (ABC). Carpal instability was not detected after distal partial ulnectomy; therefore, a stabilisation method was not required. Limb function was excellent after surgery, with no lameness and no recurrence detected by the owner at 2, 6 and 24 weeks postoperatively. The veterinary examination at 12 weeks postoperatively confirmed the owner's outcome assessment. Relevance and novel information: To the authors' knowledge, this is the first report describing a distal partial ulnectomy with ulnar styloid process excision in a cat. Despite disrupting the short ulnar collateral ligament, this technique provided excellent short-term limb function with no need for carpal joint stabilisation. This technique allowed for the complete excision of a distal ulnar ABC and avoided cyst debridement, which could be associated with haemorrhage, recurrence and malignant transformation. Distal partial ulnectomy should be considered for distal ulnar bone lesions in cats.

Upper Extremity Stress Fractures.

BACKGROUND: Stress injuries are often missed secondary to their insidious onset, milder symptoms, and subtle or initially absent findings when imaged. MAIN BODY: This review aims to provide strategies for evaluating and treating upper extremity stress fractures. This article outlines the classic presentation of each fracture, the ages during which these injuries often occur, the relevant anatomy and biomechanics, and the mechanism of each injury. Diagnostic imaging and management principles are also discussed, including the use of conservative versus surgical management techniques. SHORT CONCLUSION: Upper extremity stress fractures are often mild injuries that resolve with conservative management but can lead to more serious consequences if ignored. Given their increasing incidence, familiarity with diagnosis and management of these injuries is becoming increasingly pertinent.

What do we need to address when we treat neglected Monteggia fracture in children.

Monteggia fracture is a relatively uncommon injury in pediatric patients, accounting for less than 2% of forearm fractures, characterized by a combination of ulna fracture and radial head dislocation. Neglected Monteggia fractures define as those that have not received treatment within 3 weeks. In children, ulna fractures are easily diagnosed while radial head dislocation may be overlooked, necessitating open reduction after neglecting the Monteggia fracture and potentially causing additional trauma to the child. This study aims to review the pathological characteristics of neglected Monteggia fractures based on the length ratio of the ulna and radius, relative positions between the proximal ends of the ulna and radius, the integrality of annular ligament and the pathological change of proximal radioulnar joint. The findings will provide valuable insights and guidance for managing neglected Monteggia fractures.

Intramedullary Threaded Nail Fixation of Distal Ulnar Fractures: The Surgical Technique and Case Series.

BACKGROUND:  To describe the surgical technique of non-compressive intramedullary threaded nail (IMTN) fixation of distal ulnar neck fractures and present the clinical and radiographic outcomes of four patients treated with this novel technique. METHODS: At a single Level 1 Trauma Center, a retrospective review was conducted for patients with distal ulnar neck fractures treated with retrograde IMTN between 2022 and 2024. Exclusion criteria included inadequate follow-up. A single surgeon performed all procedures using percutaneous retrograde IMTN fixation through the central disc of the triangular fibrocartilage complex (TFCC). Patients initiated a range of motion (ROM) protocol two weeks post-operatively. Post-operative radiographic images were used to calculate the ratio of IMTN diameter to the distal ulnar medullary isthmus diameter proximal to the fracture site. Radiographic changes in displacement, angulation, and ulnar variance were calculated between the first and last follow-up radiographs. Functional outcomes including grip strength and ROM were collected. RESULTS: Four patients with distal ulnar neck fractures were treated with retrograde IMTN between 2022 and 2024. They were followed for a minimum of three months post-operatively. All were female with an average age of 65 years. All distal ulna fractures were associated with operatively treated intraarticular distal radius fractures. All patients were treated with 75 mm length and 4.5 mm diameter IMTNs. IMTN-to-Isthmus ratio was greater than 60% in all cases. Average radiographic displacement and angulation were unchanged at the final follow-up. The average ulnar variance increased by 1.2 mm. At the final follow-up, there were no post-operative complications. No cases demonstrated ulnar-sided wrist pain, nonunion, or required revision surgery. CONCLUSIONS: Retrograde IMTN fixation is a novel surgical technique for the treatment of distal ulnar neck fractures. We found limited but promising post-operative radiographic and functional outcomes in our patients without reported ulnar-sided wrist pain, nonunion, or need for hardware removal.

[ZHANG Weihua's experience in treatment of cervical spondylotic radiculopathy with ulna-tibia needling therapy combined with decompression-loosening manual manipulation].

The paper introduces professor ZHANG Weihua's experience in treatment of cervical spondylotic radiculopathy (CSR) with ulna-tibia needling therapy combined with decompression-loosening manual manipulation. Using "palpating, detecting and imaging observing", professor ZHANG Weihua gives the accurate diagnosis for the location, the stage and the severity of the disease. According to the nature of the disease, CSR is treated in three stages. He proposes the academic thought, "taking the tendons as the outline, regarding the meridians as the essential, rooting at qi and blood, co-regulating tendons and bones". The ulna-tibia needling therapy and decompression-loosening manual manipulation are combined in treatment. In the ulna-tibia needling therapy, the acupuncture is delivered at the lower 1/3 of the cutaneous regions of taiyang and shaoyang meridians, on the ulnar region (belt-like distribution). The decompression-loosening manual manipulation is operated in 3 steps, i.e. relaxing the nape region, decompressing and relaxing (includes positioning rotational wrenching, upward and backward elevation) and supination wrenching, and analgesia and regulating tendons; and the manipulation for analgesia and regulating tendons is supplemented to enhance the effect.

Conservative Approach to Type III Ulnar Club Hand: Case Report.

Ulnar club hand is a rare condition of the upper limbs, for which treatment depends on the degree of morphological and functional impairment, correlating with the radiographic classification of Dobyns, Wood, and Bayne. The aim of the present study is to report a case of a 6-year-old male patient, followed up for type III ulnar club hand (total ulnar dysplasia). Despite the initial difficulty of manipulating objects and performing everyday tasks, conservative physical therapy treatment provided strength gain and development of functional skills for daily life. We conclude that patients with type III deformity can be properly managed with rehabilitation although they require outpatient follow-up until skeletal maturity is reached, as dynamic deformities and new functional limitations may lead to need for corrective surgeries.

A case report of primary hydatidosis of ulna and adjacent soft tissue.

Hydatidosis, is a zoonotic disease prevalent in sheep-raising regions globally. Musculoskeletal hydatidosis is uncommon and usually remains asymptomatic over a long period. The detection of musculoskeletal hydatidosis often signifies extensive cyst spread within the bone marrow cavity, making treatment difficult with a high recurrence rate. Unlike the conventional surgical approach for visceral hydatid cysts, treating osseous hydatidosis requires a strategy akin to oncologic therapy. We report a rare case of primary hydatidosis affecting the ulna and adjacent soft tissue in a 58-year-old woman. She presented with a painless forearm mass evolving over six years, accompanied by recent onset tenderness and restricted elbow joint mobility. Imaging revealed a cystic mass in the forearm, an intra-ulnar bone lesion, and an olecranon fracture. The primary diagnosis of musculoskeletal hydatidosis was made based on clinical findings and radiological imaging. Treatment involved resection of 2/3 of the proximal ulna and pericystectomy for the soft tissue hydatid cyst. Diagnosis of musculoskeletal hydatidosis is vital for effective preoperative planning, as internal fixation often fails without eradicating the infestation. Treatment typically involves radical operation with wide excision of the affected bone and adjacent joint structures, coupled with chemotherapy. Clinicians in endemic regions should consider musculoskeletal hydatidosis in the differential diagnosis of osteolytic lesions and slow-growing cystic masses. Diagnosis relies on clinical, serological, and radiological assessments.

Displaced sigmoid notch fracture and higher patient age are associated with distal radioulnar joint subluxation.

Background/aim: Distal radius fractures (DRFs) are frequently associated with distal radioulnar joint (DRUJ) instability. The purpose of this study is to evaluate the effect of the sigmoid notch and ulna styloid fracture types on DRUJ subluxation following closed reduction and casting of DRFs via calculating radioulnar ratio (RUR) on postreduction computed tomography (CT) images. Materials and methods: In our study, postreduction CT images of 202 patients with distal radius fractures were evaluated retrospectively. CT images were evaluated for RUR, sigmoid notch fracture, and ulna styloid types. Sigmoid notch fractures were classified as nondisplaced in the sigmoid notch fractures (NDS) and displaced sigmoid notch (DS) fractures; ulna styloid fractures were grouped as the proximal half ulna styloid (PHUS) and distal half ulna styloid (DHUS) fractures. Results: The mean age of Rozental type 3b (62.8 years) was significantly higher among others. The mean RUR value was significantly higher in Rozental type 3a in compared to type 1a and type 2 fractures. PHUS fractures were more common with DS fractures than DHUS fractures. Conclusion: DS fractures and higher patient age are associated with DRUJ subluxation on postreduction CT images following DRFs. DS fractures are seen more commonly with PHUS fractures than DHUS. Patients with PHUS should be carefully assessed for sigmoid notch fractures and DRUJ congruency. These findings could be helpful for preoperative decision making in the treatment of DRFs.

Erythropoietin as promoter of engraftment for treatment of radius/ulnar non-union fracture in a dog: Case report.

Background: Fractures with large bone defects and non-unions are a great challenge for veterinary orthopaedists. In small dog breeds, this complication is commonly encountered in fractures of the radius and ulna due to poorer vascularisation of the distal antebrachium region. Case Description: A case of radius/ulnar non-union in a 1.5-year-old Pinscher occurring after trauma and two successive unsuccessful osteosyntheses is described. During the operative revision, after the removal of existing bone implants, the bone defect was filled with cortical autologous bone graft. Autocancellous bone mixed with erythropoietin was applied proximally and distally to the cortical autograft for stimulation of bone healing. The post-operative period was without complications. As early as the 9th post-operative week, the animal was able to bear weight on the limb, without signs of lameness, pain, and swelling. Radiologically, a very good bridging of the graft was observed. Fifteen weeks after the operative revision, the fracture was completely healed with excellent clinical outcome. Conclusion: The application of autogenous cortical bone graft and cancellous autograft mixed with erythropoietin demonstrated an excellent therapeutic effect and resulted in complete regeneration of the large bone defect over a 15-week period.

Insights into digit evolution from a fate map study of the forearm using Chameleon, a new transgenic chicken line.

The cellular and genetic networks that contribute to the development of the zeugopod (radius and ulna of the forearm, tibia and fibula of the leg) are not well understood, although these bones are susceptible to loss in congenital human syndromes and to the action of teratogens such as thalidomide. Using a new fate-mapping approach with the Chameleon transgenic chicken line, we show that there is a small contribution of SHH-expressing cells to the posterior ulna, posterior carpals and digit 3. We establish that although the majority of the ulna develops in response to paracrine SHH signalling in both the chicken and mouse, there are differences in the contribution of SHH-expressing cells between mouse and chicken as well as between the chicken ulna and fibula. This is evidence that, although zeugopod bones are clearly homologous according to the fossil record, the gene regulatory networks that contribute to their development and evolution are not fixed.

Ulnocarpal Abutment Syndrome With Triquetrum Degeneration.

We present the case of a 47-year-old patient with a congenital positive ulnar variance and elucidate its effects on nearby structures in relation to ulnocarpal abutment syndrome (UAS). While magnetic resonance imaging (MRI) helped to identify soft tissue changes in the wrist, the use of an arthrogram, in this case, allowed for a more comprehensive and detailed analysis of the ligaments and soft tissues. Image findings included a complex degenerative tear of the disc of the triangular fibrocartilage (TFCC), a degenerated triquetrum, and partial tears of the scapholunate and lunotriquetral ligaments. Mild dorsal angulation of the lunate was noted, representing dorsal intercalated segmental instability (DISI), suggesting scapholunate ligament injury. Palmar classification was utilized to classify the extent of the TFCC injury as Type IIE. This case shines a light on the presentation of UAS in a patient that was not the usual demographic affected by this pathology, as well as their UAS affecting the triquetrum rather than the more commonly associated lunate.

Effect of different ulnar osteotomies on loading of the distal radioulnar joint: a finite element analysis.

BACKGROUND: Ulnar impingement syndrome is a prevalent source of ulnar carpal pain; however, there is ongoing debate regarding the specific location of shortening, the method of osteotomy, the extent of shortening, and the resulting biomechanical alterations. METHOD: To investigate the biomechanical changes in the distal radioulnar joint (DRUJ) resulting from different osteotomy methods, a cadaveric specimen was dissected, and the presence of a stable DRUJ structure was confirmed. Subsequently, three-dimensional data of the specimen were obtained using a CT scan, and finite element analysis was conducted after additional processing. RESULTS: The DRUJ stress did not change significantly at the metaphyseal osteotomy of 2-3 mm but increased significantly when the osteotomy length reached 5 mm. When the osteotomy was performed at the diaphysis, the DRUJ stress increased with the osteotomy length, and the increase was greater than that of metaphyseal osteotomy. Stress on the DRUJ significantly increases when the position is changed to pronation dorsi-extension. Similarly, the increase in stress in diaphyseal osteotomy was greater than that in metaphyseal osteotomy. When the model was subjected to a longitudinal load of 100 N, neither osteotomy showed a significant change in DRUJ stress at the neutral position. However, the 100 N load significantly increased stress on the DRUJ when the position was changed to pronation dorsi-extension, and the diaphyseal osteotomy significantly increased stress on the DRUJ. CONCLUSIONS: For patients with distal oblique bundle, metaphyseal osteotomy result in a lower increase in intra-articular pressure in the DRUJ compared to diaphyseal osteotomy. However, it is crucial to note that regardless of the specific type of osteotomy employed, it is advisable to avoid a shortening length exceeding 5 mm.

Huge Distal Ulna Giant Cell Tumor Treated with Wide Local Excision and Extensor Carpi Ulnaris Tenodesis - A Rare Case Report.

Introduction: Giant cell tumors (GCT) are a relatively uncommon type of non-cancerous bone growth, representing around 4-10% of all bone tumors. These tumors tend to exhibit local aggressiveness and are typically prevalent in individuals between 20 and 40 years old. Commonly observed locations for GCT include the distal femur, proximal tibia, and the distal end of the radius. However, occurrences at the distal end of the ulna are rare, accounting for only 0.45-3.2% of cases. Case Report: In this instance, we present the case of a 36-year-old male diagnosed with a GCT specifically located in the left distal ulna. Our approach involved managing the patient through the complete removal (en-bloc resection) of the distal ulna. Following this, we performed an extensor carpi ulnaris (ECU) tenodesis to stabilize the proximal stump. After 2-year follow-up, the patient exhibited positive outcomes, displaying satisfactory wrist joint mobility and functionality without any signs of tumor recurrence. Conclusion: This case emphasizes the effectiveness of wide resection as a viable treatment for huge GCTs in the distal ulna. Utilizing tenodesis with the tendon of ECU significantly contributes to stabilizing the ulnar stump, leading to improved wrist function.

Adamantinoma of the ulna: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Adamantinomas are rare, low-grade, malignant skeletal tumors accounting for only 0.33-0.48 % of primary malignant bone tumors. CASE PRESENTATION: An 11-year-old boy with adamantinoma of the ulna was treated with en bloc resection, kryptonite bone cement, and plate fixation. The surgery resulted in marked pain relief and good functional recovery. No evidence of recurrence was observed for 5 years postoperatively, and the Musculoskeletal Tumor Society score was 93. CLINICAL DISCUSSION: This case of an 11-year-old previously treated for an aneurysmal bone cyst (ABC) illustrates the complexity of diagnosing adamantinoma, especially in atypical locations like the ulna. The successful use of en bloc resection and synthetic bone graft highlights the importance of accurate diagnosis and advanced surgical methods in achieving favorable outcomes in pediatric orthopedic oncology. CONCLUSION: Ulnar adamantinomas are rare and can be difficult to diagnose. The successful treatment of this tumor, as described in this case report, can help guide the management of similar cases in the future.

Risk Factor Analysis for Growth Arrest in Paediatric Physeal Fractures-A Prospective Study.

Background: Fractures through the physis account for 18-30% of all paediatric fractures, leading to growth arrest in up to 5.5% of cases. We have limited knowledge to predict which physeal fractures result in growth arrest and subsequent deformity or limb length discrepancy. The purpose of this study is to identify factors associated with physeal growth arrest to improve patient outcomes. Methods: This prospective cohort study was designed to develop a clinical prediction model for growth arrest after physeal injury. Patients ≤ 18 years old presenting within four weeks of injury were enrolled if they had open physes and sustained a physeal fracture of the humerus, radius, ulna, femur, tibia or fibula. Patients with prior history of same-site fracture or a condition known to alter bone growth or healing were excluded. Demographic data, potential prognostic indicators, and radiographic data were collected at baseline, during healing, and at one- and two-years post-injury. Results: A total of 332 patients had at least six months of follow-up or a diagnosis of growth arrest within six months of injury. In a comparison analysis, patients who developed growth arrest were more likely to be older (12.8 years vs. 9.4 years) and injured on the right side (53.0% vs. 45.7%). Initial displacement and angulation rates were higher in the growth arrest group (59.0% vs. 47.8% and 47.0% vs. 38.8%, respectively), but the amount of angulation was similar (27.0° vs. 28.4°). Rates of growth arrest were highest in distal femoral fractures (86%). Conclusions: The incidence of growth arrest in this patient population appears higher than the past literature reports at 30.1%. However, there may be variances in diagnostic criteria for growth arrest, and the true incidence may be lower. A number of patients were approaching skeletal maturity, and any growth arrest is likely to have less clinical significance in these cases. Further prospective long-term follow-up is required to determine risk factors, incidence, and true clinical impact of growth arrest when it does occur.

Ulnar Buttress Arthroplasty without Ulnar Stump Stabilization for Giant Cell Tumor of Distal Ulna.

Purpose Reconstruction and stabilization of ulnar stump after distal ulna tumor resection is still a matter of debate. We present the outcomes of ulnar buttress arthroplasty without stabilization of the ulna stump in giant cell tumor of bone (GCTB) of the distal ulna. Methods Evaluation of functional outcome was performed using Musculoskeletal Tumor Society 93 (MSTS93) score, Modified Mayo Wrist score (MMWS), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. We also assessed the hand grip strength, range of motion at the wrist, and ulnar carpal translation. Results The study included 8 patients with Campanacci grade 3 GCTB of the distal ulna with a mean follow-up of 35.5 ± 9.1 months. The mean resection length was 7.7 ± 1.3 cm. The mean hand grip strength on the operated side was noted to be 90 ± 0.04% of the contralateral side. Mean MSTS93 score was 27.9 ± 1.25, mean MMWS was 86.9 ± 4.58%, and the mean DASH score was 4.9 ± 1.67, depicting a good to excellent functional outcome with low degree of disability. No radiocarpal instability, ulnar carpal translation, prominence, or instability of the proximal ulnar stump was noted in any patient. Conclusion Reconstruction of the distal radioulnar joint using iliac crest bone graft for ulnar buttress without stabilization of the ulnar stump after resection of the distal ulna is an effective reconstruction option with good functional outcome and preservation of good hand grip strength. Level of Evidence Level IV, Therapeutic study.