///

Distal ulna fracture fixation using the Synthes 2mm LCP Distal Ulna Plate

    Overview

    Learn the Distal ulna fracture fixation using the Synthes 2mm LCP Distal Ulna Plate surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Distal ulna fracture fixation using the Synthes 2mm LCP Distal Ulna Plate surgical procedure.
    Distal ulna fractures rarely occur in isolation and are usually associated with a distal radius fracture. Combined distal radius and distal ulna fractures in adults typically present in the elderly (> 65 years old) and are associated with osteoporosis. Ulnar styloid tip fractures are very common and are associated with 55% of distal radius fractures. The majority of these are stable and are treated conservatively. Ulnar metaphyseal fractures are less common and are only associated with 5-6% of distal radius fractures.
    With the wrist in neutral rotation, the ulnocarpal joint bears nearly 20% of the load across the wrist. As the forearm rotates into pronation or when gripping, there is a relative increase in ulnar length and the proportion of load transfer through the ulnocarpal joint will increase.
    The distal ulna can be subdivided into three regions. The ulnar styloid tip, the ulnar styloid base / ulnar head, and the distal ulnar metaphysis. The ulnar styloid is the anchor for the Triangular FibroCartilage Complex (TFCC) and the ulnocarpal ligaments. The TFCC preserves the congruence between the distal radius and ulnar head; and the proximal carpal row. The TFCC has superficial and deep components. The superficial ligaments are attached to the ulnar styloid tip, and the deep fibres are attached to the fovea of the ulnar head at the base of the ulnar styloid.
    A distal ulnar metaphysis fracture can be defined as a fracture that is within 5cm of the distal ulnar dome of the ulnar head.
    The stability of the DRUJ is determined by the bony anatomy (and the shape of the sigmoid notch of the distal radius), and the surrounding ligaments and muscles. The stabilising structures are the:
    Triangular FibroCartilage Complex (TFCC)
    Ulnocarpal ligament complex
    Extensor Carpi Ulnaris (ECU) tendon and tendon sheath
    Pronator Quadratus (PQ) muscle
    Interosseous membrane (IOM) and the interosseous ligament (IOL)
    Joint capsule
    The Synthes 2.0mm Locking Compression Plate for Distal Ulna fractures is indicated for ulnar styloid and ulnar head / neck fractures. The plate is anatomically contoured with a low profile which reduces the need for extensive soft tissue dissection and lowers the incidence for implant removal due to soft tissue irritation. The plate accepts both non-locking and fixed angle locking screws via Combi holes in the plate shaft section. Using non-locking screws in the shaft section allows for length adjustment and/or dynamic fracture compression. Distally on the under-surface of the implant, there is a cut on the plate which allows for contouring if necessary. The distal section only accepts locking screws which provide angular stability and in combination with the hook section provide good fixation to an often very small fracture fragment. The hook section also allows the plate to be applied in the correct position and gives a good indication for reference height and plate positioning. Between the prongs of the hook, a 1.1mm K-wire can be used to temporarily hold the reduction or it can be exchanged for a 1.5mm non-locking screw that can be used to stabilise a styloid tip fracture.
    Readers will also find of interest these other associated OrthOracle surgical techniques:
    Open Reduction and Internal Fixation of a Galeazzi radius fracture using Synthes LCP locking plate
    Open Reduction Internal Fixation of a Monteggia forearm fracture dislocation using the Synthes small fragment LCP plate
    Distal radius fracture : Manipulation Under Anaesthetic (MUA) and K-wire fixation
    Compound distal radius fracture: stabilised with Hoffman II External Fixator
    Distal Radius Fracture fixation , volar approach with Synthes® 2.4 mm Variable Angle locking LCP
    Distal Radial fracture fixation with dorsal approach and Synthes 2.4mm variable angle plating system
    Dorsal plating of distal radial fracture with Depuy/Synthes 2.4mm VA locking radial column plate assisted by wrist arthroscopy using Acumed ARC tower

    Indications

    INDICATIONS
    As ulnar styloid fractures are commonly associated with distal radius fractures, there is a reasonable body of evidence and literature that supports non-operative management of the ulnar styloid fracture. However, some authors report a decrease in grip strength and wrist mobility. In a paper by Kramer et al. they found that the incidence of DRUJ instability was higher in patients with an ulnar styloid fracture compared to those without. They also found that the incidence of DRUJ instability was not significantly different comparing styloid tip fractures with ulnar base fractures. This is interesting as some would hypothesise that with an ulnar styloid tip fracture, the deep fibres of the TFCC should still be attached to the fovea and the DRUJ is less likely to be unstable (which is not the case according to Kramer et al.).
    In the same paper by Kramer et al. they report their incidence of ulnar styloid nonunion (no bridging callus 6 months after injury) of 46% (the literature ranges from 22% to 63%). They also found that the incidence of ulnocarpal complaints was dependent on the presence of an ulnar styloid fracture and not on whether it had healed or not.
    To determine whether a distal ulna fracture requires fixation / stabilisation, then the decision and management question you should ask yourself is:
    Is the Distal Radio-Ulnar Joint (DRUJ) unstable?
    SYMPTOMS & EXAMINATION
    Acute fractures are painful and if significantly displaced will have a visible clinical deformity. Not infrequently the ulnar head or ulnar metaphyseal fracture will perforate the dorso-ulnar skin. Often fractures have localised swelling and bruising.
    If the distal radius fracture is being managed operatively or appropriate anaesthesia can be provided, then the DRUJ stability should be tested.
    To assess the DRUJ, the majority of surgeons would state that they would make a comparison with the normal uninjured wrist. This is impractical mid-procedure, unless you de-scrub (or prep both wrists at the beginning). Mr preferred technique is to assess the DRUJ translation with the wrist in mid-pronation / mid-supination. The forearm is then fully pronated / supinated and re-assessed. The DRUJ should be looser in the mid-rotation position and then tighten when fully pronated / supinated. I find this a more reliable method than trying to estimate the amount of translation and compare it to published values. Essentially the DRUJ should become more stable when fully pronated / supinated when compared with the mid-rotation position.
    IMAGING
    Plain x-ray imaging including both an Antero-Posterior (AP) and Lateral (Lat) radiograph are usually sufficient. CT scans are useful to assess fracture configuration and orientation for pre-operative planning. MRI scans have no role in the acute injury, as the whole area will be high signal and oedematous.
    ALTERNATIVE OPERATIVE TREATMENT
    This varies depending on whether you are treating a styloid fracture or whether the injury involves the metaphysis or ulnar head.
    If it is a styloid fracture, then options include either simple K-wire stabilisation but this often doesn’t keep the fracture compressed and reduced. Another option would be to supplement the K-wire stabilisation with a tension band wire. Some surgeons prefer to use small lag screws inserted into the styloid fracture however, I worry that the fragment would split.
    If dealing with a metaphyseal or head fracture then the only option is to apply some sort of plate. The small fragment 1/3 tubular plates (standard or locking) are often used but only allow 1-2 screws into the distal fragment, depending on where the fracture line is. Another option would be to use either a Dynamic Compression Plate (DCP) or a Locking Compression Plate (LCP) however, these are often very bulky and require secondary surgery to remove them. For fractures that are too proximal to be controlled by the 2.0mm Ulna Hook Plate, then a 2.7mm either straight or condylar plate from the Synthes LCP Compact Foot / Compact Hand range will work well, as it allows both locking and non-locking screws and is also fairly low profile. It should be noted that the Ulna Hook Plate is only 46mm in length.
    In unreconstructable ulnar head injuries salvage operations include: a Darrach procedure; Sauvé-Kapandji procedure or ulnar head replacement.
    NON-OPERATIVE MANAGEMENT
    Non-operative management of distal ulnar styloid fractures is a well-recognised technique. However, for those that are displaced and the distal radius fracture is to be treated surgically, I would always recommend assessing the stability of the DRUJ before deciding on which treatment strategy.
    For distal ulnar metaphyseal fractures:
    Malalignment is defined as > 10 degrees of angular deformity, or > 3mm of ulnar variance change, or > 1/3 translation of the fracture.
    Instability is defined as a tendency for the fracture fragments to move with passive forearm rotation.
    In these cases I would not accept non-operative management.
    CONTRAINDICATIONS
    Grossly contaminated open fractures
    Soft tissue defects that cannot be closed.
    Forearm compartment syndrome
    Kramer S, Meyer H, O’Loughlin PF, Vaske B, Krettek C, Gaulke R. The incidence of ulnocarpal complaints after distal radial fracture in relation to the fracture of the ulnar styloid. J Hand Surg Eur. 2012; 38(7): 710-717

    Setup

    Supine with an arm table
    General or regional anaesthesia
    Intravenous antibiotics prior to tourniquet inflation
    Tourniquet inflated to 250mmHg

    Operation – 1

    The PA (Postero-Anterior) radiograph demonstrates a distal radius and distal ulna fracture.
    The distal radius fracture may be intra-articular but it is hard to tell on this view. The distal radius is short compared to the distal ulna. There is also a loss of radial inclination.
    The ulna metaphyseal fracture shows radial angulation. There is no significant translation. There is also an ulnar styloid fracture, which may be old.

    The lateral radiograph demonstrates that the distal radius fracture is intra-articular and has a sagittal plane split of the articular surface.
    If you draw lines along the volar and dorsal cortices of the radius and extended them toward to the hand, the carpus (centre of the lunate) should be within these 2 lines i.e. within the ‘ball park’. Here the whole carpus is volarly translated.
    The distal radius fracture line is visible on both the volar and dorsal cortices. As the dorsal cortex is fractured, this means that the fracture pattern is a Smith’s type. If the dorsal cortex were intact, then this would be a volar Barton type fracture.

    The first step in the procedure is to pre-wash the limb.
    The forearm is washed with a soap solution to remove any grease or oil that would repel the water / alcohol based antiseptic preparation solution.

    The arm is prepared with an antiseptic solution.
    I routinely perform a double preparation using alcoholic chlorhexidine. The first batch has a dark pink stain, so that I can clearly see that the whole limb has been coated. The second batch has a very light pink stain and is used to ‘wash off’ the darker pink stain, thus using the contrasting colours to clearly see that the whole limb has been painted twice.

    Examining the limb there was a small wound on the dorsal aspect. We debated amongst the team whether this constituted an ‘open fracture’. Clues that it could communicate with the bone are:
    It won’t stop bleeding
    Fat globules mixed in with the blood
    Bone visible in the wound
    From the x-ray / CT: gas near or around the fracture

    To resolve the debate, I took the blunt end of a K-wire and gently probed the wound. This revealed a tract and bone could be felt at the base of it.

    A fluoroscopic image confirmed that the wound communicated with the ulna fracture.

    The distal radius fracture should be fixed first as this may mean that the distal ulna fracture does not require stabilisation. However, if there is persistent DRUJ instability, then the ulna fracture should be addressed.
    Also metalwork applied to the distal ulna, may compromise your ability to image the distal radius fluoroscopically and ensure that all screws are extra-articular.

    The skin incisions are drawn with a marker pen
    It should be your routine practice to pick up a skin marker pen before picking up a scalpel. This allows incisions to be planned and it also allows you to change your mind.

    There is a separate technique fully describing a distal radius open reduction internal fixation which can be read at Distal Radius Fracture fixation , volar approach with Synthes® 2.4 mm Variable Angle locking LCP
    I am sharing these following few images to highlight a couple of variations in my technique.
    I don’t use an Esmarck bandage to exsanguinate the limb. I just use elevation, so that the blood vessels are still visible and can be haemostased.
    I incise the radial side of the floor of the Flexor Carpi Radialis (FCR) tendon sheath. The ulnar side potentially risks injury to the Palmar Cutaneous Branch of the Median Nerve.
    Lifting the floor of the tendon sheath with forceps (A) and exploiting the plane of loose areolar tissue with the tenotomy scissors, you will often find perforating vessels (B) from the radial artery that supply the Flexor Pollicis Longus (FPL) and Pronator Quadratus (PQ) muscles. These can be haemostased and I believe reduce the incidence of post-operative bleeding, haematoma, bruising, swelling and pain.

    The distal radius fracture is exposed first, using a modified Henry’s approach.I do not use a West retractor as it has sharp teeth. I prefer a Weitlander self retainer.
    The tines can be placed under the radial floor of the FCR tendon sheath and this creates a barrier to retract the radial artery. On the ulnar side, the PQ is retracted and this distributes the pressure applied to the median nerve.

    The distal radius plate is applied initially to the volar aspect of the distal fragment.I like to temporarily apply the plate using 1.25mm K-wires. This allows the position to be accurately controlled and checked using fluoroscopy.
    The distal radius plate has K-wire holes distal to the distal screw row. On the ulnar side, a K-wire placed through this hole should be parallel with the joint and sub-chondral on the lunate fossa lateral view.
    When using fixed angled locking screws in the distal row, if the wire is not in the joint, then you can be assured that any screw inserted in the distal row will also not be in the joint because the ulnar sided screws are parallel to the wire and are more proximal.

    The plate is then reduced on to the distal radius shaft to correct the articular surface angulation and restore the volar tilt.A second 1.25mm K-wire is inserted through the plate into the shaft to hold it in place while radiographs are taken to confirm the plate position and fracture reduction.
    Here 11 degrees of volar tilt have been restored.
    Remember the AO rule of of 11s:
    11 degrees of volar tilt
    11 mm of radial height (measured from the radial styloid to the ulnar head)
    22 degrees of radial inclination

    An AP radiograph demonstrates that the distal radius plate is correctly positioned over the distal fragment and is not overhanging the DRUJ or radial styloid.
    Proximally the plate is not aligned with the distal radius shaft however, this isn’t a mistake. The distal radius articular surface inclination has not yet been corrected.
    The plan is to insert some screws into the distal fragment and only when it has been adequately captured, can the inclination be restored. Correcting the distal radius inclination (i.e. moving distal and rotating clockwise) will cause the proximal end of the plate to translate radially and overlie the diaphysis. The shaft K-wire will need to be removed before trying this reduction manoeuvre.

    The distal row locking screws are drilled with the 1.8mm drill bit.I routinely fix distal radius fractures in the semi-pronated/supinated position. This allows the drill depth to be confirmed fluoroscopically using a large C-arm and ensures that all screws are extra-articular.
    The drill must be held horizontally to allow clearance of the table.
    There is a rolled bandage under the distal ulna. This helps to achieve a lunate fossa view x-ray, and ensure that the drill is extra-articular. It also allows the weight of the hand to help restore the radial inclination.
    The assistant can apply pressure to the dorsal aspect of the distal radius and this helps reduce the fracture on to the plate.
    If you try this in the supinated position, the wrist has to be flexed to reduce the distal fragment on to the plate and thus reduces your visibility / access to the distal radius.

    The 2.4mm locking screws are inserted into the distal row.I usually apply the plate initially distally using a K-wire through the ulnar sided distal row hole. If you use the fixed angle screw guide and the K-wire is extra-articular, you can be confident that the drill / screw will also be extra-articular, as the wire is the most distal aspect of the plate.
    Once the distal row is secure, I then use the plate to correct the volar tilt / radial inclination / radial shortening / radial translation and temporarily fix it to the diaphysis with a K-wire, while confirming the reduction with the C-arm.
    It should be noted that variable angle screws can be substituted for fixed angle screws (but not vice versa).

    The distal radius fracture length, alignment and rotation have been restored to their pre-injury position. In this patient, they have probably had a previous distal radius fracture that has been treated conservatively.
    The ulna metaphyseal fracture shows > 1/3 translation. Also if the forearm is supinated / pronated, the fracture is unstable. It is therefore indicated to treat this with open reduction internal fixation.
    It should be noted that the ulnar-sided distal row screw is actually extra-articular and is within the Dorsal Ulnar Corner (DUC) fragment. Due to the 11 degrees of volar tilt, the volar rim appears shorter than the dorsal rim.

    Having dealt with the radius, attention turns to the distal ulna. The DRUJ stability is assessed and in this case it was found to be unstable because the metaphyseal fracture was unstable.
    The joint line is identified with the aid of the C-arm. This is important because the Dorsal Cutaneous Branch of the Ulnar Nerve (DCBUN) passes over the ulna close to here.
    In a recent cadaveric study the DCBUN was found to pass proximal to the ulnar head in 9% of specimens (type 1), distal in 77% (type 2) and over the ulnar styloid in 14% (type 3).
    Leechavengvongs S et al. Surgical anatomy of the dorsal cutaneous branch of the ulnar nerve and its clinical significance in surgery at the ulnar side of the wrist. J Hand Surg Eur Vol. 2019 Mar; 44(3): 263-268.

    The ulnar sided skin incision is made, distally and in the mid-point of the subcutaneous border of the ulna.

    Careful blunt dissection is used to expose the distal ulnar and avoid inadvertent injury to the dorsal cutaneous branch of the ulnar nerve (DCBUN).Trainee’s often remember that the Dorsal Cutaneous Branch of the Ulnar Nerve arrives from the Ulnar Nerve at a mean distance of 6.4cm proximal to the ulnar styloid. However, they often cannot recall its’ course from the distal forearm to the dorsal aspect of the hand.
    The DCBUN is volar to the distal ulnar when it branches from the Ulnar Nerve. It then travels distally towards the hand on the volar surface. It crosses the Flexor Carpi Ulnaris (FCU) and then pierces the deep antecubital fascia and becomes subcutaneous at a mean distance of 5cm proximal to the pisiform. The nerve is at risk as it traverses from the volar aspect of the distal forearm to the dorsal / ulnar aspect of the hand.
    Remember that the majority of nerves cross distal to the ulnar styloid (i.e. 77%). 14% cross over the ulnar styloid and 9% cross proximal to the ulnar head. Therefore when exposing the distal ulnar metaphysis and styloid, you will encounter the DCBUN in approximately 23% of cases (14% + 9%).
    Leechavengvongs S et al. Surgical anatomy of the dorsal cutaneous branch of the ulnar nerve and its clinical significance in surgery at the ulnar side of the wrist. J Hand Surg Eur Vol. 2019 Mar; 44(3): 263-268.

    The traumatic wound edges are excised. This is an inside-to-outside puncture, so theoretically should have less contamination.
    According to the Gustilo-Anderson classification this would be a Grade I injury because it is low energy and the wound is less than 1 cm.

    The traumatic wound is thoroughly irrigated with sterile saline and the wound tract is washed out.

    The distal ulnar fracture is exposed.I like to expose either the anterior or posterior surface of the distal ulna as this helps to confirm that the reduction is correctly aligned. It is very easy to have a visibly reduced surface but radiographically there is an angular or rotatory deformity.
    The ideal area to apply the plate is in the bare area between the Flexor Carpi Ulnaris (FCU) and Extensor Carpi Ulnaris (ECU) tendons.

    The 2.0mm Ulna Hook Plate is applied distally first and hooked over the ulnar styloid.Distal ulna fractures are often deceptively complicated and have either a sagittal or coronal split. The bone is often osteoporotic and has an articular surface arc of 270 degrees.
    The fractures are also usually transverse or comminuted, so it makes it impossible to apply a reduction clamp without getting in the way of the plate.
    The plate has a hook on it that is placed over the ulna styloid and then it can be pulled proximally to reduce it on to this fragment (this often displaces the fracture). I prefer to apply the plate to the distal fragment and then use the plate / bone construct to re-align it with the proximal diaphysis.

    The drill guide is screwed into the locking screw plate hole of the ulna hook plate and drilled with the 1.5mm drill.The locking screws are inserted with the aid of a fixed angle calibrated drill guide. The holes are drilled with a 1.5mm diameter drill bit and these are for a 2.0mm locking screw.

    Operation – 2

    A 1.5mm drill hole is created.
    Within the distal ulnar fragment, the drill hole should be uni-cortical. If you drill through the far cortex you will be in the distal radioulnar joint (DRUJ) and will damage the cartilage.
    The drill bit has a laser mark on it, so that the hole depth can be read from the calibrated drill guide.

    A 2.0mm fixed angle locking screw is inserted distally into the ulna plate.

    Once the distal ulnar fragment and plate are securely fixed, this can be reduced on to the proximal fragment.The reduction is checked both visually and with fluoroscopy.
    Sometimes a non-locking screw is required to provide some initial stability. This is inserted through the oblong shaft plate hole. The pilot hole is drilled with the same 1.5mm drill bit, using a free hand drill guide / soft tissue protector. The hole depth is measured and an appropriate length screw is selected. A 2.0mm non-locking screw is inserted and loosely tightened to allow the final reduction to be adjusted.

    When satisfied with the ulna fracture reduction, the shaft locking screws can be inserted.The process for inserting the locking screws is repeated:
    The fixed angle locking screw drill guide is screwed into the plate.
    The hole is drilled with a 1.5mm drill bit
    The hole is bi-cortical in this section of the bone
    The hole depth is measured with a depth gauge (or can it be read using the drill bit laser mark and the calibrated drill guide)
    A 2.0mm locking screw is inserted and tightened with the torque limiting screw driver

    Fluoroscopic images are taken to check the reduction, implant positioning and screw lengths of the ulna hook plate.Both fractures have been satisfactorily reduced and the screws are extra-articular.
    An astute observer would note that this patient has a previous nonunion of their ulnar styloid. The patient is also ulnar positive and this is likely to be secondary to a previous distal radius fracture that has been managed conservatively.

    A distal radius ‘skyline’ view is taken to ensure that the screws are not too long.This image demonstrates that the distal radius screws are not crossing the dorsal cortex of the distal radius. Therefore the screw tips should not irritate the dorsal tendons or risk causing an attrition rupture.
    Also note the sigmoid notch and ulnar head which demonstrates that the radius screws are extra-articular to the DRUJ and the ulnar head screws are safely within the bone.

    The wound is closed in layers with an absorbable suture.I like to use interrupted sutures using an inside-out / outside-in technique, so that the knot is deeper than the opposed skin edges and won’t cause a stitch abscess.
    Continuous sutures are possible however, if one bite fails, then the whole suture is de-tensioned. In elderly patients’, the soft tissues are very delicate, so I worry that they could pull out and the wound opens up.

    A subcutaneous absorbable suture is used to close the skin.The deeper layer provides the strength to the wound closure, so I’m happy to use a continuous suture to oppose the skin edges which will already be closely approximated.

    The wounds are dressed and a bandage is applied.I like to use a non-adherent dressing such as a Jelonet or Mepitel that is then covered with gauze. I find the adhesive dressings quite difficult to remove in the clinic when the patient returns for a post-operative wound check.

    Some surgeons would prefer to use a plaster backslab.
    The rationale for using plaster is one of the following:
    To provide additional support to the fixation
    To allow the soft tissues to settle
    To improve the patient’s post-operative pain
    Personally I don’t feel wrist fracture surgery requires additional support if adequate fixation has been achieved. I also don’t feel the soft tissues are at risk, as the blood supply to the hand and forearm is very good, so the plaster does not prevent any wound issues (which are very rare anyway).
    Finally the plaster could help reduce the patient’s pain. However, it has not been found to have a statistically significant reduction in the amount of analgesia used.
    It’s also quite heavy for an elderly patient and may limit their function and contribute to wrist stiffness.

    Post Operative

    Elevate the limb to reduce any immediate bleeding / swelling
    Immediate mobilisation of fingers and thumb (when the block has worn off) to prevent any stiffness
    The hand can be used for light weight tasks e.g. eating with cutlery
    The patient should attend the clinic in 10-14 days for:
    Wound check and trimming / removal of sutures
    Assessment of peripheral nerves (particularly the median nerve, palmar cutaneous branch of the median nerve and dorsal cutaneous branch of the ulnar nerve)
    Check radiograph
    Physiotherapy to restore wrist motion

    Recommended Reading

    In a paper by Nunez et al. they report their results from 37 patients treated with the Ulna Hook Plate. They treated 18 acute fractures, 10 nonunions and performed 9 ulna shortening osteotomies. Bone healing was achieved in all cases. The mean follow up for all cases was 25 months (range: 3-53 months) and no patients had reported hardware related symptoms or required further surgery for implant removal.
    In a paper by Lee et al. they report their results from 25 patients treated with the Ulna Hook Plate. They treated 25 patients with acutely unstable distal ulna fractures. All patients united their fractures with good alignment and they concluded that they had satisfactory function when compared to the contralateral limb and no cases of chronic DRUJ instability.
    Nunez FA Jr, Zhongyu L, Campbell D, Nunez FA Sr. Distal Ulnar Hook Plate: Angular Stable Implant for Fixation of Distal Ulna. J Wrist Surg. 2013: 2; 87-92
    Lee SK, Kim KJ, Park JS, Choy WS. Distal Ulna Hook Plate Fixation for Unstable Distal Ulna Fracture Associated With Distal Radius Fracture. Orthopedics. 2012 Sep; 35(9): e1358-64
    Leechavengvongs S et al. Surgical anatomy of the dorsal cutaneous branch of the ulnar nerve and its clinical significance in surgery at the ulnar side of the wrist. J Hand Surg Eur Vol. 2019 Mar; 44(3): 263-268
    Kramer S, Meyer H, O’Loughlin PF, Vaske B, Krettek C, Gaulke R. The incidence of ulnocarpal complaints after distal radial fracture in relation to the fracture of the ulnar styloid. J Hand Surg Eur. 2012; 38(7): 710-717

    Reference

    • orthoracle.com

    Tags:

    You might be interested in

    Dark mode powered by Night Eye