Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
4Activity
0 of .
Results for:
No results containing your search query
P. 1
Sagittal Rotational Malunions of the Distal Radius: the Role of Pure Derotational Osteotomy (2009)

Sagittal Rotational Malunions of the Distal Radius: the Role of Pure Derotational Osteotomy (2009)

Ratings: (0)|Views: 21|Likes:
www.drpinal.com - F. Del Piñal, F.J. García-Bernal, A. Studer, J. Regalado, H. Ayala and L. Cagigal.

Sagittal rotational malunion after distal radius fractures was identified in eight patients by the
presence of a ‘‘hinge’’ point on the volar cortex on the lateral radiograph, and the ulnar head being shorter than the anterior lip of the radius on the posterior–anterior radiograph. The surgical correction consisted of preplating the distal fragment with a volar locking plate before an osteotomy through the ‘‘hinge’’ point, and correcting the dorsal tilt of the distal fragment. Any dorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion and grip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsal sagittal tilt improved by 261, from 231 to +31. Ulnar variance improved by 3 mm, from +1.5 to 1.5mm, becoming identical to the opposite side. A pure derotational osteotomy corrected theapparent shortening of the radius and restored the volar tilt.
www.drpinal.com - F. Del Piñal, F.J. García-Bernal, A. Studer, J. Regalado, H. Ayala and L. Cagigal.

Sagittal rotational malunion after distal radius fractures was identified in eight patients by the
presence of a ‘‘hinge’’ point on the volar cortex on the lateral radiograph, and the ulnar head being shorter than the anterior lip of the radius on the posterior–anterior radiograph. The surgical correction consisted of preplating the distal fragment with a volar locking plate before an osteotomy through the ‘‘hinge’’ point, and correcting the dorsal tilt of the distal fragment. Any dorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion and grip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsal sagittal tilt improved by 261, from 231 to +31. Ulnar variance improved by 3 mm, from +1.5 to 1.5mm, becoming identical to the opposite side. A pure derotational osteotomy corrected theapparent shortening of the radius and restored the volar tilt.

More info:

Published by: Comunicación Piñal on Feb 26, 2013
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF, TXT or read online from Scribd
See more
See less

03/20/2013

pdf

text

original

 
SAGITTAL ROTATIONAL MALUNIONS OF THEDISTAL RADIUS: THE ROLE OF PUREDEROTATIONAL OSTEOTOMY
F. DEL PI
N ˜
AL, F. J. GARCI ´A-BERNAL, A. STUDER, J. REGALADO, H. AYALA and L. CAGIGAL
Instituto de Cirugı´ a Pla´ stica y de la Mano, Private Practice and Hospital Mutua Monta
n ˜
esa, Santander, Spain
Sagittal rotational malunion after distal radius fractures was identified in eight patients by thepresence of a ‘‘hinge’’ point on the volar cortex on the lateral radiograph, and the ulnar head beingshorter than the anterior lip of the radius on the posterior–anterior radiograph. The surgicalcorrection consisted of preplating the distal fragment with a volar locking plate before anosteotomy through the ‘‘hinge’’ point, and correcting the dorsal tilt of the distal fragment. Anydorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion andgrip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsalsagittal tilt improved by 26
1
, from
À
23
1
to +3
1
. Ulnar variance improved by 3mm, from +1.5 to
À
1.5mm, becoming identical to the opposite side. A pure derotational osteotomy corrected theapparent shortening of the radius and restored the volar tilt.
Keywords:
Distal radius, Fracture, Malunion, Osteotomy, Bone graft
Malunion after a distal radius fracture usually occurswith dorsal tilting and radial shortening. The tilt is easilymeasured on the lateral radiograph, and the shorteningon the posteroanterior film.In some dorsally tilted malunions the volar cortex actsas a hinge point at the fracture line, and the distalfragment rotates on it, but does not translate. Thisoccurs if there is only dorsal comminution: the distalfragment, unsupported dorsally, pivots on the volarcortex slowly rotating in the cast (Jenkins, 1989), orwhen the reduction was insufficient from the beginning.This represents a ‘‘sagittal rotational malunion’’, andthere is no shortening despite the appearance on aposterior–anterior radiographic view (Fig 1).Such a sagittal rotational malunion can be recognisedon the lateral radiograph, by the ‘‘preservation’’ of thevolar cortex and by having the anterior rim of the radiuslonger than the head of the ulna, confirming the absenceof shortening (Fig 2A). This deformity can be correctedby a derotation osteotomy alone rather than the morecomplex three-dimensional reconstruction (Figs 2B–D).The purpose of this paper is to present the surgicaltechnique and results of derotational osteotomy in eightpatients with rotational malunion of a distal radius fracture.
METHOD
All operations were performed under axillary block onan out-patient basis. The arm was exsanguinated andtourniquet applied. Cancellous bone from the olecranonwas first harvested through a 2.5-cm transverse incision.The cavity was filled with Surgicel
s
, and the wound wasclosed in a single layer with a 3/0 subcuticular nylon.The malunion site was approached through a 6 to8cm incision radial to the flexor carpi radialis sheath(FCR) with a 10mm radially directed back cut in theproximal wrist crease. The space between the FCR andradial vessels was developed. The pronator quadratuswas then elevated subperiosially and reflected ulnar-wards. This exposed the malunion site and the radius.Dissection was continued to the dorsum of the radius,going deep to the brachioradialis. The thickenedperiosteum was elevated, and divided proximal to theextensor tendon compartments making several trans-verse cuts, until the tendons were exposed. Adequatereduction of the distal fragment may not be possiblewithout division of this thickened periosteum as it actsas a restraint.The locking plate was then applied volarly, prior tothe osteotomy, as recommended by Prommersbergerand Lanz (2004). The transverse part of the plate wasplaced distal to the hinge point of the malunion. K-wireshelped ascertain that the distal pegs were subchondralfor a strong hold (Fig 3). When the surgeon was satisfiedwith the position, all the distal screws and pegs wereinserted. At the end of this step of the operation, theplate should form an angle with the radial shaft in thesagittal plane equal to the angle calculated pre-operatively on the lateral radiograph to achieve correc-tion of the deformity.To avoid loss of volar cortical bone when usingan oscillating saw, the osteotomy was performed with a1-mm K-wire. A series of perforations parallel to the
SAGE Publications
The Journal of Hand Surgery (European Volume, 2009) 34E: 2:
r
2009 The British Society for Surgery of the Hand. Published by SAGE. All rights reserved.
160–165
 
articular surface, to the dorsal cortex, were made alongthe exact hinge point of the malunion (Fig 4). After theK-wire perforations were completed, the distal radius,fixed with the plate, was bent dorsally to break theweakened palmar cortex. Several attempts were neededin most cases, and in some an oscillating saw wasrequired to cut the very sturdy ulnar cortex.The distal radius with its attached plate was thenreduced to the shaft of the radius, by pushing the distalfragment volarly, as in a closed distal radius fracturereduction. The use of a lamina spreader to distract thedorsal tissues helped achieve a gentle reduction. Weavoided the forceful use of bone clamps to bring thestem of the plate to the shaft of the radius as we feared
Fig. 1 Malunited distal radius fracture with true dorsal tilting and apparent shortening of the radius. (A) The sclerotic rim appears to show apositive ulnar variance, and the dorsal tilt of the distal radius (B). (C) The contour of the distal radius has been highlighted by dots, it can beseen that volar rim of the radius (V) is actually distal to the head of the ulna, but the dorsal rim (D) is proximal. (D) On the same P–A viewas in (A), the volar lip (with dots) is clearly distal to the head of the ulna confirming the inaccuracy of the variance measured in (A). A finegrey line has been drawn tangentially to the ulnar dome across all the radiograms. A fine black line marks the volar rim of the radius.Fig. 2 Pure sagittal malrotation: diagnostic pointers, planning and execution (same case as in Fig 1). (A) A clear hinge point corresponding to theoriginal fracture line can be seen (arrow), attesting to preservation of the volar cortex length. The distal volar rim can be seen distal to thehead of the ulna confirming the ulna minus variance (stippled in black). (B) The hinge point will be used as the rotation point of the distalfragment. (C) Pure rotation on the fulcrum will correct dorsal tilting preserving the radial length. (D) The result on this patient. A fine greyline has been drawn tangentially to the ulnar dome across all the radiograms. A fine black line marks the volar rim of the radius.
SAGITTALROTATIONAL MALUNIONSOFTHEDISTALRADIUS 161
 
that the screws could pull out of the bone. Once theplate lay easily on the shaft, it was held temporarily bytwo bone clamps. Careful reduction of the fragments atthe hinge point assured that the volar cortex continuitywas restored; otherwise, shortening and incompletevolar tilt correction will ensue (Figs 5A and B).Additionally, in order to compensate for some collapsethat may have occurred at the osteotomy site, the firstscrew on the stem of the plate was placed eccentrically todistract the osteotomy and restore the normal radiallength (Figs 5C and D).The dorsal bone gap was filled with the cancellousbone from the olecranon. The pronator quadratus wassutured over the plate, if possible. At the first post-operative visit, 24 to 48 hours later, a removable splintwas applied and the patient encouraged to start activerange of motion exercises. After 4 to 6 weeks patientsgradually discarded the splint.This operation was carried out in eight patients. Therewere three females and five males, aged 23 to 60 years(mean 37 years). All but two patients were involved inheavy occupations prior to the accident. At the time of their referral 3.5 months to 3 years (mean 10 months) allwere off work because of their wrist except for twopatients, one of whom had reduced her work and sportactivities due to wrist pain. Six patients were coveredunder workers’ compensation, and were on sick leave orinvolved in litigation. Seven patients had previouslybeen treated in a cast and one had fixation with K-wires.Patients confirmed an improvement in pain on avisual analogue 10cm scale from 7.25 (range 6–9) pre-operatively to 0.50 (range 0–2) at follow-up between 6and 35 months. Active flexion–extension changed from
Fig. 3 The plate has been provisionally stabilised with K-wires to the distal fragment. An intravenous needle, used for reference, will help to placethe plate as distal as possible, and to keep the ulnar K-wires subchondrally.Fig. 4 Once the plate has been securely fixed distally, osteotomythrough the hinge point, is carried out. In order to preserve thelength of the volar cortex intact, the osteotomy is performedwith a 1-mm K-wire.
162THEJOURNAL OF HAND SURGERY VOL. 34E No. 2 APRIL 2009

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->