80: Corrective Osteotomy of Malunited Distal Radius Fractures

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Procedure 80 Corrective Osteotomy of Malunited Distal Radius Fractures

Jesse B. Jupiter

Indications

image Deformity by itself may or may not be symptomatic. A decision for surgery should be based on functional impairment, pain, loss of motion, and limitation of grip strength.

image Alteration of radiocarpal alignment will affect normal carpal kinematics and changes in the vectors of the extensor and flexor tendons (Fig. 80-1).

image Dorsally malunited fracture can result in a midcarpal instability (Figs. 80-2 and 80-3).

image Although there is no fixed radiographic criteria for correction of deformity, the lower limits of deformity at which symptoms are likely to be present include radial deviation of 20 to 30 degrees, sagittal tilt of 10 to 20 degrees dorsally, and radial shortening of 0 to 2 mm. Articular incongruity greater than 2 to 3 mm may also require osteotomy.

image

FIGURE 80-1

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FIGURE 80-2

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FIGURE 80-3

Relative Indications for Osteotomy

image Limited function

image Pain

image Midcarpal instability

image Distal radioulnar joint incongruity

image Prearthritic articular incongruity

Relative Contraindications for Osteotomy

image Advanced degenerative arthritis

image Fixed carpal malalignment

image Limited functional capabilities

image Extensive osteoporosis

Examination/Imaging

Clinical Examination

image Along with standard examination of wrist and forearm mobility, examination should include digital mobility, grip strength, and neurovascular function. Trophic changes or soft tissue edema would preclude surgical intervention.

Imaging

image Standard anteroposterior, lateral, and oblique radiographs of both wrists are essential for preoperative planning.

image For most deformities, tracings can be made from the anteroposterior and lateral radiographs and superimposed on each other. The angle and precise location of the deformity can be identified in the frontal and sagittal planes (Fig. 80-4).

image By superimposing the tracings in the sagittal and frontal planes and drawing a line from the most volar and dorsal lips, a perpendicular line can be drawn midpoint on each line. Where these two intersect will define the type of osteotomy required and the need for lengthening of the distal fragment (Fig. 80-5).

image

FIGURE 80-4

image image image

FIGURE 80-5

Timing

image Osteotomy can be considered when no soft tissue trophic changes or swelling exist, radiographs show limited disuse osteopenia, and digital motion is recovered.

image In the absence of trophic changes, early surgical intervention (6 to 12 weeks postinjury) can facilitate correction through incompletely ossified fracture callous, minimize the development of soft tissue contracture and distal radioulnar joint stiffness, and limit the duration of economic and psychological impact on the patient.

Positioning

image The patient is supine with the involved arm on a standard hand table and upper arm tourniquet in place.

image The ipsilateral iliac crest may be prepared if autogenous bone graft is to be used.

image Image intensification is essential.

Exposures

Volar

image The distal part of the anterior Henry approach involves exposure between the flexor carpi radialis and radial artery (Fig. 80-6).

image The muscle belly of the flexor pollicis longus is retracted ulnarly to expose the pronator quadratus, which is elevated from its insertion on the radius (Fig. 80-7).

image Exposure and realignment of the distal fragment are improved by Z-lengthening of the tendon of the brachioradialis.

image Small Hohmann retractors are placed along the borders of the distal radius at the site of the deformity (Fig. 80-8).

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FIGURE 80-6

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FIGURE 80-7

image

FIGURE 80-8

Pearls

The site of the deformity must be exposed completely before osteotomy.

Intraoperative imaging will confirm the location and direction of the deformity.

Additional exposure is aided by release of the proximal sheath of the flexor carpi radialis as it enters the proximal palm.

Pitfalls

Avoid injury to the palmar cutaneous branch from the median nerve.

Dorsal

image The skin incision is between 6 and 8 cm extending 2 to 3 cm distal to the Lister tubercle (Fig. 80-9).

image Opening the extensor retinaculum can be done either between the second and third or between the third and fourth extensor compartments.

image The extensor pollicis longus (EPL) is elevated out of the compartment, whereas the second and fourth extensor compartments are elevated between the volar sheaths of the compartments.

image Small Hohmann retractors are placed on both sides of the distal radius metaphysis at the level of the malunion (Fig. 80-10).

image

FIGURE 80-9

image

FIGURE 80-10

Pearls

The entire metaphysis should be visualized to help judge rotational malalignment.

Pitfalls

Disruption of the retinacular coverage of the second and fourth extensor compartments will expose the extensor tendons to the underlying plate.

Branches of the radial sensory nerve are at risk with dissection along the radial column.

Procedure

Volar Approach—Dorsal Malunion

Step 1

image The radiocarpal joint is located, and a smooth K-wire is placed parallel to the articular surface.

image Two additional K-wires are placed perpendicular to both the distal fragment and radial shaft (Fig. 80-11).

image The distal limb of the volar plate is temporarily screwed to the distal fragment with the proximal limb of the plate subtending the deformity angle in the sagittal and frontal planes (Fig. 80-12).

image

FIGURE 80-11

image

FIGURE 80-12

Step 1 Pearls

Careful preoperative planning will define the deformity in all planes in order to place the implant in a manner in which it will facilitate correction of the deformity.

Step 1 Pitfalls

The application of the distal limb of the plate must put the distal screws in the subchondral bone to provide optimal support of the distal fragment.

Step 2

image The osteotomy cut is made parallel to the articular surface in the sagittal plane (Figs. 80-13 and 80-14).

image The plate is reattached to the distal fragment (Fig. 80-15).

image

FIGURE 80-13

image

FIGURE 80-14

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FIGURE 80-15

Step 2 Pearls

One should consider creating the osteotomy with the distal limb of the plate still attached.

Complete the osteotomy with a thin osteotome to avoid risk for injury to the extensor tendons.

Step 2 Pitfalls

Failure to create the osteotomy parallel to the articular surface can lead to translation during realignment.

Step 3

image By supinating the distal fragment while pronating the radial shaft, the dorsal callous and periosteum are released (Fig. 80-16).

image A laminar spreader is placed in the osteotomy to help regain some length and help reduce the distal fragment (Fig. 80-17).

image

FIGURE 80-16

image

FIGURE 80-17

Step 3 Pearls

If the distal fragment has disuse osteoporosis, caution must be taken when trying to use the plate to help in the reduction.

The small laminar spreader is most useful in reduction and lengthening.

Step 3 Pitfalls

Failure to release the dorsal callous and periosteum will make it very difficult to achieve reduction.

Step 4

image Using the laminar spreader, the length is gained while the proximal limb is realigned to the radius shaft (Fig. 80-18).

image The plate is attached to the shaft with screws (Fig. 80-19).

image Bone graft or bone substitute is packed into the defect from the radial side.

image

FIGURE 80-18

image

FIGURE 80-19

Step 4 Pearls

The use of a bone clamp will help bring the proximal limb of the plate onto the radius shaft.

Bone substitutes will be effective with less morbidity than iliac crest graft.

Step 4 Pitfalls

Poor preoperative planning will make it difficult to use the implant and to perform the reduction.

Screw penetration through the dorsal cortex can produce tendon irritation or rupture.

Postoperative Care and Expected Outcomes

image A volar splint and bulky dressing remain for 7 to 10 days, after which time active motion is started.

image The adjuvant use of a splint will depend on the patient’s needs.

image The ultimate outcome regarding strength and motion may take up to 12 to 18 months to reach (Fig. 80-20).

image

FIGURE 80-20

Procedure

Correction of Volar Malunions

image The surgical approach is similar to that already described.

image Volarly angulated malunions require a palmar open wedge osteotomy.

image Volarly displaced malunions tend to heal with a pronation deformity of the distal radius (Fig. 80-21).

image

FIGURE 80-21

Pitfalls

Care should be taken not to overcorrect the physiologic palmar tilt when manipulating the distal fragment into extension.

Screw penetration through the dorsal cortex risks attrition tendinitis and rupture.

Procedure

Dorsal Approach

Step 1

image A smooth Kirschner wire is inserted through the dorsal wrist capsule parallel to the articular surface.

image Two threaded 2.5-mm Kirschner wires are inserted on both sides of the deformity to subtend the angle of correction (Fig. 80-22).

image A distractor can be attached to the pins to help gain length and maintain the corrected alignment (Fig. 80-23).

image

FIGURE 80-22

image

FIGURE 80-23

Step 1 Pearls

A small distractor is helpful to slowly gain length and realign the distal fragment (Fig. 80-23).

Placement of the K-wires follows the orientation determined by the preoperative plan.

If angular correction alone is required, the osteotomy is made parallel to the joint surface (Fig. 80-24).

If rotational correction is also required, the osteotomy should be made perpendicular to the distal fragment in both the frontal and sagittal planes.

image

FIGURE 80-24

Step 1 Pitfalls

Incorrect placement of the osteotomy may create a secondary deformity.

Failure to release the brachioradialis tendon will inhibit lengthening of the distal fragment.

Step 2

image Using a thin blade, the osteotomy is made parallel to the distal K-wires.

image The distractor can facilitate slow lengthening (Fig. 80-25).

image

FIGURE 80-25

Step 2 Pearls

When creating the osteotomy, the volar cortex can be left intact if an opening wedge without lengthening has been planned.

Temporary stabilization of the osteotomy can be done by placing smooth K-wires obliquely across the osteotomy.

Step 2 Pitfalls

Avoid the osteotomy cut entering the sigmoid notch!

Step 3

image Implant selection can be either two small 2.4-mm plates, one dorsally on the intermediate column and one between the first and second extensor compartments or, alternatively, an implant shaped to the dorsal anatomy of the distal radius.

Step 3 Pearls

Careful image control is needed to confirm the alignment correction and position of the proposed implant.

If two small 2.4-mm plates are to be used, the dorsal plate on the intermediate column is placed first to check position of the distal screws (Fig. 80-26).

image

FIGURE 80-26

Step 3 Pitfalls

The distal locking screws can penetrate the radiocarpal joint unless the distal part of the plate is bent slightly to direct the screws in a proximal direction.

Step 4

image The three-dimensional defect created by the osteotomy is filled with either cancellous iliac crest graft or a bone substitute (Fig. 80-27).

image Closure of the extensor retinaculum is done with the EPL tendon outside the closure to prevent ischemic rupture of the avascular portion of the EPL at the Lister tubercle.

image

FIGURE 80-27

Step 4 Pearls

Applying the internal fixation before placing the bone graft allows cancellous graft or bone substitute to be used.

Angular stable locking plates have avoided the need for structural support with corticocancellous bone graft.

Step 4 Pitfalls

Overcorrection of the distal fragment can result in volar displacement of the distal fragment.

Closure of the extensor retinaculum without transposition of the thumb extensor risks tendon rupture.

Postoperative Care and Expected Outcomes

image See volar approach.

Evidence

Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg [Am]. 1996;78:739-748.

The authors retrospectively compared 10 malunited distal radius fractures that had been corrected early (6 to 14 weeks after injury) against 10 malunited distal radius fractures that were corrected late (30 to 48 weeks) and found that the results were similar. However, they preferred an earlier correction because it was technically easier and reduced the overall period of disability. (Level IV evidence)

Prommersberger KJ, van Schoonhaven J, Lanz UB. Outcome after corrective osteotomy for malunited fractures of the distal end of the radius. J Hand Surg [Br]. 2002;27:55-60.

A large series of corrective osteotomies for dorsal (n = 29) and palmar (n = 20) malunited distal radius fractures is presented, together with objective follow-up data at 18 months. The authors conclude that function is correlated with restoration of alignment, and patients with multiplanar deformities fare less well after surgical correction. (Level V evidence)

Ring D, Roberge C, Morgan T, et al. Osteotomy for malunited fractures of the distal radius: a comparison of structural and nonstructural autogenous bone grafts. J Hand Surg [Am]. 2002;27:216-222.

This retrospective study compared the use of cancellous bone graft versus a corticocancellous bone graft after corrective osteotomy of malunited distal radius fractures. Radiographic and functional results were comparable between both groups, and the authors preferred cancellous bone grafting because it was simpler. (Level IV evidence)

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