Corrective osteotomy for intra-articular malunion of the distal part of the radius. Surgical technique

Distal radius fractures

The management of distal radius fractures has evolved considerably in the last two decades. Techniques and hardware have improved so much that the surgeon can usually assure good results in these debilitating fractures. Yet no one method can be used for all injuries, as the personality of each fracture demands a customized approach. Furthermore, what works in one age group may not work in another. For this reason, every available treatment has its own space in our options. The need for surgeons to be well versed in all techniques is critical. We offer a concise update of important evolutionary and current treatment guidelines for this common fracture.

Reconstruction of a Portion of the Articular Surface of the Distal Radius With a Vascularized Osteochondral Graft From the Proximal Phalanx of the Great Toe

Distal radius fractures are among the most common injuries to the upper extremity and have a bimodal distribution in younger male patients and older women. Young men suffer from high-energy injuries and older women from fragility fractures. Approximately 50% of these are intra-articular. Timely and appropriate treatment usually will lead to an acceptable outcome, but loss of congruity of the articular surface remains a difficult problem to manage. We report here on the case of a 16-year-old boy with malunion of the radial articular surface with lack of motion and pain. He was managed by replacing the displaced and damaged segment of the radial articular surface with a vascularized osteochondral graft from the proximal phalanx of the great toe. This matched the shape of this portion of the radius quite well, and he has had improvements in motion and pain in the 10 months since that time. The donor site has not caused him any difficulty to date.

Management of malunions of the distal radius

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

Repositioning osteotomy for intra-articular malunion of distal radius with radiocarpal and/or distal radioulnar joint subluxation

BACKGROUND

Intra-articular malunion of the distal radius may be complicated with radiocarpal and radioulnar joint subluxation, which may result in joint stiffness and loss of function. Conventional corrective osteotomy emphasizes on the restoration of the articular step-off. However, little information is available concerning the restoration of a concentric functioning joint through osteotomy.

METHODS

From 2002 to 2007, 12 patients with chronic intra-articular distal radius fractures were evaluated at an average follow-up of 33.6 months after repositioning osteotomy. The average time from initial injury to reconstructive operation was 11.3 months. The indication for osteotomy included dorsal or volar subluxation of the radiocarpal joint, distal radioulnar joint, or both in addition to articular incongruity. A preoperative computed tomography scan or rapid prototyping (RP) models were performed as part of the surgical planning. Operation was preceded by volar, dorsal, or both approaches. Repositioning osteotomy and internal fixation were also performed. Radiographic analysis and the Disability of Arm, Shoulder and Hand score were used for the outcome assessment.

RESULTS

All osteotomy sites healed and all events of radiocarpal and radioulnar subluxation were corrected. The average correction was 13.8 degrees (palmar tilt of the radius) and 1.9 mm in ulnar variance. The mean Disability of Arm, Shoulder and Hand score improved from 64 to 18.

DISCUSSION

Conventional corrective osteotomy via an extra-articular approach was favorably performed to correct an extra-articular malalignment or nascent intra-articular malunion. Problems of abnormal architecture after an intra-articular fracture of the radius are complicated with subluxation of carpus or distal radioulnar joint, which require repositioning via precise articular approach. Both reconstructed computed tomography images and rapid prototyping models are very useful tools in preoperative planning for intra-articular osteotomy. Simulated osteotomy and joint repositioning can be performed in solid models before commencement of actual operation.

CONCLUSION

Repositioning osteotomy consistently restores joint alignment and achieves functional improvement either in cases of nascent simple malunion or complex intra-articular malunion.

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.

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.