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. 2011 Jun;82(3):360-4.
doi: 10.3109/17453674.2011.579517. Epub 2011 Apr 19.

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Johan H Scheer  1 , Lars E Adolfsson
Affiliations

Pathomechanisms of ulnar ligament lesions of the wrist in a cadaveric distal radius fracture model

Johan H Scheer et al. Acta Orthop. 2011 Jun.

Abstract

Background and purpose: Mechanisms of injury to ulnar-sided ligaments (stabilizing the distal radioulnar joint and the ulna to the carpus) associated with dorsally displaced distal radius fractures are poorly described. We investigated the injury patterns in a human cadaver fracture model.

Methods: Fresh frozen human cadaver arms were used. A dorsal open-wedge osteotomy was performed in the distal radius. In 8 specimens, pressure was applied to the palm with the wrist in dorsiflexion and ulnar-sided stabilizing structures subsequently severed. Dorsal angulation was measured on digitized radiographs. In 8 other specimens, the triangular fibrocartilage complex (TFCC) was forced into rupture by axially loading the forearm with the wrist in dorsiflexion. The ulnar side was dissected and injuries were recorded.

Results: Intact ulnar soft tissues limited the dorsal angulation of the distal radius fragment to a median of 32(o) (16-34). A combination of bending and shearing of the distal radius fragment was needed to create TFCC injuries. Both palmar and dorsal injuries were observed simultaneously in 6 of 8 specimens.

Interpretation: A TFCC injury can be expected when dorsal angulation of a distal radius fracture exceeds 32(o). The extensor carpi ulnaris subsheath may be a functionally integral part of the TFCC. Both dorsal and palmar structures can tear simultaneously. These findings may have implications for reconstruction of ulnar sided soft tissue injuries.

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Figures

Figure 1.
Figure 1.
The TFCC is forced into rupture (specimen 4). The ulnar head is bald. Note the ECU tendon sheath torn out of its groove in the distal ulna. US: ulnar styloid with a type-1 fracture; bold arrow: longitudinal force applied to the forearm.
Figure 2.
Figure 2.
Classification of ulnar styloid fractures. Palmar view. Type 1: distal to the base where superficial horizontal fibers of the TFCC insert, as well as the dorsal UT ligament (Sasao et al. 2003). Type 2: base fracture; goes through a line perpendicular to the ulnar shaft and into the proximal limitation of the fovea, but does not involve the articular surface of the ulnar head. Type 3: proximal to a Type 2 fracture. Arrow: ECU tendon sheath.
Figure 3.
Figure 3.
Sequence of displacement of the distal radius fragment in specimen 4. A. Before TFCC disruption. B. Maximum displacement. C. Pressure released.
Figure 4.
Figure 4.
Type-1 foveal TFCC fiber disruption. A. Oblique palmar view. A hole is visible in the palmar capsule and foveal fibers are disrupted. Bold arrow: tension of the soft tissues in the direction of the UC, UT, and UL ligaments. B. Transverse view. Small arrow: the dorsal separation between the ECU tendon sheath and the TFCC.
Figure 5.
Figure 5.
Type-2 foveal TFCC fibre disruption. A. Oblique palmar view. Complete disruption of the palmar capsule with either a sagittal rupture of the superficial fibers of the radio­ulnar ligaments (upper panel) or an ulnar styloid fracture of type 1 (lower panel). B. Transverse view. Arrow: the dorsal separation between the ECU tendon sheath and the TFCC.
Figure 6.
Figure 6.
Fracture through the base of the ulnar styloid (type 2). A. Oblique palmar view. The TFCC was displaced together with the ulnar styloid fragment. B. Transverse view. Note the absence of dorsal separation between the ECU tendon sheath and the TFCC.
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References

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