The effect of rotational malunion of the radius and the ulna on supination and pronation

The Role of 3D technology in corrective osteotomy for forearm malunion

Forearm malunion affects upper limb function, impairing rotation, grip strength, and dexterity. Traditional osteotomies, based on two-dimensional imaging and intraoperative adjustments, may fail to address the intricate three-dimensional aspects of forearm deformities. Advances in 3D technology, including imaging, virtual surgical planning and 3D-printed patient-specific guides, have transformed corrective osteotomy by enhancing precision and predictability. This paper discusses the limitations of traditional methods, the role of 3D imaging in detailed deformity analysis, the benefits of virtual planning and the use of 3D surgical guides to improve outcomes. The use of 3D technology in both paediatric and adult cases is illustrated in a supplementary series of case reports. Future improvements in artificial intelligence, robotics and augmented reality are expected to enhance 3D-guided osteotomies further, making them more accessible and cost-effective.

Level of Sagittal Plane Fit of Plates on the Radial Shaft: A Cadaveric Study Comparing Precontoured and Straight Titanium Plates

BACKGROUND

During radial shaft fracture fixation, it is important to contour the plate appropriately to restore the radial bow in order to maintain normal forearm mechanics and motion. The aim of this study was to investigate the fit of precontoured radial shaft plates versus surgeon-contoured plates.

METHODS

Six 10-hole Acumed® precontoured volar and dorsolateral radius plates and twelve 10-hole Synthes straight titanium 3.5 mm LC-DCP plates were drilled with arrays of 1.5 mm diameter holes to permit measurement of the plate distance off bone. Plates were applied to 6 cadaver radii and secured with a screw on each end. Three plate conditions were tested: precontoured plates, precontoured plates with further surgeon contouring, and straight plates with surgeon contouring. Surgeon contouring time for each plate was recorded. Each plate was divided into 3 equal regions, and the average distance gaps for each region and the entire plate were calculated.

RESULTS

For the volar side, precontoured plates had a larger total gap compared to that plate with additional surgeon contouring (1.4 mm difference) and the straight surgeon-contoured plates (1.2 mm difference). On the dorsal side, there was no difference in fit between the 3 plate conditions at any location. No differences were found in plate contouring times.

CONCLUSIONS

The precontoured dorsal plate fit was as good as the surgeon-contoured plates indicating this plate could potentially be used in fracture surgery without further bending. The precontoured volar plate was under-contoured, on average, and would likely require further bending to restore the radial bow.

[Posttraumatic torsional deformities of the forearm : Methods of measurement and decision guidelines for correction]

Forearm fractures are common in all age groups. Even if the adjacent joints are not directly involved, these fractures have an intra-articular character. One of the most common complications of these injuries is a painful limitation of the range of motion and especially of pronation and supination. This is often due to an underdiagnosed torsional deformity; however, in recent years new methods have been developed to make these torsional differences visible and quantifiable through the use of sectional imaging. The principle of measurement corresponds to that of the torsion measurement of the lower limbs. Computed tomography (CT) or magnetic resonance imaging (MRI) scans are created at defined heights. By searching for certain landmarks, torsional angles are measured in relation to a defined reference line. A new alternative is the use of 3D reformation models. The presence of a torsional deformity, especial of the radius, leads to an impairment of the pronation and supination of the forearm. In the presence of torsional deformities, radiological measurements can help to decide if an operation is needed or not. Unlike the lower limbs, there are still no uniform cut-off values as to when a correction is indicated. Decisions must be made together with the patient by taking the clinical and radiological results into account.

Successful joint preservation of distal radius osteosarcoma by en bloc tumor excision and reconstruction using a tumor bearing frozen autograft: a case report

Background

The wrist joint is an extremely rare site for osteosarcoma. Joint structure preservation to maintain good limb function is well described in case of knee osteosarcoma, whereas it is not described in case of wrist joint osteosarcoma. In this report, we present the first case of joint preservation surgery to treat distal radius osteosarcoma using a tumor bearing autograft treated with liquid nitrogen.

Case presentation

A 46-year-old male presented with swelling and pain in the right wrist and was diagnosed with conventional osteosarcoma of the distal radius. The patient responded well to neoadjuvant chemotherapy and the tumor shrank remarkably. Wide tumor excision to preserve the radiocarpal joint and reconstruction with a tumor bearing frozen autograft were performed. Partial bone union was detected 3 months postoperatively and complete bone union was detected 9 months postoperatively. Following the surgery, there was immediate commencement of the range of motion (ROM) training in both the wrist and fingers. At the final postoperative follow-up of 41 months, the patient had normal ROM in the wrist, fingers, and forearms, with a score of 100% in the Musculoskeletal Tumor Society (MSTS) score and was disease free.

Conclusion

We present the first case in which en bloc tumor excision with joint preservation of the wrist and reconstruction using a tumor bearing frozen autograft were performed. The surgery yielded excellent hand, wrist, and forearm function at the final follow-up.

Prediction of normal bone anatomy for the planning of corrective osteotomies of malunited forearm bones using a three-dimensional statistical shape model

Corrective osteotomies of the forearm based on 3D computer simulation using contralateral anatomy as a reconstruction template is an approved method. Limitations are existing considerable differences between left and right forearms, and that a healthy contralateral anatomy is required. We evaluated if a computer model, not relying on the contralateral anatomy, may replace the current method by predicting the pre-traumatic healthy shape. A statistical shape model (SSM) was generated from a set of 59 CT scans of healthy forearms, encoding the normal anatomical variations. Three different configurations were simulated to predict the pre-traumatic shape with the SSM (cross-validation). In the first two, only the distal or proximal 50% of the radius were considered as pathological. In a third configuration, the entire radius was assumed to be pathological, only the ulna being intact. Corresponding experiments were performed with the ulna. Accuracy of the prediction was assessed by comparing the predicted bone with the healthy model. For the radius, mean rotation accuracy of the prediction between 2.9 ± 2.2° and 4.0 ± 3.1° in pronation/supination, 0.4 ± 0.3° and 0.6 ± 0.5° in flexion/extension, between 0.5 ± 0.3° and 0.5 ± 0.4° in radial-/ulnarduction. Mean translation accuracy along the same axes between 0.8 ± 0.7 and 1.0 ± 0.8 mm, 0.5 ± 0.4 and 0.6 ± 0.4 mm, 0.6 ± 0.4 and 0.6 ± 0.5 mm, respectively. For the ulna, mean rotation accuracy between 2.4 ± 1.9° and 4.7 ± 3.8° in pronation/supination, 0.3 ± 0.3° and 0.8 ± 0.6° in flexion/extension, 0.3 ± 0.2° and 0.7 ± 0.6° in radial-/ulnarduction. Mean translation accuracy between 0.6 ± 0.4 mm and 1.3 ± 0.9 mm, 0.4 ± 0.4 mm and 0.7 ± 0.5 mm, 0.5 ± 0.4 mm and 0.8 ± 0.6 mm, respectively. This technique provided high accuracy, and may replace the current method, if validated in clinical studies. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2630-2636, 2017.

A case report of an isolated fracture through the radial bicipital tuberosity

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An isolated fracture through the radial bicipital tuberosity is rare.

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The posterior approach has lower complication and is suitable for this fracture.

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IM nailing is not recommended in fractures through the radial bicipital tuberosity.

Introduction

Generally, anatomical reduction of shaft fractures through operative treatment is necessary to restore the anatomical relationship of the forearm bones. However, a number of nerves and vessels are located in the proximal radius, which complicates surgery. In this study, we aimed to reduce postoperative complications by using a posterior approach.

Presentation of case

We describe an isolated fracture through the radial bicipital tuberosity in a 69-year-old man caused by direct blunt force and our management of the fracture. The patient underwent an operation for the fracture under brachial plexus block. The injury was explored using the posterior approach, and plate fixation was performed after confirming the absence of obstacles to rotation on pronation and supination. One year later, the patient did not have any difficulties in activities of daily living.

Discussion

Since an isolated fracture through the radial bicipital tuberosity is more distal than the radial head and neck and more proximal than a common radius diaphysis fracture, we had to consider a different operative approach. The nerve and blood vessels of the forearm, such as the radial nerve and artery, run in a complicated fashion around the proximal radius; thus, we chose the posterior approach because of its simpler surgical technique and lower complication risk, compared with the anterior approach.

Conclusion

Surgeons can obtain a favorable treatment result using the posterior approach to the fracture and reduce complications by ensuring with rigid fixation using a locking plate.

Factors determining outcome of corrective osteotomy for malunited paediatric forearm fractures: a systematic review and meta-analysis

The aim of this study was to identify predictors of a superior functional outcome after corrective osteotomy for paediatric malunited radius and both-bone forearm fractures. We performed a systematic review and meta-analysis of individual participant data, searching databases up to 1 October 2016. Our primary outcome was the gain in pronosupination seen after corrective osteotomy. Individual participant data of 11 cohort studies were included, concerning 71 participants with a median age of 11 years at trauma. Corrective osteotomy was performed after a median of 12 months after trauma, leading to a mean gain of 77° in pronosupination after a median follow-up of 29 months. Analysis of variance and multiple regression analysis revealed that predictors of superior functional outcome after corrective osteotomy are: an interval between trauma and corrective osteotomy of less than 1 year, an angular deformity of greater than 20° and the use of three-dimensional computer-assisted techniques.

LEVEL OF EVIDENCE

II.

Corrective Osteotomy for Malunited Diaphyseal Forearm Fractures Using Preoperative 3-Dimensional Planning and Patient-Specific Surgical Guides and Implants

PURPOSE

Three-dimensional planning based on computed tomography images of the malunited and the mirrored contralateral forearm allows preoperative simulations of corrective osteotomies, the fabrication of patient-specific osteotomy guides, and custom-made 3-dimensional printed titanium plates. This study aims to assess the precision and clinical outcome of this technique.

METHODS

This was a prospective pilot study with 5 consecutive patients. The mean age at initial injury was 11 years (range, 4-16 years), and the mean interval from the time of injury to the time of corrective surgery was 32 months (range, 7-107 months). Patient-specific osteotomy guides and custom-made plates were used for multiplanar corrective osteotomies of both forearm bones at the distal level in 1 patient and at the middle-third level in 4 patients. Patients were assessed before and after surgery after a mean follow-up of 42 months (range, 29-51 months).

RESULTS

The mean planned angular corrections of the ulna and radius before surgery were 9.9° and 10.0°, respectively. The mean postoperative corrections obtained were 10.1° and 10.8° with corresponding mean errors in correction of 1.8° (range, 0.3°-5.2°) for the ulna and 1.4° (range, 0.2°-3.3°) for the radius. Forearm supination improved significantly from 47° (range, 25°-75°) before surgery to 89° (range, 85°-90°) at final review. Forearm pronation improved from 68° (range, 45°-84°) to 87° (range, 82°-90°). In addition, there was a statistically significant improvement in pain and grip strength.

CONCLUSIONS

This study demonstrates that 3-dimensional planned patient-specific guides and implants allow the surgeon to perform precise corrective osteotomies of complex multiplanar forearm deformities with satisfactory preliminary results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Predictive factors for re-displacement in diaphyseal forearm fractures in children-role of radiographic indices

Background and purpose - Manipulation and cast immobilization is the primary management for diaphyseal forearm fractures in children, and re-displacement is the most common complication. We wanted (1) to analyze the incidence of re-displacement in a group of children treated with close reduction and casting; (2) to determine predictive factors such as demographics, mechanism of injury, affected bone, fracture pattern, degree of initial displacement and angulation, and reduction accuracy; and (3) to determine the prognostic effect of previously defined radiographic indices. Patients and methods - We prospectively studied 269 consecutive children with closed and complete middle-third diaphyseal fractures treated with close reduction and casting from October 2014 to April 2015. Factors analyzed included demographics, initial fracture features, having a non-anatomical reduction, and the radiographic indices of cast quality. Results - There were 189 fractures of both bones (70%) and 80 solitary fractures (30%). The overall re-displacement rate was 11%. According to multivariable analysis, independent predictors of re-displacement were initial angulation >10° (RR =5) and failure to achieve an anatomical reduction (RR =2). Statistically significant radiographic indices regarding increased rate of re-displacement included cast index ≥0.7 (RR =5), Canterbury index ≥1.1 (RR =3), and 3-point index ≥0.8 (RR =6). Interpretation - Our results suggested that fractures with a higher degree of initial angulation and non-anatomical reduction more often result in re-displacement. Moreover, the casting quality examined with the radiographic indices played an important role in the success of a non-operative management.

Measurement of Malrotation on Direct Radiography in Pediatric Distal Radius Fractures: Prospective Observational Study

The aim of this prospective study was to test a mathematical method of measuring the malrotation of pediatric distal radius fractures (PDRFs) from direct radiographs. A total of 70 pediatric patients who presented at the Emergency Department with a distal radius fracture were evaluated. For 38 selected patients conservative treatment for PDRF was planned. Anteroposterior and lateral radiographs were taken of all of the patients for comparison before and after reduction. Radius bone diameters were measured in the coronal and sagittal planes on the healthy and fractured sides. Using the diameter values on the healthy side and the new diameter values on the fractured side in the rotation formula, the degree of malrotation between the fracture ends was calculated. The mean follow-up period was 13.5 months. Patients' mean age was 10.00 ± 3.19 years (range, 4-12 years). The rotation degree in the sagittal plane significantly differed between the proximal (26.52°±2.84°) and distal fracture ends (20.96°±2.73°) (P = 0.001). The rotation degree in the coronal plane significantly differed between the proximal (26.70°±2.38°) and distal fracture ends (20.26°±2.86°) (P = 0.001). The net rotation deformity of the fracture line was determined to be 5.55°± 3.54° on lateral radiographs and 5.44°± 3.35° on anteroposterior radiographs, no significant difference was observed between measurements (P >0.05). The malrotation deformity in PDRF occurs with greater rotation in the proximal fragment than in the distal fragment. The net rotation deformity created between the fracture ends can be calculated on direct radiographs.

LEVEL OF EVIDENCE

Diagnostic, Level II.

Shaft Fractures of Both Forearm Bones: The Outcomes of Surgical Treatment with Plating Only and Combined Plating and Intramedullary Nailing

Background

Plate fixation is the most commonly used technique for the treatment of shaft fractures of both forearm bones (SFBFBs). However, all fractures are difficult to treat with plate fixation because of soft tissue injuries, fracture patterns, or the patient's condition. The purpose of this study is to compare the functional results of plate fixation only and combined plate and intramedullary (IM) nail fixation in SFBFBs.

Methods

Fifty-nine cases of SFBFBs that were surgically treated from June 2007 to July 2012 were retrospectively reviewed. In this study, 47 cases that were followed up for more than 12 months were included. All SFBFBs were divided into two groups according to the methods used for internal fixation: plate fixation only (group A) and combined plate and IM nail fixation (group B). The fixation methods were determined intraoperatively. Plate fixation was considered as the first option in all cases, but combined plate and IM nail fixation was selected as the second option if it was difficult to be fixed with plate only. Groups A and B comprised of 31 and 16 cases, respectively. The functional results were evaluated by the Grace and Eversmann rating system and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

Results

In groups A and B, a radiologic union was achieved in 30/31 and 14/16 cases and average union time was 11.1 and 17.8 weeks, respectively. According to the Grace and Eversmann rating system, group A had excellent results in 15 cases, good in 14, acceptable in one, and unacceptable in one. Group B had excellent results in three cases, good in nine, acceptable in two, and unacceptable in two. The average DASH score was 7.1 points (range, 0 to 19.2 points) in group A and 15.1 points (range, 0 to 29.6 points) in group B. Three cases of nonunion with unacceptable results achieved a bony union by additional procedures and the functional results of these cases improved to good or excellent.

Conclusions

The functional results and the average union time were superior in group A than in group B. However, we think that combined fixation is a useful method for SFBFBs that cannot be treated with plate fixation only.

Reconstruction of malunited diaphyseal fractures of the forearm

The forearm is a complex anatomical and functional unit with unique osseous, soft tissue and articular relationships. Disruption of these important relations can have a significant impact, leading to pain, instability of the radio-ulnar articulation and reduced range of motion. The gold standard for treating forearm fractures in adults remains anatomic reduction, stable plate fixation and preservation of the surrounding blood supply. Failure to achieve these goals may lead to malunion, requiring reconstructive surgery, which can be technically challenging. In this review, we discuss the essential aspects of anatomy and pathomechanics, clinical and radiological assessment and the state of the art in pre-operative planning and deformity correction surgery.

Three-dimensional imaging of children with severe limitation of pronation/supination after a both-bone forearm fracture

INTRODUCTION

Although both-bone forearm fractures in children may result in severe limitation of forearm rotation, finding the cause remains a diagnostic challenge. This study tries to evaluate the role of rotational malunion, bony impingement and contractures of the interosseous membrane.

PATIENTS AND METHODS

Children (5-16 years) who suffered from a both-bone forearm fracture in diaphysis or distal metaphysis with a limitation of pronation/supination ≥40° at ≥6 months after trauma were included for analysis with conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

A total of 410 children with a both-bone forearm fracture were prospectively followed in four Dutch hospitals. At a median of 205 days, 7.3 % suffered from a limitation of pronation/supination ≥40°. 14 children were included (median limitation of 40°) and the radiographs revealed a median maximum angular malunion of 16°. CT analysis showed rotational malunion of both radius (median 19°) and ulna (median 9°). MRI analysis revealed neither bony impingement nor contractures of the interosseous membrane.

CONCLUSIONS

Three-dimensional imaging of children with a severe limitation of pronation/supination after a both-bone forearm fracture revealed rotational malunions of both radius and ulna without bony impingement or soft tissue contractures.

LEVEL OF EVIDENCE

Prospective multicenter study, Level 2.

Radial head dislocation during proximal radial shaft osteotomy

The following case report describes a 48-year-old female patient with a longstanding both-bone forearm malunion, who underwent osteotomies of both the radius and ulna to improve symptoms of pain and lack of rotation at the wrist. The osteotomies were templated preoperatively. During surgery, after performing the planned radial shaft osteotomy, the authors recognized that the radial head was subluxated. The osteotomy was then revised from an opening wedge to a closing wedge with improvement of alignment and rotation. The case report discusses the details of the operation, as well as ways in which to avoid similar shortcomings in the future.

Early conversion to below-elbow cast for non-reduced diaphyseal both-bone forearm fractures in children is safe: preliminary results of a multicentre randomised controlled trial

INTRODUCTION

This multicentre randomised controlled trial was designed to explore whether 6 weeks above-elbow cast (AEC) or 3 weeks AEC followed by 3 weeks below-elbow cast (BEC) cause similar limitation of pronation and supination in non-reduced diaphyseal both-bone forearm fractures in children.

MATERIALS AND METHODS

Children were randomly allocated to 6 weeks AEC or to 3 weeks AEC followed by 3 weeks BEC. The primary outcome was limitation of pronation and supination after 6 months. The secondary outcomes were re-displacement of the fracture, complication rate, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, complaints in daily life and assessment of radiographs.

RESULTS

A group of 23 children was treated with 6 weeks AEC and 24 children with 3 weeks AEC and 3 weeks BEC. The follow-up rate was 98 % with a mean follow-up of 7.0 months. The mean limitation of pronation and supination was 23.3 ± 22.0 for children treated with AEC and 18.0 ± 16.9 for children treated with AEC and BEC. The other study outcomes were similar in both groups.

CONCLUSIONS

Early conversion to BEC is safe in the treatment of non-reduced diaphyseal both-bone forearm fractures in children.

LEVEL OF EVIDENCE

Multicentre randomised controlled trial, Level II.

Conversion to below-elbow cast after 3 weeks is safe for diaphyseal both-bone forearm fractures in children

BACKGROUND

It is unclear whether it is safe to convert above-elbow cast (AEC) to below-elbow cast (BEC) in a child who has sustained a displaced diaphyseal both-bone forearm fracture that is stable after reduction. In this multicenter study, we wanted to answer the question: does early conversion to BEC cause similar forearm rotation to that after treatment with AEC alone?

CHILDREN AND METHODS

Children were randomly allocated to 6 weeks of AEC, or 3 weeks of AEC followed by 3 weeks of BEC. The primary outcome was limitation of pronation/supination after 6 months. The secondary outcomes were re-displacement of the fracture, limitation of flexion/extension of the wrist and elbow, complication rate, cast comfort, complaints in daily life, and cosmetics of the fractured arm.

RESULTS

62 children were treated with 6 weeks of AEC, and 65 children were treated with 3 weeks of AEC plus 3 weeks of BEC. The follow-up rate was 60/62 and 64/65, respectively with a mean time of 6.9 (4.7-13) months. The limitation of pronation/supination was similar in both groups (18 degrees for the AEC group and 11 degrees for the AEC/BEC group). The secondary outcomes were similar in both groups, with the exception of cast comfort, which was in favor of the AEC/BEC group.

INTERPRETATION

Early conversion to BEC cast is safe and results in greater cast comfort.

3-Dimensional deformity analysis of malunited forearm diaphyseal fractures

PURPOSE

Several biomechanical studies using cadavers have revealed that axial rotation deformity of the forearm bones reduces forearm motion. However, little information is available on the 3-dimensional deformity patterns, including axial rotation deformity in malunited diaphyseal fractures of the forearm. The complex deformity of both forearm bones is difficult to assess on plain radiographs or cross-sectional images. Therefore, we assessed osseous deformity in malunited diaphyseal fractures of the forearm using 3-dimensioinal analysis.

METHODS

We examined 21 patients (16 malunions of both forearm bones and 5 isolated radial malunions). Three-dimensional computer models of bilateral radius and ulna were created from computed tomography data. We evaluated deformity by superimposing the mirror-image bone model of the contralateral normal bone onto a model of the affected bone.

RESULTS

In 21 radial malunions, extension (n = 17) and pronation (n = 16) deformities were common. This tendency was seen particularly in proximal malunions. Average extension, valgus, and pronation deformities were 18°, 2°, and 16°, respectively. In 16 ulnar malunions, valgus (n = 15) and pronation (n = 12) deformities were common. Average flexion, valgus, and pronation deformities were 1°, 11°, and 6°, respectively. Extension deformity of the radius and valgus deformity of the ulna were correlated with restriction of forearm motion.

CONCLUSIONS

Malunited diaphyseal fractures of both forearm bones showed complex deformities, which suggests that 3-dimensional modeling may be a more effective method than standard computed tomography or radiographs. Pronation deformity of the radius may be caused by the supinator and pronator muscles. In addition, the deformity pattern of both bones may indicate that valgus and internal rotation force in the neutral forearm position is applied to both forearm bones after injury.

CLINICAL RELEVANCE

Three-dimensional forearm osteotomy, including rotational realignment, is necessary to obtain anatomical reduction.

Plate osteosynthesis versus intramedullary nailing for both forearm bones fractures

PURPOSE

Given the continuing improvements in nail implants, intramedullary nailing could become an alternative treatment option to osteosynthesis for the treatment of fractures in both forearm bones, with the proper indication. The aim of this prospective study was to evaluate and compare the results of plate osteosynthesis and intramedullary nailing for the treatment of diaphyseal fractures in both forearm bones.

METHODS

Sixty-seven patients (mean age, 41 years; range, 22-76 years) of this prospective study were divided into two groups according to treatment randomly: ORIF group (plate osteosynthesis) and IMN group (intramedullary nail). The results were assessed on the basis of the time to union, functional recovery (range of motion and functional outcomes [Grace and Eversmann rating system and DASH]), restoration of the ulna and the radial bow, operating time, exposure time to fluoroscopy, complications, and patient satisfaction. The ratio of the magnitude of the maximum radial bow on the injured side to that on the contralateral side (i.e., "the ratio of the contralateral side") was determined to evaluate the effectiveness of radial bow restoration between groups.

RESULTS

The time to union and the exposure time to fluoroscopy were significantly shorter in ORIF group than in IMN group. The presence of butterfly segment and severe displacement were factors leading to the increase in the time of union in IMN group. No intergroup differences were observed in the restoration and magnitude of the maximum radial bow on the injured side. However, ORIF group showed a significantly improved ratio of the contralateral side compared to IMN group. In terms of the location of maximum radial bow and ratio of the contralateral side, significant differences were found between groups. The functional outcomes did not significantly differ between the two groups, irrespective of the time of assessment. All patients achieved union in both groups, with the exception of a single case of nonunion in IMN group and one case of refracture after implant removal in ORIF group.

CONCLUSION

Based on the significant differences in the ratio of the contralateral side, plate osteosynthesis resulted in a more excellent extent of restoration to the conditions prior to the injury. Nevertheless, such significant differences in the restoration of the bow had no effect on the final clinical outcome. If the indication is properly selected, our results suggested intramedullary nailing can be acceptable and effective treatment options for fractures in both forearm bones.

Re-displacement of stable distal both-bone forearm fractures in children: a randomised controlled multicentre trial

INTRODUCTION

Displaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires.

METHODS

Consecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n = 128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture.

RESULTS

A total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (± 9.4)° vs. 14.3 (± 13.6)°) but more complications (14 vs. 1).

CONCLUSIONS

Pinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique.

Corrective distal radius osteotomy: including bilateral differences in 3-D planning

After a fracture of the distal radius, the bone segments may heal in a suboptimal position. This condition may lead to a reduced hand function, pain and finally osteoarthritis, sometimes requiring corrective surgery. Recent studies report computer-assisted 3-D planning techniques in which the mirrored contralateral unaffected radius serves as reference for planning the position of the distal radius before corrective osteotomy surgery. Bilateral asymmetry, however, may introduce length errors into this type of preoperative planning that can be compensated for by taking into account the concomitant ulnae asymmetry. This article investigates a method for planning a correction osteotomy of the distal radius, while compensating for bilateral length differences using a linear regression model that describes the relationship between radii and ulnae asymmetry. The method is evaluated quantitatively using CT scans of 20 healthy individuals, and qualitatively using CT scans of patients suffering from a malunion of the distal radius. The improved planning method reduces absolute length deviations by a factor of two and markedly reduces positioning variation, from 2.9 ± 2.1 to 1.5 ± 0.6 mm. We expect the method to be of great value for future 3-D planning of a corrective distal radius osteotomy.

Three-dimensional analysis of acute plastic bowing deformity of ulna in radial head dislocation or radial shaft fracture using a computerized simulation system

BACKGROUND

Little 3-dimensional biomechanical investigation of plastic bowing deformity of the ulna has been reported, and the purpose of this study was to conduct such an investigation to elucidate mechanisms of injury and appropriate treatments.

METHODS

Ten cases of traumatic plastic deformity of the ulna in pediatric patients, 4 with chronic radial head dislocations (Monteggia equivalent) and 6 with malunited radial shaft fractures, were analyzed for rotational deformities in the axial plane and bending deformities in the sagittal and coronal planes in Euler angle space by use of a 3-dimensional computerized simulation system with a markerless registration technique.

RESULTS

Deformed ulnae with radial head dislocations had 18.7° ± 17.4° of external rotation in the axial plane and 10.4° ± 7.0° of extension in the sagittal plane whereas those with malunited radial shaft fractures had 12.5° ± 12.7° of internal rotation and 6.3° ± 5.6° of flexion displacement compared with mirror images of the opposite ulnae. Absolute values of rotational deformities in both groups were larger than those of sagittal and coronal bending deformities.

DISCUSSION

Most major traumatic plastic bowing deformities of the ulna involved rotation rather than bending. External rotational stress on the ulna is suspected to cause radial head dislocation, and internal rotational stress results in radial shaft fracture during falls onto outstretched arms. Therefore the correction of rotational deformities of the ulna should be considered in the treatment of chronic radial head dislocations and malunited radial shaft fractures.

Computer-assisted corrective osteotomy for malunited diaphyseal forearm fractures

BACKGROUND

Corrective osteotomy for malunited diaphyseal forearm fractures remains a challenging procedure. We developed a computer-assisted system for corrective surgery, including a three-dimensional simulation program and a custom-made osteotomy template, and investigated the results of corrective surgery for malunited diaphyseal forearm fractures with use of this technology.

METHODS

Twenty patients (fifteen male patients and five female patients) with malunited diaphyseal forearm fractures were managed with three-dimensional corrective osteotomy with a custom-made osteotomy template based on computer simulation. We performed osteotomy of both radius and ulna in fourteen patients and osteotomy of the radius alone in six patients. The median age at the time of surgery was eighteen years (range, eleven to forty-three years). The median duration between the time of injury and the time of surgery was thirty-three months (range, five to 384 months). The minimum duration of follow-up was twenty-four months (median, twenty-nine months; range, twenty-four to forty-eight months). To evaluate the results, we compared preoperative and postoperative data from radiographs, forearm motion, grip strength, and pain.

RESULTS

The average radiographic deformity angle preoperatively was 21° (range, 12° to 35°) compared with the normal arm; the radiographic deformity angle was improved to 1° (range, 0° to 4°) postoperatively. The distal radioulnar joints of both sides were symmetric on postoperative radiographs regarding the relative lengths of the radius and ulna. In eighteen patients who had a restricted range of forearm motion preoperatively, the mean arc of forearm motion improved from 76° (range, 25° to 160°) preoperatively to 152° (range, 80° to 180°) postoperatively (p < 0.01). However, forearm supination was still restricted by ≥ 70° in three patients who had been younger than ten years old at the time of the initial injury and who had long-standing malunion for ninety-six months or longer. Painful recurrent dislocation of the distal ulna or radial head resolved or decreased in five patients. Average grip strength improved from 82% to 94% compared with that of the contralateral, normal side.

CONCLUSIONS

Computer-assisted osteotomy can provide excellent radiographic and clinical outcome for the treatment of malunited diaphyseal forearm fractures. Satisfactory restoration of forearm motion can be achieved even in relatively long-standing cases in adults.

Three-dimensional deformity analysis of malunited distal radius fractures and their influence on wrist and forearm motion

Little information exists about three-dimensional (3-D) deformity patterns of malunited distal radius fractures including axial deformity. The current study aimed to clarify the 3-D deformity pattern of malunited distal radius fractures and reveal the influence of osseous deformities, including axial rotation deformity, on wrist and forearm motion. The deformity of 20 dorsally tilted malunions were evaluated using 3-D computer models created from CT data, and correlations between deformity components and range of motion were assessed. The 3-D deformity analysis showed that axial malalignment in pronation, which showed a correlation with the degree of radial tilt deformity, was very common. A radial tilt deformity of > 5° was observed in only 45% of cases. Although the range of wrist flexion and extension showed a correlation with dorsal tilt deformity, the range of forearm pronation and supination did not correlate with distal radius deformities.

Three-dimensional assessment of bilateral symmetry of the radius and ulna for planning corrective surgeries

PURPOSE

The contralateral unaffected side is often used as a reference in planning a corrective osteotomy of a malunited distal radius. Two-dimensional radiographs have proven unreliable in assessing bilateral symmetry, so we assessed 3-dimensional configurations to assess bilateral symmetry.

METHODS

We investigated bilateral symmetry using 3-dimensional imaging techniques. A total of 20 healthy volunteers without previous wrist injury underwent a volumetric computed tomography of both forearms. The left radius and ulna were segmented to create virtual 3-dimensional models of these bones. We selected a distal part and a larger proximal part from these bones and matched them with a mirrored computed tomographic image of the contralateral side. This allowed us to calculate the relative displacements (Δx, Δy, Δz) and rotations (Δφx, Δφy, Δφz) for aligning the left bone with the right bone segments. We investigated the relation between longitudinal length differences in radiuses and ulnas.

RESULTS

Relative differences of the radiuses were (Δx, Δy, Δz): -0.81 ± 1.22 mm, -0.01 ± 0.64 mm, and 2.63 ± 2.03 mm; and (Δφx, Δφy, Δφz): 0.13° ± 1.00°, -0.60° ± 1.35°, and 0.53° ± 5.00°. The same parameters for the ulna were (Δx, Δy, Δz): -0.22 ± 0.82 mm, 0.52 ± 0.99 mm, 2.08 ± 2.33 mm; and (Δφx, Δφy, Δφz): -0.56° ± 0.96°, -0.71° ± 1.51°, and -2.61° ± 5.58°. There is a strong relation between absolute length differences (Δz) between the radiuses and ulnas of individuals.

CONCLUSIONS

We observed substantial length and rotational differences around the longitudinal bone axis in healthy individuals. Surgical planning using the unaffected side as a reference may not be as useful as previously assumed. However, including the length difference of the adjacent forearm bones can be useful in improving length correction in computer-assisted planning of radius or ulna osteotomies and in other reconstructive surgery procedures.

CLINICAL RELEVANCE

Bilateral symmetry is important in reconstructive surgery procedures where the contralateral unaffected side is often used as a reference for planning and evaluation.

Rapid prototyping in orthopaedic surgery: a user's guide

Rapid prototyping (RP) is applicable to orthopaedic problems involving three dimensions, particularly fractures, deformities, and reconstruction. In the past, RP has been hampered by cost and difficulties accessing the appropriate expertise. Here we outline the history of rapid prototyping and furthermore a process using open-source software to produce a high fidelity physical model from CT data. This greatly mitigates the expense associated with the technique, allowing surgeons to produce precise models for preoperative planning and procedure rehearsal. We describe the method with an illustrative case.

Complex radius shaft malunion: osteotomy with computer-assisted planning

We report about two cases with a combined axial and angular malunion of the radius shaft with functional loss of pro-supination. For the preoperative planning, a computer simulation was developed that allows the quantification of the malunion by comparing the 3-d surface model of the impaired bone with the contralateral anatomy. The proximal parts of the left and right radii are superimposed, while the different positions of the distal parts are used to quantify the malunion. This task is performed fully automatically which reduces the overall planning time. The osteotomies were performed according to the results of the computer-aided planning. The first case showed 1 year postoperatively an increase of pronation from 40° to 70° at expense of supination from 95° to 90°. The patient was practically pain-free and reported functional improvement. The second case showed 6 months postoperatively an improvement of supination from 15° to 40° and of pronation from 50° to 60°. The computer-assisted operation planning facilitated the quantification of combined axial and angular malunions which were difficult to detect on plain radiographs.

Correlation of malrotation deformity in distal radius fractures with radiographic analysis: cadaveric study

PURPOSE

The radiographic parameters commonly used for evaluating distal radius fractures are radial length, palmar tilt, radial inclination, and articular congruity. Rotation of the distal fragment is not routinely evaluated after distal radius fractures. The purpose of this study was to define the appearance of distal fragment malrotation on conventional radiographs and to correlate varying degrees of malrotation with the corresponding radiographic findings.

METHODS

Six distal radiuses from embalmed cadavers were cut and stabilized in 10 degrees, 20 degrees, and 30 degrees of pronated malrotation. Posteroanterior, lateral, and oblique (45 degrees pronated view) radiographs were taken and radiographic measurements were made of radial length, palmar tilt, radial inclination, and rotation.

RESULTS

With malrotation, the visible cortical width of the distal fragment mismatched the visible cortical width of the proximal fragment. This was most evident on the oblique view (p < .05) and measured 2.2 mm for 10 degrees of rotation (standard deviation [SD] 0.6), 3.4 mm for 20 degrees of rotation (SD 0.8), and 5.3 mm for 30 degrees of rotation (SD 2.2).

CONCLUSIONS

The radiographic parameter of rotation should be considered when evaluating distal radius fracture reduction. Malrotation is best seen on a 45 degrees oblique pronated radiographic view as a mismatch of the cortical width of the distal fragment compared with the cortical width of the proximal fragment. In the absence of radial shortening, a 5.3-mm mismatch is associated with 30 degrees of malrotation and is the upper limit of acceptability.

Intraobserver and interobserver reliability of radial torsion angle measurements by a new and alternative method with computed tomography

OBJECTIVE

To evaluate the intraobserver and interobserver reliability of radial torsion angle measurement using computed tomography.

METHODS

Twelve pairs of cadaver radii and 116 forearms from 58 healthy volunteers were evaluated using axial computed tomography sections measured at the level of the bicipital tuberosity and the subchondral region of the radius. During digital imaging, the angle was formed by two lines, one diametrically perpendicular to the radial tubercle and the other tangential to the volar rim of the distal joint surface. Measurements were performed twice each by three observers.

RESULTS

In cadaveric bones, the mean radial torsion angle was 1.48º (-6º - 9º) on the right and 1.62º (-6 º - 8º) on the left, with a mean difference between the right and left sides of 1.61º (0º - 8º). In volunteers, the mean radial torsion angle was 3.00° (-17° - 17°) on the right and 2.91° (-16°- 15°) on the left, with a mean difference between the sides of 1.58º (0º - 7º). There was no significant difference between each side. The interobserver correlation coefficient for the cadaver radii measurements was 0.88 (0.72 - 0.96) and 0.81 (0.58 - 0.93) for the right and left radius, respectively, while for the volunteers, the difference was 0.84 (0.77 - 0.90) and 0.83 (0.75 - 0.89), respectively. Intraobserver reliability was high.

CONCLUSION

The described method is reproducible and applicable even when the radial tubercle has a rounded contour.

Three-dimensional corrective osteotomy of malunited fractures of the upper extremity with use of a computer simulation system

BACKGROUND

Three-dimensional anatomical correction is desirable for the treatment of a long-bone deformity of the upper extremity. We developed an original system, including a three-dimensional computer simulation program and a custom-made surgical device designed on the basis of simulation, to achieve accurate results. In this study, we investigated the clinical application of this system using a corrective osteotomy of malunited fractures of the upper extremity.

METHODS

Twenty-two patients with a long-bone deformity of the upper extremity (four with a cubitus varus deformity, ten with a malunited forearm fracture, and eight with a malunited distal radial fracture) participated in this study. Three-dimensional computer models of the affected and contralateral, normal bones were constructed with use of data from computed tomography, and a deformity correction was simulated. A custom-made osteotomy template was designed and manufactured to reproduce the preoperative simulation during the actual surgery. When we performed the surgery, we placed the template on the bone surface, cut the bone through a slit on the template, and corrected the deformity as preoperatively simulated; this was followed by internal fixation. All patients underwent radiographic and clinical evaluations before surgery and at the time of the most recent follow-up.

RESULTS

A corrective osteotomy was achieved as simulated in all patients. Osseous union occurred in all patients within six months. Regarding cubitus varus deformity, the humerus-elbow-wrist angle and the anterior tilt of the distal part of the humerus were an average of 2 degrees and 28 degrees, respectively, after surgery. Radiographically, the preoperative angular deformities were nearly nonexistent after surgery. All radiographic parameters for malunited distal radial fractures were normalized. The range of forearm rotation in patients with forearm malunion and the range of wrist flexion-extension in patients with a malunited distal radial fracture improved after surgery.

CONCLUSIONS

Corrective osteotomy for a malunited fracture of the upper extremity with use of computer simulation and a custom-designed osteotomy template can accurately correct the deformity and improve the clinical outcome.

Correction of forearm malunion guided by the preoperative complaint

Diaphyseal malunion of the forearm may cause loss of pronation and supination, a painful distal radioulnar joint, and aesthetic problems. Seventeen patients (10 males, seven females; mean age, 20.6 +/- 9.3 years) were operated on because of symptomatic malunion after a pediatric forearm fracture. Six patients had predominant loss of pronation (Group 1), four had predominant loss of supination (Group 2), and seven had a painful distal radioulnar joint (Group 3). An osteotomy of the radius was performed in seven patients and of both forearm bones in 10. All patients were available for clinical and radiologic assessments at a minimum followup of 6 months (mean +/- standard deviation, 3.7 +/- 2.3 years; range, 0.5-9.9 years). Release of the contracted interosseous membrane frequently was necessary for patients in Groups 1 and 2 to allow for correction and did not result in weakness, instability of the distal radioulnar joint, or synostosis. The overall improvement in range of motion after osteotomies for patients with a supination deficit was much better than in those with a pronation deficit. All patients in Group 3 gained a pain-free and stable distal radioulnar joint and their range of motion was unchanged. Therefore, ability to improve overall range of motion through forearm osteotomies is dependent on the patients' preoperative complaint.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Alaskan three-dimensional osteotomy: surgical correction for long bone malunions

The Alaskan three-dimensional osteotomy corrects angulation in 2 planes and rotation and length deformities for long bone malunions. The technique was performed on 3 patients with forearm malunions to improve forearm rotation, alleviate pain, and allow patients to return to more normal activities. Progress was monitored for a minimum of 2.5 years. Patients were pleased with the outcome, demonstrating range of motion recovery, pain relief, and enthusiastic return to normal activity. The simplicity and reproducibility of this effective technique are enhanced using precision surgical instrumentation.

The rotational effect of pronation and supination osteotomies of the forearm in a cadaver model: a comparison of osteotomy sites on the radius and the ulna

The purpose of this study was to investigate the effect on forearm rotation of rotation osteotomies at the distal and proximal levels of the radius and the ulna. Rotation osteotomies of 15 degrees and 30 degrees were made in the distal and proximal one-third of the radius and the ulna in ten cadaver specimens and changes of forearm arc of rotation were compared after osteotomy at the four sites. This study identifies the proximal ulna as the best of these sites for rotation osteotomy because of the high gain in the rotated direction and minimal loss in the opposite direction.

Fluoroscopic and magnetic resonance cross-sectional imaging assessments of radial and ulnar torsion profiles in volunteers

PURPOSE

Planning an osteotomy to correct rotational malunions of the forearm is difficult because the uninvolved side is the only available reference to assess radial and ulnar torsions. This study was designed to compare the reliability of 2 methods for the determination of the torsion profile of both forearm bones and to assess side differences further in volunteers.

METHODS

Fluoroscopy in combination with goniometry and magnetic resonance (MR) cross-sectional imaging were used to determine torsion profiles of the radius and the ulna in 24 asymptomatic volunteers. Interrater and interside reliabilities were assessed.

RESULTS

For the radius, interclass correlation coefficients were less than 0.65 with fluoroscopy and greater than 0.80 with magnetic resonance imaging (MRI). For the ulna, both methods had an interclass correlation coefficient of greater than 0.90. Maximum side-to-side differences assessed with fluoroscopy and MRI were 25 degrees and 34.5 degrees for the radius and 20 degrees and 32 degrees for the ulna, respectively. There were no statistical differences between sides using both methods for both forearm bones.

CONCLUSIONS

Fluoroscopy coupled with goniometry is a valuable method for assessing the torsion profile of the ulna. MR cross-sectional imaging is better to assess the torsion profile of the radius; however, a side difference in torsion profile of up to 35 degrees for the radius and of up to 20 degrees for the ulna should be considered physiologic. Hence, only side differences greater than these limits may serve as an indication for an axial osteotomy in the clinical setting.

Assessment of radial and ulnar torsion profiles with cross-sectional magnetic resonance imaging. A study of volunteers

BACKGROUND

We determined whether the torsion profiles of the radius and ulna could be reliably assessed with cross-sectional magnetic resonance imaging and whether these torsion profiles were comparable on the two sides of volunteers.

METHODS

We assessed magnetic resonance imaging cross sections of the left and right forearms of twenty-four asymptomatic volunteers. The torsion profile of the ulna was defined as the angle formed between a line tangential to the volar cortical surface of the distal part of the humerus and a line connecting the center of the ulnar head and the center of the ulnar styloid. Use of paired proximal and distal landmarks resulted in five different methods of assessment of the radial torsion profile. Intrarater and interrater reliabilities and side-to-side variability were assessed.

RESULTS

This method of assessment of the ulnar torsion profile had intraclass and interclass coefficients of 0.95 and 0.91, respectively. A method previously described by Bindra et al. had the best combined intrarater and interrater reliabilities for assessment of the radius. The mean differences between the right and left sides of the volunteers were the lowest with the use of these two methods; nevertheless, the maximum side-to-side difference was > 30 degrees with techniques.

CONCLUSIONS

Torsion-profile assessment with cross-sectional magnetic resonance imaging had high intrarater and interrater reliabilities. However, individual side-to-side variations in the radial and ulnar profiles are important considerations.

CLINICAL RELEVANCE

Cross-sectional magnetic resonance imaging is currently the only available method to quantify rotational malunion of the radius and ulna. Its low side-to-side reliability warrants comparison between the imaging results and the clinical findings. A side-to-side difference in the rotation profile may serve as a reason to perform an axial osteotomy when the results of the clinical and magnetic resonance imaging assessments are consistent with each other.

Rotational deformity in malunited fractures of the distal radius

PURPOSE

To evaluate rotational deformity in malunited fractures of the distal radius and its effect on forearm rotation.

METHODS

Thirty-seven patients with a symptomatic malunion of the distal radius (25 with dorsal angulation and 12 with volar angulation) were assessed for rotational deformity of the distal fragment. Spiral computed tomographic scans were taken of both wrists. Rotational deformity was evaluated by comparing the radial torsion angle of the injured and uninjured sides according to Frahm. Multivariable regression analyses were used to identify the radiologic parameter that had the most important influence on forearm rotation.

RESULTS

Of the 37 patients, 23 showed a rotational deformity of the distal radius. In both dorsally and volarly angulated malunions, pronation and supination deformities were identified. There was a tendency toward more pronation deformities with volar malunion. Volar angulated malunion with a rotational deformity of less than 10 degrees showed the smallest amount of forearm supination. Losses of pronation-supination did not correlate with the amount of rotational deformity.

CONCLUSIONS

This study showed that rotational deformity is common with angulated malunions of the distal radius. The effect on forearm rotation should not be overestimated. Pretreatment computed tomographic scanning of both wrists to identify and measure malrotation of the distal radius may be helpful to improve the outcome after corrective osteotomy.