Corrective osteotomy for malunion of the distal radius

Forty-five patients were reviewed on average 5.7 years after corrective osteotomy for symptomatic distal radius malunion. Restoration of anatomy and function was assessed compared with the contralateral wrist. It was found that osteotomy of the distal radius alone did not completely restore normal anatomy and relieve symptoms, and in several cases a second operation was needed. Osteoarthritic changes in the radiocarpal and radioulnar joints were common, and they correlated with restriction in range of motion, but not with pain. Range of motion and grip power were reduced compared to the unaffected hand, but only loss of supination and ulnar deviation correlated with an unsatisfactory subjective result. The result was good or satisfactory in 33 of the 45 patients. We conclude that reconstructive procedures in patients with distal radius malunion may not completely restore normal function, and every effort should therefore be made to prevent malunion in the treatment of distal radius fractures.     

Corrective osteotomy for malunion of the distal radius

Positive ulnar variance due to inadequate correction of radial length is a common disorder after radial corrective osteotomy. To avoid this complication we performed a combination of ulnar-shortening osteotomy and radial corrective osteotomy in 6 of 22 radial corrections. The indication for the combined procedure was a relative ulnar length of minimally 6 mm. The functional outcome was fair in 1 and good in 5 cases with combined osteotomy. Overall, the functional results were good in 17 cases, and pain in the distal radioulnar joint was observed in 3 of 22 patients. Positive ulnar variance was the reason for pain in only 1 patient. Eventually, 2 hemiresections of the ulnar head (Bower's arthroplasty) were performed. It appears that a combination of ulnar shortening and radial osteotomy is a reliable technique, which can reduce symptoms and need for secondary operations on the ulnar side of the wrist.     

Corrective osteotomy for intra-articular malunion of the distal part of the radius

BACKGROUND: Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most strongly associated with arthrosis and diminished function after such fractures. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the potential for additional injury, osteonecrosis, and nonunion. METHODS: Twenty-three skeletally mature patients were evaluated at an average of thirty-eight months after corrective osteotomy for an intra-articular malunion of the distal part of the radius. The indication for the osteotomy included dorsal or volar subluxation of the radiocarpal joint in fourteen patients and articular incongruity of > or =2 mm as measured on a posteroanterior radiograph in seventeen patients. Six patients had combined intra-articular and extra-articular malunion. The average interval from the injury to the osteotomy was six months. The average maximum step-off or gap of the articular surface prior to the operation was 4 mm. RESULTS: One patient had a subsequent partial wrist arthrodesis because of radiocarpal arthrosis, and three patients had additional surgery because of dysfunction of the distal radioulnar joint. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final articular incongruity averaged 0.4 mm, and the final grip strength averaged 85% of that on the contralateral side. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley, and 43% according to a modification of the rating system of Green and O'Brien. CONCLUSIONS: The results of corrective osteotomy for the treatment of intra-articular malunion are comparable with those of osteotomy for the treatment of extra-articular malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.     

Corrective osteotomy for volar instability of the distal radioulnar Joint associated with radial shaft malunion

Volar instability of the distal radioulnar joint is an uncommon wrist disorder. We report three cases of recurrent volar instability of the distal radioulnar joint secondary to fracture of the radial shaft. In all cases, X-rays showed a volar apex deformity of the radial shaft. Opening wedge osteotomy and iliac bone grafting was performed on the distal diaphysis of the radius instead of on the radial shaft, in order to adjust the distal radioulnar joint more easily. Pre-operative dislocations and painful clunks disappeared in all three patients. However, slight instability of the distal radioulnar joint remained in all cases. Osteoarthritis of the distal radioulnar joint was noted in one patient 31 months after the operation. All of the patients were satisfied with the results and did not desire further operations.     

Derotational osteotomy of the proximal radius and the distal ulna for congenital radioulnar synostosis

Objective  To evaluate the clinical and functional results of a technical procedure in the surgical treatment of congenital radioulnar synostosis in children. Materials and methods  A prospective study had been undertaken from January 1992 to December 2004. Thirty-four patients with congenital radioulnar synostosis that are fixed in pronation were recruited. Congenital radioulnar synostosis was classified for two types according to Tachdjian’s criteria. All patients were treated by resection of the proximal radius and the distal ulna to remove a segmental bone of both parts of the forearm. After K-wires are inserted intramedullarly into both bones, the forearm is derotated manually, followed by cast immobilization. Results  There were 34 patients (52 forearms) with congenital radioulnar synostosis, whom the average age at surgery was 6 years and 3 months. There were two types of congenital radioulnar synostosis: Type 1 in six forearms (11.6%) and Type 2 in 46 forearms (88.4%). The preoperative forearm rotation ranged from 65° to 85° pronation. The postoperative forearm rotation angle was corrected from 0° to 30°; the best end position appears to be 70–100% of pronation. Of the patients, 78.8% had good or excellent results. All patients were operated on without complications; five patients had loss of correction during cast immobilization. Overall, the patient’s ability to perform daily activities showed a marked improvement after surgery. Conclusion  This method is a simple and safe technique to derotate the forearms of patients with congenital radioulnar synostosis that are fixed in pronation.     

Corrective osteotomy using Hoffmann II external fixators for extra-auricular malunion of the distal radius

The authors present the technique and clinical results of a corrective osteotomy for malunion following extra-articular fractures of the distal radius. External fixation allows restoration of the length of the radius with minimal damage to the periosteum. It allows early mobilization of the radiocarpal joint. The position of the distal pins provides intraoperative visual control of the angular correction. The minimal invasive approach decreases the risk of iatrogenic lesion of an extensor tendon or a sensitive branch of the radial nerve. This technique is easy and reliable.     

Effects of distal radius malunion on distal radioulnar joint mechanics--an in vivo study.

Patients with a malunited distal radius often have painful and limited forearm rotation, and may progress to arthritis of the distal radioulnar joint (DRUJ). The purpose of this study was to determine if DRUJ congruency and mechanics were altered in patients with malunited distal radius fractures. In nine subjects with unilateral malunions, interbone distances and dorsal and palmar radioulnar ligament lengths were computed from tomographic images of both forearms in multiple forearm positions using markerless bone registration (MBR) techniques. The significance of the changes were assessed using a generalized linear model, which controlled for forearm rotation angle (-60 degrees to 60 degrees ). In the malunited forearm, compared to the contralateral uninjured arm, we found that ulnar joint space area significantly decreased by approximately 25%, the centroid of this area moved an average of 1.3 mm proximally, and the dorsal radioulnar ligament elongated. Despite our previous findings of insignificant changes in the pattern of radioulnar kinematics in patients with malunited fractures, we found significant changes in DRUJ joint area and ligament lengthening. These findings suggest that alterations in joint mechanics and soft tissues may play an important role in the dysfunction associated with these injuries.     

Effects of distal radius fracture malunion on wrist joint mechanics

An experimental model using a static positioning frame, pressure-sensitive film (Fuji), and a microcomputer-based videodigitizing system was used to measure contact areas and pressures in the wrist. Contact areas and pressures were compared in a group of wrists between the normal state and with simulated distal radius fracture malunions of varying degrees. In simulated malunions, radial shortening to any degree slightly increased the total contact area in the lunate fossa, and was significant at 2 mm of shortening. By angulating the distal radius more than 20 degrees either palmar or dorsal, there was a dorsal shift in the scaphoid and lunate high pressure areas, and the loads were more concentrated, but there was no change in the load distribution between the scaphoid and lunate. Decreasing the radial inclination shifted the load distribution so that there was more load in the lunate fossa and less load in the scaphoid fossa.     

Corrective osteotomy for malunion of the distal radius in young and middle-aged patients: an outcome study

INTRODUCTION: We report the outcome of osteotomy for malunion of the distal radius. MATERIAL AND METHODS: Twenty-one wrists in 21 patients (mean age 38 years) with a malunion of the distal radius were treated with an osteotomy. An opening wedge osteotomy was performed when the distal radioulnar joint (DRUJ) could be saved; a closing wedge osteotomy was done when the DRUJ was treated with resection (Darrach) or arthrodesis (Sauvé-Kapandji). The clinical and radiographic outcomes were evaluated together with the DASH score (disability of shoulder and hand). RESULTS: Extension improved to an average of 48 degrees in the Smith-type group and flexion improved to an average of 51.8 degrees in the Colles-type group. The postoperative DASH-score averaged, respectively, 17.3 and 33. There were four poor, four fair, seven good and six excellent scores on the scale of Fernandez and there were four poor, seven fair, three good and seven very good results on the Fernandez point score. Grip strength postoperatively averaged 70% of the contralateral side. Radiographically, there was a correction of increased volar tilt of the articular surface from 30.6 to 4.0 degrees in the Smith-type group and a correction of increased dorsal tilt of the articular surface of 24.6 degrees (from -21.3 to 3.3 degrees) in the Colles-type group. Nine patients had surgery on the distal ulna at the time of the radial correction. Their average DASH score was 16.8 compared to the 33.97 average DASH score of those with radial correction without ulnar surgery. CONCLUSION: Osteotomy of the distal radius in cases of malunion gives favorable outcomes. Treatment of the DRUJ is mandatory.     

Hand laterality recognition in distal radius and/or ulna fracture

IntroductionHand laterality, an important ability to determine the orientation of a limb is common to get affected after short term immobilization. Distal radius and/or ulna fracture is a commonly encountered fracture resulting from upper-limb trauma. Conservative treatment using closed reduction and plaster cast application to immobilize the joint remains choice of treatment over surgery in the treatment of these fractures. There is a paucity of literature reporting impairment in hand laterality after long term immobilization as commonly performed in patients with distal radius and/or ulna fractures. Understanding effect of immobilization on hand laterality in distal-end radius/ulna fractures warranted present investigation.PurposeTo evaluate hand laterality based on the accuracy and response time for hand determination after plaster cast removal in distal radius and/or ulna fracture.Study designProspective cross sectional study.MethodologySubjects (n = 60, age range = 40-59 years, females (n) = 28 and males (n) = 32) were shown 24 real-hand images with various degrees of angular rotation and instructed to identify the hand as left and/or right. Accuracy (% correctly identified) and Response time (milliseconds to identify left or right hand in the image) of motor imagery during hand laterality task were recorded. Pain intensity before and after the hand laterality task were noted using Visual Analogue Scale. Repeated measures of ANOVA and t tests were used to analyze the accuracy and response times among two groups.ResultsThe experimental group showed significantly (P < .05) lower accuracy and longer response time as compared to the control group. No significant difference in the accuracy and response time were noted in the immobilization of the dominant and the non-dominant hand within the experimental group (P > .05). Also, there was no change in pain pre- to post-hand laterality task.ConclusionFindings of this study could aid in enhancing the understanding of post-immobilization effect on hand laterality and open new arenas for assessment and rehabilitation of distal-end radius and/or ulna fractures where immobilization is the principal treatment.     

Corrective osteotomy of malunited distal radius fractures

The malunion of the distal radius may result in shortening, radial impaction, volar angulation, dorsal displacement or rotatory deformity. For restoration, the anatomy and kinematics of the distal radioulnar joint and the triangular fibrocartilaginous complex (TFCC) are of importance. This nonunion consists of the articular disk, a meniscus homologue, the ulnar collateral ligament, and the dorsal and palmar radioulnar ligaments. Malunion of the distal radioulnar joint leads to an increase in loading on the individual parts, as well as pain and a decrease in supination and pronation. Osteotomy is indicated if the angulation of the malunion is more than 20 degrees in the frontal or sagittal plane. Corrective osteotomy requires detailed preoperative planning with calculation of the correct position in all planes. The most common operation that has proved to be effective is osteotomy of the radius, insertion of a trapezoidal bone graft in place, and internal fixation with a dorsal or volar plate.     

桡骨远端骨折后下尺桡关节对应关系的变化及临床意义

目的：研究桡骨远端骨折整复后桡骨纵向短缩距离（△h）对下尺桡关节旋转功能的影响。方法：临床60例患者，分别测定每一例患者桡骨远端骨折拆除外固定后桡骨纵向短缩距离△h和下尺桡关节的旋转受限角度γ，△h根据临床测定值分为0mm～、2mm～、4mm～、≥5mm4个区间，γ根据疗效评定标准分为优、良、可、差4个等级。分别计算出在每个区间上的优良可差的例数，并作统计学处理，得出相应的结论。结果：①无尺侧变异组：40例，相关系数r=0．7402，P〈0．0005，2mm～与4mm～组间P〈0．05。②正向变异组：10例，相关系数r=0．7576，0．0005〈P〈0．001，△h在0mm～与2mm～组间P=0．02〈0．05。③负向变异组：10例，相关系数r=0．8242，0．0005〈P〈0．001，△h在4mm～与≥5mm组间P：0．005〈0．01。结论：①无尺侧变异组：桡骨远端骨折整复后短缩距离△h≥4mm时，下尺桡关节旋转功能受限严重，故△h〈4mm。②正向变异组：桡骨远端骨折整复后短缩距离△h≥2mm时，下尺桡关节旋转功能受限严重，故△h〈2mm。③负向变异组：桡骨远端骨折整复后短缩距离△h≥5mm时，下尺桡关节旋转功能受限严重，故△h〈5mm。     

Rotational stability of diaphyseal fractures of the radius and ulna fixed with Rush pins and/or fracture bracing

The rotational stability of fractures of the radius and ulna treated with Rush pins and/or fracture bracing was studied in six fresh cadaver forearms. Forearm rotation and fracture site motion (rotation) were measured as functions of applied forearm torque and rotation (pronation-supination). Values were obtained from the forearm: (1) intact and with both bones fractured; (2) without fixation; (3) with a fracture brace; (4) with Rush pins; and (5) with a combination of Rush pins and a fracture brace. A brace was ineffectual in reducing fracture site motion when the wrist was rotated to specified angles compared to fracture site motion for the forearm with no fixation treatment rotated to the same angles. When loading to specific torque levels, however, the brace reduced fracture site motion to one-half the motion with no fixation treatment. Under both loading conditions, Rush pin fixation significantly and markedly reduced the fracture site motion (to approximately one-eighth of the motion with no fixation treatment), whereas a brace in conjunction with Rush pins did not significantly further reduce the fracture site motion. The radius showed more motion at fracture site than the ulna.     

The importance of the distal radioulnar joint for reconstructive procedures in the malunited distal radius fracture

Clinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignment of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.     

Acute dislocations of the distal radioulnar joint and distal ulna fractures

This article reviews acute dislocations of the distal radioulnar joint (DRUJ) and distal ulna fractures. Acute dislocations can occur in isolation or in association with a fracture to the distal radius, radial metadiaphysis (Galeazzi fracture), or radial head (Essex-Lopresti injury). Distal ulna fractures may occur in isolation or in combination with a distal radius fracture. Both injury patterns are associated with high energy. Outcomes are predicated on anatomic reduction and restoration of the stability of the DRUJ.     

Matched distal ulna resection for posttraumatic disorders of the distal radioulnar joint.

In 1985 we published the results of the matched ulna resection in 44 patients, the majority of whom had rheumatoid arthritis. The matched ulna resection maintains the continuity of the distal ulna to the ulnar sling mechanism, including the triangular fibrocartilage complex (TFCC), and resects the distal ulna in a smooth, curved, convex fashion to match the contour of the radius throughout forearm rotation. This article presents the results of the procedure in patients with posttraumatic and mechanical disorders of the distal radioulnar joint. Good to excellent results were noted in 24 of 32 patients. The outcome was related to the severity of the patient's initial problem.