Extra-articular distal radial fracture malunion

A comparison of 3-D CT and 2-D plain radiograph measurements of the wrist in extra-articular malunited fractures of the distal radius

Two-dimensional (2-D) plain radiographs may be insufficient for the evaluation of distal radial malunion, as it is a three-dimensional (3-D) deformity. This study introduced a 3-D measuring method that outputs radial inclination, ulnar variance, palmar tilt and axial rotation. To this end, a standardized and clearly defined coordinate system was constructed that allowed 3-D measurements closely resembling the conventional 2-D method in 35 patients. Mean differences between 3-D and 2-D measurements in affected wrists were 1.8° for radial inclination, 0.8 mm for ulnar variance and 3.7° for palmar tilt. In addition, inter- and intra-observer reproducibility of all 3-D and 2-D measurements were good or excellent (intraclass correlation coefficient >0.75), with 3-D reproducibility always better than 2-D. Axial rotation was present in all patients with a mean of 7.9° (SD 6.9). Although the differences between 2-D and 3-D measurements were small, 3-D evaluation enables the assessment of axial rotation and brings us closer to a routine 3-D evaluation of malunion.Level of evidence: III.

Z-Corrective Osteotomy in Malunited Extra-Articular Fractures of Distal Radius

PURPOSE

We sought to assess clinical, radiological, and functional outcomes following treatment of extra-articular malunions of the distal radius using a multiplanar z-corrective osteotomy.

METHODS

Fifteen patients with extra-articular distal radius malunions (13 dorsal and 2 volar) underwent z-corrective osteotomy and volar plate fixation without bone grafting. Correction and maintenance of each deformity was evaluated in terms of various radiographic indices (radial height; volar and radial tilt); osteotomy union; pain (visual analog scale); grip strength; range of motion; Disabilities of the Arm, Shoulder, and Hand scores; and Mayo wrist scores.

RESULTS

The mean follow-up was 16.4 months. The mean radial height was corrected from -1.3 mm to 4.9 mm. The mean ulnar variance improved from 4.3 mm to -0.4 mm. The sagittal radial tilt and radial inclination were restored from a mean of -17.9° (dorsal) to 3.3° (volar) and from 12.0° to 17.2°, respectively. The Disabilities of the Arm, Shoulder, and Hand and Mayo wrist scores improved from means of 36 and 56 preoperatively to 24.8 and 73.3, respectively, at 6 months and further to 20.6 and 77.6, respectively, at the last follow-up. There were no nonunions or tendon-related problems. The mean pain score decreased from 4.1 preoperatively to 1.0 at 6 months and 0.8 at the last follow-up. The mean grip strength improved from 5.6 kg preoperatively to 15.6 kg at 6 months and 19.7 kg at the last follow-up. There was a statistically significant improvement in range of motion at the wrist.

CONCLUSIONS

The z-osteotomy provides correction of deformity in all 3 planes, along with restoration of radial height. It also maintains a broad area of bone contact between the 2 osteotomized bone fragments, facilitating bony union and eliminating the need for bone grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outcome Measurement for Distal Radius Fractures

Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.

The Dorsal Periosteal Curtain for Distal Radius Osteotomy Via the Volar Approach

Volar wedge osteotomy and angle stable volar plating is now considered a standard approach for correction of distal radius malunion. In previous descriptions of the technique, soft tissue release has been performed with periosteal incision in line with the bony osteotomy. We present a technique whereby the dorsal periosteum is incised more proximally creating a dorsal vascularized periosteal "curtain." Our technique has several advantages including systematic release of restraining soft tissues to allow better distraction and reduction of the malunion; a dorsal periosteal curtain of vascular tissue with which to contain bone graft, protect extensor tendons and expedite healing; and better access to locally available bone graft. The previously described rotation-advancement of pronator quadratus is also used for plate coverage. We have found this technique straightforward to execute and teach, and useful in mitigating against some of the potential risks of the standard technique.

Distal Radius Malunion

Malunion remains the most common complication of nonsurgical treatment of fractures of the distal radius and represents a common clinical entity. Symptomatic treatment often involves corrective osteotomy. Surgical correction is a challenging problem with unpredictable clinical outcomes. Prevention of malunion of a distal radius fracture is the best course of action. With maintenance of volar cortical contact and the use of volar fixed-angle devices, bone grafting may not be necessary in certain cases of malunion correction. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment.

In Vivo Contact Characteristics of Distal Radioulnar Joint With Malunited Distal Radius During Wrist Motion

PURPOSE

To determine whether distal radioulnar joint (DRUJ) contact characteristics were altered in patients with malunited distal radius fractures.

METHODS

We obtained computed tomography scans at 5 positions of both wrists of 6 patients who had unilateral malunited distal radius fractures with dorsal angulation from 10° to 20° and ulnar variance less than 3 mm. We reconstructed 3-dimensional images and mapped contact regions of DRUJ by calculating the shortest distance between the 2 opposing bones. The contact areas of the DRUJ were measured and the contact region centers were calculated and analyzed. The values of the malunited side were compared with those of the contralateral uninjured side.

RESULTS

In the uninjured wrist, the contact areas of the DRUJ increased slightly from wrist flexion to extension and ulnar deviation. In the malunited wrist, we found the contact areas of DRUJ to be progressively reduced from 20° flexion to neutral, 40° extension, and 20° extension, to ulnar deviation. The centroid of this area on the sigmoid notch moved to distal from flexion to extension. Compared with the contralateral uninjured wrist, the contact area significantly decreased during wrist extension and ulnar deviation, and significantly increased during wrist flexion. The centroids of this area on sigmoid notch all moved volarly in all selected wrist positions.

CONCLUSIONS

The contact areas of the DRUJ and the centroid of contact area on sigmoid notch are altered in patients with malunited distal radius fractures. The contact area of the DRUJ increases during wrist flexion and decreases during wrist extension and ulnar deviation. The centroids of the contact area on sigmoid notch move volarly during wrist flexion-extension and ulnar deviation.

CLINICAL RELEVANCE

The in vivo findings suggest that alterations in joint mechanics may have an important role in the dysfunction associated with these injuries.

Treatment of reducible unstable fractures of the distal radius: randomized clinical study comparing the locked volar plate and external fixator methods: study protocol

BACKGROUND

Various treatments are available for reducible unstable fractures of the distal radius, such as closed reduction combined with fixation by external fixator (EF), and rigid internal fixation using a locked volar plate (VP). Although there are studies comparing these methods, there is no conclusive evidence indicating which treatment is best. The hypothesis of this study is that surgical treatment with a VP is more effective than EF from the standpoint of functional outcome (patient-reported).

METHODS/DESIGN

The study is randomized clinical trial with parallel groups and a blinded evaluator and involves the surgical interventions EF and VP. Patients will be randomly assigned (assignment ratio 1:1) using sealed opaque envelopes. This trial will include consecutive adult patients with an acute (up to 15 days) displaced, unstable fracture of the distal end of the radius of type A2, A3, C1, C2 or C3 by the Arbeitsgemeinschaft für Osteosynthesefragen-Association for the Study of Internal Fixation classification and type II or type III by the IDEAL32 classification, without previous surgical treatments of the wrist. The surgical intervention assigned will be performed by three surgical specialists familiar with the techniques described. Evaluations will be performed at 2, and 8 weeks, 3, 6 and 12 months, with the primary outcomes being measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and measurement of pain (Visual Analog Pain Scale and digital algometer). Secondary outcomes will include radiographic parameters, objective functional evaluation (goniometry and dynamometry), and the rate of complications and method failure according to the intention-to-treat principle. Final postoperative evaluations (6 and 12 months) will be performed by independent blinded evaluators. For the Student's t-test, a difference of 10 points in the DASH score, with a 95% confidence interval, a statistical power of 80%, and 20% sampling error results in 36 patients per group.

DISCUSSION

Results from this study protocol will improve the current evidence regarding to the surgical treatment these fractures.

TRIAL REGISTRATION

ISCRTN09599740.

Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach?

Background There are various technical variations to consider when performing a corrective osteotomy of a distal radius malunion. We chose two of the more commonly reported techniques and compared the results of volar (palmar) osteotomy and fixation with dorsal osteotomy and fixation. Method Within a continuous cohort of patients who had undergone corrective osteotomy for a malunited Colles fracture, two groups could be identified retrospectively. In 8 patients a dorsal approach was used. A structural trapezoidal graft, subtending the amount of correction, was inserted into the osteotomy gap and stabilization was performed with a thin round-hole mini-fragment plate. In 14 patients a palmar approach and a palmar fixed-angle plate was used for correction of the malunion and for angular stable rigid fixation of the two fragments. The osteotomy gap was loosely filled with nonstructural cancellous bone chips. A retrospective comparison of the two groups was performed to see whether the outcome was affected by the use of either operative technique.The demographics, the preoperative amount of deformity, range of motion, pain, and force were comparable for both groups. All osteotomies healed without loss of correction. After a minimal follow-up of one year, radiographic appearance, objective functional parameters were assessed and subjective data (Disabilities of the Arm, Shoulder, and Hand [DASH] score and special pain and function questionnaire) obtained. Results These data did not show statistical difference for the two groups except for the amount of final wrist flexion. This parameter was significantly better in patients who had palmar approaches and fixed-angle plates. Conclusion Corrective osteotomies of distal radius malunions can be done in either way. It might result in some better flexion, if performed volarly.

Management of malunions of the distal radius

Despite encouraging results from small case series, correction of distal radius malunion remains a challenging procedure with uncertain outcomes. The most appropriate treatment for a distal radius malunion is prevention. If a symptomatic malunion is discovered, correction should be undertaken as early as possible. It is recommended that action be taken within six months of the primary injury to decrease the negative impact of soft-tissue contracture on the eventual reconstruction. Although some patients complain about residual problems after malunion surgery, corrective surgery has been shown to improve both radiographic and functional outcomes, and may prevent future secondary problems.

OSTEOTOMY OF THE DISTAL RADIUS USING A FIXED-ANGLE VOLAR PLATE

OBJECTIVE

Skewed consolidation of the distal radius, due to sequelae of fractures, may cause functional incapacity, thus leading such patients to present pain, loss of strength and diminished mobility. Based on the excellent results obtained from surgical treatment of unstable fractures of the distal radius through a volar approach and use of rigid fixation with a fixed-angle volar plate, we started to use the same method for osteotomy of the distal radius.

METHODS

A retrospective review was conducted, and 20 patients treated between February 2002 and October 2009 were found. The mean length of follow-up was 43.9 months (range: 12 to 96 months). The surgical indications were persistent pain, deformity and functional limitation subsequent to a dorsally displaced fracture.

RESULTS

The mean preoperative deformity was 27° of dorsal tilt of the distal radius, 87° of ulnar tilt, and 7.3 mm of shortening of the radius. All the osteotomies consolidated and the final mean volar tilt was 6.2°, with ulnar tilt of 69.3° and shortening of 1 mm. The mean mobility of the wrist increased by 19.9° (flexion) and by 24° (extension). Mean forearm supination increased by 23.5° and pronation by 21.7°. Grip strength increased from 13.4 to 34.5 pounds.

CONCLUSION

Use of a fixed-angle volar plate for a volar approach towards osteotomy of the distal radius enables satisfactory correction of the deformities and eliminates the need for removal of the synthesis material caused by tendon complications.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.

Muscle moment arms in the first dorsal extensor compartment after radial malunion. A cadaver study

BACKGROUND

Functional loss is a common complication of the fractured distal part of the radius. The purpose of the present study was to determine if the moment arms of the first dorsal extensor compartment are altered by distal radial fracture malunion. We hypothesized that the moment arms of the abductor pollicis longus and extensor pollicis brevis are significantly affected by dorsal angulation, radial inclination, and radial shortening, the most common deformities accompanying distal radial malunion.

METHODS

Moment arms of the extensor pollicis brevis and abductor pollicis longus were estimated in twelve cadaver wrists with use of the tendon-displacement method, which involves calculating the moment arm as the derivative of tendon displacement with respect to joint angle. Tendon displacement was quantified in different wrist postures before and after a closing-wedge osteotomy simulating a complex malunion of an extra-articular radial fracture.

RESULTS

The simulated distal radial malunion resulted in a decrease in the wrist flexion moment arm for both the extensor pollicis brevis (p = 0.0003) and the abductor pollicis longus (p < 0.0001). The wrist flexion moment arms for the extensor pollicis brevis and abductor pollicis longus decreased by a mean (and standard deviation) of 114% +/- 75% and 77% +/- 50%, respectively, after the osteotomy. The wrist radial deviation moment arms for the extensor pollicis brevis and abductor pollicis longus increased by 16% +/- 26% (p = 0.071) and 28% +/- 44% (p = 0.043), respectively, after the osteotomy. Radiographs of the wrist that were made before and after the osteotomy indicated that radial tilt changed from 11.1 degrees of volar angulation to 14.8 degrees of dorsal angulation, radial inclination decreased from 21.8 degrees to 7.7 degrees, and radial height decreased from 11.6 to 4.4 mm.

CONCLUSIONS

Distal radial malunion alters the mechanical advantage of the muscles in the first dorsal extensor compartment.

Corrective osteotomy for deformity of the distal radius using a volar locking plate

Dorsally angulated malunions of the distal radius have historically been corrected with an opening wedge osteotomy fixed with a dorsal plate. Volar locking plates may facilitate a less morbid approach to corrective osteotomies of the wrist. Eight consecutive patients with an average age of 40 years (range, 15-52 years) underwent correction of a distal radius deformity through a volar approach. Clinical follow-up averaged 17.4 months (range, 7-41 months). Preoperative radiographs revealed an average of 24 degrees of dorsal tilt in patients with dorsal deformity. Postoperatively, their average measurement was <3 degrees of volar tilt. Patients were initially ulnar-positive with an average of 4 mm ulnar-positive variance (range, 2-7 mm). This corrected to less than 1 mm postoperatively. Postoperative disabilities of the arm, shoulder, and hand (DASH), SF-12, and Mayo Wrist scores averaged 10.8, 40.5, and 82.5, respectively. There were no nonunions, and no plates required removal. Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate.

Management of post-traumatic malunion of fractures of the distal radius

Distal radius malunions are a common cause of patient morbidity. This review of the literature surrounding distal radius malunion covers the demographics, pathologic anatomy, and indications for surgery, surgical techniques, and salvage options. Particular emphasis is placed on subject areas that have not been reviewed as extensively in previous articles, including: intra-articular malunion, computer-assisted techniques, bone graft alternatives, and volar fixed-angle plate osteosynthesis.