80: Corrective Osteotomy of Malunited Distal Radius Fractures

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


image

FIGURE 80-2


image

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).


image

FIGURE 80-6


image

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.

Related posts:

28: Pronator Teres Rerouting 34: Reconstruction of the Central Slip with the Transverse Retinacular Ligament for Boutonnière Deformity 32: Crossed Intrinsic Tendon Transfer 26: Reconstruction of Key Pinch in Tetraplegia Patients 33: Correction of Swan-Neck Deformity in the Rheumatoid Hand 30: Synovectomy

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Mar 5, 2016 | Posted by in Hand surgery | Comments Off on 80: Corrective Osteotomy of Malunited Distal Radius Fractures

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