malunion colles

8/4/2019 malunion colles

1/12

Journ al of the American Academ y of Ortho paedic Surgeon s270

Malunion is a recognized cause of

suboptimal function after distal

r ad ius fr ac tu re . The ob jec t ive

find ings and subjective comp laints

of a symptomatic malunion have

come to be better appreciated as

patients of all ages have demand-

ed h igh levels of fun ction after th iscommon injury . Furtherm ore, ad-

vances in the u nderstand ing of the

biomechanics of the hand-wrist-

forearm u nit have led to imp rove-

ments in surgical techniques for

r e s t or i n g t h e n o r m a l a n a t o m i c

relationships, resulting in better

function for patients with a mal-

union.

Anatomy

The distal radius includ es the radi-

al metaphysis, with its thin dorsal

cortex and the rich trabecular net-

work sup porting the radiocarpal

and distal radioulnar articular sur-

faces . This h igh ly specia l ized

platform perm its execution of

the complex motions demanded by

a vast a rray of activities.

The distal articular su rface of the

radius is contoured an d spatially

oriented to direct the motions of

the carpa l bones. The art icular

margin of the distal radius is the

point of attachment for the radio-scaphocapitate, radiolunotrique-

tral, radioscapholunate, and dorsal

radiotriquetral ligaments, which

provide stability to an d guide force

transmission about the radiocarpal

articulation.

An equally important articula-

t ion, the dis ta l radiou lnar jo int

(DRUJ), is composed of the sig-

moid notch, or fossa, of the radius

and the ulnar head. The portion

of the ulnar head that articulates

with the sigmoid notch is calledt h e u l n a r s e a t ; t h e p o r t i o n

und er the triangular fibrocartilage

is considered the ulnar pole .

The relat ionship of the concave

s i g m o i d n o t c h , w i t h i t s l a r g e r

r a d i u s o f c u r v a t u r e , a n d t h e

s m a l l e r u l n a r s e a t p e r m i t s a

un ique combinat ion of ro ta t ion

and t rans la t ion.1 However , the

area of art icular contact is rela-

tively small and has little inherent

stability imparted by the osseous

structure.

M ot ion a t t he D R U J i s con-

trolled by stabilizing soft tissues

about the distal ulna, including

the volar and d orsa l radioulnar

ligaments, the articular disk of the

triangular fibrocartilage complex

(TFCC), the DRUJ cap sule , th e

extensor sheaths of the fifth and

s i x t h c o m p a r t m e n t s , a n d t h e

pronator quadratu s . The radio-

carpal unit translates dorsally and

distal ly about the stable ulna in

supination, delivering the ulnar

head volarward. In pronation, theradiocarpal un it translates volarly

and p rox im a l ly , de l ive r ing th e

ulnar seat dorsally.

Dr. Graham is Attending Surgeon, Section of

Hand and Upper Extremity Surgery, Depart-

ment of Orthopaedic Surgery, Cleveland Clinic

Foundation, Cleveland, and Assistant Clinical

Professor of Orthopaedic Surgery, Ohio State

University, Columbus.

Reprint requests: Dr. Graham, Section ofHand and Upper Extremity Surgery, Depart-

ment of Orthopaedic Surgery, Cleveland Clinic

Foundation, 9500 Euclid Avenue - A51,

Cleveland, OH 44195.

Copyright 1997 by the American Academy of

Orthopaedic Su rgeons.

Abstract

Malunion of a distal radius fracture may result in functional limitation and

pain. Reestablishing the geometry of the metaphysis and the alignment of the

articular surface, restoring the relationship at the distal radioulnar joint, and

respecting the soft-tissue envelope are elements of a successful reconstruction.

The author describes a systematic approach to evaluation and t reatment, includ-

ing the indications for surgical correction, techniques of reconstruction, and

potential complications. Salient aspects of postsurgical rehabilitation and sal-

vage procedures are discussed.

J Am Acad Orthop Surg 1997;5:270-281

Surgical Correction of Malunited Fractures

of the Distal Radius

Thomas J. Graham, MD


2/12


Vol 5, No 5, September/October 1997 271

Radiographic Evaluation

Five familiar measurements can be

used to evaluate the distal end of

the radius: rad ial inclination, rad ial

length, ulnar variance, radial tilt,

and radial shift.

On a posteroanterior (PA) radio-graph, the inclination of the radial

platform is the angle between a line

draw n from the t ip of the radial

s ty loid to th e most d is ta l u lnar

aspect of the lunate facet and a line

perpend icular to the longitudinal

axis of the rad ius (Fig. 1, A). The

average ra dia l inc l inat ion i s 22

degrees.2

Radial length is measured on a

PA film by determining the longi-

tud inal difference between a line

perp endicular to the long axis of

the radius drawn at the radial sty-

loid and another line tangential to

the distal articular surface of the

ulna (Fig. 1, B).2 With this method,the normal rad ial length is app roxi-

mately 11 mm . I do not favor this

method, as it does not truly assess

the DRUJ, where length inequity

has its greatest imp act. Instead, I

p re fe r t o r ecord u lna r va r i ance

(Hultens variance), or radioulnar

length.3,4 Both methods reflect the

relationship of the articular sur-

faces of the radius and ulna at the

DRUJ, and both are useful because

they take into account the anatomic

and mechanical impact a fracture

wi th med ia l fragment d isplace-

ment may have on wrist and fore-

arm function. A PA view of the

normal wrist should also be taken,because there can be differences in

the d istal radioulnar relationship

among individuals.

Ulnar variance, or radioulnar

length, can be calculated in a variety

of ways, all of which yield similar

results.3 This variable is determined

by draw ing a line perpendicular to

the long axis of the radius at the sig-

Fig. 1 Calculation of radiographic measurem ents of the distal radius. A, On a PA radiograph, the radial inclination (RI) is the angle sub-tended by a p erpendicular to the long axis of the rad ius and a line reflecting the articular surface of the radius. B, On a PA film, the radiallength (RL) is the d istance between tangents draw n at th e radial styloid and the ulnar pole, perpend icular to their shaft axes. C, The ulnarvariance, or radioulnar length, also measured on a PA film, reflects the axial relationship between the ulnar pole and the ulnarm ost aspectof the distal radius. In the drawing on the left, the radioulnar length is neutral. The drawing on the right d emonstrates a prominent ulnaat the DRUJ. D, On a lateral radiograph, the radial tilt (RT) is the angle between the articular surface and a line p erpendicular to the rad ialshaft. E, On a PA film, the radial shift (RS), or radial width, is a comparison measurement made between the malunited radius and thenoninjured radius. It is the distance between p arallel lines draw n tangent to the radial styloid an d the long axis of the radius.

A B C

D

RT

RL

RI

E

Volar Dorsal

RSRS


3/12

Malunited Distal Radius Fractures


moid notch and then measur ing

how much of the ulnar head is dis-

tal to that line (Fig. 1, C).

Ulnar variance has important

pr ognostic imp lications. Aro and

Koivunen4 classified three types of

r ad iou lna r r e l a t ionsh ips a t t he

DRUJ after distal radius fractures.Axial shortening of the radius by

less than 3 mm, d esignated grade 0,

was considered acceptable. Grade

1 includ ed fractures w ith 3 to 5 mm

of shortening. A fracture with more

than 5 mm of radia l shor tening

at the DRUJ was termed grade 2.

Good or excellent functional results

occurred in 96% of their patients

with a grade 0 radioulnar relation-

ship. Functional impairment was

reported in the other two groups,

which correlated directly with the

length disparity. When dorsal or

radial malalignment or displace-

ment of the distal articular surface

of the radius was combined w ith

radial shortening, the result was an

even greater decrement in clinical

outcome.

The radial tilt is measured on a

latera l film (Fig. 1, D). The norm al

pa lm arw ard o r i en ta t ion o f t he

articular surface, or platform, is

m easured by com par ing a l i nedrawn through the volar and dor-

sa l margins of the dis ta l radius

wi th th e long axis of the rad ia l

shaft. The normal radial tilt is ap-

proximately 11 deg rees. Mann et

al5 have shown that d orsal tilting is

not found in the noninjured adult

wrist, and that women generally

have slightly more palmar tilt than

men.

The radial shift, or radial width,6

is the distance between the longitu-

dinal axis of the radius and a linedrawn tangential to the radial sty-

loid. This measu rement reflects the

shor t en ing and r ad ia l co l l apse

often seen in comminuted distal

radius fractures and is related to

radial inclination, rad ial length,

and ulnar variance. In preopera-

tive planning, the radial shift of the

malunion i s compared wi th the

relationship in the non injured con-

tralateral wrist (Fig. 1, E).

When evaluating posttraumatic

radial d eformity, it is also imp or-

tant to assess fracture location and

adequacy of reduction, particularlyintra-articular displacement at the

rad ioca rpa l jo in t ,7 t he s igm oid

fossa, and the u lnar head.

Biomechanics

Changes in the osseous architec-

tur e affect the mechan ics of the

rad iocarpal joint, th e DRUJ, and

the forearm axis. For examp le, do r-

sal tilting of the radial platform

shifts axial loading through the

w r i s t do r sa l ly and u lna r ly and

decreases the joint contact area .8

Dorsal tilting may also produce a

carpal collapse pattern similar to

that seen in dorsal intercalated seg-

ment instability (DISI) but without

interosseous ligament disruption9

or secondary midcarpal instabili-

ty10 (Fig. 2).

The relationship between radial

malunion and kinematic alteration

at the DRUJ and anatomic distor-tion of the TFCC has been studied

by Adams,11 who observed that the

greatest change in kinematics at the

DRUJ accompanies r adial shor ten-

ing. Loss of rad ial inclination and

dorsal tilting of the platform in the

s a g i t t a l p l a n e h a d a m o d e r a t e

effect. Dorsal disp lacement of the

d i s t a l f r agm ent caused l i t t l e

change. Radial shorten ing created

the greatest strain in th e articular

disk and in the volar and dorsal

radioulnar ligaments of the TFCC.

Fur the rm ore , he obse rved tha t

deformity of the radius alone in the

presence of an intact TFCC did not

perm it dislocation of the DRUJ.

Fig. 2 A, Radiograph of a m alunited d istal radius fracture w ith dorsal tilting of the plat-form in the sagittal plane. Note the dorsal posture of the lunate and the increases in thescapholunate angle and the capitolunate angle. B, Normal rad iocarpal and intercarpalalignment in the sagittal plane. C, The collapse pattern often seen with distal radialmalunion w ithout intercarpal ligament disruption.

A B C

Normal Malunion


4/12



Clinical Presentation

The symptom complex that f re-

quently accompanies radial mal-

union includes pain, motion loss,

and weakness. The location of the

pain can be variable and multifo-

cal. Causes of pain include gener-alized synovitis, osteocartilaginous

damage due to the initial injury or

resulting from altered mechanics or

ulnocarpal abutment, a TFCC tear,

and arthrosis at the wrist joint or

the DRUJ. It is important to differ-

entiate mechanical pain from dys-

t roph ic sym ptom s . Loca l i z ing

symptoms to the radial side or the

u lna r s ide o f t he w r i s t has an

impact on treatment, particularly

with respect to surgical manage-

ment of the d istal ulna.

Although decreased motion can

be observed in any plane of wrist

motion or forearm rotation, radio-

carpal flexion is typically dimin-

ished d ue to d orsal angulation of

the distal radius. Sup ination loss is

a p redictable complaint and clinical

finding; pronation is usually dimin-

ished to a lesser extent. The combi-

nation of al tered m echanics and

pain resul t s in decreased gr ip

strength. Recording of wrist andforearm m otion in all planes and

gr ip-s t rength measurements i s

important.

PreoperativeConsiderations

Indications

Not all malunited distal radius

fractures require surgical treat-

ment . The decis ion to proceed

with a rad ial osteotomy or an ulnaros teoplas ty , or both , should be

based on a combination of factors,

including the location and intensity

of pain, the functional impact of

mot ion loss and d ecreased gr ip

strength, and the radiologic find-

ings . Of these fac tors , c l in ica l

symptoms and functional losses are

most imp ortant.

Fernandez12 observed a patho-

logic displacement of the flexion-

extension arc with a change in rad i-

al tilt greater than 25 degrees. He

also found that less severe deformi-

ties (10 to 15 degrees of dorsal tilt-ing f rom norm al) may resul t in

midcarpal instabil i ty in patients

w i th p reex i s t ing w r i s t l ax i ty .

Fourr ier e t a l13 conclud ed f rom

their study of 64 radial malunions

t h a t s y m p t o m s a n d f u n c ti on a l

impairment resulted from a loss of

sagittal tilt of 10 to 20 degrees and

that a 20- to 30-degree loss of radial

inclination h ad a severe effect on

function.

Laboratory studies support the

concep t t ha t m a lu n ion im pa i r s

function and may be an accelera-

tor of arthrosis.8,11,14 Dorsal tilt in

the ran ge of 20 to 30 degrees alters

the forces on the radial articular

cartilage and thus m ay cause de-

generative change.8,14 On the basis

of laboratory studies and clinical

surveys, Graham and Hastings15

suggested four radiographic crite-

ria for assessing h ealing of a distal

rad ius f rac ture . These cr i ter ia

focus on the position of the radialplatform, the status of the DRUJ,

and the congruity of the articular

surface a t the radiocarpal jo int

(Table 1).

How ever, these criteria are not

absolute. Individ ual variations in

normal anatomy and the clinical

impact of the malunion must be

t aken in to cons ide ra t ion . The

greatest variability appears to be in

the patients response to a change

in rad ial tilt. Many patients willtolerate a dorsal tilt in the range of

10 to 15 degrees (approximately 25

degrees of deviation from normal);

pa t i en t s w i th dor sa l t i l t i ng in

excess of 20 degrees have a greater

r i sk o f deve lop ing sym ptom s .

Pred ic t ab ly , shor t en ing o f t he

radius, with the accompanying d is-

turbance a t the rad iocarpal and

radioulnar joints, seems to have the

most direct correlation with devel-

opment an d intensity of symptoms.

There are no well-established

criteria for articular incongruity a t

the DRUJ. There is relatively little

articular contact between the u lnar

seat and the sigmoid fossa; maxi-

mum contact at neutral rotation is

about 60%, and contact is as little

as 10% at the extremes of prono-

sup ination. It is conceivable that

intra-articular malunion could be

tolerated. How ever, personal ex-

perience indicates that step-offs of

1 to 2 mm at the DRUJ can causesymptoms.

G r a h a m a n d H a s t i n g s15 d e-

scribed four clinical groups based

on the above-m ent ioned r ad io -

Table 1

Radiographic Criteria for Acceptable Healing of a Distal Radial Fracture

Radiographic Criterion Acceptable Measurement

Radiou lnar length Radia l shor ten ing of


5/12


graphic criteria and developed a

systematic approach to the surgical

treatment of symptomatic distal

rad ial ma lun ions (Table 2). Pro-

cedures selected on the basis of

these guidelines resulted in im-

provements in wrist motion, pro-

nosupination, and grip strength.In groups I, II, and III, the DRUJ

was salvaged . Reconstru ction of

the DRUJ with or without realign-

ment of the radial platform with

respect to the radiocarpal joint uni-

formly resulted in subjective im-

provement and enhancement of

wrist and forearm function. Pa-

tients who underwent DRUJ abla-

tion had a higher comp lication rate

due to instability and radioulnar

impingement. However, group IV

pa t i en t s a l so dem ons t r a t ed the

grea t e s t im provem ent i n g r ip

strength, with elimination of pain-

ful ulnocarpal abutment or DRUJ

arthrosis.

These f ind ings ind ica t e t ha t

restoration of DRUJ alignment is

technically feasible and is clinically

indicated even when the primary

pain seems to emanate from the

DRUJ. Distal ulna r ablation should

be reserved for arthritic joints and

incongruous joints that cannot berealigned.

Al though complaints about a

p rom inen t u lna a re f r equen t i n

patients with a m alunion, cosmetic

improvement alone is not an indi-

cation for surgical interven tion.

Preoperative discussions should

emphasize that the goals are pain

relief and anatomic restoration.A gray area in clinical decision

making is the situation in which a

young patient (aged less than 40

years) has a radial malunion that is

considered un acceptable on the

basis of radiographic criteria yet is

only minimally symp tomatic. The

natural history of long-standing

radial malunion is unknown, and

the results of biomechanical studies

are only suggestive of an increased

risk of arthrosis. Anatom ic derange-

ment, motion, pain, and the desired

level of activity must be the key

determining fac tors . Operat ive

treatment of asymptomatic patients

and those with minor impairment is

seldom ap propriate.

The degree of funct ional im-

provem ent varies. In the series of

Graham and Hastings,15 wrist flex-

ion improved to a slightly greater

degree than wrist extension. Sup i-

na t ion w as the m os t im proved ;

however, pron ation also increased.In a l l group s , gr ip s t rength im-

proved to ap proximately two thirds

of that on the contralateral side.

Timing of Distal Radial

Osteotomy

The optimal timing for osteotomy

continues to be debated. Postponing

the osteotomy until fracture consoli-dation, recovery of motion, and

reversal of osteopenia have occurred

is appealing; however, in cases of

severe deformity, impaired function,

and pain, earlier intervention may

be ind icated. An early, or nascent,

distal radial osteotomy can be per-

formed in the first 4 to 8 weeks after

fracture. If a fracture originally

treated by closed method s shows

increasing collapse, takedown of the

callus and anatomic reconstruction

with a bone graft and internal fixa-

tion will redu ce the rehabilitation

time. There is also a potential bene-

fit to rebalancing the soft tissues and

preventing contracture.

Jupiter and Ring16 compared the

results of early and late reconstruc-

tion of the malunited distal radius.

(Early reconstruction was defined as

that performed an average of 8 weeks

after injury; late osteotomies were

performed on average at 40 weeks.)

The results were comparable andslightly favored early reconstruction.


Table 2

Criteria for Patient Grouping and Treatment Recommendations in Study by Graham and Hasting s15

Group Radial Radioulnar DRUJ Reducible by Acceptable DRUJ Reconstruction

Assignment Measurements Length Radial Osteotomy Articular Surfaces Indicated

Group I Unacceptable Unacceptable Yes Yes Distal radial

osteotomy

Group II Acceptable Unacceptable NA

*

Yes Ulnar shorteningGroup III Unacceptable Unacceptable No Yes Distal radial osteotomy

and ulnar shortening

Group IV Unacceptable Unacceptable No No Distal radial osteotomy

and distal ulnar ablation

*N A = not app licable to this group because no distal radial osteotomy was p erformed in group II patients.


6/12



These investigators conclud ed that

the osteotomy was technically easier

and the overall period of disability

was shor ter with early correction.

Contraindications

If the radiocarpal or intercarpal

joints exhibit advan ced d egenera-tive arthrosis, a radial osteotomy

wil l provide l i t t le symp tomat ic

relief. The quality of the bone stock

is important; severe osteoporosis is

a re la t ive cont ra indicat ion, but

advanced age alone is not. If non-

mechanical symptoms or sympa-

thetically m ediated p ain dom inates

the p resen ta t ion , t he op e ra t ion

should be postponed.

Preoperative Planning

The success of radial osteotomy is

dependent on jud icious patient selec-

tion, meticulous preoperative plan-

ning, and careful surgical execution.

At a minimum, a full set of radio-

graphs of the injured and the con-

tralateral, noninjured w rist should be

obtained. These stud ies are usually

adequate for the necessary calcula-

tions and template preparation.17,18

Computed tomography is helpful in

assessing the articular surfaces. In

patients with complex intra-articularinvolvement, preoperative wrist

arthroscopy may be useful.

More sophisticated methods of

planning, includ ing trigonometric

calculations, have emerged. Nom o-

gram s have been deve loped to

facilitate prediction of the size and

shape of the graft that is required

for the correction.19 C om pute r -

generated mod els have also been

developed to assist the surgeon in

cases of comp lex deformity.20

A thorough und ers tanding of the steps of the operation (Fig. 3)

will facilitate intraoperative prepa-

ration. The possible need for pro-

visional external fixation,21 lamina

spreaders, power equipment, fluo-

roscopy, and var iable f ixat ion

devices should be anticipated.

Surgical Techniques

Extra-articular Radial Malunion

Most radial malunions present

with sh ortening , loss of radial incli-

nation, and dorsal t i l t ing of the

rad ius. The goal of reconstru ction

is to restore the alignment of the

radiocarpal joint and the DRUJ by

performing an osteotomy through

the site of the original fracture and

supp or t ing the d i s t a l f r agm ent

with a corticocancellous bone graft

and intern al fixation. My preferred

A B

D E

C

Fig. 3 Steps in performance of a distal radial osteotomy. A, The location of the incision ismarked. B, Position of guid e pins. Pin A is an intra-articular or juxta-articular p in used to

jud ge the orientation of the rad ial articular sur face. Pin B diverge s from being pa rallel topin A in an an gle that will eventually be the amou nt of correction yielded by the osteoto-my (hatched line represents level of osteotomy); it is placed at the eventual site of the mid-dle hole of the plate and can be used to secure the intraoperative external fixator. Pin C isan optional pin that can be used to judge the recovery of radial inclination; it divergesfrom being par allel to the joint in the angle of eventu al correction. Pin D is placed d orsallyperpend icular to the axis of the radius and will be parallel to pin B when the correction iscomp lete; it can be a half-pin used to erect the intraop erative external fixator. Pin E is the

companion pin to pin C if correction of inclination is to be monitored; it is perpendicular tothe axis of the rad ius in the radial-to-ulnar direction. A second external fixator based onpins C and E can be used, but I prefer to simply place smooth wires in these positions todiminish the hole size. C, The geometry of the radius has been restored through theosteotomy site, and an external fixator m aintains the correction held by the lamina spread-ers. Note th at all pin pa irs (i.e., B and D, C and E) are par allel after correction. D, Harvestof the bicortical graft from th e iliac crest. The graft is usu ally taken from the sup erior crestand the outer table, although the inner-table contour may be more su itable in some cases.E, Plate fixation stabilizes the osteotomy construct.

Angle of

inclination

correction

Angle of

sagittal

correction

Line parallel

to joint

Line parallel

to joint

A

A

B

B

C

C

D

D

E

E


7/12


surgical approach to reconstruction

of a typical radial malunion is sum-

marized in Figure 3.

A dorsally angulated malun ion is

exposed by a longitudinal or slight-

ly curved dorsal incision extending

from the midcarpal level to the radi-

al metadiaphysis (Figs. 3, A; 4, A).Skin flaps are raised by dissecting

the areolar suprafascial plane. The

third dorsal compartment is then

incised. The extensor pollicis lon-

gus is retracted rad ially and left

transposed at the end of the proce-

dure.

Subperiosteal dissection of the

second and fourth dorsal compart-

ments is performed to fully expose

the malun ited radiu s. A smooth

wire is inserted into th e radiocarpal

joint or parallel to it just proximal

to the subchond ral bone (Fig. 3, B).

This wire is the locator for the joint

and will be a guide to appropriate

positioning of the distal fragment

after osteotomy.

I r em ove the p rom inence o f

Listers tubercle, find the center of

what will become the distal frag-

ment, and then p lace a part ial ly

threaded Schanz pin that will be

used for intraoperative construc-

tion of a small external fixator. The

pin has a thread diameter of 2.0 or

3.0 mm . The hole created by the

pin will become the central screw

hole for the fixation plate. The pini s p l aced such tha t t he ang le

between the partially threaded pin

and the smooth wire is the angle

needed to correct the volar tilt.

A second partially threaded pin

is placed p erpend icular to the long

axis of the radius in a proximal

location. This pin has a du al pu r-

pose; it will be the proximal anchor

for the intraoperative fixator and

will also be the standard by which

the distal fragment orientation will

be judged for sagittal correction.

When the correct volar t i l t i s

gained (as predetermined from the

contralateral radius), the proximal

and distal pins should be parallel;

thus , the f ixator and the rad ius

make a perfect quadr ilateral (Fig. 3,

C) . Fluoroscopy is help ful for

intraoperative confirmation of pin

placements and alignmen t correc-

tion.

Smooth 0.045-inch wires can

also be inserted from th e lateral

aspect of the radius to guide the

correction of rad ial inclination, if

desired (Fig. 3, A). The proximal

pin is placed 90 degrees to the longaxis of the rad ius. The distal pin is

placed at an angle divergent from

the articular surface such that it

will be parallel to the proximal pin

when the desired angle of correc-

tion is achieved .

The os teotomy is car r ied ou t

with an oscillating saw or osteo-

tomes and must be proximal to the

sigmoid notch of the radius. The

usual level of the os teotomy is

about 2.5 cm proximal to the radio-

carpal joint, near the proximal base

of Listers tubercle, which is typi-

cally at the level of the fracture

deformity. I tend to make the os-

teotomy perpendicular to the long

axis of the radius in the PA plane,

rather than parallel to the joint ,

a l t hough the l a t t e r i s pe r f ec t ly

acceptable an d creates less volar


A B C D

Fig. 4 Distal radial osteotomy. A, Incision and dissection down to the level of the fascia, incision of the third dorsal compartment, andtransposition of the extensor pollicis longus (in retractor). B, Lamina spread ers are u sed to establish orientation of the d istal fragment.External fixator is in place to maintain correction before graft insertion. C, Graft placement. (Because distraction was released while har-vesting the graft, the void size does not m atch graft dimensions.) D, Graft in place (with fixator on) before remo val of external fixator an dplate application.


8/12



displacement of the d is ta l frag-

ment. Among the reasons for my

preference is that it establishes a

relatively flat proximal base for the

corticocancellous graft, creates a

less severe slope from radial to

ulnar at th e distal edge of the graft,

and provides more bone about therad ial styloid for p otential fixation.

In the sagittal plane, I typically

create the osteotomy parallel to the

malunited joint. It mu st be recalled

that the spatial relationships about

the ar t icular surface have been

changed; articular penetration by

the saw or os t eo tom e m us t be

avoided.

Limi ted volar re lease of the

prona to r quadra tus can be pe r -

formed through the osteotomy site

to better mobilize the distal frag-

ment . Use of small lamina spread -

ers will facilitate positioning of the

distal fragment and will stabilize

the relationship if an external fixa-

tor is ap plied (Figs. 3, C; 4, B). The

void created by p ositioning the dis-

tal fragment in the d esired orienta-

tion is the best guide to the amou nt

of bone that will have to be har-

vested from the iliac crest, althou gh

the dimensions should be close to

the calculations performed in pre-operative planning.

Before deciding on the f inal

graft dimensions, the provisionally

s tabi l ized const ruct i s taken

through the range of motion. The

wrist flexion-extension arc should

be imp roved. I have not found it

necessary to perform a limited d or-

sal radiocarpal capsulotomy, but it

can be considered . A provisional

check of pronosupination will dic-

tate whether adjunctive DRUJ cap-

sulectomy wi l l be necessary ,depend ing on the d egree of resid-

ual pronation or supination con-

tracture.

A t t h i s po in t , t he a l ignm ent

shou ld be checked w i th f luo -

roscopy or radiography. A trape-

zoidal bicortical graft, taken from

the ou te r t ab l e o f t he i l ium , i s

placed such that its cortical mar-

gins are on the dorsoradial aspect

of the rad ius (Figs. 3, D; 4, C). Only

in f r equen t ly i s t he i l i um th in

enough to yield a tricortical graft

that can be intercalated in the void.

It is the superior aspect of the iliacwing that will become the radial

aspect of the graft, with the cortical

bone from the inner or outer table

fo rm ing the dor sa l s t ru t o f t he

graft. Therefore, the sup erior por-

t ion of the i l iac wing should be

inspected to d etermine whether the

osseous architecture of the inner or,

more commonly, the outer table

better suits the p atients anatomy.

The goal is an intercalated graft

well stabilized between the radial

fragments. Placing it in the void

w hi l e t he cons t ruc t i s s l i gh t ly

overdistracted by the fixator and

lamina spreaders and then careful-

ly releasing the distraction is ad-

vised (Fig. 4, D). Fixation of the

graft can be d one by any of several

meth ods (Fig. 3, E). I pr efer plate

fixation with an oblique T plate

(Fig . 5) , but I have used mini

condylar blade plates in patients

with thin rad ii (Fig. 6). Kirschner

wires can also be used to fix the

graft in place.

Two other alternatives for per-

forming an osteotomy of the dor-

sally t i l ted rad ial platform h ave

been described. The first is the

trapezoidal osteotomy, wherein abone graft of specific proportion is

taken from the malunited d orsal

radius itself (Fig. 7).22 After radial

os t eotom y th r ough the l eve l o f

deformity, the corticocancellous

trapezoidal graft is rotated into th e

void for support of the distal frag-

ment. This procedu re observes the

basic principles already described

but has the theoretical advantage

that pelvic donor-site morbidity is

avoided. It should be reserved for

the patient with a wide rad ius in

the radioulnar dimension and the

patient with a strong aversion to

il iac-crest harvest or some con-

traindication, such as prior har-

vests.

The second alternative is a closing-

w edge os t eo tom y o f t he d i s t a l

radius.23 Radial platform correc-

tion may be effected with this tech-

nique, but it requires both resection

Fig. 5 PA (A) and lateral (B) views of the wrist of a p atient with a d orsally tilted, short-ened radial articular surface. C an d D, Reconstruction w ith an opening-wedge osteotomyand fixation with an oblique T plate restored near-anatomic relationships at the radio-carpa l joint and th e DRUJ. Care mu st be exercised to avoid intra-articular penetr ation withthe screws in the d istal fragment.

A B C D


9/12



of a l a rge por t ion o f t he r ad ia l

metap hysis and sacr i fice of the

DRUJ. There is little role for this

reconstruction, as more desirable

alternatives exist, except perhaps

for very low-demand patients with

poor bone stock.

If the radial platform demon-

strates excessive volar tilt in the

sagittal plane, the app roach taken is

opposi te to that for dorsa l t i l t .

Exposure can be performed throu gh

the distal aspect of Henrys flexorcarpi radialisradial artery interval

for a straightforward malunion or

through a more generous approach

in which the carpal canal is released

and the skin is incised on the ulnar

side of the volar aspect of the fore-

arm. The la t ter app roach is re-

served for pat ients wi th severe

deformity, those with medial-side

int ra-ar t icular malunion of the

radius, and those with concomitant

median or ulnar neuropathy. The

radius is then exposed by entering

the interval between the ulnar neuro-

vascular bundle and the flexor digi-

to rum pro fund us t endons . The

pronator quadratus is elevated from

the la tera l s ide of the rad ius ineither exposure.

An opening-wedge osteotomy

from the volar aspect should ac-

complish the correction. A precon-

toured T plate can be used to fix the

distal fragment and intercalary graft

and thereby restore the integrity of

the volar rad ius (Fig. 8). Typically,

there is minimal shortening in volar

malun ions, and anatomic correction

will require only an osteotomy and

plate stabilization, with a minimum

of grafting. If surg ery is requiredon the ulnar side, the options for

exposure of the ulna include addi-

tional deep dissection through the

same dorsal approach used to per-

form the osteotomy and/ or addi-

tional incision from the volar side or

the subcutaneous border.

Intra-articular Malun ion

Correction of an intra-articular

malunion is more challenging than

reconstruction of an extra-articular

m a lun ion . M any pa t i en t s have

both an intra-articular and an extra-

ar t icular m alunion of the dis ta l

radius. Cross-sectional imaging isgenerally necessary to characterize

the location an d extent of d eformity.

Wrist arthroscopy may have a role

in preoperative and intraoperative

assessment.

Saffar described alternatives for

the surgical management of intra-

articular malunions based on the

location of the incongruity.24 His

recommendations are summarized

in Table 3.

Saffar d oes not p ropose rad io-

scaphoid fusion and radioscapholu-

nate fusion as alternatives for treat-

ment of some intra-articular malu-

nions, but these procedures should

be considered . There are as yet no

outcome studies that establish the

efficacy of intra-articular corrective

osteotomies. A long-standing intra-

articular malunion is a technical

challenge, and there is a high likeli-

hood that wrist arthrodesis may

eventually be required . If the mal-

union is intra-articular with respectto the DRUJ, an ablation procedure

may be preferable to a diff icult

reconstruction and lengthy rehabili-

tation.

Surgical Handlin g of the Ulnar

Side o f the Wrist

I prefer reconstruction of the

DRUJ relationship by radial osteot-

o m y a n d / o r u l n a r o st e o p la s t y ,

wh en possible. In some cases, non-

ana tom ic hea l ing o f t he d i s t a l

radius w ill be noted, but the radio-graphic measurements of the plat-

form will still be acceptable with

the except ion of the rad ioulnar

length . In th is s i tua t ion, u lnar

shortening may restore the DRUJ

and p rov ide pa in r e l i e f a s t he

apposing articular surfaces of the

Fig. 6 PA (A) and lateral (B) views of the wrist of a p atient with a d orsally tilted, short-ened articular su rface. C an d D, A dorsal opening-wed ge osteotomy was used. Becausethe radius was extremely narrow, minicondylar blade plates were used to secure thegraft.

A B C D

Fig. 7 Schematic of a trapezoidal osteot-omy. The corticocancellous graft used tocorrect the m alunion is harvested from th edorsal surface of the radius.


10/12



radius and ulnar are adequate ly

redu ced. Of course, the articular

cartilage must be of good quality.

Preoperative planning should min-

imize the need to perform ulnar

shortening when a radial osteoto-

my is done, but occasionally it is

needed.

If the DRUJ is not reducible byradia l os teotomy or i f a r thros is

exists on the ulnar or radial aspect

of the joint, some type of ablation is

indicated. How ever, ablation of

the ulna potentially compromises

the axial load ing chara cterist ics

about the wrist and may result in

decreased strength and stability.25

The opt ions for abla t ion of the

DRUJ fall into three general cate-

gor ies 26-28: (1) complete d is ta l

ulnar excision (Darrach resection

and its variations), (2) partial distalu lnar excis ion (e .g . , Bowers

hemiresection interposition tech-

nique, Watsons matched resec-

t ion ), and (3) d i s t a l r ad iou lna r

arthrodesis with creation of a prox-

imal ulnar p seudarthrosis (Sauv-

Kapandji procedu re).

The decision to do an ulnar-side

procedure often comes after recon-

struction of the radius. In most

cases , a wel l -p lanned and wel l -

executed radial osteotomy will re-

store the DRUJ and lead to recovery

of forearm rotation, obviating the

need for surgery on the ulnar side. Ibelieve there is little difference in

outcome between the various types

of ulnar resections performed in

conjunction w ith rad ial osteotomy,

provided one adheres to recom-

mended indications and techniques.

Excessive distal ulnar excision with-

out stabilization, performance of the

hemiresection interposition tech-

nique when there is an incompetent

TFCC, or ulnar surgery when there

is global forearm -axis instability

(e.g., after an Essex-LoPresti injury)

can lead to suboptimal results. If

the situation calls for DRUJ ablation,

the Darrach resection or th e hemire-

section interposition technique is

genera lly effective.

Postoperative Care andRehabilitation

A sugar-tong splint is applied at

the conclusion of the operation,

which is changed to a short-arm

cast 10 to 14 days later. A remov-

able orthosis is substituted at 4 to 6

weeks , and gent le wr is t mot ion

and forearm rotation are begun.

When tenderness at the fracture

site diminishes or when definitive

signs of healing are identified rad io-graph ically, the orthosis is d iscon-

tinued. A systematic, but not overly

rigorous, regimen of rehabilitation is

used to restore motion and strength.

A concentrated effort is made to

restore forearm rotation, especially

supination.

Com plications and SalvageProcedures

Complications after distal radial

os t eo tom y inc lude f a i lu re to

ach ieve the d es ir ed a l ignm en t ,

ne rve dam age , nonun ion a t t he

os t eo tom y s i t e , and ins t ab i li t y

about the ulnar stump after resec-

tion. One par ticular comp lication

is l imitat ion of pron osup ination

due to DRUJ capsular contracture.

In a subset of patients, the radial

platform and the DRUJ are ana-

tomically realigned by rad ial os-

t eo tom y, bu t fo rea rm ro t a t ion

A B

Fig. 8 A, Malunion after a volar marginfracture. B, Anatomic restoration after avolar opening-wedge osteotomy, bonegrafting, and plate ap plication.

Table 3

Surgical Options for Treatment of Intra-articular Malunion, According to

Saffar24

Description of Malunion Surgical Options

Scaphoid facet m alunion Intra-articular osteotom y

Radial styloidectomy

Proximal row carpectomy

Lunate facet m alunion Osteotom y for posterom ed ial fragm ent

Radiolunate fusion for global

involvement

Global w rist involvem ent Early in tra-articu lar osteotom y

Wrist denervation

Total w rist fusion

Anterior or posterior rim malunion Simple bone resection


11/12



r em ains lim i t ed . I f pa th o log ic

changes a t o ther locat ions have

been excluded, a contracted DRUJ

capsule may be the cause of prono-

supination loss, necessitating surgi-

cal treatment.

The DRUJ capsule, a structure

distinct from the TFCC, is particu-larly suited for its role in accomm o-

dating the ulnar seat during fore-

arm rotation.29 Its volar and dorsal

components, continuou s with th e

stout proximal portion of the cap-

sule, are thin and capacious, allow-

ing motion at the DRUJ. In the

pathologic state, the capsule loses

its compliant nature and becomes

thick and scarred. This contracture

a lone has been show n to l im i t

DRUJ mot ion. A DRUJ capsulecto-

my is an effective way to restore

pron osupination. The TFCC mu st

be preserved w hen excis ing the

capsule.

Due to the nature of DRUJ rela-

t ionships du r ing rota t ion, volar

capsulectomy restores supination,

and dorsal capsulectomy restores

pronation; a combination is some-

times necessary. Volar capsu lecto-

my is performed through the inter-

val between the flexor carpi ulnaris

and the ulnar neurovascular bun-dle and then p erforming an exci-

sion of the scarred capsule, protect-

ing the volar rad ioulnar ligament.

Dorsal capsulectomy is similarly

performed; the fifth dorsal com-

partment is incised, and the exten-

sor digiti minimi is transposed to

allow access directly to th e capsu le.

This operation can be combined

with radial osteotomy when intra-

ope ra t ive l im i t a t ion o f p rono-

supination is noted after successful

anatom ic correction.

For seve re o r l ong- s t and ingdeformities, additional procedures

may be necessary. Release of the

pronator quad ratus may be n eces-

sary to achieve optimal improve-

ment. Staged lengthening by dis-

traction method s can be used in the

t r ea tm en t o f d i s t a l r ad ia l m a l -

unions resulting from trau ma in an

a d u l t p a t i e n t o r d u e t o g r o w t h

arrest in the distal radial physis.30

This is technically difficult to plan

and execute but is one of the few

motion-sparing procedures avail-

ab le fo r t he t r ea tm en t o f som e

severe deformities.

Some salvage procedures were

previously mentioned in the sec-

tion on intra-articular malunions

(Table 3). Comp lete fusion of the

wrist is the u lt imate salvage for

g loba l de fo rm i ty o r a r th r i t i s .

Partial fusions (radioscaphoid or

radioscapholunate) may have a

role in relieving pain and provid-

ing s tabi l ity . The pat ient mustaccept a d ecrease in m otion or even

elimination of motion as the trade-

off for pain relief and sta bility. A

distal ulnar resection can be con-

sidered if only the ulnar column is

pro blematic. H owever , persistent

instability of the radiocarpal unit

about the distal ulnar stump may

necessitate further surgery.

Summary

The planning and execution of sur-gical reconstruction of a malunited

distal radius fracture p resent a clin-

ical and techn ical challenge. The

surgeon shou ld establish his or her

own person al criteria for acceptab le

hea l ing and func t ion based on

available data and clinical experi-

ence, bearing in mind that not all

radiographic malunions are symp-

toma tic. Surgical han dling of the

distal ulna requires an understand-

ing of the anatomy and mechanics

of the DRUJ, as well as flexibility in

choosing w hether to reconstruct or

ablate the articulation. Preoper-

ative planning is critical to ultimate

success. Distal rad ial osteotomy is

among several procedures used as

salvage techniques after subopti-

mal healing of the original fracture;

the best results follow a natomic

res to ra t ion o f t he in i t i a l r ad ia l

injury.

Acknowledgments: I should like to thank

my friends and mentors Hill Hastings II,

MD, and William B. Kleinman, MD, for

their support and assistance in developing

many of these concepts, as well as for case

materials.

References

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3. Palmer AK, Glisson RR, Werner FW:

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