The rotational effect of pronation and supination osteotomies of the forearm in a cadaver model: a comparison of osteotomy sites on the radius and the ulna

The purpose of this study was to investigate the effect on forearm rotation of rotation osteotomies at the distal and proximal levels of the radius and the ulna. Rotation osteotomies of 15 degrees and 30 degrees were made in the distal and proximal one-third of the radius and the ulna in ten cadaver specimens and changes of forearm arc of rotation were compared after osteotomy at the four sites. This study identifies the proximal ulna as the best of these sites for rotation osteotomy because of the high gain in the rotated direction and minimal loss in the opposite direction.     

The effect of pronation and supination on the minimally displaced scaphoid fracture

The amount of rotation that occurs at the scaphoid waist fracture site with pronation and supination of the forearm is studied in 10 upper extremities from cadavers. Two colinear metal markers were placed in the osteotomized scaphoid and a below-the-elbow cast was applied. Spiral volumetric computed tomography scanning of the scaphoid was done with multiplanar reformation to evaluate displacement of the metal markers. Four of the 10 specimens also were studied without any immobilization. The total magnitude of motion from pronation to supination averaged 0.2 mm in the specimens with a below-the-elbow thumb spica cast, and 2.4 mm in specimens without immobilization. The current study showed no significant rotation at the minimally displaced scaphoid waist fracture site during pronation and supination in a below-the-elbow cast. Furthermore, there is unacceptable rotation at the fracture site in the absence of a cast. Based on this study, a below-the-elbow thumb spica cast seems adequate for fracture immobilization; however, clinical correlation is needed.     

The effect of elbow position on the range of supination and pronation of the forearm

A kinematic study was performed to examine the influence of elbow position on the range of supination and pronation of the forearm. The ranges of supination and pronation were measured in 50 volunteers (25 men and 25 women) using a custom-designed jig which constrained unwanted and confounding movements of the limb. Measurements were taken with the elbow in full extension, 45 degrees flexion, 90 degrees flexion and full flexion. The data showed a reciprocal relationship between the range of supination and the range of pronation of the forearm which depended on the degree of elbow flexion. As the elbow is flexed, the maximum angle of supination increases while the maximum angle of pronation decreases (p<0.001). The converse is true as the elbow is extended (p<0.001).     

The effects of ulnar axial malalignment on supination and pronation

BACKGROUND: Forearm fractures are common injuries in both adults and children. Despite efforts to obtain anatomical alignment, axial rotational malunions occur, resulting in a decreased range of motion and a poor appearance. The objective of this study was to quantify loss of forearm rotation after simulation of ulnar malunions in supination and pronation. METHODS: Six fresh-frozen cadaveric upper extremities (mean age at the time of death, 79.4+/-2.8 years) were used to quantify loss of forearm rotation after simulation of axial rotational malunions of the ulna. First, maximum forearm rotation in supination and pronation was measured at torques of 6.8, 13.6, and 20.4 kilograms-centimeter applied with use of a custom jig. Following a midshaft ulnar osteotomy, a custom adjustable internal fixation plate was used to simulate axial rotational malunions of the ulna of 0, 15, 30, and 45 degrees in both directions. Measurements in supination and pronation were then repeated at the prespecified torques. Analysis of variance, with a p value of 0.05, was used for statistical analysis. RESULTS: In all instances, a decrease in forearm rotation after simulation of the ulnar rotational malunion was accompanied by an increase in rotation in the opposite direction. Supination and pronation were significantly influenced, whereas the total arc of rotation was not affected by ulnar rotational malunion. At a torque of 20.4 kilograms-centimeter, pronation malunions of 15, 30, and 45 degrees resulted in a mean loss of supination (and standard error of the mean) of 5+/-1, 11+/-1, and 20+/-1 degrees, respectively, and supination malunions of 15, 30, and 45 degrees resulted in a mean loss of pronation of 4+/-1, 10+/-2, and 18+/-4 degrees, respectively. The ratio of the simulated rotational malunion to the loss of motion was larger than one. CONCLUSIONS: Ulnar rotational malunions do not lead to a significant change in the total arc of forearm rotation. Instead, loss of motion in one direction is accompanied by increased motion in the opposite direction. Even with a 45-degree ulnar rotational malunion, forearm rotation decreases no more than 20 degrees.     

Biomechanics of pronation and supination of the forearm

Pronation-supination, the rotation of the forearm around its longitudinal axis, is an important motion because it allows the hand to be oriented, allowing one to take food and carry it to the mouth, perform personal hygiene, and live autonomously. The motion depends on the integrity of two bones, the radius and the ulna, as well as joints, ligaments, and muscles. In every pathological case, as described in this article, the anatomical features must be restored for normal function.     

Corrective osteotomies of the radius and ulna for supination contracture of the pediatric and adolescent forearm secondary to neurologic injury

PURPOSE: To present the authors' experience with internal fixation of the radius and ulna as a surgical option for correction of supination contracture of the forearm. METHODS: Twelve patients (13 limbs) had an osteotomy of the radius and ulna for a supination deformity secondary to a residual brachial plexus or spinal cord injury. Surgery consisted of proximal ulna and distal radius osteotomies combined with plate fixation. RESULTS: The average age of the patients at the time of surgery was 11 years. Five limbs had fixed supination deformities and 8 limbs lacked pronation beyond neutral. The average preoperative supination deformity (either fixed or measured at midarc) was 76 degrees. The average intraoperative correction was 86 degrees. The average follow-up period was 16 months. The average midrange resting position maintained at final follow-up evaluation was 2 degrees of pronation. All limbs ultimately obtained radiographic and clinical union of the osteotomy sites. Complications included 6 plate fractures; however, only 1 patient required revision internal fixation. CONCLUSIONS: The combination of a proximal ulna and distal radius osteotomy with internal fixation can provide excellent correction, but the implant must be strong enough to hold the osteotomies rigidly in the corrected position during the time needed for union. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

旋前旋后外旋型三踝骨折的手术治疗

目的：探讨旋前、旋后外旋型（IV度）三踝骨折的手术方法和临床疗效。方法：2000年3月至2006年7月,对42例旋前、旋后外旋型（IV度）三踝骨折行切开复位内固定术,男31例,女11例;年龄19～76岁,平均40.5岁。开放性损伤4例,闭和性损伤38例。根据Lauge-Hansen分类,旋前外旋型IV度三踝骨折18例,旋后外旋型IV度三踝骨折24例。受伤距手术时间2h～27d。内、外踝均采用标准内、外侧切口。如需行后踝骨折处理,则将内踝切口延长,同时显露内、外及后踝。整复固定的顺序是后踝、内踝、外踝和下胫腓联合。骨折复位固定完成后,行踝部正侧位及踝穴（Mortise）位X线检查。结果：全部患者均获得随访,时间6～24个月,平均13.5个月。骨折愈合时间12～16周,疗效根据梁军等改良Baird-Jackson的主客观及X线评价标准进行评定,包括疼痛、踝关节的稳定性、行走能力、跑步能力、踝关节活动范围、踝关节X线测量等。本组优20例,良16例,可4例,差2例,优良率85.7%。术后未发生感染、骨不连、骨折畸形愈合等并发症,但发生1例下胫腓骨三皮质固定螺钉断裂。结论：手术治疗的关键在于恢复并稳定踝关节的解剖关系,最大限度恢复踝关节功能。     

Treatment of malunion of the distal radius

Malunions of the distal radius are common. Although the best treatment is prevention, symptomatic malunions can be salvaged through more careful fracture management, by corrective osteotomy or, in the presence of post-traumatic arthritis, radiocarpal arthrodesis. Dynamic midcarpal instability following radius malunion does not respond as well to ligament repair or intercarpal arthrodesis as it does to osteotomy of the radius and correction of the malunion deformity.     

前臂双骨折的手法治疗

前臂双骨折是日常生活及劳动工作中常见的损伤。因前臂主司旋转功能 ,骨间膜对前臂的旋转活动是有制约作用的 ,它为前臂的旋转运动限定了一个范围。若骨折复位不当 ,前臂按旋转轴所进行的旋转运动 ,超出了此范围 ,前臂的旋转活动必将受到骨间膜的牵扯而受限。因此 ,治疗前臂双骨折应象对待关节间骨折一样 ,力争解剖复位或近解剖复位[1] 。根据我院名老中医章宝春先生的手法 ,自1993年 8月至今共以手法治疗 136例闭合骨折患者 ,效果优良 ,现总结如下。1　临床资料本组 136例 ,男 83例 ,女 5 3例 ;年龄最小 8岁 ,最大 75岁 ,均为闭合骨折。直…     

Surgical exposures of the radius and ulna

The forearm contains many muscles, nerves, and vascular structures that change position on forearm rotation. Exposure of the radial shaft is best achieved with the Henry (volar) or Thompson (dorsal) approach. The volar flexor carpi radialis approaches are used increasingly for exposure of the distal radius. Although the dorsal approach is a safe utilitarian option with many applications, its use for managing fracture of the distal radius has waned. Potential complications associated with radial exposure include injury to the superficial branch of the radial nerve, the lateral antebrachial cutaneous nerve, and the cephalic vein. Dorsal and ulnar proximal radial exposures are associated with increased risk of injury to the posterior interosseous nerve. With surgical exposure of the ulna, care is required to avoid injuring the dorsal cutaneous branch of the ulnar nerve.     

An experimental study of instability during supination and pronation of the fractured scaphoid

Rotatory instability of scaphoid fractures was studied by a method not used previously. On two fresh specimens the scaphoid bone was fractured by osteotomy, and the fracture was fixed by a Hoffmann apparatus extending from the distal radius to the 1st, 2nd and 3rd metacarpals. This permits free rotation in the forearm. The scaphoid fragments were marked by Kirschner wires. No movement occurred between the fragments when supination/pronation was kept within the normal range of movement.     

Corrective osteotomy for malunion of distal diaphyseal/metaphyseal radius or ulna fracture affecting stability of the distal radioulnar joint

BackgroundWe postulated that residual distal radioulnar joint (DRUJ) instability after distal diaphyseal or metaphyseal fracture in the radius or ulna may occur due to malaligned or malunited bony structures as well as primary or secondary soft issue stabiliser. Here, we report the outcomes of corrective osteotomy in a retrospective study.MethodsPatients undergoing the osteotomy for DRUJ instability between March 2000 and February 2018 were included in the study. Thirteen patients were evaluated. The initial injury occurred at a mean age of 12.3 years and corrective osteotomy was performed at a mean age of 20.8 years. The mean follow-up period was 33.1 months. The male to female ratio was 8:5 and the corrected radius/ulna ratio was 11:2. DRUJ instability was diagnosed clinically and radiologically based on the stress/clunk test and the distance between the cortex of the radius, and the radioulnar ratio. All osteotomies in the radius and ulna were of the open wedge type and were performed using plates/screws.ResultsThe radioulnar ratio was significantly higher than the normal ratio (p < 0.001). All osteotomies healed well without any serious complications. The preoperative distance between the cortex of the radius and ulna was significantly decreased at the final follow-up, from 4.74 ± 0.82 to 1.16 ± 0.46 mm (p < 0.001). Positive findings of two instability tests were all converted to negative. The ranges of motion of the flexion-extension and pronation-supination arcs were significantly improved. Finally, preoperative VAS pain and DASH scores improved to 0.23 ± 0.44 and 3.92 ± 1.84, respectively (p < 0.001).ConclusionsMalunited radius or ulna plays a role in DRUJ instability, affecting the bony geometry in terms of the relationship between the sigmoid notch and ulnar head. Treatment of malunion by corrective osteotomy represents a useful option for resolving instability.Level of evidenceLevel IV, Retrospective therapeutic study.     

旋前、后外旋型三踝骨折的手术治疗

目的总结旋前后外旋型（Ⅳ度)三踝骨折切开复位内固定的手术方法和疗效。方法1996年3月～2002年10月，对48例旋前、后外旋型（Ⅳ度)三踝骨折行切开复位内固定术．男27例，女21例；年龄l7～85岁．平均42.8岁。根据Lauge-Hansen分类．旋前外旋型Ⅳ度三踝骨折20例．旋后外旋Ⅳ度三躁骨折28例。受伤距手术时间2h～21d。内侧采用标准内踝切口显露内踝骨折，外侧采用腓骨后缘纵行切口显露外踝骨折。如需行后踝骨折处理．则将内踝的切口延长．外侧采用经腓骨的Gatellie-Chastang手术入路同时切开显露内、外及后踝。整复固定的顺序是后踝，内踝、外踝和下胫腓联合。骨折复位固定完成后，行踝部正侧位及踝榫(Mortise)位X线检查。满意复位的标准为：(1)踝榫的正常关系恢复，(2)踝的负重排列与下肢纵轴成直角．（3)关节面的外形轮廓光滑，结果仝部患者均获得随访，随访时间6～36个月．平均13个月，骨折愈台时间为12～16周。随访时疗效评定根据Baird-Jackson评分系统进行评定：优26例，良15例，可5例．差2例；优良率为85．4％。术后未发生感染、骨不连、骨折畸形愈合等并发症．但发生1例下胫腓三皮质固定螺钉断裂。结论躁关节的解剖复位可获得最佳的临床结果，采用切开复位内固定术治疗三踝骨折可保证踝关节获得解剖复位．最大限度地恢复踝关节功能。     

The functional importance of malunion in distal radius fractures

The purpose of our study was to investigate which radiological parameter had the maximal detrimental effect on functional outcome following malunion of distal radius fractures. Sixty-four women over 40 years of age who had sustained low-energy wrist fractures were included in the study. The mean age of the patients was 64 years. We compared the ulnar variance, radial inclination and palmar tilt of the fractured wrist to the non-injured contralateral side on radiographs obtained after fracture healing. The functional outcome was assessed at a mean follow-up of 28 months. Wrist mobility, grip strength, and pain with daily activities were determined and combined to give a final outcome rating. An increase in ulnar variance was found to be the most important radiological parameter affecting functional outcome and the outcome tended to be influenced by age, hand dominance and the presence of articular involvement.