Higher-Than-Expected Rates of Distal Radioulnar Joint Fixation in Radial Shaft Fractures: Location of Fracture Matters

Abstract

Background:

The purpose of this study was to evaluate rates of distal radioulnar joint (DRUJ) fixation based on location of the radial shaft fracture and risk factors associated with postoperative complications following radial shaft open reduction internal fixation (ORIF).

Methods:

Adult patients who underwent isolated radial shaft ORIF from 2014 to 2018 were identified from American College of Surgeons National Surgical Quality Improvement Program database and stratified by fracture location and by the presence or absence of DRUJ fixation. Preoperative patient characteristics and postoperative complications were compared to determine risk factors associated with DRUJ fixation.

Results:

We identified 1517 patients who underwent isolated radial shaft ORIF, of which 396 (26.1%) underwent DRUJ fixation. Preoperative patient characteristics and postoperative complications were similar between cohorts. Distal radioulnar joint fixation was performed in 50 (30.7%) of 163 distal radial shaft fractures, 191 (21.8%) of 875 midshaft fractures, and 3 (13.0%) of 23 proximal shaft fractures (P = .025). Risk factors for patients readmitted include male sex (odds ratio [OR] = 12.76, P = .009) and older age (OR = 4.99, P = .035). Risk factors for patients with any postoperative complication include dependent functional status (OR = 6.78, P = .02), older age (50-69 vs <50) (OR = 2.73, P = .05), and American Society of Anesthesiologists (ASA) ≥3 (OR = 2.45, P = .047).

Conclusions:

The rate of DRUJ fixation in radial shaft ORIF exceeded previously reported rates of concomitant DRUJ injury, especially among distal radial shaft fractures. More distally located radial shaft fractures are significantly associated with higher rates of DRUJ fixation. Male sex is a risk factor for readmission, whereas dependent functional status, older age, and ASA ≥3 are risk factors for postoperative complications.

Keywords

forearm anatomy wrist fracture/dislocation diagnosis surgery specialty distal radius

Introduction

Radial shaft fractures are known to compromise hand function and are reported to be caused primarily by high-energy trauma, such as crush injuries or motor vehicle accidents.^1-5 As closed reduction and immobilization of radial shaft fractures have been shown to result in high rates of malunion and overall poor outcomes in both adult and pediatric patients,^6,7 open reduction internal fixation (ORIF) is regarded as the standard of care to provide optimal anatomical reduction and stability.⁸ Furthermore, these debilitating fractures can be further complicated by the presence of a distal radioulnar joint (DRUJ) injury. The DRUJ is integral to wrist and forearm function and motion. Injury to the DRUJ is commonly missed on initial assessment, as it can be initially asymptomatic and even unnoticeable from some clinical and radiographic examinations.⁹

Injury to the DRUJ has been previously studied in association with distal radius fractures^10-13 and in the fractures of the distal one-third of the radial shaft (Galeazzi fracture-dislocation)^14-16; however, few publications have studied the rate of concomitant DRUJ fixation with ORIF of radial shaft fractures in all locations or the risk factors associated with postoperative complications or readmission after radial shaft ORIF.

The aim of this study was to determine the rate of concomitant DRUJ fixation relative to radial shaft fracture location (proximal, midshaft, or distal) in patients undergoing isolated radial shaft ORIF as well as the risk factors associated with postoperative complications or readmission after radial shaft ORIF. We hypothesize that DRUJ fixation occurs more commonly in distally located radial shaft fractures.

Materials and Methods

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, all patients undergoing radial shaft ORIF between 2014 and 2018 were identified using the Current Procedural Terminology (CPT) codes 25515, 25525, and 25526, of which codes 25525 and 25526 also indicated the presence of DRUJ fixation. The CPT codes for ulnar shaft ORIF (25545 and 24685) were excluded to provide only isolated radial shaft ORIF. No identifiable patient information was included in this public-use database, exempting the study from institutional review board approval. Patients were stratified by location of radial shaft fracture based on diagnostic International Classification of Diseases (ICD)-9 and ICD-10 coding (S52.1, 813.0—proximal; S52.3, 813.2—midshaft; S52.5, 813.4—distal) and by the presence or absence of DRUJ fixation. The following were excluded by the ACS-NSQIP database: patients younger than 18 years old, patients with incomplete or missing data, and patients admitted under acute trauma pathway.¹⁷

Patients were stratified into 2 groups based on whether or not DRUJ fixation was performed. Preoperative patient demographic factors and comorbidities were collected and compared between cohorts (Table 1). Postoperative complications, classified as either major or minor, and readmissions were recorded and compared between cohorts (Table 2). The ACS-NSQIP database defines postoperative complications and readmissions as events occurring within 30 days after operation.

Table 1.

Preoperative Patient Characteristics, Radial Shaft ORIF.

Preoperative Characteristic	Total	Distal radioulnar joint fixation, No. (%)	No distal radioulnar joint fixation, No. (%)	P value
Total	1517	396 (26.1)	1121 (73.9)
Age, y				.362
<50	812 (54)	222 (56.1)	590 (53.3)
50-69	510 (33.9)	123 (31.1)	387 (35)
≥70	181 (12)	51 (12.9)	130 (11.7)
Sex				.739
Female	710 (46.8)	182 (46)	528 (47.1)
Male	807 (53.2)	214 (54)	593 (52.9)
DRUJ fixation				<.001
No DRUJ fixation	1121 (73.9)	0 (0)	1121 (100)
Percutaneous DRUJ fixation	233 (15.4)	233 (58.8)	0 (0)
Open DRUJ fixation	163 (10.7)	163 (41.2)	0 (0)
Obesity class, kg/m²				.481
Nonobese (18.5-29.9)	941 (70.1)	228 (67.9)	713 (70.9)
Underweight (<18.5)	19 (1.4)	4 (1.2)	15 (1.5)
Obese (≥30)	382 (28.5)	104 (31)	278 (27.6)
ASA class				.616
1-2	1219 (80.9)	310 (79.9)	909 (81.2)
≥3	288 (19.1)	78 (20.1)	210 (18.8)
Hypertension	310 (20.4)	79 (19.9)	231 (20.6)	.837
History of diabetes	104 (6.9)	34 (8.6)	70 (6.2)	.142
History of pulmonary disease	42 (2.8)	5 (1.3)	37 (3.3)	.052
History of cardiac disease	6 (0.4)	2 (0.5)	4 (0.4)	1.00
History of smoking	350 (23.1)	89 (22.5)	261 (23.3)	.796
Chronic steroid use	29 (1.9)	6 (1.5)	23 (2.1)	.648
Nonindependent functional status	12 (0.8)	4 (1)	8 (0.7)	.800

Note. Percentages reported in parentheses. ORIF = open reduction internal fixation; DRUJ = distal radioulnar joint; ASA = American Society of Anesthesiologists.

Table 2.

Thirty-Day Postoperative Complications After Radial Shaft ORIF.

Complication	Total,No. (%)	Distal radioulnar joint fixation, No. (%)	No distal radioulnar joint fixation, No. (%)	P value
Total	1517	396 (26.1)	1121 (73.9)
Any complication	39 (2.6)	11 (2.8)	28 (2.5)	.906
Major complications	17 (1.1)	7 (1.8)	10 (0.9)	.252
Death	2 (0.1)	1 (0.3)	1 (0.1)	1.00
Sepsis	2 (0.1)	0 (0)	2 (0.2)	.972
Wound dehiscence	2 (0.1)	2 (0.5)	0 (0)	.115
Pulmonary embolism	2 (0.1)	2 (0.5)	0 (0)	.115
Ventilator >48 h	1 (0.1)	1 (0.3)	0 (0)	.586
Unplanned intubation	1 (0.1)	1 (0.3)	0 (0)	.586
Return to operating room	11 (0.7)	3 (0.8)	8 (0.7)	1.00
Minor complications	23 (1.5)	5 (1.3)	18 (1.6)	.809
Superficial SSI	9 (0.6)	2 (0.5)	7 (0.6)	1.00
Pneumonia	2 (0.1)	1 (0.3)	1 (0.1)	1.00
Urinary Tract Infection	3 (0.2)	0 (0)	3 (0.3)	.709
DVT or thrombophlebitis	0 (0)	0 (0)	0 (0)
Transfusion	9 (0.6)	2 (0.5)	7 (0.6)	1.00
Renal insufficiency	0 (0)	0 (0)	0 (0)
Unplanned readmission	14 (0.9)	6 (1.5)	8 (0.7)	.259
Operating time, min, mean (SD)	79.9 (38.9)	86.5 (47.4)	77.5 (35.2)	<.001
Length of stay, d, mean (SD)	1 (2.3)	1 (2.3)	0.9 (2.3)	.387

Note. Percentage of patients with the presence of complication in each group shown in parentheses. ORIF = open reduction internal fixation; SSI = surgical site infection; DVT = deep venous thrombosis.

Bold print signifies significant P values.

Multivariate logistic regression analyses were performed to determine risk factors contributing to the need for DRUJ fixation in radial shaft ORIF procedures. Statistical analysis was performed using the R Statistical Software Package. Student t test, χ² contingency testing, and multivariate logistic regression were conducted. All variables were controlled for in a multivariable regression analysis to identify independent variables significantly associated with DRUJ fixation. All individual complications were reported, with patients having more than 1 complication being counted only once in the “Any Complication” category. P values ≤.05 were deemed statistically significant.

Results

Of the 1517 patients who underwent isolated radial shaft ORIF, 396 (26.1%) underwent DRUJ fixation: 233 via closed reduction and percutaneous pinning and 163 via DRUJ ORIF (Table 1). Radial shaft fracture location was available via ICD coding for 1061 patients and showed that DRUJ fixation was performed in 50 (30.7%) of 163 distal radial shaft fractures, 191 (21.8%) of 875 midshaft fractures, and 3 (13.0%) of 23 proximal radial shaft fractures (P = .025) (Table 3 and Figure 1). The mean operating time for radial shaft ORIF with DRUJ fixation (86.5 minutes) was greater than radial shaft ORIF without DRUJ fixation (77.5 minutes) (P < .001) (Table 2). Other preoperative patient characteristics and postoperative complications were similar between cohorts (Tables 1 and 2).

Table 3.

Rates of Distal Radioulnar Joint Fixation by Radial Shaft Fracture Location.

Location of radial shaft fracture	Total	DRUJ fixation, No. (%)	Rate of DRUJ fixation by fracture location	P value
Total	1061	244	23.0%
Distal	163 (15.4)	50 (20.5)	30.7%	.025
Middle	875 (82.5)	191 (78.3)	21.8%
Proximal	23 (2.2)	3 (1.23)	13.0%

Note. DRUJ = distal radioulnar joint.

Multivariate analyses revealed that male sex (odds ratio [OR] = 12.76, 95% confidence interval [CI] = 1.88-86.93, P = 0.009) or advanced age (age ≥70 vs <50) (OR = 4.99, 95% CI = 1.12-22.31, P = .035) was a significant independent risk factor of readmission after radial shaft ORIF. Patients of dependent functional status (OR = 6.78, 95% CI = 1.35-34.16, P = .02), older age (50-69 vs <50) (OR = 2.73, 95% CI = 1-7.44, P = .05), and an American Society of Anesthesiologists (ASA) ≥3 (OR = 2.45, 95% CI = 1.01-5.91, P = .047) were significantly more likely to develop a postoperative complication. Readmission or complication rates did not differ significantly between patients who required DRUJ fixation and those who did not (Table 4).

Table 4.

Results of Multivariate Analyses for Risk Factors Associated With Any Complication and Readmission.

Readmission/Risk Factor	Odds ratio (95% confidence interval)	P value
Readmission
Functional status: dependent vs independent	13.7 (0.92-204.35)	.058
Male vs female	12.76 (1.88-86.39)	.009
History of COPD vs none	6.03 (0.81-44.93)	.079
Age: ≥70 vs <50	4.99 (1.12-22.31)	.035
Smoking vs not smoking	2.95 (0.89-9.73)	.076
Distal radioulnar joint fixation vs no fixation	2.52 (0.82-7.76)	.107
Any complication
Functional status: dependent vs independent	6.78 (1.35-34.16)	.020
Age: ≥70 vs <50	3.13 (0.88-11.14)	.077
History of COPD vs none	2.96 (0.97-9.04)	.056
Smoking vs. not smoking	2.95 (0.89-9.73)	.076
Age: 50-69 vs <50	2.73 (1-7.44)	.050
ASA: ≥3 vs 1-2	2.45 (1.01-5.91)	.047
Distal radioulnar joint fixation vs no fixation	1.22 (0.55-2.7)	.624

Note. Other risk factors with P value >.10 not shown. ASA = American Society of Anesthesiologists; COPD = chronic obstructive pulmonary disease.

Bold print signifies significant P values.

Discussion

Determining preoperative risk factors associated with DRUJ fixation in radial shaft fractures can help surgeons identify patients with DRUJ injuries which may be missed on clinical examination and radiographic imaging. Our study determined the overall rate of DRUJ fixation in radial shaft ORIF to be 26.1% and 30.7% specifically in distal radial shaft fractures. More distally located fractures are significantly associated with higher rates of DRUJ fixation at the time of radial shaft ORIF. The DRUJ fixation was not associated with an increased rate of readmission or perioperative complications. Multivariate analyses showed that risk factors for readmission after radial shaft ORIF include male sex and older age. Risk factors for developing a complication after radial shaft ORIF include older age, ASA ≥3, and dependent functional status.

Prior texts and publications have cited that Galeazzi fractures occur at approximately a “1 in 4” rate, an estimate that appears to be based on a 1989 study by Chapman et al.¹⁸ More recently, the single-center study by Tsismenakis and Tornetta¹⁴ found the rate of intraoperatively determined DRUJ instability to be 11% (7 out of 66 patients) after radial shaft fixation. Ring et al¹⁵ described the rate of DRUJ injury in isolated radial shaft fractures to be 25% (9 of 36 patients). Our database review of 1517 patients determined the overall incidence of intraoperative DRUJ fixation to be at 26.1%.

Various radial shaft fracture patterns and characteristics have been shown to be predictors of DRUJ injury. The retrospective study by Rettig and Raskin⁵ of 40 patients who underwent isolated radial shaft ORIF showed that 55% (12 of 22) of type I (distal third of the radius) Galeazzi fractures had intraoperative DRUJ instability compared with only 6% (1 of 18) of type II (middle third of the radius) Galeazzi fractures. Korompilias et al¹⁹ found that 54% of patients with distal third radial shaft fractures required DRUJ stabilization after radial shaft ORIF compared with 12% of patients with middle third radial shaft fractures and 11% of patients with proximal third radial shaft fractures. Tsismenakis and Tornetta¹⁴ similarly found that radial shaft fractures distally located (<7.5 cm from wrist) and radial shortening predict DRUJ instability. Ding et al²⁰ found that radial shaft fracture obliquity >30° had a high sensitivity for detecting DRUJ instability. In addition, ulnar variance greater than 2 mm and ulnar styloid fractures also play a role associated with DRUJ.^14,21,22 Takemoto et al²¹ showed that for each 1 mm of ulnar variance away from neutral, there was a 26% increase in the odds of having DRUJ instability after radial shaft fracture. The results of this study indicate that rates of DRUJ fixation increase in more distally located radial shaft fractures (distal > middle > proximal), which is consistent with previous studies.

Although DRUJ injury is most common in distal radial shaft fractures, our study indicates that DRUJ fixation is also relatively common in midshaft (21.8%) and proximal shaft fractures (13.0%), and therefore it is important for surgeons to investigate possible DRUJ injury in middle and proximal radial shaft fractures. Unfortunately, DRUJ dislocation in radial shaft fractures can be easily overlooked.^23,24 Delayed DRUJ injury identification can lead to wrist pain, limited pronation and supination, reduced grip strength, and arthritis.^10,25 Furthermore, inadequate radial shaft reduction and persistent DRUJ incongruity have been reported to lead to significant morbidity.^4,22

Trauma has been identified as the major cause of Galeazzi fractures, specifically via motor vehicle accidents, sports, and falling injuries.^5,20,26 There has been a reported bimodal distribution of radial and ulnar shaft fracture between young men (age 10-20) and older women (age 60+), but overall, forearm shaft fractures occur predominantly in men across all age groups.^27-29 Studies have indicated open fractures to occur in less than 10% of isolated radial shaft fractures.¹⁸ Our results show that patient preoperative characteristics did not significantly predict DRUJ fixation and that DRUJ fixation was not a risk factor for readmissions or complications. However, we showed that older age is a risk factor for readmission after radial shaft ORIF and that risk factors for complications after radial shaft ORIF include dependent functional status, older age, and ASA ≥3.

There are several limitations to this study. First, this study was a retrospective review using the ACS-NSQIP database. As a result, although data collection is consistent across the centers contributing to this database, we are unable to control for perioperative patient management, how intraoperative diagnosis of DRUJ injury was achieved, the decision-making involved in performing DRUJ fixation, and how DRUJ fixation method was selected. We were also unable to collate patient satisfaction or outcomes scores, as this is not collected as part of the ACS-NSQIP data input. In addition, the ACS-NSQIP database provides complications and readmissions only in the 30-day postoperative period, which limits our ability to examine long-term outcomes and complications beyond the postoperative period. Furthermore, there is a possibility that some of the reported readmissions and complications may be due to reasons other than the radius fracture treatment. Second, while our study was able to distinguish differences in rates of DRUJ injury in relation to radial shaft fracture location using ICD coding, we were unable to incorporate radiographic analysis. Finally, as with any study using ICD and CPT codes, the reliability of our results depends largely on the quality and accuracy with which these codes were applied. The ICD coding limits reporting of radial shaft fractures as “upper,” “middle,” or “distal,” which unfortunately contributes to observer subjectivity. Moreover, the CPT codes provided information as to whether DRUJ fixation (overall stabilization) was performed, and DRUJ injuries managed without surgical fixation were not included. The NSQIP database does not provide information regarding the specific DRUJ fixation procedure performed, namely, percutaneous pinning of the joint or ORIF of the ulnar styloid. Furthermore, the CPT codes analyzed can be heterogeneous, which may prevent accurate comparison of postoperative complications.

Despite these limitations, important conclusions can be drawn from our study given the large sample size and validated data provided by ACS-NSQIP. We demonstrated an overall 26.1% rate of DRUJ fixation in the setting of radial shaft ORIF. Furthermore, our results suggest that the instability of the DRUJ can be commonly associated with any radial shaft fracture, not just those of the distal one-third of the radius (Galeazzi fractures). This study also identified risk factors associated with patient readmission and postoperative complications after radial shaft ORIF, which can be used to identify high-risk individuals on a national scale. Results from this study can increase surgeon awareness of DRUJ injury in all types of radial shaft fractures (proximal, middle, and distal), and the risk factors described can assist the formation of clinical guidelines to predict readmission and postoperative complications after radial shaft ORIF. This study highlights the need for careful attention to be paid to the DRUJ when undertaking fixation of any and all radial shaft fractures.

Footnotes

Ethical Approval

As this study utilized a publicly available and de-identified database, it was not considered human subjects research and was therefore exempt from IRB approval.

Statement of Human and Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. This article does not contain any studies with human or animal subjects.

Statement of Informed Consent

Informed consent was not obtained as this was a de-identified database study that is open to use by participating institutions.

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.

ORCID iD

Aneesh V. Samineni

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