University of Groningen Fracture of the distal radius Oskam, Jacob IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 1999 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Oskam, J. (1999). Fracture of the distal radius: selected issues of epidemiology, classification and treatment Groningen: s.n. Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 01-10-2018
90 CHAPTER 9 CORRECTIVE OSTEOTOMY FOR MALUNION OF THE DISTAL RADIUS: THE EFFECT OF CONCOMITANT ULNAR SHORTENING OSTEOTOMY. J Oskam, K M Bongers, A J M Karthaus, A J Frima, H J Klasen. Departments of Surgery, University Hospital Groningen and Deventer Hospitals Groningen, the Netherlands Archives of Orthopaedic and Trauma Surgery 1996; 115: 219-222
91 Residual complaints following corrective osteotomy for malunion of the distal radius are generally localized in the distal radioulnar joint. Usually, symptoms can be attributed to a length discongruency in the distal radioulnar joint due to inadequate correction of radial shortening. To treat postoperative positive ulnar variance, additional Darrach or Bowers resection has been proposed (3,9). However, following distal ulnar resection or hemiresection, pain, loss of grip strength and ulnar subluxation often remain (4). Ulnar shortening osteotomy has been said to create a better function in the distal radioulnar joint because of a lower risk of distal radioulnar instability (9). To avoid postoperative positive ulnar variance we performed 6 ulnar shortening osteotomies concomitantly to 22 radial corrections. The idea behind this policy was to reduce the number of secondary distal ulna (hemi)resections. We will evaluate whether appropriate functional results could be achieved and how many secondary operations were ultimately performed on the ulnar side of the wrist. METHODS AND MATERIAL During the period 1982-1993, 22 consecutive distal radial corrective osteotomies in 21 patients were performed. The mean interval between the injury and the corrective procedure was 10 months (4-120 months). The wrist function of 12 men and 9 women, with a median age of 42 years (19-59 years) was investigated. Preoperatively, all patients complained of wrist pain, diminished wrist movement, and loss of grip strength. Moreover, serious impairment of daily activities existed in all patients. A Colles fracture was present in 20 wrists, and a distal radius with a concomitant distal ulnar fracture or an intra-articular pilon fracture was diagnosed in 2 other cases. The Colles type fractures were extra-articular in 8 cases, and intra-articular in 12 wrists. Seventeen patients were treated conservatively by means of closed reduction and a dorsal splint for six weeks. External fixation was performed in 3, and K-wire fixation in 2 wrists as primary operative treatment. The radiocarpal angle on the lateral projection, and the radial inclination angle and
92 relative ulnar length on the postero-anterior projection were employed as radiological parameters of wrist anatomy (6,11). Radiographs were made 6 and 12 weeks postoperatively to monitor bone healing. The anatomical end result was studied on a radiograph after one year. A radiocarpal angle ranging from 10 degrees volarly to 10 degrees dorsally, a radial inclination angle of 20-30 degrees, and an ulnar variation of -2 to +4 mm were considered to be physiological (6,11). The functional end results of the wrist were judged as good when no pain with use was obtained, and fair if moderate discomfort with use was obtained, if those patients returned to normal activities completely. Surgical technique An X-ray of the opposite wrist was used as indicator of the normal anatomical situation. The surgical approach to the radius was accomplished through a longitudinal volar incision in the second compartment in 10 operations, and a dorsal incision in the third compartment in 12 operations. Depending on wether the radius should also be corrected in the saggital plane (radial inclination), the correction was performed either by an opening linear osteotomy or by an opening biplanar wedge osteotomy. A corticocancellous bone graft from the iliac crest was cut in such a shape that it restored volar and radial tilts. Internal fixation was performed with a small T-plate. Exercises were started at two weeks postoperatively. In six patients (Case no. 9,10,13,16,21,22) concomitant ulnar shortening osteotomy was performed through a separate ulnar incision as described in an earlier paper (7). The indication for this procedure was a positive relative ulnar length of minimally 6 mm. RESULTS Follow up data, after a median period of 30 months (range 12-84) could be obtained in all cases. Healing of the radial osteotomy was radiographically adequate in all 22 wrists within three months. Moreover, disturbance of bone union was not observed in any of the ulnar shortening osteotomies.
93 Two different radiological patterns of distal radius malunion could be distinguished: one in which a disturbance of the radiocarpal angle prevails, and one in which a combination of radial deviation with severe radial shortening is characteristic (Fig 1). Ulnar-shortenings were mostly performed in the latter group. It can be seen in Figure 1, that both dorsal and volar tilts were corrected. The radiocarpal angle could be restored adequately in all but 2 patients. In these two patients a postoperative dorsal tilt of circa 20 degrees remained. With respect to the radial inclination angle Figure 1 shows that the most common preoperative pattern was severe radial deviation of the joint surface. However, the radial inclination angle could not be corrected anatomically in all wrists. Figure 1 also shows that the relative ulnar length after correction was usually within the range of -2 to +4 mm. An ulnar variance of -3 mm was observed in Case no.14, but no residual complaints occurred. During follow up all patients reported improvement of wrist function. Good results were observed in 17 patients ( Case no. 2-6, 9-16, 18, 19, 21). A fair functional result was found in 5 patients. In the group with ulnar shortening in combination with radial correction, good results were achieved in 5 out of 6 patients. Case Localisation pain Anatomical disorder 7 Radioulnar Discongruency sigmoid notch 8 Radioulnar Positive ulnar variance 17 Ulnocarpal Chondropathy ulna head 20 Radiocarpal 22 Radioulnar Discongruency sigmoid notch Table 1. Survey of postoperative wrist pain in 5 patients with a fair functional outcome following corrective osteotomy.
94 The precise localisation of postoperative wrist pain in the 5 patients with a fair functional outcome are displayed in Table 1. It appears that mainly the ulnar side radiocarpal angle degrees 60 40 20 0-20 -40 0 5 10 15 20 25 case no. PRE POST radial inclination degrees 40 20 0-20 0 5 10 15 20 25 case no. PRE POST
95 rel. ulnar length mm 15 10 5 0-5 0 5 10 15 20 25 case no. PRE POST Figure 1. Pre- and post-operative measurements of radioanatomical parameters of 22 wrists corrected for a distal radial malunion. (PRE= preoperative, POST= postoperative) of the wrist was involved. Positive ulnar variance due to a failure to restore radial length was only observed in case no. 8. Furhermore, osteoarthritis in the radioulnar joint due to fracture involvement of the sigmoid notch (incisura ulnaris) of the distal radius was found in case no. 7 and 22. In order to relieve persistent pain in patient no. 7 and 8, secondary hemiresection of the ulna head was performed. This resulted in improvement of wrist function without pain. DISCUSSION This study shows that most of the corrective procedures we performed were technically and functionally adequate because wrist anatomy could be restored, and all patients reported improvement of wrist function (4,5). The postoperative disorders in our series consisted of incongruency of the radial sigmoid notch and ulnar head chondropathy, both of which have been described previously and are generally not attributed to technical failure (5). During follow up no poor functional results were observed and all patients were able to resume their normal daily
96 are quite acceptable. Positive ulnar variance appears to be the most common cause for residual radioulnar pain after correction of wrist deformity (3). Inadequate lengthening of the radius is the most likely cause of this postoperative complication. It has been reported that the maximum length that can be achieved by solely radial correction is circa 6-7 mm. (5). If larger length discrepancies have to be corrected single radial osteotomy may not be sufficient. Therefore, we think that if problems of restoring radial length are to be expected, an concomitant ulnar shortening osteotomy should primarily be performed. For that reason, we performed 6 concomitant ulnar shortening osteotomies, with a good functional outcome in 5 of the 6 wrists. Furthermore, a relatively too long ulna could only be observed in 1 out of 22 corrections. The first reports on failure following correction were published 50 years ago (2,10). At the time, it had already been reported that disorders in the distal radioulnar joint commonly induce pain and malfunction, and that Darrach resection may relieve these symptoms. Fernandez confirmed the drawback of residual radioulnar pain following radial corrective osteotomy in 1982, and suggested that positive ulnar variance was the most likely cause (3). Consequently, he performed additional Darrach resection in 8 of 20 patients (40%). However, Darrach resection can provoke ulnar subluxation and instability (1). Therefore, hemiresection of the ulnar head has been developed and can be considered as a better alternative in combination with radial corrective osteotomy nowadays, because stability of the distal radioulnar joint is maintained (4, 9). Stability of the distal radioulnar joint is determined by surface congruity, and condition of the ligaments (8). Since ulnar hemiresection causes pseudarthrosis, loss of distal radioulnar stability may occur. To stabilize the distal radioulnar joint in case of posttraumatic positive ulnar variance, we reported earlier that length incongruency can be meticulously corrected (7). From this point of view, we found hemiresection of the ulnar head not the optimal physiological solution, and now we prefer to perform an ulnar shortening osteotomy if we expect that radial lengthening will not restore congruency in the distal radioulnar joint. Partial resection of the ulna head has been reported to be a reasonable alternative (9).
97 However, it is not yet known whether the functional results of hemiresection are good in the long term. Therefore, we advocate reconstruction of the distal radioulnar joint by means of ulnar shortening osteotomy, while additional hemiresection of the ulnar head should only be performed if anatomical reconstruction is impossible. REFERENCES 1. Bieber EJ, Linscheid RL, Dobyns JH, Beckenbaugh RD. Failed distal ulnar resections. J Hand Surg 1988; 13A: 193-200. 2. Campbell WC. Malunited Colles fractures. JAMA 1937; 109: 1105-8. 3. Fernandez DL. (Correction of post-traumatic wrist deformity in adults by osteotomy, bonegrafting, and internal fixation. J Bone Joint Surg 1982; 64A: 1164-78. 4. Fernandez DL. Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal end of the radius. J Bone Joint Surg 1988; 70A: 1538-51. 5. Fernandez DL. Distal radius fractures. Reconstructive procedures for malunion and traumatic arthritis. Orthop Clin North Am 1993; 24: 341-63. 6. Friberg S, Lundstrom B. Radiographic measurements of the radio-carpal joint in normal adults. Acta Radiol Diagn 1976; 17: 249-56. 7. Oskam J, Kingma J, Klasen HJ. Ulnar-shortening osteotomy after fracture of the distal radius. Arch Orthop Trauma Surg 1993; 112: 198-200. 8. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist-anatomy and function. J Hand Surg 1981; 6A: 153-62. 9. Posner MA, Ambrose L. Malunited Colles fractures: Correction with a biplanar closing wedge osteotomy. J Hand Surg 1991; 16A: 1017-26. 10. Speed JS, Knight RA. The treatment of malunited Colles s fractures. J Bone Joint Surg 1945; 27A: 361-7. 11. Steyers CM, Blair WF. Measuring ulnar variance: a comparison of techniques. J Hand Surg 1989; 14A: 607-12.
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