Abstract
Purpose:
We evaluate the clinical and functional outcome of open primary repair of acute TFCC tears in distal radius fracture, when there is gross intraoperative distal radioulnar joint (DRUJ) instability after fixation of the distal radius, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed.
Methods:
A retrospective review of our institution’s distal radius fracture database over a 4-year period (January 2010 to December 2013). A total of 12 (1.38%) out of 3379 patients had an open TFCC repair in the same setting as fixation of distal radius. Assessment of outcome involved the analysis of objective and subjective clinical and functional outcomes.
Results:
All patient regained Activities of Daily Living (ADL) independence; eleven out of 12 patients (91.7%) returned to pre-injury function and 8 out of 11 patients (72.7%) returned to their jobs. DRUJ stability was preserved in 10 patients (83.3%) with 10 patients (83.3%) having grip strength of at least 50%, compared to the uninjured hand, and 7 (58.3%) with grip strength of more than or equal to 75%. Complications of surgery identified can be classified into 4 broad categories: infection, neurological complications, persistent DRUJ instability and prolonged pain.
Conclusion:
The authors believe a primary open repair of the TFCC should be considered when patients present with instability during intra-operative DRUJ ballottement test after distal radius fixation, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed.
Introduction
Distal radius fractures are often associated with ulnar styloid fractures and adjacent soft tissue injuries. 1,2 Triangular fibrocartilage complex (TFCC) tears have been found to be the most commonly associated soft tissue injury in distal radius fractures. 3,4 A study of patients with distal radius fractures by Bombaci et al. 5 revealed that associated TFCC injury was seen in 45% of the patients. As an important stabilizer, 6 TFCC allows smooth motion of the wrist and forearm, distributing load between the ulna and ulnar carpus and stabilizing the distal radioulnar joint (DRUJ). Disruption of the TFCC is associated with symptoms such as ulnar-sided wrist pain and palpable click with forearm rotation. 6 An untreated TFCC tear can affect the long-term functional outcome of the affected limb due to DRUJ instability and decreased grip strength. In a study of 51 patients, Lindau et al. 7 reported that 10 out of 11 patients with complete peripheral TFCC tears had DRUJ instability at 1-year follow-up compared to 7 out of 32 patients with only partial or no peripheral tears. These patients with DRUJ instability also had a worse functional wrist score. Another study by Mrkonjic et al. 8 on patients with untreated TFCC tears after 13–15 years from the date of injury identified a similar pattern of increased laxity of DRUJ, decreased grip strength and poorer Gartland, Werley and Disabilities of Arm, Shoulder and Hand (DASH) scores.
In the current medical literature, some authors have adopted the approach of primary repair of TFCC tears in the same setting as the distal radius fracture fixation, and it has been shown to be associated with good outcome. 9,10 In our institution, we have a similar approach of open primary repair of TFCC when there is gross intraoperative DRUJ instability in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed. In this study, we evaluate the clinical and functional outcome of open repair of acute TFCC tears.
Methods
In our institution, we maintain a prospective database of all distal radius fractures, including those managed non-surgically. In this study, we performed a retrospective review of this database over a 4-year period (January 2010 to December 2013), and we analysed data on patients who underwent open TFCC repair together with distal radius fracture fixation.
In our study, besides data on patient demographics and details of the injury, details of the surgical intervention, post-operative complications and both clinical and functional outcomes were collated and analysed. Ranges of motion, grip strength, ability to return to work, duration before return to work and DASH scores obtained on follow-up were analysed as part of the assessment of objective clinical and functional outcomes. The presence of pain, joint instability, neurological disturbances and scar appearance during follow-up visits were analysed as aspects of subjective clinical outcome. Post-operative functional status was studied based on Katz Index of Independence in Activities of Daily Living (ADL). 11
Data compiled was analysed using Statistical Package for the Social Sciences® Version 20.0.
Results
During the 4-year period analysed in our study, our institution managed a total of 3379 patients with distal radius fractures. Of these patients, 867 (25.7%) were managed with distal radius fracture fixation. In this group of patients who were managed surgically, 12 patients (1.38%) had an open TFCC repair in the same setting as fixation of distal radius.
Of the 12 patients who underwent TFCC repair, 9 were males. The mean age at the time of surgery was 50.5 years (range: 32–73 years), and the mean length of hospital stay is 6.1 days (range: 1–16 days). At the time of injury, 11 patients were active members of the workforce, while 1 was a retiree. All 12 patients were community ambulant and independent in their ADL prior to the injury.
All 12 patients sustained unilateral distal radius fractures and the dominant hand was involved in 4 of the cases. Five of the patients sustained the fracture from a fall on an outstretched hand, while the others were involved in a road traffic accident. Table 1 shows the
Preoperative radiographic features of distal radius fractures in all 12 patients.
All 12 patients presented with instability during intraoperative DRUJ ballottement test after fixation of the distal radius fracture; thus, open repair of TFCC was performed. The DRUJ ballottement test to assess for DRUJ stability was performed following a standardized technique 12 with the patient’s forearm in a neutral position and the examiner applying dorsal and volar forces on the distal ulna, with the radius stabilized by the examiner’s opposite hand.
All 12 cases of distal radius fracture fixation were performed via a standard volar approach with the Titanium Variable Angle LCP Two-Column Volar Distal Radius Plate 2.4 from Synthes GmbH Johnson (Singapore). Intraoperatively, after fixation of the radius fracture, in the event of DRUJ instability, the surgical management will depend on the presence of ulnar styloid fracture. In the absence of ulnar styloid fracture or if the styloid fragment is too small for fixation, an open TFCC repair will be done through a separate ulnar-sided longitudinal incision. With the dorsal cutaneous branch of ulnar nerve preserved, the DRUJ capsule is incised longitudinally. By retracting the capsule volarly and dorsally, the ulnocarpal joint is exposed and the avulsed TFCC identified. Running PDS 3/0 is sutured to the periphery of the TFCC, leaving the two ends of the suture long. Two 21-gauge needles are drilled from the ulnar cortex of the ulna towards the fovea and are used to guide the two ends of the PDS 3/0 suture back to the ulnar cortex of the ulna. The PDS 3/0 is secured with the forearm in neutral position, and the wound is closed in layers. For 10 out of our 12 patients, two 1.6 mm Kirschner wires, from radius to ulna, were used to protect the TFCC repair for 6 weeks. The remaining two patients were placed in a forearm Muenster Splint for 6 weeks. After 6 weeks, protected mobilization of the forearm is commenced for 3–4 weeks. This is followed by further strengthening exercises.
Mean follow-up period was 22.0 months (range: 12–48 months). Markers of subjective outcome of surgery assessed on follow-up are summarized in Table 2.
Summary of the subjective outcome of each patient.a
aPresent (+); absent (−); (number of months before symptom resolution).
Based on a clinical examination at 1-year follow-up, 10 out of 12 patients (83.3%) presented with a negative DRUJ ballottement test, indicating a clinically stable DRUJ, and 10 patients (83.3%) had a grip strength of at least 50%, compared to the uninjured hand, and 7 (58.3%) had a grip strength of more than or equal to 75% (refer to Table 3). The ranges of motion at the final clinical follow-up review are listed in Table 4.
Objective grip strength measurement compared to contralateral uninjured hand at 1-year post-surgery review.
Ranges of motion of affected wrist, assessed during post-operative follow-up.
With respect to the objective functional outcome, ability to return to their prior functional status was analysed and DASH scores were calculated based on DASH questionnaires administered. The questionnaires were administered at 1 year after the surgery for five of the patients, 2 years after for five others, 3 years after for one patient and 4 years after for one patient. The mean DASH score was 8.05 (range: 0–31.03), and all patients were able to regain independence in their ADL. In our study, 8 out of 11 patients (72.7%) who were working prior to the injury were able to return to their pre-injury occupations. One was not able to return to work due to lack of confidence in carrying loads. Two other patients regained pre-injury functional status but had retired for reasons not related to upper limb function.
Complications of surgery identified in our study can be classified into three broad categories: infection, neurological complications and persistent DRUJ instability.
Infection
A 42-year-old male, who initially sustained a closed injury, presented with a pseudomonas infection of the ulnar wound 3 weeks postoperatively – this resolved with antibiotic therapy.
Neurological complications
Four patients (33.3%) presented with sensory disturbances – one had radial nerve neuropathy and three patients experienced hypoaesthesia of the hypothenar region supplied by ulnar nerve. Symptoms in all four patients resolved with conservative management. A 66-year-old female experienced self-limiting high radial nerve neuropraxia, likely secondary to intraoperative tourniquet application. A 58-year-old male presented with ulnar neuropathy, experiencing weakness of the ulnar-innervated intrinsic muscles in addition to numbness over the hypothenar region, which were seen in two other patients.
Persistent DRUJ instability
Out of the 12 patients, one presented with wrist instability. A 32-year-old male presented with ulnar styloid pain with associated tenderness on pronation and DRUJ ballottement at 3-month follow-up. At 4- and 5-month follow-up, the pain persisted with associated decreased grip strength despite intensive hand therapy. At 6-month follow-up, the DRUJ ballottement test suggested joint instability, requiring reconstruction. A DRUJ reconstruction, based on the technique described by Adams and Berger, 13 was performed 8 months after the initial surgery, with improvement in stability and grip strength post-operatively.
Discussion
While we acknowledge that management of TFCC tears associated with distal radius fractures remains controversial, our study aims to look at the outcome of open repair of TFCC tears. Our study shows favourable outcome with all patient regaining ADL independence: 11 out of 12 patients (91.7%) returning to pre-injury function and 8 out of 11 patients (72.7%) returning to their jobs. DRUJ stability was preserved in 10 out of 12 patients (83.3%) with 10 patients (83.3%) having a grip strength of at least 50%, compared to the uninjured hand, and 7 (58.3%) with a grip strength of more than or equal to 75%.
Nevertheless, there were incidences of subjective grip weakness (four patients), neurological disturbances (four patients) and wrist instability (one patient). These are subjective post-operative complaints that prospective patients should be counselled on before surgery. As shown in our data, despite the repair of the TFCC, one patient (8.3%) required subsequent DRUJ reconstruction. Hence, a possible need for subsequent DRUJ reconstruction for persistent post-operative DRUJ instability should be advised to patients.
As our study is a single-arm assessment of outcome, results in cases whereby TFCC repair was not performed were not identified and an analysis between these two groups was not possible.
Our study is retrospective involving different surgeons from our unit, with differing intraoperative and post-operative regime. Intraoperative method of TFCC repair employed included bone tunnel or suture anchor. Post-operative stabilization regime involved either the use of K-wire for 6 weeks (12 patients) or the use of Muenster Splint for 6 weeks (two patients).
Conclusion
In conclusion, the authors believe that an open primary TFCC repair should be considered when patients present with instability during intraoperative DRUJ ballottement test after fixation of the distal radius fracture, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed. However, in view of the limitations highlighted in our study, a prospective and double arm assessment of surgical outcome would be required to show definite evidence for open primary TFCC repair.
Footnotes
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.