Sagittal Rotational Malunions of the Distal Radius: the Role of Pure Derotational Osteotomy (2009)

7/29/2019 Sagittal Rotational Malunions of the Distal Radius: the Role of Pure Derotational Osteotomy (2009)

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S A G I T T A L R O T A T I O N A L M A L U N I O N S O F T H ED I S T A L R A D I U S : T H E R O L E O F P U R E

D E R O T A TI O N A L O S T E O TO M YF. DEL PIN AL, F. J. GARCIA-BERNAL, A. STUDER, J. REGALADO, H. AYALA and L. CAGIGAL

Instituto de Cirug a Plastica y de la Mano, Private Practice and Hospital Mutua Montan esa, Santander, Spain

Sagittal rotational malunion after distal radius fractures was identified in eight patients by thepresence of a hinge point on the volar cortex on the lateral radiograph, and the ulnar head beingshorter than the anterior lip of the radius on the posterioranterior radiograph. The surgicalcorrection consisted of preplating the distal fragment with a volar locking plate before anosteotomy through the hinge point, and correcting the dorsal tilt of the distal fragment. Anydorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion andgrip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsalsagittal tilt improved by 261, from 231 to +31. Ulnar variance improved by 3 mm, from +1.5 to

1.5 mm, becoming identical to the opposite side. A pure derotational osteotomy corrected theapparent shortening of the radius and restored the volar tilt.

Keywords: Distal radius, Fracture, Malunion, Osteotomy, Bone graft

Malunion after a distal radius fracture usually occurswith dorsal tilting and radial shortening. The tilt is easilymeasured on the lateral radiograph, and the shorteningon the posteroanterior film.

In some dorsally tilted malunions the volar cortex actsas a hinge point at the fracture line, and the distalfragment rotates on it, but does not translate. Thisoccurs if there is only dorsal comminution: the distalfragment, unsupported dorsally, pivots on the volarcortex slowly rotating in the cast (Jenkins, 1989), orwhen the reduction was insufficient from the beginning.This represents a sagittal rotational malunion, andthere is no shortening despite the appearance on aposterioranterior radiographic view (Fig 1).

Such a sagittal rotational malunion can be recognisedon the lateral radiograph, by the preservation of thevolar cortex and by having the anterior rim of the radiuslonger than the head of the ulna, confirming the absenceof shortening (Fig 2A). This deformity can be correctedby a derotation osteotomy alone rather than the more

complex three-dimensional reconstruction (Figs 2BD).The purpose of this paper is to present the surgicaltechnique and results of derotational osteotomy in eightpatients with rotational malunion of a distal radius fracture.

METHOD

All operations were performed under axillary block onan out-patient basis. The arm was exsanguinated andtourniquet applied. Cancellous bone from the olecranonwas first harvested through a 2.5-cm transverse incision.

The cavity was filled with Surgicels, and the wound wasclosed in a single layer with a 3/0 subcuticular nylon.

The malunion site was approached through a 6 to8 cm incision radial to the flexor carpi radialis sheath(FCR) with a 10 mm radially directed back cut in theproximal wrist crease. The space between the FCR andradial vessels was developed. The pronator quadratuswas then elevated subperiosially and reflected ulnar-wards. This exposed the malunion site and the radius.

Dissection was continued to the dorsum of the radius,going deep to the brachioradialis. The thickenedperiosteum was elevated, and divided proximal to theextensor tendon compartments making several trans-verse cuts, until the tendons were exposed. Adequatereduction of the distal fragment may not be possiblewithout division of this thickened periosteum as it actsas a restraint.

The locking plate was then applied volarly, prior tothe osteotomy, as recommended by Prommersbergerand Lanz (2004). The transverse part of the plate was

placed distal to the hinge point of the malunion. K-wireshelped ascertain that the distal pegs were subchondralfor a strong hold (Fig 3). When the surgeon was satisfiedwith the position, all the distal screws and pegs wereinserted. At the end of this step of the operation, theplate should form an angle with the radial shaft in thesagittal plane equal to the angle calculated pre-operatively on the lateral radiograph to achieve correc-tion of the deformity.

To avoid loss of volar cortical bone when usingan oscillating saw, the osteotomy was performed with a1-mm K-wire. A series of perforations parallel to the

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articular surface, to the dorsal cortex, were made alongthe exact hinge point of the malunion (Fig 4). After theK-wire perforations were completed, the distal radius,fixed with the plate, was bent dorsally to break theweakened palmar cortex. Several attempts were neededin most cases, and in some an oscillating saw wasrequired to cut the very sturdy ulnar cortex.

The distal radius with its attached plate was thenreduced to the shaft of the radius, by pushing the distalfragment volarly, as in a closed distal radius fracturereduction. The use of a lamina spreader to distract thedorsal tissues helped achieve a gentle reduction. Weavoided the forceful use of bone clamps to bring thestem of the plate to the shaft of the radius as we feared

Fig. 1 Malunited distal radius fracture with true dorsal tilting and apparent shortening of the radius. (A) The sclerotic rim appears to show a

positive ulnar variance, and the dorsal tilt of the distal radius (B). (C) The contour of the distal radius has been highlighted by dots, it can be

seen that volar rim of the radius (V) is actually distal to the head of the ulna, but the dorsal rim (D) is proximal. (D) On the same PA viewas in (A), the volar lip (with dots) is clearly distal to the head of the ulna confirming the inaccuracy of the variance measured in (A). A fine

grey line has been drawn tangentially to the ulnar dome across all the radiograms. A fine black line marks the volar rim of the radius.

Fig. 2 Pure sagittal malrotation: diagnostic pointers, planning and execution (same case as in Fig 1). (A) A clear hinge point corresponding to the

original fracture line can be seen (arrow), attesting to preservation of the volar cortex length. The distal volar rim can be seen distal to the

head of the ulna confirming the ulna minus variance (stippled in black). (B) The hinge point will be used as the rotation point of the distal

fragment. (C) Pure rotation on the fulcrum will correct dorsal tilting preserving the radial length. (D) The result on this patient. A fine grey

line has been drawn tangentially to the ulnar dome across all the radiograms. A fine black line marks the volar rim of the radius.

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that the screws could pull out of the bone. Once theplate lay easily on the shaft, it was held temporarily bytwo bone clamps. Careful reduction of the fragments atthe hinge point assured that the volar cortex continuitywas restored; otherwise, shortening and incompletevolar tilt correction will ensue (Figs 5A and B).Additionally, in order to compensate for some collapsethat may have occurred at the osteotomy site, the firstscrew on the stem of the plate was placed eccentrically todistract the osteotomy and restore the normal radiallength (Figs 5C and D).

The dorsal bone gap was filled with the cancellousbone from the olecranon. The pronator quadratus wassutured over the plate, if possible. At the first post-operative visit, 24 to 48 hours later, a removable splintwas applied and the patient encouraged to start activerange of motion exercises. After 4 to 6 weeks patientsgradually discarded the splint.

This operation was carried out in eight patients. Therewere three females and five males, aged 23 to 60 years(mean 37 years). All but two patients were involved in

heavy occupations prior to the accident. At the time oftheir referral 3.5 months to 3 years (mean 10 months) allwere off work because of their wrist except for twopatients, one of whom had reduced her work and sportactivities due to wrist pain. Six patients were coveredunder workers compensation, and were on sick leave orinvolved in litigation. Seven patients had previouslybeen treated in a cast and one had fixation with K-wires.

Patients confirmed an improvement in pain on avisual analogue 10 cm scale from 7.25 (range 69) pre-operatively to 0.50 (range 02) at follow-up between 6and 35 months. Active flexionextension changed from

Fig. 3 The plate has been provisionally stabilised with K-wires to the distal fragment. An intravenous needle, used for reference, will help to place

the plate as distal as possible, and to keep the ulnar K-wires subchondrally.

Fig. 4 Once the plate has been securely fixed distally, osteotomy

through the hinge point, is carried out. In order to preserve the

length of the volar cortex intact, the osteotomy is performed

with a 1-mm K-wire.

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a pre-operative arc of 971 (range 641401) to 1371 (range1181501). Pre-operative forearm rotation arc was 1451

(range 1001801

) and improved to 1751

(range1601801). Grip strength measured with a Jamardynamometer was 44% of the contralateral side pre-operatively (range 3355%), and 95.5% at follow-up(range 86105%). At follow-up patients had a DASHscore of 6 (range 016) compared to a pre-operativescore of 54 (range 3874).

Radiographically all osteotomies healed. A correctionof the dorsal tilt of 261 (range 20361) was achievedpostoperatively (average correction from 231 (201 to291) to +31 (091)). Despite the fact that the radius wasnot lengthened, on the PA view, the ulnar varianceimproved an average of 3 mm (range 24 mm) by thederotation osteotomy (pre-operative ulna of +1.5 mm(range 03.5) to

1.5 mm (range

3 to +1.5)

postoperative) (Fig 6), being identical to the contral-ateral side.

In every case a standard exploratory dry arthroscopyfollowed the osteotomy (del Pin al et al., 2007). Dorsalsynovitis was present in most patients, possibly as a partof triquetrum chondromalacia-ulnar detachment (Nishi-kawa et al., 2002), synovectomy was carried out asrequired. Three patients had ulnar styloid excision forimpingement of a non-united ulnar styloid through amini-open incision. One patient had arthroscopicreattachment of the TFCC at the fovea with a boneanchor (Atzei et al., 2005).

One patient sustained a displaced olecranon donorsite fracture, when she fell down a flight of stairs 22 daysafter surgery. The fracture was fixed and iliac crest bonegraft used. This patient fared the worst with a DASHscore of 16. One patient had symptoms of carpal tunnelsyndrome at follow-up and is being treated with a splintat night.

DISCUSSION

Some malunited radius fractures that appear shortenedmay have just healed in malrotation. Typically the

fracture was in most cases treated non-operatively.Despite the moderate deformities seen on plain radio-

graphs, some patients may report deceptively severesymptoms, and can benefit enormously from this simpleosteotomy.

True shortening, that occurs due to volar comminu-tion or when the continuity of the volar cortex is lost,will not be corrected by the operation described in thispaper (Fig 7). Restoration of the hinge point on thevolar cortex is critical, as otherwise shortening andincomplete correction of the volar tilt will occur (Fig 5).Several authors recommend removal of the plate beforecarrying out the osteotomy (Henry, 2007; Malone et al.,2006; Prommersberger and Lanz, 2004). This can leavethe distal segment unstable, making the reduction moredifficult, and can jeopardise secure screw fixation. Wetherefore recommend that the osteotomy is performedwith the plate applied.

While sagittal malalignment will be directly addressedby the operation, and any prono-supination deformityof the distal fragment will be corrected by the plate(Fernandez, 1993; Prommersberger et al., 2004), thetechnique of pure derotational osteotomy as presentedhere will not correct the loss of radial tilt. This can beconsidered a major drawback as the loss of radialinclination can compromise grip strength (Fernandez,1993; Jenkins and Mintowt-Czyz, 1988). Conversely,Warwick et al. (1993) failed to correlate radial tilt losswith clinical outcome after Colles fractures, and

Altissimi et al. (1986) only found a negative effect whenthe radial tilt loss was greater than 201 (less than 51radial tilt). Furthermore, in Kienbo cks disease radialclosing wedge osteotomy has been recommended, with-out adverse effects reported at the 10-year follow-up(Wada et al., 2002). Although some spontaneouscorrection was also achieved with our technique,perhaps by the plate itself, the operation will not correctmajor (less than 51) loss of radial tilt.

True shortening as well as dorsal tilting can lead toulnar head overload and symptoms (Pogue et al., 1990;Short et al., 1987). The correction on the sagittal plane

Fig. 5 Effect of lack of volar cortex restoration is shown in a clinical case. (A and B) If the surgeon fails to appropriately engage the volar cortex

(yellow circle), shortening and insufficient tilt correction will ensue. (C and D) After restoration of the volar cortex (white arrow), the length

and the volar tilt of the radius have both improved.



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obtained by the rotational osteotomy, together with theconcomitant treatment of associated ulnar pathologydetected by arthroscopy, was sufficient to correct theulnar symptoms in this group of patients. The contribu-tion of each one of them on the disappearance of theulnar symptoms is unknown.

Several papers have suggested that bone graft donorsite morbidity can be avoided by the use of non-structural bone grafting, or bone substitutes. Theolecranon is a useful donor site even though one ofour patients suffered a fracture after a fall 22 days after

surgery. We empirically now advise all patients whenharvesting bone from the olecranon, to continuouslywear an elbow protection as used by skateboarders for5 weeks.

Incomplete osteotomies have been previously sug-gested for distal radius fracture malunions (Fernandez etal., 2002; Jupiter and Fernandez, 2002). However, theclues to decide when to carry an incomplete osteotomyor a tridimensional reconstruction have not been clearlystated or are based on complicated methods. Byidentifying the hinge point on the lateral radiogram,

Fig. 6 Pure sagittal malunion. (A and B) Pre-operative; (C and D) 1 year after the operation.

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and ascertaining that the volar lip of the radius is distalto the ulnar head, the surgeon can be assured that thesimpler incomplete osteotomy would correct the radiusdeformity.

This study is preliminary because of the small numberof patients and short follow-up. However, the resultshave been encouraging, and the radiological correctionseems reproducible.

References

Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term resultsof conservative treatment of fractures of the distal radius. ClinOrthop Relat Res. 1986, 206: 20210.

Atzei A, Luchetti R, Carita E, Papini-Zorli I, Cugola L. Arthroscopicallyassisted foveal reinsertion of the peripheral avulsions of the TFCC.J Hand Surg Suppl. 2005, 30: 40.

Fernandez DL. Reconstructive procedures for malunion and traumaticarthritis. Orthop. Clin. North Am. 1993, 24: 34163.

Fernandez DL, Jupiter JB, Nagy L. Malunion of the distal end of theradius. In: Ferdandez DL, Jupiter JB (Eds.) Fractures of the distal

radius, New York, Springer, 2002: 289344.Henry M. Immediate mobilisation following corrective osteotomy of

distal radius malunions with cancellous graft and volar fixed angleplates. J Hand Surg Eur. 2007, 32: 8892.

Jenkins NH. The unstable Colles fracture. J Hand Surg Am. 1989, 14:14954.

Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Collesfracture. J Hand Surg Eur. 1988, 13: 29193.

Jupiter JB, Fernandez DL. Complications following distal radialfractures. Instructional Course Lect. 2002, 51: 203219.

Malone KJ, Magnell TD, Freeman DC, Boyer MI, Placzek JD.Surgical correction of dorsally angulated distal radius malunions

with fixed angle volar plating: a case series. J Hand Surg Am. 2006,31: 36672.

Nishikawa S, Toh S, Miura H, Arai K. The carpal detachment injuryof the triangular fibrocartilage complex. J Hand Surg Eur. 2002,27: 8689.

del Pin al F, Garcia-Bernal FJ, Pisani D, Regalado J, Ayala H, StuderA. Dry arthroscopy of the wrist: surgical technique. J Hand SurgAm. 2007, 32: 11923.

Pogue DJ, Viegas SF, Patterson RM et al. Effects of distal radiusmalunion on wrist joint mechanics. J Hand Surg Am. 1990, 15:72127.

Prommersberger KJ, Froehner SC, Schmitt RR, Lanz UB. Rotationaldeformity in malunited fractures of the distal radius. J Hand SurgAm. 2004, 29: 11015.

Prommersberger KJ, Lanz UB. Corrective osteotomy of the distalradius through volar approach. Tech Hand Upper Extremity Surg.2004, 8: 707.

Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanicalstudy of distal radial fractures. J Hand Surg Am. 1987, 12: 52934.

Wada A, Miura H, Kubota H, Iwamoto Y, Uchida Y, Kojima T.Radial closing wedge osteotomy for Kienbocks disease: an over 10year clinical and radiographic follow-up. J Hand Surg Am. 2002,

27: 17579.Warwick D, Prothero D, Field J, Bannister G. Radiological

measurement of radial shortening in Colles fracture. J Hand SurgEur. 1993, 18: 5052.

Received: 20 September 2007Accepted after revision: 27 July 2008Dr Francisco del Pin al, Dr Med, Caldero n de la Barca 16-entlo, E-39002 Santander, Spain.Tel.: +34942 364696; fax: +34 942364702.E-mail: [email protected], [email protected].

doi:10.1177/1753193408097324 available online at http://jhs.sagepub.com

Fig. 7 Schematic representation of the two main possible displacements, in the sagittal plane, after an extraarticular Colles fracture: Pure

rotational malunion (above) and translational and rotational malunion (below), with the expected results by a derotational osteotomy.

Complete correction of the deformity will be achieved by a derotational osteotomy if proper technique is carried out (above right).

Conversely, a short radius will result if the technique is inaccurate, or if it is used to treat combined (translational and rotational) malunions

(below right).


Sagittal Rotational Malunions of the Distal Radius: the Role of Pure Derotational Osteotomy (2009)

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