Dome-shaped osteotomy for distal radius fracture malunions

After having hinted to the various component of the malformity caused by malunions of the distal radius fracture, the various possibilities of correcting this deformity are described. The difficulty to correct all the components of the deformity are considered. Then a Dome-shaped osteotomy of the distal radius is described that allows to correct all the deformities in all the directions as the gliding plane of the osteotomy is spherical. The ulnar plus and the DRUJ alterations are corrected by means of an added Sauvé-Kapandji procedure that guarantees against any painful movement of the DRUJ preserving effective prono-supination.     

Trapezoidal osteotomy of the distal radius for unacceptable articular angulation after Colles'' fracture

Loss of radial palmar tilt in malunion of Colles' fractures alters wrist biomechanics, abnormally loading the tenuous dorsal ligament complex. This can result in midcarpal instability with synovitis, pain, weakness, and possible articular degeneration. An osteotomy to correct radius alignment using a trapezoidal corticocancellous bone graft has been devised. The graft is harvested from the dorsal radius adjacent to the osteotomy and malunion site. When turned 90 degrees, a properly designed trapezoidal graft restores radial length, inclination, and palmar tilt in one step. Functional results in 15 patients at 46 months (range, 18 to 116) were comparable with a series using iliac crest graft and plate- and-screw fixation. This simple technique avoids disruption of the extensor retinaculum and reoperation for hardware removal as Kirschner-wire fixation proved adequate.     

Function after distal radius fracture

Follow-up of 154 patients 3.5 years after a distal radius fracture treated by reduction and immobilization in plaster demonstrated that the initial displacement influenced their function. The classification of Older et al. (1965) was prognostic for the outcome. Residual deformity had the greatest influence on the function. The most frequent late problem was instability and tenderness in the distal radioulnar joint.     

Function after distal radius fracture

Follow-up of 154 patients 3.5 years after a distal radius fracture treated by reduction and immobilization in plaster demonstrated that the initial displacement influenced their function. The classification of Older et al. (1965) was prognostic for the outcome. Residual deformity had the greatest influence on the function. The most frequent late problem was instability and tenderness in the distal radioulnar joint.     

Recovery after fracture of the distal radius

Stretching exercises are an important part of recovery after sustaining a fracture of the distal radius. However, from the patient's perspective, painful stretching exercises can be counterintuitive after injury. Stretching exercises are straightforward and do not require a significant amount of coaching. It is ultimately the protectiveness, passivity, and sometimes a sense of futility that require coaching. The key for the provider is to empathize with the difficult and counterintuitive nature of the recovery process.     

Computer-assisted distal radius osteotomy

PURPOSE: To establish the accuracy, precision, and clinical feasibility of a novel technique of computer-assisted distal radius osteotomy for the correction of symptomatic distal radius malunion. METHODS: Six patients underwent a computer-assisted distal radius osteotomy and were followed-up for an average of 25 months. Objective radiographic measurements and functional outcomes, as measured by clinical examination including grip strength and range of motion, and Disability of the Arm, Shoulder and Hand (DASH) questionnaires, were used. RESULTS: The mean radiographic parameters included an increase of radial inclination to 21 degrees from 12 degrees (normal, 23 degrees ). Dorsal and volar tilt (malunion) were corrected to 9 degrees from -30 degrees and 21 degrees, respectively (normal, 10 degrees ). Ulnar variance was corrected to 1.9 mm from 7.5 mm (normal, +1.5 mm). Normal is defined as the average of the contralateral limb radiographs. The mean clinical outcome measures at an average of 25 months included a DASH global score of 14, a DASH individual item average score of 1.6, and an average affected side grip strength of 79% when compared with the unaffected side. CONCLUSIONS: The results of the computer-assisted technique were comparable with published results of traditional non-computer-assisted opening wedge osteotomy techniques. This technique allows a surgeon to accurately and precisely recognize and correct 3-dimensional deformities of the distal radius including axial malalignment (supination). The technique has the added benefit of reducing radiation exposure to the patient and surgical team because fluoroscopy is not used during the procedure. Additional benefits of the computer-assisted technique include the ability to perform multiple surgical simulations to optimize the alignment plan, and it serves as an excellent teaching tool for less-experienced surgeons.     

Digital gangrenes after distal radius fracture

The reported complication rates of the distal radius fractures vary widely from 6% to 80%. Unlike damage to neural and tendinous structures, vascular complications have been extremely rare. We described an unusual case of distal radius fracture complicated with digital gangrenes because of occlusion of radial and ulnar arteries.     

尺骨短缩术治疗桡骨骨折后尺骨撞击综合征

目的 评价尺骨短缩术治疗尺骨撞击综合征的效果及其影响因素. 方法 2002年1月至2006年12月对28例诊断为腕部尺骨撞击综合征患者给予尺骨截骨短缩治疗,采用改良的Gartland and Werley腕关节功能评分系统判定治疗效果;分析尺骨短缩数量与手术效果的关系. 结果 本组术前尺骨阳性变异23例,中件变异3例,阴性变异2例;术后阳性变异3例,中性变异4例,阴性变异21例.尺骨变异术前平均(3.1±2.3)mm,术后平均(0.9±1.4)mm,差异有统计学意义(t=4.32,P<0.05).按改良的Gartland and Werley评分:术前平均为(62.6±4.3)分,可21例,差7例;术后评分改善到平均为(92.2±7.8)分,优22例,良3例,可2例,差1例,腕关节功能评分术前与术后比较差异有统计学意义(t=10.45,P<0.05).3例切断尺桡远端韧带,4例部分切断尺桡远端韧带.6例术前存在远端尺腕部背侧半脱位,尺骨短缩术后明显改善. 结论 尺骨短缩术能显著改善桡骨远端骨折后继发尺骨撞击综合征的功能评分和临床症状;但尺骨短缩过多,远侧尺桡关节间压力增大,则影响手术效果.     

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 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.     

Triplane fracture of the distal radius

A case of triplane fracture of the distal radius is reported in a 13-year-old boy. This exceptional fracture showed displacement, and was healed by closed reduction and 6 weeks of external immobilization. Eighteen months later, the patient showed complete physeal arrest of the distal radius, with radio-ulnar length discrepancy but without any repercussion on wrist mobility. The patient was declared asymptomatic 3 years after the injury. Prompt, physiological physeal arrest reduces the potential of growth deformity. These fractures must be treated conservatively by closed reduction (if displacement exists) and external immobilization, just like a normal one-plane fracture. We may suppose that final radio-ulnar discrepancy could lead to a painful and symptomatic ulno-carpal conflict in adult life. The following characteristics can be associated with this rare fracture: (1) occurrence close to the end of the growth period, as in other types of triplane fractures; (2) evolution towards partial or complete growth arrest of the physis, not requiring treatment and (3) stability of the fracture after closed reduction. In the present case, as in the other reported cases, it may also be added that orthopaedic treatment has been the rule, in contrast with triplane fractures occurring in the distal tibia, in which surgical treatment is indicated.     

Unusual fracture of the distal radius

A case of an unusual variant (Frykman's Type VII) of a Colles' fracture is presented. Cadaver dissection was utilized to study the distal radioulnar joint. The recommended mechanism of reduction is in supination and ulnar deviation. The final result demonstrated an excellent range of motion in a reasonable period of time.     

Evaluation of carpal instability after distal radius fracture]

In this study carpal stability was assessed in a group of patients with distal fractures of the radius. The aim of this study was to: assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, determine the type of instability and its correlation to fracture type and patient age, assess the influence of bone fragment dislocation on the type of instability. For a clinical evaluation of carpal instability results of physical examination and X-ray examination performed in both static and dynamic conditions were taken into account. In 33% of the examined cases different types of instability were noted. Carpal instability was found more often among younger patients, predominantly of the dorsal type. The type of observed instability depended mainly on the injury mechanism and fracture type of the distal radial epiphysis. Fracture type did not influence the frequency of carpal instability, whereas direction and degree of bone fragment displacement did correlate to the type of primary or secondary instability.     

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.