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Letters to the Editor to:

Scientific Articles:
J. Sebastiaan Souer, David Ring, Stefan Matschke, Laurent Audige, Marta Marent-Huber, Jesse B. Jupiter, and the AOCID Prospective ORIF Distal Radius Study Group
Effect of an Unrepaired Fracture of the Ulnar Styloid Base on Outcome After Plate-and-Screw Fixation of a Distal Radial Fracture
J Bone Joint Surg Am 2009; 91: 830-838 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Ring and colleagues respond to Mr. Al-Fakayh
David Ring, MD, PhD, Jesse B. Jupiter, MD, J. Sebastiaan Souer, MD   (11 September 2009)
[Read Letter to the Editor] Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures
Omar Al-Fakayh   (11 September 2009)

Dr. Ring and colleagues respond to Mr. Al-Fakayh 11 September 2009
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David Ring, MD, PhD,
Physician
Massachusetts General Hospital,
Jesse B. Jupiter, MD, J. Sebastiaan Souer, MD

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Re: Dr. Ring and colleagues respond to Mr. Al-Fakayh

dring{at}partners.org David Ring, MD, PhD, et al.

Mr. Al-Fakayh clearly restates part of the rationale that has led many of us to think of base of ulnar styloid fractures as a marker for poor outcome, which our data clearly show is not the case. Mr. Al-Fakayh also correctly restates the shortcoming of our study — that there was no specific evaluation of DRUJ instability; however, the 2-year follow-up and few symptoms and no procedures related to the DRUJ is fairly convincing. At a minimum, our data confirm that the concern regarding base of ulnar styloid fractures is overstated. In terms of pure science, we agree with Mr. Al-Fakayh’s proposed study design; however, does data such as ours make randomization to operative treatment of an ulnar styloid base fracture in 50% of patients unethical?

We think the next study might be a prospective cohort study with specific evaluation of the DRUJ, or perhaps a clinical trial comparing two nonoperative treatments (for instance free forearm motion immediately versus immobilization in mid-supination for several weeks). For this to be meaningful, we will need to develop a clear definition and an objective and quantifiable measure of DRUJ instability. In any case, we are all in agreement that science will be the ultimate arbiter of this debate.
Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures 11 September 2009
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Omar Al-Fakayh,
Specialist Registrar
Aberdeen Royal Infirmary, Aberdeen, United Kingdom

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Re: Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures

alfakayh{at}hotmail.co.uk Omar Al-Fakayh

To the Editor:

I read with great interest the study by Souer et al. (1) and I have a few comments. It is well known that distal radius fracture is associated with ulnar styloid fracture in more than 40% of cases (2). It has been suggested that injuries to the ulnar styloid will lead to instability of the distal radio-ulnar joint (DRUJ) (3,4). The authors suggested that there is no difference between the groups regarding DRUJ stability, although it was not assessed clinically or radiographically. As previous research has identified, distal radioulnar joint instability may lead to long-term problems with wrist pain (5) and May et al. found that all distal radial fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture (3).

I agree with the authors that comparing outcomes between patients with ulnar styloid fractures and those without will provide some information about the impact of the unrepaired ulnar styloid fracture on the outcome of distal radius fracture fixation. However, the best way to answer this question is to select a group of distal radius fracture patients with associated ulnar styloid fractures only and then to randomize them to have the ulnar styloid fixed or not and compare the outcomes of these two cohorts of patients.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References

1. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M, Jupiter JB, AOCID Prospective ORIF Distal Radius Study Group. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixation of a distal radial fracture. J Bone Joint Surg Am. 2009;91:830-8.

2. Logan AJ, Lindau TR. The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment. Strategies Trauma Limb Reconstr. 2008;3:49–56.

3. 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. 2008;27:965–71.

4. Stoffelen D, De Smet L, Broos P. The importance of the distal radioulnar joint in distal radial fractures. J Hand Surg Br. 1998;23:507-11.

5. 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.