So, our goals are to cover the major testable points here and to identify new literature that may support best practices. I don't sit on the previous slide. This is many thanks to Ryan Calfee who helped me with this lecture because we switched our talks so I could get to my family vacation this weekend. So, the effective age on maintaining close reduction decreases with advancing patient age. Basically, as you get older, the likelihood that your reduction is going to stick goes down. This is a study basically looking at that. The probability of unacceptable results, the three lines are at one week, initial reduction, one week, and two weeks. And basically, if you have a good reduction at two weeks, the likelihood of maintaining that reduction is obviously higher than if maintaining that reduction through the end is higher, but still pretty unacceptably low as you get older. So, there's a 50% chance that you're going to lose that reduction in an 82-year-old even if at two weeks they're stable. So, this is actually relatively helpful in treating, you know, the non-high trauma scapodistal radius fracture because, you know, we'll see these patients at one or two weeks and they're looking pretty good. If you aren't seeing these elderly patients back with some frequency, they can come back at four weeks and you'll say, oh my goodness, this is nothing like what we left you with two weeks ago because they still will lose their reduction. So, the Academy of Orthopedics has their treatment recommendations and they have a couple for dysarthritis fractures which can affect how we practice. Unacceptable reduction is an indication for some sort of treatment. If the radius is more than three millimeters short, dorsal tilt of greater than 10 degrees or an intra-articular displacement of greater than two millimeters, it seems like really good testable numbers. The recommendations are the use of some sort of rigid immobilization for non-operative care of displaced fractures and also the recommendation of vitamin C supplementation to prevent CRPS. So, we're going to talk just a little bit about that. So, this is one, two studies by one author that really pushed this and it was a good study but it has really taken off to be like one of the only recommendations the Academy has made on the treatment of dysarthritis fractures and Dave Ring has really called into question its validity. This other study in 2014 showed no difference, Dave Ring has showed no difference in finger motion with the use of vitamin C and I think that the thought is that the diagnosis of CRPS is so difficult to make, it's a very hard study to really get good data on. So, while this has been shown to be effective, it's also something that doesn't inherently make sense and may just be a little bit of a statistical blip. So, the surgical outcomes, so most studies, this is basically the only testable question, find equivalent results at one to two years regardless of how you do it. So, it doesn't matter if you go Volar or Dorsal or use an external fixator and we'll show a lot of data basically to support this but that's worth remembering. Internal fixation will generally provide earlier return to function at six to 12 weeks but by six months basically everyone's caught up depending on what other techniques you've used. So, any questions specifically about surgical technique are going to be very specific to the fracture that they're showing you about why you would go Dorsal or Volar use an X-Fix, maybe because there's a wound or infection but not because of the results of one over the other. So, Volar plating versus pinning, Tamara Rosenthal did this prospective randomized trial, 22 pinnings, 23 Volar plates, dashboard favored the plates at six, nine and 12 weeks and at six and nine weeks they had better motion and strength but the outcomes were similar at one year, no difference with the plating. Now, this is showing their return of motion, basically at six weeks they start off a decent amount apart because you can't really move the wrist with the pins in but by the time you get to a year, actually not statistically significant but the pins are moving better than the plates and so no real difference. Again, return to function, their disability is high at the beginning, less high with the plates at the very beginning but by a year pretty comparable and no statistically significant differences. Here are four other comparative studies really looking at that same bit of information and basically coming to the same conclusion. In the beginning, maybe it's a little better, in the end they're about the same. Pronator Quadratus, do we need to fix it? So these, there are two studies, one with 60 patients prospectively split between repairing and not, showed no difference in one year in objective or patient rated measures, no difference in the rate of re-operation or complications and then much bigger trial, not as maybe randomized but showed in 606 patients no difference with repair of the Pronator Quadratus. So fix it if you want but you don't need to if you don't want to. Post-AB rehabilitation, randomized control studies showing volar plating immobilized at two weeks versus six weeks. So no objective or patient based differences by three or six months. So again, in the short term maybe a little bit better with the therapy but in the long term no difference. And so the implication of that is that, you know, if you're worried about your fixation, you can probably hold them a little bit longer. If you feel like you've got things relatively stable, it's pretty safe to move them early. One of the important things in looking at, I think, randomized control studies, and this is a little bias of mine, is just because there's no difference doesn't mean that one's better, right? So if you said, well, there's no difference so why bother fixing the Pronator? Well, there's no difference so why not fix the Pronator? You know, so it doesn't really guide you one way or the other. So you have dealer's choice but a lot of times people will kind of take a randomized control study that shows no difference and says, okay, well, the simpler thing must be the way to go then. But that isn't actually proven by this. This is just proven that there is no difference. The timeline of recovery consistently documents improvements for a long time, which we should also be telling our patients the minute they come into our office. I saw a patient as a second opinion nurse supervisor in the hospital so mad at the doctor that took care of her, mainly because he just didn't tell her it was going to take so long. She was doing great. She had a great outcome. She had a great fixation and just didn't understand that this is like, oh, in six weeks I'll be back to doing everything I want and it was a year of therapy and working through stiffness to get recovered. So that is a really important fact for people to share with their patients. So the long-term outcomes, intra-articular fractures result in a high prevalence of osteoarthritis, although it is largely asymptomatic, which we all know. So 76% rate of arthrosis at 7.1 years, 13 of 16 at 15 years, 68% with arthrosis at 38 years, resulted in less motion but no functional detriment or increased pain and no need for further interventions. This is strongly correlated with residual articular displacement. Chuck Arbfarb did this study in 2006, which is the same thing I was taught as a resident because Jesse published it in 1986. Basically more than two millimeters of articular displacement leads to arthrosis, but is it clinically significant? So distal radius fractures in the elderly, we have two groups of people taking this course typically. It's people that have just finished fellowship and are getting ready to take their CAQ after a year or two of practice. They've all trained at like trauma centers and see everything crazy that goes on with the distal radius. And then we have the people that are reserving who are mainly seeing this group. And the treatment, you know, when you come out into practice, you just assume that everybody gets plates and screws for every distal radius fracture. And then when you get into the community, you realize that most of these people can be managed pretty effectively with a cast or a splint. So close reduction, unlikely to maintain reduction in very elderly or low-demand patients, as we talked about before, that loss or reduction goes up as they age and as time goes on. 37 of 44 reduced fractures lost their reduction. And overall, 53 of 60 fractures malunited. So ones that didn't, that were reduced and even ones that weren't reduced all went on to malunion with a really high rate. Randomized control study of reduction or no reduction showed no difference in 30 patients on the final radiographic outcomes. So for a lot of these elderly patients, I think what we can say is either they need to be fixed or they can be left alone. But there's no real important role for close reduction in most of these patients. Because if you really want to change their reduction, it needs to be done with an operation. The impact of malunion may not be that big in this group. ORF versus cast in 73 patients over the age of 65 showed no difference in range of motion, pain, dash, at six months. It did improve the x-rays. We love to treat x-rays. And grip strength was better, but they also had a higher rate of complication, obviously. Another study here in 2005 randomized control test of cast versus pin fixation, extra-articular fractures over 60. So getting into what we would start to consider younger patients. One year, no change in functional outcome despite the x-rays being better. So if you're treating x-rays, do a surgery. If you're treating the patient, maybe consider not. Osteoporosis obviously affects dysradious fractures occurring and then other medical issues. So often, dysradious fracture is a predecessor to a hip fracture. It's more prevalent among patients with dysradious fractures, osteoporosis is. Case control study of 749 fractures versus 608 controls, excuse me, 18% were osteoporotic females versus 5% in the controls. Males were 17% were osteoporotic versus 13 in the controls. So obviously, it's a, excuse me, independent risk factor for osteoporosis. They're also associated with an increased risk of subsequent hip fracture. And basically, the odds go up astronomically in the first month, 17 times in the first month, especially with patients over the age of 60. So that's what this chart is showing, the little hatch, the small columns to the right of the tall ones are just the control population who haven't had a dysradious fracture, but those that have are at really high risk for a hip fracture in the subsequent months. Cortical thickness is a way to evaluate osteoporosis on wrist films and in wrist x-rays. Basically, this study in 2015 showed it to be a better measurement than density on plain radiographs. Obviously, density is affected by the x-ray technique and the way we move our mouse on our screen to make it look more or less dense. But the measurement of the thickness of the cortices can really give you some insight as to how much osteoporosis they have. So complications of dysradious fractures. So volar plate complications reviewed by Song in 2011 demonstrated that they're overall rare, 47 out of 594, 14 with tendon irritation and only one FPL rupture, eight intra-articular screws, seven had loss of fixation, five with DRUJ-related complications. Similar complication in this other study in 2013 at five years and 303 patients. So relatively good operation, but not perfect. So retrospective review of flexor-tendon complications, we have this study here looked at two groups of patients differentiated by the plate design, Acumed versus Hand Innovations DVR, which was DePuy, now is Biomet, I think. It's hard to keep track. But basically, the names of the plates are not so important, but what's important to realize is where these plates are sitting. So when I started in practice, this was kind of the only dysradious plate available. Then this one came out and a lot of people thought, oh, this would be great, it has locking screws in the shaft. But the positioning of it is very distal. And as a result, we've had problems with it. And any plates that are very distal, it's not this plate, it's not this company, will give you the advantage of maybe better stabilization at the risk of more tendon complications. So basically, looking at this watershed line, which is two millimeters proximal to the ulnar side of the joint line and 10 to 15 millimeters proximal to the radial side of the joint line, that watershed, any plate that goes beyond that is at risk for these tendon complications. You have to be aware of it. I have a partner, actually, I think he was one of the authors on this paper, who still loves that very distal plate, but just takes it out when he needs it. When he needs that distal fixation, he uses it, but then he'll take it out. But it does provide you with different sorts of stability. So basically, this study had three ruptures with these distal plates and no ruptures with the DePuy Hand Innovations plate. Ruptures were noted in cases where the plate was placed volar to the critical line and or distal to the volar rim. So if the plate is too distal or not right on the bone, you're at risk for more of these tendon problems. These are pictures from their study, and that's that critical line. The farther distal you get, the worse it gets. Additional factors related to flexure tendon problems are plates resting off the bone. As we said, if they're not all the way down on the bone, that'll give you trouble. Any residual dorsal tilt will pull those tendons more across those plates and the fracture and maybe give you trouble. FPL and FTP to the index are the most commonly affected. FPL by far the most, and then after that, FTP to the index, just based on where those tendons traverse that line. Reported somewhere between four and 68 months after fixation. So this is a patient of mine, 23-year-old dominant hand. I would say I was aggressive in fixing this fracture, because it was reasonably well-reduced when I saw her in the office. But, you know, we have these new plates, so we had to use them. And these are the pictures, and we'll come back to this x-ray in a second. Here she is at five weeks post-op, and she is just doing amazing. And I am thinking, boy, am I great. And then she came back eight months later and asked, should the swelling in my wrist be getting bigger or not? And you can see all this inflammation on her tendons and her FPL is kind of like half worn through. And if we go back, if I can figure that out. If we look at my x-rays, not even very critically, but it's very, very distal. See in different pictures here. Very, very distal and not really applied to the bone. I think the other post-op x-ray shows that better. The intraoperative flora, you can really see that just a millimeter or two that that is off, but it's enough that with that distal positioning, it's really rubbing on the FPL. And this is actually the first of this acumen plate that I put in right when it came out, like in 2003 or four, something like that. But, you know, just, you know, definitely something to look at. You know, just, you know, definitely something to be aware of and learn from and avoid that. Or again, if you're, if you feel there's a need for that fixation, there's nothing wrong with that. It's just, you have to know that that's a problem and take that plate out. So avoiding flexor complications is the position of the plates proximal to that watershed line, tightly applied to the bone, remove the hardware of signs of tendon irritation occur to prevent rupture. Extensor complications, basically putting the screws in too long. EPL, EDC, ECR, BNL complications, possibly related to vascular compromise of the fracture. It is something you can see EPL ruptures with operatively treated fractures, although not as common as with the non-operatively treated. Drill penetration and screw prominence, obviously are related to these problems. This dorsal anatomy, I think seeing this picture really helps you understand why those screws that you're putting through or pegs, whatever you like, are at risk for causing tendon injuries and why you can be convinced they're in the bone when they're not because of that prominence of the Lister's tubercle. It's a convex surface. And Lister's tubercle hides the depressed third compartment so that third compartment basically sits behind here and from a lateral radiograph, you'll think you're in the bone when really your screw is in the tendon. So here's some dorsally prominence screws. And you know, it doesn't look too bad, but that's because you have some overlap and those are really through the radial cortex and give you some problems with the extensors more proximally. Again, more about this morphometry of Lister's tubercle. The depth of the EPL groove ranges from one to five millimeters and the distance between the tip of the tubercle and the depth of the groove vary between four and 10 millimeters. So you can see this ultrasound is a really great ultrasound image of the prominence of a screw being perfectly hidden by Lister's tubercle. So unicortical drilling for extra articular fractures. If you don't have a need to be through that dorsal cortex, probably not worth doing it. Penetrating the third extensor compartment by drilling may harm the EPL tendon, even if you don't put the screw there. So avoiding putting the drill there can be a good thing. Screws at least 75% of the length of the dorsal cortex do not sacrifice construct length. That's particularly true in extra articular fractures, non-comminuted fractures. Obviously, the more comminution you have, the more dorsal you have to get those screws to maintain the reduction. These radiographs I find to be incredibly helpful. We have a better picture, I think, in another, but basically these are described to show those dorsal screws where they may be prominent. And this one shows it very nicely, both the image on the right, which shows you how to do it, and then the image in the middle, which basically can show you the prominence of Lister's tubercle, and so you know that this long screw is in the longer bone, and that this screw, if you made that that same length, would have been outside of the bone. Same thing here. So this view is really helpful to avoid that prominence, and they've shown a really high correlation between the radiograph and the CT scan, and you can see it very well. It takes a little bit of finicking on a bigger arm sometimes. It's also a little harder with a mini C-arm. It's a lot easier with a big C-arm, obviously, to get a lot of arms under there and get that view, but it's really valuable to make sure that your screws are in the right spot. Another view, which I don't think I have shown here, but one of my fellows taught it to me, who's here, Dr. Sauerdecker, basically if you extend the wrist and do that same image, it really shows you very nicely the distorida ulnar joint, and so we'll see a complication of a screw placed in the distorida ulnar joint later, and that can show that to you as well. So neurologic complications, retraction can occur with retraction of the median nerve, so you want to create a mobile window. If you need to work very far ulnar, you might work on the ulnar side of that nerve rather than trying to pull it all the way over to the ulnar nerve. The palmar cutaneous branch can be at risk. I've shown 8% to 11% rate of that nerve being within the FCR sheath, so always when you're opening that sheath, you want to stay on the immediate radial side so that you're not, even if it is in the sheath, you're not anywhere near it. Osseous complications, losing support of the bone. The strength of support decreases as the screws become more proximal, and so you can see here, you know, this is a biomechanical study, these screws down here versus these screws up here, and I think the problem with biomechanical studies in distoridus fractures is it's really hard to reproduce a distoridus fracture. They have a broken bone, but no fracture occurs in this configuration with just two good pieces of bone, but obviously in most distoridus fractures, this bone is all dusted and has no structural rigidity, so you can see why these, I mean, this study still bore out that it's not as good, but in a real person, this would be even less stable. This probably wouldn't hold anything, and it really is the subchondral bone that we're relying on to hold this up, and so those screws have to be under that, or you can basically expect that the fracture is going, they're eventually going to be under the subchondral bone. It's going to collapse to that point in a lot of these patients. This is a patient of mine that just shows a really, really distal fracture and the importance of getting those pins just under the articular surface to support that, and even with these distal fractures, you can hold these with a volar plate, but it requires you to be really careful about the placement. Osteoscomplications is obviously one of the big ones is recognizing the loss of the lunate facet, so that's a common problem with these certain combinations of these injuries, and so looking at that on the lateral and doing something preoperatively, not finding it afterwards to prevent that, so some sort of other buttress plate or some fragment-specific fixation to prevent loss of that fixation. Obviously, you want to avoid articular screws. Putting screws into the joint is usually a bad thing. It is possible and I'm sure common to occur at the radiocarpal joint. It's probably as common or more common in the distal radioulnar joint, where you're kind of paying less attention compared to the, this is the surface we're all focusing on. This is a case I did arthroscopically assisted, and again, you can see just how close to the surface that peg is. You can see the peg is right here, kind of sitting under that subchondral bone, but it's only a millimeter or two away, and so you want to be distal, but not too distal. So complications of external fixation. You can have injuries to the superficial branch of the radial nerve in the forearm, so it's probably worth making incisions for the pins rather than trying to do them percutaneously. CRPS and contracture has been described with over-distraction of the radius through an external fixator, so you want to restore the palmar tilt with palmar translation, not with just pulling on it as hard as you can, and obviously assessing that mid-carpal joint to make sure that it's not over-distracted. Percutaneous pinning can also nail these nerves or tendons, and so some people advocate, based on studies like this, would show that almost 100% penetration of one of these structures with percutaneous pinning, either a tendon or a nerve, so maybe making incisions to just spread down to the bone when you're gonna pin a fracture. Casting complications. We don't see as much of this, I think, as we used to, because we do have a lot of tools to fix these unstable fractures, but still, you'll see patients that come in with this sort of a cast and just a horrible hand, and can really set people back a long way. I mean, you're better off just letting this be displaced and let it heal malunited than something like this, where their hand just comes in looking horrible. Yeah, this is a patient I saw with cast disease. You know, basically had been put in a really tight cast, swelling, carpal tunnel, CRPS, stiffness, and just takes a year to recover, and recovery is never complete with this. They never get their full grip back. So, associated carpal pathology, just like with the scaphoid fractures, when you fall on your wrist, you hurt more than just the one thing, so all based on series with arthroscopically-assisted distal radius fixation. Will Geisler and others basically have showed a high instance of other scapholunate lunofaracuitral and other soft tissue injuries. They're associated with intraarticular step-off, ulnar variance, and ulnar styloid fractures. The natural history. So, 10 of these had a grade three SL tear, 41 had a grade zero to two. None were treated, and at 14 months, oop. Basically, the grade three had four out of six had pain, and six of them had an SL widening, whereas the zero to two, only 14% had pain, and SL dissociation was relatively uncommon. So, definitely, as you get into grade three injuries with greater carpal instability, it may be something to consider surgical treatment to prevent that. Distal radius fractures associated with TFC-CRs are very common. Pretty much, you can almost assume there's gonna be some sort of TFC-CR injury with a distal radius fracture. 13-year follow-up, one had a repair. 17 of the 38 had dilaxity of the DRU-JAN exam with a little bit lower grip, but basically, their overall results were pretty good. Their DASH scores were very acceptable, only slightly worse than those that didn't have a TFC-CR, and did not really diminish the long-term outcome of these injuries. So, the literature suggests a high instance of concurrent carpal injury. However, the clinical importance of intercarpal ligament injuries associated with these fractures is still not known. It may not be necessary to treat all the lesions, and obviously, you just have to have those, the best thing, obviously, the most important thing is to identify them, and then have the discussion with the family and the patient about whether or not you want to address it. Obviously, the stiffness complications of scapular ligament repair combined with distal radius fracture, ORIF, in an elderly patient is really hard to justify in my mind. So, I'll have that discussion with a patient, and say, for me, I would live with it, and when it gets to be slack, I'll have my PRC, but I don't know that I would put myself through that combination. But, you know, obviously, you have a young guy that has this combination, you might be a little bit more aggressive. Likely, most low-grade lesions and TFC-CR injuries are not destabilizing, and are inconsequential. So, the ulnar styloid fractures, the effect of no ulnar styloid fixation. So, in this study here, zero of 138 were fixed. 32 were splinted in supination for four weeks, because they had some DRUJ instability. 1.4% of these had some chronic DRUJ instability. So, just, if you have an ulnar styloid fracture, and you can get stability with splinting and position, then that is usually the acceptable treatment. They do not all need to be fixed. The presence of an ulnar styloid fracture, 144 patients, three who had gross instability were excluded. Otherwise, the Michigan Hand Questionnaire, no difference in the results between those with the styloid fractures and those without. Styloid union and pain really showed no difference in those that went on to union versus those that had an non-union. So, a lot of the time, these ulnar styloid fractures can be left alone. So, definitely the testable question here is, if they have instability of the DRUJ, then you want to consider fixation of the ulnar styloid. But without it, there is really not a significant indication. So, in summary, no need to perform fixation if the DRUJ is stable. Only if it's unstable when stressed in all forearm positions. So, if you can get them in a supination and keep it stable, then that's usually considered acceptable. This is something I added this year, and it's not in your handout. I apologize, there's only a couple of slides. But basically, this group out of Australia has talked a lot about residual radial translation. And the correction of that may even eliminate the need to fix those ulnar styloid fractures that we're currently fixing. So, that a lot, the concept, and I kind of like it, but there's not a lot of good data. So, this is probably not testable yet. Maybe soon. Is that the, by fixing the radial translation of the distal radius, you can address the instability at the DRUJ. And it may lead to, that radial translation may lead to detensioning of the pronator quadratus, as well as the intraosseous, the oblique bundle of the intraosseous membrane. That seems like a great testable thing, because these studies have been out for a couple years, so that could have found its way to the test by now. Basically, that, and we'll show some pictures here that show the deformity. So, what they basically propose in their paper is this measurement of the ulnar border of the radial shaft, transecting a line of the lunate, that is, and this line of the lunate is drawn across on a PA film, in line with the angle of the distal radius. And showing that the majority of the lunate should be kind of, this should be in the middle, or mostly on the ulnar side, not on the radial side. So, this is a case that they showed with, even despite the fixation of the ulnar styloid, persistent DRUJ instability, and they propose it's because of this translation, that the radius is translated here. So, you see this fracture here, the distal radius is translated radially. The majority of the lunate is sitting out here, relative to the ulnar shaft of the radius. Once they fixate it, the ulnar line here moves most of the lunate over here to the ulnar side. And in the couple years that I've been looking at this, it really is remarkable how once you get that translated, not only does it change the position of the lunate, obviously, it also tightens the DRUJ. So, this is a case they did a corrective osteotomy. Basically, someone who had deriogated stability did this correction. You can see they got about to the midpoint of the lunate with this correction. My pointer is going particularly slow. There's another case of theirs. Again, we all see this pattern where the distal radius is translated radially, and sometimes that's hard to correct. So, what they're showing here, basically, is they put this plate on, and unfortunately, I put these in the wrong order. So, it's this one. Then, there's this picture right here where the plate is on distally at an angle and not corrected. Then, they put a clamp across here to translate the shaft radial word and the metathesis ulnar word and, basically, how that changes the alignment. Right here, you can see you barely have any lunate on the ulnar side. Here, it moves the lunate back up over the ulna, and that is predictive of better DREJ instability. Since they've observed this and started doing it over the last couple years, they have really stopped fixing ulnar styloid fractures. We must be getting near the end. All right, biomechanical evaluations of vulnar plating, looking at, basically, where the pins are placed and the length. So, moving the screws proximal, away from the subcondal bone, as we talked about before, weakens the construct. Getting at least four screws distally, maybe divided among two rows, has been shown to increase the stability. I don't know that I, again, this is a biomechanical study. What I don't like about this, again, is that we don't really see dysaureus fractures with a nice big chunk of bone like this where you can get two rows of screws in, like these cadavers with just a big, yes, in this particular construct, like a distal shaft fracture, I'm sure that's better. But as we talked about before, most of your fixation is coming from the subcondal bone of the radius, and maybe that is not so clinically important. You don't, obviously, have to fill all of the distal rows, and it depends on the plate construct you use. Sometimes the, in certain constructs, the next to last row is the one that reaches the most distally, whereas the distal row actually doesn't reach as far distally. So these are just kind of testable things because they're biomechanical studies. Additional locking screw at the metathesis can improve the rigidity, and that is probably a common thing that I see as well where patients, because the bone in that metathesis region is kind of soft, if you don't have a locking screw, sometimes that becomes a spinner in a lot of cases. So having some sort of locking fixation there can obviously help. And then unicortical lock screws, at least 75% of the length are equivalent to bicortical fixation. And again, they're showing here, they don't want you to be penetrating dorsally. Now these, I would say, are really, really not 75% on this particular picture that they included in their study. This looks like it's a little short of that, but you don't want to be out here. You want to be somewhere short of penetrating the dorsal cortex. Pegs versus screws. So pegs have been shown to be significantly weaker following cyclical loading and also under torsional loading. It's all that I use is pegs, but biomechanically, again, in these sort of constructs are not as good as screws because, of course, in these biomechanical studies, the screws actually can hold onto something, whereas in most of the disarray fractures, the purchase of those threads is probably not as clinically significant as they are in the biomechanical studies. The clinical series suggests increased technical difficulty removing the pegs, and I absolutely agree with that because you don't have the threads to back them out. They're a pain in the neck to get out if you need to do so. And that is all I have.

distal radius fractures

reduction

patient age

surgical outcomes

ulnar styloid fractures

complications

peg removal