Treatment of the neglected distal radius fracture

Comparative Analysis of Radial Corrective Osteotomy and Sauvé-Kapandji Procedure for Malunited Distal Radius Fractures in Older Adults

PURPOSE

Malunited distal radius fractures frequently occur in the older population, posing a dilemma in selecting ideal management for symptomatic patients. Radial corrective osteotomy (RCO) and the Sauvé-Kapandji procedure (SK) have been used to treat this challenging condition. However, it remains unknown which approach is better for the older population. The objective of this study was to compare the outcomes of RCO with those of SK for the treatment of symptomatic distal radius malunion in older adults.

METHODS

Thirty-three patients aged ≥60 years, with malunited distal radius fractures, were randomized to be treated with either RCO or SK and followed for a minimum of 2 years. The primary evaluation parameter was grip strength, and secondary outcome parameters were surgical time, range of motion of the wrist, exercise-related wrist pain assessment using visual analog scale scores, radiographic results, patient-reported outcomes evaluated using the Disability of the Arm, Shoulder, and Hand (DASH), and Patient-Related Wrist Evaluation (PRWE) scores.

RESULTS

The average follow-up duration was 36.7 ± 10.2 months. The grip strength was significantly higher in the RCO group. The surgical time was shorter in the SK group than in the RCO group. The postoperative wrist range of motion and visual analog scale scores for exercise-related pain alleviation were similar in both groups. The ulnar variance decreased in both groups and was similar when compared with the postoperative images. The DASH and PRWE scores were similar between the RCO and SK groups.

CONCLUSIONS

Radial corrective osteotomy and SK surgeries have similar clinical and functional outcomes in patients aged ≥60 years. Grip strength is higher in the RCO group than in the SK group. However, the operating time to accomplish SK is shorter than RCO.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Comparing radial lengthening osteotomy with ulnar shortening osteotomy to treat ulnar impaction syndrome after distal radius fracture malunion

INTRODUCTION

Distal radius mal-unions often cause radius shortening and ulnar impaction syndrome. The modern treatments of ulnar impaction syndrome following distal radius mal-union are ulnar shortening osteotomy (USO) and distal radius lengthening osteotomy (DRLO). However, there are few studies to compare long-term outcomes of these two treatments. This study compares isolated USO to DRLO for the treatment of ulnar impaction syndrome following distal radius mal-union.

MATERIALS AND METHODS

We retrospectively reviewed 68 patients with extra-articular distal radius mal-unions treated by isolated USO in 36 patients and DRLO in 32 patients. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters including sigmoid inclination, DASH score, and perioperative complications were analyzed. Mean follow-up was 62.6 months.

RESULTS

The postoperative VAS scores for pain on exertion were less in the DRLO group than the USO group (1.2 vs. 2.8, p = 0.02). The DASH scores were 16.7 and 29.8 in the DRLO and USO groups, respectively (p = 0.02). The reduction of pain and improvement of function showed significantly better in the DRLO group. The mean operative time was shorter in the USO group. Most of the sigmoid inclinations were changed in DRLO. There were two re-operations following USO for painful nonunion and two patients had subsequent DRUJ osteoarthritis at the last follow-up.

CONCLUSION

Although both treatments improved range of motion, grip strength, and VAS for pain, DRLO was found in better reduction of pain and improvement of function. USO is a simpler procedure with a shorter operative time but it has an increased potential to cause subsequent osteoarthritis of the DRUJ as its incongruity of DRUJ after USO especially in reverted inclination. DRLO can be a preferred method for treating USWP in relevant distal radial mal-union.

New functions for the proprioceptive system in skeletal biology

Muscle spindles and Golgi tendon organs (GTOs) are two types of sensory receptors that respond to changes in length or tension of skeletal muscles. These mechanosensors have long been known to participate in both proprioception and stretch reflex. Here, we present recent findings implicating these organs in maintenance of spine alignment as well as in realignment of fractured bones. These discoveries have been made in several mouse lines lacking functional mechanosensors in part or completely. In both studies, the absence of functional spindles and GTOs produced a more severe phenotype than that of spindles alone. Interestingly, the spinal curve phenotype, which appeared during peripubertal development, bears resemblance to the human condition adolescent idiopathic scoliosis. This similarity may contribute to the study of the disease by offering both an animal model and a clue as to its aetiology. Moreover, it raises the possibility that impaired proprioceptive signalling may be involved in the aetiology of other conditions. Overall, these new findings expand considerably the scope of involvement of proprioception in musculoskeletal development and function.This article is part of the Theo Murphy meeting issue 'Mechanics of development'.

Three-Dimensional Compared with Two-Dimensional Preoperative Planning of Corrective Osteotomy for Extra-Articular Distal Radial Malunion: A Multicenter Randomized Controlled Trial

BACKGROUND

Malunion is the most frequent complication seen after a fracture of the distal end of the radius. The primary aim of this study was to compare patient-reported outcome measures (PROMs) after corrective osteotomy for malunited distal radial fractures with and without 3-dimensional (3D) planning and use of patient-specific surgical guides.

METHODS

From September 2010 to May 2015, 40 adult patients with a symptomatic extra-articular malunited distal radial fracture were randomized to 3D computer-assisted planning or conventional 2-dimensional (2D) planning for corrective osteotomy. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Secondary outcomes included the Patient-Rated Wrist Evaluation (PRWE) score, pain and satisfaction scores, grip strength, and radiographic measurements at 3, 6, and 12 months postoperatively.

RESULTS

From baseline to 12 months of follow-up, the reduction in the mean DASH score was -30.7 ± 18.7 points for the 3D planning group compared with -20.1 ± 17.8 points for 2D planning (p = 0.103). Secondary functional outcome by means of the PRWE resulted in a similar reduction of -34.4 ± 22.9 points for the 3D planning group compared with -26.6 ± 18.3 points for the 2D planning group (p = 0.226). There were no significant differences in pain, satisfaction, range of motion, and grip strength. Radiographic analysis showed significant differences in the mean residual volar angulation (by 3.3°; p = 0.04) and radial inclination (by 2.7°; p = 0.028) compared with the templated side, in favor of 3D planning and guidance. The duration of preoperative planning and surgery as well as complication rates were comparable.

CONCLUSIONS

Although there was a trend toward a minimal clinically important difference in PROMs in favor of 3D computer-assisted guidance for corrective osteotomy of extra-articular distal radial malunion, it did not attain significance because of (post hoc) insufficient power. Despite the challenge of feasibility, a trial of large magnitude is warranted to draw definitive conclusions regarding clinical advantages of this advanced, more expensive technology.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Ulnar Shortening Versus Distal Radius Corrective Osteotomy in the Management of Ulnar Impaction After Distal Radius Malunion

BACKGROUND

Distal radius malunions lead to functional deficits. This study compares isolated ulnar shortening osteotomy (USO) to distal radius osteotomy (DRO) for the treatment of ulnar impaction syndrome following distal radius malunion.

METHODS

We retrospectively reviewed 11 patients with extra-articular distal radius malunions treated for ulnar impaction with isolated USO. This group was compared to a 1:1 age- and sex-matched cohort treated with isolated DRO for the same indication. Pain visual analog scale (VAS), wrist motion, grip strength, radiographic parameters, and perioperative complications were analyzed. Mean follow-up was 14.8 months.

RESULTS

VAS scores improved. Wrist range of motion improved in both cohorts with the exception of radial deviation, pronation, and supination in the USO cohort, which decreased from a mean of 17°-16°, 67°-57°, and 54°-52°, respectively. There was no significant difference between groups in regard to change in pain or range of motion, with the exception of pronation and ulnar deviation. The mean tourniquet time was shorter in the USO group. The final ulnar variance was 1.8 mm negative in the USO group and 1.1 mm positive in the DRO group. There was 1 reoperation following USO for painful nonunion, while there were 2 reoperations following DRO for persistent ulnar impaction.

CONCLUSIONS

An improvement in range of motion, grip strength, and VAS with restoration of the radioulnar length relationship was observed in both cohorts. USO is a simpler procedure with a shorter tourniquet time that can be an attractive alternative to DRO for ulnar impaction syndrome after distal radius malunions.

The Proprioceptive System Regulates Morphologic Restoration of Fractured Bones

Successful fracture repair requires restoration of bone morphology and mechanical integrity. Recent evidence shows that fractured bones of neonatal mice undergo spontaneous realignment, dubbed "natural reduction." Here, we show that natural reduction is regulated by the proprioceptive system and improves with age. Comparison among mice of different ages revealed, surprisingly, that 3-month-old mice exhibited more rapid and effective natural reduction than newborns. Fractured bones of null mutants for transcription factor Runx3, lacking functional proprioceptors, failed to realign properly. Blocking Runx3 expression in the peripheral nervous system, but not in limb mesenchyme, recapitulated the null phenotype, as did inactivation of muscles flanking the fracture site. Egr3 knockout mice, which lack muscle spindles but not Golgi tendon organs, displayed a less severe phenotype, suggesting that both receptor types, as well as muscle contraction, are required for this regulatory mechanism. These findings uncover a physiological role for proprioception in non-autonomous regulation of skeletal integrity.

Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion

PURPOSE

To report outcomes of patients with distal radius fracture malunions treated with corrective osteotomy and orthogonal volar and radial "90-90" plate fixation.

METHODS

We performed a retrospective review of all patients who underwent distal radius corrective osteotomy and 90-90 fixation from January 2008 through December 2014. Demographic data, injury history, prior treatments, and clinical examination values were recorded. Preoperative radiographic measurements were used to classify the type and severity of deformity. The outcomes were patient-reported pain levels, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) functional scores, and radiographic outcomes. Secondary outcomes, including complications and the need for additional surgeries, were also noted.

RESULTS

Thirty-nine cases (31 extra-articular, 8 combined intra- and extra-articular) were included. At mean postoperative follow-up interval of 4 years, significant improvements were observed clinically in wrist flexion-extension arc, grip strength, pain, and Quick Disabilities of the Arm, Shoulder, and Hand scores. Radiographically, significant postoperative improvements were noted in ulnar variance, radial inclination, intra-articular stepoff, and radial tilt, with volarly and dorsally angulated malunions corrected to 9° and 7° of volar tilt, respectively. Twelve patients (31%) underwent additional surgery, the most common being plate removal in 7 patients, 3 of which involved removal of the radial plate.

CONCLUSIONS

For patients with symptomatic malunion of the distal radius, corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intra-articular component.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Corrective distal radius osteotomy following fracture malunion using a fixed-angle volar locking plate

Post-traumatic distal radius deformity may cause severe morbidity, and corrective osteotomy is often necessary to realign the functional axis of the wrist to correct symptomatic malunion. The aim of this retrospective study was to review the short-term results of a single surgeon’s series of distalradius corrective osteotomies following fracture malunion using a fixed-angle volar locking plate for 20 patients(16 women) of an average age of 57 (range 19–83) years [corrected].At short-term follow up (average 14 months, range 12-15 months), no complications were noted and radiological union was confirmed in all cases at an average of 3 months. The average post-operative Disability of the Arm, Shoulder and Hand score was 13.48 (range 0-48.33) and an objective improvement was noted in movements at the wrist joint. A statistically significant improvement was achieved in ulnar variance, radial inclination, dorsal tilt, and supination.

Current concepts in the treatment of distal radial fractures

Distal radial fractures are among the most commonly encountered traumatic fractures of the upper extremity. Initial trauma mechanism, fracture pattern, associated injuries, and patient age influence treatment and outcome. Although stable fractures are commonly treated conservatively, the past decade has seen changes in surgical practice and techniques. Indications for surgery have been extended and refined based on new insight into the pathophysiology of the distal end of the forearm and technological advances in implant design. Despite the frequency of this fracture, only limited higher-level evidence exists to guide practitioners in decision making for this injury. This article highlights key concepts in the treatment of distal radial fractures and summarizes current evidence.

Isolated ulnar shortening osteotomy for the treatment of extra-articular distal radius malunion

PURPOSE

To report the clinical outcomes and complications for a cohort of patients who had extra-articular distal radius malunions treated with isolated ulnar-shortening osteotomy (USO). A second purpose was to define the dorsal angulation limit that would still result in clinical and functional improvement after isolated USO for distal radius malunion. We postulated that patients with up to 20° dorsal or volar tilt could be successfully treated with isolated USO.

METHODS

We conducted a retrospective chart review for all patients who had an isolated USO for the treatment of ulnar impaction syndrome after distal radius malunion between January 1990 and December 2011. A total of 18 patients underwent isolated USO after distal radius malunion. The mean age of the patients was 53 years and the mean duration of follow-up was 34 months. We used Wilcoxon signed-rank tests to compare preoperative and postoperative range of motion; pain; Quick Disabilities of the Arm, Shoulder, and Hand scores; and radiographic measurements.

RESULTS

Average intraoperative ulna shortening was 5.6 mm. Average flexion-extension arc improved from 79° preoperatively to 105° postoperatively. Average pronation-supination arc improved from 121° preoperatively to 162° postoperatively. Average visual analog scale pain score improved from 4.1 to 1.9. Average Quick Disabilities of the Arm, Shoulder, and Hand score improved from 43 to 11.

CONCLUSIONS

This case series demonstrated a significant improvement in pain score and range of motion after isolated USO for distal radius malunion. Patients with up to 20° dorsal tilt and radial inclination as low as 2° demonstrated improved clinical and functional outcomes after isolated USO. Given the comparable functional outcomes with shorter operative times and lower complication rate requiring fewer secondary surgeries, isolated USO is an attractive alternative to distal radius osteotomy for the management of distal radius malunion in patients with up to 20° dorsal tilt.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Radiographs late in the follow up of uncomplicated distal radius fractures: are they worth it? Clinical outcome and financial implications

Fractures of the distal radius are common. Displacement can quickly lead to secondary osteoarthritis. Early follow up radiographs are subsequently paramount to facilitate for early attempts at reduction. Developing callus eventually makes this impractical. In the absence of complications we propose that radiographs may become obsolete at the later stages of follow up. We investigate whether clinical deformity, range of wrist movement and grip strength are independent of radiographs taken later than 2 weeks into the follow up of uncomplicated cases. Local cases between May 2009 and December 2011 were reviewed. Devised criteria regulated case selection. Data was collected from radiological software and occupational therapy clinical notes. Fractures were placed in short or term follow up groups dependant on whether they were imaged later than 2 weeks into follow up. T-tests compared our outcomes measures between these groups. 138 cases were included; 77 short term; 61 long term. No cases reported visible clinical deformity. There were no significant differences between grip strength or range of wrist movement for the short and long term groups. No cases required intervention for late displacement. Although complications may justify delayed imaging, our results suggest radiographs late in the follow up of uncomplicated distal radius fractures have no impact on our outcome measures. Further studies are required to confirm this. Financial regulation means any potential benefits from the removal of these unnecessary radiographs should be recognised. Established radiological follow up regimes need to be devised.

Early correction of paediatric malunited distal metaphyseal radius fractures using percutaneous callus osteoclasis ("Calloclasis")

INTRODUCTION

Closed reduction of secondary displacements of distal metaphyseal radius fractures is an easy procedure only when performed within the first ten to fifteen days post-trauma, prior to the occurrence of malunion. When a hard bony callus prevents proper reduction, an open osteotomy is generally advocated.

HYPOTHESIS

We suggest the use of a less invasive technique which aims at correcting early malunion when closed reduction is made impossible: the percutaneous callus osteoclasis.

MATERIALS AND METHODS

Callus osteoclasis consists in a series of multiple bone-drilling in a postage stamp pattern performed under image intensifier using a large diameter pin, at a distance from the growth plate. Once the bone has been weakened, reduction is obtained by using the pin as an intrafocal lever. The pin is then pushed through the opposite cortex to ensure postero-lateral stabilization.

RESULTS

Twenty-one patients were managed using this technique and reported good results with no complications.

DISCUSSION

This technique offers a low aggressive management of malunions and may be performed within two to six weeks after trauma.

LEVEL OF EVIDENCE

Level IV. Multicenter retrospective study.

The role of bone allografts in the treatment of angular malunions of the distal radius

PURPOSE

Two cohorts of patients who had corrective osteotomies and volar platings for malunited fractures of the distal radius were compared retrospectively to determine whether the time to union and the outcome were affected by bone allograft.

METHODS

Patients in the first group (n = 14) did not receive any bone graft; patients in the second group (n = 14) had allograft bone chips following volar plating. Indications for surgery, surgical technique, and postoperative rehabilitation were the same in both groups. Volar cortical contact was maintained using a volar locking plate in all patients. Radiographic parameters of deformity correction, time to union, wrist and forearm range of motion, grip strength, patient-rated wrist evaluation and Disabilities of the Arm, Shoulder, and Hand questionnaire were used to evaluate the outcome before and after the surgery. Average follow-up time was 36 weeks. Patients who had diabetes, who smoked, who had a body mass index of more than 35, and who required lengthening for deformity correction were excluded from the study.

RESULTS

Osteotomies in both groups healed without loss of surgical correction. Final outcome and time to union revealed no significant differences, clinically or statistically, between the 2 groups. The Disabilities of the Arm, Shoulder, and Hand score was improved in both groups.

CONCLUSIONS

When volar cortical contact was maintained using a volar locked plate, bone allograft at the osteotomy site did not improve the final outcome.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Clinical outcomes of corrective osteotomy for distal radial malunion: a review of opening and closing-wedge techniques

BACKGROUND

Radial corrective osteotomy is an established but challenging treatment for distal radial malunion. There is ongoing discussion over whether an opening or closing-wedge osteotomy should be employed. The purpose of the present study was to retrospectively compare the clinical and radiographic results of conventional opening-wedge osteotomy with those of our closing-wedge technique.

METHODS

We retrospectively evaluated forty-two patients with extra-articular distal radial malunion who were managed with corrective osteotomy and were followed for a minimum of one year. Twenty-two patients were managed with radial opening-wedge osteotomy and interpositional bone graft or bone-graft substitute, and twenty were managed with simultaneous radial closing-wedge and ulnar shortening osteotomy without bone graft. The selection of the surgical procedure was determined by the surgeon. Each patient was evaluated on the basis of objective radiographic measurements and functional outcomes as determined on the basis of clinical examination, including range of wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand (DASH) score.

RESULTS

The mean duration of follow-up was thirty-six months (range, twelve to 101 months) for the opening-wedge cohort and twenty-eight months (range, twelve to eighty-seven months) for the closing-wedge cohort. The two techniques were comparable in terms of complications. Postoperative volar tilt and ulnar variance improved significantly compared with the preoperative status in each cohort (p < 0.05). Restoration of ulnar variance to within defined criteria (-2.5 to 0.5 mm) was significantly more frequent in the closing-wedge cohort than in the opening-wedge cohort (p < 0.001). The postoperative mean extension-flexion arc of the wrist (p < 0.001) and Mayo wrist score (p = 0.008) were significantly better in the closing-wedge cohort. Differences between the two cohorts in terms of the pronation-supination arc, grip strength, pain-rating score, and DASH scores were not significant.

CONCLUSIONS

The closing-wedge osteotomy technique is an effective reconstructive procedure for the treatment of extra-articular distal radial malunion. It is significantly better than the opening-wedge osteotomy technique in terms of the restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score.

Effect of calcium phosphate bone cement augmentation on volar plate fixation of unstable distal radial fractures in the elderly

BACKGROUND

Calcium phosphate bone cement increases the stability of implant-bone constructs in patients with an osteoporotic fracture. The purpose of this randomized study was to determine whether augmentation of volar locking plate fixation with calcium phosphate bone cement has any benefit over volar locking plate fixation alone in patients older than sixty-five years of age who have an unstable distal radial fracture.

METHODS

Forty-eight patients (fifty unstable distal radial fractures) were recruited for this study. The mean patient age was seventy-three years. Surgical procedures were randomized between volar locking plate fixation alone (Group 1) and volar locking plate fixation with injection of calcium phosphate bone cement (Group 2). The patients were assessed clinically at three and twelve months postoperatively. Clinical assessments included determinations of grip strength, wrist motion, wrist pain, modified Mayo wrist scores, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Radiographic evaluations were performed immediately postoperatively and at one year following surgery. The adequacy of the reduction was assessed by measuring radial inclination, volar angulation, and ulnar variance.

RESULTS

The two groups were comparable with regard to age, sex, fracture type, injury mechanism, and bone mineral density. No significant differences were observed between the groups with regard to the clinical outcomes at the three or twelve-month follow-up examination. No significant intergroup differences in radiographic outcomes were observed immediately after surgery or at the one-year follow-up visit. Furthermore, no complication-related differences were observed, and there were no nonunions.

CONCLUSIONS

Augmentation of metaphyseal defects with calcium phosphate bone cement after volar locking plate fixation offered no benefit over volar locking plate fixation alone in elderly patients with an unstable distal radial fracture.

Computer-assisted versus non-computer-assisted preoperative planning of corrective osteotomy for extra-articular distal radius malunions: a randomized controlled trial

Background

Malunion is the most common complication of distal radius fracture. It has previously been demonstrated that there is a correlation between the quality of anatomical correction and overall wrist function. However, surgical correction can be difficult because of the often complex anatomy associated with this condition. Computer assisted surgical planning, combined with patient-specific surgical guides, has the potential to improve pre-operative understanding of patient anatomy as well as intra-operative accuracy. For patients with malunion of the distal radius fracture, this technology could significantly improve clinical outcomes that largely depend on the quality of restoration of normal anatomy. Therefore, the objective of this study is to compare patient outcomes after corrective osteotomy for distal radius malunion with and without preoperative computer-assisted planning and peri-operative patient-specific surgical guides.

Methods/Design

This study is a multi-center randomized controlled trial of conventional planning versus computer-assisted planning for surgical correction of distal radius malunion. Adult patients with extra-articular malunion of the distal radius will be invited to enroll in our study. After providing informed consent, subjects will be randomized to two groups: one group will receive corrective surgery with conventional preoperative planning, while the other will receive corrective surgery with computer-assisted pre-operative planning and peri-operative patient specific surgical guides. In the computer-assisted planning group, a CT scan of the affected forearm as well as the normal, contralateral forearm will be obtained. The images will be used to construct a 3D anatomical model of the defect and patient-specific surgical guides will be manufactured. Outcome will be measured by DASH and PRWE scores, grip strength, radiographic measurements, and patient satisfaction at 3, 6, and 12 months postoperatively.

Discussion

Computer-assisted surgical planning, combined with patient-specific surgical guides, is a powerful new technology that has the potential to improve the accuracy and consistency of orthopaedic surgery. To date, the role of this technology in upper extremity surgery has not been adequately investigated, and it is unclear whether its use provides any significant clinical benefit over traditional preoperative imaging protocols. Our study will represent the first randomized controlled trial investigating the use of computer assisted surgery in corrective osteotomy for distal radius malunions.

Trial registration

NCT01193010

DISTAL RADIAL FRACTURES IN PATIENTS OVER 60 YEARS OLD: ORTHOGONAL PLATES VERSUS VOLAR PLATE

Objective: To compare the results from surgical treatment between volar plates with angular stability and orthogonal plates in unstable distal radius fractures, in patients aged over 60 years. Methods: The patients were divided into two groups that were treated with volar plates or orthogonal plates. Clinical and radiographic results were analyzed prospectively. Results: The study groups presented similar clinical and radiographic results six months after the operation. However, three months after the surgery, the volar plate group had superior results. Conclusion: Both group presented good functional results. Surgical treatment enabled early rehabilitation. The orthogonal plate technique required a longer learning curve, presented more complications and worse initial results.

Treatment of extra-articular distal radial malunions with an intramedullary implant

PURPOSE

Malunited distal radius fractures pose considerable problems, especially for young, active individuals. Surgical correction with osteotomy, bone grafting, and internal fixation with plates and screws has been the treatment of choice. Locked intramedullary fixation is an alternative technique to provide bony stability while minimizing soft tissue irritation in the management of acute distal radius fractures, with acceptable clinical results. The purpose of this study was to describe our experience with the use of an intramedullary device combined with grafting to repair distal radial malunions. This fixation device is inserted through the radial styloid and obtains distal fixation with 3 fixed-angle locking screws.

METHODS

Thirteen patients underwent distal radius malunion repair with an intramedullary implant and grafting. There were 6 male and 7 female participants with an average age of 51 years (range, 18-72 y). Patients were evaluated at an average follow-up of 24 months (range, 13-38 mo). Clinical outcome was measured by range of motion of the wrist and forearm, and grip strength, and by using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We analyzed radiographs to determine time to union and adequacy of correction.

RESULTS

All of the malunions healed, with an average time to healing of 11 weeks. Patients' average range of motion at follow-up was 56 degrees of flexion, 66 degrees extension, 85 degrees pronation, and 84 degrees supination. Mean grip strength was 83% of the unaffected side, and the average Disabilities of the Arm, Shoulder, and Hand score was 21. Radiographs taken on the latest follow-up showed correction to the following average parameters: 20.6 degrees radial inclination, 11.0 mm radial height, +1.0 mm ulnar variance, and 2.1 degrees volar tilt.

CONCLUSIONS

The technique presented in this report demonstrates the effectiveness of an intramedullary nail combined with bone graft or graft substitute in repairing malunited fractures of the distal radius. The results show reliable correction of the deformity and good functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-term outcomes of corrective osteotomy for the treatment of distal radius malunion

Corrective osteotomy is an established but challenging treatment for distal radius malunion. Short- and intermediate-term results have been previously published while long-term results have not. The long-term results of 22 patients treated with corrective osteotomy for symptomatic distal radius malunion are presented (range 6-24 years, mean 13 years). All patients completed the DASH questionnaire and the modified Gartland and Werley, and Green and O'Brien scores postoperatively. Wrist alignment was assessed through standard wrist radiographs. Average wrist flexion-extension was 72.5% of the contralateral limb. Grip strength averaged 71%. The DASH score averaged 16 points corresponding to mild perceived disability. Results were categorized as fair on both the Gartland and Werley score (average 9 points) and the modified Green and O'Brien score (average 67 points). Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis. The outcome presented may be a reflection of the use of stricter evaluation instruments or reflect the development of post-traumatic arthritis.

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.

Nonunion of distal radius fracture and distal radioulnar joint injury: a modified Sauvé-Kapandji procedure with a cubitus proradius transposition as autograft

The Sauvé-Kapandji (SK) procedure is indicated in distal radius nonunion or malunion and distal radioulnar joint (DRUJ) instability. It can also be used to treat the rheumatoid wrist with severe degenerative changes in the DRUJ. The main objective is to allow a pain-free range of movement. We present a patient with rheumatoid arthritis and distal radius nonunion who, after three operations, was treated with the SK procedure. The clinical and radiological results were excellent. A 53-year-old woman diagnosed with rheumatoid arthritis fell on her forearm at home 2 years ago. Examination at an outpatient clinic revealed a distal radius fracture classified as type V according to the Frykman classification. She had been operated three times with open reduction internal fixation using a plate, screws, and bone allograft. She came to our institution with a distal radius nonunion, positive post-traumatic ulnar variance, and ulnar nerve paresis. The range of movements was 20 degrees -10 degrees flexion-extension and 40 degrees -30 degrees pronation-supination, and she needed daily fentanyl. We performed a modified SK procedure with an autologous iliac crest bone graft and ulnar bone graft from the osteotomy area (cubitus proradius), bone morphogenetic protein, and a low profile distal radius plate. After 1 year of follow-up, the distal radius fracture has healed and the wrist is pain-free with a complete range of movement in flexion-extension and pronation-supination. The main indication for the SK procedure is post-traumatic positive ulnar variance and associated ulnocarpal impaction. The cubitus proradius bone graft transposition is an interesting technical note that makes this case a challenge for skilled orthopedic hand surgeons.

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.

What counts: outcome assessment after distal radius fractures in aged patients

OBJECTIVES

Outcome of surgical interventions at the distal radius does not only depend on the type of intervention used, it also depends on the way the outcome is measured. Substantial differences in outcome assessment between different measurement tools and poor correlation among them result in the question about the best instrument for the evaluation of treatment after distal radius fractures. The aim of the review is to discuss pros and cons of the parameters that are available to assess the outcome after distal radius fractures. The review should help to choose the appropriate instruments for a given research question in aged patients with distal radius fractures.

DATA SOURCES AND SYNTHESIS

Objective and subjective measures were reviewed with respect to their suitability in outcome assessment. Radiological parameters like inclination, palmar slope, and length of the radius are most common and used to determine especially surgical success. Grip strength and range of motion are considered objective and used as study endpoints in many studies. Functional tests like the Jebsen test provide a realistic feedback about disability but require special skills and resources of the testing personnel. Patient self-assessment adds perceived patient benefit. The patient-rated wrist evaluation (PRWE) provides a reliable and valid instrument for subjective outcome assessment.

CONCLUSIONS

A combination of objective and subjective parameters should be used to assess the outcome of different treatment strategies due to the known discrepancies. Objective parameters like shortening, radial shift, or others should be clearly defined in the study methodology.

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.

Malunion of the distal radius

Fractures of the distal radius are common injuries. Acceptable results typically can be obtained with appropriate surgical or nonsurgical management. However, a small percentage of these fractures can progress to symptomatic malunion, which traditionally has been treated with osteotomy of the distal radius. Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. In formulating a treatment plan, the surgeon also must consider such technical variables as the type of osteotomy, the use of bone graft or bone-graft substitute, and the means of fixation to stabilize the osteotomy. Simultaneous implementation of an ulnar-side procedure, an intra-articular osteotomy, and soft-tissue releases also may be necessary. Some cases may be more appropriate for wrist fusion or other salvage procedures.

Surgical correction of dorsally angulated distal radius malunions with fixed angle volar plating: a case series

PURPOSE

To report our experience using a fixed-angle volar plate in conjunction with a corrective osteotomy and cancellous bone graft for the treatment of distal radius malunions with dorsal angulation in 4 patients.

METHODS

Four consecutive patients had a volarly based opening wedge osteotomy with a fixed angle volar plate and cancellous bone grafting for the treatment of a dorsally angulated distal radius malunion. Data collected retrospectively included a visual analog pain scale, grip strength, range of motion, radiographic parameters, and each patient's subjective functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire. Motion, strength, and radiographic values were compared with the contralateral arm for each patient.

RESULTS

The average time from initial fracture to corrective osteotomy was 346 days. The average length of follow-up evaluation was 13.5 months. The flexion-extension arc of motion increased an average of 21 degrees to a value of 84% of the contralateral side; the pronation-supination arc of motion increased an average of 20 degrees to a value of 98% of the contralateral side. The average tilt of the radius improved from 26 degrees extension to 2 degrees extension; the average radial inclination improved from 22 degrees to 24 degrees; the average ulnar variance excluding the 1 patient who had a distal ulna resection improved from 5 mm to 1 mm. The average retrospective Disabilities of the Arm, Shoulder, and Hand score improved from 30 to 7; the average retrospective visual analog pain scale score improved from 4.5 to 1. The average grip strength increased from 20 to 29 kg, which corresponded to 73% of the contralateral extremity.

CONCLUSIONS

The rigid characteristics of fixed angle volar plates can provide an alternative to the traditional techniques of distal radius osteotomy including structural bone grafting and dorsal plate fixation or external fixation. In addition these plates are strong enough to allow for early postoperative motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.