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Distal radius malunion , correction
- 1. MANAGEMENT OF DISTALRADIUS MALUNION BY CORRECTIVE OSTEOTOMY AND BONE GRAFTING WITH DEFINITIVE FIXATION By Dr kishore vemula Final year postgraduate Department of orthopaedics SVRRGGH.
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- 6. Post op protocols •All patients are immobilised for 2 weeks for soft tissues to heal • After suture removal advised mobilisation • No wt bearing and strenous activities upto radiological healing • Regular follow ups
- 7. MANAGEMENT OF DISTALRADIUS MALUNION BY CORRECTIVE OSTEOTOMY AND BONE GRAFTING WITH DEFINITIVE FIXATION
- 8. Introduction • Despite improvementsin treatment since early 1980’s malunion remains a common cause of residual disability in distal radius fractures • “Wrist will enjoy perfect freedom in all its motions and can be completely exempt from pain’” colles observation in 1814
- 9. • Malunion canbe caused by failure to achieve or maintain accurate reduction or by inadequate duration or type of immobilisation. • Rduction is difficult in communition, osteoporosis • Old age is commonly assosciated with malunions
- 10. Malunion - deformities •Extraarticular -Decrease in • Radial length • Decrease in radial inclination • Loss of normal volar tilt • Intraarticlar - articular step ≥2mm • DRUJ incongruency or instability. - Step of 1-2mm at distal radioulnar joint or combination of these can occur
- 11. Clinical features • Decreasein Radial length- druj pathology, pain at druj • Decrease in radial inclination– impaired ulnar deviation • Loss of normal volar tilt – Dorsal tilt- deformity, decreased wrist flexion, carpal instabiliy pattern – Excessive Volar tilt – deformity, decreased extension, mid carpal instability . Articular step--- radiocarpal arthritis pain at wrist .druj instability--- pain at dista radio ulnar joint
- 12. Clinical features • Excessivedorsal angulation ≥15-20 for long time can alter the wrist biomecanics and can cause DISI pattern instabiliy pattern • Excessive volar angulation ≥20 can leas to VISI pattern.
- 13. Clinical features • Excessivedorsal tilt can cause median nerve compression • Long term- attritional rupture of EPL tendon
- 14. Predictors of pooroutcomes fernandez et al • Distal radius articular step of • DRUJ step of 1-2mm • Doral tilt morethan 15-20 • Volar tilt of morethan 20 • Radial length of lessthan 6mm • Radial inclination of lessthan 10 ≥2mm
- 15. Radiographic evaluation • Ap/lateral views in neutral rotation • Cotralateral wrist also for measurement and comparision • Ct san- for articular step • Mri- itegrity of TFCC & Intercarpal ligaments
- 16. Operative treatment • Notall patients of distal radius malunion requires surgery • Not indicated in patients with – Minimally symptomatic – Not interfering daily activities – Malunion in acceptable range – Very old age Asymptomatic patient with even gross deformity in old age--- not indicated
- 17. GRAHAMS CRITERIA FORRADIOLOGICAL ACCEPTABLE DISTAL RADIUS MALUNION • Radial length- shortening of < 5mm • Radial inclination- >15 • Radial tilt – dorsal < 15 Volar < 20 • Articular incongruency – step of < 2mm at radiocarpal joint
- 18. INDICATIONS • All symptomaticmalunions • Signifigantly interfere with daily activities • Asymptomatic young patient but with deformity that can cause problems in future • Symptomatic old with high functional demand with good bone stock
- 19. contraindications • active CRPS •osteopenia • advanced radiocarpal arthrits • poor soft tissue coverage • acceptable function despite deformity
- 20. STRATEGIES OF TREATMENTOF DISTAL RADIUS MALUNION • PROCEEDURES TO CORRECT DEFORMITY OF DISTAL RADIUS…. DRO • PROCEEDURES THAT TREAT PATHOLOGY AT DRUJ…ULNAR SHORTENING, SAUVE KAPANDJI,DURRACH’S • SALVAGE PROCEEDURES– WRIST ARTHRODESIS, PROXIMAL ROW CARPECTOMY
- 21. TREATMENT OF EXTRAARTICULAR MALUNION •1. FERNANADEZ OSTEOTOMY… for dorsal angulation open wedge metaphyseal osteotomy with bone grafting and internal fixation with plate. • 2. SHEA OSTEOTOMY for volar angulation open wedge metaphyseal osteotomy with bone grafting and internal fixation with plate • 3.INTRAMEDULLARY FIXATION WITH micronail • 4. EXTERNAL FIXATION
- 22. Fernandez osteotomy • Dorsalapproach • Preclinical evaluation radial parameters , bone graft size • Mark osteotomy 2.5 cm proximal to joint • Perform osteotomy transverse in coronal plane and oblique in sagittal plane • Osteotomy must be parallel to joint surface • Distract at osteotomy site, • Bone graft from iliac ctrest, trim it • Fixed across the osteotomy site by holding reduction • Plate and screws( t plate)
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- 24. Shea osteotomy • Volarhenry approach • Preclinical evaluation radial parameters , bone graft size • Mark osteotomy 2.5 cm proximal to joint • Perform osteotomy transverse in coronal plane and oblique in sagittal plane • Osteotomy must be parallel to joint surface • Distract at osteotomy site, • Bone graft from iliac ctrest, trim it • Fixed across the osteotomy site by holding reduction • Plate and screws( t plate)
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- 26. Proceedures to correctDRUJ incongruency • These proceedures may require either single or in combination with distal radius osteotomy based on maintainance of DRUJ congruency after DRO • DRUJ that maintained with DRO alone can be left with DRO alone. • DRUJ not maintained with DRO alone may require these proceedures.
- 27. Proceedures to correctDRUJ incongruency • DRUJ preservation surgeries; Ulnar shortening osteotomy • DRUJ ablation sugeries; 1.Darrach’s pcedure 2.Bowers arthroplasty- partial resection of distal ulna 3.Sauve- kapandji Proceedure - druj fusion + prox ulnarpsseudoarhosis
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